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Lupine Publishers|Antibiotic Resistance Pattern of Nesseria Gonorrhoea at the Genitourinary Medicine Clinic, Hospital Kuala Lumpur, Malaysia

Abstract

Background: In the era of super bugs, there is a need to monitor antibiotic resistance patterns. Due to the emergence of antimicrobial resistance worldwide, local antibiotic resistance patterns should be monitored periodically to alert early intervention. This audit was conducted to analyse the antibiotic resistance patterns among the gonococcal urethritis cases that presented to the Genitourinary Medicine (GUM) Clinic, Hospital Kuala Lumpur (HKL), Malaysia.

Methodology: This is a retrospective study on the antibiotic resistance patterns based on 370 culture positive gonorrhoea obtained from urethral swab samples sent between 2011 and 2015. Antimicrobial susceptibility testing by standard disc diffusion method was performed to detect sensitivity to penicillin, tetracycline, ciprofloxacin, cefuroxime, azithromycin and ceftriaxone. All data was obtained from microbiology report and patient records.

Results: A total of 370 positive culture isolates of N.gonorrhoeae (new and recurrent cases) from 2011 to 2015 were reviewed. Highest level of resistance detected was to azithromycin (100%, 64/64) followed by tetracycline (82.8%, 293/354). Resistance to penicillin was noted in 60.9% (224/368) of all isolates. Both penicillin and tetracycline showed a decreasing resistance trend from 2011-2015. The fourth commonest antibiotic resistance was to ciprofloxacin at 46.5% (158/340). Cephalosporins tested were cefuroxime and ceftriaxone, which showed resistance rates of 2.7% (6/219) and 0.8% (3/364), respectively.

Conclusion: The complete resistance to azithromycin is alarming since it is a common antibiotic used to treat urethral discharge using the syndromic approach. Penicillin and tetracycline resistance remain high in Malaysia and other Western Pacific countries. The current first line antibiotic for treating gonorrhoea in GUM Clinic, HKL is ceftriaxone. Clinicians should be aware of the newly discovered increase in resistance observed to ceftriaxone.

Keywords: Neisseria gonorrhoeae; Gonorrhoea; Antibiotic Resistance

Introduction

The last decade has seen Neisseria gonorrhoeae emerging as a true superbug, bringing.com closer to a time of untreatable gonorrhoea. This diplococcal microbe is able to recombine its genes and invade the immune system through antigenic variation. It is also naturally competent to acquire new deoxyribonucleic acid (DNA), enabling N. gonorrhoeae to spread new genes, disguise itself with different surface proteins, and prevent the development of immunological memory an ability that has led to antibiotic resistance and has made vaccine development difficult. Gonorrhea is a debilitating disease, which was responsible for an estimated 445,000 years lived with disability in 2015, according to a systemic analysis for the Global Burden of Disease Study [1]. Patients infected with N.gonorrhoeae are known to present with urethral discharge, malaise and symptoms that may suggest a urinary tract infection. Nevertheless, urogenital gonorrhea may be asymptomatic in 40% of men and often manifests as urethritis [2,3].

Unfortunately, it is also asymptomatic in more than half of women [4]. In men, untreated urethral infection can lead to epididymitis, reduced fertility, and cause urethral strictures. In women, if present, symptoms are non specific and include abnormal vaginal discharge, dysuria, lower abdominal discomfort, and dyspareunia. The lack of discernible symptoms results in unrecognized and untreated infections, which can lead to serious complications [5]. Overall, 10%-20% of female patients develop pelvic inflammatory disease (PID) and, consequently, are at risk for infertility [6]. Pregnancy complications associated with gonorrhea include chorioamnionitis, premature rupture of membranes, preterm birth, ectopic pregnancies, and spontaneous abortions [5,7,8]. Infants of mothers with gonococcal infection can be infected at delivery, resulting in neonatal conjunctivitis (ophthalmia neonatorum). Such untreated conjunctivitis may lead to scarring and blindness.

Extragenital infections are common in both sexes and frequently occur in the absence of urogenital infection [9,10]. Rectal infections are usually asymptomatic but can manifest as rectal and anal pain or discharge. Pharyngeal infections are mostly asymptomatic, but mild sore throat and pharyngitis may occur. Although bacterial concentrations are generally lower than in other infection sites, the pharynx is thought to be a favourable site for resistance emergence due to acquisition of resistance traits from commensal Neisseria spp [11]. Disseminated gonococcal infections with gonococcal arthritis also occur. Because they are frequently asymptomatic, extragenital infections often remain untreated, despite their key role in disease transmission. Co-infection with other major Sexually Transmitted Infections (STIs) HIV, Herpes simplex virus, Chlamydia trachomatis, Mycoplasma genitalium, and Treponema pallidum are common and may result in synergistic effects on transmission and disease severity. Attempts to treat and control gonorrhoea are compromised by the emergence and spread of antibiotic resistant N.gonorrhoeae. Antibiotic resistance pattern vary between different geographical areas. It is therefore important to know the local antibiotic resistance pattern, so that appropriate treatment can be instituted. In Malaysia, Kanamycin was used as the first line antibiotic to treat gonorrhoea during the early 1970’s and 80’s, which was subsequently changed to Spectinomycin, followed by Ceftriaxone since the early 1990’s [12] There are many surveillance programmes on antibiotic resistance patterns of N.gonorrhoeae such as GRASP (Gonococcal Resistance to Antimicrobial Surveilance Programme), that is based in London, UK, and WHO (World Health Organization) Antimicrobial Surveilance Programme [13,14].

Materials and Methods

All patients with positive culture for gonorrhoea, who attended the GUM clinic in HKL between 2011-2015, were included in this study. Antimicrobial susceptibility testing by standard disc diffusion method was performed to detect sensitivity to Penicillin, Tetracycline, Ciprofloxacin, Cefuroxime, Azithromycin and Ceftriaxone. Data was obtained from patient records and formal microbiology laboratory results.

Results

370 positive culture isolates of N.gonorrhoeae from patients seen in 2011-2015 were included in this study. Most of the data were obtained from the microbiology laboratory results. Demographic data was available for 98 patients only. More than half of the patients (58.2%) were between 21-30 years old. Most patients were Malay (83.7%), followed by Indian (9.2%). Overall, the heterosexually orientated patients represented about 73% of gonococcal urethritis cases. Majority of cases (92%) tested negative for HIV (Tables 1 & 2). The highest level of resistance detected was to azithromycin (100%, 64/64), followed by tetracycline (82.8%, 293/354). Resistance to penicillin was noted in 60.9% (224/368) of all isolates. Both penicillin and tetracycline showed a decreasing resistance trend from 2011-2014, but increased in 2015. The fourth commonest antibiotic resistance was to ciprofloxacin at 46.5% (158/340), followed by cefuroxime 2.7% (6/219). Resistance to ceftriaxone was 0.8% (3/364), although reviews previously in 2001-2005 showed no resistance [12]. The results were compared to data obtained from the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) and WHO (World Health Organization) Antimicrobial Surveillance Programme [13,14].

