On norms and bodies: findings from field research on cosmetic surgery in Rio de Janeiro, Brazil

Abstract

Brazil has the second highest rate of cosmetic surgery worldwide, provided in a large number of public and private clinics and hospitals, especially in the southeast. This qualitative field research in Rio de Janeiro included participant observation and in-depth interviews with 18 women cosmetic surgery patients, 10 key informants (e.g. psychologists and sociologists) and 12 plastic surgeons. Fifteen of the women were either pre- or post-operative; three had not decided whether to have surgery. When asked about their motivations and expectations of the surgery, the majority of the women said they wanted to be “normal”. Most of the surgeons said they acted as empathic companions from decision-making through surgery and beyond. Many of the key informants were critical of what was happening to medical ethics in relation to cosmetic surgery. With the growth in a consumer culture, they saw ethics in medicine becoming more bendable and subject to the “law” of the market. The cult of the body has become a mass phenomenon and taken on an important social dimension in a society where norms and images are broadcast widely by the media. The trend towards body-modification by cosmetic surgery at an early age is increasing dramatically. What demands critical thinking and further investigation are the consequences of cosmetic surgery for physical and mental health.

Résumé

Le Brésil est le deuxième pays au monde pour le taux de chirurgie esthétique, pratiquée dans un grand nombre de cliniques et d’hôpitaux publics et privés, particulièrement dans le Sud-Est. Cette recherche qualitative de terrain à Rio de Janeiro comprenait l’observation de participants et des entretiens approfondis avec 18 patientes, 10 informateurs clés (par exemple des psychologues et des sociologues) et 12 chirurgiens esthétiques. Quinze des femmes étaient en phase pré ou postopératoire ; trois n’avaient pas encore décidé de se faire opérer. Interrogées sur leurs motivations et ce qu’elles attendaient de l’intervention, les femmes ont déclaré dans leur majorité vouloir être « normales ». La plupart des chirurgiens ont affirmé qu’ils agissaient comme compagnons empathiques depuis la décision jusqu’à l’intervention et au-delà. Beaucoup des informateurs clés critiquaient l’évolution de l’éthique médicale par rapport à la chirurgie esthétique. Avec la croissance dans une culture de consommation, ils jugeaient que l’éthique médicale devenait moins stricte et se soumettait à la « loi » du marché. Le culte du corps est devenu un phénomène de masse et revêt une dimension sociale importante dans une société où les normes et les images sont véhiculées largement par les médias. Les modifications corporelles par la chirurgie esthétique tendent à augmenter de manière spectaculaire chez les jeunes. Les conséquences de la chirurgie esthétique sur la santé physique et mentale doivent faire l’objet d’une pensée critique et de recherches supplémentaires.

Resumen

En Brasil existe la segunda tasa más alta del mundo de cirugía cosmética, ofrecida en un gran número de clínicas y hospitales públicos y particulares, especialmente en el sureste. Esta investigación cualitativa de campo en Río de Janeiro comprendió observación participante y entrevistas a profundidad con 18 mujeres pacientes de cirugía cosmética, 10 informantes clave (p. ej. psicólogos y sociólogos) y 12 cirujanos plásticos. Quince de las pacientes eran pre o postoperatorias; tres no habían decidido si tener cirugía. Cuando se les preguntó acerca de sus motivaciones y expectativas de la cirugía, la mayoría de las mujeres dijeron que querían ser “normal”. La mayoría de los cirujanos dijeron que actuaron como acompañantes empáticos desde la toma de decisiones hasta la cirugía y más allá. Muchos de los informantes clave criticaron lo que estaba sucediendo a la ética médica con relación a la cirugía cosmética. Con el crecimiento de una cultura de consumismo, vieron la ética en la medicina volverse más flexible y sujeta a la “ley” del mercado. El culto del cuerpo se ha vuelto un fenómeno de masas y ha asumido una importante dimensión social en una sociedad donde las normas e imágenes son transmitidas extensamente por los medios de comunicación. La tendencia hacia la modificación del cuerpo por cirugía cosmética a temprana edad está aumentando drásticamente. Lo que exige pensar críticamente y realizar más investigaciones es las consecuencias de la cirugía cosmética para la salud física y mental.

