PR ACTICE GUIDE

Psychological evaluation
of patients undergoing
cosmetic procedures
Acknowledgements
We would like to acknowledge the following people
who provided their expert review of the content
of this practice guide:
Dr Gemma Sharp MAPS
Dr Ben Buchanan MAPS
Dr Ryan Kaplan MAPS
Dr Toni Pikoos MAPS

Australian Psychological Society. (2023).

Psychological evaluation of patients undergoing
cosmetic procedures. Melbourne, Vic: Author.

Disclaimer and Copyright

This publication was produced by The Australian
Psychological Society Ltd (APS) to guide psychologists
in best practice in the assessment of individuals seeking
to undergo a cosmetic procedure. The information
provided does not replace clinical judgment and
decision-making. While every reasonable effort has
been made to ensure the accuracy of the information,
no guarantee can be given that the information is free
from error or omission. The APS, their employees and
agents shall accept no liability for any act or omission
occurring from reliance on the information provided,
or for the consequences of any such act or omission.
The APS does not accept any liability for any injury,
loss or damage incurred by use of, or reliance on, the
information. Such damages include, without limitation,
direct, indirect, special, incidental or consequential.
Any reproduction of this material must acknowledge
the APS as the source of any selected passage,
extract or other information or material reproduced.
For reproduction or publication beyond that permitted
by the Copyright Act 1968, permission should be
sought in writing.
Table of Contents

Introduction............................................................................................................. 4
IIntroductory statement ................................................................................................ 4
Consultations and external review............................................................................... 4
Definition of cosmetic procedures as covered in this practice guide....................... 4
Procedures not considered ‘cosmetic’ and not covered in this practice guide....... 5
Limitations ...................................................................................................................... 5

Background .............................................................................................................. 6
Prevalence of people seeking cosmetic procedures or surgery............................... 6
Potential adverse outcomes.......................................................................................... 6
Patient characteristics associated with adverse outcomes ..................................... 7

Psychosocial assessment of adults...................................................................... 10

Aims and outcomes of an assessment ...................................................................... 10
Assessment step-by-step........................................................................................... 10
Key areas for evaluation .............................................................................................. 11
Rating scales and assessment measures.................................................................. 16

Concluding the assessment.................................................................................. 17

Providing feedback to the client and referrer............................................................ 17
Client feedback ............................................................................................................ 17
Referrer feedback ........................................................................................................ 17

Psychosocial assessment of minors..................................................................... 18

Assessment of minors ................................................................................................. 18

Summary ................................................................................................................ 19

References ............................................................................................................ 20
Introduction

In 2023, the Medical Board of Australia Consultations and external review

issued the updated ‘Guidelines for A draft version of this practice guide was reviewed
by experts in the area (please see the section
registered medical practitioners who
‘Acknowledgements’ for a list of these experts).
perform cosmetic medical and surgical The writing and editorial team revised the guide in
procedures’1 which come into effect response to reviewer suggestions.

from 1 July 2023. The Medical Board Reviewers were asked to review and provide feedback
on the guide, including a focus on the following three
of Australia guidelines make clear that questions for each section:
some patients may be unsuitable for • Are there significant gaps (in the coverage of this
cosmetic surgery and mandate the topic, the literature, other)?
• Are there errors in the content?
referral of patients of concern for a
• Is the structure logical and easy to use?
psychological evaluation to establish
their suitability for the intended
procedure.
Definition of cosmetic procedures
as covered in this practice guide
Under the Medical Board of Australia
guidelines, a patient is considered to The ‘Guidelines for registered medical
require an assessment/evaluation prior practitioners who perform cosmetic
to undergoing a cosmetic procedure if medical and surgical procedures’ provide
they are: the following definitions for cosmetic
procedures and these have been adopted
• under the age of 18 and seeking a major
in this practice guide:
cosmetic procedure; or
Cosmetic surgery and procedures: These are
• an adult or a minor displaying indicators
operations and other procedures that revise
of significant underlying psychological
or change the appearance, colour, texture,
problems which may make them an
structure or position of normal bodily features
unsuitable candidate for any cosmetic
with the dominant purpose of achieving what
procedure.
the patient perceives to be a more desirable
appearance.
Cosmetic surgery: These procedures involve
More recently, the Medical Board of Australia joined
cutting beneath the skin. Examples include;
the Australian Health Practitioner Regulation Agency
breast augmentation, breast reduction,
(Ahpra) in conducting an independent review into
rhinoplasty, surgical face lifts and liposuction.
the regulation of medical practitioners who perform
cosmetic surgery. The final report was released in Non-surgical cosmetic procedures: These
September 2022 2 and it is anticipated that there procedures do not involve cutting beneath the
may be further developments in the field following skin, but may involve piercing the skin. Examples
on from this report which may impact the evaluation include: non-surgical cosmetic varicose vein
procedure undertaken by psychologists. treatment, laser skin treatments, use of CO2
lasers to cut the skin, mole removal for purposes
This practice guide has been developed by the
of appearance, laser hair removal, dermabrasion,
Australian Psychological Society (APS) to provide
chemical peels, injections, microsclerotherapy
guidance to APS member psychologists undertaking
and hair replacement therapy.
evaluation of individuals’ psychological suitability to
undergo a cosmetic procedure. This practice guide
reviews and synthesises current evidence about best
practice in the assessment of such individuals.

