The Rhetorical Limits of the "Plastic Body"
 Original article
Quarterly Journal of Speech, v90 n3 p327-358 Aug 2004. Available on InformaWorld
This essay analyzes the "plastic body" as it is produced in the discourse of plastic surgery. The contemporary industry has constructed a popular image of plastic surgery as a readily available and personally empowering means to resolve body image issues, on the presumption that any body can become a "better" body. The ideology underlying the industry emerges out of analysis of the rhetoric of surgeons and patients. The rhetorical efforts of amputee "wannabes,"who seek elective amputation and who use arguments similar to those of mainstream plastic surgery applicants, reveal the paradoxes and contradictions in decision-making about who has access to these procedures. The essay concludes that the concept of the plastic body is based less on medical technology and skill than on rhetorical power and suggests that this body of discourse has important implications for medical and technological advances that have enlarged the possibilities for body alteration practices.
This article is a good discussion on the topic, but as many others, ignores the fact that Body Integrity Identity Disorder covers a wider range of required impairments than solely amputation.
We also wonder at the effectiveness of this paper in getting BIID sufferers to the goal of being able to receive surgery as a treatment option to the condition?
The most socially sanctioned and physically altering body alteration techniques are those belonging to plastic surgery. Although surgery and other medical techniques have for centuries been used to alter the human body, the dramatic and often controversial techniques involved in plastic surgery have brought it to the forefront of the public's knowledge about body augmentation, leading some to describe the contemporary era as a "plastic surgery culture."
Would it not also be true that many plastic surgeries considered mundane today would have been perceived as anathema 75 years ago?
Public accounts of plastic surgery imply that there is an augmentation for every body and for every part of the body, including some of the more idiosyncratic forms, such as having one's toes shortened to fit designer shoes, "umbilicoplasty" or "designer bellybutton" surgery to create the perfect bellybutton shape, "laser vaginal rejuvenation" or "designer vagina" surgery to reshape a vagina to display a youthful appearance and increase sexual pleasure, and penis enlargements that boost a man's sexual ego, if not sexual function. What may be obscured by the apparent ubiquity of plastic surgery is an understanding that realizing the body's plastic potential is not a simple matter of personal desire[Emphasis added]. Because surgeons control the means to actualize body alteration desires, surgical applicants must confront the medical community's ideological perspective on the healthy body and how this influences surgeons' choices about which bodies and desires will receive surgical attention and which will be rejected as inappropriate.
It is indeed not purely a matter of personal desire. But it is also not purely controlled by surgeons or the medical community. One of the greatest differences between these plastic surgeries (many would consider unnecessary) and the surgeries required by transabled individuals is that for those suffering from BIID, it is not a question of choice or desire. It is not merely preference, but a need (regardless as to the origin of that need, be it psychological, neurological or neuro-psychological).
The first phenomenon is that, over the course of the last century, plastic surgery advocates have engaged in a concerted, commercial effort to redefine the human body as a plastic, malleable substance which surgeons can alter and people should want to alter in order to realize their body image ideals. These messages convey to the public the apparent ease and wonder of plastic surgery and associate body augmentation with individual empowerment, making surgery a desirable solution for individuals with body image issues.
Then, plastic surgery advocates have succeeded, as we do believe surgery is a desirable option for transabled individuals. But this may not be linked solely to the efforts of the fore-mentionned advocate, but instead, to the fact that talk therapy and medication does not work. In other words, surgery is a last resort for us. The fact that plastic surgery advocates have managed to give the idea that surgery is "easy" and "accessible" only makes it more difficult for BIID sufferers to accept that surgeons refuse us these surgeries.
The third phenomenon includes challenges to the medical community's definition of the better body produced through surgery. In particular, I focus on a group of surgical applicants known as amputee "wannabes," who desire amputation of one of their healthy limbs in order to make their bodies "whole." Wannabes are a compelling example for rhetorical analysis because they articulate their augmentation desires through statements that are nearly identical to mainstream plastic surgery applicants, but they are not granted the same legitimacy by the medical community, thereby bringing into focus the role that the body plays in arguments about its plastic potential.
