‘Everything has beauty, but not everyone sees it.’ Confucius

Body dysmorphic disorder (BDD) is a type of mental illness. It is a somatoform disorder characterised by a preoccupation with an imagined deficit or a slight physical anomaly in appearance; and has often been referred to by clinicians as ‘imagined ugliness’. Such individuals are highly convinced of the validity of their claim, which causes significant distress and impairment in social and occupational functioning. BDD patients tend to have difficulty working or going to school, experience difficulty in sexual relations and may become housebound. Sometimes, the distress experienced can even lead to unnecessary cosmetic procedures, acts of self-mutilation, suicidal ideations, suicide attempts and may even require hospitalisation.

Body dysmorphic disorder is differentiated from standard concerns of body image by its severity and chronic nature. BDD patients are consumed by their perceived defect making it difficult to think of anything else. Nearly all individuals with BDD engage in time-consuming behaviours adopted to examine, disguise or improve the body part. Such behaviours are usually conducted in a meticulous and ritualised manner, and patients find them very hard, if not impossible, to resist. Such compulsions include excessive grooming, touching, contorting, skin picking, hair pulling, mirror checking and glancing at reflective surfaces. On the other hand other patients go to lengths to avoid being confronted by their reflection. Camouflaging with make-up, hats, clothes or hands is also very common; many making sure they are never seen without these safety measures in place. Excessive reassurance seeking and comparing the ‘defected’ part with that of others is also characteristic of BDD.¹

Body dysmorphic disorder is closely associated with several other mental illnesses, including obsessive compulsive disorder (OCD), major depressive disorder (MDD), social phobia and anorexia nervosa; patients with BDD reporting similar symptoms to the aforementioned conditions. These include (but not exclusively): compulsions and rituals, lowered mood, loss of self-esteem, a sense of personal guilt and worthlessness, suicidal ideation, fears of negative evaluation, with a resultant avoidance of social situations, feelings of social defectiveness and shame, marked body image disturbances and dissatisfaction, an ensuing drive to ‘enhance’ appearance as well as an undue emphasis on physical appearance during evaluations of self-worth.

Prevalence

Currently, the prevalence of body dysmorphic disorder is unknown. Preliminary data suggest that it may be about two per cent in the general population.² However, due to the secretive nature of BDD patients, it is possible that prevalence rates are higher. Of relevance to the current article, BDD prevalence in aesthetic and beauty clinics has been projected to be eight times higher than community samples; with 14 per cent prevalence in dermatology patients³ and nine per cent prevalence in cosmetic surgery patients.⁴ Body dysmorphic disorder patients will most often initially present themselves to dermatologists, cosmetic surgeons, gynaecologists and other medical professionals; and it may be up to 10–15 years before they seek help from mental health professionals. This can lead to improper treatment, and unnecessary economic and psychological suffering. It is, therefore, essential that other medical professionals are aware of BDD and can recognise the signs and symptoms.

Mirror, mirror – patients with BDD frequently return for repeat cosmetic surgery procedures and are unable to ‘see’ the change that the cosmetic surgeon is referring to.

Gender differences

The most commonly perceived flaws in BDD relate to the face; hair; skin and nose, especially the shape and size of the nose; thickness and projection of the lips; or look of the cheeks or chin. Although other body parts can be affected including genitals, thighs, buttocks, abdomen, hands, feet, shoulders, hair and back. There is a general consensus that BDD afflicts equal numbers of men and women, ranging from 1.4 to 2.2 per cent of men and 1.9 to 2.5 per cent of women.⁵ Yet consistent gender differences have been documented in terms of the specific body areas triggering fixation; male distress was predominantly associated with baldness, body build and genitals, whereas major female concerns tended to centre upon skin, breast size and overall body weight.⁶ These discrepancies reflect culturally mediated gender norms and suggest that existing social values exert an impact on the content of BDD symptoms.

Although, to date, large-scale surveys have reported a low prevalence of female BDD patients with a genital preoccupation, cases can be found both in the literature⁷ and in specialist body image/psychological clinics. When genital preoccupation in females does occur it tends to be part of multiple concerns about the body. With regards to genitals, most of these women report their labia are either bulky, asymmetrical, misshaped, too long or protruding. However, when gynaecologists are consulted, in the large majority of cases, size and shape of the labia were within normal ranges.

Treatment for body dysmorphic disorder

Though a full appraisal of available treatments for BDD is beyond the scope of this article, the most efficacious modalities to date relate to pharmacological and/or psychological interventions. Selective serotonin reuptake inhibitors are recommended as the current medication of choice for BDD; while cognitive behavioural therapy is also reported to have moderate therapeutic success.

Cosmetic surgery

In contrast, the results of cosmetic surgery are unpredictable in BDD and most commonly give rise to long-term dissatisfaction. Several studies assessing cosmetic procedure outcomes for BDD have found that these medical treatments tend to be ineffective; BDD diagnoses, psychiatric comorbidities and high levels of functional handicap remained at follow-up, despite subjective reports of initial patient satisfaction.⁸ Patients with BDD frequently return for repeat cosmetic surgery procedures and are unable to ‘see’ the change that the cosmetic surgeon is referring to.

The number of vulvoplasty and labioplasty procedures rebated by Medicare in Australia has more than doubled in the past ten years, with nearly 1500 procedures in the financial year 2009–10⁹. As more women are seeking ‘vaginal rejuvenation’ procedures, lessons from the cosmetic surgery literature must be taken into consideration. At present, no psychosocial studies have been completed on the prevalence of BDD in women seeking labiaplasty either in Australia or internationally.¹⁰

With these facts in mind, a number of recommendations can be made with regard to genital cosmetic surgery:

• Mandatory psychological screening for all women seeking vaginal ‘rejuvenation’ procedures, to detect those with underlying mental health issues, including BDD.
• Gynaecologists to define when the degree of protrusion, or hypertrophy, of the labia is no longer a minor defect (which would exclude a diagnosis of BDD).

Sometimes it can be difficult to distinguish BDD patients from those seeking plastic surgery for aesthetic reasons, due to similar levels of body dissatisfaction and preoccupation. However, a number of authors have now established that BDD patients also experience higher levels of anxiety, depression and social dysfunction compared to other cosmetic surgery patients.¹¹ These latter symptoms can be used to distinguish BDD patients.

In addition, it should be noted that few validated long-term safety or outcome data are presently available in this relatively new field of genital cosmetic surgery. It is important that training guidelines for practitioners be established and that long-term outcome, psychosexual and safety data be published. The genital plastic surgeon must have sufficient training in sexual medicine and mental health to withhold these procedures from women with mental impairments, including body dysmorphic disorder.