Active ageing and the culture of perfection¹

Abstract

In the last two decades, Active Ageing acquired significant importance in scientific and political forums as a new paradigm of public policies to meet challenges posed by the ageing population. Defined by the WHO as to emphasize society’s responsibility regarding quality of life as people age, the Active Ageing paradigm represents, nowadays, a progressive narrowing of action scope and accountability. In recent years, assuming the logic of individual accountability, it serves as basis for the accusation of individual negligence in not adopting a healthy lifestyle. This study analyses the websites of several Portuguese medical clinics specialized in anti-ageing medicine, where one can find advertisements of the services provided, and, in some cases, opinion articles drawn up by doctors of this medical specialty, for a lay audience. Considering the increasing international dimension of the aesthetic and hormonal enhancement biotechnologies market, the ideal of Active ageing can, today, be at the service of the culture of perfection.

Keywords:
Active Ageing; Anti-Aging Medicine; Enhancement

Resumo

Nas últimas duas décadas, o envelhecimento ativo adquiriu expressão relevante enquanto paradigma de políticas públicas para fazer face aos desafios colocados pelo envelhecimento demográfico. Definido, primeiramente pela Organização Mundial da Saúde (OMS), de forma a enfatizar a responsabilidade da sociedade no seu conjunto relativamente à qualidade de vida ao longo do processo de envelhecimento, o paradigma do envelhecimento ativo, atualmente, tem vindo a concentrar-se, sobretudo, no adiamento da idade da reforma e na redução dos custos com a saúde nos últimos anos de vida, a partir de uma lógica de responsabilização individual. Para a elaboração deste artigo, foram consultados vários sítios on-line de clínicas médicas portuguesas nas quais se praticam consultas/tratamentos de medicina antienvelhecimento, analisando os anúncios publicitários dos serviços prestados, bem como artigos de opinião redigidos pelos próprios médicos dessa especialidade, dirigidos a um público leigo. Conclui-se que, a par da responsabilização individual pela saúde e, de forma mais geral, pela forma como se envelhece, assistimos hoje à expansão de um amplo mercado de produtos e serviços antienvelhecimento que nos permitem argumentar que o ideal de envelhecimento ativo poderá estar ao serviço de uma indústria da perfeição.

Palavras-chave:
Envelhecimento Ativo; Medicina Antienvelhecimento; Aprimoramento

Introduction

The concept of “Active Ageing” (AA), adopted and widely promoted in recent years by the European Union (EU), was previously established by the World Health Organization (WHO) based on research developed in various scientific areas. The first publications using this concept are already two decades old, dating back to the late 1990s.²

In 2002, the WHO issued a publication targeted at implementing public policies to promote active aging (WHO, 2002), defined as an optimization process of opportunities for health promotion, participation and safety, to improve quality of life as people age. This first definition establishes the three essential pillars of this new paradigm: health, participation and safety.

The health pillar transcends the strictly physical to encompass mental health and social well-being, all of which are recommended for public policies intervention. On the other hand, the concept of activity refers to continued participation in the cultural, social and economic domains of civic and community life and not only active participation in the job market. Finally, the existence of a social protection system (whether public or private) is necessary to ensure an adequate level of socio-economic security, without which it would be impossible to guarantee either the health or participation of the older people population.

Besides highlighting the importance of public policies aimed at social transformation considered necessary for a more effective inclusion of older people, there is also a very clear message for their personal accountability, which itself must seek to remain active and strive to ensure their health, participation and safety. As this concept gained momentum in the political sphere, official publications in this regard have become, within the EU, increasingly focused on an economic imperative - that of maintaining the older population in the workforce - with a strong emphasis on personal responsibility (São José; Teixeira, 2014).

Thus, a progressive confusion of scales analysis is seen in these official publications within the EU, where the social dimension of the ageing process (demographic ageing) is subsumed in its individual dimension, by promoting a healthy norm based on an ideal of “third age” full of opportunities for those who take on personal responsibility for aging successfully (Rowe; Khan, 1987). The essential locus of intervention to consolidate the emergence of this healthy norm is the body of aging individuals, now called to act to mitigate harmful effects of the aging process (such as disease and dependence), which should be delayed, or even, if possible, stopped.

