INTRODUCTION
“Currently, we live in an exaggerated litigation society, where even the small details
of everyday life and common annoyances end up in front of a judge” (the numbers of
judicialization in medicine)1.
We become people who are psychically weakened by society’s demands and run the risk
of becoming spiritually and psychically ill.
According to a survey carried out in 2016 (ISAPS/ IBOPE), Brazil was the second country
where the most cosmetic surgeries were performed, with 1.45 million in total. The
United States led, with 1.48 million procedures, and Russia appeared in third place,
with 579,000 surgeries2.
Since the beginning, plastic surgery has improved self-esteem and acceptance in a
society that idealizes the cult of the body.
According to Lima et al.3, in the article “The ideology of the perfect female body. A question with the real”,
“[...] the body is an object of private property in which the subject can do anything;
however, capitalist society omits that ‘this can do anything’ is an illusion, as it
imposes standards for the body ideal. Therefore, the subject is a mere executor of
the norms of consumption in his own body [...]” (p. 50).
The pressure of consumption and the ease of undergoing plastic surgery becomes an
obsession in these patients’ lives.
This enormous suffering increases when these standards are exposed at all times by
the media as attainable, purchasable, and healthy, transforming bodies into true laboratories
to achieve complete well-being and especially the solution to all problems in the
lives of these people4.
The details of the human mind, such as personality disorders and image disorders,
are decisive in the search for plastic surgery. If they are not correctly diagnosed,
they cause future problems, such as dissatisfaction with results and lawsuits.
“The screening of psychological aspects in the selection phase is decisive for the
success or failure of the aesthetic surgical procedure. That is, patients’ mental
health interferes with the perception of surgery results” 5.
Evolution of the doctor-patient relationship
Camila Vasconcelos cites Foucault in her article “Medical responsibility and judicialization
in the doctor-patient relationship” that: “[...] the power relationship is articulated
to discourse, configuring an underlying dimension of communication between people.
It is a relationship between power and knowledge inherent in the discourse itself,
in which someone carrying the fact of knowledge – knowledge – elevates him to the
condition of power in a given environment that recognizes him as such”6.
The relationship between service providers and their customers has ethical and unethical
aspects.
For a professional in Plastic Surgery to carry out his work, 6 years of graduation
in Medicine, 2 years of medical residency in General Surgery, and 3 years of medical
residency in Plastic Surgery are required.
The professional without adequate training harms patients’ health, physical, and,
mainly, mental well-being. Many carry out procedures outside the legislation.
On the other hand, the increase in the number of professionals, even qualified ones,
puts pressure on relationships towards a purely mercantilist trajectory, ignoring
the main thing, which is the patient’s emotions.
When looking for a plastic surgeon, the person has numerous questions, insecurities,
and uncertainties. The professional present there is often fixated on the number of
patients to be operated on, not on the service quality.
The doctor-patient relationship to provide humanized care is increasingly scarce in
Plastic Surgery. This ends up becoming negative in all aspects, as there may be dissatisfaction
on the part of the patient with the result of the surgery, and if he has a personality
disorder that was not identified from the beginning in the preoperative consultations,
this patient is a candidate to cause future problems for that professional.
According to Pellegrino (1993), quoted by Vasconcelos6, “The doctor’s knowledge, therefore, is not private property; it is not intended
primarily for personal gain, prestige or power. Rather, the profession holds medical
knowledge in trust for the patient’s good. By accepting the provenance of medical
education, those who enter medicine become part of an alliance with the society that
cannot be unilaterally dissolved. Medical students, from day one, enter a community
bound by a moral pact. They accept the privileges of medical education in exchange
for the physician’s knowledge management responsibility” 6.
Psychic disorders and the influence of the media and social networks
“Human beings traverse history in search of the fullness and perfection of the body.
The actors change, the scenario changes, the sociocultural context, the tastes and
interpretations, the meaning, and the search for the ideal body remains4.”
To what extent does undergo plastic surgery have its limitations? Due to the influence
of the media, it ends up becoming an obsession in some people’s lives, wanting to
“be” or look like a certain celebrity, such as famous actresses and actors, comic
book characters, and dolls like Barbie and Ken.
Many of these images posted on social networks, which directly influence these people,
undergo several modifications, not correspond to reality.
“The body is a living organism that has its own characteristics and with its own uniqueness.
