CPD: Cosmetic Interventions on Children

Dr Mehvish Khan discusses the impact cosmetic interventions can have on young patients and advises ethical treatment approaches.

Worldwide, the medical aesthetic specialty is expected to grow over
the next five years from US $53.3 in 2017 to $73.6 billion in 2022.1
Cosmetic interventions are increasingly becoming accepted by the
public as ‘normal’ and the aesthetic market is globally expanding,
particularly in Asia, Russia and Brazil.1
With this rise in the demand for aesthetic interventions, it can be
assumed that the number of children/adolescents seeking cosmetic
procedures (surgical and non-surgical) is also expected to rise.
In 2016, according to the American Society of Plastic Surgeons,
229,551 cosmetic procedures (surgical and non-surgical) were
performed on 13-19-year-olds, the top three procedures being laser
hair removal, rhinoplasty, and laser skin resurfacing.2
Not only are these procedures accessible to the younger age group,
but they are recognised as desirable. Social media, cosmetic surgery
apps and television have a major role in promoting false ideals of
beauty that are unrealistic and may pressure the young mind to
conform to these at a very susceptible time of their development,
damaging their self-esteem and increasing self-consciousness.3
An experimental examination involving 189 participants, majority
female (M age = 19.84, SD = 4.82 years) found a correlation between
the exposure to reality television shows featuring surgical make-overs
and the desire to alter one’s own appearance using cosmetic surgery.4
Puberty is a crucial time at which body image development begins.
There are many influencing factors, other than sociocultural influences,
that shape how children think of themselves and these include
approval, attention, neglect and criticism from parents, close family
members or even peers.5
Very little research is available on the psychological state of
adolescents who seek cosmetic interventions. This is why, in my
opinion, practitioners should place more focus on this when they
perform these procedures on such vulnerable patients, whose
bodies are still developing and who are still finding their identity and
embracing their sexuality.6
It has been concluded by a recent study (2015) by University of
Washington researchers, that self-esteem is seen to develop in
individuals as early as five years of age.7
Self-esteem and self-worth can either be stable traits or can
fluctuate over time.8
Linked to this, however, are many complex
processes that contribute to the way an individual behaves such
as, physical, cognitive, social, and emotional changes that can
disrupt the adolescent’s sense of continuity, which may in turn
damage self-esteem.9
When dealing with individuals at this crucial age of development and
vulnerability, it is vital that practitioners try to understand as much
as they can about the young person’s personality, their motivations
and aims behind seeking cosmetic interventions, and whether the
procedure can be of any benefit to the young patient.
As this is a rather unexplored area of aesthetic medicine and the
demand for cosmetic procedures for the young is increasing, there
is a need for official guidelines targeted specifically at aesthetic
practitioners, regardless of their professional medical background, to
ensure the intended procedure is in the best interest of the patient.
This paper intends to shine light on this growing concern and
discusses the professional and legal obligations that practitioners
have when dealing with young patients, under the age of 18, seeking
either non-surgical or surgical cosmetic interventions.
Professional obligations
Bioethicists often refer to the four basic principles of healthcare
ethics when evaluating the merits and difficulties of medical
procedures. The principles of ethics published in 2001 by acclaimed
authors and philosophers Beauchamp and Childress (Table 1)
provide a criteria that must be respected to ensure ethical practice.10
These principles offer a framework that can be applied not only in
a clinical setting but anywhere a practitioner is responsible for the
welfare of a patient.11
The General Medical Council (GMC), Nursing and Midwifery Council
(NMC) and the General Dental Council (GDC) have all established a
professional code of practises based on these principles.12,13,14
In November 2017, a self-regulating body that aims to provide a
register of safe practitioners for the public, the Joint Council for
Cosmetic Practitioners (JCCP) was formed.15 It welcomed the Nuffield
Council of Bioethics’ report on ethical issues
related to cosmetic procedures, which was
released in June 2017.16
The release of this report is timely as the nonsurgical cosmetic industry is growing rapidly
and concerns are rising regarding patient safety,
malpractice and public awareness due to lack of
regulation and guidelines.

Regarding cosmetic interventions in young patients, the publication
by the Nuffield Council on Bioethics17 and the General Medical
Council (GMC)18 provides some valuable guidelines to practitioners
in relation to important questions, addressed below, that may
arise when dealing with minors. There are limited other official
guidelines for aesthetic practitioners in regard to treating young
people other than some manufacturer guidelines and small
mentions in the code of practice of some aesthetic companies,
associations and bodies.19
Who can seek medical interventions?
Children under the age of 18 are capable of making decisions
regarding cosmetic treatments for themselves as there is no
prohibitory law against it. Some banned procedures for this age
group, such as tattoos, carry no ‘gain’ for the child in question,
whereas, cosmetic interventions for the right reasons and on the
right patients can be considered beneficial.20,21,22,23
This brings us to the principle of ‘beneficence’; acting in the best
interest of the patient when considering cosmetic interventions in the
young. Anyone can seek cosmetic interventions. It is solely down to
the practitioner to decide whether to offer treatment, keeping in mind
patient autonomy as well as beneficence and non-maleficence.18
How young is too young and who decides?
According to the law, anyone under the age of 18 is a child.
However, those above the age of 16 are presumed competent to
consent for procedures for themselves unless they are deemed incompetent by the practitioner.25 This is
established after an assessment of how
the child deals with the decision-making
process by analysing their ability to
understand the procedure and assess the
risks.18 The Family Law Reform Act 1969
also gives the right to consent to treatment
to anyone aged 16-18.24 Those below the
age of 16 years old can consent if they
are deemed ‘Gillick competent’, and if the
practitioner considers that the treatment
is in their best interest and they cannot
be persuaded to involve their parents.24,26
Gillick competency assesses the patient’s
transition from child to adulthood and is
based on the patient’s maturity and intelligence.26 Where there is
a conflict of interest between the patient’s relatives and the young
patient in question, the practitioner should decide whether or not
to treat based on the best interests of the young patient.27 Here,
the practitioner’s professional morals and ethics come into play, as
well as their sound judgment on competency.

