Hektoen International

A Journal of Medical Humanities

About face: from revulsion to compassion

Sylvia R. Karasu
New York City, New York, United States


L’antigrazioso (“Anti-graceful”) by Umberto Boccioni (1882–1916), demonstrating an artist’s abstract rendition of asymmetrical, deformed features.4

Skin Graft (Transplantation)
(1924) by Otto Dix1

Winter, 1563 by Giuseppe Arcimboldo (1527–1593) demonstrating an artist’s rendition of grossly deformed features5


“I was too ugly to go to school,” writes Lucy Grealy in her painful memoir Autobiography of a Face.1 At the age of nine, Grealy was diagnosed with a rare Ewing’s sarcoma of her jaw that necessitated disfiguring surgery, radiation, and chemotherapy. “I was my face,” she said.1 She felt her ugliness was profoundly shameful and a “great personal failure.”1 During those years after her treatment, she was subjected to cruel taunts and ridicule from her classmates and she even heard strangers say, “What on earth is that? That is the ugliest girl I have ever seen.”1 In her attempt to normalize her appearance, Grealy endured the pain and suffering of thirty-eight operations, none of which led to a permanent reconstruction of her sunken, deformed face.2 She wrote, “I became an expert on the reflected image, its numerous tricks and wiles, how it can spring up at you at any moment from a glass tabletop, a well-polished door handle, a darkened window, a pair of sunglasses…”1

The Ugly Duchess (also known as A Grotesque Old Woman), (c. 1525–1530) demonstrating an artist’s rendition of grossly ugly androgynous woman.6

Though Grealy had no further evidence of cancer by age ten, she ultimately suffered the devastating consequences of her illness throughout her short life: she became addicted to opiates and died of a heroin overdose at age thirty-nine, a few years after she wrote her memoir.2

Likewise, the unnamed narrator in Kobo Abe’s The Face of Another, who suffers a severe chemical burn to his face as a result of an accidental explosion in his own laboratory, never recovers and becomes psychologically and physically marred by the accident.3 Left with keloid scars that leave his face “ravaged,” he describes himself as a monster—the “repulsiveness of my face—the leech-like corrosion.”3 He says, “I felt like an oily dustcloth, spotted with shame.”3 He bemoans that the “loss” of his face caused “a conspicuous change” in how people evaluated him: “…the world made no attempt to recognize a man’s personality without the passport of his face,” how “worldly prejudice” deprives “a man of citizenship along with his face.”3

Mary Shelley’s monster, created by scientist Victor Frankenstein, is also deprived of citizenship by virtue of his monstrous appearance.4 Frankenstein had a goal to “bestow animation upon lifeless matter.”4 He fashions from discarded body parts a creature, variously described as “hideous,” “a filthy daemon,” and “a thing such as even Dante could not have conceived” with an “unearthly ugliness that rendered it too horrible for human eyes.”4 Even the monster itself became “terrified” when it saw its own reflection. It was only, though, when rejected by Frankenstein himself and shunned repeatedly by society because of its appearance alone that the monster wreaks violent havoc on the community.

The community, as well, spurns those who appear too different in a 1960 television episode, Eye of the Beholder, from Rod Serling’s The Twilight Zone.5 A State Leader blares from a large television screen, not unlike Big Brother in Orwell’s 1984;6 conformity of a “glorified unified society” is the rule.5 A woman’s face, described as a “pitiful lump of flesh,” is thoroughly concealed behind bandages after a plastic surgical reconstruction to correct her facial deformities.5 Toward the end of the drama, when the bandages are removed and the woman learns that the surgical repair was unsuccessful and all therapeutic options exhausted, viewers shockingly discover the woman is actually quite beautiful.5 All the physicians and nurses are the ones who have the ugly, misshapen features of pig-like creatures. The episode concludes with the distraught, stigmatized woman exiled to live with “her kind.”5 A nurse reminds one physician that he expresses “treasonous thoughts” when he asks, “What is the difference between beauty and something repellant?” Why shouldn’t people be allowed to be different?”5

Bust of Nefertiti 
Photograph by Philip Pikart2

Goffman notes that the Greeks were the ones to originate the concept of stigma—an attribute that makes someone different.7 Goffman notes that a stigma is “deeply discrediting” and considered “a bodily sign designed to expose something unusual and bad,” usually with a moral connotation.7 A person with a stigma is “tainted” or “discounted” and “not quite human,” says Goffman.7 When a stigma is visible, it provides “a means of communicating” to others.7