Table 1: Demographic characteristics of patients with gonorrhoea.

Table 2: Summary of antibiotic resistance pattern of N.gonorrhoeae (2011-2015) in HKL.

Discussion

Azithromycin

The rate of resistance to Azithromycin in this study was higher than expected. All 64 samples tested for sensitivity to Azithromycin showed resistance. In Singapore, no resistance to Azithromycin has been documented [14]. Similarly in England & Wales and Australia, the rate of resistance is significantly lower, at 1% or less [13,14] (Table 3). Studies have indicated concerns for increasing resistance to Azithromycin, likely due to delay in diagnosis of gonorrhoea and suboptimal dose of Azithromycin used [15].

Table 3: Comparison of N.gonorrhoeae antibiotic resistance pattern in HKL with other countries.

Tetracycline

The rate of resistance to Tetracycline is high. In our study, 82.8% of N.gonorrhoea isolates were resistant to Tetracycline. This is slightly lower, compared to an earlier analysis done in HKL from 2001-2005, where 86.8% of isolates were resistant [12]. The resistance rates in England & Wales was similar to ours [13] (Table 3). Looking at the trend, there was a reduction in resistance rates from 87.1% in 2011 to 63.2% in 2014. However, the rate increased to 91.1% in 2015 (Table 2). In HKL, Doxycycline is sometimes used to treat non-gonoccocal urethritis but never as primary treatment for gonorrhoea. Tetracycline has never been used for treating gonorrhoea in HKL as the resistance is very high. Nevertheless, the resistance pattern is continuously monitored for epidemiological purposes.

Penicillin

Since the 1940’s, Penicillin was successfully used to treat gonorrhoea, but quickly developed decreased sensitivity and deemed not a suitable treatment after 1970. This can be due to Penicillinase Producing N.gonorrhoeae (PPNG) or Chromosomal Mediated Resistance N.gonorrhoeae (CMRNG) [16]. Our study shows that the rate of N.gonorrhoeae resistance to Penicillin has reduced, from 82.2% in 2011 to 53.6% in 2015 (Table 2). Compared to an earlier study done in HKL in 2001-2005, there was a slight drop in resistance to penicillin in HKL from 64.4% to 60.9% in 2011-2015. However, our resistance rates were much higher compared to the resistance rate reported in England & Wales of 22.6% (Table 3) [13].

Ciprofloxacin

In the early 1990’s, Ciprofloxacin was widely used especially by general practitioners to treat gonorrhoea although studies had already began demonstrating the beginning of reduced sensitivity to quinolones. The resistance to Ciprofloxacin in HKL showed a steady increase from 10.0% in 2011 to 62.7% in 2015 (Table 2). When compared to an earlier review in HKL from the period 2001- 2005, we can see marked increase in resistance to Ciprofloxacin from 10.4% to 46.5% in 2011-2015 (Table 3). The resistance rate reported in HKL from 2011-2015 was similar to England & Wales and Australia, which reported resistance of 37.3% and 34.7% respectively (Table 3) [13,14]. Among the Asian countries, Singapore reported the lowest resistance to Ciprofloxacin (10.0%) [14]. Other Asian countries, like the Phillipines, Thailand and China reported an alarmingly high resistance to Ciprofloxacin, which is between 74.4%-100% (Table 3) [14].

Cephalosporin–Cefuroxime and Ceftriaxone

Although Cefuroxime is not a recommended treatment for gonorrhoea, its resistance pattern is monitored for epidemiological purposes. Our study showed a resistance rate of 2.7% to Cefuroxime in 2011-2015, whereas an earlier study in 2001-2005 showed no resistance to Cefuroxime (Table 3). Susceptibility testing for Ceftriaxone use in the treatment of gonorrhoea in HKL between 2001-2005 indicated no resistance, however, recent data from 2011-2015 showed a resistance rate of 0.8% (Table 3). Ceftriaxone is the first line treatment of gonorrhoea in HKL and clinicians should be aware that we are seeing a small percentage of resistance in some cases. No resistance was noted in Singapore and the Phillipines (Table 3) [14]. Resistance rates to Ceftriaxone in Thailand and China are significantly higher, at 19.9% and 36.9% respectively (Table 3) [14].

Conclusion

Attempts to treat and control gonorrhoea are compromised by the emergence and spread of antibiotic-resistant N.gonorrhoeae. WHO expert committee has recommended that treatment regimen be altered once resistance to a particular antibiotic reaches 5%. High rates of resistance to Penicillin and Tetracycline have been documented in HKL and in the Western Pacific region. Within 15 years, a marked increase in Ciprofloxacin resistance (10% to 46.5%) is evident. Resistance to Cefuroxime and Ceftriaxone was discovered, which was not found in the previous study. Ceftriaxone remains the first line antibiotic in treating gonorrhoea in HKL, and clinicians need to be aware of the small percentage of resistance detected to Ceftriaxone.

Acknowledgement

We would like to thank the Director General, Ministry of Health, Malaysia for permission to publish this study, and the staff from Genitourinary Medicine Clinic, HKL for data collection.

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Sociology of Fashion

At the dawn of history, fashionable clothes, which were produced locally, could be afforded only by the upper classes. Gradually, and when groups of people developed better production skills and techniques, ideas, tastes, and fabrics could be diffused through war and conquest or traded, thus increasing the classes that had ac- cess to fashionable garments. The relevance of fashion increased with the modernization process of the West, i.e., during the nineteenth century. In the 1920s, Marshall (1923, p. 260) noted, “Until a little while ago it was only the rich who could change their clothing at the capricious order of their dressmakers: but now all classes do it.” With the recent growth in prosperity and the increased importance of consumption, mass markets, urbanization, density, and at least some social mobility (Slater 1997), the role of fashion grew even further.

However, a lingering question remains. Do the characteristics of fashion change with its empirical context? Or does fashion present stable features across cultures and historical periods? Craik (1993, p. 4), for example, proposes that we should see fashion as a general phenomenon that is not linked to the historical development of European societies. It appears from our review that although fashion is a type of change that can be found at any historical period or in any culture, its extent and features depend on several factors related to the type of social order at play in the context under consideration. Beyond the important point highlighted above of the existence and extent of a class structure, a crucial structural factor is whether the fashion is deployed in an industrial context or not. This raises the question of the domain of fashion.

Fashion as a social phenomenon is not restricted to the domain of clothing and dress. For example, Blumer (1969, p. 275) lists the following fields that fashion affects: “painting, sculpture, music, drama, architecture, dancing, and household decoration.” All of these have a clear aesthetic dimension, like fashion, but his list continues with “medicine, . . . business management, . . . mortuary practice, . . . literature, . . . modern philosophy, . . . political doctrines.” Even scientific or philosophical truth may be a matter of fashion (see Gadamer 1993, Luhmann 1997).

