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Generations

By Bayer, Kathryn

Why visible signs of aging are met with increasing disdain.

Apprehensions about aging are certainly not new. Ponce de Leon's well-known search for the fountain of youth took place in the sixteenth century, and the quest has continued unabated ever since. It is said that in the iooos the Hungarian Countess Elizabeth Bathory bathed in the blood of young Virgins in an attempt to retain the beauty of her youth and reverse the signs of aging. The modern cosmetics industry reinforces its cultural influence by addressing similar concerns.

Considering this long history, it would be erroneous to suggest that present-day dermatologists and plastic surgeons have only recently manufactured the need for their anti-aging products and services. Still, the expansion of the influence of contemporary medicine into the management and reconstruction of the aging body's appearance is historically noteworthy. Unfortunately for those in midlife and beyond, current medical aesthetics increasingly suggest that the more one's skin changes with age and diverges from youthful standards, the less "normal" and desirable an individual's appearance becomes.

Today's advertisements constantly remind us that wrinkles and sagging are now not only unacceptable signs of aging, they are manifestations to be prevented and corrected. Many physicians now legitimize the cultural battle against aging, which means traditional cosmetic promotions and anti-aging quacks no longer act alone. In his bestselling book, The Wrinkle Cure (2000), the dermatologist Nicholas Perricone asserts that "wrinkled, sagging skin" is "a disease, and you can fight it" (p.i). To Perricone and like-minded popular authorities, the visually significant and unwelcome "disease" of aging can be combated through the use of nutrient-based, scientifically formulated "cosmeceuticals." Other healthcare professionals offer nonsurgical anti-aging cosmetic procedures such as Botox injections and microdermabrasion for those seeking expedited results. Plastic surgeons promise the most dramatic age-defying changes through surgical reconstruction of the body's exterior. It seems that this millennium's fountain of youth is technological and restores youthful appearance with scientific and medical know-how. Statistics show that use of such age-defying measures is growing each year among women and men.

The increasing use of anti-aging cosmetic technologies raises several important questions: If aging is a natural process to be experienced by all, why are visible signs of aging met with increasing cultural disdain? Why, for many, does looking younger mean greater happiness and improved social standing? What are the cultural effects when doctors employ medical authority on a mass scale to define "appropriate" appearances of aging? Does a technological fountain of youth ultimately strengthen ageist sentiments? The following discussion will address these questions.

'POSITIVE AGING'

Over the course of the twentieth century, improvements in sanitation, healthcare, and nutrition dramatically increased the average lifespan in the United States. At present, it is for the most part taken for granted that an average American will live beyond the middle years. Americans no longer focus simply on living longer; we want to live better-and look better-as we age. Science, medicine, and other fields aim to make this goal possible by slowing our biological clocks, fighting the diseases of age, and restoring our sense of youth. Many gerontologists and related practitioners now focus on "positive aging" rather than traditional conceptions of aging that emphasize the "problems of aging," with the goal of providing alternative representations of later life and challenging ageist stereotypes. Indeed, many forces are currently working to alter the experience and image of aging in order to improve what aging feels like as well as what aging looks like.

At first glance it would seem that so-called positive aging could only serve to counter the "systematic stereotyping and discrimination" typical of ageism (Butler, 1975, p.n). After all, any conceptions of aging that battle those of inevitable physiological and social decline must be liberating. Given the recent influx of representations depicting happy, independent, and active individuals in their later years, it seems there should be less resistance to growing old. Yet many representations of "mature" health, well-being, and activity are easily confused with a need to retain and reflect youth; thus "positive aging" soon equates with anti-aging for many.

In order to understand how this shift occurs, it is necessary to consider the source of these new images of aging and the motivations behind them. Only then can we assess the potential cultural effects of positive aging and determine if a positive-aging movement will actually fight ageism, or if it is simply the next well-intended, enthusiastically adopted concept to be then co-opted, branded, and ultimately controlled by the marketplace.