While all that is true, and the rest of the paper is solid, I find it somewhat offensive that BIID sufferers are used as a mere rethorical concept to challenge perspective. I tire of being the object of discussion where nothing happens, where people just talk and talk and talk, and push forward thought-provoking concepts, when what we need is ACTION!
The "plastic" in plastic surgery comes from the Greek plastikos , "to shape or mold," and relates to the techniques for shaping and the object that is to be shaped, meaning that plastic surgery presumes that the body is plastic. This presumption forms the basis on which popular and medical discourse, particularly in the 20th century, established the body's plasticity to the degree that people today "perceive the malleability of the body as commonplace," a perception "writ so deep in the collective unconscious that it is hard to speak of a 'natural' body." In one sense, this perception is not entirely novel as medicine has always regarded the body as a plastic substance that could go from health to illness and back again based on how doctors diagnosed and treated their patients.
It might be useful to consider the social model of disability here, as opposed to the medical model. These diagnosis from doctors, considering themselves the ultimate authority in health and welfare, might be changed, or the solutions would be modified, if patients were listened to and included in said diagnosis and treatment plans.
Indeed, without the belief that medicine can transform bodies, medicine would seem to have little to offer. Bodies in plastic surgery, however, usually are not so much ill as they are "wrong," and they are not healed so much as they are corrected or beautified. These distinctions kept plastic surgery at the fringes of medical knowledge until recently, when it emerged as a visible, desirable, and discussable part of everyday life. Augmentation now factors into definitions of better, healthier, and even happier bodies.
This seems to promote health as only "physical", a very Western view of health. A more hollistic approach, taking on hand both body and mind would expand the perception of BIID.
Advances in plastic surgery were slow, largely owing to a lack of technological innovation and to the perception that it was an unnatural and immoral science that meddled with nature and the social order and, therefore, was unworthy of serious medical study or public acceptance.
Yet, moral sensibilities have changed. How long will it be before society and the medical community is ready to accept that Body Integrity Identity Disorder can be relatively easily (albeit not simply) treated by providing surgery to remove the offending limbs, or stop function of eyes, spinal cord, ears, etc?
Plastic surgery in the 19th century was generally regarded as the province of quack doctors more interested in self-promotion than healing. They advertised experimental plastic surgery procedures (some of which ended tragically for their patients), boasted about celebrity clients (many of whom vehemently denied having surgery), and performed facelift operations on public stages in front of paying audiences. These stunts raised public awareness about the plastic potential of the body, but the carnivalesque atmosphere of these demonstrations did little to improve plastic surgery's standing in the eyes of the traditional medical establishment.
Could the same be said of the media circus that surrounded the Falkirk surgeries conducted by Dr. Smith?
Medicinal practitioners of this era demonstrated a lack of empathy for quality of life issues beyond survival and did not see the merit in attending to a patient's personal appearance, dismissing such concerns as mere vanity.
But surgeons today continue to misunderstand quality of life issues, and have a negative perception of what life with a disability is like. In that respect, things haven't changed significantly.
[...] the impetus to seek plastic surgery for many is the desire to have their bodies reflect an idealized mental image they have of themselves. Surgery is looked on as a means to "restor[e] order and mak[e] the psyche happy through the establishment of a unitary identity," with alteration of the physical body as the means to this end. This "mind over matter" perspective permeates the plastic surgery industry's public promotions, the justifications for surgery offered by patients, and the judgments made by plastic surgeons.
Perhaps in that way, we see a relationship between people seeking "normal" plastic surgeries and those with BIID. Yet, the chasm remains: BIID sufferers do not wish for surgery out of a mere preference.