As seen in the above examples, facial deformities, whether from birth or acquired through disease or trauma, are particularly devastating because the face is the “most individualistic, distinguishing physical feature.”8 To a considerable extent, emotional expressions, as well as one’s entire identity and sense of self, originate from facial appearance.8 From birth, infants are particularly attracted to the human face; people even envision faces in inanimate objects (e.g. clouds).9 A facial deformity may be considered a “social disability” since the first impression given to others may have a lasting impact on one’s self-esteem.8

Throughout history, philosophers, artists, and writers have accepted some version of Plato’s “beholding beauty with the eye of the mind.”10 This is not so when there are facial anomalies: “…almost all individuals will agree that the face is deformed and not physically beautiful, i.e., where the deformity is concerned, beauty is no longer in the eye of the beholder.”8 Further, people have always had particular aversions, hostility, fear, and confusion about facial deformities, as well as considerable misconceptions about their etiology.11

What makes a face considered beautiful depends on several characteristics, such as ideal proportions, bilateral symmetry, averageness (i.e. “proximity to a population mean”), youthfulness, and sexual dimorphism (i.e., indicating “sexual maturity and reproductive potential”).8 Beauty can have powerful consequences: sixteenth century playwright Christopher Marlowe wrote in Doctor Faustus that Helen of Troy, whose abduction led to the Trojan War in Homer’s Iliad, had a “face that launched a thousand ships.”12 Philosopher David Hume described beauty as giving “pleasure and satisfaction to the soul” whereas deformity creates “uneasiness.”13 Arthur Schopenhauer writes that beauty is a “personal advantage….an open letter of recommendation, predisposing the heart to favor the person who presents it.”14 More recently, research has demonstrated that those who are attractive are often seen as brighter and more competent and are even more likely to be hired and achieve greater social status.15 Meta-analyses have shown attractiveness is a “significant advantage for both children and adults in almost every domain,” and “contrary to conventional wisdom, there is strong agreement both within and across cultures about who is and who is not attractive.”16 Says Victor Hugo, “Beauty has only one type, ugliness has thousands…”17

In his compendium On Ugliness, Umberto Eco writes, “In every century, philosophers and artists have supplied definitions of beauty… But this did not happen with ugliness. Most of the time it was defined as the opposite of beauty…”18 Eco notes that the term ugly refers to something out of proportion, and he found that most of the synonyms for ugly “contain a reaction of disgust, if not of violent repulsion, horror, or fear” and implies a sense of unpredictability.18 It derives from Old Norse, “to be feared or dreaded.”19

Christ Carrying the Cross demonstrating an artist’s abstract rendition of asymmetrical, deformed features.3

Ugliness is “beauty’s shadow.”20 Observing ugliness engenders powerful negative responses that often include loathing.20 Says psychoanalyst Hagman, “Ugliness is not a quality of things; rather, it is a psychological experience that is felt to be external to the self.”20 Hagman emphasizes that a person’s reaction stems from psychological conflict and unconscious fantasies, often of a sexual or aggressive nature.20 He explains that the experience of ugliness “results from the severe disruption of a person’s sense of aesthetic organization,” such that a person “feels shocked at the perception of chaos, disfigurement, and horror,” rather than simply feeling “a disturbing sense of messiness and disorder.”20 Paradoxically, ugliness generates an “interactive response” because people often experience not only fear and revulsion but also “fascination and even attraction.”20 Furthermore, ugliness may be “bracketed in moral or aesthetic condemnation” as a means of defending against the anxiety it stimulates.20

There are, of course, patients who have the disorder of imagined ugliness, a term first delineated by Phillips21 for those with body dysmorphic disorder21,22,23 These patients torment themselves, sometimes to psychotic proportions, with illusory defects, often of the face. For those who suffer, their lives are “held captive by the stigma of a perceived deformity.”23

