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A Better Me

By Greg Rienzi
As more teenagers ask for cosmetic surgery and performance-enhancing drugs, doctors weigh the risks, the benefits, and the ethical quandaries.

A pediatrician can expect to hear an inventory of common adolescent concerns on a standard well visit: stomach pain, trouble sleeping, a host of puberty-related issues. Ah, the glory years of pungent sweat and acne. Now imagine an otherwise healthy 15-year-old boy in the examination room asking about a nose job, or a 14-year-old girl keen on liposuction.

For Cora Collette Breuner, a top pediatrician in Seattle, such scenarios are not hypothetical. Breuner has seen an increase in healthy kids ages 11 to 17 inquiring about physical enhancements. Some ask about simple aesthetic procedures, such as skin peels or laser hair removal. “They tell me, ‘I’m thinking about getting a tattoo or piercing’, or ‘I don’t like the way my eyebrows look,’” Breuner says.

Other requests, though, are for surgical and nonsurgical interventions, such as plastic surgery to reshape a chin or breasts, or for medication that might offer a physical or mental boost. These appeals—from kids and their parents—are not born of a pressing medical need but rather because of a desire to improve oneself.

Breuner’s not the only pediatrician navigating these enhancement conversations. In her role as chair of the Committee on Adolescence for the 65,000-member American Academy of Pediatrics, Breuner hears from doctors across the country that young patients are increasingly talking about body and mind enhancements. There is no data yet to quantify how much these requests have increased in recent years, but Breuner says the anecdotal evidence points to patients looking to doctors and medicine to improve their status quo.

A self-conscious teenager is nothing new; neither is the human desire to augment the body for beauty. What is new, though, is the scope of surgeries that these young patients are requesting. In 2015, according to the American Society of Plastic Surgeons, there were some 64,470 cosmetic surgical procedures performed on people ages 13–19. Rhinoplasty was by far the most common cosmetic procedure requested, but teens are also willing to undergo chin augmentation, breast asymmetry reduction, and a wide variety of laser treatments. More than 161,000 minimally invasive procedures (e.g., chemical peels, laser hair removal, collagen injections) were performed in 2015. Those numbers are up slightly from the previous year and could go higher. We live at a time when reality TV stars like Kylie Jenner are setting the bar with morphing looks, evidenced by a well-publicized lip augmentation at age 16. One of the latest in this slew of body enhancements is labiaplasty, a plastic surgery procedure that alters the folds of skin surrounding the vulva. Trying to achieve normalcy and beauty is an age-old practice, but things are definitely changing when “vaginal rejuvenation” has entered teen vernacular.

“If the patient has a goal that may be outside the bounds of medicine but requires a physician to participate, such as surgery and prescriptions, the physician has to make a decision about whether or not to participate.”

As a result, the relationship between doctors, parents, and young patients just got more complex. What’s a doctor to do when confronted with an enhancement request? Seems like the simple answer should be no, right? Well, it’s more complicated than it seems.

Margaret Moon, a Johns Hopkins pediatrician and bioethicist, remembers when she first heard doctors discussing medical enhancement requests. A few years ago, a colleague of hers shared a story about parents who had requested a growth hormone, not because their son was hormone-deficient, but because the teen had eyes on a college baseball career. Every inch helped, the parents believed. Around this time, Moon had also been hearing stories from other pediatricians about an uptick in requests for Ritalin and Adderal—prescription stimulants typically given to those with symptoms of attention deficit hyperactivity disorder—but from patients who doctors suspected wanted to use them as study drugs. The prescriptions would help them focus.

Medical enhancements are under scrutiny in the pediatric community, as the distinction between enhancements and traditional treatments has blurred. Their use in children also raises significant issues concerning the goals of pediatric medicine, the role of the caregiver, and the complex nature of the parent-child-pediatrician relationship, according to Moon. A member of the American Academy of Pediatrics’ Bioethics Committee who looks into the ethical and moral implications of medical research and practice, Moon says that when talking with other committee members, it became clear that teen enhancements deserved some attention.

“Medicine is hard enough,” says Moon, a core faculty member with the Johns Hopkins Berman Institute of Bioethics. “Faced with requests for enhancements, health care providers need more help. It’s not as simple as saying yes or no to the patient, but [rather] providing more information on what enhancement means for the individual and that particular case. You can’t just paint enhancement with a broad brush and say, here’s what it means for everyone.”

Moon says enhancement requests put doctors in a tricky position to distinguish between the desire for a purely cosmetic upgrade and the patient’s wellness and happiness. She gives the hypothetical example of a youth with a large nose who requests rhinoplasty because he’s miserable about his appearance and how others perceive him. He might even be the victim of bullying in school.