It is nonetheless hard today to find studies and records of fashions—whether of objects, practices, or representations—that are not re- lated to clothing and dress. There are, how- ever, some notable examples such as the study of the mechanisms that underlie the use and diffusion of children’s first names (Besnard & Desplanques 1986, Lieberson 2000, Lieberson & Bell 1992). First, as pointed out by Lieberson & Bell (1992), first names constitute an intrigu- ing case of fashion because, unlike clothing and dress or objects in general, the use and diffusion of first names do not depend primarily on the organized actions of firms, professions, and occupational groups. Similarly, institutional factors such as religious norms or legal constraints, if they sometimes determine the mechanisms defining the choice of names, rather define the pool from which they can be chosen. Zuckerman (2012, p. 225)—who broadly sees fashion as a form of “temporal discontinuity” characterized by a “high degree of concentration in social valuations at a single point in time”—reviews additional cases, including some diffusion studies of managerial practices (Strang & Macy 2001). He argues that fashion cycles can emerge when “quality differences are relatively minimal” and when no principle anchors valuations in objective reality, giving way to the social construction of value (Zuckerman 2012, p. 239).

Other fields have been explored through a fashion lens; this is the case, for example, for the telecommunications industry (Djelic & Ainamo 2005), research in management (Abrahamson 1991, 1996), or even science itself (Barnett 1998). These studies, though few in number, support what Blumer (1969) stated about the domain of fashion: that it can potentially expand to any field of human activity; this idea was also put forward and developed by Lipovetsky (1987 [1994]) in his analysis of the spread of what he saw as the “fashion form” to other, nonsartorial fields. Fashion is a central social phenomenon, mechanism, or process that can be applied to any domain. As Braudel (1992, p. 328) wrote, “Fashion...is the way in which each civiliza- tion is orientated. It governs ideas as much as costume, the current phrase as much as the coquettish gesture, the manner of receiving at table, the care taken in sealing a letter.”

FASHION AS AN INTERDISCIPLINARY TOPIC

For a long time, fashion as a social phenomenon has had no specific disciplinary home, and only recently have “Fashion Studies” departments emerged, as well as dedicated academic journals such as Fashion Theory, launched in 1997 and edited by Valerie Steele, and Critical Studies in Fashion and Beauty, launched in 2010 and edited by Diana Crane, and Susan Kaiser. Because of the current interdisciplinary focus of fashion research, we highlight the main sociologically relevant insights on fashion from other disciplines, their limitations, and the extent to which a sociological approach to fashion can and needs to distinguish itself from developments in other disciplines. Philosophy, economics, geography, and cultural studies are studied in more detail because of the greater amount of work devoted to fashion in these disciplines. We conclude with fashion studies and ask whether there is a distinct sociological voice in this field. Philosophy For centuries, in the Western world, the philosophical debate on fashion—often confounded

with luxury—was focused almost exclusively on moral questions (Godart 2011), until Adam Smith (1759 [1982], pp. 194–98) switched the attention to the actual philosophical mecha- nisms of fashion in which he saw the result of an imitation process rooted in what he called “sympathy,” a feeling through which individu- als relate to others. By imitating the fashions of the rich, Smith argued, individuals participate in their glory and happiness.

Kant, Nietzsche, Gadamer, and Heidegger have also discussed fashion. Philosophers, more generally, have echoed Kant’s (1798) dictum that there is no utility to be gained from what is in fashion. For example, Svendsen (2006, p. 157) recently adopted a critical perspective on fashion and concluded that what fashion “can offer does not, despite everything, add all that much to our lives.” Kant also mentioned gen- der, class, and diffusion, themes that Simmel (1904 [1957]) most likely later picked up from him (Gronow 1993).

Nietzsche (1878 [1996], pp. 363–65), more- over, was one of the first to explicitly link fashion to modernity. For him, fashion—which he opposed to the “national costume”—emerged with modernity. The existence of a fashion capital, Paris, was a way to uproot dress from its traditional origins and give way to modernity. Nietzsche, like philosophers in general, was ambivalent vis-a`-vis fashion, seeing it as a positive force driving modernity, but also echoing Kant, describing it as “the wheel of taste and vanity” (Nietzsche 1878 [1996], p. 364).

Philosophers have also discussed the applicability of the concept of fashion to social phenomena beyond clothing and dress. When talking about the truth, Gadamer (1990, pp. 42– 43), following Kant, acknowledges that there is an element of fashion in scientific practice and work (Gadamer 1993, pp. 51, 228). Gadamer suggests that fashion is highly important, but neither he nor Nietzsche can provide us with a definition. Heidegger, who is seen by many as extremely conservative, also could not avoid the notion of fashion. He suggested that what is in fashion is characterized by newness and change, but that additionally it lasts only for a short

while (Heidegger 1982, pp. 8–9). Hence, time is a central tenet in the understanding of fashion. In sum, philosophy is a useful stepping stone for sociologists of fashion because it suggests productive avenues for defining the concept, even though it is often stuck in a “fear of fashion” and a negative moral judgment on this social phenomenon (Hanson 1990).

Economics

In economics, fashion is often seen as being the opposite of rationality. The “irrationality” of fashion is a widely shared view among economists: Nystrom (1928, p. 68, emphasis in original) wrote that fashion is akin to, “for want of a better name, a philosophy of futility.” Veblen (1899) analyzed money and the time spent on fashion—which he lumped together with luxury—as a form of what he called “conspicuous consumption.” According to Veblen, fashion, and especially women’s fashion, is merely an expression of the wealth of the head of the family of its wearer. But this criticism of fashion is a theme not only developed by classical economists, but also prevalent among more contemporary scholars who imagine conditions under which consumers would be better off “by banning the use of fashion” (Pesendorfer 1995, p. 771).

Economists are not only critical of fashion; some are quite cynical. Marshall (1923, p. 244) wrote, “Rumour says that many a fashion in dress has been planned at a meeting in Paris of representatives of leading dealers and manufacturers.” More recently, Becker & Murphy (2000) have analyzed fashion and fads. They see fashion as a case somewhat different from the standard markets oriented to material and individualistic value. Though the authors clearly make use of some sociological ideas as they expand the rational choice perspective, the analysis is essentially restricted to leaders and followers. There is still a central assumption “that utility does not directly depend on the consumption or status of anyone else” (Becker & Murphy 2000, p. 107). Other economists have attempted to model fashion (Bikhchandani)

focusing on diffusion and cascade mechanisms among individuals, shedding some light on how micro-individual decisions lead to macro processes such as fashion.

Although economists, like philosophers, of- ten perceive fashion as being immoral, superficial, or irrational—a view that some sociologists might find unsatisfactory owing to their expectation of value neutrality from social scientists (Weber 1958 [1991])—the modeling of fashion phenomena by economists can be useful to sociologists who are interested in fashion as a diffusion mechanism.

In economic geography, the focus is on the global production of fashion, the distribution of knowledge, the features of industrial districts, and the upgrading of the position of low-cost countries in the fashion value or commodity chain (Gereffi 1999). Geographers have, to a lesser extent, analyzed consumption. This field has merged core geographical concepts such as place and concentration with ideas from business economics, such as branding, and ideas from sociology, including networks. The interest geographers have shown in fashion needs to be interpreted in the light of their attention to the spatial concentration of many cultural industries (Power & Scott 2004).

