17. Psychological Considerations

Gladys Caamaño^{1, 2}

(1)

Surgical Psycho-Prophylaxis and Psycho-Oncology, Hospital de Clínicas, Buenos Aires University, José de San Martín, Buenos Aires, Argentina

(2)

Faculty of Medicine, Universidad del Salvador (USAL), Buenos Aires, Argentina

Gladys Caamaño

Keywords

Arguments for the choice of silicone injectionDepressionPersonality disorderDoctor-patient relationshipImportance of the breasts in female symbolizationPsychological evaluationSurgical psychoprophylaxis

Why is it that, even though most of society appears to embrace individuality—differences in personalities, interests, and aptitudes—it is so much less willing to accept differences in appearance? No two individuals are exactly the same; even identical twins can be told apart by those who know them well. Yet society has created norms for what people look like: not too short or tall; not too light or heavy; favoring muscular men and slim, full-breasted women. Physical beauty is viewed as paramount.

Why does society value variety in everything else but only seek perfection in appearance? The answer to this question is complicated. A great variety of coexisting psychological and social factors drive this intense need, especially for women, to “possess beauty and obtain perfection.” One contributor is the social environment that is increasingly committed to promoting consumption, its sole aim being to sell and generate profits. Companies sell products to beautify women, and women are sold on the need to purchase them. For some, beauty is sought at almost all costs.

From early childhood, we collect all kinds of life experiences that will ultimately determine who we are as adults. In order for this adequate construction to be achieved, many factors are essential. One of these is a loving and competent mother figure. Evolutionary development focuses on the maximum importance of early bonds, the support necessary for someone to develop self-strength, while developing close relationships with others. The personality we ultimately have will be the product of self-strength and secure attachments with others. Without this, we grow in self-doubt and look to others to see how they perceive us, hoping that their perceived gaze and actions toward us show no evidence of disdain. Such disdainful looks become weights upon our backs, pulling us down. For some, the irrational response to this is to strive to become perfect.

It is only once someone has developed a secure, self-confident personality—able to decide what is good and what is not, able to think about their own desires, and how to achieve their goals—and that someone has the ability to recognize what is good and what is not good for their health. It is also then when a person feels assured that their body belongs to themselves alone, to live with and enjoy as it is, not how others might think it should be. Such a person’s appreciation for their own body depends much less on its appearance, than its level of health.

However, such a level of self-confidence is increasingly difficult to achieve today, and many have personality defects that predispose them to needing to compete against others, in ways like their appearance, merely to validate their own worth. This may manifest in what they wear, what they own (like a fancy car, which they might not even be able to afford), or how they themselves look in a mirror.

In other words, the material world has tried to libidinize everything. The ability to seduce becomes an obsession, one only attainable by replacing values with products, replacing yourself with what the media tells you who you should be. This marketing attempt that drives people to change themselves to seduce others used to largely be restricted to women. Now, with increasing acceptance, albeit reluctant, of transgenderism, birth males who identify themselves as females are also being lured into this. However, such change is expensive, especially when it comes to altering not only your clothes but yourself. For many, inadequate finances and insurance, and/or the lack of adequate information, prevent them from accessing the healthcare services they need. Perhaps ignorance of the consequences or a self-desire to minimize or disavow such risks, perhaps the council of a close friend, and perhaps the lure of a procedure that promises to be quick and simple results lead them to seek out those outside the healthcare sector, even if it means having an illegal procedure performed in a seedy hotel or a person’s home. They somehow manage to look past all this, perceiving only the potential to finally achieve their perfect version of themselves.

Real problems arise not only after the procedure, when symptoms develop and their perfect selves start to change for the worse but also when they have to face “repairs” that may make them look even worse. Gone is that perfect image they once had for themselves, leading to tremendous fear and frustration; and to psychological consequences that may not be known until after the magical results, they still hoped for fail to come to fruition. Their faith in traditional healthcare becomes shaken. It was, after all, someone in a seedy hotel or their home who once made them look beautiful. Now, doctors are destroying that beauty forever.

When we, as psychotherapists, see such patients, we see emotionally and psychologically battered women and transgender females. If we accept the importance of breasts as a symbol of gender, then the total or partial loss of one or both breasts often causes patients to feel a loss of identity. Such patients’ psychological suffering varies in magnitude, largely based upon how confident and secure they were initially. However, it also depends on other factors, like their chronological age, future family plans, whether or not they are part of a stable couple, and whether they have children and how old those children are. It also may depend on career factors, like how important their physical appearance is or is perceived by them to be, in terms of their acceptance in the workplace and opportunities for career advancement.