Psychological evaluation of patients undergoing cosmetic procedures 4

ADVANCE COPY
Guidelines for registered medical
practitioners who perform
cosmetic surgery and procedures

Effective from: 1 July 2023

Procedures not considered ‘cosmetic’ Limitations

and not covered in this practice guide This practice guide applies to plastic surgery when
The ‘Guidelines for registered medical practitioners it is performed only for cosmetic reasons. It does not
who perform cosmetic medical and surgical apply to reconstructive surgery or surgery considered
procedures’ provide the following definitions for to be medically justified. In practice, this can be a grey
procedures not considered cosmetic and so not area with some patients reporting the motivation to
included in this practice guide: be functional or physical whilst also desiring surgery
for cosmetic reasons.1 Regardless, determining
Procedures which are medically justified: Surgery whether a procedure is medically justified ultimately
or a procedure may be medically justified if it involves falls to the treating medical practitioner. For the
the restoration, correction or improvement in the psychologist, of primary concern in the evaluation is
shape and appearance of body structures that are the client’s emotional and cognitive preparedness,
defective or damaged at birth or by injury, disease, and their psychological fitness to undergo the
growth or development for either functional or procedure.
psychological reasons. Surgery and procedures that
have a medical justification and which may also lead While every effort has been made to provide the
to improvement in appearance are excluded from reader with current, up to date information on the
the definition. assessment of this client group, research is ongoing
and relevant new original studies and systematic
Reconstructive surgery: The medical specialty reviews may be published after this practice guide
of plastic surgery includes both cosmetic surgery has been finalised. It is also likely that Ahpra will
and reconstructive surgery. Reconstructive surgery continue investigating this field and update existing
differs from cosmetic surgery as, while it incorporates guidelines and recommendations accordingly.
aesthetic techniques, it restores form and function as
well as normality of appearance. As per ethical standards, psychologists offering
evaluations for clients wishing to undergo body
Gender affirmation surgery: As per the guidelines, modification procedures need to ensure that they are
this practice guide does not apply to assessment competent to deliver such services. Clinicians need
for procedures related to gender affirming medical to ensure they are educated and have expertise in the
treatment. Practitioners are advised to undertake particular procedure they are assessing for and have
adequate training and supervision to ensure they a clear understanding of what is involved with each
provide evidence-informed psychological care in procedure, alternatives, its limitations, risks, recovery,
this context. and physical and emotional impact. Given the rapidly
advancing field of body modification and cosmetic
procedures offered, clinicians need to undertake
continuing professional development and take steps
to ensure that they remain competent to practise
within this field.

Psychological evaluation of patients undergoing cosmetic procedures 5

Background

Prevalence of people seeking Potential adverse outcomes

cosmetic procedures or surgery Although this field of research is characterised by
Unfortunately, national data is not available on the methodological limitations, what is known suggests
prevalence of cosmetic procedures or surgery use that the majority of people seeking a cosmetic
in Australia for a number of reasons. Currently, procedure are satisfied with the outcome and report
cosmetic procedures can be performed by a range improvements in self-esteem, quality of life and
of practitioners, including medical practitioners such relationships.6-8 Research also suggests however that
as plastic surgeons, GPs and dermatologists, and a minority do experience adverse psychological and
non-medical practitioners such as beauticians, and social outcomes.8
there is no single body to which such data is reported; Where there is dissatisfaction with the outcome of
secondly such procedures are elective, so are not a procedure, the patient may experience personal
covered and therefore recorded by Medicare.4 distress and adjustment problems, social isolation,
relationship strain, requests for additional and
unnecessary procedures, financial risk and anger
toward the service provider and his or her staff.8
A survey conducted by the Cosmetic Physicians
In some individuals, pre-existing mental health
College of Australasia in 2015, estimates that
concerns, particularly body dysmorphic disorder
Australians collectively spend more than 1 billion
(BDD) may indeed worsen following the procedure.9
dollars a year on minimally or non-invasive
cosmetic procedures, with around one quarter Those seeking cosmetic procedures may be at
of the 1020 respondents reporting to have higher risk for self-harm and suicide than the
had some kind of procedure performed in the general population, though research is scant.10-13
preceding month, double the number reported While the reason for this increased risk is unclear,
in the previous year.5 There is a consensus that it is speculated that unmet expectations (particularly
the use of cosmetic surgery in Australia is on where expectations are unrealistic), lack of a
the rise,4 and that the uptake of non-surgical clear understanding of the procedure undertaken
cosmetic procedures are also increasing rapidly. (particularly risks and recovery associated with
the procedure), mental health issues, or distress

IN AUSTR ALIA (2015)

>$1b
Spent per year on
90% 35-50
Of procedures are Most common
non-invasive performed on women years of age
procedures

Most popular Most popular Most popular non-

procedure for women procedure for men surgical procedure
for men and women
Breast Liposuction
Augmentation Botulinum
Toxin Injections

Psychological evaluation of patients undergoing cosmetic procedures 6

associated with medical complications arising from
the procedure may all contribute to negative mood, Potential adverse outcomes include:
and to the increased risk of suicide.13,14 • dissatisfaction with the outcome of the
BDD in particular is associated with an increased risk procedure.
for suicide and self-harm, with rates similar to that • personal distress and adjustment problems.
of anxiety and depression and greater than that of • social isolation.
most other mental health disorders.12,15-17 In addition to • relationship strain.
the reasons for increased suicide risk above, which
• requests for additional and unnecessary
are all relevant to understanding suicide risk in BDD,
procedures.
being refused cosmetic surgery or other cosmetic
procedures is also thought to be a particular risk • financial risks.
factor, due to the importance people with BDD can • anger toward the service provider and staff.
place on cosmetic surgery being a solution to their • worsening of pre-existing mental health
distress, and the degree of distress they experience concerns (particularly body dysmorphic
in relation to their perceived flaw.10,12 This is often disorder (BDD)).
exacerbated by poor or absent insight, which • risk of self-harm.
characterises up to 60% of patients with BDD.18
Cosmetic professionals treating unsuitable patients
are at risk of experiencing adverse outcomes
themselves, including harassment by the patient,
Patient characteristics associated
repeated demands for unnecessary procedures, with adverse outcomes
complaints, and legal action.8,10 Practitioners may Research suggests that adverse outcomes are more
also experience threats of physical violence or in likely in patients with certain characteristics, most
rare cases, actual harm from dissatisfied clients.10 commonly those with:
Psychologists conducting evaluations of the • unrealistic goals or expectations for the procedure
psychological suitability of clients seeking to undergo
• lack of a clear understanding of the risks and
cosmetic procedures may be wrongly perceived
emotional and physical recovery associated with
as “gate keepers” for these procedures. This may
the treatment.
put them at risk of experiencing negative reactions
• external motivations for the procedure.
from clients which they evaluate as being at high
psychological risk in relation to their requested • identity concerns.
procedure. It is important for both referring cosmetic • negative self-image and other psychosocial issues.
professionals and psychologists to be aware of this • certain mental health concerns such as body
risk of negative reactions and ensure that it is clearly dysmorphic disorder.
communicated to clients that the decision regarding
such procedures is ultimately made by the cosmetic Unrealistic goals or expectations
professionals themselves, after considering the Research suggests that unrealistic goals – such
evaluation feedback of the psychologist. as a desire to achieve perfection rather than for
To counter the idea of being perceived as a “gate more realistic, specific or functional improvements
keeper”, psychologists can frame their evaluation are associated with poorer outcomes.19 Unrealistic
around identifying psychological risk and providing expectations include those in which the hope is for
recommendations about how the client might be best distal, exaggerated or global life improvements, such
supported before, during, and after a procedure (if as obtaining a job promotion, or attracting a new
one was to occur). romantic partner. Unrealistic expectations may also
be reflected by vague descriptors such as a desire to
be ‘prettier’ or for a feature to be ‘nicer’,13,20 or by being

