Workshop 2 report: Professionals, practitioners and beauty norms

The workshop was the second in a series orgainsed by the BeautyDemands project and was held on 3 and 4 June 2015 at the Nuffield Council on Bioethis, London.


Hugh Whittall & Heather Widdows

Hugh Whittall introduced the workshop and gave an overview of the role of the Nuffield council on bioethics.

Heather Widdows then introduced the BeautyDemands project. She discussed the aims of the network and the workshop, as well as current and future work in terms of the blog and social media as well as more traditional outputs of papers, special issues, and/or edited collections and policy briefing papers.

Finally, the aims of Workshop 1 were introduced, as well as the format and expectations of the workshop.


Nichola Rumsey, ‘I don’t like the way I look: the tyranny of normative discontent’

Abstract: Significant levels of dissatisfaction with appearance have been reported in more than 70% of the population. This talk will offer a brief overview of the evidence relating to the impacts of this 'normative discontent' on the psychological wellbeing and physical health of those affected and of current understanding about the psychological factors motivating people to seek appearance-enhancing surgery. Recent research has shed some light on the short-term impacts of cosmetic surgery and on the psychological risk factors for poor post-operative satisfaction. Ways of embedding effective pre-operative screening and postoperative follow-up into routine care will be discussed.

Discussion: Is beauty really unrelated to success in the job market and professional world more generally? Participants mentioned other studies which have suggested that ‘beauty matters’ in this regard, with ‘good looking’ candidates being judged to have performed better at interview and having a higher call-back rate, for example. In reply, Nichola suggested that this way well be the case in the short-term, but not over the long haul: studies show that we only consider appearance for a very short time (maybe as short as 15 seconds). But even so, in a competitive job-market might this give someone the edge they need?

Tension between the idea that beauty matters is a myth and the idea that poor self-image can be an important source of low self-esteem. In other words, not liking the way we look is a driver of low self-esteem, yet changing the way we look doesn’t boost self-esteem. Need to tackle unrealistic and pernicious beauty norms so that people are happier with the way they look.


Mark Henley, ‘I don’t like the way I behave: The conflict between emotion, ethics and enterprise’

Abstract: Cosmetic Practice is unique in that the successful outcome of any intervention is a matter of perception rather than objective technical assessment. Whilst it is fashionable to think of cosmetic procedures and surgery as lifestyle choices, a feeling of personal vulnerability is a shared experience for patients/clients and practitioners. Much emphasis has correctly been placed upon the welfare and protection of the individual seeking the intervention but creating a culture where there is a similar emphasis upon the professional welfare and emotional wellbeing of individual practitioners may benefit the population in a much more sustainable fashion than continued attempts to achieve best practice by regulation alone. Developments in UK mainstream training and professional practice which have been achieved over the last decade will be discussed. These have contributed to a positive culture change in cosmetic surgical practice which it is hoped will assist the many remaining challenges to be overcome.

Discussion: Example given of a cosmetic surgeon who insisted on breast reconstruction after double mastectomy, against the patient’s wishes. Mark replied that this kind of insistence was now rare, but that some surgeons will think they know what is best for the patient. It was also pointed out that there can be a financial incentive to do mastectomy and reconstruction at the same time rather than as two separate procedures, to save on cost. However, evidence has suggested that it is actually better for patients to have reconstruction later.

Issue of consent: Given that we know that many people wanting cosmetic surgery have low self-esteem, and given how pervasive beauty norms are, how can we make know that people’s consent to treatment is reliable? Mark emphasised that profession needs to operate with a lower threshold for screening than at present.


Chris Khoo, ‘Towards the regulation of cosmetic practice’

Abstract: I would like to take you on a journey through my specialty of plastic, reconstructive and aesthetic surgery, and then focus on the present situation with regard to cosmetic provision. How is an individual’s concept of personal beauty affected by the norms of society? What are the current trends? We’ll need to work through some definitions: for example, cosmetic and aesthetic. Who provides treatments, and how are practitioners trained and regulated? Where does the law stand, and how can patients be best protected, (sometimes from themselves)? And what mechanisms are in place to control the provision of cosmetic services? Our time will touch on issues of consent, safety and regulation, and I hope that we can share perceptions, and suggest ways of improving the patient experience.

Discussion: Why, given that both patients and surgeons have an interest in regulation, is there no political will for regulation? Answer: legislation will be very expensive. Of course, some measures could be easily introduced, e.g. advertising could be banned. However, this is hard to enforce and has only had limited success where it has been introduced, e.g. in France. Ideally, regulation needs to come at a higher level, but, again, this will be expensive.


