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Cosmetic procedures practice and promotion 'cause for serious concern,' says ethics body

June 21, 2017

"There are legal age limits for tattoos and sunbeds. Children should not be able to walk off the street and have an invasive cosmetic procedure."

New developments and marketing have made an increasing range of surgical and non-surgical cosmetic procedures -- including botox, dermal fillers, implants, and skin lightening, as well as newer techniques such as 'fat freezing' and 'vampire' treatments -- big business and widely accessible.

Today (22 June) the Nuffield Council on Bioethics publishes a wide-ranging new report, Cosmetic procedures: ethical issues, which makes a series of recommendations that highlight areas of concern for the practice and promotion of invasive cosmetic procedures. The report primarily focuses on the UK, but as cosmetic procedures and appearance ideals are global phenomena, and having looked at evidence from other parts of the world, we hope the report will help those asking similar questions elsewhere.

A ban on offering 'walk in' cosmetic procedures to young people

Under 18s are bombarded by social media and popular culture that focus on body image. The Council is concerned that they feel the need to conform to appearance 'ideals'. These expectations are exacerbated by apps that present cosmetic surgery as a game.

Jeanette Edwards, Professor of Social Anthropology from the University of Manchester, who chaired the Council's inquiry, said: "We've been shocked by some of the evidence we've seen, including make-over apps and cosmetic surgery 'games' that target girls as young as nine. There is a daily bombardment from advertising and through social media channels like Facebook, Instagram and Snapchat that relentlessly promote unrealistic and often discriminatory messages on how people, especially girls and women, 'should' look."

The report recommends that social media companies collaborate to carry out independent research to better understand how social media contributes to appearance anxiety, and to act on the findings.

Taking into account appearance pressures on young people, the Council also recommends a ban on providing invasive cosmetic procedures to people under 18, unless a team of health professionals, including specialists, GPs and psychologists, are involved.

Professor Edwards said: "Under 18s should not be able to just walk in off the street, and have a cosmetic procedure. There are legal age limits for having tattoos or using sunbeds. Invasive cosmetic procedures should be regulated in a similar way."

More data and improved testing for unproven products and procedures

The Council's report also calls for a complete overhaul of the regulation of products used in cosmetic procedures - particularly dermal fillers. Fillers that have no formal quality or safety approval can currently be bought freely in the UK, and there are no limits on who can inject them.

The report recommends that the UK Department of Health should make all dermal fillers 'prescription-only', which, as well as placing limits on which fillers can be used, will mean that those prescribing them need to take professional responsibility for their injection.

Mr Mark Henley, a plastic surgeon and member of the Council's inquiry group, said: "We need to overturn the belief that fillers are risk-free. I've seen serious and long-term injuries from fillers in my clinic. Even fillers injected properly can cause lumps [granulomas] that have to be surgically removed. They have even been known to cause blindness and loss of facial soft tissues in rare cases."

The Council says that the UK Department of Health must work with professional bodies to ensure that information on the number and type of cosmetic procedures carried out in the UK is collected and made publically available. Data and research are also needed to improve the very poor evidence base on the outcomes of procedures. Professor Edwards said: "These procedures are not trivial. To help people make good decisions, they need access to high quality information which they often don't get. We also need better information on whether these procedures provide the long-term physical and psychological benefits that people often hope for."

Improvements needed for an unregulated industry

The Council believes it is unethical that there is nothing to stop completely unqualified people from providing risky procedures like dermal fillers. It says that anyone offering invasive cosmetic treatments should be trained and certified before being allowed to practise. The Council also calls for an awareness campaign to help people check their practitioner's credentials.

Professor Edwards, said: "It should be easy for people to check that the person giving them a cosmetic procedure is properly qualified and trained, but at the moment it isn't." The Council also calls on the Government to fully implement recommendations made by the Keogh report in 2013 so the public can be assured that those providing cosmetic procedures, the places where they are carried out, and the products used are all properly regulated.
Notes to Editors:
  • The Nuffield Council on Bioethics is an independent body that examines and reports on ethical issues in biology and medicine. It is funded by the Nuffield Foundation, Wellcome and the Medical Research Council, and has an international reputation for advising policy makers and stimulating debate in ethical issues that impact on society.

  • The Council is entirely independent of any provider of cosmetic procedures.

  • The Cosmetic procedures: ethical issues report is the product of an inquiry carried out by an interdisciplinary Working Group that included expertise in cosmetic procedures, anthropology, appearance research, disability, race issues, psychology, philosophy, regulation, ethics and law. The report was informed by the views of people who have had, would consider, or who would never consider a cosmetic procedure; young people; practitioners, 'provider' companies, regulators, insurers; and academics.

  • In 2013, in a report commissioned by the Department of Health, Sir Bruce Keogh described aspects the cosmetic procedures industry as a "crisis waiting to happen".

Other key recommendations in the report include:
  • Professional standards and 'quality-marking' of providers of both surgical and non-surgical procedures

  • Educational resources on body image for all children, delivered through the school curriculum

  • Stronger standards and enforcement by the Advertising Standards Authority of material that promotes particular appearance 'ideals' (mirroring the Transport for London response to controversial 'Beach Body Ready' posters)

  • A more responsible approach from social and broadcast media platforms, including the banning of cosmetic surgery games or apps aimed at children

  • Better information for users and a code of practice for those providing cosmetic procedures

Facts and figures:
  • There is very little publicly available information about the size and value of the cosmetic procedures market, and of the number of procedures carried out, other than estimates by market research companies, suggesting sustained growth.
    • One estimate for the UK sector in 2015 (including surgical and non-surgical procedures) was £3.6 billion, up from £720 million in 2005. In the US, the cosmetic surgery market alone was assessed in 2015 as $20 billion.
    • An estimate from 2009 suggested 1.2 million procedures took place a year in the UK (of which 90% were non-surgical and 10% surgical)
    • Products and procedures previously used in medical care are now being 'repurposed' for cosmetic uses when claims for effectiveness are often not based on evidence. Examples include:
    • using dermal fillers and botox in different body areas, like feet and ears.
    • 'fat freezing' as anon-surgical alternative to liposuction
    • 'Vampire' treatments, injecting elements of the patients' blood into their face and breasts
  • Results of a 2012 poll of a group of UK plastic surgeons [members of the British Association of Aesthetic Plastic Surgeons] revealed that more than two thirds (69%) had seen people with complications following temporary fillers, and 4 in 10 (41%) reported seeing patients who either needed corrective surgery, or who were assessed as untreatable, due to the damage caused.

  • Mounting pressures to 'look good' resulted in NSPCC's ChildLine service receiving nearly 1600 contacts from girls worried about body image last year (2015/16), up 17% on the previous year. NSPCC highlighted the increasing number of counselling sessions with young people where issues of body image were raised.

  • Twenty seven percent of late teens care more about their appearance than their physical health, according to a 2017 survey by the National Citizen Service.

  • Evidence shows that people with pre-existing mental health problems are more likely to have worse psychological outcomes after cosmetic procedures 0- this might include people with body dysmorphic disorder and people taking medication for anxiety.

Nuffield Council on Bioethics

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