1. Dipl.-Ing., Speaker of the Globalhealth Academy for Aesthetic Medicine
2. Dipl.-Päd., Psychologist and Consultant Globalhealth Academy for Aesthetic Medicine

Preliminary remarks

The following series of articles is intended to stimulate discourse and reflection on aesthetic activity. For this reason, some topics are also provocatively pointedly presented. The authors developed this series after evaluating several hundred discussions during the support of the members of NETWORK- Globalhealth on the one hand and a series of discussions that took place during the SUMMER ACADEMY 2013 in Mallorca on three topics that occupy the most aesthetically working physicians permanently: The identity to aesthetic medicine, the question of patient communication and the doctor-patient relationship, as well as the question of patient recruitment. In this respect, this series is actually more of a joint work of all members of the NETWORK. The first topic describes the social conditions under which aesthetics are practiced today.

The social significance of aesthetic medicine: on the hereafter

The social acceptance of aesthetic medicine and its treatments can be considered in a differentiated way: In the states of the New World, such as the USA, Brazil or Venezuela, acceptance is comparatively high, which can be seen, among other things, from the fact that patients report on their treatments in their social environment. In Europe, on the other hand, especially in German-speaking countries, most patients, according to aesthetically working physicians, are usually not speaking about their treatments, often not even to their own spouse or best friend. This difference sheds a significant light on social acceptance, because if it were higher and aesthetics were not taboo, it could also be communicated openly. The demand that it is desirable to increase and improve the social acceptance of aesthetic medicine can probably be supported by every aesthetically working physician.

Although the social acceptance has not been adequately present, let alone increased, the number of aesthetic treatments has nevertheless been increasing continuously for years. The reasons for this increase in the number of treatments will be analyzed in the course of this series of articles, in which a historical digression is initially planned.

Causes of social non-acceptance

Let us first look at the reasons for the low level of social acceptance. To this end, it seems sensible to analyze the attitude of the respective opinion leaders towards aesthetic medicine. First and foremost, medicine should be regarded as the health system and the physicians who represent the official dominant opinion. Aesthetic medicine is not accepted and excluded as medicine by all other professional groups because it does not heal in the narrow sense. Aesthetic medicine is thus de facto excluded from the field of medicine. It is only and exclusively used to fill the clinicians’ wallets. This discrediting argument of moneymaking, in addition to the lack of any intention to heal, means that medical institutions such as health insurance companies and medical associations also share the same opinion.

Funnily enough, this argument is put forward by people who suspect that they are trying to distract themselves from making money, such as double diagnostics and very expensive equipment diagnostics. There are even medical associations that do not award CME points for further training in the aesthetic field. The attitude of the insurance companies is clear, as discreditation plays right into their hands. Since aesthetic treatment is not associated with a cure for a disease, the costs associated with it are categorically rejected. As far as we know, exceptions are hair removal in patients (Germany) who have undergone a gender change and other aesthetic treatments that are associated with common diseases. Strangely, the question of whether hair removal after a sex change can be regarded as a cure for a disease is not asked here.

The following chapter elucidates the German situation. The attitude of the media can be described as ambivalent: very rarely are there informative articles on various aesthetic procedures, but they do exist. The physicians, who often are authors of such articles, then use these seemingly objective texts primarily to sell themselves and the treatments they prefer. Apart from a few exceptions, there is virtually no information in reputable health magazines on TV. At the very most, if at all, to report on a new procedure – usually critically. Further broadcasts are not even located in the health sector, but serve a completely different target group via the vehicle of the personal “patient story”, whereby then an aesthetic treatment brings the (illusory) solution to the problem: For example, a young girl suffers from small breasts. her parents give her a breast augmentation for her 19th birthday because they can no longer watch their daughter’s suffering. Such and similar stories are pure fiction, because as a rule the clinics and doc- tors presented there cover the treatment costs themselves in exchange for publicity. The third section of published opinion deals with maltreatment. According to the motto “Bad News Are Good News”, an individual fate is then documented, whereby the treating physician almost always gets off badly, sometimes even rightly. however, these individual medical errors lead to all other practitioners also being included in this negative criticism. Sensation sells well and telecasts are information goods. In short, if one wants to describe the attitude of the media, one has to realize that they actually do not have a clear opinion, but instead of serious information the boulevard dominates the scene. Portals and rating portals are establishing themselves as a new power on the Internet, where economic interests often hinder objective presentations or evaluations.