To treat or not to treat?
The British Association of Aesthetic Plastic Surgeons (BAAPS)
and British Association of Plastic, Reconstructive and Aesthetic
Surgeons (BAPRAS) clearly state in their codes of practice that
patients, under the age of 18 years, seeking surgical aesthetic
procedures must undertake a full assessment to assess the risks
and benefits of the treatment as well as the repercussions. The
practitioner must outline these to the patient seeking the treatment
through clear and concise communication.29
Similarly, the GMC advises that doctors carrying out cosmetic
interventions on young patients should do an assessment of best
interests by considering the patient’s views as well as the parent’s
view and those close to the minor. Practitioners should involve the
child in the decision as much as possible. Cultural and religious
beliefs are also taken into account. The GMC states under their
0-18 years: guidance for all doctors that all relevant information
should be provided and discussed with the young patient, whether
or not they have the capacity to consent.18
Individuals have the right to choose or refuse treatment and their
confidentiality must be respected unless it threatens their best
interest.18 However, when we are faced with a young
patient, to adhere to the principle of beneficence, it is
vital to judge as an experienced practitioner whether
the subject is competent or not to make the decision of
undergoing a cosmetic procedure.18,17
This can be achieved by performing a thorough history
to establish the maturity of the patient, their motivations
for seeking treatment and their expectations, as this is
vital in achieving a rewarding outcome and will ensure
the best interest of the young patient. Even if the young
patient is competent, it is encouraged to advise them to
involve their parents or guardians.30
Minors must be given enough time to ask questions
and express their feelings and shouldn’t be pressured
into having a procedure by either parents, peers or
partner.31 This would be the duty of the practitioner to
look out for, by involving the child as much as possible in
decision-making.18 It may be useful to possibly offer the young patient a private consultation without the presence of a third
person or by directing questions and receiving answers only from the
patient in concern. Patient history obtained should include any past
cosmetic interventions, any past emotional or physical trauma, social
interactions, past psychological disorders and how they feel in general
about themselves; self-esteem and body image.
It is generally acknowledged that it is difficult to assess body image
in young people because of the increased self-consciousness and
dissatisfaction with physical appearance that is common at this
stage of development.5
To adhere to the third principle ‘non-maleficence’, it is crucial to rule
out body dysmorphic disorder (BDD), otherwise more harm can be
done than good.
Psychiatric disorders, such as BDD, can limit a young patient’s ability
to make an informed decision about cosmetic interventions and to
accurately appreciate the risks and benefits of these procedures that
may lead to a worsening of their condition and further destroying
their self-esteem.31
In an article by the Penningtons Manches’ specialist cosmetic surgery
team, it was reported that there is an increase in significant cosmetic
surgery procedures, such as labiaplasty, amongst young teenage girls
who suffer from BDD. This led to The Royal College of Obstetricians
and Gynaecologists’ (RCOGs’) Ethics Committee to propose a ban
on cosmetic labiaplasty for teenagers as they stated that the external
genitalia is still developing for girls under the age of 18 and the risks
outweigh the benefit.33
In 2005, consultant plastic surgeon Mr Nick Parkhouse spoke to the
BBC about how plastic surgery was inappropriate for most teenagers
and that, in his opinion, just a very small cases of teenage/child
cosmetic surgery, such as cleft palates and prominent ear correction
are beneficial.31,32
A Dutch study examined the psychological state of 12 to 22 year
olds over a six month period, with some of them undertaking
cosmetic surgery. The study found over time that their
dissatisfaction with their appearance decreased regardless of
whether they had surgery or not, with a higher degree of selfesteem seen in those over 18,34 deeming Mr Parkhouse’s statement
valid about the inappropriateness of aesthetic treatments in
the young. A psychologist or psychiatrist referral may be useful
if the patient’s request is unclear or may seem bizarre, if their
expectations are unreal or their perception of their undesired
feature is exaggerated. A cooling-off period must be given to
all patients after an initial consultation, but I believe that this is
particularly important for young patients.31 Where there is an
element of doubt of whether to go ahead, the practitioner must
consult with other specialists or colleagues to ensure that the
procedure is of benefit to the young person.
Conclusion
There is no legal restriction in the UK for young patients (under 18)
seeking cosmetic interventions. Aesthetic medicine is a rapidly
growing sector and cosmetic procedures are performed by
practitioners other than those who are medically trained, which
increases the need for clear guidelines when dealing with the
young vulnerable population. Some guidelines are provided by the
GMC, and the Nuffield Bioethics report has addressed this growing
concern. Furthermore, practitioners must understand their professional
obligations before offering such appearance-modifying treatments
and ultimately do what is in the best interest of the physiologically and
psychologically developing patient.

Dr Mehvish Khan holds a degree in Biomedical Sciences
and Medicine. Due to her passion for science and art, she
has decided to pursue her career in the field of aesthetics
and is currently undertaking her Master’s Degree in
Aesthetic Medicine at Queen Mary University of London.

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