Whether a deformity is real or imagined, patients expect more than technical expertise from their physicians. Shelley’s Frankenstein described the “enticements of science” where “in a scientific pursuit there is continual food for discovery and wonder.”4 Sometimes, though, physicians may fail to see beyond the discovery and wonder. What made Lucy Grealy’s travails so much more arduous, for example, was that throughout her years of contact with healthcare professionals, she received sterile treatment, for the most part, without much warmth or empathy. Her two years of chemotherapy after her initial surgery were particularly grueling—she experienced a “rude” physician… “I could only flinch at his roughness.”1 Later, no one seemed to listen to her and see beyond her deformity. In her discussion of Grealy’s memoir, Shannon writes of the paradox of “intimacy without intimacy” in professional encounters, i.e., the extraordinary “vulnerability of a patient who sits nearly naked on a hard exam room table waiting to reveal details of a highly personal nature…”24 It is even worse when the ravages of an illness are visible to others. It is the peculiarly “human ability to be self-aware and self-conscious” that makes people, and especially patients, more helpless.24 Eco shares Shannon’s perspective when he “appeals for compassion” after cataloguing the innumerable ways artists and writers have incorporated images of ugliness throughout their works.18 The provocative question remains whether ugliness is perceived differently in the context of medicine from that in art.25 Gilman26 has written, “How the culture of medicine defines and uses the distinction between ‘healthy/beauty’ and ‘illness/ugliness.’” This appeal for compassion, though, is undoubtedly nowhere more relevant than in the practice of medicine.



  1. Grealy L. Autobiography of a Face. New York: Perennial Edition, 2003. (147, 7, 124, 220, 73, 74).
  2. Oates JC. “Do You Love Me?” (Review of Truth & Beauty: A Friendship by Ann Patchett. New York: Harper Collins Publishers, 2004.) The New York Times Book Review, May 16, 2004. (http://www.nytimes.com/2004/05/16/books/do-you-love-me.html?_r=0 retrieved 1/15/2017).
  3. Abe K. The Face of Another. (Translated by E. Dale Saunders from the Japanese). New York: Vintage International, A Division of Random House, Inc., 1966 (22, 180, 14, 37, 98, 16, 98, 140).
  4. Shelley M. Frankenstein or The Modern Prometheus (The 1818 Text). Oxford, England: Oxford University Press (Oxford World Classics paperback), 2008 (36, 56,40, 76, 187, 90, 33).
  5. Serling R. “Eye of the Beholder.” Twilight Zone, Television Series, 1960. https://archive.org/details/TwilightzoneEyeofthebeholder (retrieved 1/15/2017).
  6. Orwell G. Nineteen Eighty-Four. New York: Plume, Harcourt Brace and Company (The Penguin Group): (Centennial Edition), 2003.
  7. Goffman E. Stigma: Notes on the Management of Spoiled Identity. New York: A Touchstone Book, published by Simon & Schuster Inc., 1963 (1, 3-5, 48).
  8. Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford, England: Wiley-Blackwell Publishing Ltd, 2011 (54, 16, 5, 18, 6-7).
  9. Little AC, Jones, BC, DeBruine LM. “The Many Faces of Research on Face Perception.” Philosophical Transactions of the Royal Society of London: Series B: Biological Sciences, 2011; 366(1571): 1634-37.
  10. Plato. “Symposium.” In: The Dialogues of Plato. Translated by Benjamin Jowett. Chicago: William Benton, Publisher, Encyclopedia Britannica, Inc. Great Books of the Western World (Robert Maynard Hutchins, Editor-in-Chief), Volume 7: 149-173, 1952, 167.
  11. Shaw WC. “Folklore Surrounding Facial Deformity and the Origins of Facial Prejudice.” British Journal of Plastic Surgery, 1981; 34(3): 237-246.
  12. Marlowe C. Doctor Faustus. Cambridge: The Harvard Classics. (Scene XIII). http://www.bartelby.com/19/2/23.html. (Retrieved 1/13/2017).
  13. Hume D. A Treatise of Human Nature (Book II: Of The Passions, Section VIII: “Of Beauty and Deformity”). The Project Guttenberg EBook. http://www.gutenberg.org/files/4705/4705-h/4705-h.htm (Retrieved: 1/13/2017).
  14. Schopenhauer A. The Wisdom of Life (Chapter II: “Personality, or What a Man Is.”) http://transfinite.thought.org/philosophy/schopenhauer/S2/chapter2.html (retrieved 1/15/2017).
  15. Hahn AC, Perrett DI. “Neural and Behavioral Responses to Attractiveness in Adult and Infant Faces.” Neuroscience and Biobehavioral Reviews, 2014; 46(Pt. 4): 591-603.
  16. Langlois JH, Kalakanis L, Rubenstein AJ, Larson A, Hallam M, Smoot, M. “Maxims or Myths of Beauty? A Meta-analytic and Theoretical Review. Psychological Bulletin, 2000; 126(3): 390-423.
  17. Hugo V. “Preface to Cromwell” (1827). Paras. 31-60 (Famous Prefaces. The Harvard Classics. 1909-1914). http://www.bartleby.com/39/41.html (retrieved 1/18/2017)
  18. Eco U. (Editor) On Ugliness. Translated by Alastair McEwen. New York: Rizzoli, 2014 (Fourth Printing). (8, 16-17, 437).
  19. Oxford English Dictionary, “Ugly” http://www.oed.com/view/Entry/208564?rskey=N3690&result=1#eid (retrieved 1/16/2017).
  20. Hagman G. “On Ugliness.” The Psychoanalytic Quarterly, 2003; 72(4): 959-985.
  21. Phillips K. “Body Dysmorphic Disorder: The Distress of Imagined Ugliness.” American Journal of Psychiatry, 1991; 148(9): 1138-1149.
  22. Grocholewski A, Kliem S, Heinrichs N. “Selective Attention to Imagined Facial Ugliness is Specific to Body Dysmorphic Disorder.” Body Image, 2012; 9(2): 261-269.
  23. Naini FB. “Pablo Picasso’s ‘Girl Before a Mirror’: The Agony of Imagined Ugliness.” Archives of Facial Plastic Surgery, 2009; 11(1): 72-73.
  24. Shannon MT. “Face Off: Searching for Truth and Beauty in the Clinical Encounter. Based on the Memoir, Autobiography of a Face by Lucy Grealy.” Medicine, Health Care and Philosophy, 2012; 15(3): 329-335.
  25. Henderson GF. Ugliness: A Cultural History. London: Reaktion Books Ltd, 2015, (46).
  26. Gilman SL. Picturing Health and Illness: Images of Identity and Difference. Baltimore:  The Johns Hopkins University Press, 1995, (73).



