Differential knowledgeability: the case of the chosen breast

ABSTRACT

Women’s choice to undergo breast augmentation surgery with silicone implants may develop into a choice to surgically remove them. In our paper, we employ dimensions of power relating to such decisions to elaborate differential knowledgeability as organizing the temporal dimension of the process and its potential for changing the meaning of a decision formerly taken. Until recently, the possibility of differential access to knowledge relating to silicone implants’ hazards was not explored from a temporal perspective, thus leaving vague the weight of women’s participation in digital platforms that constitute knowledge-supporting space. Our findings relate to a turning point in which increased knowledgeability manifests a change in women’s perception of augmentation surgery as a risk and fed a reflexive process towards a decision to remove the implants surgically. The neoliberal discourse our research participants adopted to describe their experiences demonstrates self-critical perception; thus, their increased knowledgeability did not influence the balance of power between women and medical professionals. Our findings also relate to the development of emotional ambivalence post implants removal surgery, anchored in the research participants’ separation from their culturally appreciated former appearance.

KEYWORDS:

• Differential knowledgeability
• augmentation surgery
• implants removal surgery

Introduction

Global statistics indicate that 253,594 women underwent breast implant removal surgery; still, breast augmentation is a popular cosmetic surgical procedure worldwide (ISAPS, 2021: 9). Until the early 1990‘s augmentation surgery candidates were poorly informed about medical risks, as no significant long-term studies had yet been conducted (Boulton & Malacrida, 2012). Information relating to the health implications of silicone implant use began to emerge in the 1990s (Zimmerman, 1998), and the US FDA website continuously updates about possible risks relating to implants (FDA, 9.8.2022). Augmentation surgery, thus, validated the critical feminist discourse over the pressure on women to ‘amend’ their bodies to comply with feminine appearance standards (Wolf, 2002; Young & Leder, 1992).

Researchers have already studied breast augmentation surgeries with silicone implants from psychological and sociological perspectives. However, to date, existing studies have not considered the ‘becoming’¹ of the withdrawing subject within a timeline starting with the choice to undertake augmentation surgery. We propose to examine becoming by focusing on the development of differential knowledgeability. We define it as the temporal accumulation of knowledge involved in any specific action-related choice, and utilize it to challenge Giddens’ use of knowledgeability as a stable agentic capability in late modernity. The temporal perspective indicates that access to knowledge relating to risks bears potential to change the meaning of a decision formerly taken. Increased accessibility to knowledge may result a change in three power dimensions (I. A. Reed, 2013), reflecting Differential knowledgeability as grounded in resources, and as facilitating a critical stance towards previously adhered to normative imperatives. As our research participants are Hebrew-speaking women, narrative sharing in the digital realm can mitigate inaccessible knowledge due to language barrier, knowledge relating to possible risks, and alternatives available for resolving. In exploring our research participants’ stories of their becoming process, we focused on their increased knowledgeability, digital encounter’s weight in changing perspective of past choice taken to augment their breasts, and the reflexive process that instigated a choice to act to remove the implants surgically. Before answering our research questions as to the knowledgeability development and the weight of the online discourse in changing a meaning of past choice taken – we begin the theoretical framework with the discussion of power dimensions, continue with experts’ power, the feminist stance, the Israeli context, and the significance of narrative sharing in the digital realm.

Power dimensions relating to breast augmentation surgeries

Breast augmentation surgery with silicone implants was first performed in the early 1960s (Champaneria et al., 2012) and, as mentioned above, became a popular cosmetic surgical procedure. It seems that the phenomenon is here to stay, a viewpoint gleaned in part from the proliferation of digital platforms emphasizing the importance of appearance. For example, American research examining various parameters influencing the decision to undertake augmentation surgery identifies the Instagram platform as the most influential factor (Zahedi et al., 2020). But as implied by Giddens’ (1991) concept of late modernity agency – can (young) women, subjugated to the power of consumption, develop a knowledgeable self-reflexivity in achieving choice? An introduction to I. A. Reed’s (2013) dimensions of power may be conducive to the discussion.

