Beauty, Women's Bodies and the Law: Performances in Plastic 3030279979, 9783030279974

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Beauty, Women’s Bodies and the Law Performances in Plastic Jocelynne A. Scutt

Beauty, Women’s Bodies and the Law

Jocelynne A. Scutt

Beauty, Women’s Bodies and the Law Performances in Plastic

Jocelynne A. Scutt University of Buckingham Buckingham, UK

ISBN 978-3-030-27997-4 ISBN 978-3-030-27998-1 (eBook) https://doi.org/10.1007/978-3-030-27998-1 © The Editor(s) (if applicable) and The Author(s) 2020 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover illustration: © Alex Linch/shutterstock.com This Palgrave Macmillan imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents

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Introduction—The Body Plastic 1 Brain & Body, Brain vs Body 2 The Body Perfect/Imperfect 3 The Body as Image 4 My Body, Your Opinion 5 The Body as ‘I’

1 1 5 11 16 20

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The Body Beneath the Knife 1 The Body in the Beauty Parlour 2 The Body on the Operating Table 3 The Criminal Body and the Body in Crime 4 The Criminal, the Civil and the Role of the Law

29 30 42 58 66

3

Above the Shoulder Blades 1 Her Crowning Glory 2 Oh! My Face … a Retroussé Nose & Pinned Ears 3 Around the Eyes & Rounded Eyes … 4 For Bee-Stung Lips, Whiter-Than-White Teeth, Receding Chins & Measures Under the Neck 5 Plastic Faces or ‘The New Normal’?

79 79 88 97 102 109

v

vi

CONTENTS

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All Above the Waist 1 Over and Above the Bosom 2 Bust, Bosom, Breasts … 3 Reclaiming Our Bodies, Our Selves—Beginning with Breasts & Chests

150

5

Below the Belt and Under the Waist … 1 Muffin Top Madness 2 Around the Fatty Abdomen 3 Within the Fatty Abdomen 4 What Lies Beneath … 5 Bad Body Hair … Comes Good?

165 165 171 180 187 198

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Our Rounded Bits … 1 Rounding Up vs Rounding Down 2 The Bottom as Bustle … 3 Bottoms, Hips, Thighs … 4 Exposing My Midriff or Where Are My Abs? 5 Suction Up, Suction Down

211 212 219 222 232 236

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Extremities: From the Tips of Her Fingers to the Tips of Her Toes 1 The Moons of My Nails, O’er My Elegant Hands … 2 Upon Raising Her Arms to the Sky 3 From My Elbows to the Bush Within My Armpits 4 Legs, Knees, Ankles & Feet … 5 Feet, Ankles, Knees & Legs … 6 To the Tips of Her Toes— 7 Fingers, Hands, Nails, Toes—The Extremities That Count

283

Conclusion: Beyond the Body … 1 Recovering the Body … 2 My Body, My Self—

297 298 307

8

119 120 134

249 249 257 262 269 274 279

Bibliography

325

Index

373

CHAPTER 1

Introduction—The Body Plastic

Desiring normality she was labelled with vanity Whilst some said she chose every change to her body In plastic

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Brain & Body, Brain vs Body

The painter Gwen John was both gifted artist and muse to the sculptor Rodin. She painted and she posed, exercising cerebral artistry and physical dexterity in her own work whilst responding intellectually and bodily to Rodin’s creativity. For an artist, painting is creative and physically demanding. This is nowhere better exhibited than through Gwen John’s Self -Portrait in a Red Blouse.1 In the biography Gwen John—A Life, Sue Roe explains that the picture ‘would have required endless, meticulous concentration’.2 Finding it physically strenuous, even exhausting, Gwen John herself ‘likened painting in oils to doing housework’.3 Her words are echoed by women working in the arts, including sculpture,4 ceramics,5 photography,6 craft,7 filmmaking8 and directing.9 As director and filmmaker Karen Buczynski-Lee says:

© The Author(s) 2020 J. A. Scutt, Beauty, Women’s Bodies and the Law, https://doi.org/10.1007/978-3-030-27998-1_1

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Making a film is like constructing a jigsaw puzzle, moving, thinking and communicating multidimensionally to translate artistic vision into the film medium. Without physical and mental multitasking, filmmaking cannot happen.10

This epitomises Gwen John’s life. In her work, as in the work of the sculptor Camille Claudel,11 another of Rodin’s muses, she exemplified the reality that women are both brains and body, body and mind. Yet the way women’s bodies have been regarded over time tends to undercut this truth. It is not simply that many looking upon the work of artists or sculptors may fail to realise that the figure of the woman there represented is more than body, more than emotional energy or inspiration for the man (as it usually is)12 who painted or sculpted her. In all life’s realms, woman-as-body rather than woman-as-mind or, better still, woman-as-mind-and-body, has a propensity to dominate. Thus, the invention of photography and film heralded new ways to represent women in the same old way. Woman-as-body was confirmed and promoted through these new mediums, harbingers of the twentieth-century invention of the beauty contest13 and the film actor as star, then as celebrity. In the Countess de Castiglione, Abigail Solomon-Godeau provides an example of the way photography solidified the traditional notion of woman-as-object, despite the Countess’ engagement as a director of her own images, bringing ingenuity, creativity, skill and knowledge of the camera and what it could do. As Solomon-Godeau recounts, from the mid- to the end of the nineteenth century, Countess de Castiglione was photographed relentlessly by Louis Pierson of Mayer & Pierson.14 On some accounts, in her younger years, then as she aged, photographers Adolph Braun and Gaston Braun respectively trained their lenses untiringly upon her, too. Yet she was equally untiring. This woman who has historically been depicted as a willingly accommodating human object was anything but. However apparently compliant in the eye of the camera (and the cameraman) she might appear, the Countess was at work, mind and body. Both famous and infamous in her pursuit of the celluloid image, she was photographed in poses unconventional for one of her class, déshabillé, legs akimbo and flying, head winsomely leaning towards the camera. Styling her essay ‘The Legs of the Countess’, Abigail Solomon-Godeau reclaims the Countess as actor and director of herself as subject. She draws attention to the three types of women who publicly populated the period of the Second (French) Empire and the Third (French) Republic when the Countess figured in the eye of the lens. These three were the

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prostitute, uniting (to paraphrase Solomon-Godeau) in her person both the commodity and the seller; the dancer or actress being ‘the spectacle within the spectacle – who is perceived as a type of circulating goods’; and the ‘beautiful, worldly woman’, both idea and ideal ‘endlessly hypostatized, scrutinized and dissected’.15 It was at this time that Karl Marx wrote ‘The Fetishism of Commodities’.16 Solomon-Godeau remarks and reflects upon this, drawing attention to the increasing fetishisation and commodification of women and women’s bodies during this period. Simultaneously, the industrial revolution led to a downgrading of skills on which women prided themselves and for which they had had some acknowledgement. Industrialisation homogenised production and, hence, the work and the workers creating the product. Women as workers took on the role of automaton in the factory, or body on the street. Women who did not work in the world of industry became celebrated as ‘the lilies of the field’.17 Idealised as neither toiling nor spinning, they graced society as objects to be looked upon, their value lying in the bodies they inhabited and the clothes they wore.18 The following century, the focus on women’s bodies, and women as bodies, if anything deepened. Women’s attention to their own bodies as if they were canvases to be worked upon and titivated, transformed and changed at the hands of women themselves, or through the hands of others employed to renovate their person, intensified. Writing in 1993, Susan Bordo examined this phenomenon. She expressed concern that in the 1980s, ‘a decade marked by the reopening of the public arena to women’, women were ‘spending more time on the management and discipline of our bodies than we have in a long, long time’.19 For Bordo, the principal influence in this is not ‘chiefly … ideology’, but ‘the organization and regulation of the time, space, and movements of our daily lives’. This, she said, ‘trains, shapes and impresses’ women’s bodies with ‘the stamp of prevailing historical forms of selfhood, desire, masculinity, femininity’.20 Women’s bodies, rather than brains, were foregrounded, the trap set by ever-increasing cosmetics and perfume production—alongside a growing aesthetic, cosmetic and plastic surgery industry. Today’s women, Susan Bordo posits, are engaged in the pursuit of ‘an ever-changing, homogenizing, elusive ideal of femininity’, a pursuit without end.21 Women are required constantly to ‘attend to minute and often whimsical changes in fashion’. Women’s bodies thereby become ‘docile bodies—bodies whose forces and energies are habituated to

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external regulation, subjection, transformation, improvement’. The ‘central organizing principles’ of women’s daily lives, from when we rise in the morning to going to bed at night, are the ‘exacting and normalizing disciplines of diet, makeup, and dress’.22 And, faced with this daily regime, where our bodies are a focus of our everyday living—not from vanity, nor from narcissism, but because this is the way lives at least in the Western world are ordered, our bodies are never good enough. In Flesh Wounds—The Culture of Cosmetic Surgery, Virginia L. Blum also highlights women’s connection with their physical selves and, through this, identifying their own physical imperfections. She refers to ‘the perceived flaws of the female body’,23 providing an opening for plastic surgeons who view themselves ‘as “healers” of cosmetic defects’.24 They see their work, too, as healing the ‘emotional desperation’ of women who detect flaws in their bodies writ large—sufficiently large, that is, to seek the surgeon’s scalpel. Surgeons, Blum writes, conceive of their work not as damaging healthy bodies, but as ‘helping’ women to reconstruct not only their bodies, but their lives. Albeit on the one hand apprehended as miracle work, making and remaking the ideal, the work they do on women’s bodies is ‘maintenance’, says one surgeon. The obligation falling upon women is that akin to the good householder who paints the house regularly, as required.25 In the same vein, the good householder would ensure that the gutters are kept free of weeds and bird droppings, leaves and other detritus, or repair bulging window frames and shutters, or replace or reorder sagging brickwork and tiles gone awry. Unable to do this alone, the householder must call upon the skilled services of specialists. When maintenance of women’s bodies is required, therefore, the skilled specialist provides the answer. Virginia Blum identifies a moralism creeping in. Middle-class morality requires home upkeep. This segues effortlessly into a moral imperative for the ageing woman. Here, Blum apprehends the work of Robin Tolmach Lakoff and Rachel L. Scherr who in Face Value: The Politics of Beauty observe that sometimes ‘in the popular media it is suggested that a woman has a virtual moral duty – to herself and those who must behold her …’. This requires that she ‘remove those wrinkles and bags, tuck that tummy, raise those breasts’.26 Or, rather, that she seek out an aesthetic, cosmetic or plastic surgeon to do so. The imperative of normality infuses the surgeon’s exposition and justification, too. If twenty-five years classifies as maturity and if, at this age, a woman ‘had exactly the right amount of skin coming from the brow down

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to the first fold [of the eye or the neck] and exactly the right amount of skin coming to the eyelashes … and that was normal, then is it normal to allow time to change it’? The question is clearly rhetorical, for of course it is not ‘normal’, in the surgeon’s eyes, to ‘allow’ change whereby ‘the skin begins to slide down over the jaws and the bags begin to show’.27 This notion of what is normal harks back to the ancients and their ideas of female bodily construction as perfection. In Femininity Susan Brownmiller recalls that the classical Greeks determined what was ‘perfect’, as did the Goths, whilst the Renaissance envisioned another shape and form as the ideal.28 For the Greeks, ‘in the perfect female torso the distance between the nipples of the breasts, the distance from the lower edge of the breast to the navel, and the distance from the navel to the crotch were units of equal length’.29 With the coming of the Goths, this changed: Centuries later, the Gothic ideal was strikingly different. With the breasts reduced to oval spheres … ‘distressingly small’, and with the stomach expanded to a long ovoid curve that suggests an advanced state of pregnancy, at least to the modern eye, … ‘the navel is exactly twice as far down the body as it is in the classical scheme’.30

Contrarily, perfection of form in Renaissance Italy was demonstrated by ‘a rounded body’, sporting ‘full hips and large breasts’. This vision should be topped off by ‘strawberry blonde hair’ above a high forehead, the whole embraced by ‘pale skin’.31

2

The Body Perfect/Imperfect

The female archetype does not remain static. Nor does ‘everyone’ conform or strive to do so. Sometimes resistance to the demands of appearance and bodily construction (whether real or created by dress, fashion and other artifice) surface, as Elizabeth Shackleton’s Pocket Diaries of 1765 and 1766 reveal.32 In The Gentleman’s Daughter, Amanda Vickery writes of Shackleton and her fellow Georgians, their habits as consumers of fashion and household accoutrements, and their place on the social scene. Elizabeth Shackleton was not, observes Vickery, a ‘slavish imitator of elite modes, nor a passive victim of the velocity of fashion’. Such lack of conformity, insurrection even, was supported by her recording in her Pocket Diary a sardonic poem, mordantly mocking the

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demands placed upon women’s bodies to comply with prevailing social strictures: Shepherds I have lost my waist. Have you seen my body? Sacrificed to modern taste, I’m quite a Hoddy Doddy. Never shall I see it more, Till common sense returning My body to my legs restore, then I shall cease from mourning. For Fashion I that part forsook where sages plac’d the belly Tis lost and I have not a nook for cheesecakes, tarts or jelly!33

Nonetheless the imperative that governs women’s appearance infuses every age, so that at the end of the eighteenth- and into the nineteenthcentury Britain revered a particular look, hair along with facial features playing a vital role. Hence, the Duchess of Devonshire, aunt to Lady Caroline Lamb who was later worshipped then pilloried for her looks, her rejection of convention, and her ‘tempestuous … liaison’ with Lord Byron, possessed ‘red-gold curling hair, grey eyes, and an always laughing mouth’.34 Her sister Henrietta, Lady Bessborough, ‘had dark eyes and hair and a softer less lively disposition’. This led Elizabeth Jenkins, Caroline Lamb’s biographer, to nominate Henrietta as ‘altogether perhaps the more interesting of the two’. However, the perspective formed through an early twentieth-century woman’s eyes and intellect was not replicated when the women lived, for the Duchess was considered by the society of the time as ‘the most fascinating woman of the age’. Her sister rated not so well.35 Forward, then, to the Victorian era, where the dominant paradigm featured women showcasing nipped-in waists, their bodies conforming to the required ‘hourglass’ shape, hips and bosom swelling above and below into rounded perfection. The look was achieved by the wearing of tightly structured corsets which pulled women’s bodies into a smoothly sculpted form.36 In Victorians Undone—Tales of the Flesh in the Age of Decorum, Kathryn Hughes recounts the contradictions between the way a woman’s body should be, and the way the body of a woman might be represented in art.37 Dante Gabriel Rossetti painted his muse, Fanny Cornforth (aka Sarah Cox), ‘from the torso up’, her brocaded costume ‘falling open to reveal her thick pillar of a neck and her creamy chest’.38 Her body is ‘plush’ with a ‘tumble of red-gold hair’ falling over her forehead, disclosing ‘facial features [that] are full but not quite heavy’. Painted in 1859, the portrait, known as Bocca Baciata, displayed the ‘tilt

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of her head tactfully foiling the beginning of a double chin’,39 such artifice able to be avoided had the twentieth-century surgeon’s knife been so readily available as now. Indeed, when it first went on display, the sitter’s body was regarded as wanton, her style that of a floosy, her bulges and her features poorly reminiscent of those required of the ‘good’ Victorian lady.40 The painting was likened to a foreign print, a euphemism for the pornographic representations that came into popularity through distribution in seaside towns of these images on postcards. The passing of the age of Victoria brought with it a new ideal. In The Spectacular Modern Woman—Feminine Visibility in the 1920s, Liz Conor recounts the influence of photography, film and beauty competitions in dictating how a ‘real’ woman should look in the 1920s and 1930s.41 She was flat bosomed, narrow hipped, long of leg, with pretty knees, elbows and wrists, her slender calves tapering towards well-turned ankles. As Conor observes, the ideal was rarely if ever achieved by reason of nature. She cites Russian filmmaker Lev Kuleshov, who perfected through montage the archetypal woman of film: I shot a scene of a woman at her toilette: she did her hair, made up, put on her stockings and shoes and dress – I filmed the face, the head, the hair, the legs, the feet of different women, but I edited them as if it was all one woman …42

‘Thanks to my montage’, he averred, ‘I succeeded in creating a woman who did not exist in reality but only in cinema’.43 From the last century and into the present, the demand for the ideal travels to the most intimate parts of a woman’s body, with culture, race and ethnicity playing their part. Notions of womanly perfection as allied to cultural, racial and ethnic imperatives formed part of the contradictory response to the Fanny Cornforth portrait. Some viewers swam against the tide by declaring it ‘a superb thing, so awfully lovely’, focussing particularly on her lips.44 These were described as ‘slack’ or Mulatto lips, despised on the one hand, yet longed for on the other, for what they represented: sexual availability and pleasure. This is reminiscent of the contradictory approach to women’s lips when reddened by rouge or, later, lipstick: the colouring being associated with actresses, prostitutes or fallen women. It brings into play, too, the paradox of Western or Anglo-Saxon features being prized over African, Middle Eastern or Asian characteristics, whilst some at the same time being secretly admired

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and imitated. Bee-stung lips, achieved by design not nature, today imitate Fanny Cornforth’s mouth. The Brazilian butt lift seeks to enable women’s flat bottoms to imitate the rounded curves of their African sisters. These complimentary imitations are matched in the reverse by the renunciation of and growing revulsion for vulva that are perceived to be other than perfect. The growing demand for labiaplasty (‘cosmetic labiaplasty surgery’ or CLS) revives the vision of the ‘Hottentot Venus’ with her rounded buttocks and ‘elongated’ labia minora. In 1810, Sarah Bartmann, a Khoi woman from the Cape of Good Hope, was brought to London as a slave, then becoming an exhibit, representing female African sex and sexuality.45 As Camille Nurka and Bethany Jones note in ‘Labiaplasty, Race and the Colonial Imagination’, the protrusion of Sarah Bartmann’s labia minora from between the labia majora was a bodily conformation observed a century earlier by Captain Cook in his excursions around the Cape. As Nurka and Jones confirm, Khoi women’s genitals were the subject of scientific interest.46 ‘Enlarged’ labia were classed as signifying lower evolutionary development, with Nurka and Jones remarking, too, upon the association of this genital design with a lack of cleanliness, sexual laxity and even a propensity towards prostitution. Sarah Bartmann was charged with suffering from a bodily dysfunction or distortion, labial hypertrophy. This classification of a normal bodily construction as abnormal or deformed, Nurka and Jones postulate as associated with the addition of labiaplasty to the contemporary clinician’s repertoire. ‘Racial and sexual deviancy’, they acknowledge, ‘are no longer readily apparent in the medical literature – presumably because they are recognised as belonging to a flawed scientific explanatory model …’. However, this ‘does not mean that they do not still resonate in what we might call the “white cultural unconscious” as a central motivating force in the desire for labiaplasty’.47 The ‘containment’ of the body, Nurka and Jones affirm, ‘as well as cleanliness’, provide a core feature to the way in which labiaplasty is marketed to women.48 This is a reminder of ‘deeply held anxieties about feminine non-conformity’ which are exploited by the aesthetic, cosmetic and plastic surgery industry. Women themselves inculcate these anxieties, which reach expression, too, in the market for skin-whitening and hair-straightening products which can be dangerous, with life-changing consequences.49 As for labiaplasty, dangers lie in the increased attention paid by clinics to so-called labial hypertrophy. This is replicated in the minds of today’s women who travel, in increasing numbers, to the operating tables of aesthetic, cosmetic and

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plastic surgeons seeking to have this ‘excess’, ‘excessive’ or ‘surplus’ tissue excised. Whilst accepting Susan Bordo’s thesis that it is the ordinary, everyday routine that focuses women’s attention on the body, that so many women are propelled into the world of aesthetic, cosmetic or plastic surgery with its consequent dangers, together with the potential for dissatisfaction, requires further explanation. It is consistently attributed to motives beyond the daily routine. Sometimes, body dysmorphia or body dysmorphic disorder (BDD) is alluded to. In ‘Body Dysmorphic Disorder in Plastic Surgery’, Kashyap K. Tadisina, Karan Chopra and Devinder P. Singh observe that BDD is defined by three principal characteristics. First comes ‘an obsession or preoccupation with a minor or non-existent flaw in physical appearance’.50 Secondly, this ‘causes functional impairment or significant distress’ which, thirdly, ‘is not explained by another psychological disorder’.51 Patients are generally youthful, with the obsession growing from the mean age of approximately 16 years, until the first surgical consultation is generally sought when they are in their thirties. Tadisina, Chopra and Singh identify the ‘distinguishing symptom of BDD’ as ‘significant body image dissatisfaction’ accompanied by ‘obsessive-compulsive behaviors, including mirror gazing, comparing personal features, excessive camouflaging, skin picking, reassurance seeking and even “self-surgery” practices’.52 Rather than seek psychiatric help, as a consequence of ‘poor insight’, BDD sufferers are likely to consult plastic surgeons. Although referral to a psychiatrist is recommended, a plastic, aesthetic or cosmetic surgeon has a discretion as to whether to operate to satisfy the patient. This can be unwise, for research has it that BDD sufferers are unlikely to be satisfied and can react by engaging in ‘violent or threatening behavior toward their surgeon’.53 Eva Fisher’s study undertaken in 2012 of 225 members of a BDD support group found that principal discussion incorporated disclosure of personal experiences and asking about the experiences of others, seeking support, engaging in conversations and telling stories. Concerns about appearance were high on the list, with comments relating to ‘feeling ugly, depressed, guilty, ashamed, angry, and suicidal’ along with disclosure of ‘compulsive behaviours’. These included constant checking of appearance in mirrors or photographs and social comparisons, whilst plastic surgery topped the list in this category of contributions,54 consistent with the findings of Tadisina, Chopra and Singh.55

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Nevertheless, perusal of the literature confirms that BDD is attributed to a small number only of those seeking bodily changes.56 The vast numbers walking into clinics and being wheeled into operating theatres are not relegated to the realms of those suffering psychiatric illness. Women seeking or undergoing procedures are frequently cited as saying they are driven by a wish to appear normal’.57 Some researchers and surgeons say it is nature and the wish to gain a ‘natural’ appearance, or the desire to achieve ‘normality’.58 Some writers raise a desire for ‘beauty’ or the spectre of a self-centredness, egotism, women’s narcissism or conceit in endeavouring to gain and claim bodily perfection.59 Others assert that agency is the driving force, the woman taking control over her body, appearance and shape, making decisions wholly attributable to her and her capacity for and exercise of choice.60 Research from Australia sees the impact of Covid-19 generating an upsurge in facelifts—not able to fly abroad on holidays, women have spare funds, with lockdown meaning they can hide away without suspicions of their ‘having work done’, and facemasks meaning they can conceal bruising when outdoors.61 The same research identifies Zoom meetings, a consequence of the coronavirus pandemic, revealing to women their ‘turkey’ throats, teeth, nose and eye ‘defects’, requiring beauty treatments, surgical and non-surgical procedures, and a need to adjust the configuration of their smiles. However, the proposition that there is a sole motivation for any woman is too superficial a way to analyse what is happening here. A multiplicity of factors may spawn the desire, but what is clear is that ultimately the shape, size, dimensions and nature of women’s bodies and how they are transformed is driven not by women, but by how the ‘perfect body’ is seen in the eyes of the surgeon or practitioner implementing the changes a woman says she needs. Just as the fashion industry is dominated by male designers, the aesthetic, cosmetic and plastic surgery industry is peopled in the main by male protagonists. Elizabeth Morgan in The Complete Book of Cosmetic Surgery: A Candid Guide for Men, Women and Teens ,62 draws attention to the tradition of the ‘before’ and ‘after’ photographs intrinsic to the industry. These images are employed by practitioners and appear in magazines and advertisements, persuading women that they too should enter into the world of the new body, the improved body, the ‘after’ replacing the ‘before’. Seeing danger in these projections, Morgan observes that the ‘illusion of change of character can be added to the photographs, so that “improvement” becomes a quality of the representation’. Thus, as prospective patients or clients, women see in these

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photographs that not only can the body be changed, but with change to the body comes enhancement to the personality or a personality boost. At the hands of the surgeon, the person as a whole is changed. Surgery is represented as wreaking miracle conversions of a woman not only into a beauty but into belle of the ball, conversationalist, and ‘new woman’ all in one, although this is not driven, or necessarily driven, by a desire to increase the number of beaus. Following this theme, in Making the Body Beautiful—A Cultural History of Aesthetic Surgery,63 Sander L. Gilman remarks upon the impact of photography. There is, he says, a ‘constant bleed between the world of medical photography and the general world of visual culture’.64 These images represent that the surgeon’s prowess lies not only in ‘altering the body, but also … the altered state of mind of the patient’.65

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The Body as Image

Television has taken this into an extended visual territory. As Susie Orbach’s Bodies explains, television’s many makeover shows, including The Swan, 10 Years Younger, Extreme Makeover ‘show a relentless display of the ordinary body – usually female – in the process of reconstruction’.66 These entertainment programmes incorporate the ‘before’ and ‘after’ exemplar. Women’s ‘cheekbones, teeth, noses, lips, wrinkles, lines, breasts, pecs, legs, bums’ are acted upon. Together with ‘chins, feet, labia, stomachs, midriffs, hairlines, ears, necks, skin colouration, body hair’ they ‘become putty in the hands of cosmetic surgeons, dentists and dermatologists’.67 Such transformations are projected as both enormously skilled, though easy, with fairy tales such as Cinderella and the Ugly Duckling coming to mind, although The Mermaid, living her life above the sea as if she were walking perennially on razor blades, may be more apt. Danger and risk are hidden. Yet just as they exist in the operating theatre and the clinic, they lie on the set and in the television studio, albeit unseen or concealed, a veiled or unacknowledged warning that body renovation can be hazardous. Alongside the surgical dimension of the body-changing explosion lies the parallel world of the beauty industry. At the hands of these professionals, the hairdressers, manicurists, pedicurists, beauticians and the like, transformations are again projected often as the natural outcome. Though in this, as in the surgical dimension, what is ‘natural’ has a particular meaning. Every woman who walks into the salon or spa will

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walk out a new woman, hair, hands, feet, nails, lips, eyelashes renewed and changed, so that not only her features are transformed but her self and even her life are transfigured. The beauty industry is populated mainly by women working on women’s bodies. Products they use remain as women invented them or are lines descended from many originally devised by women, including African American inventors Theora Stephens (hair pressing and refined curling iron)68 and Lyda Newman (patented hairbrush featuring health, brushing and efficiency improvements),69 and cosmeticians such as Polish-American Helena Rubenstein (skin and perfume products).70 Consumerism is a driving force, which Laurie Pennie identifies in her work, Meat Market—Female Flesh Under Capitalism, as ‘punishing and policing’ women’s bodies through a barrage of thousands of seemingly endless messages ‘informing us that we do not look young enough, slim enough, white enough and willing enough’.71 The messages are both subtle and direct, advancing into every woman’s personal space and psyche through public sources including film, television, advertising and print media, and added to by women’s friends, colleagues and acquaintances. Laurie Pennie concludes that women are ‘corralled into rituals of consumption and self-discipline that sustain a bloated global market in beauty, diet, fashion and grooming products’, to women ‘three quarters of [whom live] in countries where food is plentiful [but they] go hungry every day in an effort to take up as little space as possible’.72 Anorexia nervosa, bulimia, and body dysmorphic disorder (BDD), along with dangerous surgery and dangerous products are part of this consumer culture and an outcome of it. Yet that danger and risk accompanies the changes to their bodies sought by women in surgeries and beauty parlours, and that women are prepared to submit themselves to the danger and risk, leads inexorably to the question of what is the driving force. Women are not helpless in this, and research shows them variously asserting they ‘want to be normal’, or ‘beautiful’.73 In this, they assert their agency as they define it. Choosing the surgeon or practitioner, selecting the operation or procedure, this is an assertion of ‘I will make my body as I want it’. However, the practitioners operate as artisans, moulding women’s bodies to their own specifications and perspective as to what is a woman, what is aesthetically pleasing to them … This is exemplified starkly in the commentary of Daniel Man, author of The Art of Man: Faces of Plastics Surgery.74 Man prides himself on his ability to ‘read’ his patient. This enables him to make her body as she wants it, he says:

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I try to envision the inner person, the inner beauty and the potential that are lying so close to the surface. When I look at her, I visualise a finished work of art that truly expresses how she feels inside.75

He, of course, has an advantage. The ‘finished work of art’ that he envisages will, all being well with his technique, proficiency, skill and all other aspects of surgical intervention at optimal level, be his vision. Whether it will be his patient’s is another matter. The contention that he, the plastic surgeon, can ‘truly express how she [the patient] feels inside’ does not follow. The result may satisfy the patient despite not being precisely as she envisaged it. Or it may be welcomed by her as completely to her own visualisation. Yet this is unlikely to be always so, not the least because another person, whether or not an aesthetic, cosmetic or plastic surgeon with a high regard for his own abilities, cannot see inside the head of another, nor experience their ‘inside feelings’. On a lesser scale likely to have resonance with most women, it is surely a rare woman who has not been to a hairdressing salon with a vision of herself renewed, to find the hairdresser remakes her hair in the vision the hairdresser perceives as ‘right’ for the client. How many women have returned home, simply to brush out the new hairstyle, wash it, or even re-dye it or, despite her misgivings, wait out the time it takes for nature to take its course and her own hair, her own look to reassert itself. It is true that sometimes, the visions are identical or the client discovers that the hairdresser’s vision is just as she wanted it, even though departing from her earlier instructions. That this can happen in so relatively innocuous place as a hair salon (ignoring for the moment more ominous and lasting hazards of hairdressing), where hair cut generally regrows, dyes wash out and fade over time, permanent waves eventually straighten, and straightened hair regains its frizz, surely presages the chances of its happening in the dire circumstance of an operating theatre or a clinic engaged in a non-surgical procedure of some relative permanence. That a not insubstantial part of the business of aesthetic, cosmetic and plastic surgeons is ‘fixing up’ their own or other surgeons’ perceived errors or misinterpretations of what women want76 confirms that ‘truly expressing what their patient feels inside’ is not certain. That the surgeon can assert he experiences the ‘inside feelings’ of the woman who lies on his operating table is, however, instructive in itself. How do these ‘inside feelings’ come about? To investigate the origin is not to deny women’s intelligence, intellect, wit or capacity for

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decision-making. It is, however, to give proper regard to the world in which every woman lives where, whatever her country and wherever in her country she lives, mainstream media and the advertising industry, gossip and celebrity recitations via magazines or online, in social media and by word of mouth are pervasive. No one surely asserts that men are not influenced by advertising. Nor that advertising is not influential: its continued and all-encompassing sweep is certainly proof enough. It is hardly useful, therefore, to deny its impact on women. Similarly with the media generally. To say it is influential and influences women, like men, is not to categorise women as incapable or mindless or lacking in intellectual capacity. When in 2013 the UK Department of Health undertook its Review into the Regulation of Cosmetic Interventions ,77 it commissioned a review of the impact upon young women of the search for bodily perfection through aesthetic, cosmetic and plastic surgery. The findings of the independent report, Regulation of Cosmetic Interventions —Research among Teenage Girls,78 tends to replicate the work of Suzanne Fraser carried out in Australia, with recourse to UK and US sources, published ten years earlier. Fraser’s book, Cosmetic Surgery, Gender and Culture,79 looked particularly at the magazine industry. She found that nature, agency and vanity were recurring themes in the motivations lying behind women’s entry into the world of bodily alteration through surgery. However not only did they surface in women’s magazines, they were replicated commonly in popular culture as well as feminist, medical and legal writing and discussion about cosmetic surgery.80 Most articles assumed that women’s pursuit of beauty ‘is a natural and unquestionable practice’, albeit the ‘occasional piece’ projected the view that ‘personality, not appearance, is what matters’. Longer articles ‘primarily informed readers about the possibilities of cosmetic surgery, offering an emphasis on best-case results, and engendering a generally positive attitude towards cosmetic surgery’. The journalist going incognito or under cover to sample the clinics’ approach and discover what was available was not uncommon.81 Articles reviewing instances of celebrity surgery ranged from the titillating ‘where the reader is invited to wonder at the strange, sometimes sad and often extravagant cosmetic surgery experiences of famous people’. Curiosity, horror, pity and admiration were encapsulated within these tales, says Fraser, sometimes all at once. Magazines in the glossy and more expensive category ran advertisements for surgeons and products as well as the stories, which Fraser surmises ‘presumably helps to

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shape the positive tone in which the articles [appearing in Cosmopolitan, Cleo and Elle] are written’.82 Fraser found that articles appearing in the early 1990s not infrequently touched on the ‘negative effects of silicone breast implants’, this coinciding with debate in the United States and Australia about the availability of these prostheses and their impact.83 Overall, her review led her to conclude that the notion that a monolithic view of cosmetic surgery projected by women’s magazines was unsustainable. It was ‘not feasible’ to postulate that women’s magazines ‘are universally positive on the subject’. Nevertheless, her findings in relation to the late 1990s seem to confirm that the breast implant scare was not lasting, with the need for any warning or cautioning to readers being far from the minds of magazine writers and editors: ‘articles opposing cosmetic surgery [were] found less frequently in magazines published in 1999, compared with those published at the beginning of the decade’. Additionally, through the 1990s, ‘advertising and editorial functions increasingly merged to produce features promoting cosmetic surgery and providing lists of surgeons and clinics’. Criticism did not disappear entirely, but ‘advertising techniques changed as higher advertising budgets were made available, and a much larger presence in women’s magazines resulted’.84 Ten years on, the United Kingdom study, the Regulation of Cosmetic Interventions , found that the teenage girls were ‘surrounded by images that either “talk of” cosmetic interventions or allude to them’.85 Principal sources of a ‘first impression’ that people could alter their bodies by recourse to surgery were ‘programmes on television, magazines … and other digital and social media …’. The conclusion was that these teenagers developed an awareness of surgical alteration and enhancement being available, through their exposure to media that was ‘accessible and appealing to children’, despite is being aimed ostensibly at adults. Sometimes ‘mainstays’ of the girls’ reading, and sometimes ‘guilty pleasure’, celebrity magazines including ‘OK, Heat, Closer, Look, Star, Bella and More were … extremely influential’. These were ‘prime sources of mainly gossip and speculation about the famous and cosmetic procedures’.86 The study concluded that the media and advertising industries were highly influential in the girls’ lives, just as they would be in the lives of their adult counterparts. Some of the girls had, through accessing sites or reading spam emails, or by the operation of cookies or pop-ups, unintentionally invited providers into their lives:

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While this research did not back up [an] earlier suggestion that providers may be ‘grooming’ young girls of 16+ to have procedures when they turn 18, it provides a picture of young girls being confronted by TV programmes, adverts, emails, Tweets, videos and other social media promoting cosmetic interventions and specific providers in different ways.87

The findings were that ‘while many of the girls claimed to ignore’ these influences, ‘some campaigns are clearly making an impact’. Furthermore, some of the girls had engaged in ‘some limited sampling of the offers’.

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My Body, Your Opinion

Peer pressure was identified by the Regulation of Cosmetic Interventions as a significant factor for both girls and adult women, propelling them into an acceptance of ‘the body beautiful’ to be determined by reference to cosmetic surgery standards, and to be obtained by recourse to cosmetic procedures.88 Such sources and influences communicated expectations which some of the girls recognised as ‘putting unrealistic pressure on young people and feeding the greatest pressure of all for teenagers, the judgement of their peers’.89 This matched earlier research looking at the impact on adults, which found peer pressure operating significantly, too. ‘People within their extended network who had had procedures … exercised a powerful influence on adults in their circle’.90 Despite this, women tend to shy away from acknowledging the pressure to conform to conventional or traditional standards of beauty comes from without. As Anuschka Rees reports in Beyond Beautiful , in 2010 Dove conducted a study which found 72 per cent of women saying they experienced ‘a huge amount of pressure to look attractive’.91 Yet they attributed the pressure to themselves, nullifying the influence of peers, society, cosmetic companies, the fashion industry, the beauty industry or the advertising daily imprinting itself on their brains in the way of celebrity surgeons making celebrity bodies into the surgeons’ conceptions of beauty. For Rees, outside influences do matter. She notes that ‘only a decade ago’ (circa 2010) cosmetic surgery was ‘a hush-hush topic’: Now, magazines review the newest procedures [just as] they review designer collections, and people openly talk about trying out lip fillers for fun and how their boob job was the best thing they ever did for themselves.

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Celebrities [once] came under fire for getting plastic surgery; nowadays, no one bats an eye when teenage celebrities show up with a whole new face and become social media stars with beauty empires.92

This, she says, constitutes ‘the normalization of “getting work done”’, asking whether this is ‘harmful, helpful, or no big deal’.93 Yet the continuing emphasis that aesthetic, cosmetic or plastic surgery renders women’s bodies or parts thereof ‘normal’ or that the procedures create ‘natural’ features is insidious if it leads girls and women into a belief that they must achieve ‘normality’ or a ‘natural appearance’ by resorting to the clinic and operating table. By what sleight of hand, or resort to fallacious argument can it be asserted that ‘the natural’ proceeds from the unnatural … namely the insertion of foreign objects (implants for example) or products (dermal fillers, Botox et al.) into women’s bodies? As Suzanne Fraser says, ‘nature is a culturally produced category, containing elements that shift over time and are themselves shaped, enabled and procured by humans’.94 Thus one finds numerous references to natural products and procedures that will produce a natural look. Dermal fillers are promoted as an ‘increasingly popular treatment choice among patients in the 40-60 age group as they offer age appropriate, and long-lasting results with very low risks of complications’.95 A ‘natural looking enhancement to lips’ is manufactured by multiple injections of dermal filler, the discomfort being minimalised by another injection, this time of lidocaine gel.96 These examples are replicated throughout the literature, whether popular media or clinical treatises. A concern that young women and girls are being led inexorably into this world of the ‘unnatural natural’ is not where the matter should end. Adult women are beguiled into believing that their bodies are wrong and must be righted, with contentions that they act entirely of their own freewill being lauded despite the danger and damage that they ‘welcome’ thereby into their bodies and lives. As Simone de Beauvoir said in the middle of last century, ‘every individual concerned with justifying his [or her] existence experiences his [or her] existence as an indefinite need to transcend himself’. But, she continues: … what singularly defines the situation of a woman is that being, like all humans, an autonomous freedom, she discovers and chooses herself in a world where men force her to assume herself as Other: an attempt is made

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to freezer her as an object and doom her to immanence, since her transcendence will be forever transcended by another essential and sovereign consciousness.97

‘Women’s drama’, she adds, ‘lies in this conflict between the fundamental claim of every subject, which always posits itself as essential, and the demands of a situation that constitutes her as inessential’. Thus, one must ask: How, in the feminine condition, can a human being accomplish herself? What paths are open to her? Which ones lead to dead ends? How can she find independence within dependence? What circumstances limit women’s freedom and can she overcome them?98

When woman has been defined as Other, how is feminine reality constituted? In The Woman in the Body—A Cultural Analysis of Reproduction, Emily Martin refers to the way anthropology, through a critical perspective on ‘underlying cultural assumptions in scientific visions of the body’ can ‘document ways that bodies of women and men are inevitably entangled in the operations of power’. Certainly, anthropological analysis of the aesthetic, cosmetic and plastic surgery industry would discover a cradle of masculine power. The industry is, in the main, populated by male surgeons. Male surgeons, in the main, carry out their work on women patients. Far from escaping her role as ‘Other’, the woman is confirmed in it by the very nature of the patient–doctor relationship combined with the female–male diadem. This not to say that she is a dupe, swindled into subjecting herself to the scalpel. But the notion that she is fully autonomous both in that relationship and in the world which constrains women’s freedoms through culture, socio-economic values and realities, and the intersectionalities of class, status, race and ethnicity must be challenged or at least questioned. Apart from the minor incidents of concern that women are presenting with body dysmorphia or body dysmorphic disorder (BDD), these doctors accept that women’s concerns about their bodies are founded in fact and that their psychological well-being is at risk if the procedures requested are not carried out. No medical operation is lawful unless there is a valid consent from the patient, and the operation is for the patient’s benefit.99 As there is no physical benefit in inflicting grievous bodily harm,

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actual bodily harm or unlawful wounding upon a woman’s body, which cutting into her torso or legs, or arms or face or other body part, or extracting or injecting fat or some other product into her body constitutes, then lawful justification must be found. This requires identification of a benefit accruing to her in the nature of well-being. Here the psychological dimension comes into play. As Virginia L. Blum says, cosmetic surgery is arguably distinctly different from that of a general surgeon whose work involves efforts to save lives. This is because in cosmetic surgery ‘harm is done to a healthy body, cuts being made, blood flowing for no known medical reason’.100 Hence, plastic surgeons are bound to justify the work they do by recourse to the claim of psychological necessity. The purported need to repair psychological damage replaces the general surgeon’s role of restoring physical impairment.101 Healthy bodies are pathologised, though care must be taken to ensure that this is not to the extent of diagnosing body dysmorphia (BDD). Why do these surgeons so readily accept women’s medical need to undergo aesthetic, cosmetic or plastic surgery, when the medical world is notorious for its failure to accept conditions classified as ‘women’s ills’ as real? When women on the contraceptive pill presented with ‘side effects’ in the 1960s, their complaints were rejected as psychosomatic. Recognition of their complaints as based in reality came about only when medical practitioners began publishing articles in respected medical journals such as The Lancet .102 Maya Dusenbery writes, in Doing Harm—The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick, of women’s struggle to have chronic fatigue syndrome or myalgic encephalomyelitis (ME/CFS) accepted as a physical medical condition, not as evidence of women’s purported propensity to developing psychosomatic ‘illnesses’ or engaging in malingering.103 Maya Dusenbery reports that an Australian study carried out in 1996 and involving fifty patients found that albeit eventually diagnosed with ME/CFS, in their search for an explanation, more women (85%) than men (30%) had received psychiatric diagnoses: Their expressed emotion or signs of distress appear to have influenced the diagnosis, regardless of other symptoms. In contrast, men’s accounts of their symptoms and their choices about treatment were usually given credence.104

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Aesthetic, cosmetic and plastic surgery remains gendered.105 Most patients are women. Yet rather than be dismissed as pathologically challenged, the women are accepted as having real conditions requiring real solutions involving surgery. It seems that the aesthetic challenge of ‘beautifying’ women’s bodies has greater appeal than taking seriously those medical conditions that are misdiagnosed and dismissed as all in women’s minds. Yet the risks and danger constituted by body beautifying treatment in surgeries, clinics and salons, are real. The possibility of recourse to legal action by women who have been harmed is ever present, raising the potential application of the law. In this regard, what to make of the assertion that women seeking this treatment and subjecting themselves to it do so by way of untrammelled agency and unprescribed autonomy? Is the contention that women who suffer harm and damage are entitled to legal solutions to be dismissed as ‘victim feminism’?

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The Body as ‘I’

In the 1990s, authors such as Christine Hoff Summers in Who Stole Feminism claimed that feminism was being undermined by ‘fainting couch feminism’106 or, as Naomi Wolf expressed it in Fire With Fire, feminist assertions that women were ‘beleaguered, fragile, intuitive angels’ weakened the feminist project.107 Women, it was contended, were being pressed into acting as victims when they should be standing up straight, ignoring the slights and, worse, crimes committed against them. Date rape was no offence, simply a college student who changed her mind. Rape was exaggerated in the name of seeking sympathy. Criminal assault at home was the fault of women seeking to get back at beleaguered husbands, sexual harassment resulted from women’s own inappropriate conduct and clothing on the job … Consistently with this philosophy, women who complain about negative consequences of aesthetic, cosmetic and plastic surgery are, like the woman date raped, seeking compensation for having willingly hired a surgeon and should bear the consequences. Yet do these contentions stand up to scrutiny? Women are victimised by unlawful acts. Women suffer damage and injury through civil wrongs. Why should women abjure legal remedies for fear of being classed as helpless, hopeless and lost, incapable of standing up for themselves, or denying the agency and autonomy that got them into whatever situation they are

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in, in the first place? When the legal system exists to provide compensation for damage to the person no one asserts that men should not avail themselves of it. Men are not denied the right to take legal action, or told it is ‘victimising’ themselves to do so. Why should women be deprived of recourse to law? The answer requires an exploration of the multiplicity of procedures now available for the manipulation of women’s bodies into bodies conforming to external visions of female beauty and feminine form. It demands a reply through an analysis of laws available to redress procedures gone wrong. As Hannah Abel-Hirsch says of Sara VanDerBeek’s exploration of representations of the female form in ‘Birth & Being’, an exhibition of women’s photography: From the earliest iterations of the female form, women have been both empowered and burdened by symbolism. Their body is never just their own …108

The question is whether women can regain control over our person and personality, through actively using the law to assert rights to our own bodies. Some would argue that through having acquiesced to external demands of what our bodies should be, like the girl who is raped on a date, women are denied this right. Others would say that having readily adopted measures that recreate our bodies, women’s active agency, ready acquiescence or compromising complicity rules out any rights to legal redress. Ironically, this harbours a contradiction. The assertion that women exercise untrammelled agency in changing our bodies, absent any influence of peer pressure, advertising, custom or fashion, ironically stands in the way of women exerting agency in claiming rights to the law. By this diktat, women must forever be in performance, our bodies recreated by the knife of the surgeon reducing us to plastic iterations of our bodies ourselves. The words of Luce Irigaray sound a warning. In Through the Looking Glass she pictures herself, standing silent for a moment, musing. Her voice recovered, she ponders, then speaks out loud to herself. ‘Then it really has happened, after all! And now, who am I? I will remember, if I can!’ She is determined to do so, to regain her memory, to remember herself. Yet determination is little help for, after a lengthy period of puzzlement, the conundrum continues to confront her. Who is she? She answers, the only answer she can find: ‘L, I know it begins with L’.109

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Do the changes women are making, now, to their bodies, in clinics and surgeries and salons and beauty parlours, challenge both their and our reality, the realities of our bodies, our brains, our intellect, our very selves. In the process of wrapping ourselves in the plastic of procedures undergone for perfection, do we risk, like Luce Irigaray’s alter ego, the danger of forgetting who we are.

Notes 1. Self -Portrait in a Red Blouse, held by the Tate. See Cecily Langdale, Gwen John, p. 18; cited Sue Roe, Gwen John—A Life, Vintage/Random House, London, UK, 2002, pp. 33–34. 2. Sue Roe, ibid., p. 34. 3. Ibid. 4. See for example ‘Ten Female Sculptors’, Widewalls, https://www. widewalls.ch/10-contemporary-female-sculptors/ (accessed 20 January 2020). 5. See for example ‘Judy Chicago—Biography and Legacy—American Painter, Sculptor, and Installation Artist’, The Art Story, https:// www.theartstory.org/artist/chicago-judy/life-and-legacy/ (accessed 20 January 2020). 6. See for example Editors of Encyclopaedia Britannica, ‘Dorothea Lange— American Photographer’, Encyclopaedia Britannica, https://www.britan nica.com/biography/Dorothea-Lange (accessed 20 January 2020). 7. See ‘Judy Chicago …’, ibid. 8. ‘Kathy Mueller—Creative Community Consultant’, au.linkedin.com, https://www.linkedin.com/in/kathy-mueller-a119a03/?originalSubd omain=au (accessed 20 January 2020). 9. See for example Stella Duffy, ‘Here’s Why We Have to Stop “Empowering” People’, Visionary Arts Foundation, 30 September 2019, https://visionaryarts.org.uk/stella-duffy-heres-why-we-need-tostop-empowering-people/ (accessed 20 December 2019); Charlotte Higgins, ‘Women in the Theatre: Why Do so Few Make It to the Top?’ Guardian, 10 December 2012, https://www.theguardian. com/stage/2012/dec/10/women-in-theatre-glass-ceiling (accessed 20 February 2020); StageMilk Team, ‘What Does a Theatre Director Do?’ StageMilk, https://www.stagemilk.com/what-does-a-theatre-direct or-do/ (accessed 20 February 2020). 10. Personal communication, Italy, 19 February 2020; see also ‘Karen Buczynski-Lee,’ U -tube, https://www.youtube.com/channel/UCj l86eP-330cT6LY5f7IkZw (accessed 20 January 2020); ‘Karen Buczynski-Lee—Professional Filmmaker’, au.linkedin.com, https://au.

1

11.

12.

13. 14.

15. 16.

17.

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linkedin.com/in/karen-buczynski-lee-73172119 (accessed 20 January 2020); ‘Tag—Karen Buczynski-Lee’, Women’s History Network, https:// womenshistorynetwork.org/tag/karen-buczynski-lee/ (accessed 20 January 2020). Editors of Encyclopaedia Britannica, ‘Camille Claudel—French Artist’ (also known as Camille-Rosalie Claudel), https://www.britannica.com/ biography/Camille-Claudel (accessed 20 January 2020). Unfortunately, as noted by the Editors, Camille (also known as Camille-Rosalie) Claudel had her career as a sculptor ‘cut short’ when she was committed to an asylum. Not uncommonly, women combining the role of muse with that of artist-in-her-own-right experience tempestuous lives with tempestuous endings or, sometimes, survival. See for example Naomi Blumberg, ‘9 Muses Who Were Artists’, Encyclopaedia Britannica, https://www.bri tannica.com/list/9-muses-who-were-artists (accessed 20 January 2020). On male dominance in painting and the failure to acknowledge women in the role see for example Germaine Greer, The Obstacle Race: The Fortunes of Women Painters and Their Work, Martin Secker & Warburg, New York, NY, USA, 1979; reprinted Tauris Parke Paperbacks, New York, NY, USA, 2001. See Liz Conor, The Spectacular Woman—Feminine Visibility in the 1920s, Indiana University Press, Bloomington, IN, USA, 2004. Abigail Solomon-Godeau, ‘The Legs of the Countess’, The MIT Press, vol 39, Winter 1986, pp. 65–108, https://www.jstor.org/stable/ 778313 (accessed 20 January 2020). Ibid., p. 68. Karl Marx, ‘The Fetishism of Commodities’ in Ian McIntosh, Classical Sociology Theory—A Reader, New Edinburgh University Press, Edinburgh, UK, 1997, pp. 68–71; see also Rebecca Tromsness, ‘Marx: Summary of “The Fetishism of Commodities”,’ OwlCation, 20 June 2014, https://owlcation.com/social-sciences/Analysis-of-Marx-The-fet ishism-of-commodities (accessed 20 January 2020). Matthew 6:28–29, 6:25–34, ‘Therefore I tell you, do not be anxious about your life, what you will eat or what you will drink, nor about your body, what you will put on. Is not life more than food, and the body more than clothing? Look at the birds of the air: they neither sow nor reap nor gather into barns, and yet your heavenly Father feeds them. Are you not of more value than they? And which of you by being anxious can add a single hour to his span of life? And why are you anxious about clothing? Consider the lilies of the field, how they grow: they neither toil nor spin, yet I tell you, even Solomon in all his glory was not arrayed like one of these …’, or Luke 12:27, ‘Consider the lilies, how they grow: they neither toil nor spin, yet I tell you, even Solomon in all his glory was not arrayed like one of these.’ See ‘Consider the Lilies of the Field’,

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18. 19.

20. 21. 22. 23.

24. 25. 26. 27. 28. 29. 30. 31.

32.

33. 34.

35. 36. 37. 38. 39. 40. 41.

Open Bible, https://www.openbible.info/topics/consider_the_lilies_of_ the_field (accessed 20 February 2020). Ibid. Susan Bordo, Unbearable Weight: Feminism, Western Culture and the Body, University of California Press, Berkley/Los Angeles, CA, USA, 1995 (original publication circa 1993), p. 165. Ibid., p. 167. Ibid. Ibid., pp. 165–166. Virginia L. Blum, Flesh Wounds—The Culture of Cosmetic Surgery, University of California Press, Berkley/Los Angeles, CA, USA, 2003, p. 81. Ibid., p. 13. Ibid., p. 76. Robin Tolmach Lakoff and Rachel L. Schurr, Face Value: The Politics of Beauty, Routledge, London, UK, 1984, p. 171. Virginia Blum, ibid., 2017, p. 76. Susan Brownmiller, Femininity, Linden Press/Simon & Schuster, New York, NY, USA, 1984, p. 23. Ibid. Ibid. Eugene Lee Yang, Mark Celestino and Kari Koeppel, ‘Women’s Ideal Body Types Throughout History’, Buzzfeed, https://www.buz zfeed.com/eugeneyang/womens-ideal-body-types-throughout-history (accessed 20 January 2020). Amanda Vickery, The Gentleman’s Daughter—Women’s Lives in Georgian England, Yale University Press, New Haven, CN, USA and London, UK, 1998, pp. 174–176. ‘Poem Given Me by Mrs Parker of Marshfield’, quoted Amanda Vickery, ibid., p. 178. Elizabeth Jenkins, Lady Caroline Lamb, originally published Victor Gollancz, London, UK, 1932, Cardinal/Sphere Books, London, 1972, p. 10. Ibid., p. 9. Eugene Lee Yang et al., ibid. Kathryn Hughes, Victorians Undone—Tales of the Flesh in the Age of Decorum, 4th Estate/HarperCollins, London, UK. Ibid., p. 217. Ibid. Ibid., pp. 220–221. Liz Conor, ibid.

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42. Lev Kuleshov, quoted in Jay Leyda (ed), Voices of Film Experience: 1894 to the Present, Macmillan, New York, NY, USA, 1977, pp. 249–250; quoted Scot McQuire, Visions of Modernity: Representation, Memory, Time, and Space in the Age of the Camera, Sage, London, UK, 1997, p. 80; Liz Conor, ibid., p. 1. 43. Ibid. 44. Kathryn Hughes, ibid., p. 221. 45. Camille Nurka and Bethany Jones, ‘Labiaplasty, Race and the Colonial Imagination’, Australian Feminist Studies, vol 28, no 78, 2013, pp. 417–442, http://dx.doi.org/10.1080/08164649.2013. 868332 (accessed 20 October 2019). 46. Ibid., p. 422. 47. Ibid., p. 436. 48. Ibid. 49. See for example ‘The Dangers of Using Skin Whitening Products’, Oxford Biolabs, 21 June 2018, https://uk.oxfordbiolabs.com/ blogs/news/the-dangers-of-using-skin-whitening-products (accessed 19 December 2019); Caleb Backe, ‘The Dangers of Hair Straightening Explained’, MapleHolistics, 11 November 2018, https://www.mapleh olistics.com/blog/dangers-hair-straightening/ (accessed 19 December 2019). 50. Kashyap K. Tadisina, Karan Chopra and Devinder P. Singh, ‘Body Dysmorphic Disorder in Plastic Surgery’, Interesting Case, 21 June 2013, www.ePlasty.com(accessed 12 January 2020). 51. Ibid. 52. Ibid. 53. Ibid. 54. Eva E. Fisher, ‘Am I Ugly or Do I Have BDD? Personal Disclosure and Social Support on a Body Dysmorphic Disorder Online Forum,’ PhD Dissertation, Colorado State University (CSU), Fort Collins, Co, https://www.academia.edu/40247165/DISSERTATION_Am_I_u gly_or_do_I_have_BDD_Personal_disclosure_and_social_support_on_a_ Body_Dysmorphic_Disorder_Online_Forum?auto=download&email_ work_card=download-paper (accessed 19 April 2020); https://mounta inscholar.org/handle/10217/176770 (accessed 2 August 2020). 55. Tadisina, Chopra and Singh, ibid. 56. ‘Body Dysmorphic Disorder’, NHS, https://www.nhs.uk/conditions/ body-dysmorphia/ (accessed 19 December 2019). 57. See for example Kathy Davis, Reshaping the Female Body—The Dilemma of Cosmetic Surgery, Routledge, New York, NY, USA, 1995, pp. 88–92. 58. See for example Elizabeth Haiken, Venus Envy: A History of Cosmetic Surgery, Johns Hopkins University Press, Baltimore, MD, USA,

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59.

60. 61.

62. 63. 64. 65. 66. 67. 68.

69.

70. 71. 72. 73. 74. 75. 76. 77.

1997; Motivation and Emotion/Book/2014/Cosmetic Surgery Motivation, https://en.wikiversity.org/wiki/Motivation_and_emotion/Book/ 2014/Cosmetic_surgery_motivation (accessed 20 January 2020). Also Virginia Blum, ibid., pp. 76–80, citing the plastic surgeon’s view. See for example Sander L. Gilman, Making the Body Beautiful— A Cultural History of Aesthetic Surgery, Princeton University Press, Princeton, NJ, USA, 1999. See for example Kathy Davis, ibid., chapter 6 generally and particularly pp. 60–64, 117, 157. Zona Black, ‘Zoom Calls Have Australians Rushing for Cosmetic Surgery’, The New Daily, https://thenewdaily.com.au/life/wellbe ing/2020/07/20/cosmetic-surgery-coronavirus-popular/ (accessed 16 August 2020). Elizabeth Morgan, The Complete Book of Cosmetic Surgery: A Candid Guide for Men, Women, and Teens , Warner, New York, NY, USA, 1988. Sanders L. Gilman, ibid. Sanders L. Gilman, ibid., p. 41. Ibid., p. 39. Susie Orbach, Bodies , Profile Books, London, UK, 2009, 2010, 2016, p. 81. Ibid. Farida Dawkins, ‘Theora Stephens’, Face2FaceAfrica, 20 March 2018, https://face2faceafrica.com/article/womens-history-month-meet-the ora-stephens-inventor-refined-pressing-curling-iron (accessed 20 January 2020); ‘Theora Stephens and Lyda Newman’, Black History Month, https://www.bustle.com/articles/67033-african-american-female-invent ors-who-created-the-beauty-products-that-we-love (accessed 20 January 2020). ‘Lyda Newman (bc 1885)’, Biography, https://www.biography.com/act ivist/lyda-newman (accessed 20 January 2020); ‘Theora Stephens …’, ibid. ‘Power Beauty Since 1902’, Helena Rubenstein.com, https://www.hel enarubinstein.com/ (accessed 20 January 2020). Laurie Penny, Meat Market—Female Flesh Under Capitalism, Zero Books, John Hunt Publishing, Alresford, UK, 2011, p. 1. Ibid. See for example Kathy Davis, ibid., pp. 88–92. Daniel Man and LC Faye Shelkofsky, The Art of Man: Faces of Plastic Surgery, Beauty Art Press, Naples, FL, 1998. Ibid., p. 34. See for example Virginia L. Blum, ibid. Department of Health, Final Report —Review of the Regulation of Cosmetic Interventions, 2013, https://assets.publishing.service.gov.uk/

1

78.

79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97.

98. 99.

100. 101. 102.

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government/uploads/system/uploads/attachment_data/file/192028/ Review_of_the_Regulation_of_Cosmetic_Interventions.pdf (accessed 20 October 2019). Independent Research, Regulation of Cosmetic Interventions —Research among Teenage Girls, Department of Health, Job No. 623/Version 1, 11 March 2013, https://www.gov.uk/government/publications/ review-of-the-regulation-of-cosmetic-interventions (accessed 20 October 2019). Suzanne Fraser, Cosmetic Surgery, Gender and Culture, Palgrave Macmillan, Basingstoke, UK, 2003. Ibid., p. 61. Ibid., p. 62. Ibid., pp. 62–63. Ibid. Ibid., p. 63. Independent Research, ibid., p. 12. Ibid. Ibid., p. 5. Ibid. Ibid. Ibid. Anuschka Rees, Beyond Beautiful , Ten Speed Press/Crown Publishing, Emeryville, CA, 2019, p. 39. Ibid., p. 176. Ibid. Suzanne Fraser, ibid., p. 67. Ian Strawford, ‘Understanding Collagen-Stimulating Dermal Fillers’, Aesthetics Journal, vol 7, no 2, January 2020, pp. 41–43. Sharon Bennett, ‘The Secret to Beautify Lips with Restylane Kysse™’, Aesthetics Journal, vol 7, no 2, January 2020, p. 60. Simone de Beauvoir, The Second Sex, 1949, trns Constance Borde and Sheila Malovany-Chevallier, Vintage/Jonathan Cape, London, UK, 2011, p. 17. Ibid. GT Laurie, SHE Harmon and G. Porter, Mason & McCall Smith’s Law & Medical Ethics, 10th edn, Oxford University Press, Oxford, UK, 2016, chapter 4 ‘Consent to Treatment’. Virginia L. Blum, ibid., p. 13. Ibid. ‘The Side Effects of The Pill’, American Experience, https://www.pbs. org/wgbh/americanexperience/features/pill-side-effects/ (accessed 19 January 2020).

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103. Maya Dusenbery, Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick, HarperCollins, New York, NY, USA, 2018. 104. Cited Maya Dusenbery, ibid., p. 257. 105. Kathy Davis, ‘A Dubious Equality: Men, Women and Cosmetic Surgery’, Body and Society, vol 8, no 1, 2002, pp. 49–65. 106. Christine Hoff Summers, Who Stole Feminism? How Women Have Betrayed Women, Touchstone, New York, NY, USA, 1995. 107. Naomi Wolf, Fire With Fire: New Female Power and How It Will Change the 21st Century, Vintage/Random House, New York, NY, USA, 1993. 108. Hannah Abel-Hirsch and Sara VanDerBeek, ‘Birth and Being’, Female in Focus—A Celebration of Women in Photography, https://femaleinfocus. com/ (accessed 20 January 2020). 109. Luce Irigaray, Alice’s Adventures Through the Looking Glass, chapter 3, cited Carolyn Burke, ‘Irigaray Through the Looking Glass’, Feminist Studies, vol 7, no 2, Summer 1981, pp. 288–306, p. 298, https://www. jstor.org/stable/3177525 (accessed 20 February 2020).

CHAPTER 2

The Body Beneath the Knife

Women’s bodies Targets Under the surgeon’s knife Every body part besieged by Botox Laser/ Liposuction Hair extensions False nails Implants and fillers, foot, face, breast and bottom Brows brushed thick Eyelashes extended Labia narrowly trimmed Neatly packed and tended Knifed into submission, natural Legs remoulded Ankles narrowed, knees reshaped, toes shortened, lengthened, straightened Hips and shoulders realigned Remade, refashioned, redesigned Reformed, remodelled Whittled, carved, sculpted, shaped © The Author(s) 2020 J. A. Scutt, Beauty, Women’s Bodies and the Law, https://doi.org/10.1007/978-3-030-27998-1_2

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Nothing sacred, not really ours Nor really us Plastic prevails So In the mirror Who stares back?

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The Body in the Beauty Parlour

The proposition that women’s bodies can be allowed to walk daily on the street, exist in the paid workplace or appear anywhere in public without enhancement or embellishment is becoming less and less acceptable. Just as clothing maketh the woman, with employer demands that women wear high heels to the office, renounce trousers or pants in the executive suite, behind the receptionist desk, working at a computer terminal, seated in a work cubicle or anywhere else on a business premises, so too with women’s personal attributes. Once, make-up, false eyelashes, tattooed eyeliner and false bosoms were the signature of a woman on the stage, or a signal that she haunted alleys and backstreets in hope of a paying customer, or appeared in movies labelled ‘porn’. In the twentyfirst century, these are signifiers of mainstream woman. Hence, in 2011 a ‘team of scientists and psychologists’ from Harvard and Boston Universities in collaboration with the Dana-Farber Cancer Institute, disclosed data gleaned from their study that women wearing make-up are perceived as ‘more competent, attractive, likeable and trustworthy’.1 The study’s finding was that this follows, whether women are made-up in a ‘natural’, ‘professional’ or ‘glamorous’ style, and whether the images are flashed before the eyes of participants in the study or are viewed by them for more lengthy periods. Funded by Procter & Gamble, a huge conglomerate making much of its money through selling cosmetics (mainly to women), the study was labelled ‘independent’. The implication? It must be believed. This, at least, was the thrust. The message to all women seeking survival or promotion in Western democracies was unmistakeable. To get on in business or succeed in professional life, women must first spend extravagantly at cosmetic counters all over the country then get out the make-up palette. Better still, make their way to the nail salon, the hairdresser,

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the spa and cosmetologist for the experts to apply lotions, unguents, creams, gels, ointment, balms—and on top of all that, the make-up. Even the prospect of working from home, engaging in online conferencing and scheduling meetings via Zoom in the time of Covid-19 has its implications for beauty and beautification.2 The hiatus in hairdressing appointments, temporary closure of nail salons and an interruption in the activities of clinics has not inhibited the beauty industry. Achieving ‘medical-grade skincare’ is essential when Botox wears off and, ‘with everyone on home quarantine’, a woman’s business profile is threatened by ‘unflattering zoom angles’. One New York plastic surgeon relates to Forbes that ‘without disclosing numbers’, growth in her medical-grade skin care line has ‘exceeded 500%’.3 Online cosmetic sales burgeon, and even the cancellation of elective surgery has not prevented a steady stream of enquiries about aesthetic, cosmetic and plastic surgery possibilities. This spawns the advice from yet another plastic surgeon to ‘stay home, stay safe’, whilst using the time productively in ‘researching about a procedure or treatment you have always wanted’.4 The creation of a woman through deft and deliberate use of cosmetic sculpting and camouflage is, however, not new. In The Spectacular Modern Woman—Feminine Visibility in the 1920s, Liz Conor reflects on the early twentieth-century invention of the woman as spectacle. Women emerged as types, the approach driven by innovations in visual technology, particularly the cinema. Liz Conor cites Russian filmmaker Lev Kuleshov inventing cinematic techniques placing the ‘spectacle of the “new woman” before the public’.5 This development occurred simultaneously with the 1920s identification of women as being or becoming classified as ‘the modern woman’: the City or Business Girl, the Screen Star, the Beauty Contestant, or the Flapper. Women had for long been represented in art as body types—the full-bodied type more frequently dominant, the less pronounced endowments of others nonetheless having some prominence. Peter Paul Rubens’ (1577–1640) voluptuously configured nudes stimulated notions of desire as located in the Rubenesque model. The earlier curvaceousness of the Venus de Milo combined sleekly rounded body lines with the modesty of hand-over-pudenda, a hidden yet exposed sexuality projected through a visual image. And, earlier than that, the Venus impudica or Venus impudique (‘immodest Venus’) with her rounded abdomen and thighs supporting pendulous breasts projected passion as associated with womanly flesh. Yet Edgar Degas’ (1834–1917) slender-bodied, lithe limbed dancers swirled and twirled

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into fashion alongside the vogueishness of Amedeo Modigliani’s (1884– 1920) models’ elongated faces and lean bodies. Some women would have been influenced by these images. Those whose lives were led in the public eye, whether as artists’ muses themselves, actresses or ladies of the night would have been particularly susceptible to the fashion of the body. The modern era of public transport, together with the development of department stores, released many more women into public space. Liz Conor reflects on this as setting the stage for women to reflect more critically upon their own appearance, with their appearance being subjected to more intense critique. ‘Public womanhood’, she writes, ‘gained “cultural influence” by earning academic degrees, lecturing and speaking in public, travelling alone, attending theaters and dance halls, shopping in department stores, and riding bicycles’.6 So, too, with the growth of office jobs, librarianship, nursing and teaching. These new avenues of paid employment led women and girls onto streets and ferries, and into omnibuses, then onto the tube as it became more acceptable. Along with this freedom of movement came subjection to the male gaze. Public exposure made women more aware of their bodies, of how they looked—and were looked at. Sitting on public buses or in railway carriages meant opening oneself up to public scrutiny. Some women relished the attention which came from being under observation. Footpaths and offices becoming ‘theaters to these types of City Girl, places where [they] distracted, displaced, and visually overpowered men’. They wanted, says Conor, ‘to be part of the scene as spectacles, reputedly shortening their skirts to excite more attention …’.7 One ‘smart Yankee tourist’ met with the ire of the notorious Australian daily the Truth when she appeared on one of Melbourne’s major thoroughfares parading ‘in an extra short skirt, … her stockings rolled down below the knees’. This ‘bare-legged belle’ responded to criticism with a retort that in New York City ‘everyone is wearing bare knees … rouged and tattooed’.8 Beauty contests, often aimed at attracting women as competitors with the lure of a Hollywood contract, became de rigueur. Newspapers ran competitions and photographers and other professionals began to dictate women’s bodily and facial perfection. This analysis followed the pattern adopted towards the end of the preceding century by famed criminologist Caesare Lombroso in his search to identify the ‘perfect criminal’ by measuring every conceivable facial feature. Closely positioned eyes, low hanging forehead, large flapping ears, thin cruel lips signified criminality.9 The beauty contestant analysists selected features and their relationship to

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each other arriving at the antithesis of the Lombrosian type. For them, the perfect face comprised symmetrical features with a precise distance required between wide-set eyes, a retroussé nose rather than a Roman one, forehead exact in its dimensions, lips full but not too full, upper lip proportionate, chin delicately rounded. Not only were these studies in perfection utterly different from Lombroso’s. They focused on purity in breeding. Notions of ethnic and racial superiority, albeit not necessarily stated, crept in, ordaining what was, and was not, ‘beauty’.10 Women who did not conform to the perfect type sought to do so. Despite a backlash from sections of the popular press, and protestations from feminists that beauty competitions ‘judged and measured’ each entrant ‘as though she were an animal’,11 some women were caught up in striving for perfection. That they were obliged to seek out means of doing so did not discourage them. Being charged with vanity and selfobsession was no deterrent. In Australia, the Sunraysia Daily condemned ‘vain women’ who appeared ‘to be watching themselves while they speak, listening to themselves, visualising themselves’. Being ‘greedy for admiration they … [were] too engrossed in themselves’, so that even ageing did not stand in the way of self-admiration. Their vanity would ‘not allow’ the ageing woman ‘to admit that her day is over’.12 Increasingly artificial means came to create or enhance beauty, and age did not admit of defeat. Clinging to youth or its pretence was reinforced by the growing self-help industry of dyes and potions that could be administered at home, and the increased commercialisation of the beauty industry. To quell the belief that women were self-obsessed narcissists, bodily perfection as a health goal became fashionable. Products advertised originally as magical or glamourous were converted into natural adjuncts to healthy living.13 Yet ‘how do I look’ continued as one of the most commonly asked questions whether by a woman of her best friend, husband or partner, or (in the tradition of fairy tales) her mirror. Women’s bodies and women’s beauty took centre stage. The pre-eminence of one shape over another may prevail, but the message remains. The 1920s bosomless look is replaced by the Marilyn Monroe breasted hourglass, thence to the slender limbed Twiggy of the 1970s, and into the 1980s where pronounced breasts compete with the bulging bottoms of the 2000s, and budding lips expand exponentially into full-blown swellings—yet bodies and beauty remain determinative of what is a woman.

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In light of this, what of demands from the 1970s and earlier struggles for entry to university, the professions and trades? Do these calls for women to be recognised as more than mannequins or ornaments for a man’s arm, dressed up dolls with little but marriage on their minds, slaves to the kitchen or to mind-numbing work in an office, a factory or field have meaning? Have we ‘come a long way, baby’, or are women inexorably enmeshed in a culture that sees artifice as more acceptable than the reality of women’s physiognomy? Are women’s real bodies ‘out’, whilst contrivances projected as ‘real’ women constitute the perfection and beauty for which (once) real women must aim? In Bodies , first published in 2009, Susie Orbach observes that over the thirty years prior to her writing, ‘an obsessive cultural focus on the body’ has developed.14 Everywhere, she writes, ‘we see evidence of the search for a body’. Whether it is presented as ‘preoccupation, health concern or moral endeavour, almost everyone has a rhetoric about trying to do right by their body’. This enforces and reinforces the notion that the body is unacceptable as it is. It is ‘not at all right’. Orbach concludes that the body is now a focus for ‘our malaise, aspiration and energy’.15 In this, she is both right and wrong. In 1970 Germaine Greer’s Female Eunuch acknowledged the problem existing then, as it had for centuries, of women’s bodies ‘being treated as aesthetic objects without form’.16 This was so for women themselves, in regarding their own bodies, as well as for the men in whose gaze they registered their existence.17 In so doing, said Greer, both the bodies and the whole woman are deformed. The various usages of women’s bodies, whatever their shape or character, ‘are deformations of the dynamic, individual body and limitations of the possibilities of being female’.18 However, the key truth of Bodies is Orbach’s recognition of the crushing obsessional nature of today’s focus on the body. Young women, old and older women, indeed women of any age and often not even into puberty do not learn only that their bodies are defective. They learn constantly through social and mainstream media, advertisements, film, television series, the ubiquitous red carpet of Hollywood and Cannes that anything, any body part can be fixed. In the 1970s, women were concerned about weight, diet, bodily appearance as exemplified by the weight (losing weight) industry already working overtime, and women’s magazines laden with fashion, recipes, how to dress (the mantra of perpendicular stripes, not horizontal), makeup and diets. Orbach herself recognised this in her early work, Fat Is a Feminist Issue.19 But despite this age-old malaise, the 1970s aspiration

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and energy were directed towards shifting from this concern to position women substantively in the world. Women claimed a right to become and to be legitimate operators at all levels of society and in all institutions, without reliance on frippery or furbelow. Kate Millett in her own original work, Sexual Politics , effectively revived Simone de Beauvoir’s Second Sex from twenty years earlier, Millett engaging in her own critique of literature, art, culture from the perspective of an American scholar.20 Earlier Betty Friedan’s The Feminine Mystique contested the notion that woman’s place was in the suburbs, content with three children, cat, dog, people carrier and a husband returning from his daily effort in the city designed to keep woman, children, animals and both cars (his and hers) afloat financially.21 Schulamith Firestone in The Dialectic of Sex added intellectual ballast and ten years later Susan Brownmiller followed up her peon against women’s subjection to rape, Against Her Will , with her new book, Femininity.22 Robin Morgan led in the radical movement, challenging the myth of bra burning, whilst leading women together on demonstrations and sit-ins, their bodies freed from brassiere and stepin constraints.23 Jo Freeman published her vital work on the Women’s Liberation Movement’s organisational approach to securing change, The Tyranny of Structurelessness ,24 advocating that attention be paid to power hidden under the cry for freedom from constraining organisational and hierarchical demands. Then, after doing a journalistic stint as a Playboy Bunny at Hugh Hefner’s club, Gloria Steinem wrote her expose decrying the institutionalised objectification of the woman under the Bunny ears.25 Almost instantly, however, the 1970s saw a raft of books and articles published as an antidote to the rejection by the Women’s Movement of lipstick, bras and step-ins (a modified corset or girdle), and the replacement of stockings and suspenders with pantyhose. When American women demonstrated in Atlanta at the Miss American contest, throwing underwear (including bras) and other paraphernalia into a ‘Freedom Trash Can’, it was inevitable that the establishment would respond.26 Marabel Morgan’s The Total Woman, advertised as having sold more than ten million copies, was perhaps the most popular of the anti-feminist tomes of the time.27 She advocated that women enfold themselves in saran wrap—a transparent plastic used to preserve left-over food—before greeting a husband just home from work. An alternative was to spread oneself liberally in jam or honey whilst making supper for a husband lying prone on couch or carpet watching evening television. In this context, ‘wife’ was supposed to equal ‘supper’.

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Although the book and her accompanying seminars had a reputedly massive audience, it is doubtful that many women went to the lengths Marabel Morgan suggested.28 Yet perhaps a return to her bizarre instructions for feminine enhancement would be less damaging to women than a visit to today’s beauty parlours, and—extraordinary though it may seem—even less dangerous or humiliating. And certainly, less expensive. Australians are reputed to spend ‘a collective $AUS 1billion-plus’ on cosmetic procedures annually, calculated as coming in at 40 per cent more (per capita) than the United States.29 In June 2019, the Sydney Morning Herald reported that spending on basic beauty routines ‘is out of control’. ‘Basic’ maintenance for women in their early twenties and thirties ‘is costing [them] the equivalent of a house deposit’.30 At a conservative estimate, approximately $AUS 14,000 (some £8000) is spent by each woman on ‘standard’ treatments. This includes ‘six to eight-weekly haircuts and colour, regular blow waves, (preventive) Botox, non-fat fillers, professional teeth whitening, eyelash extensions and refills, microdermabrasion, SNS nails [Signature Nail Systems], pedicures and laser hair removal’.31 Over and above this, cash is being laid out on skin care and make-up in the privacy of a woman’s own bedroom or bathroom, plus salon facials, waxing and spray tans, as well as ‘special events’ including the racing season, the festive season and celebrations such as birthdays, weddings and Valentine’s Day. Adding these into the estimates of women’s annual expenditure would amount to ‘hundreds of thousands of [dollars] over the course of a woman’s life’.32 Investigating, writer Kasey Edwards asked a trader in stocks and shares to estimate how an alternative approach of investing the $AUS 14,000 would look. On the basis of ‘net returns of about seven to eight percent’, over about a decade that figure ‘could be rapidly swelling towards $AUS 250,000’ (£140,000). Even if simply left in a bank term deposit for some six years, that same $AUS 14,000 could gain a woman a six-figure sum.33 Yet entering a beauty parlour is not the only way a woman can be regaled with methods and mechanisms for spending money to become beautiful. In London, venturing into a large department store in Oxford Street means being assailed on all sides by ‘product’ representatives bearing potions, lotions and pastes in tubes, jars and containers of all dimensions, or brandishing hair wands, lash curlers or body shapers of all sorts and sizes. Sauntering into shopping malls brings with it a need to avoid salespeople imploring passers-by to sample a wide variety of perfume, cosmetics and beauty treatments. American, Australian and

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other major capital cities carry their own brand of cosmetic confrontation, with department store refurbishments undertaken regularly to position make-up and perfume counters at the forefront of luring the customer. In the 1980s, competition between Opium, Obsession, Tresor and Shalima was at its height.34 In 1983 in Melbourne and Sydney, New York and San Francisco, department stores positioned scent-bottle-atomisers at every major entryway, spraying Angel on every woman passing through their doors. The scent wafted inside between display counters, into elevators and up the escalators, filling passageways and drifting outside into the malls. Meanwhile, in the 2000s, beauty salons adopt more and more fanciful methods of pampering the body, more and more ways of ensuring that women’s pockets and purses open wide in the search for the perfect body with flawless features, and the face of beauty—according to conventional diktat. Even pop-up or home-based practitioners can be found providing such services at reduced rates. Want puffed-up lips? This comes not by the sting of a bee, but through the injection of chemical fillers, or agitating the lips with capsicum or chilli. Collagen and more recently developed products using hyaluronic acid operate akin to scaffolding, although ‘care must be taken’ to avoid ‘creating ridges’ giving the mouth ‘an ugly edge’.35 Silicone implants or ‘Permalip’ last longer—though they cost twice as much: $AUS 2000 to $AUS 4000 (some £2000) as opposed to $AUS 1000 to $AUS 2000 (some £1500) for several months of a protuberant pout. Then— it’s back to the beauty (sic) parlour to be relieved of another hefty sum to refurbish the lips now threatening to droop or deflate. Worried about fading eyebrows or wanting better defined arches? Microblading at $AUS 1000 (£600) ‘is not that painful’, it’s ‘pretty quick’, and you can have high arches or straight arches or mildly curved arches tattooed into your brow.36 It takes anaesthetic cream, the wielding of a ‘scalpellike instrument’ (microblade), scratching pigment into your skin, two weeks of healing, at least five applications of aftercare cream, wearing a plastic head-shade in the shower and three follow-up visits. But, hey presto, the arches are well-defined … Then again, it’s trimming, plugging, waxing or threading as usual. Still, what about an end to wrinkles? This requires a good dose of botulism or, as advertised, its commercially named Botox. Rather than the death that follows upon a botulism bout, Botox targets ageing’s most visible facial indicator, the dreaded creases, folds and furrows. Of course, this has costs, too. Yet perhaps rather than the monetary outlay, the so-called ‘side’ effects should be centre stage.

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Lessening or alleviating frown-lines may cause life-threatening conditions that, once detected—even at their most mild stage—dictate an immediate call to the doctor or the nearest hospital’s emergency department. These include short-term and sometimes long-term ‘side effects’: • Problems with swallowing, speaking or breathing, caused by weakening of facial or throat muscles; • Loss of strength and ‘all-over muscle weakness’, as well as double or blurred vision, ‘drooping or swelling’ eyelids, dry eyes, loss of capacity to speak, hoarseness or inability to articulate clearly, loss of bladder control; • Dry mouth, discomfort or pain at the site of injections, tiredness, neck pain, headaches; • Allergic reactions including ‘itching, rash, red itchy welts, wheezing, asthma symptoms, dizziness or feeling faint’.37 Even so, said one Botox website in November 2011, ‘no confirmed serious case of spread of toxin effect’ has been reported from betweenthe-eyes Botoxing.38 Nonetheless, if these symptoms occur, a sufferer ought not to ‘drive a car, operate machinery, or do other dangerous activities’.39 Readers may wonder about unconfirmed serious cases—and what classifies as a confirmed non-serious case, but merely receives advice that the ‘potential risk of spreading viral diseases’ such as Creutzfeldt-Jakob Disease (CJD) via human albumin—present in Botox—is ‘extremely rare’: ‘no cases of viral disease or CJD’ have ‘ever’ been reported ‘in association with human serum albumin’.40 In 2019 the site warned that Botox ‘may cause serious side effects that can be life threatening’ advising that if ‘any of these problems’ is experienced ‘hours to weeks’ after a Botox injection, then medical help should be sought immediately.41 The problems listed included those relating to swallowing (which ‘may last for several months’), speaking or breathing, attributed to weakening of associated muscles. These ‘can be severe and result in loss of life’. An additional warning flagged the highest risk as present if such problems existed prior to injection.42 This and other services, treatments and products provided by salons in the pursuit of women chasing beauty raise the question of legal liability. What responsibilities devolve upon those providing the products and delivering the services? Product liability is governed by negligence law

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and statutory provisions. In the United Kingdom, operating alongside common law negligence, the Consumer Protection Act (‘the Act’) covers statutory liability for defective products. Similar laws exist in other jurisdictions, including the United States and Australia. This means that where defective products cause harm to the bodies of those upon whom they are used, the client or patient can sue for compensation. Strict liability is imposed on defective product manufacturers, meaning that there is no need to prove negligence. Under the Act, the onus lies on the patient or client to prove, on the balance of probabilities, that: • The product complained of was defective; and • The product was the most likely cause of the injury of which the client or patient complained. Action can be taken against the manufacturer of the product or of a component part of the product and/or against any party responsible for any essential characteristic of the product resulting from an industrial or other process. An injured person can also include, in their action, a respondent party with their name or trademark attached to the product and so holding itself out as the producer. Action is also available against a respondent party who imported the product into the European Community.43 As the Act provides, product safety encompasses: • Monitoring the safety of products; • Providing consumers with information enabling them to understand risks, • Warning consumers of potential risks; and • Taking action where a safety problem is detected. A key issue is ‘what is a defect’ or ‘what is defective’. In Wilkes v DePuy 44 the court determined the question by reference to an objective test, based on what the public at large are entitled to expect of the product. The case involved not a cosmetic or cream or similar beauty product, but a metal hip replacement implanted for mobility (not aesthetic or cosmetic) reasons. However, the principle applies to product liability generally, including cosmetics, hair and eyelash extensions, false nails and other products of the hair salon and beauty parlour.

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In Wilkes v DePuy, suffering from osteoporosis, Mr Wilkes had a CStem implant inserted into the hollow of his thighbone. Some three years after the operation, the stem fractured, with some metal debris shed at the joint. This required insertion of replacement parts. Five years later, a further fracture necessitated further revision, sending Mr Wilkes back to the operating theatre, from which he emerged sporting a replacement model of a different type. Mr Wilkes sued DePuy International Limited, manufacturer of the metal components making up the artificial hip. In assessing how the public’s ‘expectation’ of the product should be measured, the court referred to an earlier case A v National Blood Authority.45 There it was held that the requirement of safety does not mean ‘an absolute level of safety, nor an absolute liability for any harm caused by a harmful characteristic’.46 Rather, the question is, ‘is the safety or the degree or level of safety or safeness which persons generally are entitled to expect’. In assessing the question, that means it is the public at large or persons generally whose expectation should be measured, not that of the individual claimant. This is particularly relevant to claims involving beauty products, whether cosmetics or breast implants or other prosthetics, fillers or inserts, for individual expectations may be unrealistic, going beyond that of the public at large or persons generally. Furthermore, safety is not measured by what the public at large actually expect, but what they are entitled to expect.47 Summing up this aspect, the court in Wilkes v DePuy concluded that in considering whether a product suffered from a defect: … the court must assess the appropriate level of safety, exercising its judgment, and taking into account the information and the circumstances before it, whether or not an actual or notional patient or patients, or indeed other members of the public, would in fact have considered each of those factors and all of that information.48

Again where beauty product claims arise, this analysis resonates, for client or patient expectations and wishes of transformation may be so high or wilfully exaggerated as to pass over proper consideration of information dispensed or fail to consider factors relevant to the product’s application. Referring to Wilkes v DePuy, in A Practical Guide to Cosmetic Surgery Claims ,49 Victoria Handley lists the circumstances a court will take into account, whether or not a claimant considered them:

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All aspects of the marketing of the product; The use of any mark in relation to the product; Instructions and warnings; What might reasonably be expected to be done with the product at the time the product was supplied.50

If damage suffered by the client or patient is caused in whole or in part by the defect, then the product’s producer is liable. The client or patient is obliged to prove on the balance of probabilities that there is a causal link between the damage and the product defect, but is not obliged to prove what caused the lack of safety or why the product failed.51 But what must be borne in mind, as the court in Ide v ATB Sales Limited 52 pointed out, is that no medicinal product, ‘if effective, can be absolutely safe’. This applies, too, to cosmetics and beauty treatments generally, and each case must be considered on its own merits. Claimants must remember that time limits apply to claims under consumer legislation such as the Consumer Protection Act. This means that if action is not launched within the time limit running from when the damage occurred or when the client or patient became aware of the damage, then the claim will be dismissed automatically. Some cosmetic surgery or even beauty treatments may not show immediate damage, coming to light years after the application of a particular product. This may apply, for example, with breast implants and liposuction, where ruptures or circulation of fat deposits to other parts of the body may occur long after the patient or client has left the surgery or salon. In this case, to come within the three-year limitation period the argument has to be made that action was taken immediately the damage came to light, or within three years after it did so. The three-year limitation can run from that date, rather than the date of the operation or procedure itself. Defences of contributory negligence and volenti non fit injuria are particularly cogent in claims relating to cosmetic and beauty treatments. As for contributory negligence, this could occur where the product is used at home and some misstep in its application is made, contributing to the damage. The person using the product without regard to the instructions, or varying its application by missing out steps or ignoring some requirements whilst following others, who suffers damage could then be seen as having some responsibility for contributing to the harm. Any claim for compensation will be cut down accordingly. The second defence of volenti non fit injuria encompasses the willing acceptance of risk—which

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may well apply to clients eager to transform their body or some feature of it. The literal translation of the Latin is ‘to a willing person, injury is not done’. Theorists who argue that women exercise agency in undergoing aesthetic, cosmetic and plastic surgery, even when it is known to be risky—even highly risky—need to be aware that they are advocating for complete responsibility where women are harmed or even seriously damaged by the procedures to which they submit. Their argument of ‘agency’ undercuts the legal rights of women to compensation for harm and damage. Other defences include the argument that the product was defective by reason of its having been required to comply with a legal requirement, or that the product is not genuine, but a copy of the manufacturer’s own product. Just as copying is a feature of the fashion industry, it can be prevalent in the pharmaceutical and cosmetic industries.53 Yet not only copying is a problem. ‘Puffing’ through false or exaggerated advertising of a manufacturer’s own products can persuade women that their hopes for a new life through bodily transformation can be realised. What about such representations or misrepresentations made to women undergoing treatments or procedures delivered to beautify: are these to be accepted simply as within the bounds of beauty advocacy, or is there a liability in the cosmetic or other company that makes extravagant claims? What of client autonomy and issues of consent? These issues arise not only in the beauty parlour, but in the clinic, the surgery and the hospital setting.

