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Research
Cosmetic surgery history and health service use in midlife: Women's
Health Australia
Rafat Hussain, Margot Schofield and Deborah Loxton
Abstract
Objective: To explore, among middle-aged women, the relationship
between having ever had cosmetic surgery and the frequency of
use of other health services.
Design: Retrospective analysis of cross-sectional survey data
from the Women's Health Australia (WHA) study.
Setting and participants: A nationally representative sample
of the "mid-aged" (45–50 years) cohort of women who
participated in the 1996 WHA baseline postal survey. Responses
were received from 14 100 women (a response rate of 54%).
Results: Seven per cent of women reported ever having had cosmetic
surgery. After adjusting for demographic variables, multivariate
analysis confirmed that women who had had cosmetic surgery were
significantly more likely to use health services more frequently
(eg, surgical procedures, consultations with specialists and alternative
healthcare providers). Cosmetic surgery was also associated with
a greater number of chronic illnesses and use of medication for
anxiety and sleep problems.
Conclusion: Further research is needed to determine whether cosmetic
surgery is directly related to health conditions or to attitudinal
or psychosocial variables. Such research should examine whether
alternative interventions may be more cost-effective in dealing
with the issues that motivate women to seek cosmetic surgery.
The demand for cosmetic surgery is growing rapidly in many Western
countries,1,2 apparently fuelled by societal perceptions of the
ideal body image.3,4 For example, a large population-based study
in Devon, UK, found that concern about physical appearance is
widespread among the general population and does not vary markedly
by socio-economic status or standard of living.5 Similarly, a
US study has shown that many Americans are dissatisfied with their
physical appearance.6
An important healthcare consequence of widespread dissatisfaction
with body appearance has been the marked increase in elective
cosmetic surgery procedures for primarily aesthetic reasons.7
In the United States, the top five cosmetic surgery procedures
performed in 2001 were rhinoplasty, liposuction, eyelid surgery,
breast augmentation and facelifts, amounting to a total of over
1.2 million surgical procedures. An additional 3.2 million chemical
peels, microdermabrasions and botulinum toxin A injections were
performed during the same year.8 These figures include only selected
procedures conducted by certified cosmetic surgeons or therapists
and exclude procedures conducted by general surgeons and other
specialists.
In Australia, there is no national coordinated system for collecting
information on cosmetic surgery patients, procedures or outcomes.
Such data are not available through the Australian Health Insurance
Commission records, as these procedures do not usually carry a
Medicare insurance rebate. Nor does the Australian Society of
Plastic Surgeons (Marlene Watson, Chief Executive Officer, ASPS,
personal communication) or the Australasian College of Cosmetic
Surgery (Dr Anoop Rastogi, Secretary, ACCS, personal communication)
maintain a database on the number and type of procedures conducted
in Australia. There is very limited information on the prevalence
of cosmetic surgery, the characteristics of people who undergo
cosmetic procedures or their reasons for doing so. A recent ASPS
survey found that approximately 50 000 cosmetic surgery procedures
were conducted by its members (Marlene Watson, ASPS, personal
communication). The ASPS survey figures do not indicate cosmetic
procedures carried out by medical practitioners who are not surgeons
or plastic surgeons, and are therefore likely to be an underestimate
of the prevalence of cosmetic surgery in Australia.
The Australian Longitudinal Study on Women's Health, known as
Women's Health Australia (WHA),9 is the first large-scale national
survey to provide information on prevalence of cosmetic surgery
and the demographic characteristics of users. Using data from
the WHA survey, our aim was to explore the relationship between
cosmetic surgery and the use of other health services.
Methods
WHA is a longitudinal study of factors affecting the health and
wellbeing of three national cohorts of women who were aged 18–23
years ("young"), 45–50 years ("mid-age") and
70–75 years ("older") at baseline in 1996.9 The study
sample was selected from the Medicare database, maintained by
the Health Insurance Commission, which contains the names and
addresses of all Australian citizens and permanent residents.
From each of the three age groups a random sample was selected,
with intentional over-representation of women from rural and remote
areas. Further details of the recruitment methods have been described
elsewhere.9
Ethical approval for the study was obtained from the Human Research
Ethics Committee of the University of Newcastle.
