Promoting cosmetic surgery
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e7535 (Published 08 November 2012) Cite this as: BMJ 2012;345:e7535
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As the alternate MWIA NGO rep to the United Nations I strongly support the position of MWIA and think its vital for all physicians to work as activists to address the human rights of women and girls who have been the victims of violence and need surgery to alleviate their suffering.
Competing interests: No competing interests
In their head-to-head on the ban on advertising for cosmetic surgery Sally Taber and Fazel Fatah discuss whether self-regulation and industry standards in advertising of cosmetic surgery are sufficient to protect patients or whether these are better served through an outright ban on advertising.
The discussion neglects an important aspect of safeguarding UK consumers from direct marketing by cosmetic surgery providers to the public: an increasing number of UK patients travel abroad to receive cosmetic surgery.
In 2010, 63,000 UK residents travelled to access treatment abroad [1]. Our research indicates that around 30% - 18,300 - of these were cosmetic tourists. This echoes results of a survey conducted by Which? magazine that found 28% of medical tourists travelled for cosmetic procedures [2]. It is likely that this is a growing trend: a recent survey found that 97% of all people considering cosmetic surgery would consider travelling for these procedures [3].
Moreover, our research reveals that most patients identify and choose foreign providers via the internet. This underlines the necessity to extend consideration for regulation or banning of advertising of cosmetic surgery to the internet and specifically consider medical tourists. If such actions lie beyond the reach of national regulators there is greater urgency for accessible information and guidance for those considering traveling abroad for cosmetic surgery. We found that patients who travelled for cosmetic treatment are unlikely to consult their GP out of embarrassment or fear of being judged. Hence, communication on how to ensure that such guidance reaches potential medical tourists requires additional thought.
A ban on advertising by UK providers will address some of the concerns raised by the recent PIP scandal, as may regulation of advertising if measures are in place to enforce this. However, the increasing number of patients travelling abroad for cosmetic procedures means that a comprehensive review of cosmetic surgery needs to consider this or risk that its recommendations are little more than a short term ‘band aid‘ as more and more UK residents travel abroad for treatment.
The authors have recently completed a two year research project on UK medical tourism funded by the NIHR. This included quantitative analysis and qualitative interviews, including with UK residents who had travelled abroad to access cosmetic surgery.
[1] Smith R, Lunt N, Hanefeld J. The implications of PIP are more than just cosmetic. The Lancet. 2012; Volume 379, Issue 9822.
[2] Which? We expose medical tourism pitfalls: Do your homework before you go, urges Which? Which? [Internet]. 2008 1/11/2011. Available from: http://www.which.co.uk/news/2008/03/we-expose-medical-tourism-pitfalls-1....
[3] Nassab R, Hamnett N, Nelson K, Kaur S, Greensill B, Dhital S, et al. Cosmetic tourism: public opinion and analysis of information and content available on the Internet. Aesthetic Surgery Journal. 2010;30(3):465-9.
Competing interests: No competing interests
The subject of female genital cosmetic surgery is a node at the intersection of a number of deep and complex debates within UK society.
The first is the issue of normality. Statistically normality is concerned with acceptable deviations from the mean but normality is more often socially defined in terms of tolerability. The crucial issue then becomes who or what decides what is tolerable. Should society define normality? Should normality be defined by the medical profession and if so should this be a collective decision or an individual one? Should normality be defined by the person who is paying the surgical bill? If this is the case, is cosmetic surgery unacceptable on the NHS but acceptable if paid for privately?
Cosmetic dentistry rarely attracts the same criticism as cosmetic genito-plasty.
This brings into consideration a second issue, which is the way in which the value of a woman is socially defined. Feminist sociology has argued that women are demeaned by visual objectification which defines their worth by their bodily appearance. Objectification can be internalised so that some women define their own worth, according to their appearance, judged on a scale of perceived masculine preference. The cultural trap created by this internalisation is that the appearance of feminine perfection is an artificial creation, aided by air-brushing, make-up, depilation and cosmetic surgery. It is ultimately unobtainable (or at any rate unsustainable). A strange aspect of the cultural subjection of women to value judgements based on unobtainable perfection is that any number of individual men and women may disagree with the judgement, but at a broad cultural level, it remains. Cosmetic genital surgery vividly feeds the myth of female bodily perfection, under the guise of ‘normality’. If the debate about cosmetic surgery focussed around teeth or ears, the underlying issue of cultural misogyny would be less apparent.
Finally the tension between autonomy, consent and non-malificence is pertinent for the medical profession. In general if a competent adult fully understands the risks and benefits of a procedure, consents to it, (and is able to pay for it), then respect for his or her autonomy would indicate that the procedure should be carried out. This is not always so straightforward. If an adult makes a request for surgery which seems to be against his or her best interest, we may question whether he or she is competent to consent. An example might be the refusal to operate on someone who requests extreme surgery because of underlying body dysmorphic disorder. We might also question whether the person has come under undue pressure to request the procedure, which is close to the stance the profession takes on requests for FGM, even if requested by the woman herself. Arguably a request for cosmetic genito-plasty could fall into this category, with the undue pressure arising from cultural expectation, interpreted by someone especially vulnerable. The problem with this approach is that it quickly slides into medical paternalism (or maternalism) and a rejection of women’s autonomy and capacity to consent. Any blanket diminution of female autonomy by the medical profession must be treated with the utmost caution.
As a woman and a doctor my gut instinct is to reject cosmetic genito-plasty and support measures which lead to it being restricted or banned. Nonetheless there are complex issues involved which deserve to be debated more fully, and which may lead to a greater understanding of the cultural context in which female cosmetic genital surgery occurs.