The notion of fashion brand is relatively new in economic geography (Power & Hauge 2008), and it is a core product of the interrelation between producers and consumers (Aspers 2010b). The focus has been on the firms that manufacture or retail the clothes (Tokatli 2007, Tokatli et al. 2008), whereas consumption has been somewhat neglected. The uneven development of the value chain is a leading theme: The producers of garments get only a small fraction of the value of the products sold in stores to the final consumers. It is in this light that one should see the relatively large discussion of upgrading within geography. Upgrading is about “enhancing the relative competitive position of a firm” (Schmitz & Knorringa 2000, p. 181), which often means

that a producer-firm gets closer to the final consumer market. There are at least three ways to upgrade: Producers can upgrade their work processes and their products; they can take the knowledge from one sector and make use of it in another (Gereffi 1999, pp. 51–55; Humphrey & Schmitz 2002, p. 1020); and a firm can functionally upgrade, which involves moving into design and marketing.

Geographers have studied the changing pattern of global garment production chains not only by focusing on areas in which production has grown, but also by looking at the consequences of the increased pressure on producers in Europe and North America who are struggling against the competition from countries with low wages (Evans & Smith 2006). The geography literature has generated new knowledge on the production of clothes and has tied local consumption to global markets and industrial chains reaching across the globe. This knowledge, which helps shed light on the spatial structure of fashion, can readily be merged with the research produced in sociology and cultural studies, and indeed the disciplines of economic geography and economic sociology have often been fruitfully combined in research (Whitford 2006).

Cultural Studies

Cultural studies and sociology are historically and intellectually intertwined through a series of common concepts and references, but nowadays they constitute two distinct academic disciplines with their own traditions and institutions. The interest in fashion by cultural studies is multifaceted and in many ways overlaps with that of sociology. Kaiser (2012) gives an overview of the different fields covered by the cultural studies of fashion: nations and the transnational, ethnicity, class, gender, sexuality, and the body.

The cultural studies of fashion arguably started with the work of Hebdige (1979), who developed the concept of “subculture” as applied to youth cultures in the United Kingdom, notably the Punks. At the heart of this approach lies the concept of homology, through which all the different aspects of a given subculture are characterized by correspondences. For ex- ample, Hebdige explained that the Punks talk like they dress, their opposition to mainstream society being expressed in both domains. This approach has been further developed by, for ex- ample, Hodkinson (2002), who has studied the Goth subculture, also in the United Kingdom. Hodkinson’s central contribution has been to question the empirical validity of the concepts of subculture and homology that, at least in the Goth context, are looser than what was expected from Hebdige’s conceptual apparatus. The concept of a subculture, as related to fashion, has since been expanded to non- Western settings by, for example Kawamura (2012), who studied Japanese youth subcultures from an ethnographic point of view and showed how Japanese teens have become producers of fashion outside of commercial fashion houses (Kawamura 2006). Another central theme in the cultural studies of fashion, notably as seen through a feminist lens, is its ambiguity and ambivalence, a theme central in the work of Wilson (2003). Wilson explains that fashion should not be rejected by feminist theory, but rather should be seen as a means of artistic and political expression. Nonetheless, she notes that fashion is inherently ambiguous in the sense that it can also be used for homogenization and oppression. This ambiguity has also been noticed in the use of tattoos, which can be analyzed both as an opposition to the commodification, and as a commodification, of bodies (Fisher 2002). The question of globalization and the role of fashion in this process are also central in cultural studies. For example, exploring the notion that fashion is an essentially urban phenomenon (Wilson 2003), scholars have asked how cities shape, and are shaped by, fashion; this theme is most notable when ex- amining the emergence of urban centers in the global fashion system (Breward & Gilbert 2006) beyond the traditional “big four” of Paris, New York, Milan, and London (Breward 2003). Another important topic explored in the context of globalization is whether it leads to a homogenization of dress practices around the world and how “national fabrics” fare in this environment (Paulicelli & Clark 2009). Research agendas on fashion in cultural studies and sociology can certainly be merged. We argue that paying attention to structure, in addition to culture (Friedland & Mohr 2004, Pachucki & Breiger 2010), is where sociology can add value to cultural studies of fashion, and in this sense fashion is a great site to explore the culture/structure conundrum. Fashion Studies: Toward an Integrated Paradigm As noted by Giusti (2009, p. 9), there has been a recent “explosion” of fashion studies. Fashion studies, or “fashion-ology” (Kawamura 2005), is an interdisciplinary approach to fas ion. Several recent books pay heed to Kawamura’s intuition and look at fashion from an interdisciplinary angle. In these books, the sociology of fashion, while playing a central role, is mixed with other disciplines. For example, Giusti (2009), synthesizing the developments of several disciplines dealing with fashion, has argued that organizations need to be at the center of a reflection on this topic. In a special themed section on fashion in a 2011 issue of Organization Studies, the role of fashion in management studies is analyzed. The editor, Barbara Czarniawska, writes that “an understanding of fashion may be the key to comprehending many puzzling developments in and among organizations” (Czarniawska 2011, p. 599). This paves the way for adding managerial perspectives to fashion-ology. There are also concrete suggestions on how a fashion-ological approach could be further developed. For example, starting with the idea that fashion is a “total social fact” at the crossroad of various spheres of social life, Godart (2012) has detailed different regimes and principles of fashion that have emerged historically. Tulloch (2010) has defined the object of fashion studies as “style-fashion-dress,” a conceptual system that constitutes a mixed

research object (Kaiser 2012). Carter (2003) has laid a foundation of fashion studies by identifying its classics, an important task that we also undertake in this article.

Nonetheless, the evolution of fashion re- search toward interdisciplinarity, which seems to be a major trend, raises the question of the role of sociology in this moving academic con- text. More precisely, a lingering question that sociologists need to address (Edwards 2011) is whether a specifically sociological point of view on fashion exists. In addition, to what extent should sociologists integrate knowledge from other disciplines into their own research? While we have, at least partially, addressed the second question above, answering the first implies going back to the roots of sociological fashion theory.

THE ROOTS OF SOCIOLOGICAL FASHION THEORY

The study of fashion in sociology has prestigious roots that are important to understand to better grasp the types of questions that the field is addressing today (Carter 2003; Godart 2011; Kawamura 2005, 2011). Classical socio- logical research has tied the theoretical analysis of fashion to social structure. The first fully articulated sociological theory of fashion is the “trickle-down theory” or the “class distinction approach” (Davis 1991). Its roots can be traced back to the work of Mandeville (1714 [1924], p. 129, original spelling):

We all look above ourselves, and, as fast as we can, strive to imitate those, that some way or other are superior to us[;] . . . the Women of Quality are frighten’d to see Merchants Wives and Daughters dress’d like themselves. . . . Mantua-makers are sent for, and the contrivance of Fashions becomes all their Study, that they may have always new Modes ready to take up.

