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More than just filler: an empirically informed ethical analysis of non-surgical cosmetic procedures in body dysmorphic disorder
  1. Natalie M Lane1,2
  1. 1 Department of Psychiatry, NHS Lanarkshire Mental Health Services, Glasgow, Scotland, UK
  2. 2 Department of Global Health & Social Medicine, King’s College London, London, UK
  1. Correspondence to Dr Natalie M Lane, Department of Psychiatry, NHS Lanarkshire Mental Health Services, Glasgow G71 8BB, UK; natalie.lane{at}nhs.net

Abstract

Objectives To identify and analyse ethical considerations raised when individuals with body dysmorphic disorder (BDD) consult for non-surgical cosmetic procedures.

Methods Ethical analysis was conducted addressing the issues of best interests and capacity to consent for non-surgical cosmetic procedures in individuals with BDD. Analysis was informed by the findings of semistructured interviews with non-surgical cosmetic practitioners and mental health professionals.

Findings Non-surgical cosmetic interventions were viewed not to be in the best interests of individuals with BDD, as they fail to address core psychological issues, result in dissatisfaction post-procedure, and risk harm. Referral to mental health services was advocated, however numerous obstacles to this were perceived. The issue of capacity to consent to non-surgical cosmetic procedures raised questions regarding whether standard capacity assessment is sensitive to the manner in which BDD may influence decision-making processes. In addition, concerns were voiced that decisions made by individuals with BDD in this context may be judged foolish, and thus wrongly equated with lack of capacity.

Discussion/conclusions Ethical analysis, informed by the available evidence base, suggests that it is generally not in the best interests of individuals with BDD to undergo non-surgical cosmetic intervention, and referral to mental health services is indicated. Analysis of capacity draws parallels between BDD and anorexia nervosa, as decision-making capacity in both conditions can be impaired by pathological values derived from the disorder. Means of differentiating clinical assessment of pathological values from inappropriate value judgements are advocated, in order to safeguard against the latter encroaching into capacity assessment.

  • psychiatry
  • applied and professional ethics
  • capacity
  • informed consent

Data availability statement

All data relevant to the study are included in the article.

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Introduction

Body dysmorphic disorder (BDD) is a chronic psychiatric illness with a significant burden of morbidity and mortality.1 It is characterised by an overwhelming preoccupation with a perceived defect in one’s appearance. However, in the eyes of others, this ‘defect’ is non-existent or very slight, and thus out of proportion to the psychological distress and impairment in social functioning that it generates.2 3 Appearance preoccupation is typically accompanied by repetitive behaviours such as mirror checking, and camouflaging with cosmetics or clothing. Any feature can become the focus of preoccupation, however the skin is most commonly implicated, with acne, visible veins and wrinkles frequently cited ‘defects’.4 The psychosocial impact of BDD is striking: around one-third of individuals with the condition are unable to attend employment or education.5 Furthermore, suicide rates are high: around half of affected individuals experience suicidal ideation, while around one-quarter attempt suicide.6–8

BDD has a population prevalence of around 2%.9 10 Prevalence is higher among individuals who consult for cosmetic procedures, with studies suggesting that 5%–15% of this group are affected.11 In keeping with this, a retrospective study of 289 individuals with BDD found that around 75% had sought cosmetic intervention.12

In recent years, safety concerns have been highlighted regarding the UK non-surgical cosmetic procedures sector. The 2013 Keogh Report, commissioned in the wake of the Poly Implant Prothese (PIP) breast implant scandal, drew attention to the lack of restrictions on who can perform non-surgical cosmetic procedures (such as Botox and dermal fillers).13 Health Education England investigated this issue, and set out a standardised framework for training of non-surgical cosmetic practitioners.14 15 Since then, the Nuffield Council on Bioethics has undertaken an ethical evaluation of the industry, advocating further changes to promote ethical good practice, including prohibiting irresponsible advertising, and mandatory product safety regulation.16

These reports laudably emphasise the need for practical and ethical oversight in the expanding non-surgical cosmetic sector. However, none consider in detail the unique ethical challenges raised by individuals with BDD, despite this group comprising a significant proportion of those consulting for procedures. Literature search using PubMed yielded a small number of medicolegal papers addressing the related, but distinct, topic of cosmetic surgery in BDD. These concur that BDD contraindicates surgery, as impairs capacity to consent.17 18 One further paper investigates cosmetic labiaplasty in adolescents with BDD from a bioethical perspective.19 However, the sparse data available suggests that the outcomes of labiaplasty in this group are markedly better than other cosmetic interventions, thus generalisable conclusions cannot be drawn.19 20 Only one published case scenario specifically addresses the ethical issues surrounding non-surgical cosmetic intervention in BDD. This concludes that such procedures should be avoided as ‘a diagnosis of BDD is often prima facie evidence of inability to provide informed consent’, and are unlikely to benefit the individual, while risk causing harm.21

