The Medical Board of Australia has just released draft supplementary guidelines for cosmetic, medical and surgical procedures. Overall, they’re condescending towards recipients of cosmetic surgery and take aim at the wrong target – it’s the purveyors of these services rather than consumers who need to be regulated.
Most Australians have a friend or a family member who’s had a procedure that could be classified as cosmetic surgery. Members of my own family have had Botox injections and breast reductions. I have close friends who’ve had blepharoplasties (eyelid modifications) and liposuction and have, myself, had laser treatment to remove a burst vein on my cheek.
Cosmetic surgery is ubiquitous and increasingly acceptable but it still makes many people wary. This is particularly the case when we hear of the very young seeking it out. Such cultural unease is the result of the grey area that cosmetic surgery occupies, sitting as it does at the strange nexus of beauty treatment, medical procedure and consumer item.
So it’s timely for the Medical Board of Australia (MBA) to be thinking about regulating cosmetic surgery. But the draft guidelines it’s offering will be about as helpful for dealing with cosmetic surgery as a band-aid on a gangrenous leg.
The consultation paper contradicts itself, firstly by categorising cosmetic surgeries as “medical and surgical procedures … achieving what the patient perceives to be a more desirable appearance or boosting the patient’s self- esteem.” And then advising that if “there are indications that the person has self-esteem or mental health problems, the person should be referred to a GP or an appropriately qualified health professional.”
So cosmetic surgery is all about boosting self-esteem but surgeons need to watch out for patients with self-esteem problems? That’s like telling an oncologist to watch out for people with cancer. What’s worse, the very doctors who stand to gain financially from performing the surgeries will be responsible for checking these self-esteem issues.
Regardless of this contradiction, the issue of mental health is very problematic when it comes to cosmetic surgery. Ten years ago, when I embarked on a project to interview people about their reasons for cosmetic surgery, the ethics committee at my university insisted that I give each interviewee a list of psychologists they could visit. The insulting assumption was that these (mostly) women must be unhinged because they wanted cosmetic surgery.
The ridiculousness of the situation hit me hardest when I apologetically handed the said sheet of contacts to a partner in a huge city law firm. The sun glinted off the harbour behind her in her corner office as she dropped it straight into her wastepaper basket.
Nobody questions the mental health of someone wanting a knee reconstruction. Equally, they don’t question the mental health of someone wanting a severe scar minimised. But wanting larger breasts, smoother skin or less droopy eyelids makes us cringe and demand the person asking for the operation be assessed for mental stability and for self-esteem issues.
This approach may, in part, result from our tendency to forget that cosmetic surgery is no longer simply a medical procedure that the medical profession has control over. Patients do their own research, learning about what’s possible from the internet, reality television, and word of mouth. They assess their looks based on movie stars and television personalities.
Crucially, they seek out surgeons not as experts but as technicians. If one won’t do what he’s asked (the vast majority of cosmetic surgeons are men), they find another. And if they can’t afford what they want in Australia, they go to Thailand or Malaysia.
People have come to see cosmetic surgery as a right, a consumable, or something anyone can have if they can pay for it. The practice has moved way beyond being an issue about self-esteem and mental health. For many, it’s simply part of good grooming or fashion – just another aspect of everyday life.
It’s not these information-armed patients who need regulating and assessing in this industry, it’s the doctors, who are making large amounts of money and have already built mini-empires. In order to make a real change to the cultures of cosmetic surgery, we need to legislate that only plastic surgeons (who are genuine registered specialists with many years of training) be permitted to perform cosmetic surgery.
Right now, “cosmetic surgeons” may be plastic surgeons, but are more likely to be general practitioners or others who have undergone some basic training. This training sometimes amounts to as little as a weekend workshop or, worse, watching an instructional DVD. These are the people who will be responsible for referring patients to GPs or psychiatrists if they appear to have “self-esteem” or mental health issues. And what qualifications do they have to diagnose mental health issues? Perhaps they could attend a weekend workshop or watch a DVD for that as well.
Sue Ieraci
Public hospital clinician
This essay presents a confusion of ideas. It is hard to see whether the author has read the draft consultation paper carefully.
Ms Jones alleges "Overall, they’re condescending towards recipients of cosmetic surgery and take aim at the wrong target – it’s the purveyors of these services rather than consumers who need to be regulated."