Mandeville held a positive view of fashion and luxury in which he saw key drivers of pros- perity. Spencer (1897) identified two central

processes of fashion: “reverential imitation,” i.e., to follow the fashion of the upper class be- cause of its status; and the more challenging “competitive imitation,” i.e., to show that there is nothing special about the upper class. Tarde’s (1890 [1903]) approach was more neutral, axiologically speaking. He brought in the central aspect of diffusion of fashion in the form of imitation. He distinguished two forms of imitation: customs, which are an imitation of the past and the local; and fashions, which are an imitation of the present and the nonlocal, such as styles and designs created in another country.

The idea of fashion as imitation and distinction was further developed by Veblen (as discussed above) and Simmel, who are usually seen as the two modern fathers of the trickle- down theory. Simmel (1904 [1957]) started with an idea of two opposing forces in society: unity (inclusion) and difference (exclusion). Unity essentially entails an idea of belonging, such as to a group, whereas difference refers to the uniqueness that sets an individual apart from others. Simmel argued that the upper class drives the fashion cycle by making sure, when introducing a new style, that people in classes below them are not dressed in the same way. Thus, the upper classes maintain their role by excluding other classes. For each member of a class, however, it is primarily inclusion, not exclusion, that is the main issue, implying that class structure is partly constructed as a result of fashion consumption patterns.

By imitating others, according to Simmel, we decrease our psychological tensions because we can thereby belong to a group or a community. By focusing on the collective level, Simmel rejects the purely psychological explanation of fashion. This is most clearly expressed when he writes that “the [fashion] leader allows himself to be led” (Simmel 1904 [1957], p. 549). How- ever, to dismiss the psychological dimension of fashion is not to omit the existential experience of individuals, each of whom has his or her own unique experience. Simmel’s approach set the tone for sociologists, not least because he rejected an object-centered analysis of fashion and focused instead on social dynamics.

Furthermore, Simmel offered a structural analysis of gender and argued that gender is—at least partially—made through fashion. Finally, Simmel defined important conditions for fashion to exist: People must have the chance to make choices, relatively unfettered from laws; and they must be economically capable to act.

The concentration of people in space, empirically observable in large cities like Berlin, is part of Simmel’s explanation of fashion. A further component of his theory is the way he connects fashion to the conditions of his time. Furthermore, Simmel’s work is not only a theory of fashion; it is also a theory of society. Simmel’s approach implies that fashion is in society and part of its constitution, but it is also something that can be studied as a result of social interactions within societies. This goes beyond the simple causal analysis that sees fashion as a product or a mirror of the evolution of society (Robenstine & Kelley 1981). The economic historian Sombart (1916) explained that the fast pace at which goods were regarded as obsolete and were replaced was caused by mobility, by the concentration of people in cities, by the preference for change, and above all, by the pressure to change. Sombart did not present a theory of fashion but did list characteristic traits of what he nonetheless called a theory of fashion. The first is the increased number of objects that are drawn into the logic of fashion; the second is the general extension of fashion; and the third is the increased pace of fashion. Sombart looked both at the production side, for example the design of garments, and the consumption side when trying to understand fashion. In fact, in contrast to Simmel and Veblen, Sombart stressed the role of the producing companies for the creation and maintenance of fashion. In doing so, he also spoke about socialization of consumers as key elements in modern capitalism.

The trickle-down theory, which constitutes the “standard theory of fashion” (Godart 2011), was challenged by Blumer (1969), who developed his own “collective selection” theory

in which the movements of fashion come first, followed by the distinction and imitation gamings of social classes. In his view, designers and other tastemakers play a key role by translating tastes into designs. This perspective opened the way to multiple challenges to the trickle-down approach, and empirical studies demonstrated other movements such as trickle-across or trickle-up that saw the evolution of fashions as being across social classes or from the bottom up (Crane 1999, McCracken 1989). Similarly, Vinken (2005, p. 4) saw fashion as inherently “performative,” as a source of negotiated societal change rather than as a mirror of social structure. The collective selection approach has also been used to understand, for example, commercials (Solomon & Greenberg 1993) and to constitute a full-fledged “symbolic interactionism” theory of fashion (Kaiser et al. 1995). Finally, Davis (1991, 1992) used the collective selection approach as a starting point for his own sociological approach based on the ambivalence of fashion and advocated for the need to look at the industry to understand the underlying mechanisms of fashion.

FROM DIFFUSION TO PRODUCTION

The Production of Fashion

Despite the potentially unlimited domain of fashion, sociologists have largely studied the apparel industry when exploring fashion. On the basis of these studies, one can outline several themes that have captured their interest. We begin by discussing the production of fashion. Essentially, this literature unveils what is happening before the act of purchase by final customers in stores or online. Although fashion, strictly speaking, comes into being only when consumers make choices, their choices are framed by what is offered. We must remember that, although the existence of a market is not a necessary condition for the existence of fashion (Lieberson 2000), any domain in which we find fashion can be seen as an opportunity for profit making in capitalist societies. We are not suggesting that production is more relevant than consumption, but we do argue that to understand fashion, we must combine consumption and production, as advocated, for example, by McRobbie (1997).

The study of fashion diffusion has focused on two main topics: the understanding of the overall process and the identification of fashion leaders. The fashion process has been theorized in various ways, notably as a “product life cycle” (Sproles 1981), but the nature of fashion is such that some styles can come back over time (Cappetta et al. 2006). Moreover, fashion leaders have been defined as “the first members of their social group to learn about and wear a new fashion when it appears in the market” (Goldsmith et al. 1996, p. 242). They make the success or failure of styles (Polegato & Wall 1980) and thus are the ones who drive the fashion cycles.

Barber & Lobel (1952) lamented the broad use of the concept of fashion and suggested a focus on “the American class structure, age-sex roles, and economic system,” three interrelated dimensions. They pointed out that what made the American fashion industry specific was the existence of mass production, whereas France was still emphasizing haute couture, i.e., high- quality custom-made garments, mostly for women. They opened the way for comparative studies of the fashion industry. Blumer (1969) focused on the producers themselves. Although his perspective is a general statement about fashion, it is also an attempt to look at the creative process as one of gradual decisions of several actors, acknowledging the tension between art and commerce that exists at the heart of fashion. Bourdieu (1984b) offered a detailed description of Parisian haute couture by studying the structure of this field. Specifically, he looked at the polarization between conservative and innovative fashion houses and the ensuing field dynamics. Fashion is a window on the economy and capitalism: “Fashion is the favored child of capitalism. It stems from the latter inner characteristics and expresses its uniqueness unlike any other phenomenon of our social life in our time” (Sombart 2001, p. 225).

The Fashion Industry’s Structure

As suggested by Aspers (2001, 2010a) and Godart (2012), the fashion industry, like any other industry, can be described using the model developed by White (2002), in particular the idea that a market is constituted by multiple networks that connect an upstream of sup- pliers to a downstream of customers through a market interface made of producers. The fashion industry can thus be considered an interface that links a set of suppliers, for example tex- tile makers, to customers all over the world. In this instance, producers may be luxury fashion houses such as Chanel, ready-to-wear firms like Hugo Boss, or mass-market chain store producers such as H&M. These producers are organizations (Giusti 2009) in which creative teams draw their inspiration from several sources— for example, art (Hollander 1993)—to design items that will please customers. The study of the organizations and their fate can then be con- ducted from a “production of culture” (Crane 1997) or a “genealogical” (Wenting 2008) point of view.

