In the monthly "Ethical Inquiry" series, we examine ethical questions, highlighting a broad array of opinion from journalism, academia, and advocacy organizations. Our intent is to illuminate and explore the complexity of some of the most vexing ethical questions of our time.

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Ethical Inquiry: May 2011

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Is “Ethnic Modification” Surgery Ethical?

“Ethnic modification surgery” refers to cosmetic surgery techniques and special considerations for particular ethnic features, primarily focusing on the eyes and nose. Examples include Asian blepharoplasty or “double eyelid surgery” and African American or Jewish rhinoplasty (“nose jobs”).

Some view these procedures as steps towards equal opportunity for members of minority groups. Others see the desire for these procedures as extensions of the social, cultural and geopolitical factors that have led to the widespread oppression and discrimination of these minority groups.

In this “Ethical Inquiry” we will explore some of the questions surrounding these procedures.

Are these minority groups simply responding to the same societal pressures for beauty that all Americans experience, or are their motivations for surgery compounded by much deeper societal issues? Are minority groups, passively or actively, trying to erase the racial markers that separate them from societal norms? Is it ethical for plastic surgeons to perform these “ethnic modification” surgeries?  

Background: The emergence of “Ethnic Modification” Surgery

Recently, the patient profile for cosmetic surgery in the U.S. has changed, with interest growing across all ethnic groups. The American Society for Aesthetic Plastic Surgery reports [PDF] that of the 10 million domestically performed cosmetic procedures in 2009, 22% were for minority patients, predominately of Hispanic (8.9%), African (6.2%) and Asian (4.4%) heritage.

In their 2009 analysis “Socioeconomic Impact of Ethnic Cosmetic Surgery: Trends and Potential Financial Impact of African American, Asian American, Latin American, and Middle Eastern Communities have on Cosmetic Surgery,” (Seminars in Plastic Surgery, 2009) Wimalawansa, McKnight and Bullocks observe that ethnically oriented cosmetic procedures, primarily rhinoplasty (noses) [click here for images – commercial website]  and blepharoplasty (eyes), [click here for images – commercial website] are growing twice as fast as other procedures, offering new markets for practitioners. With this growth, ethnic specialties have been created to address the specific surgical needs of these populations.

“Ethnic modification” procedures are marketed as opportunities for minorities to receive the same surgical attention Caucasians have had for decades. On commercial websites such as that of Dr. Babak Azizzadeh’s practice in Beverly Hills and that of Glasgold Group Plastic Surgery, new technologies are touted as means of allowing for “ethnically sensitive,” “ethnically appropriate,” or “ethnic corrective” procedures that ensure every effort is made to conserve each patient’s ethnic roots.

Sensitivity to ethnic “types” during surgery

Some doctors claim to be simply modifying features without erasing identity. By improving the technical aspects of ethnic cosmetic surgery and ensuring that each procedure is carefully tailored to the patient, surgeons are enhancing the aesthetic options for minorities while striving to reduce the risk for “ethnically incongruent outcomes.” “Non-Caucasian patients presenting for cosmetic surgery tend to have similar motivations and desires as those of their Caucasian counterparts.” observed Wimalawansa, McKnight and Bullock in “Socioeconomic Impact of Ethnic Cosmetic Surgery: Trends and Potential Financial Impact the African American, Asian American, Latin American, and Middle Eastern Communities Have on Cosmetic Surgery.” Now, cosmetic surgeons are promoting these surgical procedures for minorities without making them look Caucasian.

In the introduction to the 2008 medical reference book Aesthetics and Cosmetic Surgery for Darker Skin Types, editor and physician Pearl Grimes discusses how the traditional neoclassic canons are being thrown out and replaced by new, ethnic models.

On the website of his practice Dr. Ashkan Ghavami discusses the concept of “racial incongruity” as a common and unfortunate consequence of surgeons who are not ethnically specialized. As he describes it on his website, “‘racial incongruity’ refers to an imbalance between the physical traits of [an] individual and their ethnic background.” He maintains that his training and expert, ethnic-conscious procedures will eliminate this mishap.

