Select Committee on Health Fourth Report

Early sources of contact for women contemplating breast augmentation

The GP

33. Even though at least 80% of breast implant operations take place in the private sector,[42] the majority of women still first approach their GP. According to the market research conducted by the Breast Implant Information Service, 58% of women contemplating breast augmentation visited their GP but only 15% received any verbal or written information and "a shocking 66% said that their GP did not make any attempt to find out whether they wanted the surgery for the right reasons".[43] Only 25% of GPs "looked at or examined their [women's] existing natural breasts".[44] Ms Heasman said that "there is a general lack of knowledge amongst GPs and they tend to be very judgmental and moralistic". Such attitudes were not confined to male doctors.[45] She felt that GPs education in this area was "severely lacking".

34. The Parliamentary Under Secretary of State, Gisela Stuart MP, (the Minister), told us that the Government did have responsibility for attempting to inform women as fully as possible, whether through GPs, NHS Direct or websites.[46] She told us that NHS Direct would promptly send out the Breast Implant information leaflet (see below, paragraph 37) to women who contacted it and that the MDA's own website had had over 5000 hits in the last five months.[47]

35. We are not convinced that GPs are providing an adequate service to women consulting them prior to undertaking breast augmentation surgery. The fact that such an operation is usually undertaken for 'cosmetic' reasons, and not on the NHS, perhaps militates against GPs giving this matter as much attention as they should. Given that 10,000 women each year undergo this surgery, and that over half first consult their GP, we feel that this is an area where DoH could offer more guidance.

Other influences

36. Perhaps surprisingly, much of the evidence presented to us suggested that women were often reluctant to discuss or even disclose their decision to undergo breast augmentation to their partners, friends or family.[48] Even when outside parties are involved, their influence may be of doubtful value. Maxine Heasman of the Breast Implant Information Society told us of one young woman seeking breast implants who had told her clinic that she was 18 years of age when she was in fact only 16:

"She had the operation because she was pushed into it by her 31 year old boyfriend and the clinic made no attempt to find out what age she was."

Ms Heasman thought that no woman under 25 should be allowed to have breast implants for purely cosmetic reasons. Yet the operation can legally be performed on anyone over the age of 16. In a recent notorious case, the parents of a 15 year old girl who ran their own cosmetic surgery business, planned to pay £3,250 to give their daughter breast implants as a sixteenth birthday present.[49]

Information Booklet

37. Following the publication of the IRG Report the DoH in October 2000 published a booklet Breast Implants: Information for Women Considering Breast Implants, whose contents purport to be based on the IRG Report. Already the booklet is out of date, listing implants which are no longer available. The booklet itself has incurred a number of criticisms. Ms Irwin, who was on the committee drawing up the booklet, in her memorandum describes her "personal Everest" to have included in the booklet "a short paragraph on risks reported by silicone casualties, surrounded though it is by reassuring caveats from the DoH".[50] Christine Williamson of Silicone Support UK also wanted far more emphasis on the risks of implants. She also pointed to a more immediate failing: "nobody I have spoken to on the help line [she runs] has so far been presented with it by a surgeon or any body".[51] However, Ms Heasman's impression was that the booklets were being distributed, and the Minister told us that the entire 80,000 print run of the first edition had now been distributed. A second edition was in preparation.[52]

38. The booklet has not been without its critics. Leigh, Day & Co solicitors described it as "less informative than similar publications available in other jurisdictions".[53] For example, the information published in the US equivalent offered sample questions for women to ask, rather than the checklist provided by DoH; it also gave clear advice on reporting adverse incidents, whereas the UK document makes no mention of the fact that these should be reported to the MDA (see below, paragraph 65). Mr Balen also drew attention to what he felt were a number of deficiencies in the scope of information contained in the UK booklet compared with that to be found in the document supplied by the US Food and Drug Administration:

"With saline implants in the British booklet, the advantages are stated as being 'long history of use'. In the American booklet - and bear in mind that these products are largely supplied from America - 'saline implants, long term safety and effectiveness have not been studied' ... As regards pregnancy and breast feeding, the Department of Health booklet says 'Do not interfere with ability to breast feed'. The American booklet says 'May affect your ability to produce milk for breast feeding. Not known if silicone can pass through the nipple. One study reported up to 64% of women with implants were unable to breast feed.'"[54]

39. We are not convinced that the DoH booklet Information for Women Considering Breast Implants gives sufficient information as to the risks of these products. We believe that a more precautionary approach is required. We recommend that the section "The Silicone Controversy" which gives some attention to anecdotal evidence of women reporting illness, should be included in the section "consequences and potential risks" rather than under its current heading of "General Issues".

40. Perhaps an even more fundamental omission in the DoH booklet lies in the absence of any mention of the effective moratorium on silicone breast implants in the USA, Canada and Australia. We asked the Minister whether she thought more should be done to make women in the UK aware of this situation. She replied that the implants were available in the whole of Europe, and that the Government took the view that its job was a continual review of risks against benefits, and that it would make available all evidence on adverse incidents and other research indicating risk.[55] We do not regard this as a satisfactory response. We believe that it is absurd that the DoH booklet Information for Women Considering Breast Implants makes no mention of the moratorium. We recommend that the revised edition of the DoH booklet draws attention to those countries banning silicone gel implants. Women contemplating this operation are entitled to this information.