Given the limited existing literature addressing the topic of non-surgical cosmetic intervention and BDD, empirical methods were indicated to highlight the relevant ethical issues warranting further analysis. The current study represents the first in-depth ethical analysis of non-surgical cosmetic procedures in individuals with BDD, based on empirical investigation of the views and experiences of cosmetic practitioners and mental health professionals.

Methods

Six participants were interviewed between April and June 2017: two senior clinical psychologists; one consultant psychiatrist; one consultant dermatologist; and two cosmetic practitioners (both trained physicians now exclusively working in non-surgical cosmetic practice). All participants reported contact with individuals with BDD within clinical/cosmetic practice. Participants were recruited through purposive sampling targeting members of a professional body for UK clinicians; individuals who engaged with the Nuffield Council on Bioethics; and those involved in UK postgraduate medical education. Signed informed consent was obtained, and face-to-face interviews conducted (with one phone interview) and audio recorded. A topic guide was followed including: experience of individuals with BDD seeking non-surgical cosmetic intervention; decision-making processes regarding whether to provide such intervention; impact of BDD on capacity; and optimal management of such individuals. Audio files of interviews were transcribed verbatim. A grounded theory inspired approach guided data coding and analysis. Manual, line-by-line coding was conducted, and coded transcripts analysed to give rise to themes. Two themes underwent in-depth ethical analysis: the best interests of the individual with BDD; and the impact of BDD on capacity to consent to non-surgical cosmetic procedures.

Results

Theme 1: best interests of the individual with BDD

Cosmetic procedures are not in the best interests of individuals with BDD

Participants suggested that non-surgical cosmetic interventions should not be carried out on individuals with BDD as they are not in their best interests. This was deemed to be the case as the core problem in BDD is psychological rather than aesthetic, thus: ‘…it just doesn’t deal with the central problem’ (No 2, clinical psychologist). Similarly, a cosmetic practitioner advocated: ‘…the way to treat these people is not by addressing their physical thing on their face’ (No 3, cosmetic practitioner).

Moreover, participants found that individuals with BDD tended to remain dissatisfied after procedures, due to the original appearance concern resurfacing (No 1, dermatologist), or a new preoccupation developing in its place (No 4, psychiatrist).

In addition to being unlikely to confer benefit, concern was voiced regarding the potential psychological harm of non-surgical procedures in this group. A cosmetic practitioner feared that intervention would ‘feed into’ appearance preoccupation, ‘reinforcing their negative belief’ (No 5, cosmetic practitioner). Similarly, a dermatologist worried that cosmetic procedures could delay effective management:

I would not encourage them [cosmetic practitioners] to manage aesthetically without having somebody managing their BDD at the same time… I would have big concerns then, that would be dangerous…in terms of…continuing disease, and frankly, suicide. (No 1, dermatologist)

Apprehension was also expressed regarding the physical risks associated with non-surgical interventions (No 1, dermatologist). A cosmetic practitioner described a raft of adverse effects of dermal fillers including blindness, blood vessel occlusion and face ‘break down’ (No 2, cosmetic practitioner).

Lack of empirical evidence to inform risk/benefit analysis

Participants expressed a desire to inform their decision-making with empirical evidence, however bemoaned the paucity of research related to BDD and non-surgical cosmetic intervention. A psychiatrist asserted that ‘the data is not there’, and called for well-designed, prospective studies of the outcomes of non-surgical cosmetic procedures in this cohort (No 4, psychiatrist). In addition, the development of a ‘culture of proper assessment and audit’ within the cosmetic sector was advocated by one psychologist, who proposed that the outcomes of every non-surgical cosmetic procedure be routinely recorded to inform best practice (No 2, clinical psychologist).

Referral to mental health services is in the best interests of individuals with BDD

Onward referral of individuals with suspected BDD to mental health services was advocated. Cosmetic practitioners recalled having done this in their own practice, either by referring directly to private services, or writing to the individual’s general practitioner (with consent). Referral for mental health assessment was considered essential as psychological and psychiatric interventions have proven effectiveness in the treatment of BDD (No 4, psychiatrist). Additionally, mental health treatment was considered intuitively appropriate as it targets the psychological crux of the disorder (No 2, clinical psychologist).