Competing interests: No competing interests
The most important issue regarding female genital aesthetic surgery is that it is regulated. It is not acceptable that any doctor can set up in Harley Street, and persuade vulnerable mothers that their equally vulnerable daughters can enhance their sexual satisfaction by undergoing this barbaric surgery.
Competing interests: No competing interests
It really concerns me that we are being driven by social fashion. I have had a mother describe her daughter's genitalia as 'large' and 'abnormal.' I took pains to reassure the child that we have so much variety and that she was normal. Beware the patient who is unhappy about their body image, too often have they had depression or needed help in accepting themselves. Surgery is not going to help that and would be hindering a psychological process.
Genitalia surgery is one of the causes of difficult postoperative pains to manage.
Competing interests: No competing interests
As vice-president of the Northern-European Region of MWIA, I reject all cosmetic surgery of the vagina and the other female genital organs. Health care should take care of diseased and disabled women and not use the surgical knife in normal women.
Competing interests: No competing interests
I support the position of MWIA and urge specialists and experts to channel their energies towards assisting the millions of girls and women who require reconstructive surgery following FGM/FGC.
Competing interests: No competing interests
I think the topic on vaginal rejuvenation should be totally rejected by FIGO and not promoted. Taking into consideration the multiple functions of the vagina any unecessary surgery will definitely do more harm than good to a young woman who is yet to give birth to young ones. This is where cosmetic surgery is purely on monitary gain than the humanitarian part of it. PLEASE STOP IT.
Competing interests: No competing interests
I applaud Dr Godlee for reigniting debate on female genital cosmetic surgery. As a plastic surgeon I have closely followed this debate since 2008 and have seen labiaplasty rates increase dramatically in Australia over this period.
In August 2012 the Australian Federation of Medical Women Council approved a position statement on female genital cosmetic surgery, which will be presented to members for formal acceptance on November 17, 2012. The position statement recognises women’s autonomy and right to choose. It advocates for informed consent and education. It opposes media depictions and advertising that could create unrealistic or inaccurate perceptions of the appearance of normal female adult genitalia. It opposes the promotion of products and surgeries that make unproven claims of enhancing female sexual satisfaction or attractiveness and it opposes advertising that directly or indirectly encourages the indiscriminate or unnecessary use of regulated health services (such as female genital surgery).
The debate about female genital surgery requires critical reasoning and sensitivity. With this in mind I highly recommend an excellent article published this week by the Public Policy Advisory Network on Female Genital Surgeries in Africa, titled “Seven Things to Know about Female Genital Surgeries in Africa”. I wholeheartedly agree with its assertion that: “Female genital surgeries worldwide should be addressed in a larger context of discussions of health promotion, parental and children's rights, religious and cultural freedom, gender parity, debates on permissible cosmetic alterations of the body, and female empowerment issues.”
I am pleased to learn from Professor Serour's response that the FIGO Ethics Committee is now studying this subject. I would like to see FIGO speak out about the rise in female genital cosmetic surgeries and the lack of evidence backing these increasingly heavily advertised and sometimes trademarked procedures. Doing so would see FIGO follow in the footsteps of the American Congress of Obstetricians and Gynecologists and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. It would also further open this topic up for much-needed international debate and research.
Dr Jillian Tomlinson
Secretary, Australian Federation of Medical Women
Competing interests: No competing interests
Re: Promoting cosmetic surgery
Advertising is one thing. What material is actually put into the advert to promote a service is another.
The missing link is very often the absence of some form of independent assessment and verification of the genuineness of the safety and fitness for purpose of the cosmetic surgery services being advertised.
For such assessment and verification to be truly meaningful, the process should not only include the education, qualifications, credential s and continuing professional training of surgeons, physicians and others actually performing the services, but also the adequacy of
• the facilities within which the assessment of patients takes place and procedures is undertaken
• the nursing and other support staff
• the ethical framework within which services are offered
• the insurance and indemnity arrangements that are in place for supporting patients where things go wrong
• infection prevention and control
• audit
• and much else besides
In many parts of the world, independent holistic accreditation of clinics and hospitals – which undertakes to independently assess all of the factors mentioned above - is considered the gold standard.
The approach is somewhat analogous to an individual applying to a university to read for a degree, studying, and ultimately being examined – if the candidate does not make the grade, they are not granted a degree. With accreditation, hospitals and clinics can approach and commission recognised schemes such as JCI of the USA, ACHS from Australia, Accreditation Canada and the UK’s QHA Trent, who will then work with them and assess them and, if they prove to be truly safe and fit for purpose, accredit that healthcare service provider(1). On the other hand, if the healthcare provider cannot meet the standards, they are not granted accreditation.
If accreditation is granted, that success can be, and usually is, flagged up on the web site and in the promotional literature of the healthcare provider.
The independent accreditation system may not be perfect, and there may be other ways of achieving the same ends, but it is most definitely better than nothing. Accordingly it may be in the best interests of any members of the UK public who are contemplating undergoing not just a cosmetic procedure but also any other form of surgery (bariatric, transplantation, orthopaedic etc.) or procedures such as assisted conception/IVF to begin familiarising themselves with the concept, whether they are looking towards the private sector in the UK or overseas as a medical tourist for their healthcare needs.
It may also be of value if the GPs who are advising those patients were to take a look too.
1. Green, S.T. and King, H. (2012) 'Independent Health Care Accreditation: Medical Tourism and Other International Aspects', in Risks and Challenges in Medical Tourism: Understanding the global market for health services, Hodges, J.R., Turner L. and Kimball A. (eds), ABC Clio, pp. 230-250.
Competing interests: The author is a Director of QHA Trent UK.