This 2023 guide for patients and practitioners contains essential information from AHPRA’s Guidelines for registered medical practitioners who perform cosmetic surgery and procedures and the APS’s Practice Guide: Psychological evaluation of patients undergoing cosmetic procedures.

In short – psychological screening is now mandatory for everyone seeking cosmetic surgery and procedures. All patients will be assessed for underlying psychological conditions such as body dysmorphia, and in some cases, will be referred to an independent psychologist, psychiatrist or GP for an in-person, comprehensive assessment.

As of July 2023, Australian patients undergoing cosmetic procedures may need to undergo a psychological assessment first.

If you’re planning cosmetic surgery or a cosmetic procedure – such as a facelift, nose job, liposuction, breast implants, Botox or fillers – you will now have to undergo mandatory psychological screening. From there, if you show signs of a potential underlying psychological condition (like body dysmorphia), you will be referred to a psychologist, psychiatrist or GP for them to further evaluate.

On 1 July 2023, the Medical Board of Australia (MBA) and the Australian Health Practitioner Regulation Agency (AHPRA) issued new guidelines for the practice and advertising of cosmetic surgery and procedures in Australia.

Key highlights:

• Compulsory psychological screening for all cosmetic surgery and procedure patients
• GP referral required for all cosmetic surgery patients
• 2 mandatory consultations before cosmetic surgery
• 7-day cooling-off period before booking surgery or paying deposit
• Stronger regulations around informed consent
• New restrictions and regulations around advertising
• Additional responsibilities for patients under 18
• Higher standards and mandatory CPD requirements for practitioners
• New model for accrediting cosmetic surgery and safeguarding the title “surgeon”
• Accredited facilities required for cosmetic surgery premises
• Tightening financial arrangements to prevent conflicts of interest

These reforms resulted from an independent review prompted by serious concerns about consumer safety, advertising practices and clinical governance in the sector. They prioritise patient safety and ensure informed consent, leading to better patient care and outcomes.

In this guide, we provide an overview of essential information from AHPRA’s new guidelines and the Australian Psychological Society’s practice guide to cover everything you need to know about psychological referrals and assessments for cosmetic surgery and procedures. This simple yet comprehensive guide is for prospective and existing patients, GPs, medical professionals, cosmetic clinics and anyone working in the industry.

Who do these guidelines apply to?

These guidelines apply to cosmetic surgeries and non-surgical cosmetic procedures – i.e., operations and procedures that change normal bodily features with the main purpose of achieving a “more desirable” appearance. These reforms apply to procedures performed only for cosmetic or aesthetic reasons; they do not apply to reconstructive surgery, gender affirmation surgery or procedures with medical justifications.

• Cosmetic surgery – involves cutting beneath the skin
  • Examples: breast augmentation, abdominoplasty, rhinoplasty, blepharoplasty, surgical face lifts, cosmetic genital surgery, liposuction and fat transfer

• Non-surgical cosmetic procedures – does not involve cutting beneath the skin, but may pierce the skin
  • Examples: injectables such as Botox and dermal fillers, thread lifts, laser treatments, fat dissolving injections, sclerotherapy and microsclerotherapy, CO₂ laser skin resurfacing, cryolipolysis (fat freezing), laser hair removal, dermabrasion, chemical peels and hair transplants

These new guidelines came into practice on 1st July 2023. There will be a three-month grace period for medical practitioners to comply with these guidelines and update their practice and advertising.

Enhanced Regulations to Better Safeguard Cosmetic Patients

The new guidelines focus on enhancing patient safety, enabling informed consent, and fostering more responsible and ethical industry practices.  

Summary of the new guidelines

Recognising conflicts of interest:

Medical practitioners performing cosmetic surgery or procedures must prioritise the patient’s care and well-being over other interests.

Assessment of patient suitability:

All cosmetic surgery patients require a GP referral. Non-surgical cosmetic procedure patients do not require a referral, unless significant psychological issues are detected.

The practitioner performing the surgery or procedure must thoroughly assess the patient’s reasons, motivations, expectations and psychological state. Patients found to have significant underlying psychological issues such as body dysmorphic disorder (BDD) will need to be referred to an independent psychologist, psychiatrist or GP for further evaluation.

