I have a love-hate relationship with dermatologists. Scratch that — I have a hate-hate relationships with dermatologists except for one fine doctor who drastically improved my life. I’ve had acne on and off since I was about 15, and I’ve lost track of how many doctors I’ve seen about it. I’ve smeared countless lotions on my face, taken countless pills (including one that made me simultaneously ravenous and stomach-achey, which still seems impressively weird to me), and suffered frequent bouts of self-loathing about it. I did find one doctor when I lived in Seattle who was both kind and effective, and I had about two miraculous years of clear skin. Now I’m grudgingly back under dermatological care after watching that nice clear skin follow the pattern of redness, acne, and scarring that I know so well.
Acne is often extremely uncomfortable for all kinds of reasons beyond appearance: it itches, it makes your skin sensitive to the touch, it can come with dry skin OR oily skin (both of which are uncomfortable). It hurts! There are a lot of reasons to want to treat acne even without the social stigma, which is of course huge.
But here’s the thing about acne: it’s a medical condition whose most drastic effects are cosmetic. That word, “cosmetic,” is a troubled one. Here are its first three definitions from the OED:
1. a. Having power to adorn, embellish, or beautify (esp. the complexion)
b. Of surgery: improving or modifying the appearance. Of prosthetic devices: re-creating or imitating the normal appearance.
2. fig. That affects appearance only, superficial; spec., intended merely to improve appearances.
It’s the tension between definitions 1 and 2, hinged on that word “merely,” that gives me pause. On the one hand, as we know full well here, there is a lot of social power tied up in appearance, in looking “normal” for whatever your culture deems as normality. On the other hand, there is something so dismissive about that figurative link between “cosmetic” and “superficial” — the phrase “intended merely to improve appearances” drips with condescension. (I should note that I’m not attributing that condescension to the good lexicographers at the OED! I think the tone captures quite well the way “cosmetic” is used figuratively.) In fact, to me this definition perfectly distills one of the great rhetorical tricks of patriarchy, which is to define women’s value in terms of appearance, and simultaneously to define appearance as something so utterly trivial that only completely shallow and useless creatures — like, say, women! — would care about it.
Which is why I’m especially troubled by this NYT article about dermatologists who are turning their offices into mini-spas for “cosmetic” patients — i.e., those who come in for Botox and the like, and who pay out of pocket — while keeping the same style of brutal (in)efficiency for those pesky “medical” patients who come in with, say, acne, or, I don’t know, skin cancer. As with any medical trend story, there are some horror stories (like the woman whose first doctor recommended skin bleaching for a strange mole, and whose second doctor correctly diagnosed it as melanoma). But what I find most disturbing is the way the line between doctoring and beautifying is blurred: patients report doctors attempting to upsell them on beauty treatments when they come in for skin problems. At the same time, other doctors seem to have a bright line dividing “cosmetic” patients and “medical” patients:
In an interview, Dr. Susan H. Weinkle, a dermatologist in Bradenton, Fla., said that she typically spends more time with cosmetic patients because they come in wanting to look better, the kind of amorphous desire that takes longer to satisfy than defined medical problems. One of her staff members always calls a beauty client to follow up, she said.
“It is very rare that you would call an acne patient and say, ‘How are you doing with that new prescription?’ ” Dr. Weinkle said. “But with a cosmetic patient, the consultant calls them the next day.”
“Instead of laying on an exam table with a paper liner, you have them lay on a sheet,” said Deborah Bish, a former nurse who works as a practice consultant in Yardley, Pa. “You have to class it up for these patients.”
You have to class it up for these patients. Class is, of course, the not so hidden factor here. I’m willing to bet that it’s not just “cosmetic” patients who “come in wanting to look better” and would appreciate some information about how to care for their skin’s appearance as well as its ailment — but it’s only the cosmetic patients who are voluntarily spending their own money to look better. And, of course, “looking better” in our culture is a signifier of class status: clear skin, straight white teeth, smooth shiny hair (and, of course, a firmly sculpted figure) all indicate both the time and the money to devote to adornment, embellishment, and beautification. (Tangent: back in 2000, my friend and I met Al Gore at a political rally. We were both shocked — and I mean really shocked — to discover that he has crooked teeth. The Vice President! Whose dad was a Senator! Why wouldn’t they fix his teeth? I’ve been trying to unpack that reaction of ours ever since.)
So “cosmetic” is at once considered shallow (these rich women and their Botox spas!), as if it’s all about vanity rather than about classed, gendered, and racialized cultural mandates, and a jackpot — a never-ending demand that savvy dermatologists can milk for fabulous amounts of money.* If you’re unlucky enough to be one of the many people who depend on the bureaucratic nightmare that is health insurance for your dermatology treatment, you get the short end of every damn stick: you wait longer, you get less time with the doctor, you get the paper liner instead of the sheet, and you still get doctors trying to convince you to get microdermabrasion along with your acne lotion (and to do so, of course, they have to tell you what’s so much worse about your skin than you even thought).
I don’t know what the answer to this is apart from a revolution in the US health care system as well as an overthrowing of the beauty myth. Since both of these are a long time coming, I turn the floor over to you while we plan the uprising. A good part of our energy here at SP goes towards pointing out that what are touted as medical concerns about fat people are often aesthetic mandates in disguise. How does clear skin fit into this system? What are your experiences with acne and with dermatologists? How do your cosmetic practices fit in with your self acceptance?
*”According to a presentation for doctors from Allergan, the makers of Botox, a medical dermatology practice might have a net income of $387,198 annually, but a dermatologist who decreased focus on skin diseases while adding cosmetic medical procedures to a practice could net $695,850 annually.”