Although capsular contraction and implant rupture are recognized complications of silicone implants, Jacobson frames silicone autoimmune disease as a classic example of a social construct: "The disease was the falsification and cover-up of scientific data; the disease was the failure of industry and plastic surgeons to inform women of the risks."

This reminds me of something Al Levin said . . .The defense has bought the science and are now claiming that the world is flat, water is dry and fire is cold.

Yep, looks like this is what we have here – Our hair loss, blurred vision, mental confusion and fatigue along with all of the other symptoms were only caused from a lack of information. Where do they get these people ???

Vol. 284 No. 13,

October 4, 2000

Cleavage: Technology, Controversy, and the Ironies of the Man-Made Breast

by Nora Jacobson,

302 pp, $52, ISBN 0-8135-2714-7,

paper, $20 ISBN 0-8135-2715-55,

Piscataway, NJ, Rutgers University Press, 2000.

Reviewed by

Janet E. Shepherd, MD

The fiasco surrounding silicone breast implants has been variously blamed on manufacturers who made them, plastic surgeons who inserted them, women who requested them, the US Food and Drug Administration (FDA), greedy lawyers, and the media who sensationalized the story.

In this fascinating book, medical sociologist Nora Jacobson examines the positions of all of these players using a methodologic approach known as social constructionism. This approach eschews "objective realities" in favor of examining the processes through which members of society create their own realities. Certainly, few other contemporary conflicts have exhibited so many layers and versions of "reality."

Jacobson first explores how breast implants became a reality at all and how the concept of breast augmentation came to be accepted by our society. In a chapter entitled "The Medical Construction of Need," she hypothesizes that the existence of the technology created the need. The availability of a seemingly "natural" device for breast enhancement led to defining the perfect breast. In one study, only 13 of 100 women could claim this ideal form. It followed that those not so well endowed "would be happier if, somehow, they could have a pleasing enlargement from within."

A medical construction, however, requires more than desire. It requires need. This was established through psychological studies demonstrating positive effects in women who underwent implant surgery. The breast was seen as "key to the gates of normal feminine activity, and social, economic and emotional fulfillment."

With the onset of the feminist era, the psychology of breast implants took on a new reality. Now the choice to undergo surgery became not so much a move toward enhanced femininity but one more example of a woman’s right to choose. Women had a right, as informed consumers, to choose physical self-improvement.

Jacobson devotes an entire chapter to the profession of plastic surgery, "the specialty nearest sculpture in the living." She attributes much of the creation of need to these players and their focus on aesthetics, improvements in technique, and the doctor-patient relationship. These qualities, which are generally viewed as positive, take on negative aspects in this story, where they led to ready reliance on Dow Corning’s promotion of a device that may have been inadequately tested.

Jacobson is gentler in her handling of the silicone "victims" yet writes of "the creation of silicone disease." Although capsular contraction and implant rupture are recognized complications of silicone implants, Jacobson frames silicone autoimmune disease as a classic example of a social construct: "The disease was the falsification and cover-up of scientific data; the disease was the failure of industry and plastic surgeons to inform women of the risks."

Finally, she studies the FDA and its role at the center of the controversy. She reviews the history of the agency and its imperative to regulate first drugs, then medical devices. But the FDA too had its own reality in this conflict. The silicone breast implant controversy arose during a time when the Bush administration was working to deregulate industry. The FDA was forced to walk a thin line between accommodating the current political climate and asserting its authority as a federal agency.

Jacobson is a stylish writer, and she tells a compelling tale. Her prose is especially sparkling in witty asides that point out the absurdities in the story and had me chuckling wryly with her at times. Unfortunately, many of these barbs are directed at plastic surgeons, and negative comments about them abound; for example: "The collaborations that developed . . . showed the willingness of plastic surgeons to borrow expertise when it suited their purposes." In another book dealing with plastic surgery, Venus Envy,1 Elizabeth Haiken presents, in my opinion, a more balanced view of this specialty.

In the end, Jacobson lays the responsibility for the silicone implant fiasco at the feet of plastic surgeons, Dow Corning, patients, lawyers, and the media. "The problem of implants was a problem of clashing meanings," she concludes.

As a physician, I came away from Jacobson’s book both enlightened by the story and conscious of its far-reaching implications. I was forced to take a long look at how we in the medical profession frame the realities of the collusion between medicine and industry, marketing in medicine, and patient autonomy and consent. Future medical debacles may be avoided, it seems, depending on the definitions we construct.

AUTHOR/ARTICLE INFORMATION

Janet E. Shepherd, MD

Boulder, Colo

REFERENCES

1. Shepherd JE, reviewer. Review of: Venus Envy. JAMA.

1998;279:2006.

Books, Journals, New Media Section Editor: Harriet S. Meyer, MD, Contributing Editor, JAMA; David H. Morse, MS, University of Southern California, Norris Medical Library, Journal Review Editor; adviser for new media, Robert Hogan, MD, San Diego.