Doctor, doctor, make me the most beautiful

Once upon a time...

A young woman who asked her doctor to inject her lips. 

As this was the fourth time in a short space of time, the doctor hesitated, but the young woman insisted.

When she looked in the mirror, it was a disaster... for life.

The young woman sued the doctor and he was convicted.

The story is not a figment of the imagination, and doctors have asked me about it.

The question they asked me was: what could I do to avoid being convicted?

My answer: listen.

Let us study the different contexts in which the young woman's request is expressed: the social context (1), but also her entourage (2) and finally intimacy (3).

In early childhood, the "beauty" of little girls is emphasized by their parents and those around them. This has been well documented for many yearsi. In fairy tales, princesses - with whom little girls are identified - are almost always "very beautiful".

In Snow White, the queen asks her mirror, "Mirror, mirror, tell me that I am the most beautiful. And the mirror tirelessly replies that someone else is more beautiful than she is. It's not just in fairy tales that women are compared and contrasted according to a pseudo-criterion of "beauty" (whose characteristics change over time and space).

Naomi Wolfii's book Le mythe de la beauté (The Beauty Myth ) has documented this phenomenon and denounced the industries (cosmetics, pharmaceuticals, plastic surgery...) and advertisers who exploit and reinforce these beliefs for colossal profits even today. Women's entire bodies are examined with a fine-toothed comb, clippers, scalpels, and so on.

Socially, the injunction is that a woman must be "the most beautiful".

It would not be surprising if the mass distribution of pornographic content viewed from an early age were to lead more and more women - and probably men too - into the offices of plastic surgeons. Surveys probably exist on this subject (find them).

The close circle is immersed in this society, and while some are critical, many are not at all. Some encourage the quest for the Grail of "perfection", whose criteria vary in time and space.

Professional circles exert major pressure on people to conform to a certain image as a condition of exercising a profession. In a documentary entitled Sois belle et tais-toi, by Delphine Seyrigi, Jane Fonda denounced the injunctions she received when she entered Hollywood, where she was asked to dye her hair and undergo an operation that involved breaking her jaw to hollow out her cheeks. Analysis of images of movie stars may or may not reveal an evolution in these criteria today (to be done...).

It is particularly among teenagers that the influence of the group towards the trivialization of certain behaviors, however aberrant and dangerous to health, is particularly evident. Let's think, for example, about competitions to see who can be the thinnest and whose size will not exceed the width of an A4 sheet of paper (held vertically - of course).

Within the couple, controlling behaviors of some partners take many forms and affect women's bodies.

The injunctions reported by the women victims of this violence are manifested by emotional blackmail and the trivialization of the acts.

For example, some women are told by their partners "if you love me, you'll have your breasts, face, buttocks, etc. done", or "if you don't have them done, I'll leave you", topped off with comments such as "it's no big deal, you had your wisdom teeth done".

It's in this ocean of influences and injunctions that patient and doctor navigate. Professional ethics, primum non nocere, require him to be aware of this, and not to forget to check where his patient is: on an ocean liner or an island like him? or adrift on a frail skiff? or even plunged into the ocean without managing to catch a lifeline?

The doctor who receives a patient first listens to her words.

As a practitioner, the physician can immediately see the technical dimension of the person's request. In particular, if the request is obviously "aberrant or impossible", he or she may leave it at that. In this case, it will be important to direct the patient towards resources so as not to leave her in solitude and incomprehension when faced with a sudden and incomprehensible reaction. The risk - in this case a commercial one for the physician - is that she will make him look bad.

In the event of a request that is not immediately aberrant from a technical point of view and with regard to the patient's health, listening will allow us to understand the origin and the basis of the patient's need.

In this context it is important to understand:

• How does the person formulate his or her request or need, and what meaning does he or she give to it?

• If the person is a couple, how does the partner influence the patient's request? Is this a problem? It's important to check that there's no blackmail, trivialization or coercion, conditions which could later create suffering and frustration for the patient, and which also present a risk to the doctor (at least in terms of reputation).

• How did the patient's environment inform, guide or even constrain her request?

• How have social injunctions affected the person's request? Is she aware of it? Is it possible to discuss it with her, or is she closed to any exchange?

The practitioner will be able to evaluate the different techniques available and propose different methods by informing the patient of the benefits/risks of each.

Going back to the story that started this article, what was the difficulty encountered?

The physician performed injections at the patient's request.

It was at his insistence that he proceeded with injections that he did not want to do for some time.

However, the patient's insistence does not transfer the responsibility for the consequences of medical acts to her. The responsibility always lies with the physician. It is up to the physician, as a professional, to refuse to perform medical procedures if necessary.

The difficulty for the doctor is to explain his refusal to the patient who "wants everything and right away". He fears for his reputation and his patients.

To formulate his/her refusal, an awareness of the three circles: societal, entourage and intimacy and an understanding of the influence of these three circles in the patient's request are assets to enable her to find the words.

If this explanation is not sufficient, in order to help the person understand this decision taken in the best interest of the person, it is possible to propose a psychotherapeutic follow-up with a professional who may be specialized in the question of self-image.

In any case, the doctor must accept to expose himself to the anger of his/her patient. It is up to him to weigh the "benefit/risk" of risking the bad press that the patient will give him versus the consequences of an inappropriate medical act, physical, psychological and legal injuries (which will eventually be reflected in the insurance policies).

They are concerned about the development of professional liability litigation against doctors. Their question is: how can we avoid convictions following patient complaints?

Of course, I could talk to you about consent forms, but the bottom line is: listen to your patients and know how to say no when the request is dangerous for her or for you.

All rights reserved to Me Choralyne Dumesnil 2023

This text is based on a paper given at the 32nd Salon de gynécologie obstétrique pratique held from March 15 to 17, 2023 at the Palais des Congrès in Paris. Thanks to Ms Rosa Carballeda, AIUS