Reed’s first dimension is relational, reflecting power that is based on the structural positions of the interacting parties; thus, medical professionals can access reliable available knowledge, as opposed to potential digital literacy of a layman expressed in limited access to reliable information, that a language barrier could emphasize; the second, is discursive power, creating an interpretation of what is considered normative and ‘natural’ by published regulation and information, as well as by marginalizing such knowledge due to marketing interests; and, finally, the third is performative power, which refers to a pragmatic form of action that can change reality by first-hand experiences that substantiate the relevance of seeking knowledge (I. A. Reed, 2013). Each of these power dimensions may shape differential knowledgeability, as it enhances the odds for accumulation of knowledge, particularly hazards that constitute the becoming of the withdrawing subject rejecting previous choices. The relational dimension indicates a structural change, as information is accessed in the digital realm; The discursive dimension indicates a possible opportunity to embrace a critical stance of experts’ refusing to trust their marketing efforts; and the performative dimension results from overcoming relational power, formerly characterizing a standpoint of limited access to knowledge. Going further, as the human agent increases knowledgeability, the performative dimension is expressed in generating a choice to act. Because choices are often taken in the context of partial reliable information of potential hazards accessible to lay people, differential knowledgeability somewhat challenges Giddens’ notion of knowledgeability; and the actor’s practical consciousness as an integral part of the reflexive monitoring of action (Giddens, 1991). His notion of knowledgeability assumes agentic access to knowledge (Giddens, 1984), ignoring the politics of experts controlling realms of knowledge (M. I. Reed, 1996). Below, we attend to this politics.

Medical experts and the availability of information

The US FDA website lists numerous potential consequences of augmentation surgery, including an alarming association of silicone implants to large cell lymphoma. Women contemplating augmentation surgery need to consider that implants insertion is temporary and will need to be replaced or removed after a few years (FDA, 9.8.2022). Regardless of our research participants’ language barrier in accessing knowledge pertaining to risks, we relate below to a patient’s expectation in approaching medical experts. M. I. Reed (1996) explains that experts’ power increased in the late modern age. Leaning on Schaffer’s claim that experts seek to persuade society of their access to rare esoteric information by way of their specialist skills, Reed explains how society legitimizes the high professional positioning of experts, as they are perceived as able to provide solutions for problems that allegedly cannot be resolved by other groups (M. I. Reed, 1996).

Today’s doctor-patient relations dominant approach emphasizes patient autonomy in deciding how they wish to be treated (Kaba & Sooriakumaran, 2007). A patient’s signature on a consent form blends law, medicine and bioethics aimed to enhance a patient’s understanding before his care (Madeira et al., 2017). Nevertheless, relational power is still maintained, as potential risks of augmentation procedures are sometimes presented vaguely by medical professionals (Boulton & Malacrida, 2012), also expressed as an ongoing concern of the US FDA (Christensen, 2021). Validating discursive power dimension as well, a paper examining the PIP implant recall scandal in France indicates that patients perceived risk differently than the authorities and some doctors (Greco, 2015). In addition, research comparing online information about potential risks in augmentation surgeries indicates the poor quality of the medical practitioner’s websites (Palma et al., 2016). The lack of reliable information about the potential hazards of augmentation surgery questions the knowledgeability that Giddens (1984) perceived as bearing the potential to repel acceptable routine actions, as it also exposes the individual to understanding risks derived from modern society’s rapid development (Beck, 1992).

On top of information on medical risks being differentially accessible, augmentation surgery’s possible hazards can be diminished by emphasizing the psychological well-being that the procedure can open up for the patient. American research on aesthetic clinic brochures suggests that the medicalization of beauty combines medical and therapeutic discourse (Merianos et al., 2013). Moreover, Cabanas and Illouz (2019) see the neoliberal zeitgeist logic as promoting the therapeutic ethos of a free, responsible, and autonomous human agent who should direct her resources to obtain happiness. The formula for happiness cannot be attained by critically engaging with unchangeable life circumstances, such as social structure. The human agent should focus on increasing her well-being through a series of activities narrowed to the realms of her control. The possibility of women perceiving the choice to augment their breasts as an effort to increase well-being corresponds with a New-Zealand study examining the framing of the augmentation surgery in clinic websites – the surgery is presented as a self-defining act, and a woman’s choice to augment her breasts is presented as shaping her own body (Hopner & Chamberlain, 2020).