Patient consultation type and timing:

All cosmetic surgery patients must have at least 2 pre-operative consultations, with at least 1 in person with the performing medical practitioner. A cooling-off period of 7 days is required before surgery can be booked or a deposit paid.

Additional responsibilities for patients under 18:

Patients under 18 are subject to specific requirements. For cosmetic surgery, this involves assessing their capacity to consent, considering their parents’ or guardians’ views, and a cooling-off period of at least 3 months. For cosmetic procedures, this includes a ban on Botox or dermal fillers and a cooling-off period of at least 7 days.

Informed consent:

Patients must be provided with comprehensive information about the surgery or procedure, including its risks, costs and potential outcomes. For cosmetic surgery, informed consent must be obtained at a consultation at least 7 days before the surgery and reconfirmed on the day itself.

Patient management:

The performing medical practitioner is responsible for managing the patient’s care, including post-operative/post-procedure care. There needs to be adequate arrangements and protocols for emergencies and complications.

Provision of patient care by other health practitioners:

The performing medical practitioner retains overall responsibility for the patient’s care, even if assisted by other health practitioners.

Complaints:

Patients have the right to make complaints, and practitioners must inform patients about the range of complaint mechanisms available.

Training and experience:

Medical practitioners must have appropriate knowledge, training and experience to perform cosmetic surgery and procedures safely. They will need to undergo regular continuing professional development (CPD) related to their scope of practice.

Qualifications and titles:

Medical practitioners must not make misleading claims about their qualifications or expertise. They must clearly inform patients about their registration type.

Advertising and marketing:

All advertising material, including online and social media platforms, must comply with relevant guidelines and advertising codes. Advertising should not use misleading tactics, glamorise cosmetic procedures, minimise their complexity, downplay risks, exaggerate results or imply unrealistic outcomes.

Facilities:

Cosmetic surgery and procedures must be performed in facilities that are appropriate for the procedure’s risk level and the patient’s risk profile, and be equipped to manage complications and emergencies. Cosmetic surgery must be performed in accredited facilities.

Financial arrangements:

Payment should not be requested until after the cooling-off period. Financial inducements (e.g. commissions) to agents for patient recruitment, free or discounted surgery or procedures for promotion, financing schemes, and encouraging patients to take on loans for surgery are prohibited. Medical practitioners must not have a financial conflict of interest and should disclose any financial interests that could influence the advice given to patients.

Role of psychological screening in the new guidelines

The medical practitioner performing the cosmetic surgery or procedure, or prescribing the cosmetic injectable, will have to perform psychological screening to assess the patient’s suitability for the surgery or procedure. This includes a pre-screening assessment test (PAT) for BDD.

The performing medical practitioner must:

• Discuss and assess the patient’s reasons and motivation for requesting the surgery or procedure including external reasons (e.g. a perceived need to please others) and internal reasons (e.g. strong feelings about appearance). Discuss the patient’s expectations of the surgery or procedure to ensure they are realistic.

• Assess the patient for underlying psychological conditions such as BDD, which may make them an unsuitable candidate for the surgery or procedure. For cosmetic surgeries, the practitioner doing the assessment must use a validated psychological screening tool to screen for BDD. The process and outcome of the assessment and screening must be documented in the patient’s record, for all patients seeking cosmetic surgery.

• Refer the patient to an independent psychologist, psychiatrist or GP for evaluation if the screening indicates that they have significant underlying psychological issues which may make them an unsuitable candidate for the surgery or procedure.

• Discuss other options with the patient, including treatments offered by other practitioners and the option of not undergoing the surgery or procedure.

• Decline to perform the surgery or procedure if they believe it is not in the best interests of the patient.

Psychological screenings and assessments help to minimise the likelihood of adverse outcomes. They allow practitioners to understand the patient’s motivations and expectations for the procedure, assess their suitability and provide an additional layer of protection.

What happens when someone is referred for psychological evaluation?

When a patient is referred to a psychologist, the psychologist will conduct a detailed assessment to identify risks and recommend ways to support the patient in relation to the procedure.