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Consent is at the heart of bodily touching, whether it’s a question of medically required treatment, cosmetic enhancement or surgical augmentation. Various levels of assault and battery apply to intentional touching of another person’s body without consent. As Lord Lane CJ held in Faulkner v Talbot,54 proof of hostility, rudeness or aggression is not required and, because the actual damage is constituted by interference with bodily integrity, nor is there any need to prove physical or economic harm for a claim to succeed. As was said in Collins v Wilcock: The law cannot draw the line between different degrees of violence, and therefore prohibits the first and lowest stage of it; every man’s person being sacred, and no other having the right to meddle with it, in even the slightest manner.55

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The reason surgeons and other medical practitioners can carry out their work legally is that the touching—whether causing damage such as bruising, wounding or serious or grievous bodily harm—is consented to by the patient or patient’s parent, guardian or other appropriate person, and it is for the patient’s benefit. For those whose work requires it, including cosmetologists, hairdressers, beauty specialists, manicurists, podiatrists, pedicurists, eyebrow threaders and microbladers, waxers and razorblade wielders, dentists, therapists and the like, the same principles apply. Similarly with licenced tattooists and body artists, although ‘extreme body art’ is a problematic field.56 The second question is the standard of care that is to be expected from the practitioner. When medical operations go wrong, questions arise as to the professionalism of the practitioner and the care they have taken not only in conducting the operation but in discussion with the patient. This includes the issue of risk and quality of information conveyed to the patient. How much risk and explanation of it is required to be given by doctor to patient so that the patient’s consent qualifies as ‘informed’ at a level sufficient to satisfy the courts? If a case is brought in battery, Chatterson v Gerson held the question to be ‘was the patient informed in “broad terms” of the nature of the procedure proposed?’ This sets a high threshold for claimants which, as Jo Samanta and Ash Samanta say in Medical Law, generally makes it difficult for an action in battery based on ‘want of disclosure’ to succeed.57 However, successful claims are possible, as in Schweizer v Central Hospital 58 and Cull v Royal Surrey County Hospital,59 where patients sued for trespass to the person. In one, consent had been given by Mrs Cull to an abortion, but the end result was hysterectomy. In the other, Mr Schweizer gave consent to a toe operation, only to be presented with a completed back operation. Hence, to configure it starkly, were a woman consenting to a rhinoplasty to wake from a general anaesthetic to find her ears pinned back, whilst her original nose remained, she should succeed in an action against the surgeon and hospital for trespass. More problematic is the situation where consent is given to a breast augmentation, the woman consenting to a DD breast size, the resultant operation producing breasts of greater or lesser dimensions. Here, negligence is the more likely line of pursuit. In negligence cases brought by patients who, having been operated on, are harmed by or dissatisfied with the outcome, courts grapple with paternalism, autonomy, medical knowledge and expertise. The principal legal cases addressing these questions and setting down the principles do

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not involve plastic surgery or cosmetic procedures. However, because they set the standards, decisions in these cases are key in determining whether a plastic surgeon or cosmetic specialist is likely to be held liable when injury or harm occur, or when patient dissatisfaction surfaces. A US case fixes the cardinal principle of medical treatment. In 1914, in Schloendorff v Society of New York Hospital, Justice Cardozo said that every human being ‘of adult years and sound mind’: … has a right to determine what shall be done with his own body; and a surgeon who performs an operation without the patient’s consent commits an assault.60

This principle or its equivalent is followed in the United Kingdom and other common law countries like Canada, Australia and Aotearoa/New Zealand. But when Justice Cardozo talks of consent what is actually meant? The notion of ‘informed consent’ emerges into the surgery and operating theatre, spa and salon or pop-up practice, and thence, when ‘things go wrong’, into the courtroom. Considered on the most basic level, when a patient makes an appointment with a doctor and attends at the surgery to present the doctor with their concerns, the assumption arises that the patient has come for a discussion and potentially an examination. If the examination is routine, say a blood pressure test or taking blood for tests to be conducted by a pathologist, the assumption is generally that the patient gives an implied consent. The practitioner (nurse or doctor) takes out the blood pressure equipment when asking the patient to roll up a sleeve or remove a jacket or shirt to ensure that the band is wrapped firmly around the upper arm. Inserting a needle to extract blood, the practitioner warns ‘it may sting’ or ‘hurt’ and the patient can withdraw, but generally the needle goes in, the blood is taken, a plaster is affixed to the spot of needle entry and the patient departs, knowing that the results will be conveyed when available. On a similarly basic level, this applies with beauty salon treatments. Defending against bad hair days, the client makes an appointment, stipulating what is required—say shampoo, semi-permanent colour, blow dry. Upon arrival, the assumption is that they (and the salon) know what is intended—colour selected in a consultation between client and hairdresser or colourist, colour mixed then applied to hair, the client advised that the colour will remain for (say) 20 minutes or half an hour. Then comes a move to the basin, water, shampoo and conditioner. Next, back

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to the original chair, a question about ‘product’ such as mousse and a ‘yes’ (consent) or ‘no’ (no consent) from the client. A hairdryer is turned on, the hairdresser completing the blow dry. If she had not had colour applied at that salon previously, a colour test should have been undertaken 24 or 48 hours earlier, colour applied behind the client’s ear to guard against a negative reaction when the whole head is covered. Without the test, and the client suffers an allergic reaction to the colour, the salon is open to legal challenge. One Marine Agency Insurance company in listing the ‘Top 9 Reasons’ for a lawsuit against a hairdresser’s salon does not include allergic reaction to dye, effectively confirming that salons generally do test.61 Nonetheless, failures occur, and a business support service lists this as a potential claim.62 As to content of the products used, the client rarely asks and is rarely advised. The assumption is that, as a professional with the (presumed) requisite training, the hairdresser or colourist uses products containing hair- and body-friendly ingredients, sound and without defects. Sometimes, these assumptions are misplaced, giving rise to injury, complaints and legal action. So, too, in the doctor’s surgery: if equipment is faulty or products are contaminated or produce allergic reactions, lawsuits may arise from injuries sustained. So long as European regulatory regimes are maintained in the United Kingdom, medical devices and diagnostic kits and delivery systems for drugs are subject to strict regulation. Failure to comply underpins legal liability.63 Regimes and regulations may differ in Australia, Canada, Aotearoa/New Zealand and the United States, but generally product and equipment defects and mishandling come within statutory guidance and control.64 If the United Kingdom renounces the EU standards, it can be expected to adopt a regulatory regime generally consistent with the standards existing in these countries. As to principles of legal liability governing medical practitioners and clinicians, dentists or beauty industry professionals, sometimes claims may be brought under contract law between a private practitioner and patient (though not for procedures on the National Health Service [NHS]). In Canada a contractual claim against a plastic surgeon succeeded where, preceding the operation, the doctor told the patient: ‘There will be no problem. You will be very happy’.65 There was a problem. The patient was not very happy. This was deemed an express contractual warranty binding on the surgeon, making the surgeon liable in contract. Generally, however, claims are pursued in tort, a civil wrong. The claimant bears the

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burden of proof ‘on the balance of probabilities’, relying upon the negligence of the practitioner. The patient must establish that the defendant (surgeon, hairdresser, therapist, manicurist, masseuse …) owed them a duty of care, that the duty of care was breached and that the damage was caused by the defendant’s failure. The duty arises from the relationship between the parties, patient or client and doctor or practitioner or hairdresser … A claim may also be brought against the medical practice or the beauty salon itself, or the spa owner/operator or management. Once the duty of care is established, the onus is on the claimant or litigant to show that the duty was breached. This is proven by evidence that the standard of treatment given by the defendant to the claimant ‘fell below the standard expected of [the defendant] by the law’.66 The standard expected is that which relates to the type of practice or procedure the defendant holds her or himself out to provide. This is illustrated by a case involving a skin complaint treated by a practitioner trained in and applying Chinese herbal medicine. In Shakoor v Situ (T/A Eternal Health Co) the patient had consulted the Chinese herbal medicine specialist, knowing that that was his speciality. Following the therapy, the patient suffered acute liver failure and died. The court dismissed the claim, basing its decision on the fact that the defendant had applied the treatment consistent with the traditional practices of Chinese medicine, in which he was trained. He had not held himself out to be a medical practitioner so, said the court, he could not be judged by the standards applied to competent medical practitioners.67 Finally, where substandard treatment is found, for the claim to succeed the court must decide whether it is because of this substandard treatment that the claimant suffered a legally recognised harm.68 In other words, did the defendant’s acts or omissions cause the harm? Harm that is recognised by the law as actionable and compensable or warranting damages includes physical injury or psychiatric illness. For claims of psychiatric damage to succeed, an identifiable psychiatric or psychological condition or illness must be proven. Stress or distress can be a symptom or sign of such condition or illness. But without evidence before the court of psychiatric illness or a psychological condition the claim fails.69 Two further matters must be borne in mind. Just as is so under consumer legislation, limitation periods apply in negligence claims. First, the Limitation Act 1980 requires that a claim for negligence must be lodged with the court by filing a statement of claim within three years of the conduct causing the damage complained of. This rule can be varied,

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but in circumscribed circumstances. Say the damage is not discovered immediately. As with the application of the limitation period principle under consumer legislation, this can happen with implants whether breast, or tooth and gum, fillers or other substances imported into the body by aesthetic, cosmetic or plastic surgeons, or other practitioners. Once the damage is known, or the claimant ought reasonably to have known of it, then the three-year limitation period begins running. If the time runs out before an action is instituted, then that puts an end to the claim. Secondly, a question of contributory negligence might arise. When a claim is lodged, the defendant may institute a counterclaim for contributory negligence, averring that the claimant herself contributed to the damage. Say that the claimant undergoes liposuction or implant surgery. She is told by the practitioner not to exercise for several weeks, or to stick to gentle walks or slow, rhythmic movements that do not engage that part of the body which underwent the procedure. Contrary to advice, she begins back at the gym almost immediately, working out with dumbbells in a vigorous routine because she believes that exercise will help to reduce any prospect of fat, suctioned away by liposuction, returning. Or she attends a bootcamp, taking part in long, strenuous walks and deep breathing exercises, showing off her new contours. If her claim is accepted by the court, namely that there was a breach of duty owed by the defendant, that the defendant breached it, and that damage was caused thereby, the court may also find that the whole of the damage was not a result of the defendant’s conduct alone. Rather, the cause of the damage lies with both the defendant and the claimant. Compensation calculated as due to the claimant will therefore be cut down by the claimant’s contributory negligence. If the compensation is calculated at, say, £30,000, and the claimant’s contributory negligence is calculated at one-half or fifty per cent, the defendant will be ordered to pay her £15,000 only. The case of Karen Turner v Mr Nigel Carver, decided in 2016, has some similarity with these facts, as Ms Turner did not follow the post-operation advice of the surgeon, Mr Carver. Her claim foundered on the failure to prove negligence. However, had she succeeded in establishing negligence, her damages would have been reduced because of her ignoring the surgeon’s post-operative advice.70 Returning then to beauty treatments, spas and hairdresser and beauty salons are ripe for investigation of how the law applies. Take the hairdresser example. A regular at the salon, the client has a standard appointment including a permanent or semi-permanent colour. Throughout her

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time as a client, the woman’s hair has been coloured with a particular product. The salon decides to try a new hair dye, fails to do a test on the client, and the client experiences an allergic reaction to the dye. Suffering a fainting fit, she is sent home in a taxi at the salon’s expense. Overnight, a severe rash breaks out all over her body, her scalp develops suppurating boils, her hair falls limp and lifeless. The injury is caused by the hair dye, the salon owes the client a duty of care arising from the relationship between the client and the salon. The breach of duty lies in the failure to test the new product on the client 24 or 48 hours ahead of the appointment and using the new product without this caution. Had the test been done, the danger would have been evident and disaster averted. Failure to test opened the client to suffering physical injury. As long as the connection can be made between the dye and the reaction, the claim is likely to succeed. Or say the appointment was to fix the client’s hair for a special night out. She displays proudly a temporary black henna tattoo fixed on her left shoulder and one on her right forearm, done to impress her friends. She asks the hairdresser to select a contrasting dye for her hair. The dye is applied from existing stock, and just as she leaves the salon and later at home, she suffers fainting, boils, rash, and hair limp and lifeless. She misses the party, her condition worsens overnight, an ambulance rushes her to hospital where, having suffered a serious anaphylactic reaction, she is bedridden for days. The breach of duty of care lies in the salon’s applying the hair dye having failed to ask whether the tattoo was ‘black henna’. This is crucial, for black henna carries illegally high levels of PPD or paraphenylenediamine, a chemical in hair dye at maximum levels controlled by law. PPD levels in black henna tattoos can render a person highly sensitive to PPD in hair colour, despite the hair dye having been used safely on the client previously. The case rests on the salon knowing, or that it should have known of the potential impact of exposure to PPD through black henna tattoos, and the legal level of PPD in the salon’s shampoo. The NHS warns specifically of this risk, publicising the death of a woman whose black henna tattoo had been applied five years before she suffered a serious anaphylactic reaction to dye when colouring her hair.71 In a cosmetic or plastic surgery setting, the duty of care lies in the doctor– or practitioner–patient relationship. For example, the patient undergoes one of the most popular body-changing procedures, liposuction. She complains of dimpled thighs or cellulite. She wants her thighs made smooth and believes liposuction will effect this by removing the

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fat that forms the lumps. Excitedly she hears the doctor will use laser liposuction, a new procedure he says is less invasive than the traditional method. Telling her she may well see the results as soon as the procedure is complete, he says nothing about the risks of third-degree burns, charring, scarring or infection, or that she may need to return to the surgery for revision. Nor does he say this is the first time he’s used the equipment, and he’s had no training on it. At the same clinic, another patient undergoes traditional liposuction, this time with liposuction removing adipose tissue from her buttocks (too fat, she thinks) and into her thighs (too thin). This liposuction fat transfer she believes will make her bottom perky, her thighs smoothly contoured. There is some risk the doctor says, but only about 0.3 per cent of patients suffer complications. The first patient emerges from the tiny operating theatre with smooth thighs and is thrilled, her husband admiring. She imagines wearing short skirts again, even daring short-shorts. Her thighs are tingling, there’s a burning sensation, but she’s been told this is normal and will pass. It doesn’t. She develops serious burns, undergoes treatment for what seems like weeks on end, and emerges with serious scarring. The second patient returns home delighted. She’s hoping the bathing costume she wore so desirably in years past has retained its elasticity, to match the taut curves beneath her bottom. As she reaches into the smartly built-in wardrobe, moving gently for yes, there is some pain, she suddenly collapses and dies before the ambulance or medics can reach her. The verdict? Cause of death pulmonary fat embolism. An independent senior consultant tells the inquest that the risk of fat embolism is a known risk of liposuction, whether performed with or without fat transfer. If the operation does involve fat transfer, there is a risk of its disrupting blood vessels with resultant fat embolism.72 In each case, the patient must establish breach of the duty of care. Where the patient died, duty of care is breached if the doctor has failed to meet the standard of care the law expects in delivering the treatment. As the potential for pulmonary embolism is a known risk of liposuction, the doctor is obliged to exercise care taking this into account. If it could be shown that the doctor failed to bear this potential in mind, this failure causing the death, then the doctor would be liable. What if the doctor injected more fat into the woman’s thighs at a more rapid rate than clinically advised, then that could breach the standard. Alternatively, perhaps the woman suffered an underlying condition making her vulnerable to pulmonary embolism. If this could and should have been known to the

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practitioner by proper diligence in examining the patient and taking her history before embarking on the procedure, that could underpin liability. Another argument could be that the patient should have been warned by the practitioner of this particular risk, with advice of steps she could take in exercising care to guard against that outcome. As to the laser liposuction case, the question is whether the burns and scarring were caused by the doctor’s conduct in carrying out the procedure. Lack of training would be relevant. Although burns can happen, they may be the result of the doctor’s inability to use the equipment to the standard of a properly competent medical practitioner—likely because of that training deficit. A breach could lie in a failure to advise the patient how to read postoperative signs of burns early, so as to seek medical care and attention immediately. A breach could also arise in that knowing that burns can be an outcome, the doctor failed to advise the patient as to post-operative care that would lessen the possibility of scarring. Additionally, being a relatively new therapy may affect the standard required.73 This is particularly germane to the beautifying bodies field, because new procedures and new products come onto the market at a seemingly rapid rate. The original test for determining the standard of care owed to patients by medical professionals was set in Bolam v Friern Hospital Management Committee.74 The House of Lords held that the professional would not be in breach of their duty of care if acting in a manner that accorded with practices accepted as proper by a responsible body of medical professionals with expertise in the same field. There could be disagreement between groups of these professionals, however, that did not mean that the doctor would be liable. So long as there was a group which considered the professional’s conduct ‘proper’, then the doctor would be considered to have met the required standard. This test was disputed on the ground that it allowed medical practitioners to set their own standard. In Bolitho v Hackney Health Authority 75 it was held that if a body of opinion says that the doctor’s standard is a proper one, the court must be satisfied that the opinion rests on a logical basis. This can be regarded at least to some extent as applying an increased critical perspective to the work of professionals such as medical practitioners, yet there remains a substantial reliance on, effectively, doctors’ self-assessment of what is an acceptable standard.76 More recently, Montgomery v Lanarkshire Health Board 77 set a standard relating to patient autonomy. Before addressing this principle, however, it is important to consider against whom a patient or client can take action.

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What if the doctor, hairdresser or beauty practitioner does breach their duty of care, yet holding them liable gains the damaged patient or client nothing beyond emotional satisfaction, if that? Although individual professionals are likely to be insured if they are prudent, and some professions require practitioners to take out their own insurance against potential errors, people injured or suffering pain or serious damage will be advantaged if the salon, clinic, hospital or hospital trust carries insurance. If the party suffering from a botched procedure wants financial recompense, wisdom lies in suing the party with the greatest likelihood of paying out a damages claim, most likely to be an institution or business. Here, vicarious liability is the key. Vicarious liability is the legal term given to circumstances where one party engages in wrongdoing, and a second party is held liable. Sometimes, the second party has some ‘primary liability’—that is, has engaged in some form of wrongdoing, too, so is equally to blame or has some blameworthiness. Sometimes, however, the second party has no primary liability—having engaged in no blameworthy conduct at all. At first glance, this may seem unfair. However, public policy comes into play, balancing rights and responsibilities. So here it is that public policy governs the field, and public policy dictates, effectively, whether vicarious liability applies. This can be particularly important where errors occur in procedures involving beauty treatments or cosmetic surgery, plastic surgery or less intrusive measures such as cutting and shaping hair, affixing acrylic nails, straightening corkscrew curls or frizzy hair, applying permanent waving lotion, gels and hairspray, or whitening or tanning skin. Does the business bear responsibility and hence liability for compensation? Or does liability lie solely with the practitioner who applies the lotion or adhesive, colouring agent or dye, wields the scissors or hairdryer, wraps the body in mud packs or guides the client into a chair and positions her head under an all-enveloping dryer? Originally, vicarious liability covered the employer/employee relationship only. This meant liability lay in the claimant establishing, on the balance of probabilities, that: • The wrongdoer—errant hairdresser, slapdash beauty practitioner, less-than-professional medical practitioner or surgeon—was an employee; and (that being so) • The wrongdoing was done in the course of employment.

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Advances in the law of vicarious liability mean that today it can apply to situations beyond employer/employee (a contract for service). Considering changes in the industrial world, this is particularly important. Employers have sought to escape responsibility for employee on-costs including holiday pay, superannuation or national insurance, sick leave pay, maternity and parental leave, and similar work-related benefits as well as avoiding payroll and other taxes by classifying workers as independent contractors (a contract for services). This development is pronounced in hairdressing and the beauty industry as a whole, where workers are asked to supply their own equipment and even to hire the chair allocated to the clients whom they beautify. Now, rather than simply look at the stated contractual terms between the parties or whether a worker is ‘part and parcel of the organisation’ (a test developed by Lord Denning)78 courts consider the parties’ relationship as a whole. As well, if the relationship is ‘akin to employment’ then vicarious liability may apply. In Lee Ting Sang v Chung Chi-Keung,79 a case involving a worker injured on a construction site, the court listed a number of factors to be taken into account in determining the working relationship, including whether the worker: • Is closely supervised—although if the worker is skilled, the impact of this factor is lessened; • Is an integral part of the organisation or business; • Provides their own equipment and/or hires their own workers; • Bears a financial risk as a part of the working relationship and/or profits from their good management of the work done; • Determines their own working hours or has their working hours set by the organisation or business; • Works for the organisation or business as their ‘boss’ or manager, or is in business on their own account.80 In Various Claimants v Catholic Child Welfare Society (the Christian Brothers case)81 the court listed factors which make it fair, just and reasonable for vicarious liability to be imposed on an organisation or business as a matter of public policy. Although insurance is not a sole reason for determining liability, it is a matter to be taken into account. This follows, because the employer is more likely to be able to compensate a client or patient suffering damage and generally will be insured against the

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risk. Further, the business or organisation will have created the risk by having the activity carried out as a part of the business activity. Whether to a greater or lesser extent, the party doing the damage or causing the injury will be operating under the control of the business or organisation. Finally, the damage or injury will have been caused as a consequence of activity carried out on behalf of the business or organisation. These principles were set down by reference to the employee/employer relationship. However, the court went on to say that in the absence of an employment contract, where the relationship has like incidents as employment, then it ‘can properly give rise to vicarious liability on the ground that it is “akin to that between an employer and employee”’.82 This is not the whole answer, however, because liability also is governed by whether the employer, organisation or business has authorised the doing of the act which led to or caused the injury or damage, or if the employee was off ‘on a frolic of his own’.83 Was the employee ‘engaged on her or his employer’s business’?84 Employers have been held liable where an employee drove contrary to the employer’s instructions, driving negligently in rushing through the factory gates to clock in on time, or paid a minor to carryout work tasks, despite the employer’s prohibition.85 Hospitals have been held vicariously liable for the negligence of doctors in their employ or in a relationship akin to that of employer/employee, just as have local authorities for negligent acts by their teachers.86 The principle can be extrapolated to hairdressers or beauticians, eyebrow threaders or waxers, microbladers and manicurists taking shortcuts or leaving creams or dyes or other products on the client beyond the allotted time, or clients under hairdryers for longer than usual. Even where an employee’s acts are not negligent but intentionally harmful and so subject to criminal action, an employer can be held liable. The rule governing this is whether acts or conduct, albeit not authorised, ‘are so connected with acts that [the employer] has authorised that they may rightly be regarded as modes – although improper modes – of doing them’.87 An employer will not be vicariously liable, however, if the intentional or criminal conduct was ‘so divergent from the employment so as to be plainly alien to and wholly distinguishable from the employment’. In Harrison v Michelin Tyre Co 88 the court held that this question must be determined by reference to the reasonable man (or person). Finding for or against employer liability rested upon ‘whether a reasonable man looking at all the circumstances would think that the incident was part and parcel of the employment’.89

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At the same time, attention must be paid to the client or patient and their role in the process. Ultimately, cases may turn directly on the question of consent. This is particularly problematic in the case of aesthetic or cosmetic or plastic surgery, where women consent to surgical operations and cosmetic procedures as well as non-surgical or ‘non-invasive’ measures that are not designed to save life, nor to improve health as conventionally understood. Yet the risks can be high, some would say disproportionately so. Susie Orbach in Bodies posits that the very existence of surgical and non-surgical means for ‘transforming the body’90 generates a craving to make use of all these measures to remake our bodies. Indeed, it becomes an obligation, even a moral duty, to act. The fact that we ‘can transform the body’, says Orbach, ‘makes it a site of dissatisfaction which can be overcome’.91 Since the means of overcoming this sense of dissatisfaction is so readily available, the point is reached where failing to do so is not to be tolerated. Women are accustomed to hearing exhortations such as ‘why on earth doesn’t she do something about her hair’. Nowadays, sotto voce exclamations as to a woman’s failure to ‘do something’ about her wrinkles, her grey hairs, her untidy eyebrows, her sagging bosom … are not uncommon. Hence, ‘the overcoming of dissatisfaction [with our bodies] has … come to take centre stage’.92 Plastic surgery and plastic surgeons, cosmetic surgery and cosmetic surgeons, beauticians and personal trainers represent to us, whether through advertisements or the internet, or popular magazines or upmarket publications, that we can change everything about our bodies. This leads women to enter into agreements to have their bodies altered, whatever the price. So the woman wanting smooth thighs puts her body into the hands of the surgeon, ready to subject herself to a procedure he tells her is new. Rather than enquiring about potential dangers, her focus is on ‘new’ as in ‘good’ and getting rid of the cellulite that plagues her days. Instead of pausing to reflect that it may be unorthodox to go under anaesthetic to have fat sucked from her thighs or transposed from one part of her body to another, or that an operation is serious, and not to be submitted to lightly, she thinks only of lithe legs and gently curved hips, and reviving past bathing costume glories. Here, in the laser liposuction and traditional liposuction examples, each patient put her life and well-being at risk, yearning to improve bodily features by remaking those that existed naturally. Wanting this, each sought out the clinic, secured the surgeon, and acquiesced in the treatment. In the first case, it was consent to undergo laser liposuction. In

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the second, consent was to submit to the traditional procedure. Yet was this consent in the legally required sense, that is, informed consent? In neither case was the patient informed of the risk associated with liposuction, and in the first the patient was denied knowledge of the doctor’s lack of competence in using the equipment, through lack of training and lack of experience. Turning, then, to negligence cases setting the parameters of informed consent, originally the Bolam case set the leading test.93 The basic principle in Bolam’s case for consent to medical treatment is that general risks must be disclosed to the adult patient with the capacity to make decisions for treatment.94 According to Bolam, a duty lies on the practitioner to inform the patient of risks of an operation or a procedure. However, this does not mean there is an obligation to advise of every possible risk. If a practitioner fails to disclose a minor risk, and the patient having consented without that information suffers injury or harm because that risk ensues, is the doctor liable in negligence? The principle established by Bolam’s case is that so long as there is a body of professionals in the same field who would not have disclosed that minor risk, then liability does not accrue. As with the legal standard of medical care and treatment, it does not matter that another body of professionals in that field would hold otherwise. This principle has been criticised as paternalistic. Nonetheless, it was followed by the courts until the decision in Montgomery v Lanarkshire Health Board.95 The Montgomery case instated the principle of autonomy in patient– doctor decision-making. Applying this in the context of negligence, the patient’s case is that first, the doctor did not disclose the risk. Therefore, the patient ‘consented’ to the operation or procedure without knowing that the risk was present. When the risk happens in the course of or as a consequence of the operation or procedure, the patient then argues that, had the risk been disclosed, she or he would not have gone ahead with the operation. That is, would not have consented. Hence, the argument runs that secondly, the doctor has failed in her or his duty of care and thirdly that the injury or harm has been sustained as a result. For a claimant to win a negligence claim on the ‘lack of informed consent’ basis, the court must be satisfied, on the balance of probabilities, that the patient’s injury was caused by the practitioner’s failure to obtain the patient’s valid consent. The argument relating to informed consent was formulated in the United States in 1957, in Salgo v Leland Stanford Junior University Board of Trustees, when it was said that a duty lies on the medical practitioner to inform the patient of ‘any facts which are necessary to form the

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basis of an intelligent consent by the patient to the proposed treatment’.96 The court went on to refer to ‘informed consent’: In discussing the element of risk, a certain amount of discretion must be employed consistent with full disclosure of facts necessary to an informed consent.97

In Law and Medical Ethics , GT Laurie, SHE Harmon and G. Porter observe that in the United Kingdom, following Montgomery’s case, a person ‘should not be exposed to risk of harm unless he has agreed to that risk and he or she cannot properly agree to – or, equally importantly, make a choice between – risks in the absence of factual information’.98 The issue then becomes one of ‘to what extent must or should particular details be divulged’ and the overarching question of ‘by what general standard should the information be judged?’99 In Montgomery it was held that practitioners have a duty to take reasonable care to ensure that patients are aware of ‘material risks’. What is ‘adequate information’ about ‘material risks’ is judged in the particular case from the perspective of a reasonable person in the patient’s position. Returning then to the women undergoing liposuction, whether each gave an informed consent must be judged by the Montgomery standard. First, did the practitioner using laser liposuction discharge his duty to take reasonable care to ensure that his patient was aware of material risks? Was adequate information about the material risks imparted to the patient, judging this by reference to a reasonable person in the patient’s position. The information that could have been imparted was (a) the lack of training and experience of the practitioner; and (b) the possible risk of suffering burns from the laser treatment. If she had been provided with that information, would the patient have consented? An assessment would have to be made from the material in the particular case, including the woman’s evidence. Would she have withdrawn consent if told of the inadequacies in training and experience of the practitioner? This highlights a difficulty with surgery aimed at making the body beautiful. There is a trend for women to take enormous risks with their bodies. Sarah Marsh in ‘Botched cosmetic surgery …’ reports that the ‘alarming’ rise in reports of ‘botched cosmetic procedures in the UK has prompted doctors and campaigners to call for better legislation to protect against rogue practitioners’.100 Marsh reports that in 2017, some 72 per cent of all complaints were from patients who had used social media to locate

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a practitioner. She includes a case study where the complainant booked an appointment with a woman who was running the business from her home. The procedure involved lip fillers and the treatment was ‘incredibly painful’ as well as taking an extraordinarily long time.101 After some weeks, the filler began leaking from a hole at the side of the woman’s mouth. Swelling began to subside, but the filler remaining was lumpy and her lips were uneven. Seeking professional help, she discovered that the filler was inserted wrongly, and was not positioned as it should have been. This story is not isolated. Save Face, an accredited practitioners register having government approval and cited by Marsh, attributes the rise in demand for body enhancing (or harming) procedures to reality stars and celebrities who trumpet their body modifications on social media, television, and any other available publicity forum. This self-promotion in turn promotes desire in the audience for the publicised changes, although it is most likely that photoshopping and other media manipulation is projecting a double falsehood: first, the false corporal body manufactured by fillers, Botox, microblading, liposuction, waxing, laser treatment, facials, eyelash extensions, full body baths; and secondly, the false ‘imagined body’, the one shaped and reshaped by digital editing and promoted as if it is the real thing. As for the risk of laser burns in the one case and the pulmonary fat embolism in the other, is there any certainty that being informed of these risks and their potential harm would have made the woman draw back? Perhaps the risk of death might give pause, yet even there the hankering after what Naomi Wolf termed the beauty myth might overrule natural caution.102 Indeed, the Final Report —Review of Regulation of Cosmetic Interventions , commissioned by the UK Department of Health and published in 2013, pointed out that those considering cosmetic surgery ‘have a natural tendency to focus on outcome’.103 Doing so means that they can pay insufficient attention to risks and limitations, and may need guidance to reorientate their focus. A distinction could be drawn, the Report said, between cosmetic procedures and surgery generally. In the latter, ‘patients may have no knowledge of the procedure but are acutely aware of, and alert to, the risks’. With aesthetic procedures, people actively seeking them out ‘may have a tendency to underplay the risk’. This contrasts sharply with ‘the apprehensive patient required to undergo a significant (general) medical procedure’.104 Perhaps a crucial distinction is that patients in the latter category are set to undergo operations to save their lives, to repair their bodies following

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motor collisions, workplace machinery accidents or other such mishaps, or to relieve disease or bodily malfunction. In the former category, the aim is to boost or enhance a well-functioning body, so that there is little thought of the damage that an operation or procedure aimed at augmentation might do. Alternatively, the seeker after the perfect body accepts that there can be no pain without gain. Just as a prize athlete works out relentlessly, driving their body to new and greater heights, the plastic surgery aficionado sees the operation or procedure as their way of gaining a better body through the effort of going under the knife. That in the end the expectation may exceed the outcome, or the outcome may actually damage rather than improve the body, much less raise its appearance to greater heights, raises a crucial question about medical operations, consent and the criminal law.

3

The Criminal Body and the Body in Crime

In 1934, Mr Donovan took a young woman of seventeen years into his garage to strike her repeatedly with a cane. His aim, it appears, was his own sexual gratification. The young woman, he said, consented. She nevertheless having suffered bruising, the transaction came to police attention. Donovan was prosecuted for indecent assault and causing actual bodily harm. Possibly taking a dim view of unorthodox sexual activity occurring in a domestic garage, the court gave short shift to the proposition that as the young woman had consented, there was no crime. Justice Swift in R v Donovan said that where a person intends to inflict bodily harm, that is ‘… any hurt or injury calculated to interfere with the health or comfort’ of the victim …’ so long as it is ‘not transient or trifling’, the victim’s consent cannot render otherwise unlawful conduct lawful.105 Donovan was convicted. Similarly where Mr Emmett tied a plastic bag around his partner’s head and neck, and on another occasion dripped lighter fluid onto her abdomen, then set it alight.106 His claim that she consented as part of a sexual game designed to gain both parties sexual gratification held no force when the matter came to trial. In R v Emmett, he, too, was found guilty.107 Clearly, though, this rule is not absolute. Otherwise, surgeons would be prosecuted daily for carrying out their work. So would beauticians conducting procedures that require breaking of the skin or result in bruising, such as Botox, fillers, derma blading …

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A surgeon’s intention in cutting into a patient’s body when conducting a medical operation is to ‘inflict bodily harm’. The ultimate proposition is that in so doing, the surgeon will effect a positive outcome, although this aim cannot always be assured. But from the law’s perspective, the initial intention and the infliction of bodily harm amount to common law battery, actual bodily harm, unlawful wounding or grievous or serious bodily harm, depending upon the magnitude of the damage. What renders this otherwise criminal conduct lawful is that the surgeon operates with the requisite professional skill and care, the patient consents, and the operation is for the patient’s benefit. Where the law gets into difficulty, however, is in the area of body embellishment and adornment. This begins to slide into the territory, or some of the territory, occupied by plastic, cosmetic and aesthetic surgeons and other professionals working in body augmentation. For example, so long as a tattooist or piercing specialist is registered with a licence renewed annually and carries out the job with care and skill to the standard set down, now, by Montgomery 108 they are acting lawfully. Although their time is spent inflicting actual bodily harm or unlawful wounding (by breaking both layers of the skin to complete ear piercing, for example), they do their job lawfully, piercing their clients’ skin and body parts (ears, tongue, navel and so on) with instruments designed for the purpose.109 Similarly with tattooing: the licenced tattooist pierces the skin of the client and injects coloured fluid to ensure the design is visible and permanent. What, however, of a licenced body artist operating from registered premises who advertises tattooing, acupuncture, electrolysis, semi-permanent skin colouring, ear piercing and ‘other’ skin piercing, including more radical services such as bifurcating tongues, piercing labia, nipple and penis, cutting off ears, or placing objects under the skin? Some of these services are similar to those conducted in plastic, cosmetic and aesthetic surgery, or in beauty parlours, such as embedding fillers in lips and cheeks, injecting Botox, microblading, removing body hair by wax, electrolysis or other means, and the like. Does the law class all of them legal because consent is obtained and the work is of a good standard, or do the courts enforce actual bodily harm and similar laws, rendering the activity criminal? This question arose in 2018 in Regina v BM .110 BM was charged under section 18 of the Offences Against the Person Act 1861 with three counts of wounding with intent to do grievous bodily harm. The counts related to, first, an allegation that BM had removed a customer’s ear; secondly, that he had removed a customer’s

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nipple; and thirdly, that he had cut a customer’s tongue, dividing it to create a reptilian appearance. BM did not dispute doing these acts. His defence was that each of the three customers had consented. Two other matters were potentially open to prosecution, but no charges had at that time been laid. One was the insertion of transdermal implants into a customer’s scalp. The other was inserting an object (which appeared to be a large metal ‘eye’) under the skin of another customer’s hand. Insofar as all these operations or procedures necessarily involved cutting, with associated bleeding and bruising, the issue was squarely that which was before the court back in 1934 in Donovan. The only difference was that rather than undertaking the work surreptitiously in the family garage, BM had professional premises operated lawfully as a tattoo and body piercing parlour under the Local Government (Miscellaneous Provisions) Act 1982. The lawfulness related to his licenced work of tattooing and body piercing. ‘Body modification’, accepted as describing the wounding constituting the three counts on which BM was to be tried, is unregulated and anyone can assume the role of body modifier. BM’s premises were not licenced for the activities the subject of his criminal prosecution, and the question was whether in assuming the role of body modifier BM’s practice had entered an unlawful realm. The three procedures were conducted without anaesthetic. Signed consent forms were produced in evidence for two. An ear, nose and throat specialist and a consultant plastic surgeon gave evidence as to the pain and damage caused by removal of an ear, both in the operation itself and as to future harm. The plastic surgeon gave evidence relating to the nipple removal and tongue splitting. He spoke of the pain and continuing health consequences, saying that the procedures would ‘never be done by a reputable surgeon for aesthetic purposes or … any other purpose’.111 The court referred to cases defining the meaning of ‘actual bodily harm’, ‘wounding’ and ‘infliction of grievous bodily harm’. Actual bodily harm is accepted as meaning any injury ‘calculated to interfere with the health and comfort’ of the victim, but must be ‘more than transient or trifling’.112 A wound is constituted by breaking of the whole of the skin—dermis and epidermis, and includes inner skin within cheek, lip and urethra. Infliction of grievous bodily harm means really serious bodily harm. Cases including Donovan were considered, where convictions were upheld for inflicting various levels of harm and damage ‘not transient or trifling’ despite the victims’ consent. The court also set out situations where harm and damage were caused but not considered to breach the

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law. These included properly conducted games or sports, lawful chastisement or correction, dangerous exhibitions or jostling in a crowd.113 Reference was made to surgical procedures, with no particularly definitive basis being set for its being lawful rather than breaching the criminal law as battery, actual bodily or grievous bodily harm or wounding: Many of the acts done by surgeons would be very serious crimes if done by anyone else, and yet the surgeons incur no liability. Actual consent, or the substitute for consent deemed by the law to exist where an emergency creates a need for action, is an essential element in this immunity; but it cannot be a direct explanation for it, since much of the bodily invasion involved in surgery lies well above any point at which consent should even arguably be regarded as furnishing a defence. Why is this so? The answer must in my opinion be that proper medical treatment, for which actual or deemed consent is a prerequisite is in a category of its own.114

BM’s defence counsel submitted in the consent argument that the procedures should be accepted as producing results ‘akin to body adornment … widely accepted in British culture and other cultures’, and that a customer’s autonomy to request and consent to the procedures should be respected.115 The prosecutor argued that the procedures carried out by BM were ‘in truth, medical, amounting to cosmetic surgery’. As ‘serious irreversible procedures not warranted medically’ they should be held to be contrary to the criminal law.116 The court agreed, saying that it could see ‘no proper analogy between body modification, which involves the removal of parts of the body or mutilation as seen in tongue splitting, and tattooing, piercing or other body adornment’. The court added that what was done for reward was ‘a series of medical procedures performed for no medical reason’.117 The case of R v Brown 118 is cited as a touchstone for determining that consent to actual or serious bodily harm is no defence to a prosecution for those crimes. R v Brown has been subjected to critical analysis, being seen as problematic in that the practices leading to the charges were sado-masochistic acts carried out by men on one another in neither a garage nor a tattoo parlour, but a private club. The activities included penis piercing and what outsiders might class as anal abuses. However, none of the men complained and none apparently sought medical treatment. There appears to be some currency in the critique alleging that the triggering factor in the prosecution and conviction was the homosexual

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status of the men involved, for the outcome contrasts with R v Wilson.119 There, Mr Wilson carved his initials into his wife’s buttocks. The carving festered, Mrs Wilson sought medical assistance, and the doctor’s concern resulted in police action. However, the prosecution foundered on the proposition that Mrs Wilson was said to have consented and the injury was a consequence of a procedure akin to tattooing. This is a poor argument, for apart from anything else Mr Wilson was not a licenced tattooist and the conduct was not carried out on licenced premises. Furthermore, cutting with a knife into flesh is hardly comparable to practised employment of a tattooist’s needle. That the parties were married was added by the court as what might be seen as an afterthought, or it could have held a significance in the decision. As well, as the court saw it, there was no sexual imperative present. Further, unlike R v Brown, where the potential vulnerability of young men to be inveigled into the sado-masochistic club culture (as the court envisaged) was referred to, in R v Wilson there was no acknowledgement of the vulnerability of a wife to her husband’s possessory expression of marital ownership through violence. On the other hand, R v Emmett involved sado-masochism within a heterosexual (though unlike R v Wilson unmarried) relationship, and Mr Emmett was convicted. Perhaps the better approach is to focus on the principle established by R v Brown and R v Emmett, putting R v Wilson to one side as wrongly decided. This would focus on the policy question of whether the law should deny the relevance of consent to bodily harm where this is carried out for purposes not allied to surgical interventions for health reasons. This then raises an issue of the level of bodily harm that eliminates consent as an exculpatory factor. R v Donovan is, in this regard, rightly open to challenge, for Mr Donovan was convicted of assault and indecent assault. Both are low on the scale of harm according to existing law. An argument might be made that such low-level harm should be able to be consented to by willing adults. As for R v Brown, there the level of harm was in issue. Although the majority held that actual bodily harm should not be able to be consented to (leaving medical reasons to one side), in dissent it was said that the level should be set higher. That is, dissenting authority said that actual bodily harm should be able to be consented to lawfully in non-medical circumstances (just as consent is lawful to that level of surgical harm). However, ran the dissent, where the level of harm is ‘serious’ or ‘grievous’, consent should be irrelevant unless the purpose is health-related in the regulated circumstances of hospitals, clinics and surgeries, and qualified and licenced medical or

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health personnel.120 This distinction about consent and level of harm does have some persuasiveness, for there are other circumstances such as sport where the assumption is that players consent to low-level violence— pushing and shoving, banging into one another and so on. At the same time, the traditional acceptance of lawful infliction of serious or grievous bodily harm consented to for medical reasons could be distinguished from its infliction where there are no medical reasons. Clearly an argument can be made that as a matter of public policy the law should not countenance consent as a justification for or defence to the infliction of serious or grievous bodily harm in circumstances other than those involving surgery or medical treatment taken for health reasons. There is unlikely to be universal agreement on such a policy, however, for it brings into sharp focus the conduct determined by the court to be unlawful in Regina v BM . The issue becomes one of whether as a matter of policy consent can or cannot be a defence to body modifications done for aesthetic reasons (in the eyes of the party requesting them or by reason of group culture). Then, if so, should a licencing system for practitioners and a health certificate for premises be introduced (as exists in some jurisdictions)121 for those trained and qualified in body arts to carry out these procedures? If body modification practices beyond tattooing and piercing of ears and navels, for example, are to remain unlawful, how does this sit with some of the practices carried out by beauticians, aesthetic and cosmetic surgeons and plastic surgeons which have no discernible or at least immediately obvious health purpose or rationale. It is here that questions arise as to the nature and status in law of some of the body modifications being carried out on women in pursuit of beauty. Some onlookers may reel away in revulsion or consternation when a person with a bifurcated tongue comes into view. Certainly it is different from prominently pouting lips, however, these too can engender revulsion or consternation. Are false nails, exaggeratedly projecting from finger tips, so distinguishable from a serpent’s tongue or a missing ear? Are size DD breasts or breasts that appear like two peaches on a washboard to ‘pass’, whilst ‘body modifications’ condemned by the court as breaching the criminal law do not? Critiquing Regina v BM , Samantha Pegg makes the point that the way the court has sought to delineate what will offend against the criminal law, albeit consented to, and what will not, is unsatisfactory.122 That some body modifications lacking medical value are seen by the court as acceptable because of religious endorsement, yet BM’s handiwork is criminalised despite a subculture that accepts

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it, may be open to challenge. The proposition that BM’s customers may be suffering from body dysmorphia or body dysmorphic disorder (BDD), removing their capacity for full, free consent, sits oddly, when the criminal law does not take that view in the case of extravagant or overstated body modifications conducted by beauticians, plastic surgeons or cosmetic and aesthetic surgeons. This conundrum of what is acceptable and what not arose recently in three instances where police considered prosecuting plastic surgeons for conducting labia reductions or modifications carried out on women. The question arose as to whether these procedures should be prosecuted under the Female Genital Mutilation Act 2003.123 The Act provides that it is an offence to ‘excise, infibulate or otherwise mutilate the whole or any part of a girl’s labia majora, labia minora or clitoris’. The Act further states that no offence is committed if an ‘approved person’ performs a surgical operation on a girl which is necessary for her physical or mental health. Approved persons for the purposes of this provision include registered medical practitioners.124 Reactions to these proposed prosecutions were mixed. At the time, activist women from the organisation Object were demonstrating in Harley Street against ‘designer vaginas’ and protesting against removing naturally growing hair from women’s pubic areas. Kat Cooke, in ‘Why is Labiaplasty being compared to FGM?’ quotes a consultant cosmetic and reconstructive surgeon and a consultant plastic surgeon, each of whom carry out labiaplasty procedures. Both averred that patients had the labia reduction procedure for medical reasons. One said his patients found fault with their inability to exercise because ‘the labia is so large’, complained that they were restricted in the clothing they could wear and the exercise in which they could engage, as well as being unhappy about sexual intimacy. This triggered their desire for the operation. He would not, said this surgeon, ‘operate purely for cosmetic reasons’, adding that a ‘functional component’ was necessary. The other surgeon said ‘very few’ of his clinic’s patients had the surgery for cosmetic reasons, over 95% doing so ‘for physical symptoms or because of psychosexual symptoms’. It was ‘very insulting’, he declared, for them to be compared to female genital mutilation (FGM) victims ‘taken at a young age to an often-unknown individual’ to have their genitalia ‘completely mutilated’. Many of those victims attended at his clinic for reconstructive surgery, he said, and comparing their initial subjection to cutting, to women who consented to the procedure was, he said, ‘just degrading’.125 Yet as Camille Nurka points out in Female Genital Cosmetic

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Surgery, female genital cosmetic surgery ‘refers to a range of surgical procedures that are performed on the vagina and vulva when there is no indication of gynaecological disease’.126 These ‘aesthetic and restorative’ procedures ‘aim to make the genitals look appropriately feminine, to reduce physical and mental discomfort, and to enhance sexual feeling’. Some argue that the reduction of physical and mental discomfort does have a health component, thus making the procedures legitimate in medico-legal terms. This may also be said about the enhancement of sexual feeling: if every human being is entitled to a ‘good’ sex life, then the improvement of this component of human existence can be classed as an improvement to health and healthy living. Where a woman’s genitals have been ravaged through culturally imposed female genital mutilation (FGM) reconstruction could certainly qualify as rightly capable of lawful consent, the operation or procedure being aimed at restoring what ought never to have been removed and denied to any woman. Yet Camille Nurka’s assessment, in focusing on the notion that a woman’s genitals must be ‘worked on’ surgically so as to ‘look appropriately feminine’ raises a raft of questions. These include ‘the male gaze’ and women’s striving for bodily perfection which is dictated by external demands that equate plastic manipulation of women’s body parts so as to conform to a false vision of genital flawlessness and bodily excellence or rightness. Women seeking body modifications of the increasingly standard type performed by physicians, surgeons and beauty practitioners often say they simply wish their bodies to be ‘natural’ or ‘normal’. As Nurka says, claims published in 2007 in the Australian Cosmetic Surgery Magazine that ‘in the majority of women, the labia minora are covered by the labia majora (outer lips) and are seen only with the legs separated’ are no longer a part of professional discourse.127 Rather, she observes, advertising language now ‘reflects an acknowledgement of genital diversity’. This she attributes to ‘demands from feminist gynaecologists, urologists and psychologists for evidence based claims’.128 Normal and natural are not what proponents of cosmetic surgery claim, when they seek to impose upon women and women’s bodies conformity to standards set by reference to the images portrayed in Liz Conor’s work on the history of The Spectacular Modern Woman 129 or twenty-first-century images of celebrities’ bodies photoshopped into an externally imposed orthodoxy of ‘what a woman’s body looks like’—really meaning ‘what a woman’s body should look like’.

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4

The Criminal, the Civil and the Role of the Law

It is difficult to leave aside the criminal law without further reflection. Stories do surface of mothers taking their young daughters to plastic, cosmetic or aesthetic surgeons for breast augmentation and for labia surgery.130 Young women’s bodies are only just developing. To interfere with the delicate structure of the breasts when they are at the growing stage is questionable.131 Surgery can interfere with growth of milk ducts and impair breast-feeding capacity as an adult, or impair the breasts’ sexual sensitivity. Bad enough if this happens to an adult woman, but for a growing adolescent who needs time to consider her future, interference seems wrong. Promoting the idea that an adolescent’s genitals require correction and beautification is dubious at minimum. This raises questions, too, about capacity to consent. If mothers are consenting for their daughters, this surely encroaches on their autonomy and capacity to make their own decisions. In Gillick v. West Norfolk and Wisbech Health Authority 132 it was held that consent for medical treatment where the subject is a child lies with the parents, except that if and when the child achieves a significant understanding and intelligence to enable him or her to understand fully what is proposed, then the child has the right to consent without parental intrusion. This is a determination to be made on the facts of the individual case and with medical treatment it is the doctor who, generally, makes the assessment. Additionally, s. 8(1) of the Family Law Reform Act 1969 gives a minor of 16–18 years powers of consent to medical and surgical treatment equivalent to those of an adult. The Gillick case is taken as a general guide in Australia, too. In the United States the law is similar in that the age of majority and minority applies so that those under the age of 18 years cannot consent to surgery, but ‘adolescents between the ages of 12–17 years may be found to be capable of giving “assent”’ along similar lines.133 Cosmetic surgery where minors are the subject raises particular issues, however. In the United States, restrictions are set by the Food and Drug Administration agency (FDA) on breast implants. With saline-filled breast implants for breast augmentation, the FDA has approved them for women aged 18 years and above only, whilst approving them for breast reconstruction in women of any age. Saline-filled implants are also used for ‘revision surgeries’, that is, correction or improvement of results of an original surgery.134 Silicone

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gel-filled breast implants are ‘approved for breast augmentation in women age 22 or older’.135 For breast reconstruction, FDA approval extends to women of any age. Silicone gel-filled breast implants, too, are used in revision surgeries for ‘correction or improvement’ of an original surgery. In the United Kingdom, as was observed in Regina v BM , restrictions on minors’ capacity exist in various circumstances. Tattooing is one of them, restricted by the Tattooing of Minors Act 1969. Should such limits apply to cosmetic surgery? Recognition of body dysmorphia (BDD) also requires consideration, even if only in reflection, although arguably the problem may be more needing of consideration.136 Regina v BM saw it as a possibility with the three procedures there in question: bifurcated tongue, outer ear removal, and removal of a nipple. In Bodies Susie Orbach speculates on the dysmorphia phenomenon.137 Yet labelling as dysmorphic women attending the wide range of professionals now providing body-changing procedures and amateurs setting up as body beauty makers, is questionable. Doing so is simply to label them all over again, when they are seeking to escape from the strictures of a world where women remain lower paid, continue to be clustered in traditional women’s fields, are less represented in political and legal institutions, and whilst present in educational institutions in more proportionate numbers, still occupy the lower rungs. At the same time, the desperation women must experience deep down, in seeking to have their bodies made over so invasively, surely is counterproductive. To be so unhappy with one’s body that radical surgery is seen as the answer, or to be so determined to improve oneself, that altering one’s body is pursued as the solution, seems counterintuitive. Ultimately the same woman is very likely to be internally demanding recognition as a whole woman without the intervention of body shapers. Neither civil law nor criminal law has been kind to women. Almost one hundred years ago, for the first time, a common law court acknowledged women as persons.138 Not being recognised in law as persons deprived women of identity, economic independence, access to ‘male’ trades and professions, political representation, and legal status. Women were classed together with children and persons lacking mental capacity. Our bodies existed, yet our minds were denied. Today, the body shaping industry relentlessly drives women back into a space where our bodies are not ourselves. Women are being distanced from our bodies as if the body were a palette to be drawn upon, a clay to be moulded into what is projected as the perfect woman. Yet physical perfection is always out of reach,

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because there is always a new product, a new procedure, a new shape to be pursued. Women’s bodies are sites of manipulation into conformity with a shape that is dictated from outside ourselves. Historical treatises on body changing illustrate how women’s bodies have ever been controlled, with race and physical superiority related to class and criminality, intimately linked to surgical and like interventions, including tanning or skin whitening, puffing up our bosoms or toning them down, grasping after larger bottoms, or hankering after boyish hips. When women’s condition is considered, on every level consent is in issue. With the bodily intrusions now being forced upon us and into our mind-space by an ever-growing multi-million-dollar industry designed to falsify women’s bodies, women confront yet again the mind–body separation. However much it may be said that women are the masters of our souls, the captains of our destiny, the reality insofar as the dominant culture is concerned is that our bodies take centre stage. Pervasive is the view, expressed through the media and prominent in the fact that women’s brains are not valued in the same way as men’s, that body image is women’s prime goal. If this were not so, if women’s brains were valued equally, it would not be that in the United States only ever have four women taken a key role on the presidential ticket of a major political party: Geraldine Ferraro, VP candidate to Walter Mondale (Democrat); Sarah Palin, VP candidate to John McCain (Republican), Hillary Clinton, Presidential nominee (Democrat); Kamala Harris, VP candidate to Joe Biden (Democrat). Nor would it be that the United Kingdom has ever had two women Prime Ministers only—Margaret Thatcher (Conservative) and Theresa May (Conservative), or that Australia has only ever had one female Prime Minister (Julia Gillard), although women have featured more prominently as Premiers or Chief Ministers of Canberra, ACT (Labor and Liberal), Western Australia (Labor), Northern Territory (Labor), Victoria (Labor), Queensland (Labor), New South Wales (Labor and Liberal) and Tasmania (Labor). Or that major companies and boards do not feature equal numbers of women and men as directors or chief executive officers, female professors are fewer than their male counterparts, factories more often feature foremen than forewomen and, despite women now being entitled to sit equally with men on juries, juries continue more often to elect men as foremen.139 The list goes on … When they seek justice for redress for harm and damage, women and their bodies enter a legal system shaped by men as judges, advocates, barristers, solicitors and attorneys, with women taking these roles at the

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beginning of the twentieth century, not before, and with appointments to senior positions in law firms and as magistrates and judges occurring far more recently. Nor do women in positions of power dominate the industry that creates the damage and harm bringing women into the legal system for reparation. Women’s bodies feature publicly as if they are the central focus of our lives, denying our humanity as whole human beings. From our foreheads to our toes, from our collar bones to our finger tips, from the crowns of our heads to the intimacy of our vulva, women’s bodies are sites to be shaped by forces outside our control. Divided into body parts, swathed in the plastic of performance, women continue to be denied personhood. As Elizabeth Cady Stanton and Susan B. Anthony said in The Revolution, way back on 18 November 1869, ‘no class of citizens’, no man or woman, ‘can ever feel a proper self-respect’, can ever experience themselves as entitled or worthy, ‘until their political equality – their citizenship – be fully recognised’.140 The law and the way it regards women, its capacity for encompassing women as equal whether as litigants or lawyers, is integral to the question of body, image and citizenship. Women must demand our full citizenship, incorporating ourselves as wholly human. Just as men’s citizenship is constituted not by brawn or body, or brain alone, but by the whole person, women too must be recognised beyond the body, as more than our parts. Forsaking plastic, that we are ourselves entire.

Notes 1. Luke Malone, ‘Makeup: the Key to Success?’ Sydney Morning Herald, 26 October 2011, https://www.smh.com.au/lifestyle/beauty/makeupthe-key-to-success-20111025-1mhik.html (accessed 31 October 2011). 2. See American Society of Plastic Surgeons, ‘Plastic Surgery During COVID-19 Pandemic’, Plastic Surgeon Match, https://www.plasti csurgery.org/news/press-releases/american-society-of-plastic-surgeonsreleases-new-guidance-for-resuming-elective-procedures-amid-covid19 (accessed 16 August 2020); Zona Black, ‘Zoom Calls Have Australians Rushing for Cosmetic Surgery’, The New Daily, 20 July 2020, https:// thenewdaily.com.au/life/wellbeing/2020/07/20/cosmetic-surgery-cor onavirus-popular/ (accessed 16 August 2020). 3. Cecilia Pelloux, ‘The Plastic Surgeon Changing the Face of Post Covid19 Beauty’, Forbes , https://www.forbes.com/sites/ceciliapelloux/

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4.

5. 6. 7. 8. 9.

10.

11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

2020/05/26/the-plastic-surgeon-changing-the-face-of-post-covid-19beauty/#2059891b7db5 (accessed 16 August 2020). Danica Lo, ‘Cosmetic Surgery During The Coronavirus Pandemic: Is It Safe?’ Tatler Hong Kong , 27 April 2020, https://hk.asiatatler.com/ style/cosmetic-surgery-coronavirus-covid (accessed 9 May 2020). Liz Conor, The Spectacular Modern Woman, Indiana University Press, Bloomington, IN, USA, 2004, p. 2. Ibid., p. 48. Ibid., p. 49. Ibid., p. 66. Caesare Lombroso, Criminal Man, original publication 1889, reprinted GP Putnam’s Sons, New York, NY, USA, 1911; Nicole Hahn Rafter and Mary Gibson (trns), Tseng Information Systems Inc., Durham, NC, USA, 2006; Caesare Lombroso and Guglielmo Ferrero, Criminal Woman, the Prostitute and the Normal Woman, original publication 1893, reprinted Nicole Hahn Rafter and Mary Gibson (trns), Tseng Information Systems Inc., Durham, NC, USA, 2004. Af Afia A. Ofori-Mensa, ‘Beauty, Bodies, and Boundaries: Pageants, Race, and U.S. National Identity’, PhD Thesis, University of Michigan, Ann Arbor, MI, USA, 2010, https://deepblue.lib.umich.edu/handle/ 2027.42/78957 (accessed 20 November 2019); Aro Velmet, ‘Beauty and Big Business: Gender, Race and Civilization Decline in French Beauty Pageants, 1920–37’, French History, vol 28, no 1, March 2014, pp. 66–91, https://academic.oup.com/fh/issue/28/1 (accessed 20 November 2019). Liz Conor, ibid., p. 162. ‘Vain Women: The Self-Flatterer and Her Fate’, Sunraysia Daily, 17 March 1923, p. 6. Jill Julius Matthews, ‘Building the Body Beautiful: The Femininity of Modernity’, Australian Feminist Studies, vol 5, Summer 1987, p. 27. Susie Orbach, Bodies , Profile, London, UK, 2009, 2010, 2016, pp. 72– 73. Ibid., p. 73. Germaine Greer, The Female Eunuch, Palladin, New York, NY, USA, 1971, p. 41. See, for example, John Berger, Ways of Seeing, Penguin, Harmondsworth, UK, 1972. Germaine Greer, ibid. Susie Orbach, Fat Is a Feminist Issue, Random House, London, UK, 1978, 1988. Kate Millett, Sexual Politics , University of Illinois Press, Chicago, IL, USA, 2006, 1969; Simone de Beauvoir, The Second Sex, HM Parshley, trns, Knopf, New York, NY, USA, 1954.

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21. Greer, ibid; Betty Friedan, The Feminine Mystique, W. W. Norton, New York, NY, USA, 1963. 22. Schulamith Firestone, The Dialectic of Sex: The Case for Feminist Revolution, Wm Morrow, New York, NY, USA, 1970; Susan Brownmiller, Femininity, Simon & Schuster/Linden Press, New York, NY, USA, 1984; Susan Brownmiller, Against Our Will—Men, Women & Rape, Simon & Schuster, New York, NY, USA, 1975. 23. Robin Morgan (ed.), Sisterhood Is Powerful, Vintage, New York, NY, USA, 1970. 24. Jo Freeman (aka Joreen), ‘The Tyranny of Structurelessness’, Jo_Freeman.com (originally 1970), https://www.jofreeman.com/jor een/tyranny.htm (accessed 12 January 2013). 25. Gloria Steinem, published in Show Magazine, 1963, see ‘Gloria Steinem: Biography’, Biography, https://www.biography.com/activist/gloria-ste inem (accessed 4 April 2018). 26. ‘No More Miss America’, Redstockings, 22 August 1968, http://www. redstockings.org/index.php?option=com_content&view=article&id= 65&Itemid=103 (accessed 4 April 2018). 27. Mirabel Morgan, The Total Woman—How to Make Your Marriage Come Alive, FH Revell, Ada, MI, 1973, Pocket Books, New York, NY, USA, 1990. 28. Nathan Raban, ‘Exploiting Our Archives … Women Hating Women: The Toxic Anti-feminism of Self-Help Guru Marabel Morgan’, Nathan Raban Blog, 9 July 2018, https://www.nathanrabin.com/happy-place/ 2017/4/28/women-hating-women-the-toxic-anti-feminism-of-selfhelp-guru-marabel-morgan (accessed 30 July 2018). 29. Zona Black, ‘Zoom Calls Have Australians Rushing for Cosmetic Surgery’, The New Daily, 20 July 2020, https://thenewdaily.com.au/ life/wellbeing/2020/07/20/cosmetic-surgery-coronavirus-popular/ (accessed 16 August 2020). 30. Kasey Edwards, ‘What Women Are Expected to Spend on Beauty Amounts to a House Deposit’, Sydney Morning Herald, 11 June 2019, https://www.smh.com.au/lifestyle/beauty/what-women-are-expectedto-spend-on-beauty-amounts-to-a-house-deposit-20190609-p51vzn. html?utm_medium=Social (accessed 12 June 2019). 31. Ibid. 32. Ibid. 33. Ibid. 34. Cheryl Wischhover, ‘Therry Mugler’s Angel Perfume Celebrates 20 Years in the US’, Fashionista, 27 February 2013, updated 10 April 2014, https://fashionista.com/2013/02/thierry-muglers-angel-per fume-celebrates-20-years-in-the-us-a-look-back-at-the-scent-and-the-fas hion-behind-it (accessed 21 November 2019).

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35. Jenny Stocks, ‘Plump Up Your Pout: Bee-stung Lips Make Women Seem Younger Say Scientists, Here’s How You Can Look Swell …’, Daily Mail, 14 January 2010, https://www.dailymail.co.uk/femail/ beauty/article-1243038/Plump-pout-Bee-stung-lips-make-women-you nger-say-scientists-heres-look-swell-.html (accessed 31 October 2011). 36. Sophia Phan, ‘Everything You Need to Know Before Microblading Your Eyebrows’, Sydney Morning Herald, 26 June 2019, https://www. smh.com.au/lifestyle/beauty/all-the-things-i-wish-i-knew-before-i-paid1000-to-get-my-eyebrows-done-20190621-p51zup.html (accessed 26 June 2019). 37. ‘Own Your Look’, Botox Cosmetic, https://www.botoxcosmetic.com/ home.aspx (accessed 2 November 2011). 38. Ibid. 39. Ibid. 40. Ibid. 41. ‘Own Your Look’, Botox Cosmetic, https://www.botoxcosmetic.com/ home.aspx (accessed 2 May 2019). 42. Ibid. 43. Withdrawal of the United Kingdom from the European Union may affect this provision, however, so long as it remains in the Act it remains operative. 44. Wilkes v DePuy (2016) EWH 3096 (QB). https://www.bailii.org/ew/ cases/EWHC/QB/2016/3096.html (accessed 20 January 2020). 45. A v National Blood Authority [2001] 3 All ER 289. https://www. bailii.org/ew/cases/EWHC/QB/2001/446.html (accessed 20 January 2020). 46. Ibid., at para [31]. 47. Ibid., at para [31]. 48. Wilkes v DePuy, at para [72]. 49. Victoria Handley, A Practical Guide to Cosmetic Surgery Claims , Law Brief Publishing, Somerset, UK, 2017. 50. Ibid., p. 47. 51. Ide v ATB Sales Limited (2008) EWCA Civ 414. https://www. bailii.org/ew/cases/EWCA/Civ/2008/424.html (accessed 20 January 2020). 52. Ibid. 53. Medicines and Healthcare Products Regulatory Agency, ‘Counterfeit Medicines: What Pharmacists Should Know’, Gov.UK, 11 December 2014, https://www.gov.uk/drug-safety-update/counterfeit-medicineswhat-pharmacists-should-know (accessed 19 November 2019); Hetty Tullis, ‘Thirteen Terrifying Dangers of Counterfeit Makeup’, The Talko, https://www.thetalko.com/13-terrifying-dangers-of-counterfeitmakeup/ (accessed 19 November 2019).

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54. Faulkner v Talbot [1981] 3 All ER 468, 471. 55. Blackstone’s Commentaries, iii, 120, cited Collins v Wilcock [1984] 3 All ER 374, 378. 56. See R v BM [2018] EWC Crim 560; Samantha Pegg, ‘Not So Clear Cut: The Lawfulness of Body Modifications’, Criminal Law Review, vol 7, 2019, pp. 579–598, and further this chapter Sect. 3, “The Criminal Body and the Body in Crime”. 57. Jo Samanta and Ash Samanta, Medical Law, 2nd edn, Oxford University Press, Oxford, UK, 2016. 58. Schweizer v Central Hospital [1974] 53 DLR 3rd 494. 59. Cull v Royal Surrey County Hospital (1932) 1 BMJ 1195. 60. Schloendorff v Society of New York Hospital 10 NE 92 (NY, 1914). 61. ‘Top 9 Reasons for a Law Suit Against a Hair Salon’, Marine Agency Insurance, https://marineagency.com/top-9-reasons-for-a-law uit-against-a-hair-salon/ (accessed 1 March 2019). 62. ‘Hairdressing Claims—Suing Hairdressers’, NHF/NBF , http://www.hai rdressingclaims.co.uk/suing-a-hairdrsser (accessed 1 March 2019). 63. Arty Rajendra and Mary Smillie, ‘Fact Sheet: Intellectual Property Considerations for Medical Devices ’, European IPR Helpdesk, September 2015, www.iprhelpdesk.eu (accessed 4 April 2018). 64. See, for example, Australian Competition and Consumer Commission (ACCC), ‘Products, Recalls, Report an Unsafe Product, Product Safety Australia, https://www.productsafety.gov.au/ (accessed 20 November 2019). 65. La Fleur v Cornelis (1979) 28 NBR (2d) 569, NBSC; see also GT Laurie, SHE Harmon and G. Porter, Mason & McCall Smith’s Law & Medical Ethics, 10th edn, Oxford University Press, Oxford, UK, 2016, p. 135. 66. Laurie, Harmon and Porter, ibid. 67. Shakoor v Situ T/A Eternal Health Co [2001] 1 WLR 410; see also Shakoor v Situ, http://self.gutenberg.org/articles/Shakoor_v_Situ (accessed 20 January 2020). 68. Laurie, Harmon and Porter, ibid. 69. Ibid., and see Fairlie v Perth and Kinross Healthcare NHS Trust [2001] SCT (OHCS), https://www.scotcourts.gov.uk/search-judgme nts/judgment?id=667f8aa6-8980-69d2-b500-ff0000d74aa7 (accessed 4 April 2018). 70. Karen Turner v Mr Carver reported Hill Dickenson, https://www.hil ldickinson.com/insights/articles/cosmetic-surgery-it-realistic-expect-sur geons-assess-their-prospective-patients (accessed 19 December 2019). 71. ‘Set Up a Simple and Effective Allergy Alert Testing System with NHF/NBF’, NHF/NBF , https://www.nhf.info/advice-and-resour

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72.

73. 74. 75. 76.

77.

78.

79.

80. 81.

82. 83.

84. 85. 86. 87. 88.

ces/blog/health-and-safety/how-to-set-up-our-allergy-alert-system/ (accessed 1 March 2019). See Brenda Lau, ‘Liposuction Gone Wrong: Widower Sues Doctor, Clinic and Company to Seek Damages’, Malpractice & Legal, 17 August 2016, https://today.mims.com/liposuction-gone-wrong-widower-sues-doctor--clinic-and-company-to-seek-damages (accessed 18 August 2016). Laurie, Harmon and Porter, ibid., pp. 149–150. Bolam v Friern Hospital Management Committee [1957] 1 WLR 583. Bolitho v Hackney Health Authority [1998] AC 232; [1997] 4 All ER 771 (HL). Other jurisdictions have been far more critical and ready to apply a standard that does not simply ground the rules governing medical negligence in ‘medical judgment’. See, for example, the Australian High Court in Rogers v Whitaker [1992] HCA 58; (1992) 175 CLR 479 (19 November 1992), http://www.austlii.edu.au/cgi-bin/viewdoc/au/ cases/cth/HCA/1992/58.html (accessed 20 January 2020). Montgomery v Lanarkshire Health Board [2015] UKSC 11; [2015] 2 WLR 768, https://www.bailii.org/uk/cases/UKSC/2015/11.html (accessed 20 January 2020). See Stevenson, Jordan & Harrison Ltd v MacDonald and Evans [1952] 1 TLR 101 and Bank voor Handel en Scheepvaart v Slatford [1953] 1 QB 248. Lee Ting Sang v Chung Chi-Keung [1990] 2 AC 374, https://www.cas emine.com/judgement/uk/5b2897ce2c94e06b9e19b5b5 (accessed 19 November 2019). Ibid.; and see generally Mariel Irvine, A Practical Guide to Vicarious Liability, Law Brief Publishing, Somerset, UK, 2018. Various Claimants v Catholic Child Welfare Society (the Christian Brothers Case) [2010] EWCA Civ 1106, https://www.supremecourt. uk/cases/docs/uksc-2010-0230-judgment.pdf (accessed 19 November 2019). Ibid., at paras [34] and [35]. Per Baron Parke in Joel v Morrison (1834) 6 C&P 501, at para [5], https://www.casemine.com/judgement/uk/5a8ff71f60d03e7 f57ea7e6d (accessed 19 November 2019). Rose v Plenty [1976] 1 WLR 141. See generally Mariel Irvine, A Practical Guide, Law Brief Publishing, Somerset, UK, 2018, pp. 27–32. Ibid., p. 32. Salmond on the Law of Torts, cited Mariel Irvine, A Practical Guide, ibid., p. 35. Harrison v Michelin Tyre Co [1985] 1 All ER 918.

2

89. 90. 91. 92. 93. 94.

95. 96.

97. 98. 99. 100.

101.

102. 103.

104. 105. 106. 107. 108. 109. 110.

111. 112.

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Mariel Irvine, A Practical Guide, ibid., p. 37. Susie Orbach, Bodies , Profile Books, London, 2009, 2010, 2016, p. 24. Ibid. Ibid. Bolam case, ibid. On children’s capacity to consent, see Gillick v West Norfolk and Wisbech Health Authority [1984] QB 581; [1984] 1 All ER 365; [1985] 3 All ER 402 (HL). Montgomery v Lanarkshire Health Board [2015] UKSC 11; [2015] 2 WLR 768. Salgo v Leland Stanford Junior University Board of Trustees, 317 P 2d 170 (Cal, 1957); and see Laurie, Harmon and Porter, ibid., pp. 112– 113. Ibid. Ibid., p. 114. Ibid., p. 115. Sarah Marsh, ‘Botched Cosmetic Surgery: Law Change Urged as Complaints Treble’, The Guardian, 18 February 2018, https://www. theguardian.com/lifeandstyle/2018/feb/18/botched-cosmetic-sur gery-law-change-urged-as-complaints-treble (accessed 13 March 2019). ‘Case Study—“It Looked Like It Was Migrating from My Lips to My Face”’, The Guardian, 18 February 2018, https://www.theguardian. com/lifeandstyle/2018/feb/18/botched-cosmetic-surgery-law-changeurged-as-complaints-treble (accessed 13 March 2019). Naomi Wolf, The Beauty Myth, Vintage, New York, NY, USA, 1990. Review Committee, Final Report: Review of the Regulation of Cosmetic Interventions, Department of Health, London, UK, 2013 (April), https://assets.publishing.service.gov.uk/government/uploads/sys tem/uploads/attachment_data/file/192028/Review_of_the_Regula tion_of_Cosmetic_Interventions.pdf (accessed 13 May 2016), para 5.5. Ibid. R v Donovan [1934] KB; [1934] All ER 207. R v Emmett, Times, 15 October 1999. Harrison v Michelin Tyre Co [1985] 1 All ER 918. Montgomery, ibid. ‘Tattoo, Piercing and Electrolysis Licence’, Gov.uk, https://www.gov. uk/skin-piercing-and-tattooing (accessed 12 February 2018). Regina v BM [2018] EWCA Crim 560; see also Samantha Pegg, ‘Not So Clear Cut: The Lawfulness of Body Modifications’, The Criminal Law Review, no 7, 2019. Regina v BM , Ibid., para [23]. Ibid., para [22].

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113. Ibid., para [23], citing Attorney General’s Reference (No 6 of 1980) [1981] QB 715; para [25], citing R v Brown [1994] AC 122. 114. R v Brown [1994] AC 122, cited para [28]. 115. Regina v BM , ibid., para [34]. 116. Ibid., para [37]. 117. Ibid., para [42]. 118. R v Brown [1994] AC 122. 119. R v Wilson [1996] Crim LR 573. 120. See Lord Slinn’s judgment in R v Brown, ibid. 121. See, for example, the United States and Canada: MDHHS, ‘Body Art Facility Licensure’, Michigan Department of Health and Human Services, https://www.michigan.gov/mdhhs/0,5885,7-339-71551_ 27716_73975---,00.html (accessed 19 November 2019); Washington State Department of Licenses, ‘How to Get Your License: Body Piercing Artists’, Tattoos, Body Piercing, Body Art and Permanent Cosmetics, https://www.dol.wa.gov/business/tattoo/piercinglicense. html (accessed 19 November 2019); Winnipeg Community Services, ‘Body Modification Establishment’, City of Winnipeg, https://winnipeg. ca/cms/BLES/LS/business_licenses/body_modification_establishmen t.stm (accessed 19 November 2019). 122. Samantha Pegg, pp. 597–598. 123. Kat Cooke, ‘Why Is Labiaplasty Being Compared to Female Genital Mutilation?’ Aesthetics Journal, 5 January 2017, https://aestheticsjo urnal.com/feature/why-is-labiaplasty-being-compared-to-female-gen ital-mutilation (accessed 4 April 2017). 124. S. 1 (1) Offence of female genital mutilation. Note that s. 1 (2) covers a surgical operation in relation to labour or after giving birth if for purposes connected with the labour or birth. 125. Kat Cooke, ‘Why is Labiaplasty …’. 126. Camille Nurka, Female Genital Cosmetic Surgery—Deviance, Desire and the Pursuit of Perfection, Palgrave Macmillan, Cham, Switzerland, 2019, p. 3. 127. Ibid., p. 199. 128. Ibid. 129. Liz Conor, The Spectacular Modern Woman, ibid. 130. Kat Cooke, ibid. 131. Florence Williams, Breasts —A Natural and Unnatural History, W. W. Norton, New York, NY, USA, 2012. 132. Gillick v West Norfolk and Wisbech Health Authority [1984] QB 581; [1984] 1 All ER 365; [1985] 3 All ER 402 (HL). 133. Canice E. Crerand and Leanne Magee, ‘Cosmetic and Reconstructive Breast Surgery in Adolescents: Psychological, Ethical, and Legal Considerations’, Seminars in Plastic Surgery, vol 27, no 1, 2013, pp. 72–78, p. 75.

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134. FDA, ‘Types of Breast Implants’, US Food and Drug Administration, 23 October 2019, https://www.fda.gov/medical-devices/breast-implants/ types-breast-implants (accessed 20 January 2020). 135. Ibid. 136. See, for example, Eva E. Fisher, ‘Am I Ugly or Do I Have BDD? Personal Disclosure and Social Support on a Body Dysmorphic Disorder Online Forum’, PhD Dissertation, Colorado State University (CSU), Fort Collins, Co, https://www.academia.edu/40247165/DISSERTAT ION_Am_I_ugly_or_do_I_have_BDD_Personal_disclosure_and_social_ support_on_a_Body_Dysmorphic_Disorder_Online_Forum?auto=dow nload&email_work_card=download-paper (accessed 19 April 2020); https://mountainscholar.org/handle/10217/176770 (accessed 2 August 2020). 137. Susie Orbach, ibid. 138. Edwards v AG of Canada [1929] UKPC 86; [1930] AC 143; Edwards v AG of Canada [1930] AC 128, http://www.bailii.org/uk/cases/ UKPC/1929/1929-86-html (accessed 12 May 2015). 139. See, for example, Jocelynne A. Scutt, ‘The Gerrymander of Sex: Women, Men and the Politics of History’ in JA Scutt, The Sexual Gerrymander— Women and the Economics of Power, Spinifex Press, Nth Melbourne, Australia, 1994, pp. 3–17; Jocelynne A. Scutt, ‘Fair Shares of Our Heritage: Women, Men and the Socialist Ideal’ in JA Scutt, The Sexual Gerrymander …, pp. 17–37; Jocelynne A. Scutt, The Incredible Woman—Power & Sexual Politics, 2 vols, Artemis Publishing, Melbourne, Australia, 1997. 140. Elizabeth Cady Stanton and Susan B. Anthony, The Revolution, 18 November 1869, quoted Jocelynne A. Scutt, ‘Introduction—Money, Power and Politics’ in JA Scutt, The Incredible Woman—Power and Sexual Politics, vol. 2, Artemis Publishing, Melbourne, Australia, 1997, p. ix.

CHAPTER 3

Above the Shoulder Blades

Just as in all societies, all cultures have at one time or another constrained women’s bodies, similarly all religions have dictated women’s dress and demeanour, too. Religions have directed women to cover their heads, and their hair. Hair has been classed as provocative, ungodly, and fated to send men into frenzies … Up until the 1960s, the Roman Catholic Church and the Church of England required women to wear hats to church, and Judaism continues to direct women to cover their heads: wigs replace or camouflage women’s hair still …1

1

Her Crowning Glory

Historically, a woman’s hair has been at the heart of women’s attraction. Lustrous locks, twirling curls, sweeping bangs, short bobs, blonde beauty, burnished manes, Titian tresses, brunette mops, gamine cuts, glossy ringlets, jet black braids, cornrows, and even topknots, plaits and shortcropped, flat-chopped fringes fill the pages of romance novels, abound in period and contemporary television and feature films, and are seen on the streets or emerging from beauty parlours in real life. Psychologists contend that sexually alert women employ their hair wantonly, flipping tantalising strands over one shoulder, cheekily twirling wisps around a suggestively cocked finger, or dipping their heads to look up from under seductive fringes, flirting. Monica Moore and Diana Butler’s research, observing women’s behaviour in a variety of student recreational and relaxed settings, identified eleven techniques they attributed as designed © The Author(s) 2020 J. A. Scutt, Beauty, Women’s Bodies and the Law, https://doi.org/10.1007/978-3-030-27998-1_3

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to appeal to men’s sexual interest.2 Of these eleven methods, two placed hair in the forefront as alluring. The ‘head toss’ saw the woman flipping her head backward, then briefly lifting up her face. For the ‘hair flip’, the woman ‘raised up one hand, pushing it through her hair’.3 Women who engaged in these practices were readily approached by men, whilst women who did not were more likely to be left alone. Conventional attractiveness was not a lure on its own. Less attractive women received male attention over and above that directed to those with eye-catching features or a more striking appearance, so long as they employed one or other or more of these identified practices.4 That the women’s hair flipping or head tossing might be unconscious, force of habit, or simply a consequence of fringes or strands falling into the eyes rather than flirting, has some force. The truth may be that at least in some instances men project their own desires onto these actions, interpreting them wrongly as seeking male attention. For the hair signifies danger, too. That women’s hair is provocative, driving men mad with desire, lies at the root of the insistence that it be hidden from view. Religion and culture have mandated the covering of women’s hair, even at the pain of death. During the Inquisition, when witches were burned at the stake, Heinrich Kramer and Jacob Sprenger’s Hammer [ or Anvil] of Witches , published in 1486 and followed by many more editions, classified all women as evil, or at least potentially so. Hair and dress featured at the heart of women’s wickedness. Citing Proverbs xi, ‘As a jewel of gold in a swine’s snout, so is a fair woman which is without discretion’,5 Kramer and Sprenger declared women perfidious in the tradition of St Paul who, in his Letter to Timothy recorded in 1 Tim. 2:9–12, declared that women should ‘come with shamefacedness and sobriety; not with braided hair, or gold, or pearls, or costly array …’. This chimes with 1 Corinthians 11:6, ‘If a woman does not cover her head, she should have her hair cut off; and if it is a disgrace for a woman to have her hair cut or shaved off, she should cover her head’. Yet the Bible was not alone. The modesty required of women adherents to Islam at one time demanded that they repudiate the wearing of hair tied on atop the head in buns or displaying a side parting. This, it was considered, would be to adopt the style of Western women, nonbelievers, or prostitutes.6 Constructing a bun on the top of the head was likened to creating ‘the hump of a camel, leaning to one side’, and associated with ‘immoral’ women. As for parting the hair on the side, this too was associated with immorality, blasphemy or Western ways. Ultimately, despite such rulings not necessarily being immutable, controls over how

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women’s hair is worn may remain. Hence one authority surmises that the prohibition on side partings and buns arose from such styles ‘having been a fashion unique to [unbelievers] and immoral women at one time’. Once the fashion ceased to be exclusive to certain women, the ban against hair being worn in this way ceased. Nevertheless, according to this same authority, a plait worn to one side and hanging down a woman’s back, or hair pulled back into a bun or tress at the nape of the neck, is acceptable, but only if covered by the hijab.7 The same would follow for head hair, however worn, so long as the hijab is obligatory apparel. The law has not been immune from characterising women’s hair as signifying malevolence, wickedness or looseness of character. Judges considering the status of woman-as-witch tapped into the hair-as-signifierof-evil trope, too. In 1599 the English judge Sir Richard Martin surmised that the hair of a witch ‘could not be cut off’,8 and centuries later this trope was followed by a deliberate albeit contradictory shearing off women’s hair, they being charged with having collaborated with the enemy during the First and Second World Wars. Meanwhile, religious demands that women’s hair be ‘not seen’ in public or in the church, synagogue or mosque conformed to St Paul’s diktat. Christian women were compelled to wear hats to church on Sundays, Jewish women must wear wigs covering their real hair, and the donning of scarves by Muslim women remains culturally or, for some, religiously required. As for hair being a feature of women’s beauty, this leads to timeless public concentration, boosted by the media, encompassing gossip and celebrity magazines, television, Hollywood, Cannes and the BAFTAs, and social media in all its permutations. Marilyn Monroe’s blondeness accompanies remembrance of Greer Garson’s flaming red hair, with a digression into royalty-as-celebrity with Diana Spencer’s fringe and hairstyle variations, thence to Kate Middleton’s lanky locks and Meghan Markle’s deliberately dishevelled ponytail, on to television land and Jennifer Aniston’s hair of many colours—the ‘poker straight brown, brown curls and waves, black streaks, flaming brown …’,9 then back to earlier Hollywood and Lauren Bacall’s ‘dirty-blonde hair … worn in [the] deeply-parted waves she insisted on doing herself’,10 and salons offering hair styled short, hair styled long, quiffed side partings, full-bodied curls and finger waves, elegant up-dos, wisps, tufts and waist-length manes. This in turn emphasises the historical use of heat, cold, vinegar, lemons and lemon juice, dyes and potions for altering or enhancing women’s hair colour, curls or straight strands, whilst the recent glorification of

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greying phenomenon has prompted a move from the traditional coverup to the flaunting of it.11 Yet perms, hair-straightening and ironing, curling, extensions and other hair enhancements give rise to risk, danger and damage, promoting litigation against hairdressers, dye-manufacturers and producers of hairdressing equipment. In addition to civil wrongs including false and misleading advertising, these prompt criminal activity and prosecution, too. An Australian report confirms the gaoling of an airport baggagehandler who combed women’s luggage for hair from brushes and clothing, amassing some fifty samples neatly packaged in plastic. This earned him a maximum two years’ imprisonment.12 In the United Kingdom, cutting off a woman’s hair is recognised as actual bodily harm. In DPP v Smith,13 Mr Smith’s ex-girlfriend went to his house and, discovering that he was asleep in bed, went upstairs to his bedroom. Upon her waking him, Mr Smith pushed her down on the bed, sat on her, grabbed her hair (which she wore in a ponytail), and cut it off. Apart from the push and ponytail grab, the cutting of the hair was the sole physical attack. The ex-girlfriend bore no bruises, scratches or cuts. Nor was there evidence of psychiatric injury, although she experienced emotional upset and distress. Mr Smith was charged with ‘assault occasioning actual bodily harm’ under Section 47 of the Offences Against the Person Act 1861. The magistrate held there was no case to answer, deciding that the cutting of hair did not constitute ‘actual bodily harm’. As there was no charge of common assault, Mr Smith went free. However, the appellate court decided otherwise. Relying on earlier decisions14 the court said that actual bodily harm requires no ‘evidence of external bodily injury’, nor a break in the skin’s surface, nor a bruise. Sir Igor Judge, president of the court, went on to remark that hair is ‘an attribute and a part of the human body’.15 Even if the hair above the scalp’s surface is ‘no more than dead tissue’, he said, ‘it remains part of the body and is attached to it’. Whilst so attached, ‘it falls within the meaning of “bodily” in the phrase “actual bodily harm”’. It concerns the individual victim’s body: It is intrinsic to each individual and to the identity of each individual … [An] individual’s hair is relevant to his or her autonomy. Some regard it as their crowning glory. Admirers may so regard it in the object of their affections.16

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There was no suggestion that Mr Smith did anything with his victim’s hair other than cutting it. However, reports from India, Kashmir and Myanmar confirm haircut crimes that do involve more. Gangs and lone thieves lurk in alleyways or blatantly accost women on the street. Similarly, police in Venezuela warn of gangs roaming the malls and stealing women’s hair at gunpoint. Women and men known as ‘piranhas’ focus on long-haired women in Maracaibo shopping centres, stalking them, then forcibly chopping off their hair or demanding they tie their hair into a ponytail before the scissors relieve them of their locks. Once having departed the victim’s head, the hair is sold for $US 600–$US 800 depending upon length. It ends up as extensions matched to the colour and texture of the new owner’s hair.17 Although hairdresser and beauty salons are generally regarded as havens of calm and tranquillity away from the world’s hurly burly, even a substitute for expensive counselling and advice, a client may wonder about the possibly less peaceful origin of the hair being affixed to her head as extensions. Setting this prospect to one side, salons can be places of peril in other regards. Despite the absence of ‘HazMat’ signs, water, chemicals and electrical equipment are a treacherous combination. Just as for supermarkets and shoppers, clients face slipping on damp floors, with the added danger of hair remnants, soap-suds or gels and other slick substances. Yet this is the least of the risks. Dyeing, bleaching, washing, conditioning, braiding, weaving extensions into the hair or applying adhesives to fix them to the scalp, and even cutting or trimming can lead to disaster—for the client and the salon. Generally, hair salons test dyes on clients at least 24 hours before appointments, yet such testing is not infallible. From the United Kingdom, to Australia, to the United States, to China, salons are sued, sometimes successfully, sometimes not, where hair ‘snaps off an inch from the scalp’ after bleaching, causing the loss of extensions plus depression and humiliation, ‘falls out in clumps, … turning into a “mullet” after a poor dyeing job’, or a ‘severe allergic reaction’ leaves the client ‘with swollen eyes and burns covering her face’.18 A plan to go forth with ash green tresses gently framing the face goes awry when a client, visiting a Sichuan salon, undergoes four applications of the dye, only to ‘become bald and experience burns on her scalp …’.19 In New York, an aspiring Brazilian model has a photo-shoot cancelled as, in spite of anticipating emerging with ‘spectacular hair that would help launch her modelling career’, she loses her ‘golden locks’, winding up ‘with a

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disastrously scorched, patchy head’. An appointment stretches into eight hours, commencing with the client suffering ‘stinging’ as if fire or hot pepper were being ‘rubbed into her head’ albeit the potion used is a ‘natural organic product’ applied to hydrate the hair. Then, her hair begins to fall out, wisps then strands spreading around her. Tendrils fall, burn and crumble about her feet when a straightening iron is used on her bangs. The would-be supermodel looks in the mirror. The result? ‘Freaking out’, going ‘into shock’, then suffering ensuing ‘physical and emotional trauma’. Her hair and scalp ‘burned, her modeling plans ruined, and she cannot show herself publicly’. In short, runs the law suit, ‘she looked like a “monster”’. It could be six years, an expert says, ‘before her thin hair and chronically greasy scalp return to normal’.20 In 2018 a woman was reported as suing a beauty salon for £1 m claiming ‘her hair treatment caused her a life-changing stroke’. Lawyers alleged that during a £200 ‘cut and colour’, their client’s hair was washed six times ‘to get the colour right’. This saw the client ‘collapse from a condition described by experts as “beauty parlour syndrome”’. The ‘impact of the sink on the back of her neck’ led to the stroke, ‘turning her life upside down’, leaving her not only in social isolation, but ‘isolated from [her] own body’. The 47-year-old nurse, treated to the visit by her husband, ‘left the salon with a headache’ she attributed to going without eating during the lengthy appointment. However, the following day ‘she lost her sight and felt dizzy’, then passed out. She said doctors at St John’s Hospital, Livingston, told her she had suffered a stroke which her solicitors argued resulted from ‘dissection of the vertebral artery – a clot caused by trauma in the neck which stops blood getting to the brain’. With no family history of strokes, this mother-of-two was left unable to drive, she could not work, the family home was sold, and she ‘struggles to speak, read and write’, her independence lost entirely. The claim is that the salon staff failed to ask their client to attend for a hair ‘strand test’, which ‘would have prevented the need for it to be re-washed six times’. The salon is said to have been negligent ‘by failing to offer her a front-facing sink or to provide neck protection during the treatment’.21 In such a case, both direct liability on the part of the salon is central to a claim, as well as vicarious liability coming into play. The construction of the salon, including the style of the sink, would be advanced as the direct responsibility of the salon. A claim might also be launched against

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the manufacturer of the sink, on the basis of its being unsafe and ‘responsible’ for the stroke. What brings vicarious liability into the equation is the stated failure of staff to have the client undergo the hair ‘strand test’. If such a failure can be proven on the balance of probabilities, together with establishing a causal relationship between the failure and the client injury, the question then becomes one of whether the salon itself bears responsibility for staff error. If the staff or staff member responsible come within the category of ‘employee’ or are working in a capacity ‘akin to employment’, the issue is one of whether what the staff did—or, here, failed to do—was a result of activity being taken by them on behalf of the salon owner or operator. Was the staff’s activity a part of the business activity of the salon and was the staff member or members under the control of the salon owner or operator.22 If so, liability is established and the salon is answerable. Contributory negligence could apply where a client who knew she should undergo the strand test went along with the staff oversight, happy to avoid that step. This would affect the level of damages or compensation, reducing them consistent with the percentage of the negligence attributed to her fault. Styling products and a vast range of hair treatments employ chemicals, requiring careful monitoring particularly of the length of time they are left on the hair. Damage to hair or head caused by the application of shampoo, conditioner, mousse, dyes and other hairdressing paraphernalia raises issues of liability. Because clients’ reactions differ, some may be allergic to individual products or particular chemicals. Burns to the scalp and other injuries can result from treatments reacting against the client’s skin or hair. Allergic reactions can follow on failure of hygienic practices by salons or hairdressers, with diseases or rashes transmitted from one client to another. Bald, scaly patches on the head can be caused by scalp ringworm, and painful skin blistering results from impetigo. Dermatitis is painful and recurring, whilst influenza and other viruses and even Hepatitis B or C, or HIV/AIDs can be spread by failures of cleanliness and lack of sanitising brushes and combs. Salons need to take care not only with equipment and products and the premises as a whole, but must ensure staff maintain their own bodily cleanliness and health regime. Health and safety regulations must be followed scrupulously, with attention paid to the chemical components in so many beauty products. Not only hair and heads can suffer damage. Chemicals can cause eye injuries, too. Meanwhile, the simple act of cutting and trimming hair can be hazardous, blades slipping to nick or cut neck, scalp or ears, generating

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their own scramble of litigation. Cuts can cause harm beyond the cuts themselves, through potentially generating an exchange of bodily fluids. In An Introduction to Beauty Negligence Claims ,23 Greg Almond cites a case where general damages (for pain and suffering) were awarded in the amount of £7250 (in 2020 currency levels £9750). In Smith v Hair Associates the injuries were not only physical but mental or emotional, a combination likely to follow a vast number of such claims, if not all. Perhaps understandably, where the harm included chemical burns to the scalp and permanent patches of baldness, the claimant suffered psychological damage and mild adjustment disorder, for which cognitive behavioural therapy (CBT) was recommended.24 This case involved a failure to carry out a patch test where 17-year-old Ms Smith sought a half-head highlights treatment, something she had previously had done at a different salon. The procedure involves applying highlight solutions and foils to the hair, with the hairdresser beginning from the back of the head. Ms Smith immediately suffered a burning sensation and, reaching back, found the foils were extremely hot. Despite her request that the hairdresser pause and remove the foils, the hairdresser continued with the process, assuring her that all was well. When with the continuing application the burning sensation did not cease, but increased, a second request to ‘stop’ was obeyed. The hairdresser herself then apparently experienced the foils as being overheated. The evidence was that she began removing the foils, then donned gloves to continue taking them from Ms Smith’s hair and head. After the solution was washed out, Ms Smith felt patches indicating to her that clumps of her hair were missing. The salon manager, called to address the problem, assured her that all was well, instructing the hairdresser to continue to dry and style the hair. Later that month, and suffering pain and blistering, Ms Smith visited her medical practitioner who diagnosed burns to the scalp and loss of hair. Referred to a burns specialist, she underwent a skin graft. This required many operations and left her with horizontal scarring on the back of her head. It was unclear whether the damage was caused by the products or lack of care in handling them.25 The salon alone was proceeded against and accepted liability. However, in accordance with the principle established in Donoghue v Stevenson,26 liability can lie with the manufacturer of hair products, as with beauty treatments. Furthermore, in accordance with Watson v Buckley and Osborne, Garrett & Co Ltd (Ogee), distributors of these products can be liable, too.27 This covers not only products employed by professionals in salons or at clinics or spas, but products

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used at home. Users can suffer hair loss, delayed regrowth or permanent loss of hair, and painful reaction to chemicals in hair products. Reaction to hair dye can involve burning or blistering of scalp or skin, particularly the neck area, swelling to head, face or eyes, and flaking or itching of the skin, often causing rashes or swelling. Although it related to shock and gastro-enteritis rather than any of these conditions, Donoghue v Stevenson, a landmark case, illustrates the way liability is established as against the manufacturer. Here, the manufacturer of ginger beer, Stevenson, was liable to Donoghue, a consumer, when a foreign object found its way into the manufacturing process.28 The ginger beer was bottled in opaque glass. Mrs Donoghue did not realise until the last of the contents were poured out that a snail in an advanced state of decomposition inhabited the bottle. Stevenson argued against liability for the harm suffered, denying there was any relationship between the company and the consumer. A friend, and not Mrs Donoghue, had purchased the drink at the café where they sat enjoying company and conversation—at least, until the desiccated snail appeared. This meant that Mrs Donoghue had no action in contract. Accordingly, Stevenson contended that she had no remedy. The House of Lords held otherwise. As the manufacturer, Stevenson’s expectation was that persons such as Mrs Donoghue would consume the product—after all, that was the purpose of producing ginger beer for the market. Hence, Stevenson owed a duty of care to Mrs Donoghue under the ‘neighbour’ principle. If a fault in production caused injury to her as a consumer, this was a breach of that duty and Stevenson was liable to her in negligence for her injuries. Albeit Caparo Industries Plc v Dickman has effected some modification of this rule,29 the principle remains. If it is ‘fair, just and reasonable’ to find a duty of care lying between the parties, and there is a sufficiently proximate relationship between them, the manufacturer will be liable for harm their product causes. As for product distribution, in Watson v Buckley and Osborne, Watson, a hairdresser, contracted with Ogee Ltd, the distributor, to purchase hair dye. Without testing the dye, Ogee assured Watson that it was ‘perfectly safe’. Watson had requested that the dye contain no more than 4 per cent chromic acid. Unfortunately, it contained 10 per cent chromic acid, a failure in the manufacturing process. In using the product, Watson developed dermatitis, and sued Ogee. The initial negligence lay with the manufacturer in making a production error in percentage of chromic acid

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in the dye. However, Ogee’s failure as distributor to test the dye or otherwise take steps to ascertain the acid composition or product safety, meant that liability extended to them. A duty was owed to the end user, in this case Watson. Ogee were careless in promoting the dye as safe. Ogee could not argue a lack of liability simply because they were not the manufacturers so were not the original creators of the negligence. Just as the manufacturer in Donoghue v Stevenson knew and intended that the ginger beer was to be consumed, Ogee knew and intended that the product they passed on was designed for use by ‘end users’. Their duty of care included the necessity of taking reasonable precautions to ensure that the product was safe. Failing to do so rendered them liable. Here, if the skin condition had developed on one of Watson’s clients, Watson would have been in the position of the café that sold the ginger beer to Mrs Donoghue’s friend. Albeit a contractual responsibility could arise, liability for negligence would not fall upon Watson as the hairdresser, but upon Ogee as the distributor—as well as upon the manufacturer. This picture is matched in other ways by the beauty or hair product that fails to live up to its promise. Although it may not result in injurious damage and harm, promises of golden glory, shining brilliance or long-lasting colour and conditioning can fall short. False, deceptive or misleading advertising is a problem not only in the pharmaceutical industry, but with hair, cosmetic and beauty products. The prevalence, possibility and even probability of false promises is such that generally these are covered by consumer or trade practices law. The Australian regulatory system is contained in the Consumer and Competition Act 2010 (Cth),30 whilst in the United Kingdom Consumer Protection from Unfair Trading Regulations governs the conduct of advertisers.31 In the United States, deceptive advertising, misleading labelling and similar practices are covered by state and federal laws. The Federal Trade Commission Act 1914, the Food, Drug and Cosmetic Act 1938 and the Uniform Deceptive Trade Practices Act 1966 are a clear source of authority for taking action where beauty and cosmetic industries engage in promoting their products as able to achieve miracles or other unrealistic transformations.32

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Oh! My Face … a Retroussé Nose & Pinned Ears

False advertising is prevalent when it comes to body image. Nowhere has the clamour for youth and youthful beauty been more pronounced than on the face. Male faces, like women’s, age. Oscar Wilde’s The Picture

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of Dorian Gray (published initially in the July 1890 issue of Lippincott’s Monthly Magazine) captures well the desire to remain youthful, at the cost of selling one’s soul to the devil. Yet though men, like women, may seek eternal youth not only in fiction, the passage of years has greater implications for women than for men. Older men remain attractive in conventional terms, nowhere more visibly than in film. Examples abound of actresses playing mother to actors who are of or about the same age, or even younger than their ‘sons’. In Forest Gump, Sally Field (born 6 November 1946) played Tom Hanks’ (9 July 1956) mother. The eleventh Star Trek movie (2009) saw Winona Rider (29 October 1971) ‘mother’ Zachary Quinto (2 June 1977). Perhaps the apotheosis of this Hollywood ‘woman:ancient, man:youthful’ message occurred in the Alexander biopic, with Angelina Jolie (4 June 1975) playing mother to Colin Farrell (31 May 1976). No elixir of youth yet having been discovered, plastic, cosmetic or aesthetic surgery is called upon to undo the ageing process or at least disguise it. Facial reconstruction is not new. From before and after the time of ‘The Man in the Iron Mask’ (c. 1640-19 November 1703), when speculation arose as to precisely who it was behind the mask and whether the mask was to conceal identity or degenerative features,33 various methods have aimed at making the face young or reconstructing it to cover up flaws or time-related changes, including disease as well as ageing. In this renovation, the nose features prominently alongside cheeks, cheekbones and facial skin, as do ears. In the nineteenth century sexually transmitted diseases resulted in nasal damage. Syphilis could be injurious to adults who engaged in unprotected sexual intercourse. It also created secondary victims, babies being born with damaged noses or even without a nose at all. In his major work Making the Body Beautiful Sander L. Gilman recounts the ‘cultural history of aesthetic surgery’. He references the work of Viennese practitioner Johann Friedrich Dieffenbach, who made his name pioneering ‘repair and replacement’ of body parts, including the nose. Flattened or depressed nasal tips were built up through employing external excisions that reconfigured the skin. A flap of skin from an arm was partly sliced, the arm raised to face height, and the flap attached to the nose. This meant that blood and nutrients remained passing through the flap, so that the graft had a high chance of success. The flap was severed from the arm and wholly stitched to the nose, once the graft had ‘taken’. Dieffenbach also proposed a ‘gold

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bridge’ to repair sunken noses, although the only known instance of this operation was satisfactory until the bridge began to shift, going from right to left, then collapsing altogether into the nasal sinuses.34 Later surgeons such as Harold Delf Gillies saw that it was not only the outer flesh of the nose and the bridge that affected sunken and otherwise defective nasal organs. The mucous nose lining was recognised by Gillies as essential to nasal construction, its absence through disease being part of the problem. The grafting of a new epithelial lining into the new nose meant lifting the nose from the face so that the lining could be incorporated, then stitching the organ back into its original position.35 This early surgery targeted flapping or ‘bat’ ears, too, although ears presented far less difficulty. Cartilage could be removed from behind the ears so as to shorten the distance from skull to the body of the ear, the remainder then stitched flush against the skull. Where they reached major wagging proportions, lobes could be trimmed before stitching the remaining cartilage flat. Yet not only disease dictated surgical interventions. Cultural expectations or notions of what is normal led to people of particular ethnic or race backgrounds seeking out surgeons for aesthetic reasons. The flat broad nose associated with Africa, the long or pendulous nose fitting into an anti-Semitic trope, the snub or sunken ‘Oriental’ nose all required ‘correction’ so that their owners could fit expectations of ‘normality’. The dominance of the Western or Caucasian stereotype dictated surgical correction so that long noses were shortened, flat noses built up by raising bridges, short noses extended by the addition of cartilage. Today, rhinoplasty is a cosmetic surgical intervention commonly sought after. The American Society of Plastic Surgeons calculated numbers of rhinoplasty operations increasing between 1997 and 2005 by almost 47 per cent.36 In 2013 rhinoplasty was rated as the fifth most common cosmetic surgical procedure worldwide, ‘accounting for 8.8% of the total surgical procedures globally’, with ‘an increase in the diversity of demographics seeking the procedure across ethnic, gender, age and socioeconomic backgrounds’.37 Pinning of ears is also high on the list of cosmetic surgical interventions, although it may now be so common as to raise little attention— unless something goes wrong. So long as ears are flat to the head, they are relatively innocuous, albeit studs and earrings, sometimes in multiples, can make them a spectacular feature. However, noses do go through fashions. The straight Roman nose has been seen as handsome, as has the aquiline nose—although not when gracing women’s faces. Rather, the

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retroussé nose has been a ‘must’ for women, the small, upturned nose, or one ‘shapely’ and ‘tip-tilted’ giving an edge to those seeking an acting career or more broadly show business success. There is a history here, for as far back as the sixteenth century according to Agnolo Firenzola (1493–1546) this was the favoured contour, albeit the upturn should be modest, not too exaggerated. Neither, however, should the nose tip ‘drop’. Declaiming upon the ‘Beauty of Women’, Firenzola pronounced that the profile was equally important as face-on appearance: … besides being of a proper size [the nose] must be narrow rather than wide, and taper from the top to the base … and at the tip should turn up very little and stand out as it were in relief; colored but not red; with an almost invisible line marking the boundary of the two nostrils, which at first must rise and then softly slope away and finally end, diminishing both at the same line.38

Contentions that women have undergone rhinoplasty to make themselves more attractive (whilst if admitting it, women are minded to assert that the operation is to make them feel ‘normal’) arise in discussion of Marilyn Monroe and more recently Marie Osman, Jada Pinkett Smith, Scarlett Johannsson, Meghan Markle …39 Yet everyone seems to end with the same nose shape, small, shapely, tip-tilted, upturned (though only slightly). One of the first to announce with great fanfare that she was to subject herself to ‘a nose job’, the Australian stage performer and one of Australia’s first television stars, Dawn Lake, had her straight nose altered to conform to just this shape.40 Perhaps because she went from an exceedingly straight nose to the upturned tilt, a pronounced change, she considered it necessary to make it public to avoid scoffing or speculation. She gained an ordinary nose of the standard manufactured type, and great publicity. Fortunately, nothing went wrong. This was not so, however, for Mrs Mijin Zahir who was unhappy with her ‘new’ nose immediately after she saw it. The surgeon undertook revision surgery but neither this, nor three subsequent operations (carried out by a different surgeon) mollified her. Mrs Zahir did not, however, succeed in her claim. In Zahir v Vadodaria 41 the court said that the question to be answered by expert witnesses and hence by the court was ‘whether the surgical technique used was acceptable’. That was the measure to determine liability, not whether the patient was or was not satisfied.

