Introduction
With rare exceptions (Twiggy, the flappers of the 1920s, and the short-term infatuation with waifs/”heroin chic” celebrities like Kate Moss, Calista Flockhart or Keira Knightley), American popular culture has upheld the archetype of heterosexual attractiveness as the bountifully-endowed female (Scodel, 1957). Bar girls in Occupation-era Japan were the first to undergo breast augmentation in order to increase their appeal to American servicemen. By 1962, Timmie Jean Lindsey of Texas became the recipient of silicone breast implants. It would be fifteen years before the FDA began to regulate implants and another twenty before scientific commissions on both sides of the Atlantic could conclude that silicone implants did not cause lupus, autoimmune diseases or other widespread side-effects.
As belief in adverse physical side-effects waned, on the other hand, evidence arrived about unanticipated mental disorder outcomes. As if the prevalence of depression and the related phenomenon of suicide in the general population were not bad enough, primary health care and mental health professionals must deal with a significant workload of patients who undergo elective cosmetic surgery procedures and, contrary to a priori expectations, fall prey to depression and suicide. Women who undergo breast implants seem particularly at risk of depression and suicidal ideation.
Significant new work has been devoted since the turn of the century to investigating and quantifying this phenomenon. Nonetheless, there remains scope for addressing the key research question: whether post hoc observation of depression and suicide rates in the medium and long term are induced chiefly by implant failures and side-effects; by disappointment at not obtaining the anticipated benefits; or whether women who undergo breast augmentation were already saddled by poor body image, negative self-esteem and latent depression from the very beginning.
The null hypotheses to be tested are as follows:
- H01 : There is no difference in depression and suicidal ideation prior to, and after undergoing a breast implant.
- H02 : There is no difference in overt attractiveness to, and frequency of intimacy initiated by, the husband or cohabitating partner of a breast implant patient both before and after the procedure.
- H03 : There is no difference in depression and suicidal ideation among women who have trouble-free surgeries and those experiencing either silicone leakage or local disfigurement.
Literature Review
Around the time two Texas physicians were developing implants, Scodel (1957) attempted to refine an explanation for the large-breast fetish in Freudian terms. After all, he could already point to a 1922 assertion by Tridon that men breastfed as infants grow up attracted to women with well-developed breasts. This postulate of oral satisfaction met with a contradictory view by Gorer (1957, cited in Scodel, 1957): the common fetish springs from having been frustrated while awaiting bottle-feeding time. Scodel found little empirical support for the Freudian idea that the fetish springs from oral dependence although later authors asserted that the Freudian construct of reaction formation might be an equally valid explanation.
By then, Playboy men’s magazine featuring exclusively generously-endowed nudes had been in circulation for four years and there was no escaping the widespread fascination of American males with that standard of female allure. There was no denying, either, the power of mainstream advertising, especially on television and in women’s magazines, constantly holding up the ideal of women who were thin, ravishingly shapely, bore classic Caucasian features, and boasted baby-smooth skin well into middle age. Between 1992 and 2000, Bazner (2002) reports, breast augmentation rates jumped nearly six-fold, liposuction demand rocketed nearly 500%, and eyelid surgeries nearly tripled. By 2006, the American Society of Plastic Surgeons announced, the number of women undergoing breast augmentation had reached 329,396, more than double what it was in 1997. Seeking to unravel the interrelationships between openness to cosmetic surgery on one hand, and, on the other, the extent to which the culture’s definition of attractiveness had been internalized, “objectified body consciousness, self-esteem…public self-consciousness”, the author (pp. 11-12) investigated the grossly disproportionate skew of female cosmetic surgery patients by administering the “Acceptance of Cosmetic Surgery Scale” to a convenience sample of 359 male and female introductory psychology students.
The author’s findings reveal that even young women (average age of respondents: 19 years) were prepared to undergo cosmetic surgery themselves to restore youthfulness, heighten beauty, and enhance heterosexual attraction. Such positive attitudes correlated rather strongly with paying attention to their looks and figure and spending more time with their physical enhancement toilette despite recognizing the inherently distasteful prevalence of objectifying women for their bodies.
True, there is evidence that, at least initially, not all women are plagued by abysmally poor self-esteem or unsatisfactory sexuality even prior to undergoing the procedure. After advertising for volunteers via cosmetic surgeons’ offices, Figueroa-Haas (2009) administered self-esteem and sexuality questionnaires to 84 women pre- and post-augmentation surgery. At baseline, findings were unremarkable but it was striking how both global measures improved markedly. In particular, the author reported that participants “…experienced every measure of sexuality more strongly (including) arousal, sexual desire, sexual satisfaction, and lubrication” (p. 380). However, one must concede that the sample size was exploratory in nature and Figueroa-Haas was careful to warn surgeons that they should assess prospective patients carefully for body dysmorphic disorder.
In August 2007, Lipworth, Nyren, Ye, Fryzek, Tarone, and McLaughlin made headlines in both the popular press and stakeholder Web sites with a study done under the auspices of Tennessee’s Vanderbilt University Medical Center that highlighted, among others, the three-fold greater risk for suicide among women who had had implants. The research consisted of a retrospective study on the medical histories and death certificates of 3,527 females, employing a cut-off of twenty years post-surgery. The women had received their implants from 1965 to 1993. Among others, the findings included: mortality rate higher than the population at large within the two decades under review; the peak odds ratio for suicide was encountered among those getting implants in middle age; women who underwent the cosmetic surgery procedure were at greater risk of such mood disorders like depression and body dysmorphic disorder; and most ominously, the implant cohort also evinced higher odds ratios for death due to alcohol dependence, accidents (consistent with depression or dysthymia) or drug abuse. Between 10 and 19 years after obtaining the implants, the suicide risk among such women was quantified at 4.5 times greater than the general population. From 20 years onwards, the risk rose markedly to 6 times more.