This is how, along with individual health accountability and, more generally, the way one ages, we witness today the expansion of a wide market of products whose purpose muddles health promotion and enhancement (Edmonds; Sanabria, 2016). From drugs that improve cognitive, sexual or social performance to “natural” products developed in large production and distribution chains for the same purpose, encompassing prescribed or illicit use of hormonal therapies, up to resorting to cosmetic or prosthetic surgeries and the use of cosmetics, reaching the field of regenerative medicine, “enhancement technologies” are generally defined as interventions targeted at improving human functioning or characteristics beyond what would be strictly necessary to repair the body, regarding health maintenance (PCB, 2003).

To understand this social phenomenon, we must observe the role of biomedicine in recent years in making available a wide range of biotechnologies that assist human nature (Strathern, 1992), were the fusion between technology and the human body is such that lead us to reconsider traditional boundaries between “nature” and “culture” (Hogle, 2005) and to outline the imagery of the “Cyborg,” by which anthropology has debated the emergence of body-machine entities (Haraway, 1991). Looking at the controversial field of anti-aging medicine (AAM), we observe a recurring discourse with emphasis on personal accountability on the aging process by its professionals, in which health is confused with enhancement, constituting further evidence of the emergence of a biopolitics (Rose, 2001) that can essentially be characterized as “healthism” (Crawford, 1980), as will be discussed later. As such, AA can be today at the service of the culture of perfection.

Methodology

As for a first approach on the study of the AAM in Portugal, focusing on the analysis of the phenomenon in Lisbon, a documentary analysis based on websites browsing of several medical clinics, in which one can find not only advertisements for the services provided, but also opinion articles written by the doctors themselves, addressed to a lay public, was carried out. A critical analysis of this content was made in comparison with the scientific literature as to contextualize this specific phenomenon, as well as the broader theme of the AA.

For the elaboration of this article, between April and July 2019, the content of the websites of a group of medical clinics (listed below) in which AAM appointments/treatments are practiced was analyzed. The list of clinics compiled sought to be exhaustive in regard to Lisbon, complemented by the analysis of the content available on the websites of some clinics outside the Portuguese capital, based on the relevance of the information presented, concerning the objectives of this research.

All citations in the article were taken from online publications until July 30, 2019, and their provenance identified by the name of the clinic, as listed below, along with the online address.

• Dra. Ivone Mirpuri Clinic (Lisbon),³ associated with the Study Group on Anti-Aging Medicine.⁴

• Dr. Pinto Coelho Clinic (Lisbon).⁵

• Dra. Paula Vasconcelos Clinic - Anti-aging, Functional and Regenerative Medicine (Lisbon, Cascais and Porto).⁶

• Milénio Clinic - Aesthetic medicine and Anti-aging (Lisbon and Algarve).⁷

• Dr. Fernando Póvoas Clinics - Aesthetic medicine and Anti-aging (Lisbon, Porto, Luanda).⁸

• Acqua Health Care Clinic (Lisbon).⁹

• Clínica do Poder (Lisbon).¹⁰

• New Age Institute (Porto).¹¹

• Porto Medical Clinic.¹²

• Age Clinic (Porto).¹³

• Uno Integrative Clinic (Braga).¹⁴

• Guimarães Private Clinic.¹⁵

• Clinic4You (Coimbra).¹⁶

Anti-aging medicine

Anti-aging medicine (AAM) has been developing more intensely since the beginning of the 21st century, with the explicit objective of intervening on the aging process, understood by its promoters as being associated with a deterioration, which can and should be a focus of biomedical intervention. One evidence of its growth in the last two decades is the increase in the number of publications involving anti-aging in scientific journals specialized in the subject, with dissemination of results in scientific conferences, attracting the interest of biotechnology companies, regarding a growing consumer market (Mykytyn, 2006). Many of AAM professionals come from different medical specialties and even from health intervention areas outside of biomedicine, for example, associated with so-called alternative or complementary medicines, being an intervention and scientific research field still in the process of consolidation and in search of scientific and social legitimacy.