Also important is their perception, realistic or fantasized, of likely postoperative outcomes and sequelae, which, again, is influenced by their own, innate sense of self-confidence and security. The loss of any body part is psychologically traumatic and, for some, even as subtle as the loss of a toe. However, the loss of one or more breasts has much more massive implications for most women, whether born female or transgender. As opposed to a toe or finger, or even a kidney, this mutilation is immediately visible. Even hidden by their blouse, they still must see themselves as they really are in the mirror. It also is almost impossible for them to hide their mutilation when they are trying to be physically intimate with another person.

The mutilation of one or both breasts affects one’s image of oneself, as well as one’s sexuality. Young or expectant mothers may fear weakening bonds with their children, feeling shame at being unable to breastfeed their child, or being unable to go swimming with their family. Even carrying a child may cause them to fear that the child will sense their abnormality if, for example, their breasts end up being uneven. They may even feel that, in losing such a vital component of their femininity, they are less of a woman, less of a mother.

Klein’s Theory of Object Relations: Good and Bad Breasts

To fully appreciate the importance of the mother’s breast in love relationships, it is necessary to take a brief tour of theoretical models regarding the development of one’s psychological apparatus. I begin by describing a theory proposed by Melanie Klein, whose work is a fundamental contribution to the psychological approach that we take with each of our patients.

Melanie Klein theorized about object relationships and organized them into two positions, which she termed the “paranoid schizoid position” and the “depressive position.” She used the designation “position” because, throughout a person’s life, individuals use them and adapt them as needs arise. In addition, anguish and defenses that appear within the first few months of a traumatic event may reappear throughout life, according to one’s circumstances.

During early development, infants seek their mother’s breast and, as it is offered, perceive it as either a “good breast” or a “bad breast,” depending on how successful and easy feeding is. The baby projects amorous emotions onto gratifying (“good”) breast experiences, when feeding is easy and satisfying, and frustration onto difficult (“bad”) breast experiences, when feeding is difficult or less than satiating. At the same time, these emotions and attachments are internalized. This fragmentation is a defense mechanism characteristic of the paranoid schizoid position, which consists of keeping unpleasant experiences separate from pleasant ones, thereby affording the ego a relative level of security. Good breast experiences also allow infants to internalize the concepts of loss and restoration.

Thus, in a child, the feeling is born that there is at least one good thing (the mother’s breast) that gratifies him (or her), providing sustenance, warmth, and affection, fostering his/her first experiences with love. Meanwhile, the child also develops the feeling that bad things also exist, which he/she hates. Throughout the child’s life, these two feelings will both be internalized and projected, depending on the position that person finds himself in, which contributes to reinforcing his primitive sense of love. The love that is offered by the mother through her breast becomes a protagonist for the child’s subsequent psychological development, continuing into adulthood. According to Klein, greater trust in this internalized “good breast” generates feelings of inner security, a precondition for the development of a stable and integrated self and good relationships with others.

The “depressive position” arises in times of pain or loss, like when the breast is taken away before the baby is satisfied. In such times, the “depressive position” is reactivated. However, if, over the course of early development, the person has learned that bad breasts will eventually be replaced by good breasts, then he or she will have faith that bad times later also will end and good times return. In this way, the evolution of one’s grief (normal or pathological) is determined by how the newborn once learned to overcome loss. This duality, between the schizophrenic and depressive positions, indicating change and loss, respectively, is therefore created during a newborn’s first days but persists throughout life. Moreover, how the infant learns to deal with that duality will be utilized throughout life. In other words, changes and losses that occur later in life largely depend upon a person’s experiences as a newborn: whether she/he gained confidence that a bad breast ultimately will be replaced by a good one or not.

Jacques Lacan’s Theory of Mirrors, Ego, and Subjects

Somewhere between the ages of 6 and 18 months old, infants start to recognize themselves in reflective surfaces, like a mirror. In other words, they come to know they actually exist as they appear in a mirror. However, because they are so premature in their physical, intellectual, and emotional function, they also are completely dependent upon others. More specifically, they are dependent on their mother. Prior to Lacan, Freud had already theorized that an infant’s biologically determined helplessness predestines them to, even as adults, emphasize social nurture over material nature, due to the protracted period of time they spend, as neonates, infants, and then young children, totally dependent on others. In short, though we know we exist, we need others to help us truly identify ourselves, just like we need a mirror to see our own faces.