Graduate Session

Rebecca Nash, ‘The horror of imperfection: the web, aesthetic surgery and the perpetuation of deficient female bodies’

Abstract: Adhering to prevailing aesthetic standards is a central facet of contemporary consumer culture. How individuals do so has evolved with technologies and influence from media imagery. With growth of media and services, the latter half of the twentieth century saw aesthetic surgery procedures become both increasingly popular and largely normalised within societies. The emergence and growth of the Web has potentially altered how aesthetic surgery is researched, discussed, and pursued. The Web is the largest human information construct in history. Individuals have gone from mostly consuming various edited materials, to being producers and consumers of Web content. It is argued here that the web enables employment of what Wegenstein and Ruck (2011) term a cosmetic gaze, on a scale not previously seen.

This study employed multimodal critical discourse analysis (MMCDA) of multiple Web spaces --‐ gauging a snapshot of how aesthetic surgery is represented online. Online news content, surgery provider websites, online discussion forums, and online video content were examined. Across a two--‐month period, 165 articles were retrieved from English language online news sources, along with 78 forum threads consisting of 1136 total posts, data from 10 aesthetic surgery provider websites – UK--‐based and international --‐ and 10 of the ‘most viewed’ videos from YouTube located using keywords ‘cosmetic surgery’.

It was found that the Web is visually and linguistically producing and eliciting responses from individuals and companies that denigrate female bodies in different ways. Altered bodies are positioned in contrast to unaltered bodies, judged unworthy of praise due to perceived lack of labour, such as exercise. Pre--‐ surgery unaltered bodies are problematised through the construction of multiple physical flaws. Post--‐surgery bodies are critically discussed as either successes – usually when the results of surgery is invisible --‐ or failures if the results look ‘fake’ or procedures have been botched. Bodies judged as excessively altered are turned into a spectacle of horror to be derided by users. Injuries sustained during botched procedures were often focused on – with photographic evidence playing a central role in sensationalising stories. Although there were some exceptions where individuals were praised as ‘natural beauties’, they remained a small minority.

Aesthetic surgery in some spaces is advocated as a solution to perceived imperfections and low body image; in others, it is driving low body image. Bodies that have undergone – or are perceived to have undergone --‐ aesthetic surgery are variably applauded for being ‘improved’, criticised as ‘fake’, or derided as deservedly ‘grotesque’ if something goes wrong. Web users are faced with spaces that do not provide a cohesive or consistent representation of ideal bodies or aesthetic surgery, but perpetuate the notion that female bodies are aesthetically deficient altered or unaltered.


Kirsty Lee, ‘Beauty and the beast: exploring the relationship between childhood bullying and beauty values’

Abstract: In this paper, I will discuss what is known about the relationship between bullying by peers and attitudes towards cosmetic surgery. It is well known that messages about beauty in modern culture are pervasive. It is no surprise then that body dissatisfaction starts early. Body dissatisfaction is particularly prevalent in females, who are not only exposed to these omnipresent messages from a young age, but also receive more personal comments and judgements about their appearance. Despite these cultural influences, body satisfaction or esteem is distinctly damaged by another source –peers. Evidence suggests there is a bi-directional and long-lasting relationship between peer victimisation and negative body perceptions. For example, victimisation in adolescence predicts body shame in adults, and evidence is now highlighting a link between teasing and cosmetic treatments. The prevalence of teasing in patients undergoing a cosmetic treatment is approximately 40%. As females are much more likely to have a cosmetic treatment, the majority of research has thus focused on them and we know little about males. A point of interest is that generally males with actual or perceived lower body mass indexes (BMIs) are more likely to be victimised, and males with lower BMIs appear more accepting of cosmetic treatments. In an attempt to further explore the relationships between bullying, body esteem, and interest in cosmetic treatments, I am conducting a study on children aged 11-16 years. The key research questions are: Does bullying predict interest in cosmetic treatments in 11-16 year olds? Is the effect direct or is it mediated by perceived attractiveness or body esteem? Compared to victims, are bullies and bully-victims more or less interested in cosmetic treatments, and how do they differ from neutral children? What value do children involved in bullying place on beauty ideals (attractiveness and weight) for themselves, their friends and romantic partners? Do these values differ from neutral children? And does sex, age, or self-esteem moderate any of the relationships? I will discuss the existing research on these questions, where research exists. By examining these relationships more closely, we can better understand the extent to which bullying is a driving factor in a person’s interest in cosmetic treatments. It might then be possible to offer psychological interventions to individuals with treatable psychological disorders, rather than reinforcing the belief they are not good enough as they are.