“Misery matters,” Moon says. “Even if Johnny’s nose works normally, it is making him feel miserable. If medicine’s goal is to help patients live a strong and healthy life and his nose can be altered surgically, is it wrong to agree to perform the surgery? That is the choice we have to make.”

Moon’s goal is to foster better guidance for physicians on how to respond to patient requests for enhancements, which can raise a host of ethical quandaries. Just defining “enhancement” comes under some debate. Nearly 20 years ago, noted bioethicist Eric Juengst described human enhancement as a medical intervention designed to improve capability, appearance, or performance unrelated to an identified disease or disorder, or to improve human form or functioning beyond what is necessary to sustain or restore good health. More recently, Australian philosopher and bioethicist Julian Savulescu, editor of the Journal of Medical Ethics and the books Human Enhancement and Enhancing Human Capacities, expanded that definition, arguing that enhancement can also be defined “as any change in the biology or psychology of a person that increases the chances of them leading a good life in a given environment or set of circumstances.”

But who defines the border between normal and abnormal? What value might surviving temporary suffering or anguish have in forming the tenacity and resilience of a person? Moon says the line of enhancement versus necessary therapy is often fuzzy.

For every obvious case of purely cosmetic enhancement—drugs to strengthen athletic performance or a Botox injection for more perfect skin—there are cases that fall into a gray area. Moon has heard of pediatric patients asking for blood pressure drugs known to reduce anxiety, not because of a diagnosed anxiety disorder but for relief from final exam pressure or an intense theatrical audition. Patients sometimes hope for antidepressants to make them feel better after a breakup.

“This can be a confusing situation for the medical provider,” Moon says. “They’ll say, ‘It’s my responsibility to make my patients well,’ but the patient’s sense of well-being may not be parallel with the physician’s definition of medical well-being. If the patient has a goal that may be outside the bounds of medicine but requires a physician to participate, such as surgery and prescriptions, the physician has to make a decision about whether or not to participate. We don’t have a good framework for making that choice.”

Enhancement requests put doctors in a tricky position to distinguish between the desire for a cosmetic upgrade and the patient’s wellness and happiness.

Some in the medical community have already started to redraw the lines and clarify the role of the provider. For example, a growing interest among teen girls for plastic surgery on breasts and genitals recently prompted the American Congress of Obstetricians and Gynecologists to provide better guidance to membership in this area. Julie Strickland, chair of the group’s Adolescent Health Care Committee, says that the ACOG membership was getting more inquiries for labiaplasty. Patients, typically girls between the ages of 12 and 17, were requesting evaluation and possible treatment because they felt their genitals were misshapen, overgrown, or somehow abnormal. While the number of labiaplasty surgeries in 2015 for girls 18 and under was a modest 400, that number amounts to an 80 percent increase from the year before. The group speculated that genital area waxing and shaving, now routine, played a part in awareness, as did greater access to an idealized view of genitalia through the internet.

“Adolescence is a time of anxiety about bodies and vulnerability to external definitions of normal,” Moon says. “In addition to highly sexualized advertising, young girls have easy access to pornography and images of idealized genitalia, but limited exposure to information about the wide variations of normal.”

Fashion trends also played a role. Strickland says that many of the girls interested in the procedure reported pinching, chafing, or irritation when wearing specific types of clothing like skinny jeans. There wasn’t much guidance, Strickland says, on how doctors should navigate the process of evaluating these girls and giving them recommendations.

The ACOG’s new guidelines, which appeared in the May 2016 issue of Obstetrics & Gynecology, stress that providers should educate their patients that “normal” labia and breasts come in all shapes and sizes, and like other body parts, they’re still developing during puberty. What might seem out of proportion now won’t always be the case. “It’s really important for our patients to understand this normal growth and development period,” Strickland says.

Those recommendations are consistent with existing guidelines from the American Society of Plastic Surgeons on breast augmentation and reduction among teenagers. If it’s strictly for cosmetic or aesthetic reasons, the society recommends surgery should generally be delayed until age 18. In all cases, it’s recommended that patients who ask for any form of enhancement be made aware of the dangers. Plastic surgery carries with it the immediate risks of bleeding and infection, and there’s also potential of nerve damage and scarring among other complications.

Parental consent is required for plastic surgery procedures performed on individuals younger than 18, and the ASPS advises parents to evaluate the teenager’s physical and emotional maturity. Moon and others suggest that physicians screen patients for body dysmorphic disorder, which is an obsession with an imagined or slight defect in appearance, and other mental health issues, like depression.