The feminist perspective and the critical stance

Research on breast surgeries in France and Italy indicates that the procedure itself is guided by normative ideas of how a female body should look (Greco, 2016). Critical researchers suggest that women’s breasts are perceived as objects to be seen and interpreted by others. Young and Leder (1992) relate to perception of ideal breast as big, round and firm in patriarchal cultures and in the current perception of a Barbie doll ideal. Articles and advertisements allegedly offer women various choices to change their appearance surgically, but structurate a narrow perspective of normative appearance. Cultural context relies on fashion – a cultural product that dismisses any breast that does not match the standards of the ‘official breast’ (Wolf, 2002); thus, risk potential exists as well in a choice not to participate in the body amendment project.

From a different perspective, Kathy Davis rejects the critical perception that reduces a woman’s choice to undergo augmentation surgery to being passive and subject to social perceptions of ‘acceptable’ beauty norms. Exploring in terms of agency, Davis presents women as active, creative agents employing surgical procedures to appropriate normative femininity (Davis, 1995). Gagné and McGaughey (2002) employs two opposing perspectives to conceptualize the nature of the beauty regime. Women choosing augmentation surgery are active choosing agents but remain in the confines of the hegemonic ideal of feminine beauty. The male gaze shapes medical institutions and fashion norms, and women internalize its standards, though over time achieved control and great power in embodying the hegemonic ideal of feminine beauty.

Taylor discusses consumer perspectives relating to augmentation surgeries. Women perceive it similarly to decisions regarding contemporaneous fashion norms, though expressing acknowledgement of the surgery’s risks. This perspective relates to the possibility of women being manipulated by market interests, and with their consent the female body is opened for profit (Taylor, 2012). In challenging the distinction sociologists make between individual acts of choice and cultural influence, Schwarz (2018) recommends engaging with choice and culture in the same realm. Culture is not oppositional to choice, but can enable or narrow choice; analysing how people choose holds the potential to reveal a cultural pattern of choice practices (Schwarz, 2018)—especially with regard to consumer culture as organized in criteria of desired appearance value. Numerous possibilities constitute the cultural mindset that glorifies consumer choice (ibid), which can generate a sense of urgency in choosing to undertake breast augmentation surgery.

The Israeli context

Breast augmentation surgery with silicone implants is the most popular cosmetic procedure in Israel; according to The Israeli Society of Plastic & Aesthetic Surgery (TISPAS) in 2020 this procedure was undertaken by approximately 10,000 women (Toyzer, 2021). Since 2011, TISPAS indicated an increasing trend of women choosing to remove silicone implants (Koren, 2011). As most of the cosmetic procedures in Israel are performed in the private sector, it is worth mentioning that in Israel, The Ministry of Health recognizes the increasing trend of private medicine use and perceives it positively, as it has significant advantages such as operational efficiency and improved hospitalization conditions (SCOI, 8.5.2013).

In Israel, The Patient’s Right Law 1996 requires a patient’s explicit consent to any procedure performed on them by signature on a consent form. As informed choice relating to medical treatment is dependent on the knowledgeability of the risks entailed, the law 1996 also outlines the doctor’s obligation to the patient, including details of the potential risks. As of July 2019, TISPAS website recommends using an updated consent form for breast augmentation with silicone implants detailing potential hazards (TISPAS, 1.7.2019).

Facebook groups as a source of knowledge

Groups on the Facebook platform offer a private space for users with mutual interests to discuss and share information (Pi et al., 2013). Closed Facebook groups of women can create a secure and judgement-free social space (Mesmer & Jahng, 2021). For Hebrew-speaking women, a designated Facebook group could assist in mitigating information inaccessible due to language barrier. Between Giddens’ (1984) claim relating to knowledgeability potential and Beck’s (1992) claim focusing on deteriorating trust as part of consumption risk understanding, we link to a process in which a Facebook group is used by active agents who begin to collect and share information regarding the risks that breast augmentation surgery entails. Thus, we present our research questions: how does knowledgeability develop for these women? And did the online discourse reflect a change in the meaning of their past choice to augment their breasts?

Research methods

The results presented in our paper are based on semi-structured interviews with twelve women who decided to undergo implant removal surgery. The analysis of the interview material was assisted by digital observation on an Israeli Facebook group established to engage in women’s decision to reverse augmentation surgery, and by newspaper articles.