Key Words:

• cosmetic surgery
• female genital mutilation
• female genital cosmetic surgery
• body image
• adolescents
• Brazil

This paper arises from an inter-disciplinary research project, crossing political science, anthropology, and psychology, on the subject of female genital mutilation (FGM) and cosmetic surgery as “normalising practices”. Both phenomena have gained public attention in recent times. FGM is now practised globally as a result of the international migration of people from cultures where it is endemic. It has become widely known through the media, and is criticised internationally as interference in the bodies of girl infants and children. Western countries are in the forefront of expressing concerns about the practice of FGM and many have passed legislation to ban it within their borders, e.g. Great Britain and Austria.¹²

At the same time, new technologies for cosmetic surgery have been and are being developed in Western countries, and more and more people are undergoing these procedures, the great majority of them women. The American Society of Plastic Surgeons divides these procedures into four categories, based on the extent and reason for the surgery involved. In the USA in 2009, they report that there were 12.1 million cosmetic procedures, 1.7 million cosmetic surgical procedures, 10.4 cosmetic minimally invasive procedures, and 4.9 million reconstructive procedures.³

The central working thesis of our research is that both FGM and cosmetic surgery are forms of disciplining and normalising the female social body and strategies of adjustment to social norms and ideals of being a woman. This thesis is based in the analysis of both these practices of Canadian anthropologist Janice Boddy, who argues that:

“[They] derive from the presumption that female bodies are in need of improvement and continuous monitoring; both enlist women as agents of their self-modification and enjoin them to self-surveillance and restraint; both work to instill in women a desire to conform, to become what they ‘ought’ to be.”⁴

Women who are the subjects of these practices are not forced to engage in them by any external power but are schooled to participate in them by themselves; that is, the disciplinary power works by itself. Foucault’s concept⁵ that “the self and the body are normalised by society through social techniques and institutions” underlies Boddy’s use of the concept of “normalisation” in her work. Furthermore, she points to the dominance of a Western perspective within the discourse on female genital mutilation and argues that “Western practices of body-modification or body mutilation” are contained in that discourse. Thus, she thinks that bulimia, anorexia and depilation (hair removal), as well as cosmetic surgery, are forms of body-modification that have parallels with the discourse on FGM and should be considered as having an analogous function in the reproduction of social and gendered subjects. Thus, even though the two sorts of practices differ in their own contexts, female genital mutilation conforms to the same kind of normalising of women’s bodies as cosmetic surgery in the West, creating and defining femininity.

Authors like Mohanty in 1991⁶ and Sheldon and Wilkinson in 1998⁷ comprehend FGM as a manifestation of the abuse of women in a male-dominated system of ideals and norms of beauty. However, they also criticise the rejection of FGM by those who at the same time accept cosmetic surgery in Western countries. Other authors, for example Gruenbaum,⁸ do not disagree that FGM can have negative consequences for women’s health, but argue that social customs like FGM should not be treated as pathologies because the people whose customs are under attack will not share such an analysis. Feminist perspectives on cosmetic surgery circle around the following considerations: on the one hand, cosmetic surgery may be grasped as an expression and reproduction of hierarchical gender relations, whereby women are subject to beauty norms to a much higher extent than men.⁹ On the other hand, the decision of the individual to use cosmetic surgery may be understood as an expression of agency or autonomy and self-determination regarding a person’s own body.¹⁰

Our research, then, aimed to question and scrutinise the comparability of both practices at a political, cultural, social and individual level within one inter-disciplinary research process, where experience and self-awareness of the body and social norms and ideals interrelate. To this end, from the discipline of psychology, I conducted empirical research in Rio de Janeiro, Brazil, on the social and cultural relevance of body norms and the current significance and practice of cosmetic surgery.

Why Brazil?

Brazil (and specifically Rio de Janeiro) was chosen for field research on cosmetic surgery because it has the highest number of cases of cosmetic surgery per capita in the world. Only the USA exceeds Brazil in the total number of cosmetic surgeries conducted every year. Within Brazil, São Paulo and Rio de Janeiro are the two main centres for this surgery and have the largest number of public and private beauty and cosmetic studios, clinics and hospitals (in Portuguese, studios de beleza, clinicas de beleza and clinicas e hospitaís de cirurgia plástica) in the country.¹¹ In fact, there seem to be an endless number in Rio de Janeiro. In some areas, I found at least one on every corner as I moved around the city.