Despite this multidisciplinary background, most of these specialists, including some of the Portuguese experts, are affiliated to the American Academy of Anti-Aging Medicine. One of this area pioneers in Portugal, founder of the New-Age Medical Institute in Porto, graduated in medicine at the University of Porto, with subsequent postgraduate training held in the United States, defines AAM as follows:

A preventive and proactive medicine that aims to increase longevity with quality of life, through a medical, nutritional and exercise program adjusted to each patient. It emerged 12 years ago in the United States and led to the creation of the American Academy of Anti-Aging Medicine, which encompasses doctors, naturists, naturopaths, physiatrists... (Romariz, 2010)

Despite the absence of a perfect consensus among health professionals, and while some direct their efforts mainly to maintaining health as the aging process occurs, where others actively seek an increase in substantial longevity, a pronounced optimism about the results to be achieved in years to come within this area of intervention is recurrent among different practitioners of AAM.

This Portuguese specialist is optimist and finds no limits to what science can bring to the fight against the “aging disease”:

Anti-aging medicine sees aging as an incurable disease, but whose symptoms are known, namely Alzheimer’s, heart disease, diabetes... Its purpose is to prevent the onset of these symptoms, enabling people to stay healthy for longer. [...] At present the maximum life span is 122 years, but I believe one day it will be possible to live forever. (Romariz, 2010)

Despite this scathing statement, some researchers of AAM as a social phenomenon observed that classify the aging process as a disease is infrequent among these health professionals, for whom aging is almost always understood as a “natural” process, but that can and should be the target of biomedical intervention. For, they argue, what is truly emblematic of human nature is the continuous effort to free itself from biological constraints and, therefore, nothing more natural than seeking an optimization of the aging process (Mykytyn, 2008).

Despite different conceptions about the aging process, in a field of medical intervention comprised of specialists with different basic backgrounds, from different countries characterized by specific social and cultural contexts, there are some recurring topics in the advertising discourse of AAM advocates. At its basis is a possibility of dissociating aging and disease, as long as its medical orientations are followed. This allows, on the one hand, the “medicalization” of the aging process, by which social control is exercised by medicine, leading to a loss of individual autonomy (Zorzanelli; Ortega; Bezerra Júnior, 2014). On the other hand, paradoxically, it emphasizes the importance of individual health responsibility, namely for the adoption of a healthy lifestyle, persistently recommended. To the director of a medical clinic in Lisbon, founder of the Study Group on Anti-Aging Medicine:

We don’t die because we’re OLD. We die because of age-related degenerative diseases. [...] And if we think about all these pathologies, obesity, for example, participates in the genesis of all of them. And obesity, such as tobacco, alcohol, high glucose levels, diets high in trans fat or low in polyunsaturated fatty acids, omega3 fruits and vegetables, such as physical inactivity, all these factors could be worked out by education and acquiring “healthy habits and lifestyles.” (Dr. Ivone Mirpuri Clinic)

Associated with individual health accountability, messages of individual empowerment are often found in the discourse of AAM professionals, which often give rise to slogans that accompany health products or interventions intended to be marketed: “The desire to change your life has to start with you [...]. The anti-aging program teaches you how to better control your health” (Dr. Ivone Mirpuri Clinic); “Give life to years and years to life [...]. The health of each of us is the result of choices we have made and make in our lives” (Dr. Paula Vasconcelos Clinic); “Through healthy habits we can prevent diseases with higher mortality and consequently achieve more years of useful life” (Acqua Clinic); “We help you build your Personal Power. We work so you can express your charisma in full, effectively exercising your potential” (Clínica do Poder).

The message of empowerment is often associated with the reconstruction of old age in light of an ideal of eternal youth:

Growing younger as you grow old [...]. This is my invitation to you. My mission is to implement a new, integrated health model, to promote, whatever the age, high levels of well-being and health. Teach you to grow old without getting old. (Dr. Pinto Coelho Clinic)

Therefore, AAM advocates seek to define a new optimized health standard, in which health is confused with enhancement and, at least in one of the analyzed cases, the negative impact of the aging process is confused with the concept of active aging:

To all those who want to optimize their health, delay the rate of active aging and reduce the probability of diseases emergence (cardiovascular, joint diseases, neurodegenerative, tumor, etc.) [...]. In short, Anti-Aging Medicine is aimed at all those who feel old on the outside and new on the inside, but also to those who feel new on the outside but old on the inside! (Porto Medical Clinic)

We offer to approximate the biological, metabolic and hormonal parameters of individuals from the age of 40 to those found in a 22-year-old healthy person. After reaching the height of their performance in the mid-twenties, the human being begins to age. (Dr. Pinto Coelho Clinic)