The interviewees, all members of the Facebook group, were in their 30s and 40s and had undergone augmentation surgery in their 20s. Most described themselves as living with partners; all have children, and some have an academic-level education. The financial status of most of the interviewees was presented as stable; two described having financial difficulties. We conducted the interviews between 2020 and 2021. As the research process started after the outbreak of the COVID-19 pandemic, the interviews were conducted either by video or telephone. We established trust with our research participants by disclosing that one of us had undergone a similar process. We have changed the interviewees’ names to preserve their anonymity. All the interviews were recorded and transcribed.

We observed a Facebook group that is ‘private’, thus only its members have access to its content, and the group can be located through a simple keyword search. Today, the group has approximately 3,700 active Hebrew-speaking members. We choose this group due to its administrator’s positive response. She agreed to participate, as she perceives raising awareness of the hazards of implants and transferring information between women as a personal calling. Each post uploaded to the group is preauthorized by its administrators. The group’s posts split into instrumental consulting and narrative sharing of the process undertaken by its members. Instrumental requests arise before removal surgery (surgeon recommendations, costs, insurance coverage) and afterwards (supporting bras, ways of reducing scarring).

In line with the principles of the grounded theory approach, we followed focused coding enabling comparison with the digital observation data (Charmaz, 2006). The initial coding revealed central themes organized around the temporal dimension of participants’ experiences. During the data analysis, additional themes were extracted: interaction with surgeons, performative aspect in the Facebook group, and neoliberal discourse characteristics deployed by the interviewees.

The becoming process – from implanting to explanting

Our research examines differential knowledgeability and elaborates on it by power dimensions on a temporal basis. Our findings reflect the temporality of women’s journey – starting with experiences of low body image, they approached medical experts with a sense of urgency and underwent augmentation surgery. After a while, a turning point emerges, responding to health deterioration alongside participating in active discourse in the Facebook group. Increased knowledgeability then appears to feed the becoming of the withdrawing subject.

Approaching medical experts to “cure” low body image and define “natural” beauty

All the interviewees stated that they were displeased with the appearance of their breasts before the augmentation surgery; they perceived their breasts as too small or as uneven. Some had a negative perception of their appearance since early youth; some described confining behaviour and using various clothing strategies to hide or disguise their physical appearance. The interviewees described their younger selves as driven with a sense of urgency to act, as Michal put it: ‘It was my dream. I said I am doing it [the augmentation surgery, and then] I will be complete’. Going for an augmentation surgery was decided upon without hesitations or in-depth inquiries. In terms of Reed’s power dimensions, the starting point is characterized by a relational power deficit of limited structural accessibility to knowledge of embedded hazards. The discursive power deficit is twofold: full adherence to beauty standards negating their appearance is accompanied by a sense of responsibility to produce their own appropriate body, understood as crucial for their wellbeing.

The interaction with the prospective breast augmentation surgeons – all men – was described as technical-functional, with the discussion focusing on the size and shape of the desired breasts. Resembling Davis’ (1995) interviewees aspiring to appropriate normative femininity, the interviewees expressed their targeted appearance as ‘natural’ looking breasts:

I did not want anything that would look fake … I told him [the surgeon] that I do not wish to have breasts like [Israeli celebrity] as they are upright like she cannot breathe

(Yifat).

By asking for natural breasts, the interviewees expose a discursive power deficit (I. A. Reed, 2013) generated by the adherence to the culturally defined ‘natural’ or ‘normative’. The interviewees could not recall discussing potential hazards; several reported not knowing that the implants were temporary. The women recalled signing consent forms, albeit in a process that they described as formal and bureaucratic:

They [surgeons] do not tell us [about the hazards]; they ask you to sign on a form. Now, you are not going to sit and read the entire story. You sign on what everybody signs. Like, what’s going to happen? If this one signed and this one signed, why shouldn’t I sign? So, you sign, without thinking, without knowing, much like when you enter childbirth and sign [consent] for an epidural. Are you really interested in the risks? Everybody did it, and you will do it

(Reut).

Here the performative power deficit emerges in following the ritual of signing a bureaucratic form, acting to establish oneself as an obedient follower of the physician’s instructions, while grounding one’s trust in the routine: ‘are you really interested in the risks’. The routinization of the stage in which knowledgeability could develop, together with the trust of many anonymous others, means that knowledgeability is excluded from the encounter. Knowledgeability could not be included in the encounter as long as interviewees treated doctors within the framing suggested by Wolf (2002) as standardizing the ‘normal’ body, not just their medical expertise – but attributing their expertise to the aesthetic realm as well:

He [the surgeon] said that 250 cc would look better … I said: listen, don’t do anything that will not look good … eventually, he said: ok, 220-230-250, let’s do 250, 235. It was agreed, like, minutes before the surgery

(Michal).