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In Making the Body Beautiful , Sander L. Gilman observes that the impetus to change one’s nose was not invariably associated with fame and celebrity or seeking them, or appearance for appearance sake, but addressed racism and notions of morality. Thus, he says, angst associated with changing the shape of the nose ‘was rooted in notions of the permanence of racial markers’. Miscegenation lay at the heart: In early twentieth century discussions of ‘mixed races’, it was often the ‘impure’ physiognomy that gave a clue to the decline of the pure races … In the United States and in Germany, where ‘racial mixing’ had resulted in ‘mixed-race’ individuals with perceived qualities of both races, there was a constant anxiety about having ‘black’ or ‘Jewish’ features. To be seen as ‘mixed race’ was to be seen as being of lower moral character.42

This did not, however, dictate wholesale attempts to rejuvenate the face in its entirety. Although facial reconstruction received a major impetus as a consequence of harrowing damage to the faces of soldiers wounded in battle during the First World War, the desire to halt the ageing process has been pre-eminent for many women. Facelifts first concentrated upon the skin. This approach addressed sagging, tired-looking and wrinkled skin comprising folds, furrows and grooves as the most evident sign of ageing. It is no surprise that the remedy was seen as pulling the skin tightly back behind the hairline and stitching it firmly. This meant that stitches were hidden behind the ears and could be covered by the hair. Bobs conveniently concealed scars where the wrinkles were removed from the forehead, and curls could be arranged to cover scarring from drawing the skin of the cheeks back towards or even behind the ears. Suzanne Noel is one of the earliest recognised plastic surgeons who worked on women’s faces. The foundation of her knowledge and practice was her experience in training with the facial reconstruction team working to recover or improve the often seriously marred looks of wounded soldiers.43 For Noel’s clients, beauty or regaining youth for reasons of vanity was not always the impetus. Women who had found independence through moving into fields formerly occupied solely or mainly by men were at risk of losing their jobs to demobbed soldiers returning from the front. The imperative to remain youthful or at least youthful looking in order to retain employment was a strong incentive to seek out Noel’s skills. This followed, too, for women making their name on the stage or in the

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escalating film industry. Suzanne Noel promoted her work by emphasising that ‘looking younger’ or ‘looking better’ meant that women were energised, regaining joy in life and the feeling of being wanted in the workplace as well as being desirable as women. She said that aesthetic surgery was a procedure to be ‘highly respected’ and that its ‘moral worth’ should be ‘favoured everywhere’.44 However, the technique had its limitations. Skin can be stretched only so far, before a woman takes on the visage of a china doll or, worse, finds her features settled into a rictus grin, ordinarily the consequence of facial muscles contracting when the body is gripped by tetanus or strychnine poisoning. Skin also loses its elasticity when tugged and pulled as required to remove the sagging, and can eventually become wafer-thin. This makes it more susceptible to wrinkling and drooping. Thus, albeit the second facelift by this method can be longer lasting, with a lengthier time before flaccidity or ‘bagging’ appear, the loss of skin elasticity means that the procedure can set up a cycle of stretch and pin, sag and droop, stretch and pin, sag and droop. Eventually, those subjecting themselves to what at first appears to be a rejuvenating process find they are not only ageing, but their appearance is worse than had they simply let nature take its course. Surgeons began raising doubts about the longevity of the results. A reassessment of the practice led to the recognition that the surface skin was imprinted with a problem that lay deeper. The face comprises ligaments and muscles, and it was here that the next steps were taken. The new technique was applied beneath the skin, Tord Skoog leading the change with his landmark work, Plastic Surgery: New methods and refinements, published in 1974. Skoog posited that the fibrous tissue and muscle lying beneath the subcutaneous fat immediately below the skin of the face should be the target of surgeons seeking to ‘tighten’ and render more youthful looking the faces of their patients. A student of anatomy, he recognised that it is not only the skin that ages, but the layers of flesh, muscle and fibre that create the face. Firm, youthful muscles and fibres are a significant part of the foundation of the flesh of the face. As they grow slack with age, this underlying laxity both matches and underpins the sagging of the skin.45 This was not, however, the full answer. Osteoporosis or ‘bone loss’ produced the final answer for plastic or aesthetic surgeons seeking to cater to clients who wished to stem facial ageing or, in reality, disguise it. The face is attached to the skull and most specifically to the bones that surround the cavities that hold the eyes and mouth and the lesser

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nasal cavity. Bones shrink with age and some wear thin, lessening their capacity to hold up the tissue, muscle and fat comprising the face. The new technique built on this understanding, with the advantage of less risk of nerve damage being caused through operating solely on the fibrous tissue and muscle. On the other hand, the technique requires superior skill and advanced training. Rebuilding bones, incorporating fatty tissue or injecting paraffin wax is a specialised technique. This means that those who are less skilled may stay with the fibrous tissue and muscle approach, albeit it requires its own dexterity and ability to circumvent the nerves of which there are many in the facial area. It means that those without the requisite expertise may venture into this more complicated field of surgery, with its own consequent risk.46 Each facelift technique has its own hazards, from the stretching of the skin, to the focus on the underlying layer of fibrous tissue and muscle, and thence to the bone structure and attachment of the facial flesh of skin, tissue, muscle and fat. Nerve damage is one of the principal risks. It can cause relatively minor discomfort including numbness, tingling or mild though persistent pain. However, it can also result in paralysis, lopsidedness, sagging or weakness of muscles. During the operation, a failure to separate the tissues accurately or ensure skin flaps have a sufficient blood supply through the procedure, or any delay in stopping bleeding all have potential consequences. One of the worst outcomes can be necrosis of the skin, a result of late diagnosis of blood leaking around the sutures. Clots can be removed, but this involves going into the seamline of the cut, which has its own dangers. Wounds can suppurate, where carelessness results in hair getting into the surgical lesion. Hypertrophic scars are relatively rare, however, tension on the seamline and skin that is susceptible to scaring can result in unsightly marks, blemishes or pockmarks. Pigmentation of the skin is another possibility, as well as the contours of the face being deformed or asymmetrical. The loss of hair follicles can be permanent, causing patches of baldness requiring restoration by further surgical intervention. Though risk of infection is low, this can occur with minor or major consequences depending upon its severity and how soon it is addressed. Even where non-surgical interventions such as laser treatment are selected to avoid cutting and anaesthetic (which has its own danger), the operation can fail.47 In the midst of speculation as to whether this ageing film actress or that, this older supermodel or that, this maturing celebrity or that has submitted to the knife or taken up other anti-ageing techniques,

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horror stories centred on plastic surgery gone wrong abound. The ubiquitous facelift is the source of many stories of catastrophe or failure. Aggrieved patients come from a variety of backgrounds and ages, for albeit the facelift was conceived as a remedy for the older woman to recover her past bloom, what is today considered as requiring an injection of youth is malleable. Not only well-known personalities or those categorised as famous may seek out plastic surgeons, nor be distressed by the outcome. Whether the distress or damage to the face—generally the most visible part of the body and that upon which human identity is so often founded—can be compensated for by monetary awards may be dependent on its level of seriousness. In the 2000s, the UK damages awards for facial scarring range from £1000 to £2200 for minor scarring, to a maximum of £62,000 for severe scarring for women (as opposed to £42,000 maximum for men). Between these ranges, scarring visible from a short distance warrants compensation in the range of £11,500–£19,500 for women (as against £6000–£11,500 for men).48 An alternative is to seek remedial treatment, yet this may be unable to repair or undo the damage and can even exacerbate it. Assessments of post-surgical satisfaction are variable. Various measures are employed, with the risk of possible cultural bias in their constituent parts and in their application. The World Health Organisation Quality of Life (WHO-QofL) is an assessment method designed to measure a person’s positive satisfaction taking into account variables including socio-economic status, subjects’ cultural and political systems, objectives, expectations, standards and concerns. Physical health, psychological wellbeing, social relationships and environment are included. As an example of outcomes, Seyed Jaber Mousavi et al. report that cosmetic rhinoplasty ‘is believed to have a remarkable effect on a patient’s physical and mental health when investigated from an evidence-based medicine approach’, bearing in mind both objective and subjective outcomes.49 They found satisfaction in their Iranian patient cohort six months after the operation. At the same time, they observed that previous studies of Iranian rhinoplasty patients showed ‘a variety of outcomes ranging from positive to negative quality of life’, with one study suggesting that rhinoplasty surgery was ‘not found to have any beneficial impact on mental health’, whilst others suggested ‘a reduction in quality of life post-rhinoplasty surgery’. They quote similarly for studies conducted on patients outside Iran.50

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Quality of life measures cannot be limited to those who, having undergone facial surgery for aesthetic reasons, return to everyday life with what might be seen as enhanced features. As the phenomenon of seeking facial beauty or recovering youth, or simply wishing to ‘look normal’ has a global reach, it is unsurprising that stories of botched surgery or non-surgical interventions are international. Hence, the tale of the 40-year-old woman from Wales who lodged a claim for personal injury against a cosmetic surgery clinic in Belgium, listing lack of symmetry on the left side of her face. Numbness and scarring, prominent around her ears and eyes, had to be hidden by her hair which she grew long for this purpose, she said, adding that she was ‘now too embarrassed to be seen in public’. The Elyzea Cosmetic Surgery Group, with offices in Paris, Utrecht, Manchester, London and Brussels denied liability whilst considering they ‘had a moral responsibility to try to put things right’. Saying that the Surgery Group ‘provides aftercare to correct errors’, the spokesperson added that generally patients ‘are not reimbursed’.51 In one of the more unusual cases of litigation in which complaints range from curious to the horrifying to the bizarre, an Australian woman dissatisfied with the results of facelift surgery lost her Queensland Supreme Court appeal. Litigation centred around the woman’s claim that the facelift had been substituted for a ‘tummy tuck’. Admitted to hospital for the abdomen operation, one hour before it was to take place the woman was advised by the surgeon that it could be ‘life threatening’ and he refused to do it. She claimed he then offered a ‘full cosmetic facelift and eyelift’ so long as she agreed to the new operation being undertaken for the same price as the tummy tuck, which she had prepaid, and going ahead on the original schedule. In consequence of her unhappiness with the outcome, the claim went first to the Health Quality and Complaints Commission, then to the Australian Health Practitioner Regulation Agency (AHPRA), next to the Queensland Civil and Administrative Tribunal and finally to the Supreme Court as a negligence claim for damages for personal injury. The judge dismissed the claim on the basis of delay and identified flaws in the case.52 Meanwhile, in Taiwan, a botched facelift which ‘burned from the inside out’ left the client, in her 50s, suffering ‘horrific blisters’. She suffered second-degree burns at a Taipei clinic which employed a ‘non-invasive’ procedure, Thermage treatment. Using patented radio-frequency technology, the treatment applies heat to the skin’s deeper layers in order to smooth, tighten and contour the skin through causing existing collagen

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to contract and encouraging growth of new collagen. Usually the procedure takes between 30 and 90 minutes, however after an hour the woman ‘experienced a sharp pain on her face’ then blisters appeared, growing to ‘horrific’ size. She sought hospitalised medical help. Despite treatment for the burns, her face was left ‘covered in dark scars’ from the burn wounds. Two to three months were noted as being required for the condition to settle before corrective treatment could be undertaken at another clinic.53

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Around the Eyes & Rounded Eyes …

The eyes are the window to the soul. Banal though the saying may be, it has a universal resonance. Eyes have a special place in both the history and the present of cosmetic surgery. That women are daily subjected to ‘the male gaze’ dictates to a large extent how women are seen. This in turn has implications for how women see ourselves and the expectations this places upon a woman’s upkeep of her body. Thus, Elizabeth I maintained her standing not only because of her perceived strength in matters of state and personal life, but through adopting stratagems to preserve her appearance. This included face paint and wigs, she being ‘firmly of the belief’ that ‘the eyes of her people would not so easily discern the marks of age and the decay of natural beauty’.54 Contentions as to what is ‘natural’ and what ‘beauty’ are not only dictated by age, however. Cultural, social and economic expectations, deriving from the ethnocentric idea that ‘Western’ is ‘better’ than ‘Eastern’ mean that a considerable aesthetic element based in negative notions about the shape of eyes infuses cosmetic surgery and other beauty treatments on the eyes. Edward Said’s conceptualisation of ‘Orientalism’ as an assertion of superiority on the part of Western nations and a patronising representation by the West of the countries and cultures of the East (constituted by Asia, the Middle East and North Africa) highlights the issue generally.55 Although ‘the East’ is romanticised, with Western fashion often appropriating clothing and artefacts from China, Japan and other ‘oriental’ nations, racism and ethnophobia impact negatively on people who are genuinely from those countries or who have their familial origins there. The eyes are the physiological feature primarily seen as signifying Eastern ethnicity. Charles Darwin’s view that the ‘obliquity of the eye … proper to the Chinese and Japanese’, was exaggerated so as to emphasise ‘Eastern’ beauty and contrast it with ‘the eye of the red-haired barbarians’56 is no longer fashionable. Rather, enthusiasm to reconstruct their

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eyes so as to appear ‘Western’, or at least more so, is dominant. Gilman explains it bluntly: The most commonly sought aesthetic procedures … are nose jobs (rhinoplasty) and eyelid surgery (blepharoplasty). Asian-American women, whose ‘blank’ look is equated in American society with ‘dullness, passivity, and lack of emoting’, have ‘their eyelids restricted, their nose bridges heightened, and the tips of their noses altered.57

Gilman further observes that eyelids found in Semitic cultures are often classed stereotypically as denoting their owner as ‘tired, sleepy, relaxed or threatening’ and even ‘conspiratorial’—an anti-Semitic trope. This, too, can generate the desire to ‘Westernise’ the feature. Importantly, changing the eyes is versatile. It can ‘normalise’ the face in Western terms, can create such a subtle change that onlookers do not detect that the difference has come about through surgery, or can change the whole ‘look’ of the face. This versatility adds to the blepharoplasty statistics. Joanna Finkelstein in The Fashioned Self writes of Korean housewives being a ready market for eyelid surgery, whilst Eugenia Kaw’s research, pinpointing Asian American women seeking cosmetic surgery for their eyes, records the ‘medicalisation’ of ‘racial’ features.58 Surgery to ‘correct’ such eyes—to Westernise or ‘Americanise’ them—involves the creation of a double eyelid, achieved by a non-incision process, although this is only one of some thirty-two procedures developed in Japan to ensure ‘a clear-cut, double eyelid fold’ mimicking Western eyes.59 Similarly in China plastic surgeons have addressed ‘the eye (or eyelid) problem’ using varied techniques. One process developed during the Second World War involves creating a fine scar line, by stitching along the eyelids. The scar gives an illusion of the desired ‘double eyelid’ simulating the supratarsal fold.60 Gilman observes that Vietnam along with Korea, Japan and China ‘reflect the globalization of standards of beauty rooted in Euro-American stereotypes’. The youth ideal is not to be ‘too Asian’. This is expressed by Asian Americans as wanting to fit into what is perceived to be the so-called acceptable American norm, so that: … among Asian Americans in California, double-eyelid surgery has become ‘the gift that parents offer their daughters when they graduate from high school or college’.61

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The perception that ‘West’ is better does not mean that Western women abjure blepharoplasty. One of the highest rates of growth in plastic or cosmetic surgery is associated with drooping eyelids, hooded eyes or overhanging eyelids, or fatty deposits which give the eyes a bulbous appearance. Nor does it all focus solely upon the upper eye, or eyelid. Crows’ feet, wrinkles, lines, or bags beneath the eyes, or asymmetrical eyes, feature, too. These can be a result of ageing, or can be a consequence of genetic make-up. Saving time as well as money, some women have dark lines tattooed on their eyelids—top, bottom or both to mimic eyeliner, obviating the need to apply this cosmetic daily. Eyebrows are also manipulated—Marlene Dietrich and Greta Garbo allegedly shaved theirs, then redrew them as narrow curves. In the 1920s Clara Bow and others plucked and winnowed theirs, giving them a downward look, the angle reputedly making Bow look ‘permanently sad’. The 1950s saw a return to a more natural look, with stars such as Marilyn Monroe achieving this by modest plucking simply to tidy the line. In the 1960s it was back to more severe plucking, yet women of the 2000s are said to follow the fashion of bushy eyebrows a’la Cara Delavigne.62 Yet care must be taken even with eyebrows. Too severe plucking or threading can result in unsightly or unflattering brows, or their being so narrow as to be almost invisible. It takes four to six months for eyebrows to regrow, the length of time being affected negatively by tweezing and waxing, cuts, burns and other damage to eyebrow hair follicles caused by trauma, stress and anxiety, pregnancy, ageing, thyroid disease, harsh makeup or eczema, psoriasis or other skin conditions. Age, also, can affect regrowth and as eyebrows tend to become less distinct with ageing, artificial measures should be taken with care.63 Yet whatever can go wrong with eyebrows, it is the eyes which require most tender care. Every organ of the body is precious, yet the eyes are extremely susceptible to harm. Here, the slip of the tweezers or tattooist’s hand or equipment, or that of threaders, can cause untold damage leading to negligence claims. Blepharoplasty is generally a day procedure, the operation on the upper eyelid taking up to an hour, that on the lower lid taking up to two hours. A blepharoplasty to correct, repair or enhance the upper eyelids requires an incision to be made along the crease of the eyelid, where the skin folds naturally. Excess muscle, skin or fat is removed surgically, then the cut is closed so as to hide the scar in the eyelid’s natural fold. As for lower eyelids, similarly cutting is required, this applied on the skin below the lower lashes or the inside of the eyelid. Small amounts of skin may

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be cut away, the main target being removal of fat from bags under the eyes. Some operations require the inclusion of support for eyelid muscles and tendons, and in all cases the usual practice is for suture strips to be applied after surgery to support the eyelids. Up to one week after the procedure, these thin, sticky strips are removed. Temporary consequences include redness, bruising, light scarring and mild pain, with patients being advised to rest away from work for up to a week, wear sunglasses and avoid driving. Other temporary side effects may result, namely difficulty in closing eyes for sleeping due to numb and puffy eyelids, watery eyes which are sensitive and may suffer irritation, heavier bruising with an appearance similar to a black eye, and pink scars that do eventually fade.64 The next category of after-effects can include double or blurred vision—again temporary, and blood collecting under the skin (haematoma) which generally does not need treatment, disappearing after some weeks. More concerning are noticeable scarring and eyes being, or appearing to be, slightly asymmetrical. Just as with any operation, according to the National Health Service (NHS) there is a ‘small risk’ of an allergic reaction to the anaesthetic, infection, excessive bleeding and a blood clot developing in a vein. However, although said to be ‘rare’, more serious problems can follow. Blepharoplasty can result in eye muscle injury, drooping of the lower eyelid so that it sags away from the eye and turns outwards, or the lower eyelid being pulled down so as to show the white of the eye below the iris. In the worst cases, blindness can result although the National Health Service says this is ‘extremely rare’.65 Nevertheless, however ‘rare’, cosmetic surgery to the eyes is not immune from going wrong. The outcome may be one of disappointment because the imagined promise is not there (which can result in psychological problems and repeated trips to surgeons for corrective surgery or repairs) or it can cause lasting physical health problems. A Newcastle case illustrates the risk that side effects said to be temporary may have a greater longevity. There, the woman had undergone gastric bypass surgery, losing 58 pounds. Inevitably, some of that went from her face. Her upper eyelids worried her the most, however, the advice was that she have work done on both upper and lower lids.66 After the operation, her eyes ‘were constantly streaming’, with ‘tears pouring down [her] face when [she] was trying to go to sleep’. Her son, she said, told her she looked ‘weird’ whilst napping and it was then she realised that her eyes remained open

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during her sleeping hours. Both effects are recognised as possible temporary outcomes, yet in this case they lasted longer, giving an appearance of being potentially ongoing. The surgeon and surgical practice resisted any claim, observing that over 7000 patients had undergone a ‘surgical episode’ at the practice during the relevant period (January to December 2014) and fewer than 1.9 per cent of patients ‘felt they had cause for complaint with any aspect of the service’. Only one legal claim was said to have been instituted during that same period.67 Although a general view appears to be that blepharoplasty errors are few, on the other hand patients come forward with concerns they see as serious, despite the medical practitioners’ view that problems are rare. One surgeon acknowledges seeing an ‘unfortunate side effect … far too often with eyelid surgery’, namely ‘aggressive removal of excess skin and fat [leaving] hollows under the eyes or below the brows’. This outcome is acknowledged as ‘very aging and unnatural looking’. The remedy is grafting structural fat ‘to smooth the eye area and fill in hollows’.68 However, as a corrective measure this puts the patient through two operations rather than the one which would have been anticipated originally. Nonetheless, and noticeably, this is not unusual. Where problems identified by patients are accepted as real, generally the surgically recommended remedy is further surgery. Thus, a patient with concerns about eyes that ‘sit too deep in the inner corner and eyelid width is uneven’ is advised that the result, Post Upper Blepharoplasty Syndrome (PUBS) ‘is all too common’. It includes ‘high upper eyelid crease, upper eyelid ptosis, lash ptosis and a compensatory eyebrow elevation’. Lash and eyelid ptosis are medical conditions constituted by ‘drooping or falling of the upper eyelid’, sometimes known as lazy eye. It can be caused by ageing, birth, injury, trauma or infection, muscle weakness, nerve damage, skin looseness above the upper eyelid or a tumour behind the eye or eyelid. In this instance, it is a consequence of surgery and, by that means, possible nerve damage or injury to the muscle during the initial operation. Fixing it would require not simply ‘revision’ but ‘an actual reconstruction’ as the patient’s upper eyelid creases were made ‘far too high’ by the surgeon doing the blepharoplasty.69 Health message boards and blogs are replete with people complaining of what they describe as botched eye surgery, sometimes involving the corrective surgery applied as the remedy.

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For Bee-Stung Lips, Whiter-Than-White Teeth, Receding Chins & Measures Under the Neck

In Beauty and Misogyny, her treatise on ‘harmful cultural practices in the west’, Sheila Jeffreys writes compellingly of the contradictory role makeup plays in women’s lives. She critiques the time taken to apply it, time that might be better spent on activities not requiring the same monetary and potentially emotionally draining investment. Lipstick provides a central puzzle, in that it could be seen as a ‘very strange practice in which women smear toxic substances on their lips several times day’, taking into their bodies ‘an estimated 3 to 4.5 kilos in a lifetime’s use’.70 As Sheila Jeffreys observes, this tends to be regarded as a ‘natural’ activity for women, one that would better be understood as a harmful cultural practice. However, lipstick plays a relatively minor role, today, in the array of decorative and toxic procedures carried out on a woman’s lips. Botoxing, fillers and the phenomenally enlarged lips they spawn once appeared only on Hollywood stars, starlets and celebrities. Now they are an everyday spectacle. Speculation has it that Goldie Hawn, Britt Ekland, Jennifer Garner, Nicole Kidman, Melanie Griffith, Demi Moore, Kylie Minogue and more have had this treatment, even on a regular basis for some.71 Indeed, as with so many treatments or procedures designed to enhance, improve, make more natural or normal, or provide women with autonomous ownership of their own bodies, ‘the look’ can be maintained only by repeated visits to the clinic, spa or salon. Yet the cupid’s bow of the 1920s, with Clara Bow promoting this lip configuration physically and by her stage name,72 is a precursor and has its origins even further back. The chocolate box beauty was juxtaposed against the lipstick phenomenon which was preceded in turn by the use of rouge to redden lips. This chimed with earlier centuries’ assessments of beauty associated with lips carrying an implicit sexual subtext—as illustrated in the famous Dante Gabriel Rosetti portrait of Fanny Cornforth, Bacca Baciata,73 now made explicit by the red dye. Eventually painted lips lost their dubious status, spreading from stage actress, where colour had been seen as racy, to women lacking pretensions to showiness or show business. Reflecting back on religious and cultural notions of women’s head hair as prompting and even promoting immorality, today prettifying women’s lips and so staving off the ageing process is advanced by some plastic surgeons as necessary from a moral, rather than immoral, perspective. Thus in Face Value: The Politics of Beauty, Robin Lakoff and Raquel Scherr remark

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upon the subtext in popular media that a woman ‘has a virtual moral duty – to herself and to those who must behold her – to remove those wrinkles and bags, tuck that tummy, raise those breasts …’ and rid herself of the senility of her upper lip.74 The receding chin and the too strong jawline, the wrinkled ‘gobbler’ neck or multiple chins also once carried connotations associated with (im)morality, as with laxity (the chin) or criminality (the jawline), or represented greed and gluttony (the chins), the dissolute sot, or witchcraft and sorcery (the irredeemably furrowed neck).75 This history led these bodily configurations to be regarded with a contempt propelling their owners into the hands of quacks and butchers then, with the burgeoning growth of the beauty industry, into the rooms of its companions and competitors, the plastic, cosmetic or aesthetic surgeon. Reconstruction of regressive chins was an early plastic surgery practice, aimed at making faces ‘ordinary’. The idea and ideal of normalisation was employed as the rationale for surgical intervention involving bone restructuring and grafting. Today’s practices are mostly directed towards reconfiguring jaws, jowls and necks to hide ageing—or endeavour to do so. Visual criteria identified in 1980 to ‘assess the youthfulness of the neck’ and which remain as the current measure include ‘a clear jawline … with no jowl overhang’, subhyoid depression giving ‘an appearance of a long and thin neck’, an ‘anterior border of the sternocleidomastoid muscle’ (the muscle enabling rotation of the neck) visible to the eye, and an ill-defined cervicomental angle (the angle formed by the horizontal and vertical planes of the neck).76 Bone enhancements using implants can address the regressive chin or jaw problem.77 Less drastic measures are available too. In an ‘advertorial’ published in Aesthetics , the journal published monthly ‘for medical aesthetic professionals’, solutions of a comparatively minor or non-surgical kind are described. In ‘Successful Jawline Treatment’ Heather Muir explains the use of a variety of commercial products to restore or at least improve the loss of definition in the jawline of her client. This involves injections in a bolus (a small rounded mass) ‘to lift the tissue quickly and provide structure’.78 That the jawline and chin comprise an animated area means that care is required in not producing a cemented or fixed appearance. The bone of the lower jaw—the mandible—is the only facial and skull bone (besides the middle ear ossicles) that is moveable. Undertaking the jaw procedure requires injecting a bolus of the product ‘deeply down to the bone’, then two further injections into the muscle. Next come deep injections ‘on each side of the pre-jowl sulcus’

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(the area on either side of the chin that creates a hollow appearance as loss of volume causes the skin to sag), employing a fanning technique. Finally, ‘orange peel’ dimpling (on the thighs or upper legs known as cellulite) requires attention, as this can be ‘particularly noticeable’ when the client ‘smiles or talks’. Further injections employing the fanning technique are required. Just as with similar procedures addressing ageing, this is not a ‘one off’ operation. The particular client has been attending for some eight years.79 Wrinkles beneath the chin are more difficult to shift. In the past, loose neck skin could be pulled tight in the course of a facelift. However, this was rarely successful. Even into the 1970s, withered or sagging necks were seen by cosmetic surgeons to be beyond recovery. When the skin lost its elasticity there was so much of it that had to be shorn from the body, and the lack of pliability or springiness meant that the skin relapsed quite quickly. Relatively soon, the wrinkles of the neck had reinstated themselves, leaving patient dissatisfied and upset, and surgeon disappointed, even thwarted.80 Yet in the mid-1970s this changed. Bryan Mendelson’s In Your Face explains that a practice was developed, publicised to the profession in 1974, where the neck was contoured by ‘shaping the underlying platysma muscle layer as well as removing excess subcutaneous fat’. Although it lengthened the time of the operation considerably, the transformation appeared to be ‘miraculous’.81 Today, prospective patients learn that a ‘lean and tight’ neck can be achieved through ‘various injectables’, although excessive and aggressive procedures must be avoided, for this can itself lead to premature ageing.82 The injectables include botulinum toxin A, dermal fillers, platelet-rich plasma and platelet-rich fibrin, mesotherapy, bio-remodelling and bio-revitalising agents, thread lifting and fat-dissolving agents. Of these, botulinum toxin A appears to be the most popular, despite there being as yet no published research of long-term effects. Potential complications that are known depend upon the technique employed, but ‘typically include muscle soreness or neck discomfort, difficulty lifting the head from the pillow from a [lying] position, and headaches’. Complications said to be ‘rare’ include dry mouth, hoarseness and difficulty in swallowing, along with ‘masticatory and speech disturbances’.83 Whether a rash of legal actions will be precipitated once the long-term effects become known is a matter for the future. However, what is known is that ageing cannot be staved off forever. Ultimately, even if the product itself does not generate harm to the patient or client’s health, psychological risk through a lack of satisfaction with

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the outcome remains real. Bearing in mind the outcome in Zahir v Vadodaria,84 namely that the measure for courtroom success lies in the medical quality of the treatment, not approval on the part of the patient, legal action is no answer. Taking the matter to court may well not avail the woman dissatisfied that multiple and continuing treatments—whether for eight years, 10 years or more—no longer provide an illusion of youth. As for double chins and plump necks, the extensive adoption of the practice of liposuction opened up possibilities for the area under the chin and jaw. Invented to address deposits of fat collecting on buttocks, hips, thighs and abdomen, surgeons with an eye to making the best of facelifts introduced it as a part of this process. Fat that refuses to disappear despite a healthy diet and exercise is sucked out. This enables the body to take on a more fashionably contoured shape. Conforming to a lifestyle that enables the patient to maintain a healthy weight means that the operation can meet with a lasting success. However, it is more likely to have a positive result if the skin is tight, with a positive elasticity. This means that it is not an answer to the scraggy, wrinkled and withered neck. Bryan Mendelson observes that some other neck conditions are unable to be improved by the process—where, for example, there is little or no definition between chin and throat, and despite the introduction of fat-melting injections for double chins, ‘neck rejuvenation’ remains ‘a key topic’ for plastic surgeons today.85 Meanwhile, dentists are in great demand, offering services that include ‘smile makeovers’, crowns, teeth whitening, periodontal treatment, veneers, dentures, bridges, implants, orthodontics and treating ‘an incorrect bite’.86 As explained in The Million Dollar Smile, a failure to smile ‘can be perceived as sadness, anger, or pain [and] also as a coverup … the inclination or need to hide imperfections or to simply hide anything’.87 Women smile more than men, and a smiling woman is evaluated more highly than an unsmiling one.88 Smiling is also more prevalent when power relations are involved: the less powerful smile more than the powerful.89 Research indicates that this is even more pronounced with the Covid-19 uptake of online conferencing via Zoom, which is ‘causing us to reassess our smiles’.90 Faced with a presumed potential for improving social interactions and employment prospects, women may therefore be even more drawn to undergoing expensive, even dangerous, dental surgery. In their ‘ordinary’ guise, dentists are important to oral health. Oral hygiene is important, and a failure to care for one’s teeth can lead to

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severe health problems including periodontal disease, recession of gums, loss of teeth, continuing bone loss affecting the jaws and thence changes to the entire structure of the mouth. Reconstruction is not, therefore, isolated to those who simply want ‘whiter than white’ teeth to be shown off in mouth splitting smiles. In the past, lost or disfigured teeth could be replaced by dentures or bridges or partial dentures (an alignment of a small number of ‘lost’ teeth, like dentures to be fitted into the mouth in the morning and removed at night). Then came crowns or caps— artificial teeth fitted over chiselled down ‘real’ teeth used as a base for each permanent white-enamelled or porcelain (sometimes gold) cap, or (now more likely) zirconium or ceramic crowns. Veneers, being porcelain shells that fit over the front and edges of teeth, each shell being bonded to an individual tooth, are generally employed ‘to alleviate flaws on a patient’s teeth’.91 Veneers are used where patients ‘are not satisfied with the colour or shape of their teeth’ or to correct gaps, cracked or chipped teeth. Sometimes they are used to address what clients see as ‘too long’ or ‘too short’ teeth: the original teeth are ‘adjusted’, with veneers ‘applied to correct that issue’.92 They are sometimes adopted by patients as a better option than teeth whitening. Advances in dentistry have led to the introduction of dental implants, which replace lost teeth or teeth that require removal. Missing teeth affect the ability to chew food, where the digestive process begins. Beyond this practical consequence of the everyday, missing teeth ‘eventually cause … facial muscles to deteriorate’ and this alters facial appearance.93 The procedure for dental implants is not simple, requiring a three-step process. First, a titanium screw is inserted into the jaw, replacing and imitating the tooth root. This is left to heal so that it becomes a part of the jawbone. Next, a post or ‘implant abutment’ is attached to the ‘root’, jutting from the gum and into the mouth. Finally, a crown is applied to the abutment, so that it replaces the tooth—root and ‘cap’ or crown. So long as there remains sufficient bone in the jaw, an implant can replace all the teeth, one tooth or the front teeth so as to enhance the smile and enable good chewing of food. The conclusion of proponents is that implants are ‘the best option in terms of preventing bone loss and restoring the bite and smile to what it needs to be and to what patients would like it to be’.94 Yet dentistry, like medicine, is not infallible. In addition, unqualified ‘practitioners’ entering the field cause damage and harm, and do so illegally. As the National Health Service points out,95 despite more and more people ‘paying for brighter, whiter teeth’, bleaching cannot make

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teeth brilliant white although it ‘can lighten the existing colour by several shades’.96 This process should be carried out by regulated dental professionals such as dental therapists or hygienists on a dentist’s prescription, or by dentists themselves. More than one visit is required, with a mouth guard taken from an impression of the patient’s teeth and provided to the patient so that they apply bleaching gel regularly over two to four weeks. Beauty salons offer teeth whitening illegally unless a qualified dental professional is present, and clients’ oral health can be placed at risk. A quicker process is laser whitening, but patients need to be advised of the risks associate with laser treatments. Risks accompany bleaching teeth at home, even when under the care of a dentist. A mouthguard must be made specifically to the fit of the patient’s mouth, otherwise the bleaching gel can leak. This can be a feature of home kits, because the guard will not have been made to the measure of the user’s mouth. Leaking gel can cause blisters, and sensitivity of gums can arise from the process even when carried out by a dentist or other dental professional.97 Dental implants, crowns and caps carry risks, too. One dental site lists the risks for dental implants as relating to the surgery itself or occurring in the first six months after implantation, or long-term complications and risks. Because the implant process involves surgery, it carries the general risks of surgery, although dentist George Ghidraj observes that risks of complications ‘is considered to be very low – less than 5 percent according to current statistics’.98 Problems that do occur are ‘usually minor and easily treated’. Complications can include bleeding, even severe bleeding if mistakes are made, requiring compression, vasoconstrictive medication, cautery or artery ligation. Ghidraj notes that generally ‘bleeding is kept under control’. Next, he lists infection, a common surgical risk amounting in present times to ‘less than 1%, … most being minor’. Accidental nerve damage is said to be ‘the most common issue’, causing ‘lingering pain, tingling and numbness in the teeth, gums and lips (mostly the lower lip) or chin’ for an indeterminate time. Patients ‘will recover’ after a period, in the instance of minor nerve damage. Problems with sinuses and instability of the implants are possible risks.99 Complications within the first six months involve a failure for the implant to integrate, arising out of existing health conditions, poor oral hygiene, accidents during the surgery, or the consequence of heavy smoking or high alcohol consumption. Referring to the most recent research, Ghidraj notes the ‘most important factor’ as ‘primary implant

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stability’ arising from lack of a healthy quantity of bone in the jaws.100 Long-term complications can arise from ‘an improper design of the prosthetic restoration or inappropriate care and maintenance. Ultimately, implants fail as a consequence of ‘loss of bone around them or mechanical failure of the implant’. Implants can also chip, break or fail to satisfy the patient. Such complications, whether in surgery or within six months or long-term, potentially arise if the procedure is carried out by an untrained person illegally, so that both civil and criminal action can ensue. Victoria Handley in A Practical Guide to Cosmetic Surgery Claims lists risks of cosmetic dental implant surgery as ‘infection at the implant site, injury or damage to surrounding structures, such as other teeth or blood vessels, nerve damage … and sinus problems …’. Sinus problems occur, she advises, ‘when dental implants placed in the upper jaw protrude’ into a sinus cavity. Nerve damage ‘can cause pain, numbness or tingling’ in natural teeth, the gums, the lips or the chin’.101 Michael Hill, a barrister working in medical and dental negligence, reports on dealing with dental negligence claims including ‘implant failures, lingual nerve injuries, restorative failures, consent failures, inappropriate restorative materials, poor infection control, systemic infection, prescription errors, and inferior alveolar nerve injuries’ (damage to a branch of the mandibula nerve), amongst others.102 Not all will be associated with cosmetic dentistry performed on those seeking the ‘million dollar smile’. However, some may be. A dental negligence claim for £125,000,103 with damage that could be replicated in other surgeries, reportedly ended in an out of court settlement for £60,000 for pain, suffering and loss of amenity (PSLA). Clamp v K lists the patient’s injuries as resulting in symptoms including ‘prolonged pain, difficulty eating and speaking for four-and-a-half years, numbness to her lips, sinusitis, and an adjustment disorder’.104 The claim was that the defendant had assessed and planned the treatment inadequately and therefore negligently, that the surgery employed ‘poor surgical skills’ in placement of the crowns and bridgework, and that the crowns and bridgework were ‘of an unacceptable standard’. The adjustment disorder was met with advice that the patient should undergo cognitive behavioural treatment, and it was accepted that she would require treatment in the future.105

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Plastic Faces or ‘The New Normal’?

The move away from traditional surgery to what are perceived to be less invasive methods has led to even greater dependence on professionals whose job it is to help people, particularly women, feel better about themselves and their bodies. Some of these new treatments can be applied by practitioners lacking formal qualifications and, sometimes as it proves, skill. Botox and collagen are possibly pre-eminent in the panoply of purportedly non- or less invasive procedures and their use extends from ridding the face of wrinkles and thence of all expression, and turning lips into pouts, in their worst guise sometimes described as a ‘trout pout’.106 One, collagen, is a filler, so is used to smooth out blemishes and wrinkles. Collagen stimulators are employed to stimulate the body to make collagen itself, adding body to the lips, making them plumper or smooth. Botox is a toxin, derived from Botulinum Toxin type A, working primarily to paralyse muscles, ironing out wrinkles or smoothing them. Yet even when women undergoing these treatments get what they want—plump lips and fewer or no wrinkles—their sacrifice in time and money is not rewarded by public acclaim or admiration. Too often, onlookers remark upon the loss of expression that comes with Botoxing wrinkles out of existence, and the all-too-plump pouting of overblow lips. These problems tend to be par for the course: what the client wants, the client gets. Problems also arise from faulty application of the treatments, product defects, flaws or shortcomings in the work, or dangerous encouragement to self-application.107 ‘I want to look normal’ is a mantra frequently heard when researchers undertake studies of women going through procedures designed to ‘enhance’ their looks or ‘stop’ the ageing process. As with cosmetic, plastic or aesthetic surgery, women emerge from clinics, salons and spas convinced that the faces they now sport are ‘normal’.108 Yet as Suzanne Fraser questions in Cosmetic Surgery—Gender and Culture, what is normal? what is natural?109 Sheila Jeffreys in Beauty and Misogyny questions the ‘natural’ and ‘normal’ proposition in a world permeated by misogyny.110 Liz Conor’s The Spectacular Modern Woman illustrates how quickly women became acculturated to 1920s notions of bodily ‘perfection’ transmitted through the film industry, beauty competitions and the imperatives of fashion.111 Facial proportions and symmetry, prompted by the work of Leonardo Da Vinci, generated a striving for conformity to notions of beauty and perfection measured by facial composition of

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women promoted as ‘the most beautiful’. Yet women displaying the exact measurements were relatively few, if they truly existed in every particular at all, and all were Caucasian or, like the famous 1930s Hollywood actress Merle Oberon (1911–1979) (who claimed she was from Australia (Tasmania) rather than acknowledge her Indian heritage),112 presented themselves as such. The amount of time and money that go into creating the appearance of ‘normal’ or ‘natural’ belies the contention that what emerges is in fact either normal or natural. The pain suffered and sometimes short-term or long-term damage in creating plastic perfection contradicts the mantra, too. Nevertheless, not all actors, supermodels or celebrities embrace the move towards ‘designer bodies’ and their parts. This should spell caution to ‘ordinary’ women seeking to emulate them. Not only the risk of harm and damage puts them on the alert. Some adopt the ‘growing older gracefully’ model of ageing along the lines expressed by Kate Beckinsale. Speaking of the way her 65-year-old actress mother, Judy Loe, has resisted treatments or surgical intervention, Beckinsale says that her mother was ‘always very, very beautiful’ and ‘still is, in her sixties’. She is sure, says Beckinsale, that her mother feels: ‘“Wouldn’t it be nice if my neck did this?” but not to the degree of cutting parts of herself off and dragging them behind the ears’. Saying that she is of a similar view, Beckinsale concludes that her preference is for her mother’s looks, rather than the ‘wind-tunnel faces’ seen in Los Angeles. To be enjoyed when one has it, beauty is a bounty, ‘a gift’ to be handed on to one’s daughter and, then, ‘you enjoy the fact that she has it …’.113

Notes 1. Jocelynne A. Scutt, ‘Conclusion—Up from Under—Women, Law and Culture’ in Scutt, Women, Law & Culture—Conformity, Contradiction & Conflict, Palgrave Macmillan, Basingstoke, 2016, p. 286. 2. Monica M. Moore and Diana L. Butler, ‘Predictive Aspects of Nonverbal Courtship Behavior in Women’, Semiotica, vol 76, nos 3/4 1989, pp. 205–215, https://www.deepdyve.com/lp/de-gruyter/ predictive-aspects-of-nonverbal-courtship-behavior-in-women-hNFPar 7ZCg (accessed 2 December 2019); Monica M. Moore, ‘Nonverbal Courtship Patterns in Women: Context and Consequences’, Ethology and Sociobiology, vol 6, no 4, 1985, pp. 237–247, https://www.scienc edirect.com/science/article/abs/pii/0162309585900160 (accessed 2 December 2019).

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3. Ibid., 1989, pp. 207–208. 4. Monica M. Moore and Diana L. Butler, ibid.; Monica M. Moore, ibid. 5. Heinrich Kramer and Jacob Sprenger, Mallus Malificarum, 1486, https://hist121.weebly.com/uploads/1/1/0/6/1106521/kramer_ and_springer_-_malleus_maleficarum.pdf (accessed 2 April 2019). 6. ‘Ruling on Women Parting Their Hair or Wearing It in a Bun’, Islam Question & Answer, https://islamqa.info/en/answers/45674/ ruling-on-women-parting-their-hair-and-wearing-it-in-a-bun (accessed 2 December 2019). 7. Ibid. 8. Cited Keith Thomas, 1971, p. 464. 9. ‘30 Gorgeous Jennifer Aniston Hair Colour Designs’, Hairstyle Celebrities Design, https://designpress.com/design/jennifer-anistonhair-color/ (accessed 19 April 2019); Angel, ‘Twenty Hollywood Hairstyles’, lovely-hairstyles.com, https://www.lovely-hairstyles.com/20hollywood-hair-styles.html (accessed 19 April 2019). 10. Alexandra Tunell, ‘Remembering the Signature Look of Lauren Bacall’, Harpers Bazaar, https://www.harpersbazaar.com/beauty/hair/advice/ a3196/the-beauty-look-of-lauren-bacall/ (accessed 19 April 2019). 11. Daisy Buchanan, ‘So Now Kate’s a Mother She’s Allowed a Grey Hair? Well, Thanks for Telling Us,’ The Guardian, 8 November 2013, http:// www.theguardian.com/commentisfree/2013/nov/08/kate-grey-hairduchess-of-cambridge-mother (accessed 14 November 2013). 12. ‘Man Jailed for Stealing Women’s Hair’, Reuters, 2 March 2007, https://www.reuters.com/article/us-australia-hair-idUSSYD52443200 70302 (accessed 19 April 2019). 13. DPP v Smith [2006] EWHC 94 Div Ct (QB). 14. R (T) v DPP [2003] Crim Law 622 and R v Chan Fook [1994] 1 WLR 689; see also Kate O’Hanlon, ‘Law Report: Purely Psychiatric Injury Was Capable of Amounting to Bodily Harm’, Independent, 30 July 1997, https://www.independent.co.uk/news/people/law-reportpurely-psychiatric-injury-was-capable-of-amounting-to-bodily-harm-125 3269.html (accessed 20 January 2020). 15. DPP v Smith [2006], ibid, https://alt.uk.law.narkive.com/0iCtpxjn/ dpp-v-smith-hair-cutting-as-actual-bodily-harm (accessed 20 January 2020). 16. DPP v Smith [2006], ibid. 17. Toyin Owoseje, ‘Venezuela: Thieves Stealing Women’s Hair at Gunpoint’, International Business Times, 26 August 2013, https:// www.ibtimes.co.uk/venezuela-thieves-stealing-women-s-hair-gunpoint497714 (accessed 19 April 2019); Adam Coozer, ‘New Street Crime: Stealing Women’s Hair’, ReadJunk, 13 May 2007, https://www. readjunk.com/news/junk/new-street-crime-stealing-womens-hair/

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18.

19.

20.

21.

22.

23. 24. 25. 26. 27. 28. 29. 30.

(accessed 19 April 2019); ‘Bandits Stealing Women’s Hair Strike Fear into Kashmir’, AP Archive, 28 October 2017, https://www.youtube. com/watch?v=l5N_5SCH4a0 (accessed 19 April 2010); ‘Hair Thieves Striking Fear in India’, BBC, 3 August 2017, https://www.bbc.co.uk/ news/world-asia-india-40749640 (accessed 19 April 2019). Margaret Hartmann, ‘Woman Sues Salon After Dye Job Makes Her Hair Break Off’, Jezebel, https://jezebel.com/woman-sues-salon-after-dyejob-makes-her-hair-break-off-5245723 (accessed 14 July 2018); Jenny Awford, ‘Woman Demands £16,000 from Salon After “Her Hair Fell Out”…’, The Sun, https://www.thesun.co.uk/fabulous/8820891/ woman-bleach-hair-fell-out-mullet-jessica… (accessed 20 July 2018); Hattie Gladwell, ‘Woman Who Had Severe Reaction to Hair Dye Can Never Dye …’, https://www.thesun.co.uk/fabulous/8820891/womanbleach-hair-fell-out-mullet-jessica… (accessed 20 July 2018). Pui Fun, ‘Woman Forced to Go Bald After Dyeing Hair 4 Times in Salon’, World of Buzz, 10 September 2017, https://www.worldo fbuzz.com/woman-forced-go-bald-dyeing-hair-4-times-salon (accessed 20 September 2017). Rich Calder and Erin Calabrese, ‘Aspiring Model Sues Salon for $1.5m Over Botched Hair Treatment’, Metro—New York Post, 20 May 2014, https://nypost.com/2014/05/20/aspiring-model-suessalon-for-1-5m-over-bad-haircut/ (accessed 14 April 2019). Auslan Cramb, ‘Woman Sues Beauty Salon for £1 Million Over Claim Her Hair Treatment Caused A Stroke’, Telegraph, 6 August 2018, https://www.telegraph.co.uk/news/2018/08/06/woman-sues-beautysalon-1-million-claim-hair-treatment-caused/ (accessed 2 September 2018). See generally Various Claimants v Catholic Child Welfare Society [2010] EWCA Civ 1106, per Hughes LJ, https://www.supremecourt.uk/ cases/docs/uksc-2010-0230-judgment.pdf (accessed 20 January 2020). Greg Almond, An Introduction to Beauty Negligence Claims , Law Brief Publishing, Somerset, UK, 2019. Ibid., p. 13. Ibid., p. 15. Donoghue v Stevenson [1932] AC 562, [1932] UKHL 100. Watson v Buckley and Osborne, Garrett and Co Ltd (Ogee Ltd) [1940] 1 All ER 174. Donoghue v Stevenson [1932], ibid. See Caparo Industries Plc v Dickman [1990] 2 AC 605, [1990] 2 WLR 358. Originally the Trade Practices Act 1974 (Cth), the name change to this federal law operating throughout Australia does not alter the basic law

3

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32.

33.

34.

35. 36.

37.

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and provisions contained in the original Act. See Australian Competition Law, ACL, https://australiancompetitionlaw.org/legislation/197 4tpa.html (accessed 2 December 2019). ‘Marketing and Advertising—The Law’, Gov.UK, https://www.gov.uk/ marketing-advertising-law/regulations-that-affect-advertising (accessed 2 December 2019). Gibbs Law, ‘False Advertising Laws’, Gibbs Law Group LLP, https:// www.classlawgroup.com/consumer-protection/false-advertising/laws/ (accessed 2 December 2019). Numerous recitations of this history, real or imagined, can be found. See John Noone, The Man Behind the Iron Mask, Sutton Publishing, Stroud, UK, 1980. Sander L. Gilman, Making the Body Beautiful —A Cultural History of Aesthetic Surgery, Princeton University Press, NJ, USA, 2001, pp. 55– 57. Ibid., p. 58. Cited Mohammad Ahmadpanah, Saeed Mosavi, Mohsen Dallband, Mohammd Zandi, Majid Saleh and Marzieh Nazaribadie, ‘The Study of Psychological Characteristics, Body Image, Quality of Life, and General Health of Rhinoplasty Applicants’, Psycho Physiology, vol 4, no 3, August 2017, http://ajnpp.umsha.ac.ir/article-1-94-en.html (accessed 20 January 2020). Seyed Jaber Mousavi, Jason Abbas Aramideh, Seyyedeh Sanam Fattahi, Aminda Amanolahi and Mohammadhossein Hesamirostami, ‘Quality of Life Before and After Rhinoplasty Surgery Measured with SF36, RSES, and WHOQOL-BREF’, European Journal of Plastic Surgery, 29 January 2018, https://doi.org/10.1007/s00238-018-139 2-5n (accessed 2 December 2019). ‘A Perfect Nose in the Sixteenth Century, from the Dialogue of Messer Agnolo Firenzola (1493–1546), the Florentine, on the “Beauty of Women”’ in Harry Hayes, An Anthology of Plastic Surgery, Aspen Publishers In., Rockville, MD, USA, 1986, p. 226. Skarlet, ‘Before and After Plastic Surgery—Photos of 1950s Hollywood Stars’, ReelRunDown—Celebrities, https://reelrundown.com/celebr ities/Plastic-Surgery-in-the-1950s-and-Today (accessed 14 September 2018); ‘Marie Osmond—Before and After Photos’, CelebritiesWith.com, https://www.celebritieswith.com/marie-osmond-plastic-surgery/ (accessed 14 September 2018); ‘Scarlett Johansson—Did She Get a Nose Job’, TheStars.com, https://www.thestarsmag.com/scarlett-joh ansson-plastic-surgery/ (accessed 14 September 2018); Alice, ‘Meghan Markle Plastic Surgery, Before and After’, Celebrity Plastic Surgery.com, 2 June 2017, https://cbplasticsurgery.com/plastic-surgery/meghanmarkle-plastic-surgery/ (accessed 14 September 2018).

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40. Gordon Farrer, ‘Life and Limb: Show Biz Mourns an Old Trouper’, The Age, 3 January 2006, https://www.theage.com.au/entertainment/ celebrity/life-and-limb-show-biz-mourns-an-old-trouper-20060103-ge1 ikv.html (accessed 14 September 2018). 41. Zahir v Vadodaria [2016] EWHC 1215 (QB), https://www.bailii.org/ ew/cases/EWHC/QB/2016/1215.html (accessed 20 January 2020). 42. Sander L. Gilman, ibid., pp. 111–112. 43. See Bryan Mendelson, In Your Face—The Hidden History of Plastic Surgery and Why Looks Matter, Hardie Grant Books, London, UK, 2013, pp. 127–131. 44. Suzanne Noel, La chirugie esthetique: son role sociale (Aesthetic Surgery and Its Social Significance), 1926, cited Mendelson, ibid. 45. Torg Skoog, Plastic Surgery: New Methods and Refinements, WB Saunders, Philadelphia, USA, 1974. 46. Mendelson, ibid., pp. 158–162. 47. See generally Greg Almond, ibid. 48. ‘Facial Scarring’, LawontheWeb—The UK’s Legal Information Website, https://www.lawontheweb.co.uk/legal-help/injury-compensation-amo unts (accessed 21 March 2019). 49. Seyed Jaber Mousavi, Jason Abbas Aramideh, Seyyedeh Sanam Fattahi, Aminda Amanolahi and Mohammadhossein Hesamirostami, ‘Quality of life …’, 2018, ibid. 50. Ibid. 51. ‘Woman Sues Over Allegedly Botched Facelift’, International Medical Travel Journal, 14 May 2009, https://www.imtj.com/news/womansues-over-allegedly-botched-facelift/ (accessed 14 June 2018). 52. Sophie Cousins, ‘Facelift Woman’s Appeal Tossed Out’, Brisbane Times, 10 April 2013, http://news.ninemsn.com.au/ealth/2013/04/10/12/ 54/facelift-court-appeal-tossed-out (accessed 11 April 2013). 53. Gemma Mullin, ‘Botched Facelift Leaves Woman Covered in Horrific Blisters “After Being Burned from the Inside Out”’, The Sun, 23 April 2019, https://www.thesun.co.uk/news/8919577/botched-fac elift-blisters-burned-inside-out/ (accessed 24 April 2019). 54. Elizabeth Norton, The Lives of Tudor Women, Head of Zeus Ltd, London, UK, 2016, pp. 276–277, citing J. Clapham, Elizabeth of England: Certain Observations Concerning the Life and Reign of Queen Elizabeth by John Clapham, EP Read and C Read, eds, 1951, p. 86. 55. Edward W. Said, Orientalism, Pantheon Books, New York, NY, USA, 1978. 56. Charles Darwin, Descent of Man, John Murray, London, UK, 1871, p. 579. 57. Sander L. Gilman, ibid., p. 99.

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58. Joanna Finkelstein, The Fashioned Self , Cambridge University Press, Cambridge, UK, 1971; Eugenia Kaw, ‘Medicalization of Racial Features: Asian American Women and Cosmetic Surgery’, Medical Anthropology Quarterly, vol 7, no 1, 1983, pp. 74–89. 59. Sander L. Gilman, ibid., p. 101. 60. Khoo Boo-Chai, ‘Plastic Construction of the Superior Palpebral Fold’, Plastic and Reconstructive Surgery, vol 34, 1964, p. 38. 61. Sander L. Gilman, ibid., pp. 108, 109. 62. Caroline McGuire, ‘How Eyebrows Evolved Since the 1920s: From Marlene Dietrich to Cara Delavinge’, MAILOnline, 27 April 2015, https://www.dailymail.co.uk/femail/article-3057188/Madonna-scaterpillars-Marlene-Dietrich-s-shocked-shape-Pamela-Anderson-s-pen cil-lines-Cara-Delevingne-s-bushy-brow-eyebrows-evolved-1920s.html (accessed 14 February 2019). 63. Adrienne Santos-Longhurst, ‘How Fast Will My Eyebrows Grow Back?’ HealthLine, 7 December 2018, https://www.healthline.com/health/ how-fast-will-my-eyebrows-grow-back (accessed 14 February 2019). 64. NHS, ‘Eyelid Surgery’, NHS Cosmetic Procedures, https://www.nhs. uk/conditions/cosmetic-procedures/eyelid-surgery/ (accessed 12 April 2019). 65. Ibid. 66. Sam Escobar, ‘Woman’s Botched Surgery Forces Her to Sleep with Her Eyes Open’, Daily Mail/GoodHouseKeeping, 17 September 2015, https://www.goodhousekeeping.com/beauty/a34484/botchedeyelid-lift-surgery/ (accessed 24 April 2019). 67. Ibid. 68. ‘What Complications Can Come from a Blepharoplasty? How Do You Handle Them?’ Eyelid Surgery, 20 May 2019, https://www.realself. com/question/blepharoplasty-complications-eyelid-surgery (accessed 14 April 2019). 69. ‘Has My Upper Eyelid Blepharoplasty Gone Wrong’, RealSelf.com, 28 May 2018, https://www.realself.com/question/omaha-ne-upper-eyelidblepharoplasty-wrong (accessed 14 April 2019). 70. Sheila Jeffreys, Beauty and Misogyny—Harmful Cultural Practices in the West, 2nd edn, Routledge, New York, NY, USA, 2015, pp. 101, 102. 71. See for example ‘Melanie Griffith Plastic Surgery Before and After Botox Injections’, Celebie, https://celebie.com/melanie-griffith-plasticsurgery-before-and-after-botox-injections/ (accessed 14 April 2019); ‘Nicole Kidman Plastic Surgery Before and After Photographs’, 20 October 2015, Plastic Surgery Gossip for Celebrities, http://latestpla sticsurgery.com/nicole-kidman-plastic-surgery-before-and-after-photos/ (accessed 14 April 2018); Amy Miles, ‘Jennifer Garner Plastic Surgery 2019’, Celebrity Surgery, https://www.isuwft.com/633/jennifer-garner-

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72.

73. 74. 75.

76. 77. 78. 79. 80. 81. 82. 83. 84. 85.

86.

plastic-surgery.html (accessed 14 April 2018); Caty Stud, ‘Goldie Hawn Plastic Surgery—Is It a Good or a Bad Decision?’ Celeb Awe, 4 April 2016, http://celebawe.com/goldie-hawn-plastic-surgery-bad-good-dec ision/ (accessed 14 April 2016); Images, https://www.bing.com/ima ges/search?q=nicole+kidman+jennifer+garner+melanie+griffiths+botox+ lips&qpvt=nicole+kidman+jennifergarner+melanie+griffiths+botox+lips& FORM=IGRE (accessed 6 June 2019). Editors of Encyclopaedia Britannica, ‘Clara Bow—American Actress’, https://www.britannica.com/biography/Clara-Bow (accessed 14 April 2018). See Kathryn Hughes, Victorians Undone—Tales of the Flesh in the Age of Decorum, 4th Estate/HarperCollins, London, 2017, pp. 217–221. Robin Tolmach Lakoff and Raquel L. Scherr, Face Value: The Politics of Beauty, Routledge, London, UK, 1984. Caesare Lombroso, Italian criminologist, developed an entire theory of criminality based on physiology, with some characteristics denoting the born criminal (strong), others supporting the notion of the accomplice or ‘hanger-on’ (weak). See for example Caesare Lombroso, The Female Offender, first published 1895, reprinted Rare Books Club, London, UK, 2012; Caesare Lombroso, Encyclopaedia Britannica, https://www.bri tannica.com/biography/Cesare-Lombroso (accessed 12 July 2015). On connections between the body (women’s bodies) and power including witchcraft, generally Barbara Garlick, Suzanne Dixon and Pauline Allen, Women and Power—Historical Perspectives and Revisionist Views, Greenwood Press, Westport, CT, USA, 1992. Souphiyeh Samizadeh, ‘Treating the Neck with Toxin’, Aesthetics, vol 7, no 3, February 2020, pp. 31–33, p. 32. Bryan Mendelson, ibid., pp. 167–168. Heather Muir, ‘Successful Jawline Treatment’, Aesthetics, vol 7, no 1, December 2019, p. 36. Ibid. Bryan Mendelson, ibid., pp. 164, 165. Ibid., p. 165. Ibid., p. 32. Ibid., p. 33. Zahir v Vadodaria [2016] EWHC 1215 (QB). Ibid., p. 167; Emine Saner, ‘The Rise of Non-surgical Beauty: “My Mum Said My Lip Looked Like a Rubber Dinghy”’, The Guardian, 3 April 2017, https://www.theguardian.com/lifeandstyle/2017/apr/ 03/non-surgical-cosmetic-procedures-botox-lip-filler-beauty (September 2017). Twelve Leading Dentists in the United States, The Million Dollar Smile—Changing Lives With Cosmetic Dentistry, Blue Ocean Publishing Group, Duneden, FLA, USA, 2018, p. 2.

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87. Ibid., p. 6. 88. Ronald E. Riggio, ‘Sex and Smiling: When Is a Smile Not a Smile’, Psychology Today, 17 December 2011, https://www.psychologyto day.comj/us/blog/cutting-edge-leadership/201112/sex-and-smilingwhen-is-smile-not-smile (accessed 19 December 2019). 89. Ibid. See further Julie A. Woodzicka and Marianne LaFrance, ‘Working on a Smile: Responding to Sexual Provocation in the Workplace’ in Ronald E. Riggio and Robert S. Feldman (eds), Applications of Nonverbal Communication, Lawrence Erlbaum Publishers, Mahwah, NJ, USA, 2005, pp. 139–155. 90. Zona Black, ‘Zoom Calls Have Australians Rushing for Cosmetic Surgery’, The New Daily, 20 July 2020, https://thenewdaily.com.au/ life/wellbeing/2020/07/20/cosmetic-surgery-coronavirus-popular/ (accessed 16 August 2020). 91. Julie A. Woodzicka and Marianne LaFrance, ibid., p. 65. 92. Ibid., pp. 65–66. 93. Ibid., p. 124. 94. Ibid., p. 132. 95. NHS, ‘Teeth Whitening—Healthy Body’, Health A-Z , https://www. nhs.uk/live-well/healthy-body/teeth-whitening/ (accessed 2 December 2019). 96. Ibid. 97. Ibid. 98. George Ghidraj, ‘Dental Implants—Risks and Complications’, Infodentis, https://www.infodentis.com/dental-implants/risks-and-compli cations.php (accessed 2 December 2019). 99. Ibid. 100. Ibid. 101. Victoria Handley, A Practical Guide to Cosmetic Surgery Claims , Law Brief Publishing, Somerset, UK, 2017. 102. Mike R. Hill, ‘Dental Negligence Claims’, Clinical and Dental Negligence, https://www.mikehillbarrister.co.uk/dental-negligence (accessed 19 December 2019). 103. Ibid. 104. Victoria Handley, ibid., p. 112. 105. Ibid. 106. See ‘Lip Service: Melanie Griffith’s Trout Pout Bigger Than Ever’, Evening Standard, 11 July 2008, https://www.standard.co.uk/sho wbiz/lip-service-melanie-griffiths-trout-pout-bigger-than-ever-6928162. html (accessed 14 April 2016). 107. See Denis Campbell, ‘More Patients Sue Plastic Surgeons Over Faulty Cosmetic Operations’, The Guardian, 8 January 2012, https://www. theguardian.com/society/2012/jan/08/patients-sue-plastic-surgeonsfaulty (accessed 31 August 2016).

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108. See for example Kathy Davis, Reshaping the Female Body—The Dilemma of Cosmetic Surgery, Routledge, Oxford, UK, 1995. 109. See for example Suzanne Fraser, Cosmetic Surgery—Gender and Culture, Palgrave Macmillan, Basingstoke, UK, 2003, particularly chapters 3 and 4. 110. Sheila Jeffreys, ibid. 111. Liz Conor, The Spectacular Modern Woman, Indiana University Press, Bloomington, IN, USA, 2004. 112. Nadra Kareem Nittle, ‘Famous Celebrities Who Passed for White in Hollywood’s Golden Age’, liveaboutdotcom, https://www.liveabout. com/hollywood-celebrities-who-passed-for-white-2834730 (accessed 2 December 2019). 113. ‘Kate Beckinsale: Hollywood Hates Women’s Bodies’, The Age, 4 July 2012, http://www.theage.com.au/lifestyle/beauty/kate-beckinsale-hol lywood-hates-womens-bodies-20120704-21gwo.html (accessed 4 July 2012).

CHAPTER 4

All Above the Waist

Bouncy breasts perky breasts splendidly displayed Drooping breasts sagging breasts covered up crudely Sensitive breasts milky breasts hormones rudely rioting Implants leaking Underwires jabbing Push-ups prodding mercilessly Ribcage narrowed trapping lungs Shoulder blades shortened lengthened hollowed twisted into shaped desire Décolleté whitened Turkey neck trimmed Shoulders painted alabaster This is normal Mirrors tell us Gazing in

© The Author(s) 2020 J. A. Scutt, Beauty, Women’s Bodies and the Law, https://doi.org/10.1007/978-3-030-27998-1_4

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to infinity Is that me, I ask the mirror? Mirror looks back on Plastic me

1

Over and Above the Bosom

For a woman of fashion, décolleté, shoulders and neck are prized features. In his pre-Raphaelite portrait the Bacca Baciata, Dante Gabriel Rosetti pictured in oils the seductiveness and sensuality of a woman’s upper torso. Rosetti’s model was Fanny Cornforth, the principal inspiration for the sensuous figures that came to dominate his work. Just as it was in Rosetti’s time and earlier, this segment of a woman’s anatomy remains a beauty target today. Elizabeth I is a ready source of cosmetic history and fashion’s deadly potential, on face, neck and upper body being a significant feature of her daily toilet. Her legendary regal demeanour was created and enhanced by her clothing, her skin and her complexion. The fashion she followed and led promoted the idea that ladies were immune from the sun’s rays. The aristocratic notion that work was solely for the toiling classes infused women’s quotidian powder and paint routine, making their faces pale, their shoulders creamy, their chests and the upper bosom soft and chalky white. This pastel look was achieved by design. Oils, pastes and creams were employed to whiten the skin and cover youthful blemishes and spots, graduating to covering or at least trying to render invisible the lines, wrinkles and liver spots developing with age. Oils and unguents were invented to create an illusion of alabaster skin. The leading fusion was ceruse, comprising white lead mixed with vinegar. Mercury, sulphur and turpentine were used, too. They, along with lead, are toxic chemicals. A cumulative poison, lead can be absorbed through the skin. All who used it as a foundation or topcoat on face and neck, chest, bosom, shoulders and arms subjected their bodies daily to potential damage to kidneys, harm to the central nervous system and impairment of the cardiovascular system, and put at risk the production of red blood cells. If they used these potions or added lime, they risked serious damage

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to the skin where the deadly ointment was applied, so that ‘skin, once so white and shining, [became] finally scarred and black, with holes eaten into the sad flesh right down to the bosom’.1 When pregnant, women ran the risk of transporting toxicity through the blood stream and into the developing foetus. If they breastfed or used wet nurses or ladies in waiting who employed the same beauty treatments, they put their children in jeopardy, too. Applying toxins to their bodies meant pregnant women could and did suffer miscarriage. Some developed sterility. Nonetheless, these potions did their job as far as concealing perceived defects of skin and complexion as well as the reality of age. They did, at least, for some— though not necessarily up close. Remarking of a visit in 1602 to the court of Elizabeth I the year before she died, one courtier said he was ‘impressed by a glimpse of her “snow white skin”’ and ‘even in her old age’ (she was born on 17 September 1533) ‘she did not look ugly, when seen from a distance’.2 Today, online marketing, advertising and websites, and the shelves of department stores, pharmacies, supermarkets, speciality stores and chemists are filled with jars, tubes, bottles (plastic and glass), packets, powders, ointments, liquids, gels, creams and oils promoting themselves as remedies for any and every perceived flaw in women’s bodies, skin and complexions. Ageing is a principal target, with celebrities, supermodels, retired supermodels, actresses of stage, screen and television anchoring advertising campaigns. One website advertises a hydroquinone cream to treat age spots.3 Generally beginning to appear when people reach 40 years, these arise primarily from exposure to the sun. Appearing on the face, hands and neck as ‘flat brown, black or yellow spots’ they can ‘reveal a person’s age’. They are ‘not dangerous in any way’ says the website, and there is ‘no medical reason to get rid of them’.4 Nonetheless, hydroquinone cream is a ‘very effective bleaching cream which can significantly reduce the appearance of age spots’, and is available over the counter. Yet, concludes the item, readers must ‘be aware that [the product] has been banned in many European and Asian countries due to its potential carcinogenic properties. Potential users can, however, be assured that it is ‘still widely available in the US’.5 Other remedies suggested have not been banned, but for a condition that is ‘not dangerous in any way’, one might question whether applying Retin-A (available only on prescription), which exfoliates the skin, removing the hyperpigmented layer, or glycolic

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acid which always requires the application of moisturiser after use and ‘can be quite harsh on the skin, sometimes causing redness and discomfort’, is necessary or sensible.6 Home remedies such as lemon juice, honey and yoghurt, or buttermilk require a twice-a-day application with results showing up in several months. Perhaps, if wishing defects to disappear more quickly, the commercial remedies despite their dangers or discomforts may be worth it? That ‘remedies’ remain on the market indicates that women are ready to adopt methods for advancing or recovering their beauty, despite the cost in monetary and health terms. Particular areas of the skin feature highly in promotions. Cleavage is a major target for cosmetic attention, for it is there that the skin tends to deteriorate more rapidly. Staying in the sun too long or indulging regular or sometimes aggressive bouts of sun tanning whether in the open or under tanning machines has a deleterious effect. Apart from the potential for contracting skin cancer,7 this becomes even more noticeable with age. Aged or ageing skin can become leathery, marred by age spots, or develop a crêpey appearance. A newly coined expression denoting discolouration and wrinkling of décolletage skin is now in vogue, ‘clinkles’ or ‘cleavage wrinkles’. This contemporary signposting, harking back to the sixteenth century, indicates that the area is ripe for new remedies. Along with underwear manufacturers, the cosmetic industry obliges. Lesley Reynolds reports in a Daily Express column that at a cost of £45 a ‘special anti-wrinkle bra’ exists to be worn ‘to help stop formation of chest creases and soften those … already [there]’. This is effected by constructing into the bra ‘a comfortable layer of cushioning between the breasts’ which prevents their ‘being squeezed together while you sleep’.8 As for cosmetics, dehydration and a lack or deficiency of natural oil requires a rigorous regime of cleanser and moisturiser, preferably together with higher-strength products. Reynolds recommends seeking advice from skin clinics and salons with ‘qualified staff’. She classes products thus sought as ‘an investment buy’ meaning they are costly but are supposed to deliver ‘dramatic results’. She recommends an ‘intensive fourweek course’ with one product for which the initial outlay is £110. It is ‘brilliant’ she says, for ‘tackling fine lines, pigmentation and restoring healthy looking skin’. Another recommended product for daily use costs £50 and is ‘full of peptides’ assisting in the promotion of ‘cellular regeneration and hydration’. Exfoliation is recommended next, to address the ‘build-up of dead skin cells’ that ‘make your décolletage look dry [and] lifeless’, as well as accentuating wrinkles and lines. This does not require

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the same expensive outlay, however, as ‘a handful of sugar mixed with some olive oil or honey’ serves as a ‘gentle home made scrub’.9 Beyond oils and unguents, women can seek out treatment at clinics, including chemical peels and glycolic acid treatment, anti-ageing injections, pulsed light treatment to spur cell regeneration and the production of natural collagen, and a course of radio frequency ‘to lift and firm the skin’ in the cleavage area. These may generate the wonders they promise, yet they also present their own risks. As solicitors dealing with negligence claims will point out, professional treatment of a high standard will generally eliminate the potential for damage. However, less proficient treatment can result in permanent skin damage, permanent skin discolouration, post-inflammatory hyperpigmentation of the skin, and ‘inappropriate’ scarring.10 This highlights the potential, even probable, conflict between the legal standard of what is ‘satisfactory’ and a woman’s standard of ‘satisfaction’, as held in Zahir v Vadodaria.11 There, the outcome of a ‘nose job’ operation was challenged by the patient, who was unhappy with the result. Patient satisfaction was not, however, the question to be determined, held the court. Rather, it was the acceptability of the surgical technique. Hence, a woman who considers any scarring to be ‘inappropriate’ will not have her assessment govern liability. Whether the surgical technique was acceptable despite scarring is the determinative question—thereby deeming whatever scarring there is as ‘appropriate’ (sic). Clients and patients must be warned of the risk of scarring. The duty to inform of this risk comes within the practitioner’s duty of care. Scarring will be significant for the patient, but the question is whether having been informed of the risk the woman is deterred or goes ahead anyway. If she does, running the risk or believing that somehow she will escape it, her consent will be ‘informed’. This is an important factor, brought into sharp relief in the landmark case Montgomery v Lanarkshire Health Board.12 In line with the outcome of that case, courts will consider carefully whether the doctor or other professional gave such a warning. A failure to do so, because the doctor or professional considers that it is not necessary as the risk will be minimal, or is unimportant or a ‘natural’ outcome and therefore anticipated by the patient, will more than likely bring about liability. The Montgomery case extends into the ‘consent to surgery’ (or other health treatments or procedures) the need for a court in a claim of negligence not only to consider the doctor’s view of what risks should be conveyed. The patient’s view of what should be advised,

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what information should be given, before she or he could consent to a procedure or operation is relevant, too. However, research indicates that the risk of scarring is generally conveyed to those undergoing cosmetic or aesthetic surgery, and patients or clients agree to take the risk.13 Claims relating to the preservation of cleavage do not remain at the door of the civil court alone. Mr Ian Paterson, a consultant surgeon, cynically used his female patients’ trust and desire to retain a cleavage after mastectomy to enable him to carry out unnecessary and unwarranted operations.14 Over a fourteen-year period between 1997 and 2011, Mr Paterson conducted breast operations in relation to which he was sentenced, in May 2017, to a maximum of fifteen years imprisonment. He was charged with seventeen counts of wounding with intent (contrary to section 18 of the Offences Against the Person Act 1861) and three of unlawful wounding (section 20 of the Act). These crimes were committed upon patients with concerns about breast lumps or nipple discharges. Despite a frequently contrary diagnosis or one that did not require the radical surgery inflicted upon them, patients were subjected to operations Mr Paterson conducted by a procedure dubbed ‘cleavage sparing mastectomy’. This involved operating so as to leave behind tissue for cosmetic reasons, designed to give an illusion of the natural breasts remaining. Where the patients did suffer from breast cancer, this increased the risk of the cancer’s recurrence. Where they did not suffer from the condition, they were left with a figment of a cleavage, and a major disfigurement of one or both breasts. In sentencing Mr Paterson, the judge noted that it was ‘difficult to overstate the psychological effect’ of the surgeon’s offending upon the patients. As one woman said in evidence: ‘Now and probably for the rest of my life, when I look in the mirror I see a victim of Paterson, who took away part of being a woman’.15 Unsurprisingly, however important cleavage might be, cleavage being ‘spared’ was not enough. A ‘charming and charismatic individual’,16 Mr Paterson was described as having ‘misused’ these characteristics ‘deliberately … to manipulate’ his patients into believing they were being treated appropriately, often over lengthy periods of years. As well, said the trial judge, Mr Paterson endeavoured to employ his ‘charm and charisma’ to persuade an ultimately unpersuadable jury. The crimes (carried out on nine women and one man) were attributed by the judge not only to the misuse and abuse of ‘charm and charisma’ but to ‘arrogance’ and ‘self-aggrandisement’. With a ‘lack of remorse’ factored into the sentence,17 he was sentenced to fifteen years

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on each of the counts of wounding with intent, and four on each count of unlawful wounding. Being served concurrently, this meant a maximum term of fifteen years, half to be served in prison, the remainder on licence. On appeal against leniency of the sentence, the Court of Appeal increased the terms on the ‘wounding with intent’ offences from fifteen to twenty years, again served concurrently and with the other terms intact.18 If Mr Paterson commits any offence whilst on licence, he risks returning to prison. Having been struck off, at least he is no longer able to practice medicine. The procedure ‘invented’ by Mr Paterson and its being employed against women’s interests illustrates how the importance of cleavage in women’s lives can leave them vulnerable to the ravages of charlatans who may be motivated by power, or money, or both. Yet the dangers do not end there. What about fatty deposits or the underlying bone structure of the upper part of the body? The pursuit of the body beautiful, or supposed beauty, is dictated by dominant notions of what is attractive and what is accepted generally as ‘normal’. This leads women to adopt or search for increasingly dangerous or even impossible remedies, as may be so with shoulders and shoulder blades, and clavicles, although the humped back can have health dangers and may be susceptible to curative treatment. In popular language a ‘widow’s hump’, ‘dowager’s hump’ or ‘buffalo back’, the humped back generally concerns those who develop it, desiring to find ways of correcting it. More professionally described as the cervicodorsal hump, the condition can be a side effect of medication, including that taken to treat obesity, can arise from long-term use of steroids, or may result from Cushing’s syndrome. There, the body produces an oversupply of the hormone cortisol and can cause fat to accumulate at the back of the neck. The problem is not necessarily one of flesh, however. Rather it can result from ageing and osteoporosis, more often afflicting women due to a decreased capacity to absorb calcium. This is the origin of the term ‘widow’s or dowager’s back’, associated with the longer lifespan of women over men in the middle ages. Where they did not die in childbirth or from disease or other afflictions, women lived through menopause and, through bone loss, developing a convexity of the back of the neck below the seventh vertebrae.19 Bone loss can produce deformities in the bone structure remaining, causing kyphoscoliosis, the hump that develops on upper back or neck. When associated with excess fat, this can cause obstruction of the vertebral artery, interfering with flow of blood to the

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brain. Thus, seeking a cure is not only an exercise in vanity, nor about seeking normality: the consequences of taking no action can be serious. Plastic surgeons recommend liposuction as the first step.20 Cost in the United States is quoted as between $US 1500 and $US 4000, the lower estimate generally applying when the operation is conducted under local anaesthetic with oral sedation, the cost rising according to the type of anaesthetic required. Overall cost will rise or fall dependent, too, upon the number of areas or amount of work required. The cost rises further with laser liposuction, to approximately $US 5500. There, fat is suctioned out through a thin tube, having been liquified by means of laser energy. Laser removal provides the possibility of smoother skin and a shortened recovery time, because the greater ease with which the fat is removed means it is a ‘less aggressive procedure’. UK costs for this type of treatment can range from £1200 to £3250, to £4500 with the laser option. Being a relatively new technique, an experienced surgeon is recommended.21 Preventative measures taken before the hump develops or when a woman may be at risk during menopause are recommended. Highfrequency ultrasound or pulsed current with up to between 10 and 15 treatments is recommended, followed by physiotherapy and massage. Exercise including regular sessions at the gym should be part of the therapy, with a nod to ‘folk remedies including sage, St John’s wort, and aloe vera’. The condition is, it is said, ‘treatable’.22 However, where the problem lies with the bones, and this is generally the underlying cause of the fatty deposits, deposits once removed may simply return. Just as with so many of the procedures women undergo in the quest for perfection— or ‘normality’, dealing with the fat by liposuction can be a temporary measure, requiring regular treatment every six months or so. For complaints about too narrow shoulders or too wide shoulders or shoulders disproportionate with hips, a recourse to clothing adapted to improve body shape was last century’s recommendation. Thus, according to the Cambridge Daily News of June 1939, wide hips and narrow shoulders could be rectified by illusion, with ‘light colours above the waist [and] thicker fabrics such as a quilted blouse topping a thin crepe skirt’.23 More, this apparent imperfection could be hidden by building up the bust and shoulders ‘with tucked vestees, widely spaced lapels, padded shoulders and epaulets …’.24 Today, however, the solution advanced is far more drastic. The problem being bone-related, or both bone and fat, disproportionate shoulders come to cosmetic surgeons’ attention. They

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may—or may not—be able to provide an answer. Even where alterations can be made, the possibilities for these modifications meeting the owners’ wishes are not certain. Clavicular reduction osteotomies (incision or transection of the bone) is a procedure reducing shoulder width by some 2 cms on either side. This is advanced by plastic surgeons as a possible solution for the woman complaining that her shoulders prevent her from wearing the shirts with tight straps she favours. Despite saying her shoulders ‘aren’t the biggest issue’ for her, she explains they are ‘too big’ for her body because there is ‘excess fat/muscle on [her] upper shoulders’.25 The opposite problem, where a prospective client seeks to widen her shoulders by an inch or ‘at least 2cm per each shoulder’, gains an initially positive response too. Clavicular extension or lengthening osteotomies (shoulder widening) ‘can be done by either deltoid implants or a clavicular lengthening procedure’. Here, the recommendation is that implants are ‘far simpler’ and ‘produce the same amount of shoulder widening’. In an online Q&A blog run by a plastic surgery clinic, a surgeon responding to the prospective client observes that clavicular lengthening is ‘reserved for the most motivated of shoulder widening patients’, effectively indicating that such a procedure is more complex and carries a higher risk.26 Having the most movement of any joint, the shoulder is described as ‘exceptional’.27 Comprising ‘many smaller joints and bones’, the shoulder is at risk of serious impairment through daily life—accidents, work-related incidents, cycling and car collisions, or simply everyday wear and tear. An injury to any aspect of the shoulder ‘may have a damaging influence on a range of movement within the shoulder and body’.28 Deliberate intrusion into the workings of the shoulder, then, requires meticulous attention to the enormity of the risk. Little wonder that generally the cosmetic surgery industry is not enamoured of entering into this field, and specialised training in bone surgery is indicated. Information provided to patients would need to be significant and comprehensive, with the potential enormity of the procedure ‘going wrong’ being pointed out clearly and without equivocation or room for misunderstanding. As the consequence of a poor outcome may be substantial, consent to such an operation, whether shortening or lengthening of the bones, would require full, complete and all-inclusive information in order to withstand a claim for negligence. Risks can arise for patients and practitioners where bone is taken from another part of the body to fix a ‘problem’ bone. In Gary Nordgren v

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State of Louisiana this arose when bone from Nordgren’s knee was transferred into his arm.29 The operation for Mr Nordgren was to repair an arm injury. When performing triceps 2 dips, he had fractured his right humerus where, seven years earlier, he had sustained a gunshot wound. As the fracture did not completely heal, a gravity cast was placed on it initially then, when it again did not improve, another type of cast was applied. Still, the fracture refused to mend. An orthopaedic examination by a surgeon and surgery resident resulted in advice to Mr Nordgren that he could continue with a non-surgical treatment programme or undergo surgery in an attempt to restore the fracture to health. Mr Nordgren was told this included the possibility of an autograft procedure, an operation under general anaesthetic, with bone being harvested from the patient’s body and grafted onto the bone requiring a supplement. He opted for the surgery.30 Thus the Nordgren case involved surgery for the explicit repair of bodily damage. Lengthening shoulders or clavicles for the perfection of beauty can be distinguished in purpose. However, the issue as it arose in Nordgren may be replicated in the ‘beauty treatment’ case, for Mr Nordgren complained that he had not been properly advised and had not consented to the site of the bone removal. If bone were to be removed from a woman’s body to be grafted to her shoulders or clavicles, the principles as stated in Nordgren, a US case, should provide a guide. Consent is crucial in the state of Louisiana, just as it is in the United States generally and elsewhere. The form signed by Mr Nordgren and styled an ‘informed consent form’31 carefully noted that the treatment was an ‘open’ procedure using an ‘internal versus external fixation of right humerus facture’ with ‘possible use of bone autograft, allograft, or other bone substitute’. It stipulated that the operation was to the right side, and that Mr Nordgren agreed that more procedures could be performed by the doctors if this were required. It noted also that the patient asked all the questions he had about the treatment, the risks, and the alternatives, and chose to proceed with the treatment. For Mr Nordgren, the problem arose because bone was taken from his knee, which he said he had not contemplated, neither of the practitioners had suggested, and he had not agreed to. He said the proposal was that bone would, if needed, be taken from his hip. However, the surgeon testified that the word ‘hip’ is not in his medical vocabulary and he ‘could not recall’ telling Mr Nordgren that his hip ‘would or could be used’ for the graft. He said further that he ‘does not indicate to his

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patients the location of the autograft in detail’ but ‘will tell them that he will borrow bone from a part of the body where they are less likely to need it’. His practice was, he added, to ‘give examples of sites if the patient asks questions’, but rarely does a patient ‘ask exactly which bone will be the donor site’. Mr Nordgren, he said, had ‘very few questions’ though he could not recall what they were.32 The negligence case was originally dismissed, but went on appeal. The appellate court first established the elements a plaintiff must prove where the action lies in an alleged failure to obtain informed consent. As laid out in Snider v Louisiana Medical Mutual Insurance Co.: • A material risk existed that was unknown to the patient; • The physician failed to disclose the risk; • The disclosure of the risk would have led a reasonable patient in the patient’s position to reject the medical procedure or choose another course of treatment; and • The patient suffered injury.33 Referencing a 1997 case, Lugenbuhl v Dowling, the court then set out clearly the two bases upon which ‘informed consent’ could be challenged.34 Noting that ‘no consent’ cases may have the patient suffering ‘damages to his dignity, privacy and emotional well-being’, the court said that the ‘more common’ ‘material risk’ case involves the failure of the medical practitioner to inform the patient of a material risk of the procedure performed. The ‘less common’ cases have the doctor failing to notify the patient of the type or the parameters of the procedure to be performed. Mr Nordgren’s contention was that his claim fell within the second category, because he never consented to his knee being used as the harvest site. This meant that if Mr Nordgren could establish that the medical practitioner misrepresented to him that his hip would be the harvest site, then he would defeat the statutory presumption that his consent was valid and effective. Applying this reasoning to the shoulder surgery case, if a woman undergoes shoulder bone or clavicle lengthening, the feat to be effected by grafting bone from another part of her body, if she is told one part of her body will be used but another part is employed, she may succeed in a case of negligence. For Mr Nordgren, his claim lay in that he began immediately suffering pain in his knee and it was this—an injury to his knee,

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to which he said he had not consented—that put him on the medical negligence trail. Because a genuine issue of material fact surrounded the consent issue, Mr Nordgren’s case was revived to go to trial. If a breach of duty could be established, then it would remain to prove that the breach caused him mental anguish or loss of dignity or both, and that the infection he suffered in the knee arose from the bone removal operation.35 This follows for the woman seeking damages in such a circumstance: having once established breach of duty, the question would be did she suffer pain and anguish and loss of dignity, or any physical harm because of the bone removal. Not only shoulders are in issue. In the 1980s, the singer Cher (then the female partner of singing duo Sonny & Cher) was reputed to have had ribcage surgery. Show business rumour was that at least the bottom pair of her ribs were removed, and possibly the pair above, to provide her with a narrow waist. Such gossip was risible, said Cher, for if it were true, how could she make health club commercials ‘wearing next to nothing’: I’d be scarred all over. And could I wear the kind of clothes I do if I’d had all those many operations? Wouldn’t there be visible scars everywhere? … I’ve had my nose done, my breasts done, and had braces on my teeth. The rest is nonsense.36

In the 1990s, she hired a British physician to examine her and report publicly on the results. He confirmed that however her ‘narrow-waisted look’ had been achieved, ribs had not been removed for this purpose. Yet five years later in her 1995 book Reshaping the Female Body – The Dilemma of Cosmetic Surgery, Kathy Davis repeats the claim, observing that Cher had ‘reputedly undergone dozens of operations …, most dramatically [having] two ribs removed to emphasize her waist’.37 So the speculation continues, just as such tittle-tattle has circulated since 1920s’ claims of actresses ‘undergoing the knife to remove one or two ribs for the sake of a shapelier waist’.38 Today, just as women enquire about narrowing of the shoulders, some women seek out plastic surgeons to remove a rib pair or rib pairs. As to plastic surgery on the shoulders, caution is expressed by one plastic surgeon, who adds that orthopaedic surgeons ‘may perform corrective surgery’ on them, but ‘are unlikely to perform this for cosmetic purposes’.39 Medical reasons for chest surgery can dictate procedures for pectus excavatum, a condition where the sternum and rib cage have

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sunk into the chest, or pectus carinatum, where the sternum projects abnormally forward, creating a ‘pouter pigeon’ look. Operations are ‘performed by some plastic surgeons and occasionally thoracic surgeons’ in such cases.40 Yet doubts arise around the procedure’s safety. Shoulder surgery is ‘quite extreme’, whilst narrowing rib carriages is ‘even more extreme’41 and, involving the removal of bone, inevitably pain follows. One woman seeking rib removal says this is ‘not a particularly daunting issue’. The response is that risks associated with lessening the functionality of the rib cage, in particular, underpins a reluctance on professionals’ part to develop or undertake such a procedure for cosmetic reasons. However, if the woman is determined she may find help ‘in foreign countries such as Brazil’.42 Where better defined collar bones are desired, the debate as to plastic surgery for cosmetic reasons once more focuses on risk. A desire to shorten ‘long’ or ‘elongated’ collarbones raises the spectre of risk, too. As well as being a recognised beauty feature, collarbones have an important anatomical relevance. Left and right clavicles lie horizontal to the ribcage and sternum (the breastbone), making up the shoulder girdle, mirrored on the back by the shoulder blades. Broken clavicles can be repaired; however, this simply resets the break so that the collarbone returns to its original position. Shortening or lengthening these bones can interfere with the structure of the chest cavity which houses the heart and the lungs. Seeking to recreate collarbones to create a hollowed-out look just below the shoulders, nestling at the base of the neck, can also impact negatively on the structure of the upper body. Sometimes, a remedy may be anticipated as lying in weight gain or exercise, as where a 15-yearold asks a plastic surgery online Q&A blog for a solution to ‘protruding collarbones’ she has had ‘ever since [she] was 10’.43 Raising an accompanying problem of ‘two bumps on [her] collarbone’ which she seeks to ‘make less visible’, she asks for advice on exercises to gain weight or some method ‘to cover it up’. The response is that the bumps are ‘the normal end of the clavicle’ and no surgery can change this. Further, there is ‘nothing you can do other than gain weight, but this is a very normal appearance’.44 Nevertheless, women seek out plastic surgeons to achieve collarbone restructuring in the name of beauty. Most collarbone questions directed to online plastic surgeons ask how to remedy clavicles deemed ‘too long’. Hence, ‘can each side of the collar bones be shortened a little for really long clavicle bones?’ and ‘is it possible to shorten my collar bone/clavicle? It’s long and makes my shoulders

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stick out at the sides, which is uncomfortable and unattractive …’. One correspondent says she feels lopsided whilst walking, and that ‘one side is about an inch or more longer than the other’. Another worries about her ‘very wide’ shoulders and ‘narrow hips’, wondering if it is possible to shorten the shoulders, or widen the hips as an alternative. However much she tries, says a third, she ‘cannot get fat to try and make [her] body proportional’. In light of this, is there ‘any way to correct my clavicle and narrow it, to remove the excessive broad look and imbalance I get from it?’45 Another frames her concern as to whether a procedure can ‘shave down’ clavicles which are too long or prominent, and what of ‘protruding clavicles’? Then a question comes from across the globe: Hello, after a bit of searching I cannot find a surgeon who will file down excess bone from my clavicles, have you ever heard of this procedure? They can do it in the USA but I need someone here in Sydney, it’s fairly minor work and purely cosmetic, the bones stick up like golf balls on top, have put muscle on the surrounding area but they still stick up badly. Many thanks.46

Following up the question whether shortening of collarbones can be done, a prospective client wonders ‘if so, how is it done and does it affect the shoulders in any way?’47 One adds ‘how much would it cost?’ The response to such concerns raises the ‘functional nature’ of the clavicle, meaning that reducing collarbones for cosmetic reasons is not something that a plastic surgeon is likely to do. If those seeking reduction are determined, then an orthopaedic surgeon ‘would be the most likely specialist to perform the procedure’. One plastic surgeon comments that he is unaware of anyone who ‘routinely performs this procedure’.48 Women wishing to emphasise their collarbones seek plastic surgery advice, too. One wants her clavicles ‘to show more’. Saying she ‘loves the aesthetic of prominent collarbones, [as] the most beautiful part of the body’, another wonders whether there is a procedure available that would give her collarbones a better defined and more structured appearance. She complains that despite constant exercise, this part of her upper chest has ‘no definition’.49 The consequences of ageing and its impact on the collarbone come into the equation, too: As I’ve gotten older, there is this ‘hollow hole’ effect happening with my front neck muscles protruding at the collar bones. The skin is literally

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‘sucked’ into the gap between the collar bones with the front neck muscles forming a ‘V’. Help! I call it stringy neck.50

Would Kybella work ‘on neck, jawline, and clavicles/shoulders?’ asks one.51 The would-be client who enquires about Kybella effectively speculates on whether a procedure developed to reduce a double chin could be effective in reducing fat on the chest. She assumes that this chest fat conceals the desired definition of her collarbones. Yet Kybella is, so far at least, recommended for fat around the lower chin area, not fat in the chest area. Furthermore, it is doubtful whether clavicles would become more defined if fat were removed by a series of injections. Ultimately whether collarbones are attractively defined or not is dependent upon genetics and bone structure. Removing the fat by Kybella (if possible and agreed by surgeons to be done) may not reveal the shapeliness sought.52 In any event, being a fundamental part of chest cage construction, reservations expressed about shortening the length of the collarbones would apply equally, or more so, to their surgical reconstruction.53 The alternative is to take up contouring, the solution recommended by make-up artists and beauty salons. It lacks permanency, but is painless and far less costly than seeking out plastic surgery in Brazil, or running a series of Kybella injections in the hope that the process for reducing fat chins works on the chest to expose the clavicles.54 The level of risk seems to rule out surgery in favour of cosmetics. Margot Peppers writes that ‘highlighting and contouring to bring out the bone structure in a woman’s face’ is now applied to the collarbone. Observing that the sought-after appearance of the clavicles of dancers and models transpires because dancers and models are more slender, this is not the universal answer. Others, she says, ‘are simply genetically graced with the right bone structure …’. Those with neither advantage are now able to ‘fake it with the clever use of make-up’, used by some ballerinas as a standard technique. This involves contouring the clavicles in much the same way as contouring of the cheekbones is realised. Collarbone contouring is accomplished through a make-up session costing $US 25 or approximately £20. First, translucent powder is applied to ‘waterproof the skin and keep the make-up from rubbing off on clothes’. Foundation comes next, to even out the skin tone, leaving the chest ‘feeling silky and smooth’ and giving the skin ‘beautiful luminosity’. Cream-based products rather than powder are preferred for contouring, because ‘creams

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blend better on the skin …’. The subject seeking clavicle definition then shrugs her shoulders forward ‘to emphazise [the] collarbones’, and the shape of the bones above and below is brushed with a bronzer, ‘creating a shaded effect’. The flatness of the chest is thus reconstructed by the application of make-up, which gives an illusion of two distinctly protruding bones. This is further emphasised by the application of a highlighter or luminizer. Concluding the treatment, one make-up artist observes that a woman’s collarbone ‘has always had an air of sexy mystique’. Whether this is because the clavicle is proximate to neck and breasts, ‘two major erogenous zones’, or because the bones ‘showing depth recreate the look of a woman taking a breath’, eschewing cutting the skin, puncturing and jabbing with needles, breaking or shaving of bones may be the better way of ‘playing into a woman’s desire to look delicate and feminine, as antiquated as that desire may seem’.55 So long as the products used are properly tested and applied, the potential for error arising out of surgical intervention or injections can be obviated. At the same time, care needs to be taken with the products that are applied to the skin as make-up. Allergies, rashes, dermatitis, boils and blisters need to be avoided. For the United Kingdom the Consumer Protection Act 1987 and the Consumer Rights Act 2015 govern consumer rights in the use and application of beauty products and cosmetic treatments. If professionals apply the products, they run the risk of a negligence claim if they do not ensure that the products themselves are safe, or that the woman to whom they are applied is tested before application. Techniques used by professionals also need to be of the requisite standard because a duty of care is owed to the client, a duty that includes application of products in a way that is safe. If the products are applied at home, the user needs to be sure she follows the instructions carefully and applies the products as directed. Otherwise, if the skin is damaged or distressed, she will run the risk of any negligence claim being defeated or compensation being reduced on the basis of her contributory negligence.