Although fashion, especially the production of garments, is a global affair, national fashion industries still prevail, each with their specific features. Djelic & Ainamo (1999) have explored some of these features, distinguishing the French model organized around umbrella conglomerates such as LVMH and PPR, the Italian model based on local economic clusters, and the American model based on licensing. Cities also have specific identities that are attached to the designs produced within their confines, such as in the case of Milan, which represents a cachet of quality and excellence in ready-to-wear (Segre Reinach 2006).

The fashion industry, like all creative industries (Caves 2000), is characterized by a high level of uncertainty (e.g., Bielby & Bielby 1994, Godart & Mears 2009). Thus, several institutions (Kawamura 2005) mitigate the uncertainty in this industry—the “fog of fashion” (White et al. 2007, p. 194)— and facilitate the production process, such as fashion magazines (Moeran 2006) or fashion

museums (Steele 1998a) that help diffuse fashion knowledge to the population; fashion schools that create a common understanding of what fashion is, for example, in an urban setting (Rantisi 2002a,b); fashion fairs that constitute “temporary clusters” (Bathelt & Schuldt 2008) and help the exchange and diffusion of fashion ideas; or forecasting bureaus that diffuse industry-specific knowledge about trends and styles to producers (Godart 2012, p. 70). Additionally, the fashion industry is ordered around several professions such as fashion designers—who are often organized in national professional associations, such as the Council of Fashion Designers of America in the United States and the Chambre Syndicale de la Haute Couture in France (Kawamura 2004)—or fashion photographers (Aspers 2001), as well as occupations such as fashion models (Godart & Mears 2009, Mears 2011). Fashion designers have been the objects of specific research. For example, Volonte ́ (2008) explored the social role of fashion designers, noting that the fashion process would not exist without professions to bring it to life.

Manufacturing

The garment sector was one of the first to be industrialized in the eighteenth century (Farnie & Jeremy 2004). It is also one of the first to have become global, initially with the supply of raw material and later with full-package solutions. However, as pointed out by Dunlop & Weil (1996), large segments of the apparel industry are still characterized by the wide use of the “Progressive Bundle System” (PBS) established in the 1930s, in which each day is devoted to a single operation, whatever its length, leading to a slow production process. New, modular techniques have emerged, however, that accelerate production and sustain the rise of fast fashion that supplies customers with ever-changing de- signs at low cost (Doeringer & Crean 2006).

The production of fashion is often com- pleted in close collaboration with the buyers, and one strategy that is often employed to bridge the uncertainty of the market is

the formation of long-lasting ties between producers and their supplies (Aspers 2010a, Uzzi 1996). The buying and selling of clothes are conducted not only in the consumer market, but also in fairs (Skov 2006). In some cases, garments are traded via several steps before consumers can purchase them, and these intermediary traders have influence on what is available in retail (Entwistle 2009). Strictly speaking, garments are the output of the production process; these become fashion items if and only if they are accepted first by fashion editors and other gatekeepers and, above all, the final customers (Aspers 2010a).

The Fashion Industry’s Environment

Fashions do not evolve in a social vacuum, and their evolution and diffusion are constrained by legal frameworks. First, sumptuary laws (Hunt 1996)—which were abolished for the most part in the West but still exist elsewhere—constrain the consumer regarding clothing (such as the colors that can be worn and by whom), food, and the like. However, the relationship of fashion to regulations goes beyond the existence of formal and legal norms about what people can wear (keeping in mind that informal norms always exist). Fashion, as an industry and change process, can be constrained by law as to what can be designed and produced. The debate regarding intellectual property in fashion has been polarized between two positions. According to the first position, fashion is essentially a status-based industry. What matters are not the designs but the labels and logos, and they need to be legally protected (Raustiala & Sprigman 2006). The second position is that fashion needs intellectual property law to protect innovation. In this perspective, a certain level of imitation (“remixing,” which consists of combining designs) could be authorized (Hemphill & Suk 2009). This legal debate addresses the question of the nature of fashion: Is it located in the objects themselves, and thus capable of being owned, such as, for example, through intellectual property rights, or is it a purely social mechanism that is the result of

interaction between actors? This debate around intellectual property in fashion also sheds light on the core mechanisms at play and on the necessity of imitation for fashion to exist.

Another set of constraints that weigh on fashions are moral norms. They explicitly make the link between the production and consumption sides because they often originate from clients and modify practices among producers. The main research topic here is ethical fashion. Fashion, as an industry, has often been criticized because of poor working conditions, particularly in low-cost countries, and because of its impact on the environment. Research has shown that despite these concerns, consumers are not necessarily ready to pay a premium price for ethical fashion—that is, clothing that is produced under sustainable social and environmental norms ( Joergens 2006)—unless they trust the brands that produce ethical fashion and have a good knowledge of their practices (Shen et al. 2012).

THE CONSUMPTION OF FASHION

Why Consumption Matters

First and foremost, consumption refers to the purchase of services and goods, such as clothes, but more importantly, it also refers to the use of such services and goods and to a way of life in general. Consumption is largely relational (Aspers & Beckert 2011), given that the act of purchase relates an individual to what others think and do. Hence, individuals are not born with an innate interest in fashion and a propensity to make social distinctions, but they are born into a society in which fashion and social distinctions are taken for granted and valued. It is through usage that fashion comes into being, for example when firms use a certain form of advertising directed at customers or when people exhibit and display their bodies in certain ways. We repeat, how- ever, that fashion is not necessarily connected to a market context, in which producers offer alternatives from which consumers can choose.

Today, we must take into account the in- creased importance of consumption facilitated by the Internet (Kawamura 2006). Indeed, in many Western economies, fashion is characterized by its reflexive character, shown in the way the environment affects and is affected by fashion. In addition, we can increasingly see this trend occurring in large emerging economies such as India, Brazil, Turkey, or China. Furthermore, fashion represents the clearest sign of a general “aestheticization” of social life (Postrel 2004)—both material, including most consumer objects and the appearance of the body, and immaterial, including ways to talk and express oneself. In line with this trend, some sociologists have studied the role of fashion as an economically important phenomenon, using terms such as “aesthetic markets” (Aspers 2001) and “aesthetic economy” (Entwistle 2009).

Several approaches try to account for the mean- ing people attribute to clothes and adornment in modern societies, notably through the act of consumption. The semiotics of fashion, for ex- ample, by Barthes (2006) assumes that there is a “lexicon and syntax” in clothing that resemble the structure of a language. Barthes is also clear in his approach; he does not focus on what he sees as sociological factors, such as, for example, manufacturing, but on fashion texts that are extracted from fashion magazines.