Performative power is present in the situation, suggesting the possibility of criticizing the doctor who might go wrong with his aesthetic perception. Stating ‘don’t do anything that … ’ is a negotiating statement that introduces her power as a patient who won’t accept just any result. At the same time, negotiation is preserved to the aesthetic where the speaker perceives herself as owning the right to a separate opinion relating to feminine beauty. However, assuming the medical expertise of their surgeon meant that in the short-term knowledgeability continued to be excluded.

Turning point: health deterioration and understanding its origin

With time, most interviewees experienced a decline in their health. Some described life-threatening conditions such as severe damage to liver functions; most indicated they had experienced respiratory and dermatological problems, exhaustion, and physical pain:

Suddenly … I was weaker. My immune system was more vulnerable … I didn’t think it was important. I didn’t connect it to the implants. I don’t know; I thought it was the age, and I felt like an 80-year-old woman: my tiredness, my skin, my hair falling off

(Yael).

Again, the relational power deficit becomes explicit: her structural position is characterized by a complete lack of access to knowledge that would introduce suspicion towards the surgery. The available cultural tool kit for Yael to interpret her situation is that of the old woman stereotype, pointing to a discursive power deficit in which no critical stance can be developed for her understanding of old age nor understanding of her body. This was true for other interviewees, who did not relate their conditions to their silicone implants. Some described consulting with their family doctors but remaining oblivious to the source of their medical problems:

I’m telling you for sure that I didn’t connect (illness to implants); I didn’t even think about it … I had intense headaches all the time and a high fever … like, how could I have known? I did so many tests, and most of the tests came out fine

(Yifat).

Similar to American women exposed to potential hazards associated with silicone implants by watching TV (Zimmerman, 1998, p. 4), some interviewees had their knowledgeability awakened by TV talk shows or narrative-sharing on social media. A most powerful experience described as they become familiar with the digital group:

Somehow the implants removal Facebook group popped up. Once inside, I saw that each woman listed her symptoms, and I started … marking ‘v’ against each one that wrote, I marked ‘v’ as I also have it

(Reut).

Exposure to the group’s discourse became a turning point in which their discursive power emerged: ‘The night I joined the group, a sigh of relief came out first. I am not alone’. (Lea). The Facebook group became a source of discursive power through the accessibility of information, sharing, mutual support, and empowerment. The emotional alliance helped accumulate discursive power, shaping a collective perspective regarding their distress as individuals. According to Summers-Effler (2002), collective emotional alliance drives women to raise their voices. Thus, one woman’s problem ceases to be her personal problem; it instead becomes a collective problem, opening a social gateway for resolving it.

Knowledgeability was up and alive for members who shouldered the responsibility for researching and locating information about hazards. The performative power cultivated differential knowledgeability for those who were part of the accelerated activity resulting from the group’s discourse:

I tell them to move to private [chat] and give them my number, saying that anybody who wants can call. Not everything you can say in writing … when you know the whole picture, it helps you more

(Ravit).

Some group members demonstrated performative power dimension in connecting to their agentic capabilities, becoming withdrawing subjects and agents of knowledge for themselves and others. Resembling Zimmerman’s (1998) research participants, interviewees felt empowered when conveying information to support other women. Interviewees described with gratitude the warm atmosphere created by the group members, as women willingly dedicated their time to assist others in coping with their painful conditions:

There were two women there that truly motivated me, [took the] time to connect with me on WhatsApp, pushed and motivated me, and I have decided that I’m going to [do] the [implants removal] surgery

(Miri).

Performative power owned by knowledgeable members who began the process earlier is transmitted to others, influencing relational power dimension relating to accessible knowledge. Further, they transform their discursive power by using the group to underline alternative normative settings, in which the norm is to claim performative power for oneself and act by undergoing a process towards increased knowledgeability and implant removal.

Interacting with implants removal surgeons

As opposed to the short technical process of finding the augmentation surgeon, the interviewees described approaching prospective surgeons for implant removal from a sceptical position, anchored by their increased knowledgeability:

I remember entering an office, and it was a very unpleasant experience: [they said] ah, she is [from] one of the crazy women’s groups … it was very upsetting, but it directed me … I experienced it as some kind of frequency or energy that did not work for me: going to a doctor and not getting the legitimization or acknowledgement of what I or my body was experiencing. This is not a place that I want!… [the belittling interaction] directed me to find the doctor whom I would want to work with

(Aya).