The performing medical practitioner will make the final decision based on the psychologist’s report.

Objective of psychological assessments

The main objective of the psychological assessment is to determine if the patient is a suitable candidate for the proposed procedure. It helps to minimise the risk of negative outcomes and provide psychological support and treatment for the patient if required.

The psychosocial assessment aims to:

• Assess the patient’s psychological suitability and capacity to undergo the procedure
• Evaluate psychological risks and identify any contraindications for the procedure
• Determine whether the patient may benefit from psychological intervention prior to the procedure
• Reduce the incidence of adverse psychological outcomes

The assessment can result in three outcomes:

1. Minimal or no concerns about the patient’s capacity to consent and undergo the procedure.
2. Concerns about the patient’s current readiness, but with psychological intervention the risks may decrease.
3. Significant risk of adverse psychological outcomes. Includes recommendations for psychological intervention and support if the patient decides not to proceed.

The Importance of a Mental Health Check-In for Cosmetic Procedures

Understanding adverse psychosocial outcomes and risk factors

While most people report satisfaction and positive outcomes from cosmetic procedures, a minority experience adverse psychological and social effects. When a patient is dissatisfied with the outcome, they may experience personal distress, adjustment problems, social isolation, relationship strain, requests for additional and unnecessary procedures, financial risk and anger toward the service provider and their staff. Patients with pre-existing mental health conditions, particularly BDD, may experience a worsening of their symptoms following the procedure.  

It is important to understand the factors associated with negative and positive psychosocial outcomes.

Factors that increase the risk of adverse outcomes:

• unrealistic expectations
• inadequate understanding of the procedure
• external motivations
• identity issues
• relationship distress
• poor self-image
• low self-esteem
• certain mental health issues
• distress associated with medical complications arising from the procedure

Factors that increase the likelihood of positive outcomes:

• support from loved ones
• realistic expectations
• understanding of the procedure including its risks, limitations and recovery time
• understanding self-care requirements

The connection between mental health and cosmetic procedures

People who seek cosmetic surgery and procedures experience more mental health issues than the general population. While more research is required, it is likely that they experience more depression, anxiety, eating disorders, obsessive-compulsive disorders and trauma. They are at higher risk of poorer outcomes, self-harm and suicide.

Not all mental health disorders should be considered absolute contraindications for cosmetic procedures, as research is inconsistent regarding benefits and adverse outcomes. However, BDD is generally considered a contraindication.

BDD – a significant risk factor for adverse outcomes

According to the APS, BDD is estimated to affect around 1.9% of the general population. The prevalence of BDD is significantly higher within populations that seek cosmetic surgery and procedures – 7-13% in the American population; 3.2-16% in the international population; 25% in the Australian population. 

Patients with BDD tend to experience a high degree of distress in relation to their perceived flaw, and view cosmetic surgery or procedures as a solution to their distress. Therefore, being refused the surgery or procedure is another risk factor. The more severe their distress, the higher the likelihood of poorer post-procedural outcomes.

BDD is generally associated with:

• poorer psychological outcomes
• repeat cosmetic treatments
• unnecessary surgical interventions
• dissatisfaction with the procedure

Secondary risks associated with likely dissatisfaction:

• hostility towards treating medical staff
• increased risk for self-harm
• increased risk of harm to others such as the treating practitioner
• risk of worsening of pre-existing mental health concerns, body image issues or BDD symptoms

It is worth noting that mild to moderate BDD symptoms may not necessarily be contradictions, especially in procedures that have less ambiguous outcomes. In these cases, it is especially important that patient expectations are well-managed.

Psychological assessments for patients under 18

There are additional factors involved when assessing patients under 18. This includes the consideration of developmental aspects such as ongoing physical development, fluctuating body image satisfaction, peer and family influences, identity development, changes in self-esteem and heightened appearance concerns. It is important to ensure the minor has enough maturity to make an informed decision and has support from their parents or guardians. It is necessary to distinguish whether their motivations come from internal sources or external influences like media and peers.

Who is Required to Undergo a Psychological Assessment?

