AGING in the BIOSOCIAL ORDER: Repairing Time and Cosmetic Rejuvenation in a Medical Spa Clinic

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doi: 10.1111/tsq.12080 The Sociological Quarterly ISSN 0038-0253 AGING IN THE BIOSOCIAL ORDER: Repairing Time and Cosmetic Rejuvenation in a Medical Spa Clinic

Stephen Katz* Trent University

Jessica Gish McMaster University

This article examines the relationship between biosocial meanings of aging and anti-aging culture, whereby new standards of measuring age derive from nonchronological models of plasticity. The ﬁrst part explores recent models of functional age, sexual performance, and cognitive health, while the second part outlines the cosmetic rejuvenation practices, discourses, and technologies of medi-spa clinics that promise to repair the effects of time on the bodies of aging women. Both parts illustrate the sociological signiﬁcance of the aging body in posttraditional society as the object of increasing public anxieties about the health of aging populations and ethical concerns for extending life.

Growing older in Western societies is contradictory. As we live longer in rapidly aging national populations, traditional age boundaries become increasingly blurred as do the meanings of chronological age itself. We are even reassured that we are as young, or as old, as we feel since age is no longer the only way to measure living in time. The anti- aging industry has clearly contributed to this undermining of chronological age with its arsenal of age-reversing products and activities. However, as this article argues, the loosening of age from its biological foundations flourishes because of a politics of life that has redistributed and molecularized the capacities of the body as part of a wider biosocial order of aging. Biosociality, as elaborated below, is a state of reversal between culture and nature, whereby biomedical, pharmacological, and cosmetic technologies, aimed at improvement and enhancement, are endowing the aging body with an expansive plasticity. Illustrations of biosocial aging are explored in the first part of this article’s review of functional age, sexual performance, and cognitive health. The second part follows with the case of a Canadian medical spa, a hybrid between a medical clinic and a spa, where bodywork cosmetic procedures for repairing time are performed. The medi-spa is an ideal ethnographic opportunity to see how professional expertise, empowering discourses, and hopeful clients negotiate between the dreams of anti- aging plasticity, the limits of cosmetic rejuvenation, and the technologies of molecularization. We take the idea of molecularization from Nikolas Rose, who defines it as:

*Direct all correspondence to Stephen Katz, Department of Sociology, Trent University, 1600 Westbank Drive, Peterborough, ON, Canada K9J 7B8; e-mail: [email protected]

The “style of thought” of contemporary biomedicine that envisages life at the molecular level, as a set of intelligible vital mechanisms among molecular entities that can be identiﬁed, isolated, manipulated, mobilized, recombined, in new practices of intervention, which are no longer constrained by the apparent normativity of a natural vital order. (Rose 2007:5–6)

In our case, the technologies of molecularization are the machinery that materializes and makes visible this style of thought within the body as an explanatory system for aging. Our conclusions consider some of the ethical implications of biosocial bodywork procedures that restore and extend life.

CHRONOLOGICAL AGE IN THE BIOSOCIAL ORDER The Lifecourse and the Aging Body The lifecourse is one of gerontology’s most inﬂuential ideas. Conceived as a challenge to earlier life span and human development models that naturalized age categories, lifecourse research widened the purview of aging to include social and historical dimensions. Glen Elder (1974), in his book Children of the Great Depression, is widely credited for situating the lifecourse within unique historical circumstances, intersected by the transitions of individuals, cohorts, families, and generations (Elder 1975). By the 1990s, it was rare to ﬁnd a sociological study of aging untouched by the lifecourse perspective, and in 1997 the American Sociological Association’s section on aging was renamed Sociology of Aging and the Life Course. Critical writers have extended the lifecourse literature to sociological perspectives on policy, diversity, gender, and trans- national movements (Settersten 2003; Calasanti and Slevin 2006; Clarke 2011; Grenier 2012). Globally, researchers look at lifecourses in terms of “linked lives” that span con- tinents, cultures, and economies (Dannefer 2003; Phillipson 2009, 2013), while anthro- pologists deconstruct the notion of a universal lifecourse in their work on diverse cultures (Sokolovsky 2009). Lifecourse data have also become vital to advocacy groups lobbying for better health, labor, retirement, education, and pension programs (see Marshall 2009). Despite these progressive developments in lifecourse research, conceptual gaps and inconsistencies remain. For example, popular health and psychological studies emphasize matters of individual choice, attitude, and lifestyle to the exclusion of historical contingency and structural inequality. Most importantly for our purposes is the problem of the marginalization of the aging body within lifecourse models attributed to their tendency to combine time-based and age-based phenomena within prestructured trajectories, transitions, pathways, and strategies (see Dannefer and Kelley-Moore 2009). As a result, in such models the body’s role in later life appears as a passive and static effect of factors of health, risk, and longevity, rather than as a material, temporal, experiential, and cultural force of its own apart from such factors. A cor- rective to this problem comes from sociological work that focuses on the embodied lifecourse in material contexts. For example, Wainwright and Turner’s (2003, 2006))

The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society 41 Aging in the Biosocial Order Stephen Katz and Jessica Gish work with the Royal Ballet of London explores the idealization of youthful bodies where dancers learn to perform the style, stamina, and competence of an elite physical capital that rewards them with prestigious roles despite the shortening of their careers attributed to increased injuries and longer recovery times. Similarly, Emmanuelle Tulle (2008) writes about older veteran masters long-distance runners whose bodies provide the means for expressing and understanding aging. By adopting disciplined and taxing training routines, the runners come to know themselves as subjects shaped by a particular embodied lifecourse regime. In addition to dance and sport, research on the materiality of embodied aging in relation to dress (Twigg 2013) and dementia (Kontos 2011; Kontos and Martin 2013) demonstrates the phenomenological interplay among biological age, biography, and culture. Critical and ethnographic investigations such as these put the body back into the lifecourse and thus inform our study here. However, we also need to think about how the temporality of the lifecourse itself has been rerouted within a post-traditional culture marked by unprecedented population longevity and time-altering biotechnologies, as the next section argues.

