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.
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 non-surgical cosmetic industry is growing rapidly and concerns are rising regarding patient safety, malpractice and public awareness due to lack of regulation and guidelines.
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
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 self-esteem 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.
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.
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