2

Bust, Bosom, Breasts …

The breasts have been and continue to be that part of women’s anatomy forming a major target if not the major target when it comes to women’s bodies and notions of beauty. Over the ages, women’s breasts have been signifiers of class and status, femininity, intelligence or lack of it, morality

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or its absence, and cultural, racial or ethnic origins.56 For Hippocrates, the breasts of both women and men held a prominent place intellectually: alike, they ‘have thick veins in both breasts that make the greatest contribution to a person’s intelligence’.57 Notwithstanding this assessment, rather than acumen, aptitude or brain power, shape, size and contour have dominated the discourse surrounding women’s breasts. Some cultures or fashion periods want them perky and even petit, some prefer pendulous breasts, some associate the softness of women’s breasts with lesser brain power, some promote breast beauty as associated with rounded bulk.58 As Kathy Davis says in Reshaping the Female Body, for Western culture, ‘breasts are probably the most visible symbol of femininity and, therefore, central to women’s identity and bodily self’.59 Hollywood stars over the generations have been identified by reference to their bodies and particularly to their breasts. Recognised for their acting ability, Mae West, Marilyn Monroe, Diana Dors, Jayne Mansfield, Jane Russell and Sophia Loren are iconic ‘bosom factor’ representatives of the screen. For them there was no suggestion that their breasts were false or enhanced by implants.60 In her autobiography, Goodness Had Nothing to Do With It , Mae West asserted that her breasts’ ‘good condition’ followed from regular application of natural products, namely water which she sprayed on every morning, and cocoa butter which she massaged into them every night. Sometimes she followed the cocoa butter routine in the mornings as well.61 Nonetheless in Science on Trial , Marcia Angell, a stringent critique of 1990s awards to women claiming that silicone implants had caused them loss of well-being and life-damaging injury, reports that the ‘first known attempt to enlarge a woman’s breasts occurred in Germany in 1895’.62 Today, artificially enhanced breasts appear as a standard feature, at least for many stage, cinema screen and television stars. Particularly for those who fill the ranks of ‘reality tv’ performers, breast augmentation may be de rigueur. In 1989, US self-reporting studies estimated that of 1000 women, some nine had had breast implantation surgery. The estimate rose to at least two million in 2000, with ‘close to 200,000 [prospectively] implanted every year’.63 In 2002 in the United States 268,808 implant procedures were recorded, and in 2005, breast augmentation came third after rhinoplasty (‘nose reshaping’) and liposuction as the most common plastic surgery undergone for cosmetic reasons. By 2006, breast augmentation led the list of plastic surgery procedures, and in 2016 it continued as the most popular procedure, with 84 per cent of operations involving

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silicone implants, and 16 per cent using saline implants.64 By 2017, breast augmentation procedures numbered 300,378, up three per cent from the previous year.65 For the United Kingdom, from 2010 through to 2018, the total of breast augmentation surgeries varied, ranging from 9430 in 2010, 10,015 in 2011, then back to 9854 in 2012. In 2013 the number peaked at 11,135, reducing to 7745 in 2018. From the peak to the 2018 trough, the numbers varied between roughly 9000 and 7700.66 It is difficult to assess in any scientifically valid way whether these procedures enhance the lives or well-being of the thousands of women undergoing them. Andrea L. Pusic et al. in ‘Measuring Quality of Life in Cosmetic and Reconstructive Breast Surgery: A Systematic Review of Patient-Reported Outcomes Instruments’ studied numerous patientreported outcome measures ‘developed and validated for use in cosmetic and reconstructive breast surgery patients’.67 The authors began with the proposition that cosmetic and reconstructive breast surgeons ‘strive to satisfy their patients with respect to aesthetic results, body image, and quality of life’.68 They discovered that clinical outcomes are increasingly measured, by reference to patient satisfaction with quality of life becoming more pronounced as an intended result. Yet the authors concluded that the instruments for measuring outcomes were not designed so as to bring any about any real confidence that these measures were being met. Their intensive literature review found that many instruments purporting to provide useful measures were ‘ad hoc questionnaires’. Only seven ‘had undergone any degree of development and validation’, and none was ‘appropriately developed or validated’ in accordance with criteria developed by the reputable body in the field of medical evaluation, the Medical Outcomes Trust, and ‘none could be recommended without reservations’.69 Furthermore, the four breast augmentation surgery instruments amongst the seven were developed by private industry, ‘with limited information published about their development and validation processes’. One of these was a product of Dow Corning, the company known for producing silicone breast implants, and another was produced by McGhan Medical Corporation, focused on its own Saline-Filled Mammary Implant Augmentation Clinical Study.70 Readers may not be blamed for inferring that self-interest may have influenced satisfaction outcomes resulting from the use of these instruments and, in any event, as Pusic et al. concluded, the flawed nature of the instruments meant that the outcomes were unreliable.

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Whatever the ‘satisfaction’ results, and however well or poorly assessments after the operation measure outcomes, women continue to undergo breast implant operations. Jane Fonda admits to plastic surgery, although being reticent as to precisely what: it is rumoured that in her early forties she underwent a facelift, repeated in 2010, and ‘many also believe she has undergone breast augmentation surgery’.71 The supermodel Cindy Crawford has been quoted as saying of body shape with a particular emphasis upon breasts: You start out happy that you have no hips and boobs. All of a sudden you get them, and it feels sloppy. Then just when you start liking them, they start drooping.72

Can the resort to plastic surgery be attributed to apeing or being influenced by the celebrity factor, or are other factors at play? As well as being a source of pleasure for women and a source of nourishment for offspring, as Davis in Reshaping the Female Body observes, breasts ‘more than any other body part, [are] “up for judgement”, problematic, and subject to various forms of correction …’. 73 From handkerchiefs or tissues stuffed down the front of a woman’s dress, to padded or uplift bras, to breast enhancement pills, creams, gels and other medications, to augmentation by surgical intervention, a woman’s bust is a focus of public notice and commercial exploitation. Yet despite all this attention, what is so often overlooked is the almost magical nature of women’s breast development and its extraordinary capacity to provide nutrition for a baby whilst simultaneously being an accepted part of a woman’s body, playing a role in her sex life by its being a highly sensitive sexual organ, and taking on a significant role as a fashion feature. From the age of nine or ten years, the onset of puberty is signalled by the emergence of breast buds. Young girls’ breast area becomes tender with the slightly defined nipples and areola rising gently from the chest as the flesh beneath begins to expand. But what is seen from the outside is so little recognised as indicating the complex steps directed by nature beneath the skin. Milk ducts and surrounding fatty tissue develop, a precursor of what is to come with the development of the breast as an organ capable of producing milk that emerges from the nipple. The hormones estrogen and progesterone play a significant part. Estrogen dictates the growth of fatty tissue, whilst upon menstruation progesterone is released from the ovaries to stimulate glands to produce milk, and firm and shape the breasts

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into the contours that attract (stereotypically male) attention. During the menstrual cycle, breast glands release hormones that prepare the breasts for pregnancy. If conception does not occur, the breasts regain their usual size. This cycle recurs throughout a woman’s life from the time of puberty and up to menopause.74 Yet sometimes this development is marred by perceived errors in breast construction—including ‘too small’ breasts, ‘too large’ breasts, inverted nipples, ‘too large’ or ‘too dark’ nipples, ‘too small’, ‘too large’, ‘too dark’, ‘too pale’ aureoles (or areolas), lumpiness, asymmetry of the breasts, droopy, sagging or insufficient ‘perkiness’. Sometimes, breasts are struck by the development of cancerous cells requiring treatment. Early treatment is possible, leading to saving the breasts from surgery or requiring relatively minor surgical intervention. However, sometimes breast removal is diagnosed as necessary to stop the cancer spreading, a risk relating to proximity of lymph nodes and breasts. Where breast cancer is recognised as having genetic links, some women take the pathway to mastectomy before there are any signs of cancerous growth or its likelihood. Angelina Jolie is one famous proponent of this approach, with others less prominent adopting it too.75 Breast cancer is now the most treatable of cancers with the greatest success rate in battling it.76 However, mastectomy remains as a feature of breast cancer treatment. The removal of a breast or breasts has in turn led to ways of replacing the breast artificially, an option sought by many women although some abstain from this approach.77 That implants are available for reconstructive purposes where a woman has suffered breast cancer throws into sharp relief the issue of ‘normalisation’ versus ‘beautification’ or reconstruction for reasons of physical or physiological health, contrasted with reconfiguration of breasts not for health reasons, but for cosmetic purposes. Although both have a cosmetic element, in one the woman seeks replacement of what she has lost through surgery and would be intact but for the cancer or prospect of cancer—a disease that can be deadly.78 In the other, the woman seeks to have healthy breasts reshaped or redesigned to fit into a socially or culturally constructed norm. Yet even in the latter instance, arguments are readily advanced that the condition of healthy breasts can support surgical intervention. Breast reduction surgery can be available on the National Health Service (NHS), depending upon the problems experienced by the prospective patient. If, as a consequence of the size of her breasts, a woman suffers backache, shoulder or neck pain, skin irritation, rashes and

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skin infections under the breasts, shoulder grooves caused by bra straps and the weight of the bust, an inability to exercise or participate in sports, or psychological distress including depression or low self-esteem, breast reduction can be advised.79 Some NHS Clinical Commissioning Groups (CCGs) do not fund breast reduction surgery at all, whilst some include additional conditions such as breast size, weight, age, cigarette smoking, and whether alternative approaches including seeking professional advice on bra size and fitting have been tried without success. The NHS acknowledges that the benefits of reduction ‘may outweigh any potential problems’,80 however, for women whose breasts are ‘only moderately large’ the risks may outweigh the benefits. Risks include the tendency for breasts to droop as time passes, an unwelcome alteration in breasts’ shape and look, a decrease or increase in size through losing or gaining weight, potentially defeating the purpose of the reduction, interference with the capacity to breastfeed, loss or lessening of nipple sensation, and scarring. Scarring can be mild and rectified by Vitamin E treatment or simply with the passage of time. Some skin is, however, prone to keloid scarring where scarring appears to build an extra layer of skin. This is an overreaction of the skin’s healing process and can produce redness, itching, lumps, swollen blood vessels in the skin or skin darkening. Exercise and dieting may seem to be a better option, however, for women with very large breasts this can be an unrealistic proposition. Yet surgery is risky, and information provided to prospective patients is a vital component of consent. Just as it arises for surgery generally, how much information and how it is to be conveyed arises for breast reduction and for breast augmentation. The law governs surgical interventions whether for medical or aesthetic or cultural reasons. Decided in 2016, Karen Turner v Mr Nigel Carver 81 illustrates how courts will look at the question of consent based on what information is provided to prospective patients. Ms Turner had undergone several breast surgery operations to increase her breast size. She approached Mr Carver for a further augmentation. The claims of medical negligence against Mr Carver arose because Ms Turner was dissatisfied with the result, in part because she considered her breasts now to be ‘too large’. Prior to the operation, Ms Turner and Mr Carver held ‘detailed discussions’ about ‘the surgical options, the size of breast implants to be used, and the risks of surgery’. Written information sheets ‘which reflected the matters discussed’ were also provided to Ms Turner.82 Initially, she was pleased with the outcome and three months later underwent liposuction with Mr

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Carver performing the operation. A further operation was required seven months later. One of the breast implants required a change of position. A serious complication developed, whereby a ‘haematoma … required emergency surgical drainage’. Subsequently Ms Turner began complaining that her breasts had not been made sufficiently large, then that they were too large. At the negligence trial she claimed that the implants were ‘far too large’, producing ‘an unnatural result’. Further, she said, inadequate information as to the surgical risks had been provided to her and, had the risks information been sufficient, she ‘would not have undergone the breast augmentation operation’.83 Ultimately, Ms Turner’s claim failed. Although Mr Carver’s notes, taken contemporaneously with the consultations and discussions about risks and the provision of information, were found by the court to be ‘not as full as they could be’, this did not result in success for Ms Turner’s claim. The court said that Mr Carver had ‘both orally and through the provision of the detailed information sheets’ provided Ms Turner with ‘sufficient information’ about the surgical risks.84 Her consent was therefore valid. As to her complaint about the augmented size of her breasts, evidence from Mr Perks, an expert witness appearing for Mr Carver, was that the question should be whether the ‘cosmetic outcome’ was ‘outside the very wide range of natural human variation’.85 As the augmentation came within the range, the court held that there was no negligence on Mr Carver’s part. Rather, Ms Turner suffered from ‘buyer’s remorse’. That is, her dissatisfaction with the outcome was akin to the position of Mrs Zahir who complained that the outcome of rhinoplasty was aesthetically disappointing. Just as in Zahir v Vadodaria 86 the court determined that the issue was ‘whether the surgical technique used was acceptable’, so it was for Ms Turner. That the surgery had been conducted to the acceptable standard was determinative, not the patient’s unhappiness. The case reflects the debate as to the pressure women may experience from external sources implying that women’s breasts, as with other parts of their bodies, should meet some particular standard. That Ms Turner vacillated about the outcome, first assessing the resultant breasts as being insufficiently large, then concluding they were over-large seems to indicate that she was searching after some mythical ‘perfect’ breast size. In ‘The Body Image Dissatisfaction and Psychological Symptoms among Invasive and Minimally Invasive Aesthetic Surgery Patients’, Rokhsareh Y. Yazdandoost, et al. observed that both social and intrapersonal motives generate the desire for aesthetic surgery. Unsurprisingly,

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those who sought procedures for altering their bodies—this research focusing on rhinoplasty and breast augmentation—had a higher body dissatisfaction rating than the control group who did not travel this path of body ‘enhancement’. The conclusion that people having ‘high psychological investment on their appearance … are more likely to experience body image dissatisfaction’87 will come as no surprise. This may indicate that undergoing surgery to ‘correct’ the body may not result in satisfaction, unless the procedure has the effect of reducing the woman’s level of psychological investment in her appearance. Yazdandoost, et al’s research showed that those who are unhappy about their bodily appearance ‘accept consistent information and ignore information that is in conflict’ with their own negative view of their body construction.88 Hence, if they continue to harbour concerns, as did Ms Turner, despite the operation, the change to their bodies will not be accepted as perfecting what was perceived to be wrong. This will impact on the nature of consent to aesthetically invasive surgery. It raises questions of choice and what this means in the world Sheila Jeffreys identifies in Beauty and Misogyny as infused with culturally defined notions of beauty and women’s bodies seen through a patriarchal lens.89 Ms Turner’s initial complaint that the augmented breasts were too small or smaller than she had wanted, reversed by the complaint of ‘too large’, might be attributed to body dysmorphia (BDD).90 It could be attributed to Sigmund Freud’s querulous complaint voiced in the plea ‘what do women want’, meaning ‘do they even know what they want’.91 However it is explained, it provides another insight into how women enter into agreements for undergoing aesthetic, cosmetic and plastic surgery and other procedures, and whether the end is, indeed, in their best interests. It raises questions about the way consent is defined in the law of surgery and other beauty procedures, and whether protestations that women are acting fully and indisputably in accordance with agency are founded in the realities of women’s lives in a world dominated by ‘the male gaze’.92 Bearing this in mind, where women seek breast implants, whether the impetus is replacement of a breast or breasts lost through surgery or the desire to have a larger bosom, caution is dictated. The first breast implant is reputed to have taken place in 1962, an experiment where the patient bargained her way into having her ears pinned back, in return for undergoing the breast operation.93 With small breasts that were ‘sagging’ after

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she had born six children by the age of 29 years, Timmie Lindsay had silicone implants inserted into her chest. Going from a ‘B’ cup to a ‘C’ cup, she was satisfied. The surgeons expressed satisfaction, too. It was not until some ten years later that she began experiencing problems. This involved minor pain and ‘some hardening’ of the silicone. By the 1980s, the pain ‘had increased much more’, involving ‘shooting pain in the breast areas’. Additionally, she experienced rashes and dry mouth. Some 40 years later, at the age of 79, she began to suffer ‘tearing’ of the implants’ casing. Hers were Dow Corning silicone implants, which towards the end of the 1990s was enmeshed in legal action taken by women numbering, in the end, some 300,000 in total.94 Timmie Lindsay’s first hints of something wrong coincided with the timing of the first product liability action launched against Dow Corning in 1977.95 In 1992, growing concerns about the safety of breast implants eventually prompted a ban on Dow Corning’s lucrative trade. Ruptures, leakage and displacement or movement of the implants from one part of the body to another led to the US Food and Drug Administration (FDA) placing a prohibition on their manufacture. By 1995, some 20,000 women had joined action as claimants. The numbers continued to grow, including women from Canada, Italy, the Netherlands, the Far East and Australia. Juries returned verdicts against Dow, finding the company responsible for damage to women’s fitness and well-being, and illnesses suffered by them. The illness and damage to health was attributed to the silicone breast implants. Dow was found to have failed to undertake proper testing and to have concealed from the market and the individual women the impact on women’s health, despite this becoming known to Dow. Dow declared bankruptcy in 1995. By 2014 pay-outs were still being made to women with claims of being injured by the product.96 Despite the law suit and global challenges to Dow Corning from women around the world who had been fitted with silicone implants, by 2006 the ban was lifted. Production of silicone implants and their surgical implantation into women’s bodies recommenced. Women sought out the operation despite enormous publicity, including numerous interviews with women complaining of major disasters and side effects and claiming compensation.97 It seemed almost as if a new generation of women, who would have grown up with the publicity surrounding the Dow Chemical saga and its impact on women’s breasts, bodies and psychic as well as physical health, chose to ignore it or to enter the realms of those who consider ‘it won’t happen to me’. Yet simultaneous with the pay-outs

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being made to the earlier cohort of women impacted by the consequences of breast-invasive silicone, a fresh outbreak of harm to women from silicone implants erupted in France. In late 2011, the French health authorities recommended that breast implants made with low-grade silicone should be removed from the market.98 This accompanied a recommendation by the French government that 30,000 French women who had had their breasts augmented by the implants should have them removed. The basis for the alert was the fact that the silicone gel leaked into the chest cavity, and was found to cause inflammation of the breasts and chest area. On top of that, the failure rate of the operation was some five per cent, subsequently upgraded to 5.5 per cent, both estimates being said by the French authorities to be ‘unacceptably high’.99 The seriousness of the French reports took some time to impact fully in the United Kingdom. The initial response of the British health authorities was to say that amongst more than 40,000 British women the failure rate was ‘closer to one percent’ and women with the French implants need not undergo ‘routine removal’. Indeed, their proposition was that health risks associated with removal of the implants, necessarily carried out by an operation requiring general anaesthetic, should be borne in mind. This informed the British health authorities’ recommendation. However, the Health Secretary at the time, Andrew Lansley, then told the media that no reliable statistics were held in the United Kingdom on ruptures or leakage of silicone. By February that year, some 3512 women had been referred to the National Health Service for care, potentially extending to removal of the implants. The Department of Health said that all the implants had been fitted by private clinics. By that time some 1400 scans had been conducted by the NHS to determine whether the implants were ruptured and leaking. The NHS undertook to provide all 40,000 British women with an examination and, where indicated, to remove the implants if the women requested it. Reimbursement was to be sought by the NHS from the private clinics. Although some of the private clinics had ‘disappeared’ or gone out of business, of those remaining some finally offered their former patients similar care, with a number of women taking that route. Following implant removal and a period of recovery, some women were refitted with implants by the NHS or were charged by the private clinics to have new implants incorporated into their breasts.100 Poly Implant Prostheses (PIP), the manufacturer of the implants comprising industrial silicone (ordinarily used as a mattress filler), was

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estimated to be the third largest manufacturer of silicone implants in the world. In late January 2012, Jean-Claude Mas, the French businessman who founded and ran PIP, was arrested in southern France. It was alleged that his company had sold approximately 400,000 sets of implants, both on the French domestic market and exported around the globe. In addition to the 30,000 distributed in France and 40,000 dispensed in the United Kingdom, estimates calculated the exports included 9000 in Australia and 4000 in Italy, with more than 25,000 sold in Brazil. Upon his arrest, reports said Mas was being subjected to a judicial investigation into ‘manslaughter and involuntary injuries’.101 Eventually he was gaoled for four years for fraud, fined e75,000 (at the time £45,000) and banned from providing medical services or being a company director. Four other PIP executives received gaol terms between one and four and a half years.102 Women impacted by concerns about the implants took to the streets to express their concerns. The month of the PIP revelations in the media, some 60 women ‘protested in London’s Harley Street, calling on doctors to replace PIP breast implants for free’. Placards read ‘Toxic Time Bombs’, ‘Health Before Wealth’, ‘Innocent PIP Victim’ and, more graphically, ‘We Did Not Ask for Toxic Boobs’. Transform, a cosmetic surgery firm, and The Harley Medical Group were the objects of their anger.103 Women on the march said they were ‘distraught’ when first discovering ‘there was a problem with the implants’. One said she was ‘in tears for three days’ and ‘hadn’t slept’. Another said she was ‘angry’, ‘frustrated’ and ‘crying every day. They are so happy to take our money but not prepared to help support us’. She had been ‘quoted £3000 to have [the implants] replaced’.104 One woman’s concern was for the daughter she was breastfeeding. Not uncommonly when implant dangers are in issue, women who are breastfeeding suddenly become alert to the consequences for their babies. Fitted some years before a woman becomes pregnant, the danger arises when implants rupture or leak silicone into the breasts. The procedure was carried out on Lucy Petagine in 2001, with her breast size going from an ‘A’ to a ‘D’ cup. Her child was born in 2007, and after the birth the right implant ruptured. Her NHS doctor ‘said it wasn’t a risk and she could breast feed as normal’.105 However, at 18 months, her daughter was ‘diagnosed with an incurable brain tumour’. Petagine’s fear of the implant being at fault was not assuaged when doctors said ‘they

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could not rule out a link between her breast implants … and [her daughter’s] illness. The implants were manufactured by PIP using industrial grade silicone.106 Problems for women having had breast augmentation or reconstructive surgery after mastectomy did not rest with PIP alone. When the PIP scandal first broke, health authorities issued a warning to doctors not to use a German breast implant. Silimed implants, fitted for ‘as many as 20,000 women’ in the United Kingdom, were said to have a coating ‘which previous studies … found could release a cancer-causing toxin into the body over a number of years’. The risk was ‘considered extremely small’, however a product of the same kind, with the same coating, was withdrawn in 1991.107 In September 2015 it was reported that the UK regulator had stepped into suspend sale of implants made by Silimed.108 Silicone implants carry the risk that ruptures are unable to be detected definitively unless a magnetic resonance imaging (MRI) scan is undertaken. This is a consequence of the silicone gel ‘staying in the “pocket” which is the space surrounding the breast implant’, which means that there is no appearance of deflation of the breast. In the United States, the FDA (Food and Drug Administration agency) recommends that surgeons advise patients that they should obtain an MRI scan within three years after the initial implant operation, then every two years.109 This is to ensure that if a rupture occurs, it will be located relatively promptly. The implants can then be replaced, if the woman wishes it, and this will cut down the potential for long-term problems arising from silicone leakage. Concerns of possible impact on breast cancer means the FDA requires annual mammograms on women over forty.110 Not only gel or silicone implants are in question. Although in the United States the FDA has decided against a complete ban on textured breast implants, opting for implants to carry stronger warnings as they do not comprise a large part of US sales of implants, Australia is considering a ban. The question is whether a ban is needed ‘to protect women from the risk of developing a rare type of lymphoma’ in surrounding tissue.111 Researchers are considering information provided by regulatory agencies from Canada, the United Kingdom, Ireland, Japan, France and Aotearoa/New Zealand as well as the United States. They are taking into account breast implant-associated anaplastic large cell lymphoma (BIAALCL) reports of 78 confirmed cases of Australian patients, including four deaths.112 One US recipient of textured implants suffered ‘skin necrosis, a muscle torn off her sternum from the reconstruction and

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chronic pain’.113 Experiencing frozen shoulder so severe that she could not ‘pull on [her] pants or hug [her] kids’, she fell into ‘bursts of tears and rage’. The microscopic crevices built into the implants are designed to hold the implant steady by locking onto the surrounding tissue. Yet this feature, intended to prevent ‘drift’ of implants from their ‘correct’ position to other parts of the chest (even in some cases migration to under the arm), presents prime conditions for bacteria biofilm to survive, and can irritate the scar tissue that forms around the implant capsule.114 Saline implants are subject to concerns, too. These implants comprise a silicone shell containing saline, which gives the implant is bulk. They do not harbour the same ‘silent rupture’ problem of silicone gel implants, because saline implants ‘tend to flatten very quickly’115 once split, torn or broken. A leaking valve is not so quickly detected, but generally will be identified eventually by the naked eye. Problems listed by Lady Care Health116 as potentially arising from saline implants include breast pain, breast tissue atrophy—shrinking or thinning of breast tissues and skin, capsular contracture leading to breast hardening, hematoma, infection, necrosis or death of breast skin or tissues, inflammation of the breasts, rupture of the implant, a reduction in breast milk production, complications in breast cancer screening and reduction in breast sensation. Infection is a potential problem. In Lancet Infectious Diseases , Brigitte Pittet, Denys Montandon and Didier Pittet report that infection ‘is the leading cause of morbidity that occurs after breast implantation’.117 They report that it ‘complicates 2.0–2.5% of interventions in most case series’. In the main, infections develop during the acute post-operative period, however some can develop long after surgery. The greater risk of infection lies with implants for breast reconstruction or reconstitution rather than breast augmentation, but in both instances the origin of infection is not clear. Pittet, Montandon and Pittet identify potential sources as ‘a contaminated implant, contaminated saline, the surgery itself or the surgical environment, the patient’s skin or mammary ducts’.118 Additionally, reports suggest that a cause can be the ‘seeding of the implant from remote infection sites’. That this problem can arise ‘years or even decades after surgery’119 means that in such cases where negligence claims are pursued, the limitation of action period would run from the time the woman became aware, or should reasonably have become aware, of the infectious condition. For implants generally—saline and silicone, the US Food and Drug Administration agency (FDA) emphasises that breast implants ‘are not

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lifetime devices’ so that the longer the implants are maintained within a woman’s body, ‘the more likely that she will need surgery to remove or replace them’.120 Complications and ‘adverse outcomes’ most frequently experienced include ‘capsular contracture, reoperation, and implant removal (with or without replacement)’, whilst other ‘common’ complications are noted as ‘implant rupture with deflation, wrinkling, asymmetry, scarring, pain, and infection’. As well, the FDA observes that although it is ‘very low’ there is ‘an increased likelihood’ for women with breast implants being diagnosed ‘with anaplastic large cell lymphoma (ALCL)’.121 In addition to purely physical health-related conditions, a reduction in breast sensation is a potential outcome, yet women continue to pursue breast augmentation surgery with the insertion of foreign material into their bodies. This is indicative of the power of socio-cultural demands that women’s bodies conform to a particular paradigm. Women seem prepared to give up, or at least run the risk of being denied, the inclusion of their breasts as a significant contributor to their sexual lives. The loss, in particular, of nipple sensation denies women a key source of enjoyment for a fulfilled sex life. Yet now the pursuit of supposed bodily perfection is leading women to deliberately put their nipples at risk, in a way that almost certainly could lessen, if not reduce to zero, the heightened sexual sensitivity of this part of the breast. Nipple reduction surgery, to remove ‘the excess part of the nipple’, is done by cutting away small pieces of the flesh. Small incisions are made so that tiny pieces can be removed, then the nipple is refashioned into a smaller protuberance, having lost part of its bulk.122 The procedure can shorten the length of the nipple, reduce its bulk, or ‘disappear’ nipple droopiness. Modifying the width requires removal of a section from the middle of the nipple, with the remaining tissue ‘growing together’, decreasing the width. This procedure employs chemicals ‘dissolved to get the end results’.123 Transfigurations do not end there. The areola can be altered too, reducing its circumference. This is designed to make the breasts look more youthful and to give an illusion of smaller nipples. Hence, the brown outer area of the areola is removed surgically, with the surrounding skin ‘then brought inwards in a purse string fashion to surround the areola’.124 Stitches, which are absorbable, are used to reduce the areola’s aureoles.125 Ultimately, however, the question is who determines that part of the nipple is ‘excess’? Why does a woman consider that her nipples are, bluntly, not ‘right’ or not ‘normal’? The natural variance in human bodies, whether male or female, is not

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inconsiderable. With body parts, the same goes: putting to one side signs that indicate disease or potential disease, that one woman’s nipples vary from the shape, size, colour of another’s does not mean that one woman’s are right, the other’s wrong. And with this surgery, what are the risks? Recitations of risks on various clinical and health sites are variable. Hence, one site says that for nipple reduction, long-lasting side effects can include difficulty with breastfeeding or nipples appearing uneven through surgery having reduced one nipple more than the other.126 Other potential harm, damage and side effects include infection, bleeding and scarring, although these are said to occur ‘only if there has been a complication with the surgery’.127 Bearing in mind the sensitivity of breasts and particularly the nipples, that there is no reference in this site’s list to loss of sensation or even possible loss of sensation is difficult to understand.128 One article does observe that doctors ‘leave the center of [the] nipple in place to reduce the risk of sensation loss’, whilst another claims that in reducing nipple height and width, sensation can be preserved.129 An alternative site recognises that ‘the chance of losing all feeling’ in the nipples is a risk, nonetheless saying that this ‘loss of sensation’ may last ‘only a few weeks’ during healing, whilst simultaneously acknowledging that this ‘may last for an extended period of time’.130 Reference is also made to infection, plus ‘prominent scarring bleeding and bruising on or around the nipples’.131 Corinne O’Keefe Osborn lists loss of nipple sensation as a possible risk of areola reduction surgery, along with ‘reduced ability to breastfeed, although the former is said more likely to be temporary and damage to milk ducts is said to be rare.132 Together with these specific complications, she identifies risks of areola reduction as including infection, swelling and bruising.133 Interference with the ability to breastfeed and ‘decreasing the feeling in your nipples’ are listed as ‘a common side effect of breast surgeries’ by another clinical site,134 whilst yet another consultant catalogues possible outcomes with an estimate of longevity. Here the advice is that prospective patients should think carefully before embarking on the surgery, because once done, the change cannot be undone.135 Yet obviously nipple ‘improvements’ (if this is what they are) have possible long-term effects of the surgery.136 They will also be subject to the body changes experienced by all human beings over time. Just as bodies naturally age, so ‘new’ nipples age and do not retain their perfected shape. As for ‘possible risks and complications’, Osborn lists scarring, the severity of which

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is said to vary, sometimes ‘fading so much as to be nearly invisible’ whilst for others being and remaining ‘very noticeable’. ‘Areola tattooing’ is a suggested means of possible improvement.137 Yet tattooing in itself carries risks and dangers.138 Because tattoos are made by a needle breaching the skin, the Mayo Clinic points out that this means skin infections ‘and other complications’ can occur. These are listed as including allergic reactions, skin infections, ‘other skin problems’ including inflammation from the tattoo ink, called ‘granuloma’, or keloids (overgrowth of scar tissue causing raised areas of scarring), blood-borne diseases or MRI (magnetic resonance imaging) complications.139 Tattoo dyes are responsible for allergic reactions, and ‘even years after … the tattoo’ can cause an itchy rash. Hepatitis B and C or staphylococcus aureus are bloodborne diseases that can arise from contaminated tattooing equipment and, although rare, ‘swelling or burning [may occur] in affected areas during MRI exams’. The pigments creating the tattoo can affect the quality of the MRI image.140 Writing of the apparent fashion in nipple reduction, Eva Wiseman asks: ‘What does the trend for smaller nipples say about us?’141 She notes a ‘30% rise in women requesting a smaller nipple size’ in 2016, causing the Plastic Surgery Group to predict this to increase even further in 2017. Bearing in mind the rapidly changing focus upon different parts of women’s bodies, from cleavage, to sculptured clavicles, to shoulders, ribs, breasts, and now nipples and aureoles, women might wonder as does Wiseman where it will stop. With caustic wit, Wiseman posits the disappearance of nipples altogether.142 As for the PIP industrial grade silicone story, Naomi Wolf expresses concern about the ever-growing involvement of ‘financial stakeholders’ in regulatory agencies, most particularly the FDA.143 For Wolf, the problem is women’s vanity or, rather, the contention that women’s vanity lies at the base and heart of the burgeoning beauty market. So long as women’s vanity is blamed for the very existence of the industry that promotes the pursuit of the body beautiful however defined, real accountability for those reaping financial rewards from inventing products that harm women will be lacking. So too as regards those who ensure for commercial reasons that women can place themselves in harm’s way, with clinics readily available to cater to the latest body-changing fashion. Wolf laments that so much that should be available and made known to women before they embark on surgical paths strewn with mishaps is concealed or records are not kept, information not collected.144 The law as expounded in Montgomery v Lanarkshire

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Health Board 145 does require information sufficient to make a woman’s consent real. However, this does not necessarily nor always guard against women’s embarking on risky operations or pursuing procedures that do not involve surgery. Furthermore, where defects, damage and duplicitous conduct of manufacturers come to light and one product goes off the market, another comes forward to take its place. This is the lesson of breast implants, tried out on women like Timmie Lindsay, whose story records that she, like the women to whom Naomi Wolf alludes, was treated like a guinea pig in the interests of breast and implant surgery.146 It is the lesson of surgical and other techniques tried out on women, too. Yet if as Dante Rosetti’s oils profess,147 women’s breasts are so precious—how is it that they are subjected to so much derogatory comment, criticism, ribald jokes, humiliating taunts and demeaning language, ensuring that so many women are persuaded to put them at risk? One surgeon estimates an increase of 25 per cent of patients seeking nipple reduction over the year 2017.148 How is it that so many women, numbers growing, subject themselves to potentially damaging and dangerous interventions that alter their breasts? As Florence Williams in Breasts points out,149 the development of women’s breasts is truly wonderous. Why is nature not enough?

3 Reclaiming Our Bodies, Our Selves---Beginning with Breasts & Chests In 1971 the Boston Women’s Collective published what became a groundbreaking classic, with its first commercial printing by Simon & Schuster in 1973. Our Bodies, Our Selves , grew out of a course entitled ‘Women and their bodies’, run by the Boston Women’s Collective in the recognition that women were being ill-served by the medical profession, conventional medicine and health regimes.150 Around the same time, a women’s collective in the United States produced a video for women, ‘Speculum Speaks’. The idea behind the book and the video was to reempower women by providing information to women, by women, about women’s own bodies. Amongst other images, the video showed barebreasted women discussing size, shape and general appearance, revealing that none of them possessed symmetrical breasts: in every case, one breast was larger (sometimes slightly, sometimes significantly larger) than the other. Today, however, googling ‘Speculum Speaks’ does not enable the searcher to locate the 1970s women’s collective video. Rather, numerous

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pornographic sites and their links appear. This in itself supports the proposition that women’s efforts to reclaim our own space, our own identity, our own bodies are systematically undermined.151 Yet this is not, of course, new. The history of women’s breasts provides a text-book exemplar of the way in which women have sought to gain authority over their own bodies, whilst notions of possession, ownership and self-pronounced expertise intrude, passing authority into the hands of the medical profession and, before that, men who relied upon magic to give them power and influence. So it is that powerful men have laid claim to setting the standards to which women must conform or at least aspire. At the same time, the somewhat contradictory demand is relayed, namely that women should achieve this ‘natural’ outcome by recourse to artificial means. This is then topped by the proposition that women are simply exercising agency, fully aware and utterly independently wishful for every procedure that is done to them, their breasts and their bodies. In 1558 John Baptista Porta published Natural Magick, reportedly ‘a best seller’ from the start.152 For him, of ‘all the Ornaments of women’ the breast is ‘the chief’. This meant retaining, after childbearing, ‘round, small, solid, and not flagging or wrinkled Breasts’. Securing this outcome required crushing and pounding Hemlock, mixing the mash with vinegar, and spreading it upon the bosom. Even the breasts of virgins should be treated in this way, for it would ‘stay with them, so that [their breasts] would not increase’.153 An alternative was to bash limestone into a powder, mix it with egg and other potions including frankincense, mingle this with hot vinegar and paste the resultant concoction onto the chest where it should ‘remain all night’. Seeds of pomegranates, herbs, green pineapples applied together with the earlier mixtures would recover drooping breasts so as to ‘make them like the round, hard, solid Breasts of Virgins’.154 Four hundred years later, this advice was being replicated in the production of commercial products. ‘Lifestyle Advice’ published in the Cambridge Daily News of June 1939 advanced the advantages of a cream one could buy for firming body flesh. Wetting the skin, then rubbing the cream ‘until it disappears’ would do the trick. So long as ‘treatment has been regular and thorough, within a week or so a great difference will be noticed’.155 The twentieth-century recommendation saw no drawback to using the cream, ignoring any potential impact upon a woman’s health. Baptista Porta did consider the prospect of the mixtures he promoted as having a potential for interfering with a breast-feeding woman’s capacity to

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produce milk, or to produce milk to the liking of the baby she sought to feed.156 However, he brushed that possibility to one side, elevating the firmness and shapeliness of the breasts as pre-eminent. Such a cavalier attitude is replicated today in discussions of breast surgery to augment a perfectly healthy woman’s size, curves and shapeliness of chest, even to the extent of producing so prominently large mammary glands as to be nothing other than obviously artificially induced. So it is that inevitably a long list of risks appears in A Practical Guide to Cosmetic Surgery Claims , Victoria Handley’s recitation of what gives rise to cosmetic surgery claims involving breast augmentation and implants.157 These include bleeding into the breast tissues causing swollen, painful breasts; infection resulting in unsightly scarring; reduction or loss of nipple sensation; lumps (but not cysts); pain under the arm or in the armpit; for ruptured implants— silicone in the lymph nodes in quantity sufficient to amount to injury; hardening of the breast following rupture; ripping; the breast feeling hot; psychiatric injury attributable to the breast injury; pain; denting, softening or other significant changes in breast shape; bottoming out—where implants fall under the breast line; similarly when the skin attached to the breast bone comes away and gives the appearance of one large breast.158 Yet the message continues to be purveyed, seemingly universally, that there is ‘something wrong’ with women’s breasts as they are. Suzanne Fraser observes in Cosmetic Surgery, Gender and Culture that there is a difference where recourse to surgery and other means of recovery are undertaken when people’s bodies have been damaged by war or industrial accidents, physical attack or disease.159 However, not only repair and regeneration occur in the clinics and operating theatres of plastic surgeons and their cosmetic and aesthetic surgeon counterparts. Indeed, the likelihood that surgery and non-surgical intervention for cosmetic or aesthetic reasons outnumber those for repair or regeneration is all too real. Women whose breasts and chests have developed without interventions that are damaging or disease ridden enter these clinics and operating theatres in large numbers despite the healthy nature of their body parts. There is no little irony in the juxtaposition of the idea that differences in women’s breasts and their constituent make up are not uniform, so are natural, yet surgery is available to ‘rectify’ this:

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Like breasts, areolas vary widely in size, color, and shape. It’s perfectly normal to have large or differently sized areolas. If you’re uncomfortable with the size of your areolas, reduction is possible.160

Further confirmation of such differences is research asking participants ‘to rate images of areolas on a scale of one to five, in order of “attractiveness”’, thence indicating ‘if the diameter of the nipple areola were “too big”, “too small”, or “just right”’.161 All images in the study were the breasts of real women—in other words, real breasts. Despite their being natural, some breasts were deemed to be ‘wrong’. Thus, if the nipple size ‘occupied more than 50 percent of the breast … approximately 92 percent of participants deemed the nipple “too big”’. Yet ‘too small’ was bad, too: 78 per cent ‘found that if the nipple areolar complex was less than 15 percent of the breast width, it was … “too small”’. When breasts were viewed straight on to the camera or eye, the ‘just right’ nipple occupied ‘some 25 to 30 percent of the breast’.162 This survey was conducted by the Plastic Surgery Group. Made up of the British Association of Aesthetic Surgeons and the British Association of Plastic Reconstructive and Aesthetic Surgeons, the results came from British subjects. Hence, ‘rightness’ and ‘wrongness’, what was aesthetically pleasing and what was not, was framed in notions arising out of Western sensibilities—or biases.163 Had the study been conducted with another ethnic cohort, the outcome may have been different. Cultural, ethnic and racial differences in notions of beauty and bodily construction and conformity are well-documented.164 Western ideals can have some pre-eminence due to the dominance of Western media, although a strong minority ethnic identification can lead to resistance against this lure.165 In Things No One will tell Fat Girls 166 Jes Baker writes that women are ‘more likely to be told by the world that we are good people than anything else’. Descriptors such as ‘funny, creative, intelligent, communicative, generous, maybe even extraordinary’ are employed to emphasise how ‘good’ a woman is. Meanwhile, the words denied to women are those that could convey ‘that our bodies are perfect just the way they are …’. Women are taught, Jes Baker continues: … that our outsides are flawed, and not only that, but the majority of our worth lies in our physical appearance, which of course is never ‘good enough’ …167

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Bearing this in mind, women need to ask whether traversing the path of physical reconstruction is the answer. The consequent physical and potentially psychological risks are not all that renders this problematic. Even absent errors, harm and damage, the result may not be as wished for. Yet as the case of Zahir v Vadodaria illustrates the law will not compensate nor provide redress for dissatisfaction, however deeply felt.168 Rather than become enmeshed in the creation of a plastic bosom, bust or breasts, women may better take forward looking action, reclaiming our real bodies as ourselves.

Notes 1. Barbara Ewing, The Fraud, Sphere, London, UK, 2009, pp. 223–224. 2. Elizabeth Norton, The Lives of Tudor Women, Head of Zeus Ltd, London, UK, 2016, p. 277. 3. wikiHowstaff, ‘How to Remove Age Spots’, https://www.wikihow. com/Remove-Age-Spots (accessed 17 April 2019). 4. Ibid. 5. Ibid. 6. Ibid. 7. ‘How Do Sunbeds Cause Skin Cancer’, Cancer Research UK, https:// www.cancerresearchuk.org/about-+cancer/causes-of-cancer/sun-uvand-cancer/how-do-sunbeds-cause-skin-cancer (accessed 20 January 2020). 8. Lesley Reynolds, ‘Does Your Chest Give Your Age Away?’ Daily Express, 13 June 2013, https://www.express.co.uk/life-style/style/407 044/Does-your-chest-give-your-age-away (accessed 19 April 2017). 9. Ibid. 10. Cosmetic Surgery Solicitors, ‘Chemical Peels Gone Wrong’, Chemical Peel Claims, https://www.cosmeticsurgerysolicitors.co.uk/our-services/ chemical-peels (accessed 14 April 2018). 11. Zahir v Vadodaria [2016] EWHC 1215 (QB), https://www.bailii.org/ ew/cases/EWHC/QB/2016/1215.html (accessed 20 January 2020). 12. Montgomery v Lanarkshire Health Board [2015] UKSC 11; [2015] 2 WLR 768, https://www.supremecourt.uk/cases/docs/uksc-20130136-judgment.pdf (accessed 20 January 2020). 13. Victoria Handley, p. 86. 14. R v Paterson (31 May 2017), Nottingham Crown Court, https://www. judiciary.uk/wp-content/uploads/2017/05/r-v-paterson-sentencingremarks-mr-justice-jeremy-baker-20170531.pdf (accessed 2 December 2019).

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15. Quoted R v Paterson [2017] EWCA Crim 1625 (on appeal), at para [9]. 16. Ibid, para [63]. 17. R v Paterson (31 May 2017), ibid, paras [63], [64], [65]. 18. Ibid, para [50]. 19. See ‘Causes of and Treatment Exercises for Widow’s Hump’, Articles on Spinal Curvature and Posture, http://back.vsebolezni.com/deformaciispiny/vdovij-gorb.html (accessed 14 April 2018); ‘How Much Does the Removal of a Buffalo Hump Cost?’ RealSelf.com, https://www.realself. com/plastic-surgery/answers/shoulder (accessed 14 April 2019). 20. ‘How Much Does the Removal …’, ibid. 21. Nora McClellan, ‘Laser Liposuction’, RealSelf.com, 6 November 2018, https://www.realself.com/laser-liposuction (accessed 14 April 2019). 22. ‘Causes of and Treatment Exercises …’, ibid. 23. James Milner, ‘Hatless Women Will Not Be Admitted’, Cambridge News, 29 June 2019, pp. 20–21. 24. Ibid. 25. Plastic Surgery, ‘Is There a Surgery to Make My Upper Shoulders Smaller?’ RealSelf.com, https://www.realself.com/plastic-surgery/ answers/shoulder (accessed 14 April 2019). 26. Ibid. 27. Grieves Solicitors, ‘Shoulder Injury Claims and Shoulder Surgery Negligence Compensation’, Personal Injury Specialists: Claim Calculator, https://www.grieves-solicitors.co.uk/compensation-calculator/shoulder (accessed 15 December 2019). 28. Ibid. 29. Gary Nordgren v State of Louisiana, Through the Board of Supervisors of the Louisiana State University and Agricultural and Mechanical College Through Louisiana State University Health Sciences Center-Shreveport, and Todd Darren Jaeblon, DO and Joseph Marc Vonvillain, MD, No 53,480-CA Court of Appeal Second Circuit State of Louisiana, 22 July 2020, https://www.la2nd.org/archives/docs/e5e97b.pdf (accessed 23 July 2020). 30. Ibid, p. 2. 31. The law as appearing in the relevant Louisiana provisions is set out ibid. at pp. 8–9 and is a thorough rendition of the matters to which the medical profession must address their minds and how clear and complete they must be when informing patients for the purpose of ‘informed consent’. On consent in the United Kingdom, see Montgomery v Lanarkshire Health Board [2015], ibid. 32. Ibid, p. 3. 33. Snider v. Louisiana Medical Mut. Ins. Co., 13-0579 (La. 12/10/13), 130 So. 3d 922 (2013); cited Gary Nordgren v State of Louisiana, ibid, p. 10.

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34. Lugenbuhl v. Dowling, 96-1575 (La. 10/10/97), 701 So. 2d 447 (1997). 35. Gary Nordgren v State of Louisiana, ibid., pp. 13–15. 36. Quoted Chris Tyler, ‘Celebrity Myths: Cher Did Not Remove Her Ribs’, dbTechno.com, 9 June 2013, http://www.dbtechno.com/curiosity/ 2013/06/09/celebrity-myths-cher-did-not-remove-her-ribs/ (accessed June 2019). 37. Kathy Davis, Reshaping the Female Body—The Dilemma of Cosmetic Surgery, Routledge, London, UK, 1995 pp. 4, 18. 38. Chris Tyler, ‘Celebrity Myths …’, ibid. 39. Ibid. 40. Plastic Surgery, ‘Extreme Plastic Surgery: Procedures to Narrow Shoulders and Rib Cage?’ RealSelf.com, https://www.realself.com/plastic-sur gery/answers/shoulder (accessed 14 April 2019). 41. Ibid. 42. Ibid. 43. Plastic Surgery, ‘Plastic Surgery and Collarbone Questions & Answers from Surgeons’, RealSelf.com, https://www.realself.com/question/Cla vicle-shortening-surgery-possible (accessed 4 June 2018). 44. Ibid. 45. Ibid. 46. Plastic Surgery, ‘Why Is My Collarbone Protruding and How Can I Make it Less Visible’, RealSelf.com, https://www.realself.com/que stion/san-diego-ca-collarbone-protruding-lot-visible (accessed 4 June 2018). 47. Ibid. 48. Ibid. 49. Plastic Surgery, ‘Plastic Surgery and Collarbone Questions …’, ibid. 50. Ibid. 51. Ibid. 52. Your Look/Your Way, ‘Kybella: Injectable Double Chin Reduction’, HealthLine.com, https://www.healthline.com/health/kybella#howdoes-it-work (accessed 4 April 2018). 53. Plastic Surgery, ‘Why Is My Collarbone Protruding …’, ibid. 54. Margot Peppers, ‘Are contoured COLLARBONES the New Beauty Must-Have? Femail Learns the Make-up Tricks to Fake a Chiselled Clavicle’, Mail OnLine, 31 July 2014, https://www.dailymail.co.uk/ femail/article-2704841/Are-contoured-COLLARBONES-new-beautyFemail-learns-make-tricks-fake-chiseled-clavicle.html (accessed 4 June 2017). 55. Ibid, and see also ‘How to Have Prominent Collarbones’, WikiHow.com, https://www.wikihow.com/Have-Prominent-Collarbones (accessed 4 April 2018).

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56. See for example Eleanor Morgan, ‘Why Does Fashion Ignore Big Breasts?’ The Guardian, 13 August 2015, http://www.theguardian. com/fashion/2015/aug/13/why-does-fashion-ignore-big-breasts? CMP=EMCNEWEML661912 (accessed 14 August 2015); Will Pritchard, Outward Appearances: The Female Exterior in Restoration London, Bucknell University Press, Lewisburg, PA, USA, 2008; Kirk Combe, ‘Women Signifiers’, The Eighteenth Century, vol 52, no 2, 2011, pp. 211–214, https//muse.jhu.edu/ (accessed 4 April 2019). 57. Hippocrates, Epidemics, cited JC McKeown, A Cabinet of Ancient Medical Curiosities –Strange Tales and Surprising Facts from the Healing Arts of Greece and Rome, Oxford University Press, Oxford, UK, 2017, p. 75. 58. See for example Naomi Wolf, The Beauty Myth, Chatto & Windus, London, UK, 1990, p. 5; Lesley Ann Dean-Jones, Women’s Bodies in Classical Greek Science, Clarendon/OUP, Oxford, UK, 1994; Florence Williams, Breasts —A Natural and Unnatural History, W. W. Norton, New York, NY, USA, 2012, chapter 1, ‘For Whom the Bell Tolls’, pp. 13–36; Nigel Barker, The Sexual Wiring of Women’s Breasts’, Psychology Today, 7 May 2013, https://www.psychologytoday.com/intl/blog/the-human-beast/ 201305/sexual-wiring-womens-breasts (accessed 9 June 2019); and generally Susan Bordo, Unbearable Weight: Feminism, Western Culture, and the Body, University of California Press, Berkley, CA, USA, 1997. 59. Kathy Davis, 1995, ibid., p. 60. 60. Perrya, ‘The First Breast Implant, 1962’, HubPages, 23 November 2016, https://hubpages.com/style/Breast-Implants-Make-BiggerBoobs (accessed 10 June 2019). 61. Mae West, Goodness Had Nothing to Do With It , Mcfadden-Bartell, ISFD, http://www.isfdb.org/cgi-bin/fc.cgi, 1970; ‘Mae West: Cocoa Butter Breasts’, maewest.blogspot.com, 21 August 2014, https:// maewest.blogspot.com/2014/08/mae-west-cocoa-butter-breasts.html (accessed 10 September 2014). 62. Marcia Angell, Science on Trial —The Clash of Medical Evidence and The Law in the Breast Implant Case, W. W. Norton, New York NY, USA, 1997, p. 35. 63. Brigitte Pittet, Denys Montandon and Didier Pittet, ‘Infection in Breast Implants’, Lancet Infectious Diseases, vol 5, February 2005, pp. 94–106, http://infection.thelancet.com (accessed 20 February 2020). 64. American Society of Plastic Surgeons, ’Plastic Surgery Statistics Report 2016’, National Clearinghouse of Plastic Surgery Procedural Statistics, https://www.plasticsurgery.org/documents/News/Statistics/ 2016/plastic-surgery-statistics-full-report-2016.pdf (accessed 20 January 2020).

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65. American Society of Plastic Surgeons, ‘New Statistics Reveal the Shape of Plastic Surgery, Plastic Surgeon Match, https://www.plasticsurgery. org/news/press-releases/new-statistics-reveal-the-shape-of-plastic-sur gery (accessed 20 January 2020). 66. Conor Stewart, ‘Breast Augmentation Procedures Performed in the United Kingdom(UK) 2010–2018’, Statista—Health & Pharmaceuticals, 21 January 2018, https://www.statista.com/statistics/589880/bre ast-augmentation-cosmetic-surgery-united-kingdom-uk/ (accessed 20 February 2020). 67. Andrea L. Pusic, Constance M. Chen, Stefan Cano, Anne Klassen, Colleen McCarthy, E. Dale Collins, and Peter G. Cordeiro, ‘Measuring Quality of Life in Cosmetic and Reconstructive Breast Surgery: A Systematic Review of Patient-Reported Outcomes Instruments’, Plastic and Reconstructive Surgery, vol 120, no 4, 15 September 2007, pp. 823– 837, at p. 823, https://experts.mcmaster.ca/display/publication782069 (accessed 11 June 2019). 68. Ibid. 69. Ibid., p. 825. 70. Ibid., pp. 825–827. 71. Amy Miles, ‘Jane Fonda—Plastic Surgery 2020’, Celebrity Surgery, https://www.isuwft.com/1758/jane-fonda-plastic-surgery.html (accessed 6 August 2019); Surgery Miracle, ‘Jane Fonda Plastic Surgery Before After, Breast Implants’, Surgery Miracles, 3 July 2020, https://www.surgerymiracles.com/jane-fonda-plastic-surgery-beforeafter-breast-implants/ (accessed 6 August 2019). 72. Cindy Crawford, ‘Quotes—Quotable Quotes’, Good Reads, https:// www.goodreads.com/quotes/60123-you-start-out-happy-that-youhave-no-hips-or (accessed 11 June 2019). 73. Davis, Reshaping the Female Body, ibid. 74. See generally ‘Stages of Breast Development’, BreastHow, https://www. breasthow.com/stages-of-breast-development/ (accessed 11 June 2019); also Williams, Breasts , ibid. 75. Angelina Jolie’s genetic history meant that the mastectomy was also undertaken to reduce her risk of ovarian cancer. See Melissa Conrad Stoppler, ‘Angelina Jolie’s Mastectomy’, MedicineNet.com, 13 June 2018, http://www.medicinenet.com/angelina-jolie-mastectomy/views. htm (accessed 22 June 2018); ‘Angelina Jolie’s Surgery to Reduce Her Risk of Ovarian Cancer’, CancerAustralia.gov.au, 25 March 2015, https://canceraustralia.gov.au/about-us/news/angelina-jolies-sur gery-reduce-her-risk-of-ovarian-cancer (accessed 27 March 2015); ‘Angelina Jolie Announces Preventive Mastectomy—Information for Women About Family History of Breast and Ovarian Cancer’, CancerAustralia.gov.au, 15 May 2013 (http://canceraustralia.gov.au/about-

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us/news/angelina-jolie-announces-preventive-mastectomy (accessed 20 May 2013). Aaron Kandola, ‘What Are the Most Curable Cancers?’, Wellness Wire Newsletter—Medical News Today, 7 August 2018, https://www.medica lnewstoday.com/articles/322700.php (accessed 11 August 2018). See for example Penelope Mortimer, My Friend Says It’s Bullet Proof , 1967, republished Virago, London, UK, 1989. See generally Karen Berger, John Bostwick and Glyn Jones, A Woman’s Decision—Breast Care, Treatment & Reconstruction, 4th edn, Quality Medical Publishing Inc., St Louis, MI, USA, 2011. ‘Breast reduction on the NHS’, NHS Health—A to Z , https://www.nhs. uk/conditions/breast-reduction-on-the-nhs/ (accessed 11 April 2019). Ibid. Alaw Owen, ‘Cosmetic Surgery: Is It Realistic to Expect Surgeons to Assess Their Prospective Patients’ Psychological Profile?’ Hill Dickenson, https://www.hilldickinson.com/insights/articles/cosmetic-surgery-itrealistic-expect-surgeons-assess-their-prospective-patients (accessed 19 December 2019). Ibid. Ibid. DAC Beachcroft, ‘DAC Beachcroft Successfully Defend Cosmetic Surgery Claim on Consent’, DAC Beachcroft, 18 November 2016, https://www.lexology.com/library/detail.aspx?g=98228b2b-ddb04614-baff-a64861652504 (accessed 19 December 2019). Ibid. Zahir v Vadodaria [2016], ibid. Rokhsareh Y. Yazdandoost, Niki Hayatbini, Ali Asghar Asgharnejad Farid, Banafsheh Gharaee and Noor Ahmad Latifi, ‘The Body Image Dissatisfaction and Psychological Symptoms Among Invasive and Minimally Invasive Aesthetic Surgery Patients’, Psychological Symptoms in Aesthetic Surgery, vol 5, no 2, May 2016, pp. 148–153, https://www. ncbi.nlm.nih.gov/pmc/articles/PMC5003950/ (accessed 20 January 2020). Ibid., p. 152. Sheila Jeffreys, Beauty and Misogyny—Harmful Cultural Practices in the West, 2nd edn, Routledge, New York, NY, USA, 2015. ‘Body Dysmorphic Disorder (BDD)’, National Health Service, https:// www.nhs.uk/conditions/body-dysmorphia/ (accessed 19 January 2020). On Freud, see Jeffrey Masson, The Assault on Truth: Freud’s Suppression of the Seduction Theory, Farrar, Straus and Giroux, New York, NY, USA, 1984.

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92. See Rose McGowan, Brave, HarperCollins, New York, NY, 2018, generally and particularly ‘The Death of Self’, pp. 113–131. 93. Perrya, ‘The First Breast …’, ibid. 94. Ibid; see also Naomi Wolf, ‘The Silicone Breast Implant Scandal’, The Guardian, 16 February 2012, http://www.guardian.co.uk/commentis free/cifamerica/2012/feb/15/silicone-breast-implant-scandal-naomiwolf (accessed 17 February 2012). 95. ‘Dow Corning’, B.I.A. Aesthetic Surgery Information and Support, http://www.breastimplantadvice.com/dow-corning/ (accessed 14 April 2019). 96. ‘Jury Faults Dow Chemical in Breast Implant Trial’, Washington Post, 19 August 1997, http://www.washingtonpost.com/archive/politics/ 1997/08/19/jury-faults-dow-chemical-in-breast-implant-trial (accessed 14 April 2018); ‘Dow Corning’, ibid.; ‘Breast Implant Law Suits’, McIntyreLaw.com, https://mcintyrelaw.com/defective-medical-devices/ breast-implant-lawsuit/ (accessed 14 April 2018). 97. See for example Henry Jenny, Siliconegate. Exposing the Breast Implant Scandal, H. Jenny, London, UK, 1994; Mary White Stewart, Silicone Spills: Breast Implants on Trial, Praeger Publisher, Santa Barbara, CA, USA, 1998. 98. David Jolly and Maia de la Baume, ‘British Seek Data on Suspect Breast Implants’, New York Times, 4 January 2012, https://www.nytimes. com/2012/01/05/world/europe/05iht-implants05.html (accessed 4 March 2013). 99. Ibid. 100. ‘New Figures Show Almost 1000 Women Have Already Had Faulty PIP Implants Removed by the NHS’, PIP Breast Implants Blog —Hugh James, 16 October 2012, https://pipimplantsblog.blogspot.com/ 2012/10/new-figures-show-almost-1000-women-have.html (accessed 12 January 2014). 101. ‘Ex-head of French Breast Implant Maker Arrested’, Associated Press, 26 January 2012; Lachlan Mackinnon, ‘Dodgy Breast Implant Boss Held in Police Raid—Swoop as UK Firms U-Turn’, Daily Mirror, 27 January 2012; Peter Allen, ‘Frenchman Behind Breast Implant Scandal Charged with “unintentional wounding”’, Daily Mail, http://www. dailymail.co.uk/news/article-2092588/Frenchman-breast-implant-sca ndal-charged-unintentional-wounding.html#ixzz113ThhxF (accessed 30 January 2012). 102. Ewan Palmer, ‘PIP French Breast Implant Boss Jean-Claude Mas Jailed for Four Years’, International Business Times, 10 December 2013, https://www.ibtimes.co.uk/pip-french-breast-implant-boss-jeanclaude-529049 (accessed 12 December 2013).

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103. Neil Millard, ‘PIP Breast Implant Victims March on Private Clinics’, The Sun, 14 January 2012, https://www.thesun.co.uk/archives/news/304 671/pip-breast-implant-victims-march-on-private-clinics/ (accessed 16 January 2012). 104. Ibid. 105. Chris Pollard and Rhodri Phillips, ‘Burst PIP implant “Gave My Breast-Fed Girl Cancer” Horrified Mum’s Claim’, The Sun, 3 February 2012, https://www.thesun.co.uk/archives/news/348030/ burst-pip-implant-gave-my-breast-fed-girl-cancer/ (accessed 14 February 2012). 106. Ibid. 107. ‘German Implants Alert’, Daily Mail, 30 January 2012; Jo MacFarlane, ‘Now German Implants Spark Cancer Fears for 20,000 British Women’, Mail OnLine, 29 January 2012. 108. Plastic Surgery, ‘Sale of Silicone Implants Made by Silimed Suspended by UK Regulator’, The Guardian, 24 September 2015, http://www.the guardian.com/society/2015/sep/24/sale-of-silicone-implants-madeby-silimed-suspended-by-uk-regulator?CMP=EMCNEWEML661912 (accessed 27 September 2015). 109. ‘Breast Implants’, FDA, https://www.fda.gov/medical-devices/imp lants-and-prosthetics/breast-implants (accessed 19 January 2020); see also Virginia Handley, ibid., p. 107. 110. Ibid. 111. Irvin Jackson, ‘Textured Breast Implants May Face Ban in Australia After Cancer Review’, AboutLawSuits.com, 8 May 2019, https://www.aboutl awsuits.com/australia-breast-implant-review-156429/ (accessed 11 May 2019). 112. Ibid. 113. Renee Ridgeley, ‘Opinions. I Beat Breast Cancer. Then I Found Out My Implants Could Cause lymphoma’, The Washington Post, 18 April 2019, https://www.msm.com/en-us/health/voices/opinions-i-beatbreast-cancer-then-i-found-out-my-implants-could-cause-lymphoma/arBBW2KAE (accessed 23 April 2019). 114. Ibid.; Irvin Jackson, ‘Textured Breast Implants …’, ibid. 115. Victoria Handley, ibid., p. 107. 116. Breast Health, ‘Problems of Saline Breast Implants’, LadyHealthCare, http://www.ladycarehealth.com/problems-of-saline-breast-implants/ (accessed 14 April 2018). 117. Brigitte Pittet, Denys Montandon and Didier Pittet, ‘Infection in Breast Implants’, Lancet Infectious Diseases, vol 5, February 2005, pp. 94–106, http://infection.thelancet.com (accessed 20 February 2020). 118. Ibid. 119. Ibid.

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120. FDA, ‘Types of Breast Implants’, US Food and Drug Administration, 23 October 2019, https://www.fda.gov/medical-devices/breast-implants/ types-breast-implants (accessed 20 January 2020). 121. Ibid. 122. ‘Nipple Reduction Surgery in England and Wales’, UKHealthCentre,https://www.healthcentre.org.uk/cosmetic-surgery/nipplereduction-surgery.html (accessed 4 April 2019). 123. Ibid. 124. Areola Reduction, Nuffield Health, https://www.nuffieldhealth.com/tre atments/areola-reduction (accessed 12 June 2018). 125. Ibid.; see also Corinne O’Keefe Osborn, ‘Areola Reduction Surgery: What to Expect’, HealthLine.com, 19 April 2018, https://www.health line.com/health/areola-reduction (accessed 21 April 2018). 126. ‘What Is Nipple Reduction Surgery’, Cadogan Clinic, https://www.cad oganclinic.com/nipple-reduction/ (accessed 18 April 2019). 127. Ibid. 128. ‘Do I Need Downtime After Areola or Nipple Correction Surgery’, Cadogan Clinic, https://www.cadoganclinic.com/do-i-need-downtimeafter-an-areola-correction-treatment (accessed 19 December 2019). 129. ‘What Is Nipple Reduction Surgery’, ibid. 130. ‘Nipple Reduction Surgery—Risks and Side Effects’, UK HealthCentre,https://www.healthcentre.org.uk/cosmetic-surgery/nipple-red uction-risks-side-effects.html (accessed 19 December 2019). 131. Ibid. 132. Corinne O’Keefe Osborn, ibid. 133. Ibid. 134. ‘What Can Cause Large Areolas and Is This Normal?’ HealthLine, https://www.healthline.com/health/womens-health/large-areola (accessed 19 December 2019). 135. ‘Suitability for Nipple Reduction Surgery’, UK HealthCentre, https:// www.healthcentre.org.uk/cosmetic-surgery/nipple-reduction-suitability. html (accessed 19 December 2019). 136. ‘Long-Term Effects of Nipple Surgery’, UK Health Centre, https:// www.healthcentre.org.uk/cosmetic-surgery/nipple-reduction-longterm-effects.html (accessed 19 December 2019). 137. ‘Corinne O’Keefe Osborn’, ibid. 138. Healthy Lifestyle. Adult Health, ‘Tattoos: Understand Risks and Precautions’, Mayo Clinic, https://www.mayoclinic.org/healthy-lifestyle/ adult-health/in-depth/tattoos-and-piercings/art-20045067 (accessed 19 December 2019). 139. Ibid. 140. Ibid.

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141. Eva Wiseman, ‘What Does the Trend for Smaller Nipples Say About Us?’ The Guardian, 15 January 2017, https://www.theguardian.com/ lifeandstyle/2017/jan/15/what-does-the-trend-for-smaller-nipples-sayabout-us?utm_source (accessed 15 January 2017). 142. Ibid. 143. Naomi Wolf, ‘The Silicone Breast …’, ibid. 144. Ibid. 145. Montgomery v Lanarkshire Health Board [2015], ibid. 146. Perrya, ‘The First Breast …’, ibid. 147. See Kathryn Hughes, Victorians Undone—Tales of the Flesh in the Age of Decorum, 4th estate/HarperCollins, London, UK, 2017. 148. Cited Sarah Kinonen, ‘More Women Are Undergoing Nipple Reduction Surgery. Here’s Why’, Allure, 25 July 2017, https://www.allure.com/ story/nipple-reduction-surgery-trend (accessed 19 December 2019). 149. Florence Williams, ibid. 150. ‘Issues and Impact’, Our Bodies Our Selves —Information Inspires Action, https://www.ourbodiesourselves.org/issues-impact/ (accessed 19 December 2019). 151. See for example Susan Faludi, Backlash—The Undeclared War Against Women, Vintage, London, UK, 1991; https://blindhypnosis.com/bac klash-the-undeclared-war-against-american-women-pdf.html (accessed 2 December 2019). 152. Harry Hayes, ‘Prevention of Breast Hypertrophy and Sagging (circa 1558)’ in Harry Hayes, An Anthology of Plastic Surgery, Aspen Publications Inc., Rockland, MD, USA, 1986, pp. 64–65. 153. Ibid. 154. Ibid. 155. James Milner, ibid., pp. 20–21. 156. Ibid. 157. Victoria Handley, A Practical Guide to Cosmetic Surgery Claims , Law Brief Publishing, Somerset, UK, 2017. 158. Ibid., pp. 106–107. 159. Suzanne Fraser, Cosmetic Surgery, Gender and Culture, Palgrave Macmillan, Basingstoke, UK, 2003, pp. 5–6. 160. Corinne O’Keefe Osborn, ibid. 161. Sarah Kinonen, ibid. 162. Ibid. 163. See for example Cortney Warren, ‘The Race to Be Beautiful. Developing a Stronger Ethnic Identity Can Improve Your Body Image’, Psychology Today, 4 August 2014, https://www.psychologyto day.com/us/blog/naked-truth/201408/the-race-be-beautiful (accessed 19 December 2019).

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164. See for example Maya A. Poran, ‘The Politics of Protection: Body Image, Social Pressures, and the Misrepresentation of Young Black Women’, Sex Roles, vol 55, pp. 739–755; Liya M. Rakhkovskaya and Cortney S. Warren, ‘Ethnic Identity and Endorsement of Thin-Ideal Media in Female Undergraduates’, Body Image, vol 11, pp. 438–445; Cortney S. Warren, ‘Body Area Dissatisfaction in White, Black, and Latina Female College Students in the United States: An Examination of Racially-Salient Appearance Areas and Ethnic Identity’, Ethnic and Racial Studies, vol 37, pp. 537–556. 165. Ibid. 166. Jes Baker, Things No One will Tell Fat Girls, Seal Press, Berkley, CA, USA, 2015, p. 9. 167. Ibid, pp. 9–10. 168. Zahir v Vadodaria [2016], ibid.

CHAPTER 5

Below the Belt and Under the Waist …

A fat stomach never breeds fine thoughts. St Jerome

1

Muffin Top Madness

Men have ‘love handles’. Women have ‘muffin tops’. The distinction is striking. A man certainly would look more streamlined without the love-handle ring of fat around his waist, and many would prefer to rid themselves of this bodily augmentation. Yet the colloquialism applied to a man is endearing, bespeaking affection: there is a woman (or a man as the desire may be) available to hold those handles with tenderness, fondness, even devotion. Not so for ‘muffins’ or ‘muffin top’. The swellings appearing below a woman’s waist and above her hips bear a nickname that signifies shame, disgrace and indignity. The term signals that the fat resembles dough oozing out over the top of a cake tin, baked firm, forming an extra layer or ballooning mound. ‘Muffin top’ suggests that the solid lumps of adipose tissue swelling on each side of the female body are a product of overeating. If only she had not ingested that last slice of cake, eaten yet another bread roll, gorged on that secret stash of Easter eggs, gobbled that entire box of truffles, swallowed whole a bar of chocolate, joined in the festive season fun quite so much eating turkey, roast potato and peas all at once. Could she not have foresworn the lot, stuck to a lettuce leaf, an asparagus spear, a mushroom? As she sinks beneath the censure and condemnation, the solution stares from every © The Author(s) 2020 J. A. Scutt, Beauty, Women’s Bodies and the Law, https://doi.org/10.1007/978-3-030-27998-1_5

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website, every women’s magazine and fashion journal. Liposuction or, more drastic measures called for, the plastic surgeon’s knife. Sometimes the message delivers an additional joy, for the offending fat can be transferred to another part of the body (mostly breasts, sometimes buttocks). Nevertheless, some sites do, at least, suggest what is often described as the ‘conservative measure’, namely ‘good’ eating and exercise. This suggestion is passed over so quickly, however, as to be but a flash and then gone, the favoured knife or laser or suction treatment looming as the preferred solution. In ‘How to Lose a Muffin Top & Belly Fat Fast’, readers are told that it’s not simply a case of ‘wardrobe choices’.1 Not only does muffin top project an unattractive appearance, it is dangerous to your health, advises Kimberly Caines. Yet Linda Bacon and Lucy Aphramor contest the ‘dangerous to your health’ notion projected by traditional sources, including the World Health Organisation (WHO). They say that the ‘“thin is better” mind-set’ itself has ‘damaging ramifications … on people of all sizes and on health inequalities’.2 Nonetheless, the number of women seeking to rid themselves of adipose tissue in the area between waist and hips indicates that the ‘fat is bad, thin is good’ mantra has traction, extending to the muffin top just as it encompasses other parts of the body. Ironically for those attributing to overeating the adipose tissue that spills into bulges above the body line of shorts, jeans and pants, subcutaneous fat is nature’s protection against starvation.3 Nevertheless, for women who are persuaded that fat must be banished from below the waist and above the hips, ‘How to Lose a Muffin Top …’ advises that ‘all the sit-ups in the world’ won’t do it. This does not, however, mean that a rush to the surgery is advised. Rather, a ‘comprehensive exercise plan’ and ‘sensible low-calorie diet’, although bringing about reduction over time, does make lasting results more likely.4 One can follow ‘an eating strategy for fat loss’ by reducing calorie intake ‘to between 1200 and 1800 [as] this helps most people to lose weight’.5 But an eating strategy (in other words, dieting) will not do it alone. Ridding the body of the muffin top requires exercise, too. This means at least 150 minutes a week of ‘moderate-intensity exercise’ to promote good health,6 and ‘strength training’ to ensure systematic attention to all major muscle groups of the body equally.7 Yet it can be said with some certainty that such a regime may not suit everyone. Hence, liposuction and surgery beckon.

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One website sets down specific criteria for those seeking muffin top erasure by liposuction.8 A ‘stubborn layer of excess fat’ is a prerequisite, with clients being persuaded to lose ‘as much weight as possible’ before the operation. Non-smoking or relinquishing the habit at least two weeks before is essential, with a commitment to maintaining nonsmoker status for the entirety of the recovery period. Clients must be eighteen years or above, with a stable weight and BMI (body mass index) under 30.9 The alternative method of diet and exercise should have been tried without results. Similarly, yet with an additional feature, another site advises that the optimal candidates for muffin top liposuction are those who are healthy and ‘within the normal weight range’. Their ‘“bumps” of fat [are] in limited areas’, with ‘thick skin’ being advantageous, for following the suction this ‘can shrink the area down’.10 Various types of liposuction are available, to be employed where the problem is fat. Where it is skin, then liposuction is no answer. Loose or hanging skin requires excision, just as for those famed ‘bat wing’ arms. However, when liposuction is advised, as well as the traditional version, smart liposuction and vaser liposuction are now on the market. Smart liposuction works from outside the body, a specially calibrated laser liquefying the fat through the top layers of skin. It is recommended as less invasive and with less potential for harming muscle and tissue.11 Advantages are less bruising and a quick recovery, although a compression garment may be required to be worn for a period. Up to eight pounds of fat can be removed, and because incisions are small, generally any scarring will be mild. Yet potential for asymmetrical results is present, albeit ‘observed in very few candidates’.12 Bleeding and infection, although rare, can occur, and as laser is involved thermal injury (skin burns) and skin damage can result.13 Vaser liposuction is a smart liposuction procedure which exaggerates natural cell vibration. Its rationale is that as all body cells vibrate naturally, amplifying the vibration will break down the fat cells. It can be performed surgically or non-surgically, the non-surgical version conducted under local rather than general anaesthetic, which generally is less dangerous. Not only is the non-surgical procedure suitable for muffin tops, it ‘can be used on a number of different areas in a single procedure’.14 Ultrasonographic waves employed by vaser liposuction break down fat tissue selectively. Therefore, with a good surgeon, the risk of damage to connective tissue and nerves is alleviated or at least lessened. A positive prognosis for minimal scarring can also be anticipated. What there

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is, is generally located in spots least visible to the onlooker, whilst good results show ‘homogenous skin with no irregularities’.15 Vaser liposuction evades or seriously lessens risks occurring with traditional liposuction, such as ‘haematoma, blood clots, fat clots, infection, deep vein thrombosis, cardiac and pulmonary complications, excessive fluid loss, fluid accumulation, leg swelling, sensitivity to sensation, pain, severe scarring and poor incision healing’, as well as ‘damage to nerves, blood vessels [and] muscles’.16 The ‘most common’ negative consequences, including redness, bruising and swelling, are described as ‘typically subsiding within 1-2 weeks after surgery’, resulting from patients’ bodies ‘adjusting to the new contours and the incisions healing’.17 However, some surgeons are less laudatory of the procedure, predicting the need for corrective surgery in some instances.18 Both temporary side effects and possible long term damage are cited. Temporary outcomes include swelling, potentially ‘cresting’ at 48 hours then ‘gradually disappearing’ over three weeks. A particular feature of vaser liposuction is drainage from the sites of incision ‘for a day or so after surgery’. Skin contraction (‘lipodermatochalasis’), said to be ‘a powerful effect’ of vaser liposuction, lasts from six to 14 weeks after the operation, gradually lessening over that time. Potential damage to nerves is highlighted, experienced as a ‘numbness and ultimately burning sensation along the path of the nerve’, although this is said to subside generally after ‘about six weeks’. Vaser liposuction patients face a possible risk of second or even third-degree burns, requiring warnings. In An Introduction to Beauty Negligence Claims , Greg Almond observes that non-surgical procedures carry risks, but that those associated with surgical ‘solutions’ such as tummy tucks and liposuction ‘carry a much more serious degree of risk’.19 The fundamentals here are those arising in all plastic, cosmetic or aesthetic surgery claims. First, is the consent test satisfied according to the Montgomery v Lanarkshire Health Board standard or test.20 Secondly, as with Zahir v Vadodaria 21 what role does dissatisfaction play? Both consent and satisfaction (or lack of it) were relevant for Karen Turner who atop of breast augmentation sought liposuction. She then suffered haematoma, requiring draining. In Karen Turner v Mr Nigel Carver 22 the claim revolved principally around the breast augmentation, as noted earlier.23 The issues are, however, on all fours with liposuction. The court asked, first, whether Ms Turner had been advised or informed, to the requisite standard, of the nature and risks of the procedure, to make her consent to the operation real. Here,

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the court held that the information conveyed to her orally and by written information sheets might have been more comprehensive but nonetheless was adequate. Hence, this provided no basis for a negligence claim. As for the second aspect, Ms Turner’s dissatisfaction was not determinative. Rather, the court asked whether the surgeon in undertaking the procedure had done so at a satisfactory standard of expertise. Patient ‘satisfaction’ was not the measure. That being so, Ms Turner’s claim was dismissed.24 However, medical negligence firms highlight the serious potential for harm inherent in liposuction.25 Not all practitioners are highly trained in liposuction procedures, and ‘instances of substandard training [can lead] to potentially serious damage to body organs’. The damage ‘may be temporary or permanent’, or even in some instances ‘may be lifethreatening’.26 Infection and swelling are said not to be ‘as common as many people expect’, bearing in mind ‘the insertion of foreign bodies and entry point cuts’. Nevertheless, these occur and can bring further problems and complications. Sometimes, removal of excess fat leaves ‘holes’ in the patient’s body, a condition classed as a side effect and known as ‘seroma’. These pits or cavities ‘may be filled by other bodily fluids’, requiring removal. Further in addition to scarring and burning, bruising and bleeding, potential for infection and complications requiring further treatment, the removal of fat by liposuction is ‘fairly crude and sometimes it is not possible to ensure symmetry’. Fat can be injected to effect a balance, but requires facing all the risks of the first operation, meaning that a patient or client will be subjected to risks not once, but twice. Alcohol or other fluids employed to breakdown the fat can cause allergic reactions, sometimes mild yet possibly ‘severe and life-threatening’. This means that pre-operative tests should be conducted and a failure to do this could substantiate negligence claims where a negative reaction occurs. Reduced sensation is said ‘not necessarily to be a commonly occurring side-effect … but there will be instances where this happens’. This can be temporary but the risk of nerve damage is such that permanent damage is possible.27 Risks and dangers too often have consequences. For those undergoing liposuction, more, not less, surgery is proposed as the answer. That means corrective surgery. ‘Shark bites’ is the term given to ‘overzealous aspiration’.28 Here, the risk lies with the surgeon who is too ambitious in removing fat. Taking too much leaves the patient freed from muffin

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tops, but now she bears dimpled contours (cellulite), or even valleys and troughs, in their place. Is any of these liposuction quests to eliminate the muffin top ‘better’? Some surgeons recommend one or other as ‘the’ liposuction method, whilst others decry the notion that ‘this machine or method is better than that’. One says that prospective patients should be wary if a surgery advocates a particular type of machine. Technique and surgical skill are the essential criteria, not the style or type of procedure or mechanics: While I believe that the VASER represents the safest and most effective tool for accomplishing lovely, natural improvements in body contour, it is critically important … that the tool used is not nearly as important as the surgeon using it on you. The surgeon you choose will make a much greater difference to the outcome you achieve …29

However, as Greg Almond warns in An Introduction to Beauty Negligence Claims , false, misleading and deceptive advertising permeates too many clinical sites. Using words such as ‘best surgeons’, ‘safe’ and ‘results’, advertising can persuade women eagerly seeking bodily transformation that their practitioner is ‘perfect’, despite a lack of skill.30 Yet even with the greatest expertise, procedures can go wrong. At the same time, if the surgeon is skilled and the procedure carried out to the requisite standard, if consent is inadequate or lacking, a claim for negligence can succeed nonetheless. Albeit not involving cosmetic surgery, Anita Border v Lewisham and Greenwich NHS Trust 31 illustrates this well. The claim was that the doctor’s negligence resulted in Mrs Border’s developing an infection, following insertion of an IV line into her left arm. She suffered a ‘permanent and fairly serious case of oedema … causing her a permanent and material level of disability’. In the first instance, the trial judge found that Dr Prenter had acted ‘in accordance with accepted practice … [and that] many (perhaps the great majority of) responsible A&E doctors would have done’ as he did.32 The negligence claim was dismissed. However, the appeal explored the question of consent and whether it was valid. The case underscores the potential for damage not only directly associated with a cosmetic procedure, but arising out of some other injury when the body is vulnerable through undergoing cosmetic surgery.

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Following an operation, Mrs Border fell, damaging her right arm, which was suspected of being broken. The normal practice upon reception of a patient to Accident & Emergency (A&E) was accepted as being the insertion of an IV line (a cannula). In this case, the obvious place for the cannula was the arm not suspected of injury. However, Mrs Border explained that she had recently had surgery, with the lymph nodes in her left arm ‘having been cleared’. She told Dr Prenter that he ‘mustn’t cut that arm or I might get an oedema’. Having considered the possible options (including insertion into one or other of her legs), Dr Prenter did use her left arm for the IV line. Disputed evidence at the trial related to how far Mrs Border’s warning was taken into account and ‘how much Dr Prenter said to [her] about his decision to insert the cannula’. Dispute also surrounded the evidence of ‘whether she consented expressly or impliedly by word or gesture to his decision to insert it into her left arm’.33 The trial judge accepted that ‘waiting to see’ if it was necessary to insert the IV line would have been negligent. On this basis, the claim was dismissed. On appeal, however, the court’s key focus was on consent. Mrs Border’s evidence was that the insertion had taken place so quickly that she had no time to even consider what was happening, much less consent to it. The trial court had accepted this evidence, and the appellate court relied on that finding. It held that Dr Prenter was in breach of his duty of care by inserting the cannula without Mrs Border’s consent.34 This decision provides a clear direction to practitioners working in cosmetic, aesthetic and plastic surgery and beautification procedures, whether medically trained or qualified as beauticians or other professionals. Consent must be clearly articulated. Otherwise, a negligence claim can succeed. At the same time, a woman’s eagerness to achieve the end she desires may generate a consent that a court will deem to be clearly articulated. This is a real danger.

2

Around the Fatty Abdomen

When Susie Orbach wrote Fat is a Feminist Issue,35 she verbalised this problem in the context of women’s eagerness to be ‘thin’ and too ready adoption of sometimes perilous regimes in order to achieve this. Her book is a reminder of how important it is for women to recognise that what might appear to be a worthwhile goal may, in the end, be the reverse. Ridding the body of adipose tissue is often desired, but the methods and means of doing so can bring unanticipated misery. Fat can become an

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obsession, and certain parts of the body may be particularly loathsome. Traditionally, women’s waists are supposed to be slender. An ‘hour glass figure’ might be admired in popular novels of a certain era. However, even if the waist in between takes on a narrow appearance, just as fat immediately above the waist is regarded as odious, so too the fat beneath it. Commonly but wrongly called the ‘stomach’, the part of women’s bodies lying above the mons veneris and below the waist, with navel positioned in the middle, is frequently the target of a woman’s ire. ‘My fat stomach’, ‘my poking out tum’ or ‘my belly, not beautiful’ are phrases often uttered when women discuss the body parts they abhor. Again, one answer is liposuction, although in extreme cases surgery or banding of the (real) stomach to cut down on calories through cutting down on food may be decreed: the smaller the stomach, the smaller (hopes the banded woman) the abdomen and, potentially, other ‘fat’ bits will disappear. Still, besides learning to love one’s body, a proposition advanced by Linda Bacon and Lucy Aphramor in Body Respect ,36 alternatives to the surgical option are available. An ‘eating strategy for fat loss’ can be adopted.37 However, as fat is usually reduced proportionately, ‘a little from your thighs, a little from your tum’, fat loss may need to be targeted. As banding and bariatric treatment aim to cut down eating, the prospect that it will rid the patient of specific fat targets is unlikely. The Beverly Hills Rejuvenation Center advances five alternatives to removing the offending fat by surgical cutting. Instead of a ‘tummy tuck’ or liposuction, these are the ‘top five plastic surgery’ procedures for a woman to consider before she goes under the knife.38 CoolSculpting, laser liposuction, Zerona, P Vanquish ME and VelaSmooth™ are proposed as plastic surgery alternatives ‘that actually work’. Rather than considering a surgical operation, those seeking a solution ‘for losing [their] belly fat’ having tried other methods should ‘stop now!’ Why risk scarring and surgical complications that come with surgical medical procedures, when there are excellent alternatives for non-surgical stomach fat removal that can give you the results you’ve been looking for.39

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CoolSculpting is a technique using ‘controlled frostbite’ in fat areas.40 The procedure is based on knowledge from frost bite experiments or reallife experience of frostbite. When frostbite develops, freezing of the fat cells under the skin occurs first. If the process stops at that stage, the skin remains undamaged. Thus, in the panoply of possibilities for ridding the body of fat around the abdomen, CoolSculpting aims to freeze the fat cells. Once they die, the remaining debris is absorbed into the body. As it disappears, the body becomes firmer and more slender. CoolSculpting as a ‘fat removal technology’ is approved by the US Food and Drug Administration (FDA). It is also available in the United Kingdom.41 Another alternative is VelaSmooth™, which commences with toning. A ‘roller and vacuum’ effect ‘manipulates the underlying tissues’, urging a smoother appearance on the abdomen.42 Next, massage therapy facilitates infrared light and radio frequency waves to ‘reach the layer of fat and break down the cells’. The synchronicity of this procedure, using suction, light and heat, raises metabolism levels to ‘shrink and destroy’ fat cells. Next comes laser liposuction. As with other areas of the body, this employs light therapy and lasers to melt fat. The melted fat cells ‘are absorbed [into] the body’s lymphatic systems [creating] a tummy tuck without … far more expensive … plastic surgery’ having ‘potentially unwanted side-effects’.43 An additional benefit is that the process restructures the skin’s collagen layers, ‘improving elasticity’. This ‘further eliminates the dimpled skin effect’ commonly known as cellulite.44 Zerona P is a variation on laser liposuction. Now a recognised treatment in its own right, it requires forty minutes of lying under rotating lights. Clinics say that this ‘causes fat to be released’ painlessly from cells, with the residue again absorbed into the body creating ‘minimal side effects’.45 The final option in this abdomen fat defeating series, Vanquish, is a procedure described as ‘using a highly sophisticated, non-invasive device’, said to be ‘one of the best plastic surgery alternatives for belly fat removal’.46 Vanquish employs a metallic belt which is curved to lie over the abdomen without touching the skin. The Vanquish belt releases highfrequency radio waves. These match ‘the thermal energy of [a woman’s] fat cells, leaving the surrounding issues intact’. Thus, lying naked or lightly clothed beneath this fat removal belt in the body sculpting salon, women hope that the fat that lies beneath the fashionable belts worn clasped around their bodies in the outside world may disappear, together with all the dismay it generates with it.