Study sample
Our study sample was the "mid-age" (45–50 years) cohort
of WHA women who participated in the 1996 baseline survey. The
cohort consisted of 14 100 women (representing a survey response
rate of 54%). The sample was largely representative of the general
population of Australian women aged 45–50 years, with a slight
over-representation of married women, employed women, and women
with post-school education.9
Measures
In a self-completed postal questionnaire, women were asked to
indicate whether they had ever had various surgical procedures,
including "any cosmetic surgery (eg, for face, breasts, fat
removal, etc)". (There was no further elaboration of what
procedures would be defined as "cosmetic surgery".)
Affirmative responses to types of surgical procedures other than
cosmetic surgery (eg, hysterectomy, repair of prolapsed vagina,
mastectomy, cholecystectomy, and other specified procedures) were
summed to give a total score for the number of non-cosmetic surgical
procedures (maximum score, 9).
The frequency of use of health services was assessed by asking
women how many times within the past 12 months they had consulted
each of the following for their own health: a family doctor or
general practitioner, a hospital doctor, a specialist doctor,
an allied health professional (eg, optician, dentist, physiotherapist,
podiatrist, dietitian, counsellor), or an alternative health practitioner
(eg, chiropractor, naturopath, acupuncturist, herbalist). Responses
were coded on a three-point scale (0, 1–4, or 5+ times).
Health status was measured using the Medical Outcomes Study Health
Survey, Short Form (SF-36),10 a widely used and validated measure
of health-related quality of life. The physical health component
summary (PCS) and mental health component summary (MCS) scores
calculated from the SF-36 were standardised using the cohort means
for WHA.11 Participants were asked whether they had ever been
diagnosed with any of 15 chronic health problems, such as various
cancers, diabetes, cardiovascular and respiratory problems. Affirmative
responses were summed to give a total score for the number of
chronic conditions.
Medication use was assessed by asking women if they had taken
any medication for anxiety, sleep problems or any chronic illness
in the four weeks prior to the survey, or if they were currently
taking hormone replacement therapy.
Demographic data gathered by the survey included current marital
status, country of birth, highest level of education achieved,
occupational status (coded as professional, paraprofessional or
managerial; administration and sales; trade, machine work, manual
work, or other work; or never in paid work), area of residence
(categorised, by postcode, as large city, other metropolitan,
large rural, small or other rural, or remote),12 and State of
residence.
Analysis
Initial exploratory analyses involved computing cross-tabulations
for a range of variables relating to demographic factors, health
status, health service utilisation and medication history. To
correct for oversampling of women from rural and remote areas,
observations were weighted (area-adjusted) so that the study population
was representative of the Australian population for women of this
age group.
As the outcome variable — having had cosmetic surgery — was dichotomous
("yes"/"no"), the crude odds ratios (ORs)
were computed using logistic regression. Correlation coefficients
were assessed for categorical and continuous-level data by Spearman
and Pearson correlation coefficients, respectively. There was
no marked difference in the distribution of cosmetic surgery cases
by age, thus obviating the need for age adjustment of results.
A number of multivariable logistic regression models were run
to examine the association between the history of cosmetic surgery
and health service use, after adjustment for demographic and health-status-related
factors. The final model was rerun using the backward elimination
method described in SPSS.13
Results
Seven per cent of respondents reported that they had had cosmetic
surgery.
Univariate analysis
At the univariate level, cosmetic surgery was significantly associated
with demographic variables such as occupation, marital status,
country of birth, area of residence and State of residence. Women
employed in professional, administrative and sales positions were
more likely to have had cosmetic surgery than women working in
trade, mechanical or other occupations. Separated or divorced
women were more likely to have had cosmetic surgery than currently
married women. Women from non-English-speaking countries were
less likely to have had cosmetic surgery than women born in Australia.
Rates of cosmetic surgery were higher in capital cities and metropolitan
areas than rural or remote areas, and higher in South Australia
than other States.