The recently gained performative power triggered knowledgeability to the extent that the belittling interaction with an aesthetic clinic becomes another source of information, resulting in her articulating a criterion for a prospective implant removal surgeon: respect for her as someone ‘to work with’ rather than an obedient patient – a professional who would be able to acknowledge her experience and change in her inner self. Echoing findings presented by Fredriksen et al. (2008), Aya developed an attentive approach to her body following the online discussions. At the knowledgeable stage, interviewees described adopting a sceptical and self-aware position.

Nevertheless, the glorying perspective of the medical expert was not dimmed by the contextual circumstances of the removal surgery. The interviewees attributed fantastic and unique skills to their chosen implant removal surgeon, using superlatives like ‘incredible’ and ‘amazing’.

Emotional ambivalence anchored in separation from a culturally appreciated appearance

Some interviewees expressed ambivalent feelings about their body post-removal, describing the decision to remove the implants in terms similar to losing a loved one:

For me, it was a hard time … I’m just mourning about how I will live without the implants in my body and what I will do with myself … I’m telling you, every day I cry, cry out my soul, for real … I miss them very much … it’s something that becomes an integral part of you

(Yael).

Departing from culturally appreciated standards of appearance involves an emotionally demanding process. The interviewees described the implant removal surgery as complex, and the recovery process as long and challenging. While most interviewees reported feeling healthier post-removal, some described their breasts had turned ugly, scarred, and shrivelled:

My left breast is sunk in its sockets. Now there is nothing there … something very flat. It was very rough … I was afraid to show my breasts to my husband, but he reassured me. But, like, I remember this kind of gaze [he had]. He was also shocked at how it looked. It looks terrible

(Michal).

Being supported and empowered in their digital communal realm, supporting others as their knowledgeability developed – none of this was enough to protect them from the pain of separation from their former, culturally appreciated appearance. It seems that a strong emotional ambivalence is an integral aspect of a woman’s relationship with her newly shaped body, manifested in terms of longing for her former appearance, which she loved and possibly perceived as a social resource.

The sense of well-being that the interviewees described as accompanying the emotional ambivalence instigated an understanding of the meaningful process – a process they experienced as life-changing:

On 11.11.2019, at 11:00, I underwent the [removal] surgery. My wedding didn’t have such [a date] … it was, for me, a place to commit for me and to the Lord that I’m here and reconnecting to my body. It’s not just happening to me. I am willing to take this thing upon myself

(Aya).

Discourse and performance in the Facebook group

The group’s regulations stipulate ‘criticism and judgemental [attitudes]—not in our group’; all prospective members must actively accept this condition before being added to the group. The group’s narrative, alongside the instrumental discourse promoting educated choice, also highlights unrestricted support between its members. Thus, for example, when a member narrates her rehabilitation experience post implants removal surgery, other members respond with support and encouragement as discursive validation of her choice and effort to recover.

The active discourse indicates that it meets the objectives defined by the group’s founders. The absence of critical discourse is demonstrated in posts relating to issues extending beyond mere interest in implants removal surgery – for example, alternatives that will enable keeping their breast volumes, such as fat transplant, hyaluronic acid, and insertion of better-quality implants. Also, in observing the group’s discourse, it seems that its members did not engage with a feminist critical perspective, as to questions of need or necessity to amend their bodies to comply with normative appearance standards.

Regarding their increased knowledgeability, the members post articles from the press and discuss them, particularly when they validate their experiences and anchor their position as knowledge agents. For example, a member posted a link to an article in the mainstream daily Israel Hayom with the headline ‘A connection has been found between silicone implants and damage to the nervous system’. Her post generated active discourse among the group members, including requests for the academic source of the claims.

From a performative aspect, and as an integral part of the empowering experience relating to the implants removal surgery, members of the group created a ritual norm, posting ‘after’ photos (see figure 1), presenting plasters, drains and bandages that accompanied the surgical procedure.

Figure 1. Performative aspect post-removal surgery (pictures sent by the interviewees, published with their permission).