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Yet, not all women take an alternative route or, taking it, not all women are satisfied. The resort to surgical methods is next. This means an abdominoplasty or ‘tummy tuck’. Requiring a general anaesthetic, the operation is carried out whilst the patient is unconscious. Excess skin and fat are removed from the middle and lower abdomen. The aim is to tighten the muscle and facia of the abdominal wall, relieving the abdomen of fat and making it firmer. Prospective patients are assured that the firm abdomen may remain ‘long lasting’.47 However, retaining the flat stomach fashioned by the tummy tuck is dependent upon the patient’s keeping to a healthy diet and a healthy weight. But the operation is not designed to help people lose weight. Weight gain can undo good results. Added pounds can leave the body in a worse condition than before, and the side effect of scarring can add to this. A ‘bikini scar’ may be almost inevitable with a standard abdominoplasty, as is a scar around the navel. Weight gain may lead to unsightly stretching of the scars. Women with limp muscles and abdominal skin following pregnancy may be advised to have this operation. Similarly, it may be recommended for a woman with abdominal scarring from an injury or earlier surgery; or who suffers from loose or baggy skin following major weight loss; or requires another operation such as hernia repair.48 Those for whom the procedure is not recommended include heavy smokers. Light or moderate smokers who undergo the operation are told to stop smoking for several weeks before and to renounce the habit at least for the recovery period of the operation. The overweight are not generally good candidates, nor are those with existing medical conditions such as heart disease or diabetes or with a history of haematoma (blood clots).49 Depending upon the fat and skin requiring removal, a standard or a mini tummy tuck is specified. The latter is adopted where the amount of skin or fat requiring removal is small, whilst the former applies where a greater volume of excess fat and skin necessitates a more major operation. Two cuts are needed for both, one around the navel, one from hip to hip in the pubic area, along the bikini line, although in the mini procedure the cut at the bikini line can be shorter. Cutting is required to expose the abdominal muscles in order to tighten them. Then the excess fat and skin is removed. Depending upon whether it is standard or mini, the operation may take from two to four hours in length.50 The NHS estimates the timing as ‘between two and five hours’, advising that most people undergoing the surgery should remain in hospital for several nights. For the standard abdominoplasty, the NHS also expresses the abdominal muscle tightening as ‘realignment’,

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and advises that a new hole should be cut for the navel, which is raised during the operation, and then ‘stitched back in place’ at the end of the procedure.51 Side effects labelled as temporary include pain and bruising, numbness extending from months to years, fluid-filled swelling above the scar, and difficulty in being able to straighten the body when standing. Some scarring should eventually fade, despite its at first being red and raised. White or pale scarring remains permanently, although various scar lightening processes can be tried to make the scars less obvious. The procedure brings with it the ordinary risks of any operation, particularly one under general anaesthetic, and can ‘occasionally’ result in abdominal pain or cramps, numbness or pain down the leg, wounds failing to heal, and collection of blood (haematoma) or fluid under the skin. ‘Bulges’ under the skin, extra skin at the scar edges (colloquially ‘dog ears’), or scars developing into thick, obvious ridges or keloid scarring are further risks.52 If any of these outcomes is attributable to negligence, litigation can result. Here, as in Karen Turner v Mr Nigel Carver,53 the skill of the practitioner will arise, and the question of how in-depth was the information and discussion of the operation and its risks. Post the Montgomery case and subsequent consent cases following Montgomery, practitioners are advised by insurers and underwriters to review their consent forms and their consent process. In ‘Mitigating Risks to Mitigate Costs’, medical and health care insurance consultant Martin Swann recommends amongst other measures ‘training around consent, the consultation process and managing customer expectations’.54 This will help practitioners to get their records in order should any negligence claim arise. However, apart from a recommendation that patients should be ‘identified and referred’ where there are concerns about their mental well-being—a nod to the possible presence of body dysmorphic disorder (BDD), there is nothing that touches upon the problem of cultural pressures that press women, in particular, into potentially life-threatening operations in search of an unrealisable goal of an entirely transformed body and life. As a tummy tuck is not considered suitable for those seeking weight reduction, surgical liposuction may be advised. Surgical sites devoted to liposuction for tummy tucks and other procedures do indicate possible detrimental consequences for patients. A website providing a ‘Question & Answer’ facility indicates that some patients, at least, experience negative outcomes, whether directly related to the liposuction treatment itself, or arising from anxiety about having undergone the procedure. One woman

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expresses concern that having had a mini tummy tuck and liposuction of the flanks or upper edges of her thighs, together with ‘sculpting’ at her waist and liposuction of upper and lower abdominal muscles, nine weeks later she is ‘still very numb in upper and lower front and back, and of course hardness under the incision’. Worried that the numbness ‘does not seem to be getting better’, she ‘can only feel [her]sides and they are very sore and tender to touch’. Despite having lost some 10lbs, she has ‘gained a muffin’.55 Another says that in 2014 she underwent liposuction ‘of [her] belly and muffin top’. Some months later, she ‘noticed a significant decline’ in energy, feeling fatigued constantly—as she puts it, ‘24/7 and never feeling rested’. Prior to the procedure she ‘worked out 5-6 days a week … bootcamp 5 days a week followed by 30 minutes in the gym at 5:25am’. Now, however, she has ‘zero energy’ whilst ‘maybe working out in the evening once or twice a week’. Can this be a consequence of hormonal changes and would liposuction be the cause, she asks.56 Responses vary. One surgeon says that liposuction can cause ‘metabolic as well as hormonal changes’ and the condition the questioner describes requires a diagnosis. Another says ‘no one has proven any physiological changes from removing fat surgically other than simply that fat has been removed’, adding that there are ‘no known changes in hormones’, nor are any health benefits known, so ‘hopefully’ the outcome is a more aesthetic appearance. A third advises that ‘this far out from surgery’, he is unaware of liposuction causing the problem described: ‘certainly a patient can have low energy after surgery but that should resolve in a matter of weeks to months’. One raises the possibility of a problem with thyroid function and one observes that most patients ‘have less energy than usual for at least 3 months after surgery’. This the clinician attributes to ‘the energy it takes your body to heal and the lingering effects of anesthesia and pain medication’. If the change in energy levels comes about several years after liposuction, then it is ‘not surgery related’.57 All advise a visit to the general practitioner or primary doctor. Without doubt what is shown is that some patients, at least, may suffer post muffin top surgery anxiety. Where complications can develop, warnings must be given to potential patients or clients. This is so for all operations or procedures, including those that are aesthetic or cosmetic, and those solely for health reasons. This arose in David Spencer v Hillingdon Hospital Trust.58 There, it was a

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hernia operation. Nevertheless, the principle applies to surgery and procedures conducted in the name of beauty or, as some express it, to gain normality, or simply ‘be normal’.59 For Mr Spencer, pain in the groin sent him to the doctor. Diagnosed with a hernia in the right and left side of the groin, on 19 January 2010 he went into surgery advised that, to avoid an open wound operation, both hernias would be repaired by use of a laparoscope. He was also told that the operation may have to be converted from a laparoscopic to an open procedure.60 Upon receiving this advice, he asked Mr Chaudhry, the locum general surgeon, to assure him that should there be a need for conversion to an open procedure, priority would be given to repair of the right-hand side hernia. He then signed the consent form containing a warning of risks: ‘Bleeding, infection, scar, recurrence of problem, conversion to open procedure, injury to bowel’.61 Before the operation, pneumatic boots were placed upon Mr Spencer’s feet and legs, the purpose of these being to improve the patient’s circulation, reducing risk of deep vein thrombosis. However, there was no reference in the consent form, nor on 19 January in the discussions with Mr Chaudhry or any other hospital staff of the risk of a deep vein thrombosis or pulmonary embolism arising from the operation, nor of immobility that would be caused by such an outcome. Nor was there any advice as to the signs or symptoms that would accompany development of those conditions. It transpired that open surgery was required. Mr Spencer’s aforestated desire for the right-hand side hernia alone to be operated upon was respected. All went well and he was discharged that day. Around some time in February, however, he suffered two acute episodes of pulmonary embolism. His evidence was that had he been warned of the potential for this outcome, he would have sought medical advice earlier. This brought into sharp relief the duty borne by practitioners in respect of their responsibility to impart ‘risk’ to their patients or clients. Respect for patients or clients in interactions with the medical profession (and hence with other professions with similar responsibilities) was key in the court’s consideration. Quoting extensively from Montgomery v Lanarkshire Health Board,62 the court in Mr Spencer’s case observed that an adult person ‘of sound mind’ is ‘entitled to decide which, if any, of the available forms of treatment to undergo, and consent must be obtained ‘before treatment interfering with [the patient’s] bodily integrity is undertaken’.63 This, said the court, means that the doctor is therefore ‘under a duty to take reasonable care to ensure that the patient is aware of

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any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments’. The test to be applied to the question of materiality—as in ‘material risks’—is: … whether in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.64

Materiality of risk ‘cannot be reduced to percentages’, the court went on, for the ‘significance of a given risk is likely to reflect a variety of factors besides its magnitude’. This includes, said the court, ‘the nature of the risk, the effect which its occurrence would have upon the life of the patient, the importance to the patient of the benefits sought to be achieved by the treatment, the alternatives available, and the risks involved in those alternatives’.65 Assessment of information and risks to be imparted to any patient ‘is therefore fact-sensitive, and sensitive also to the characteristics of the patient’.66 Mr Spencer was not in the ‘at risk’ category of patients, namely those harbouring conditions that could make them susceptible to deep vein thrombosis. Nonetheless, the court considered that he ought to have been warned. The potential for deep vein thrombosis did exist. Had he been warned, when he and his wife did raise with the hospital and his general practitioner unrelated symptoms, he would have referred to the hardness in his legs. As it was, he attributed this to his ‘being laid up’ and not having had exercise. However, hardness of legs is a warning sign of deep vein thrombosis. Had Mr Spencer been alerted to the risk, it was evident that he would have referred this to the medical people whom he and his wife did contact. For the court, Mr Spencer’s characteristics as a patient, exemplified by the clarity of his instructions should the procedure change from laparoscope to open surgery, confirmed this.67 Yet it is all very well for courts to refer to ‘characteristics’ of patients as significant to determining the quality of consent. Courts are not renowned for valuing women in the same way men are valued according to law.68 Similarly, when it comes to practitioners working in the aesthetic, cosmetic and plastic surgery industry, sensitivity to the characteristics of the patient must be understood against the backdrop of history, culture and socio-economic attitudes towards women. Women’s position as patients is not unproblematic. The Boston Collective writing Our

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Bodies, Our Selves were alert to this: this was the basis of their establishing workshops for women and self-publishing the book, originally 193 pages and titled Women and Their Bodies .69 An earlier case, Sidaway v Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital 70 saw the medical profession, backed up by the court (one judge in dissent), acting in accordance with professional superiority and sex/gender stereotyping. The patient, Mrs Sidaway, was diagnosed as having a genetic defect in her spine. The surgeon, Mr Falconer, who had treated her on an earlier occasion, fused the upper vertebrae and all appeared well. Some years later, and now in her late sixties, Mrs Sidaway began experiencing pain in her upper shoulder, which Mr Falconer had treated on the earlier occasion. This upper shoulder problem was diagnosed as requiring further surgery on the spine. The operation involved risks beyond those ordinarily accompanying an operation carried out under anaesthetic. The two risks identified were damage to the spinal cord and damage to the nerve root in the area of the operation. These risks were small, however, the potential damage ranged from tingling or pins and needles in the hand, to paraplegia (the latter below 1 per cent of risk). There was no contest as to Mr Falconer’s skill in deciding that the operation was appropriate and was done with skill. The question was whether he ought to have warned Mrs Sidaway of the spinal cord and nerve root risks. The trial judge determined that Mr Falconer (deceased by that time so not giving evidence) would have extended some warning about the nerve root risk, but not about the spinal cord risk, nor that the operation was one of choice: it was not a matter of life and death. On appeal, the court by majority decided against Mrs Sidaway’s right to have been advised of the risk of partial paralysis, and against Mr Falconer’s duty to so advise her. The court concluded that a doctor, ‘concerned lest a warning might frighten the patient into refusing an operation which in his view was the best treatment in the circumstances’ was acting in the best interests of the patient in failing to warn.71 The court in Montgomery effectively reversed this decision. The Montgomery court agreed not with the majority in Sidaway’s case, but with the dissenting judge, focusing on respect for the patient.72 It remains, however, that women can be disadvantaged as patients, through the patient–doctor relationship being that of female–male.73 Indications are that within the beauty industry this authority remains problematic—in a way unfavourable to women. Suzanne Fraser in Cosmetic Surgery, Gender and Culture writes of this

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in her analysis of impact gender and culture have upon women’s participation in the search for the perfect body.74 When judges talk of ‘respect’ for the patient, the influence of gender and culture upon their perspectives of what constitutes respect when it comes to the female patient requires recognition. This will influence their decision-making, just as it will influence the decision-making of the practitioner and what is imparted to the woman seeking a slimmer body, a slender waist, an absence of fat. Gender and culture will influence the woman patient, too, in her acceptance (or not) of the magnitude of risks associated with gaining the desired physique. Some procedures designed to ‘perfect’ women’s bodies are more risky than others. Some have long-term implications for women’s health. Some have side effects that women would prefer to avoid. With the plethora of existing procedures, their availability drenching popular culture through magazines, television, internet sites, gossip and entertainment, women do have ‘choice’ within the beauty industry. But that choice is constrained both by notions of how women’s bodies should look, and that the ‘choices’ are in the nature of the procedures available. That in treating the fatty abdomen, outcomes can vary, there are alternatives. But what then? Numerous surgical websites recount tales of success or, less often, failure. As these sites are designed to garner clients, the low reporting of dissatisfaction is no doubt understandable. Where there is disaster, disappointment or distress, there is always an alternative. For the woman who has experienced her fatty abdomen procedure as damaging, or finds the adipose tissue returns, besides accepting her body as it is, what are the choices? What option is there where the problem is overweight, yet the tummy tuck does not provide a remedy? One ready-made alternative is taking the bariatric or stomach modification route. This means venturing into the interstices of the body.

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Bariatric operations aim to reduce the stomach’s capacity for holding food, ensuring that patients eat less, losing weight. Patients and practitioners appear to be investing faith in them for, whether or not the aim is met, bariatric operations are increasing within the United Kingdom and globally. As far back as 2008 the NHS reported that in one year stomach surgery had ‘soared by 41 percent’. For 2007, gastric bypass operations totalled 2448. A year later, the number was 3459.75 In 2010

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children as young as 14 were reported to be ‘having invasive weightloss surgery on the NHS at up to £14,000 a time’.76 Critics blamed the increase on publicity surrounding celebrities exhibiting substantial weight loss, including losses of ‘more than five stone’ following gastric band surgery.77 NHS figures categorise the increase as linked directly to obesity, reporting in 2018 that hospital admissions where obesity was a factor increased by 18 per cent on 2015–2016 admissions. For 2018, obesity was ‘either a primary or secondary diagnosis’ in 617,000 admissions to NHS hospitals. That figure was 525,000 for 2015–2016. For both periods, figures of 10,705 and 9929, respectively, listed obesity as the primary diagnosis. For 2016–2017, women comprised approximately two-thirds or 66 per cent of admissions with obesity being primary or secondary diagnosis. For that same period, there were 6760 ‘Finished Consultant Episodes’ (FCEs) for bariatric surgery, a 5 per cent increase on 6438 FCEs for 2015–2016. NHS records show 77 per cent of these patients as female.78 Arguments exist about what constitutes ‘obese’ and the relevance of body mass index (BMI) to health and well-being.79 Notwithstanding this, under NHS admission protocols, those patients undergoing bariatric surgery in NHS hospitals will generally be at weight levels that interfere substantially with their everyday lives, risking their longevity. That is, they have a body mass index (BMI) of 40 or above, or 35 or above plus a serious health condition such as high blood pressure or type 2 diabetes, which weight loss may improve.80 Patients undergoing these procedures in private clinics are categorised differently. Depending upon general health and weight loss history, patients accepted for private bariatric surgery generally qualify with a BMI of 30 and above.81 At this stage, when approaching a private clinic, it may fairly be said that a woman is aiming at drastic measures. Drastic measures include ingesting a gastric balloon, or procedures variously termed stomach stapling, gastric sleeve, gastric bypass, gastric banding and lap-banding. These terms are sometimes overlapping or replicate each other. The aim of all, however, is to make it physically impossible for the patient, once back from the operating theatre and into the world, to eat in the amounts eaten prior to the surgery. The body’s physical construction, whether of the stomach or small intestine, is reconfigured or changed to prevent the body accommodating more than small meals. The Elipse Gastric Balloon, like the OBalon82 or SpatzIII83 and their counterparts, is a non-surgical, ‘swallowable’ weight loss treatment.84 The

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patient ingests a capsule attached to a catheter. Once in the stomach, the capsule releases the balloon which is inflated with gas or a salinesolution through the catheter. The capsule degrades in the stomach, and the inflated balloon remains in position for some six months (the SpatzIII can remain for 12 months), and more than one balloon can be inserted. Once the balloon reaches its lifetime end, a valve is triggered, the balloon deflates, and the material left behind is digested. Alternatively, the balloon is removed. Both types work on the same principle. As for efficacy, the Bariatric News report points out that weight loss is ‘relative to a patient’s commitment to a healthy lifestyle’ which includes regular exercise and healthy eating. Some reports say that a patient ‘can expect to lose 1520% of their total body weight’, while a ‘typical patient’ generally can depend upon losing one to two pounds a week or, over the six months of the balloon’s being in place, ‘between 25 and 50 pounds’.85 Beside weight loss, reports promoting the procedure advise that improvements may accrue as regards diabetes, high blood pressure, high cholesterol, joint pain, breathing problems and heart problems.86 However, not all is so positive. Some patients report optimistic outcomes, others are highly critical. A surgical prognosis is that in the first days after insertion patients commonly experience vomiting, nausea and gastric discomfort, though these ‘rarely continue in the longer term’.87 Abdominal or backpain can occur, as well as indigestion, a ‘sense of abdominal heaviness’ and gastro-oesophageal reflux where acid leaks from the stomach. As for complications, one surgeon says these are not experienced by most people, however, the risk of injury during the balloon insertion or removal, causing bleeding or perforation is present. The balloon could leak or deflate, although this is said to be ‘rare’.88 Another says that most patients experience ‘limited side effects’, and the first six months of the balloon treatment results in a loss of ‘more than 30 percent of excess weight’. Patients can, however, suffer frustration from ‘some uncomfortable side effects’ and can regain weight following removal of the balloon.89 As for direct patient assessments, one says that two days after having the balloon fitted, she suffered sickness and vomiting, with three weeks off food. Now, not having been ill ‘for the past week’ and ‘getting better each day’ she calculates that she has ‘turned the corner’. Nonetheless, although by this time she ‘should be on small portions of solid food’, her diet consists of ‘soft food’.90 Another reports confidently of a lowered cholesterol and blood pressure, improvement to diabetes through better

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stabilised blood sugar and less need for medications. ‘Losing weight actually saved me’, she says, observing that her weight loss has given her ‘an energy [she] didn’t think possible …’91 On the other hand, a patient declares that she intends having the balloon removed two months early. The pain and discomfort are too much to bear and, she says, she ‘hasn’t lost anything in two months’. The weight loss she has experienced she attributes to diet, and ‘the balloons didn’t make it any easier’. Rather, they made her feel even more uncomfortable. ‘Worthless’, she says.92 Apart from giving up altogether, what are the alternatives? The three bariatric operations listed by the NHS are the gastric band, gastric bypass and an adaptation, the biliopancreatic diversion, and sleeve gastrectomy.93 In outlining ‘which type of weight loss surgery is best?’ the NHS advises that comparatively: • weight is usually lost more quickly with gastric bypass or sleeve gastrectomy rather than following gastric banding; • significant weight loss is generally achieved by most people with gastric bypass or sleeve gastrectomy than with a gastric band; • gastric bypass and sleeve gastrectomy generally carry a higher risk of serious surgery complications; • if, following the operation, serious problems arise, because gastric bands are removable, the operation can be reversed.94 In the United States, one surgery lists advantages and disadvantages of five types of bariatric surgery.95 These five include gastric sleeve, gastric bypass, duodenal switch, LAP-BAND® and AspireAssist. AspireAssist involves connecting a port to the abdomen, with a tube leading into the stomach. After eating, the patient attaches a tube and pump to the port, which empties part of the stomach contents into a clear plastic container. When the process is complete, the patient empties the container after having detached the tube, pump and container for reuse after the next meal. The process means that fewer calories can be absorbed by the body. Advantages outlined are that being day surgery, the procedure requires a shorter hospital time than other bariatric operations apart from the gastric balloon. As for food and drink, ‘gastric balloon and AspireAssist have their own guidelines’ with a potential for being far less strict than those applying to the other bariatric surgery methods. However, like the gastric balloon, AspireAssist is ‘at the lower

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end of the weight loss spectrum’ with a projected possibility of a 25 to 30 per cent excess weight loss after one year.96 One could conclude that the less stringent food and drink regime requirements impact upon weight loss potential. A description of AspireAssist as a possibly reliable medical adaptation of bulimia seems apt. Addressing the more serious operations of gastric band (the LAPBAND® of the US listing), gastric bypass and its adaptation the biliopancreatic diversion, and sleeve gastrectomy,97 these require a lengthier hospital stay—potentially measured in days. As well as providing for possibly greater and sometimes dramatic weight loss, they carry more risk. They also bring with them an additional problem of further surgery, for weight loss patients ‘who no longer fit their skin’.98 Patients may find that with the loss of weight their skin does not spring into a taut body shape. This problem follows those who lose a great deal of weight, or are older with less skin elasticity, requiring an abdominoplasty or tummy tuck, or an ‘apronectomy’ removing an apron of skin hanging over the groin or pubic area. Weight losers in this situation can experience depression, body hatred or self-hatred and anxiety, as well as risking skin infections. As applications by private bariatric surgery patients seeking tummy tucks to excise excess skin rarely gain NHS approval, this means another private operation with the expense that entails. Many resort to crowd funding by posting pleas, together with graphic photographs, on the internet.99 Gastric banding involves insertion of a silicone band around the upper part of the stomach to reduce its size, termed a ‘lapband’ if it is adjustable. The NHS describes the operation as creating a small pouch, with foods and liquids passing from the pouch and through the stomach to the small intestine, so that digestion and absorption remain the same.100 Gastric banding means that the patient can comfortably ingest less food. It requires changing food habits and adjusting to a healthy dietary regime. A gastric bypass or ‘Roux-en-Y bypass’ similarly requires a change of dietary behaviour. The surgeon staples a small part of the upper stomach, again reducing its size. A section of the lower intestine is diverted into the pouch created by the stapling. Food comes down the oesophagus and into the pouch, then passes into the ‘plumbed’ intestine. Thus it bypasses the major part of the stomach, as well as bypassing the upper part of the intestine immediately attached to the stomach in its natural configuration.101 A more radical gastric bypass, termed a biliopancreatic diversion, sees the resection or removal of up to 70 per cent of the stomach, and a ‘rearrangement’ and more lengthy bypass of the small intestine.102 Not

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only can less food be ingested, but less will be digested as it has less intestine to carry out that task. The procedure can be combined with a duodenal switch which includes removal of the gallbladder. The aim is to have the stomach ‘secrete fewer hunger-causing hormones’ so that the patient experiences fewer pangs of hunger, and the body absorbs fewer minerals and calories.103 With the sleeve gastrectomy, rather than simply ‘barring’ a part of the stomach from receiving food, as with the duodenal switch, part of the stomach is actually cut off. A diagram of this procedure shows the greater part of the stomach removed, the remainder configured to replicate the small intestine, so that it appears to be an extension of it.104 Because removal of the stomach is even more pronounced than with the duodenal switch, even less hunger should be experienced and the body will be able to absorb even fewer calories and minerals. Hence, there should be a greater and more rapid weight loss. At the same time, those undergoing bariatric surgery should make regular medical appointments to ensure their condition is stable, must consider a lasting exercise programme, and may require a permanent diet of supplements to make up for the nutrients no longer absorbed naturally from eating.105 These three approaches are drastic. Understandably, they carry the greatest risks. General surgical risks include blood clots and wound infection, possibly with oozing pus and pain in or around the wound, or skin which feels hot, appearing swollen and red.106 As major procedures, the most extreme possibility is dying during the operation or following it if complications set in. The NHS emphasises that this is ‘very rare’, citing UK statistics that ‘suggest only around 1 in 1400 people’ dies within a month of undergoing weight loss surgery.107 However, there are other risks. In addition to loose skin requiring further surgery, the NHS identifies gallstones as a common outcome within the first year or two. This is likely to cause severe abdominal pain, and possibly less common symptoms of high temperature, jaundice, chills, shivering, a quickened heartbeat and itchy skin as well as confusion. A cholecystectomy, removing the gallbladder altogether, may be required.108 Constipation, repeated vomiting and difficulty in swallowing can result from a blocked gut, as well as malnutrition. For gastric bypass and sleeve gastrectomies, particular risks include leakage of food into the gut, with symptoms similar to gallstones apart from the itchy skin, confusion and jaundice but with the added problem of fast breathing. A risk with gastric banding is that the band can slip, causing vomiting, nausea and heartburn.109 Malnutrition can develop. Casualties suffer symptoms including

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pins and needles, pallid skin, palpitations and shortness of breath, feelings of weakness, a lack of energy, and general fatigue, exhaustion and debilitation.110 Yet perhaps the most common failure may be that patients find it difficult to realign their dietary habits. Some will be able to do so for a time, yet revert to their original pattern. The consequence is that they do not lose weight or, having done so, experience a subsequent weight gain.111 Simply saying that expansion of the stomach is not possible because a person’s appetite is cut down as there is less stomach to fill and fewer ‘hunger hormones’ simply ignores the reality of overeating as a habit hard to break. Patients taking the stomach-banding or stapling route may eat less and remain thin or thinner for a time, then old habits return with a vengeance. The stomach expands to its former size or, worse, enlarges. This then puts patient’s bodies and lives at risk, for the banding can break or staples burst causing internal bleeding and other damage with life-threatening potential.112 Although extremely rare and some clinicians dispute it, the stomach itself can burst through the ingestion of too much food and the body losing the natural gag reflex which would expel the excess.113 Where there is risk, there is potential for negligence. Where there is negligence, there is potential for legal action. Thus, although consensus exists amongst many practitioners that gastric bypass is ‘gold standard’ bariatric surgery,114 mistakes can—and do—happen. With other bariatric procedures available, in an arena well populated with practitioners and patients, risk increases. This is particularly so where patients desire to achieve an appearance than is simply not possible. In the end, losing weight leaves a person with the same basic body shape—simply with less fat. This then has the potential to take them down the track of more body changing techniques, in a field where dissatisfaction with natural bodies is growing, or where women are persuaded that the artificial body is natural.115 Striving for an artificially induced perfection, an outcome desired to conform to a plastic ideal, women are induced to believe that what exists naturally requires change. Having addressed the stomach, this focuses attention on the area beneath the waist. Below the stomach, at the junction between the thighs and under the pubic bone, a place of women’s physiological and sexual uniqueness awaits intervention. The most intimate part of the body arrives in the surgery. The designer vagina comes onto the market.

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What Lies Beneath …

The vagina and the vulva, particularly the labia minora and labia majora, are a growing site of surgical or non-surgical alteration. In Female Genital Cosmetic Surgery 116 Camille Nurka observes that, together with anecdotal reports from cosmetic surgeons, press reports, television and social media indicate ‘a marked rise in popularity of cosmetic labiaplasty procedures’.117 Women seek to be remade ‘virgins’ or, in the belief that there is something wrong with them, to have their genitals ‘tidied up’. Tidying up is generated by a conviction that ‘too much’ skin in the vulva region is offensive or that any display of ‘too much’ to a lover or potential lover will somehow cause repulsion. Vaginal contraction or narrowing and hymen reconstruction are sought not only to conceal that the hymen has been broken (rendering the woman impure or even a whore), but in response to the proposition that a woman’s vagina suffers from being flaccid or loose. Such vaginal laxity must be guarded against or eliminated whenever it appears, for tightness is the womanly requirement demanded in satisfying husband or partner. Camille Nurka lists the range of available cosmetic procedures for women’s genitals as including ‘reduction of the labia minora, or labiaplasty; reduction of the clitoral hood (labiaplasty and clitoral hood reduction are often performed together); “augmentation”, or enlargement, of the labia majora; vaginal tightening, or vaginal “rejuvenation”, and perineoplasty; “G-spot amplification”; clitoral reduction; and hymenoplasty, or hymen reconstruction’.118 She also includes ‘clitoral reconstruction for women who have had the clitoris excised in ritual cutting practices’, that is female genital mutilation (FGM). Apart from the effort to repair this damage to girls and women’s genitals, most genital surgery involving vulva and vagina is undertaken ‘where there is no indication of gynaecological disease’.119 Congenital conditions or ailments and disorders arising from bodily changes can lead to women seeking surgical solutions. The young woman who discovers her vagina is not fully developed and despite possessing ovaries her body has matured without a uterus faces a situation different from that of a woman persuaded that her naturally developed vagina is defective.120 What causes Rokitansky syndrome (Mayer-RokitanskyKuster-Hauser or MRKH syndrome) is unclear. The girl or woman possesses XX chromosomes, ovaries and female genitalia, developing breasts and pubic hair at puberty. The vagina’s shortness means that sexual

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intercourse can be difficult or impossible. Desirous of being a mother, the woman may seek alternatives to giving birth.121 This is different from the situation where surgery or ‘solutions’ are sought for cosmetic reasons. So, too, with prolapsed organs. Women can suffer a bladder prolapse (cystocele), prolapsed rectum (rectocele), prolapse of the top of the vagina or prolapsed uterus.122 These conditions can be mild or severe. Depending upon severity they can be painful and debilitating, even excruciatingly so. The conditions can arise collectively or individually, and do so because the pelvic ligaments or pelvic floor cease to support these organs or any one of them. Causes include childbirth, ageing, menopause, excess fat from overweight putting pressure on the abdomen, persistent constipation or coughing, gynaecological surgery such as hysterectomy, or congenital conditions. Where particularly severe, the vagina can fall so far that it intrudes into the groin. Similarly with the rectum, and where the condition affects the bladder, a woman may suffer from serious incontinence. Bulging organs protrude into other abdominal organs, disrupting women’s health and everyday lives, including their sex lives and psychological well-being. Frustration, pain, anger and anxiety are natural and it is understandable that women seek relief. This is a normal response to a life-limiting condition. However, the question is whether surgery is the right choice. For many women, it has been the wrong choice, leading to more pain and suffering, and legal action. The vaginal mesh scandal has dominated the news from at least 2017. For the United Kingdom, between the years 2006 and 2016, ‘more than 92,000 women in England [were] treated with a polypropylene surgical material’ inserted as a mesh patch or vaginal tape.123 Women were advised by medical specialists that they were ‘going for a simple, low-risk operation that takes just 20 minutes’. Yet the mesh had an impact unanticipated by those treated: agonising pain caused by the mesh cutting into the vagina, sensitive tissue inflammation, often at intense levels, burning and stinging urinary infections, leg pain and cuts to the urethra or bladder.124 In the United States, ‘traumatic complications’ suggested that ‘one in 15 women fitted with the most common type of mesh support will require surgery to extract it’.125 In Australia, evidence in the Federal Court alleged that Johnson & Johnson, manufacturers of the product, ‘tried to stop French authorities’ from publishing ‘a report warning against the use of its untested pelvic mesh devices’. This was said to have happened two years after the devices were first inserted

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into Australian women’s bodies.126 In the Australian action, women were allegedly denied warnings that the Johnson & Johnson vaginal mesh devices ‘posed a particular risk for patients with compromised immune systems’. This, ‘despite its being “well-known” before the products were first sold in Australia’.127 In Scotland, the government ‘asked health boards to suspend the use of mesh devices’. In the United States, the FDA (Food & Drug Administration) issued safety warnings of the risks. In Australia, the device was taken off the market. In a July 2017 review for the United Kingdom, the NHS ‘acknowledged that some women suffered severe and life-altering complications’, calling for patients to be ‘fully informed of the benefits and risks of the procedure’. Nevertheless, despite calling for ‘more data’ the NHS at that time concluded the use of the implants was ‘safe’.128 The NHS position would not rule out actions by women alleging negligence in the manufacture or production of the mesh implants. Following Donoghue v Stevenson 129 and the proposition that a manufacturer owes a duty of care to those coming within the ‘neighbour’ concept, Caparo Industries Plc v Dickman 130 clarified the question of ‘who is my neighbour’ or ‘to whom do I owe a duty of care’ by reference to three principles. To establish a manufacturer’s duty of care to the user of a product produced by that manufacturer, the claimant is required to prove, on the balance of probabilities: • Proximity of the claimant to the manufacturer; • The manufacturer’s knowledge of to whom the product would be provided, and for what purpose; and • The manufacturer’s knowledge that the user (claimant) would rely upon the safety of the product and its stated purpose. How might these principles apply, then, to the mesh devices causing harm and damage? The marketing of the mesh devices to hospitals, surgeries, clinics and medical and nurse practitioners meant that, as intended, the mesh devices were employed for use in the bodies of women suffering from medical or health conditions requiring medically diagnosed care. This would likely establish sufficient proximity between the end user—the women patients—and the mesh device manufacturer. Once having established that element, claimants must prove at least a 51 per cent chance that the manufacturer would have knowledge that the mesh devices would

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be provided to them, for the purpose of improving or correcting their vaginal or uterine condition. If that were proven, the final hurdle remains, namely proof to the degree of at least 51 per cent that the manufacturer knew or ought to have known that the women would rely upon the safety of the mesh devices and the purpose for which they were produced, namely, to improve or rectify the vaginal or uterine condition from which they suffered. Once the duty of care is established, the claimant needs to prove, again on the balance of probabilities, that the manufacturer was negligent. That is, there was a breach of the duty by the manufacturer and the harm or damage was caused by that breach. To prove negligence, women damaged or harmed by the mesh implant would, to gain compensation, bear this burden of proving their case. Ironically, the surgical path was taken as if it were the easy or best solution, despite alternatives. This meant women’s bodies were put at risk, whereas changes to lifestyle are painless and costless. Avoiding heavy lifting and aiming for a healthy weight, can ensure that the pelvic floor is not weakened further. Pelvic floor exercises can prevent prolapse, as well as managing and treating a prolapse already developed. These exercises aim at increasing muscle tone and strength, ‘helping to “lift up” the prolapsed organs.131 For uterine prolapse, a pessary is a temporary solution, although ‘side effects may include bleeding and bladder weakness’,132 the latter undoubtedly being a considerable drawback. Hormone replacement therapy (HRT) may be recommended where menopause is seen as driving the problem. Increasing oestrogen levels is designed to ‘rebuild muscle strength, alleviating the symptoms and preventing the prolapse from worsening’,133 although HRT carries its own risks.134 One website recommends its own product as having the capacity to stimulate muscle tightening, building strength and tone over time. This is effected through a handheld machine transmitting neuromuscular electrical stimulation (NMES) into the body by using electrode pads or a vaginal probe.135 Where prolapse is severe, is doubtful that these non-surgical methods will be fully effective, and surgery may be called for. However, here resort to surgery is health driven, not cosmetically compelled. Yet otherwise, cosmetic compulsion drives Western female genital surgery. Ten years ago, the US genital cosmetic surgery industry was estimated as worth $U S6.8m or £4.4m.136 The British Journal of Obstetrics and Gynaecology reported at the same time that the UK figures had increased by 70 per cent from 2007 to 2008, with the NHS conducting

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699 labiaplasty operations in 2007 and 1118 the following year.137 For 2010 to 2011, the number rose slightly to 1226, however, since then the market has increased further.138 In Australia, where Medicare covers the cost, calculated at $AUS 3500 to $AUS 9000,139 Kirsten Braun and Matty Silver report on the popularity of the procedure.140 In the United States numerous websites offer genital surgery for women, while the London Harley Medical Group advert to ‘cosmetic gynaecology’ as ‘one of our fastest growing surgical procedures, with women increasingly realising that they don’t have to simply accept something that’s making them unhappy’.141 UK psychological studies indicate that doubts women harbour about their genital construction drive them to search for a surgical solution.142 The range of procedures is described in various ways. Some cosmetic surgeons offer ‘vaginal tightening’ and ‘restoring vaginal muscle tone’ which can be performed together with ‘vaginal wall repair’ or labia reduction.143 Vaginoplasty is the terminology used by others, describing the procedure as ‘vaginal reshaping and tightening surgery’ whilst a woman can also seek out ‘clitoral hoodoplasty surgery’ from the same surgery.144 Others explain that a ‘hoodoplasty’ may be necessary when the client chooses a labiaplasty, for ‘prominent labia minora are more often than not accompanied by a prominent clitoral hood’ requiring trimming of both.145 Kirsten Braun addresses the nature of all procedures so far available to women seeking genital surgery. She describes labiaplasty, vaginoplasty, hymenoplasty, labia majora augmentation, vulval lipoplasty, clitoral hood reduction, and G-spot augmentation.146 Some of these effect permanent changes, whilst others may require repeat intervention. G-spot augmentation is promoted as designed to increase women’s sexual pleasure. The 1960s ‘sexual revolution’ brought with it a solid round of attention being paid to the clitoris, as well as the purported discovery of the ‘G’ spot. Some fifty years later, according to Cosmopolitan, some continue to find difficulty in locating it. An erogenous zone described as being located at the front and underneath the vaginal wall, the Grafenberg spot comprises ‘ultra-sensitive, erectile-like issue’. When touched it swells from ‘about the size of a 5p piece … expanding to the size of a 10p piece’ and for women ‘may be a “key” to orgasm’.147 Augmentation requires an injection of collagen or a similar product into the G-spot, making it more prominent by increasing its size and more able to be felt and touched. On average, effects are expected to last for some three to four months. The

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G-spot then having returned to its original size or at least diminished, the procedure must be repeated. Some women may wonder whether the operation may hinder rather than enhance sexual pleasure. Partially covering the vaginal entrance, the thin layer of skin known as the hymen is torn when a woman engages in sexual intercourse or vaginal masturbation. A hymenoplasty reconnects the hymen’s torn edges, creating an illusion that the woman has not engaged in any sexual or masturbatory activity. If there are no remnants of the hymen remaining, then a full-scale replication of the hymen through grafting fine skin is required. Some women seek out the operation so that on their wedding night an obligatory showing of blood can satisfy cultural or religious beliefs, as well as persuading the groom that he has indeed married a virgin. Other women request it in order to ‘give their partner a “gift” of virginity’.148 Where an illusion of a pre-childbirth vagina is required, vaginoplasty is the answer. Excess tissue is removed from the vaginal lining, with the vagina being refashioned into an organ with a smaller diameter through ‘vaginal rejuvenation’.149 With both vaginoplasty and hymenoplasty, the woman is perfectly healthy. However, intrusion into the genital area through undergoing such operations may have the consequence of interfering with good health. This can happen, too, with surgery on the external parts of the genital area, where labia and clitoral hood are the target. The most commonly performed genital cosmetic surgery, labiaplasty is pursued by some women because the labia protrude so as to chaff, causing a rash and irritation or interfering with sporting activities such as bike riding.150 Others believe the labia are odd or unsightly, abnormal in size or shape. The operation reduces the size of the labia minora (the inner lips) so that they are concealed behind the outer lips (the labia majora). If the lips are asymmetrical, they can be refashioned so as to mirror one another in size. On the other hand, in another approach to supposed genitalia perfection, a woman may seek plumping of the lower regions, or removal of fat. Plumping up of the outer lips, labia majora augmentation, is effected by taking fatty tissue from one part of the body and transporting it into the outer lips. The opposite practice, removal of fat by liposuction, is directed towards ensuring that the mons pubis is less prominent: vulval lipoplasty removes fatty tissue from the fleshy pad that sits immediately above the cleft of a woman’s genitals. Finally, the hood of skin protecting the clitoris can be removed in a clitoral hood reduction procedure, so that ‘the glans (or head) of the clitoris is exposed.151

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It is questionable whether all this attention being paid to a woman’s genitalia is medically required. This is particularly concerning since many of the procedures are performed in an operating theatre under general anaesthetic, with the consequent risks that such an operation ordinarily carries. It is major surgery, with commensurate risk. The Victorian Department of Health and Human Services says that if a woman is ‘concerned about the way [she] looks’ or is contemplating cosmetic treatments ‘as a confidence boost’, wisdom may lie in recognising there are alternatives.152 The Department lists possible complications of cosmetical genital surgery as risks of general anaesthesia ‘including allergic reaction, which may (rarely) be fatal’; bleeding or infection which are general surgical risks; scarring that can be severe, as well as raised and itchy or reddened, and keloid may develop. As to risks specific to genitals, labia may be fashioned asymmetrically—requiring an operation to correct this if symmetry is desired, and other complications may require further surgery. Permanent colour change to the labia may result, and there may be tissue death (necrosis) along the wound, or skin loss.153 There is a risk of scalloping along the labia edge, blood clots, damage to other genital areas, and dissatisfaction with results.154 A paradox for women who seek this surgery to make their genitals more attractive to their partners, is that the aim is directly associated with sexual activity, yet the surgery may serve only to lessen or even destroy her sexual satisfaction. Pain during sex, changes in sexual arousal and nerve damage and loss of sensation are real risks. Yet just as with other parts of a woman’s body undergoing surgical intrusion in the name of beauty and vanity, nature or ‘normalisation’, control or agency,155 women are enjoined to endanger themselves or at least put themselves at risk. Efforts are made to persuade prospective patients that there is a ‘normal’ genital construction that does not acknowledge the natural variation in women’s body parts. Just as the 1970s film ‘Speculum Speaks’ showed the divergence of women’s breasts in shape, size and symmetry, so it demonstrated this for women’s vulva. However, some forty years later Lih-Mei Liao and Sarah M. Creighton draw attention to the power of ‘medical framing’. In Female Genital Cosmetic Surgery—Solution to What Problem? 156 published in 2019, they observe that medical framing of some bodily attributes ‘as normal and others as abnormal can have powerful effects on how people think and feel about (their) bodies’.157 Thus it is that words describing the natural

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configuration of body parts in negative medical terms—as medical problems or medically unsound—‘trump the reality of diverse combinations of female-typical and male-typical sex characteristic in human beings’. This then ‘puts pressure on people for self-surveillance, self-judgement and self-regulation of appearance and comportment to fit with cultural norms’.158 In describing the prepubertal appearance of human female genitals and their development, Naomi S. Crouch explains how changes occur over time, and that differences exist between girls and women at various ages, and between girls and women at the same age. In ‘Female Genital Anatomy’ she notes that the genital tract ‘remains essentially quiescent from birth and during early childhood’.159 The labia minora ‘remain very thin and small, and the vulva generally has a flattened appearance’. With the onset of puberty, the genital tissue begins to change. Over years, pubic hair develops and the labia minora ‘elongate and darken in colour, and usually protrude beyond the labia majora’. Fat pads develop slowly on the mons pubic and labia majora, whilst the clitoris enlarges. Upon reaching adulthood, women’s labia minora ‘vary in appearance’ but ‘are darker than the surrounding tissue’ and display ‘a wide variety of dimensions’.160 It is not unusual, says Crouch, for labial width to measure up to 5 cm at the widest part, and sometimes beyond’. Furthermore, it is ‘common and usual’ for labia minora ‘to protrude beyond the labia majora’. This, she adds, is ‘not necessarily understood by girls and women’.161 This renders women vulnerable to the ubiquitous nature of a vulva-correcting or vulva-normalising industry or vulva-beautifying industry that can be accessed at the tap of a key or manipulation of the cursor on a screen. As Virginia Braun reflects in ‘Selling the Perfect Vulva?’ labiaplasty and genital cosmetic procedures aimed at the vulva and vagina generally ‘have become (somewhat) mainstreamed and legitimised … despite critique of both cultural hypocrisy and legally dubious standing when genital “cosmetic procedures” are considered alongside laws banning “female genital mutilation”’.162 In 2007, writing in the Australian Cosmetic Surgery Magazine, Lauren Alexander declared that for the majority of women, ‘the labia minora are covered by the labia majora (outer lips) and are seen only with the legs separated’.163 Recognising that this is not consistent with the adult women’s genital configuration, in 2019 Camille Nurka suggests that the proposition that genitals are ‘wrong’ when the labia minora protrude

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beyond the labia majora is taking a less prominent place in industry advertising.164 There is, she says, ‘not a shred of valid evidence’ supporting the notion that labia minora ‘common to most women’ or ‘average’ are ‘hidden behind or flush with the labia majora’.165 Now, industry advertising language ‘is changing to reflect an acknowledgement of genital diversity’. This she attributes to ‘demands from feminist gynaecologists, urologists and psychologists for evidence-based claims’.166 Nonetheless, surgical interventions continue and women continue to subject themselves to correcting perceived flaws. Inevitably, this raises the question of body dysmorphia (BDD). Research in the field of cosmetic and aesthetic surgery conducted on women’s genitals is scant, despite the increased focus on women’s vulva as a target area for the scalpel.167 Of the research that has been carried out, the reasons for women’s taking up this surgery are explored by Rufus Cartwright and Linda Cardozo.168 They found women nominating ‘two distinct reasons’ for undergoing the procedure: discomfort or aesthetic dissatisfaction. Elsewhere, three reasons have been articulated. Ros Bramwell and Claire Moreland’s system of assessment titled the Genital Appearance Satisfaction (GAS) scale was developed by reference to a sample of 135 women.169 This identifies genital appearance, impact on daily living, and impact on sex. Expanding on these, one can be described as functional, for example explaining to the clinician that their labia rubbed against their underwear, tights or pantyhose, or interfered with penetrative intercourse through becoming caught up in their vagina. One is aesthetic in terms of engagement in sexual relations: wishing to present well to a sexual partner. One is cosmetic (as in beautification) or achieving normality: simply wishing to possess genitals that conform to an understanding of what ‘real’ genitals look like.170 Ultimately the beautification and normality goals seem to be an expression of the same proposition, namely that genitals should ‘look’ a certain way and if they do not they are neither ‘normal’ nor attractive. David Veale et al. sought to apply or validate the GAS scale against a sample of women seeking labiaplasty. They added a broader range of measures, including ‘disgust sensitivity’, body image quality of life, sexual functioning, depression and anxiety. Factoring these in complied with the researchers’ hypothesis that: … a measure of genital dissatisfaction would correlate with (1) disgust sensitivity as women seeking labiaplasty may be more prone to disgust

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towards the genitalia, (2) quality of life relating to their body image because genital dissatisfaction will affect body image, (3) sexual satisfaction since women seeking labiaplasty report interference in their sexual life and (4) depression and anxiety because of the interference of their genital appearance in their life.171

Body dysmorphic disorder (BDD) was found to be a factor, defined as ‘a preoccupation with a perceived defect that is not observable or appears slight to others and the person’s concern is markedly excessive to the extent of being significantly distressing or causing impairment in social, occupational or other important areas of functioning’.172 Noting that previous studies of labiaplasty patients have found their labia are in ‘the normal range’, the study similarly found the labia of those in the BDD category to be in ‘the normal range’. The recommendation was that BDD should be factored into clinical assessments of those seeking labiaplasty. The need for a psychological assessment of prospective candidates for cosmetic, aesthetic and plastic surgery has arisen in cases involving negligence claims. Returning to Karen Turner v Mr Nigel Carver,173 her apparent predisposition to having her body modified through multiple cosmetic or aesthetic operations and wanting more raised concerns as to possible body dysmorphic disorder (BDD). She had undergone a series of procedures including breast augmentations (plural) and an approach to Mr Carver for a further augmentation, as well as liposuction. Her dissatisfaction with the outcome generated her unsuccessful claim in negligence and, following the case, the General Medical Council (GMC) issued ‘Guidance for all Doctors Who Offer Cosmetic Interventions’. This sets out standards for practitioners providing cosmetic procedures. Fundamental is the advice that doctors ‘must consider their patients’ psychological needs’. In conjunction with this, doctors must consider whether ‘referral to another experienced professional colleague, such as a psychologist, is appropriate’: When you discuss interventions and options with a patient, you must consider their vulnerabilities and psychological needs. You must satisfy yourself that the patient’s request for the cosmetic intervention is voluntary.174

Yet will this really help? One of the ironies here is that physicians themselves appear to play a not insignificant role in confirming women’s

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desire for cosmetic, aesthetic or plastic surgery. Women’s genital appearance is something upon which physicians appear to have a well-defined view. In ‘No (Wo)man Is an Island – The Influence of Physicians’ Personal Predisposition to Labia Minora Appearance on their Clinical Decision Making’, Berend van de Lei et al. found that taking into account their ‘specific gender and specialty’, the ‘personal predisposition’ of physicians concerning the size and appearance of labia minora was influential ‘in their clinical decision making regarding a labia minora reduction procedure’.175 The survey of 210 physicians, ninety-six males, sixty-eight females and including eighty general practitioners, forty-one gynaecologists and forty-three plastic surgeons working in the Netherlands had them appraise four pictures showing a vulva. Each image ‘displayed different sizes of labia minora’. Ninety per cent of the physicians believed, ‘to a certain extent’, that the image of the vulva with very small labia minora ‘represents society’s ideal’. More plastic surgeons ‘regarded the picture with the largest labia minora as distasteful and unnatural’ in comparison with general practitioners and gynaecologists. Having deemed them to possess distasteful and unnatural genitals, these plastic surgeons regarded women possessing them proper candidates for labia minora reduction procedures. Furthermore: Irrespective of the woman’s labia minora size and the absence of physical complaints, plastic surgeons were significantly more open to performing a labia minora reduction procedure than gynecologists … Male physicians were more inclined to opt for a surgical reduction procedure than their female colleagues.176

The researchers concluded the necessity for ‘heightened awareness of one’s personal predisposition vis-à-vis referral and willingness to operate’. Those asserting that women are exercising untrammeled agency in seeking body upgrades, change or beautification and normalisation might wonder whether women would make a different choice if the aesthetic, cosmetic or plastic surgeon whom they consulted did not have a vision of the ‘ideal’ labia minora. At the same time, they may object to the proposition that psychological intervention is dictated, at least for the woman patient. Others will accept that body modifications can be taken to extremes, yet may be minded to question from where the impetus comes. This raises the question whether medical and media representations of women’s bodies, along with advertising suggesting that surgery

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or non-surgical interventions can lead to ‘perfection’ or ‘betterment’ require an antidote. What about women exercising agency in critically assessing aesthetic, cosmetic and plastic surgery, and taking aim at an industry designed to generate a desire for changes to the bodies with which women are born?

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Women’s HealthVictoria publishes online images of women’s genitals to show women that far from abnormal, their construction is exactly what nature intended—for them and for others. The reality is that ‘about half of all women’ are constructed with labia minora longer than the labia majora. The images illustrate that labia come in ‘all shapes and sizes’ as do other parts of the lower part of women’s bodies.177 Some commentators critique genital cosmetic surgery on the assumption that exploitative images of women being so readily available on the internet, with genitals conforming to a highly artificial and fabricated design, affects how women regard the most intimate parts of their bodies. Pornographic representations explicitly revealing women’s genitals and so readily available on the web are seen as a critical element. Others opine that the lopping of women’s pubic hair, with the revelation of what lies beneath in a way not previously seen, has led directly to the growing obsession with reconstruction of women’s genitalia. Kate Lister in ‘From Pompeii to Victorian Erotica’ observes that the removal of pubic hair has its own history, with evidence of the practice ‘dating back to the Ancient World’. The Turkish museums of Nigde and Anatolian Civilisations in Ankara ‘both hold examples of obsidian razors dating to 6500BC, … the oldest known examples of hair removal in the Muslim world’.178 Caitlin Moran in How to Be a Woman surmises that the removal of women’s pubic hair in pornography has one purpose, namely to ensure that shots of a woman’s genitals whether in full display or during sexual intercourse exhibit ‘more’ if the hair is removed or severely trimmed.179 Hence, the origin of the ‘full Brazilian’ which removes all pubic hair, presenting a woman as if she is prepubertal, in other words, a child. Woman can also adopt the ‘bikini-line trim’ so as to wear high cut bathing suit bottoms and show no pubic hair, or the ‘landing strip’, almost a full Brazilian but leaving a strip of hair just above the clitoral hood.180 Shaving this area or any part of it, whether at home or at the

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beauty salon, carries like risks as shaving any other part of the body— legs, underarms—including cuts and abrasions, bleeding, infections from unhygienic equipment, burning from hot wax, ingrown hairs and rashes. Potentially, razor slippage in this area, or the use of laser, electrolysis or other modern procedures, are more dangerous due to the sensitivity of the area, both physically and physiologically. There is, however, a fight back for pubic hair. Again, actresses, supermodels and celebrities including Cameron Diaz and Gwyneth Paltrow are said to be leading the way.181 Yet it is women activists who are taking a political stand, full muffs akimbo. The ‘Muff March’ led down Harley Street by women from Object took issue with genital surgery and the denuding of women’s pubis, turning adult women’s genital area into the smoothness with which female babies are born.182 This protest may herald a move away from surgery which is harmful to women’s sense of ourselves as adult human beings, and hence to a world where less litigation will find its way into the innermost parts of women’s bodies. If pubic hair is rehabilitated, perhaps women’s genitals can be properly esteemed as they really are, too.

Notes 1. Kimberly Caines, ‘How to Lose a Muffin Top & Belly Fat Fast’, LiveStrong.com, https://www.livestrong.com/article/333495-how-tolose-a-muffin-top-belly-fat-fast/ (accessed 4 April 2018). 2. Linda Bacon and Lucy Aphramor, Body Respect , BenBella Books, Dallas, TX, USA, 2014, p. xvii. 3. ‘Adipose Tissue: The Period of Adaptation to Starvation’, ALPF Medical Research, https://www.alpfmedical.info/adipose-tissue/the-per iod-of-adaptation-to-starvation.html (accessed 4 April 2018). 4. Kimberly Caines, ibid. 5. Ibid. 6. ‘Physical Activity Basics’, Centers for Disease Control and Prevention, https://www.cdc.gov/physicalactivity/basics/index.htm (accessed 14 April 2018). 7. Kimberly Caines, ibid. 8. ‘Muffin Top Liposuction’, London Lipo Institute, 1 October 2018, https://www.lipolondon.com/muffin-top-liposuction/ (accessed 18 December 2018). 9. BMI is calculated as weight (in kilograms) divided by height (in metres). ‘Normal’ BMI is less than 25, ‘overweight’ is between 25 and 30, and ‘obese’ is 30 and above. Linda Bacon and Lucy Aphramor, ibid., pp. 8,

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10.

11. 12. 13. 14.

15.

16. 17. 18. 19. 20.

21.

22.

23. 24. 25.

26. 27. 28. 29. 30.

12, 14–15, 31–32 are critical of reliance on BMI as an indicator of healthy weight or fitness. ‘Muffin Top Liposuction/Liposculpture’, Newman Plastic Surgery, https://temecula-plastic-surgery.com/body/muffin-top/ (accessed 14 April 2019). ‘SmartLipo’, Clinic Compare, https://liposuction.cliniccompare.co.uk/ how-much-does-smart-lipo-cost-uk (accessed 4 April 2019). ‘Laser Liposuction Risks’, Health, https://healthhearty.com/laser-liposu ction-risks (accessed 18 April 2019). Ibid. ‘Vaser Liposuction’, Transform, https://www.transforminglives.co.uk/ cosmetic-surgery-for-women/weight-loss/vaser-liposuction#p6bsUxBzS glQFTcr.99 (accessed 4 April 2019). ‘Vaser Lipo Complications and Side Effects’, RealSelf , https://www. realself.com/question/vaser-liposelection-side-effects (accessed 4 April 2019). Ibid. Ibid. Ibid. Greg Almond, An Introduction to Beauty Negligence Claims , Law Brief Publishing, Somerset, UK, 2019, p. 93. Montgomery v Lanarkshire Health Board [2015] UKSC 11, https:// www.supremecourt.uk/cases/docs/uksc-2013-0136-judgment.pdf (accessed 20 January 2020). Zahir v Vadodaria [2016] EWHC 1215 (QB), https://www.casemine. com/judgement/uk/5a8ff74560d03e7f57eaaa66 (accessed 20 January 2020) . Simon Perkins, ‘Karen Turner v Mr Nigel Carver, DACB Successfully Defend Cosmetic Surgery Claim on Consent’, DAC Beachcroft, 18 November 2016, https://www.dacbeachcroft.com/en/gb/articles/ 2016/november/dacb-successfully-defend-cosmetic-surgery-claim-onconsent/ (accessed 19 December 2019). See Chapter 3 at 2. Bust, Bosom, Breasts. Ibid. ‘Liposuction Negligence Claims’, LegalExpert.co.uk, https://www.legale xpert.co.uk/clinical-medical-negligence/how-to-claim/liposuction-neg ligence-claims/ (accessed 19 December 2019). Ibid. Ibid. ‘Vaser Lipo Complications and Side Effects’, ibid. Ibid. Greg Almond, ibid., p. 94.

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31. Anita Border v Lewisham NHS Trust [2015] EWCA Civ 8, https://www.bailii.org/ew/cases/EWCA/Civ/2015/8.html (accessed 19 December 2019). 32. Ibid., para [10]. 33. Ibid., para [6]. 34. Ibid., paras [13], [27]. 35. Susie Orbach, Fat is a Feminist Issue, 1978 (first edn), Arrow Books, London, UK, 2006. 36. Linda Bacon and Lucy Aphramor, ibid. 37. Kimberly Caines, ibid. 38. ‘The Top 5 Plastic Surgery Alternatives for Belly Fat Removal’, Beverly Hills Rejuvenation Center, https://bhrcenter.com/plastic-surgery-altern atives-belly-fat/ (accessed 4 April 2018). 39. Ibid. 40. Ibid. 41. ‘BodySculpt’, Transform, https://www.transforminglives.co.uk/non-sur gical-treatments/women/coolsculpting?utm/ (accessed 4 April 2019). 42. ‘The Top 5 Plastic Surgery Alternatives …’, ibid. 43. Ibid. 44. Ibid. 45. ‘Zerona Body Contouring’, Discover Laser—Medical Aesthetic Skin Clinic, https://www.discoverlaser.co.uk/body-treatments/zerona-bodycontouring/ (accessed 4 April 2019). 46. Ibid. 47. Anthony Attwood, ‘Tummy Tuck (Abdominoplasty)’, Bupa, https:// www.bupa.co.uk/health-information/cosmetic-surgery-and-proced ures/tummy-tuck (accessed 18 April 2018). 48. Ibid. 49. Ibid. 50. Ibid. See also ‘Tummy Tuck (Abdominoplasty)’, NHS, https:// www.nhs.uk/conditions/cosmetic-procedures/tummy-tuck/ (accessed 4 April 2018). 51. ‘Tummy Tuck … ibid. 52. See generally ibid., and Anthony Attwood, ibid. 53. Simon Perkins, ‘Karen Turner v Mr Nigel Carver, ibid. 54. Martin Swann, ‘Mitigating Risks to Mitigate Costs’, Aesthetics Journal, vol 7, no 4, March 2020, pp. 63–65, p. 64. 55. ‘Liposuction and Muffin Top Questions & Answers from Doctors’, RealSelf , https://www.realself.com/liposuction/answers/muffin-top (accessed 18 April 2019). 56. Ibid. 57. Ibid.

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58. David Spencer v Hillingdon Hospital Trust [2015] EWHC 1058 (QB), https://www.bailii.org/ew/cases/EWHC/QB/2015/1058. html (accessed 19 December 2019). 59. See for example Kathy Davis, Reshaping the Female Body—The Dilemma of Cosmetic Surgery, Routledge, New York, NY, USA, 1995. 60. David Spencer v Hillingdon Hospital Trust, ibid., para [6]. 61. Ibid. 62. Montgomery v Lanarkshire Health Board [2015], ibid. 63. Ibid., para [87], cited David Spencer v Hillingdon Hospital Trust, ibid., para [30]. 64. Ibid. 65. Ibid., para [89], cited David Spencer v Hillingdon Hospital Trust, ibid., para [31]. 66. Ibid. 67. David Spencer v Hillingdon Hospital Trust, ibid., para [65]. 68. See for example Catharine Mackinnon, Feminism Unmodified: Discourses on Life and Law, Harvard University Press, Boston, MA, USA, 1987; Jocelynne A. Scutt, The Incredible Woman—Power and Sexual Politics, vols I and II, Artemis Publishing, Melbourne, Australia, 1997. 69. ‘About Our Bodies Ourselves’, Our Bodies, Our Selves —Information Inspires Action, https://www.ourbodiesourselves.org/ (accessed 19 December 2019). 70. Sidaway v Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital [1985] AC 871, https://www.globalhealthrights. org/wp-content/uploads/2013/01/HL-1985-Sidaway-v.-BethlemRoyal-Hospital-Governors-and-Ors..pdf (accessed 19 December 2019). 71. Ibid. 72. Montgomery v Lanarkshire Health Board, ibid., at para [86]. 73. See for example Maya Dusenbery, Doing Harm—The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick, HarperCollins, New York, NY, USA, 2018; Maya Dusenbery, ‘How Can Women Better Advocate for Themselves’, Quora:Forbes, https://www.quora.com/How-can-women-better-adv ocate-for-themselves-as-patients/answer/Maya-Dusenbery?ref=forbes& rel_pos=1 (accessed 19 December 2019). 74. Suzanne Fraser, Cosmetic Surgery, Gender and Culture, Palgrave Macmillan, Basingstoke, UK, 2003, Chapter 3, pp. 61–96. 75. Daniel Martin, ‘Number of Patients Having Stomach-Stapling Surgery on the NHS Nearly Doubles in Just One Year’, Daily Mail, 27 May 2008, https://www.dailymail.co.uk/news/article-1022208/Numberpatients-having-stomach-stapling-surgery-NHS-nearly-doubles-just-year. html (accessed 10 June 2009).

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76. James Chapman, ‘Obese Britain: Growing Number of Young Teens Having Gastric Band or Stomach Stapling Surgery on the NHS’, Daily Mail, 25 September 2010, https://www.dailymail.co.uk/health/article1315039/Obese-Britain-Young-teens-having-gastric-band-stomach-sta pling-surgery-NHS.html (accessed 27 September 2010). 77. Ibid. 78. Source NHS Digital, ‘Hospital Admissions Where Obesity Is a Factor Increased by 18 per cent’, 4 April 2018, NHS, https://webarchive.nat ionalarchives.gov.uk/20180529133634/https://digital.nhs.uk/newsand-events/latest-news/hospital-admissions-where-obesity-is-a-factorincreased-by-18-per-cent (accessed 14 April 2018). 79. Linda Bacon and Lucy Aphramor, ibid. 80. ‘Weight Loss Surgery’, Healthier Weight, https://www.healthierweight. co.uk/gastric-band/nhs-or-private/ (accessed 14 April 2019). 81. Ibid. 82. John Rabkin, ‘Six Types of Weight Loss Surgery’, Bariatric Surgery Source, https://www.bariatric-surgery-source.com/types-of-bariatric-sur gery.html (accessed 14 April 2018). 83. ‘Intragastric Balloon’, RealSelf , https://www.realself.com/review/ intragastric-balloon-spatz-iii-12-month-balloon-worth?offset=0&sle=0 (accessed 14 April 2019). 84. ‘Elipse Gastric Balloon: Swallowable, Nonsurgical Weight Loss Treatment’, Bariatric News , 4 April 2017, https://bariatricjournal.com/eli pse-gastric-balloon/ (accessed 10 April 2017). 85. Ibid. 86. Ibid. 87. ‘11 Things You Need to Know About a Gastric Balloon’, Ramsey Health Care, https://www.ramsayhealth.co.uk/blog/2014/08/21/11-thingsyou-need-to-know-about-a-gastric-balloon (accessed 11 April 2017). 88. Ibid. 89. Jeffrey A. Quinlan, ‘Gastric Balloon Reviews—The Patient Perspective’, Bariatric Surgery, https://www.bariatric-surgery-source.com/gastric-bal loon-reviews.html#downsides (accessed 14 April 2019). 90. Ibid. 91. Ibid. 92. ‘Reviews’, RealSelf , https://www.realself.com/review/miami-fl-intrag astric-balloon-gastric-balloon-results-md-south-florida (accessed 14 April 2019). 93. ‘Types—Weight Loss Surgery’, NHS Weight Loss Surgery, https://www. nhs.uk/conditions/weight-loss-surgery/types/ (accessed 4 April 2018). 94. Ibid. 95. John Rabkin, ‘Six Types …’, ibid. 96. Ibid.

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97. ‘Types—Weight loss …’, ibid. 98. Paula Cocozza, ‘“I Just Want to Cut It Off”: The WeightLoss Patients Who No Longer Fit Their Skin’, The Guardian, 2 January 2018, https://www.theguardian.com/lifeandstyle/2018/ jan/02/i-want-to-cut-if-off-weight-loss-patients-excess-skin (accessed 5 January 2018). 99. Ibid. 100. ‘Eating After Gastric Banding’, The Whittington Hospital NHS Trust, https://www.whittington.nhs.uk/document.ashx?id=1946 (accessed 14 April 2018). 101. ‘What Is Gastric Band?’ RWJBarnabas Health, https://www.rwjbh.org/ site-search/?C=bariatric+surgery (accessed 14 April 2019). 102. ‘Duodenal Switch’, Bariatric Surgery, https://www.bariatric-surgerysource.com/types-of-bariatric-surgery.html (accessed 14 April 2019). 103. Ibid. 104. ‘Vertical Sleeve Gastrectomy’, Bariatric Surgery, https://www.bariatricsurgery-source.com/types-of-bariatric-surgery.html (accessed 14 April 2019). 105. ‘GP Guidance: Management of Nutrition Following Bariatric Surgery: August 2014, BMSS/British Obesity & Metabolic Surgery Society, http:// www.bomss.org.uk/wp-content/uploads/2014/09/GP_GuidanceFinal-version-1Oct141.pdf (accessed 4 April 2018). 106. ‘Risks—Weight Loss Surgery’, NHS, https://www.nhs.uk/conditions/ weight-loss-surgery/risks (accessed 17 November 2017). 107. Ibid. 108. Ibid. 109. Ibid. 110. Ibid. 111. ‘5 Ways to Prevent Stretching Your Stomach After Gastric Bypass’, Weight Loss Surgeries, https://www.obesitycoverage.com/weight-losssurgeries/gastric-bypass/5-ways-to-prevent-stretching-your-stomachafter-gastric-bypass (accessed 4 April 2018). 112. ‘29st Man Died After Gastric Band Burst’, The Scotsman, 4 March 2010, https://www.scotsman.com/news/uk-news/29st-man-diedafter-gastric-band-burst-1-793436 (accessed 18 November 2017); Melissa Dahl, ‘Can Eating Too Much Make Your Stomach Burst?’, NBC News, https://www.nbcnews.com/health/body-odd/can-eating-toomuch-make-your-stomach-burst-f1C6436940 (accessed 18 November 2017); ‘Can Your Stomach Explode?’, New Health Advisor, https:// www.newhealthadvisor.com/can-your-stomach-explode.html (accessed 4 April 2018). 113. Melissa Dahl, ibid.; ‘Can Your Stomach …’, ibid.

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114. ‘Gastric Bypass Surgery—The “Gold Standard” Weight Loss Surgery’, Upper GI Surgery, https://uppergisurgery.com.au/gastric-bypass-sur gery-the-gold-standard-weight-loss-surgery/ (accessed 4 April 2018); ‘Gastric Bypass Surgery’, Phoenix Health, https://www.phoenix-hea lth-co.uk/treatment-options/gastric-bypass-surgery/ (accessed 4 April 2018). 115. See for example Suzanne Fraser, ibid., and Chapter 4, 97–121. 116. Camille Nurka, Female Genital Cosmetic Surgery—Deviance, Desire and the Pursuit of Perfection, Palgrave Macmillan, Basingstoke, UK, 2019. 117. Ibid, p. 4. 118. Ibid, p. 3. 119. Ibid. 120. Miranda Larbi, ‘I Was Born with No Vagina or Womb and Without Surgery I’ll Never Have Sex’, The Sun, 12 June 2019, https://www.thesun.co.uk/fabulous/9278960/born-no-vaginawomb-never-have-sex-surgery/ (accessed 12 June 2019). 121. ‘Disorders of Sex Development’, NHS, https://www.nhs.uk/condit ions/disorders-sex-development/ (accessed 12 June 2019). 122. ‘Overview—Pelvic Organ Prolapse’, NHS, https://www.nhs.uk/condit ions/pelvic-organ-prolapse (accessed 4 April 2019). 123. Kath Sansom, ‘Vaginal Mesh Left Me in Agony: When Will Women’s Health Be Taken Seriously?’ The Guardian, 27 April 2017, https:// www.theguardian.com/commentisfree/2017/apr/27/vaginal-meshwomen-health-bladders-bowels-sex-lives-nhs-operations (accessed 27 April 2017). 124. Ibid. See also Barbara Ellen, ‘Vaginal Mesh Scandal: Women Don’t Need Body-Shaming on Top of Their Pain’, The Guardian, https:// www.thejguardian.com/commentisfree/2017/oct/01/vaginal-mesh-sca ndal-women-don’t-need-body-shaming (accessed 2 October 2017). 125. Hannah Devlin, ‘Revealed: Johnson & Johnson’s “Irresponsible” Actions over Vaginal Mesh Implants’, The Guardian, 29 September 2017, https://www.theguardian.com/society/2017/sep/29/rev ealed-johnson-johnsons-irresponsible-actions-over-vaginal-mesh-imp lant (accessed 2 October 2017). 126. Christopher Knaus, ‘Johnson & Johnson Tried to Prevent Report About Pelvic Mesh Device, Court Hears’, The Guardian, 10 July 2017, https://www.theguardian.com/australia-news/2017/jul/10/johnsonjohnson-tried-to-prevent-report-about-pelvic-mesh-devices-court-hears (accessed 2 October 2017). 127. Christopher Knaus, ‘Johnson & Johnson Accused of Failing to Warn Patients at Higher Risk from Vaginal Mesh’, The Guardian, 10 April 2018, https://www.theguardian.com/australia-news/2018/apr/

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128.

129.

130.

131. 132. 133. 134.

135. 136.

137. 138.

139. 140.

141.

142.

10/johnson-johnson-accused-of-failing-to-warn-patients-at-higher-riskfrom-vaginal-mesh (accessed 10 April 2018). Editorial, ‘The Guardian View on Vaginal Mesh Implants: Trust Data and Patients’, The Guardian, 16 August 2017, https://www.thegua rdian.com/commentisfree/2017/aug/16/the-guardian-view-on-vag inal-mesh-implants-trust-data-and-patients (accessed 17 August 2017). Donoghue v Stevenson [1932] AC 562, https://www.scottishlawrepo rts.org.uk/resources/donoghue-v-stevenson/case-report/ (accessed 20 January 2020). Caparo Industries Plc v Dickman [1990] UKHL 2, https://www.liquis earch.com/caparo_industries_plc_v_dickman/judgment/court_of_app eal (accessed 20 January 2020). ‘Meet the Solution to Prolapse’, Kegal 8, https://www.kegel8.co.uk/ articles/prolapse.html (accessed 4 April 2019). Ibid. Ibid. ‘Risks—Hormone Replacement Therapy (HRT)’, NHS, https://www. nhs.uk/conditions/hormone-replacement-therapy-hrt/risks/ (accessed 4 April 2019). ‘Meet the Solution …’, ibid. Viv Groskop, ‘The Muff March Against “Designer Vagina” Surgery’, The Guardian, 8 December 2011, https://www.theguardian.com/lif eandstyle/the-womens-blog-with-jane-martinson/2011/dec/08/muffmarch-designer-vagina-surgery (accessed 14 April 2018). Ibid. David Veale, Nell Ellison, Ana Costa, Dudley Robinson, Angelica Kavouni and Linda Cardozo, ‘Psychological Characteristics and Motivation of Women Seeking Labiaplasty’, Psychological Medicine, vol 44, no 3, 2014, pp. 555–566, http://dx.doi.org/10.1017/S00332917130 01025 (accessed 14 April 2019). Camille Nurka, ibid., p. 5. Kirsten Braun, ‘What Is Genital Cosmetic Surgery?’ Women’s Health Queensland, https://womhealth.org.au/conditions-and-treatments/gen ital-cosmetic-surgery (accessed 4 April 2018); Matty Silver, ‘The Female Genital Surgery Conspiracy’, Sydney Morning Herald, 7 March 2013, https://www.smh.com.au/lifestyle/the-female-genital-sur gery-conspiracy-20130304-2fge9.html (accessed 8 March 2013). Isaac Manyonda, ‘Vaginoplasty—Vaginal Reshaping & Tightening Surgery’, Harley Medical Group, 7 November 2018, https://www.har leymedical.co.uk/cosmetic-surgery-for-women/the-body/cosmetic-gyn aeclology (accessed 13 April 2019). David Veale, Nell Ellison et al., ibid.; see also R. Bramwell and C. Morland, ‘Genital Appearance Satisfaction in Women: The Development

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144. 145. 146. 147.

148. 149. 150. 151. 152.

153. 154. 155. 156.

157.

158. 159. 160. 161.

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of a Questionnaire and Exploration of Correlates’, Journal of Reproductive Infant Psychology, vol. 27, 2009, pp. 15–27; NS Crouch, R. Deans and L. Michala, ‘Clinical Characteristics of Well Women Seeking Labial Reduction Surgery: A Prospective Study’, British Journal of Obstetrics and Gynaecology, vol. 119, 2012, pp. 504–505. ‘Vaginal Tightening Surgery with The Hospital Group’, The Hospital Group, https://www.thehospitalgroup.org/cosmetic-surgery/body/vag inal-tightening (accessed 17 June 2018); David Veale, Ertimiss Eshkevari, Nell Ellison, Ana Costa, Dudley Robinson, Angelica Kavouni and Linda Cardozo, ‘A Comparison of Risk Factors for Women Seeking Labiaplasty Compared to Those Not Seeking Labiaplasty’, Body Image, 2014, http://dx.doi.org/10/1016/j.bodyim.2013.10.003 (accessed 4 April 2019). Isaac Manyonda, ibid. ‘Labiaplasty and Hoodplasty’, Haumea Clinic, https://www.cosmeticgenital-surgery.co.uk/labiaplasty-hoodplasty (accessed 4 April 2018). Kristin Braun, ibid. ‘Where Is the “G” Spot? Everything You Need to Know’, Cosmopolitan, 19 March 2019, https://www.cosmopolitan.com/uk/love-sex/sex/ a561/find-your-g-spot-67194/ (accessed 4 April 2019). Kristin Braun, ibid. Ibid. Ibid. Ibid. Better Health, ‘Cosmetic Genital Surgery—Labiaplasty and Phalloplasty’, Department of Health and Human Services, Victoria, https:// www.betterhealth.vic.gov.au/health/conditionsandtreatments/cosmeticgenital-surgery-labiaplasty-and-phalloplasty (accessed 2 January 2019). Ibid. Kristin Braun, ibid. See Suzanne Fraser, ibid. Sarah M. Creighton and Lih-Mei Liao (eds), Female Genital Cosmetic Surgery—Solution to What Problem? Cambridge University Press, Cambridge, UK. Lih-Mei Liao and Sarah M. Creighton, ‘Female Genital Cosmetic Surgery—Solution in Pursuit of a Problem’, in Sarah M. Creighton and Lih-Mei Liao (eds), ibid., pp. 1–10, p. 5. Ibid. Naomi S. Crouch, ‘Female Genital Anatomy’ in Creighton and Liao (eds), ibid., pp. 11–22, p. 13. Ibid. Ibid.

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162. Virginia Braun, ‘Selling a Perfect Vulva?’ in Creighton and Liao (eds), ibid., pp. 23–32, p. 27; see also Sarah B. Rodriguez, ‘The History of Female Genital Cosmetic Surgery in the United States—From Marginal to Mainstream’, in Creighton and Liao (eds), ibid., pp. 33–41. 163. Lauren Alexander, ‘Labioplasty Explained’, Australian Cosmetic Surgery Magazine, issue 35 (February–April 2007), p. 190. 164. Camille Nurka, ibid., p. 199. 165. Ibid. 166. Ibid. 167. See for example, Nurka, ibid.; David Veale, Ertimiss Eshkevari, Nell Ellison, Linda Cardozo, Dudley Robinson and Angelica Kavouni, ‘Validation of Genital Appearance Satisfaction Scale and the Cosmetic Procedure Screening Scale for Women Seeking Labiaplasty’, Journal of Psychosomatic Obstetrics & Gynaecology, vol 34, no 1, 2013, pp. 46–52, p. 51. 168. Rufus Cartwright and Linda Cardozo, ‘Cosmetic Vulvovaginal Surgery’, Obstetrics, Gynaecology and Reproductive Medicine, vol 18, no 10, 2008, pp. 285–286, https://www.researchgate.net/publication/223227116_ Cosmetic_vulvovaginal_surgery (accessed 19 December 2019). 169. Ros Bramwell and Claire Moreland, ‘Genital Appearance Satisfaction in Women: The Development of a Questionnaire and Exploration of Correlates’, Journal of Reproduction and Infant Psychology, vol 27, 2009, pp. 15–27. 170. See for example Camille Nurka, ibid.; ‘Are My Labia Normal?’, Women’s HealthVictoria, http://www.labialibrary.org.au/Women’sHealthVictoria Home (accessed 13 January 2017). 171. David Veale, Ertimiss Eshkevari, Nell Ellison, Linda Cardozo, Dudley Robinson and Angelica Kavouni, ibid., pp. 46–47. 172. Ibid., p. 47. 173. Karen Turner v Mr Nigel Carver, ibid. 174. Quoted Alaw Owen, ‘Cosmetic Surgery: Is It Realistic to Expect Surgeons to Assess Their Prospective Patient’s Psychological Profile?’, Hill Dickinson, 11 December 2017, https://www.hilldickinson.com/ins ights/articles/cosmetic-surgery-it-realistic-expect-surgeons-assess-theirprospective-patients (accessed 19 December 2019). 175. Berend van der Lei, Welmoed Reitsma, Marian JE Mouits, Merel Koning and Astrid Pascal, ‘No (Wo)Man Is an Island—The Influence of Physicians’ Personal Predisposition to Labia Minora Appearance on Their Clinical Decision Making: A Cross-Sectional Survey’, Journal of Sexual Medicine, vol 8, pp. 2377–2385, 19 May 2011, https://www.onlinelibrary.wiley.com/doi/epdf/10.1111/j. 1743-6109.2011.02321.x (accessed 19 January 2020). 176. Ibid.

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177. ‘Are My Labia Normal?’, ibid. 178. Kate Lister, ‘From Pompeii to Victorian Erotica’, Inews the Essential Daily Briefing, http://inews.co.uk/opinion/comment/from-romantimes-to-victoria-erotica-public-hair-was-a-sign-of-health-and-vitality/ (accessed 16 January 2019). 179. Caitlin Moran, How to Be a Woman, Ebury Publishing, London, UK, 2011. 180. ‘Pubic Hairstyles—A Basic Guide’, The Landing Strip, https://www.lan dingstrip.org/basic-pubic-hairstyles/ (accessed 17 January 2019). 181. Eva Wiseman, ‘The Bald Truth About Shaving Off Pubic Hair’, The Guardian, https://www.theguardian.com/lifeandstyle/2017/aug/ 27/the-bald-truth-about-shaving-off-pubic-hair (accessed 3 September 2017); Beverley Turner, ‘Pubic Hair Is Back Ladies …’, The Telegraph, 15 November 2013, http://www.telgraph.co.uk/women/womenslife/10452327/pubic-hair-s-back-laidies.-The-men-dont-care-and-thewomen-cant-be-bothered.html?fb (accessed 22 November 2013). 182. Viv Groskop, ‘The Muff March Against “Designer Vagina” Surgery’, The Guardian, 8 December 2011, https://www.theguardian.com/lif eandstyle/the-womens-blog-with-jane-martinson/2011/dec/08/muffmarch-designer-vagina-surgery (accessed 14 April 2018).

CHAPTER 6

Our Rounded Bits …

She’s a tall woman bottom baring narrow flanks and hips She’s a thin woman hips - good flat yet rounded btm She’s a middling woman flat hips, haunches, hamstrings, buttocks flaring She’s a tiny woman great big bum She’s a short woman yet, oh, her hips her childbearing - oh, her hips childbearing She’s a small woman and no bottom none no bottom © The Author(s) 2020 J. A. Scutt, Beauty, Women’s Bodies and the Law, https://doi.org/10.1007/978-3-030-27998-1_6

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none at all She’s a fat woman, hidden hips wearing stripes vertical strictly strictly never horizontal magazines tell her so She’s a fat woman inside fun and flab and fifteen pounds adipose plain simple fat inside yet dieted into scrawny woman She’s a scrawny woman now lamenting loss of adipose seriously She’s a scrawny woman in the surgery seeking liposuction fat back And back it comes So plastic woman art thou satisfied happy Now?

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Rounding Up vs Rounding Down

Australian artist, etcher, sculptor, writer, editorial cartoonist and amateur boxer Norman Lindsay (22 February 1879–21 November 1969) and Peter Paul Rubens (28 June 1577–30 May 1640), recognised as the most influential artist of Flemish baroque tradition, specialised in the fullfigured model as subjects.1 Worlds and centuries apart, they each thereby won international acclaim. History is not so clear as to any consistency

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in this adulation of the fuller-figured woman—whether as muse or in the ordinary, everyday world. WC Fields is reputed to have called Mae West ‘an overfed python’ and ‘a plumber’s idea of Cleopatra’.2 Yet she stood up for curviness and statuesquely rounded bodies, as she possessed one. This was at a time women were required to follow the then popular physique exhibited by Ida Lupino, Constance Cumming, Alice Faye, Joan Blondell, Fay Wray and their cinema screen competitors and imitators in the 1930s, then Greta Garbo, Joan Crawford, Bette Davis, Katherine Hepburn and more in the following decade. ‘Round’ was out. Slim, or thin and even wiry dominated Hollywood. Yet for all this, West declared: ‘A curve is the loveliest distance between two points’,3 determinedly exhibiting hers to contradict the stereotype. Decades later Germaine Greer in The Female Eunuch refers to curves, too.4 Greer observes that the man demonstrating his appreciation of an attractive woman does so in mime, ‘undulating his two hands in the air and leering expressively’.5 This, she adds, conjures up the vision of a woman—a male-defined desirable one—being ‘all boobs and bulges’, narrowed waist lying between the most prominent swellings, breasts and hips. Speaking historically and from a 1970s perspective, she confirms the bosom is ‘the most highly prized curve of all’.6 Yet simultaneously, for a woman this part of her anatomy is a burden. Men do not see beyond it to the real woman affixed and, once the breasts are aged and droopy, stretched, wizened, withered or darkened, the woman joins the ranks of her sisters who never did possess the desired dimensions of this feature to be admired and cossetted, as though owned by her partner, husband or male companion of the day. As for the buttocks, fetishism attached to this part of a woman’s anatomy ‘is comparatively rare in our culture’ Greer goes on to note, though reflecting that this has not always been so. She cites HH Ploss and M. and P. Bartels in Woman, published in London in 1935. Extolling the adipose layer that ‘may be considered a most important secondary sexual character in women’, Ploss and Bartels decry ‘angular and flat surfaces’ in a woman as ‘something alien and repellent’.7 Such abundance was not de rigueur forty years later, when Jean Shrimpton and Twiggy graced the modelling stage as mannequins whose thin (and for Twiggy almost stick-like) bodies were to be emulated and admired. Cultural stereotyping might decree that for the working class, ‘curve’ would remain alluring to men, at least. The concomitant of this was that the ‘fashionable’ middle class sought slender and slim, a body

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shape to which all women might aspire, whatever their class or class origins. Yet the pressure on women to conform to an ideal, this time thin (and sometimes a little curve will do), in Germaine Greer’s words causes ‘the thinnest women [to] diet because of an imagined grossness somewhere’.8 Alternatively, women agonise over the curvaceousness of their silhouette, fretting at their curves bouncing beneath a tee-shirt, or nibbling on dry toast to lose them. Thus it is that curvy girls fight genetics and appetite, persuaded that their bodies, wrong as they are, must be righted. Meanwhile, fighting genetics and perceived lack of appetite, thin girls strive to be a little curvy, on the assumption that this is how their bodies should be. The curvaceous versus slender, fat versus thin, obese versus skinny debate continues in the twenty-first century. Alongside books and magazine articles, websites and online advice from slimming clinics, beauty salons, spas and medical partnerships extolling the means for fat to become slim or skinny to become rounded are the blogs and books and texts declaring that fat is beautiful. Less often does one come across declarations that skinny is okay, although sometimes it surfaces. In extolling its virtues, some websites egregiously promote anorexia and bulimia.9 In Things No One Will Tell FAT Girls ,10 subtitled ‘A Handbook for Unapologetic Living’, Jes Baker writes that despite her being ‘intelligent, snarky, kind, radical, compassionate, self-starting, outgoing, funny, opinionated, cheerful, loud, and a million other things’, what she is mostly judged upon is that she is ‘pretty damn fat’.11 Friends, acquaintances or strangers might tell her to employ euphemisms such as ‘just chubby’, ‘fluffy’, ‘curvy’, ‘chunky’ or ‘plus-size’ but, she says, she will resist: ‘Naw girl, I’m Fat’. Not ‘inherently bad’, ‘fat’ should be used so as to recover it as an adjective, a ‘benign descriptor of size’.12 Her aim, and that of her book, is to overcome a learned aversion to fat. Fat should disappear neither as a word nor a condition. What does need to go is fat hatred. Jes Baker recognises, however, that it is not only ‘fat’ that is targeted. Bullying in the form of derogatory words and advice as to how to achieve a good body, a proper body, a real body—even a ‘natural’ body—is aimed at thin women, too. Instructions include ‘eat a sandwich’, ‘must be nice to be so thin’ (often said with a scornful sneer, upraised eyebrows, or sometimes with an insulting gesture), ‘do you have an eating disorder’ (with offensive tone or, perhaps worse, a patronising expression of feigned concern), ‘you’d look so much better if you’d just put some meat on your bones’, ‘how can you be insecure when you’re so small’, ‘you’re

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so skinny, I hate you’, ‘“real” women have curves’, ‘of course you’re cold, you have no fat on you’, or (whether or not designed to make the woman on the receiving end feel guilty, unworthy or unattractive) ‘I wish I had your problem’.13 She acknowledges the learning that is inculcated into women’s psyche and understanding, the ‘self-hate, indoctrination, and brainwashing’ that women receive throughout their lives, aimed at their bodies and hence at themselves. She does not suggest the surgeon’s scalpel, the laser machine or liposuction. This cultural programming, she avers, needs to be replaced with ‘body love’.14 Jes Baker does not suggest this is easy. Nor does Sonya Renee Taylor who advocates ‘The Power of Radical Self-Love’ in her book, The Body Is Not an Apology.15 Body shape propaganda from birth to the grave is powerful. Taylor expresses it as living in a world ‘constructed of body shame and body terrorism’, where ‘the journey to self-love will at times be a daunting one’.16 Yet does this mean that women who do take what on its surface may appear to be the easy route of gaining slimness or curves do so because, rather than making their own independent decisions, they are slaves to social and cultural demands? Are women seeking surgical or non-surgical means of fat reduction or curve enhancement dupes of the system? Or do women take the cosmetic, aesthetic or plastic surgery or non-surgical path to relieve themselves of adipose tissue, or to gain or regain it, as active agents in total control? ‘Agency’ and ‘choice’ are contested rhetoric in the struggle for women’s autonomy and against patriarchal oppression. In 1990, in The Beauty Myth—How Images of Beauty Are Used Against Women, Naomi Wolf concluded that the question was not whether or not women strive to gain or lose weight, or do so, but ‘lack of choice’.17 Women made legal and economic advances through the 1960s, 1970s and 1980s into the professions and world of non-traditional work and culture. By the 1990s, however, this had generated a corresponding demand for women’s conformity to ‘standard’ female or feminine norms. During the decade of the 1980s, said Wolf, ‘… the more strictly and heavily and cruelly images of female beauty have come to weigh upon us …’.18 In this, she identified a consequential exponential rise in eating disorders, whilst cosmetic surgery was ‘the fastest-growing specialty’. Alongside this, pornography ‘became the main media category’ outpacing joint growth of mainstream films and records and threatening to become mainstream itself. She cited research which found ‘thirty-three thousand American women’ telling researchers that they ‘would rather lose ten to fifteen pounds than achieve

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any other goal’. In this, Naomi Wolf juxtaposed women’s position at the end of the twentieth century unfavourably as against ‘unliberated grandmothers’ of decades earlier. In 1960, Ethel Kirsop left her post of 25 years to return to the competitive world of job applications and interviews once more. Secretary to the ‘top’ man in the organisation, who retired, she became secretary to his successor, a man whom she had ‘loathed for 20 years’. During the six months of working for him, she taught him all she knew about the business. Holding the position she did, this meant she imparted to her new boss substantive and comprehensive knowledge, a boon to him as the incoming manager although he never would have acknowledged it. Upon resigning, she had to compete with a younger cohort in the job market. She was 54 years old. ‘Fortunately for me’, she says: I did not look that age. I put my age back 10 years, a sensible move. It meant I had no memory lapses about dates: instead of saying you were born in 1904, you simply moved everything forward 10 years to say you were born in 1914. Ten is a good, round number.19

Reflecting on this juggling of age, Ethel Kirsop’s words are telling. ‘When I hear people remark, with a curl of the lip, about women’s “vanity” in reducing their age’, she adds, ‘I recommend they try to get a job at 45 or 55. They will soon discover a need to lower their age. Vanity runs a poor second to necessity’.20 This taps into Naomi Wolf’s exposition, although Wolf names it the ‘professional beauty qualification’, with a more and more common solution being changing one’s body, not recording a deceptive year of birth or lowering one’s age.21 Her thesis is that economic value and professional status ‘peak early’ for women—contiguous with youth and beauty. Despite opportunities provided newly to women in the early 1970s, which might be assumed to lead to their taking senior management and other top-level roles in business and the professions, this has not occurred. Citing figures from management, law and academe, Wolf concludes that the glass ceiling ‘works to the advantage of the traditional elite’, namely men, and its ‘good working order is reinforced by the beauty myth.22 Only one to two per cent of upper management are women; only five per cent of partners in law firms are women, despite half the law school graduates and 30 per cent of associates in private firms being female; and women fill only five per cent of full professorships at the top universities.

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This presents a challenge to every woman embarked on what she believed was a trajectory towards senior career success. Naomi Wolf explains that having made advances within their profession, ‘older American women … are being forced to see the signs of age (the adjunct of male advancement) as a “need” for plastic surgery’. Whilst their male peers see ‘old, successful men who look their age’ in the generation above them, women lack any such role models.23 Women, she says, will turn to cosmetic surgery in recognition of an obligation not personal, but professional. This accompanies their commitment to remaining on their career path and advancing into senior positions that should rightly be theirs. Age for men carries authority. Greying sideboards enter a man into the realms of the distinguished chief executive officer and statesman. Men continue to look their age and be successful, growing older and more powerful despite it or, more likely, because of it. Not so for women competing against their male counterparts. Thus, it is Wolf’s thesis that in order to stay in the game women will be forced to conform to the younger beauty myth model. Yet ten years into the twenty-first century, Kat Banyard in The Equality Illusion contests this. Focusing on body changing or conformity practices such as dieting, she asks if these conceal the question whether women would take this route if ‘true gender equality were achieved’.24 She refers to a discussion with three fifteen-year-old young women who emphasised the importance of going to school ‘looking good’.25 One says: ‘If you’re slim and pretty it transforms your life …’ Another chimes in: ‘I don’t like my hips’.26 Seven years later, in ‘My body shape may be in fashion …’, Charlie Brinkhurst-Cuff reflects upon a scene in the film Bridget Jones’ Diary where, playing the main character Bridget, Renee Zellweger slides down the fire station pole that takes firefighters to the fire engines below.27 Aided by dialogue, the image is projected to create the illusion that Bridget has a problem of ‘too large a bottom’. This is ridiculous, even taking into account that the star apparently distorted her bodily appearance by following a weight-increasing diet to make her perceived outline conform to the character’s never-ending though unsuccessful search for the perfect (that is, thin) body. The film Bridget is neither obese nor overweight. Her body shape, contours, bearing, deportment and weight are replicated all over the country, indeed all over the world, wherever women of her particular genetic make-up exist, with similar food and nourishment as standard fare. Yet so many women adopt that oh,

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too familiar phrase when dressing, whether in bathing costume, shorts, jeans, pants, culottes, jumpsuit, bodysuit, skirt, frock, dress—long, short, mini-length, calf length or floor length, on-shoulder, off-shoulder, coldshoulder, strapless, Bardot style, denim, cotton, lace, satin, silk … as Charlie Brinkhurst-Cuff declares: ‘Does my bum look big in this?’28 However, since 2001 and Bridget Jones in the cinema, as BrinkhurstCuff confirms, the fashion has switched: ‘Big bums are what all the gymbunny bloggers are working towards with their “gains”’. This change in fashion from ‘skinny, flat-chested women, all the rage during the “heroin chic” era of the 90s’, to the ‘curvy black woman’ of 2017 resulted in Kim Kardashian’s posterior ‘popularising the aesthetic trait of black women’.29 This in turn led Charlie Brinkhurst-Cuff to ‘become more accepting of [her own] body shape’. Part of the reason, she observes, is because this structure or silhouette has gained a cachet of social desirability. Renouncing the habit that informed her dressing for the eight years immediately past, Brinkhurst-Cuff went from a ‘painstaking attempt’ to conceal her ‘large bum in oversized skater skirts to proudly celebrating a good big booty twerk’.30 Certainly, this change is good for the women whose body shape it valorises, as for them the figure is truly natural, or real. Yet Charlie Brinkhurst-Cuff is not naïve. Her body shape ‘may be in fashion just now’, she says, but the question is, ‘for how long?’ And for those whose bodies do not conform to this newly minted fashion, the question is whether to ignore the pressures of popular media, online blogs, advertising ploys of salons and clinics, and decide determinedly to ‘love’ a’la Jes Baker and Sonya Renee Taylor the body shape one has.31 Or is the answer to slide onto the slippery slope of performing plastic body modification at the hands of an aesthetic or cosmetic surgeon. In 2013, the American Society of Plastic Surgery reported a 16 per cent growth in Brazilian butt lift procedures.32 In 2012, only 19 per cent of plastic surgeons were doing ‘butt’ augmentations. In 2013 the number had risen to 30 per cent. A New York board-certified plastic surgeon was reported as being amazed at the numbers, concluding: ‘It’s with J.Lo, and Beyoncé, and everyone else having a great derriere … I think people [sic] see that and want to mirror image it’.33 A curvy black profile demonstrably in vogue, women sought out large buttocks, resorting to surgery to get one. This brought with it a surge in medical negligence claims, a significant number spawned by the death of patients on the operating table or shortly thereafter.34

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The Bottom as Bustle …

Charlie Brinkhurst-Cuff emphasises that she, ‘like most feminists’, does not believe that body parts ‘should be seen as fashionable or unfashionable commodities’. Critical of cultural appropriation that notoriously includes song, music and dance,35 she adds bodily features and physical and physiological configuration.36 Appropriation of particular body types or features, often once despised through notions of cultural or social superiority, has happened not only with rear ends or buttocks. In 2015 The Guardian asked whether the ‘new bushy brow’ displayed by some celebrities and models, was being taken over by ‘big lips’ created through the injection of Botox and fillers.37 Preceding this, Vogue pronounced in 2014 that ‘big bums were back in fashion’.38 These trends BrinkhurstCuff links to ‘black people’s bodies’. Fashion items artificially produced for some women they may be to some, yet they are a natural feature of many African women or those having their ancestral origins in Africa.39 Today’s hankering after a ‘Brazilian butt’ may be attributed to copying this feature. Yet rather than linking it with its predominantly African source, universally Kim Kardashian and Jennifer Lopez are seen as leading the ‘trend’. This replicates the far earlier appropriation of hefty haunches, imitated by Western women and having its roots in slavery. However uncomfortable the nineteenth-century bustle, its prominent place in the fashion panoply meant that today’s Brazilian butt could be secured by women with far less pain. The bustle came about through developments in clothing styles. The French tournure created a fashionable rounded look for the fashionable woman who sought to project this rear end feature. Deriving from the Latin tornatura or tornatus, the word tournure originated immediately from the French word for turning.40 The English version of the tournure was the bustle. Coming into its own in the 1870s, the bustle had several revivals. Its antecedents lay in various paddings and pillows, linings and waddings strapped on to women’s bodies and concealed under their skirts, or built into the skirts themselves so that as the woman or her maid—sometimes maids—fitted the clothing over her head or around her body, the stuffing came with it. A fashion statement was created by the crinoline, designed to round out the woman’s body. A wire bell-shape under her skirts made her waist appear small, giving a roundness to her hips. Stays and corsets catered to this desire for the rounded look, too, these body shaping garments of fortified elastic sometimes strengthened by bone ribs sewn into columns

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of reinforced material. The buttressed raiment helped to emphasise the waist, the bosom bulging over the top and hips and rear ends puffing prominently below.41 Such foundation garments were known from the sixteenth century by various labels including ‘cork rumps’, ‘bearers’ and ‘bum rolls’.42 As the hooped skirt or crinoline went out of fashion, dresses began to be bunched at the back. The material that had covered the enlarged wired hoop beneath the dress, stayed attached at the waist. The material that previously had stretched evenly around the woman’s body now became a feature from the rear. Decorations of frills, ribbons and bows depended upon the fashion trend of the day. A crinolette provided support, so that rather than drooping against the woman’s own buttocks, the fabric stood out in an elegant curve falling rounded from her waist.43 The framework of the early bustle was slightly curved to encircle the body, though the rear was fuller. This gave the frock a rear roundedness. Gradually, the hoop’s circumference altered, so that it was effectively a half-frame, the prominent part now located at the posterior. Dating from 1869 to 1876, the bustle comprised a short overskirt covering the frame and a longer skirt falling beneath to the ground.44 Some bustles were plumped by horsehair, originally an addition to the crinoline. Some were puffed up with paper, The Times being a popular source.45 With passing time, they became more and more exaggerated, appearing as a shelf jutting from the woman’s waist and holding the skirt out from her body like a ledge or mantel. This style featured with the second coming of the bustle, in the 1880s. A trail of fabric swooped down from the waist, over the projection, to fall in the lustrous folds of a train following her in her stately progression of house visits. Mesh bustles and braided wire bustles were popular. Bodices became more structured and tailored so as to set off the bustle with greater emphasis.46 By the mid-1880s, the bustle had developed to accommodate the woman who wished to sit as well as walk and stand. The invention of a collapsible bustle meant the bustle adapted to the woman’s being seated, the wire frame collapsing as she sank to couch or cushions, then springing back as she stood.47 As the fashion receded, the bustle relaxed from the more extravagant shape, until by 1905 it had gone completely from the London, Washington and New York fashion scene.48 It cannot be coincidental that the bustle replicated the posterior look of many women who had been captured and enslaved from Africa, transported to Europe and the Americas. Charles Worth is accredited with

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having brought the bustle back into vogue in the 1880s.49 When running his fashion house together with his partner Otto Gustaf Bobergh at 7 rue de la Paix, the brain, skeleton and sexual organs of Sarah Baartman were on display in a Paris Museum. Baartman was the Khoikhoi woman brought to England from Africa as a slave. She was one of ‘at least two Khoikhoi women who, due to their large buttocks, were exhibited as freak show attractions in nineteenth century Europe’.50 Images appearing in magazines and on display whilst she lived and long after she died conspicuously featured her generous derrière. Today, there is little doubt that this attraction, intriguing the men who flocked to see her, impacted not only upon fashion, but on how Western women wanted to be seen. The buttocks displayed by the ‘Hottentot Venus’ as she was known were spectacular. The man who profited from showing her nationally and internationally had no doubt of her attraction. Other women with similar distribution of fatty tissue around their hips, thighs and bottoms were familiar as a part of the slave community, as were those who were freed and lived in Britain and the United States, France and elsewhere. Sarah Baartman’s influence was not quelled by her death at twenty-six in 1815. That her remains stayed on display for decades is a testament to the impact she had as a focus of intrigue and charm. Contentions that ‘Western’ ‘white’ women would not have sought to imitate their African ‘black’ sisters are remote from reality. Of course, African women were seen as ‘inferior’ due to their slave status and the racism and racial superiority afflicting the age. Yet this did not prevent ‘superior’ ‘white’ women handing over their children to African women who had been forcibly transported as slaves. Nor did it prevent them from using slaves as wet nurses to feed their precious ‘white’ children milk and to care for their everyday needs. It did not stand in their way when they wished to have servants dressing them daily, washing their clothes, sewing their underwear, struggling to tighten their stays to nip in their waists.51 Nor did it prevent them from seeing the attraction these women held for their fathers, husbands and sons. Numerous instances can be cited of ‘white’ men, many of considerable prestige and in positions of high authority, engaging in sexual relations with African women, the women their slaves and mistresses or victims and sometimes survivors of rape and other forms of sexual exploitation at the hands of these men. Thomas Jefferson is one of the more notorious, but any suggestion that his sexual exploitation of Sally Hemmings is an isolated episode in the history of slave-ridden America is simply unsustainable.52

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Baartman’s influence lives on. This is affirmed in the modern-day iterations of the ‘large buttocks’ as a feature a‘la Kardashian, Lopez and Nicky Minaj.53 Today’s appreciation of the larger bottom is viewed by African women and their descendants with some scorn, despondency, sadness and wry humour. Vogue’s ‘thumbs up’ for the ‘big bot’ is not met with acclaim. As Brogan Driscoll exclaims, ‘… a body part is not a passing trend’.54 Natasha Mwansa enjoins: ‘It seems [as if] a black woman’s body is only desirable … when a white woman is wearing it’. 55 Echoing these words, Pontsho Pilane’s ‘open letter’ to ‘Dear Vogue’ ended with a ‘Sigh’, saying how kind it was of the fashion bible to acknowledge ‘the big bums that our mothers, their mothers and ourselves have carried long before you ever turned this way’. Adding insult to injury, putting Vogue’s ‘stamp of approval on what has been there for centuries’ was accompanied by ‘attributing the trait’ mostly to white women.56 And so desirable is it, that women subject themselves to injections, implants or fat transfer to gain the very bottom Natasha Mwansa, Pontsho Pilane and Charlie Brinkhurst-Cuff possess naturally. Now, ‘as a curvy black woman’, Brinkhurst-Cuff experiences on the one hand ‘a sweet glimpse of how white people have felt for decades’ together with the question ‘how long will it last’.57 Yet white women who more rarely come by this shape without help, seek help with a vengeance, too often at great risk to themselves.