Psychological evaluation of patients undergoing cosmetic procedures 7

too rigid and specific about the desired outcome with a specific aspect of their appearance, those
and having a “list” of desired criteria for the selected experiencing positive outcomes from their cosmetic
procedure. procedure typically report being otherwise satisfied
with their overall body image and sense of self.26
Unrealistic expectations may also be exacerbated
through social media use, by the client using filtered Conversely, pre-existing poor self-concept, low self-
or edited images of themselves to indicate their esteem, negative global body image, and relationship
desired surgical outcome, or consuming content distress are associated with poorer outcomes.8
on social media that has been digitally altered,
influencing their surgical goals.21 It is therefore Mental health concerns
important to examine how social media may play a Although the actual prevalence of mental health
role in shaping the client’s desire and expectations disorders in this population is poorly understood,10
for surgery. a sizable minority, proportionately greater than
that found in the general population, are thought
External motivations for the procedure to experience mental health issues. Importantly,
External motivations such as cultural background, research suggests this may increase the risk for
family or partners influencing the client to undergo the patient dissatisfaction and poorer outcomes.10,27-29
cosmetic procedure, rather that the client themselves Though there is little research in this area26 the full
being the driver of the process, or the belief that complement of mental health disorders is likely seen
the surgery or procedure will improve relationships, in the cosmetic procedure-seeking population,­with
the likelihood of employment, or popularity are also depression, anxiety, eating disorders, obsessive-
associated with poorer outcomes.8,14 compulsive disorders, and trauma history believed to
be overrepresented.8,10,19,28,31
Identity concerns
Some patients seeking cosmetic surgery report
In some cases, a certain physical characteristic trauma as a key motivation for undertaking the
may be linked to a patient’s personal, cultural, or surgery, to rectify or change parts of their body that
familial identity. Without adequate consideration they feel were aged, ridiculed, or shamed through a
of the ramifications of altering this trait, the patient traumatic experience. For some, this reflects a desire
may experience a loss of identity or ruptures within to treat the trauma through body modification,
relationships following the loss of a shared physical but for others, surgery may be a later step in their
familial or cultural characteristic.22 recovery from a traumatic experience.32

Negative self-image and other psychosocial It must be noted however that high prevalence
issues mental health disorders should not be considered
‘absolute’ contraindications for cosmetic procedures
Individuals seeking cosmetic procedures or
as research evidence is inconsistent regarding the
surgery do so in response to dissatisfaction with
benefits and adverse outcomes associated with a
an aspect of their appearance, and the majority
range of mental health issues.6,10
report being satisfied with the outcome of their
cosmetic procedure and with the specific change in Body dysmorphic disorder (BDD) however is
their appearance.23 Many also experience broader generally considered a contraindication for cosmetic
positive outcomes post cosmetic intervention, such procedures and has received the most attention in
as increased confidence and a more positive body studies characterising cosmetic procedure-seeking
image.8,24 populations. BDD is estimated to affect around
1.9% of the general population33 with slightly more
A positive global self-concept, despite dissatisfaction
females affected (2.1%) than males (1.6%).33
with an aspect of one’s physical appearance, is
associated with good outcomes from cosmetic Within populations seeking cosmetic surgery
interventions.25 Satisfied patients for example often or other procedures however, the prevalence is
report feeling that their outward appearance did not considerably higher. Among American samples, rates
match their otherwise positive internal self-concept, of BDD among individuals presenting for cosmetic
and cite wanting to align the two as motivation for surgery range from 7-13%.10, 33 International studies
surgery.25 Therefore, apart from dissatisfaction using rigorous methods of evaluation estimate

Psychological evaluation of patients undergoing cosmetic procedures 8

the prevalence of BDD cosmetic surgery-seeking
populations to be in the range of 3.2‑16%. Higher Risk factors for poorer
rates of BDD have been reported in those seeking outcomes
rhinoplasty,33,34 dermatological treatments,35,38 penile
• unrealistic expectations
augmentation, and labiaplasty.10,37 An Australian
for the procedure.
study found 25% of people seeking minor cosmetic
• external motivations or
procedures screened positive on a BDD screening
being influenced by others
questionnaire.38
to have the procedure.
Unlike other mental health issues where mixed • identity concerns.
outcomes of cosmetic procedures have been
• negative self-image.
reported, BDD is generally associated with
• relationship issues.
poorer psychological outcomes, repeat cosmetic
treatments, unnecessary surgical interventions, • certain mental health issues
and dissatisfaction with the procedure.14,39,40 such as body dysmorphic disorder.
Given the likely dissatisfaction, secondary risks
include hostility towards treating medical staff,
increased risk for self-harm and although rare,
increased risk of harm to others such as the treating
Within an evaluation of an individual’s suitability
practitioner.9,12,40,41 There is also a risk of worsening
to undergo a cosmetic procedure, it is important
of pre-existing mental health concerns, body image
for a psychologist to conduct a thorough
issues or BDD symptoms.28,42,43
psychological and psychosocial evaluation,
Degree of distress, reflecting substantial attending to all aspects of the client’s mental
preoccupation and dissatisfaction with appearance, health, risk factors, and other factors relevant
is considered an important factor in predicting poor to understanding the client’s motivation for
post-procedural outcomes in individuals with BDD, the cosmetic procedure, expectations about
with severity of symptoms associated with poorer the psychosocial impact of the procedure, and
outcomes.44 Mild to moderate BDD symptoms may comprehension of the risks and emotional/
not necessarily preclude cosmetic procedures, physical recovery associated with the
especially in procedures that have less ambiguous procedure.
outcomes (e.g. reducing labia size in labiaplasty
may be considered a less ambiguous outcome
versus more subjective nose shape/size changes
in rhinoplasty). However, in such cases it remains
important that patient expectations are well-
managed.45,46

