By Ruth Holliday - Professor of Gender and Culture.
(This post was originally published by the Sociological Review )
Cosmetic surgery for working-class and lower middle-class patient-consumers is a source of value. It is a type of body-capital that can be exchanged in the (service) labour market (and in relationships when one is ‘back on the market’). However, the symbolic value of cosmetic surgery is also limited by a middle-class discourse that situates it as a lazy and dangerous practice undertaken by cultural dopes emulating the impossible and mediated bodies of celebrities. Cosmetic surgery tourism compounds these anxieties, because medical tourism threatens ‘national healthcare’ – i.e. the contract by the state to care for the medical needs of its citizens – and pushes healthcare choices onto individuals. Middle-class discourses again represent patient-consumers of cosmetic surgery as unworldly and ill-equipped to make such choices – as risky and reckless travellers who return to drain the resources of ‘our’ national health service.
But what are the actual experiences of such travellers? How do they navigate their choice of surgeon, clinic and destination – especially given that these destinations are mediated by ‘agents’ (medical tourism intermediaries)? And what new and unexpected socialites do medical tourists encounter as part of such ‘clinical trails’?
In March 2012, as part of our three-year project on cosmetic surgery tourism, we travelled to Tunisia alongside a group of ‘patient-consumers’ from the UK. 27-year-old Lorna, a North Sea oil-rig worker, wanted a breast augmentation and liposuction. 45-year-old hairdresser, Anita, from the South of England sought a facelift, and 52-year-old Sally, a school administrator, wanted breast implants replaced, eyelids lifted, eye bags removed, the muscles in her chin and neck tightened, and a neck lift. These three women, much like the 105 other men and women we met in destinations across Eastern Europe and East Asia, were seeking a little extra ‘value’ for their bodies/selves in a neoliberal climate in which looks are traded in the markets for jobs and relationships. For these and other participants, looking good means feeling good, because cosmetic surgery marks a body worth investing in – a body of value. Seeking surgery means taking (back) control of one’s own body and life, so that even small changes to appearance have the effect of ‘empowering’ those travelling abroad for cosmetic surgery.
Lorna, Anita and Sally were not wealthy, well travelled, cosmopolitans as some literature on cosmetic surgery tourism implies. Neither were they reckless, ill-informed, chancers, operated on by ‘cowboy’ surgeons, and returning to be ‘patched up’ by the NHS, as many newspapers would have us believe. Lorna, Anita and Sally had ‘done their research’. They had navigated a vast array of online information (and mis-information), about the skills and results of surgeons, about the facilities and cleanliness of clinics, and they had monitored in real time a steady stream of patients, via agents’ Facebook pages, who had trodden this path before them – just as they would post their stories for future travellers. They had taken all possible steps to keep risk to a minimum (although they could not have anticipated the PIP and Allergan breast implant scandals, which happened after this research took place).
Their clinic was a ‘temporary medical assemblage’ of British agents, French-Tunisian and American surgeons, Brazilian ‘medical devices’, and a Tunisian hospital, cutting costs of facilities and aftercare (but also making legal redress when things go wrong almost impossible). However, the patients had not fully considered the implications of their location. Lorna, Anita and Sally had previously holidayed in Spanish and Greek resorts, and images of their off-season holiday hotels where they would recuperate looked just like the Costas.
Their agent presented their destination clinic as ‘in the Mediterranean’ so they knew what to expect. They had not been told Tunisia was an African country. They had not been told Tunisia was a Muslim country. Their formal education had barely touched on African geo-politics. What they knew about Muslims they had mostly garnered from racist British tabloid newspapers. They had no framework for conceptualizing the civil war raging just across the border in Libya, with whom their Tunisian hospital had a cross-border healthcare agreement.
Arriving at the airport, Lorna, who spoke no French, took a taxi to the hospital with a driver who spoke no English. She was shocked that Tunisia looked to her like a ‘third world country’ and to see what she described as ‘gangs of men hanging about at the side of the road’. She was taken to a hospital room by a nurse, who also spoke little English, and told to be ready for surgery first thing in the morning. She was terrified. Sally, who had arrived a few days earlier and had undergone multiple surgeries was also distressed. In the hospital, imagined in advance as a ‘medi-spa’ (an image unchallenged by her agent), she heard people screaming at night, and howling wolves who might breach the hospital’s boundaries and attack as she lay vulnerable in her bed (in reality local puppies crying for their mother). Lorna, Sally and Anita also worried about going to the hospital canteen where they feared groups of men would ‘judge’ them for not being covered. However, their greatest shock was reserved for those they described as ‘war torn’ – casualties of the Lybian conflict, devastated by the loss of loved ones and wielding the horrific wounds of battle – being treated in the next ward.