  1. Etching by Otto Dix, Skin Graft (Transplantation) from the Portfolio War, Museum of Modern Art, NYC. Copyright 1924, Artists Rights Society (ARS), New York/VG Bild-Kunst, Bonn. Copyright, The Museum of Modern Art/Licensed by SCALA/Art Resource, NY. (Exclusive permission obtained to use this image from both ARS and Art Resource for Hektoen International.)
  2. Bust of Nefertiti, Neues Museum, Berlin, photo taken by Philip Pikart, permission granted to use through WikimediaCommons.org/GNU Free Documentation License under Creative Commons Attribution, CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/deed.en), demonstrating the beauty of symmetrical features.
  3. Detail from Christ Carrying the Cross, Follower of Hieronymus Bosch, (Museum of Fine Arts, Ghent, Belgium (1510-1535), WikimediaCommons.org / Public Domain, demonstrating the exaggerated asymmetrical features of ugly faces.
  4. L’antigrazioso (“Anti-graceful”) by Umberto Boccioni (1882-1916), (Private Collection) 1912, WikimediaCommons.org/Public Domain, demonstrating an artist’s abstract rendition of asymmetrical, deformed features.
  5. Winter, 1563, by Giuseppe Arcimboldo (1527-1593), Kunsthistorisches Museum, Vienna. WikimediaCommons.org/Public Domain, demonstrating an artist’s rendition of grossly deformed features. (Part of series, The Seasons.)
  6. The Ugly Duchess (also known as A Grotesque Old Woman), (c. 1525-1530), attributed to Quentin Metsys, National Gallery, London. WikimediaCommons.org / Public Domain, demonstrating an artist’s rendition of a grossly ugly androgynous woman.



SYLVIA R. KARASU, MD, is a Clinical Professor of Psychiatry at Weill Cornell Medicine and a member of the Institutional Review Board of The Rockefeller University. The senior author of The Gravity of Weight (2010) and The Art of Marriage Maintenance (2005), Dr. Karasu is a cum laude graduate of the University of Pennsylvania and has her M.D. degree from Einstein College of Medicine. She is a Distinguished Life Fellow of the American Psychiatric Association, a graduate of the New York Psychoanalytic Institute, an elected Fellow of the New York Academy of Medicine, and in private psychiatric practice in NYC.


Highlighted in Frontispiece Summer 2017 – Volume 9, Issue 3
Winter 2017  |  Sections  |  Literary Essays

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