Carolyn Mair, ‘Beauty in fashion’

Abstract: Fashion is an important global economy which was worth approximately 1.8 trillion USD in 2013. It exerts a powerful and pervasive influence on individuals’ daily life and helps shape and facilitate the expression of their identity. However, fashion is also associated with negative outcomes such as body dissatisfaction, low self-esteem and feelings of marginalisation and exclusion. Despite the growing evidence on the negative impact of fashion and media images, the problem remains. Body dissatisfaction has been identified as one of the most consistent and robust risk factors for eating disorders in women and a significant predictor of low self-esteem, depression, and obesity. The Mental Health Foundation reports that 1.6 million people in the UK are affected by serious mental health problems manifesting in an eating disorder. Although eating disorders can have a range of aetiologies, in many cases they are attributed to the influence of obsession with slimness promoted through the media and fashion. One of the consequences of increased body dissatisfaction is a rise in the use of body-altering interventions on the part of people who do not conform to the ideal of the white, thin, young fashion models. In a recent review of the literature, the American Psychological Association’s Task Force on the Sexualisation of Girls reported a rise in the demand for cosmetic surgeries and non-surgical beauty treatments among young girls. In middle-aged women, body dissatisfaction and media exposure predict attitudes towards and consideration of surgical and non-surgical cosmetic interventions. This presentation will discuss current understanding of psychological implications of ‘beauty in fashion’ and outline proposals to address them.

Discussion: Has fashion industry improved? Some evidence of this, e.g. more ‘plus-size’ models. However, in reply it was pointed out that there remains a real lack of diversity in fashion.

Why is this? Is there any basis in the idea that thin, tall, white models sell, while others don’t – that, as one designer put it, ‘black models don’t sell’? No, studies have shown that people are more likely to buy products if models look more like them. This challenged the widespread idea that advertising often works best when it encourages us feel unhappy about how we look, bad about ourselves, etc.


Ian Jenkins, ‘Defining Beauty: The body in ancient Greek art’

This talk discussed the current exhibition ‘Defining Beauty: The body in ancient Greek art’ at the British Museum in London. For centuries the ancient Greeks experimented with ways of representing the human body, both as an object of beauty and a bearer of meaning. The remarkable works of art in the exhibition range from abstract simplicity of prehistoric figurines to breathtaking realism in the age of Alexander the Great. These works continued to inspire artists for hundreds of years, giving form to thought and shaping our own perceptions of ourselves.


Sara Creighton, ‘Female genital cosmetic surgery (FGCS): A gynaecologist’s view’

Abstract: Gynaecologists and plastic surgeons are increasingly likely to be consulted by women and girls seeking surgical treatment for perceived genital abnormalities. Most commonly requested is a labiaplasty where the labia minora are reduced in size by the removal of a strip or wedge of labial tissue. The primary motivation for women requesting labiaplasty is concern about genital appearance although practical difficulties with hygiene, discomfort during sex and tampon insertion as well as discomfort with exercise and tight clothing are often mentioned. Female genital appearance is variable and depends upon the relative sizes and shapes of the labia majora and minora, clitoris and vaginal introitus. There is limited scientific research on female genital anatomy but small studies have shown that most women seeking labiaplasty have labia minora that fall within normal limits

There are no accurate data on the total numbers of procedures performed. NHS labiaplasty figures rose five fold between 2000 and 2010. Recent numbers of NHS procedures have decreased although this is likely to be due to a change in commissioning health care rather than reduced requests for surgery. Labiaplasty is now listed as a “procedure of uncertain benefit” and requires specific justification from the surgeon for each individual case. Even prior to this designation the majority of labiaplasties were performed in the private sector.  The exact number of private cases performed is unknown as there is no requirement for surgeons in the private sector to record numbers performed. Widespread advertising by the large number of private clinics suggests that labiaplasty is easily accessible and frequently performed.

There are currently no controlled trials or prospective studies investigating the clinical effectiveness or risks of labiaplasty procedures. Available studies offer scant descriptions of methodology and are usually authored by the operating surgeons resulting in little independent evaluation. There are no data on the efficacy of treatment for functional problems, and pre- and post-surgical symptoms such as physical discomfort, appearance and sexual dissatisfaction are difficult to assess. Where labiaplasty is performed for cosmetic reasons, the evidence of efficacy comes mainly from responses to questions from the surgeons. Short-term satisfaction rates of up to 100% have been claimed, but there is no robust evidence to substantiate this conclusion. Whilst short-term risks such as infection, bleeding and wound dehiscence are reported, there are no data on other potential physical and psychological risks such as revision operations for dissatisfaction with the initial result. Long-term impacts such as damage to genital sensitivity and sexual function and an increased risk of perineal trauma during vaginal delivery have been mooted but not explored

 Clinicians should provide women and girls with accurate information on the normal genital variation and also on the lack of data on the risks and outcomes of surgery. Simple measures to alleviate genital discomfort may be of benefit. Counselling and short-term, focused psychological treatments for body image distress, sexual difficulties and low self esteem are available. Labiaplasty should not be performed in girls under the age of 18 years to allow completion of pubertal development. If adult women chose to undergo labiaplasty, fully informed consent is mandatory as is the case for all surgical procedures. Further research is required to establish normal variation for external genitalia and to set objective measures for the success and long-term risks of all FGCS procedures including labiaplasty.