Most gerontologists support the notion of positive aging when it refers to efforts to prolong the duration of healthy, happy life. Many also recognize that "no currently marketed intervention-none- has yet been proved to slow, stop or reverse human aging" (Olshansky, Hayflick, and Carnes, 2004, p.98). Yet some physicians do believe that current medical technologies can effectively slow, stop, and reverse the appearance of aging. Dermatologists and plastic surgeons lead the movement that employs the latest technologies to redefine and improve what aging looks like. The majority of this activity now occurs within the "cosmeceutical" and cosmetic surgery industries, where science and medicine negotiate with consumer culture to define what are to be the universally acceptable appearances of aging. Enthusiasts for cosmeceutical and cosmetic surgical procedures assert that gaining control over aesthetic aspects of aging is indeed aging positively, but critics question this particular expansion of medicine into nonmedical territory.

Critics of anti-aging cosmeceuticals and cosmetic procedures question the motivations and implications of the relationship between medicine and the medical marketplace. They also question the effects of medical aesthetics of aging on cultural attitudes and behaviors toward aging and the aged. Are age-defying products and procedures liberating technologies? Or do the aesthetics on which they are based reinforce ageist sentiments? The debate must be further explored.

'COSMECEUTICALS'

The term cosmeceutical combines the terms cosmetic and pharmaceutical and refers to a topical skin treatment formulated to improve personal appearance, promising added benefit beyond those afforded by traditional cosmetics or moisturizers. Cosmeceuticals sell at retail stores, and marketing revolves around the promise of deeper, longer-lasting effects that consumers usually associate with drugs. Cosmeceuticals generally fall into the categories of skin care, hair care, and hair growth. Some, like the over-the-counter hair growth product Rogaine, meet the Food and Drug Administration definition of a drug, but most of these products, notably in the skin-care area, do not meet this stringent definition and are regulated as cosmetics. In fact, there is no regulatory definition of a cosmeceutical and thus, "at present the word is basically a marketing term" (Packaged Facts, 2002, p.5). The growth of the cosmeceutical market indeed represents what some refer to as "silver industries" (see, e.g., Cutler, 2004-5), wherein substantial profits are to be had by catering to the desires and fears of older consumers.

Despite a lack of accreditation, the cosmeceutical market successfully promotes its relationship with science and the latest technology. In just a brief period, from 1997 to 2001, this market increased from approximately $3.8 billion to almost $5.1 billion (Packaged Facts, 2002). The enormous opportunity prompted reformulation of several cosmetic products to include and highlight ingredients that allowed them to be touted as anti-aging and wrinklefighting. While many consumers associate higher-end products sold at department stores and specialty stores with superior benefits, massmarketed cosmeceuticals sold at mass retailers, supermarkets, and drugstores currently promote the same capabilities and at more affordable prices. Implying or asserting an association of cosmeceutical skin-care products with the medical specialty of dermatology is currently the mainstream trend for cosmeceuticals at all price levels. In fact, one would be hard-pressed to find a leading prestige cosmetic brand that did not refer to dermatology in general or, more recently, directly associate its cosmeceuticals with a particular dermatologist.

Many dermatologists recognize the profits to be made in retail and have developed their own cosmeceutical skin-care lines. Using their medical credentials to capitalize on existing cultural insecurities associated with aging, a number of such healthcare providers now compete in the market with cosmetic brands to ofter more youthful appearances. According to descriptions in the anti- aging category on Sephora.com, a cosmetics retail site, "Dr. Brandf" cosmeceuticals use dermatological technologies to create a "marriag\e between science and nature." "MD Skincare" the brand of a physician, Dennis Gross, is promoted on the basis of his expertise in cosmetic dermatology and "the anti-aging process." Nicholas Perricone currently is the best known physician in the cosmeceutical market and personifies those who have entered the cosmeceutical marketplace in a major way.

