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Skin Deep

This summer three British transsexuals who want to be women won their appeal against the local health authority which had refused them a sex-change operation. In a case widely publicized in the UK, the Court of Appeal upheld an earlier High Court ruling that the authority had acted unlawfully, without consideration of what was “the proper treatment of a recognized illness.” The significance of this is that transsexuals in Britain, of whom around 1,000 are currently awaiting surgery, will now be able to demand to have their sex-change operations on the National Health. The solicitor representing the transsexuals commented at the end of this long-drawn-out case that the estimated å£200,000 spent on it could have funded twenty sex-change operations.

One of the transsexuals, known as “A,” was quoted as saying that the sex-change operation was essential to ending years of misery. “A” regards her male physique as a “deformity.” The agonizing sense of dislocation of a man who has been “born into the wrong body, and should really be a girl” emerged earlier in Jan Morris’s Conundrum (1974), a small classic of twentieth-century autobiography, the most convincing account of a sex change yet. Trapped in her male body, and known then as James, Morris endured military service (the 9th Lancers) and newspaper journalism (The Guardian and The Times), covering the war in Palestine and the ascent of Everest before taking the flight to Casablanca, where her penis and testicles were surgically removed and her vagina created in an expensive private clinic. No NHS option in the Britain of that time.

James/Jan Morris equated her conundrum with ideas of soul or self: “I think of it not just as a sexual enigma, but as a quest for unity.” Since then cultural historians have been productively exploring the connections between people’s perceptions of the body they see themselves as, ideally, inhabiting and their happiness of mind. In his earlier study of aesthetic surgery, Creating Beauty to Cure the Soul,1 Professor Sander L. Gilman gave a fascinating account of the origins of these ideas, tracing them back to Enlightenment philosophers’ understanding of a beautiful body as the visible expression of human virtue. Conversely, ugly bodies signified unhealthy spirits. Follow through this argument and the Jew’s nose comes to represent the Jew’s permanently sick soul.

In Creating Beauty to Cure the Soul Gilman concentrates on the complex relationship between aesthetic surgery and psychoanalysis in the late nineteenth and twentieth centuries, which offered parallel possibilities of transformation, one of the body, the other of the mind. While retracking over some of the same material, Making the Body Beautiful is a broader-based, less overtly academic work, written with some of the breeziness of Roy Porter’s energetic sociomedical overviews and containing an unforgettable collection of historical before-and-after photographs. Gilman’s book also differs in its focus from Elizabeth Haiken’s Venus Envy: A History of Cosmetic Surgery.2 Where Haiken drew the majority of her examples and conclusions from the US, Gilman ranges much more widely. His book shows a dazzling European erudition.

Central to Gilman’s thesis is the notion of “passing.” The reason for the popularity of plastic surgery (over 1.9 million operations in 1996 in the US alone) has been the way it helps people to “pass” into the social group with which they identify emotionally. The face was where it started. With their primitive grafts of flaps of skin, the earliest aesthetic surgeons were working to eliminate the facial evidence of unacceptable racial origins or undesirable disease. Gilman cites the sixteenth-century Italian surgeon Gaspare Ta-gliacozzi as the originator of flap graft techniques to replace a nose missing because of trauma or syphilis. These “virtual” noses had their inconveniences: they tended to get livid in cold weather; hard blowing could dislodge them. The techniques soon fell into disuse. More lasting was Tagliacozzi’s humane perception that a person without a nose was bound to be unhappy, and that this unhappiness could lead to illness.

The “cure” for the missing nose was rediscovered in 1794 in India, then under British colonial rule. News of the “very curious, and, in Europe, unknown chirurgical operation,” involving the use of a skin graft from the forehead, circulated in London in the Gentleman’s Magazine. By the early nineteenth century in Germany, Johann Friedrich Dieffenbach was pioneering more sophisticated methods, using a nasal bridge, to restructure the sunken syphilitic nose. In 1892, the American aesthetic surgeon Robert F. Weir butchered a live duck in the operating theater and used the duck’s breastbone to replace the nasal bridge of a syphilitic man of twenty-six.

Plastic surgery, a term in use from the early nineteenth century, was initially seen as nose surgery. Gilman gives detailed, often poignant case histories of Jews’ noses, Irish noses (often combined with notorious jug ears), Oriental noses, negroid noses, tumorous noses, such as appeared in cruel caricatures of J. Pierpont Morgan. He toys with the suggestion that President Clinton’s nose has dubious comic overtones reminiscent of W.C. Fields.

New surgery was developed to turn noses regarded as racially inferior into socially desirable features. In transforming the Irish immigrant “pug” nose into a real American nose, the late-nineteenth-century surgeon John Orlando Roe operated from within the nose so deftly that he left no scar. Roe also perfected a method of shaving the tumors off the face of a drunkard in a way that could transform his face into that of a good family man. “One could disguise the drunkard—but could one change his character?” Such questions are at the heart of Gilman’s book.