In advocating for a rephrasing of the concept of health towards an optimized ideal, AAM professionals also advocate a reshaping of clinical practices characteristic of the biomedical model, towards a new preventive and personalized medicine, based on some key therapeutic pillars:

What medicine currently does is extend the patient’s life as to prolong the disease. We must be foresighted, preventing and delaying the onset of so-called degenerative diseases, today achieved through a body balance working the five pillars on which anti-aging medicine is based: Nutrition, Exercise, Supplementary feeding, Hormone replacement, vital and the one I dedicate myself most, and Lifestyle change. From the synergy of these elements we can increase our vitality, slow down our aging and eventually extend our longevity. (Dr. Ivone Mirpuri Clinic)

Despite some variability regarding the introduction of therapeutic valences considered essential for the characterization of what constitutes an AAM appointment, the recurrence of an emphasis placed on lifestyle alteration (including physical exercise practice, management of mental and emotional stress and better nutrition) is observed, as well as the therapeutic use of bioidentical hormones:

From the age of 35, hormonal production decreases by about 1 to 2% per year. A 50-year-old has, relatively speaking, half the hormones he had at 30. Thus, hormonal measurement and restoration is essential to anyone who wants to return to their mid-thirties levels. (Dr. Pinto Coelho Clinic)

If the focus on lifestyle changing is something that has already been defended by the WHO as a fundamental field of intervention for biomedicine professionals, at least since the Ottawa Charter for Health Promotion (WHO, 1986), enabling the emergence of the so-called “new public health” (Lupton, 1995), on the other hand, the use of hormones for therapeutic purposes has been the main focus of criticism from AAM opponents, particularly doctors of other specialties, which indicate its possible association with the development of cancer or cardiovascular diseases:

So-called anti-aging therapies, which employ hormones, high-dose vitamins and other compounds, create risks for their users and increase the likelihood of cancer, dementia and cardiovascular disease. They are a decoy, the illusion of a “fountain of youth,” and strongly condemned by the Federal Council of Medicine and the Brazilian Society of Geriatrics and Gerontology. (Tavares, 2017)

The use of hormones in the context of hormone replacement treatment (HRT) during menopause, to obtain a new balance and avoid the consequences of endogenous hormones deprivation, dates back to the 1930s.

However, its mass use occurs only in the years 1980/1990, resulting from a slow but successful process of menopause “medicalization” (Lock, 1993). Nevertheless, its use has never been without criticism, and from the first decade of the 21st century, the controversy intensified when some published scientific studies provided evidence for the argument that the risks associated with HRT (especially breast cancer and heart problems) outweighed its benefits (Heiss et al., 2008). Further studies showed the opposite, that the benefits outweigh the risks, whenever HRT is used by women under 60 years of age or less than ten years of menopause, concluding that the risk associated with estrogens use for breast cancer is minimal and the risk of cardiovascular disease is reduced if treatment is started before 60 years of age (Shifren; Gass, 2014). Recent studies have brought new evidence of increased risk of breast cancer associated with the daily use of combined estrogen and progesterone (CGHFBC, 2019).

Outside scientific controversy, knowledge of the risks associated with this type of treatment exists in the general public sphere, evidenced by the commercial success of a new alternative that appeared on the market - bioidentical hormones. These are usually derived from plant extracts, but chemically modified in the laboratory to become molecularly identical to human endogenous hormones. Therapy with bioidentical hormones usually refers to the use of sex hormones: estrogen, progesterone, testosterone (Fishman; Flatt, Flatt; Settersten, 2015).

First marketed by AAM practitioners, and then by gynecologists and some alternative and complementary medicine therapists, the use of bioidentical hormones met the eagerness of many women for a less risky therapy, as “natural” as possible, effective in controlling the undesirable symptoms of menopause, with or without a scientific basis.

However, the use of hormones for therapeutic purposes has assumed different configurations according to the various social and cultural contexts of implementation, becoming a relevant field of social analysis, unveiling contemporary values and discourses not only related to the menopause, but also the biomedicine and the aging process in general.

Moreover, the ethnographic analysis of their daily uses helps to understand how these values and discourses intersect with facing different types of social problems, across classes, especially in situations of great uncertainty. This analysis show how its use is often established on the threshold between the search for better health and the search for enhancement.