Psychological evaluation of patients undergoing cosmetic procedures 9

Psychosocial assessment of adults

Aims and outcomes of an assessment psychological intervention might be made to

address psychological concerns identified during
The primary aim of conducting a psychological the assessment, and to support the person with the
assessment is to evaluate the client’s suitability possible distress caused by the recommendation
to undergo a proposed cosmetic procedure, so not to proceed with the desired procedure.
as to reduce the incidence of adverse outcomes
and provide greater opportunity for those needing It is important that these three potential outcomes
psychological support and treatment, to access the are clearly outlined to the client at the outset of the
assistance they require. assessment/evaluation, and that consent is obtained
to communicate the outcome of the evaluation to the
The assessment therefore aims to: referring health professional prior to commencing the
• evaluate the psychological capacity of the assessment.
candidate to provide informed consent, undergo
the intended procedure, and assess their risk of
experiencing a poor psychological outcome. Aims of an assessment:
• evaluate and address any identified risk of • Assess the client’s psychological suitability
psychological distress, suicide, self-harm or and capacity to undergo the procedure.
harm to others, and determine whether, in the
• Assess and address risk.
client’s individual situation, such a risk may be a
• Evaluate and identify any contraindications for
contraindication for the intended procedure.
the procedure.
• determine whether psychological intervention
• Determine whether psychological intervention
prior to undergoing a cosmetic procedure might
prior to the procedure may be of benefit
be warranted to reduce the risk of an adverse
psychological outcome. • Reduce the incidence of adverse.
psychological outcomes for the client.
• reduce the incidence of adverse psychological
outcomes associated with unnecessary procedures,
or procedures where the prognosis is poor.
• Provide psychoeducation about the possible
psychological impacts of the procedure including Assessment step-by-step
risks and recovery associated.
A comprehensive psychosocial assessment generally
There are three potential outcomes of a involves thorough assessment and consideration of
psychosocial assessment. The psychologist the client’s:
may determine that: • psychological and social functioning.
• there are minimal or no concerns for the person’s • developmental history.
capacity to provide informed consent and undergo
• family history, including family mental health
the cosmetic procedure.
history and cultural background.
• there are concerns regarding the person’s current
• educational and vocational history.
readiness to undergo the cosmetic procedure,
• health history, including previous surgeries and
however with psychological intervention the
drug/alcohol history.
patient may address those issues, and following
re-evaluation may be considered to be at lower • relationship history.
risk of adverse psychological outcomes following • current mental state.
the procedure. • mental health history and treatment, including the
• the person is considered a poor candidate for identification and evaluation of any possible mental
the cosmetic procedure or surgery being at health disorders and associated symptoms.
significant risk of an adverse psychological • coping skills and level of insight.
outcome, with it being clearly communicated that • current social support.
there is a high likelihood of significant adverse
• u
 nderstanding of the procedure they are
psychological outcomes. A recommendation for
undertaking.

Psychological evaluation of patients undergoing cosmetic procedures 10

An assessment ideally involves not only interviewing has been noted by others, and whether the degree of
and observing the identified patient, but obtaining difference perceived by the client, or their response
collateral information from family and significant to this perceived difference is exaggerated or
others.30 distorted in any way.
The next section details the key areas to evaluate Poorer outcomes have been found in patients who
specifically around a clients’ intended cosmetic are vague in their descriptions of what it is about
procedure. the specific body part they do not like, and what
they would like changed; for example, rather than
describing the length of their nose, or a bump, they
report just ‘not liking’ their nose, that it is just ‘not
When conducting an evaluation of a right’ for their face, or that they just feel ‘ugly’.9,41
client seeking a cosmetic procedure, In contrast, being too rigid and specific about
assessment should also focus on the desired outcome, for example “I would like
evaluating the client’s: those nostril shapes or that nose slope”, or giving
contradictory descriptions, for example, “I want the
• perception of the identified ‘flaw’ and degree
hump of my nose removed, but really don’t want
of pre-occupation with the ‘flaw’.
my face to look different”, can also be associated
• history of dissatisfaction with the perceived with poorer outcomes.9,40 Often clients desire an
flaw and reason for seeking change now. emotional gain from the procedure such as “I want
• motivations for seeking the cosmetic to feel more confident”, without recognising that
procedure, and their desired outcomes, modifying the external body will not automatically
goals and expectations. bring about an internal, emotional change which
• consultations with other cosmetic might lead to regret and dissatisfaction. Thorough
practitioners and previous cosmetic evaluation and seeking clarification from the client
interventions. about the desired change in appearance, and
• relationships with others and their degree of expected emotional gains, is therefore an important
support for the cosmetic procedure. aspect of a psychological evaluation.
• self-concept and self-esteem in relation Assessing the degree of pre-occupation with
to the physical trait. the perceived flaw may also be informative in
• cultural and familial identity in relation determining the client’s suitability for the intended
to the physical trait. procedure. Clients who are highly pre-occupied with
• mental health, and the presence or absence the perceived flaw are more likely to have poorer
of a mood, anxiety, or eating disorder, body psychological outcomes from cosmetic procedures,47
dysmorphic disorder, trauma history or any and may also be indicative of BDD.
other mental health disorder which may
significantly impact on the client’s perception History of dissatisfaction with the perceived
of their body and their body image, and flaw and reason for seeking change now
the severity of any such disorder and Clients may report longstanding dissatisfaction or an
its symptoms. emerging dissatisfaction, as well as a range of triggers
that may have given rise to their desire for the cosmetic
procedure. This may include a history of teasing,
bullying, negative comments from a sexual partner,
Key areas for evaluation partner violence, or other significant life events.6,8,48-54
In particular, special care is needed with clients whose
Perception of the identified ‘flaw’ and degree of
motivation for body modification is associated with
pre-occupation with the ‘flaw’
“ridding” the body of reminders of past trauma such as
This includes an evaluation of the accuracy of the sexual trauma, childhood abuse, and/or resemblance
client’s perception and whether the client’s perception of the physical trait to an abusive parent.55
of the physical characteristic in question is realistic
and reasonable, whether the perceived difference

