Written by Yushi Song
‘Long illness makes the patient into a good doctor.’
– a Chinese saying (Jiubing Cheng Liangyi, 久病成良醫)
‘The relation between what we see and what we know is never settled.’
– John Berger, Ways of Seeing
During my childhood, my grandmother tried all kinds of methods to make me finish my food. Her belief was that once the food is served, you should always finish what is on your plate, no matter how full you are to show respect for both the farmer and the chef. She alarmed me that how many grains of rice I left would be how many pimples I get in the future. I found it difficult to believe but it frightened me that I would try as hard as possible to eat until the last grain of rice. Yet still the nightmare came true. I do not clearly remember when the first pimple bumped out on my skin, but then they became a part of my life that marked my experience since middle school. At first it was just some bumpiness filled with pus, hard on the inside and painful on the outside. But then things went out of control — they multiply, ripen, perish, and then appear again, leaving a bloody, inflamed, and messy residue. I became more and more aware of the fact that my skin was uneven, I prayed those annoying zits would all be gone tomorrow before sleep only to discover more the next morning. Fighting against acne became part of my life, characterised by visiting dermatologists, watching YouTube beauty gurus’ stories on how they treated their acnes, and buying new topical medicines, beauty creams or lotions just trying to get rid of them.
But this mindset has somehow changed for me during the past few years. On one hand, they finally stop popping up, for which I am extremely grateful, whilst I have been fairly accustomed to the life of some irregular bumps on my skin. On the other hand, such a break from acne enabled me to reflect on my experience with it, questioning why I had such a hard time, both physically and psychologically, with those indurations on my skin. It was definitely more than some supernatural curses from the farmers who grew food and chefs who served food for me, or the physical pain under my skin. Acne, as those ‘incurable yet controllable’ bumpiness on the skin, is infused with meanings that one cannot avoid but to embody (NHS website, 2020). Getting acne is exciting and scary at the same time. It symbolises a passage from boy(girl)hood to maturity, representing energy of the adolescence and thrill of maturation. Yet it is also unwanted amongst growing youngsters as a sign of uncleanness and not well-received in the beauty standard. Teenagers in the UK diagnosed with acne are even more likely to develop MDD (major depressive disorder), and physicians are recommended to ‘monitor mood symptoms in patients with acne and initiate prompt MDD management or seek consultation from a psychiatrist when needed’ (Vallerand et al., 2018, p. 2). In this paper, I would like to explore some aspects of the doctoring and embodying of acne, especially on examining how the blemishes of skin became powerful enough to affect one’s self-identity.
Human beings visualise a body mostly through skin. Unlike other organs we have, skin is neither inside nor outside but more likely to be perceived in between. Skin can be used to sense the self and the others, to display and provide information of one’s age, health, etc., and we experience our skin in both the natural and social world. Skin is treated ‘not only as the boundary of the individual as a biological and psychological entity but as the frontier of the social self as well.’ (Turner, 2012, p. 486) Skin plays the key role in the invention of race, rendering skin colour from its natural being to a state of meaningfulness, ‘naturalis[ing] a social order built upon generations of European violence, genocide and enslavement directed at racialised peoples.’ (Carey, 2017, p. 21) The question of ‘why it is that people look the way they do’ entails more than a curiosity on biology and evolution, but rather interrogating why some people are not in conformity with normal and seeking for meanings in the social world (Jablonski, 2004, p. 612). Skin became the frontier of the creation of the self and socialisation, as humans decorate, cover, and uncover their skins according to their gender, age, social status, etc. Hence skin is complicated as it is both private and public, subjective and objective, partial and whole, natural and social, with many meanings that are directly related to power and authority.