Plastic surgery's mind/body dynamic has been addressed in several studies that seek to explain why Westerners are so concerned with using augmentation technologies to improve body image. These analyses explore possible influences on individuals, such as psychological issues like low-self esteem or cultural influences such as mass-mediated body images, which compel them to seek relief through the "scalpel psychiatry" of plastic surgery.
For a majority of transabled individuals, it is not a question of low self-esteem. And one could not reasonably argue that cultural influences make us need impaired bodies, considering the prevalent bias against disabilities in our cultures (certainly that bias is alive and well in Western societies, and even more active in Asian cultures)
A rhetorical analysis of plastic surgery discourse identifies several tensions - personal desire and public promise, physical and imagined bodies, psychological need and professional ethics - that are in conflict in the production of a plastic body as a physical object and as an imagined construct. The plastic body is a contested subjectivity whose meaning shapes and is shaped by the ways that the body can be discussed, by whom, and toward what end, as well as the socio-political implications of people seeking to make their bodies conform to an idealized image. This perspective differs from the usual ways in which plastic surgery is discussed publicly, which is in terms of the end product - the visible, post-surgery body. Before a single incision is made, however, the plastic body as an object of discourse has been sculpted rhetorically to reflect the varied interests of patients, surgeons, and, in some instances, communities [Emphasis added]. Even in situations in which surgery is rejected, a new body is produced because the applicant's body is redefined as unsuitable for surgery, which alters its rhetorical status. Approval of surgery is made on the assumption that the refurbished body will improve the individual patient and be a public statement affirming the benefits and appropriate uses of plastic surgery [Emphasis added]. Rhetoric, thus, is a vital component of the development of bodies in plastic surgery culture, and it influences individual decisions about and public knowledge of the human body.
And so, the perceived negativism of having an impairment, or a disability directly influences the surgeon's decision not to provide surgery as a treatment option for BIID sufferers.
The post-surgery body is a living advertisement, which constrains the types of surgeries doctors are willing to perform because they do not want just any body to be an example of the effects of medical intervention. Those who challenge these restrictions, such as amputee wannabes, agree with the surgeons that the body is an important site of rhetorical signification, but argue that the limits surgeons place on acceptable body alterations are ill-conceived and too narrow.
Wannabes view surgical amputation as a means to diversify social interpretations of the body and to admit and appreciate, rather than stigmatize, differences in bodily form.
I rather thought that we viewed amputation (read surgery) as a means to align our physical body with our body schema. In other words, as a means to finally find peace of mind!
For surgeons, plastic surgery is a way of combatting unfair circumstances, of triumphing over nature, and achieving the idealized body to which a person is entitled.
The question of course is, "who's ideal are we talking about?". Obviously, the ideal body for someone with BIID is less than perfect in the eyes of society or surgeons.
One researcher notes that "repeatedly what surgeons have told me they love about surgery is exactly the way these operations can turn around people's lives."
And turning around our lives is exactly what we are after. It is somewhat ironic that the very thing that surgeons love could be provided to what the BIID individual needs, yet because of the surgeon's own prejudices, they won't provide this turn around.
As publicized, plastic surgery is about open access and personal ntitlement: "No patient should have to jump through hoops to benefit from plastic surgery." Even in countries without socialized medicine, such as the United States, the popular perception is that the only obstacle to surgical alteration is price. This is a false impression because being able to afford elective surgery is the not the only or even the most significant hoop through which prospective patients must jump. The more substantial yet less discussed requirement for surgery is the ability to demonstrate psychological health. Medical researchers point out that, "The subject is allocated property rights over [his or her] looks[,] and the value of his [ sic ] property (and hence the need for repairs to it) is determined by a calculus based on his own assessments," but "the exercise of property rights is dependent, however, upon the constitution of a 'rational' subject."
Rationality is quite different from psycholigical health. People with BIID are lucid and rational. They are not psychotic, nor deluded. Yet, that is not sufficient.