Psychological evaluation of patients undergoing cosmetic procedures 11

Research over the COVID-19 pandemic has also In the assessment, include an evaluation of:
revealed a significant proportion of people feeling
• whether the client’s goals for the procedure are
preoccupied or concerned with the appearance
realistic
of their facial features, which emerged while
spending greater time on video-calls. In turn, this is • the motivations for undergoing the procedure
thought to be a factor underlying recent growth in and what is driving the client’s desire to alter their
interest in both surgical and non-surgical cosmetic appearance
procedures.56,57 Viewing one’s appearance through • how the client would feel if they were unable
a camera lens can lead to a distorted sense of to have the procedure or deemed unsuitable to
facial appearance, which may underlie motivations undergo the procedure
for surgery. It is important to assess whether an • the client’s understanding and appreciation of
individual’s concerns only developed recently, and if what the procedure involves, the limitations of the
this is related to video-calls or ‘selfie’ cameras they procedure, the associated physical and emotional
may benefit from further psychoeducation around recovery, any associated risks of adverse physical
potential image distortion. and emotional outcomes, and the possible risk
of imperfections and requirements of surgical
Motivations, desired outcomes, goals, and revisions in the future.55
expectations for the cosmetic procedure
Consultations with other cosmetic practitioners
Expectations around cosmetic surgery have been
or experience of previous cosmetic
categorised as surgical, psychological, and social.
interventions
Surgical expectations address the specific physical
changes expected as a result of the procedure. Clients may have a history of seeking treatment
Psychological expectations include those which for the perceived flaw or for other perceived flaws.
relate to potential improvements in psychological Consulting multiple practitioners, having a history of
functioning as a result of surgery. Social expectations undergoing multiple procedures, or having previously
address the potential social benefits.13 been refused treatment, are considered ‘red-flags’
for BDD and for poorer outcomes from cosmetic
Social media has also had a significant influence interventions.39,41
on the normalisation of cosmetic procedures and
has been associated with increased uptake of When several options are offered to achieve the
procedures, especially for those who spend more desired outcome, exploring how the client has
time on social media platforms, follow more accounts, come to select a particular procedure and chosen
and have lower self-esteem.58 In addition to this, a particular health professional (for example, the
social media filters and photo editing applications amount and type of research a client has undertaken
may be associated with increased acceptance of to select a reputable health professional, or if
cosmetic procedures,59 as well as the development of they have chosen a health professional based on
unrealistic expectations for surgical outcomes.60,61 expectations such as, ‘this professional achieves the
kind of nose that I like’) can also be very informative
Many cosmetic practitioners now advertise their in the assessment/evaluation. Recent data from the
services and work on social media. Due to a Ahpra review2 has indicated that patients who made a
historical lack of regulation around advertising complaint following cosmetic surgery were more likely
these procedures, patients may develop unrealistic to have found their treating doctor or surgeon on
expectations of physical, psychological, or social social media, as opposed to other means which may
benefit from consuming this content.2,62 be more regulated (e.g. Ahpra register).
Better outcomes are believed to be seen in people
for whom expectations are realistic, specific, and Relationships and the support of others
proximal to the procedure. Poorer outcomes are Relationships with others can have a large influence
more often seen in those for whom expectations are on the person’s desire to undergo a cosmetic
unrealistic, vague and distal (for example, believing procedure. Family and friends can have a supportive
a procedure will change one’s entire life or result in influence, a coercive influence, or be significantly
greater career opportunities). opposed to the procedure. Parasocial relationships
with social media influencers may also impact and

Psychological evaluation of patients undergoing cosmetic procedures 12

normalise cosmetic procedures.58,63 The client may Cultural, familial and personal identity
also believe that the procedure will improve their For some, cultural and familial identity may be
relationships with others, such as with their partner or important to consider, particularly in regards to facial
their chance of attracting a partner. features and cosmetic procedures to alter facial
A history of bullying or teasing from childhood or characteristics. Explore the perceived flaw in terms
more recent negative comments from a partner of it being a potential cultural or familial trait, and
may contribute to the client’s perceptions of whether this forms part of the person’s identity, even
themselves.48-52 Research suggests an association if the trait itself is seen in a negative light.
between intimate partner violence and likelihood of Explore a range of potential outcomes in the event the
undergoing cosmetic surgery.6,52 characteristic is altered – might it affect relationships
Although rare, body dysmorphic disorder ‘by proxy’ with others, with the self? Loss of identity might result
has also been documented, in which the focus is where the physical characteristic in question is shared
on an imagined defect or flaw in the appearance of amongst family members or a certain cultural group.24
another individual. The preoccupied individual can Some patients may require more psychological
exert considerable influence on the other and can adjustment to their change in appearance than
be a significant motivator for the procedure.64,65 others, which may relate to the type of procedure.
The assessment of the client should therefore screen More extensive ‘type-change’ procedures which
for this, particularly in cases where the presenting more radically alter appearance (such as rhinoplasty)
client is a minor and is being encouraged towards the may require more adjustment and may result in more
procedure by a parent or guardian. adverse outcomes in regards to loss of identity than
An evaluation of the client’s relationships with others ‘restorative’ procedures (such as botox or facelifts).66
therefore includes clarification of whether:
Mental health
• members of the client’s social and family network
A comprehensive mental health assessment, covering
share a similar view of the client’s perception of the
the full range of potential mental health disorders
perceived flaw.
should be conducted. Such an assessment includes
• family or other significant people are coercing or a mental state examination and symptom review,
otherwise driving the client’s motivation for the covering in particular, diagnostic criteria for mood
procedure. disorders, anxiety disorders, eating disorders and
• other members of the family have undergone the body dysmorphic disorder; these being the most
same or similar procedure(s). commonly cited mental health concerns in the
• the client is seeking to address relationship stress cosmetic procedure-seeking population. The main
(such as improve a romantic relationship) or diagnostic criteria are noted below, however more
attract a potential partner through altering their complete criteria and specifiers are found in the most
appearance. recent edition of the Diagnostic and Statistical manual
for Mental Disorders.67
Self-concept and self-esteem
The client should also be asked about whether
Better outcomes are seen in clients where their
symptoms they are experiencing impact on their
self-worth and self-concept are not defined by
day-to-day functioning including their capacity to
the presence or absence of the perceived flaw.
attend to their work, activities of daily living, and
While self-esteem might improve with a change in
relationships.68 Level of insight about their mental
appearance, clients are more likely to experience
health issues, coping skills, previous treatments, or
positive psychological outcomes from their cosmetic
lack of seeking previous treatment, should also be
procedure if what they are seeking is to align their
explored.
external appearance with an already positive body
image and self-concept.24 Interview questions, as in all interviews, should aim to
clarify the presence, absence, duration and frequency
In the assessment therefore, include evaluation of
of symptoms, without leading the client to answer in
the client’s self-concept, identity and self-esteem in
a specific way.68 Observations of client behaviour in
relation to the perceived flaw.