Rio de Janeiro is not only associated with beach culture, carnival, football and hedonism, but also with beautiful and perfect bodies. In recent decades, a boom in the beauty industry and the growing popularity of cosmetic surgery can be observed. In a worldwide survey conducted by Unilever, 63% of Brazilian women were reported to have said that they would like to have cosmetic surgery (the largest percentage of any national group).¹²

The official statistics on cosmetic surgery in Brazil, published by the Sociedade Brasileira de Cirurgia Plástica (SBCP) in 2009,^* of all plastic surgery procedures (629,000) in Brazil, two-thirds were cosmetic and one-third reconstructive. Of the cosmetic surgery patients, 88% were women and 15% were adolescents under the age of 18, 38% were aged 19–35 and 34% aged 36–50. An increase in “tourism” to Brazil for cosmetic surgery has also been observed, which is ascribed to lower prices than in the USA and Europe, and also to Brazilian expertise in plastic surgery. The most frequently sought surgeries were breast augmentation, followed by liposuction, abdominoplasty (tummy tuck), breast reduction, and surgeries on the face, including eyelid surgery, rhinoplasty (nose modification) and face lifts. In research conducted by Datafolha, two-thirds of cosmetic surgery patients were categorised as caucasian and one-third as coloured or black. The most frequented locations for cosmetic surgery were private hospitals (58%), followed by private clinics (28%) and public hospitals (14%).¹³

Some authors have analysed why the body is considered to have such an important role in Brazilian culture. North American anthropologist Alexander Edmonds, who conducted field research in Rio de Janeiro in 2002, talks about a “democratic concept of beauty” in Brazil, which implies that “the poor have the right to be beautiful too”. He believes, as Gilberto Freyre suggests,¹⁴ that in Brazil physical appearance is an essential element in the construction of uma identidade nacional brasileira (a national Brazilian identity). Edmonds points out the association between social class and beauty in Brazil, and asks whether beauty practices can be regarded as a means of social mobility, or a form of esperanca popular (in this context hope for better social status) in Brazil.¹⁵ Brazilian anthropologist Mirian Goldenberg also talks of the high value assigned by Brazilians to the body (o corpo como valor), especially by cariocas (people from Rio), and of the body itself as a status symbol.¹⁶ The ideal of eternal youth – hand-in-hand with permanent discontent with the body as it is, always needing improvement – is denoted by the local expression for a trained and well-shaped body – “a boa forma”. Is Goldenberg right to say that Brazilians see the body as economic, symbolic and physical capital?¹⁶ What is the most crucial characteristic of Brazil’s body-cult, and why is it so important to transform, modify, adapt and correct one’s body in Brazil? My research sought to answer these questions.

Body fashions and beauty ideals are common to every culture and at all times in history, and people of both sexes have shaped their bodies to meet the predominant beauty ideals of their societies. Thus, the body is a social body, which “embodies” signs and symbols of a culture,¹⁷ and which is individual and public at the same time. Surgery on a healthy body, according to Ensel,^18† reverses the actual intention of “healing” in medicine. In this context, the phenomenon “cosmetic surgery” can be seen as an indication of how societies and individuals who practise it think about and express themselves through their bodies.

The development of female genital cosmetic surgery (FGCS) is relatively new. In the mid-1980s the first operations of this type, as we know them today, were conducted in the USA. Accurate numbers on how many women actually undergo FGCS and its consequences are not known. Some research on this issue uses critical cultural approaches in their analysis.¹⁹²⁰ The authors refer to pictures of and ideas about female bodies, which form the basis for this practice. Virginia Braun notes that the profile of the “natural” vs. the “perfect” female body represents the role-model for these interventions, and comes from pornographic depictions of the female body.¹⁹ The construction of “normality” vs. “deviance” or “normal” vs. “abnormal” regarding female genitals and their surgical alteration is culturally shaped in the discourses of aesthetic medicine and the media. My aim, looking at this issue in Brazil, was to find out if these dichotomous perspectives were culturally constructed or if there might exist some kind of “global” norms. This paper, reporting part of my research, focuses on three main issues:

•	What motivates people’s decision to modify their own bodies and what arguments do they give for doing this? What were the subjectively perceived advantages and disadvantages of cosmetic surgery in relation to the person’s status in society and economic factors?
•	Is female genital cosmetic surgery being practised in Brazil? What are the main reasons for having this type of surgery? Who is having it? What do the surgeons think are the main indications for it and the main risks?
•	How do plastic surgeons view cosmetic surgery on adolescents aged 14 to18, in relation to questions of professional ethics and whether informed choice on the part of patients is possible at such a young age?