On the contrary. The definition given for cosmetic surgery is to distinguish it from plastic surgery - which is done not just to alter appearance but also function…
Read moreMeredith Jones
Senior Lecturer at University of Technology, Sydney
Of course there is a benefit to having guidelines for cosmetic surgery.
My point is that these proposed guidelines are misguided.
Rather than teaching non-plastic surgeons how to be more aware of patients who may suffer 'self-esteem' issues, I suggest that non-plastic surgeons be much more tightly regulated themselves. This is not limited to 'cosmeticians' but to those doctors who have not trained in plastic surgery as a speciality.
Such people are indeed 'purveyors' rather than 'providers'--they market heavily, advertise, offer incentives, and 'super-size' their services by offering extra procedures at 'discounted' prices.
Sue Ieraci
Public hospital clinician
"I suggest that non-plastic surgeons be much more tightly regulated themselves. "
That is precisely the intent of the draft guideline. It covers pre- and post-operative care, formulating a management plan, providing adequately detailed information, having plans for pain relief and review of complications, planning follow-up etc. Importantly, it outlines the practitioner's responsibility to act within their limits of training.
The last paragraph specifically addresses commercial conflicts and professional behaviour - precisely the concerns you state in your last sentence.
Again, I fail to see how this paper is "misguided" - it seems to be aimed at precisely the type of regulation that is needed.
Meredith Jones
Senior Lecturer at University of Technology, Sydney
Too much is left to the discretion of the very practitioners who stand to gain the most, financially, from performing cosmetic surgery. For example:
"You are responsible for ensuring that you have the necessary training, expertise and experience to perform a particular cosmetic procedure with reasonable care and skill."
But what is that training? What constitutes expertise and experience? I think that these procedures should only be conducted by plastic surgeons. Not by anyone who has a medical degree and has decided to call him or herself a cosmetic surgeon. Certainly not by people without medical degrees at all.
Sue Ieraci
Public hospital clinician
Ms Jones, perhaps you have not realised that this is just one specific guideline within a complex regualtory system for medical practitioners.
"Cosmetic medicine" is a newly emerging area, driven by public demand. The MBA is moving to speficially regulate this practice. It is not possible to define each individual procedure which needs specialist training in plastic surgery - many proceedures cross over specialties. Many GP's, for example, handle minor skin lesions very competently. To restrict…
Read moreMeredith Jones
Senior Lecturer at University of Technology, Sydney
As a researcher who has looked at the global cosmetic surgery industry for more than ten years, I take issue with the statement '"Cosmetic medicine" is a newly emerging area, driven by public demand'. Cosmetic surgery has a long and complex history. The best books to read about this are Elizabeth Haiken's 'Venus Envy' and Sander Gilman's 'Making the Body Beautiful'.
The development of the industry has happened partly due to 'public demand', as you say, but it has also happened in connection with…
Read moreSue Ieraci
Public hospital clinician
Again, Ms Jones, I'm not sure that you have an overall view of the way medicine is regulated. A sociological viewpoint is only one aspect to this complex area.
My reason for mentioning the difference between cosmetic and plastic surgery is that this is the context of the draft policy you are criticising.
I cannot agree that cosmetic medicine is not new - you may have been researching its sociological aspects for "more than ten years" - but the other specialties in medicine have been around…
Read moreMeredith Jones
Senior Lecturer at University of Technology, Sydney
In fact, the well-documented history of cosmetic surgery shows that it goes back to at least 600BC (see Gilman, reference in my previous post). The practice grew hugely in the 1900s because of antiseptic and anaesthetic developments (see Haiken, reference in my previous post) and because surgeons saw a niche market.
'Suturing of wounds, removal of superficial skin lesions' are obviously things that any medical practitioner is trained to do--I doubt that many people would say that these need regulation. But implants? Abdominoplasty? The multitude of operations that fall under the banner of 'facelifts'? Are we really happy for these complex and dangerous procedures to be done by anyone who has simply gone through 'medical school and residency training'?
Sue Ieraci
Public hospital clinician
Ms Jones - " Are we really happy for these complex and dangerous procedures to be done by anyone who has simply gone through 'medical school and residency training'?" Is that really what you read from my reply? I was trying to explain why it is not simple to have, as you called for " ...regulations define and list each individual procedure and then list the specialities that are allowed to perform them?" I explained why this is the case.