Biosociality, the Post-Traditional Lifecourse, and Functional Age Physical age throughout the lifecourse has traditionally been framed within binaries of nature and culture, with the body falling to the inevitabilities of nature. This nature– culture binary has changed today, however, in ways that Paul Rabinow has characterized as biosocial. During his research on the Human Genome Project, Rabinow used the term “biosocial” to signal the shift in the status of nature as the biological ground for the life sciences. The natural, he claimed, was becoming identified with a kind of plasticity that left it open to the intervention of new pharmacological, bioengineering, and cultural imperatives. Thus, Rabinow (1996:99) predicted that nature will be “remade through technique and will finally become artificial, just as culture becomes natural.” The Human Genome Project also “brought into question long established ideas of what counts as nature or natural” (Gibbon and Novas 2008a:3). This unfixing and reversing of the boundaries between nature, culture, reality, and artificiality, result- ing as well in new life forms and experiments with finitude (Franklin and Lock 2003), are familiar themes in the literature on “post-human” culture (Hayles 1999), “bio- postmodernism” (Newton 2007), “cybernatural life” (Waldby 2000), and the “fourth nature” (Featherstone and Hepworth 1998). However, Rabinow and associated Foucauldian thinkers have looked more closely at biosocial technologies as the blue- prints of collective life in general because of their resonance with political and commercial rationalities geared to regimes of health and lifestyle (Rose 2007; Gibbon and Novas 2008b), the capitalization of biological materials (Cohen 2005), and the globalization of biosecurity policing (Braun 2007). Central to this biosocial vision of modifiable life, including aging, is that it can be improved, enhanced, and optimized beyond what is needed to sustain good health (DeGrazia 2005; Hogle 2005, 2007). And this is where ethical debates about the limits of enhancement and longevity find themselves today (Schermer et al. 2009; Turner 2009), a point to which we will return at the end of the article. Furthermore, the biosocial order is one that encourages people to

42 The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society Stephen Katz and Jessica Gish Aging in the Biosocial Order congregate as biocitizens around issues of medical treatments and environmental risks (Rose and Novas 2005). As we suggest below, in our case anti-aging medicine and cosmetic bodywork have also become powerful agents for animating biocitizens to pursue a positive aging science of restoration and repair in contrast to the negativity of geriatric medicine (Mykytyn 2006). The biosocial loosening of life from nature meets posttraditional society where age boundaries have become blurred and indeterminate. As sociologists of posttraditional society contend, “late” (Giddens 1990), “second” (Beck 1992), or “liquid” (Bauman 2000) modernity is a period in which the conventional stages of life have become contingent and negotiable. New work, retirement, residence, and intergenerational relations have created conditions whereby the experience of aging is no longer chiefly defined by chronological age. This is evident in the making of the third age (in the U.K.), a term coined by Peter Laslett, to designate an intermediate life stage between adulthood (second age) and old age (fourth age). Typified as a time of independence and disease-free living (Laslett 1987; Carr and Komp 2011), the Third Age presumes a distinction from a darkened fourth age, or old, old age as ter- minal decline. Indeed, as Gilleard and Higgs (2010) argue, it is not chronological age itself but the loss of choice and agency that distinguishes the Fourth Age as a kind of “black hole” of helplessness and dependency. Thus, the social and health status of a third ager heavily depends upon the maintenance of a healthy, active, and modifiable aging body that resists the limits of nature and fate (Katz 2005; Gilleard and Higgs 2013), an image supported by leisure, retirement, financial, and travel industries that cater to “seniors,” “boomers,” “empty nesters,” and other newly marketed “ageless” consumers. Echoing the cultural erosion of chronological age boundaries, the gerontological community has also struggled with alternative age definitions (see Lassen and Moreira 2014). Chronological age has come to be seen as both scientifically restrictive and ageist in its stigmatization of older people (despite the gains made by pension movements that politicize age markers).1 Leonard Cain (1964), an early architect of the lifecourse model, states that for the gerontological sciences to advance, “an open, unencumbered exploration of alternatives to chronological aging is needed to determine the onset of old age” (Cain 2003:321). James Birren is clear that chronological age lacks predictive value and conceptual rigor: “Chronological age is only an index, and unrelated sets of data show correlations with chronological age that have no intrinsic or causal relationship with each other” (Birren 1999:460). The gerontological doubting of the value of chronological age harkens back to the (biosocial) idea of functional age formulated by I. M. Murray (1951). Murray struck on functional age as an articulation point for other bodily “ages” beyond chronological age. Hence, talk of a person having the heart of a 20-year-old, the bones of a 40-year-old, the lungs of a 60-year-old, and so on became revelatory. In particular, for Murray and those which followed (e.g., Heron and Chown 1967), physiologic and chronologic ages vary relative to each other, producing in the end a measurable age based on functions (also advantageous to life insurance companies, according to Murray).

In 1963, functional age was already a key concept in the Normative Aging Study conducted at the American Veterans Administration Outpatient Clinic in Boston. Results of the longer-term study were gathered into a special issue of the International Journal of Aging and Human Development in 1972. The journal’s editorial entitled, “Is Functional Age Functional?” poses functional age as an alternative to chronological age, yet also asks, “Are we ready, as a society, to base age-related decisions upon scientific findings rather than tradition and expediency?” (Editorial [no author listed] 1972:143). The editor’s response is enthusiastically affirmative, and the journal praises functional age as a unifying concept that includes psychological and behavioral as well as biological functions, thus extending the purview of functional health to a person’s whole life (see Katz 2006). While later criticisms of functional age measurements arose (e.g., Costa and McCrae 1985), functional age was embraced by the professional health community because of its connection to health promotion and independent living programs. For our purposes, the importance of the idea of functional age is the way it served and continues to serve a dual biosocial role. First, it entrenches age into every- thing that can be measured as functional or dysfunctional, and thus redistributes physical aging across a horizon of opportunities for intervention (Katz and Marshall 2004). Second, in appearing to diversify aging and liberate it from the constraints of chronological biomarkers, functional age categories and measurements make aging more acceptable and hopeful. If we think of our lifecourses in terms of a changing con- stellation of functional ages, then no single age is determinate or permanent. We can embody a host of ages, work on some, and leave others aside, while choosing which represent our most successful identities. Two of these identities are based on sexual performance and cognitive competence, which the next sections review.