3

Bottoms, Hips, Thighs …

Surveying ‘treatments’ available for enlarging women’s bottoms, the reconstruction of the body seems limitless. Narrowing hips (even bone alteration wanted by some, though denied as dangerous to pelvic construction, protection of organs and even to perambulation or everyday walking), thinning ‘thunder’ thighs, and a striving for the desirability of a space between the top of the legs all come into play. Whilst some women are having their buttocks ‘shaved’ or lessened in size through liposuction, with the surplus being used to enlarge their breasts, others are having bottom implants or transferring surplus thigh into ‘too small’ bottoms. Where once the size of hips was seen as vital for childbearing, hips are now regarded as ‘good’ or ‘bad’ depending upon whether broad or narrow from an aesthetic perspective. The rounded bits prized by Marilyn Monroe and imitated by padding over the body and under the

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clothes are now hated or extolled, to be chopped or vacuumed from the torso, or replicated by padding over the bones and under the skin. Following up from their 2013 report, in 2014 the American Society of Plastic Surgeons (ASPS) statistics confirmed the trend. Plastic surgery on women’s bottoms was on the rise, with 10,000 buttock augmentations being performed in the United States.58 For 2018, the ASPS annual statistical report recorded buttock augmentation with fat grafting rising by 19 per cent from 2017, with 20,301 procedures conducted in 2017, rising to 24,099 a year on. Buttock implants had sunk by 28 per cent, from 1356 down to 946, with alternative procedures taking over. Buttock lifts showed a rise of 256 per cent from 1356 in 2000, to 4808 in 2017, plateauing at 4824 for 2018. The rise in buttock surgical intervention is apparent, with the inventiveness of procedures revealed in statistics over time. ‘Buttock lift’ was the only buttock augmentation procedure available, or at least taken up, in 2000: neither fat grafting augmentation nor implants were conducted by ASPS surgeons in that year. Of the 17.7 m operations in 2018 (up two per cent), the top five cosmetic surgical procedures, topping the 1.8m mark (up one per cent), comprised breast augmentation up four per cent, liposuction up five per cent, rhinoplasty and eyelid surgery down, respectively, two and one per cent, and the tummy tuck maintaining its previous figure of 130,081 procedures.59 Nonetheless, the ASPS reported that the ‘Brazilian butt lift was the hottest growing procedure’ for 2018, ‘fuelled by the millennials’, generally taken as those born between 1981 and 1996.60 In the United Kingdom, Harley Buttock, the Harley Street Clinic webpage devoted to the gluteus maximus and how to artificially enhance it, provides the three surgical procedures women seek to achieve the bottom beautiful. Buttock injections, the Brazilian butt lift and buttock implant procedures are described in uplifting terms.61 For women wanting to rid themselves of adipose tissue from one part of their bodies, whilst simultaneously seeking to add buttock contours, the Brazilian butt lift is projected as the answer. For those who through ageing, a naturally slender body, or previously having had fat removed without its reappearing, fat grafting or lipofilling may be recommended.62 The Brazilian butt lift commences with fat collection. This requires liposuction to remove adipose tissue from thighs, hips, flanks or stomach. The Harley Street Clinic method employs a ‘fine vibrating cannula’, this being ‘less invasive’, protecting living fat cells more effectively.63 The fat is transferred to the rump through Lipivage, ‘a closed system … which

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protects the fat from contamination and lowers damage to the fat cells to ensure better fat survival’. An incision is made on each side of the bottom with the fat injected into the muscle layers. They are ‘smoothed … so the fat cells gain a good blood supply’. This provides ‘the best chance for [the cells’] survival’. The aim is to ‘create a smooth, more rounded buttock’.64 This is done through a layering technique designed to ensure that there are no irregularities in the contours now taking hold of the buttocks, and to provide ‘a significant but natural increase’ in their volume. The amount of fat added to each side of the rear end is, on average, approximately 300–350 cc. This requires some 700 cc or above of adipose tissue taken from the target area, because impurities must be filtered before the fat is transferred into the body. By taking adipose tissue from thighs or abdomen, and from the upper and outer buttock areas if this is feasible, the goal is to ensure that the emerging shape has a lift or greater lift and is more rounded. The desired result is said to ‘look very natural’ because fat from the woman’s own body is used. As well as there being ‘little chance of infection or rejection’, the tissue assumes the characteristics of the woman’s buttocks. Employing blood growth factors and blood platelets can add to the operation’s success.65 Buttock implant surgery can be undertaken on its own, or together with fat transfer, so that it is a Brazilian butt lift—implant combination. Implants are said to ‘generally provide a larger increase’ in buttock size than for injections to the bottom or the Brazilian butt lift.66 Implants are also said to be superior to injections, for injections may require repeat surgery, whilst implants provide a more lasting result. The procedure optimally requires a hospital stay with home visit follow up for checks and changes to dressings. The implants comprise silicone, the size range being 200 ml (cc) to 560 ml (cc) for each implant—that is, for placement on each side of the buttocks. If the posterior has lost elasticity, is drooping or withered with age, sagging, flabby, baggy or flaccid, or is naturally flat, lacking in fat or deficient in contouring, soft silicone implants ‘can be designed to look and feel natural’.67 Results are dependent on factors relating specifically to the individual patient’s posterior and the area surrounding the gluteus maximus. Skin elasticity and condition are relevant factors when considering implant surgery to the rear end. Buttock injections are advertised as ‘buttock enlargement and reshaping’, the process ‘adding volume to the hips, and filling in hip dips’.68 If a woman wants a rounded body, particularly behind and even enhancing

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her hips, this is one way to achieve it. Nonetheless, as realistically follows for body enhancing procedures, it is unable to be guaranteed forever. Just as natural bodies change with time and age, there is little reason to suppose that unnatural bodies will fail to do so. No one, and no body, however much titillation, touching up or major surgery, can be immune to time. In any event, buttock injections are time-limited, requiring repeat visits. The procedure requires injections of hyaluronic acid or a collagen stimulator, such as are used on the face or other parts of the body where plumping is sought. Hyaluronic acid or hyaluronan, a substance existing naturally in the neural, epithelial and connective tissues of the body, brings about results said to be seen ‘immediately’ and with greater volume than collagen.69 Following sedation and using a cannula, the substance is injected deep into the flesh, a process said to ‘avoid lumpiness’. Although it may be different for different patients, generally the newly created contours can last from nine to eighteen months.70 Then, if the process has been to the patient’s liking, she may return for another bout. Even if it has not met with her appreciation, a woman may return to the same clinic and surgeon, or believing another practitioner may do a better job, may go elsewhere. A return could be indicated earlier, for ‘readjustment’. As for collagen stimulator buttock injections, these use a non-naturally occurring substance, a poly-l-lactic acid collagen under sedation. Four or six vial sessions are required, at some £440 or £425 for each vial treatment. Once results appear, calculated as ‘after six to eight weeks’ following the ‘multiple sessions’, the procedure has a longer lasting effect.71 A plumped rear end through this process can last for some two years. However, it cannot be readjusted. Generally, an unhappy woman will have to wait the passing of the two years before her bottom returns to normal—although the procedure itself may alter what is ‘normal’ when the plumping has gone. For the woman wishing to emulate the feature possessed by Kim Kardashian and frequently presented in ‘selfies’ or displayed in the television reality show in which she appears, Harley Street Clinic advises she ‘may be better off’ with a Brazilian butt lift or buttock implants. Buttock implants provide the greatest volume. Taking the injection route, a bottom requires ‘a very large amount of filler’, calculated at 1,000 ml +.72 Whatever the size, the risk of lumpiness is said to be ‘moderate’ with a potential for migration of the filler, particularly to the upper thighs.73 The risk means that a woman seeking enhancement of her bottom may end with enhanced thighs. This may or may not be to her liking, yet

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it is not what she bargained for. The consequence will be worse where filler migrates to one thigh and not the other. An asymmetrical shape above the knees and below the groin will not be what was brokered. However, if the practitioner has exercised skill at a surgically acceptable level, this addresses conclusively one aspect of a claim for compensation, in accordance with the rule of surgical proficiency rather than patient (dis)satisfaction. As to the other element applied in medical negligence, if the patient or client has been sufficiently notified of the risk and consented in the terms required by Montgomery v Lanarkshire Health Board,74 dissatisfaction will not result in a successful negligence claim. The incontrovertible message of Zahir v Vadodaria 75 is that the patient’s discontent or unhappiness with the result of body surgery proclaimed to be enhancing cannot generate compensation for negligence. That Mrs Zahir’s dissatisfaction was with her new nose and a woman finding fat shifted from buttocks to thighs—or thigh—is disappointed or displeased with that very different body part does not alter the principle. As with any surgery, risks apply, both general and particular. Operations and procedures requiring treatment under anaesthetic, particularly a general anaesthetic, places a particular burden upon any medical team. In complicated and risky surgery, this is all the more pronounced. Apart from the ‘ordinary’ risks associated with anaesthesia, if equipment is faulty or the anaesthetist becomes distracted or fails to act with due diligence as alleged in R v Adomako,76 not only civil but criminal action can ensue. This may result in a finding of guilt, but is of little benefit to the patient who has suffered serious consequences such as brain damage or death. For the United States, Tom Baker observes that litigation has resulted in the profession improving its practices to such a high standard that anaesthetists are generally the least likely to suffer allegations of incompetence or lack of professional skill.77 Yet this does not follow for those practising outside the United States and, in any event, undergoing anaesthetic for operations that are not required for body preserving health reasons would seem unwise. Atop the risks that accompany anaesthetic, as with all surgery or cosmetic procedures, ‘ordinary’ dangers of intervention in body construction exist. Yet beyond the general, whether relating to all surgery or cosmetic procedures, buttock operations are recognised as harbouring particular perils. Implants can shift in any implant procedure. Numbness and infection can set in. With transfer of fat from one part of the body to the other, fat cells can die if vascularization occurs. This is

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particularly applicable to buttock procedures. One clinic advises that as a consequence it is unwise to sit until some time has elapsed after the operation.78 Standing or leaning or adopting a lying position ‘for three weeks’ is recommended or, if sitting is urgent, resting on thighs, not buttocks.79 Yet the most risky surgery is the Brazilian butt lift, if reports and recently documented United Kingdom concerns are indicative of the potential dangers.80 Intelligence comes from Turkey, Brazil, the United States and Thailand. An inquest held at Wakefield Coroner’s Court, West Yorkshire, heard that ‘mum-of-three’ Leah Cambridge died as a result of surgical complications following a Brazilian butt lift carried out at a private hospital in Izmir, Turkey on 27 August 2018.81 It appears that Mrs Cambridge was having fat from her abdomen, about which she had ‘become paranoid … after having her children’, transferred to her buttocks. The hospital was reportedly a ‘celebrity favourite’ for the operation. Nonetheless, she reportedly suffered from ‘complications’ during surgery, including three heart attacks. The inquest was adjourned pending further enquiries.82 Earlier, in 2011, a young woman from Hackney, London reportedly died following ‘a buttock enhancing procedure’. Twenty-year-old Claudia Adeotimi died after the operation was carried out ‘at an American hotel’.83 Joy Williams, another British woman, died in Bangkok, Thailand, following ‘buttock augmentation surgery’. Twenty-four-years of age, her wounds apparently became infected, and she died under anaesthetic.84 An October 2018 report indicated that another British woman had died ‘after Brazilian Butt lift surgery’, with an inquest into the unnamed woman, in her twenties, to be held within twelve months.85 As for Brazil, so well known for its plastic and cosmetic surgery procedures and renowned in the world of celebrities for its body shaping and reshaping skills, in July 2018 the arrest was announced of ‘Dr Bumbum’ or ‘Dr Butt’. These nicknames were given to Dr Furtado in light of his specialisation in this procedure. He was described as earning the appellations as a plastic surgeon ‘known … for his bum-enhancing surgeries’.86 Dr Furtado’s patient, Lilian Calixto, reportedly a 46-year-old bank manager, ‘died at a hospital where Dr Furtado had taken her after a procedure’. In her case, it was silicone injected into the buttocks, and she was admitted to hospital suffering from tachycardia or an abnormally fast heart rate. His lawyer denying liability, Dr Furtado declared he had ‘performed 9000 such procedures’ and had ‘a massive following on social media, including 645,000 Instagram followers’. The death he said was a

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‘fatal accident’.87 Photos of his ‘before’ and ‘after’ successes were widely available on his social media sites. The seriousness of these media reports is confirmed by the British Association of Aesthetic Plastic Surgeons (BAAPS). Following hard on accounts of a British woman’s dying overseas after a Brazilian butt lift operation, a BAAPS report warned that ‘as many as 1 in 3000 people undergoing the risky procedure die worldwide’.88 Procedures abroad might be less expensive but are said to be more dangerous, with the Brazilian butt lift having ‘the highest death rate of all procedures’.89 Injecting fat into large veins in the buttocks risks fat travelling into the heart, lungs or brain. Stories from women suffering from complications, inadequate surgery, or direct consequences arising through the procedure itself appear in the BAAPS report.90 One woman undergoing the procedure in Turkey is reported as having found ‘infected holes’ surfacing on her posterior. This left her with ‘soaking clothes’ and an unpalatable odour experienced over three months of leaking buttocks. The problem required daily bandaging and she ‘couldn’t walk properly for ages’. Yet the advent of the holes had the advantage of enabling the fat to leak out, making it ‘possible to walk again’. Originally content with her natural body, she rued having spent ‘a stupid amount of money’ to end up damaged and in pain. Another woman reported experiencing ‘a really high fever’. With no response from the medical team in Turkey, she took a month away from work to seek treatment in a National Health Service (NHS) hospital. Two years on, she reports continuing to suffer.91 The risk of being threatened or sued for libel if speaking out on social media faces women wishing to complain or warn others. Meanwhile according to the BAAPS report an increasing number of legal enquiries— from treatments in Turkey, Spain, Hungry and Belgium—are being made to solicitors specialising in cosmetic surgery claims. Skin grafts, time off work, and psychological pain are common complaints, as well as women complaining of adipose tissue transfer—confirming the recognised risk of fat wandering from bottom to thigh.92 Whilst noting the risk of fat drifting down into the upper legs, itinerant fat can be even more dangerous. Consultant Plastic Surgeon and BAAPS member, Bryan Mayou, draws attention to this in his advice provided to the BAAPS, which led to BAAPS advising in turn against going overseas.93 Mr Mayou describes the Brazilian butt lift as using the surgical technique to ‘recontour the lower back and loins with liposuction, reinjecting the unwanted fat to augment the upper buttocks’ so as to create

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‘a pert lifted effect’. He goes on to observe that if the fat is injected ‘deep into muscle tissue’ and ‘lower down on the buttocks’ the risk is that fat will be injected incorrectly into the large veins.94 Many large veins exist in the buttock area, heightening this risk and, forming an embolus, the fat ‘can pass around the blood stream, into the lungs’, causing death. Mr Mayou explains that fat grafting ‘is an established technique’ which surgeons in various countries use for ‘reconstructive and aesthetic problems’. A lack of training in these techniques is an especial problem, he advises, for ‘many of those offering the procedure’ designed to perfect the Brazilian butt lift. A mortality ‘of 1 in 3000 following’ this operation, mostly due to fat emboli, has been discovered through the work of a task force established by plastic surgeons working internationally.95 BAAPS recommended ‘that all surgeons refrain from performing these procedures until … more proven data’ is available’.96 The president of BAAPS, Simon Withey, raises the issue that often vulnerable patients are targeted by overseas clinics.97 Mr Mayou echoes this concern, concluding that with the procedure being ‘promoted by celebrities’ through social media, dangers arise in particular for ‘young and vulnerable people’ targeted by the sites and the marketing.98 This raises questions of potentially predatory conduct on the part of some working in the field, particularly if they lack the requisite training. It raises the questionable nature of the consent of young, impressionable and vulnerable people, and possible body dysmorphia (BDD). Consent can be problematic if patients and clients, or prospective patients and clients, are immature or youthful, and susceptible. In the United Kingdom, the Family Law Reform Act 1969 provides that a child aged 16 or 17 years can consent to ‘treatment’. Their consent is to be taken in the same way an adult’s consent would be. That is, with confidentiality applying between doctor and patient, for example, and full disclosure of risks and dangers in accordance with the principles set down in Montgomery v Lanarkshire Health Board.99 Whether this consent provision, relating as it does to ‘treatment’, can apply to cosmetic surgery is in issue. Carrying out surgery for repair or reconstruction following disease, damage or congenital issues such as a harelip may be distinguished as coming into the scope of consent to ‘treatment’.100 However, academics working in the field of medical law and ethics question whether the consent of a child or young person of 16 or 17 years to cosmetic, aesthetic or plastic surgery in the designer or bodily enhancement category would be considered as consent to ‘treatment’.101 This brings into play the question of competency to

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consent to, say, cosmetic surgery when the person is 16 or 17 years, in accordance with the principle established in Gillick v West Norfolk Area Health Authority.102 In addressing the capacity to consent in this circumstance of aesthetic, cosmetic or plastic surgery, the practitioner must raise matters pertaining to surgery or procedures generally, as well as those specifically relating to the particular procedure or surgical operation itself. Whether the child or young person understands the nature and implications of the surgery or procedure, including the likely effects and potential side effects, is an essential element. So is the question, generated by issues in human development and psychology, whether the child or young person can retain the information about the nature and implications sufficiently long for the decision-making process to take place. What requires consideration is whether the child or young person is of sufficient maturity and intellectual development to weigh up the information and arrive at a decision not only as to surgical procedures, but as to the risks and consequences of operations such as the Brazilian butt lift.103 Research involving young people confirms the enormous influence of social media and the pressures of conforming to particular body image requirements. Kat Banyard’s discussion with 15-year-olds as described in The Equality Illusion is indicative of many young women’s responses today.104 Jes Baker’s Things No One Will Tell FAT Girls effectively backs this up,105 and their findings are replicated in formal studies.106 Developmental psychology confirms that the capacity of human beings to make choices, and indeed to understand the concept of choice, develops over time.107 This needs to be borne in mind when practitioners comply with consent requirements. Should a young person of 16 or 17 undergo cosmetic, aesthetic or plastic surgery of enhancement, beautification or by reason of notions as to ‘what a body should be’ or ‘look like’ then courts will likely be wary about imposing a legal standard of consent applicable to adults. A parent or guardian can consent to an operation being carried out on their child or the child in their care. However, in this type of surgical intervention—aesthetic, cosmetic or plastic surgery—practitioners should remain mindful of the pitfalls surrounding consent and the potential for legal action. The child’s ‘best interests’ is the standard applied to medical treatment. It may be questionable that cosmetic, aesthetic or plastic surgery comes within that stricture. If a young person is accompanied by a parent, the practitioner should be aware that parental pressure may be present. Young women are susceptible to demands that they conform to

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a sometimes impossible standard of shape, weight and appearance. Sometimes parents impose such standards. In Re T (Adult)108 the Court of Appeal accepted evidence that a 20-year-old woman had been pressured by her mother into refusing a blood transfusion. The court ordered that the blood transfusion go ahead against her wishes (her refusal), which the court considered had resulted from her mother’s intervention. This principle would work the other way, meaning that practitioners need to be wary of the possibility that a young person could be pressured into undergoing a procedure by a parent determined to impose a particular body image upon her. Courts may also be wary as to the standard of consent for adults where an operation is recognised as being so dangerous that a professional association representing practitioners working in the area suggests they should refrain from providing it. In addition to consent, this may raise questions as to surgical precision in determining to do an operation or not. Will a skilled surgeon carry out such an operation, being aware of the enormity of the risks? The Court of Appeal in R (On the Application of Oliver Leslie Burke) v General Medical Council and Ors 109 addressed the ‘best interests of the patient’ test. Some discussion centred around whether ‘best interests’ is to be determined from a clinical perspective, or whether it ‘involves a welfare appraisal in the widest sense, taking into account where appropriate a wide range of ethical, social, moral, emotional and welfare considerations’.110 This broad interpretation was rejected on the facts at hand. However, the court made clear that it would be important to view the particular case, and what it involved, rather than adopting an inflexible approach. The concept of ‘best interests’, said the court, ‘depends very much on the context in which it is used …’, and an objective test should be applied. The conundrum has arisen where the wishes of a patient can conflict with the clinical view of ‘best interests’, as was so in Airedale NHS Trust v Bland.111 In such a case, courts have determined that despite the fact that a patient might die through refusing treatment, patient autonomy cannot be overridden. This follows where, say, the particular circumstance of the patient is that she or he devoutly believes in a religion that eschews blood transfusions. If the patient, with no pressure (unlike Re T (Adult)112 decides against a blood transfusion which doctors believe on clinical grounds is essential to save the patient’s life, the court honours the patient’s decision. Would that apply where the patient wishes to have surgery as dangerous as the Brazilian butt lift? That is, would a court

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say that the patient’s wish to undergo the operation, though seriously hazardous, should be honoured? The Court of Appeal in Oliver Leslie Burke acknowledged that the phrase ‘best interests’ is of best use ‘when considering the duty owed to a patient who is not competent’ and is easiest to apply when confined to a situation where the relevant interests are medical.113 Practitioners in the beauty industry, medically trained or trained as beauticians or with similar qualifications, need to bear this in mind. Is this ‘medical treatment’? What are ‘best interests’ objectively in this circumstance, where the client wants a procedure that is perilously unsafe? For prospective patients or clients, the expression of medical and safety concerns on the part of professionals should trigger warning bells. But will the significant caution expressed by the professional body BAAPS be taken into account? Even if one is committed to the notion that women ‘should be allowed to do what they wish with their bodies’,114 a note of restraint is surely apposite. This is especially so where young women, still classed as children through being of minority age, are the patients or clients. As every part of human bodies becomes more and more seen, at least by some, as a pallet to be worked on, this issue becomes urgent. Surely in these circumstances it is essential to question the argument that women are exercising unlimited agency, or the right to be ‘normal’ or ‘more natural than nature made me’ and so consent fully, freely and wholly aware. It is not casting aside or ignoring women’s autonomy to investigate the validity of consent where powerful pressures underpin decisions to undergo body changing procedures which are not required for health reasons. The Brazilian butt lift raises the issue graphically, because of the high risk of death. However, the upper part of the torso raises issues that may be serious, too.

4

Exposing My Midriff or Where Are My Abs?

Men exercise to tighten up and flatten their abdominal muscles, seeking the holy grail of the perfect ‘six-pack’. Some women do seek to emulate this by striving after well-defined abdominal muscles. The internet is replete with images of the ‘ten sexiest female body builders’ or ‘famous women body builders’, with blogs extolling their professionalism and commitment, and competitions featuring women with strictly defined upper bodies—along with muscular legs and arms conforming to the body builder stereotype.115

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For the woman who does hanker after a tidy six-pack arrangement beneath the bosom, although expensive in outlay and carrying all the risks accompanying surgery, it can be done. Abdominal etching or abdominal implants are available. Usually chosen by men rather than women, etching is effected by liposuction. Excess fat is sucked away, possibly to be transposed elsewhere. The surgeon then creates the appearance of ‘toned abs’ by etching grooves in the remaining layers of fat. The etched grooves are designed to give the impression that they are the real thing.116 If a potentially more lasting, though more burdensome for the body alternative is sought, this requires more radical surgery. Abdominal implants require a cut at the navel. Through this aperture the surgeon inserts individual implants on either side of the ribcage, six or eight for a man and a smaller size, more likely no more than six, for a woman.117 This may be accompanied by a tummy tuck. As always, operations involve risk. Anaesthetic is required, generating the potential for side effects or more serious consequences, as with the risk of infection.118 Side effects include swelling, bruising and aches or pain, the best outcome being that they are temporary. Inevitably, exercise and the ubiquitous diet referred to in most discussion about surgery removing adipose tissue must follow. These are essential to retain the ‘six-pack’ illusion. However, those having undergone these operations, as with all cosmetic, aesthetic and plastic surgery, must be wary of beginning any exercise regime too early. Being orientated towards performance in sporting events and body display, women who undergo abdominal implant operations are susceptible to over anticipating their capacity for a full-scale return to the sports and presentation arena. This can create difficulties with medical negligence claims if something goes wrong with the procedure. The Karen Turner v Mr Nigel Carver 119 case is relevant here, for it touches specifically upon this aspect. As noted, Ms Turner sued for medical negligence when she was dissatisfied with the outcome of the cosmetic surgery carried out by Mr Carver, the surgeon. However, not only was she unhappy about her appearance, she suffered a haematoma after undergoing liposuction. This is a not uncommon risk of liposuction and can occur with implants. Her claim for negligence was met with a counterclaim for contributory negligence. As the medical negligence claim did not succeed, the contributory negligence counterclaim was moot. However, the potential for a counterclaim in contributory negligence must be borne in mind. The case

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establishes that courts will accept the possibility of contributory negligence in claims involving cosmetic, aesthetic or plastic surgery undertaken for body enhancing or beautifying reasons. It sends a warning to patients or clients that they must follow advice given for aftercare. The evidence in the Karen Turner case was that she was informed by Mr Carver of the risks relating to the surgery. Her consent was accepted by the court as being given according to the Montgomery standard.120 It was in relation to the haematoma that the contributory negligence claim arose. When the haematoma developed, it required emergency drainage. The argument for contributory negligence lay in the instructions Ms Turner had received as to the regime she should follow after the operation. She was advised that she should not engage in strenuous exercise for some time after the operation. Contrary to this advice, she began attending her gym soon after. This was argued by defence lawyers as at least partly responsible for the haematoma. Had the claim of medical negligence succeeded, Ms Turner would have been held 2/3rds responsible for the damage she suffered. That is, effectively there was a 2/3rds chance that the haematoma would not have developed, had she foregone her visits to the gym. Had she succeeded in her initial claim for negligence, Ms Turner would have lost 66 per cent of any compensation or damages awarded, by reason of her own actions.121 Women who do seek abdominal implants or etching to emulate the body builders whose images appear on websites may be more prone to exhibiting their bodies in situations that require exercise or gym work. They should be mindful of the warnings given not to engage in strenuous activity within a certain period after the operation. Otherwise, if they do have a genuine medical negligence claim they run the risk, as did Ms Turner, of having their compensation cut. As it happens, generally women do not strive after the well-defined abdominal muscles men desire. Nevertheless, women are enjoined to pay equal attention to their midriff’s potential for unwelcome adipose. If they do not prevent its arrival, the message is clear: women must take action to rid themselves of the ‘spare tyre’ or ‘doughnut’ that settles around their six-pack region.122 If a woman wants the midriff tightened without the etching or the implants, some websites advocate exercise aimed at women who have passed through menopause. The express implication is clear. Popular feature articles reveal that after menopause, adipose tissue developing on the midriff brings with it serious health risks, including a higher risk of

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heart disease, diabetes and cancer.123 However, the existence or dreaded prospect of unsightly adipose tissue in the abdomen area above the waist leads to women of any age being advised on what to do about it. Ridding oneself of this layer of fat will enable bodily exposure in figure-hugging tops, tank tops, camisole or cami tops and vests, low-slung jeans, bikinis and other revealing swimwear. If a woman declines to reveal her naked midriff skin, she is urged to ensure that whatever is there, even when covered by less skimpy clothing, is trim, taut and tidy. Such advice can lead to eating disorders and radical exercise,124 as well as liposuction and the urge to transfer fat ‘from here to there’ if it is not discarded altogether. Kimberly Caines’ 25 Minute Body Contouring Programme is designed to help here, just as it is proposed to do so for the flabby abdomen and thighs.125 The desirable ‘curvy body’, with bust and hips in proportion and the waist positioned narrowly between, is the aimed at outcome. Body contouring aspires to create or recreate that ‘hourglass figure’ sought after by some, surging and waning in popularity but never disappearing from traditional accounts of what is attractive in a woman. Caines’ programme consists of six steps, preceded by ‘five to 10 minutes of light cardio to warm up your body’ before beginning on the exercises.126 Running briefly through the plan, Step 1 requires ‘high-intensity interval training’ (HIIT) three times a week ‘to help burn calories to eliminate excess fat from [the] middle’. A ‘vigorous cardio intensity’ is alternated with a ‘less intense recovery phase’. The suggested exercises are ‘jogging at a leisurely pace’ for two to three minutes, then launching into an ‘all out’ acceleration into a one-minute spring. This pattern should be followed for some twenty to twenty-five minutes. Next, step 2. Here, the subject should take at least two days of the week to ‘engage in strength training’. All major muscle groups in legs, arms, abdomen, hips, shoulders, back and chest are exercised. Step 3 adds to step 2, concentrating on the shoulders with lateral raises, upright rows, shoulder presses and front raises using dumbbells, machines or a cable station. Step 4 moves on to abdominal-strengthening exercises, directed towards ‘adding muscle definition and bringing out the curves of [the] waist, going down toward [the] hips’. Crunches and reverse crunches are included at this stage to ‘work the lower part of [the] abdominals’. On, then, to step 5, intended to ‘firm and define [the] lower body’. This is a recognised ‘problem area’ for women, as fat has a tendency to store in this region. Hence, embark at this step on ‘targeted leg and butt exercises [to] work the muscles under the fat’. When the fat subsides into

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nothingness or at least is reduced, the instructions reveal that ‘a shapely rear end, curvaceous hips and well-defined legs’ will make their appearance. Lunges, squats, dead lifts, step-ups and ‘hip extensions on all fours’ should be incorporated into this stage. Finally, step 6. This requires no exercise, but attention paid to ‘a healthy diet that contains food from basic food groups’. To complete the six-step regime successfully, vegetables, whole grains, low-fat or fat-free dairy, lean protein and fruits are advised. Monitoring of calorific intake is essential, as is limiting sugar, trans fats and saturated fats.127 Leading to healthy bodies and, potentially, curvy ones, this six-step programme seems admirable. Yet it could also be classed as extreme for the women engaged in an ‘ordinary’ life battling with children and partners, jobs and the everyday chores that fill most women’s lives. For many women a puffy middle may be preferable to embarking upon the sixstep regime. Furthermore, if the midriff is truly burdensome, its appeal reduced from the glory days of adolescence or pre-adolescence, its roundness disliked or even despised, the path to chopping away the fat or having it suctioned away remains. Roundness can be removed, or transferred to those parts of the body where roundness is desired.

5

Suction Up, Suction Down

In the United States, liposuction is the most sought after cosmetic surgical procedure after breast augmentation. It made up 258,558 of the 1.8m cosmetic surgical procedures carried out in 2018 by registered plastic surgeons in the United States.128 Similarly for Britain, liposuction is high on the list of body enhancement operations. The BAAPS reported the top surgical procedures for women in 2018, a rise overall of 0.6 per cent from 2017, saw liposuction rise significantly. In order of popularity, breast augmentation continued to top the list, albeit at 7727 operations it was down six per cent from 2017. Next came breast reduction, up by seven per cent and numbering 4014 operations. Third on the list was blepharoplasty (eyelid surgery), down two per cent and numbering 2820 operations. Fourth came abdominoplasty, rising by five per cent from 2017 to 2733 operations. Liposuction was next, with 2286 procedures, a rise of twelve per cent. This was followed by rhinoplasty and face/neck lift, up respectively by three per cent (2260 operations) and nine per cent (2013 procedures). Next, fat transfer, at 1330 procedures down by two

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per cent on 2017, otoplasty (ear correction) down ten per cent (532 procedures) and browlift, down fifteen per cent (328 procedures).129 When the spare tyre appears or the doughnut develops, for those who do not want the distinctive appearance of perfect abs, the liposuction surgeon will stop after removing the fat, disposing of it or swapping it to another part of the body rather than going on to etching or implants. Retaining the midriff without the adipose tissue returning means that the patient or client will be advised to begin a programme of body contouring, involving diet and exercise, but not too soon after the liposuction. If she wishes to avoid liposuction or any other invasive process to eliminate the curves of the adipose rich midriff, she can take up the same exercise, diet and body contouring programme promoted by Kimberly Caines130 in the hope that it will pare down the excess fat by a daily workout or at least tighten the muscles and help the body to regain some suppleness and springiness of the skin. Yet the appeal of liposuction is readily obvious. The offer that unwanted adipose tissue may be disposed of, by a procedure that does not require chopping at the offending flesh, will be attractive to those simply wishing to rid themselves of it. The knowledge that once removed it can be reconstituted as tissue of value, taking curves from where they should not be and creating them where they should, may be irresistible. Yet liposuction is not an answer for obesity. Cellulite and stretchmarks cannot be abolished or banished by it. As the NHS says, it’s ‘only really suitable’ for those who have ‘tried changing their lifestyle and found this hasn’t worked’.131 Yet even inside that proposition lurks a terrible, hidden truth albeit clear once stated. If a person has not been able to change her lifestyle to reduce whatever it is that she seeks to reduce naturally, to abolish a roundness that she would prefer not to have, to alter a curve or a bulge or a mound or a hillock—then what are the chances that, liposuction having solved the problem, it will creep back. The magic of liposuction has to be helped by the person upon whose body it is practised. Dietary habits must be changed from unhealthy to healthy, exercise must be taken up where exercise was lacking. There is no need to adopt the ‘6 States of Body Contouring’, but retaining old habits is likely to see the body return to its pre-liposuction shape. It is well to recall ‘what could go wrong’, even if these results are acknowledged as an ‘occasional’ outcome: lumpy or uneven results, bleeding under the skin (haematoma), persistent numbness ‘that lasts for months’, changes in skin colour in the area treated, a build-up of fluid in

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the lungs (pulmonary oedema) which can come from the fluid injected into the body, a blood clot in the lungs (pulmonary embolism), damage to internal organs during the procedure.132 Nor should the small risk running with any operation be forgotten: excessive bleeding, a blood clot developing in a vein, infection, allergic response to the anaesthetic.133 Some women may overlook side effects, in the joy of a fat roll gone, an unsightly excrescence removed. Yet side effects are not pleasant, a consequence to be expected, including bruising and swelling lasting potentially up to six months, numbness for some six to eight weeks, scarring, inflammation of the treated area, inflammation of the veins underneath the treated area, fluid emitting from the cuts, swollen ankles if legs or ankles are treated. Finally, when confronting roundness of the body, an inevitable consequence of being born female, whatever one’s genetic make-up or ethnic or race origins, women taking the liposuction fat transfer road need to remember that there is some contention, albeit disputed, that body fat once removed and reinserted can move or drift.134 If this is so, then the problem of wandering body fat is not isolated to the parts of the body that should be rounded, if a woman prefers the round to the slender look. If having fat taken from one area to another does not quarantine against the tissue slipping or seeping or subsiding into some other area, creating roundness where it ought not be or is not wanted, there remains the problem of fat as a side effect. Victoria Handley in A Practical Guide to Cosmetic Surgery Claims observes that it is ‘believed that an unwanted side effect is [that liposuction] makes other parts of the body fatter’.135 Even if research is disputed, the need to be wary remains. Handley recites the warning that for the body striving to gain the slender look, ‘although the fat will not return into the areas of the body [from which] it was removed, it will reappear elsewhere’.136 Shoulders and arms can be particularly susceptible. This would mean a return trip to surgery for more liposuction is ordained, this time to fix the upper reaches of the body. Looking generally at liposuction and medical mistakes, whether the aim of an operation or non-surgical intervention is to increase the dimensions of the bottom or some other part, or decrease it, round up or round down or do both, the problem of peripatetic corpulence can be real. In seeking the beauty of the body of a woman, the words of Maya Angelou resonate far more than the persuasive voice of any plastic surgeon, the puffing prospects of a clinic’s website or the lure of the aesthetic or cosmetic procedure.137 Noting that her secret is a matter of wonder

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to women classed ‘pretty’, like women naturally shaped with the rear end ‘discovered’ by Vogue in 2014, she asserts that neither her body nor her being is constructed to the dimensions of the fashion model or able to be described as sweet, charming or adorable. Her hips are broad, her legs hit the ground with a stride, not a tripping mein, and her arms reach out determinedly. The ‘phenomenal woman’ she is, Maya Angelou commands attention, filling a room, her voice strong, powerful, imposing, authoritative. It is this, she says, that makes her presence unassailable. A ‘phenomenal woman’, she is one of the golden women, those golden women who see no need for the surgeon’s knife. Round or curved, narrow or tapered, this is the body she has, the woman who dwells within the body for which she seeks no apology, the women who see splendour in being a body and mind, content: Women whose dreams have taken them to the top of the mountain Where they stand Faces to the wind Faces infused by the sun Golden Souls strong in the strength of the knowledge That women have been here before At the top of the mountain High on the ramparts Conquering the battlements The sun on their faces Their hands to the wind Free.138

Notes 1. See ‘Peter Paul Rubens, Flemish Artist’, Encyclopaedia Britannica, 26 May 2019, https://www.britannica.com/biography/PeterPaul-Rubens (accessed 28 May 2019); ‘Norman Lindsay Gallery’, National Trust, https://www.nationaltrust.org.au/places/norman-lin dsay-gallery/ (accessed 12 February 2019). 2. Cited E. Foley and B. Coates, ‘Mae West and Being Body Positive’ in What Would Boudicca Do? Faber & Faber, London, UK, 2018, pp. 19– 24, at p. 23. 3. Ibid., p. 20. 4. Germaine Greer, The Female Eunuch, Paladin, New York, NY, USA, 1971; Fourth Estate/HarperCollins, London, UK, 2012.

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5. Ibid., p. 38. 6. Ibid., p. 39. 7. Herman Heinrich Ploss, Max Bartels and Paul Bartels, Woman: An Historical, Gynaecological and Anthropological Compendium, trans Eric J. Dingwall, Heinemann, London, UK, 1935, p. 86. 8. Germaine Greer, ibid., p. 41. 9. Sarah Rainey, ‘Secretly Starving,’ Telegraph, https://s.telegraph.co.uk/ graphics/projects/inside-the-world-of-anorexia-blogging/ (accessed 19 January 2020). 10. Jes Baker, Things No One Will Tell FAT Girls, Seal Press, Berkley, CA, USA, 2015. 11. Ibid., p. 3. 12. Ibid. 13. Listed ibid., with commentary interposed. 14. Ibid., pp. 218, 220. 15. Sonya Renee Taylor, The Body Is Not an Apology, Berrett-Koehler Publishers, Oakland, CA, USA, 2018. 16. Ibid., p. 113. 17. Naomi Wolf, The Beauty Myth, Chatto & Windus, London, UK, 1990, p. 272; abbreviated version Vintage Classics, London, UK, 2015. 18. Ibid., p. 10. 19. Ethel Kirsop, ‘Not According to the Calendar’ in Jocelynne A. Scutt, Glorious Age—Growing Older Gloriously, Artemis Publishing, Melbourne, Australia, 1993, reprint 1994, pp. 32–41, at p. 33. 20. Ibid., pp. 33–34. 21. Naomi Wolf, The Beauty Myth, Vintage Classics Edn, London, UK, 2015, p. 26. 22. Ibid., pp. 27–28. 23. Ibid., p. 28. 24. Kat Banyard, The Equality Illusion, Faber & Faber, London, UK, 2010, p. 22. 25. Ibid., p. 26. 26. Ibid. 27. ‘Bridget Jones Diary (2001),’ Imdb, https://www.imdb.com/title/tt0 243155/ (accessed 4 April 2018). 28. Charlie Brinkhurst-Cuff, ‘My Body Shape May Be in Fashion Just Now, but for How Long?’ The Guardian, https://www.theguardian.com/ global/2017/jul/30/my-body-shape-is-in-vogue-but-for-how-long-cha rlie-brinkhurst-cuff (accessed 30 July 2017). 29. Pontsho Pilane, ‘Vogue Magazine and the “Columbusing” of the Big Booty’, The Daily Vox, https://www.thecut.com/2014/09/vogue-hasjust-discovered-big-butts.html (accessed 13 November 2014). 30. Ibid.

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31. Jes Baker, ibid.; Sonya Renee Taylor, ibid. 32. Staff Reporter, ‘Plastic Surgery Procedures on the Rise for Four Consecutive Years: Brazilian Butt Lift Procedures Increase by 16 Percent’, HNGH , 28 February 2014,https://www.hngn.com/articles/25459/ 20140228/plastic-surgery-procedures-rise-four-consecutive-years-brazil ian-butt-lift.htm (accessed 2 January 2020). 33. Ibid. 34. Brazilian Butt Lift Claims, ‘Brazilian Butt Lift Surgery—Compensation Claims’, IBB Claims, https://www.ibbclaims.co.uk/site/services/med ical-negligence-solicitors/cosmetic-surgery-claims/brazilian-butt-lift-cla ims/ (accessed 2 January 2020). 35. ‘The Lion Sleeps Tonight’ or ‘Mbube’ (recorded in Zulu) and the original ‘A-weema-weh, a-weema-wheh’, sung and recorded by Pete Seeger and The Weavers as ‘WimoWeh’ is one of the most notorious of many. See https://www.youtube.com/watch?v=vZ06MuB8_04 (accessed 4 April 2019). 36. Charlie Brinkhurst-Cuff, ibid. 37. Lauren Cochrane, ‘How Brows Became the Beauty Obsession of the Decade’, Guardian, 27 September 2016, https://www.thegua rdian.com/fashion/2016/sep/27/brows-beauty-obsession-eyebrowgrooming-cara-delevingne (accessed 2 January 2020); Sali Hughes, ‘Are Big Lips the New Bushy Brow?’ Guardian, 9 January 2015, https:// www.theguardian.com/fashion/fashion-blog/2015/jan/09/are-biglips-the-new-bushy-brow (accessed 2 January 2020). 38. Ibid. 39. Ibid. 40. Merriam Webster Dictionary, https://www.merriam-webster.com/dictio nary/tournure (accessed 14 April 2018). 41. Alanna MM McKnight, Shaping Toronto: Female Economy and Agency in the Corset Industry, 1871–1914, MA Thesis, York University Toronto, Ontario, 2012; N. Waugh, Corsets & Crinolines, Theatre Art Books/Routledge, New York, NY, USA, 1954; ‘A Short History of the Corset’, Marquise, http://www.marquise.de/en/themes/korsett/ korsett.shtml (accessed 4 April 2018). See also Laura Purcell, The Corset, Raven/Bloomsbury, London, UK, 2018. 42. Editors of the Encyclopaedia Britannica, ‘Bustle’, https://www.britan nica.com/topic/bustle (accessed 4 April 2018). 43. Ibid. 44. ‘Early Bustle 1869–1876’, Truly Victorian, http://trulyvictorian.net/his tory/1869.html (accessed 14 April 2018). 45. H. Kristina Haugland, ‘Bustle’, Love To Know—Beauty & Fashion, https://fashion-history.lovetoknow.com/clothing-closures-embellish ments/bustle (accessed 14 April 2018).

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46. ‘How to Differentiate Between Bustles 1870 & 1883’, Fashion Era, https://www.fashion-era.com/bustles.htm#How%20To%20Differe ntiate%20Between%20Bustles%20Of%201870%20and%201883 (accessed 14 April 2018). 47. Editors of the Encyclopaedia Britannica, ‘Bustle’, ibid. 48. ‘Early Bustle …’, ibid. 49. Erinn Larsen, ‘A Brief History of the Bustle’, Refashioning History, 15 February 2017, https://refashioninghistory.com/2017/02/15/a-briefistory-of-the-bustle (accessed 17 February 2017). 50. ‘Saartjie “Sarah” Baartman (before 1790–29 December 1815)’, Black Women Should Know Her Name, 8 February 2018, https:// whyshithole.com/2018/02/09/saartjie-sarah-baartman/ (accessed 20 February 2018). 51. Margaret Mitchell, Gone with the Wind, Wisehouse Classics, Sweden, 2020 (first published 1936, National Book Award, and 1937 Pulitzer Prize for Fiction) is a fictional recounting of the antebellum South, but it is taken from the real-life observations of its author. The images of Vivienne Leigh as Scarlet O’Hara being pulled into shape so as to fit into her corset by ‘Mammy’ is a recounting of truth as depicted in fiction. 52. See, for example, Gino Dimuro, ‘The Real Story of Thomas Jefferson’s Mistress and Slave, Sally Hemmings’, History Science News, 9 May 2019, https://allthatsinteresting.com/sally-hemings (accessed 2 January 2020). 53. Justin Parkinson, ‘The Significance of Sarah Baartman’, BBC News Magazine, 7 January 2016, https://www.bbc.co.uk/news/magazine35240987 (accessed 14 January 2018). 54. Brogan Driscoll, ‘Dear Vogue, Big Bums Aren’t Back in Fashion …’, Huffington Post The Blog, 12 November 2014, https://www.huffin gtonpost.co.uk/brogan-driscoll/vogue-bums-fashion_b_5809514.html (accessed 13 November 2014). 55. Natasha Mwansa, ‘The Tragic Story of Sarah Baartman and the Enduring Objectification of Black Women’, M The Establishment, 1 June 2018, https://medium.com/the-establishment/the-tragic-storyof-sarah-baartman-the-enduring-objectification-of-black-bodies-b310ef 20c739 (accessed 4 June 2018). 56. Pontsho Pilane, ibid. 57. Brinkhurst-Cuff, ‘My Body Shape …’, ibid. 58. Plastic Surgery Match, ‘2013 Plastic Surgery Statistics’, American Society of Plastic Surgeons, https://www.plasticsurgery.org/news/pla stic-surgery-statistics?sub=2013+Plastic+Surgery+Statistics (accessed 26 February 2014). 59. 2018 National Plastic Surgery Statistics, ‘Cosmetic Surgical Procedures’, American Society of Plastic Surgeons, https://www.plasticsurgery.

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60.

61.

62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74.

75. 76. 77. 78. 79. 80.

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org/documents/News/Statistics/2018/plastic-surgery-statistics-report2018.pdf (accessed 4 April 2019). Jessica Bursztynsky, ‘Millennials Fuel Plastic Surgery Boom, Record Butt Procedures’, CNBC, 19 March 2019, https://www.cnbc.com/ 2019/03/19/millennials-fuel-plastic-surgery-boom-record-butt-proced ures.html (accessed 15 January 2019). ‘Buttock Implants, BBL—Fat Transfer, Buttock Injections, Prices, Info | About’, Harley Buttock, https://harleybuttock.co.uk/ (accessed 18 January 2019). ‘Brazilian Butt Lift’, Harley Buttock, https://harleybuttock.co.uk/brazil ian-butt-lift/ (accessed 18 January 2019). Ibid. Ibid. Ibid. ‘Buttock Implants’, Harley Buttock, https://harleybuttock.co.uk/but tock-implants/ (accessed 18 January 2019). Ibid. ‘Buttock Injections’, Harley Buttock, https://harleybuttock.co.uk/buttinjections/ (accessed 18 January 2019). Ibid. Ibid. Ibid. Ibid. Ibid. Montgomery v Lanarkshire Health Board [2015] UKSC 11; [2015] 2 WLR 768, https://www.supremecourt.uk/cases/docs/uksc-20130136-judgment.pdf (accessed 20 January 2020). Zahir v Vadodaria [2016] EWHC 1215 (QB), https://www.bailii.org/ ew/cases/EWHC/QB/2016/1215.html (accessed 20 January 2020). R v Adomako [1994] 3 WLR 288 (HofL); R v Adomako [1995] 1 AC 171 (Ct Appeal). Tom Baker, The Medical Malpractice Myth, University of Chicago Press, Chicago, IL, USA, 2005. ‘The Buttock Implant Procedure’, Implants.com, https://www.implants. com/procedures/butt-implants/ (accessed 4 April 2018). Ibid. Jim Frame, ‘Why Brazilian Butt Lifts Are the Deadliest Type of Plastic Surgery’, Independent, 9 October 2018, https://www.independent.co. uk/life-style/health-and-families/features/brazilian-butt-lift-buttock-pla stic-surgery-cost-price-deadly-health-risks-a8575246.html (accessed 20 January 2020); Andrea Downey, ‘Bottom Line. British Surgeons Told to STOP Performing Brazilian Bum Lifts—As Second Brit Dies from “Deadliest Cosmetic Op”’, Sun, 4 October 2018, https://www.thesun.

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81.

82. 83.

84. 85.

86.

87. 88.

89.

90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102.

co.uk/news/7415153/uk-surgeon-brazil-bum-lift-operations-deaths/ (accessed 20 January 2020). Amy Murphy, ‘Mum “Killed by Fat Clot” from Brazilian Butt lift’, Metro, 23 January 2019, https://www.metro.news/mum-killed-by-fatclot-from-brazilian-butt-lift/1403740/ (accessed 24 January 2019). Ibid. Sara C. Nelson, ‘Mum-of-Three Leah Cambridge Died from Blood Clot Caused by ‘Butt Lift’ Procedure, Inquest Hears’, News—Huffington Post, 22 January 2019, https://swww.huffingtonpost.co.uk/entry/ butt-lift-mother-of-three-died-from-a-blood-clot-caused-by-procedureinquest-finds_uk/ (accessed 23 January 2019). Ibid. Sara C. Nelson, ‘Second British Woman Dies After Brazilian Butt Lift Surgery’, News—Huffington Post, 4 October 2018, https://www.huffin gtonpost.co.uk/entry/second-british-woman-dies-after-brazilian-buttlift-surgery_uk/ (accessed 6 October 2018). Sara C. Nelson, ‘Plastic Surgeon “Dr Bumbum” Arrested After Patient with Buttock Implants Dies’, News—Huffington Post, 20 July 2018, https://www.huffingtonpost.co.uk/entry/plastic-surgeon-dr-bum bum-arrested-after-patient-with-silicone-implants-dies_uk/ (accessed 6 October 2018). Ibid. ‘Warning over the Dangers of “Brazilian Butt Lift” Surgery’, Medical Brief , 10 October 2018, https://www.medicalbrief.co.za/archives/war ning-dangers-brazilian-butt-lift-surgery/ (accessed 12 October 2018). Ibid. See also British Association of Aesthetic Plastic Surgeons, ‘BAAPS Statement on Brazilian Buttock Lifts’, https://baaps.org.uk/ media/press_releases/1621/baaps_statement_on_brazilian_buttock_lifts (accessed 14 April 2019). ‘Warning over the Dangers …’, ibid. Ibid. Ibid. The BAAPS report cites Cheryl Palmer-Hughes of Irwin Mitchell. British Association of Aesthetic Plastic Surgeons, ibid. Ibid. ‘Warning over the Dangers …’, ibid. British Association of Aesthetic Plastic Surgeons, ibid. Ibid. Ibid. Ibid. See Jonathan Herring, Medical Law and Ethics, 7th edn, Oxford University Press, 2018, p. 187. Ibid. Gillick v West Norfolk Area Health Authority [1985] 3 All ER 402.

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103. 104. 105. 106.

107.

108. 109.

110. 111.

112. 113. 114. 115.

116.

117. 118.

119.

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Ibid., and see also Jonathan Herring, ibid. Kat Banyard, ibid. Jes Baker, ibid. Numerous articles are available, for example, Sarah Marsh and Guardian Readers, ‘You Are Expected to Live Up to an Impossible Standard,’ Guardian, 23 August 2017, https://www.theguardian.com/society/ 2017/aug/23/girls-and-social-media-you-are-expected-to-live-up-toan-impossible-standard (accessed 19 January 2019). See, for example, David R. Shaffer and Katherine Kipp, Developmental Psychology—Childhood and Adolescence, 9th edn, Wadsworth, CA, USA, 2014; Rachel Gillibrand, Virginia Lam and Victoria L. O’Donnell, Developmental Psychology, 2nd edn, Pearson Education Ltd, London, UK, 2016. Re T (Adult) [1992] 4 All ER 649, https://www.bailii.org/ew/cases/ EWCA/Civ/1992/18.html (accessed 20 January 2020). R (On the Application of Oliver Leslie Burke) v General Medical Council and Ors [2005]EWCA (Civ) 1003, https://www.familylawweek.co.uk/ site.aspx?i=ed409 (accessed 20 January 2020). Ibid., para [28]. Airedale NHS Trust v Bland [1993] AC 789, cited R (On the Application of Oliver Leslie Burke) v General Medical Council and Ors, ibid., para [29]. Re T (Adult) [1992], ibid. R (On the Application of Oliver Leslie Burke) [2005], ibid. See discussion in Suzanne Fraser, ibid, for example. See, for example, Evelyn Bergmann, ‘Top Ten Sexiest Female Body Builders You Probably Haven’t Seen Before’, SpotMeGirl, 17 March 2017, https://heyspotmegirl.com/lifestyle/10-female-bodybuild ers/ (accessed 20 January 2020); ‘Famous Female Body Builders’, Ranker—Female Professionals, 26 November 2019, https://www.ranker. com/list/famous-female-bodybuilders/reference (accessed 20 January 2020). Trudy Schrieber, ‘Abdominal Implants: The Six Pack Shortcut’, Plastic Surgery Portal, http://www.plasticsurgeryportal.com/articles/abdomi nal-implants-six-pack (accessed 14 April 2019). Ibid. On negligence involving anaesthetics, see, for example, R v Adomako [1994] ibid.; R v Adomako [1995] ibid. and generally Tom Baker, 2005, ibid. Simon Perkins, ‘Karen Turner v Mr Nigel Carver, DACB Successfully Defend Cosmetic Surgery Claim on Consent’, DAC Beachcroft, 18 November 2016, https://www.dacbeachcroft.com/en/gb/articles/

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120. 121. 122.

123. 124. 125.

126. 127. 128. 129.

130. 131. 132. 133. 134.

2016/november/dacb-successfully-defend-cosmetic-surgery-claim-onconsent/ (accessed 19 December 2019). Montgomery v Lanarkshire Health Board [2015], ibid. Simon Perkins, ibid. See, for example, Emma Innes, ‘Women Really DO Get a ‘Spare Tyre’ of Fat After the Menopause, Putting Them at Higher Risk of Heart Disease’, Mail OnLine, 28 March 2013, https://www.dailymail.co. uk/health/article-2300487/Women-really-DO-spare-tyre-fat-menopa use--putting-higher-risk-heart-disease.html (accessed 20 January 2020); Dinah Turner, ‘Beat the Bloat: Get Rid of That Spare Tyre … in Just Seven Days’, Mirror, 18 June 2012, https://www.mirror.co.uk/ lifestyle/dieting/beat-bloat-rid-spare-tyre-892679 (accessed 20 January 2020). Emma Innes, ibid. Google ‘spare tyre women fat’ and numerous websites appear that advocate vigorous exercise and strict exercise regimes. Kimberly Caines, ‘How to Get a Curvy Body’, 25 Minute Body Contouring—The Hospital Group, https://www.thehospitalgroup.org/ non-surgical/body-sculpting (accessed 4 April 2018). Ibid. Ibid. 2018 National Plastic Surgery Statistics, ibid. ‘Cosmetic Surgery Stats: Number of Surgeries Remains Stable Amid Calls for Greater Regulation of Quick Fix Solutions’, BAAPS, https:// baaps.org.uk/media/press_releases/1708/cosmetic_surgery_stats_n umber_of_surgeries_remains_stable_amid_calls_for_greater_regulation_ of_quick_fix_solutions (accessed 21 May 2019).https://baaps.org.uk/ media/press_releases/1708/cosmetic_surgery_stats_number_of_surger ies_remains_stable_amid_calls_for_greater_regulation_of_quick_fix_sol utions (accessed 14 April 2019). Kimberly Caines, ibid. ‘Liposuction’, NHS, https://www.nhs.uk/conditions/cosmetic-proced ures/liposuction/ (accessed 4 April 2019). Ibid. Ibid. Kristi Hustak, ‘FAQ—Will Fat Move Elsewhere After Liposuction?’ PSC The Plastic Surgery Channel, 29 July 2019, https://www.theplasticsurge rychannel.com/2019/07/29/faq-will-fat-move-elsewhere-after-liposu ction/ (accessed 19 January 2020); Kathleen Doheny, ‘Study: Fat May Return After Liposuction’, Radiance—WebMD, 3 May 2011, https:// www.webmd.com/beauty/news/20110503/study-fat-may-return-afterliposuction#1 (accessed 19 January 2020).

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135. Victoria Handley, A Practical Guide to Cosmetic Surgery Claims , Law Brief Publishing, Somerset, UK, 2017, p. 111. 136. Ibid. 137. Maya Angelou, ‘Phenomenal Woman Lyrics’, SongLyrics, http://www. songlyrics.com/maya-angelou/phenomenal-woman-lyrics/ (accessed 4 April 2019). 138. Jocelynne A. Scutt, ‘Women, Souls Golden’, poem.

CHAPTER 7

Extremities: From the Tips of Her Fingers to the Tips of Her Toes

My elder sister stuck up for me when my paternal grandmother charged that my toes were ugly. On each foot, the fourth and fifth snuggled too close to one another, hiding a small part of each. Growing into adulthood, however, the snuggling disappeared. Each toe stood straight and firm. Years later, I discovered a pair of glorious Chinese Laundry shoes, peep-toed, red, with a fashionable heel. They did indeed look beautiful. The toes, too, projecting in all their naked glory from beneath the red leather glow. However, wearing them whilst walking daily over the Sydney Harbour Bridge to Mosman sadly afflicted the feet, in ways my grandmother would have deplored. Well it’s only the right foot, but …1

1 The Moons of My Nails, O’er My Elegant Hands … The fingernail is the ‘hard, slightly curved cover that protects the top end of the finger’. It is ‘a horn-like keratinous envelope’ covering most primates’ finger tips and the tips of their toes.2 Evolving from the claws of bears and birds, fingernails are composed of the same substance as hooves and horns. These tough protectors of the digits of hands and feet are formed from alpha-keratin, ensuring they function as a tough carapace to the upper part of the end of the finger.3 Generally surgery on nails, fingers and hands is reconstructive, mainly an antidote to industrial, farming and general work, including severed fingers, crushed hands and fingers, crushed or torn fingernails, or conditions that can be treated by © The Author(s) 2020 J. A. Scutt, Beauty, Women’s Bodies and the Law, https://doi.org/10.1007/978-3-030-27998-1_7

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non-surgical as well as surgical means—including tendinosis, carpal tunnel syndrome and tenosynovitis. These latter are often contracted by women working in jobs involving word-processing, upholstering, machining or other repetitive work. Care, maintenance and enhancements to fingernails are generally carried out in salons, not surgeries. This raises the spectre of human trafficking or modern-day slavery, drawing attention to another aspect of the drive for female beauty. Western women who can afford to beautify their bodies are likely to find themselves being pampered and preened, threaded and tweezered, manicured and manipulated by overworked and underpaid or not-paid-at-all workers from third world countries. The nail and eyebrow business is renowned for its rumoured, even understood, connection with the underworld market in human trafficking. In August 2013 the Sunday Times and The Guardian reported on ‘slavery in plain sight’ in nail salons, stimulated by a first world demand for manicured nails. This generates and supports an illegal market constituted by a multitude of manicurists trafficked into the country. An estimate of some 100,000 Vietnamese manicurists staffing salons in the United Kingdom at that time, where only 29,000 Vietnamese-born migrants are registered, shows the extent of exploitation systemic in the nail care industry.4 Six years on, it is unlikely that the figures are reduced, whilst the likelihood of an increase due to the lucrative nature of trafficking is real. Nail salons specialise in manicures (for the hands) and pedicures (for the feet). Manicures employ massage, lotions, gels and tools to maintain or improve the condition and appearance of a woman’s hands and nails. Fingernails can be long or short, but they must display perfect moons at the base. These appear when the skin is pushed back gently by a cotton bud soaked in cuticle remover, or using a cuticle tool, a nipper or trimmer after softening the skin around the nail base. Cuticle removers generally comprise sodium hydroxide or potassium hydroxide, and are soluble in water (alkaline).5 Nail filing, tidying up of cuticles and polishing are standard. More sophisticated work involves fitting false nails which are acrylic, manufactured from plastic. Modern false nails date from the 1970s, when they were fashioned to represent the shape of natural nails and fixed to the natural nails by adhesive gel. Shaping of the part of the nail pointing beyond the ends of the fingers was followed by the application of polish in an attempt to make them look real. Too often they appeared false. The products continue to be sold, but technology has taken the artifice more than a step further. False nails can be made by applying a gel, using

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one of two processes. One requires curing with ultra violet light (UV). The other involves painting an activator onto the gel nails, or dipping the imitation nails into water. For removal, revisiting the salon is recommended. Today’s false nails are embedded in the natural nails so as to look as if they are the women’s real nails. Powdered polymer is combined with liquid, to become a hard plastic. Blending with polymers of softer consistency means the plastic can be affixed to the natural nails, bonded and shaped to look natural. The resin which forms from the polymer becomes hardened when applied to the nails, and additional ingredients make it tough and able to withstand daily life as do natural nails or, because it is acrylic, even better than the real thing. Special colour effects can be built into the nail so that it has a polished appearance from the outset. The French polish style of a natural or pale pink base with white tips can be incorporated into the false nail giving this a lifespan that far exceeds that of French polish treatment applied to natural nails.6 Albeit manicures are seen as benign, injuries cannot be ruled out. Manicurists require proper and adequate training. The United Kingdom Hair and Beauty Industry Authority (HBIA) reports ‘at least 50 per cent of the people working in the beauty industry are underqualified’, with more trained only to grade 2 level, where level of grade 4 is the highest qualification.7 Even when qualified, slipping of sharp nail tools cannot be ruled out, or nicking or cutting the skin with an electrical nail file, leaving cut flesh open to the absorption of the new nail gel. Customers must be safeguarded against allergic reactions and, when chemicals are involved, pre-treatment skin patch tests are essential. Where bonding of false nails requires chemicals, clients need to be protected against harm through the careless application of ‘beyond their use-by date’ products or improper application or ‘failure to follow product guidelines and safe procedures’.8 Some nail gels contain the chemical methyl acrylate. Classified as a hazardous substance, it can cause serious damage if breathed in or reacting on the skin.9 One ‘Hazardous Substance Fact Sheet’ lists the risks as potentially burning the skin or at least causing it severe irritation, as well as causing eye damage. Coughing and wheezing can result from nose and throat irritation, whilst damage to the lungs is possible, too. Skin allergies can result and if they do, any future contact with the substance, even slight, can cause skin irritation and itching.10 Susan Taylor, a dermatologist, clinical researcher and expert on treating skin of colour advises prudence in using this substance. A rash can develop

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on the eyelids because people naturally, though inadvertently, habitually touch their faces, particularly their eyes, throughout the day.11 A ‘red, itchy, bumpy and uncomfortable’ rash can develop, lasting up to two weeks. Relieving the rash requires treatment with cortisone cream after removing the polish—undoing the manicure.12 Butylated Hydroxyanisole, sometimes contained in nail gels, carries health risks, too. Rats ingesting it have been found to develop cancer, although this is not precisely comparable as a measure of risk for humans, because chemical levels ingested are higher than those contained in food substances to which humans are exposed.13 Notwithstanding this, Susan Taylor warns that checking the ingredients of gels is wise, because ‘we do not know exactly how much exposure you would need for cancer to develop’.14 Salons often use ultraviolet light to set or cure gel nail polish. The Skin Cancer Foundation warns of ultraviolet risks15 and Taylor notes that a gel manicure is generally required every two weeks to maintain the nails’ polished appearance, requiring exposure to ultraviolet light ‘for four to eight minutes’ each time. This, she observes, ‘can add up to significant exposure’.16 An antidote to the risk of ‘potential skin cancers on … fingers or hands …’ is, she says, to ‘apply an SPF 30 or higher sunscreen directly to hands and fingers after washing’. An alternative is setting the polish by LED (light emitting diode) for this light presently ‘is not thought to cause skin cancer’.17 Nailbeds require proper cleansing before the new nail is embedded. Failures in the mixing and sculpturing process can be serious. Polymer powder and liquid must be mixed in the correct proportions, to the correct consistency to prevent lesser nail strength or hard, brittle nails. Adhesive chemicals applied without proper care can cause nail and nailbed reactions, occasioning cracking, discolouration or misshaping of the nails, with a possibility of permanent disfigurement. Fungi or bacteria can contaminate the tiny air pockets which form between the natural and artificial nails.18 The UV process carries its own potential health risk, even skin cancer, as do toxic vapours from the nail products. Fumes must be able to escape through proper salon ventilation. Inhaling them can cause breathing complications, lung inflammation, nausea and abdominal pain, interference with vision, fainting, swallowing difficulties and, ultimately, pneumonia.19 Disregard of the need to sanitise manicure equipment, or reusing products having a once-only lifespan risks deleterious effects, including cuts, serious bacterial or fungal infections, and even diseases such as hepatitis and HIV.

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Outside the salon, fake nails have their own dangers. If they catch on furniture, are caught when shutting drawers and car doors, or snagged on office equipment such as photocopying machines, or even on underwear, tights or other clothing or jewellery, the false nail can be torn off, dragging the real nail with it.20 Time and the replacement of nails generate their own consequences. Years of false nails being applied over real nails can cause lasting damage, weakening the natural nail, making it ‘wafer thin, jagged, ingrown at the edges and prone to breaking’.21 Scraping or filing may be necessary to remove ‘old’ gel nails in order to replace them. This can tear the skin, weaken the real nail even more and provide an entry way for the gel to seep below the skin, or for bacteria to develop. Constant replacement can interfere with natural nail growth, making fixing the new nails more problematic, damaging the natural nails and potentially the nailbed beneath. Yet the unsightly remains of real nails can lead a woman back to the salon for replacement nails, to maintain an illusion of healthy, strong nails, whilst the natural nails languish, becoming more and more damaged. Negligence lawyers point to the possibility of amputation where the nail injury results in aggressive infection festering under the false nail. If detection comes too late because the women suffers the pain of infection thinking it is a natural or normal consequence of having nails affixed, or simply believes this is the price of beauty, amputation may be the only solution.22 Severance of part of a finger can warrant between £2500 and £12,000, whilst immediate pain leaving no permanent damage warrants a maximum of £1500. Claims for other nail injuries would generally come within this bracket, bearing in mind that when claims of damage to physical appearance are made, traditionally women are awarded higher amounts than men.23 One law firm specialising in negligence relates that nail injuries can have long-term effects, putting the use of hands at risk.24 Compensation claims involve ‘pain caused by the nail injury and its effect on the proper functioning’ of the sufferer’s daily life. Compensable injuries include ‘nail extension injury, nail burn after manicure and pedicure, nail infections [from] unclean apparatus, chemical reaction of cheap adhesives, unwanted cuts’ arising from salon negligence and similar claims.25 The highest sums calculated for pain and suffering ‘for all kinds of nail damage’ range up to £53,000. ‘Serious nail damage’, categorised as including ‘a range of long-term issues, including sensitivity in … fingernails’, can range from £9700 to £16,420. Where the injury includes failure of nails to grow back evenly following breakage of the nails, this too is classed ‘serious’.

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‘Moderate nail damage’ is constituted by ‘bleeding or bruising’ under the nails or breakage of nails from which claimants ‘make a full recovery’. Here, compensation ranges from £400 to £1500. Finally, sums ranging from £200 to £400 cover ‘minor damage’ which extends from ‘bruising, or slight bleeding’ to discomfort in the nails potentially ‘for several days’ after an incident of damage.26 As for hands, United States dermatologists are reportedly finding a ‘new area of interest among their self-improving clients’.27 This inevitably opens up a new field for negligence lawyers. Clients, predominantly brides who wish to post ‘close-up shots of their finger on Instagram’ arrive at a Houston, Texas, clinic ‘at a rate of three to five a week’ seeking improvements and offering up their hands to have them made to ‘look fabulous’. The treatment offered and applied consists of fillers intended to ‘remove wrinkles, add volume and give … the plump, smooth, ageless, [hands] required for the close-up shot of the wedding ring’.28 The contrary problem, leading to requests that plump hands and sausage-like fingers be reduced by liposuction, gains no traction with plastic surgeons. That liposuction works best ‘in people who are a normal weight and in areas where the skin is tight’29 seems promising, as the likelihood is that skin will be ‘tight’ on fat fingers and hands. However, the universal view of clinicians responding on the RealSelf.com site is ‘no, not possible, dangerous’. Nerves and arteries to the fingertips run on the sides of the fingers, making them prone to injury, potentially resulting in ‘permanent numbness and possible loss of [the] fingers’.30 To be effective in removing the fat, cannulas would be too large, resulting in too high a complication rate. Hands and particularly fingers ‘have very delicate and important structures’, with ‘small vessels and nerves’ susceptible to damage’.31 It could, as an aside, be asked what is a ‘sufficiently low’ complication rate but, in any event, it appears that the dangers that are acknowledged rule liposuction out of surgical consideration. Despite hands and fingers not being a regular target for plastic conversion to thinness, ‘plumping up’ withered hands is possible. With age, the skin thins, making bones, tendons and veins more visible. ‘Hand rejuvenation’ is growing in popularity because treatments are available.32 Impulse Light Treatment (IPL), skin peels and temporary fillers are employed to give aged hands a new lease of life. Now, fat transfer is possible. The aim is to render tendons and bones less obvious, to ‘volumise the back of the hand’ and ‘to disguise visible veins’.33 Using fat transfer together with IPL means that sun-spots can be removed, too. The procedure begins

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with a local anaesthetic, enabling a small amount of fat to be removed from a ‘hidden’ part of the body: say, abdomen, inner or (where it will not render the site visibly robbed of tissue) the upper part of the outer thighs. Fat is removed by suction. Then, using a specially designed cannula, the fat is injected into the backs of the hands. The operation is pronounced safe by its protagonists, for it uses the patient’s own fat cells which ‘remain completely viable after extraction’. This removes the risk of rejection that comes with fillers and lessens the potential for infections which are a real risk of implants and other invasive techniques.34 Nonetheless, bruising and swelling can follow, affecting the very small blood vessels. However, this process has greater permanence than fillers, which must be repeatedly injected. So long as the woman maintains her weight at a steady level, the plumpness of her hands, enhanced by the fat from her own body, it is said will remain.35 The move from dermal fillers to fat-of-one’s-own has an additional advantage of excluding the risk that accompanies fillers. Although said to be ‘low risk’,36 anyone seeking dermal filler treatment must be aware, and be warned by the practitioner, that risks include not only the discomfort that accompanies the procedure, but the potential for more serious damage. Classed as ‘normal’ dermal filler risks, soreness, redness, bruising and swelling are said generally to be ‘not serious’, resolving ‘on their own over time’.37 However, they can last longer, as patients or clients are warned that if they are ‘severe’ or remain beyond two weeks, this can forewarn of more sustained problems. Granulomas, nodules, irregularities, cysts and bumps fit into this category, with bumps appearing as bluish nodes or upraised skin. This happens if the practitioner is careless or less skilled, injecting the filler just under the skin surface. If the injection technique is faulty, or too much filler is injected, ‘more long lasting’, painful or sore and disfiguring lumps can mar the skin’s surface. Inflammation can set in, requiring surgical removal of the filler. Next, although described as ‘extremely rare’, infection is also ‘one of the most potentially serious dermal filler risks’.38 But this is topped by a ‘slightly more common and very serious complication’, namely tissue necrosis. If the filler is injected into a blood vessel by accident, the blood vessel can become blocked so that the surrounding tissue is deprived of oxygen and dies. The result can be disfigurement to varying degrees. The Cosmetic Standards Practice Authority (CSPA) recommends that semi-permanent or permanent-fillers be injected by medical practitioners only, and a level 7 qualification is required.39 Unfortunately, this is by no means the case.

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It is only where dermal fillers have an explicit medical purpose that they are classed as devices subject to regulation. If not, it is open to anyone in a clinic or salon to use them on clients or patients.40 The Department of Health has highlighted the lack of regulation around dermal fillers as ‘a crisis waiting to happen’.41 The Independent Report —Review of Regulation of Cosmetic Interventions observed that without a central collection of data covering complications arising from ‘cosmetic interventions’, there is no systematic record of their type or frequency. Surveying a small sample of professional groups working in the area, the Independent Report found eighty-six general practitioners providing details of ‘over 900 cases of complications’. The most common arose from botulinum toxin injections, laser/IPL treatment, and dermal fillers. One hundred and twenty-nine of the nurses surveyed reported a similar pattern. Responses from the fifty-seven plastic surgeons surveyed had 380 patients presenting with complications arising from non-surgical treatments, the most common relating to botulinum toxin injections, dermal fillers, chemical peels and laser/IPL treatments.42 In Scotland, the government has proposed new legislation for the aesthetics industry which could include licensing or registration of nonmedical practitioners engaged in performing treatments by injection. Arising out of the Consultation on the Regulation of Non-Surgical Cosmetic Procedures in Scotland, this is opposed by the British Association of Cosmetic Nurses (BACN) and other medical professionals working in the speciality. Jackie Partridge, a BACN member with clinics located in Edinburgh and Aberdeen says that BACN members: … do NOT agree that non-medics (not qualified healthcare professionals) should be receiving ANY recognition or approval allowing them to put patients at risk, by injecting when they have no medical qualification.43

The objection is based in the proposition that any type of licence in itself gives ‘approval’ that ‘what [non-medics] are doing is acceptable’.44 This raises the age-old problem of deciding whether regulation is essential for the safety of prospective clients or patients, and holding those regulated to a proper standard of professionalism, or whether registration can operate to clients or patients’ detriment by implying that those licenced are qualified to the highest standard required for injecting sometimes dangerous substances into the human body. This is effectively the proposition put by Jackie Partridge for BACN. Ultimately governments will decide for or

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against licensing. If ‘for’, then this places an obligation on government to ensure professional standards of competency and care. This applies to education and training courses and ongoing maintenance by practitioners of their skills under a licensing regime. Focusing on avenues for redress, the Department of Health’s Independent Report concluded that patients or clients with claims in negligence may be discouraged from pursuing legal action, identifying embarrassment, financial considerations and a need for prolonged commitment as principal deterrents. It is difficult to persist in claims when defendants are not only far better resourced but employ lawyers using procedural points to drag cases out, resulting effectively in a war of attrition. An additional disincentive includes the high potential for lack of insurance where procedures are carried out by non-medical practitioners, and where clinics, spas or salons may not be insured, so rendering nugatory any claim for compensation on the basis of vicarious liability.45 If liposuction is adopted as an alternative, clients and prospective clients must be made aware of the risks accompanying any operation, as well as those applying specifically to liposuction. These must be borne in mind not only in relation to hands and fingers, but to the arms that support them.

2

Upon Raising Her Arms to the Sky

The fifty-seven plastic surgeons surveyed for the Department of Health’s Independent Report added minor liposuction and autologous fat transfers to their list of procedures generating complications, reporting that ‘nearly two-thirds of the complications’ they outlined overall were ‘irreversible’.46 Still, notwithstanding the risks, the popularity of liposuction does not wane. Nor does its versatility. ‘Washerwoman’s arms’ or ‘charlady’s wings’ attract liposuction from the opposite perspective to that desiring plumped hands and beautified fingers, designed to produce memorable images of the third finger of the left hand extended gracefully at wedding ceremonies. The aim for upper arms is the removal of fatty tissue to rid the body of it entirely. Ordinarily carried out on abdomen, thighs, hips and buttocks, where the body tends to store fatty deposits, liposuction can be applied to the upper and lower arms, where attention must be paid to nerves, tendons and blood vessels. The operation begins with injection of medication and a local or ‘neighbourhood’ anaesthetic solution. This is designed to numb

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the arm, reduce swelling, bruising and loss of blood. Fat cells are then broken down by high-frequency vibrations, a high-pressure water jet, or a weak laser pulse. Next, a small incision is made to the underarm and a suction tube is attached to a vacuum machine. The suction tube is moved backwards and forwards to ‘loosen the fat and suck it out’.47 More than one incision may be required because of the length of the arm. Excess fluid and blood are drained, then the treated area is bandaged after stitching. Elasticised support or compression bandages are provided to cover the fingers and hands. Pain, swelling and infection need to be considered, calling for mild painkillers and antibiotics.48 One clinic lists the ‘after effects’ as including ‘transitory’ swelling, estimated as settling generally in ‘more than 1-2 months’, wounding (from the cutting), and the sensations of ‘deadness’ and shivering.49 Laser liposuction is an alternative to traditional liposuction, with laser being applied externally or internally to break down the fat. More expensive than traditional liposuction, risks include an allergic reaction to medications or materials employed in the surgery, infection, possibility of burns, damage to the skin and surrounding tissues, including skin necrosis (dead skin), puncture of an internal organ, fluid imbalance or the results including a change in appearance of the skin so that it looks bumpy or withered.50 Greg Almond in An Introduction to Beauty Negligence Claims confirms that liposuction, along with dermal fillers and Botox, figure amongst the most common procedures generating negligence claims.51 This assessment is confirmed in A Practical Guide to Cosmetic Surgery Claims , Victoria Handley listing one of a ‘variety of complications’ as focal excessive liposuction. Concerns about the thickening of upper arms accompanying ageing or adolescence into adulthood may lead one to adipose tissue removal by liposuction. Focal excessive liposuction can result. Handley explains that disproportionate removal of fat produces ‘an unnatural and unattractive appearance’. Excessive removal can be irregular or uneven, resulting in depressions in the flesh (lipotrops), or flesh disfigured by lumps and bumps (liponots).52 Where excessive superficial liposuction occurs, the vascular supply of the skin in that area can suffer injury. This in turn may generate necrosis or ‘full thickness skin necrosis’ (death of the affected skin).53 Damage to the skin may also cause discolouration, resulting in permanent blotchiness (‘erythema ab liporaspiration’) or pink-brown patches.54 As well as putting an end to dreams of trim, tanned limbs glowing in the sun and gleaming in the gentle dusk of long summer nights, all this harbours the potential for legal action.

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Negligence claims may be indicated, too, even if none of these outcomes occurs. Liposuction leaves behind skin no longer filled with fat, which droops. Such artificially induced drooping requires attention. Similarly, if the skin of the upper arms droops naturally (without fat removal by liposuction), the condition commonly called ‘bat wings’, then the answer is an upper arm brachioplasty or ‘arm lift’. The ‘bat wing’ problem is thus addressed by excising the excess skin employing a surgical arm lift. This the solution, too, for the droop that comes hard upon the removal of adipose by liposuction. Albeit projected as a remedy, brachioplasty can cause serious scarring along the inside of the arm, where the skin is removed and the remainder stitched to form a taut upper arm. The prospective patient confronts a dilemma. She may wear sleeves that hide the baggy skin altogether, but be denied the pleasure of flaunting her arms in sleeveless summer dresses or stunningly low-cut evening gowns. The alternative is surgery to correct the discomfort arising from the excess skin squeezed into clothing found to accommodate it, or to allow arms to appear uncovered. Yet the option for having the skin cut away means that upper arm scars remain,55 unsightly and themselves requiring skilful dressing. Having undergone an upper arm brachioplasty, the patient can wear sleeveless dresses and tops, at the expense, however, of revealing scars. Dressmaking skill required to hide the scars may be lacking and prêt-à-porter or ‘off the hanger’ frocks may not be designed to cover up cleverly. One clinic estimates that ‘as many as half’ the patients ‘develop bad scars despite the plastic surgeon’s skill and diligence in suture technique’.56 Laser may help, as might some gels and Vitamin ‘E’ cream, to at least lessen the unsightliness to some extent. However, the prospect of significant scarring must be borne in mind, and could be a given if the surgeon is not so skilled in the technique. Scarring can take some time to mature. This means that an operation may at first appear to have had an acceptable outcome or one the patient is happy to live with, however the ultimate result may not be so satisfactory. If the delay in the maturing of scarring extends beyond three years, this creates a potential problem for the launching of a negligence claim. The Limitation Act 1980 provides that ordinarily, claims must be instituted within three years of the cause of the damage. If the damage is wholly concealed until after the three-year limitation period expires, an extension of time for launching a claim may be granted. The principle is that it would be unfair to deny a prospective litigant a right to take action, if they did not know of the damage

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until after the limitation period. In such a case, the three-year limitation period begins at the time the damage complained of is discovered: that is, when the intending litigant knew of the injury or damage or when she ‘ought reasonably to have known’ that the damage accrued. This can happen with implants, for example, where damage comes long after the initial operation, or long-term damage from other cosmetic products or applications. Scarring can take from two to three years to fade,57 so it may be possible to argue successfully for an extension of the limitation period, if three years after the treatment or procedure fading fails to occur, with scars remaining unsightly. If the woman has been advised of scarring as a risk, including the possibility of long-term scarring that could be ‘unsightly’ or result in her having to conceal the underside of her arms, yet has gone ahead, this will rule out a claim. She will be seen as having consented consistent with the Montgomery v. Lanarkshire Health Board 58 definition and, if the procedure is carried out with the requisite skill, in accordance with Zahir v Vadodaria 59 her dissatisfaction will not bring her a successful result. A happier outcome can accrue for those seeking after arms that are tauter with a toned appearance, where the adipose problem is not too great, and the amount of fat to be removed is correspondingly lesser in volume. In some cases, liposuction can stimulate ‘skin tightening’.60 However, as sagging skin is a general feature of weight loss, this could be anticipated as a general outcome of upper arm liposuction. Simply relying upon stimulated tightening of the skin may be unwise. Furthermore, the suggestion that ‘an unwanted side effect [of liposuction] is that it makes other parts of the body fatter’ requires attention.61 A study of thirty-two women, eighteen being in the control group, the other fourteen undergoing liposuction, found that although the fat did not return to the liposuction sites, it did reappear in other parts of the body.62 Liposuction was carried out on the lower abdomen, hips or thighs of the fourteen subjects. The fat reappeared after about one year, accumulated in their upper abdomen and triceps.63 The finding of this reappearance of fat is disputed,64 however, a wise practitioner would warn women of the contested possibility, and a woman contemplating liposuction may wisely bear it in mind. Recalling the standard set in the Montgomery case,65 practitioners have a duty to take reasonable care to ensure that patients are aware of ‘material risks’. A preliminary issue is whether the practitioner knew or ought to have known of the existence of any particular risk. In Roe v

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Minister of Health 66 information as to risk of contamination of anaesthetic became available in 1951. Doctors operating in 1947 could not be held to a standard of knowledge coming into being some four years later. In 2018 Duce v Worcestershire Acute Hospitals NHS Trust 67 ruled similarly. There, expert evidence was accepted by the court that as at the date of Mrs Duce’s operation, the state of practitioners’ knowledge regarding neuropathic chronic post-surgical pain as a risk was not such that her practitioner should have known of it.68 This meant that Mrs Duce lost her negligence action. The trial judge determined that, first, the risk that led to the complications generating her claim was not common knowledge amongst surgeons in 2008, when the operation took place. Therefore no duty fell upon the surgeon to give a warning of it (neuropathic chronic post-surgical pain) to Mrs Duce. Secondly, even were the knowledge available then, it was more likely than not that, had she been warned of the risk, Mrs Duce would have gone ahead with the operation regardless.69 Mrs Duce’s appeal against the decision was lost unanimously. Unfortunately, as noted earlier, women seeking beauty may underestimate risk, however clearly they are informed, advised or even warned. Returning, then to the ‘fat can appear in another part of the body’ question, two issues arise. First, should a claim be made, would a practitioner be held to have known of the risk, or ‘ought to have done so’? The ‘fat reappears’ research was published in 2011 with exposure on the internet.70 In 2017 reference to it appeared in Victoria Handley’s A Practical Guide to Cosmetic Surgery Claims .71 A practitioner today could be required to know. However, the dispute supports an assumption that the research is not conclusive. The second question is, therefore, whether there is a ‘material risk’ requiring disclosure. Montgomery warned against calculating this by percentages. However, three recent cases discuss the degree of risk by reference to odds or percentage of risk requiring disclosure. Thefaut v Johnston held that a risk of up to 5 per cent should have been disclosed as ‘material’.72 In Mrs A v East Kent Hospital University NHS Foundation Trust the court said that a risk of one in 1000 did not require disclosure: there, a 3 per cent risk should have been disclosed, but a practitioner had no duty to disclose a 1 per cent risk.73 Similarly in Tasmin v Barts Health NHS Trust it was held that a one in 1000 risk was not material: it was too low.74 Both Mrs A and Tasmin involved pregnancy and risks relating to the foetus. Hassell v Hillingdon Hospital NHS Foundation Trust involved spinal surgery and the risk of paralysis. It was held that a risk of one in 1000 to one in 500 required disclosure.75 What,

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then, is ‘adequate information’ to a prospective patient or client seeking liposuction? The practitioner needs to bear in mind that what is ‘adequate information’ about ‘material risks’ is judged according to the particular case, and from the perspective of a reasonable person in the position of the patient. A reasonable patient may wish to know that there is a possibility, albeit disputed, that fat can reappear in other parts of the body. If it were true that fat removed from the lower body generates fat in the upper torso, it seems equally possible for fat removal from upper arms to ignite its appearance on thighs or abdomen. A woman seeking removal of fat from the upper arms may wish to be informed of this possibility, so that she can decide whether to take the risk. Yet women subject themselves to extraordinary risks in aesthetic, cosmetic and plastic surgery. Is it likely that a woman confronted with the possible, though disputed, risk of fat reappearance would withhold consent? Whether liposuction to arms or another part of the body, this would seem to apply. The desire for ‘perfection’ or ‘normality’ (whichever is claimed) may transcend uncertain risk.