More than in any other aspect of biomedicine, is in the specific field of AAM, starting from its concept of “optimized health,” that this boundary between health and enhancement is strained to almost complete erosion, to the extent that replacing hormone levels to return its peak (fixed by many, around 30 years of age, and by others even earlier) becomes “natural,” although only made possible by the latest technological and scientific advances:

Aging is a natural process, but it is possible to delay its appearance by identifying the causing factors [...]. Scientific and technological advances allow resources to delay the biological clock and anti-aging medicine takes advantage of these advances by developing programs of personalized nutrition, hormonal optimization, adequate physical exercise and eventual supplementation. (Milénio Clinic)

This medical intervention towards an optimized health ideal becomes not only natural, but desirable - an idealized health standard - and some AAM professionals even stress their specialty significance in solving the challenges placed by demographic aging, from an intervention on an individual scale, thus finding another argument for its social legitimacy. Thus, the individuals’ empowerment, through their individual health responsibility, is considered the basis of the solution to the social problem of demographic aging, so that no one becomes a burden on their family and the society:

The population is aging, and we need to look for ways to spend less economic resources on disease. About 90% of the resources we spend on our health are, in fact, used after 65 years of age [...]. We shouldn’t want to ever be a burden on society or family! Reason why we need to rethink medicine and health by acting in prevention. So we can grow old... young. (Dr. Ivone Mirpuri Clinic)

In opposition to their critics, specially doctors from other specialties, AAM professionals claim their relevance in helping society address problems associated with demographic aging, sustainability of social welfare systems and high health costs of older people. Moreover, according to some of these specialists, the AAM emerges, from the beginning, as a reaction to a medicine they consider to be centered around disease and thus characterized by a late intervention on health problems. AAM should, then, serve as a reference for the construction of a future medicine, preventive and personalized, which directly contributes to the reduction of health costs:

Anti-Aging Medicine was born about 20 years ago in the United States, as a movement that brought together at first 12 physicians, who for the first time thought of conceiving and promoting health differently. Not passively waiting for injuries or diseases, those physicians imagined possible to conceive a different strategy, acting preventively and predictively in people’s lives, long before pathologies manifested.

Another major factor that gave impetus to the movement was economic. There are, in the United States alone, more than 110 million people today undergoing some kind of treatment or using some kind of medication just to minimize the effects and complications of the so-called “inevitable” old age diseases [...]. Maintaining that pace resulted in the complete bankruptcy and degradation of the U.S. health system. (Clínica do Poder)

This is also how, in search of social legitimacy, some AAM advocates assert their contribution for the effective implementation of AA:

Anti-Aging Medicine will thus optimize the process of physiological aging, adapting itself to the World Health Organization’s definition of active ageing, improving opportunities for physical, social and mental well-being throughout life, and expand healthy life expectancy. (Milénio Clinic)

Intending to assert itself as a medical specialty that promotes individual health, thus redrawing important benefits for society, for some of these professionals, social legitimacy of their practice seems based on an effort to differentiate their clinical practice regarding aesthetic procedures, drawing a boundary between the health area and that of “aesthetic enhancement”: “Over the years, many people have asked us what is Anti-aging Medicine. Is it cosmetic surgery? Plastic surgery? Or cosmetic? [...] In fact, Anti-aging Medicine is none of this” (Clínica do Poder).

However, there is a recurrent coexistence between therapeutic and aesthetic services in many of the clinics analyzed, meaning that in the same website defends, simultaneously, the relevant role of AAM in the implementation of AA is defended, and the current ease of “aesthetic medicine” - directly associated with disguising aging signs - that allow “Rejuvenate at lunchtime!,” without side effects or rest period:

Our era demands doctors to have knowledge, training and experience in minimally invasive and without side effects express treatments able to define and revive men and women’ natural beauty, in a healthy way.

A non-surgical medical aesthetic procedure that can be performed “at lunchtime,” such is the with which they are performed. As such, patients can carry out their facial rejuvenation techniques without any recovery or “low” activity period. (Milénio Clinic)

This association between aesthetic and therapeutic objectives becomes possible and recurring because the scope of AAM intervention is strictly individual, without establishing any dialogue with public health, neglecting completely the social factors that determine health (Marmot; Wilkinson, 2006), and the desired social transformation, which would allow for AA implementation, results from a strictly individual intervention, as health education.