Performing cosmetic surgery means improving an imperfection and increasing the positive
traits of each patient. Therefore, the final objective of the surgery is to seek a
positive aesthetic improvement and never a transformation. A dysmorphic patient is
a dissatisfied person constantly looking for a mutation, getting into a loop from
which he will not easily get out. When the patient has dysmorphophobia, he usually
complains of a spot that cannot be objectified and should be an alarm for the specialist
visiting him” 7.
According to Pereira de Oliveira8, behind this great fantasy, there is mental suffering, often unconscious, unfortunately
not diagnosed by the professional, due to not having sufficient preparation, or for
not having an interdisciplinary team, or else that professional who does not follow
ethical norms, performing the procedure on the patient.
The doctor-patient relationship is also an extremely important factor in managing
these conditions.
Today, in the artistic world, we can encounter several celebrities with customs and
habits that are not common in our daily lives, influencing people worldwide.
Anonymous people transformed themselves physically to become famous. Many do not know,
but behind that exposed image, obsessive psychic factors transform the lives of these
subjects.
Body Dysmorphic Disorder is one of the psychopathologies observed in these people.
“The recently published World Health Organization International Classification of
Diseases states that BDD is characterized by persistent preoccupation with one or
more perceived defects or flaws in appearance that are unnoticeable or faintly noticeable
to others. Individuals experience excessive self-consciousness, usually with ideas
of reference (i.e., the conviction that people are noticing, judging, or talking about
the perceived defect or flaw).”9.
The individual triggers an obsession, in which the imaginary defect migrates to various
parts of his body. Undergoing an aesthetic surgical procedure will alleviate the psychic
pain he feels. Mental pain will turn into bodily pleasure.
In an interview for Revista Quem10, Rodrigo Alves (36), the “human Ken,” reported that he started having aesthetic procedures
because he felt ugly and excluded in childhood, with few friends. After the surgery
and the apparent changes, people began to notice him: “Today I am the fruit of my
imagination. I am everything I wanted to be in life.”
As a teenager, he had no friends; he felt insecure; he used to wear black clothes
and sat in the background in the classroom. His colleagues called him a little potato
and beat him. “It had nothing to do with my appearance; it was more with my psychology.
I excluded myself”10.
Goulart11 mentions that the perception of the body as one’s own seems natural and intuitive;
however, in reality, it is not quite like that: [...] “throughout life, the vision
of the body will be marked not only by images but also by definitions (signifiers)
and own sensations. So, we have a body that is apprehended by its imaginary aspect
(appearing), by its symbolic aspect (being), and by its real aspect (body experience
not imagined or symbolized by the subject and which emerges abruptly)”.
OBJECTIVE
In this study, we intend to evaluate how the media influences body standards in adopting
behavior to modify the body, which can cause dissatisfaction and disappointment with
the result, leading to lawsuits.
METHOD
The study consisted of 38 patients who underwent a plastic surgery procedure, all
female (aged between 19 and 57 years).
All procedures were performed in different locations and by four different teams.
The patients underwent psychological assessment and follow-up throughout the surgical
process and were invited to participate in the study, having received the Sociocultural
Attitudes Questionnaire (SATAQ-3) concerning appearance and the Body Dysmorphophobia
Symptom Scale - Body Dysmorphic Symptoms Scale.
The Questionnaire of Sociocultural Attitudes towards Appearance (SATAQ-3) is an instrument
developed to assess sociocultural pressure and internalization of the standard of
beauty. It is composed of 30 questions, with answers in the form of a Likert scale
from 1 (totally disagree) to 5 (totally agree), intended to assess the influence of
the media on the body. The sum of the responses calculates the final score, and the
score proportionally represents the influence of sociocultural aspects on body image12.
The Body Dysmorphophobia Symptom Scale is designed to measure the symptoms of Body
Dysmorphic Disorder (BDD) in individuals seeking plastic surgery who are preoccupied
and distressed about their physical appearance. The scale consists of ten items that
objectively and quickly identify BDD’s psychopathological characteristics in individuals
concerned about their physical appearance and who seek plastic surgery. The final
score corresponds to the sum of positive responses to all questions. Higher scores
indicate the presence of BDD symptoms13.
RESULTS
Of the 38 patients evaluated, 17 (44.74%) have the media as an influence concerning
their body image and have symptoms of BDD, 13 (34.21%) patients have the media as
an influence on their body image, but do not have BDD symptoms, and in eight (21.05%)
patients the media does not influence their body image, and they do not have BDD symptoms.
Tables 1
2
3
4 show the items that prevailed in evaluating the sum of the results of the four subscales
of the SATAQ-3 questionnaire.