At the univariate level, women who reported having had cosmetic
surgery had lower mean PCS and MCS scores, but the difference
was statistically significant only for MCS. There was a significant
association between having had cosmetic surgery and having a greater
number of chronic illnesses; using medications for anxiety, sleep
disturbances or chronic illness; and HRT use. Cosmetic surgery
use was also significantly higher among women who reported having
had more surgical interventions, and who, over the past year,
had had more consultations with GPs, specialists or alternative
healthcare providers. However, no significant association was
found between use of cosmetic surgery and the number of visits
to hospital doctors or allied health providers. Cosmetic surgery
use was higher among women with private health insurance than
women with no private health insurance.
Use of cosmetic surgery was not significantly associated with
education level, mean PCS score, or number of consultations with
a hospital doctor or allied health provider.
Multivariate analysis
Variables that remained significantly and independently associated
with cosmetic surgery after multivariable logistic regression
analysis and adjustment for demographic and health-status factors
are presented in the Box.
The adjusted odds ratio (AOR) for cosmetic surgery among women
who worked in professional and managerial occupations was 1.42
(95% CI, 1.13–1.78), and 1.51 (95% CI, 1.21–1.89) for those in
administrative and sales occupations, compared with women working
in trade, mechanical and other occupations.
Among the health-status-related variables, cosmetic surgery use
was significantly associated with the number of chronic illnesses
and use of medication for anxiety or sleep disturbances.
Health-service-use variables significantly associated with higher
odds of having had cosmetic surgery included the number of non-cosmetic
surgical procedures and frequency of consultations with specialists
or alternative health practitioners. A positive association was
observed between the odds of having had cosmetic surgery and the
number of other surgical procedures reported. For example, the
odds of having had cosmetic surgery were about 1.5-fold for women
reporting two non-cosmetic surgical procedures, and about 3.2-fold
for women reporting five or more procedures, compared with women
who had had no surgical procedures. Even after taking chronic
illnesses into account, women who had had five or more consultations
with specialist doctors in the past year were more likely to have
had cosmetic surgery (AOR, 1.61; 95% CI, 1.22–2.12) than women
who had had no consultations. A similar association was also found
between history of cosmetic surgery and use of alternative healthcare
providers, but the magnitude of the effect was smaller.
Although MCS score appeared to have a negative association with
cosmetic surgery, the association after multivariate analysis
was not statistically significant (P = 0.06) (see Box).
Discussion
Our study demonstrates that cosmetic surgery use is significantly
and independently related to wider health service use, notably
the number of other surgical procedures and the frequency of consultations
with healthcare providers. Our results also suggest that women
who have had cosmetic surgery are more likely to suffer from poor
physical and psychosocial health. The positive association between
past cosmetic surgery and current use of medication for anxiety
and sleep disturbances may be indicative of psychological distress.
There is empirical evidence that psychosocial factors such as
poor body image and low self-esteem play a part in women's motivation
to undergo cosmetic surgery.14,15 It has been argued that cosmetic
surgery may not be the best intervention to deal with the issues
underlying low self-esteem and poor body image,16 and the need
for preoperative psychological screening of patients requesting
cosmetic surgery has been recommended.17,18 Moreover, in the postoperative
period, general psychological complications such as anxiety, depression,
non-specific physical complaints and sleeping difficulties have
been reported to be much more common than physical problems for
patients undergoing cosmetic surgery.19
One of the major limitations of current research on cosmetic
surgery is that most of it focuses on postoperative assessment
in the short term. While there is a need for long-term evaluations
of patient satisfaction with cosmetic surgery,19-22 there is also
a need to explore whether alternative interventions such as counselling
and somatic psychotherapies may be more cost-effective treatments
for low self-esteem and negative body image among women.
An interesting finding is the higher rate of cosmetic surgery
among women in professional, managerial, administrative and sales
occupations compared with those in trade and other occupations.
This provides some empirical support for trends identified in
recent news media reports suggesting that, in occupations for
which appearance is important for job success, there may be greater
pressure on women to have cosmetic surgery.23
There is some evidence of State-based and regional differences
in the use of cosmetic surgery. Further investigation is required
to determine whether these differences reflect consumer demand
or are simply a manifestation of sampling variation.
