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Archive for Saturday, November 1, 2003

U.S. culture needs extreme makeover

November 1, 2003

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— To understand the passion behind the argument over silicone breast implants, it's best to go to the beginning. If you can stomach it.

The beginning is post-World War II Japan, when young women had industrial-strength transformer coolant injected into their breasts to meet the standards of American G.I.s.

The beginning is the 1960s, when topless showgirls in Las Vegas had liquid silicone pumped into them to make falsies for the naked eye.

The beginning is also the 1970s and '80s, after silicone was packaged in gel form and promoted as a cure, in the words of the American Society of Plastic and Reconstructive Surgeons, for small breasts that were "deformities" and "really a disease."

Of course you don't really have to go back. You could look around at our own "Extreme Makeover" era when the "reveal party" brings shrieks and tears of joy for a personal renovation project. Or you could listen to people wondering uneasily why cosmetic surgery is marketed and bought as casually as lipstick.

Today we have a mixed attitude toward nips and tucks, implants and suctions, toward renovating a body as if it were a kitchen. This mixture runs strongly but silently as we wait to hear whether the Food and Drug Administration will approve a silicone breast implant.

About a hundred people spoke before a panel of advisers at a recent FDA hearing, but few framed the question of breast implants in cultural terms. After all, the FDA doesn't have to make decisions on cultural values. It has, rather, a mandate for science and safety.

You see, 11 years ago, after many women testified about ruptures and replacements, arthritis and skimpy research, the FDA banned silicone for everyone not in a research program. The only other exception it made was for mastectomy patients, a hint of the distinction made between "necessary" and "unnecessary" surgery, between cancer and the "disease" of small breasts.

But even after the ban on silicone, women chose to "enhance" or "augment" their breasts, this time using saline implants. The annual number of breast enlargements actually grew, hugely, from 32,607 in 1992 to 225,818 last year.

By the late '90s, the Institute of Medicine found "no evidence that the silicones used in implants are toxic to humans." So, the manufacturer Inamed, which boasted last April that it was "bullish on the breast implant business," brought its new silicone product to the FDA for approval.

The problem for the FDA is how on earth you assess the risks and benefits of bigger breasts. The risk assessment is the easy part. Even the proponents, including Inamed, acknowledge that 20 percent of those with cosmetic enlargements need another operation for problems within three years. And the jury is still out on long-term problems.

But benefits? How do you measure the benefits of going from an A or B cup to a C or D? If there are benefits, how much risk are they worth?

In cases like cosmetic surgery, Americans are generally more comfortable having the experts define risks and letting individuals determine the benefits for themselves. Indeed, a plastic surgeon told the panel: "Men have the right to choose Viagra even if they have a risk of heart disease. Women have the right to make a choice like that, too, with silicone implants."

Never mind the strange analogy between impotence and small breasts. It was the rare witness who, like Joe Kelly of Dads and Daughters, suggested that this "choice" might be a nonchoice, the result of the "unchecked cultural pressure" of the "toxic beauty myth." Few suggested that the "right" of a woman to have her body carved into new dimensions might actually be pressured by those who define the "disease" of small breasts.

I know that beauty matters. I know there's a continuum of self-improvement from hair color to chin implants, from braces to face lifts. But is it freedom to choose the image a culture imposes? Is it worth facing even a 20 percent chance of more surgeries to conform to the approved bra size? And how many women take risks to feel better about a body they were taught to feel badly about?

The advisory panel recommended FDA approval by a close 9-6 vote, linking it to a strong informed consent procedure. I won't be surprised if the FDA agrees.

Today, in some tony suburbs, breast implants are a popular gift for high school graduates. We have a booming surgical self-improvement industry. With every customer who chooses to improve her self-image, I wonder what mirror we hold up that distorts it so badly.

In the matter of beauty and breasts, science can't do a risk-benefit analysis for a whole culture. It's the culture that needs the extreme makeover.




Ellen Goodman is a columnist for Washington Post Writers Group.

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