This stage of biologically ingrained “motor impotence and nursling dependence” is also when children start to link the frustrations and other negative emotions they feel when their needs are not met by others (usually their mother) and the satisfaction and other positive emotions they feel when they are. Eventually, however, they come to a point where they start to view the potential that they, themselves, can become wholly self-dependent and, as such, a whole body unto themselves. This being said, Lacan argues that this, in fact, is “misrecognition”: when you look at yourself in a mirror, you are actually being misled. He states: “Looking in the mirror does not mean seeing everything in front of him. There is no correspondence or direct and reciprocal adjustment between the body and the image; the image does not take everything; there is always an unassimilable rest.” This is because the mirror that most of us spend most of our time looking at is not made of glass but constructed by the feedback we receive from others, through their words, how they appear to be looking at us, and how they act toward us. And appeasing this mirror often drives us to modify ourselves to enhance our image. Lacan claims that “the self” suffers from a furious passion to imprint its image of itself in reality. The self also constructs the world around it to accommodate its image. It projects its own attributes onto others. It appropriates what confirms it and excludes what questions it; it ignores what threatens its own narcissistic structure. What all this means is that, when we look at others, we do two things: we project our beliefs and image of the world and how things should be onto them; but we also tend to view ourselves through their eyes. In terms of a physical appearance, then, we often judge how others look yet feel insecure about how we, ourselves, look.

Another concept that Lacan discussed was that of “body fragmentation,” which is contrary to people thinking of their body as a whole, as an indivisible unit. In truth, though we accept ourselves a whole being, we also perceive our individual body parts. Moreover, some parts stand out more to us, at different times, than others. For example, if we have pain in one body part, that body part becomes a prime focus of our attention. Similarly, if we feel that part of ourselves does not meet our perfect image of ourselves, that becomes our focus. Someone with an oversized nose looks in a mirror and is drawn immediately to their nose. A woman with breasts that they perceive to be undersized (whether or not they are below average in size) will assume that others notice this and judge her by this. Similarly, for the birth male who identifies himself as female, it is not enough for him to act like a woman; he must also look like one.

Now, consider all this in a woman or transgender female who has already decided to augment their appearance via breast augmentation but now is being told that, to correct adversely health-altering consequences of that augmentation, she must undergo surgery that will make her look worse than when she started.

A woman’s breasts are not essential to life, but they may be perceived as essential to someone’s self-confidence and sense of wholeness. As stated elsewhere in this book, they are viewed as symbols of womanhood, motherhood, seduction, and success. Their mutilation generates great upheaval in the human psyche, as well as fears of rejection, from one’s partner, from family and friends, among work colleagues, and by strangers.

One thing that is striking is the apparent absence or severe limitations of certain psychological functions when women and transgender females decide to undergo silicone injections for breast augmentation. Whereas they might be very attentive to avoid eating certain things and to exercise regularly to avoid gaining weight, such health consciousness and risk appraisal often abandon them as they decide to undergo silicone injections. Perceiving only the best-case image of themselves postinjection, they consciously minimize or even totally ignore the potential risks. Many also minimize or ignore the risks of such adverse sequelae even after they become manifest, especially when faced with surgery that they are told may be mutilating. Helping them to accept the real risks and minimize their fears of a disastrous life outcome (how their life will be with surgically diminished and/or anatomically deformed breasts) is the job of the surgeon and psychology team working together.

For the psychologist, after determining the reasons for which a given patient decided to undergo liquid silicone injections, it is important to discuss the potential psychological consequences of whatever breast mutilation reparative surgery will require. As stated earlier, the loss of any body part is virtually always associated with some degree of grieving. The same is true for the mutilation of a body part, especially one that is both as visible and as important to one’s sense of self as their breasts. Helping patients to prepare for this grief preoperatively and to deal with it postoperatively often takes considerable time.

Many patients, due to a combination of denial and shame, delay seeking help for the sequelae of their breast injections. They suffer the indignity of having done something that they could have and should have avoided. As Freud says: “The shadow of the object falls on the self.” Those who have made the clearly imprudent decision to undergo an unnecessary procedure that is both flatly rejected by the medical community and perceived as a sign of vanity by many in society may feel emotionally incapable of exposing their mistake for considerable time, if not indefinitely. For this reason, many present with disease that is much more advanced and clinically severe than it ever needed to be, both physically and psychologically, had they only presented to health professionals equipped to deal with their problem(s) sooner.