Sexual Function (and Dysfunction) In the past, postmenopausal femininity was seen to benefit from the cessation of repro- ductive function and sexual activity; late-life maturity was thus associated with a serene period of moral asexuality. For this reason, men and women were assumed to have convergent life courses, even if such an assumption was popular in an era of sexual inequality (Marshall and Katz 2006). Estrogen, isolated and synthesized in the 1930s, was initially designed as a restorative, short-term treatment for transitional symptoms for women. By the 1960s, estrogen replacement was touted as something all women should consider for the remainder of their postmenopausal lives, with Dr. Robert Wilson (1966) its most popular crusader, whose mass market bestseller, Feminine Forever, claimed that estrogen had the power to restore full womanhood to those who would otherwise be neutered by menopausal deficiencies. As rates of estrogen prescriptions climbed rapidly in the 1960s and 1970s, criticism about long-term effects emerged on several fronts. In the 1980s and 1990s, the earlier “forever feminine” trope was replaced by a health benefits discourse, which focused on the role of estrogen in preventing osteoporosis and heart disease and possibly the risk of Alzheimer’s disease (AD), which reinvigorated the Hormone Replacement Therapy (HRT) market with tens of millions of prescriptions worldwide. Most recently, popular sexology has turned

44 The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society Stephen Katz and Jessica Gish Aging in the Biosocial Order to female sexual arousal disorder, a vaguely defined disease for which there is no agreed upon diagnostic criteria and little normative data (Moynihan and Mintzes 2010). For men, the advent of Viagra (Pfizer, New York, NY) transformed the familiar problem of impotence into a crisis of erectile dysfunction, one which the drug could conveniently remedy. The development of Viagra also fit with a revised male lifecourse punctuated by andropause, a term that began appearing more frequently in the 1990s and along with androgen deficiency in the aging male. Most popular expertise sees andropause as an age-related testosterone deficiency disorder that most, if not all, men are at risk, facts promoted profitably by the pharmaceutical industry and not endrocrinological research (Loe 2004; Marshall 2007). Yet, when normal testosterone is measured at the level of a 20-year-old man, it becomes more aligned to ageless ideals of optimal functionality than to actual standards of health since we do not know the long-term health effects of testosterone treatments for older men. In lifecourse terms, the risk of midlife andropause (or viropause), like menopause, bring men closer to women’s hormonal story because “he” as well as “she” faces the despair of physical decline and postpeak anxieties. Estrogen and testosterone are female and male molecularized essences, whose ebb and flow, equilibria, and imbalances over- power all other facets of sexual aging including the effects of time on the body and the meaning of chronological age.

Cognitive Plasticity Brett Neilson (2012:62) observes that as biomedical technologies increasingly molecularize the body’s functions, the subjective experience of aging becomes less relevant: “just as capital invests in relationality and flesh (or in the vitality of molecular life), it divests in the human body. In other words, the immortalization of the flesh accompanies the amortization of the body.” We can see these effects in the functional fragmentation of sexuality, which reduces sensual sexual experience to stan- dardized measures of mechanical performance. Similarly, cognitive health has become molecularized through technologies such as brain scans and biomarker tests (Dumit 2004; Lock 2013). Unlike sexual dysfunction, however, there are no effective treatments to reverse cognitive decline despite growing anxieties about dementia. Drugs such as the cholinesterase inhibitors have proven largely ineffective, and during the past decade over 20 anti-amyloid drugs have failed, including the amyloid vaccine developed by Elan (George and Whitehouse 2011:590–1). At the same time, debates about acceptable levels of normal forgetfulness and memory deficits have surfaced in the construction of mild cognitive impairment (MCI), a predementia category of memory loss that does not meet the formal diagnostic criteria for AD. First used as an independent category by Ronald Petersen of the Mayo Clinic in 1995, MCI has become a convergence point for the neurocultural, pharmaceutical, and gerontological communities (see Petersen et al. 1999; Whitehouse and Moody 2006; Katz and Peters 2008; Moreira, May, and Bond 2009). Given that individuals with MCI have a greater than normal risk of progressing to dementia, interest has grown in testing and treating such individuals as early as possible, with the hope that one day a simple

The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society 45 Aging in the Biosocial Order Stephen Katz and Jessica Gish blood test can determine those at risk for AD. MCI, although unstable in diagnostic criteria (George, Whitehouse, and Ballenger 2011), redistributes the risk of dementia at earlier ages for more people and creates a new nonchronological boundary line demarcating third and fourth ages. The risk of dementia and cognitive decline, despite the uncertainty of medical treatments, has also inspired the emergence of a robust neuroculture aimed at maintaining cognitive fitness in the same way that sexual fitness has been championed as a harbinger of successful aging. “Neuro” brain stimulants, “neutraceutical” dietary supplements, and brain training games, such as BrainAge 2, fill the pages of retirement and lifestyle magazines. While no real evidence exists as to the cognitive benefits of such products, as with sexual function the “use it or lose it” motivational discourse treats the body as modifiable and improvable, apart from any social, environmental, and educational determinants of well-being (see George and Whitehouse 2011; Ortega and Vidal 2011; Thornton 2011; Millington 2012; Williams, Higgs, and Katz 2012). In this discourse, brain plasticity, a process that makes some sense on a synaptic or neuronal level, has become inflated to a neurocultural ideal (Pitts-Taylor 2010). And if the brain can change itself in order to combat age-related cognitive loss and enhance life, then the brain, like the rest of the physical body, requires commit- ment to regimes of care by aging biocitizens who learn to think of their health in neuroscientific terms. In the process we become, in Fernando Vidal’s words, “cerebral subjects” (Vidal 2009). Our purpose in looking at sexuality and cognition as powerful formations of functional aging is to emphasize the relationship between the molecularization of health in the body and its dissociation from chronological limits in posttraditional society. Sexual function and cognitive competence are also emblematic of the tension between age freedom and the biosocial expectations to embattle aging, which in turn raises the question of what do we really desire of our natures—consistency or plasticity? To address this question, we turn below to the example of a medical spa clinic and its clients who seek treatments to repair the damaging effects of time. Of interest to sociologists, the anti-aging medi-spa exemplifies how the biosocial order has stimulated professional, social, and technological transformations to the traditions, procedures, and competencies required of cosmetic medical practice.