Final considerations

There is little novelty in the criticisms AAM defenders move towards professionals from other medical specialties, accusing them of practicing a medicine focused on the disease and characterized by a late intervention, without training patients in individual health responsibility, particularly the orientation towards the adoption of a healthy lifestyle. In contrast, the concept of “active ageing,” within WHO, originated, to a large extent, from research carried out in various medical contexts (Foster; Walker, 2015), thus becoming necessary to rethink the role of biomedicine in the “medicalization” of old age. For, if on the one hand, it has been previously criticized for promoting the passivity of older people and their dependence on health professionals, on the other hand, today we are witnessing the promotion of healthy lifestyles and individual health responsibility.

We can trace this last trend historical development, which to some extent has never dismissed the prevalence of the former, from the emergence of a “new public health” (Lupton, 1995), which strives for proper consideration of multiple explanatory factors of diseases in biomedicine and the importance of individual health responsibility. Although apparently not directly related, it is in the broad context of these transformations, on the one hand, and the consolidation of the AA paradigm at the social and political level, on the other, that the emergence of AAM must be understood.

The concept of “health promotion,” associated with the concept of “healthy lifestyle,” was adopted by the WHO since 1986, as shown in the Ottawa Charter for Health Promotion. This article reflects the social expectations for a new public health, observable, for example, in the movement for health promotion developed in the United States and which can be understood, fundamentally, as the search for less health public expenditure, thus emphasizing the importance of assuming an individual health responsibility (Minkler, 1989).

These claims gradually resulted in a health monitoring of individual behaviors previously disregarded by the medical sphere, such as eating habits, physical exercise and substance use such as alcohol and tobacco, thus constituting an important phenomenon of social life “medicalization.” By proclaiming a new salutary norm and its dangerous deviations, what can be considered a “risk epidemic” widespread by the media (Forde, 1998), in which health, subject to multiple threats, must be preserved by a responsible personal behavior, is developed based on medical information made available by public health institutions. Once the relevant information is transmitted, each one is responsible for their own health, thus introducing an important moral dimension in this equation: developing a disease depends on more or less healthy behaviors that have been adopted throughout life, and thus deserved.

This “healthism,” term coined by Robert Crawford (1980), today widely consolidated, tends to ignore the extensive research conducted around multiple social factors as fundamental determinants of various diseases. For, if, on the one hand, it highlights the importance of healthy lifestyles, it often does so through individual campaigns, despite evidence that some a priori social factors act as determinants, including the possibility of adopting a healthy lifestyle (Marmot; Wilkinson, 2006).

Moreover, as the literature on successful aging shows, adherence to AA also depends on the physical and cognitive limits frequently associated with late old age, or fourth age (Baltes, 2003), which deprive some, earlier than others, of much of their autonomy and feeling of control over their own lives, with serious consequences on physical and mental health.

Ignoring the limits for individual adherence to AA, imposed by social determinants of health, or by physical and cognitive limits statistically associated with late old age, corresponds to a process of “reinvention of old age,” where these limits are hidden by the promotion of positive social representations of old age and in which the losses proper to the aging process are fundamentally allocated in the domain of individual responsibility, as a consequence of an unhealthy lifestyle (Debert, 1999).

Thus, the importance given to being economically active is essentially presented as something that has been transposed from the economic to the individual sphere, an “busy ethic” (Ekerdt, 1986) that proclaims unlimited development, without considering the particularities associated with the subjective experience of old age. For, in the AAM model, the notion of person does not understand the decline of the body, “opposing its constitutive conditions - autonomy, freedom, independence - to the decay of organic materiality” (Rougemont, 2019, p. 426).

Despite all the research, most advocates of AAM continue to escape the critical questioning regarding the emphasis on promoting healthy lifestyles based on individual health accountability. By its deep immersion in this “busy ethic,” where the concept of health is confused with that of enhancement, the AA paradigm may today be enabling the rise and expansion of the culture of perfection.

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Publication Dates

• Publication in this collection
  17 Apr 2020
• Date of issue
  2020

History

• Received
  27 Jan 2020
• Accepted
  01 Feb 2020