Discussion: What should be done to counteract the rise of FGCS? For GPs, the emphasis should be on emphasising how normal difference is, the downsides of surgery, and the importance of good hygiene. Once again, it is important to emphasise that we should not trivialize the matter.  

Who is to blame? Beauty norms have become very prevalent. Important to note that it is not as simple as a money-spinning thing for the medical profession. Surgeons are often concerned to help women who are deeply unhappy, and feel responsibility to do so.

Anecdotal increase in male genital surgery as well, but no detailed data for this yet. This suggests that this is a general problem about body image, rather than one which is particular to women.

Increase in FGCM in young women in particular – especially problematic.


Paquita de Zulueta, ‘Female genital cosmetic surgery: A GP ethicist’s perspective’

Abstract: I have practised as a GP in London for thirty years and have noticed a recent and growing trend in adolescents and young women who present with deep concerns, accompanied by shame and disgust, about the appearance of their normal healthy genitalia (and I shall present anonymised narratives). This personal perception is reflected more widely – there has been a five-fold rise in labiaplasties carried out in the NHS in ten years (2003-2013), with 2000 in 2010 alone, and 266 on girls aged 14yrs or younger between 2008-2012. Many more are being conducted in the private sector, with GP’s often bypassed. There are a number of reasons for this disturbing trend, but the fact that labiaplasty is normalised and permissible, yet FGM, even in its mildest form and with competent consenting adult women, is illegal, is inconsistent, and in my view represents a form of Western ethical imperialism. I will explore the ethical issues around labiaplasty – in particular the requirements for adequately informed consent, the validity of the justifications given for the procedure, the robustness of individual autonomy and the role of professional ethics in this context. I will offer some proposals that could help to remedy ignorance and mitigate prejudice regarding female genitalia in what has become a medicalised, highly commercialised and gender-specific domain.

Discussion: Is FGCM equivalent to FGM? It was suggested that although both are potentially dangerous procedures and both stem from norms than might come predominantly from men, there might nonetheless be one major difference between them: whereas FGM used to impair a woman’s sexual functioning, FGCM is sometimes seems to be used to restore a woman’s functioning, e.g. allowing them to wear the clothes they like, have sex with their partner, etc. It was replied that this might be true psychologically, but physically it could be just as damaging as FGM.

Issue of autonomy was raised: Narrowing of choices open to people as a result of constraining norms. Does this undermine traditional model of consent?

Would a ban on advertising be a good idea? Possibly, but seems to have had limited efficacy in France.

Relationship between FGCM and waxing and other practices, e.g. hair removal. Worry that there is a general change about ideals of women towards pre-pubescent ideal.


James Partridge, ‘It’s not what I need, it’s what I want’

Abstract: Insights from 23 years of supporting people with disfigurements (including those whose cosmetic surgery produced undesired results) will underpin this talk. I will review the decision-making of patients (not consumers) seeking reconstructive surgery or other treatments which are intended to improve their face’s (or body’s) functioning or appearance and how that choice-making can be enhanced by clinical teams and professionals. I will then discuss whether the purchase of ‘retail cosmetic surgery’ alters the prerequisites for good and safe choice-making and consenting and what this means for the training, regulation and information-giving/advertising by the retailers. What are the implications for the next Government in taking forward the recent Keogh Review proposals to improve the safety of the beauty industry?

Discussion: Agreement about need for greater regulation from medical practitioners. BAPRAS and BAAPS would agree with content of talk, said cosmetic surgeons. However, there needs to be an independent body to regulate these procedures. It can’t just be left to BAPRAS and BAAPS.


General Discussion

Is this special or different from other practices? Is it a matter for regulation by private bodies, or is it something that the NHS should have greater involvement in? It was noted that the NHS website had relatively little info on cosmetic surgery – and just gave links to BAPRAS and BAAPS website. But again, not enough that regulation left to BAPRAS and BAAPS who, after all, have an interest in cosmetic surgery.

Closing discussion and workshop end.

Posted on Friday 24th July 2015