According to a New York Times Magazine article tided "Perriconology" (Witchell, 2005), Perricone sells his pricey cosmeceutical line in more than 230 outlets, "everywhere from Neiman Marcus to QVC" and his New York City flagship store is scheduled to open this year. Perricone is the author of three bestselling books on skin care and aging and has minimized his dermatology practice to focus on his consumer-based business. Also according to the Times article, Perricone has decided against making the scientific research that supports his claims available for peer review, as is standard practice. The Times suggests that, like other physicians who produce ostensibly science-based cosmeceuticals, Perricone uses the discourse of medicine to promote products that are not medically or scientifically proven or PDA approved. While these products have not been shown to cause physical harm, they promote the idea that the visible changes in skin condition that accompany aging are unhealthy and undesirable, seemingly by medical and scientific standards. Of course, not all dermatologists support the entrance of medicine into the marketplace in this way, and many decline to participate (Tsao, 2004).

NONSURGICAL COSMETIC PROCEDURES

According to the American Society for Aesthetic Plastic Surgery (ASAPS), nonsurgical cosmetic procedures increased 431 percent, from approximately i.i million to 6.4 million procedures from 1997 to 2003. In comparison, cosmetic surgical procedures jumped 87 percent from under one million in 1997 to 1.8 million in 2003. Four of the top five nonsurgical cosmetic procedures in 2003 address the visible signs of aging. Botox injection, microdcrmabrasion, chemical peel, and collagen injection each offer more youthful appearance in different ways. Due to their temporary nature, quick administration, speedy recovery time, and moderate pricing (though repeat visits may become costly), men and women have found nonsurgical procedures to be an appealing new alternative to plastic surgery. In most cases, nonsurgical cosmetic procedures are not covered by health insurance, and patients pay out-of-pocket. This situation provides a lucrative incentive for doctors dissatisfied with current insurance rates.

Of all the nonsurgical anti-aging procedures available, Botox has emerged as the uncontested leader, enjoying a 3,387 percent increase in use from 1997 to 2003. In the late 19905, the pharmaceutical company Allergen formally introduced Botox for cosmetic purposes. The FDA originally approved Botox, or botulinium toxin Type A, in 1989 for multiple neurological uses, but researchers soon "discovered" its "off-label" and more popular function-the ability to diminish facial wrinkles. After several years of unapproved cosmetic use, the FDA "officially" approved Botox in April 2002 for treatment of severe glabellar frown lines (furrows between the brows). Physicians also use Botox to diminish "crow's feet" (creases that form near the outside corners of the eyes), horizontal lines in the forehead, and creases around the mouth-though the FDA has not approved these uses. Despite its birth as a pharmaceutical substance with purely medical uses, Botox is now marketed by Allergen as a consumer cosmetic product available to almost anyone who can afford it.

In order to form a market for Botox, its manufacturer, Allergen, and administering doctors exploited Americans' concerns about aging to produce patient-consumers for Botox, even though wrinkles generally hold no relevance for physical health. Still, many physicians and patients believe Botox and similar wrinkle-reducing technologies offer individuals unprecedented agency in controlling their own aging processwithout going under the knife. Yet, such options systematically buttress the notion that looking old-and thus, being old- is socially, medically, and personally undesirable. Is the increasing availability of nonsurgical, appearance"improving" technologies "win-win" for doctors and patient-consumers, or do such choices ultimately undermine an individual's ability to accept his or her aging appearance without feeling insecure or visibly inferior?

PLASTIC SURGERY

Plastic surgery possesses a longer history than contemporary cosmeceuticals and nonsurgical anti-aging procedures, dating back to the Renaissance at least (Gilman, 1999). Initial increases in plastic surgery were primarily due to the epidemic of syphilis that occurred in Europe in the late seventeenth and early eighteenth centuries. In this period, society harshly stigmatized those congenitally infected with syphilis based upon the distinguishable and grotesque nasal deformities caused by their disease. Physicians implemented plastic surgery to improve the appearance of the syphilitic nose and allow the diseased to become less visible or "pass" as "normal" in society.

In twentieth-century America, wartime doctors used cosmetic surgery to remove the marks of battle and allow veterans to pass as the everyday citizens they had been. This practice provided legitimacy to and invoked widespread interest in the benefits of cosmetic surgery. Because the public viewed wartime surgeons as reputable medical specialists, these surgeons' work reduced the belief that aesthetic procedures were limited to those who were inferior or vain. After World War I, the technological advancements of wartime cosmetic surgery began to become available-and appealingto the masses. What began as a situational medical procedure has since become a massmarketed, profit-driven industry- though "passing" remains the primary goal.