Foucault argues that power is based on knowledge and makes use of knowledge whilst reproducing new knowledge to exercise through it (Gutting & Oksala, 2018). Exploring how sexuality became an essential construct in determining moral worth, health, desire, and identity, Foucault argues that individuals incorporate control not only via other people’s knowledge of individuals, but also via individuals’ knowledge of themselves (Gutting & Oksala, 2018). The norms fabricated by the sciences of sexuality makes individuals to internalise them and monitor themselves in order to conform to such norms, making individuals to be not only controlled ‘objects of disciplines’ but also ‘self-scrutinising and self-forming subjects’ (Gutting & Oksala, 2018, original emphasis). The science of skin as well is never non-ideological, as Young writes, ‘in industrial societies the most powerful ideological practices are ones which claim that their facts are non-ideological because they are scientific.’ (Young, 1983, p. 209)
Such work of power requires us to consider acne on skin through a lens of intersectionality of dermatology and society at large. Regardless of the social importance skin implies, acne is often treated no more than a medical problem that seeks for dermatological, psychological, or pharmaceutical interventions. The causation of acne is usually analysed through genetic, hormonal, bacterial, and environmental factors deliberating sebum, poral occlusion, and inflammation (Hunter et al., 2002, p. 148-149). Some scholars have argued that acne symbolises an ‘evolutionary mismatch of human ancestry and modern environment’ due to the pro-inflammatory Western diet (Campbell & Strassmann, 2016, p. 325), whilst calling acne a ‘disease of Western civilisation’ or ‘blemish of modern society’. (Cordain et al., 2002, p. 1589; Campbell & Strassmann, 2016, p. 325) These studies suggest a hypothesis that acne is a disease of modern lifestyle considering the low prevalence of acne in non-westernised and partially modernised societies, a notion that dermatological community frowns upon as majority of dermatologists believe diet has little to do with the onset of acne (Hunter et al., 2002, p. 155). Some also argue that acne is a meaning inception for sexual selection to ‘ward off potential mates until the afflicted individual is some years past the age of reproductive maturity, and thus emotionally, intellectually, and physically fit to be a parent.’ (Bloom, 2004, p. 462)
These differences might be explainable with the idea of ‘local biologies’, which Lock defines as ‘the manner in which biological and social processes are permanently entangled throughout life, ensuring a degree of biological difference among humans everywhere that typically has little or no significance but at times bears profoundly on well-being.’ (Lock, 2017, p. 8) Acne as a somatic expression undergoes both biological and social fabrication and hence it is necessary to put the pimpled skin into context whenever possible. The picture of acne is far broader than just accusing our culture for idealising and advertising clean and clear skin whilst making the pimpled one pathological. The comprehension of acne rather keeps on evolving and travelling as our knowledge changes over time. Yet biology seems to be overriding the social processes with the rise of molecular and genetic studies. Foucault sees the emergence of bio-power replacing whilst complementing sovereign power, endeavouring to administer, optimise, sustain, and multiply the population. Such transformation was characterised by the arrival of different means of techniques of controlling the population which embarks human history upon modernity, that the exercise of power no longer poses a menace of death but rather takes care of lives of people as living beings. The biological existence of human subjects hence became a central organising feature of political and social relations. The contemporary bio-politics features a large scale of molecularization and geneticization (Rose, 2001, p. 13). Such reductionistic practices trying to grasp human bodies on a microscopic level, believing only gene can determine health, which in Lippman’s account ‘privatises and individualises health risks and responsibility and focuses attention on biological rather than social conditions, potentially increasing social inequalities and leading to victim blaming,’ whilst ‘establishing hierarchies among people on the basis of differences in their DNA.’ (Weiner et al., 2017, p. 991) Acne, as an ‘incurable yet controllable’ disease (NHS website, 2020), became to be rationalised by its heritability, which is almost 80% in first-degree relatives (Bhate & Williams, 2013, p. 476), and other factors currently understood as affecting acne is also being researched with a genetic apprehension. Whilst hormonal therapy has been widely in use with a gendered difference, with the advancement of technology would we see a transition of the treatment of acne to vast usage of genetic engineering? How would subjectivity change under such work of molecularization and geneticization?
On the other hand, for people afflicted with acne, knowledge of skin is constructed biologically, socially and culturally before the onset of their pimples. Individuals understand and embody acne within the domain of control and regulate their bodies accordingly. Such control is diffused in the form of beauty, which is further entangled with the rhetoric of health. Beauty is always entwined with power in a complex way regardless whether ‘facial attractiveness is remarkably consistent, regardless of race, nationality or age’ (Fink & Neave, 2005, p. 317). Beauty, beyond aesthetic values, became medicalised, became entangled and inseparable from health, creating a controlling power through the sense of skin normality with dermatological and social knowledge. Rabinow defines bio-sociality as a ‘truly new type of auto-production’ that emerge around and through the new genetics becoming a ‘circulation network of identity terms and restriction loci’, instead of ‘a biological metaphor for modern society.’ (Rabinow, 1996, p. 99) He writes, ‘if socio-biology is culture constructed on the basis of a metaphor of nature, then in bio-sociality nature will be modelled on culture understood as practice.’ (Rabinow, 1996, p. 99) The coalition of skin and health makes skin problem, as acne to condense the societal understanding of age, gender, race, etc., engendering a desire of patients to treat it dermatologically and socially. The multibillion-dollar skincare industry, supplying tonnes of creams, moisturisers, soaps, ointments, cosmetics and technologies to create a sense of good skin, good beauty, as well as good health. Skincare works to eliminate the bad dermatological actors as ‘tools for deceptions of health, rest, and leisure, ergo a higher social status.’ (Smofsky, 2017, p. 34) As individuals are ‘empowered through the formation of an “imagined community”, engendering a sense of kinship, where protection and support are offered, differences normalised and values reproduced’, skincare product became part of the creation of an identity. (Dimond et al., 2015, pp. 2-3) Using cosmetics became a symbol of showing the users that he/she is adhering to the modern virtue, objectifying him/her to the realm of control with the rhetoric of health and beauty.
To sum up, the blemished skin is mingling between the biomedical and social world, and patients who suffer from acne submit him/herself to the control of norms. The intersectional nature of acne requires understanding from both the dermatological and social perspectives, yet the latter one is often overlooked in practice. Such nature also creates skincare as a beholder and reinforcement of identity. I believe giving voices to the patients, paying close attention to their narratives can help us finish the incomplete picture of acne.
This article was originally submitted as the final assignment for the class Ethnographies in Medical Anthropology, 2020-2021
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