Extending the semiotic approach to fashion, some have seen fashion and clothing as a form of communication (Barnard 1996, Bohn 2000). A central semiotic idea is that the signifier, which may be a word or a garment, is given mean- ing by the signified. Thus, a signifier does not stand by itself, and only those who know the “code”—that is, “a set of shared rules” similar to a language—can understand the meaning of the garment (Barnard 1996, pp. 78–79). An object, according to Barnard, both denotes and connotes. Denotation refers to the garment’s characteristics, such as its color or fabric. Con- notation refers to the meaning of the garment in terms of, for example, its regular users. As pointed out by Aspers (2010a, p. 197), the semiotic approach cuts off what most sociologists consider the most central dimension of mean- ing, namely how actors produce, interpret, and use fashion. Researchers that attempt to un- cover the “hidden meaning” of garments (van Leeuwen & Jewitt 2001) often forget that the clothes by themselves, out of their social con- text, have no meaning. They acquire meaning because they are embedded in social relations and contexts. In this sense, clothing is, at best, a code characterized by “undercoding” (Davis 1992, p. 11). Body, Gender, and Ethnicity The relationship between fashion and the body is central. As Entwistle (2000, p. 1) pointed out, “Fashion is about bodies: it is produced, promoted and worn by bodies” and, as Benjamin (1999, p. 79) wrote, “Every fashion couples the living body to the inorganic world.” Tattoos, for example, adorn and modify bodies. They are partially driven by fashion mechanisms and are sometimes used to express “antifashion” positions (Sweetman 1999). Fashion models’ bodies are reified to fit industrial constraints (Czerniawski 2012, Entwistle 2002, Mears & Finlay 2005); clothes are used to classify bodies, as well as to define and sustain gender differences, such as the use of pink and blue for girls and boys, respectively, in the West since the 1920s (Paoletti 1987). Gender differences have a major impact on fashion, and in turn, fashion is a forceful purveyor of cultural norms and symbols that can shape and express gender differences. The feminine and masculine sides of the fashion industry are clearly delimited, with different creative and productive processes, such as different fashion shows. Today, the feminine side clearly prevails (Manlow 2007). Historically, this has not always been the case. For example, in eighteenth-century Europe, men’s fashion was at least as extravagant and significant as women’s fashion. In Europe, the nineteenth century saw the emergence of a sober and simpler dress for men. This is because, as first theorized by Goblot (1925 [2010]), in Euro- pean bourgeois families men had to show their focus on work through understated clothes but simultaneously had to display their wealth through the adornment of their wives. Today, gender boundaries are not as clearly defined, even though they are still prevalent all over the world. The more recent feminist approach to fashion has led to a deconstruction of binary gender oppositions (Kaiser 2012), paying heed to Wilson’s (2003) call not to dismiss fashion. Ethnicity has been shown to influence fashion (and to be influenced by it) in several con- texts, including the role of designers from Japan in French fashion (Kawamura 2004). Another example is Lieberson & Bell’s (1992) focus—in the case of the United States—on gender, ethnicity, and class differences to explain the choice of first names. For example, their research shows that among Caucasian Americans, girls’ first names tend to change more often than boys’ names and to be more novel. They ex- plain that this pattern fits with the wider belief that women need to be attractive through their first name, whereas men’s names are supposed to embody social stability. They conclude their study by stating that “[even in situations where organizations and institutions seek to alter and manipulate tastes and fashions, as through advertising, it is likely that there are a set of underlying societal and cultural dispositions that set limitations and boundaries around such efforts” (Lieberson & Bell 1992, p. 549). More generally, Eicher (1999) argues that ethnicity and dress have to deal with space and time, in the sense that ethnic dress varies not only with the location of its wearers (Hansen 2004) but also with the period under consideration and is in no way stable. In this sense, ethnic dress is not akin to tradition. It belongs to fashion and is a major driver of identity. Class and Identity Over time, consumption of fashion has moved from being class-oriented to lifestyle-oriented (Crane 2000, pp. 134–36). Class fashion was characterized by a centralized system of production, whose output was followed by buyers. Codes of dress and behavior meant that variation of clothes and styles was limited. A more diversified society goes hand in hand with a more diversified set of fashions. Today, we have not only more fashion industry segments than in the past but also more fashions competing with one another, and there are many more fashion capitals, consumer groups, etc. Fashion is far more diversified and also individualized. This diversity, however, has not erased important questions related to consumption and the political tensions that go with it (Enstad 1998): Who is in and who is out? Research on fashion often assumes that anyone can have access to the desired products, but in many instances, this is not the case, and research on fashion ought to take this fact seriously (McRobbie 1997). Furthermore, issues of class and inequality can today be analyzed not only using occupations, professions, and positions in the labor market, but also using consumption patterns and lifestyle-based identities, as Bourdieu (1984a) suggested. Class-based and identity fashions are not incompatible. For example, in his study of the nineteenth-century French bourgeoisie, Goblot (1925 [2010]) explained that this social class was characterized by a double mechanism that guaranteed the bourgeoisie’s existence, development, and overall identity. First, there was the barrier mechanism through which this class made sure it could control access to its ranks, and then the leveling mechanism that ensured that its members were more or less equal in order to reduce internal conflicts. Fashion was a key factor in the definition of the bourgeois identity in nineteenth-century France because, via the trickle-down mechanism, the French bourgeoisie was able to exclude other classes while fostering its own identity. However, it is also true in other contexts. For example, most societies use clothing to define class- and occupation-based identities. Social groups such as subcultures have been identified as being a highly relevant site for the exploration of fashion and its relationship to lifestyles and identity (Hebdige 1979, Hod- kinson 2002). Nevertheless, the expression of identity through fashion remains ambivalent, mostly because interpreting fashion is loaded with uncertainty (Davis 1992). From a social psychological point of view (Kaiser 1997), identity formation in relation to fashion needs to be understood in context. In this vein, Pe ́retz (1992) argued that the “vestimentary identity” of fashion buyers is partially constructed through their interactions with salespersons in the concrete setting of fashion retail. More recently, the focus has been on cognitive factors. Adam & Galinsky (2012), for example, looked at the effects of specific clothing (lab coats) on wearers. Under experimental conditions, they found that wearing lab coats increased the “attentiveness” and “carefulness” of individuals because of the identity change induced by the clothes they wore. DISCUSSION: TOWARD A THEORY OF FASHION We began this review by defining fashion negatively in relation to a set of key selected concepts—fad, innovation, style, and trend. We also analyzed its etymology. It follows from this discussion that fashion is a social phenomenon that may apply to almost any human activity. Drawing on the existing research by sociologists, as well as by others who have researched this topic, it is possible to advance the discus- sion by presenting the scientific stepping stone that hitherto has been missing: a definition of fashion. We propose to define fashion as an un- planned process of recurrent change against a backdrop of order in the public realm. A condition of the existence of fashion is the possibility for free agents to act. Fashion is essentially a social process of mutual adaptation. In this process, actors are free to decide if and to what extent they will adopt a new object, practice, or representation. However, actors can be influenced not only by their peers’ preferences but also by third parties’ strategies and institutional power. Fashion, in other words, can be influenced, but it cannot be planned or imposed. As Corona & Godart (2010, p. 286)

wrote, following Molotch (2003) and Benjamin (1999), there is “no bootcamp” for fashion. The contradictions and difficulties related to planned fashion have been shown in studies of central agencies that tried to organize fashion in the Soviet Union (Gronow 2003, Gurova 2009). Fashion emerges from a process of mutual adaptation and thus links micro decisions to macro processes, but numerous attempts to organize and tame it are made to reduce its inherent uncertainty, such as when producers try to persuade people to use, and often buy, what they offer, especially through advertising (Luhmann 2000, pp. 47–48), or when they organize the production process via professional association, fairs, or forecasting bureaus. Fashion ceases when change is not driven by actors’ wants and unrestricted choices. In other words, fashion is likely to appear only in societies in which distinctions are accepted and even desired, not in which similarity is a central guiding principle.