Psychological evaluation of patients undergoing cosmetic procedures 13

the context of their reported mood and experiences Mood disorders
should also be incorporated into the assessment to In order to clarify if the client is experiencing a current
aid diagnosis.69,70 major depressive episode, the client should be
asked about:
Body dysmorphic disorder
• the quality, responsiveness, and pervasiveness
Body dysmorphic disorder (BDD) is the most of their mood.
researched and most commonly cited disorder
• the degree of interest and pleasure in activities
associated with a heightened risk for adverse
they typically enjoy.
outcomes in cosmetic procedure-seeking populations.
The assessing psychologist must therefore be • their appetite and whether they have experienced
particularly familiar with the key criteria so as to any weight gain or loss.
appropriately evaluate the client’s presenting issues, • how they are sleeping, including lifestyle factors
behaviours and symptoms. which may be impacting on the quality of sleep.
As people with BDD may wish to present in a positive • whether they are experiencing agitation or
light during evaluation, they may not report a full conversely, a sense of ‘slowing’ of movements.
range of symptoms to the assessor. Questions which • their energy levels and experience of fatigue.
do not lead the client are important, and informal • their sense of self-worth or worthlessness, or
observations of the client outside of the consultation, excessive or inappropriate guilt.
such as in the waiting room, may reveal behaviours • their ability to think, concentrate, or make decisions.
not evident during the session.72
• their thoughts of life, death or suicide.68
Key issues to consider in the assessment The assessor should also clarify:
of BDD:
• the degree to which the client’s depressive
1. Is the client preoccupied with a perceived
symptoms are linked to their dissatisfaction
defect or flaw in their physical appearance
about their physical appearance.
that is not observable or appears only slight
to others? • the pervasiveness of the client’s symptoms
and circumstances in which symptoms improve
2.  oes the patient perform repetitive behaviours
D or worsen.
in response to the concerns (e.g. scrutinising
• whether the client ruminates about their physical
the feature of concern in the mirror, repeatedly
appearance or experiences excessive negative
seeking reassurance, excessive grooming;
thinking in relation to their appearance.
skin picking; excessive use of makeup or
other products; camouflaging the feature Anxiety disorders
with clothing, hats, or hairstyles)? The presence of any anxiety disorder should be
3.  oes this preoccupation cause clinically
D considered when conducting a mental health
significant distress or impairment in social, assessment. Concern with appearance can translate
occupational or other important areas of to anxiety in social situations and concern with
functioning? negative appraisal by others.73-76 While most research
has looked at state and trait anxiety via self-report,77
4. I s the preoccupation with appearance more
anxiety disorders of particular relevance in this
consistent with symptoms of an eating
population are:78-80
disorder (i.e. concerns relate primarily to
body fat or weight), than with a diagnosis • social anxiety disorder (social phobia).
of BDD?67,71 • obsessive-compulsive disorder.
5. I s the preoccupation with appearance limited • generalised anxiety disorder.
to discomfort with primary or secondary sex • panic disorder.
characteristics and better explained by gender • agoraphobia.
dysphoria?67