Even when such patients consult, they may censor themselves, withholding information that may be essential to their successful treatment, again, both physically and psychologically. They may, for example, not admit to feeling suicidal, due to the shame they feel admitting such weakness.

Someone’s image of their own body begins in childhood. A reawakening of this discovery occurs in adolescence as boys and girls pass through puberty. This is also when one generally awakens to their own sexuality. This includes their amorous attraction to others, whether the opposite gender, their own gender, or both. It also is when some individuals start to feel trapped within the wrong gender. In addition, the adolescent years are a time when individuals tend to develop stronger ties outside the family unit, including “best friend forever” like friendships and amorous relationships. Along with this, teens also become more critical of others’ appearances and hypercritical of their own. Proof of this is that the peak onset of anorexia, bulimia nervosa, and other eating disorders is in adolescence and young adulthood. This combination of factors might explain why so many individuals who pursue silicone injections for breast enlargement are young. Added to this are injections sought by prostitutes—girls, young women, and transgender females—wanting to increase their desirability and, hence, their clientele and financial prospects.

Early adulthood, meanwhile, is a time when individuals are most likely to enter into more long-term and meaningful intimate relationships, begin families, and break into careers. Complications from silicone injections, which can be immediate, but more often delayed by months to years, may interfere with all of these, including the ability for women to breastfeed their children. These complications thereby have the potential not only to adversely affect a person’s appearance and health but to derail current or future intimate relationships, their perceived or real ability to bond with their children, and their livelihood. And the same is true of the surgical treatment that is often required to repair the damage that silicone has caused. All of this may lead to frank decreases in self-esteem and manifestations of anxiety and depression. These numerous landmines of difficulty must be evaluated and adequately addressed prior to the silicone-injected patients undergoing reparative surgery, by a psychotherapeutic program that provides them with the basic tools they might need to mitigate the many adverse emotions that may come from their future surgery.

For this reason, the importance of interdisciplinary work is highlighted, which considers all the potential traumatic consequences of surgical treatment, for example, in addition to the surgeon and psychologist, perhaps a gynecologist to discuss female issues, a social worker to discuss employment issues, etc.

Psychological interventions for physical illness must take into account the patient’s view that their physical illness is a crisis. Such an intervention must consider two fundamental factors: (1) the patient’s current life circumstances and (2) the patient’s personality. The former includes not only the patient’s current illness but their family situation, their employment status and career goals, and their network of supportive social contacts, be they friends or professionals, who can serve as resources. The latter includes each patient’s personal resources, grounded in past experiences and development, dating as far back as childhood. Clearly, a young woman or transgender female who has grown up with loving parents and a supportive network beyond that will likely be better equipped to deal with potential disappointment over her surgical outcome than one who lacked a nurturing environment growing up.

Either way, after assessing the patient’s life circumstances and personal attributes, the psychologist must help them to augment existing coping strategies and/or develop new ones. They must emphasize to each patient that emotionally dealing with their disease will be difficult, perhaps more difficult than they can possibly surmise. In other words, with silicone injection-induced illness, the crisis does not pass with successful treatment. If anything, it may worsen, at least until the patient develops the personal and extra-personal resources to deal with it.

The following are essential tasks that psychologists must undertake:

Helping the patient to either maintain or develop a new level of emotional balance. Gomez states: “Handling balance with these patients means that, on one hand, we understand their situation of suffering; and on the other hand, we offer an open door that allows them another alternative to this suffering that is not just more suffering. Beyond that, there is an adequate level of emotional balance that is necessary to consider; that when the person’s emotions overflow, that generally does not serve him well.”
Encouraging the patient to appropriately express all their emotions: their sadness, fear, anger, frustration, sense of shame or guilt, bewilderment, etc. Note that guilt and shame sometimes are fostered by others, like family members, coworkers, or members of their church.
Helping them to preserve a satisfactory self-image and maintain a sense of competence and mastery. The crisis posed by the disease threatens self-image by questioning the patient’s ability to control situations. The self-concept is violated to the extent that the patient feels she cannot control what is happening to her.
Helping them to maintain their relationships with family and friends. One ineffective solution to their problems that many patients adopt is to socially isolate themselves. The feeling of shame over a disease they consider themselves at least partially responsible for can dominate a patient’s life and drastically curtail their social interactions. The therapist can intervene to teach and promote new forms of communication, allowing the patient to talk about issues they previously could not talk about, first with a professional and then, later, perhaps with others with whom they feel close outside the psychologist-patient dyad, like their spouse or a parent.