Aesthetic Norms, Germs and the Medicalization of Ugliness

Medicalization is the process of bringing social, legal or political problems under medical authority: this is how human problems become medical problems. The concept is typically used to refer to controversial cases, such as translating beauty norms and aesthetic preferences into medical terms, with medical consequences. One could cite a myriad of examples: the rise of plastic surgery, the booming cosmetics industry, genital reconstruction, so-called ethnic forms of surgery (e.g. removing the skin folds on eyelids in Asian individuals), the link between valuing very fit bodies and eating disorders, and the general commodification and moralization of beauty ideals in western societies.

Translating social norms of beauty and ugliness into medical terms—seeing deviations as harmful or pathological and in need of medical, surgical or pharmaceutical treatment—creates problems. It risks reducing beauty to a commodity; it preys on our vanity and desire for recognition; it exacerbates body image anxieties; and it applies questionable moral judgments to variations in body shape, size, appearance and function. Why does such a harmful practice persist?

There are some, particularly postmodern Foucault-inspired scholars, who try to explain this persistence by appealing to institutional changes in medical decision-making, such as the development of the clinico-anatomical, or clinico-somatic gaze—i.e. by explaining undesirable traits in terms of bodily causes, physicians can more easily justify their treatment. If someone’s ugliness, for example, is explainable in terms of a dysfunctional structural or developmental process, then it is more readily amenable to therapeutic interventions to return it to normality. These medicalization processes are also understood as resulting from socially determined norms—e.g. as Western societies are increasingly characterized by the social ills of individualism, corporate capitalism, the dismantling of welfare states because of the dominance of private markets, etc., individuals are beginning to see their relationship with medicine as that of a consumer, purchasing bodily and self-perfection. As medical institutions push their beautifying, anti-aging or other normalizing treatments, aesthetic norms are increasingly medicalized. On the one hand, we have social and institutional changes buttressed by dubious biological explanations, and on the other, specific social and economic interests driving the norms of a society in domains in which they cause harm.

Without fully denying either factor, however, we can complicate this picture of what drives our pathologizing or medicalizing of aesthetic norms by looking at two other dimensions: the unclear boundaries between social and biomedical harms, and the role of what is called the behavioral immune system. Together, these suggest that one central yet often overlooked explanation for this medicalization and pathologization stems from evolved psychological tendencies, which get exploited or fostered throughout our lives.

Social vs. Biomedical Harms

Some will argue that the problem with medicalization is that, when we transform social problems into medical problems, individuals are often convinced that they are suffering from conditions that they previously paid no mind to. One classic example would be turning grief into a pathology in need of pharmaceutical treatment. While such instances surely occur, is the line between what is individually or socially considered harmful and what is defined as biomedically harmful really so clear cut?

Consider height, obesity and hypodontia (lack of teeth). Medical sociologists have pointed out the recent interest in medical treatments for and public interest in height as a medical problem. Research and testimonials suggest that turning the extremes of tallness or shortness into diseases, which need to be regulated by administering hormones to stunt or foster growth, can be dangerous for those involved. Nevertheless, while a degree of tallness can be associated with greater financial success and a higher IQ, increased height also brings with it increased risks of ailments including various forms of cancer, and type 1 diabetes, and potentially decreases longevity.* There appear to be intertwined social and biological trade-offs to increased height.

There has also been much debate about the American Medical Association’s 2013 decision to pathologize obesity, based on what some see as an arbitrary level of BMI. Many in the fat acceptance community object that this medicalizes normal human bodily diversity. Yet studies abound which challenge the fat but fit idea, since obesity significantly increases an individual’s risks of arthritis, high blood pressure, diabetes, heart disease, cancer and sleep apnea—all of which are linked to underlying insulin resistance. There are also inferences one could draw from the total absence of obesity in wild animals. Of course, risks are not diseases, and fat shaming is a serious problem, but healthy obesity remains a questionable concept.

Finally, consider hypodontia. As with lack of height, poor dentition is strongly correlated with low social success and poor self-esteem. This troubling correlation is nicely described by Malcolm Gladwell in the New Yorker Magazine:

[T]hose struggling to get ahead in the job market quickly find that the unsightliness of bad teeth, and the self-consciousness that results, can become a major barrier. If your teeth are bad, you’re not going to get a job as a receptionist, say, or a cashier. You’re going to be put in the back somewhere, far from the public eye.

It is not clear that aesthetic judgments are simply translated into, and thus distorted by, medical considerations, nor that it would be preferable to remove such judgments from medicine. Many people legitimately suffer on biological and social levels and there is no reason to believe that medicine should be only about addressing biological suffering. The line between social problems and medical problems is not well defined. Individuals are therefore not necessarily harmed when we explain social problems in medical terms.

Evolution, Parasites and Human Values

It is interesting to explore the possible links between aesthetic considerations and the medical categories of normality or abnormality and broader dynamics in human cultural evolution. A growing body of research indicates that we have evolved specific psychological mechanisms that make us more likely to display negative reactions and avoidant behavior towards those individuals we perceive as morphologically—or even behaviorally—unusual or anomalous. This has been shown to hold for disabilities, obesity, deformities and even for people from other cultures and ethnic backgrounds. This underlying human tendency is shaped by a given culture, such that individuals come to learn which features constitute anomalies. As Dan Kelly points out in Yuck!, this results in interesting cultural differences—not all cultures find the same anomalies undesirable or worthy of disgust.