Sources of information prior to the operation

The role of the surgeon

41. The evidence that the Breast Implant Information Service provided on the link between the desire for cosmetic surgery and a lack of self-esteem and self-confidence, prompted us to question what efforts were made to provide psychological counselling to women, who, it seemed to us, might sometimes be seeking a surgical solution to a psychological problem. We asked Professor Sturrock of the IRG whether he thought that a surgeon - who might have a financial interest in an operation proceeding - could really be expected to offer objective advice to an often vulnerable women contemplating surgery. He told us that all good doctors should make decisions on whether to operate purely on clinical grounds, and should not be influenced by any potential financial incentive. He agreed that, in practice, financial incentives might make surgeons less objective.[56] He felt that some sort of entirely independent source of counselling and advice would be highly beneficial and pointed out that, in the NHS, for certain forms of plastic surgery a surgeon would often first refer a patient to a clinical psychologist to discuss the issues prior to surgery taking place. He wondered if this was "one kind of route that one could think about".[57]

42. We voiced our concerns about the potential conflict of interest surgeons faced in "counselling" women on whether to go ahead with surgery to the Minister. She argued that the suggestion that surgeons were likely to urge patients to undertake unnecessary surgery purely to boost their earnings was based on the unfounded assumption that there was "a terrible shortage of work" for such surgeons". She told us:

"I would not want to end up with a picture of the kind of predatory private operating surgeon out there who just takes anybody on and does not have a proper relationship. The Care Standards Act, I think, makes it quite clear [that this should not happen]."[58]

43. Our experience in taking evidence in the course of our inquiry into The Regulation of Private and Other Independent Health Care makes us far less sanguine in viewing the possible conflict of interests for surgeons counselling patients. But even if we were convinced that surgeons could be relied upon to be objective we are very far from convinced that they would be appropriate people to be counselling patients. What patients will often need to discuss are issues relating to their self-image and self-worth. Surgeons strike us as very ill-equipped and ill-qualified to tackle such issues.

44. So we believe that a key area where the Government must play a role lies in the facilitation of access to a genuinely objective and informed source of independent advice and counselling for women contemplating breast augmentation surgery. It is difficult for us to be prescriptive as to how this might be achieved and we acknowledge that a solution is not straightforward. In the first instance, the Government should consider offering specialized training within each Primary Care Trust, to provide a trained nurse counsellor who can advise in this and related areas. A woman could refer herself, or be referred by the GP, to this service, and practices should have information available on how this should be done. The Government may also wish to forge links with some of the voluntary and charitable organizations working in this area, and offer contact details in the DoH Breast Implant booklet. Finally, in an effort to reach the many women who do not approach their GP, the booklet itself might more fully reflect our concerns that many women are currently seeking a surgical solution to a psychological problem.

Information on the consequences of the operation

45. We also heard that women were still not being given objective and unbiased information about the nature of the operation and the practical consequences of a decision to undergo surgery for breast augmentation. Ms Livsey and Ms Irwin both told us that, when they had undergone their surgery in the 1970s they had been told the implants would "last a lifetime".[59] Ms Livsey was assured she would go to her grave "with the breasts of a young woman".[60] Disturbingly, things do not seem greatly to have improved in the intervening years. Dr Sarah Myhill suggested "patients are still being told their implants will last for life with no complications".[61] Ms Heasman assured us that such misinformation was still commonplace:

"Only last week I was speaking to a woman who had been told by the company that the implants have a lifetime guarantee. We all know - and this is a fact - that that is not the case ... There is a great deal of misinformation and a great deal of misconceptions and myths as well."[62]

Ms Heasman thought that even if women were better informed of some of the immediate, inevitable consequences of the surgery - that they could not lift anything heavier than two pounds,

raise their arms above their shoulders, or drive a car unless it had power steering, for at least ten days - this would give them pause for thought. She felt they were more likely to know about the more widely-publicised issues such as the silicone controversy, but less likely to know of such problems as post-operative depression or scarring. She also pointed out that "the problem of visible rippling through the skin ... is one of the most common problems and yet is not discussed".[63]

46. Mr Balen thought that women should be made aware of the true nature of problems such as haematoma or capsular contracture. He felt that women often were not made aware that a decision to have breast implants was usually irreversible in that the removal of implants without replacement was often disfiguring. He thought that one question which women should ask surgeons is "How many operations will I require in the future?" He felt that the absence of data made such a question difficult to answer, but that women were potentially facing three or four operations over a lifetime.[64] Professor Sturrock thought it would be helpful if patients could access, perhaps via the internet, information on the number of operations a particular surgeon had performed, together with details of matters such as the infection risk.[65] Elsewhere in written evidence we were informed that women often did not even know what make of implant had been fitted.

47. Patients are entitled to much more information about the practical aspects of breast augmentation surgery. We believe it is for the DoH to capture the data, via the Registry, relating to the rates of rupture of different implants, and to ensure that this information is readily available. We believe that women are entitled to objective information on the success rates of surgeons performing such operations and that they should be informed of the precise nature of these surgeons' qualifications since, as our inquiry into private healthcare revealed, there is much misinformation in this area. We recommend that women should be obliged to record that they have been clearly informed of all aspects relating to future failure rate and costs of implants as part of the fuller consent procedure we describe below.

48. We recommend that it should be mandatory that women are given written information on the make and model of breast implant with which they have been supplied.

42   Q8; Q58. Back

43   Q54. Back

44   Ev., p.26. Back

45   QQ54-55. Back

46   Q111. Back

47   Q114. Back

48   Q11. Back

49   Daily Telegraph, 5.1.01; Q145. Back

50   Ev., p.31. Back

51   Ev., p.63. Back

52   Q81; Q108. Back

53   Ev., p.74. Back

54   Q61. Back

55   Q158. Back

56   QQ17-18. Back

57   Q20; Q23. Back

58   QQ112-13. Back

59   Q40; Q46. Back

60   Q46. Back

61   Ev., p.61. Back

62   QQ52-53. Back

63   Q76. Back

64   Q65. Back

65   Q31. Back

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