Today's recipients of plastic surgery undergo the procedures to pass as more sexy, fit, and desirable. In the case of anti-aging surgeries, however, individuals alter their appearance to pass as younger than they are, though of course they can never actually become younger or effect a reversal of the calendar. Many critics argue that recipients of anti-aging surgery rarely succeed in passing anyway-they wind up looking "weird" rather than young. Still, statistics show that reducing the signs of aging through cosmetic surgery has become an increasingly popular intervention, and a profitable venture for the medical marketplace. Americans spent near $12.5 billion on cosmetic procedures in 2004 (American Society for Aesthetic Plastic Surgery, 2004). Of these procedures, two of the top five surgeries in each gender group specifically targeted signs of aging: eyelid surgery and facelift for women, eyelid surgery and hair transplantation for men. People ages 35-50 underwent 45 percent of total procedures, those 51-64 underwent 25 percent (ASAPS, 2004). It seems that many aging Americans believe that looking younger is looking better, and they hope to improve their self-image and enjoy more favorable social outcomes through surgical alteration. Here, surgery passes for selfimprovement and a viable step in the American pursuit of happiness.

MEDIA, MARKET, AND 'MIDDLE-AGEISM'

Why do so many Americans feel the need to retain youthful appearances? Changes in economic and employment patterns, the rise of image-based mediation (T.V, film, ads), and the growing significance of consumer identities-each contributes to a cultural desire for youth and to negative feelings toward old age. These cultural conditions magnify ageist sentiments rather than reduce them. Some even suggest that ageism is affecting individuals at earlier and earlier points in life. The age critic Margaret Gullette (2004) believes that new forms of ageism currently target those in their middle years and terms this phenomenon "middle-ageism." I assert that an increased incidence of and fear of falling victim to middle-ageism largely motivates the growing demand for antiaging procedures and cosmeceuticals.

The impact of globalization and its outsourcing of labor accompanied by increased technological capitalization and efficiency in many industries have eroded job security for many Americans. Age discrimination in employment, though illegal, continues. Many seniorlevel corporate employees report pressure to retire early so companies can cut the costs of higher salaries. In Aged by Culture (2004), Gullette notes the earlier age at which individuals exit from gainful employment as well as the increasing denial of full- time work to midlife men and women, particularly those over the age of 50. Gullette maintains that through middle-ageism "the defects of the middle years are contrasted explicitly with the entrepreneurial, physical, sexual, intellectual and creative accomplishments of the young." At the same time those currently in middle age, "the baby boomers," consistently hear about the so-called crisis of Social security and their future burden on society. In the capitalist culture, reflecting a youthful, vital appearance may enable workers to be identified as desirable employees and to retain dieir corporate value (and jobs) a little longer.

Images in the media compound this perceived need to reflect youth. In the case of women, it does not require deep analysis to notice that young models and actresses outnumber middle-aged and older models and actresses in popular media. Television and film content is filled with women in their 2os and 3os blessed with beauty, full social lives, and romantic opportunities. Representations in lifestyle and beauty advertisements also could lead one to believe that women over the age of 40 have less of a social and romantic life and are not a part of the definition of beauty.

Men also fall victim to ageist representations. Recent depictions of older men infilms such as 2003's Something's Gotta Give and 2OO4's In Good Company present them as less fit to perform sexually and less valued in their careers than younger men. In a 1997 analysis of the ioo topgrossing movies of the 19405 dirough the 19805, older individuals of both genders were found to be portrayed as "less friendly, having less romantic activity, and enjoying fewer positive outcomes than younger characters at a movie's conclusion" (Bazzini et al., 1997, p.54i). Just as the middle-aged find their defects in representation, so too can they find their solutions.