Mohammed, a long-term Libyan patient recovering from being knee-capped by insurgents during the theft of his car, had seen these English patients before. He was bored in the hospital and recognizing their distress took the opportunity to break up his long days and improve his language skills. He brought the cosmetic patients sugary drinks and fruit when they didn’t like the local food, he reassured them, showed them kindness and took the trouble to explain the context of their location.
He introduced them to other Libyans – a woman who could not pick up her new-born baby because of a bullet wound and others. Faced with these ‘real’ medical needs Lorna, Anita and Sally felt guilty. They began to ask themselves: how could they have travelled here for such frivolous reasons as appearance and ‘vanity’?
Confronting patients with traumatic injuries these British women had no option but to deploy ‘cosmetic surgery discourse’, which blames them for engaging in the very beauty practices that the market demands. Cosmetic surgery discourse is both gendered and classed. Middle-class people who condemn such practices want small-breasted hard-bodies disciplined by ‘appropriate’ and healthy diet and exercise. ‘Cosmetic bodies’ are constructed as lacking the discipline to go to the gym or stick to a diet seeking a quick fix, or as excessive – ‘grosteque dolls’ as MP Sarah Wollaston described them in the wake of the PIP breast implant scandal.
As I have been arguing for more than a decade (e.g. Holliday and Sanchez Taylor, 2006), feminist condemnation of the ‘fake’ beauty of celebrities like Katy Price or participants on Love Island, which they assume young, working-class girls aspire to – is more about class distinction than it is about feminist politics. This discourse limits the value that working-class women can add to their bodies because their desire for surgery constructs them as ‘cultural dopes’. As Bev Skeggs (2013) puts it, middle-class selves are self-possessive individuals that accrue value to the self through diet, exercise and cosmopolitan knowledge to ‘rent’ in the labour market. Working-class cosmetic surgery tourists are their bodies, for sale in the service economy.
However, travelling to Tunisia and befriending Libyan casualties of war, Lorna, Anita and Sally entered into convivial practices of doing community. These patient-consumers never shared a full understanding of each other’s cultures, they did not accrue value from ‘mastering’ knowledge of place and culture in the way that middle class travelers do. They are not cosmopolitans but they did engage in convivialities – a ‘being in common’ (Gilroy, 2004; Wise and Nobel, 2016). Facilitated by mobile technologies these transnational patients stayed in touch, digitally sharing culture and cash as the UK tourists tried to ‘give something back’ to those who had supported them at their most vulnerable. At the end of the research Anita stated her intention to return to visit Mohammed. She asked us, ‘have you ever read the Quran? Its quite spiritual, its quite a spiritual awakening, so that was all really interesting’. Perhaps Anita’s transformation was more cultural than physical?
Cosmetic surgery is considered ‘elective’ and usually excluded from public healthcare. ‘Patient-consumers’ are not equipped with medical expertise or knowledge of surgical qualifications, and their GPs are often reluctant to advise, disapproving of cosmetic surgeries and fearing liability. Cosmetic surgery tourists must therefore undertake considerable labour in choosing their surgeon the way they might choose an electrician or plumber. However, as neoliberal healthcare regimes substitute ‘care’ with ‘choice’ (Mol, 2008), and cut costs through healthcare rationing, more and more patient-consumers are pushed into a (largely unregulated) globalized healthcare market, and navigate journeys like those Lorna, Anita and Sally’s.
This and other stories are covered more fully in our new book exploring cosmetic surgery tourism from the UK to Eastern Europe and North Africa, and from Australia and China to East Asia: Ruth Holliday, Meredith Jones and David Bell (2019) Beautyscapes: Mapping Cosmetic Surgery Tourism, published by Manchester University Press, based on our research project ‘Sun, Sea, Sand and Silicone’.
Holliday, R and Sanchez Taylor, J (2006) ‘Aesthetic Surgery as False Beauty’, Feminist Theory 7 (2): 179-195.
Gilroy, P (2004) After Empire: Melancholia or Communal Culture?, London: Routledge.
Mol, A (2008) The Logic of Care: Health and the Problem of Patient Choice, New York: Routledge.
Skeggs, B. (2013) Class, Self, Culture, London: Routledge.
Wise, A. & Noble, G. (2016) Convivialities: an orientation, Journal of Intercultural Studies, 37 (5), 423-431.