Obstacles to accessing mental health services

Numerous obstacles were perceived to impede access to mental health services. The lack of insight of many individuals with BDD into their condition was noted to hinder engagement, as a psychologist described, ‘…they’re not ready to talk…they didn’t believe that it was a psychological thing’ (No 6, clinical psychologist). Moreover, the ‘…big stigma of being seen by a psychologist’ may further inhibit uptake (No 6, clinical psychologist). Contrastingly, a cosmetic practitioner recalled their surprise at a client’s willingness to engage in psychological therapy and relief at this being proposed (No 3, cosmetic practitioner). Long waiting times due to lack of resources and investment in specialist mental health services were further cited as impeding access (No 1, dermatologist; No 4, psychiatrist; No 6, clinical psychologist). Referring individuals onwards to private mental health services was also deemed challenging due to uncertainty who to refer to. Therefore, the need was expressed for interdisciplinary networks to form, linking non-surgical cosmetic practices and mental health services (No 5, cosmetic practitioner).

Theme 2: impact of BDD on capacity to consent to non-surgical cosmetic procedures

Assessing whether BDD can impair capacity to consent to non-surgical cosmetic intervention generated uncertainty. A psychiatrist described this issue as something they ‘grappled with’, but could reach no conclusion. They illustrated their dilemma with the example of a cosmetic practitioner warning an individual with BDD that:

This really isn’t a good idea…it’s unpredictable…you may be dissatisfied…you’re still going to have your BDD symptoms and so on. And the patient who says, ‘yeah I understand that, but there’s a chance here that I will get some improvement of my particular defect’…Are they really able to weigh up that decision making? (No 4, psychiatrist)

Contrastingly, a psychologist concluded that the criteria stipulated in the English Mental Capacity Act (MCA) (2005) definition of capacity are not overtly influenced by the presence of BDD, and thus the condition does not impair capacity to consent to non-surgical cosmetic intervention (No 6, clinical psychologist).

Relevance of the legal definition of capacity

However, uncertainty was also expressed regarding the appropriateness of the legal framework of capacity. A psychiatrist worried that decisions that appear foolish may be wrongfully taken as evidence of lack of capacity as, according to the MCA, judgement of capacity depends on whether the assessor is convinced that an individual with BDD has weighed up the facts about a cosmetic procedure properly. This led to the assertion that ‘I don’t think the law has really got it right yet’ (No 4, psychiatrist).

Discussion

The empirical component of this study generated novel insights into ethically relevant views of cosmetic practitioners and mental health professionals regarding non-surgical cosmetic procedures in BDD. These findings are used to inform in-depth ethical analysis, focusing on the issues of best interests and decision-making capacity.

What is in the best interests of individuals with BDD?

The view that non-surgical cosmetic intervention should not be carried out on individuals with BDD, as is not in their best interests, emerged as a study finding. This ethical rationale is contingent on the empirical matter of the costs and benefits of such procedures in this group.19 To date, only one study has specifically evaluated the outcomes of non-surgical cosmetic procedures in BDD.22 This retrospective study of 200 patients with BDD found 26 self-reported instances of non-surgical cosmetic intervention. Notably, 27% of interventions generated subjective improvement in the perceived appearance of the treated body part, and 19.2% led to improvement in preoccupation with the treated part. However, overall, merely 4% (one procedure) resulted in self-reported long-term improvement in BDD symptoms in general.22 A larger study evaluating the outcomes of cosmetic interventions of any kind echoed these findings. This was attributed to participants either becoming concerned about another body part; remaining distressed about lesser ‘imperfections’ in the treated area; or worrying that it would become ‘ugly’ again.12 The largest review of the literature to date concluded from evaluation of 11 studies that ‘in spite of the paucity of research and the methodological limitations, the weight of evidence thus far leans towards the conclusion that cosmetic treatment may be an ineffective intervention for the majority of individuals with BDD’.23

Concerns that cosmetic procedures may incur harm, both physical and psychological, were also elicited. There is no official process for reporting adverse events in the UK non-surgical cosmetic sector, nevertheless clinical reports exist.16 In particular, dermal fillers have been associated with subcutaneous granuloma formation, infection, blood vessel occlusion and blindness.24–26 Complications appear to be relatively common: a survey of UK plastic surgeons reported that 69% had been consulted by patients suffering from adverse effects of fillers, and 41% had seen patients who required surgery or were untreatable as a result.27