In all of these, I was interested in the extent to which the decision to go for cosmetic surgery could be regarded as an act of self-determination.

Methodology and participants

The field research took place from January to November 2008 in Rio de Janeiro. Qualitative methods of data collection and evaluation were used: ethnographic approaches included participant observation in private medical offices, beauty clinics and hospitals, and one public hospital, accompanied by the writing of memos and field notes. Semi-structured interviews were carried out with 12 plastic surgeons (ten men and two women), 15 women patients of cosmetic surgery (ages 26 to 73), three women considering cosmetic surgery (ages 35 to 59), and ten experts from the fields of psychology and psychotherapy, sociology, gynaecology and anthropology (nine women and one man), who acted as key informants. The 15 women patients were in the pre- or post-operative phase. Their surgeries primarily consisted of breast augmentation or reduction, liposuction, abdominoplasty, surgeries on the face, or hair transplantation. I met five of the women in a private surgeon’s office or clinic, and the rest in the public hospital’s plastic surgery department, Enfermeria 38 in Santa Casa de Misericórdia, founded by Brazil’s most famous plastic surgeon, Ivo Pitanguy.^*

Through the interviews, I hoped to obtain the perspectives of those most closely associated with cosmetic surgery. Through participant observation, I aimed to get a better understanding of Brazilian, and especially carioca, ways of handling the body and related cultural traits.

This research is towards my PhD dissertation. Academic mentoring and supervision in Brazil was provided by the department of psychology at the Pontificada Universidade Católica de Rio de Janeiro, which enabled me to establish contact with practising plastic surgeons and other academic experts. I followed the “snowball principle” throughout the research to find the kinds of people I wanted to meet. The interviews were conducted either in private medical offices/clinics or in privacy in a room in the public hospital. Informed consent was obtained from all participants. A tape recorder was used during the interviews, notes were written immediately after the interview and transcriptions were made either in Portuguese or English. For evaluation of the interviews, a coding list was generated based on common themes that arose, and these themes were systematically organised according to the objectives. Data analysis is still in progress.

A semi-structured interview manual was used with the women, including demographic information like marital status (eight women were married, three divorced, three single and one a widow), and profession. The main questions covered type of cosmetic surgery, the moment of decision for the surgery, motivation and expectations from the procedure, satisfaction with themselves and their bodies before and after the surgery (as appropriate), how they perceived their relationship with the surgeon, and the reactions of partners, husband and other family members. With the three women who had not yet decided, I had informal conversations about why they were considering surgery, their expectations and hopes from it, and why they had not yet made the decision. Their openness in responding to my questions helped me as a researcher to understand this phenomenon from a local point of view.

A problem-centred interview manual was used with the plastic surgeons. I asked about their motivations in becoming plastic surgeons, possible risks of cosmetic surgery, their relationship to the patients, ethical issues regarding cosmetic surgery for adolescents, demand for and possible risks of female genital cosmetic surgery, their subjective view of beauty and what they liked most in their profession.

Waiting room, plastic surgery department, Santa Casa de Misericórdia, Rio de Janeiro, 2008

Lastly, I asked the key informants how they interpreted body-modification and cosmetic surgery in Brazil, the significance of the body as an individual means of expression, possible parallels between female genital mutilation and female genital cosmetic surgery and their view of cosmetic surgery as “psychotherapy by scalpel”.^*

Findings

Motivation for undergoing cosmetic surgery

Many of the women patients mentioned a long period of suffering and discontent with their own bodies before they finally made the decision for cosmetic surgery. After pregnancy, their dissatisfaction with their bodies usually increased because their breasts and belly were no longer as flat and tight as before. The majority reported general discomfort about parts of their bodies being “flaccid”. For many, getting rid of this perceived negative bodily change was a priority for feeling comfortable with themselves. Returning to a “normal” body, which they felt they had had before pregnancy, was of major importance. As has been shown in much research on cosmetic surgery,²³²⁴ these patients generally said that their decision to undergo cosmetic surgery was not for their partner’s or husband’s sake, but only for themselves, for their own psychological well-being. In most cases, in fact, their partner or husband was totally against the surgery. There was only one woman among my respondents who felt pressured by her husband to have a facelift and eyelid surgery because of his “obsession with beauty and juvenile appearance”. “He wants me to repair everything,” she said. Some of the main reasons for cosmetic surgery were:

“I do it to gain more self-esteem.” (Age 26, business administrator, breast reduction)

“Everything will change afterwards… everything.” (Age 40, nanny, abdominoplasty)

“I wanted to be normal.” (Age 32, cashier, breast augmentation and abdominoplasty)

“I have been dissatisfied with my own body since I was 19. Now I have the money and want to change something… I also hope to find a better job.” (Age 40, housemaid, breast reduction)

“I do it to boost my self-esteem and to feel a sense of joy again.” (Age 73, retired, facelift)

“Now I can buy and wear the clothes I want to wear.” (Age 50, secretary, breast augmentation, liposuction, abdominoplasty)

Two of the three women who had not yet decided whether to have surgery mentioned that as they were ageing, they felt a lot of social pressure to enhance their looks and bodies:

“At my age, I have to do it. I have to undergo cosmetic surgery and have a facelift so as to look younger, more beautiful. All my friends are doing it.” (Age 59, language teacher)

Female genital cosmetic surgery

FGCS has become very common in Brazil in the last ten years. This was confirmed by all the plastic surgeons I interviewed. Three different types of female genital cosmetic surgery were being conducted in Brazil: the reduction of the labia minora (called labiaplastia or sometimes nynfoplastia in Portuguese), the filling or replenishing of the labia majora (preenchimento in Portuguese), and the narrowing/tightening of the vagina (vaginoplastia), which is often done after women have given birth vaginally.

Only two of the 12 surgeons said they did not get involved in this type of surgery; seven were doing the surgery themselves, and three had been present at one such procedure.

“It is a very simple and harmless surgery with almost no risk or undesirable side-effects at all.” (Plastic surgeon, male, age 42)

“I do the labia minora. Sometimes they are too big, annoying the patient. I think it is valid to do that kind of surgery. Other surgery, such as on the hymen, I don’t agree with and won’t do. The patients asking for labia minora surgery are usually between 30 and 40 years old.” (Plastic surgeon, female, age 36)

“We do it, it is common. And I think the reason that it has increased is because people speak nowadays more directly. It means they have found out it is possible to fix minor problems which, in the past, they kept hidden, especially women. Reducing the labia minora is pretty common.” (Plastic surgeon, male, age 45)

The reasons why these surgeons might advise female genital cosmetic surgery included cases of pain (while playing sports or having sex), and aesthetic or medical reasons. However, the vast majority of the patients do it for aesthetic reasons. The question about what they think women’s motivations are for having FGCS was answered by them in different ways. Some thought there must be a severe underlying psychological problem that the patient wanted to resolve through surgery.

“Women who undergo this kind of surgery usually have a masculinity complex.” (Plastic surgeon, male, age 55)

“I think if something really bothers the person, then they should get it done, I think it is a kind of a psychological problem as well.” (Plastic surgeon, female, age 34)

Others thought it was just “normal” cosmetic surgery like any other, and that women’s reasons for doing it were strongly influenced by the wish to be “normal”, not to differ from others.

I did not manage to meet any women who had had FGCS during my research. The majority of patients I interviewed were at the public hospital Santa Casa de Misericordia, where FGCS is not conducted. However, although one of my key informants, a male gynaecologist, contacted some of his patients who had had FGCS to invite them to talk with me, none of them agreed to do so. Most of my respondents also refused to discuss it and were deprecating about this type of cosmetic surgery. My impression was that cosmetic surgery on the female genitals is still taboo, at least as a topic for conversation.

The majority of the key informants, when asked about any parallels between FGM and FGCS, responded that they did not consider themselves to have any “expertise about the practice of FGM.” One answered:

“Yes, I do see a relationship between these two practices… They both represent a tremendous aggression against one’s own body.” (Psychologist, woman)

In contrast, one (female) sociologist said she thought the two practices differed in intention: one aims to diminish sexual desire (FGM) in women, in conformity with the community’s norms, whereas the other (FGCS) is performed to enhance or improve sexuality, the woman is searching for sexual pleasure as an individual. The (male) gynaecologist I talked to was also convinced that female genital cosmetic surgery could help to enhance women’s sexual pleasure and that advanced techniques in genital surgery could be used with African women who had had FGM, to regain their sexual pleasure.