Based on anthropometric studies such as “International Anthropometric Study of Facial Morphology in Various Ethnic Groups/Races” [PDF] (2005), these new models are geared at defining normative values for the specific anatomical characteristics of each ethnic group. Measurements and proportions of orbital regions, nasal heights and widths, and a variety of other ethnic features are being painstakingly defined. These norms are then used by surgeons to not only create appropriate alterations, but to preserve the inherent ethnic features of each patient from obscurity or obliteration.

In the documentary Western Eyes (2001) surgeon Charles Lee discusses how the general preferences of his patients, in terms of eyelid crease size, is intimately related to their Asian country of origin. “What I notice culturally is that as you go further towards Europe from the other side, the folds (eyelid crease) tend to get larger.” This information helps him determine the appropriate size for his patients’ eyelid creases in terms of their ethnicities.

But many surgeons emphasize that pure measurements and proportions are not sufficient to meet the demands of their patients. Dresner and Ho emphasize this in their 2008 article “Blepharoplasty in Blacks and Latinos” (in Aesthetics and Cosmetic Surgery for Darker Skin Types, by Pearl Grimes). They explain that in order to ensure that a patient’s results do not alter their ethnic identity in a negative way surgeons are encouraged to always consider the patients “needs, desires, ethnicity, sex, and individual anatomy.” As Dr. Yoon-Duck Kim discusses in her “Blepharoplasty for Asian Eyes,” (also in Aesthetics and Cosmetic Surgery for Darker Skin Types), each patient’s specialized procedure should coordinate the aesthetic ideals of their ethnicity with the specific cultural and individual preferences of each patient.

Why do it?

In Eugenia Kaw’s article “Medicalization of Racial Features: Asian American Women and Cosmetic Surgery,” (Medical Anthropology Quarterly, 1993) and Victoria Bañales’ 2005 "'The Face Value of Dreams:' Gender, Race, Class, and the Politics of Cosmetic Surgery" (in Beyond the Frame: Women of Color and Visual Representation)," several reasons are discussed for why minority women seek “ethnic modification” surgery. These reasons include: issues of teasing related to their racial features, feelings of not fitting in, struggles of living between cultures, hopes of better marital prospects, and the ability to have greater social mobility and economic success, as reasons for seeking out “ethnic modification” surgeries. (It is important to note that while many interviews have been conducted with Asian Americans seeking blepharoplasty, few analyses of these surgeries for other ethnic groups have been examined.)

Other patients focus on the anatomical details that, in their opinion, made a specific feature inappropriate for their faces. On Real Self, a website created for individuals to discuss stories and ask advice for cosmetic procedures, an African American woman, screen name "dreamission," wrote “I want to reduce the size of my nose and add a feminine more defined tip. I feel that my nose is too big for my face and don't have any shape to it.” An African American male on the same website, "248385anon," explained that his motivation for seeking ethnic rhinoplasty was that “my nose is too wide, broad, and a bit bulbous and my nostrils are a bit big for my face. I want a more in tune nose for my face without drastically changing it.”

Sharon, a young Korean American woman interviewed in the documentary Western Eyes felt that blepharoplasty would open new doors for her and allow her to be more accepted. “I am recreating myself,” she says. “I am balancing East and West. I am getting it done because I want to feel better.”

Responding to dominant aesthetic standards

In Iran, there is a trend towards surgery by women (and some men) seeking a more “western” appearance via a nose job. “A Western nose is more beautiful” says a woman in a CBS News report. Another Iranian interviewed for the piece attributes the beginning of the trend to the arrival of satellite TV from the West. Though these people are not members of a minority group in their nation, they are possibly responding to globally dominant ideals.

Ethnic modification surgery, negative cultural associations, and the “racial sciences” – a connection?