In the past few years, talk of plastic surgery has left the privacy of the physician's office and entered the public domain. Celebrities now openly discuss procedures they have undergone, while other celebrity procedures are often "outed" by the media. Cher, Greta van Susteren, Sharon Osbourne, Dannie Bonaduce, and Kathy Griffin are just a few celebrities who speak candidly about having undergone surgical and nonsurgical anti-aging procedures. Entire television series exist around the subject of aesthetic procedures including ABC'S Extreme Makeover and FX's Nip/Tuck. Popular networks FOX, Vhi, E!, TLC, and MTV also air programs dedicated to the subject. So-called reality-based programs attempt to provide viewers with a glimpse of "real people" like themselves undergoing plastic surgery and suggest that anyone can do it. With increased representations of aesthetic enhancements and new images of aging, the cultural climate has changed. Looking young is looking good, and technologically or surgically achieving a younger look is socially acceptable.

Under such cultural conditions, who would want to look "old," and why should one not use the technologies available to "enhance" his or her aging appearance?

Our responses to these questions rest on the crucial role of physicians. Americans do not always trust the messages of the media, but they do trust the opinions and recommendations of their healthcare providers. Physicians could tell older people that they look just fine, that a change in appearance with aging is normal and acceptable and to go home. But if they do, they may disappoint their patients or, more personally, sacrifice profit from out-of-pocket procedures and product sales. Some physicians contend that if they can help a patient "feel better" through aesthetic changes, it is just cause and falls within their job description. In this view, feeling better about aging is indeed aging positively, and this is the ultimate goal-even if it means changing what aging looks like.

AGING ON ONE'S OWN TERMS

Aging is on its way to appearing younger and hipper, equipped with Nike fitness gear, Viagra horns, and mass-modeled faces. Many believe that this image reflects positive aging. Yet general, consumption-based imagery cannot represent every race, class, sexual orientation, or experience and may intensify categorical inequalities of later life. Others, like me, believe that true positive aging is actually about increasing the physical and emotional comfort of individuals throughout life. Doing so requires valuing every age and refusing to let market interests define standards of aging. I personally dread the idea of obsessing over my appearance throughout my entire life far more than I dread aging itself. I hope I am strong enough to resist antiaging temptations and to enjoy my future on my own terms, without feeling insecure over my changing features. I also hope I never encounter a doctor who tells me my appearance needs medical attention. Whether in the doctor's office or in the extensive cosmetics section of the stores that sometimes seem to be on virtually every corner, the watchword ought to be "Let the buyer beware." The phrase is nowhere more applicable than among those who are beginning to feel their age.

REFERENCES

American Society for Aesthetic Plastic Surgery (ASAPS). 2004.2004 Cosmetic Surgery National Data Bank Statistics.

Bazzini, D., et al. 1997. 'The Aging Woman in Popular Film: Underrepresented, Unattractive, Unfriendly, and Unintelligent." Sex Roles 36:531-43.

Butler, R. 1975. Why Survive? New York: Harper & Row.

Cutler, N. E. 2004-5. "Silver Industries: Introduction." Generations 28 (4): 6-7.

oilman, S. 1999. Making the Body BeautifitlA Cultural History of Plastic Surgery. Princeton, N.J.: Princeton University Press.

Gullette, M. 2004. Aged By Culture. Chicago: The University of Chicago Press.

Olshansky, S., Hayflick, L., and Carnes, B. 2004. "No Truth to the Fountain of Youth." Scientific American 14(3): 98-9.

Packaged Facts. 2002. The U.S. CosmeceuticalsMarket. www.marketresearch.com. Accessed February 12, 2004.

Perricone, N. 2000. The Wrinkle Cure. Emmaus, Pa.: Rodale Books.

Sephora website. vnvwsephora.com. Accessed March i, 2005.

Tsao, A. 2004. "The Changing Face of Skincare." BusinessWeek Online. Accessed November 9, 2005.

Witchell, A. 2005. "Perriconology." The New York Times Magazine February 6: 28-31.

Kathryn Bayer, MA., is a- senior copywriter with a consumer marketing firm in Washington, D.C.

Copyright American Society on Aging Fall 2005