Our study was limited by a lack of information about the type
of cosmetic surgery undergone and the number and timing of cosmetic
procedures. As the question relating to cosmetic surgery was phrased
in a non-specific way, it was impossible to tell how women defined
"cosmetic surgery" in their own minds (whether, for
instance, some included procedures that were technically "reconstructive"
rather than aesthetic in nature). We also lacked information on
the preoperative psychological state of patients, the motivations
for and outcomes of surgery, and the reasons for use of other
health services. We were thus unable to assess whether the greater
use of services was causally related to cosmetic surgery. A long-term
prospective investigation would allow us to assess these factors
and to examine the cost-effectiveness of current procedures and
the degree of patient satisfaction with the outcomes.
Our study suggests that women who have had cosmetic surgery use
other health services more frequently and are more likely to experience
psychological distress. These findings have important implications
for health planning and point to the need for further research
into women's reasons for seeking cosmetic surgery and the extent
to which the surgery meets those needs. Furthermore, the long-term
health outcomes of cosmetic surgery, both physical and psychological,
also warrant investigation. With this information in hand, it
would be possible to make recommendations to practitioners about
improving the health outcomes for women seeking cosmetic surgery.
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Cosmetic surgery
|
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Number of respondents
|
Adjusted odds ratio (95%
CI)
|
P
|
|
|
Occupation
Professional, paraprofessional,
managerial
Administration, sales
Trade, other
Never worked
|
4317
4397
2271
169
|
1.42 (1.13–1.78)
1.51 (1.21–1.89)
1.00
0.43 (0.13–1.42)
|
0.001
|
|
Area
Capital
city
Other metropolitan area
Large rural centre
Small rural, other rural area
Remote centre, other remote area
|
7293
939
681
2084
268
|
1.22 (0.99–1.50)
1.86 (1.39–2.51)
1.13 (0.70–1.50)
1.00
0.77 (0.41–1.44)
|
0.000
|
|
State
of residence
New
South Wales
Victoria
Queensland
South Australia
Western Australia
Tasmania
Northern Territory
Australian Capital Territory
|
3269
2636
2437
973
1024
456
209
150
|
1.00
1.13 (0.92–1.42)
1.14 (0.92–1.42)
1.62 (1.26–2.10)
1.15 (0.89–1.51)
0.89 (0.53–1.51)
1.39 (0.66–2.91)
0.72 (0.41–1.26)
|
0.012
|
|
Mean
MCS*
|
11154
|
0.99 (0.98–1.00)
|
0.063
|
|
Number
of chronic illnesses
0
1
2
3
4
5+
|
3288
3596
2306
1205
486
273
|
1.00
1.52 (1.24–1.87)
1.32 (1.05–1.67)
1.46 (1.12–1.90)
1.34 (0.93–1.92)
1.42 (0.86–2.14)
|
0.004
|
|
Medications
(taken in past four weeks)
For
"nerves" (anxiety)
No
Yes
For sleep problems
No
Yes
|
10436
718
10351
803
|
1.00
1.41 (1.08–1.84)
1.00
1.39 (1.09–1.79)
|
0.012
0.009
|
|
Number
of non-cosmetic surgical procedures (ever)
0
1
2
3
4
5+
|
2866
4689
1944
1063
398
194
|
1.00
1.26 (1.02–1.55)
1.54 (1.21–1.96)
1.48 (1.11–1.97)
2.34 (1.64–3.33)
3.16 (2.02–4.94)
|
0.000
|
|
Number
of GP consultations (in past year)
0
1–4
5+
|
988
7094
3072
|
1.00
1.18 (0.86–1.62)
0.97 (0.68–1.37)
|
0.074
|
|
Number
of specialist consultations (in past year)
0
1–4
5+
|
6645
3845
664
|
1.00
1.24 (1.05–1.46)
1.61 (1.22–2.12)
|
0.001
|
|
Number
of consultations with alternative health practitioners (in
past year)
0
1–4
5+
|
8011
1877
1266
|
1.00
1.35 (1.12–1.64)
1.33 (1.07–1.66)
|
0.001
|
|
|
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Competing interests
None declared.
Acknowledgements
The research on which this article is based was carried out as
part of the Australian Longitudinal Study on Women's Health, being
conducted by the University of Newcastle and the University of
Queensland. We are grateful to the Commonwealth Department of
Health and Aged Care for funding the study. Our thanks go to Zoe
Miller for help with literature searches.
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(Received 8 Nov 2001, accepted 3 May 2002)
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