He tells a strange, macabre, and often richly comic story of shifting desires. The urgency of disguising racial origins diminished with the social acceptance of formerly marginalized races. The once-derided small, upward-tilted Irish noses, which signified the servile, suspicious immigrant classes, became the American and English fashionable ideal by the mid-twentieth century. Film starlets acquired retroussé noses set in gamine features, like the English actress Kay Kendall, whose nose had actually been formed that way in error by the famous New Zealand plastic surgeon Archibald McIndoe.

By the mid-1970s, a period of dawning ethnic pride, there were second thoughts on operations carried out to make blacks appear less negroid. It was now considered wrong to over-correct and create a nose that was racially incongruent. The much-maligned Jewish nose became an object of affection, even veneration, in the case of Barbra Streisand, seen as the acceptable face of Jewishness.

It was the development of anesthesia and antisepsis that allowed aesthetic surgery to flourish. By the end of the nineteenth century it had developed in its aims far beyond facial correction of racial difference. Gilman urges us to view the much-increased ambitiousness of both surgeons and patients in the context of the intellectual and cultural movements of the late nineteenth and early twentieth centuries. It was part of what Gilman calls “a sea change in imagining who we are and what our bodies are.”

The concept of aesthetic surgery as a Romantic calling arose among the European German-Jewish surgeons of this period. Jacques Joseph, the most influential of them all, saw himself as a sculptor of the human form, using techniques of rhinoplasty to bring his patients’ features close to an artistic classical ideal. His perfect female face had “a greco-roman profile with a 33 [degree] facial angle” and, interestingly, he used a portrait of his (non-Jewish) wife as an example, pointing out her similarity to a pencil portrait of a woman by Leonardo da Vinci.

Aesthetic surgeons overcame their relatively low status early in the twentieth century to attain respectability and even adulation. In both world wars they became the heroes of the hour. Jacques Joseph rose to fame when, in 1916, he took charge of the division for reconstructive surgery in the Charité hospital in Berlin, treating the terrible wounds endemic to trench warfare, caused as soldiers’ faces were exposed over the parapets. Gilman is at his best in a scintillating chapter on reconstructive surgery, commenting with his sometimes savage sense of irony that the sign of real success came when the patient was returned to his regiment to fight again.

The “erotic wounded warrior,” as Gilman calls him, has a haunting and ambivalent place in twentieth-century culture. Gilman might have referred here to the extraordinary series of seventy-two drawings, Studies for Facial Wounds, made in 1916 by the British artist Henry Tonks when he was attached to Harold Gillies’s facial reconstructive unit at Cambridge Hospital in Aldershot. These tragically accurate drawings are now at the Royal College of Surgeons in London. The sense of the soldier’s ruined splendor is poignant in Ernest Hemingway’s account, in A Moveable Feast, of facially wounded French World War I veterans, “les gueules cassées,” with their Croix de Guerre ribbons in their lapels. “There was always an almost iridescent shiny cast about the considerably reconstructed face, rather like that of a well-packed ski run.” Though eerie, these men remained objects of respect. Gilman points too to the physically destroyed but still vividly articulate Count Laszlo Almasy in Michael Ondaatje’s The English Patient. Ondaatje created “the horribly burned face and figure of the eponymous hero as the sign that defines all opposition to war.”

The fetid and duplicitous atmosphere of Nazi Germany encouraged the more dubious elements of reconstructive surgery. It had its role in manufacturing Hitler’s perfect military machine; in 1936 a new law authorized the state to reconstruct a soldier’s body “against his will if necessary, as to extract from it its maximum fitness.” In Fascist Italy, Mussolini’s army officers were ordered to have their eyelids examined and, if necessary, tightened up by surgery to improve their vision. Jews under the Third Reich took to aesthetic surgery to “disappear.” The circumcised penis became a thing of nightmare. Suspected male Jews interrogated on the streets of Berlin would, as a last resort, be told to drop their pants. The SS had been trained by Arab experts to distinguish between cuts made on the twenty-eighth day after birth, which identified a Muslim, and cuts made on the eighth day, which gave away a Jew.

Decircumcision has been possible for almost as long as circumcision has. Gilman finds Roman examples of surgical procedures for elongating or replicating the male foreskin. Hellenized Jews resorted to these in order to take part in the Greek athletic games, from which circumcised men were banned—rather as later Jews, excluded from dueling, went to cosmetic surgeons to fake their dueling scars. Gilman notes a greatly rising demand for decircumcision over the past decade in the United States. The rush for surgical restoration of the penis, amounting to “a small industry,” has taken place against a background of attacks on circumcision as a cruel, child-abusive, and medically unnecessary practice, and a decline in the practice of infant male circumcision itself. But, here again, human desires are variable: according to Gilman, while an “uncut” penis is currently de rigueur in gay circles in New York City, the circumcised version is more desirable in similar social settings in Germany.

  1. 1

    Duke University Press, 1998.

  2. 2

    Johns Hopkins University Press, 1997.

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