With drains on their side, pictures of the bandaged breasts post-removal presented as battle injuries – symbolic evidence of being released from sorrowful pain, as a medal for the high physical price they were willing to pay to regain their well-being. For our research participants, the Facebook group is experienced as supporting a judgement-free community; it became a central location for acknowledging the significant self-change that they had undergone. This performative ritual in the group resonates with a private-public rite of passage, which Rubin et al. (1994) relate to people who experienced significant body alternation incorporating an identity dimension and did not have an institutionalized rite of passage for acknowledging their considerable change.

It is worth noting that in a wider cultural context, such performative ritual (of women presenting their bandaged breasts post-removal surgery) has been manifested in the public sphere by Israeli celebrities who followed a similar trajectory. For example, in the daily Ma’ariv, an Israeli model quoted: ‘still recovering, it is not an easy process for the body and soul’ (Brown & Levine, 2017). Also, on Mako news website, children’s starlet said: ‘I write these words in the recovery room, this time with tears of joy in my eyes … I got my body back’ (Haleli-Abraham, 2020). Both celebrities gratefully thanked their implants removal surgeons by name.

Adopting a neoliberal discourse

The interviewees demonstrated the infiltration of neoliberal discourse beyond the business-economic field, as it forms into ‘ethics’ of proper self-conduct – discourse characterized by individualistic perception directed towards risk management (Helman, 2019). Thus, Yifat expresses in her words the need to ‘manage risks’:

In advance [we] must manage risks and say: ok, if this one had it [medical problems] and this one had it and this one, [then] probably I will have it as well

(Yifat).

Corresponding with Cabanas and Illouz’s (2019) notion of neoliberalism’s positive psychology aiming the individual to obtain happiness by avoiding critical perception of life circumstances beyond his control – our research participants did not engage in blaming the implant manufacturers or the augmentation surgeons. Thus, anchored in relational power dimension, Einat described her augmentation surgeon as a ‘charming professor’, and years later, when a rupture was discovered in her implant, she returned to the very same surgeon for its removal. ‘I went to him, he told me: don’t worry, don’t be nervous. It happens. We’ll take care of you’ in her words. Einat took full responsibility for her experience and its ramifications: ‘you know, I suppressed it [need to routine check]. My fault. My irresponsibility’. Our research participants’ inability to accept their uncalculated conduct in their past presented in the form of adult-self scolding her younger counterpart for her poor engagement with the possible risks:

This [augmentation surgery] is really a complex process … I’m angry at myself that I didn’t make proper inquiries [about possible risks] … and I’m saying: how did I insert this thing into my body

(Michal)

Michal demonstrates self-responsibility criteria in the present time, directed towards her past conduct. Proper self-conduct discourse manifests in the form of etiquette for contemporary femininity: women choose, femininity is conducted with financial awareness; femininity that distances itself from its former submissive position:

You need to make a change in consciousness … how you manage yourself in this world. If you undergo implants removal and still listen to the voices of others, you are still submissive, and you still feel that you are not yourself, but someone else’s. So you are in the same consciousness and lack of awareness … we, as women, have a choice. We choose! We choose our partners, doctors, and gynaecologists; we choose where to study and where to put our money

(Aya).

Navigating among options for amending the body is understood to depend on access to knowledge and consciousness-changing insights. Nevertheless, differential knowledgeability depends on reflexivity and courage to resist external pressures, on insisting on making one’s own calculations, considerations – and ultimately, choices.

Conclusions

Women’s choice to augment their breasts begins with a profound sense of feminine body discontent, elaborated into an urgency created by the cultural logic of choosing body-modification work as a necessary step towards meeting the standards of hegemonic femininity. This corresponds with Schwarz’ (2018) indication that choice, as a practice category, cannot be narrowed to a single logic. It is shaped by various cultural logics and professional discourses, fixed in a battle over resources and power.

Our temporal lens requires a dynamic assessment of the becoming process of the withdrawing subject whose knowledgeability implies access to reliable information on risk entailed. A turning point emerged from the analysis as salient suggesting the ground for conceptualizing differential knowledgeability as better reflecting the temporal complexity of knowledge acquisition. Before the turning point, we found limited access to knowledge. Further, we heard a limited interest in knowledge acquisition produced by routinization and trust. Indeed, the potential of women beginning to function as knowledge agents was there but was not acted upon before the turning point.