Amir Dorafshar, a pediatric plastic surgeon at Johns Hopkins, focuses primarily on facial and cranial procedures. He performs surgeries on jaws to improve a person’s smile, on chins that are too long, or on noses. While some procedures are performed on trauma victims, others are fixing congenital defects or enhancements to cosmetic appearance, such as otoplasty, the pinback of ears that can be done after the age of 6. Dorafshar says green-lighting any pediatric plastic surgery is complicated.

“We don’t have many black or white cases, but rather a lot of gray zones,” he says. “For example, when a young woman’s breast is abnormally large and has grown out of proportion, is that a medical condition? What is normal and what is just outside normal? And when does an insurance company regard this as a medical condition versus a cosmetic issue? Do they have pain, soreness, or skin problems?” Dorafshar says he weighs all these factors before opting for surgery.

The body enhancement trend goes hand in hand with the increasingly pervasive use of prescription stimulants to augment mental performance. Adderall and Ritalin abuse for nonmedical issues is most common in young adults ages 18–25, but according to a recent study published in The Journal of Clinical Psychiatry, use of these drugs has risen dramatically in adolescents. For some, these drugs are desired because they are believed to offer the extra edge needed to stay competitive and excel. Doctors may also be overdiagnosing ADHD, and handing out these drugs to children with relatively mild behavior issues. Moon and others say that the diagnosis of ADHD is subjective and needs clarifying.

Robert Findling, director of Child and Adolescent Psychiatry at the Johns Hopkins Hospital, says he educates patients to know the limitations of prescription stimulants. “We know that giving stimulants to otherwise healthy people will enhance their ability to focus and concentrate. So, yes, these drugs do work. Just like a couple of cappuccinos give people a pick-me-up to get through a late-afternoon lull,” he says. “But there is nothing magical about stimulants. If someone is asking for an enhancement, the question should be why? These drugs are not going to make you smarter. It doesn’t bump up your IQ points. They don’t make you motivated. Or take away the distractions in your life. Maybe there are some unrealistic expectations on what medicine can do.”

Strickland says one of the main reasons her organization composed the committee on new plastic surgery guidelines is that physicians are under a lot of pressure to respect the developing autonomy of the patient and not endanger the doctor/patient relationship. When someone comes to you with a complaint, she says, the instinctual reaction is to want to solve it.

“And there often is nothing satisfying with telling them there is nothing wrong with them. That can still be alienating to some people and be disappointing to them,” Strickland says. “I think that is a valid concern. Health care workers want to help, and some of these patients are very stressed about this stuff.”

Breuner believes the increase in enhancement requests may partly be attributed to more pediatricians asking directed questions to patients, both on forms and during well visits. These can trigger a now-that-you-mention-it reaction. Instead of saying, “How do you feel today?” a provider might ask if the patient is happy with his or her weight, or if there is a problem at school. We’re also living in the internet and selfie age, where kids document and share their life in pictures, and may not like what they see. “Kids do a lot of comparing and contrasting to others, no question,” Breuner says.

Parents take notice, too, and are often the originators of these conversations, according to doctors. They want what’s best for their kids, and some feel a compelling need to make sure their kids excel or feel good. Breuner remembers one parent who asked her in private about the possibility of putting her 13-year-old daughter on a birth control pill. Not because her daughter was sexually active, but so she wouldn’t grow any taller. The mother, Breuner says, was just over 6 feet tall and felt self-conscious about her height when growing up. “She didn’t want her daughter to be as tall as she was, and so she wanted me to prescribe the birth control pill, which basically stops further growth by shutting down the growth plates,” she says. “I was kind of shocked.”

Breuner invited the daughter into the conversation. Turns out, the daughter envied her mother’s height and hoped she would keep growing. “It wound up being an interesting and very rewarding appointment,” Breuner says. “Mom felt better about herself, and their relationship was strengthened. But at the time I was not ready for this. I was completely surprised by the question. I think all of us need to be ready for these sorts of questions and with the ability to give candid and authentic answers.”

As pediatricians and bioethicists continue to look for answers, Moon says, it’s important for doctors to listen to the concerns of parents and children and to get at the root of why enhancements feel necessary. It’s typical for teens to question whether or not they’re normal. But as our culture evolves—and our definitions of “normal” and “beautiful” change along with it—health care providers should be prepared to respond sensitively and honestly.

illustration of a person cutting out a silhouette
Illustration by Harriet Lee Merrion

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