Onward referral to mental health services to facilitate pharmacological and psychological management was advocated. Selective serotonin reuptake inhibitor medications and cognitive–behavioural therapy (CBT) are the recommended treatment modalities for BDD in the UK.28 A 2009 Cochrane Review (based on five eligible trials) concluded that ‘both pharmacotherapy and psychotherapy may be effective in the treatment of BDD’, with the caveat of a small evidence base.29 In addition, these treatments appear to be well tolerated, with the review reporting ‘high compliance rates, and no drop-outs due to treatment-emergent adverse events’.29

Overall, empirically informed risk/benefit analysis suggests that it is, in general, in the best interests of individuals with BDD to be refused non-surgical cosmetic intervention and referred for mental health input. There may be extreme scenarios which present challenges to this, for example, where the alternative to providing non-surgical cosmetic interventions is to risk self-mutilation which, although uncommon, is reported in BDD.4 Moreover, emerging evidence suggests that certain procedures, such as cosmetic labiaplasty, may have significantly better outcomes in BDD than others.19 20 However, this has yet to be investigated in the context of non-surgical cosmetic interventions. Further research is indicated, but in the meantime the existing evidence supports a precautionary approach.

Can BDD impair capacity to consent to non-surgical cosmetic procedures?

The English MCA (2005), used by participants to assess decision-making capacity for non-surgical cosmetic procedures in individuals with suspected BDD, stipulates that a person lacks capacity if due to an ‘impairment of, or a disturbance in the functioning of, the mind or brain’ they are unable to ‘understand the information relevant to the decision, to retain that information, to use or weigh that information as part of the process of making the decision, or to communicate his decision’.30 Spriggs and Gillam adopt a similar framework in their consideration of cosmetic labiaplasty in BDD, contesting that there is no reason to think that people with BDD are unable to ‘critically reflect and make decisions backed up by reasons’, and as such the condition does not necessarily impair capacity.19

However, the findings of this study suggest that the question of capacity in BDD is not so clear-cut. As a psychiatrist participant questioned: despite displaying apparent knowledge and understanding of the facts regarding non-surgical cosmetic procedures, are individuals with BDD able to make truly meaningful decisions, given that they are so powerfully compelled to ‘rectify’ the feature they perceive to be ugly?

This issue has not been analysed previously in the context of BDD. However, similar questions have been considered regarding individuals with severe anorexia nervosa (AN) who refuse feeding and hydration.31–34 This is the case as the intellectual abilities assessed by legal tests of capacity appear to be maintained in many individuals with severe AN, despite extremely low body weight.32 Thus, situations arise where treating clinicians’ intuition that an individual with severe AN who refuses life-sustaining treatment lacks capacity to do so, is at odds with the outcome of standardised capacity assessment.34

Parallels exist between AN and BDD in this respect: both conditions appear to evoke a sense of affected individuals being unduly influenced by features of their illness, when making decisions regarding interventions related to body image. Yet, as this does not occur in a manner that overtly impairs cognitive abilities (such as memory loss in Alzheimer’s dementia, or thought disorder in psychosis) it does not obviously impact capacity assessment.

However, this analogy is drawn cautiously, with the caveat that there remains a paucity of empirical evidence regarding decision-making processes in individuals with BDD. In contrast, there exists a small body of empirical work in patients with AN, the findings of which have been used to inform ethical analysis regarding decision-making capacity in treatment refusal.32 35–37

Nevertheless, there is merit in considering suggestions made to explicate this dissonance between the outcome of legal tests of capacity and the intuition of treating clinicians and ethicists in the context of AN as this could, in theory, enlighten understanding of capacity in BDD.

One concept that has gained prominence in the bioethical literature is that of pathological values.31 36 In brief, Tan et al propose that in individuals with severe AN decisions regarding treatment are largely dictated by values that arise from the mental disorder (pathological values)—specifically an extreme revulsion to weight gain.36 Correspondingly in BDD, affected individuals’ decisions regarding non-surgical cosmetic procedures are likely shaped by the pathological value of an intense dislike of a particular feature. In both cases, standard capacity assessment may not acknowledge the significance of these pathological values, as they do not overtly impact the ability to proceed through the cognitive processes of decision-making.38

Furthermore, Tan and Hope propose that pathological values are inauthentic, as they do not reflect the values the individual would likely hold in the absence of mental disorder. As such, decisions dictated by these values are not genuine exercises of autonomy and can, if associated with significant risk of harm, be legitimately over-ridden.36 A simple indicator that such pathological values are not inherent to the individual would be their absence premorbidly, onset contemporaneously with other features of the disorder and their waning with treatment.36

Such a trajectory is likely observable in many cases of BDD, with respect to the pathological value of an intense dislike of a particular feature (empirical work is however indicated to validate this). This supports the claim that this pathological value is not authentic and, when it underpins decisions regarding non-surgical cosmetic interventions, renders them inauthentic expressions of autonomy, so undermines capacity to consent. Impaired capacity, combined with recognition of the risk of harm posed by non-surgical cosmetic intervention, means that such decisions should not be respected.