ANTI-AGING PLASTICITY IN THE BIOSOCIAL ORDER The Anti-Aging Medi-Spa Anti-aging cosmetic enhancement medicine is a blooming ﬁeld of clients, professionals, as well as surgical and nonsurgical procedures that aim to repair, reverse, or slow the undesirable signs and conditions of aging, such as age spots, wrinkles, and skin laxity. While interest in the appearance of smooth, youthful skin dates back to ancient times (Jones 2008), unprecedented popularity in cosmetic rejuvenation exists in modern society. In the United States, growth in cosmetic enhancement shows no signs of abating with 15.1 million procedures documented in 2013 (American Society of

Plastic Surgeons [ASPS] 2013). Of these, 13.4 million procedures were cosmetic mini- mally invasive procedures, and 1.6 million were surgical procedures. The top three most popular nonsurgical procedures, botulinum toxin type A, soft tissue fillers, and chemical peels, respectively, are most commonly used for the purpose of cosmetic rejuvenation (ASPS 2013). Women are predominant users, although men are increasingly consumers of these services (ASPS 2013). Scholars attribute the increased interest and demand for cosmetic surgical procedures to modify the body in normative ways, particularly among women, to a wide array of social forces. In a well-documented historical analysis, Haiken (1997) finds that prior to World War II, cosmetic surgery was largely unpopular, but contemporane- ous and swift growth in consumer products, advertising, and the Hollywood film industry inaugurated cosmetic surgery into the popular domain. With increased media exposure, women were exposed to images of beauty as well as the belief that beauty is a moral virtue to be achieved (Haiken 1997). Medical sociologist Deborah Sullivan (2004) situates the development of cosmetic surgery within entrenched turf wars between board-certified plastic surgeons and physicians from other specialities all desiring a piece of the cosmetic surgical market. She argues that medical innovation, a political climate encouraging free trade, the deregulation of advertising, and consumer culture late in the 20th century set the scene for professional jostling and expansion within the industry. Feminists convincingly argue that women’s motivations reflect their tendency to scrutinize their own bodies/faces in relation to dominant and misogynist representations of the female body (Bartky 2003; Bordo 2003). Gerontolo- gists observe that anti-aging cosmetic medicine, including technological development in nonsurgical procedures—such as Botox (Allergan, Irvine, CA) injections, dermal fillers, and laser procedures—draw attention to the discipline and control of women’s bodies in old age. From this perspective, the use of medical cosmetic treatment is a new form of ageism used to resist or deny aging (Holstein 2001–2002; Bayer 2005; Clarke, Repta, and Griffin 2007). The ensconcing of the medical spa in urban and suburban locations is evidence of the present day popularity in cosmetic rejuvenation. Estimates report that 2,100 medi- spas were in operation in 2012 with a projected increase to 3,400 medi-spas in 2016 with a market value of $3.6 billion (Marketdata Enterprises, Inc. 2012). The medi- spa—a hybrid between a medical clinic and a day spa—is a place where people can book appointments to obtain cosmetic rejuvenation procedures. In the late 1990s, the discovery of neuromodulators for wrinkles, laser and light applications for skin resur- facing, and improvements in injectable products for volume enhancement compelled surgeons to rebrand their surgical clinics as specialized anti-aging centers while allowing physicians and other types of practitioners without surgical training to move into this industry. Technological innovation, a blossoming anti-aging culture, new images of bodily plasticity, and the absence of professional and government regulation set up the medical spa as a commercially viable business opportunity for physicians as well as newfangled specialists, medical aestheticians, and laser technicians. Today a hodge- podge of enterprising professionals capitalizes on the loosened boundaries of cosmetic

The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society 47 Aging in the Biosocial Order Stephen Katz and Jessica Gish medicine and proffer supposedly sound scientific and medical advice about how it is possible to look younger and better without surgery. Clients are attracted to the cosmetic effects of nonsurgical procedures along with the benefits of minimal discomfort, shorter recovery times, and negligible posttreatment complications. The hype (and reality) that these procedures are less risky as well as the visibility of these procedures in “an information-saturated mediascape” (Jones 2008:65) ratify the medi-spa in modern society. Here we contribute to recent analyses that expound the modern-day popularity of cosmetic and anti-aging procedures (Blum 2003; Jones 2008; Edmonds 2010) in relation to the biosocial cultural landscape that inspires this interest. We argue that the medical spa is both an effect and contributor to the present-day biosocial order. Medi- spa practice relies upon, reinforces, and exists in tension with increasingly blurred boundaries between nature and culture, as well as reinterpretations of the determinism of physical aging and of chronological age. Analyses and reflections are explicated using ethnographic findings conducted by Gish of the local medi-spa industry in western Canada. For two years, Gish undertook a field-based study of the anti-aging cosmetic enhancement industry using the variegated methods of interviews, observa- tion, and document analysis. In-depth interviews were conducted with 11 female clients and 12 medical cosmetic professionals that worked in the medi-spa industry and were recruited through a local medi-spa called Vitality Clinic. At this medi-spa, observations of physician–client interactions took place semiregularly over a six- month period for three to four hours per day, two to three days a week. Initial observations mapped out the spaces of the medi-spa (e.g., waiting room, surgical suite, and consultation rooms), and different procedures offered at the clinic and later began to focus on the interactional choreography and routines of anti-aging physician–client encounters. These observations were used to gain knowledge about the embodied, discursive, and material components of medical cosmetic work with field notes detailing how assemblages of actants, such as dominant metaphors, personal preferences, cus- tomary social events, photographic images, organic elements (e.g., hyaluronic acid), and technological objects (e.g., mirror), configured the medical encounter. In addition, observations occurred at other public places where physicians were found to promote or market their services (e.g., tradeshows and cosmenairs2) with brief jottings documented in the field. As with her observations at Vitality Clinic, Gish incorporated field notes from memory key phrases and described embodied movements as well as the working practices of physicians and their staff in order to depict how clients were enticed to agree to the terms of treatment.3 Discursive analysis of documents produced in-house by medi-spas (e.g., brochures and Web sites) and the pharmaceutical industry was also undertaken.