Psychological evaluation of patients undergoing cosmetic procedures 14

Again, the assessor should clarify if the person’s • the client has made any plans for suicide.
concerns with their physical appearance are • the client has access to means of self-harm/suicide.
relevant in understanding the aetiology of the • the client has a history of attempted suicide.91-93
anxiety symptoms, such as social anxiety being a
consequence of self-consciousness related to the If there is concern for the client’s risk for suicide, a
person’s physical appearance. collaborative, problem-solving approach should be
adopted to provide the least restrictive treatment
Eating disorders and risk-management response which maintains the
Research studies report that some people seeking client’s safety.91
cosmetic procedures, particularly body-contouring In addition, some people with BDD may engage in, or
surgery may have an underlying eating disorder, consider performing self-mutilating acts in an attempt
with the preoccupation with body weight and size to address their perceived flaw, and as such, this
thought to influence their contemplation of cosmetic risk should also be evaluated.12 Patients should be
methods to further alter their body shape.81-84 Potential asked if they have tried or been considering any home
symptoms of an eating disorder should therefore be remedies to address their concern.
carefully screened and assessed.
Harm to others
Assessors should look for signs of disordered eating Although rare, there is a potential risk for harm or of
and be familiar with the key diagnostic criteria of: litigation directed to others involved in the cosmetic
• anorexia nervosa. procedure such as treating staff, particularly when the
• bulimia nervosa. client has a pre-existing mental health or personality
• binge-eating disorder. disorder, and where the client is dissatisfied with
the outcome of a procedure or where a cosmetic
• other specified feeding and eating disorders.
procedure is withheld due to concerns for adverse
Personality disorders outcomes.40,41,94 As such, an assessment of the
Personality disorders, particularly clusters B and C client’s thoughts around treating staff, their beliefs
may be more prevalent in this population and may around the role of staff in the client’s distress, and
increase the risk for adverse outcomes of cosmetic thoughts or plans of aggression directed at others
procedures, and as such should be screened for should be included in a comprehensive psychological
within the assessment.85-88 assessment.
Clinicians should also be aware of and take mitigating
Autism steps to protect themselves against any potential
There is a high level of comorbidity between autism harm from clients who are evaluated to be at high risk
and eating disorders89 and body dysmorphia,90 which of adverse psychological outcomes if they undergo
may lead to an interest in body modification/cosmetic the procedure, as some of these clients might view
surgery. Special care may be necessary for autistic the clinician as blocking their access to their desired
individuals if they experience difficulties in coping procedure. Clinicians may also need to be aware
with change, as this may cause emotional distress of any pressure from referrers to provide a more
and deterioration of emotional state when their favourable evaluation of the client’s risk profile in
appearance is altered. relation to their desired procedure and will also need
to ensure there is no conflict of interest with the
Risk referring surgeon or other practitioner.
Self-harm/suicide Financial capacity
Due to the increased risk of self-harm and suicidality Cosmetic surgeries and procedures are often costly,
in this population, a thorough assessment of suicide and may involve hidden costs such as the need for
risk must be included as part of a comprehensive revision surgeries or a long-term treatment plan to
psychological assessment.11,12,16,91 maintain outcomes. The client’s means to pay for the
The assessor should use a collaborative approach to procedure should be considered, given that some may
obtain specific details about whether: engage in risky or dangerous methods of financing
their cosmetic procedure, such as taking out loans
• the client has had thoughts about death, dying, or
without financial security.
that life is not worth living.

Psychological evaluation of patients undergoing cosmetic procedures 15

Rating scales and assessment The Cosmetic Procedure Screening Scale (COPS),107,108
the Body Dysmorphic Disorder Questionnaire
measures
(BDDQ),109 the Dysmorphic Concern Questionnaire
Client self-report and clinician-administered (DCQ),110,111 the Body Image Disturbance Questionnaire
assessment measures are available which may (BIDQ),112 the Multidimensional Body-Self Relations
assist in the evaluation of the client. While these Questionnaire-Appearance Scales (MBSRQ-AS)112,113
tools identify areas of concern, these scales have and the Appearance Anxiety Inventory (AAI)114 are
undergone limited validation, are not comprehensive screening tools for body image disturbance and BDD
enough to evaluate all aspects of a client’s in particular.
functioning, and do not provide a definitive diagnosis
There are several clinician administered clinical
or definitive evaluation of suitability to undergo a
interviews such as the Yale-Brown Obsessive–
cosmetic procedure. They should, therefore, only
Compulsive Scale Modified for Body Dysmorphic
be used to flag further areas of assessment for the
Disorder (BDD-YBOCS),115,116 the Structured Clinical
psychologist.95,96 Screening tools do not take the
Interview for DSM-5 (SCID-5) with optional
place of a comprehensive assessment but can be
modules for the evaluation of BDD117,118 and the Mini
considered one aspect of a broad and comprehensive
International Neuropsychiatric Interview – Plus
psychosocial evaluation.45
(MINI-Plus) which includes questions around BDD.119
Tools which may be of use to the clinician include the These clinician administered tools may assist the
Derriford Appearance Scale (the DAS-59 and its short psychologist in the assessment of the patient’s
form, the DAS-24),97 the PreFACE95,96, the Q-series symptom profile as part of a broader assessment.
of patient-reported outcome measures,98-105 and the
Aesthetic Procedure Expectations (ASPECT) scale.106

Psychological evaluation of patients undergoing cosmetic procedures 16

Concluding the assessment

Providing feedback to the client Where feedback is likely to be distressing for the
client (as in the case where the recommendation
and referrer
is to not proceed with a cosmetic procedure),122
The psychologist should provide the client and issues of risk should be considered and evaluated
referrer timely feedback on their opinion of: during the feedback process with any necessary
• the client’s readiness and capacity for the risk management plans put in place. A key risk is
proposed cosmetic procedure. that a patient denied access to a procedure will
• issues the client presents with that may raise their immediately seek treatment elsewhere (“doctor
risk for an adverse psychological outcome and how shopping”).39 Clearly communicating the rationale for
these issues may result in adverse psychological the assessment outcome, developing strong rapport
outcomes. and offering an alternative solution for their distress
(i.e. referral to appropriate psychological treatment)
• recommendations for further evaluation which may
is important in attempts to mitigate this risk.123
help clarify issues regarding client risk.
• recommendations for psychotherapy which may
help address issues that increase client risk for
Referrer feedback
adverse psychological outcomes, and support and
prepare the client for their planned procedure. For the referrer, feedback should ideally be presented
• whether the cosmetic procedure is contraindicated both verbally and in writing to ensure clarity regarding
for that client, and the rationale for that conclusion. the assessment outcome and to provide adequate
Psychoeducation regarding contraindications support for the referrer’s follow-up with the client.
should also be provided to the client.120 In providing feedback to the referring practitioner,
• if the procedure was to proceed, recommendations the psychologist must be mindful of his or her
about post-procedure resilience, how to identify responsibility to protect the client’s privacy and
adverse psychological outcomes and how to seek confidentiality. Feedback to the referring practitioner
supports. should be adequate to answer the referrer’s questions
regarding the client’s fitness to undergo the proposed
cosmetic procedure. Issues which arise as part of the
Client feedback assessment that may help inform the psychologist
For the client, feedback should be provided both of the client’s fitness to undergo the procedure but
in person and in writing in the form of a detailed which are not necessary for the referring agent to
letter or report, to facilitate understanding of the know should not be disclosed.
approach taken in the assessment, and the rationale Psychologists are advised to familiarise themselves
for the conclusions drawn. Feedback to the client with the APS Code of Ethics, and the APS Ethical
should be provided in a collaborative, sensitive and Guidelines on Confidentiality which relate to the
clear manner which takes into consideration the sharing of information with a third party.
client’s own vulnerabilities, mood and mental health
issues.121 Having a clear, evidence-based rationale is
of particular importance when contraindications for a
cosmetic procedure are identified.