3 From My Elbows to the Bush Within My Armpits Not only arms matter. Arms have joints, and elbows count. Potentially wrinkly, hard-skinned, even grubby-looking despite regular washing and care, they are another part of the body to be designated unsightly. Elbow wrinkles can strike at any age, although they are likely to increase with ageing. This is due to the constant work the elbow joint devotes to ensuring that arms can do their everyday job, whether at home or in the workplace, on the sporting field or the beach, in the park, dining out or eating popcorn at the cinema. Less often seen by their owners, elbows can be neglected until glimpsed by chance in the mirror from behind. The likelihood of wrinkles, sagging and bagging becomes greater with a decrease in collagen levels and elastin tissue, both occurring with age. Home remedies and surgery feature in women’s magazines and on the internet, the aim being to increase the moisture levels of the elbows, lessen the thick texture of the skin around them and, if possible, plump them up. Injections of collagen into the elbows, so that the lower layer of the skin is smoothed with filler can decrease elbow wrinkles for three to six months.76 More expensive laser therapy stimulates collagen production, tightening skin and reducing sagging. The advantage is that it lasts

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longer. An alternative to be applied at home is a ‘beauty patch’ on each elbow, worn at night to boost hydration and increase collagen production and plumped elbows. Glycolic acids, exfoliation and moisturising regularly at night, even wearing sports elbow bandages to increase the absorption of extra-strength cream or liquid moisturiser, are less expensive ways of seeking to recover youthful elbows. At a most basic level, cutting lemons in half and applying one half to each elbow, holding the fruit firmly against the offending wrinkles and grinding gently may help.77 Unless the knife slips on the cutting board, the lemon solution is the least likely to lead to injury. Laser therapy and collagen injections carry risk, and product liability can attach to moisturisers and beauty patches if their manufacture is deficient or the products are contaminated. This is illustrated by Donoghue v Stevenson where intrusion of foreign matter in the manufacturing process led to a successful negligence claim by the end user of the product.78 Beyond manufacturing, if testing is required before sale, liability can extend to distributors, as established in Watson v Buckley and Osborne, Garrett & Co Ltd (Ogee).79 Thus, where testing is required before the distributor sells the product on, but the distributor overlooks or ignores that requirement, an assurance to the recipient—say a beauty salon or spa—that the product is safe renders the distributor liable.80 Similarly, if the distributor is responsible for labelling and labels the product as safe despite the need for testing prior to sale, the distributor will be liable in negligence if the product harms the end user. In Kubach v Hollands, the product was sold by the manufacturer to the distributor with the invoice explicitly stating that the chemical content ‘must be examined and tested by user before use’. The distributor then sold it without any testing or warning, rather, attaching a label deceptively confirming the product safe.81 The manufacturer escaped a negligence claim. The distributor bore the whole of the liability.82 That the problem in Kubach v Hollands lay with a chemical in a science experiment, not a beauty salon procedure, does not affect the application of the principle. Similarly with Donoghue v Stevenson, that the case was about a drink manufacturer rather than manufacturer of beauty products does not affect its application to creams, unguents and the like. That in Watson v Buckley the damage arose from hair dye, not moisturisers or beauty patches, does not affect the application of the principle to these products. Whether purchased and used at home, or used in salons or spas or clinics, if contaminated products are used, or products are used without required testing by distributors, or are

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sold with labels declaring them safe, women suffering harm and damage will have claims in negligence, too. Despite the possibility of harm, moisturisers may seem relatively innocuous. Defective batches are not unknown, but the greatest defect lies with the extravagant avowals made for products that do not have the regenerative or ameliorative capacities claimed. Sometimes suits for false and misleading advertising or conduct, or misrepresentation, are successful. In 2014 the United States Federal Trade Commission (FTC) determined that L’Oréal had engaged in ‘false and unsubstantiated claims’ about the capacity of its ‘anti-ageing’ serums to ‘turn back the hands of time’.83 But this win is not commensurate with the burgeoning market in beauty products or the exaggeration and puffing accompanying the release of merchandise onto the market, regularly promoted by celebrities, actresses and supermodels.84 Liability for exaggerated marketing does not necessarily remain solely with the manufacturer. In Kathleen Webster & Ors v Mark Liddington & Ors,85 clinics and practitioners’ liability for claims made in brochures arose. Isolagen Europe Ltd (IEL), a company in administration at the time of the action, devised and marketed ‘Isolagen’, competing with Botox, Bovine Collagen and other rejuvenation processes. Isolagen was significantly more expensive. Operating in the United Kingdom between 2003 and 2006, IEL claimed Isolagen ‘rejuvenated human skin’, restoring a youthful appearance to those upon whom the years were advancing.86 The company had an arrangement with doctors and clinics to carry out the treatment. Local anaesthetic was applied, enabling the clinician to remove a small skin sample from behind the patient or client’s ear. Placed in a sterile container, the sample went to IEL’s laboratory. IEL technicians cultivated ‘fibroblasts’ from the skin, employing the Isolagen process. A fibroblast is a cell type producing the extracellular matrix which is important for wound healing because fibroblasts maintain the connective strength of tissues.87 The Isolagen process required cultivation of the fibroblasts in foetal calf serum (FCS). FCS is a mixture of bovine proteins which are known to stimulate survival and growth of human cells during in vitro culture.88 Once having developed, the Isolagen fibroblasts were washed clean of FCS, then placed in a medium for creating injectate. Returned to the clinician, over a series of three sessions spanning a fortnight, the injectate was injected into the patient or client. However, there being no guarantee that

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all FCS was removed from the fibroblasts, small traces could remain in the injectate. Brochures misrepresented this, through language suggesting that the injectate contained only the cells of the patient or client upon which it was used. Thus, IEL’s own brochures and brochures based on IEL’s own information and produced by clinics including Harley Medical Centre and Wirral Aesthetic Cosmetic Clinic, said that the rejuvenation therapy would ‘utilise only your own living cells’, or that the injectate was ‘a solution using only your own cells’.89 More lengthy representations included: Unlike other collagen development companies Isolagen uses only the patient’s unique live cells to produce the patient’s own collagen.90 The patient’s immune system recognises the injection of cells as the patient’s own and does not reabsorb them or reject them as it does with other foreign materials such as Botox, collagen or hyaluronic acid.91

Once the statements were discovered to be false, because the injectate could contain traces of FCS, proceedings commenced. The plaintiffs won. The clinics appealed, contending that they could not be held responsible for the brochures content, neither those produced by IEL, nor those based on IEL information. In any event, they said, the statements in the brochures were ‘substantially accurate’.92 On the first argument, the appellate court held that the clinics producing their own brochures were responsible for the content, having adopted IEL’s representations. The clinics handing over IEL brochures were responsible, too, because in so doing they adopted IEL’s words. As to the second, ‘substantiate accuracy’ was an unpersuasive argument for ‘contrary to assertions in the brochures, a very small quantity of bovine material was likely to be present in the injectate’. This could potentially ‘cause an allergic reaction in some individuals’. The error was ‘significant’.93 Damages were based on an agreement that they would cover the cost of the treatment, in the realm of £3500 to £4000 per patient. Meanwhile, on a less intrusive level, women contemplate their underarms. The question? ‘To shave or not to shave.’ Whilst men’s thoughts turn to hair transplants, women’s focus on hair removal. Hence waxing of underarms, shaving, application of depilatory creams, electrolysis, intense pulsed light (IPL) or laser removal of hair. All are possible at the beauty parlour or at home. Waxing, depilation and shaving are traditionally home-based, and now laser and IPL machines are available on the market

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for domestic use.94 Potions, electrical and shaving equipment, heat and laser can be used to achieve desired ends safely, or relatively so. With undertrained, careless, inattentive or preoccupied operatives they can do damage, from the inconsequential to the mild to the more serious and life-changing. Product defects, whether in equipment or creams and waxes, means that home-based use can drive litigation, too. IPL is a technology used for skin treatments including sun damage and acne, as well as hair removal. It employs an intense, visible, broad spectrum pulse of light delivered by a ‘high-powered, hand-held, computercontrolled flashgun’.95 The equipment is programmed to cut out the emission of ultra violet light (UV), the treatment heating the melanin in hair to destroy it, so that it is reabsorbed back into the body.96 Deregulation of IPL in 2010 increases the prospect of errors and injury. About twenty providers or clinics remain registered with the Care Quality Commission (CQC). Albeit their details are provided on the CQC website, some twenty-one do not,97 and not all providers or clinics are necessarily listed. In reviewing cosmetic surgery claims, Victoria Handley notes that ‘an influx of therapists, not all appropriately trained, has followed deregulation’.98 Wielded by a less than proficient or untrained technician, IPL technology could inflict damage at mild or serious levels. If the machine’s programming is defective and UV is not filtered out, the treatment could be cancer-inducing, leading to negligence suits. Laser hair removal is promoted as being able to remove many hairs at one time, hastening the desired end. Lasers can work selectively on the area from which hair is to be removed, without touching the surrounds. This can be particularly attractive to the woman seeking a purge of underarm hair. Further, although by no means a ‘once off’ treatment that eliminates all unwanted hairs, never to return, for some women three to seven treatments can result in permanent removal. That will not happen with shaving—or is enormously unlikely to do so, and although regular waxing may have the effect of permanency for some, this is nowhere near as likely as with laser. Nonetheless, laser treatment always has risks, whether used for breaking down fat in liposuction or removing hair. One law firm working in the field lists ‘fairly minor’ side effects that ‘should disappear after a few days’ as including itching, which can occur during the treatment itself; tingling or slight pain on the area being treated; ‘swelling or slight irritation’ at the location of the hair follicle, and ‘redness around the treated area’ that ‘should fade gradually’.99 Operatives, particularly if not properly trained or skilled, can instigate slight bleeding,

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scabbing, or bruising (particularly if the skin is sensitive), through their failure to clean and disinfect equipment or body parts. Burns can be caused by poor or defective use of the laser equipment, or using the wrong type for the particular skin: here, the skin absorbs heat and the hair follicles remain untreated. Using equipment incorrectly can also cause hyperpigmentation or darkening of skin tone, or hypopigmentation, namely lightening of the skin tone. Darker skinned people in particular may run the risk of these skin changes.100 The most common types of negligence are scarring, infections, burns and blistering, laser burn marks, hyperpigmentation (skin darkening), irreversible damage to the skin where the laser goes too deep, uneven appearance of the skin, and reduction in muscle tone.101 As an example of levels of compensation that may be claimed, minor scarring ranges from £1800 to £5950, whilst severe scarring ranges from £5950 to £17,275. ‘Minor scarring’ is ‘for cases where there is one noticeable scar or several superficial scars’. With ‘severe scarring’, compensation is determined ‘by the quantity of noticeable scars’. Physical pain and suffering can range from £1000 to £200,000. In NB v JC 102 the claim related to burns and associated pain. An agreed out of court settlement saw the sum of £3500 paid to a 54-yearold woman for injuries caused through negligent IPL laser hair removal. In August 2012 NB, the plaintiff, suffered ‘mild superficial burns to her arms, with peeling and dyspigmentation’,103 which resolved in three to four months. The defendant JC admitted liability. Burns were ‘initially painful and obvious’, and as long as the injury lasted, NB covered up her arms for work and on social occasions. Following the procedure, she had gone on holiday but, being obliged to conceal her arms so as to shield them from sunlight, she had not had the full benefit of the holiday, nor the enjoyment ordinarily accompanying a vacation. The pain made her unable to fulfil the household’s or her own personal needs, meaning she had to gain domestic and personal assistance. Her evidence included a statement that her confidence was injured. She made no claim for psychiatric injury. To support such a claim, expert evidence is required. Here, it was lacking. At varying levels of seriousness, other methods can work, yet carry their own risks. Shaving has obvious dangers, and hair removal by waxing hurts. Here, wax is heated and applied by a broad spatula to the underarms, with paper or cloth strips applied. The wax is then lifted, taking hairs from the follicle by tugging at the strips, pulling them and the

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wax free. Too hot, and the wax can burn. Too savage a tug, and the skin can be wounded, the pain severe. Injuries can vary depending upon the part of the body to which the wax is applied.104 Overheated wax could cause up to third-degree burns. Injuries can occur through lack of training, misuse of equipment, poor equipment maintenance, or applying the wrong wax. Where wax is left on too long at too high a temperature, this can scar, sever nerves, cause numbness or destroy sensitivity. Some factors can strengthen claims for negligent waxing. A failure to pre-treat areas targeted for waxing can lead to damage. Wax may ‘react poorly with skin or hair’.105 Some bodies have an allergic reaction to waxes used by the salon. If a client fails to advise the salon of her potential for an allergic reaction, the salon could use this in a counterclaim for contributory negligence.106 Depilatory creams can harm, or do the desired job well. Shaving runs the greatest risk of causing ingrown hairs, whilst laser, electrolysis and depilatory treatments run the least risk, although other risks may be worse. Shaving means that the ends of hairs as they regrow have a sharper edge, and ‘can easily poke back into the skin’.107 If dead skin cells clog the follicle, a hair is forced to grow laterally, becoming embedded in the skin. This is a risk particularly where hair is coarse or curly—more likely with underarm or pubic hair. These are ‘danger spots’ for ingrown hairs which can be painful, becoming infected and inflamed, the hair follicles swelling into spots filled with pus.108 Cysts cause redness and irritation, particularly painful under the arm. Infection can develop if bacteria infiltrate under the skin in the moist warm underarm area. This may ultimately require medical treatment, for simply ‘popping’ the cyst does not eliminate the problem. The cyst can regrow, with accompanying pain, itching, redness and skin darkening, and potential oozing of fluid. Fever can develop in the worst cases.109 Some women may avoid the hazards of hair removal method altogether. Not all women want hair-free armpits. The 1950s and 60s saw Sophia Loren and other sophisticated European women sporting underarm hair with abandon.110 In the 1970s, the penchant for hairsmooth underarms and legs which they saw as ‘American’, was regarded by European women with amusement, whilst the Women’s Liberation Movement attacked the habit as a signifier of obeisance to patriarchy.111 Today, the popular press and online blogs rhapsodise about hairy armpits, featuring supermodels and superstars including Gigi Hadid, Madonna, Cameron Diaz and Julia Roberts.112 Nonetheless, this does not mean that

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women sporting underarm hair are necessarily free from the perils of ‘hairfree’ fashion demands. Some have the hair dyed. Others are reported to be adding underarm hair extensions to give their armpits an appearance of extra healthy growth.113 This effort to achieve the ‘natural’ look through the unnatural addition of hair portends potential litigation. Women open themselves and their beauty salons or beauty treatments to the same hazards as in extensions to head hair and eyelash extensions, and mishaps in the manufacture and application of hair dyes.114

4

Legs, Knees, Ankles & Feet …

In ‘Gender Roles in the 19th Century’, Kathryn Hughes observes that from the 1830s, women began to ‘adopt the crinoline, a huge bellshaped skirt that made it virtually impossible to clean a grate or sweep the stairs without tumbling over’.115 These skirts concealed the ankles, reputed to have been regarded as so sexually enticing, provocative or even man-maddening that they should be hidden. Although today’s ankles and knees attract less attention, notions of bodily attractiveness and the burgeoning of cosmetic surgery and non-surgical interventions means that, like the upper extremities of a woman’s body, knees and ankles, along with legs, inevitably become a target for intervention. The issue is not only ‘fat’, where thighs figure appreciably, but overly developed calf muscles or their ‘too skinny’ reverse. Looking from the knee downwards, liposuction for calves and ankles is promoted by some surgeons, though others suggest that this area is too difficult and should be avoided. Knee reconstruction is generally for footballers and other sportswomen and men whose movement suffers because of strenuous play. However, this provides cosmetic surgeons with a history available to them for guidance when women want ‘better’ (as in better looking, conforming to prevailing views of attractiveness and fashion) knees and ankles. This has implications for the rest of the body, including the spine. Beginning at the groin, in 2013 Facebook and Twitter accounts were reportedly established to honour ‘the thigh gap’.116 Modelling catwalks and dance floor performances by celebrities, or beach scenes featuring reality stars created a new fashion statement, the gap between the thighs. Plus-size model Robyn Lawley stood condemned when, wearing a corset, her image appeared on social media showing her upper middle thighs touching. At 6ft 2in and 12 stone, despite successfully sashaying down the catwalk and gracing the cover of Vogue Italia, the 24-year-old was

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reviled as ‘pig’, ‘hefty’ and ‘too fat’.117 The diktat was out. Lacking a gap at the top between the thighs when a woman stands with her legs together, her body ought not to be seen in public without the offending part covered. Caryn Franklin, co-founder of a campaign for diversity, All Walks Beyond the Catwalk, was quoted as questioning the stranglehold narcissism appears to have gained in the public and private arena, led by a patriarchal media of little depth. Denouncing the trend toward starving oneself to enter the realms of that now deemed attractive, rather than gaping thighs, Franklin sought ‘bigger and stronger’ thighs, with the ability ‘to run faster and swim longer’.118 Whether this was sufficient as an antidote to the thigh gap fashion is challenging. Hip and pelvis bone structure, genetically programmed, influences whether a gap can appear between the legs immediately below the pudenda. Changing this to create a gap could require bone surgery which so far does not appear to have been suggested. Concerns about reconstructing clavicles, shoulder bones and ribs are replicated. Just as the heart and lungs are protected by the chest bone brace, organs below the waist are protected by the brace formed by pelvis and hip bones. Less drastic means of gaining a gap may be pursued by traditional liposuction or laser liposuction, removing fat from the uppermost inner thighs, and from between the thighs above the knees, too. Women suffering from taunts of ‘thunder thighs’ may take this route.119 Sometimes the condition is a result of oedema where fluid has built up in legs or arms generally around the lower leg and arm, the ‘fat’ forming a cuff around ankles and wrists. This is attributed to hormones and lymph glands and is not treatable in the same way as fat accumulating as weight gain or being part of existing body shape.120 Where body shape is perceived problematic, reduction can be carried out successfully as weight loss surgery. This applies to reduction of ‘skin excess’ generally on the inner upper thighs but sometimes on the outer thigh region. Carried out under general anaesthetic the operation can be done ‘occasionally’ by day surgery, indicating that at least an overnight hospital stay is generally required.121 The operation can be ‘combined with other surgical procedures’. Fat is removed leaving a ‘surgical wound on the inner upper thigh in the groin region’ which ‘does not usually cause problems early on’. Patients can return to daily activities ‘fairly soon after plastic surgery’.122 Reference to ‘usually’ should spell caution to any woman considering this method. If treatment is by liposuction, risks associated with any operation are present. Scarring is possible, just as with liposuction to upper and lower

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arms. Scarring can fade, nevertheless warnings of the potential for scars to remain, leaving distinctive marks, or keloid scarring are necessary. Scars and keloid can be treated, yet the prospect of surgery followed by corrective treatment can foreshadow a seemingly endless cycle of ‘beauty’ interventions.123 Similarly with removal of fat by surgery, scarring is a beauty risk requiring corrective action that in turn carries risk. This follows, too, where ‘saggy thighs’ are corrected in the same way as ‘bat wings’ on arms, by plastic surgery removal of loose skin.124 Nonetheless, both liposuction and plastic surgery are avenues women follow in pursuit of the constructed body beautiful, whether to reduce or build up part or all of the lower limbs. Dissatisfaction leading to litigation will bring no joy, for as in Zahir v Vadodaria,125 patient dissatisfaction with the outcome of aesthetic, cosmetic or plastic surgery is not the measure for liability and compensation, just as it is not the measure in conventional surgery. As to the reduction of the legs below the thighs, one US plastic surgeon advertises on u-tube, promoting calf, ankle and knee liposuction ‘for slimmer, more defined legs!’126 The images show clear markings of the redesign of the legs, lines drawn with a felt-tipped pen (surgery approved) indicating that fat on the inner knee will be removed, as well as fat around ankles and calves. The aim is to create knees without the existing ‘fat envelope’ or paunchy look, and a slimmer calf leading down to a well-defined ankle. The slimmer leg and ankle upon which the surgery has already been performed is contrasted in the video against the naturally existing or ‘before’ leg, so that the ‘before’ and ‘after’ distinction is clear.127 Another US plastic surgeon refers not only to the fat between the knees, causing the knees to ‘knock together’, but to the ‘little bowl of fat behind the knees’.128 Images follow of a series of ‘before’ and ‘after’ legs showing knees slimmed of fat. United Kingdom plastic surgeons advertise less graphically, yet to the same effect.129 Thick calves are now termed ‘cankles’, with ‘fat growth’ attributed ‘almost solely’ to genetics. The lower leg is recommended for slimming by a single procedure, shaping the whole calf and ankle together. The doctor’s ‘artistic eye and technique’ are ‘finely honed’, to ‘assist any candidate to obtain relief from ankle and calf fat’. Looking ‘natural’ is achieved through an unnatural process—an operation—altering by engineering the look naturally generated by genes.130 The many displays on u-tube of legs the subject of calf and ankle operations at US surgeries confirm that a particular shape of leg and ankle

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is sought. The legs scheduled for slimming are by no means unsightly. Nor are they obviously unable to do their job of holding up the body to ensure its ability to negotiate its way around the world in the ordinary way. This generally holds true for legs brought to surgeries for a cosmetic increase in the shape of the calf. Sometimes, a calf or calves may be shrunken following an injury, a viral infection as with poliomyelitis, or disease. As polio causes weakening of the muscle, an insertion of fat is no answer to muscle loss and could be dangerous, although some surgeons do recommend intervention.131 If an injury results in bone loss making one leg shorter than the other, creating a limp, the insertion of fat may correct the asymmetry of calf width, yet obviously cannot ameliorate the limp. Some surgeons specialise in lengthening or shortening leg bones. A generally accepted rule provides that if one leg is shorter by 1” or more, a condition sometimes arising naturally through bones of one leg growing more quickly than the other, that can be subject to intervention.132 With naturally occurring thin calves, surgeons perform liposuction, and some do so where an ailment is the cause.133 Leg lengthening or shortening is generally practised on the femur (thigh bone) rather than the tibia and fibula (calf bones) because the femur presents greater possibilities due to its generally greater length. Lengthening can be recommended for children and young people whose bones are still in the growth stage, because breaking the bone and pinning the ends means that bone will grow in the gap, lengthening the leg naturally. However much risk there may be for children, with adults the risk is increased. Once bones cease growing, lengthening must be achieved by the insertion of steel rods. A surgeon may be found to do it, reportedly in China.134 Where a patient has reached skeletal maturity, shortening of a longer leg is indicated, with potential for ‘a very precise degree of correction’.135 Of the two recognised techniques, the Ilizarov is both more common and more straightforward as not requiring any additional grafting and plating. The Wagner procedure involves bone grafting and plating or acute lengthening. Conflicting reports exist as to their respective complications.136 Where grafting of bone from the patient’s own body is in issue, the case of Gary Nordgren v State of Louisiana is important to recall. There, bone to correct damage to an arm through vigorous exercise, which had also been damaged by a gun wound, was taken from Mr Nordgren’s knee. His contention that the hip had been related to him

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by the surgeon as a possible source was at the heart of the contest. Ultimately, the case turned on the issue of consent and provision of specific information.137 If bone were taken from a woman’s body to lengthen her lower limbs, were such surgery ever to be contemplated by an orthopaedic surgeon (which may be unlikely), then regard should be had to the principle in the Nordgren case. Full disclosure of the source of the bone graft should be notified to the patient, or the second basis of ‘informed consent’ as related in the 1997 case of Lugenbuhl v Dowling would be relevant. This is the instance of the doctor’s failing to notify the patient of the type or parameters of the procedure to be performed.138 As for shortening of lower limbs, this again focuses on the femur, with the bone cut and a section extracted. The ends of the cut bone are then joined, with screws attached to a metal plate and rod running down the bone’s centre, so that the bone incision is held in place whilst femur and limb heal.139 Risks attached to bone shortening or lengthening include bone infection (osteomyelitis), nerve injury (with loss of feeling in the leg), blood vessel injury, vascular damage during surgery leading to avascular necrosis (AVN), cartilage destruction (chondrolysis), failure of pins, rods, plates or any other ‘hardware’ required for the procedure, loosening of pins, stiffness of joints, unequal lengths of limbs.140 The general risks of surgery are of course present. Bearing all this in mind, the successful fictional outcome portrayed by Faye Weldon in The Life and Loves of a She-Devil is not necessarily reflective of real possibilities, although some of the procedures are current. Weldon has her protagonist’s body remade entirely, including lengthening her legs ‘up to her armpits’.141 For any woman seeking to emulate this, an orthopaedic surgeon’s advice rather than that of an aesthetic, cosmetic or plastic surgeon seems indicated—urgently. Fattening too-slim calves or calf augmentation involves the insertion of implants. One such operation took place in 1972 ‘on an equestrian who desired a larger calf to fill out her riding boot.142 In the absence of silicone or gel implants on the market, the surgeons employed silastic foam, cut from large blocks, in this and five subsequent procedures.143 The choice now is between silicone and gel implants. Cosmetic surgery is generally sought where a prospective patient’s calves are perceived to be disproportionate to her thighs. Nerves, blood vessels, muscle and tendons present a challenge to the surgeon to place the implant in the correct position, so as not to damage any of the leg. Particularly at risk are the popliteal

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vein (principally susceptible to thrombosis)144 and the medial sural cutaneous nerve (susceptible to injury precipitating long-term neuropathic pain).145 Solid silicone is recommended to avoid silicone leakage into the body. As with the insertion of foreign material into any part of a person’s anatomy, however, reaction from local tissue, risks of infection and migration of the implant may ensue. This harbours potential perils running well beyond the anxiety of a disfigured appearance, as a wandering implant could interfere with blood vessels, nerves and other leg tissues. Surgeons must warn of risks specifically facing patients with circulatory problems or other serious or potentially serious leg problems, for whom the procedure is better not recommended.146 On a less dramatic, more everyday level, striving for sensually silky-soft legs requires application of wax and depilatory creams, shaving or resort to laser or IPL treatment, just as these are pursued in the drive to eliminate underarm hair. Risks applying to the pursuit of the denuded armpit apply to smoothing of hair from a woman’s legs. Using products at home can generate manufacture’s liability litigation, whilst seeking the treatment at the beauty salon is no necessary protection from harm.147 Yet just as some women resist removing underarm hair, regarding it as normal or celebrating it, some glory in the hairiness of their lower limbs. At various times Lindsey Lohan, Celine Dion and Alicia Silverstone have exposed the hairs on their legs,148 similarly Mo’nique, Paris Jackson, Tyra Banks and Cameron Diaz.149 Whether this fashion will replace hairlessness is doubtful, so long as products and procedures are promoted as necessary to create ‘natural’ legs for women, to supplant the natural growth of hair on their lower limbs.

5

Feet, Ankles, Knees & Legs …

Looking from the feet upwards, foot surgery and footwear have implications for the rest of the body. Feet have been subjected to interventions that are not only damaging and dangerous, but cruel. This is graphically illustrated by the practice of foot binding in Imperial China.150 Yet foot damaging and dangerous customs exist in the Western world, too. Although hammer and mallet toes can be hereditary, shoes are a common cause. The practice of wearing high heels sees women developing bunions, hammer toes, ingrown toenails, fallen arches and other foot deformities. Corns and calluses can be treated by remedies at home or in salons, care

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being necessary with shaving or cutting instruments, hygiene and products for softening hard skin. Subjected to successful surgery, a hammer or mallet toe is unlikely to return,151 although this is dependent again upon wearing shoes that do not cramp the feet or cause the toes to squeeze and jam themselves, reigniting the problem corrected by the surgeon. High heels affect women’s posture with implications for the spine, whilst constant wear generally shortens the tendons on the backs of the calves so that walking in bare feet or flat shoes can be both painful and difficult. The irony is that the targeting of women’s feet as sexual objects and fetishes in other cultures—the Chinese foot-binding example—are recognised as torture. Meanwhile women in the West seek out surgery to improve their looks, by the introduction of dermal fillers (padding to the sole, toes or heel of the foot) and to correct foot imperfections and impediments to walking arising from their voluntarily wearing high heels … This raises the question of ‘voluntariness’ in a world where women are constrained by social and cultural diktats producing a readiness to don clothing and accessories that can be detrimental to their health and freedom of movement. The lure and allure of the Jimmy Choo shoe may override the immediate pain of walking, and the aftermath of deformed feet. Some dissatisfaction with feet comes from natural causes. Loss of fatty pad tissue on the heels, soles, or pads of the toes can arise from ageing, or be a genetic feature. Similarly for the enlargement of the big toe joint which creates a bunion, or enlargement of the little toe joint, which creates a bunionette, these can be hereditary. However, the cause can be the wearing of shoes, too pointed, too tight or too narrow, or with a high heel. Although ill-fitting shoes are sometimes responsible, high heels appear to be the major offenders. Dermal fillers are described by one clinic as ‘the latest treatment being demanded by those ladies who live for their “killer heels”’152 Because the sole of the foot is particularly sensitive, a local anaesthetic is generally applied ahead of the operation, which involves injecting into the foot material akin to that used by the manufacturer Scholl™ in their product Party Feet. ‘Party Feet’ are pads placed in shoes under the foot to provide a comfortable padding for the heel or ball of the foot, or sometimes as ankle grips to hold shoes firmly, preventing them from creating blisters by slipping up and down as well as causing the wearer to appear ungainly. The dermal filler procedure positions the material inside the foot, under the skin, instead of externally in the shoe. The patient stands

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on foam moulds so that the surgeon or practitioner can determine where the pressure points lie. This is intended to ensure that the dermal fillers are positioned correctly to take the weight of the foot.153 Hyaluronic acid is ‘injected into the hardened skin and fat pad’ to set it ‘over the join between the metatarsal and phalange bones of the big toe’. Some clinics use Restylane, a product that ‘stimulates the body’s own production of collagen’.154 Injection of the dermal filler material provides extra padding on identified pressure areas, designed to obviate need for treatment of pain in the ball of the foot (metatarsalgia). With a life of approximately six months, dermal fillers are a temporary solution.155 If the client wishes to wear high heels with the same padding protection in the future, repeated visits are indicated. Reflecting on the prosecution in Regina v BM , where part of his practice was inserting objects under client’s skin, a question surely arises as to the status of this fillers-into-the-feet practice. Dermal filler treatment is invasive. However, it is not as complicated as the problem of bunions. The Mayo Clinic lists signs and symptoms of a bunion as including persistent or intermittent pain, soreness, redness or swelling around the joint of the big toe; a ‘bulging bump on the outside of the base’ of the big toe which can cause the big toe to envelope the second toe and cause corns or calluses to develop. If arthritis sets in, the movement of the big toe can be restricted.156 Noting that bunions ‘often require no medical treatment’ Mayo recommend visiting a podiatrist or orthopaedic foot specialist if experiencing persistent pain in the big toe or foot; decreased movement in either; or difficulty finding suitably fitting shoes because the bunion impedes the fit. If there is a ‘visible bump’ on the joint of the big toe, a visit to a specialist is advised.157 Once identified, a bunion can be addressed by conservative measures or surgical treatment. Conservative possibilities include wearing more spacious or roomy, comfortable shoes, which means giving up high heels or at least modifying height and type of high heel so that the bunion is not exacerbated. Bunion pads, tapes and sleeves are available online or over the counter. Padded shoe inserts can redistribute pressure on the foot, relieving the condition stimulating the bunion and its further development. Pain killers or ice on the swelling if it throbs or becomes inflamed, particularly if standing for any length of time, is recommended.158 Surgery is not advised unless the bunion ‘causes … frequent pain or interferes with … daily activities’.159 If surgical intervention is indicated, then it can take various paths. The most severe is joining permanently the bones of the affected joint. An alternative is removing part of

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the bone to straighten the big toe, or if the bunion has caused the big toe to envelope or cover the second toe, straightening out the angle of the big toe joint by ‘realigning the long bone between the back part of [the] foot and [the] big toe’.160 Alternatively, the bone forming the bunion can be shaved, or more serious surgery can include rotation of the bone, then ‘securing it in place with pins or screws’ to realign it with the remaining toes. The bunion can disappear or at least the bulge can be ameliorated.161 Success does not mean an immediate recovery. Extensive physical therapy may be necessary. Although some patients can walk on the foot immediately, others require weeks or even months to do so. Other risks include the possibility of nerve damage, increased pain, scarring, pain transferring to other parts of the foot due to realignment and the problem having arisen at least partly from the way the body is balanced whilst walking, or style of walking, or weakening of the big toe.162 If a bunionette develops on the little toe, symptoms and treatment are similar, with similar risks of surgery. Do women therefore renounce high heels so as not to run the risk of developing bunions and thus running the further risk of bunion surgery and the hazards it entails? The debate is generally located in arguments about the sexualisation of young women, the objectification of all women, discriminatory patterns and practices relating to clothing requirements, employer and workplace demands as to women’s dress, and patriarchal acculturation. In 2017 an e-mail sent from an Australian regional school group located in country Victoria advised parents of planned etiquette classes including a workshop involving ‘deportment and presentation skills, including how to manage wearing high heels’.163 Parents were requested to ensure their daughters took high heels with them to the class. A former student of one of the schools reportedly said that the ‘use of high heels’ in the deportment class was ‘sexualising women’. Another advised that her parents were ‘not keen on paying pretty hefty fees and lots of extras’ for her to ‘learn how to wear heels’. A group of students wrote to the school ‘slamming [the proposal] as demeaning and sexist’. One parent nonetheless deemed the uproar to be ‘a storm in a teacup’. She said she would ‘support her daughter participating in the class if she wanted to’, and ‘wished’ someone ‘had shown [her] how to walk in high heels.’164 It appears that the workshop went ahead, with the high heels. The school made no comment.

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A year earlier, Nicola Thorp was ‘sent home’ from work at a ‘corporate finance company’.165 Arriving at the receptionist job wearing flat shoes, she refused to go out to buy shoes with a 2” to 4” heel. No reason was advanced when she asked ‘why wearing flats would impair [her] capacity to do the job’. Had she received one, she said, that would have been ‘fair enough’. But her advice to the employer that ‘expecting her to do a nine-hour shift on [her] feet escorting clients to meeting rooms’ in high heels was discriminatory was treated with laughter. Ordered home, she went without pay. Reporting the incident on Facebook and launching a petition generated media incredulity and more than 11,000 signatures within a few days. The Parliamentary Women and Equalities Select Committee held an inquiry on workplace dress codes.166 A year later, having heard evidence from women of a variety of discriminatory practices expressed through employers’ dress codes for female workers, the Committee concluded that new guidelines for companies were required and although the law was ‘adequate to deal with this sort of discrimination’, existing laws should be properly enforced.167 The issue has global resonance. Summer Brennan reported on a petition initiated in Japan, protesting that high heels should not be mandated workplace dress. Garnering more than 23,000 signatures,168 this effort of actor and writer Yumi Ishikawa was ‘bolstered by a clever hashtag: #KuToo’. With a nod to the #MeToo movement ‘thrown in for good measure’, #Kutoo is a pun on the Japanese words for shoe (kutsu) and pain (kutsuu).169 The Health and Labour Minister nevertheless ‘defended workplaces requiring women to wear high heels’, describing the practice as ‘necessary and appropriate’. Reminiscent of Naomi Wolf’s contention in The Beauty Myth that striving for professional success leads women into youth promoting plastic surgery,170 Brennan concludes her article on the Japanese campaign by observing that societies across the globe have not ‘reconfigured the workplace to welcome women’. Rather, societies have aimed consistently at ‘reconfiguring women to fit into a workplace that wasn’t built for them’.171 Yet the matter is conflicted, the high heel being ‘the shoe for events, display, performance, authority and urbanity’.172 In adopting the high heel as suitable apparel as so many women do, at least for some occasions, the scene is set for damaging their bodies, then seeking to repair the damage by subjecting themselves to potentially more damage through procedures introducing new hazards, including a new round of restoration and repair.

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To the Tips of Her Toes---

Yet high heels are not the only shoes that carry with them potential injury, patching up, and the need for healing. Even sports shoes specially designed for women’s feet (when playing cricket) are remarked upon in 2020 as revolutionary.173 Yet it is everyday shoes that provide everyday tribulations. Too small shoes, too tight shoes, too narrow shoes all give rise to problems for the body’s ultimate extremity, the toe. Toes are not an inconsequential body part, playing a significant role in walking, running, leaping, balance and posture. Nor are toes insignificant in the search for the perfect body. Hammer toes and mallet toes are corrected, toes shortened, lengthened or straightened, and unsightly toenails made ‘normal’. Callouses are removed and dermal filler used to plump up toes to give them a ‘good’ appearance in sandals or without shoes whether at the beach or in the bedroom. Although these interventions are advertised as improving women’s comfort, their negative consequences add to the pain caused by wearing too small shoes or shoes that do not allow free movement. That pain is replaced by the pain and constrained motion caused by operations undertaken to correct the original problem. Cosmetic procedures for toes are increasing, with beauty salons introducing more and more innovative and revenue producing treatments. Fish pedicures now accompany the standard or traditional pedicure in salon listings of therapies. First, however, the standard or traditional pedicure. The Good Spa Guide describes this as a therapeutic treatment that ‘removes dead skin, softens hard skin and shapes and treats … toe nails’.174 A good one can be ‘heaven’, so long as the client finds the pedicure that precisely suits her. Warm water softens the feet, facilitating removal of dead skin using a salt or mineral scrub and, where required, calluses and treating corns and plantar warts. Creams, oils or gels are massaged into the toes to enable the cuticles to be tidied, with extraneous, jagged or torn skin removed. The podiatrist or technician then varnishes the toenails, applying an undercoat which dries before the colouring top coat completes the task. Some treatments include a ‘gel pedicure’ where nails are bonded with a clear or coloured gel using an ultra violet (UV) light ‘for a long-lasting glossy finish’. Both this and the fish pedicure have risk potential. Risks include those related to standard beauty salon practices, cleanliness, water temperature and disinfecting pedicure tools, taking care to avoid transmission of fungal and other diseases. Technicians’ training is vital, for equipment ranges from the simplest scissors and

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nail files, to tools requiring more manipulative ability. Removing calluses or hard skin requires trained skill, along with maintenance of electrical and UV apparatus. Caution in using electrical equipment in the presence of water is particularly vital. Paraphernalia such as emery boards and pumice stones are for one-client use only, with immediate disposal guarding against transmission of infections. One New York based podiatrist estimated in 2014 that some twelve to fourteen women came to her clinic weekly, sporting fungal or viral infections, including athlete’s foot and warts, following a pedicure.175 This was a consequence of the waterjets being turned on whilst the women’s feet were in the bath. Bacteria and fungus lurk there, with the jets propelling them into the water and swirling them around the naked feet. The solution is to look for a salon using ‘pipeless footbaths or individual bath liners’, to avoid cross-contamination with previous clients.176 Even then, infections cannot be ruled out. A ‘sanitization cycle [should be run] for the required minimum of 10 minutes between each client’.177 Accidental cuts during the pedicure increase the risk of infection, as does shaving of the legs shortly before. Creating microtears in the skin, razors can ‘allow bacteria to be introduced right into the legs’.178 This, the podiatrist explained, ‘can cause serious infections, like cellulitis’, and the possible hospitalisation. She recommends foregoing a pedicure until at least two days after shaving the legs. This raises the spectre of contributory negligence. Cellulitis can, says the National Health Service (NHS), spread to other parts of the body if not treated quickly.179 Say the salon has an express policy of having clients advise them that any leg shaving has taken place more than, say three days before the pedicure. The client has shaved her legs shortly before. Intending her body to be ‘just so’ for an important event, she falsely assures the technician that shaving took place a week ago. Following the procedure, cellulitis sets in. After a lengthy hospital stay, she sets out to sue the salon. Her case for negligence may be proven on the balance of probabilities—a duty owed, breach of duty, the cause of injury being located in the salon’s pedicure, however the level of compensation will be at risk. As confirmed in Karen Turner v Mr Nigel Carver,180 contributory negligence can apply to cosmetic negligence claims. Hence, her false assurance will appear in the salon’s counterclaim, with damages reduced accordingly. As for claims generally, a solicitor specialising in negligence cases advises that the key issues are whether the salon instruments used were

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fully sterile, if re-usable and, if disposable, disposed of after each use, and was the footbath sterilised fully between customers. Similarly, did the technician carry out an effective handwashing regime before and after the pedicure. Further, did the salon ‘offer other services such as ingrown toe nail removal’, for this could transmit serious infection from that customer to the next.181 Damage to toes can involve the nails or the cuticles, with potential to develop into infection or even ‘cause some nerve damage and loss of sensation’. As with fingernails, procedures can ‘weaken and thin the nails, causing cracking and possible loss’. Sometimes, a pedicure injury can necessitate ‘removal of the nail under anaesthetic’.182 Longer term problems include ‘breathing disorders, blood poisoning, fungal infections and other micro bacterium germs’ entering the system ‘from damage to the skin layers [through] using infected cosmetic tools’. Where chemicals are used on a client for the first time (without a preceding test), she may suffer an allergic reaction with resultant consequences. If the seemingly innocuous pedicure can generate negligence claims for harm with potential hospitalisation, a fish pedicure is a far more adventurous proposition. The fish pedicure begins with thorough though gentle cleansing of the feet, which are then immersed in a tank of Garra Rufa fish, optimally for some fifteen minutes. The saliva of these fish is considered to have therapeutic powers as containing diathanol, a healing protein believed to relieve skin diseases such as eczema and psoriasis.183 The fish nibble at the client’s toes, creating a tingling and tickling sensation. Once this phase of the treatment is concluded, the standard pedicure regime takes over. The potential for litigation lies in the strict hygiene requirements salons should pursue, and to the fish treatment in particular. Salons are unlikely to cleanse the fish tank between each use, and at minimum water should be filtered five times an hour.184 Even if clients’ feet are subjected to rigorous cleansing before being put into the tank, that others’ feet have been there before, or that others’ will follow, carries risk of transmission of bacterial infections, Hepatitis C or B and HIV. If a client has an open wound, even a small one, the risk of catching or transmitting disease or infection is real. Solicitors specialising in hair and beauty treatment injuries point out that tanks ‘containing up to 200 Garra Rufa fish make perfect breeding grounds for bacteria’, which can enter from contact with fish themselves, open wounds, or ‘cuts, abrasions, or open pores’.185 The possibility of permanent scarring through skin damage from bacterial infection is real.

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On a more minor but distressing and actionable level, a break out of boils as well as ugly swelling and temporary but painful skin damage can accrue. The Garra Rufa fish fashion is yet another example of adroit marketing overcoming judicious consumerism. Before putting her naked feet into water that clearsighted forethought would anticipate may have earlier sluiced another or others’ feet, the prudent client may think twice. Perhaps some do. Many do not. In 2011 the Health Protection Agency produce a report entitled Guidance on the Management of Public Health Risks from Fish Pedicures .186 Notably, this was not focused on individual risk, but upon the implications for the health and well-being of the public as a whole. At the time, some 279 fish spas were operating across approximately one-third of local authorities throughout the country, and a higher number was surmised as being in operation. These numbers are not inconsequential, and that a cosmetic procedure could be seen as having an impact going into the entire community is salutary. The report makes the point that ordinary sanitary or sanitising means cannot be employed, because the process involves live fish which would be harmed, injured or killed by such measures. This raises concerns for the fish, as well as steps for guarding against a public health risk. The most significant risk is transmission of bacterial infection from fish to person, water to person and person to person.187 Amongst other recommendations, the Guidance concluded that spas and salons providing fish pedicures, and prospective clients, should be advised of risks. Spas and salons should warn that particular conditions could ‘increase the risk of infection, or pose an infection risk to other clients’. These conditions, expressed as not definitive, included: • Leg waxing or shaving in the last 24 hours (because as with ordinary pedicures, micro-abrasions increase infection risk); • Any open cuts/wounds/abrasions/broken skin on the feet or lower legs; • Infection on the feet (including athlete’s foot, or verruca); • Psoriasis, eczema or dermatitis affecting the feet or lower legs; • Diabetes (which exposes the client to an increased risk of infection); • Infection with a blood-borne virus such as Hepatitis B, Hepatitis C or HIV; • Immune deficiency due to illness or medication; • Bleeding disorders or being on anticoagulant medication (for example heparin or warfarin).188

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Further, clients should sign a form such as used for other salon treatments, confirming ‘they have read and understood the information, given and are not aware of any contraindications to treatment’. A client unsure about answers to any of the questions ‘should seek advice from their GP before undergoing the procedure’.189 The Guidance raises important legal issues, not only in relation to salon or spa liability for negligence claims at the behest of clients, but going to public health. As to clients, their contributory negligence potential is evident, in accordance with Karen Turner v Mr Nigel Carver.190 But beyond this, should they know of any of the conditions listed as pertaining to them, yet go ahead without considering the possible impact for other clients, the provider, or the community as a whole, this may have implications beyond contributory negligence. Persons who have knowingly infected others with sexually transmitted diseases have been found criminally liable.191 In R v. Konzani 192 a male defendant who had sexual intercourse with a woman, knowing he was infected with HIV/AIDS but not informing her, and reckless as to whether she would contract the disease, was found guilty of inflicting grievous bodily harm under section 20 of the Offences Against the Person Act 1861. Could this apply to a client undergoing a fish pedicure despite her knowing she was suffering from, say Hepatitis B, Hepatitis C or HIV, where a client following her into the fish tank contracts the disease? This would be a matter for the courts. No one in this situation should be sanguine about the possible outcome.

7 Fingers, Hands, Nails, Toes---The Extremities That Count Women’s brains matter. So do fingers, arms, hands, feet, legs and toes. If a woman cannot walk, or cannot use her arms and hands, she is rendered unable to run, write, sew, type, print, paint or sculpt. The Olympics are beyond her. Everyday life is limited. Yet the extremities have played a significant role in classifying women beyond the confines of beauty. In a society riven by class, the woman-as-worker was seen as suited only to the downstairs realm or the factory. Hence in Anything But Love, Elizabeth Hawes describes the position for a married woman in 1948 United States’ society:

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If economic necessity forces you to be productive outside your home after marriage, you will be taught how to pretend you aren’t doing it. If you show any symptoms before marriage of going after a career other than that of facilitating your search for a man, you are peculiar and eccentric. If you go about saying you want and like to be Worker, you’ll be considered dangerous.193

Women have, however, been prepared to be considered dangerous. Women’s hands were essential to the development of the clothing industry, spinning and embroidery, along with lacemaking, knitting and crocheting employing women’s strength, dexterity and artistry to ensure the rise of England as an industrial power. Women’s arms were central to the conquering of Australian bush, from 1788 when the land was invaded (or ‘settled’) by the British. Women together with husbands, parents and siblings established a thriving farming industry, clearing vast expanses of land and building blocks where they worked at erecting shacks and sheds for themselves, their families and their farming animals.194 They took up office work and teaching that, like farming, required both intellect and technical skills involving arms and hands for writing, typing and more practical purposes. As a teacher in Ninda West, in the state of Victoria, Jean Clark set to, on her first day of teaching, ‘shovelling out buckets of sand’.195 Together with ‘several willing helpers’ (all women, all employing their extremities to the task), she ‘attacked the floor, desks and windows with masses of soap and water’. In those days, she says, teachers sent into the country were given ‘an extra allowance of two shillings and sixpence a week for cleaning the school buildings every day’. Women’s writing skills have kept not only themselves but their families and, often, their extended families, or sustained them when living abroad like Stella Miles Franklin and Alice Henry, often in group settings where income was shared. Margaret Oliphant kept her husband, who died early, her sons, her nephews, her brothers and herself, writing and publishing prolifically, though ‘… working incessantly, always in fear of flooding her own market, and without the time necessary for driving harder bargains with publishers’.196 Louisa Lawson wrote poetry and prose, edited The Dawn, a leading international feminist journal in late nineteenth century Australia, and developed a publishing industry, staffed by women only, despite that bringing her into conflict with the male dominated Printers Union.197 Besides all this, she farmed, fattening calves, selling diary produce, was ‘an expert four-in-hand driver’—and took in sewing.198

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None of this could have been done, had her hands, arms, feet, toes been hampered. There is nothing to prevent women’s extremities being equally productive at the behest of her brain, just as these women employed their wit and skill in living expanded lives. Yet the aesthetic, cosmetic and plastic surgery industry meets fashion in potentially slowing women down. As Susan Brownmiller explains in Femininity, despite the body ideal for women changing over centuries, from the Greek, to the Gothic, to the Renaissance, these periods ‘do share some similarities’.199 In all three, ‘the feet and toes are wide, strong and sturdy, and the fingernails, when they show, are trimmed short and blunt by modern standards …’ Today, these similarities are no more. Fashionable dress and fashionable interventions targeting women’s bodies all have their impact, from the top of her head to the ends of her toes. As Christian Louboutin is famed for saying, heels ‘slow a woman down, giving the man more time to look at her’.200 Any shoes on the feet of a woman are more than simple foot covering. They have cultural, social, economic and historical meanings. They can enhance women’s beauty, or they can condemn women to surgical interventions, risk, and pain, and practitioners to litigation.

Notes 1. J Terry, ‘Reflections on a Childhood Blessed’, unpublished, 2007. 2. Cambridge Advanced Learner’s Dictionary & Thesaurus, Cambridge University Press, Cambridge, UK; Cambridge Academic Content Dictionary, Cambridge University Press, Cambridge, UK, https://dictionary. cambridge.org/dictionary/english/fingernail (accessed 4 January 2018). 3. Merriam-Webster Dictionary, Merriam-Webster, Springfield, MA, USA, https://www.merriam-webster.com/dictionary/fingernail (accessed 4 January 2018). 4. Holly Baxter, ‘Nail Bars: Modern-Day Slavery in Plain Sight’, The Guardian, 21 August 2013, http://www.theguardian.com/commen tisfree/2013/aug/20/nail-bars--slavery-trafficking-vietnam (accessed 21 August 2013). 5. ‘Cuticle Removers. Formulation’, Vinensia, http://formulation.vinensia. com/2008/09/cuticle-removers.html (accessed 14 April 2018). 6. Douglas D. Schoon, Nail Structure and Product Chemistry, Milady Publishing, 2nd edn, London, UK, 2006; ‘Acrylic Fingernail’, MadeHow.com, http://www.madehow.com/Volume-3/Acrylic-Fin gernail.html (accessed 14 April 2018).

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7. ‘Beauty Treatments Injury Compensation Claim Specialists’, LegalExpert.co.uk, https://www.legalexpert.co.uk/how-to-claim/beauty-treatm ent-injury-claims/ (accessed 14 April 2019). 8. Charles R. Gueli, ‘Injured at a Beauty Salon? Here’s How to Claim Fair Compensation’, InjuryClaimCoach.com, https://www.injuryclaimcoach. com/salon-insurance-claim.html (accessed 14 April 2018). 9. New Jersey Department of Health and Senior Services, ‘Methyl Acrylate’, Hazardous Substances Fact Sheet, March 2006, https://nj.gov/hea lth/eoh/rtkweb/documents/fs/1219.pdf (accessed 2 January 2020). 10. Ibid. 11. Susan Taylor, ‘The Skinny on Gel Nail Polish’, Huffington Post, 3 December 2012, https://www.huffpost.com/entry/gel-nail-polish_b_1 333236/ (accessed 2 December 2017). 12. Ibid. 13. ‘Butylated Hydroxyanisole’, Drugs.com, 17 December 2018, https:// www.drugs.com/inactive/butylated-hydroxyanisole-11.html (accessed 2 December 2019). 14. Susan Taylor, ibid. 15. ‘UV Radiation and Your Skin’, Skin Cancer Foundation, https://www. skincancer.org/risk-factors/uv-radiation/ (accessed 2 December 2019). 16. Susan Taylor, ibid. 17. Ibid. 18. Douglas D. Schoon, ibid.; ‘Acrylic Fingernail’, ibid. 19. ‘What Happens If You Inhale Toxic Chemical Fumes?’ Health.Reference.com, https://www.reference.com/health/happensinhale-toxic-chemical-fumes-b52473f87055f131 (accessed 14 April 2018); ‘Cuticle Removers…’, ibid.; Schoon, 2006, ibid. 20. ‘Fake Nails’, Bad Injuries Due to Fake Nails, TheStudentRoom.co, https://www.thestudentroom.co.uk/showthread.php?t=445 0394 (accessed 4 June 2019). 21. Charlotte Kemp, ‘Why Your Manicure Could Ruin Your Nails for Life’, Daily Mail, 1 December 2013, https://www.dailymail.co.uk/femail/ article-2516515/Why-manicure-ruin-nails-life-Horror-stories-range-wee ping-sores-bleeding-nail-beds-skin-cancer.html (accessed 10 December 2013); ‘Beauty Stories: Artificial Nails Gone Wrong’, The Girl Dish, https://thegirldish.com/2014/12/16/beauty-horror-stories-artificialnails-gone-wrong/ (accessed 20 December 2014). 22. ‘Amputations Caused by Nail Salon Infection|Injury Lawsuit’, Personal Injury Lawyers in LA, https://downtownlalaw.com/medication-err ors/amputation-caused-by-nail-salon-infections/ (accessed 14 January 2019). 23. See ‘General & Special Damages for Personal Injury’, LawontheWeb, https://www.lawontheweb.co.uk/legal-help/injury-compensat ion-amounts (accessed 21 March 2019).

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24. ‘Nail Damage Compensation Information’, Tylers Solicitors, https:// www.tylers-solicitors.co.uk/nail-damage/ (accessed 20 January 2020). 25. Ibid. 26. Ibid. 27. Will Pavia, ‘Brides Are Given a Hand in Removing Wrinkles’, The Times, 25 January 2019, https://www.thetimes.co.uk/articles/brides-offertheir-wrinkly-hands-with-filler-k0ngbz30z (accessed 4 February 2019). 28. Ibid. 29. NHS, ‘Liposuction’, NHS UK, https://www.nhs.uk/conditions/cos metic-procedures/liposuction/ (accessed 4 April 2019). 30. ‘Can You Get Liposuction on Your Fingers?’ Liposuction—RealSelf.com, https://www.realself.com/question/orlando-fl-liposuction-fin gers (accessed 14 April 2019). 31. Ibid. 32. ‘Hand Fat Transfer’, The Private Clinic of Harley Street, 65539, https://www.theprivateclinic.co.uk/treatments/fat-transfer/hand-fattransfer (accessed 14 April 2019). 33. Ibid. 34. Ibid. 35. Ibid. 36. ‘Understanding Dermal Filler Risks’, AboutPlasticSurgery.com, https:// www.aboutplasticsurgery.com/skin/dermal-fillers/dermal-fillers-risks / (accessed 20 January 2020). 37. Ibid. 38. Ibid. 39. Emma Craythorne, ‘Skin Filler Standards’, Cosmetic Standards Authority, http://www.cosmeticstandards.org.uk/uploads/1/0/6/2/106271 141/cpsa_skin_filler_standards_for_consultation_final.pdf (accessed 20 January 2020). 40. Tatiana Lapa and Rishi Mandavia, ‘Understanding HA Dermal Fillers’, Aesthetics Journal, 14 July 2017, https://aestheticsjournal.com/fea ture/understanding-ha-dermal-fillers (accessed 20 January 2020). 41. Department of Health and Social Care, Independent Report —Review of the Regulation of Cosmetic Interventions, 24 January 2013, https:// www.gov.uk/government/publications/review-of-the-regulation-of-cos metic-interventions (accessed 20 January 2020). 42. Ibid., para 4.10. 43. Jackie Partridge, quoted Aesthetics Journal, 5 May 2020, https://aesthe ticsjournal.com/news/bacn-updates-may-2020 (accessed 6 May 2020). 44. Ibid. 45. Ibid., para 7.7. 46. Ibid., para 4.10. 47. NHS, ‘Liposuction’, ibid.

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48. Ibid. 49. ‘Arm Liposuction Before and After’, Liposuction Before and After, https://www.lipobeforeandafter.com/arm-liposuction-before-and-after/ (accessed 14 June 2019). 50. Laurence Beeken, ‘What Is Laser Lipo?’ WeightLossResources.co.uk, https://www.weightlossresources.co.uk/weight_loss/surgery/laser-lipo. htm (accessed 14 April 2019). 51. Greg Almond, An Introduction to Beauty Negligence Claims , Law Brief Publishing, Somerset, UK, 2019, p. 100. 52. Victoria Handley, A Practical Guide to Cosmetic Surgery Claims , Law Brief Publishing, Somerset, UK, 2017, p. 111. 53. Ibid. 54. Ibid. 55. ‘Arm Lift’, Minneapolis Plastic Surgery, https://mpsmn.com/body-pro cedures/arm-lift/ (accessed 14 April 2019). 56. Ibid. 57. ‘How Long Does It Take for a Scar to Heal?’ Scarfade.com, http:// www.scarfade.com/blog/long-take-scar-heal/ (accessed 20 January 2020). 58. Montgomery v Lanarkshire Health Board [2015] UKSC 11; [2015] 2 WLR 768, https://www.supremecourt.uk/cases/docs/uksc-20130136-judgment.pdf (accessed 20 January 2020). 59. Zahir v Vadodaria [2016] EWHC 1215 (QB), https://www.bailii.org/ ew/cases/EWHC/QB/2016/1215.html (accessed 20 January 2020) . 60. ‘Arm Liposuction’, RealSelf.com, https://www.realself.com/question/ upper-arm-liposuction (accessed 14 April 2019). 61. Victoria Handley, ibid., p. 111. 62. Kathleen Doheny, ‘Study: Fat May Return After Liposuction’, 3 May 2011, Radiance MD, https://www.webmd.com/beauty/news/201 10503/study-fat-may-return-after-liposuction#1 (accessed 20 January 2020). 63. Ibid. 64. Ibid. 65. Montgomery v Lanarkshire Health Board [2015] UKSC 11; [2015] 2 WLR 768, https://www.supremecourt.uk/cases/docs/uksc-20130136-judgment.pdf (accessed 20 January 2020). 66. Roe v Minister of Health [1954] 2 All ER 131, https://www.bailii.org/ ew/cases/EWCA/Civ/1954/7.html (accessed 20 January 2020). 67. Duce v Worcestershire Acute Hospitals NHS Trust [2018] EWCA Civ 1307, https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/ EWCA/Civ/2018/1307.html&query=(Worcestershire)+AND+(Acu te)+AND+(Hospitals)+AND+(NHS) (accessed 2 February 2020). 68. Ibid., para [44].

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77.

78. 79. 80. 81. 82. 83.

84.

85.

86. 87. 88. 89. 90. 91. 92. 93.

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Ibid., paras [27], [28]. Kathleen Doheny, ibid. Victoria Handley, ibid., p. 109. Thefaut v Johnston [2017] EWHC 497 (QB). Mrs A v East Kent Hospital University NHS Foundation Trust [2015] EWHC 1038. Tasmin v Barts Health NHS Trust [2015] EWHC 3135 (QB). Hassell v Hillingdon Hospital NHS Foundation Trust [2018] EWHC 164 (QB). ‘Causes of Wrinkles on the Elbows: Home Remedies to Get Rid of Them’, Landurust, 26 March 2014, https://www.tandurust.com/ski ncare/wrinkles-on-elbow-causes-remedies.html (accessed 4 April 2014). ‘Wrinkly Elbows: How to Reduce Wrinkles and Loose Skin’, SOIBeauty.com, https://www.siobeauty.com/blogs/news/wrinklyelbows (accessed 14 April 2018). Donoghue v Stevenson [1932] AC 562. Watson v Buckley and Osborne, Garrett and Co Ltd (Ogee Ltd) [1940] 1 All ER 174. Ibid. Kubach v Hollands [1937] All ER 907. Ibid. Annabel Fenwick Elliot, ‘L’Oreal Forced to Admit Its Gene Boosting Anti-aging Serums Don’t Actually Turn Back the Hands of Time’, Daily Mail, 1 July 2014, https://www.dailymail.co.uk/femail/article2676642/LOr-al-forced-admit-gene-boosting-anti-aging-serums-dontactually-turn-hands-time.html (accessed 4 March 2015). Health News, ‘These 10 Skin Care Claims Are Meaningless – Here’s What to Buy Instead’, HealthLine.com, https://www.healthline.com/ health-news/these-10-skincare-claims-are-meaningless (accessed 4 April 2018). Kathleen Webster &Ors v Mark Liddington & Ors [2014] EWCA Civ 560, https://www.medicalandlegal.co.uk/wp-content/uploads/2014/ 06/Webster-v-Liddington.pdf (accessed 20 January 2020). Ibid., para [8]. Ibid., para [5]. Ibid., para [6]. Ibid., para [14]. Ibid. Ibid. Ibid., para [33]. Ibid., para [68].

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94. Sophia Charalambous, ‘8 Best Home Laser and IPL Hair Removal Machines for Long-Lasting Results’, Independent, 29 March 2019, https://www.independent.co.uk/extras/indybest/fashion-beauty/hair/ best-home-laser-ipl-hair-removal-machines-a8202271.html (accessed 4 April 2019). 95. Michael H. Gold, ‘Lasers and Light Sources for the Removal of Unwanted Hair’, Clinics in Dermatology, vol 25, no 5, 2007 (September–October), pp. 443–453. 96. Ibid. 97. ‘Registered and Unregistered Providers’, Care Quality Commission CQC, https://www.cqc.org.uk/search/site/intense%20Pulsar%20lasers? sort=default&distance=15&mode=html&f%5B0%5D=bundle%3Aprov ider (accessed 20 January 2020). 98. Victoria Handley, ibid., p. 109. 99. ‘Laser Hair Removal Burns or Negligence—How Much Compensation Can I Claim?’ LegalExpert.co.uk, https://www.legalexpert.co.uk/cli nical-medical-negligence/how-to-claim/laser-hair-removal-burns-neglig ence-claims/ (accessed 20 January 2020). 100. Ibid. See also Michelle Skelly, ‘Hypopigmentation vs Hyperpigmentation: Causes and Treatments’, LinkedIn, 17 January 2017, https:// www.linkedin.com/pulse/hypopigmentation-vs-hyperpigmentation-cau ses-michelle-skelly/ (accessed 20 February 2020). 101. Ibid. 102. NB v JC (2015), ‘Clinical Negligence Cases of Interest—March 2015’, Hempsons, 8 April 2015, https://www.hempsons.co.uk/news-articles/ clinical-negligence-cases-interest-march-2015/ (accessed 20 January 2020). 103. Ibid. 104. Legal Resources, ‘Burned with Hot Wax at Salon: Can I Claim for Pain and Suffering’, HG.org, https://www.hg.org/legal-articles/burnedwith-hot-wax-at-salon-can-i-sue-for-pain-and-suffering-49202 (accessed 20 February 2020). 105. Ibid. 106. Ibid. 107. ‘Ingrown Hairs’, NHS Homepage, 24 May 2016, https://www.nhs.uk/ condictions/ingrown-hairs (accessed 4 June 2016). 108. Ibid. 109. Zawn Villines, ‘How Should You Treat an Ingrown Hair Cyst?’ 20 February 2018, https://www.medicalnewstoday.com/articles/320 976.php (accessed 4 March 2018). 110. ‘Sophia Loren Can Make Even Armpit Hair Appear Sexy’, Vintage Everyday, 15 June 2018, https://www.vintag.es/2018/06/sophialoren-can-make-even-visible.html (accessed 21 June 2018).

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111. See for example Robin Morgan, The Word of a Woman—1968–1992, W. W. Norton, New York, NY, USA, 1992; Germaine Greer, The Female Eunuch, Harper Perennial, London, UK, 1996 (orig. pub. 1970); and Kate Millett, Sexual Politics, University of Illinois Press, 2006 (orig. pub. 1970). 112. Hayley Richardson, ‘More and More Women Are Embracing Their Hairy Armpits …’, The Sun, 11 December 2017, https://www.the sun.co.uk/fabulous/5113410/women-hairy-armpits/ (accessed 15 December 2017); Lauren Alexander, ‘Why Are Women Embracing Hairy Armpits?’ Ritely.com, 17 May 2018, https://ritely.com/whyare-women-embracing-hairy-armpits/ (accessed 19 May 2018); Emer O’Toole, The Guardian, 19 January 2014, http://www.theguardian. com/commentisfree/2014/jan/19/year-of-the-bush-female-body-haircameron-diaz-pubic?CMP=EMCNEWEML6619I2 (accessed 20 January 2014). 113. John Farrier, ‘Fashion Trend for Women: Armpit Hair Extensions’, Neatorama.com, 14 December 2014, https://www.neatorama.com/ 2014/12/14/Fashion-Trend-for-Women-Armpit-Hair-Extensions/ (accessed 15 December 2014); Morwenna Ferrier, ‘Why Dyed Armpit Hair Will Be 2015’s Most Subversive Trend’, The Guardian, 15 December 2014, http://www.theguardian.com/fashion/fashion-blog/ 2014/dec/15/why-dyed-armpit-hair-is-2015s-most-subversive-trendtaylor-swift (accessed 27 December 2014). 114. Margaret Hartmann, ‘Woman Sues Salon After Dye Job Makes Her Hair Break Off’, Jezebel, https://jezebel.com/woman-sues-salon-afterdye-job-makes-her-hair-break-off-5245723 (accessed 14 July 2018); Jenny Awford, ‘Woman Demands £16,000 from Salon After “Her Hair Fell Out”…’, The Sun, https://www.thesun.co.uk/fabulous/ 8820891/woman-bleach-hair-fell-out-mullet-jessica (accessed 20 July 2018); Hattie Gladwell, ‘Woman Who Had Severe Reaction to Hair Dye Can Never Dye …’, https://www.thesun.co.uk/fabulous/ 8820891/woman-bleach-hair-fell-out-mullet-jessica (accessed 20 July 2018); ‘Woman Died of Allergic Reaction to Her L’Oreal Hair Dye …’, Daily Mail, https://www.dailymail.co.uk/news/article-2960349/ Mother-died-henna-tatto-holiday (accessed 14 April 2012). 115. Kathryn Hughes, ‘Gender Roles in the 19th Century’, British Library: Discovering Literature—Romantics & Victorians, https://www.bl. uk/romantics-and-victorians/articles/gender-roles-in-the-19th-century (accessed 17 May 2014). 116. ‘Mind the Gap’, Idea Soup, http://thediagonal.com/2013/11/08/ mind-the-gap/ (accessed 20 November 2013). 117. Rosie Swash, ‘How the “Thigh-Gap” Became the Latest Pressure Point on Women’s Self-Image’, The Guardian, 3 November 2013, https://

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118. 119.

120.

121. 122. 123. 124.

125. 126.

127. 128.

129.

130. 131.

www.theguardian.com/lifeandstyle/2013/nov/03/thigh-gap-pressurepoint-women-self-esteem (accessed 4 November 2013). Ibid. Christina Onassis, daughter of the shipping magnate Aristotle Onassis, reportedly suffered this jibe, whilst her daughter Athina was similarly abused with an additional epithet ‘elephant’. Both underwent plastic surgery, Athina Onassis on buttocks and abdomen, Christina Onassis on thighs: ‘Heiress Has Bottom Reshaped’, Daily Mail, https://www.dailymail.co.uk/tvshowbiz/article-169885/Heiressreshaped.html (accessed 14 April 2018); Donna di Giacomo, ‘Christina Onassis (1950–1988)’, FindaGrave.com, https://www.findagrave.com/ memorial/9453/Christina-Onassis (accessed 14 April 2018). Mary Elizabeth Woods, Lymphoedema Care, Wiley Blackwell, Hoboken, NJ, USA, 2007; Jo Waters, ‘Do You Have Flabby Legs’, MailOnLine, 26 September 2016, https://www.dailymail.co.uk/health/article-380 8305/The-medica-condition-leaves-women-bigger-legs-diet-Fat-distri buting-condition-leaves-millions-big-painful-limbs.html (accessed 27 September 2016). ‘Thigh Lift Surgery’, Kent Plastic Surgery, https://www.youtube.com/ watch?v=hhTrlZhQel4 (accessed 14 April 2018). Ibid. ‘Keloids’, Drugs.com, https://www.drugs.com/health-guide/keloids. html (accessed 14 April 2018). ‘Thigh Lift’, Transform Cosmetic and Medical Aesthetics, https://www. transforminglives.co.uk/cosmetic-surgery-for-women/body/thigh-lift# eHDswg7hjWqZ0sR3.99 (accessed 4 April 2018). Zahir v Vadodaria [2016], ibid. Sacha Obaid, ‘Calf, Ankle & Inner Knee Liposuction’, North Texas Plastic Surgery, https://www.youtube.com/watch?v=aOgZbWvWZE8 (accessed 4 April 2019). Ibid. George Commons, ‘Can I Get Rid of the Fat Around My Knee with Liposuction?’ Commons MD, 19 July 2011, https://www.youtube.com/ watch?v=hhTrlZhQel4 (accessed 20 November 2012). Elena Andrew, ‘How to Get Rid of Thick Calves with the Help of Calf Liposuction UK?’, Letsmed.com, https://www.letsmedi.com/howto-get-rid-of-thick-calves-with-the-help-of-calf-liposuction-uk/ (accessed 4 April 2019). Ibid. Memet Yazar, Sevgi Kurt Yazar and Erol Kozanoglu, ‘Calf Restoration with Asymmetric Fat Injection in Polio Sequelae’, Journal of Plastic, Reconstructive & Aesthetic Surgery, vol 69 (Issue 9), September

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133.

134. 135. 136. 137.

138. 139. 140. 141. 142. 143. 144. 145.

146. 147. 148.

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2016, pp. 1254–1259, https://www.sciencedirect.com/science/article/ pii/S1748681516301358 (accessed 14 April 2018). ‘Leg Lengthening/Shortening’, Encyclopedia of Surgery, https://www. surgeryencyclopedia.com/La-Pa/Leg-Lengthening-Shortening.html (accessed 14 April 2018). Lloyd N. Carlsen, ‘Calf Augmentation’, Implants.com, 14 March 2016, https://www.drchugay.com/procedures/body-sculpting-surgery/calfimplants/ (accessed 4 April 2016). Susie Orbach, Bodies , Profile Books, London, UK, 2009, 2010, 2016, p. 82. ‘Leg Lengthening …’, ibid. Ibid. Gary Nordgren v State of Louisiana, Through the Board of Supervisors of the Louisiana State University and Agricultural and Mechanical College Through Louisiana State University Health Sciences Center-Shreveport, and Todd Darren Jaeblon, DO and Joseph Marc Vonvillain, MD, No 53,480-CA Court of Appeal Second Circuit State of Louisiana, 22 July 2020, https://www.la2nd.org/archives/docs/e5e97b.pdf (accessed 23 July 2020). Lugenbuhl v. Dowling, 96–1575 (La. 10/10/97), 701 So. 2d 447 (1997). Ibid. Ibid. Faye Weldon, The Life and Loves of a She Devil, Random House, London, 1993. Lloyd N. Carlsen, ibid. Ibid. ‘Popliteal Vein Thrombosis’, HealthLine, https://www.healthline.com/ health/popliteal-vein-thrombosis (accessed 14 April 2018). Chris Mallac, ‘Uncommon Injuries: Sural Nerve Neuropathy’, Sports Injury, https://www.sportsinjurybulletin.com/unusual-injuriessural-nerve/ (accessed 14 April 2018). Lloyd N. Carlsen, ibid. Gueli, ‘Injured at the Beauty Salon …’, ibid. Lindsey Rose Black, ‘Seven Celebrities Who Don’t Shave Their Legs and Aren’t Afraid to Show It’, Bustle, 25 December 2015, https:// www.bustle.com/articles/131932-7-celebrities-who-dont-shave-theirlegs-and-arent-afraid-to-show-it (accessed 14 April 2017). Izabella Zaydenbert, ‘Fifteen Female Celebrities Who Proudly Flaunted Their Body Hair’, Revelist, 8 September 2017, http://www.revelist. com/body-positive/celebrities-body-hair/9248 (accessed 10 September 2017).

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150. Andrea Dworkin, Woman Hating, Plume, NY, New York, USA, 1991, orig. 1974. 151. ‘Bunions and Hammer Toes’, Keck Medicine of USC, https://www.kec kmedicine.org/when-should-you-consider-surgery-for-a-bunion-or-ham mertoe/ (accessed 4 April 2018). 152. ‘Foot Cushioning with Dermal Fillers’, ConsultingRoom.com, https:// www.consultingroom.com/Treatment/foot-cushioning-dermal-filler-inj ections (accessed 14 April 2018). 153. Ibid. 154. ‘Cushioning for Feet’, ThePodiatryClinic.com, https://www.thepod iatry-clinic.co.uk/cushioning-for-feet-2/ (accessed 14 April 2018). 155. ‘Foot Cushioning …’, ibid. 156. ‘Bunions, Symptoms & Causes’, Mayo Clinic, https://www.mayocl inic.org/diseases-conditions/bunions/symptoms-causes/syc-20354799 (accessed 14 April 2018). 157. Ibid. 158. Ibid., and see also ‘Bunion Surgery Complications: Is It Worth the Risk?’, Bunion Bootie, https://bunionbootie.corn/bunion-surgery-com plications/ (accessed 4 April 2018). 159. ‘Bunions, Symptoms …’, ibid. 160. Ibid. 161. ‘Bunions Surgery …’, ibid. 162. Ibid. 163. Stephanie Corsetti, ‘High Heel Lessons for Students in Regional Victorian Christian Schools Labelled Sexist’, ABC News, 1 September 2017, http://www.abc.net.au/news/2017-09-01/etiquette-classes-invictorian-schools-labelled-sexist/8863638 (accessed 6 September 2017). 164. Ibid. 165. Nadia Khomami, ‘Receptionist “Sent Home from PwC for Not Wearing High Heels’, The Guardian, 11 May 2016, https://www.theguardian. com/uk-news/2016/may/11/receptionist-sent-home-pwc-not-wea ring-high-heels-pwc-nicola-thorp (accessed 12 May 2016). 166. Alice Ross, ‘High Heels Row: Government Response “a Cop-Out”, Says Worker’, The Guardian, 21 April 2017, https://www.theguardian.com/ money/2017/apr/21/high-heels-row-work-government-response-copout-nicola-thorp (accessed 13 November 2018). 167. Ibid. 168. Summer Brennan, ‘Listen to Japan’s Women: High Heels Need Kicking Out of the Workplace’, The Guardian, 6 June 2019 (A), https://www. theguardian.com/commentisfree/2019/jun/06/japan-women-highheels-workplace-kutoo-campaign (accessed 7 June 2019). 169. Ibid.

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170. Naomi Wolf, The Beauty Myth, Vintage, New York, NY, USA, 1990, pp. 26–28. 171. Summer Brennan, 2019 (A). 172. Summer Brennan, ‘Sex, Power, Oppression: Why Women Wear High Heels’, The Guardian, 20 March 2019 (B), https://www.theguardian. com/fashion/2019/mar/20/sex-power-oppression-why-women-wearhigh-heels (accessed 21 March 2019); also Summer Brennan, High Heel, Bloomsbury, London, 2019. 173. Madeline Hislop, ‘First Ever Cricket Shoe Designed Specifically for Women Hits the Market’, Women’s Agenda—Sport, https://womensage nda.com.au/life/sport/first-ever-cricket-shoe-designed-specifically-forwomen-hits-the-market/ (accessed 9 August 2020). 174. ‘Pedicures’, Good Spa Guide, https://goodspaguide.co.uk/features/ped icures (accessed 14 April 2018). 175. Rebecca Adams, ‘Thinking of Getting a Pedicure? Beware of the Health Risks First’, Huffington Post, 27 March 2014, https://www.huffin gtonpost.co.uk/entry/pedicure-health-risks_n_4992820/ (accessed 20 December 2019). 176. Ibid. 177. Ibid. 178. Ibid. 179. ‘Cellulitis’, NHS, https://www.nhs.uk/conditions/cellulitis/ (accessed 20 December 2019). 180. Simon Perkins, ‘Karen Turner v Mr Nigel Carver, DACB Successfully Defend Cosmetic Surgery Claim on Consent’, DAC Beachcroft, 18 November 2016, https://www.dacbeachcroft.com/en/gb/articles/ 2016/november/dacb-successfully-defend-cosmetic-surgery-claim-onconsent/ (accessed 19 December 2019). 181. ‘Nail Damage Compensation Claims in London’, claimslondon, https:// www.claimslondon.co.uk/compensation/cosmetic-and-beauty/nail-dam age-claim/ (accessed 20 December 2019). 182. Ibid. 183. ‘Fish Pedicures’, Bartletts Solicitors, https://www.beautytreatmentsolici tors.co.uk/suing-for-fish-edicure-infections.html#undefined1 (accessed 4 April 2019). 184. Ibid. 185. Ibid. 186. Health Protection Agency, Guidance on the Management of the Public Health Risks from Fish Pedicures, 31 August 2011, https://assets. publishing.service.gov.uk/government/uploads/system/uploads/attach ment_data/file/322420/Fish_Spa_guidance.pdf (accessed 20 December 2019). 187. Ibid., para 3, pp. 7–9.

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188. 189. 190. 191.

192. 193.

194.

195.

196.

197. 198.

199. 200.

Ibid., para 7, ‘Recommendations’, specifically para 7.2.1, p. 14. Ibid. Simon Perkins, Karen Turner v Mr Nigel Carver, ibid. R v. Konzani [2005] EWCA Crim 706; http://criminalisation.gnp plus.net/sites/default/files/R%20v%20Konzani%20%5bCAEW%5d%202 005_0.pdf (accessed 2 March 2020). Ibid. Elizabeth Hawes, Anything But Love, Rinehart & Company, New York, NY, USA, 1948; cited Jocelynne A. Scutt, ‘Dangerous Women’, in JA Scutt, Breaking Through—Women, Work and Careers, Artemis Publishing, Melbourne, Australia, 1992, p. 1. Jocelynne A. Scutt, ‘Reconstructing the Australian Ethos—Women, Men and Values in Australian Society in JA Scutt’, The Sexual Gerrymander— Women and the Economics of Power, Spinifex Press, Melbourne, Australia, 1994, pp. 54–83. Jean Clark, ‘Rust’, in Error Broome, Helen Gibson, Dorothy Richards, Shirley Thomas and Jean Turnely (eds), Equal to the Occasion, Cole Publications, Hawthorn, Australia, 1985, p. 105. Elizabeth Jay, ‘Introduction’, in Margaret Oliphant (ed), The Autobiography of Margaret Oliphant, Broadview Press Ltd., Ontario, Canada, 2002, p. 11. Brian Matthews, Louisa, McPhee Gribble Publishers, Melbourne, Australia, 1987. Heather Radi, ‘Lawson, Louisa (1848–1920)’, Australian Dictionary of Biography, University of Melbourne Press, Melbourne, Australia, 2010, http://adb.anu.edu.au/biography/lawson-louisa-7121 (accessed 20 January 2020). Susan Brownmiller, Femininity, Linden Press and Simon & Schuster, New York, NY, USA, 1984, p. 23. Quoted Summer Brennan, ibid.

CHAPTER 8

Conclusion: Beyond the Body …

Glamour She was magic, enchantment, exciting beyond mortals a study in charm As she magicked her life away Embodied in Plastic Plastic Embodied Synthetic she was, made from thermoplastic polymers Soft into shape Polyethylene shape Moulded She was malleable material workably supple and pliant Irreversibly deformed without breaking Later, She hardened

© The Author(s) 2020 J. A. Scutt, Beauty, Women’s Bodies and the Law, https://doi.org/10.1007/978-3-030-27998-1_8

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Recovering the Body …

Women’s bodies as sites of dispute about beauty are central to a discourse that takes place as a side event to political, economic, social and cultural power, domination, authority and control. While women subject themselves to surgical or clinical intrusion, men get on with running—and some may say ruining—the world. Women may feature more often in positions of political power and authority than ever before, yet simultaneously women acquiesce in their own subjection to a mandate that they conform to an ascendant ideal. This acquiescence itself stems from the reality of women’s subjugation to forces that they do not direct. The aesthetic, cosmetic and plastic surgery industries are not controlled by women. Some women work in them, just as they work in the beauty industry with its population of hairdressers, eyebrow threaders and microbladers, pedicurists and manicurists. Yet the economic power of these industries and the direction they take are not determined by women. Women seek body-changing operations and procedures enabling them to conform to a modish shape and style determined by clinicians who, together with those working in associated industries of fashion, photography, film and television, set the tone. Anna Wintour is the most powerful woman in the fashion industry,1 an industry that moulds women’s bodies, requiring that they conform to the au courant style and shape set on the runway stage. In this, she heads a substantially significant contributor to world wealth. In 2017 the United Kingdom fashion industry was valued at £29bn.2 Oxford Economics set it at £32bn.3 The difference lay in the inclusion of the men’s fashion industry. In 2017, womens wear value sales increased to £28.1bn, anticipated as reaching £28.7bn by 2021. Menswear accounts made up 26 per cent of the market, in 2017 growing by 3.5 per cent, yet constituting £2.4bn of the industry overall. Anna Wintour is powerful, undoubtedly, yet hers is a reflective power, not a truly initiating or determinative one. She might give imprimatur to a particular designer, or to a particular collection, or feature this designer or that fashion artist in Vogue.4 Her rejection of a fashion trend or embrace of it may make or break a fashion show or boost a designer to fame or despondency. Yet despite this, it is men overwhelmingly who in the main design fashion and choose the bodies upon which fashion is displayed. It is they who decide that women should look like waifs, with slender bambi-like limbs, displaying a thigh gap and a bikini bridge, this being the gap appearing when bikini bottoms

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‘are suspended between the two hip bones’, revealing a space between lower abdomen and the bikini’s top edge.5 The occasional appearance in a fashion show of a ‘plus’ model or a sole ‘size 24’ does not herald any substantive difference. In any event, the couturiers and designers are the final arbiters of whom they tolerate on their catwalks. What’s more, the ‘plus’ model appears to be an illusion, too. Olivia Campbell, a size 22, says it’s ‘very common’ for size 12 models to be used to showcase ranges ‘that don’t even start until a size 18, and then the clothes are pinned to their bodies’.6 Realistically, women in the industry who do not conform to the slender persona or waif image are few. Liverpool fashion students reportedly devised a better appellation for the larger size model, ‘life sized’, yet the larger model is far from what is seen as life sized in fashion and on the runways.7 The thinner the woman, and the more she matches a vision of undeveloped innocence combined with a knowing sophistication, the more likely she will appear. One model who ‘was asked to lose weight at size 8’, observed that ‘plus size’ models do not experience the same demand ‘on a day-to-day basis’ as ‘skinny models’ encounter: ‘The harsh reality of the industry is that the thinner you are, the more work you will get’. And once edging over size 6 to 8, the message comes down from the agencies that provide the women who play the catwalk role, ‘fix your measurements’.8 This echoes experiences recounted to the head of a UK all party parliamentary inquiry on body image, that models ‘are being put under enormous pressure’ to conform to an ‘unrealistic and unsustainable’ shape and size: ‘The figure of a girl at 14 or 15 will be different by the time she is 22’.9 Yet many enter the industry as adolescents then strive to maintain their younger selves by dramatic dieting and abusing their bodies. Pressure and bullying are reported as playing a part.10 Nor do women run the prostitution or pornography industry. Yet as Susie Orbach, Sheila Jeffreys, Susan Bordo and others point out, the shaping and reshaping of women’s bodies into performances in plastic is influenced markedly by pornography.11 Andrea Dworkin, Catherine Mackinnon, Gail Dines and others analyse this as an industry based in exploiting and degrading women,12 an industry said to ‘bring in more money than Amazon, Microsoft, Google, Apple and Yahoo, combined’.13 In ‘The Economics of Pornography Stripped Down’, Thao-Mi Bui records that globally, ‘porn is one of the top 10 consumers of bandwidth’, observing that sites such as Pornhub ‘attract 64 million daily visitors, accumulating 5246 centuries worth of watched content in 2016 alone’.

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Thao-Mi Bui notes that in the mid-2000s, a boom in video pornography propelled by the speeding up of the internet saw worldwide industry revenue ‘skyrocket to an estimated $US 40–50bn’.14 Prostitution revenue is estimated at $US 186bn worldwide. China tops the inventory at $US 73bn. Down the list the United States sits at $US 14.6bn, whilst further down the United Kingdom comes in at $US 1bn.15 Figures from the Office of National Statistics (ONS) set number of female prostitutes in the United Kingdom at 60,879 for 2014, with the contribution made to the domestic economy calculated at £5.314bn.16 This is likely to be an under-estimate due to the illegal nature of much of the industry, including brothel keeping, trafficking, kerb crawling or soliciting and living on the proceeds of prostitution. At such huge revenue figures, audience participation in pornography is massive and customer and management involvement in prostitution is high. This impacts on social understanding, judgement and expectation of ‘what a woman is’. As Sheila Jeffreys writes, cultural requirements of beauty have changed through the influence of both these industries. ‘Sexual objectification for sale’ and its humiliations ‘have become de rigueur in the beauty industry’.17 She lists breast implants, genital waxing, surgical alteration of the labia and ‘display of increasing amounts of flesh including naked breasts and buttocks’ as driven by pornography and prostitution, which thereby create fashion norms. Yet in this, manipulation of women’s bodies through surgical and so-called non-invasive or less invasive intervention is designed to imitate images that are themselves manipulated. Photoshopping—a male invention—is employed extensively in the fashion industry and celebrity magazines as well as in pornography.18 Images of the bodies of reality television identities, stars of stage and screen, style icons, supermodels, mannequins are contrived to appear slim, their waists narrow, their hips boyish, their thighs hollow, their breasts ‘just so’. The adolescent look is favoured and achieved through photoshopping magic. Even if, in pornography, fleshier torsos are de rigueur, they are taut, toned and flab free. Though a fashion for fat fetishism (along with fat feed(er)ism) is recognised as fulfilling a specialist male desire,19 outside the realm of Sonia Renne Taylor’s The Body Is Not An Apology—The Power of Radical Self-Love celebrating larger-bodied women as desirable in a non-fetishised sense20 fat-as-fashion is just that: specialist. Bodies are large and made larger by feeder fetishists and at least in extreme cases this can be controlling, not liberating for the women subject to the fat-feeding worship of their partners, sometimes gaolers.21 Susan Bordo

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reflects that even in 2003, ‘virtually every celebrity image’ had been digitally modified, whether in magazines, videos or ‘sometimes even in the movies’.22 ‘Selfies’ are notorious for their manipulation, and accusations of photoshopping by those in the public eye are frequent. Media stories charging vanity, self-importance and narcissism are rife. In this fashion, on a visit to India, Ivanka Trump sought to emulate the famous image of Princess Diana at the Taj Mahal. Though wearing a grin as opposed to Diana’s winsome mien, Ivanka Trump seated herself with the expanse of water in the rear, the mausoleum towering behind her. Charges of photoshopping her waistline to represent it as far narrower than the reality accompanied reproduction of this photograph in world media.23 Paradoxically, for women now dissatisfied with their images projected through Zoom meetings necessitated by the impact of Covid-19, so driven into the hands of dentists, aesthetic, cosmetic and plastic surgeons or searching for beauty products to enhance their looks or permanently change them,24 they see their real selves. This, they contrast to the photoshopped images confronting them at every turn. For Bordo, photoshopping is ‘not just a matter of deception … it is perceptual pedagogy’ or ‘How to Interpret Your Body 101’.25 These images, ‘filtered, smoothed, polished, softened, sharpened, re-arranged’ are, she says, ‘teaching us how to see’.26 The message, simultaneously blatant and subliminal, is that this is how real bodies look—or at least how they should look. Get one, is the surface and sublime message. ‘Normal’ is a word often used in the plastic surgeon’s rooms. People seeking modifications to their noses, eyes, chins, brows, necks … declaring that they want the change, simply so that they can appear and be ‘normal’. In Reshaping the Female Body—The Dilemma of Plastic Surgery, Kathy Davis argues forcefully for a recognition that women choose to undergo these body-changing operations and that this choice should be respected.27 Virginia L. Blum calls on ‘normality’ and the striving for it as propelling women into clinics and surgeries for procedures to be carried out on their bodies under the urge to fit in, to be happy, to have life contentment.28 Yet however true this might be for the person asserting she wants normality, the images projected relentlessly through social media, mainstream media and in reality shows and other performance mediums are not ‘normal’ and nor are they real. The flesh and blood women are different from the images that pretend to reflect their true dimensions and appearance. On the one hand, part of the viewer recognises this. On the other, we are convinced that if we do not

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‘look like that’ somehow, we are not ‘normal’. At the same time, the onslaught of images that are projected as ‘perfect’—perfect body, lips, hair, eyelashes—persuades us that we should look perfect, too. One of the problems pinpointed in reviews of aesthetic, cosmetic and plastic surgery is that this expectation of perfection can interfere with the capacity of the prospective patient or client to assess the risks and dangers of the treatments and operations required to achieve this aim. This is equally or even more so for the accompanying panoply of procedures available through salons, spas and beauty parlours, ‘pop up’ shops and hotels. The Final Report of the Review of the Regulation of Cosmetic Interventions carried out under Department of Health auspices in the United Kingdom in 2013 made this point. Noting that people desirous of undergoing cosmetic ‘interventions’ are ‘both patients and consumers’, the Review recommended that management of individuals’ expectations must be a part of the consent process. Making ‘purchasing decisions on procedures and products that may have a significant impact on their health and wellbeing’ anticipates that people will make informed choices.29 However, media projections of the ease of gaining bodily modification and perfection is so pervasive that even if full information of risks is provided, it may be doubtful that it will be heard or, if heard, be digested. This impacts on legal determinations as to whether a woman has consented to an operation or procedure or not. This in turn impacts on whether, when the operation or procedure ‘goes wrong’, an action for negligence will be successful. Most likely, it will not. If the woman has consented, visions of a beautiful body part fixed firmly in her mind and interfering with her capacity to take into account the risks clearly explained to her, her negligence claim is likely to founder on the altar of her own consent.30 If the woman is simply unhappy about the outcome because the result does not turn her into the plastic representation she desires as ‘normal’ or ‘beautiful’ or bodily mandatory, she will have no recourse to compensation: the law will not recognise the outcome as negligent or actionable.31 Consumer protection laws governing door-to-door sales provide for a cooling off period, recognising that people approached in their own homes by smooth-talking salespersons may regret signing up for a product, so need a period away from the coaxing and inducement to decide in a more objective and informed way whether they should go ahead with the purchase.32 Yet not only do prospective patients or clients seeking body reconstruction face a persuasive provider—persuasive

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because the product sought is so enticing and the provider is a potential magician. They do so in the context of a media and social setting infused with encouragement, even forceful eloquence. Practitioners may also offer inducements, such as ‘pay up front for this procedure at a special price, and another will be added in at no charge, or low charge’. The Review of the Regulation of Cosmetic Interventions recommended that such practices be banned and patients or clients be provided an opportunity to consider, or reconsider, their decisions before consent could be taken as given.33 Susan Bordo recognises the power of persuasion as endemic, for ‘images of slenderness are never “just pictures” as the fashion magazines continually maintain (disingenuously) in their own defence’.34 Bodies are ‘artfully arranged’ in advertisements, videos and fashion spreads, providing ‘powerful lessons in how to see (and evaluate) bodies’. They also ‘offer fantasies of safety, self-contentment, acceptance, immunity from pain and hurt’ and send powerful messages to young people, in particular. These messages ‘… speak to young people not just about how to become beautiful’. They effectively advise on ‘… how to become what the dominant culture admires, how to be cool, how to “get it together”’35 : To girls who have been abused they may speak of transcendence or armouring of too-vulnerable female flesh. For racial and ethnic groups whose bodies have been marked as foreign, earthy, and primitive, or considered unattractive by Anglo-Saxon norms, they may cast the lure of assimilation, of becoming (metaphorically speaking) ‘white’.36

That young people growing up in a society revering body modification on the one hand and on the other seeing it as ‘ordinary’ or ‘normal’ are particularly at risk was recognised by the Review of the Regulation of Cosmetic Interventions , too. Greater protection for vulnerable people is necessary, as ‘much greater emphasis on physical perfection’ has come about with cultural changes. An increasing concern about appearance is making young people, and ‘girls in particular’ vulnerable. Attitudinal research carried out for the Review ‘suggested young people see cosmetic procedures as a commodity – something they might “get done”’. This renders them particularly susceptible to persuasion, special offers and pressure to pay up front.37 Regulation of Cosmetic Interventions —Research Among Teenage Girls, the study prepared for

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the Department of Health in conjunction with the Review, focused amongst other matters on the impact on girls of ‘celebrities, media and other influences’.38 ‘Celebrity magazines’ including OK, Heat, Closer, Look, Star, Bella and More were seen by girls interviewed for the study as ‘prime sources of mainly gossip and speculation about the famous and cosmetic procedures …’39 Researchers concluded that, for the girls, these were ‘extremely influential’, whilst for many of them television programmes such as The Only Way Is Essex (TOWIE) were ‘addictive viewing’.40 Fashion-focused publications were also prominent in persuasive publicity given to cosmetic interventions, including Cosmopolitan, Glamour, Company and Marie Claire, as well as Elle and Vogue. Some ran stories where the journalist reported on procedures she had tried out for herself. Even where procedures were not referred to, seeing ‘pictures of such perfection’ the interviewees assumed surgical intervention, or lesser incursions but nonetheless body-changing procedures.41 Even where girls participate in activities providing them with opportunities for finding everyday role models engaged in character-building pursuits and outdoor activities, the persuasiveness of modern media is powerful. A Girl Guides study from 2012 found that 41 per cent of girls aged seven to ten and 62 per cent of those aged eleven to sixteen reviewed ‘felt some pressure to look the way celebrities do’.42 There is little reason to believe that these percentages will have fallen. In view of exponentially increased use of social media, selfies, texting and sexting, contending they may well have risen is hardly speculative. The position of girls now growing up in a media saturated world is grim. That of boys is equally problematic or even disturbing. Stories appear of boys and young men believing that women’s breasts are really as they are, having been modified, plumped, primped and primed at the hands of aesthetic, cosmetic or plastic surgeons. A scene between Sarah Jessica Parker and Steve Martin in the film LA Story resonates. As his hands alight on Parker’s breasts, Martin utters an expression of surprise. Parker puts his mind at ease—perhaps—by telling him that they are real.43 This distortion does not only affect the young, however. Mothers taking their daughters to plastic, cosmetic or aesthetic surgeons for body modification or parents giving their daughters procedures to augment, ‘liposuct’, chop, enhance, surface with troubling intensity. As far back as 2011, the American Society of Plastic Surgeons (ASPS) reported that more than 76,000 cosmetic procedures were carried out on teenagers in the age range thirteen to nineteen years. This ‘accounted for five percent

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of all cosmetic surgical procedures performed in the United States that year’.44 In the United Kingdom, the Advertising Standards Body (ASA), concerned particularly about the impact of cosmetic surgery advertisements on youth, has banned advertisements promoting surgical intervention in such a way as to trivialise its potential dangers. Advertisements aired on the commercial television station ITV during the reality TV show Love Island were banned as ‘irresponsible’ and ‘harmful’, and a subsequent complaint about a radio advertisement by Cosmedicare, a provider of cosmetic surgery and free consultations also resulted in a ban. The complaint stated concerns that the advertisement, which showed a woman cavorting in a bar to ‘show off her new body’ by performing a belly dance, ‘exploited young people’s insecurities about their bodies’. The complaint went on to add that the tone was trivialising and ‘linked social confidence and attractiveness to cosmetic surgery’. Responding to contentions that irresponsibility and harm were embedded in the advertisement as a whole, not only the images but the voice over, Cosmedicare justified the advertisement as providing ‘an anecdotal example of the kind of transformational benefits’ such surgery could provide. Far from supporting the advertisement, this reading of it might be seen as compounding the problem. Indeed, contrary to this rationalisation, the complaint was upheld as ‘trivialising’ the personal dangers and health outcomes of ‘what should be considered a serious and potentially risky medical intervention’.45 In the end, however, the greatest source of clientele whether for professionals or the side trade that operates in the filler, Botox and other ‘less invasive’ dimension of the industry is the adult female population. Although women have ever been at the behest of our bodies, never satisfied and always finding some flaw, the magnitude of the problem, driven by the industries that profit from women’s bodies, has become more dire. Women of non-Anglo-Saxon or Western background bear a high-level of risk due to the Caucasian imperative: ‘white’, thin, slender ankles … Skin whitening and hair straightening have plagued, and their product promoters exploited, insecurities of women of African origin,46 just as eyelid procedures and their advocates and agents have exploited the insecurities of women from east Asia.47 That the December 2017 cover of Vogue created such uproar in its being hailed as the first time a model of non-Caucasian appearance had taken the honoured spot is evidence of this bias.48 ‘Mixed race model’ Adwoa Aboah’s image graced the cover.

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She, with ‘twinkly blue eyeshadow and glossy red lips … courtesy of make-up artist Pat McGrath who … allowed Adwoa’s signature freckles to show through’, was clothed in a dress and turban by designer Marc Jacobs, whilst wearing Bhagat diamond earrings from India. Writing in the Telegraph, Bethan Holt observed that in ‘an industry plagued with a diversity problem’, the cover ‘looks to the future through a retro lens, paying homage to the glamorous exoticism of the late 1970s’.49 Here, she alludes to Jerry Hall and Bianca Jagger ‘partying at Studio 54’, whilst referencing Adwoa Aboah’s shared Ghanaian heritage with the first male Vogue editor, Edward Enninful. Adwoa Aboah’s father is from Ghana. Edward Enninful was born there. The Guardian reports that today, Adwoa Aboah is ‘one of the most photographed women in the world’.50 Now, she has appeared on Vogue’ s German, United States, Italian, Mexican and Spanish covers, as well as W , i-D and Time Magazine. Buses and shop fronts carry her image, whilst she ‘regularly adorns 100ft canvases in airports’.51 On the catwalk and in fashion spreads she has done Fendi, Gap and Versace campaigns. With a Barbie representing her, bearing her brown complexion and shaved head, as well as ‘her own line of jewellery’, she has ‘made it’. Interviewed by the Guardian, Adwoa Aboah says that at school as a teenager she felt ‘pressured, unhappy and insecure’, missing classes on numerous occasions. Following her successes, she took time out to recover from depression, addiction and bipolar disorder. Assuredly, these afflictions can hit anyone, particularly in modelling and fashion circles. Anorexia nervosa and bulimia are notorious for girls and women in these industries. Yet a significant fact to take away from Aboah’s story is that the Caucasian ideal continues to rule. Yes, other models of minority ethnic and race background come and stay, in the way of Naomi Campbell, or come and go, in the way of those who like Gitanjali Nagpal might shoot into sight, feature a time, then disappear.52 The number of those featuring prominently who fit into the minority background category are far fewer than their Caucasian counterparts as they sashay down the catwalk, fill endless pages of advertisements and television campaigns, or walk the Bafta red carpet, and its crimson or scarlet equivalents at the Oscars or Cannes.53 Along with the media, the modelling industry must bear a responsibility for the continuing and burgeoning impact of the Caucasian-led demand for body modification. In Japan, for example, models are said to have double eyelid surgery, then seek to conceal it, whilst they tread the fashion runways effectively forced to copy their ‘white’ competitors.54

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Yet the Caucasian ideal is so clearly unreal. Otherwise, surgeries and their lesser competitors, the hotel rooms, spas and ‘pop up’ sites providing procedures demanded by women persuaded that their own bodies are simply not good enough would not make the profits they do, nor have the ready clientele.55 Responsibility is also required for the impact of a ‘body diktat’ on young and younger women and girls, and the encouragement of grown women in the industry to imitate an adolescent image. That the modelling industry at various intervals protests that it is setting standards to discourage anorexia nervosa, bulimia and other eating disorders or unhealthy practices confirms their existence. Models themselves have joined in an effort to change the culture. New industry practices are required to discourage the pressure, sometimes intimidation, maltreatment and coercion, resulting in reduced health and well-being for models, and the projection of false body images for audiences.56 ‘Eat rice balls and walk around the block to lose two inches from your hips’ or ‘tone up’ and ‘shed inches off your face’, as well as recommendations for other exotically weird diets are recounted as agency demands.57 That the industry declares it is setting an ‘age’ rule, so that young women and girls below a certain age will not appear on the catwalks or in fashion shoots,58 may be honoured in the breach. If mannequins are kitted out or primped and powdered so that they appear younger than they are, the setting of an ‘age’ rule is undermined. The notion of what is a natural body for an adult woman is distorted. Against this million- and billion-dollar background, the question is whether it is possible to evade these body-changing industries, to establish an acceptance by women (and men) that women’s bodies as they are, are not only real but acceptable, even desirable. Is there a role for the law, and what of other elements in the economy, culture and society?