Anti-Aging Plasticity and Biosociality in the Medi-Spa Industry In modern society, the medi-spa is a physical and cultural space that upholds body modiﬁcation of the aging and older body as the norm. Body work is encouraged and performed to optimize aging so that people can retain youth or grow older while

48 The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society Stephen Katz and Jessica Gish Aging in the Biosocial Order looking young. In premodern society, the loss of youthful features was evidence of personal character, wisdom, and the symbolic passing of time (Gilleard and Higgs 2013). By the turn of the 20th century, the onset of wrinkling was experienced as a personal problem attributed to the presence of excess skin on the surface of one’s face. Thus, prior to the discovery of surgical facelifting techniques, in the 1900s women tried home remedies to pull tight surplus skin, such as sitting for extended periods of time with their face held tight using pieces of sticking plaster and rubber strips placed over the arch of the skull (Rogers 1971). Nowadays, nonsurgical procedures, ointments, and devices penetrate subcutaneous skin structures to target at a molecular level the biological roots of facial aging. Three-dimensional (3D) devices, such as Vectra M3 Imaging System (Canfield Imaging Systems, Fairfield, NJ), allow professionals to dis- cover and assess damage deep within the skin that is not directly visible on the skin surface. Consultation tools (e.g., TruSkin Age, Canfield Imaging Systems) produce a composite score of relative skin age that compares a person’s facial skin features with an extensive database of their peers. Skin condition and age is determined along a range of features that includes wrinkles, surface spots, and ultraviolet damage. Using these parameters, a 35-year-old woman whose skin is in excellent condition can be appraised a skin age of 29, or vice versa. Thus, in the medi-spa industry, skin aging is interpreted using the nonchronological terms of facial morphology. As with cognitive health, the advent of advanced imaging systems and a techno- scientific vocabulary contributes to the molecularization of skin aging. Contemporary language no longer defines aging in 2D terms according to the types of wrinkles etched on the surface of people’s aging faces: forehead wrinkles, crow’s feet, malar (cheek bone) wrinkles, hanging cheeks, double chin, and eye bags (Galand 1948; as cited in González-Ulloa 1980:12). Instead, an expansive and exacting terminology is used to atomize aspects of facial aging that are concealed within underlying skin structures: elastin, keratin, hyaluronic acid, rosacea, capillaries, pores, hypodermis, epidermis, collagen, retinoids, coenzyme Q10, and so on. Surface changes, such as discoloration or texture and the effects of gravity, are sidelined to track subtle changes in hidden vascu- lar and melanin conditions. Evidence of the discursive shift away from the norm of chronological age as a criterion for treatment toward the morphology of skin aging is found in the following field note of a medical encounter at Vitality Clinic between a cosmetic physician and a 50-year-old client as they negotiate an anti-aging treatment protocol:

P: I don’t like this area. Can anything be done? (The client gestures to her crow’s feet.) Dr. Barker: Botox would help soften the lines. Profractional treatment is another option. (Dr. Barker grabs a brochure and points to photographs within it.) P: I don’t understand. How can laser help my wrinkles? Dr. Barker: It’s good for the eye area, it helps with ﬁne lines. P: I’m not that old.

Dr. Barker: Profractional is good for any age. Some staff here have even had it. I have a client who is 45, she just had treatment. I know someone who is 25 that wants it. It depends on the look you want. It doesn’t matter your age. It’s for anyone. (The client points to the wrinkles around her eyes.) P: That’s just age isn’t it? Dr. Barker: Well no, it’s collagen.

In the medical encounter above, the physician explains that either injections of Botox or profractional laser treatment can address her client’s area of concern, crow’s feet. To inform the client about the capacities of laser treatment, the physician points to photographs in a brochure that sits nearby, thereby stimulating a duel in perspective between physician and client regarding eligibility criteria for treatment. The client claims that she is too “young” for laser treatment interpreting medical cosmetic treatment as needed by older people (“I’m not that old”) while denoting acceptance that the appearance of wrinkles is part of a natural age order (“That’s just age isn’t it?”). For the physician, the agent of interest is the biomarker; collagen; traditional age boundaries and the material- ization of wrinkles are irrelevant qualiﬁcations for treatment. The molecularization of skin age positions aging as an interior and concealed bodily problem, which ensures that cosmetic rejuvenation applies to everyone; “it doesn’t matter your age.” The industry popularly understands facial aging as an internal, preprogrammed process, termed “intrinsic aging,” but external factors such as sun exposure and smoking (and broadened sometimes to include stress and even marital strife) are also charged as further threats to the well-being of one’s current, and anticipated, appearance. This logic redistributes descriptions of physical aging to include not only molecular features, but an array of social factors. Yet, even as the list of causative factors broadens, the impact of each occurs at the cellular level. Even though skin aging is a natural process that exists beyond our control, the use of reparative technologies and simple lifestyle modiﬁcations, such as smoking cessation and consistent applications of sunscreen, are argued to “turn back the clock” and “slow the progression of time.” As with neurocultural enterprises, medi-spa practice rests upon an image of perpetual body plasticity that sees an aging face as able to repair itself anew:

The client appears in her mid-40s and is booked for a Botox follow-up appoint- ment. Dr. Van Horne asks, “How’s the Botox?” The client replies, “I think it looks pretty good.” Dr. Van Horne agrees and wonders whether she’d consider Sculptra [Valeant Pharmaceuticals, Laval, Quebec, Canada]. “It’s a crystal that binds to the tissue on your face. It’s an irritant that stimulates new collagen growth. It lasts longer. You might bruise, so it’s different from Botox in this way. You’ll need a few days off. I would like to grow you some cheeks.”

Modern cosmetic rejuvenation technologies enact new forms of embodiment and compel clients to interpret and articulate their identity in these terms. In doing so, the

50 The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society Stephen Katz and Jessica Gish Aging in the Biosocial Order industry both calls upon and revises “the mask of aging” trope identified by critical gerontologists as the conflict between a person’s bodily exterior and its betrayal or masking of a supposedly younger identity of the self that lies beneath (Featherstone and Hepworth 1989; Biggs 1997). This phenomenological problem of bodily betrayal is often used to denote the necessity of medical intervention. A client pamphlet for Botox Cosmetic® called “Three Good Reasons Me, Myself, and I” is an iconic example. The text instructs the reader about how the body deceives the self: “Other lines, however, like the vertical frown lines between your brows, can make you look angrier and more stressed than you are. Or perpetually tired, even when you’re well rested.” Ironically, while the pamphlet evokes conventional understandings of age identity, it is not overtly evident that Botox is a wrinkle elixir because an abnormally or excessively wrinkled face is not reproached. Instead wrinkles are ambiguously referred to as “frown lines,” and characteristics and subjective states that are readily identifiable and commonly experienced are made visible. Later the text expounds:

You may have heard about BOTOX Cosmetic®, a simple, non-surgical, safe, and best of all, effective way to help smooth out frown lines and give your face a more relaxed, refreshed look. A look that better reﬂects the way you feel inside and makes you feel more like . . . you. And isn’t that who you’re doing this for?

In a discursive shift, the self is not betrayed by the ravages of time and the effects of gravity, but by false expressions of subjective experience; an overly animated and impassioned bodily exterior that is disjointed from what the self actually feels. In many respects, the marketing strategy’s redefinition of the embodied experience of aging reflects the limited ability of Botox to actually repair the appearance of deep wrinkles at later ages. Thus, promotional rhetoric paradoxically inspires the consumer to worry about how they express themselves encouraging people at younger and younger ages to begin anti-aging treatments to prevent, in the first place, the onset of wrinkles. Physical aging is reinvented as a problem of excitability to create new forms of intervention across the lifecourse. Thus, in turn, women describe Botox injections not as a way to combat the signs of aging, but as useful in their personal and professional lives, so that bosses and school children do not mistakenly assume they are angry (Gish 2012). Here anti-aging cosmetic enhancement discourse incongruously claims the improvement of the aesthetic appearance of the face without evoking traditional age imagery (Granham 2013).

Discursive Tensions and Embodied Realities in Medi-Spa Practice Tensions arise in everyday medi-spa practice around the assumption of anti-aging plasticity or the idea that the body can be reformed or restored via medical intervention. Ethnographic observations of physician–client interactions at Vitality Clinic and other public places where physicians perform and promote anti-aging cosmetic enhancement revealed fractions between the discursive promises of restorative youth and embodied realities given the inevitability of bodily aging, consumer preferences, and the actual

The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society 51 Aging in the Biosocial Order Stephen Katz and Jessica Gish capacities of cosmetic rejuvenation. In interaction with clients, physicians (and staff) were found to anticipate and respond to these tensions through careful negotiations of consumer expectations. Medi-spa practice tacitly ensures that clients apprehend both the possibilities and limits of anti-aging plasticity so they become satisfied and returning customers. As a whole, cosmetic rejuvenation medical encounters are highly embodied activities as physicians work to align client expectations with the realities of treatment in strategic and creative ways. In particular, the goal of the medical encounter is to establish an object of treatment, an intervention, or set of interventions that enacts cosmetic rejuvenation in ways that meet the client’s definition of the situation (Gish 2012). In the following field note, a physician makes certain her client understands what aesthetic outcomes can be attained:

Dr. Barker grabs a pamphlet to show the client. “These pictures are good examples of what filler can do, although the product used here is different than what we use, but I like these pictures. You can treat the area around the mouth and nose, but you can also treat fine wrinkles around the mouth. We create a bridge with filler. You can also plump up the lips. Look at the nurse. We did her lips before Christmas. Filler is good for people who have no lips and she has none. We can show you her before and after pictures, if you like. She’s the poster child for it.”

In the absence of 3D computer simulation technology, physicians were found to draw upon 2D photographs of faces/bodies as well as virtual bodies, mainly those of staff, to negotiate with client. To further orient clients to the realities of the anti-aging treatment process and outcomes, physicians define aging ambiguously through the use of metaphors and figurative language in ways that support both essentialist and modifiable representations of the aging body. Bringing to light the limits of cosmetic rejuvenation to combat the signs of aging is critical to the management of client expectations, as the following field extract illustrates:

The client tells Dr. Van Horne that she wants to look younger and for aging to stop. He replies, “We can’t stop aging. Aging is like a river. We can’t reverse it. We can only treat the streams that ﬂow out of the river.” He takes out a pen from his pocket and draws a ﬂight of steps leading down to a river bank onto a yellow post-it note. “It’s like a river that has steps down to it. You need to be patient and go down the steps slowly, but you will eventually be able to see the river clearly.” The client says, “So don’t jump into the river too soon?” Dr. Van Horne replies, “Yes, that’s right. You have to be patient, but you will hear the water as you get closer.”