In addition, diffuse, not clearly described ideologies within our societies prevent a greater acceptance of aesthetics: One such background ideology would be, for example, that every person is beautiful as she/he is and that aesthetic treatments should therefore be categorically rejected. Such ideologies can be found on every side of the political spectrum, both in conservative circles and among “modern” conservatives with an “ecological” view of the world.

In summary, it can be stated here that aesthetic medicine is subject to social exclusion on the basis of conservative physicians, which is then causally responsible for the media approach to this topic. Exclusion, however, always leads to privatisation, and privatisation is responsible for the excesses and prejudices that serious aesthetic physicians are confronted with. The whole definition of aesthetic and non-aesthetic medicine can be problematized. The separation of reconstructive and aesthetic plastic surgery is purely arbitrary if, for example, the facial reconstruction of a burn victim clearly serves to improve the aesthetic appearance. Where does reconstructive end here and begin aesthetic?

Fig. 1: Post-war advertisement of Rama margarine.

Effects of low social acceptance on the identity of the aesthetically working Physician

We can identify two strategies to deal with the reality described above: The experienced and successful ignore the social discourse and concentrate on their activities, while beginners in particular react with uncertainty. Both strategies do not strengthen identification. Unrestricted identification with one’s own work object, however, is an indispensable prerequisite for one’s own development in the field of aesthetic medicine. It could lead to an overall increase in the acceptance of aesthetic medicine.

The thesis that the low acceptance prevents a strong identification may cause contradiction. In our opinion, any activity that wants to prevail against a social consensus has to struggle with this problem, although this consensus does not exist in the case of aesthetics. however, in the case of aesthetic medicine, a negative consensus should not be assumed, rather a controversy, because the entire approach to the subject of beautification smells very much of double standards and morality: aesthetic therapies are officially rejected, but in reality they are carried out per se.

The problem does not only exist in an external social confrontation, it also exists in an internal confrontation quasi in the mind of the physician, his inner dialogue, may he now consciously shape it or only unconsciously perceive the contradictions that touch his identity. This inner confrontation always has an impact on his actions, and this also includes communication in this context. As the saying goes, the physician makes a contradictory experience instead of the experience of a contradiction. The latter would be appropriate. All other aesthetic problems for physicians can be traced back to this weakening of identity.

Excursus: the historical development of aesthetics

The development of aesthetics and the continuous increase in demand in this area in recent decades cannot be seen separately from developments in society as a whole. If one considers the development since the end of the Second World War, in the post-war years it was initially a question of restoring the existential life functions. This period entered the phase of the economic miracle as it was called in Germany, in which it was mainly “over the top”, which led to the first aesthetic distortions, particularly in terms of weight. The era of the economic miracle was replaced by the sixty-eight generation, whose appearance led not only to political changes but above all to social diversity with different life models gaining social acceptance. This development was greedily taken up by the economy, because it was possible to increase consumption and thus also profits through diversity.

The more recent trends following the upheavals of the sixties show a development towards ever greater individualization. This development has influenced the entire consumer behavior, indeed it is even a prerequisite for an unchanged basic structure of our economic system. While in the past it was almost exclusively about the functionality of products, what counts today is primarily the external appearance, which is shown by the fact that today every simple kettle has its own design, otherwise it remains unsalable. The entire home decor, but not only them, is subject to these high standards of design. Design cannot be seen in isolation from aesthetics, but is subject to aesthetic laws. Since the end of the Second World War, society has become increasingly “aestheticized”. Aesthetic medicine in particular should be seen in this context: If aesthetics gain more and more importance within a differentiating society, this also applies to the external appearance of the members of a society. The designer brands and cosmetics reflect this trend.

This is mainly responsible for the increased number of aesthetic treatments, despite low social acceptance.

But let us not be mistaken: this development is always linked to economic prosperity. The euro crisis was a first portent; we should not assume that economic crises, which then throw people back to their basic needs, are ruled out for all eternity. Such a development would also affect aesthetics. In any case, it would be appropriate to have a plan B in one’s pocket for such, sometimes sudden changes.