Many surgeons even advocate incorporating an applicant's self-diagnosis into their pre-surgical consultations, advising colleagues to "emphasize that both [the doctor] and the patient share responsibility for the decision to proceed with surgery and for the surgical outcome itself. Furthermore, a physician-patient relationship that is egalitarian, rather than authoritarian, must be developed. The surgeon thereby allows the patient to express his [ sic ] desires, fears, and expectations." Despite such advice, egalitarian relationships between plastic surgeons and surgical applicants exist more in theory than discernible practice. When surgeons listen to someone's complaints and desires, they do so to see how the patient reveals his or her psychological state more than as an earnest collaboration on medical diagnosis. Consultations favor the surgeon's authority to the degree that they need not ponder the contradiction between the power they exert and the collaborative atmosphere they claim to provide.
This might be a prime example of the "medical model" in practice, as opposed to the "social model". BIID sufferers know what they need, and while the surgeons give the impression that they listen, in the end, they know best and make final decision NOT to provide surgery.
Ultimately, the burden falls on applicants to perform their roles as patients in a way that will win approval from the adjudicating surgeon.
Yet, the plight of transabled individual in this case is doomed to failure, as there is nothing to convince surgeons at this point in time.
Justifying a request for plastic surgery is particularly difficult because surgeons' evaluations are not based on an agreed-upon standard of a beautiful or normal body. Surgeons attempt to develop a "presurgical baseline of a patient's body image concerns," but in terms of shaping the body toward an idealized image, surgeons' views of beauty are as subjective as any artist's. Surgeons' statements that "Beauty, attractiveness, good looks and symmetry are synonymous," are quickly followed by acknowledgments that "beauty may be in the eye of the beholder."
Body image as a reason for plastic surgery, it appears to tie in our need to more "run-of-the-mill" requests for plastic surgery. The question ought to be explored of the differences between *identity* and *body image*.
And if beauty is indeed in the eye of the beholder, who are we listening to?
In the context of plastic surgery, the eye of the beholder is the surgeon's gaze, and the declaration of what counts as beauty, "like so much of plastic surgery, comes down to each surgeon's personal aesthetic." Despite the surgeon's subjective interpretation of the body, applicants must find ways to articulate their augmentation desires against a subjective standard over which they have little, if any, influence.
In this interpretation, the surgeon is the beholder, he's the individual who decides what counts. But considering the general bias medical professionals have against disabilities, is it surprising that they refuse surgery as a treatment option for BIID? We need to change their attitudes, but how does one change the attitude of an entire segment of society? Disability rights activists have introduced the social model of disabilities decades ago, and that hasn't taken a very strong hold, despite the concepts being more socially acceptable than someone wanting elective surgery to acquire an impairment.
If a surgeon is convinced by the rhetorical performance that the patient needs rather than just wants surgery, he or she can consent to approve surgery because a patient is being cured, rather than a client being serviced. Confessing through the language of illness is often used to justify commercial enhancement technologies like plastic surgery, and offers applicants strategies for legitimizing their surgical desires as necessary rather than as spurious interventions into otherwise healthy bodies.
We have been careful to point out that BIID is not merely a "want", but it is a need. It is important to note this distinction, which sets BIID apart from people into (extreme) body modification, or frivoulous and chronic desire (need?) for implants, face shaping, etc.
The language of illness also redefines the surgical act from one of elective or spurious action to a restorative or healing function, which helps plastic surgeons justify their own medical authority.
Perhaps transabled individual should stop requesting "elective" surgeries, but instead ask for "restorative" surgeries.
What may be gleaned from the intricacies of this situation is that the "illness" of a body in the context of plastic surgery is primarily a matter of an applicant's rhetorical ability to express their "wrong" bodies in the "right" way.
And what is the right way to convince someone who's already biased against your idea of the "right" body?
Surgeons themselves decree that, "The best motivation [for plastic surgery] is that of achieving an outer appearance that matches the inner spirit, thereby leading to improved self-esteem and surgical satisfaction."