The symbolic imagery used by Dr. Van Horne in this interaction cautiously traverses the nature–culture divide. Figurative language frames aging as an ill-fated, inescapable, and natural process akin to the directed, ongoing movement of river

52 The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society Stephen Katz and Jessica Gish Aging in the Biosocial Order water, so the client becomes cognizant of the impossibility of actually halting and reversing bodily aging. Although media representations of cosmetic surgery imply transmogriﬁcation (Jones 2008), the physician implies that patience is required because it takes time for repair to occur at the molecular level and to become visible to the naked eye. Thus, the embodied reality that a time gap or delay before aesthetic improvement will be detected is exposed, an important component of physician–client interactions when procedures that target underlying skin structures and processes via energy or laser devices are used. A more conventional strategy describes facial aging using medico-scientiﬁc terms with attention drawn to how intrinsic (e.g., genetics) and extrinsic (e.g., environmental) factors bring about an unsightly appearance. In the following excerpt, Dr. Barker expatiates with her client on the origins of skin aging:

Aging is genetic. We are genetically programmed to age. There are certain risk factors like diet, nutrition, lifestyle factors like smoking and sunexposure that can predispose us to aging more quickly. But aging is genetic. We can’t stop it. We can help aging by eating healthy and preventing muscle deﬁciency. We can bring our skin back, but we can’t stop aging.

Using the rationale of science and genetics, Dr. Barker defers to the inevitability of aging, but perceptibly in reference to the assumed plasticity and capacity of the body to respond to medical intervention. Together, these physicians optimistically entice their clients to have treatment without overemphasizing what cosmetic rejuvenation is able to accomplish. Even though the industry praises the virtues of medical cosmetic intervention, physicians portend in their work a technophobic stance that privileges nature over anti- aging technology. Thus, as spokespersons for anti-aging technologies (Latour 1987), physicians find ways to naturalize the technologies that they use. This strategy was most often observed when physicians talk about common filler products such as Juvéderm (Allergan) and Restylane (Valeant Pharmaceuticals, Laval, Quebec, Canada). These products are characterized in ways that naturalize their composition. For example, volume deflation is attributed to the loss of an organic substance called hyaluronic acid often described as a natural, bio-identical substance composed of a sugar- like molecule. Such promotional language about the naturalness of the products further implies that treatment is not invasive because injections of filler product replace depleted supplies of a substance that exists naturally in the body much like how energy enters and decomposes in the flows of the earth’s ecosystem. While physicians argue for the effectiveness of restorative treatments, they are careful to emphasize that the effects of repair are not definite. Clients are coached to anticipate skin aging and undergo procedures for preventative purposes to counterbal- ance bodily aging. Dr. Van Horne depicts aging in this way, “Anti-aging is like walking. You need to go slowly and anticipate the future.”In other words, looking forward to the potential ravages of time is important because of the embodied limits of cosmetic enhancement; metaphorically speaking, the clock can be turned back, but it can only

The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society 53 Aging in the Biosocial Order Stephen Katz and Jessica Gish be turned back so far. Dr. Barker clarifies, “We can’t stop the clock, the body keeps aging.” Thus, consumers are taught to control bodily aging at early ages or whenever they may first begin treatments by undergoing regularly scheduled regimes of upkeep. Clients are also reminded of the material limitations of the technologies themselves; while repair is possible, the effects are not long-lasting; thus, continued treatments are necessary. A physician explains the importance of regular Botox and filler appointments: “It lasts about four to six months. You need to continue on getting your treatments. It’s just like maintaining a haircut or a colour. You should do the same with Botox and filler because what happens is that you’re giving your skin a rest.” The industry was also observed to navigate tensions between anti-aging plasticity and consumer preferences for consistency. For those persons who begin treatment early in the lifecourse, the presumption is that a continuous look will be maintained. A laser technician explains:

A lot of people think it’s for once you have wrinkles but it’s really not. It’s for the maintenance of wrinkles. Like, I’m only 24, I’ve gotten Botox. It’s just to keep it so that when I turn 50, I’m not going to look 80. So there’s deﬁnitely ways of maintaining your age.

In the following ﬁeld note, a physician illustrates the body’s capacity for repair while keeping the theme of consistency in mind during a ﬁller demonstration:

After finishing with one side of the face, she positions her model upright on the treatment chair. She invites the audience to move closer, “Come look. Can you see how this side is now more full? It’s also helping to pull upwards the saggy skin down here.” With her hand, she points to the nasiolabial fold to demonstrate that additional skin tightening has occurred because of the cheek augmentation. She stops to tell a story about how it took her a while to get used to her own cheek augmentation. “Once I had a colleague inject four syringes of filler. I couldn’t do the injections myself, but I watched. I held a mirror in my hand and watched the whole process, providing guidance as he went. Afterwards I went home and wondered if I had finally done it and injected too much filler. I was looking in the mirror at 11:30 p.m. instead of sleeping. When I smiled I could feel the filler; it stopped my skin from moving. I looked in the mirror and thought, this isn’t me. But then I realized this is a better version of me. I was looking at how I used to look when I was younger. I was seeing how I used to see myself in the mirror, before. It took me a while to get used to it, but I did.” The physician resumes injections on the other side of the face. When she is done, she props her model upright. But before the physician can say anything further, an audience member observes aloud, “Eweee that looks so good. It looks natural.”