Yet, as a psychiatrist participant in the present study questions, how can we assess the impact of another’s values on their decision-making, without risking branding those with seemingly unwise values, giving rise to subjectively foolish decisions, as lacking capacity. This is objectionable in a liberal society, where the ‘negative liberty’ to pursue one’s own ends without external interference is celebrated.36 39

This risk appears to pose a weighty objection to including consideration of pathological values in capacity assessment. However, tests of capacity in widespread clinical use already incorporate an element of subjectivity in the clinical judgement required to determine whether an individual is able to understand, and weigh up relevant information to reach a decision. To completely standardise this process appears untenable. In fact, various domains of psychiatry (and clinical medicine generally) rely on subjective evaluation in conjunction with objective evidence, including diagnosis, risk assessment and monitoring of treatment response.

Moreover, an important distinction must be stated. Consideration of pathological values within capacity assessment does not amount to a judgement of the mere content of another’s values (which would indeed risk foolish or idiosyncratic values being wrongly equated with incapacity), but rather an in-depth evaluation of whether the individual’s overall presentation is in keeping with a mental disorder, and whether the values brought to bear in their decision-making are derived from this. The exercise of establishing the provenance of values that are suspected to be pathological is common practice in mental healthcare. Indeed, identifying and modifying unhelpful values associated with mental illness is central to psychological treatment modalities such as CBT for BDD.40

However, the fact that an element of subjective evaluation is interwoven throughout psychiatry (and medicine) should not condone complacency. Inappropriate value judgements that have no place in capacity assessment could conceivably masquerade as holistic clinical judgements, particularly given the stigma that abounds concerning mental illness.31 Safeguarding against this is likely best achieved by acknowledging and highlighting this risk. With this in mind, we must maximise transparency of capacity assessments, and ensure appropriate oversight. Practical steps towards this include the seeking of second opinions, and the proliferation of ethics committees within psychiatry, with representation from a range of relevant stakeholders.

Limitations

This study has a number of limitations. Firstly, the sample size was small, particularly given that participants from different professional groups were included. Secondly, the sampling strategy introduced selection bias. Further, larger empirical studies including the perspectives of individuals with BDD are undoubtedly indicated.

Conclusion

This empirically informed ethical analysis has illuminated important considerations raised when individuals with BDD consult for non-surgical cosmetic procedures, and given rise to a number of recommendations. Firstly, evaluation of the risks and benefits of non-surgical cosmetic intervention in individuals with BDD suggests that such procedures are generally not in their best interests, as have poor outcomes, and risk incurring adverse effects. Therefore, refusing to carry out non-surgical cosmetic intervention in this context, and instead referring to mental health services is advised. However, this recommendation is made with the caveat that the empirical evidence base is lacking. Worthwhile avenues for future research include investigation of the outcomes of different non-surgical cosmetic interventions in BDD; monitoring of adverse effects of procedures; and further evaluation of the efficacy of pharmacological and psychological treatments. Secondly, pathological values are argued to underpin certain decisions regarding non-surgical cosmetic procedures in individuals with BDD. It is proposed that such values impair decision-making capacity, as do not represent true expressions of autonomy. Therefore, decisions dictated by pathological values can, and should, be justifiably over-ridden when they risk harm, such as that associated with non-surgical cosmetic intervention. Future empirical study elucidating the decision-making processes of individuals with BDD regarding non-surgical cosmetic intervention is undoubtedly indicated to validate this claim. Overall, this empirically informed ethical analysis represents an original contribution to the evidently important but, as yet, underexplored field of non-surgical cosmetic procedures and BDD.

Data availability statement

All data relevant to the study are included in the article.

Ethics statements

Patient consent for publication

Ethics approval

Approval granted from King’s College London Research Ethics Office (reference number MR/16/17-360).

Acknowledgments

The author acknowledges the valuable supervision and feedback received from Professor Barbara Prainsack, Dr Silvia Camporesi and Dr Giulia Cavaliere while this study was being conducted at King’s College London.

References

Footnotes

  • Twitter @nataliemlane

  • Contributors NML developed the research idea; planned and designed the study; carried out data collection and analysis; conducted the ethical analysis; wrote the initial manuscript; and revised the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.