Table 1 - Sum of scores for the subscale “General internalization of socially established standards.“
| Patients evaluating |
scores |
| Media influences the patient’s body image (presents dysmorphophobia) |
323 |
| Media influences the patient’s body image (does not have dysmorphophobia) |
254 |
| Media does not influence the patient’s body image (does not have dysmorphophobia) |
191 |
| Total |
768 |
Table 1 - Sum of scores for the subscale “General internalization of socially established standards.“
Table 2 - Sum of the scores of the “Ideal athletic body” subscale.
| Evaluated patients |
scores |
| Media influences the patient’s body image (presents dysmorphophobia) |
197 |
| Media influences the patient’s body image (does not have dysmorphophobia) |
157 |
| Media does not influence the patient’s body image (does not have dysmorphophobia) |
129 |
| Total |
483 |
Table 2 - Sum of the scores of the “Ideal athletic body” subscale.
Table 3 - Sum of scores for the subscale “Media as a source of information about appearance.”
| Evaluated patients |
Scores |
| Media influences the patient’s body image (presents dysmorphophobia) |
480 |
| Media influence on the patient’s body image (does not have dysmorphophobia) |
403 |
| Media does not influence the patient’s body image (does not have dysmorphophobia) |
205 |
| Total |
1088 |
Table 3 - Sum of scores for the subscale “Media as a source of information about appearance.”
Table 4 - Sum of scores for the subscale “Pressures exerted by these standards.”
| Evaluated patients |
Scores |
| Media influences the patient’s body image (presents dysmorphophobia) |
274 |
| Media influences the patient’s body image (does not have dysmorphophobia) |
214 |
| Media does not influence the patient’s body image (does not have dysmorphophobia) |
97 |
| Total |
585 |
Table 4 - Sum of scores for the subscale “Pressures exerted by these standards.”
Figure 1 shows the subscales of the SATAQ-3 questionnaire that had the highest scores.
Figure 1 - The media as a source of information about appearance was the subscale with the highest
score, mainly influencing patients with symptoms of Body Dysmorphic Disorder.
Figure 1 - The media as a source of information about appearance was the subscale with the highest
score, mainly influencing patients with symptoms of Body Dysmorphic Disorder.
DISCUSSION
The results show that the media greatly influences people to opt for surgical and/or
non-surgical correction, especially in patients with image disorders.
The “media” effect sometimes generates “surreal” expectations or even sublimation
of results.
In cases of dysmorphia, the acceptance of the result obtained with the intervention
will rarely be positive, which can lead to problems in the relationship with the doctor,
becoming an endless “motus continuo”.
CONCLUSION
It is up to the plastic surgeon to explain the possibilities and their results, clearly
and realistically, with details and risks associated with the surgery. No makeup to
avoid future problems. The plastic surgeon should establish a good doctor-patient
relationship, based on an attentive look, with sensitivity, acceptance, and care when
relating to the patient. Based on ethical principles and moral conscience when dealing
with the patient. They are inseparable factors in the interaction of this binomial
that will result in professional success.
We cannot ignore that, aware of the professional and ethical commitment, the doctor,
in addition to human solidarity, has an indispensable role in the political and social
commitment inherent to the citizen in the transformation the now globalized world
has undergone.
The Code of Medical Ethics brings the rules of conduct that physicians must practice
and observe. Article 2nd, Chapter I, states that “the target of all physician attention is the human being,
for whose benefit he must act with the utmost zeal and to the best of his professional
capacity.” It is evident that the professional must have zeal, appreciation, respect
for the human condition, and technical competence. Chapter V (Relationship with patients
and family members) focuses on the principle of patient autonomy: priority of life
over material and moral goods, responsibility in dealing with the patient, and respect
for their vulnerability14.
Body Dysmorphic Disorder should no longer be neglected and should be identified; therefore,
the psychologist must participate with the plastic surgeon in the diagnostic and therapeutic
process. We know that surgical and plastic treatments seem ineffective in BDD and
can pose risks to the physicians who perform them since patients can become aggressive
and violent and generate litigation.
1. Hospital Ruben Berta, Cirurgia Plástica, São Paulo, São Paulo, Brazil
2. Hospital da Baleia, Belo Horizonte, Minas Gerais, Brazil
3. Fundação Hospitalar do Estado de Minas Gerais, Hospital João XXIII, Belo Horizonte,
Minas Gerais, Brazil
Corresponding author: Alexandre Kataoka Av. Paulista, 2494, cj 14, Bela Vista, São Paulo, S P, Brazil. Zip code: 01310-300
E-mail: drkataoka@hotmail.com