Gaaaah, but that's all we're asking!!!
The rhetoric of wrong bodies has "constructed a pragmatic, sensible, affordable image of cosmetic surgery [I]n it we see reflected the promise of individual transformation." This promise is manifested in surgeons' declarations that "the sound conclusion must be that there is no valid reason why anyone should be denied the boon of corrective surgery, even though they are not the victims of disease, accidents, wars, and other disasters." Yet the transformations surgeons promise are not available to all who desire them. Like mainstream plastic surgery applicants, wannabes employ wrong body rhetoric in support of their surgical requests but are far less successful in satisfying surgical gatekeepers.
Far less successful indeed. What percentage of non BIID individuals requesting plastic surgery are turned away? Compare that with the percentage of people who have BIID that are turned away!
Surgeons make a distinction between the inherent plasticity of bodies and their willingness to alter them. The farther an applicant's desires are from socially sanctioned body images, the more reluctant surgeons are to make those desires real. Because "it is, generally, not acceptable in our culture to be disabled, let alone have an unexplained desire and want for amputation or disability,"
It is not just a question of disability being acceptable in our culture, but one of perceived quality of life as well.
Further hindering the wannabes' rhetorical efforts are publicized accounts of the extremes to which some wannabes have gone in their pursuit of amputation when denied elective amputation by surgeons. [...]These accounts paint wannabes into a rhetorical corner. They aptly demonstrate the often suicidal desperation wannabes feel at not being able to receive surgical relief from their wrong bodies and make clear that, "for at least some people with the condition, the desire for amputation is not at all trivial [but] is so intense and all-consuming that it is ruining their lives."
The desperation is real, but is it not caused by the surgeon's very refusal to assist? How can they use a situation they created to refuse assistance?
At the same time, these stories raise serious doubts about wannabes' mental stability and make it easier for surgeons to claim that wannabes need psychiatric rather than surgical assistance.
Yet, psychiatric assistance, whether talk therapy, cognitive behavioural therapy or even medication don't touch BIID in any significant way!
Kevin, one of only two wannabes to date to have received a medically sanctioned, elective amputation, acknowledges, "The paradox is that by taking a leg away, I'm actually made more complete; I'm actually more of a person than I was before." He offers assurances that he feels satisfied with his decision and his new body: "I'm just normal now. Whatever normal happens to be, I'm probably it. Just relaxed, comfortable, at ease." The baseline for normality is not an abstract understanding of what a healthy body should be, but a rational subject's reporting of a satisfactory unification between the mind and body, which is what surgeons advertise as the benefits of body alteration procedures.
Going back to earlier statements, surgery helped Kevin attain exactly what the surgeons want: "The best motivation [for plastic surgery] is that of achieving an outer appearance that matches the inner spirit, thereby leading to improved self-esteem and surgical satisfaction."
By retaining the stated goal of surgical alteration but redefining the means through which it is evaluated, wannabes attempt to persuade the public and the medical community that their desire for surgical correction is earnest, rational, and legitimate.
Well, it is! Of course, the author would say that I'd obviously agree as it is my goal to have surgery accepted as a treatment option for BIID. But then, a majority of researchers on BIID agree that our desires are indeed rational, and not a reflection of delusion nor psychosis.
Demonstrating a command of their body image desires helps wannabes argue that "a healthy limb amputation is simply an extreme example of persons exercising their right to control their bodies. Surgeons and hospitals are involved only because they are the best places to get safe and tidy amputations."
I don't necessarily agree with the concept of "just being control over our bodies", but it is true that the main reason we are wanting surgeons involved is that it is safer than attempting impairments in any other manner.
If understood in terms of body autonomy and sanitary alteration, wannabes' desires are not pathological but responsible choices about reshaping their own bodies.
The problem with this argument is that the need to have an impairment, be it amputation or paraplegia (blindness, deafness, etc) is not a CHOICE. I believe that pathologising BIID is perhaps the only way for the condition to become accepted. Further, I do not believe that a pathology is, in and of itself, negative. The pathology is not one of dellusion, but one of ill matched physical body to body schema.