Moreover, fashion is a process and, as such, is extended in time. In this process, something new is introduced that replaces or complements something that already existed (Belleau 1987). Fashion need not be cumulative, although it can be (Godart 2012, p. 5). Adorno (2002, p. 463) explains this, referring to popular music: “Any rhythmical formula which is outdated, no matter how ‘hot’ it is in itself, is regarded as ridiculous and therefore either flatly rejected or enjoyed with the smug feeling that the fashions now familiar to the listener are superior.” Ferguson (2006) observed similar mechanisms in French cuisine. That this pro- cess of change and replacement of an object, practice, or representation by another has no predetermined beginning or end makes it recurrent. It is ongoing and can, but must not, be characterized by cyclical elements. Hence, cyclicality, in which older elements regularly reappear (Vinken 2005), is not necessary for fashion to exist, and innovations can become the object of fashion. In fact, what is recurring is change itself, not the elements that change. In this sense, we see cyclicality as a specific case of recurring change. The logic of this process

through which something comes in and out of fashion is the core of the theory. Obviously, not all objects, practices, or representations that are considered new in a given context will catch on and be adopted or mimicked by others. It is a selection process that takes place in which only some of the objects, practices, or representations that are considered new are taken up by others, and only these can become fashionable.

It follows that fashion is inherently relational. For something to be in fashion it must be adopted by a large number of actors. Only when a growing number of people or organizations start doing what only a few are already doing can we talk about fashion. But once a phenomenon is too common or too widespread and “everyone” has adopted it, it falls out of fashion. Social structure and status matter when we analyze the diffusion process through which we can understand the undulations of fashion. Some celebrities, role models, icons, popular peer group members, or high-status organizations are more likely to be imitated by others and thus can become fashion leaders (Aspers 2010a, pp. 43–44). Being a fashion leader may be a central element of a personal identity. But fashion may be equally important to those who follow it, those who try to be antifashion, and those who strive to be out of fashion. All these groups further the fashion process because each attitude toward fashion, whatever it is, reaffirms its centrality. Notably, the process need not be fully conscious.

Fashion is simultaneously inclusive and exclusive. Some actors may want to create differences, i.e., act to divert from what is existing or too common. This is best interpreted as an act of individuality. Others aim to make sure that they, too, are on the bandwagon, which is to say that fashion may also be seen as an act of collectivity, as Nietzsche (1878 [1996], pp. 363–65) observed. Besides, actors have different thresholds for the adoption process (Watts & Dodds 2007) so that some are early adopters, others jump on the bandwagon later, and still others decide to stay out of the process altogether.

Furthermore, fashion is public, and some form of space is needed for its diffusion. For fashion to exist, the object, practice, or representation in question must be observable by most or by all, for example on the Internet or in a mall. It must also be financially accessible to actors. Various theories of diffusion and adaptation can be used to explain how this occurs (Rogers 1983), but it is not necessary to specify all their details here, such as diffusion through observations in public or via information that is communicated in networks. Finally, our definition includes the notion of order. Change in fashion takes place against a backdrop of order; not everything can change at the same time, and fashion is somewhat constrained by what it replaces (Belleau 1987). Consequently, there can be no fashion in a situation of chaos or lack of structure. In these situations, there can be only fads. Fashion, how- ever, can take place only given a background that is more stable than what is about to change. But how is it possible to speak of both fashion in management styles, which may change only every other decade, and fashion in lipstick colors, shoe styles, or drinks, which change so often? To do this we must see both order and change in relation to time.

Something can be in flux only if there is a relatively more stable background of order than what is changing. In other words, though nothing is inherently stable, some of the social constructions, like styles, institutions, habits, and so on, are more stable than others, and as such they may provide the background that makes people perceive certain fashion changes. In sum, the phenomenological perceptions of order and change are the conditions of how long a fashion is to exist and of whether we shall speak of fashion at all. CONCLUSION: WHAT CAN BE DONE? We have reviewed the existing literature on fashion, including several disciplines related to sociology. The studies reviewed in this article, especially the more recent ones, have put fashion on the sociological map. We have seen that the central aspects of fashion—diffusion, imitation, and distinction—have been noted by most researchers. What direction should the sociology of fashion take now? There are two main tasks that we have identified. We have seen that although many scholars say that fashion is not necessarily restricted to apparel, most studies have focused on clothing and dress. Like Edwards (2011), we suggest that a sociological understanding of fashion needs to go beyond dress, even though it is a privileged setting for the exploration of fashion given its inherent features. Studying other empirical do- mains should be the focus of sociologists if they want to develop a more comprehensive under- standing of fashion as a social phenomenon and to develop a sociological voice among all the disciplines that look at fashion. Furthermore, most studies focus on one field only.

We have not seen comparative studies of fashion. It would be intriguing to study not only fashions of the same idea, object, or representation in different contexts (e.g., industries, countries, or epochs), but also fashions of different objects, practices, or representations in the same con- text. Such a perspective would allow a better understanding of social processes at play in the definition of identities, and in the development of practices and representations. The other main task is to further develop theory. That would allow us to systematize existing knowledge and to develop additional re- search. We have taken a few steps in this direction, but much more can be done. For example, if we look at the current field, production and consumption could be further combined. This would allow a better understanding of the institutional, organizational, structural, or cultural conditions under which fashion as change is de- ployed. Fashion shapes its surrounding social environment and is simultaneously shaped by it. A focus on class, gender, ethnicity, nations— to cite a few topics—can only help clarify the fashion process, as long as its inherent features as a type of change are not lost from sight. However, before further theoretical developments can be made, conceptual work is necessary. The concept of fashion has not been fully clarified. As we have explained, it is a way

of doing and making things that is bounded in space and time and involves collectives. In this sense, it is a type of change, like fads or in- novations. Exploring how these different types of change are intertwined would be a valuable exercise and would shed further light on the important sociological issue of the diffusion of practices and representations. Fashion is a key social process that can help us understand social relations in general from imitation and distinction mechanisms to identity formation, ethnicity, gender, and production and consumption. It is also closely related to canonical sociological questions such as being and order and the culture/structure conundrum. Developing research on this topic and phenomenon would facilitate the understanding of the antecedents and consequences of order and change in general.

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