Abstract: When silicone gel breast implants became the subject of a public health controversy in the early 1990s, the most pressing concern was safety. This paper looks at another, less publicized issue: the need for implants. Using a symbolic interactionist approach, the author explores the social construction of the need for implants by tracing the history of the 3 surgical procedures for which implants were used. Stakeholders in this history constructed need as legitimized individual desire, the form of which shifted with changes in the techonolgical and social context.
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Starting in the 1800’s with simple and ineffective procedure using fat redistribution to augment breasts, to a dangerous silicone gel in the 1990’s, to now using the fully bio-synthetic implant, breast augmentation has grown into a highly personalized and popular procedure for both aesthetic improvement as well as reconstruction. Advances in the technology have removed many of the major risks involved in the surgery allowing societal pressures to become a factor in determining its growth in popularity. The procedure is almost always out-patient, most related discomfort has been reduced, and recovery time continues to decrease leading to declines in price of the procedure itself as well as post-care expenses. These changes have led to an overall increase in the desirability of the procedure as well as increasing its accessibility for millions of women. Due to this decrease in risk, the debate over breast augmentation has shifted from a focus on safety and efficacy to the discrepancy between desire and need or cosmetic versus necessary. There are many strong arguments for both sides.
Has breast augmentation become a social necessity or just a social construction? The argument for necessity places high priority on the psychological well-being of women in regard to their self image and gender identity. They argue that confidence and self-esteem can be devastated by the size or loss of one’s breasts and that it is completely natural and acceptable for a woman to seek medicinal aid to restore that confidence. Considering the current perceived social norm, the idea is that it is unrealistic to expect women to be satisfied with an aspect of their body that can now so easily, with current technology, meet the perceived societal standard. The battle over insurance coverage and out-of-pocket expenses for these women is the greatest concern and topic for debate regarding current and future US health care policy and reform in regards to this procedure. As of now there are varying degrees of coverage primarily with post-operative complications. Enhancement procedures are generally out-of pocket, while post-mastectomy coverage varies by law among states. According to the paradigm of thinking a patient should be able to correct their perceived physical inadequacies and the health care system should recognize these as ailments with legitamate medical concern and accommodate patients with fully insured procedures.
On the other hand, the contrasting opinion is that given that breast augmentation is completely elective and the procedure cannot improve or restore the function of the organ, it's place our society is purely cosmetic. The belief is that the procedure deals with a non-life threatening situation and is in no way deemed necessary surgery and therefore, is only serving to contribute to social stratification, and the social construction of gender normativity and identity. In terms of insurance coverage, this position lobbies against any and all insurance coverage including procedure, post-operative care and post-operative complications. This camp of thought emphasizes patient personal responsibility as the most important factor in elective surgery and promotes the belief that health care funding should be allocated to life-saving procedures and health insurance for the 47 million people who are uninsured and should not be drained by unnecessary, non-life threatening procedures. The aim is to stop the medicalization of self image and self esteem issues that are likely to not even be curable by a surgical procedure and to promote social change for acceptance without the need for cosmetic surgical procedures, particulary breast augmentation.
We recognize that grey areas exist between these arguments, particularly in regard to post-mastectomy reconstruction. Some view this as non-cosmetic or less elective because it is not an enhancement of their natural breasts but rather replacing them and restoring original appearance. Our opinion still lies toward the no coverage side of the spectrum based primarily on our belief in minimalizing medicalization of societal and social pressures. Vast amounts of money are already being spent on essential health issues and this is non-essential surgery. Basically, money could be better spent on saving lives as opposed to subjectively improving appearance. We also have the concern that if we support breast augmentation in new coverage decisions, what other procedures will it open the door for? Will men soon be covered to reverse their baldness because it also hurts their self esteem? Botox? Calf, pectoral or butt implants? Tummy tucks? By including some cosmetic procedures and not others it makes it increasingly difficult to draw the line between the necessary and desired procedures. In light of imminent health care reform and the fact the the US already spents among the most in the world for health care per capita, the public as well as US policy makers need to re-evaluate the true purpose of the medical system and what direction is most beneficial both medically and financially for the American people.