Psychological evaluation of patients undergoing cosmetic procedures 17

Psychosocial assessment of minors

Assessment of minors of the proposed intervention, expected outcomes

including any initial discomfort, limitations to what
As with adult evaluations, a thorough assessment of can be provided, what is required of them in terms of
minors includes an evaluation of the young person’s self-care during recovery, and any potential adverse
desired goals, whether their expectations are events or risks involved.134,139
realistic, factors motivating them to seek cosmetic
enhancements, and their mental health,132-134 A number of APS resources are available to support
particularly regarding symptoms of BDD which most members in considering the ethical implications
commonly emerge in adolescence.128,135 around gaining informed consent from minors:

However, there are additional issues to consider in • Ethical guidelines for working with young people.
the evaluation of an adolescent’s preparedness and • Ethical guidelines on confidentiality.
suitability to undergo a cosmetic procedure. These
relate to their physical and emotional maturation Influence of peers and the media
and changes that are likely to occur as a natural While concerns with body image in young people
course of development,132,136 their developing sense is not a new phenomenon, increased exposure
of self and identity,137 and the potential for influence to idealised images of physical appearance via
by others.134,138 Their capacity to provide informed social media,59,61-62 and through television programs
consent should therefore be carefully considered, as revolving around cosmetic enhancements141 are
well as the role of parents or guardians in supporting adding to the influences on adolescents’ satisfaction
the decision-making process.134 with their body image,142,143 their acceptance of
cosmetic interventions, and their desire to seek
In evaluating minors, it may be beneficial to involve
cosmetic interventions to alter their appearance.144,147
parents/guardians in the assessment process and
Exposure to teasing and bullying may also play a
in communicating the outcome of the evaluation,
significant role144,148 the incidence of which appears
psychoeducation regarding the emotional impact of
to peak during adolescence.48
the desired procedure, its recovery, and associated
risks. Since some body modification procedures are Some argue that cosmetic procedures can indeed
permanent, it is important to evaluate the minor’s decrease bullying and improve social functioning in
developmental stage and maturity to ensure the young people.149 It is important however for the young
individual does not regret their decision later in life person to appreciate that altering one’s appearance
when they have a clearer sense of self and identity. cannot guarantee improved social connectedness.66
It is also important that the minor is educated about Finally, undue influence of others, including
the long-term impact of their desired procedure, family must be considered. As mentioned, whilst
for example, the need for revision following breast exceedingly rare, cases of body dysmorphic disorder
augmentation due to implants’ expiry, the possible ‘by proxy’ have been reported, where the focus is not
risk of being unable to breast feed following breast on the self, but on a perceived flaw or flaws in the
reduction, permanent scarring and imperfections appearance of another individual. The preoccupied
following rhinoplasty. individual can exert considerable influence on
the other and can be a significant motivator for
Issues to consider when assessing minors the procedure;64,65 a particular concern where the
Capacity to consent presenting client is a minor and is being influenced to
When working with minors, practitioners need to undergo the procedure by a parent or guardian.65
determine if the young person is capable of providing Body image and concerns for what is ‘normal’
informed consent for psychological assessment and/
or treatment and if parental or guardian consent is Along with a developing self-concept and concern
required or would be in the best interests of the young for physical appearance, concern for what is
person.139, 140 ‘normal’ may also emerge. Preliminary research
suggests that in some cases, education regarding
In the case of the young person intending to undergo normal development and physical changes that
a cosmetic procedure, informed consent also requires are likely to occur over the course of physical
that the young person understands fully the nature maturation can allay fears and decrease the desire

Psychological evaluation of patients undergoing cosmetic procedures 18

to change one’s physical appearance through For example, young females often gain weight in
cosmetic procedures. This seems particularly the their early 20s, and with that, dissatisfaction with
case for adolescent labiaplasty.150 breast-size may decrease without intervention.
Some research suggests improvement in body
In addition, changes in weight and body shape as
image generally occurs in early adulthood with or
young people mature means that some outcomes
without cosmetic interventions.136
from cosmetic procedures may also alter over time,
and the desired effects may be lost or distorted.

Summary

When assessing adults for their suitability to undergo development, the common experience of decreased
a cosmetic procedure, it is important to consider satisfaction with body image, the influence of
the broad range of factors which can increase the peers and family, the development of identity and
risk for adverse psychosocial outcomes. Whilst changes in self-esteem, and heightened concerns for
the evidence is mixed regarding the psychosocial appearance and what is ‘normal’ can all complicate
outcomes for individuals with depression, anxiety and the picture.136,139,150,151
other high prevalence disorders,6,10 a substantial body
Assessment of minors therefore includes
of evidence suggests an increased risk for adverse
consideration of these normative aspects of
psychosocial outcomes for those presenting with
psychosocial development. The assessment of the
body dysmorphic disorder, including post-procedural
adolescent client also includes establishing that the
dissatisfaction, distress, litigation, risk of self-harm,
client has sufficient maturity to make an informed
and in rare cases, risk of harm to others.9,12,40,41
decision, and has the support of significant others
A range of other factors, such as unrealistic goals or such as parents.150 The influence of others, including
expectations, external motivations for the procedure, the media, peers and family is also important, to
inadequate consideration of possible challenges to ensure that motivations for intervention are the
personal identity with changes in appearance, low client’s, and not externally driven.136
self-esteem beyond dissatisfaction with an aspect
Clients, whether adult or adolescent, should be
of appearance, and coercion or lack of support from
evaluated on a case-by-case basis. Ensuring the
family or friends also increase the risk for adverse
client has support from family and significant others,
psychological outcomes and need to be considered
specific goals, realistic expectations regarding
when evaluating the client’s psychological suitability
the procedure including an appreciation of what
for the procedure.8,10,13,14,19-22
the procedure involves, the associated risks
When assessing minors, a similar processes to that and limitations, the expected recovery time, and
of adults is followed, although aspects unique to the requirements for self-care to aid recovery, improves
developmental period, including ongoing physical the likelihood of positive outcomes.

Psychological evaluation of patients undergoing cosmetic procedures 19

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