It must be demanded of conservative medicine and its institutions that they face the realities, begin to rethink and end exclusion. The social significance of aesthetics is a fact that cannot be ignored, whether you personally approve of it or not. The example of historical changes in dealing with homosexual partnerships can teach conservative medicine that our society provides the necessary freedom for different life models, even if we personally reject homosexuality or aesthetics or even define them as “abnormal”.

Approaches to strengthening identity

If awareness of the identity insecurity described above alone was sufficient to solve the problem, at least for the treating physician, this would be nice. Unfortunately, however, this is not the case, otherwise the treatment of psychological problems would be extremely simple and could be solved through the act of becoming conscious, which it is not today.

So what is to be done?

This article is merely intended to show trends in how identity can be strengthened:

• First of all, it is absolutely necessary to reflect further on the subject. Such a reflection always starts with one’s own person: how does the weakening of my identity have a very concrete effect in my own practice and on me as a physician? This can be different for each individual, as already indicated. An intensive reflection without blinkers automatically leads to a strengthening of identity. This reflection should also include the doctor’s own relationship to beautification, does he or she see aesthetics as “doctoring around” on the surface, the beautiful appearance, even as a concealment of the essence of a personality? In this context also belongs the shame of one’s own need for embellishment, which makes the social taboo personally tangible, although the change of the external appearance has always been part of our human and social survival strategy.

• Aesthetic medicine does not yet have a brand essence or character. There are many reasons for this. Training is non-university, usually in the hands of individual companies. The establishment of aesthetic departments in the university clinics is not or only marginally serving the training of future generations of doctors, but is intended to help fill the scarce coffers.

• The argument of pure moneymaking is valid because aesthetic medicine has not yet agreed on ethical principles. A joint charter of all organizations and doctors and an independent and product-neutral training such as the Globalhealth Academy and other organizations have been developing for years could be the first steps towards the formation of a brand core. In short, the aesthetic physicians themselves could do a great deal to change the appearance of the public consciousness.

Fig. 2a-c: Kettle as an example of the aesthetic processes of our society towards design.

We would like to argue here that an offensively conducted debate can lead to an increase in the low acceptance and at the same time strengthen one’s own identity. This is only possible if aesthetically working physicians cooperate instead of submitting to the competitive laws of the market. This includes defending oneself against exclusion, because only exclusion leads to the undeniable negative manifestations within aesthetics and to their privatization.

The examination of conservative medicine will be discussed here as an example. To this end, the term “healing” must be problematized. healing can be described as a process that moves in a line between two antipodes, namely homeostasis and deregulation, colloquially described with the terms “disease” and “health”. Let us look at the term health: As early as 1948, the World health Organization defined the term in the preamble to its constitution as follows: “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The concept of well-being, which defines health, can be applied to aesthetic medicine without restriction. Aesthetic medicine is therefore an important part of a healing process because it makes patients feel better.

Even conservative physicians are likely to accept this argument if they refer to the principles of the WHO. Not aesthetic medicine should be on the defensive, but conservative medicine, because it is not in a position to integrate new scientific and theoretical developments, not even to take its own definitions seriously, e.g. to end Cartesian dualism and finally to accept that body and psyche are only two different sides of the same coin. The problem of a static, purely symptom-related concept of disease, whose old solutions lead to a simple cause- and-effect relationship, is nowadays carried out in large parts of conservative medicine itself, because all recent scientific research argues against adherence to static cause-and-effect relationships. The “headache pill” cannot in any way cure the problems behind the symptom, this is today clear to every physician.

Aesthetic physicians who have reflected on their weakening of identity through social controversy are in a position to offensively conduct this necessary confrontation, and by finally leading this confrontation they will strengthen their identity as their subject matter. This short line of argumentation can be built up much more intensively by a further collection of arguments, here only one direction should be pointed out.

The same applies to the debate about pure “moneymaking”: In times in which physicians are forced by an ailing health system to develop new sources of money in order to secure their own survival, in which an excessive insurance bureaucracy devours immense funds of the insured, it should not be difficult to find this argumentation.

Conclusion

Future aesthetic medicine has the task of interfering in social debate because it has important arguments to contribute to social discourse. The aim is the fight against social exclusion, because exclusion leads to aggravation and privatization of the problem. This task will also strengthen the identity of the aesthetically working physicians to their work and therefore positively influence the relationship with their own patients.