The research provides an interesting explanation as to why we pathologize anomalies: we have evolved psychological mechanisms that were selected to help us avoid infectious diseases, but these mechanisms can result in new problems in modern environments: they cause us to err on the side of caution by evoking the same set of behavioral and cognitive responses to rare individuals or traits. This suggests that our aesthetic values about the link between beauty and bodily normality may stem from our society’s parasite load. In other words, the cleaner and more hygienic a society’s living conditions—and subsequently the fewer infectious diseases it is prone to—the more open to bodily and behavioral diversity it becomes.

This is the fascinating parasite-stress theory of values and sociality developed by a variety of evolutionary biologists in the early years of the twenty-first century. Like earlier biocultural theories in anthropology, it rests on the idea of the behavioral immune system: “the human psychological adaptations and related emotions, cognitions, and behaviors that are functionally designed for avoiding contact with parasites.” According to this theory, living in conditions of low pathogen stress, i.e. with low risk of infectious diseases, is strongly correlated with more openness towards strangers, reciprocity and openness to novelty. Where contagion risk is low, the benefits of accepting and seeking out diversity outweigh the costs of not doing so. Conversely, when disease risk is high, there will be more authoritarianism and xenophobia and a much higher tendency to pathologize and marginalize difference, which is perceived to be a threat to the behavioral immune system. Infection sensitivity therefore drives our social values.

It has been argued that this regulates in-group preferences, mate choice, culinary preferences, personality, how we respond to illness and habitat preference and may even predict musical preferences, among others. Two interesting and seemingly opposite examples have been discussed. First, there is the claim that an unappreciated causal factor in the rise of 60s American counterculture was the widespread public health interventions of the 1940s. Since such interventions often take a generation to produce a psychological effect, the improved living conditions of individuals growing up in the 1940s and 50s served as the hygienic bridge between the time of their implementation and the shift in cultural values. Second, this theory even suggests an explanation for conformity under Nazi Germany: if you want to effectively ensure obedience to authority and group conformity, one key tool is to convince the population that they are being invaded by pathogens—both figuratively in terms of specific groups of people and literally in terms of the germs they bring with them. Hitler’s early public health campaigns to clean up German industries were aimed at literal filth and a variety of growing disease rates—his extermination programs transformed this aim by designating specific human groups as rats or parasites to be eliminated. In both examples, hygienic living conditions strongly shaped social values—whether unintentionally or through authoritarian governance.

This provides a strong reason to believe that evolutionary dynamics shape why we negatively perceive and respond to what is considered different or anomalous—and why this tendency is exacerbated when there is an increased risk of infectious diseases. One criticism of this theory has come from medical history and anthropology, which show that not all societies base or have based their ethno-medical theories on the idea of contagion. Perhaps this parasite theory only pertains to modern post-germ theory societies. This criticism, however, misses the point, which is that cultural evolution often provides an invisible hand explanation. While perhaps the idea of contagion was not explicitly part of ethno-medical ideas about illness, its influence could still have shaped a group’s healing practices without their conscious awareness.

The Mixed Blessings of Medicalization

So, why do we keep medicalizing aesthetic norms? In part, because medicalizing and pathologizing are all-too-human practices. According to a plastic surgeon in NJ, the cosmetic surgery industry, and those who provide treatments for undesirable bodily anomalies prey on our evolved psychological tendency to associate difference with disease. The more we perceive ourselves to be vulnerable to disease transmission, the more anomalies are seen as abnormalities. We have evolved the psychological tendency to respond to bodily differences and diseases, be they infectious or not, as contagious. And the more we equate any disease with contagion (e.g. by talking of epidemics of obesity, mental illness or even violence), the more we activate our avoidance mechanisms—hence more stigma, prejudice and xenophobia. These tendencies predispose us toward disease avoidance—and our cultural and physical environments, interacting with our developmental experiences with infections, together provide the causes of how and whether these tendencies take shape. Making these prejudices explicit could be one step towards developing more reflective and humane responses, as could repeated interaction with whatever/whomever is seen as different—but we are likely to remain strongly influenced by these unconscious environmental cues.

One implication of this research is that if we are going to challenge prejudice, racism, xenophobia and certain problematic effects of turning social beauty norms into medical problems with medical solutions, then perhaps we should focus less on the medical operations themselves, as these are only the symptom of deeper dynamics. It is also unhelpful to appeal to rationality since the mechanisms involved are largely non-rational.

So, rather than decrying medicalization, perhaps we should be championing at least a minimal medicalization of our environments. If we want to increase acceptance of bodily diversity and difference, we should start by focusing on ensuring universal access to healthcare and carrying out widespread public health interventions to provide basic resources—clean water, sanitary living and working conditions, nutritious food, etc.—to everyone: all of which will lower rates of disease, especially of contagious diseases. The less we perceive ourselves to be vulnerable to disease transmission, the more anomalies can remain anomalies. As biologist Randy Thornhill claims, “if you effectively target infectious diseases then you will liberalize the population,” thus potentially shifting the group’s overall value structure from collectivism (high levels of conformity) to individualism (high tolerance for deviation from the status quo). These psychological tendencies run through each of us, such that we can vary in our degree of individualism or collectivism at any given time. As we are always susceptible to influence, each generation, and each individual, has a unique experience of this liberalizing process.

Philosopher Carl Elliot is right to claim that the changes in medical practice by which ugliness has come to be seen as a problem requiring treatment are linked to the American values of self-transformation and authenticity. This explains the particularly American interest in enhancements and bodily modification interventions. Elliot may be on to something when he argues that, when we pathologize ugliness, it is not individuals but society that is ill. But the medicalization and pathologization of aesthetics touches on a deeper attitudinal structural: the persistent perceived vulnerability to infection through that which is seen as different. Perhaps this social illness is as much biological as it is cultural.

*An earlier version of this article included cardiovascular disease among ailments associated with tallness. This was an error.