During my field work, I could not find any published scientific research conducted in Brazil on female genital cosmetic surgery. What I did find were a large number of advertisements in magazines and newspapers claiming the advantages of cirurgia intima (“intimate” surgery). One article reported on the popularity of a plastic surgeon from Rio de Janeiro whose patients are celebrities, claiming that one of his clinic’s major successes was the biomodulação (bio-modification) of the female genital organs. This special treatment, it was said, aimed to increase the volume and diminish the flaccidity of the female genitals, which would help to enhance self-confidence and pleasure.²⁵

Adolescents and cosmetic surgery

In the last ten years, the number of adolescents who have undergone cosmetic surgery has increased dramatically, from about 5% to 15% of the total number of such surgeries each year, as estimated by the Sociedade Brasileira de Cirurgia Plástica, ¹³ and confirmed by specialists. The plastic surgeons interviewed had differing opinions on the subject of adolescents and cosmetic surgery. Half of them were strongly against conducting cosmetic surgery on adolescents and the other half said that they were doing it, but only in cases of strong asymmetries (for example, of the breasts) and in cases where the level of psychological suffering was very high (e.g. a big nose or sticking-out ears).

“Sometimes it’s necessary, you must weigh up and evaluate each case. I mean, as we have a beach culture here and sun exposure, some girls come here with huge breasts at the age of 14, which I know is not the right age to perform surgery. But they feel inferior, they become isolated, they do not socialise. So I think it’s important, even at that age, to make their breasts smaller. As long as it does not interfere with the development of the breasts.” (Plastic surgeon, male, age 45)

“Today, by 13–14 years of age, they are practically adults. These adolescents are able to make these decisions. I have a 14-year-old son and he knows everything already. He knows more than me.” (Plastic surgeon, male, age 55)

“So, when they reach 12 or 14, they are already behaving like adults and they want to have more responsibility… And they often say to me: ‘I need this surgery, it’s terrible, I cannot go out of the house, I cannot go to the beach, I can’t do anything. I cannot live with my tits.’ But I think it’s terrible to have an adolescent girl making this decision on her own… I don’t think they are ready for that.” (Plastic surgeon, female, age 34)

According to Brazilian legislation, up to the age of 18 an adolescent needs parental consent for surgery. The five psychologists I interviewed agreed that there were two main risks that should be considered before conducting cosmetic surgery on adolescents. First, the person has to be “ready”, in the sense that they feel mature enough to make such a change, which will be a non-reversible modification of his or her body. On these grounds, the psychologists argued that this was usually not the case with adolescents, due to their young age. Second, many adolescents may be trying to “cure” themselves of anxieties and insecurities concerning their own bodies and their physical development by undergoing cosmetic surgery. Plastic surgeons confirmed that in some cases adolescents come to their clinic inquiring about a cosmetic “correction” of their genitals. However, surgery may well not change anything in relation to any underlying psychological causes of their concerns. In some cases, adolescents who feel they are not “cured” with the first surgery go on to try more, and in some of these cases they may not stop wanting to modify their bodies.

According to information in Brazilian popular magazines²⁶ and the Sociedade Brasileira de Cirurgia Plastica, the trend towards body-modification by cosmetic surgery at an early age is increasing dramatically. As a participant observer, I experienced some teenagers, both boys and girls who were suffering from obesity and who intended to reduce their weight by undergoing cosmetic surgery (liposuction and abdominoplasty), instead of, for example, trying out dieting or physical training.

Discussion

The cult of the body has become a mass phenomenon and taken on an important social dimension in an information society where norms and images are broadcast worldwide by the media. Self-realisation of the individual through body-modification (tattooing, piercing, cosmetic surgery, etc) proceeds, and for a growing number of people, the body is becoming the locus of self-expression and self-determination. According to one psychoanalyst: “Cosmetic surgery is deeply seductive because it speaks so directly to the fantasy of reinventing the self.”²⁷ I question this assertion because it assumes that the self can only be reinvented by manipulating the body. Yet, as we have all been taught by our societies, culture, image and visibility are highly valued and play an important role in the formation of the self. Each individual wants to be visible and at the same time conform to social standards and norms, though of course there are exceptions. This being the case, it demonstrates very clearly the whole contradiction of cosmetic surgery: the wish for individual expression vs. the social pressure to conform to certain beauty standards.