If surgeons are willing and able to administer scalpel psychiatry in order to achieve cosmetic well-being, then surely it must be acceptable to use the same techniques to grant a tormented person a whole body.
Baz states this goal by looking directly into the camera and saying, I want you to accept that this condition exists, and that the only way that it can be sorted out is by surgery, by removing the part that that person believes should not be there. And only then can those people be given peace. And, if they're anything like me, only then can they be given the opportunity to get on with life.
Hear him out! Hear hear!
Doctors are skeptical of wannabes' claims and prefer to interpret their desires as symptoms of other psychological conditions, such as childhood neglect or sexual perversion.
This is completely ignoring the patient, a typical "medical model" response.
Most surgeons express reluctance even to consider elective amputation until further study and evaluation of the condition has provided clear legal and medical guidelines for treatment.
Yet the only study that would convince them, they won't conduct. To really prove, or disprove, that surgery works as an option, they need to provide surgery to a number of people, with psychological assessments before surgery and follow-up afterwards. This study, however, is not one that can proceed. It's a viscious circle. Medicos claim that there is no evidence that surgery works. When we point them to all the testimonial of successful surgeries, they say it was not gathered in a proper study. The study that would provide the proper proof can't take place because there is no proof that it would work!
The perception seems to be that, "If wannabes can convince the medical profession that they suffer from a mental disorder appropriately remedied by surgery[,] then the courts might consider healthy limb amputations to be legally permissible."
It is most definitely the perception many transabled individuals have. A direct result of interacting with the medical community!
I have argued in this essay that the cultural definition of the plastic body is produced rhetorically through a contentious amalgamation of individual desire, cultural knowledge, and institutional disciplining. Although the fulfillment of body image desires is a much heralded and carefully constructed feature of plastic surgery discourse, including those messages coming from the medical community, this plasticity is available only to those who fit within a particular ideological perspective on what constitutes an appropriate body.
In other words, plastic surgery is an acceptable alternative only to those who fit the mold, and those who define the mold are the ones in power as to whether or not to provide surgery! It seems hypocritical at best.
Those who challenge this definition of a healthy and whole body risk personal scrutiny, institutional marginalization, and, in many instances, public condemnation. This risk extends to applicants and physicians and illustrates the limitations placed on who can speak about body plasticity and how they can speak about it. What is revealed is that the body may be plastic, but the ideology informing its cultural production is less so.
Consequently, when wannabes challenge the scope of plasticity, they are arguing not only for their individual rights to their own bodies and psychological well-being, but they also are redefining how the body is known and understood in society. Wannabes argue that if the psychological goal of healing the mind through resculpting the body is the aim of plastic surgery, then that promise should hold for any image of the body, even those which fall outside the traditional aesthetic boundaries.
And that might be an even bigger barrier to making surgery an appropriate treatment option for BIID.
If psychological distress is the primary requirement for being granted surgical relief, then wannabes seemingly would have no trouble demonstrating their need for surgery. These individuals exhibit obvious psychological anguish stemming from a difficulty in resolving their mental and physical body images, but their requests, expressed in language nearly identical to mainstream plastic surgery patients, are rejected because the body they seek to produce does not accord with the current medical thinking about a healthy and whole body. Yet applicants desiring shorter toes or prettier belly-buttons are deemed to have the proper motivation. Psychological distress is not the primary requirement for plastic surgery; it is merely its public excuse[Emphasis added].
Somewhat hypocritical discourse on the part of the plastic surgeon then?
Although it is important to understand how cultural standards of body image pressure individuals toward normative alterations, it is equally important to recognize that these cultural norms are shifting as a result of rhetorical, political, and technological influences.
And it is important to recognise how cultural standards limit the ability of many people to be anguish or suffering free!
Note: Author's original references removed