In the above, a cosmetic physician is quite obviously promoting the beneﬁts of anti- aging cosmetic enhancement. She anticipates the belief that people desire to look

54 The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society Stephen Katz and Jessica Gish Aging in the Biosocial Order like an expected albeit refreshed version of themselves, but premised on the understanding that consistency is deﬁned in terms of a perpetually youthful appearance. Together, assumptions about anti-aging plasticity and embodied practices in the consumer-driven medi-spa have the potential to enact a bodily aesthetic that does not appear to age at all. As such, Meredith Jones, in her recent assessment of the cultural landscape of contemporary cosmetic surgery, argues that the collection of available anti-aging technologies is “less about reclaiming or reinventing youthfulness and more about attempting to create a look of indeterminate age or ‘agelessness’ ” (Jones 2008:86). Most disturbingly, the bystander’s closing statement demonstrates the power physicians have in strengthening the belief that indeterminate agelessness is what counts as a natural or normative state of being.

CONCLUSIONS In the concluding article to the special issue of International Journal of Aging and Human Development (Editorial [no author listed] 1972), aptly titled “The Ages of Me,” Robert Kastenbaum et al. (1972:210) ask: “Is it ‘healthy’ or ‘pathological’ to embrace an ever-more-youthful self-conception as one grows older?” Their response is as ambiva- lent as their question because how can one truly harmonize “inner” and “outer” ages, including chronological age, in a culture where standards of health, normality, beauty, and aging are flexible and negotiable mediation points between self, body, and society? As the clients of the medi-spa demonstrate, they are compelled to narrate such ideals and their dislocations in time in ways that signify and reinforce the molecularization of aging, even where their “ages of me” are shaped by embodied realities and the discursive clinical tensions of their doctors. Their experiences also accord with the ethical dilemmas that Sharon Kaufman (2010) has documented in her research on the limits of life extension procedures for older people. For Kaufman, as for us, “longevity- making” is not just about privileged access to medical treatments, but also a reflexive practice that involves choice, ambivalence, obligation, and responsibility. This is so because, as such treatments become less constrained by age or consistent notions of a natural life span, older people need to think about the “time left” in their lives and thereby estimate the value of more future despite the risks it may pose. Thus, for Kaufman (2010:226), reflexive longevity “referstoanemergentformoflife,amodeof knowledge, reasoning and embodiment that older persons and their families come to inhabit at the site where ethics, ageing, clinic technologies and life itself meet.” This form of life leads Kaufman (2010:228) to ask, “what kind of subject emerges when longevity becomes a reflexive practice.” This question is also central to our theoretical ideas about the biosocial order of the aging body and our ethnographic research on medi-spa practices. With both we have sought to address the forms of life we become as we attempt to control, measure, repair, or reverse the time left, entangled as that pre- cious time is within the technologies, ethics, hopes, and knowledges that constitute it. Finally, as the biosocial order creates new reflexive forms of life and inspires novel ventures in our global capitalist society which our example of the medi-spa epitomizes,

The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society 55 Aging in the Biosocial Order Stephen Katz and Jessica Gish as Kaufman suggests, then we also need to consider their historical relationships to past and present. Of the past we can ask if the natural was ever really that natural. But for the future, we should ask if we really want our nature to be as mutable as our culture, especially if that nature comes with a reinstatement of oppressive traditions about age and gender. These are questions to ponder as contemporary biosocial styles of thought travel through the life sciences and ﬁnd their way into our lives and hopes with claims to liberate us from our biological destinies in repaired, restored, and improvable ways, yet push our cultural values right back onto our body’s functions, hormones, brains, and faces.

ACKNOWLEDGMENTS Stephen Katz would like to thank Barbara L. Marshall for allowing him to share her ideas about sexual function and performance in this article. Jessica Gish would like to thank the Social Sciences and Humanities Council of Canada for its generous support of this research through a Canada Graduate Doctoral Scholarship # 767–2005-1699. She also expresses her gratitude to the physicians, staff, and clients of the Vitality Clinic who made her ethnographic work possible.

NOTES

1Debates about “normal” and “pathological” standards in aging research, especially between biogerontology and biomedicine, are beyond the scope of this article to address adequately (see Moreira and Palladino 2009; Pickard 2011; Moreira 2015). However, such debates do illustrate the impossibility of a unified “bio” science representing all registers of aging from cells to populations. 2A cosmenair or cosmetic seminar is a collection of professionals and people brought together by a medi-spa. Information about skin aging and anti-aging technologies is presented to audience members with discussion elicited about the problems brought on by bodily aging. Cosmetic physicians are typically the seminar leaders, but guest speakers from pharmaceutical companies may also be present and provide detailed information about a specific product or procedure. 3Jessica Gish has given all participants, including the medi-spa, pseudonyms in this writing. Ethical approval was obtained from The University of Calgary ethics committee. At the medi- spa, all staff members were aware that they were being studied and informed of the purpose of the study. Signed or verbal consent to participate was obtained from staff and where possible from clients. Although many clients were aware of the author’s (Gish) role as a researcher, some participants were uninformed because the fast-paced and industrious quality of the medi-spa made it difficult to obtain verbal consent without disruption to normal work routines. The author’s primary role was as a researcher, but on hectic days it became necessary for her to adopt the role of semiparticipant and complete common workplace tasks, such as preparing ice packs, finding misplaced cameras, and directing staff or client traffic, to sustain rapport in the field. Given the unusual layout of the medi-spa and treatment rooms at Vitality Clinic, physician–client interactions were semiprivate affairs. A series of five treatment rooms, while accessible by a single doorway, opened into a large hallway that cross-cut each room and allowed staff members to travel easily from one room to the next. While clients were out of view to one

56 The Sociological Quarterly 56 (2015) 40–61 © 2015 Midwest Sociological Society Stephen Katz and Jessica Gish Aging in the Biosocial Order another, conversational fragments were perceptible, and they could see physicians and staff move through the hallway to different treatment rooms. The atmosphere resembled a busy hos- pital corridor. Outside of Vitality Clinic, observations were conducted at events that were open to the public. These events varied in size from less than 20 people to hundreds of participants. In these settings, the author acted as a covert observer documenting components of medical cosmetic work. When conversations took place with women or professionals in the ﬁeld, her identity as a sociologist was revealed.

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