Is there a link between these surgeries and “racial sciences,” which helped engrain notions of superior and inferior races to begin with? The profiles of the women seeking these procedures are entangled in a multi-layered web of racial, class and gender hierarchies that historically have enforced notions of inferiority and inequality. Victoria Bañales writes in "'The Face Value of Dreams:' Gender, Race, Class, and the Politics of Cosmetic Surgery" (in Beyond the Frame: Women of Color and Visual Representation),” that “with the rise and fall of eugenics, cosmetic surgery offered an alternative and acceptable medical method of ‘cleansing’ and ‘purifying’ racial/ethnic phenotype (as opposed to previous efforts at targeting the genotype).”

While this theory may be extreme, it is important to examine the oppressive factors that influence minority populations on a daily basis when considering whether or not “ethnic modification” procedures are being sought to simply improve ethnic beauty or to erase it.

If it was simply an aesthetic choice, an individual choice, extricated and completely separate from the social/historical context, the cultural context, then you would see people actually de-lidding their eyes. But when you see systematically and you see overtime that the change is always towards whitening or Europeanizing your non-European features, then there’s no way you can call that an aesthetic or an individual choice.

– Nadia Kim, Loyola Marymount University, in the documentary Western Eyes

The human body is a visual signifier of the ethnic belonging and assigned race inscribed on each of us through features such as skin color, eye shape and nose size and shape. “Ethnic modification” surgery is specifically directed at these visual signifiers, signifiers that are historically marked by a negative rhetoric of hierarchy and racism.

The documentary Western Eyes notes that single eyelid eyes, an ethnic facial feature common in Asian populations, have often been described as “dull,” “sleepy,” “passive,” “stingy,” “sketchy,” “slanty,” or “snake-like.” These adjectives do not objectively describe eye shape, but rather stigmatize the personalities and demeanors of those possessing a particular physical feature.

Similarly negative rhetoric and perceptions in the United States surround African American noses and lips, influencing perceptions of those features by others – and even the self-perception of people with those features. The 2004 study “The Automaticity of Race and Afrocentric Facial Features in Social Judgments” [PDF] found that even with couching to avoid stereotypes, participants continued to associate negative behavior and intelligence with Afrocentric facial features.

In a related 2004 study, “The Influence of Afrocentric Facial Features in Criminal Sentencing,” (Psychological Science, 2004) the authors concluded that inmates with more Afrocentric facial features receive harsher prison sentences for the same crimes than their Caucasian counterparts.

Is it any coincidence that blepharoplasty is the most commonly requested procedure by Asian Americans and rhinoplasty by African Americans?

In “Is Asian Plastic Surgery Erasing Ethnic Identity?” Anni Zhu contends that “While ethnic correctness sounds great in principle, it’s still difficult to deny that rounder eyes, double-eyelids, a more prominent nose and chin, or bigger breasts are not in any way steps towards a Caucasian beauty standard…there is a contradiction between what the patients and surgeons are saying, and what the actual cosmetic results show.” 

A critique: “racial betrayal”

The notion of racial betrayal has been a deterrent for many ethnic women to seek surgical procedures of their racial features. Vietnamese-American Mai-Anh commented on this criticism, in terms of her upcoming blepharoplasty surgery, in the 2007 documentary Never Perfect (see the trailer on YouTube). “How can I be abandoning my [Asian] culture if I was raised in the USA?” she asks. “How do I know what Vietnamese is meant to be [since I was raised here]?” For Mai-Anh, the surgery was a means for her to better fit in to her family and cultural surroundings. “I am the only one in my family who does not have the eyelid,” she explains. “All of my family members have it, all of my friends. Getting the surgery, I am not going to be different from them.”