That the Lipworth et al. cohort also evinced a somewhat higher risk for malignant lung cancer and chronic respiratory diseases were explained as due to silicone leaking and causing scarring of lung tissue. The complications due to such imperfect technology also loomed large in a Canadian study (Tweed, 2003). Comparing a cohort of 147 British Columbia women who had received implants with a comparison group of 583 women, the Centre of Excellence for Women’s Health revealed that up to one-fourth of the formerly experienced complications had to consult physicians more often, and were confined in hospitals more frequently. The most prevalent etiology: two to five more surgeries related to the original implant. By the end of the study period, dissatisfaction with repeated procedures convinced nearly half the implant study group to have the saline-filled bags removed. As well, Tweed and her research team report that women with implants seemed unusually susceptible to localized complications (such as capsular contracture which causes pain and hardness in, by Health Canada estimates, from 25% to 70% implant patients), implant deflation, rupture, and systemic complications such as autoimmune and connective tissue diseases. The Centre did not gather any systematic measures of mental health or emotional effects, resorting instead to quoting the FDA report of Inamed studies that revealed the deteriorating quality of life and mental health indices within two years after surgery. There are also isolated findings for “breast anxiety,” pronounced dissatisfaction with the upper torso and overall body image, and depression.
Nor are based for concern confined to North America alone. A Swedish team embarked on a retrospective analysis of 3,521 women 15 to 69 years old who had had implants put in for cosmetic purposes between 1965 and 1993. On follow up that lasted till the patient’s death, loss via emigration or the end of the study period on December 31st, 1994, the team found elevated standardized mortality ratios, three times the expected incidence of suicide, and a greater-than-“normal” incidence of malignant cancers (Koot, Peeters, Granath, Grobbee and Nyren, 2003).
Methods
Definition of Criterion Variables
The independent variable is the fact of having undergone breast augmentation therapy, validity being assured by recruiting patients from among those on the waiting lists of cosmetic surgeons practicing in (CITY). The dependent variables of depression and suicidal ideation shall be measured with Beck’s Depression Inventory (BDI) and the Beck Scale for Suicidal Ideation (BSSI).
Measures
Version II of the BDI boasts heightened validity for a) now conforming with the latest depression criteria of DSM-IV; and, b) having been reworded to cater to subjects as young as thirteen. The latter means one can confidently administer the BDI to females as young as 15 years, a possibility reported by the Koot et al. (2003) prospective study. As in the prior version, BDI-II runs to just 21 items, each having four possible answers to test for increasing severity of depression. The cut-off is a score of 15. Pearson/PsychCorp (2009a) claims a mean reliability coefficient of 0.86 and excellent test-retest reliability of 0.90.
In turn, the BSSI grants clinical psychologists a convenient tool for assessing suicidal intent in patients as young as 17 years (Pearson/PsychCorp, 2009b). Two built-in screening items facilitate the task of weeding out those who are not truly characterized by suicidal intent. For outpatients, which will be the case in this proposed research, the reported average reliability coefficient currently stands at 0.87 but test-retest reliability is not too good at 0.54.
The independent variables involved in H01 and H03 will be extracted from the electronic medical records maintained by cosmetic surgeons who agree to cooperate in this study. As to H02, measurement of heterosexual attractiveness to one’s significant other can be assessed via a simple checklist or such self-report items on intimacy, orgasm likelihood, and sexual satisfaction as those employed by Haning, O’Keefe, Randall, Kommor, Baker, and Wilson, 2007.
References
Bazner, J. (2002). Attitudes about cosmetic surgery: Gender and body experience. McNair Scholars Journal, 6: 11-16.
Figueroa-Haas, C. (2009). Psychological issues associated with breast augmentation. Issues in Mental Health Nursing, 30 (6): 377-382.
Haning, R. V., O’Keefe, S. L., Randall, E. J., Kommor, M. J., Baker, E. & Wilson, R. (2007). Intimacy, orgasm likelihood, and conflict predict sexual satisfaction in heterosexual male and female respondents. Journal of Sex & Marital Therapy, 33 (2): 93-113.
Koot, V. C. M. P., Peeters, H. M., Granath, F., Grobbee, D. E., & Nyren, O. (2003). Total and cause-specific mortality among Swedish women with cosmetic breast implants: Prospective study. BMJ, 2003 (326):527-528.
Lipworth, L., Nyren, O., Ye, W., Fryzek, J. P., Tarone, R. E., & McLaughlin, J. K. (2007). Excess mortality from suicide and other external causes of death among women with cosmetic breast implants. Annals of Plastic Surgery, 59(2):119-123.
Pearson/PsychCorp (2009a). Beck Depression Inventory®-II. Web.
Pearson/PsychCorp (2009b). Beck Scale for Suicide Ideation® (BSS™). Web.
Scodel, A. (1957). Heterosexual somatic preference and fantasy dependency. Journal of Consulting Psychology (subsequently renamed the Journal of Consulting and Clinical Psychology), 21 (5): 371-4.
Tweed, A. (2003). Health complications from breast implant surgery: A Canadian study with Implications for the U.S. British Columbia Centre of Excellence for Women’s Health. Web.