The fact that people conducted surgery in 600 BC has no…
Read moreGavin Moodie
Principal Policy Adviser
It seems that much dental practice now involves what I as a layperson understand to be cosmetic procedures. Teeth braces have been used for decades, for mostly cosmetic reasons it seems. But now dentists seem to be fitting teeth caps, again mostly for cosmetic reasons. Yet there seems less sensitivity about dental cosmetic procedures than cosmetic procedures for the rest of the body.
CH Soames
Cytogeneticist
The medical professions are paradoxically some of the most scrutinised/maligned, yet covered with spangles of glamour as seen from below [the patients' viewing angle from the stretcher] of all. Medical brethren flock together defensively, and use what advantage falls to them, medical mystique included. Meanwhile they arbitrate and regulate and surveil each other and put each other through workshops and exams and self-guided learning activities. They do not enjoy people from outside their professions…
Read moreSue Ieraci
Public hospital clinician
This is an eloquent comment, but misses the point. The author's article is about regulation by the Medical Board of Australia - the regulator of the medical profession. The MBA is not an arm of the profession - it is a statutory body whose mission is to protect the public. The purpose of the draft statement is precisely to regulate the profession and protect the public.
You say "The medical profession does not like to be put on the spot." And yet, on this thread, only a medical professional has…
Read moreCH Soames
Cytogeneticist
No, the wagons was you and others who are likely not to recieve the author's criticisms well. It's a matter of focus. While psychological aspects are of course part of the picture, the author appears to be objecting to their preeminence at this stage of the process, for the reasons abovementioned.
Sue Ieraci
Public hospital clinician
What do you mean by "at this stage of the process"? This is just one document in a range of structures and guidelines that regulate the medical profession.
The author's criticisms are not aimed at me - they are about a draft document from a regulator - who is outside the medical profession. The medical profession is not "self-regulated" - the MBA is a statutory body with national and state branches. I am supporting the move by the regulator to regulate this area better.
You appear to have a…
Read moreMeredith Jones
Senior Lecturer at University of Technology, Sydney
CN Soames, what an insightful and intelligent response to my article, thank you so much. I agree with you that, in terms of the bigger picture, this debate is about power: who holds it, who is entitled to regulate it, who is 'qualified' to comment or not. It's really interesting that those selling and providing cosmetic surgery are benefiting from more widespread acceptance of it, and also benefiting from consumers who know what they want, but they are largely unwilling to have non-medical people…
Read moreSue Ieraci
Public hospital clinician
"I stand by my comments that a comprehensive list of procedures, accompanied by some rules about who can perform what, is the best way to regulate this practice."
Ms Jones - do you know of a precedent for this sort of list? Who would compile it and what would they base it on?
Meredith Jones
Senior Lecturer at University of Technology, Sydney
Ms Ieraci - somebody, at some point, has to set a precedent. The Medical Board of Australia could, for example, compile the list and send it out for comment as part of these draft guidelines. The members of the board would compile the list using both expert knowledge and common sense.
Sue Ieraci
Public hospital clinician
Ms Jones - I understand that you are sincere in applying your knowledge and experience to promote improvement in this area. What I have been trying to explain, however, is the nature of the regulatory process.
The licensing or regulatory authority of a profession is charged with setting professional standards - not clinical ones. Only some of the MBA members are medical practitioners. It is not possible to construct such a list by "common sense". Again, as I have been trying to point out, this statement is but one small part of a complex regulatory process that combines legislation, regulation and guidelines. By all means express your opinion about the prevalence of psychological issues in association with both cosmetic and plastic surgery. TO make recommendations on the specifics of the regulatory process, however, one needs to understand the structure of the regulatory process in its entirety - not just a single draft statement.
Meredith Jones
Senior Lecturer at University of Technology, Sydney
CN Soames, what an insightful and intelligent response to my article, thank you so much. I agree with you that, in terms of the bigger picture, this debate is about power: who holds it, who is entitled to regulate it, who is 'qualified' to comment or not. It's really interesting that those selling and providing cosmetic surgery are benefiting from more widespread acceptance of it, and also benefiting from consumers who know what they want, but they are largely unwilling to have non-medical people…
Read more