The turning point triggered a shift in relational power, which relate to the process of them becoming knowledgeable agents. Before choosing augmentation surgery, our research participants adopted a somewhat passive approach in interacting with their doctors. Their limited access to knowledge relating to risks revealed a relational power gap. Differential literacy occurred due to a language barrier and possibly to different meanings of risk (Greco, 2015). The becoming process of knowledgeable agents demonstrated a shift in the relational power – the power of experts is still maintained; nevertheless, women developed ability to sort medical professionals and engage with their choice to remove implants empowered by their accumulated knowledgeability. The process of becoming is reflected in their experience of themselves as owning knowledge and being entitled to reject doctors’ suggestions. Being able to share information and support other women in their distress became means of self-empowerment (Zimmerman, 1998), and knowledgeability, which was facilitated by judgement-free digital space promoting a new meaning of past choice taken. Complying with Giddens’ (1984) claim of knowledgeability potential to repel acceptable routine actions, the becoming process which we contributed here facilitated hazard awareness, which in its turn fed a reflexive process, generating performative power demonstrated in their decision to change their reality and remove the implants from their bodies.

Considering Gagné and McGaughey’s (2002) indication of women’s agency within the restraints of hegemonic ideal feminine beauty, on a personal level achieving great power by embodying it-one can understand the emotional ambivalence these women developed towards their body post-removal surgery, as they painfully departed from supposedly objective standards of ‘proper’ feminine appearance. The latter aspect emphasizes the relevance of the rhizome metaphor (Deleuze & Guattari, 1987) in describing our research participants’ becoming. In this process, one root of the rhizome was directed to increased knowledgeability, another to their developed sense of empowerment, and another root of the rhizome was stretched towards emotional ambivalence. An Additional root of the rhizome is reflected in their adopted neoliberal logic, demonstrated as self-critical perception. Taking full responsibility for their experiences and promoting perception of proper self-conduct – these emerge as complying with neoliberal positive psychology ethos, encouraging the individual to target happiness in actions narrowed to realms of her control (Cabanas & Illouz, 2019). This also demonstrates the immense relational power dimension: though their knowledgeability developed, our research participants did not challenge the powerful position of experts, which corresponds with M. I. Reed’s (1996) claim. Though relational power is maintained, increased knowledgeability of the human agent can expand options for oppositional standpoints.

Our contribution to the notion of differential knowledgeability may constitute a heuristic device grounded in three levels of becoming a knowledge agent. The first level focuses on recognizing that reliable information about potential hazards is not necessarily accessible; thus, digital groups may enhance access to knowledge and assist in overcoming a language barrier. The second level concerns the structural positions of potential members of digital groups and their ability to access them. Language from a different perspective may serve as a structural barrier for minority groups such as immigrants with individuals with reduced proficiency. Finally, discursive power is crucial for the extent to which information is published for the common good. Based on these three levels, performative power may cultivate informed choices.

Our study was limited by its narrow timeline relying on a retroactive understanding of the interviewees of their former selves. Future research could pursue a detailed follow-up of the development of emotional ambivalence in additional fields of choice in acquiring a ‘normative’ appearance: Botox injections and chemical peels, could provide two examples.

Disclosure statement

No potential conflict of interest was reported by the authors.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

No funding was received for this article.

Notes on contributors

Tammar Friedman

Tammar Friedman, Ph.D. student in Sociology & Anthropology dept. in Bar-Ilan University. Teaching Assistant in Bar-Ilan University in Cultural Studies: Introduction to Fieldwork, and Introduction to Anthropology. Research interests are body image, gender, and embodiment. ORCID: 0000-0002-2268-5755.

Smadar Noy

Smadar Noy, Faculty Member in Sociology & Anthropology dept. in Ashkelon Academic College. Research interests are body image, gender, and sociology of medicine. ORCID: 0000-0003-0099-0158.

Orly Benjamin

Orly Benjamin, Senior Faculty Member in Sociology & Anthropology dept., and the Director of Graduate Program in Social Psychology in Bar-Ilan University. Research interests are stratification, class and ethnicity, gender, and body & emotions. ORCID: 0000-0002-0307-9442.

Notes

1. To describe a phenomenon, Deleuze and Guattari (1987) employ the ‘rhizome’ metaphor of a vast network of strangling roots, spreading out in a nonlinear pattern unhindered by structure as the rhizome spreads in different directions simultaneously. Thus, emphasis is placed on the becoming process – the change from one position to another.