Assimilation and racism

Racism, in particular, is a very powerful and influential oppressor. It can be internalized and becomes an unconscious part of an individual’s understanding of herself and how she is viewed by the world in terms of her race, gender, and class; a process that has been explored by authors’ such as Nancy Krieger in her 2004 article “Embodiment: A Conceptual Glossary for Epidemiology” [PDF] (Journal of Epidemiology & Community Health, 2004) and Camara Jones in “Levels of Racism: A Theoretical Framework and a Gardener’s Tale” (American Journal of Public Health, 2000). Racism may even lead an individual to seek more Caucasian-like characteristics to alter or erase the racial markers that differentiate her from the norm in a white-dominated society.

Thus, a patient’s decision to seek plastic surgery may be less associated with a desire to be more aesthetically pleasing and more related to looking more “normal,” as defined by the media and cultural hierarchies that depict Caucasians as the dominant, most successful group.

In her 2010 Sydney Morning Herald article “A Big Snub to Ethnic Noses,” Jacqueline Maley quotes the views of Dr. Thomas Romo, the director of facial plastic surgery at Lenox Hill Hospital in New York, on ethnic surgeries. According to the article, Dr. Romo believes the popularity of ethnic rhinoplasty is resulting from the integration of immigrants and ethnic minorities into the middle class. He says “now that people [ethnic minorities] have money they have the option of doing the same thing as Caucasians… [without] changing their colour or their genetics.” The article notes that people with Greek and Italian heritage have pursued similar surgeries, as well as people from the aforementioned groups.

In “Ethnic Differences Emerge in Plastic Surgery” (The New York Times, 2011), there is the suggestion that while cosmetic surgery had been used as a part of assimilation “Today, the motivations appear as varied and complex as the procedures. Rather than striving to fit in to their new country, many immigrants reshape themselves to their home culture’s trends and tastes.” Is it more acceptable to modify ethnic features if the goal is to approach an ethnic ideal, instead of an assimilated ideal?

In "Cutting Off Your Nose to Spite Your Race: Jewish Stereotypes, Media Images, Cultural Hybridity” (Shofar: An Interdisciplinary Journal of Jewish Studies, 2007) Bernice Schrank explores the history of perceptions of the “Jewish nose” and trends regarding “correcting” it or not with rhinoplasty. She “…theorizes that the change from unacceptability to acceptability [of the “Jewish nose”] is based on an increasingly successful challenge to the American myth of melting pot sameness by the politics of ethnic difference, based on a realization by the dominant culture of the reality of ethnic hybridity and erasure.”

She also seems to caution that changing this feature might not always lead to the desired result – and that the culture may shift in ways that make such plastic surgery unnecessary or even counterproductive. Citing the example of actor Jennifer Grey, whose plastic surgery – which some feel was influenced by perceptions of a “Jewish nose” – did not lead to career success, Schrank suggests that “Grey's nose job is a cautionary tale: passing in the manner of Fanny Brice, even for a star as talented as Grey, is not a surefire ticket to success, at least not at the present time.”

A 1998 New York Times review of Venus Envy: A History of Cosmetic Surgery by Elizabeth Haiken notes that “In a probing chapter called ''The Michael Jackson Factor,'' [the author] presents black, Asian and Jewish women who seek WASP noses and Playboy breasts. They are caught in the vexed immigrants' dilemma of struggling not only to keep up with the Joneses but to look like them, too.” (Also see the first chapter of Venus Envy , and a Journal of the American Medical Association review [subscription required].)

Final Thoughts

Is it ethical for surgeons to perform these procedures, knowing that they may be contributing to a system of oppression, simply because that is what the patient wants?  If we decide these procedures are unethical, do we then deny all cosmetic surgeries to ethnic minorities because they risk feeding into a system of oppression?  How do we ethically approach and regulate the complex issues surrounding these procedures?

We invite you to continue exploring the ethical issues that arise in this context, and to share your thoughts with us on our Facebook page.

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This installment of "Ethical Inquiry" was researched and written by  Kathleen Rees ’10. Read her reflections on her Sorensen Fellowship working on issues of healthcare in rural Peru [PDF].