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My Body, My Self---

Despite increased visibility of women in positions of some power in institutions formerly populated almost solely, if not solely by men, the cravings generated in women for the bodily perfection of ‘not my body, that one’ have become more intense in the relatively recent past. Whilst stars and celebrities such as Jane Fonda and Victoria Beckham declare with much fanfare that they are renouncing the knife, or removing breast implants, and determining to return to some semblance of their original selves,59 the beauty industry continues on its ubiquitous way, accompanying its

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more intrusive counterpart, the cosmetic, aesthetic and plastic surgery complex. Writing in 2005, Sheila Jeffreys comments that the ‘brutality of beauty practices women carry out on their bodies has become much more severe in the last two decades’.60 This includes ‘breaking of skin, spilling of blood and rearrangement or amputation of body parts’. Jeffreys refers to the importation into women’s bodies of ‘foreign bodies’ in the form of breast implants, ‘placed under the flesh and next to the heart’. Cheeks, chins and labia are all of a muchness when it comes to what can be changed, what altered, what ‘remedied’. Similarly, the all-pervasiveness of beauty practices centred in the promotion of a single ‘look’ is central to Susan Bordo’s thesis. This affects women from all cultures and backgrounds.61 As an example, she employs Essence magazine with its increasing supply of myriad ‘diet and exercise features’ directed at young African American women in particular. The equation of success with slenderness, pervading as it does dominant Western culture, relentlessly undermines ‘the preservation of alternative ideals of beauty’. The ‘possibility of greater upward mobility’, says Bordo, is now generating within this youthful cohort an imposed desire for the Caucasian ‘ideal’: To imagine that African American women are immune to the standards of slenderness that reign today is …. to come very close to the racist notion that the art and glamour—the culture—of femininity belong to the white woman alone. The black woman, by contrast, is woman in her earthy, ‘natural’ state, uncorseted by civilization …62

Susan Bordo is mindful of the way the body-(re)shaping industries have parasitically incorporated feminist rhetoric to justify and boost their product. Face lifts, implants and liposuction are, she notes, ‘advertised as empowerment, “taking charge” of one’s life. “I’m doing it for me”— the mantra of the talk shows’. For Revlon, when Melanie Griffith was of an age to be acceptable to head-up a cosmetic promotion campaign, the actress intoned: ‘Defy your age’. Bordo comments sardonically upon the subtext: ‘We’re making a revolution, girls. Get our injection and pick up a sign!’63 The continual destabilisation of women’s sense of ourselves as ‘properly constructed’ rather than ‘The Other’ sets women in a never-ending pursuit of acceptability as legitimate actors in a patriarchal world. One aspect of the current state of this chase is the attack on women’s sexuality and sexual pleasure occurring in the impositions placed upon women by the body industry. Women’s breasts and now women’s genitals are a

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significant focus. Breast augmentation is at the top of the list of procedures, despite the implant scares occurring at regular intervals over the decades of the availability of this surgery.64 Now nipples, the most sensitive part of the breast and highly engaging in terms of sexual pleasure, are being remade. That it can be suggested that the surgeon’s knife, however delicately manipulated, will have no impact on sensitivity of this part of a woman’s anatomy and upon her sexual pleasure belies belief. Perhaps the surgeons’ protestations are correct. But every woman surely must question this. Just as men reportedly draw their legs together when discussion of penile and testicular surgery takes place, so women are likely to experience a tug of concern for their upper bodies when nipple ‘correction’ is touched upon. The intrusion now well-advanced by roving into the genital area is more than problematic, too. Women are likely to draw their legs together emulating men’s reaction to the possibility of a scalpel’s intrusion into their groin area. Little wonder that questions are being raised as to the possible application of female genital mutilation laws to surgical cutting of adult women’s labia and other intimate parts of the genitals.65 Can it truly be believed that surgical enlargement of the ‘G’ spot would make it more susceptible to sexual pleasure or pleasuring? What of the dangers of scalpel slippage when labia minora are shortened or made smaller or narrower so as to fit within the labia majora? Is clitoral tweaking or clitoral hood rearrangement truly suggested as not only failing to interfere with women’s sexual pleasure but enhancing it? That women are participating in operations that may leave their breasts and vulva looking ‘better’, yet running the risk of damage and denying their sexuality is an indicator of how powerful messages are of women’s bodies simply being ‘wrong’. In any event, the notion that women having come through these procedures will consider the outcome does look better is questionable. A perusal of the internet finds ready examples of women unhappy with the result of surgical invention on all parts of their bodies, the vulva and breasts not least. The internet also records women returning for more, seeking correction of what has been done, as the holy grail of flawless beauty remains out of reach. What’s more, even without these failures, women return for more. The impression gained from the ‘success’ stories is that the operations or procedures are ‘one off’. A woman goes into an operating theatre, a clinic or salon—even an hotel room—undergoes the magicking process, then comes out perfection personified. And that’s it! But that is not it. Even if the woman is perfectly satisfied, a single visit

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does not end the matter. Repeated treatments, processes, procedures or operations are required to keep up the plastic pretence. This is because the results, however ‘good’, do not last forever, whatever the clinics and surgeries, advertisements and websites might say. Not only human bodies age. The products put into them, or onto them, do, too. Botox—and you are back within six months. Colour and you are back within six weeks. Breast implants—give it ten years’ maximum for the ‘best’ shape retention. Then, ironically, the body that has been ‘done’ may age less well than the body not done too. Furthermore, the ageing associated with the product itself may lead to the body into which it has been injected becoming unsightly with age. At the same time, the advertising industry continues to propound the notion of perfection. Sometimes, displays of female dress models tied up in department store windows appear, as if women roped and tied in a fashion spectacle of their bodily beauty are the perfect depiction of the ‘real’ woman. Or beautifully dressed and embodied women are seen playing ‘dead’ in fashion shoots, as in Marc Jacobs’ 2014 campaign.66 Featuring Miley Cyrus on a moonlit beach with two companions, one alive, one dead, Cyrus ‘stares moodily into the middle distance’. One of the women is stood beside her, the other is ‘flat on her back, hair partially covering her face, with the stiff, sightless demeanour of a body in the morgue’.67 A Jimmy Choo campaign featuring Jimmy Choo shoes in 2006 predated Jacobs with a similar theme. This time no beach, but a car boot, a spade brandished by her (alive) companion, a man in dark glasses, a smart suit and burial on his mind.68 It can be no coincidence that the body part running counter to the dominant demand of ‘thin equals desirable and desired’ is that rising rapidly in the competition for which part of a woman’s body will be selected for manipulation next: a woman’s derriere. This may appear as a revolt by women against the thinness diktat in its mimicking of the buttocks of women of African origin and descent naturally possess. Yet the Brazilian butt lift is the most dangerous operation of all. Designed to bring about the now Vogue-endorsed curvaceous bottom, women pursue the Vogue seal of approval. Simultaneously in pursuit of rebellion or exercising agency, women run the risk of dying under or after the anaesthetic.69 What of the law? An indication that globally women are impacted equally by the rapid rise of the industries seeking to remake woman in plastic and that throughout the world ‘cosmetic interventions have been

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normalised’,70 the United Kingdom 2013 Review of the Regulation of Cosmetic Interventions was preceded by an Expert Group on the Regulation of Cosmetic Surgery in 2005. Between those dates came a report On the Face of It ,71 published in 2010 by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD),72 and in the same year the Australian Health Ministers’ Advisory Council published findings proposing a ‘National Framework’ to regulate the area.73 Australian states have begun taking regulatory action independently. In Victoria, the Health Services Act 1988 was amended in 2017, coming into effect in 2018 to regulate all surgery, including cosmetic surgery. Since the amending Act’s proclamation, it is illegal to74 : • Perform any surgery (including cosmetic surgery) in facilities not registered with the Victorian Department of Health and Human Services; • Perform liposuction in any unregistered facility—this to include all procedures involving more than 200 ml of ‘lipoaspirate’ (fat) being removed in total from the patient/client; • Administer anaesthetic (other than low doses of local anaesthetic) in an unregistered facility. This accords with the Act’s requirement that: • All surgery must be conducted in a registered private hospital or day procedure centre; • Liposuction and anaesthesia, including intravenous sedation and anything over and above a low dose of local anaesthetic, must be carried out in a registered private hospital or day procedure centre. More recently, in January 2020 the UK All-Party Parliamentary Group on beauty, aesthetics and wellbeing announced an inquiry into the lack of regulation of those working in the filler industry.75 In advance, the All-Party Group had under consideration: • A legal ban on fillers for those under eighteen years of age; • Restrictions on advertising of fillers on social media sites; • A central register of approved practitioners to be government maintained or endorsed.76

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Predating this, all-encompassing reviews have been undertaken in Denmark, Sweden, Hong Kong and the European Union. In Denmark regulations introduced in 2007 provide for: • All persons conducting cosmetic interventions to be registered with the Danish Health Board and open to unannounced inspections of premises and practices by the Board; • Cosmetic surgery to be performed by plastic surgeons only, if they are qualified in the field or, being qualified in another field, the plastic surgery relates to the anatomical area of their expertise— the example given is of ear, nose and throat specialists carrying out cosmetic surgery on ears and nose; • Non-surgical cosmetic procedures including botulinum toxin injections, dermal filler injections, laser or IPL for smaller vein and fine wrinkle removal or hair removal, chemical peels and sclerotherapy to be carried out by consultant dermatologists or plastic surgeons and, with botulinum toxin injections ophthalmologists and neurologists, with a requirement that laser and IPL treatments to be conducted only by those having specific qualifications; • Nurses and junior doctors may conduct botulinum toxin injections, dermal filler injections, laser or IPL treatments for smaller vein and fine wrinkle removal or hair removal, weaker chemical peels (with a pH value of 3 or over) and sclerotherapy in small blood vessels, under delegation of a consultant who maintains overall responsibility for the patient; • Non-health care professionals to perform dermal filler injections, weaker chemical peels and laser or IPL treatments to remove hair, smaller veins and fine wrinkles so long as they hold a recognised beauty therapy qualification recognised by the Danish Health board and can demonstration that this qualification meets the relevant competencies, and deemed competent by the doctor who employs them; • Patients can seek help of the National Patient Complaints board when complications and complaints arise, and patients of state and private healthcare can seek compensation through the National Patient Insurance Scheme.77

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More recently in Scotland the Consultation on the Regulation of NonSurgical Cosmetic Procedures led to the government proposing new regulatory requirements, a further confirmation of the growing concern about the extent and scope of practices affecting women’s health in particular.78 There is no doubt that the body modification industry requires firm intervention and regulation. All providers must be insured, for what use a successful negligence claim, with compensation or damages awarded, if the provider is not insured, or has no capital, income or other resources from which to pay. Legal action needs to be available as a control over poor practices and exploitative and potentially damaging procedures carried out by professionals with extensive training and qualifications, and those operating in the field with little training and few or fewer credentials. Measures need to be taken to ensure that if a clinic, surgery or company is sued successfully, they cannot leave the company behind, an empty shell, so that again there is no recompense for the person harmed. Additionally, the criminal law must be more acutely focused on what are legitimate and what are not legitimate practices. The problems arising in Regina v. BM 79 must be reviewed either by a higher court (the Supreme Court) or by legislation. Similarly for other jurisdictions such as Australia, Canada and the United States, where the scope of consent to bodily harm, body modification and the vast and growing range of aesthetic, cosmetic and plastic surgery and procedures carried out in various guises by trained and untrained, registered or unregistered practitioners must be addressed. There is a need, too, for better regulation of products used in cosmetic interventions. The European Union does regulate product development and the need for product approval, as does the United States Food & Drug Administration (FDA).80 Nevertheless, as the Final Report of the Review of the Regulation of Cosmetic Interventions points out, products used in cosmetic interventions ‘include implants, medicines such as botulinum toxin and injectable dermal fillers’, with the market expanding exponentially.81 Various forms of equipment are employed, with new apparatus and paraphernalia appearing on the market in what appears to be an escalating onslaught. The issues around the PIP breast implants scandal, the vaginal mesh scandal, scandals relating to silicone breast implants and other intrusive products injected or incorporated variously into women’s bodies illustrate too well the vulnerability of women and the potential impact on girls. This is exposed as an area of serious concern. Too little is done to ensure that women of all ages are not left

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open to misrepresentation, misapplication of merchandise and commercial wares, and application of faulty or damaging equipment, products or medications. Ultimately, however, whatever steps are taken in the law, this does not address the nub of the problem. At its heart lies the question of women and women’s identity: who are we, as women and what should we be? Who says how we should be, who dictates the ‘look’ to which we must all aspire and how is it that every one of us can be susceptible to falling into this trap? How can we escape it, if at all? Are our lives, health, wellbeing and very existence in the world to be constructed out of a dominant ideological demand, driven by cultural and racial or ethnicity biases, as to size (thin versus fat, slim versus curvaceous, hourglass versus scarecrow, slender versus beach ball), acceptable versus unacceptable features (bottom, bosoms, hair, vulva and vaginas, toes, ankles, feet …) and the changes over time dictating which part/s of women’s bodies we profess to ‘hate’, which we seek to change, and the entire question of whether it is ‘beauty’ we seek or simply to ‘look normal’, ‘ordinary’, not ‘out of place’. In The Invention of Women—Making an African Sense of Western Gender Discourse, Oyeronke Oyewumi observes that for the West, the notion of society is that it is constituted ‘by bodies and as bodies—male bodies, female bodies, Jewish bodies, Aryan bodies, black bodies, white bodies, rich bodies, poor bodies’.82 In this, she refers to ‘the corporeal body as well as to metaphors of the body’, drawing attention to ‘the sheer physicality that seems to attend being in Western culture’.83 Yet whatever the truth of the past, where cultures may have been organised with less or no concentration on the visual image of the body (as Oyewumi explains for Yoruba culture), now this emphasis on body is not isolated to the West. The statistics relating to aesthetic, cosmetic and plastic surgery generally and particularly with regard to eyes, noses and buttocks indicate that body is a central focus, with a defined meaning, and that the imperative of the perfect (sic) body is becoming or has become almost allpervasive. The plastic invasion of women’s bodies and minds—the notion that ‘fixing’ is necessary to make our bodies into what they ‘should’ be— threatens to become a global avalanche. Indeed, statistics may support a contention that, no longer simply a threat, perhaps it is. Dorothy Smith, in The Everyday World as Problematic: A Feminist Sociology, contends that a man’s body ‘gives credibility to his utterance, whereas a woman’s body takes it away from hers’.84 Despite this or

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because of it, many women of varying cultural backgrounds enter surgeries and salons to change their bodies or, rather, to have their bodies changed in an effort to gain credibility. Naomi Wolf related this in relation to women of the 1980s seeking higher level positions in business, and believing that to do so they should adopt measures to cover-up their age.85 This meant going down the surgical route and into operating theatres and clinics, or taking other less intrusive but nonetheless risky and often dispiriting modifications to make their bodies what they believed they had to be. All this, to succeed in a man’s world of commercial and corporate professionalism, which did not work in any event. And now, it seems, working from home is no antidote to the need to be seen to fit into the world of commerce, or even to communicate with colleagues, friends and family. Researchers at Swinburne and Monash Universities in Australia are presently looking at the impact on body image and interest in aesthetic, cosmetic and plastic surgery of Covid 19 and time spent on video-calls such as Zoom.86 The impact, it appears, is not inconsequential. Zona Black reports that with the Covid-19 lockdown, Australians’ ‘desire for cosmetic surgery tripled … and remains higher than normal’. This is attributed, at least in part, to video-conferencing, with Zoom the major culprit.87 Apparently ‘seeing ourselves differently … from frontfacing cameras’ is triggering the surge. One patient is quoted as saying that until she saw herself on Zoom, she had not realised that her mother’s ‘turkey neck’ was replicating itself upon her own (previously unremarked). Thus, the more we Zoom, the more ‘wrinkles, unflattering angles and perceived flaws we’re spotting’, sending us researching avidly—and fortunately for some (particularly those working in the aesthetic, cosmetic and plastic surgery industry) ‘the more time we have’ to discover just what can be done to our bodies. This includes going off to the dentist for teeth whitening, straightening, crowning, veneering and capping. A dentist alludes to a 30 per cent rise in enquiries for cosmetic dentistry. Beyond the gums, one plastic surgery clinic ‘saw a 300 percent increase in inquiries for facelifts and rhinoplasty during the first lockdown period’. Meanwhile, ‘sales of beauty products – like skin masks – rocketed in March and April’.88 Working women ‘have always wanted to get a facelift’, says the surgeon confidently, ‘but never had time to research it properly because they were too busy working’.89 Now, spending more time without make-up means noticing consequences such as ‘jowls and hooded eyelids’ which are ‘normally covered in eye shadow’. Reportedly, Zoom’s in-built mechanism for

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airbrushing features does not always ‘stand the test of time and ageing’.90 And just as Covid-19 is global, so, too, the impact of video-conferencing on the world and women. This 200 per cent increase in inquiries about neck lifts and eyelid surgeries, tripling of interest in facelifts, is replicated in the United States. Responses from a national survey of over 1000 consumers conducted by the American Society of Plastic Surgeons found 29 per cent of all respondents ‘indicating specific treatments—such as rhinoplasty, face lifts and breast augmentation’ as being ‘top of mind’ for them.91 Some 49 per cent of respondents not previously open to plastic surgery advise that they’ve changed their minds, adopting a readiness to ‘go under the knife’.92 ‘Puffing up of pouts’ is on the rise, too, with face masks able to conceal until lips and mouths are ready for the reveal, and more and more young people, scrutinising themselves not only via selfies but now through online classes and conversations, are realising that time is catching up with them, driving them to beautification.93 At the same time, standard plastic surgery procedures remain popular, without Covid-19 heralding any downturn. New inventions come onto the market without pause. A ‘low-level green laser designed for body fat reduction’ is advertised as having gone through ‘three separate clinical trials, with no known side effects’.94 With the capacity to ‘emulsify the adipose tissue and release excess fatty materials’, the machine is ‘a natural alternative for fat loss’. Perhaps its ‘green’ design may comfort users concerned about climate change and the environment. The combination of adipose removal with a sense of environmental awareness (not claimed, but subliminal?) may add a comforting level of enticement. Meanwhile, the American Society of Plastic Surgeons reports that the ‘most asked for treatments’ were ‘injectables’, followed by ‘more invasive procedures’ including 65 per cent wanting Botulinum Toxin Type A (Botox), 44 per cent craving for breast augmentation, 37 per cent desirous of soft tissue fillers, liposuction being the method of choice for 30 per cent, with abdominoplasty coming in at 24 per cent.95 Indeed, coronavirus may have influenced the latter, reports of people ‘putting on weight’ during lockdowns being commonly reported upon.96 So much effort, so much readiness to undergo operations, procedures and pushing, pressing, pulling, poking of the body, but to what end? In the very changing of their bodies, women’s position in the world is not made more powerful, at least not in ways that are self-sustaining and world enhancing. The turning of women’s bodies into plastic temples will not transform the world. Nor will it make women free.

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Still, the conquest or subjugation of women’s bodies by the surgeon’s scalpel and the beautician’s procedure, the eyebrow threader’s dexterity and the ministrations of the fish pedicurist, is not absolute. Some women have turned their backs on the prospect of performances in plastic, taking as their touchstone the 1970s vision of our bodies as ourselves … Our Bodies, Our Selves .97 Some, once having welcomed plastic intrusions into their lives, now changing their minds have readily returned into the hands of their surgeons to have breast implants removed.98 The writer George Elliot, otherwise Mary Ann Evans, once said: ‘It’s never too late to become the person you might have been.99 Would she have been impressed by the proposition that now, in the twenty-first century, the becoming of a woman as the person she can be is one shaped by cosmetic or aesthetic surgery, moulded into a plastic persona? Is this what George Elliot intended, or meant? Perhaps women now returning to their ‘ordinary’ selves, the selves that are not endowed with artificial intrusions have, albeit at the pain of surgical removal, escaped the potential longterm damage of a life directed into a plastic performance. Would that all women could renounce the plastic first, marking any return to the surgeon unnecessary, with every woman resisting the lure of the plastic through beginning, living and celebrating our lives as our own, as our very own selves.

Notes 1. See, for example, ‘The September Issue’ (film), IMDb, 2009, https:// www.imdb.com/title/tt1331025/ (accessed 7 November 2010). 2. ‘The UK Fashion and Apparel Industry: Trends and Business Opportunities’, Alliance Experts, https://www.allianceexperts.com/en/knowledge/ countries/europe/opportunities-in-the-uk-fashion-industry/ (accessed 1 May 2019). 3. ‘How Fashion Fuels the UK Economy’, CIC UK to the World, https:// www.thecreativeindustries.co.uk/industries/fashion/fashion-facts-and-fig ures/how-fashion-fuels-the-uk-economy (accessed 1 May 2019). 4. ‘The September Issue’ (film), ibid. 5. Bianca London, ‘Has “Bikini Bridge” Become the New Thigh Gap Disturbing New Selfie Fad Circulating on Social Media’, Daily Mail, 7 January 2014, https://www.dailymail.co.uk/female/article-2535098/lsbikini-bridge-new-thigh-gap-Disturbing-new-selfie-fad-circulating-socialmedia-html (accessed 18 April 2018). 6. Hannah Marriott, ‘Inbetweenie, Life-Size and Curve: The Language of Plus-Size Modelling’, The Guardian, 10 November 2015, http://www.

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10.

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12.

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theguardian.com/fashion/2015/nov/10/language-plus-size-modellingfashion (accessed 11 November 2015). Ibid. Ibid. Damien Gayle, ‘Model Who Criticised Agency: I Spoke Out About Body Shape to Protect Girls’, The Guardian, 16 October 2015, http://www.theguardian.com/lifeandstyle/2015/oct/16/modelcriticise-agency-spoke-out-body-shape-protect-girls (accessed 18 October 2015). Ibid., and see Rose McGowan, Brave, HarperCollins, New York, NY, USA, 2018, for this phenomenon of bullying and pressure into body conformity in the film and television industry. Susie Orbach, Bodies , Profile Books, London, UK, 2009, 2010, 2016; Sheila Jeffreys, Beauty and Misogyny—Harmful Cultural Practices in the West, Routledge, Oxford, UK, 2014; Susan Bordo, Unbearable Weight — Feminism, Western Culture and the Body, University of California Press, Berkeley, Calif., USA, 1993, 2003. Catharine Mackinnon and Andrea Dworkin (eds), In Harm’s Way—The Pornography Civil Rights Hearings, Harvard University Press, Cambridge, MA, USA, 1998; Gail Dines, Pornland: How Porn Has Hijacked Our Sexuality, Beacon Press, Boston, MA, USA, 2010. Joe Pinsker, ‘The Hidden Economics of Porn’, The Atlantic, 4 April 2016, https://www.theatlantic.com/business/archive/2016/04/pornog raphy-industry-economics-tarrant/476580/ (accessed 4 April 2016); Shira Tarrant, The Pornography Industry, Oxford University Press, Oxford, UK, 2016. Thao-Mi Bui, ‘The Economics of Pornography Stripped Down’, Essa, 15 September 2017, http://economicstudents.com/2017/09/econom ics-pornography-stripped/ (accessed 16 September 2017). Bui’s work is criticised by Shira Tarrant, The Pornography Industry—What Everyone Needs to Know, Oxford University Press, Oxford, UK, 2016, but it is difficult to deny the burgeoning wealth of this industry, particularly with bearing in mind the pervasiveness of pornographic images and exploits in all parts of the media and particularly (but not only) online. ‘Global Blackmarket Revenue—Prostitution Revenue’, Havoscope, https://www.havocscope.com/prostitution-revenue-by-country/ (accessed 4 April 2019). Andrew Fogg, ‘How Much Does Prostitution Contribute to the UK Economy?’ Import.io, 26 September 2014, https://www.import.io/post/ how-much-does-prostitution-contribute-to-the-uk-economy/ (accessed 4 April 2017). Sheila Jeffreys, ibid., p. 4.

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18. Creative Bloq Staff, ‘This History of Photoshop’, Creative Bloq, 13 December 2005, https://www.creativebloq.com/adobe/history-photos hop-12052724 (accessed 4 April 2018). 19. Sofia Petkar, ‘Weighing Up. What Is a Feeder Relationship and How Does Fat Fetishism Work?’ Sun, 13 November 2018, https://www.the sun.co.uk/fabulous/7729619/fat-festish-fetishism-feeder-relationship/ (accessed 20 January 2020); Mark Griffith, ‘The Fat Fetish, Explained: A Brief Look at Big Beautiful Woman Squashing Fetishes Explained’, Psychology Today, 30 June 2015, https://www.psychologytoday.com/ us/blog/in-excess/201506/the-fat-fetish-explained (accessed 20 January 2020). 20. Sonya Renee Taylor, The Body Is Not An Apology—The Power of Radical Self-Love, Berrett-Koehler Publishers Inc., New York, NY, USA, 2018. 21. Sofia Petkar, ‘Weighing Up …’, ibid.; Mark Griffith, ‘The Fat Fetish, …’, ibid. 22. Susan Bordo, ibid., p. xviii. 23. Chelsea Ritschel, ‘Ivanka Trump Accused of Photoshopping Taj Mahal Photos’, Independent, 25 February 2020, https://www.independent. co.uk/life-style/ivanka-trump-taj-mahal-photoshop-edit-india-a9359396. html (accessed 25 February 2020). 24. Zona Black, ‘Zoom Calls Have Australians Rushing for Cosmetic Surgery’, The New Daily, 20 July 2020, https://thenewdaily.com.au/ life/wellbeing/2020/07/20/cosmetic-surgery-coronavirus-popular/ (accessed 16 August 2020). 25. Ibid. 26. Ibid. 27. Kathy Davis, Reshaping the Female Body—The Dilemma of Cosmetic Surgery, Routledge, New York, NY, USA, 1995; Bryan Mendelson, In Your Face, Hardie Grant Books, Richmond, Australia, 2013, see Chapter 6 and pp. 75–76. 28. Virginia L. Blum, Flesh Wounds —The Culture of Cosmetic Surgery, University of California Press, Berkeley, CA, USA, 2003. 29. Final Report —Review of the Regulation of Cosmetic Interventions, Department of Health, London, UK, 2013, p. 13. 30. See Montgomery v Lanarkshire Health Board [2015] UKSC 11; [2015] 2 WLR 768, https://www.supremecourt.uk/cases/docs/uksc-2013-0136judgment.pdf (accessed 20 January 2020); Chapter 2 this volume. 31. See Zahir v Vadodaria [2016] EWHC 1215 (QB), https://www. bailii.org/ew/cases/EWHC/QB/2016/1215.html (accessed 20 January 2020); Chapter 2 this volume. 32. On consumer protection in door-to-door sales, see, for example, United Kingdom—‘Door to door sales’, gov.uk, https://www.gov.

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39. 40. 41. 42.

43. 44.

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uk/doorstep-selling-regulations (accessed 20 January 2020); USA— Federal Trade Commission, ‘Door-to-door Sales and the FTC’s Cooling Off Rule’, Consumer Information, https://www.consumer.ftc.gov/blog/ 2015/08/door-door-sales-and-ftcs-cooling-rule (accessed 20 January 2020); Australia—ACCC, ‘Telemarketing and Door to Door Sales’, Australian Competition & Consumer Commission, https://www.accc.gov. au/consumers/sales-delivery/telemarketing-door-to-door-sales (accessed 20 January 2020). Ibid. Susan Bordo, ibid., p. xxix. Ibid., pp. xxix–xxx. Ibid. Final Report, ibid., pp. 11–12. Creative Research, Regulation of Cosmetic Interventions —Research Among Teenage Girls, Department of Health, Job No 623/Version 1, 11 March 2013, https://assets.publishing.service.gov.uk/government/ uploads/system/uploads/attachment_data/file/192030/Report_on_res earch_among_teenage_girls.pdf (accessed 20 January 2020). Ibid., para 3.2.1, p. 12. Ibid. Ibid., p. 13. The Girl Guides Association, Girls’ Attitudes Survey, 2012, http://gir lsattitudes.girlguiding.org.uk/home.aspx (accessed 4 April 2018), cited Final Report, ibid., p. 12. ‘L.A. Story’ (1991), IDMb, https://www.imdb.com/title/tt0102250/ (accessed 4 April 2019); see also Susan Bordo, ibid., p. xiv. American Society of Plastic Surgeons (ASPS), 2011 Plastic Surgery Report, ASPS, Arlington Heights, IL, USA, 2012; cited Canice E. Crerand and Leanne Magee, ‘Cosmetic and Reconstructive Breast Surgery in Adolescents: Psychological, Ethical, and Legal Considerations’, Seminars in Plastic Surgery, vol 27, no 1, 2013, pp. 72–78. Cosmetic Surgery Solicitors, ‘Cosmetic Surgery Advert Banned for “Trivialising” Cosmetic Procedures’, Our News, 16 April 2019, https:// www.cosmeticsurgerysolicitors.co.uk/news/cosmetic-surgery-advert-ban ned-trivialising-cosmetic-procedures (accessed 20 January 2020). Gaelle Faure, ‘Melanin Goddess Model Speaks Skin Bleaching’, Women and Girls, https://www.newsdeeply.com/womenandgirls/melanin-god dess-model-speaks-skin-bleaching/?utm_source=facebook&utm_cam paign=wg-auddev&utm_medium=cpc&utm_content=melanin (accessed 10 January 2017). Yumi Nakata, ‘Japanese Double Eyelid Surgery’, GaiJinPotBlog, 19 October 2014, https://blog.gaijinpot.com/japanese-double-eyelid-sur gery/ (accessed 4 April 2018).

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48. Bethan Holt, ‘Edward Enninful’s First Vogue Cover May Not Be Surprising, but It Will Go Down in History’, Telegraph, 7 November 2019, https://www.telegraph.co.uk/fashion/people/edw ard-enninfuls-first-vogue-cover-may-not-surprising-will-go/ (accessed 20 December 2019). 49. Ibid. 50. Afua Hirsch, ‘Adwoa Aboah: I Thought I Was Hideous: I Wanted to Jump Out of My Skin’, 15 June 2019, https://www.theguardian.com/ lifeandstyle/2019/jun/15/adwoa-aboah-model-activist-mental-healthafua-hirsch (accessed 20 January 2020). 51. Ibid. 52. Andrew Buncombe, ‘Flashback for a Model Who Fell Off the Catwalk’, Independent, 31 October 2008, https://www.independent.co.uk/news/ world/asia/flashback-for-a-model-who-fell-off-the-catwalk-980267.html (accessed 20 January 2020). 53. On the role of the film industry in imposing women’s bodily conformity, see, for example, Rose McGowan, Brave, HarperCollins Publishers, New York, NY, USA, 2018, particularly ‘The Premier’, coda to Part 1, Chapter 7, ‘Death of Self’, at pp. 131–132. 54. Ibid. 55. Final Report, ibid., paras 3.18, 3.27, pp. 22, 27. 56. Steff Yotka, ‘How Sara Ziff and More Than 40 Other Models Are Leading the Charge Against Eating Disorders’, V. A New Study Takes on Eating Disorders, 2 February 2017, https://www.vogue.com/art icle/model-alliance-eating-disorder-study (accessed 20 February 2020); ‘How Eating Disorders in the Fashion Industry Are a Labour Issue’, Model Alliance/A New Model For Fashion, https://modelalliance.org/ 2017/how-eating-disorders-in-the-fashion-industry-are-a-labor-issue/ how-eating-disorders-in-the-fashion-industry-are-a-labor-issue (accessed 20 February 2020). 57. ‘How Eating Disorders …’, ibid. 58. Myla Dalbesio, ‘It’s Not Your Imagination: The Modeling Industry Is Changing’, Yahoo Style, 9 March 2015, https://www.yahoo.com/lif estyle/its-not-your-imagination-the-modeling-industry-113168855653. html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuYmluZy5jb20 vc2VhcmNoP3E9bW9kZWxpbmcraW5kdXN0cnkrc3RhbmRhcmRzJk ZPUk09UjVGRDQ&guce_referrer_sig=AQAAAAIh9AEv2vgk4Uv9cAlm 5b0EtHtbuq5RBtAUpQfcp0yQ1EX3l6SVFsZkzk7h3Usru20123wuVy 1JrMsgioyf3NT0r64wTxZQvNjJMYBivnHXItwEIIlN3uZzLNXRKnH8 DNozZ5XOyaR9yIUe9Pv69zNZPyJe1ofvOAj6_Lodu1Jy (accessed 20 February 2020); also ‘Height, Age, and Measurement Requirements of Modelling’, Modelling Wisdom, https://modelingwisdom.com/height-

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67. 68. 69.

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age-and-measurement-requirements-of-modeling (accessed 20 February 2020). Wayne Dupree, ‘82-Year-Old Jane Fonda Announces She’ll Now Give Up Plastic Surgery for “Climate Change”’, Objectivist News, 17 February 2020, https://www.objectivist.co/2020/02/82-year-old-jane-fonda-ann ounces-shell-now-give-up-plastic-surgery-for-climate-change/ (accessed 16 August 2020); Celebrity, ‘Victoria Beckham Reveals She Had Breast Implants Removed’, Huffington Post, 20 February 2014, updated 6 December 2017, https://www.huffpost.com/entry/victoria-beckhambreast-implants_n_4823387 (accessed 2 January 2020). Sheila Jeffreys, ibid. Susan Bordo, ibid., p. 63. Susan Bordo, ibid. Ibid., pp. xxv–xxvi. Final Report, ibid., fn xix. Female Genital Mutilation Act 2003 (UK). The women’s blog, ‘How Female Corpses Became a Fashion Trend’, The Guardian, http://www.theguardian.com/lifeandstyle/womens-blog/ 2014/jan/09/female-corpses-fashion-trend-marc-jacobs-miley-cyrus? CMP=EMCNEWEML661912 (accessed 10 January 2014). Ibid. Ibid. Paige Driessen, ‘Brazilian Butt Lift Is the Most Dangerous of Plastic Surgeries’, Talking Democrat, 9 September 2018, https://www.thetal kingdemocrat.com/2018/09/the-brazilian-butt-lift-is-the-most-danger ous-of-plastic-surgeries/ (accessed 10 September 2018); Kelly Oakes, ‘Brazilian Butt Lift: Why Is the Cosmetic Surgery So Dangerous and Is It Legal in the UK?’, INews, 5 October 2018, https://inews.co.uk/ news/health/brazilian-butt-lift-cosmetic-surgery-dangers-risks/ (accessed 10 October 2018). Final Report, ibid., para 1.4, p. 9. NCEPOD, Cosmetic Surgery: On the Face of It (2010), https://www.nce pod.org.uk/2010cs.html (accessed 17 October 2019). NCEPOD, National Confidential Enquiry into Patient Outcome and Death, https://www.ncepod.org.uk/ (accessed 17 October 2019). COAG, Final Report—Cosmetic and Medical Procedures: A National Framework, http://www.coaghealthcouncil.gov.au/Portals/0/Cosmetic% 20Medical%20and%20Surgical%20Procedures%20-%20A%20National% 20Framework_Uploaded%20220216.pdf (accessed 17 October 2019). For an explanation of the Act’s provisions, see: Victoria State Government, ‘Cosmetic Procedures’, Better Health Channel, https://www.betterhealth. vic.gov.au/health/conditionsandtreatments/cosmetic-surgery (accessed 2 January 2020).

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75. Natasha Clark, ‘Facing Facts—Victory for The Sun as MPs Launch Inquiry into Unregulated Cosmetic Fillers’, Sun, 23 January 2020, https://www.thesun.co.uk/fabulous/10797535/mps-launch-inquiry-unr egulated-cosmetic-fillers-sun-campaign/ (accessed 24 January 2020). 76. Ibid. 77. Cited Final Report, ibid., p. 19; see also Melanie Latham and Jean V. McHale, The Regulation of Cosmetic Procedures—Legal, Ethical and Practical Challenges, Routledge, London, UK, 2020. 78. Scottish Government, Consultation on the Regulation of Non-Surgical Cosmetic Procedures in Scotland, 17 January 2020, https://consult.gov. scot/healthcare-quality-and-improvement/regulation-of-independent-hea lthcare/ (accessed 20 January 2020). 79. Regina v. BM [2018] EWCA Crim 560; and see Samantha Pegg, ‘Not So Clear Cut: The Lawfulness of Body Modifications’, Criminal Law Review, no 7, 2019, pp. 579–598. 80. Food & Drug Administration, https://www.drugwatch.com/fda/ (accessed 4 April 2018). 81. Final Report, ibid. 82. Overonke, Oyewumi, The Invention of Women—Making an African Sense of Western Gender Discourses , University of Minnesota, Minneapolis, MN, USA, 1997, p. 1. 83. Ibid., pp. 1–2. 84. Dorothy E. Smith, The Everyday World as Problematic: A Feminist Sociology, Northeastern University Press, Boston, MA, 1987. 85. Naomi Wolf, The Beauty Myth, Chatto & Windus, London, UK, 1990, p. 272; abbreviated version Vintage Classics, London, UK, 2015, pp. 227–228. 86. Zona Black, 20 July 2020, ibid. 87. Ibid. 88. Ibid. 89. Ibid. 90. Ibid. 91. American Society of Plastic Surgeons, ‘Plastic Surgery During COVID19 Pandemic’, Plastic Surgeon Match, https://www.plasticsurgery.org/ news/press-releases/american-society-of-plastic-surgeons-releases-newguidance-for-resuming-elective-procedures-amid-covid19 (accessed 16 August 2020). 92. Ibid. 93. Zona Black, 20 July 2020, ibid.; American Society of Plastic Surgeons, ibid. 94. ‘New Fat Reduction Laser Launches’, Aesthetics, 13 August 2020, https://aestheticsjournal.com/news/erchonia-launches-new-laser (accessed 19 August 2020).

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Index

A Aboah, Adwoa, 306 ‘mixed race model’, 305 actresses/prostitutes/fallen women, 3, 7, 32, 80, 89, 94, 102, 110, 121, 130, 199, 264, 300, 308 Adeotimi, Claudia, 227 adipose tissue inc fat emboli/embolism (fat), 49, 57, 229 fat fetishism/fat feed(er)ism, 300 fat-melting injections, 105 Kybella - injections, 133 layer/s, 165, 213, 224, 235 light therapy, 173 removal by liposuction, 49, 223, 237, 258, 259 return of (fat), 180, 237 surgery removal, 100, 101, 169, 172, 173, 258, 271 transfer of (fat), 49, 222–224, 226, 235, 236, 238, 254, 257 advertising/advertisement/s, 10, 12, 14–16, 21, 34, 65, 121, 197, 218, 303, 305, 306, 310, 311 deceptive, 88, 170

false/exaggerated, 42, 82, 88, 170, 264 industry, 14, 195, 310 misleading, 82, 88, 170, 264 Advertising Standards Body (ASA), 305 aesthetic, cosmetic and plastic surgery/industry, 3, 8–10, 14, 17–20, 31, 42, 54, 59, 89, 109, 124, 141, 171, 178, 195–198, 215, 229, 230, 233, 234, 262, 271, 285, 298, 301, 302, 308, 313–315 aesthetic, cosmetic or plastic surgeon/s, 4, 9, 13, 47, 59, 63, 64, 66, 93, 103, 152, 197, 218, 273, 304 operating tables of, 9, 17 and Zoom meetings, 301 Aesthetics , 103 African American inventors/cosmeticians, 12 African American women, 308

© The Editor(s) (if applicable) and The Author(s) 2020 J. A. Scutt, Beauty, Women’s Bodies and the Law, https://doi.org/10.1007/978-3-030-27998-1

373

374

INDEX

African, Middle Eastern, Asian characteristics, 7 Against Her Will – Men, Women and Rape, 35 agency. See women, and agency; women taking control over allergy/allergic reactions, 38, 45, 48, 83, 85, 100, 149, 169, 193, 251, 258, 265, 268, 281 Almond, Greg, 86, 112, 168, 170, 200, 258, 288 American Society of Plastic Surgeons (ASPS), 69, 90, 157, 158, 223, 304, 316, 320, 323, 324 American Society of Plastic Surgery, 218 anaesthetic, 37, 54, 60, 94, 227, 233, 238, 281 local/general, 43, 126, 128, 143, 167, 174, 175, 193, 226, 255, 257, 264, 270, 275, 311 risk, 100, 175, 179, 193, 226, 261, 310 Angell, Marcia, 135 Angelou, Maya, 238, 239, 247 Aniston, Jennifer, 81 anorexia nervosa/bulimia/eating disorders, 12, 184, 214, 215, 235, 306, 307 Anthony, Susan B., 69, 77 Aotearoa/New Zealand, 44, 45, 145 Aphramor, Lucy, 166, 172, 199, 201, 203 archetypal woman of film, 7 artistic vision, 2 The Art of Man: Faces of Plastics Surgery, 12, 26 Asia/Asian, 97, 121, 305 Asian American women, 98 Australia, 10, 14, 15, 33, 39, 44, 45, 66, 68, 77, 83, 91, 110, 112,

142, 144, 145, 188, 189, 191, 202, 240, 284, 296, 313, 315, 319, 320 Australian Cosmetic Surgery Magazine, 65, 194, 208 Australian Health Ministers’ Advisory Council, 311 Australian Health Practitioner Regulation Agency (AHPRA), 96

B Bacall, Lauren, 81 Bacca Baciata, 102, 120 Bacon, Linda, 166, 172, 199, 201, 203 Baker, Jes, 153, 214, 215, 218, 230 Banks, Tyra, 274 Banyard, Kat, 217, 230, 240, 245 Bariatric News , 182, 203 Bartels, M., 213, 240 Bartels, P., 213, 240 Bartmann, Sarah (‘Hottentot Venus’), 221 as exhibit, 8 representing female African sex and sexuality, 8 beauticians, 11, 53, 54, 58, 63, 64, 171, 232, 317 ‘beautiful, worldly woman’, 3 beauty contest/competitions, 2, 7, 32, 33, 109 cosmetics, 36, 40, 41 desire for, 10 ‘Eastern’, 97 globalization of standards, 98 industry, 12, 16, 31, 33, 45, 52, 103, 180, 232, 251, 298, 300 photography, film, 7 youthful, 88 Beauty and Misogyny, 102, 109, 141

INDEX

The Beauty Myth – How Images of Beauty are Used Against Women, 75, 157, 215, 240, 278, 295, 323 ‘Beauty of Women’, 91, 113 beauty parlour/salon, 12, 22, 36–39, 42, 44, 46, 47, 59, 79, 83, 84, 107, 133, 199, 214, 263, 265, 269, 274, 279, 302 syndrome, 84 Beauvoir, Simone de, 17, 27, 35, 70 Beckham, Victoria, 307 Beckinsale, Kate, 110 ‘before’ and ‘after’, 10, 11, 228, 271 Belgium, 96, 228 Berger, Karen, 159 Beyoncé, 218 Beyond Beautiful , 16, 27 Blondell, Joan, 213 Blum, Virginia L., 4, 19, 24, 26, 27, 301, 319 Bobergh, Otto Gustaf, 221 Bodies , 11, 26, 34, 54, 67, 70, 75, 293, 318 bodily conformation/bodily changes, 8, 10, 187 bodily dysfunction/distortion, 8, 304 body dysmorphia or body dysmorphic disorder (BDD), 9, 10, 12, 18, 19, 25, 64, 67, 141, 159, 175, 195, 196, 229 body image, 68, 88, 136, 141, 195, 196, 230, 231, 299, 307, 315 The Body Image Dissatisfaction and Psychological Symptoms among Invasive and Minimally Invasive Aesthetic Surgery Patients, 140, 159 The Body is Not An Apology – The Power of Radical Self-Love, 215, 240, 300, 319

375

body mass index (BMI), 167, 181, 199 body modification (BM), 57, 59–61, 63–65, 197, 218, 303, 304, 306, 313 industry, 313 Body Respect , 172, 199 Bordo, Susan, 3, 9, 24, 157, 299–301, 303, 308, 318–320, 322 Boston Collective, 178 Boston Women’s Collective, 150 Botox, 17, 31, 36–38, 57–59, 109, 110, 219, 258, 264, 265, 305, 310, 316 Bow, Clara, 99, 102 Bramwell, Ros, 195, 206, 208 Braun, Adolph, 2 Braun, Gaston, 2 Braun, Kirsten, 191, 206, 207 Braun, Virginia, 194, 208 Brazil, 131, 133, 144, 227 Brazilian, 83 full, 198 Brazilian butt lift, 8, 218, 223, 227–232, 310 buttock augmentation, 223, 227 buttock implant/s, 223–225 buttock lift/s, 223 buttock surgical intervention, 223 breast implant/s. See implants Breasts , 150, 158 Brennan, Summer, 278, 294–296 Bridget Jones’ Diary, 217 Brinkhurst-Cuff, Charlie, 217–219, 222, 240–242 Britain/British, 6, 61, 130, 143, 153, 221, 227, 228, 236, 284 British Association of Aesthetic Plastic Surgeons (BAAPS), 228, 229, 232, 236, 244 British Association of Aesthetic Surgeons, 153

376

INDEX

British Association of Cosmetic Nurses (BACN), 256 British Association of Plastic Reconstructive and Aesthetic Surgeons, 153 British Journal of Obstetrics and Gynaecology, 190, 207 Brownmiller, Susan, 5, 24, 35, 71, 285, 296 Buczynski-Lee, Karen, 1, 22 Bui, Thao-Mi, 299, 300, 318 bustle, 219–221 Butler, Diana L., 79, 110, 111 C A Cabinet of Ancient Medical Curiosities – Strnge Tales and Surprising Facts from the Healing Arts of Greece and Rome, 157 Caines, Kimberly, 166, 199, 201, 235, 237, 246 Calixto, Lilian, 227 Cambridge Daily News , 126, 151 Cambridge, Leah, 227 camera, 2, 153 cameraman, 2 Campbell, Naomi, 306 Campbell, Olivia, 299 Canada, 44, 45, 142, 145, 296, 313 Cano, Stefan, 136 Cardozo, Linda, 195, 206–208 Care Quality Commission (CQC), 266 Cartwright, Rufus, 195, 208 Caucasian, 90, 110, 305–308 celebrity/ies, 2, 14–17, 57, 65, 81, 92, 94, 102, 110, 121, 137, 181, 199, 219, 227, 229, 264, 269, 300, 301, 304, 307, 324 cellulite, 48, 54, 104, 170, 173, 237 celluloid image, 2 Chen, Constance M., 136

Cher (laPierre/Sarkissian/Bono), 130 China, 83, 93, 97, 98, 272, 274, 300 Choo, Jimmy, 275, 310 campaign, 308 shoes, 275, 310 chronic fatigue syndrome (ME/CFS), 19 Ciavucco, Mel, 324 civil law. See law Claudel, Camille, 2, 23 Cleopatra, 213 clinic, salon or spa, 8, 10, 11, 13–15, 17, 20, 22, 31, 42, 44, 49, 51, 54, 62, 64, 86, 96, 97, 102, 109, 122, 123, 127, 143, 149, 152, 173, 181, 189, 214, 218, 225, 227, 229, 238, 254, 256–259, 263–266, 275, 276, 280, 282, 283, 301, 302, 309, 310, 313, 315 Clinton, Hillary, 68 collagen, 37, 96, 97, 109, 110, 123, 173, 191, 225, 262, 263, 265, 276 Bovine collagen, 264 claim Isolagen ‘rejuvenated human skin’, 264 Isolagen Europe Ltd (IEL), 264, 265 Collins, E. Dale, 136 compensation. See law The Complete Book of Cosmetic Surgery: A Candid Guide for Men, Women and Teens , 10, 26 complications. See risk/s Conor, Liz, 7, 23–25, 31, 32, 65, 70, 76, 109, 118 consent. See girls; law Consumer and Competition Act 2010 (Cth), 88 Consumer Protection Act 1987 (UK), 134

INDEX

Consumer Protection from Unfair Trading Regulations 2008 (UK), 88 Consumer Rights Act 2015 (UK), 134 ‘containment’ of the body, 8 Cooke, Kat, 64, 76 Cordeiro, Peter G., 136 Cornforth, Fanny (aka Sarah Cox), 6–8, 102, 120 corset/s or girdle/s, 35, 131, 219, 242, 269 cosmetic industry. See pharmaceutical/cosmetic industries cosmetics/perfume production, 3, 30, 36, 39–41, 122, 133 Cosmetic Standards Practice Authority (CSPA), 255 cosmetic surgery/industry. See aesthetic, cosmetic and plastic surgery/industry Cosmetic Surgery, Gender and Culture, 14, 27, 152, 163, 179, 202 Cosmopolitan/Cleo/Elle, 15, 191, 304 Countess de Castiglione, 2 Covid 19 inc corona virus/coronavirus pandemic, 10, 315 Crawford, Cindy, 137, 158 Crawford, Joan, 213 Creighton, Sarah M., 193, 207, 208 criminal law. See law Crouch, Naomi S., 194, 207 culture/cultural aesthetic trait of black women, 218 appropriation, 219 dominant, 68, 303, 314 East/ern – Asia, Middle East, North Africa, 97 ethnicity and, 7 gender and, 180 hypocrisy, 194 imperatives, 7

377

influence/s, 32, 180 minority background, 306 norms, 138, 194 obsessive focus, 34 race and, 7, 18 religion and, 80 requirements of beauty, 300 Semitic, 98 Western, 97, 308, 314 Westernise – feature/s, 98 Cumming, Constance, 213 Cyrus, Miley, 310 D damages inc compensation. See law dancer/actress, 3, 31, 133 as circulating goods, 3 danger/hazard/risk, 8–13, 17, 20, 22, 48, 54, 80, 82, 83, 94, 122, 125, 144, 149, 169, 171, 193, 226, 227, 229, 253, 254, 267–269, 277, 278, 302, 305, 309 The Dawn, 284 Davis, Bette, 213 Davis, Kathy, 25, 26, 28, 118, 130, 135, 156–158, 202, 301, 319 Degas, Edgar (dancers)(1834-1917), 31 Delavigne, Cara, 99 Denmark/Danish Health board, 312 regulations, 312 dentists, 11, 43, 45, 105, 107, 301, 315 dental surgery, 105 dermal filler, 17, 104, 255, 256, 258, 275, 276, 279, 312, 313 multiple injections of, 17 dermatologists, 11, 251, 254, 312 The Dialectic of Sex, 35, 71 Diaz, Cameron, 199, 268, 274 Dieffenbach, Johann Friedrich, 89

378

INDEX

diet, 4, 12, 34, 166, 174, 182, 183, 185, 214, 217, 233, 236, 237, 307 dietary habits, 186, 237 and exercise, 105, 167, 237, 308 Dietrich, Marlene, 99 Dines, Gail, 299, 318 Dion, Celine, 274 Doing Harm – The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick, 19, 28 Dors, Diana, 135 Dow Corning/Chemical, 142 global challenge/s, 142 implants, 136, 142 law suit, 142 Dr Furtado (‘Dr Bumbum’ or ‘Dr Butt’), 227 Driscoll, Brogan, 222, 242 Dupree, Wayne, 322 Dusenbery, Maya, 19, 28, 202 Dworkin, Andrea, 294, 299, 318

E East/Eastern/Far East, 97, 142, 305 ‘The Economics of Pornography Stripped Down’, 299, 318 Ekland, Britt, 102 electrolysis/depilatory treatment/s, 59, 199, 265, 268 Elizabeth I, 97, 120, 121 Elliot, George (Mary Ann Evans), 317 emotional energy or inspiration, 2 Enninful, Edward, 306 The Equality Illusion, 217, 230, 240 Essence magazine, 308 ethnicity. See race/ethnicity Europe/European, 39, 45, 121, 220, 268 European Union, 45, 72, 312, 313

The Everyday World as Problematic: A Feminist Sociology, 314, 323 Extreme Makeover, 11 F facelift, 10, 92–96, 104, 105, 137, 315, 316 Face Value: The Politics of Beauty, 4, 24, 102, 116 fairy tales – Cinderella/The Mermaid/Ugly Duckling, 11, 33 Family Law Reform Act 1969 – s. 8(1), 66, 229 Farid, Ali Asghar Asgharnejad, 140, 141, 159 fashion/fashion industry, 3, 5, 10, 12, 16, 21, 32, 34, 42, 81, 90, 99, 109, 120, 135, 137, 147, 149, 166, 217–222, 239, 269, 270, 274, 285, 298–301, 303, 304, 306, 307, 310 Western, 97 The Fashioned Self , 98, 115 fat. See adipose tissue Fat is a Feminist Issue, 34, 70, 171, 201 Faye, Alice, 213 Federal Trade Commission Act 1914 (USA), 88 ‘Female Genital Anatomy’, 194, 207 female archetype, 5 The Female Eunuch, 70, 213, 239, 291 Female Genital Cosmetic Surgery – Solution to What Problem?, 193, 207 Female Genital Mutilation Act 2003, 64, 322 female genital mutilation (FGM), 64, 65, 187, 194, 309 The Feminine Mystique, 35, 71 Femininity, 5, 24, 35, 71, 285, 296

INDEX

feminist/feminism, 20, 33, 65, 195, 284, 308 criticism/critique, 15, 32, 35 discussion about cosmetic surgery, 14 writing – inc medical/legal writing, 14 Ferraro, Geraldine, 68 ‘The Fetishism of Commodities’, 3, 23 Fields, WC, 213 fillers, 16, 36, 47, 57–59, 102, 109, 143, 219, 225, 226, 254, 255, 262, 311, 316 chemical, 37 dermal, 17, 104, 255, 256, 258, 275, 276, 279, 312, 313 semi-permanent/permanent, 255 film actor/film star, 2 film and film medium into the film medium, 2 Final Report of the Review of the Regulation of Cosmetic Interventions , 302, 313 ‘Finished Consultant Episodes’ (FCEs), 181 Finkelstein, Joanna, 98, 115 Firenzola, Agnolo (1493-1546), 91 Firestone, Schulamith, 35, 71 Fire With Fire, 20 Flesh Wounds – The Culture of Cosmetic Surgery, 4, 24, 319 Fonda, Jane, 137, 307 Food and Drug Administration agency (FDA), 66, 67, 77, 142, 145–147, 149, 162, 173, 189, 313 Food, Drug and Cosmetic Act 1938 (USA), 88 Forbes , 31, 69 France/French, 2, 143–145, 188, 219, 221, 251

379

Franklin, Stella Miles, 284 Fraser, Suzanne, 14, 15, 17, 27, 109, 118, 152, 163, 179, 202, 205, 207, 245 Freeman, Jo, 35, 71 Freud, Sigmund, 141, 159 Friedan, Betty, 35, 71 ‘From Pompeii to Victorian Erotica’, 198, 209 G Garbo, Greta, 99, 213 Garner, Jennifer, 102 Garson, Greer, 81 ‘Gender Roles in the 19th Century’, 269, 291 General Medical Council (GMC), 196 Genital Appearance Satisfaction (GAS) scale, 195 Germany, 92, 135 Gharaee, Banafsheh, 140, 141, 159 Ghidraj, George, 107, 117 Gillard, Julia, 68 Gillies, Harold Delf, 90 Gilman, Sander L., 11, 26, 89, 92, 98, 113–115 girls/young girls/teenagers impact of magazines, 15, 304 parental pressure, 230 peer pressure, 16, 21 social media, 15, 16, 304 television, 15, 304 mother/daughter and cosmetic surgery/procedures, 66 parents offer their daughters cosmetic surgery/procedures as gift, 98 sexualisation of, 277 vulnerability of, 62, 313 Goodness Had Nothing to Do With It , 135, 157

380

INDEX

Greer, Germaine, 23, 34, 70, 71, 213, 214, 239, 240, 291 Griffith, Melanie, 102, 308, 319 ‘Guidance for all Doctors Who Offer Cosmetic Interventions’, 196 Guidance on the Management of Public Health Risks from Fish Pedicures , 282 Gwen John – a life, 1, 22 H Hadid, Gigi, 268 hairdresser/s, 11, 13, 30, 43–48, 51, 53, 82, 83, 85–88, 298 Hall, Jerry, 306 Hammer [or Anvil] of Witches , 80 ‘A Handbook for Unapologetic Living’, 214 Handley, Victoria, 40, 72, 108, 117, 152, 154, 161, 163, 238, 247, 258, 261, 266, 288–290 Harmon, SHE, 27, 56, 73–75 Harris, Kamala, 68 Hawes, Elizabeth, 283, 296 Hawn, Goldie, 102 Hayatbini, Niki, 140, 141, 159 health and safety, 85 Health Protection Agency, 282, 295 Health Quality and Complaints Commission (Qld), 96 Health Services Act 1988 (Vic), 311 Hemmings, Sally, 221 Henry, Alice, 284 Hepburn, Katherine, 213 high heels. See women, and shoes Hill, Michael, 108 Hippocrates, 135, 157 Holt, Bethan, 306, 321 home inc home-based, 4, 13, 20, 31, 33, 35, 37, 48, 49, 57, 84, 107, 123, 198, 224, 262, 263, 265, 274, 278, 284, 302, 315

products inc use of, 41, 86, 134, 263, 274 remedies, 122, 262, 274 Hong Kong, 312 hormone replacement therapy (HRT), 190 ‘Hottentot Venus’. See Bartmann, Sarah Housework, 1 ‘How to Lose a Muffin Top & Belly Fat Fast’, 166 How to Be a Woman, 198, 209 Hughes, Kathryn, 6, 24, 25, 116, 163, 269, 291 Hungary, 228 I image/s, 2, 7, 9, 11, 30, 31, 65, 69, 149, 150, 153, 196–198, 215, 217, 218, 232, 234, 257, 269, 271, 299–303, 305, 306, 314 adolescent, 307 in advertisements, 10, 305 employed by practitioners, 10 in magazines, 10, 15, 221, 301 implants abdominal, 233, 234 breast, 15, 40, 41, 66, 67, 135–137, 139–143, 145–147, 150, 152, 222, 300, 307, 308, 310, 313 buttocks, 223–225 calf, 273 celebrities and, 15, 307 dangers of, 144 deltoid, 127 dental inc crowns/caps, 106–108 gel, 145, 146, 273 German breast, 145 industrial silicone (mattress filler), 143 low-grade silicone, 143 mesh, 189, 190

INDEX

PIP breast implants, 144, 313 PIP industrial grade silicone, 145 Poly Implant Prostheses (PIP), 143, 144, 149 removal of, 106, 143, 147 saline, 66, 136, 146 scandal/s, 313 silicone, 37, 135, 136, 142, 143, 145, 146, 224, 273 Silimed, 145 tooth/gum, 47, 106 transdermal, 60 vaginal mesh, 313 Independent Report – Review of Regulation of Cosmetic Interventions , 256, 257, 287 India, 83, 301, 306 industrialisation homogenised production, 3 industrial revolution, 3 insurance. See law intersectionalities class/status/race/ethnicity, 18, 134 An Introduction to Beauty Negligence Claims , 86, 112, 168, 170, 200, 258, 288 The Invention of Women – Making an African Sense of Western Gender Discourses , 314, 323 In Your Face, 104, 114, 319 IPL technology/treatment (intense pulsed light), 254, 256, 265, 266, 274, 312 deregulation of, 266 Ireland, 145 Irigaray, Luce, 21, 22, 28 Ishikawa, Yumi, 278 Italy, 5, 22, 142, 144

J Jackson, Paris, 274

381

Jacobs, Marc, 306 campaign, 310 Jagger, Bianca, 306 Japan/Japanese, 97, 98, 145, 278, 306 jaw/s, 5, 103, 105, 106, 108 Jeffreys, Sheila, 102, 109, 115, 118, 141, 159, 299, 300, 308, 318, 322 Johannsson, Scarlett, 91 John, Gwen, 1, 2 Johnson & Johnson vaginal mesh (scandal), 189 Jolie, Angelina, 89, 138, 158 Jones, Bethany, 8, 25 K Kardashian, Kim, 218, 219, 225 Kaw, Eugenia, 98, 115 Kidman, Nicole, 102 Kirsop, Ethel, 216, 240 Klassen, Anne, 136 Korea/Korean, 98 Kramer, Heinrich, 80, 111 Kuleshov, Lev - Russian filmmaker, 7, 25, 31 Kybella injections/removing fat, 133 L labial hypertrophy, 8 labiaplasty, 8, 64, 187, 191, 192, 194–196 ‘Labiaplasty, Race and the Colonial Imagination’, 8, 25 Lake, Dawn, 91 Lakoff, Robin Tolmach, 4, 24, 102, 116 The Lancet/Lancet Infectious Diseases , 19, 146 laser, 167, 199, 215, 262, 263, 266–268, 316

382

INDEX

IPL technology/treatments, 256, 265, 267, 274, 312 liposuction, 49, 50, 54, 56, 126, 172, 173, 258, 270 removal, 36, 126, 265, 266 treatment, 56, 57, 166, 266 whitening, 107 LA Story (film), 304 Latifi, Noor Ahmad, 140, 141, 159 Laurie, GT, 27, 56, 73–75 law actual bodily harm, 19, 58–60, 62 assault/battery, 42 best interests child/patient, 179, 230, 231 and body modification, 60, 61, 63 burden/onus of proof (civil) on claimant/litigant/patient, 39, 46 civil, 67 compensation/damages claim/s, 21, 142, 234, 257, 302 consent mothers/daughters (taking to surgeries), 66 parental pressure, 230 consumer/trade practices, 88 contract/contractual claim, 45 contributory negligence, 41, 47, 85, 134, 233, 234, 268, 280, 283 criminal, 58, 59, 61, 63, 64, 66, 67, 313 damages inc compensation, 20, 21, 39, 46, 51, 313 defences, 41, 60, 61, 63, 234 defendant’s acts or omissions, 46 duty of care, 46, 48, 49 duty to advise, 179 expert evidence, 261, 267 Family Law Reform Act 1969 – s. 8(1), 66, 229 fraud, 144

grievous bodily harm, 18, 43, 59–61, 63, 283 and injury/harm, 20, 44–46, 48, 58, 60, 253 insurance inc insurers/underwriters medical/health care, 229 lawful justification, 19 legally recognised harm, 46 legal remedies, 20 legal wrongs, 21 liability, 38, 45, 50, 52, 61 manslaughter/involuntary injuries, 144 manufacturer/s liability, 274 and minors/minors’ capacity, 67 negligence, 38, 253, 254 dental, 108 medical, 108, 130, 139, 218, 226, 233, 234 and paternalism, 43 and patient autonomy, 50, 231 and patient dissatisfaction/discontent, 44, 226, 271 and patient satisfaction, 123, 136 and physical injury, 46, 48 and procedure/s, 18, 21, 43, 45, 46, 58, 60, 61, 63, 65, 141, 194, 302, 313 product defect/s, 41, 109, 266 product liability, 38, 39, 142, 263 professional skill and care, 59 and psychiatric/psychological injury, 46, 82, 152, 267 public health (liability), 283 remedy/ies, 20 representation/misrepresentation, 42 risk/complications, 18, 107, 302 and standard of care, 43, 49, 50 statutory provisions, 39

INDEX

and surgery, 20, 45, 58, 59, 61, 63, 65–67, 139, 141, 178, 229, 313 time limits, 41 tort/civil wrong, 45 and treatment/s, 20, 38, 46, 47, 49, 66, 229, 266 unlawful wounding, 19, 59, 124, 125 and vicarious liability, 51–53, 84, 85, 257 volenti non fit injuria, 41 Law and Medical Ethics , 56 Lawson, Louisa, 284 ‘The Legs of the Countess’, 2, 23 Lei, Berend van de, 197 Liao, Lih-Mei, 193, 207, 208 The Life and Loves of a She-Devil , 273 life-changing consequences, 8 Limitation Act 1980, 46, 259 Lindsay, Norman (22 February 1879 – 21 November 1969), 212 Lindsay, Timmie, 142, 150 liposuction to buttocks, 49, 105, 166, 222, 224, 228, 257 for calves/ankles/knees, 269, 271, 272 etching by, 233 fat removal, 172, 259, 262 focal excessive liposuction, 258 haematoma after undergoing, 168, 233 laser, 49, 50, 54, 56, 126, 172, 173, 215, 258, 270 minor, 257 muffin top erasure by, 167 and plastic surgery, 48, 135, 172, 173, 262, 271 smart, 167 surgical, 175 traditional, 49, 54, 168, 258, 270

383

by ultrasonographic waves, 167 of upper/lower abdominal muscles, 176 to upper/lower arms, 257–259, 262, 271 vaser, 167, 168 Lister, Kate, 198, 209 L’Oréal ‘false and unsubstantiated claims’, 264 Local Government (Miscellaneous Provisions) Act 1982, 60 Lo, Danica, 70 Loe, Judy, 110 Lohan, Lindsey, 274 London Harley Medical Group/Harley Medical Centre, 191, 265 Lopez, Jennifer /J.Lo, 218, 219, 222 Loren, Sophia, 135, 268 Louboutin, Christian, 285 Louis Pierson of Mayer & Pierson, 2 Love Island, 305 Lupino, Ida, 213

M Mackinnon, Catherine, 202, 299, 318 Madonna, 268 magazine industry, 14 Making the Body Beautiful - A Cultural History of Aesthetic Surgery, 11, 26, 89, 92, 113 male designers, 10 male gaze, 32, 65, 97, 141 male protagonists, 10 Man, Daniel, 12, 26 manicure/manicurist/s, 11, 43, 46, 53, 250–253, 298 Mansfield, Jayne, 135 marketed/marketing to women, 8, 264

384

INDEX

Markle, Meghan, 81, 91 Marsh, Sarah, 56, 57, 75 Martin, Emily, 18 Marx, Karl, 3, 23 Masculinity, 3 Mas, Jean-Claude (PIP French businessman), 144 Mayou, Bryan, 228 May, Theresa, 68 McCarthy, Colleen, 136 ‘Measuring Quality of Life in Cosmetic and Reconstructive Breast Surgery: A Systematic Review of Patient-Reported Outcomes Instruments’, 136, 158 Meat Market – Female Flesh Under Capitalism, 12, 26 media/social media, 12, 14–17, 34, 56, 57, 68, 81, 143, 144, 153, 187, 197, 215, 227–230, 269, 270, 278, 301–304, 306, 311, 318 Medical Law, 43, 73 medical negligence, 74, 130, 139, 169, 218, 226, 233, 234 medicines, 46, 95, 106, 125, 150 botulinum toxin, 104, 109, 256, 312, 313, 316 Mendelson, Bryan, 104, 105, 114, 116, 319 microblading, 37, 57, 59 Middleton, Kate, 81 Miles, Amy, 115, 158 Millett, Kate, 35, 70, 291 The Million Dollar Smile, 105, 116 Minogue, Kylie, 102 minors’ capacity. See girls; law ‘Mitigating Risks to Mitigate Costs’, 175, 201 Mo’nique, 274

Modigliani, Amedeo (models)(1884-1920), 32 Monroe, Marilyn, 33, 81, 91, 99, 135, 222 Montandon, Denys, 146, 157, 161 Moore, Demi, 102 Moore, Monica L., 79, 110, 111 moral imperative for the ageing woman, 4 moralism/middle-class morality, 4 Moran, Caitlin, 198 Moreland, Claire, 195, 208 Morgan, Elizabeth, 10, 26 Morgan, Marabel, 35, 36 Morgan, Robin, 35, 71, 291 Mousavi, Seyed Jaber, 95, 113, 114 ‘Muff March’, 199 Muir, Heather, 103, 116 Mwansa, Natasha, 222, 242 myalgic encephalomyelitis (ME/CFS). See chronic fatigue syndrome N Nagpal, Gitanjali, 306 narcissism, 4, 10, 270, 301 National Health Service (NHS), 45, 48, 100, 106, 138, 139, 143, 144, 174, 180, 181, 183–185, 189, 190, 228, 237, 280 Clinical Commissioning Groups (CCGs), 139 National Patient Insurance Scheme, 312 Natural Magick, 151 negligence/contributory negligence. See law Netherlands, 142, 197 Newman, Lyda (Patented Hairbrush Featuring Health, Brushing and Efficiency Improvements), 12, 26 ‘No (Wo)man Is an Island – The Influence of Physicians’ Personal

INDEX

Predisposition to Labia Minora Appearance on their Clinical Decision Making’, 197, 208 Noel, Suzanne, 92, 93, 114 non-health care professionals, 312 non-surgical procedure/s, 10, 13, 167, 168 normal/normalcy/normality, 4, 5, 8, 12, 17, 49, 65, 84, 90, 91, 96, 102, 109, 110, 125, 126, 131, 144, 147, 153, 167, 171, 177, 188, 193, 195, 225, 232, 253–255, 262, 274, 279, 301–303, 315 nature/desire to achieve ‘normality’, 10 wish to appear ‘normal’, 10 normal bodily construction as abnormal or deformed, 8 Nurka, Camille, 8, 25, 64, 65, 76, 187, 194, 205, 206, 208 O Oberon, Merle (1911-1979), 110 obese/obesity, 181, 199, 214, 217 Object, 64, 199 Offences Against the Person Act 1861, 59, 82, 124, 283 Office of National Statistics (ONS), 300 Oliphant, Margaret, 284, 296 The Only Way is Essex (TOWIE), 304 Orbach, Susie, 11, 34, 54, 67, 171, 299 ‘oriental’ nations, racism, ethnophobia, 97 Orientalism, 97 Osborn, Corinne O’Keefe, 148, 162, 163 Osman, Marie, 91 Our Bodies, Our Selves , 150, 163, 179, 202, 317, 324

385

Oyewumi, Oyeronke, 314, 323

P Palin, Sarah, 68 Paltrow, Gwyneth, 199 Parker, Sarah Jessica, 304 Parliamentary Women and Equalities Select Committee inquiry on workplace dress codes/mandated workplace dress, 278 Partridge, Jackie, 256, 287 Paterson, Mr Ian, 124, 125 pedicure/pedicurist/podiatrist/s, 11, 36, 43, 250, 253, 276, 279–283, 295, 298, 317 peer pressure girls/young girls/teenagers, 16, 21 impact on adults, 16 Pegg, Samantha, 63, 73, 75, 76, 323 Pelloux, Cecilia, 69 Penny, Laurie, 26 Peppers, Margot, 133, 156 Permalip, 37 Petagine, Lucy, 144 pharmaceutical/cosmetic industries, 42, 88 photography, 1, 2, 21, 298 impact of photography, 11 medical photography, 11 photoshopping, 57, 300, 301 The Picture of Dorian Gray, 89 Pilane, Pontsho, 222, 240, 242 PIP scandal, 145 Pittet, Brigitte, 146, 157, 161 Pittet, Didier, 146, 157, 161 plastic, 35, 37, 58, 65, 82, 110, 121, 126, 127, 130–132, 145, 147, 152, 154, 183, 186, 251, 254, 299, 302, 310, 314, 316 intrusions, 317

386

INDEX

iterations of our bodies our selves, 21 performance/s, 69, 299, 317 persona, 317 plastic surgeons, 4, 9, 13, 19, 26, 31, 44, 45, 47, 54, 60, 63, 64, 90, 92, 95, 98, 102, 105, 166, 197, 218, 227, 229, 236, 238, 254, 256, 257, 259, 271, 273, 301, 304, 312 as “healers” of cosmetic defects, 4 plastic surgery industry/surgery. See aesthetic, cosmetic and plastic surgery/industry Ploss, HH, 213, 240 popular culture/media, 4, 14, 17, 103, 180, 218 pornographic representations, 7, 198 pornography, 198, 215, 299, 300 Porta, John Baptista, 151 Porter, G., 27, 56, 73–75 Post Upper Blepharoplasty Syndrome (PUBS), 101 ‘The Power of Radical Self-Love’, 215 PPD or paraphenylenediamine, 48 in hair colour, 48 in shampoo, 48 A Practical Guide to Cosmetic Surgery Claims , 40, 72, 108, 117, 152, 163, 238, 247, 258, 261, 288 practitioners. See surgeons/practitioners Prescott, Emily, 324 products beauty, 12, 39, 40, 85, 88, 134, 263, 264, 301, 315 consumer protection, 302 dangers/risks, 8, 12, 109 defective, 39, 42 regulation of, 313 statutory liability for, 39 prosthetics/fillers/inserts, 40

prostitute/prostitution, 3, 7, 8, 80, 299, 300 as commodity and seller, 3 psychiatric illness/injury, 10, 46 Pusic, Andrea L., 136

Q qualifications. See training inc qualifications

R race/ethnicity, 7, 18, 68, 90, 92, 97, 238, 306, 314 racial, 7, 92, 98, 135, 153, 303 seen as sexual deviancy, 8 superiority, 33, 221 Rees, Anuschka, 16, 27 Regulation of Cosmetic Interventions – Research among Teenage Girls , 14–16, 27, 57, 303, 311, 320 regulation of the time, space, and movements of our daily lives, 3 regulation, subjection, transformation, improvement, 4 Reshaping the Female Body – The Dilemma of Plastic Surgery, 25, 118, 130, 135, 137, 156, 158, 202, 301, 319 Review into the Regulation of Cosmetic Interventions , 14 Revlon, 308 The Revolution, 69, 77 Reynolds, Lesley, 122, 154 risk/s complications, 17, 49, 107, 148, 172, 183, 193 harm, 42, 55–57, 104, 110 insured (against), 52 law and, 49, 149 medical, 55, 305

INDEX

operations and, 12, 43, 49, 55, 150, 169, 175, 179, 188, 233, 238, 257, 270, 309 procedures and, 18, 22, 49, 55, 57, 124, 127, 129, 150, 168, 175, 177, 180, 186, 189, 226, 228 Roberts, Julia, 268 Rodin, Auguste, 1 muses, 2 Roe, Sue, 1, 22 Rossetti, Dante Gabriel, 6 Rubens, Peter Paul (nudes) (28 June 1577 – 30 May 1640), 31, 212, 239 Rubenstein, Helena (cosmetic industry), 12 Russell, Jane, 135 S Said, Edward, 97, 114 Samanta, Ash, 43, 73 Samanta, Jo, 43, 73 Scherr, Rachel L., 4 Scherr, Raquel, 102, 116 Science on Trial – The Clash of Medical Evidence and The Law in the Breast Implant Case, 135, 157 Scotland Consultation on the Regulation of Non-Surgical Cosmetic Procedures, 256, 313 Scotland inc Edinburgh/Aberdeen, 189, 256, 313 The Second Sex, 27, 70 Self -Portrait in a Red Blouse, 1, 22 ‘Selling the Perfect Vulva?’, 194 Sexual Politics , 35, 70 shoulder blades, 125 lengthening, 127–129, 131, 272, 273 shortening, 32, 127, 131–133, 273 Shrimpton, Jean, 213

387

side effects, 19, 38, 100, 101, 125, 142, 148, 168, 169, 173–175, 180, 182, 190, 230, 233, 238, 260, 266, 316 long term, 38, 168, 180 short term, 38 Silver, Matty, 191, 206 Silverstone, Alicia, 274 skin cancer, 252 Skoog, Tord, 93, 114 Smith, Dorothy E., 314, 323 Smith, Jada Pinkett, 91 SNS nails [Signature Nail Systems], 36 social media. See media/social media Solomon-Godeau, Abigail, 2, 3, 23 Spain, 228 The Spectacular Modern Woman – Feminine Visibility in the 1920s , 7, 31, 65, 70, 76, 109, 118 ‘Speculum Speaks’ (1970s film), 150, 193 Spencer, Diana/Princess Diana, 81, 301 Sprenger, James, 80, 111 Stanton, Elizabeth Cady, 69, 77 Steinem, Gloria, 35, 71 Stephens, Theora (hair pressing and refined curling iron), 12, 26 St Jerome, 165 Summers, Christine Hoff, 20, 28 surgeons/practitioners, 4, 5, 7, 9–16, 18–21, 26, 37, 43–48, 50, 51, 54–61, 63–66, 86, 90–93, 95, 96, 98, 100–106, 109, 123, 124, 126–133, 136, 142, 145, 150, 152, 166–171, 175–180, 182, 184, 186, 187, 189, 191, 196, 197, 215, 218, 225–227, 229–233, 236–239, 254–257, 259–262, 264, 269, 271–276,

388

INDEX

285, 301, 303, 304, 309, 311–313, 315, 317 surgical intervention/operations/procedures, 10, 13, 54, 61, 62, 64, 65, 68, 76, 90, 94, 96, 103, 110, 134, 137–139, 152, 172, 191, 195, 198, 223, 230, 236, 238, 269, 270, 276, 285, 300, 304, 305, 324 The Swan, 11 Swann, Martin, 175, 201 Sweden, 242, 312 T 10 Years Younger, 11 Taiwan/Taipei clinic, 96 Tatler Hong Kong , 70 tattoo/s, 48, 60, 61, 149 dyes, 149 Tattooing of Minors Act 1969, 67 Taylor, Sonia Renne, 215, 218, 240, 241, 300, 319 teenagers. See girls television, 11, 12, 34, 35, 57, 79, 81, 91, 121, 135, 180, 187, 225, 298, 300, 305, 306, 318 makeover shows, 11 Thailand, 227 Things No One will tell FAT Girls , 153, 214, 230 Thorp, Nicola, 278 Through the Looking-Glass , 21 tort/civil wrong. See law The Total Woman, 35, 71 training inc qualifications, 45, 49, 50, 55, 56, 92, 94, 127, 166, 169, 175, 216, 229, 232, 235, 251, 255–257, 268, 279, 312, 313 Trump, Ivanka, 301 tummy tuck/s, 96, 168, 172–176, 180, 184, 223, 233

Turkey, 227, 228 Twiggy (Lesley Lawson), 33, 213 The Tyranny of Structurelessness , 35, 71 U Uniform Deceptive Trade Practices Act 1966 (USA), 88 United Kingdom/UK Department of Health, 14, 57, 143, 256, 257, 302, 304 Expert Group on the Regulation of Cosmetic Surgery, 311 fashion industry, 298 Hair and Beauty Industry Authority (HBIA), 251 National Confidential Enquiry into Patient Outcome and Death (NCEPOD), 311 National Patients Complaints Board, 312 On the Face of It 2010, 311 United States/US, 15, 36, 39, 45, 55, 66, 68, 76, 83, 88, 92, 116, 121, 126, 128, 135, 145, 150, 183, 188, 189, 191, 221, 223, 226, 227, 236, 254, 264, 271, 283, 300, 305, 306, 313, 316 Federal Trade Commission (FTC), 264 Food and Drug Administration agency (FDA), 66, 142, 145–147, 173, 189, 313 V VanDerBeek, Sara, 21 Veale, David, 195, 206–208 victim feminism, 20 Victorian Department of Health and Human Services, 193, 311 Victorian era, 6

INDEX

Victorians Undone – Tales of the Flesh in the Age of Decorum, 6, 24, 116, 163 Vietnam/Vietnamese, 98, 250 Vinci, Leonardo Da, 109 visual culture, 11 Vogue inc Vogue Italia, 219, 222, 239, 269, 298, 304–306, 310 W waxing/spray tans, 36, 37, 57, 99, 265–268, 282, 300 weight/weight industry, 34, 105, 131, 139, 166, 167, 174, 175, 180–186, 190, 199, 215, 217, 231, 254, 255, 260, 270, 276, 299, 316 Weldon, Faye, 273, 293 Western, 30, 68, 80, 90, 98, 99, 135, 153, 190, 219, 221, 250, 305 imperative, 305, 314 nations, 97 world, 4, 274 Western or Anglo-Saxon features, 7 West, Mae, 135, 157, 213 white cultural unconscious, 8 Who Stole Feminism, 20 Wilde, Oscar, 88 Williams, Florence, 76, 150, 157, 163 Williams, Joy, 227 Wintour, Anna, 298 Wiseman, Eva, 149, 163, 209 Wolf, Naomi, 20, 28, 57, 75, 149, 150, 157, 160, 163, 215–217, 240, 278, 295, 315, 323 Woman, 213 woman and moral duty, 4, 103 woman-as-body/ies, 2 as automaton, 3 in cinema, 7 woman as human object, 2 woman-as-mind, 2

389

woman-as-mind-and-body, 2 woman-as-object, 2 women activists, 64, 199 and age/ing, 4, 6, 33, 34, 66, 67, 88, 121, 125, 134, 194, 213, 216, 217, 221, 225, 227, 232, 235, 308, 313, 316 and agency, 10, 12, 14, 20, 21, 42, 141, 151, 193, 197, 198, 215, 232, 307, 310 as artists/painters/sculptors/ craftspeople/ceramicists/ filmmakers/directors, 1 and autonomy, 20, 42, 215, 232 and beauty/beauty contest/s, 2, 7, 10–12, 14, 16, 21, 32–34, 36–38, 42, 79, 81, 109, 120, 122, 134, 135, 141, 149, 193, 216, 217, 238, 285, 298, 308 and bodily perfection/the ‘perfect body’, 10, 14, 33, 37, 65, 147, 180, 279, 302, 307 as brains and body, body and mind, 2, 68, 283 and capacity for choice, 10 and clothes/dress, 3–5, 7, 34, 80, 137, 218, 220, 221, 223, 228, 277, 299, 310 and Covid 19/corona virus/coronavirus pandemic, 10, 315, 316 as creative, 153 detect flaws in their bodies, 4 ‘emotional desperation’ of, 4 ethnicity. See race/ethnicity and fashion, 3, 10, 12, 21, 32, 34, 81, 90, 99, 120, 135, 149, 166, 218–221, 285, 300, 310 and film/cinema, 2, 12, 31, 34, 89, 93, 215 legal rights of, 42

390

INDEX

looking ‘normal’/seeking ‘normality’, 96, 109, 126 and makeup, 4 miracle conversion of, 11 of non-Anglo-Saxon or Western background, 305 and ‘normality’/‘natural appearance’, 17 physical imperfections, 4 physical selves, 4 as prospective patients/clients, 10, 232, 262, 302 public exposure/public scrutiny, 32 putty in cosmetic surgeons’ hands, 11 race/ethnicity, 7, 18, 68, 238, 306 representation, 21, 42, 67, 197, 198 and shoes, 7, 274, 275, 279, 285 and sports shoes (cricket), 279 and stockings, 7, 35 taking control over appearance, 10 body, 10 shape, 10 and vanity/self-admiration, 4, 14, 33, 92, 126, 149, 193, 216 as workers, 3 and Zoom meetings, 10, 301 ‘Women and their bodies’, 150 women’s abdomen abdominal muscles, 174, 176, 232, 234 abdominoplasty/tummy tuck, 96, 168, 172–175, 180, 184, 223, 233, 236, 316 limp muscles/muscle tightening, 174, 190 lower/upper, 174, 224, 260, 299 abs

etching, 233 implant/s, 233 agency/autonomy, 20, 21, 232 anatomy, 120, 134, 213, 309 ankles, 269 ‘cankles’, 271 arms ‘bat wing’, 167, 259, 271 brachioplasty/‘arm lift’, 259 lower, 257, 271 muscular, 232 underarms inc waxing of, shaving of, 199, 265, 267, 268 upper, 44, 257–260, 262 ‘washerwoman’s arms’/‘charlady’s wings’, 257 back cervicodorsal hump, 125 Cushing’s syndrome, 125 Kyphoscoliosis (hump on upper back), 125 widow’s hump/dowager’s hump/buffalo back, 125 bikini bikini bridge, 298 bikini-line, 198 body hair depilation/depilatory creams, 265, 268, 274 dying – underarm, 274 extensions - underarm, 269 removal of, 36, 198, 265, 268 shaving, 198, 265–268, 274, 275, 280, 282 transplants – underarm, 265 waxing, 36, 37, 57, 99, 265–268, 300 body part/s, 19, 34, 59, 65, 69, 89, 137, 148, 152, 172, 193,

INDEX

194, 219, 222, 226, 267, 279, 302, 308, 310 breasts inc bosom/s augmentation, 43, 66, 67, 135–137, 139–141, 145–147, 152, 168, 196, 223, 236, 309, 316 cancer, 124, 138, 145, 146 false, 30 implants, 15, 40, 41, 47, 66, 67, 136, 137, 139–143, 145–147, 150, 222, 300, 307, 308, 310, 313 mastectomy, 138 natural, 124, 153 as oval spheres, 5 reconstruction/reconstructive surgeons, 66, 67, 146 reduction, 138, 139, 236 removal, 138 small, 138, 141 symmetrical, 150 buttocks/bums/bottoms/derriere/rear end Vogue seal of approval, 310 Vogue-endorsed curvaceous bottom, 310 of women of African origin, 305, 310 calf/calves shaping, 271 shrunken, 272 slimmer, 271 tibia/fibula, 272 cheekbone/s, 11, 89, 133 cheeks, 59, 89, 92, 308 chest bone brace, 270 cage construction, 133 pectus carinatum, 131 structure of chest cavity, 131 chin/s

391

double, 7, 105, 133 and jaw/line, 103, 105 multiple, 103 receding/regressive, 103 clavicle/s or collarbones contouring, 133 definition, 133 left and right clavicles, 131 ‘long’ or ‘elongated’, 131 protruding, 131, 132 recreate, 131 restructuring/reconstructing, 131, 270 ‘shave down’, 132 shorten/lengthen, 127, 129, 131, 132 too long/prominent, 132 cleavage anti-wrinkle bra, 122 ‘cleavage sparing mastectomy’, 124 ‘clinkles’/cleavage wrinkles, 122 figment of, 124 and Mr Ian Paterson, 124 preservation of, 124 clitoris inc clitoral hood hoodoplasty, 191 reconstruction, 187 reduction, 187, 191, 192 collarbone/s. See clavicle/s crotch, 5 daily lives, 4 ‘central organizing principles’ of, 4 decision-making – capacity, 14 décolleté, 120 ear/s ‘bat’, 90 earrings, 90, 306 flapping, 32, 90 flat to head, 90

392

INDEX

otoplasty (ear correction), 237 piercing, 59, 63 pinning, 90 egotism, 10 elbows injections into, 262 plumped, 263 youthful, 263 eye/s upper eye/eyelid, 99–101 eyebrow/s compensatory elevation, 101 plucking/threading, 99 threader/s, 43, 53, 298, 317 eyelash/es extensions, 36, 39, 57, 269 eyelid ptosis, 101 false, 30 lower, 99 eyelid/s blepharoplasty (eyelid surgery), 98–101, 236 double eyelid, 98, 306 drooping/swelling, 38, 99–101 lower eyelid, 99, 100 supratarsal fold, 98 tattoo/ed, 30, 99 tuck, 96 upper eyelid ptosis, 101 face/facial features chin, 103, 105 jaw, 103, 105, 106, 108 jowls – inc ‘turkey’ neck, ‘gobbler’ neck, 103, 315 facelift and Covid 19/corona virus/coronavirus pandemic, 10 finger/s inc nail/s acrylic, 51, 250, 251 chemicals and, 252

curing with ultra violent light (UV), 251 enhancement of, 250 fake, 253 false, 39, 63, 250, 251, 253 French polish, 251 industry – inc trafficking, 250 polish, 250, 252 pre-treatment skin patch test/s, 251 reconstructive surgery on, 64 tips, 63, 69, 249, 254 toxic vapours, 252 flesh depressions in (lipotrops), 258 disfigured by lumps/bumps (liponots), 258 foot/feet binding, 274, 275 deformities, 274 and dermal fillers, 275 fallen arch/es, 274 fish pedicure:catching or transmitting disease or infection, 281 fish pedicure:Garra Rufa fish fashion, 281 fish pedicure:Hepatitis B or C, HIV/AIDs, 85, 149, 252, 281–283 fish pedicure:public health (liability), 283 footwear, 274 heel/s, 275, 277, 278, 285 high heels, 30, 274–279 and hyaluronic acid, 276 infection inc athlete’s foot/dermatitis/eczema/ psoriasis/verruca, 85, 87, 99, 134, 280–282 plantar wart/s, 279 as sexual objects/fetishes, 275

INDEX

shoes, 7, 274–276, 278, 279, 285 sole/s, 275, 299 forehead browlift, 237 genetic make-up (or ethnic or race origins), 99, 217, 238 genitals/genitalia/genital design reconstruction of, 65, 198 surgical enlargement of, 309 groin, 177, 184, 188, 226, 269, 270, 309 ‘G’ spot/Grafenberg spot, 187, 191, 192, 309 hair bleaching, 83 colour, 36, 44, 45, 47, 81, 83, 84, 88 colouring/dye, 48, 51 enhancements, 82 extensions, 39, 82, 83, 269 follicle, 94, 99, 266–268 hair-straightening products, 8 ingrown, 199, 253, 268 permanent waves, 13 removal – shaving, wax/ing, 265–267, 312 stealing, 83 strand test, 84, 85 style/styling products, 13, 81, 85, 86 underarm, 266, 268, 269, 274 hairline/s, 11, 92 hand/s plumping, 254 reconstructive surgery on, 249 head inc crown, 2, 7, 13, 45, 51, 58, 69, 79–81, 83–87, 90, 102, 104, 192, 219, 269, 285, 299, 306, 308 hips inc hip bones

393

brace – hip/pelvis bone structure, 270 narrow hips, 7, 132 widen hips, 132 hour glass figure, 172 hymen hymenoplasty, 187, 191, 192 reconstruction, 187 intelligence/intellect/wit, 13 jaw/jawline bone enhancement, 103 bone restructuring/grafting, 103 loss of definition, 103 lower jaw (mandible), 103 reconfiguring, 103 regressive, 103 knee/s reconstruction, 269 labia augmentation, 187, 191, 192 ‘elongated’, 8 enlargement, 187 hypertrophy, 8 inner/outer, 65, 192, 194 minora/majora, 8, 64, 65, 187, 191, 192, 194, 195, 197, 198, 309 reduction, 64, 187, 191 legs lengthening, 272 shortening, 272 waxing/shaving, 282 lines, 11, 12, 38, 66, 99, 110, 120, 122, 271 lips ‘bee-stung’, 8 reddened by rouge/lipstick, 7 ‘slack’ or Mulatto lips, 7 magazines, 14, 15, 34, 166, 262 midriff/s doughnut/spare tyre, 234, 237

394

INDEX

motivations age/ing, 33 agency/autonomy, 14 beauty/vanity, 14 choice, 180, 215 conceit, 10 control, 10 multiple, 105 narcissism, 4, 10, 270, 301 nature/natural, 10, 14, 65 normal/normalisation, 138, 193 mouth/s, 6, 8, 14, 37, 38, 57, 93, 104, 106, 107, 142, 316 muffin top inc love handles, 165–167, 170, 176 navel, 5, 59, 63, 172, 174, 175, 233 neck/s chin and throat definition, 105 double chin/s, 7, 105, 133 jowls, 103, 315 neck lift, 236, 316 neck rejuvenation, 105 wrinkled ‘gobbler’ neck/’turkey’ neck, 103 nipple/s aureole/areola—tattooing, 147, 149 excess part of, 147 illusion of smaller nipples, 147 ‘improvements’, 148 length, 147 reduction surgery— height/width, 147, 148 sensation, 139, 147, 148, 152 sexual sensitivity, 147 size, 148, 149, 153 ‘too big’, 153 nose/s

Africa/n, 90 anti-Semitic trope, 90 and Covid 19/corona virus/coronavirus pandemic, 10 flat, 90 most common plastic surgery, 135 nasal construction, 90 ‘nose job’ operation, 91, 98, 123 rhinoplasty (‘nose reshaping’), 43, 90, 91, 95, 98, 135, 140, 141, 223, 236, 315, 316 snub/sunken ‘Oriental’ nose, 90 pecs, 11 pelvis/pelvic bones, 270 pubic area/s bone, 186 ‘cosmetic gynaecology’, 191 perineoplasty, 187 pubic hair full Brazilian, 198 removal of, 198 shave/shaving, 198 ribs/ribcage narrowing rib carriages, 131 removal, 131 rib pair/s, 130 sternum (breastbone) and rib cage, 130, 131, 145 surgery, 130 self-centredness, 10 shoulders/shoulder blades/bones reconstructing, 270 shortening/lengthening, 127, 131 shoulder girdle, 131 skin ageing, 93, 122

INDEX

bleaching inc cream, 121 cancer, 122, 252 colouration, 11 contraction (‘lipodermatochalasis’), 168 and dead skin cells, 122, 266 elasticity/condition, 173, 184, 224 extra skin inc at scar edges (‘dog ears’), 175 grafts, 228 homogenous, 168 and hydroquinone cream, 121 loose/excess, 101, 167, 174, 185, 271 and medical-grade skin care, 31 products with carcinogenic properties, 121 and Retin-A, 121 spots, 120 top layers of, 167 whitening inc products, 8, 51, 68, 305 wrinkles/lines, 92, 99 spine posture implications, 273 stomachs/bellies abdominoplasty/tummy tuck, 96, 168, 172–175, 184, 223, 233, 236, 316 apronectomy, 184 banding/stapling, 172, 186 bariatric operation/s, 180 biliopancreatic diversion, 183 fat removal, 172, 173, 259, 262 gastric band/ing, 181, 183–185 gastric balloon, 181, 183 gastric bypass/Rous-en-Y bypass, 100, 180, 181. See 183—186

395

lapband/ing, 184 modifications, 180 sleeve gastrectomies, 185 small intestine, 181, 184, 185 surgery inc in NHS hospitals, 180 teeth artificial, 106 bleaching, 106, 107 braces, 130 bridges, 105, 106 and Covid 19/corona virus/coronavirus pandemic, 10 crowns/caps, zirconium/ceramic, 106 dentures/partial dentures, 105, 106 incorrect bite, 105 orthodontics, 105 periodontal treatment, 105 porcelain shells, 106 smile makeovers, 105 veneers, 105, 106 whitening, 36, 105–107, 315 thighs/thigh gap femur - lengthening/shortening, 272, 273 Ilizarov/Wagner procedure, 272 inner upper thighs, 270 outer thigh region, 270 toe/s big toe/joint, 275–277 bunion, 274–277 bunion pads/tapes/sleeves, 276 bunionette, 275, 277 corns/calluses, 274, 276, 279 cosmetic procedures, 279

396

INDEX

cramp (shoes), 275 as canvases, 3 and dermal filler, 275, 279 curves, 214, 215, 235, 237 hammer/mallet, 274, 275, 279 as docile bodies, 3 little toe/joint, 275, 277 fetishisation and commodification of, 3 pads of, 275 ‘hourglass’ shape, 6, 33, 235, 314 plump up, 279 shortened/lengthened/straightened, intimate parts of, 7, 186, 198, 309 279 maintenance of, 4 toenails management and discipline of, 3 cuticles, 250, 279, 281 moulding of, 12 damage to, 281 nature of women’s bodies, 10 ingrown inc removal, 274, 281 never good enough, 4 unsightly, 279 part/s of, 7, 17, 19, 47, 54, 59, 61, varnish, 279 65, 69, 125, 129, 132, 137, 140, 142, 148, 149, 152, 166, torso, 5, 19, 120, 223, 232, 262 172, 192–194, 198, 199, 219, vagina 222, 223, 225, 226, 232, 238, ‘designer’, 64, 186 260–262, 267, 268, 279, 302, flaccid/loose/laxity, 187 308–310, 314 mesh scandal, 188 perceived flaws, 4, 121, 195, 315 narrowing/reshaping/tightening, renovate, 3 187 represented in art, film, on catwalk, refashioned, 192 on red carpet, 2, 6, 31 ‘rejuvenation’/tightening, 187, sculpted form, 6 192 shape/size/dimensions of, 3, 10, vaginoplasty, 192 34 vulva through time lipoplasty, 192 1920s and 1930s, 7 renunciation of/growing ancients’ ideas, 5 revulsion for, 8 Goths, 5 waist Greek/Greece inc classical, 5, curves, 235 285 narrow, 130, 213 Renaissance inc Italy, 5, 285 sculpting, 176 Roman, 33 wrinkles/wrinkles and bags, 4, 11, Second (French) Empire, 2 37, 54, 92, 99, 103, 104, 109, Third (French) Republic, 2 120, 122, 254, 262, 263, 312 Victorian era, 6 wrists, 7, 270 transformations, 4, 11 The Woman in the Body – A Cultural Analysis of Reproduction, 18 vs women’s brains, 68, 283 women’s bodies A Woman’s Decision – Breast Care, Treatment & Reconstruction, 159 augmentation, 59, 137, 141, 165 before/after, 10, 11, 228, 271, 281 Women’s HealthVictoria, 198

INDEX

Women’s Movement/Liberation Movement, 35, 268 Women and Their Bodies , 179 World Health Organisation Quality of Life (WHO-QofL), 95 World Health Organisation (WHO), 166 Worth, Charles, 220 Wray, Fay, 213 Y Yazdandoost, Rokhsareh Y., 140, 141, 159

397

young girls. See girls Z Zellweger, Renee, 217 Zoom calls and beauty products, 301 and Covid 19/inc corona virus/coronavirus pandemic, 10, 315 and plastic surgery, 315, 316 and rhinoplasty, 315, 316 and teeth whitening, 105, 315 and wrinkles, 315