What did I learn in this research? I encountered individual motives on the part of patients and subjective explanations for their decisions and the behavioural models they followed. In describing these, I have tried to grasp their meanings in relation to wider cultural thinking and identity patterns. In the context of our interdisciplinary research, I hypothesised that normalisation of certain attitudes and values is taking place on a cultural, societal and individual level, where the kinds of body-modifications being carried out convey standardised ideas and images of an underlying social order. On the individual level, I found that the majority of women I interviewed wanted to “be normal”. Their wish to be normal was expressed more by modifying their bodies to adapt to social norms of beauty than by trying to express their individuality. Therefore, I argue, an internalisation of norms, values and ideals has taken place.

Another thing I found important in the whole process of cosmetic surgery was the relationship between patient and plastic surgeon. In my interviews with patients, I noticed that it was of great importance for the patient’s well-being and contentment (even if complications occurred after the surgery) that during the whole process of decision-making, but also during the time after the operation, the surgeon acted as an empathic companion, as a friend, psychologist and therapist, in a way. Many plastic surgeons noted that their relationship with their patients was more than the common doctor–patient relationship. It was their duty to be available to their patients at almost any time, and sometimes they felt they had to take on the role of psychologists. Many of the key informants were very critical of what was happening to medical ethics in relation to cosmetic surgery. With the growth in a consumer culture, they saw ethics in medicine becoming more bendable and subject to the “law” of the market. For some, Brazil is just copying North American society. For others, Brazil’s body-culture image in the eyes of the rest of the world is a false one; they believe the significance of the body is not nearly as important as “we” think. For them, Brazilian culture is characterised much more by its alegria, hospitalidade e criatividade (joy, hospitality and creativity).

It is not only at the historical-cultural and socio-political level that the phenomenon of cosmetic surgery in Brazil must be understood. Questions must be asked not only about the local situation but also its global significance. What demands further investigation are the consequences of cosmetic surgery for physical and mental health. The belief that both female genital mutilation and female genital cosmetic surgery are harmful practices for women’s psychological and physical health is a step towards a process of re-thinking and re-conceptualising individual, societal and cultural ideals and norms. Western society currently determines social standards and sets the rules for how specific (cultural) practices should be handled and understood morally. However, critical thinking and legislation (as one possible measure of such thinking) are needed which lead us to scrutinise body-modification practices that can harm girls’ and women’s physical and mental health. These responses should be welcomed.

Acknowledgements

An early version of this paper was presented at the Cosmetic Cultures Conference, University of Leeds, 24–26 June 2009. The research was part of an interdisciplinary project with a team scholarship for dissertations. From the viewpoints of social/cultural anthropology, political science and psychology, respectively Elena Jirovsky, Sara Paloni and I addressed the issue of comparability of body modification practices such as FC/FGM and cosmetic surgery. I was accompanied during the research by Joana Leal, a student of sociology at the PUC-Rio, who helped greatly with local jargon, language and cultural issues that emerged, and with conceptualising the three different interview manuals in Portuguese. I would like to thank the Austrian Academy of Science, who granted the scholarship and made the research and field work possible; my supervisors Johannes Reichmayr, Sigmund Freud University, Vienna, and Junia de Vilhena/Joana Novaes (PUC-Rio); as well as Maria do Socorro, Kerstin Tiefenbacher, Eder D, Renée Douek, Mirian Goldenberg, Gabriella Bond, the Department of Plastic Surgery at Santa Casa de Misericordia; and all of the interviewees.

Notes

* The study was conducted by Datafolha, on behalf of the SBCP, founded in 1948, the official union of about 4,000 practising plastic surgeons in Brazil. Their members have to qualify to be admitted to the Society and must follow official ethical and medical guidelines. See: <www.cirurgiaplastica.org.br/publico/index.cfm>.

† In a footnote she remarks that the terms “health” and “illness” are related to and formed by one’s culture and are therefore not sufficiently understandable with our Western biomedical model of the body. A healthy body is for Ensel a body “without organic and functional disorder”.¹⁸

* What is special about this public hospital is that it receives a mix of state and charity funds.

* Psychological problems such as an “inferiority complex” gave cosmetic surgery a therapeutic rationale.²¹ The idea of striving for happiness by recreating oneself, which emerged in 19th century philosophy of Enlightenment (still) represents the justification for cosmetic surgery.²²