When should someone be referred for a psychological assessment?

If, during their psychological screening, the patient demonstrates significant underlying psychological issues such as BDD, they will need to be referred to an independent psychologist, psychiatrist or GP for an in-depth psychological assessment.

Frequency and conditions for repeated assessments

According to AHPRA, the performing medical practitioner must assess the patient for suitability each time they seek cosmetic surgery or a cosmetic procedure. However, the medical practitioner can tailor subsequent assessments based on how long it has been since the last consultation, whether it is a repeat procedure or a different procedure and whether there have been changes in the patient’s health.

The Process of Referring a Client for a Psychological Assessment

To refer a patient for a psychological assessment, contact a psychologist, psychiatrist or GP, who works independently of the medical practitioner performing the surgery or procedure.

New Vision Psychology is a private psychology practice with decades of experience working with clinics and specialists to provide psychological assessments for clients across Sydney. We have 30+ registered and clinical psychologists who are skilled in providing professional and accurate assessments and recommendations.

To make a referral, get in touch with us:

• Phone: 1300 001 778
• Fax: 8068 1113
• Email: olivia.c@newvisionpsychology.com.au

What to expect during the psychological assessment

During the psychological assessment, the psychologist will evaluate a range of issues, including the client’s:

• perception of the identified ‘flaw’ and degree of pre-occupation with it
• motivations for seeking the cosmetic procedure, and their desired outcomes, goals and expectation
• self-concept and self-esteem in relation to the physical trait
• mental health, and the presence or absence of a mood, anxiety, or eating disorder, body dysmorphic disorder, trauma history or any other mental health disorder which may significantly impact on the client’s perception of their body and their body image

The psychologist will provide the client and referrer detailed feedback, including:

• the client’s readiness and capacity for the proposed cosmetic procedure
  • issues the client presents with that may raise their risk for adverse psychological outcomes
  • recommendations for psychotherapy which may help address those issues, and support and prepare the client for the procedure
  • whether the cosmetic procedure is contraindicated for that client, and the rationale for that conclusion
  • recommendations about post-procedure resilience, how to identify adverse psychological outcomes and how to seek supports

Roles and Responsibilities of Cosmetic Clinics and Medical Professionals

Cosmetic clinics and medical practitioners who perform cosmetic surgery and procedures must abide by these new guidelines, which outline appropriate professional conduct or practice. If the patient is found to have significant underlying psychological conditions, the performing medical practitioner is responsible for referring them for further evaluation. Serious or repeated failure to meet these guidelines may have consequences for a medical practitioner’s registration.

Given the connection between cosmetic procedures and mental health, the importance of multi-disciplinary collaboration between cosmetic clinics and psychology clinics cannot be understated. When a psychologist provides an independent assessment of the patient’s suitability for the procedure, this protects both the patient and the staff in the clinic.

Ensuring patient confidentiality and mental health support

Psychologists are bound by professional guidelines to ensure patient confidentiality and mental health support.

The psychologist’s feedback to the patient must be delivered collaboratively, sensitively, and with clarity, taking into account the patient’s vulnerabilities, mood, and mental health issues. When the feedback is likely to cause distress to the patient, such as when the recommendation is to refrain from proceeding with the cosmetic procedure, it is vital to effectively communicate the reasons for the assessment outcome and propose an alternative solution to address their distress, such as referral to appropriate psychological treatment. These measures aim to mitigate the risk of adverse reactions in response to the feedback.

When providing feedback to the referring practitioner, the psychologist must uphold the patient’s privacy and confidentiality. The feedback given should be sufficient to address their inquiries about the patient’s suitability for the proposed cosmetic procedure. However, any issues that arise during the assessment, which are not necessary for the referring practitioner to know, should not be disclosed.

Psychological Assessments with New Vision Psychology

At New Vision Psychology, we are highly experienced in providing psychological assessments. Abiding by the new guidelines, our psychologists conduct professional psychological evaluations, assessing the patient’s suitability for the proposed cosmetic surgery or procedure. Should treatment be required prior to the procedure, our psychologists will provide targeted interventions to increase the chances of positive outcomes.