An open letter from a BDD patient
trigger warning: mentions of self-harm, suicidal ideation, body dysmorphic disorder (BDD)
A few years back, I would have been the patient of your nightmares. The one who seems normal enough—pleasant, even—because they’ve mastered the art of hiding the torment driving their decisions. I’d walk into your clinic, calm and composed, clearly outlining the procedure I’d wanted. Maybe it would seem unnecessary, or perhaps reasonable enough for you to go ahead with it. You’d do everything right, delivering objectively excellent results, and I’d probably leave feeling happy—at least at first. But that fleeting sense of elation wouldn’t last long.
Some time later, I’d find myself staring into the mirror, questioning whether there was any visible difference at all. After all, if there were, wouldn’t I feel better about myself? It wouldn’t take long for doubt to creep in, convincing me that, no—there was no real change. I still hated the way I look. Desperation and hopelessness would take hold. The flaw I came to you to fix—the one consuming my thoughts and ruining my life—was still there. Or maybe I’d feel relief that it was gone, only to fixate on something new, another part of my appearance I couldn’t bear. Either way, I’d be back—whether to your clinic or someone else’s, depending on how much I’d blamed you for not meeting my impossible expectations.
I may not seem visibly distressed. I’ve learned that sharing how I feel about my appearance usually invites disbelief or even ridicule: “But you’re so beautiful!”; “Most people would kill to look like you!”; “You’re just fishing for compliments”; “Stop being vain—looks aren’t everything.” So I stay silent. I won’t tell you that a bad photo of myself can reduce me to tears, that I constantly fight the urge to hide my body, to become invisible, to disappear altogether. I won’t tell you about the thoughts of self-harm or the moments when I wonder if life is even worth living.
But what if, in a sea of aesthetic practitioners who might just shrug and go ahead with the procedure, you were one of the observant ones? Maybe you asked a few questions, dug a little deeper, and realised that my motivations weren’t healthy, that my expectations were unrealistic. You decided that saying ‘no’ was the right choice—for both of us. And that’s when everything would fall apart.
With my hopes shattered, a part of me would want to cease existing. If I couldn’t have the procedure that would make the ubiquitous unhappiness go away, I wouldn’t want to live. But another part of me may not be quite ready to give up yet. I hadn’t come this far only to walk away without a fight—and a fight I’d put up.
You, the practitioner, would seem like the gatekeeper to my happiness—the one thing standing between me and the solution to what I saw as the root cause of all my troubles. I might bargain with you, plead with you to change your mind, threaten to leave a career-ending review or just storm off. After all, there are plenty of other practitioners who would do it if you didn’t.
Deep down, I know that when you say ‘no,’ it’s because you’re acting in my best interests—that it’s part of your duty of care. But that care shouldn’t stop at simply turning me away. Without the right psychological support, this story risks taking a darker turn. I could end up seeking out a less responsible practitioner—perhaps someone without the proper qualifications. I might fall into a relentless cycle of chasing the “perfect” look, or worse, suffer the consequences of a botched procedure, spiralling to the point where coping with life feels impossible.
Unfortunately, this is not just a hypothetical scenario; this is the reality for sufferers of Body Dysmorphic Disorder (BDD). Despite a relatively low prevalence in the general population (around 2%), BDD is thought to affect around 20% of people seeking cosmetic procedures— and that’s just the diagnosed cases.
At least 50% of individuals with BDD undergo some kind of cosmetic procedure; and nearly all of them (research suggests 98%) will receive no benefit from elective cosmetic intervention- in fact, their mental health is very likely to deteriorate.
This also has serious consequences for the practitioners who encounter BDD patients: 2% of cosmetic surgeons have been physically threatened by BDD patients, while 10% have received threats of violence or legal action (Sweis et al., 2017; Wang et al., 2016). Notably, 40% of surgeons have faced threats from such patients (Ziglinas et al., 2014), and three surgeons have been murdered by patients suffering from BDD since 1991 (Sweis et al., 2017).
Even with growing awareness of the psychological issues affecting cosmetic patients, 84% of patients with BDD go undetected (Higgins et al., 2017). 80% of those with BDD experience suicidal thoughts. At least 1 in 4 make an attempt at ending their life.
Yet, it could take very little to change this. A brief pre-treatment mental health screening—or even just more awareness of the potential psychological impact—could give patients some hope for recovery and prevent them from spiralling further. You could be the practitioner who breaks the cycle—the one who helps patients like me find the support we truly need, instead of unintentionally feeding the patterns that keep us trapped.
I understand. You’re not a mental health professional, and you shouldn’t be expected to diagnose or manage complex psychological issues—mental health is a vast field in its own right. Between explaining procedures and ensuring physical safety, there’s little room for detailed psychological evaluation. But that’s exactly why tools exist to help you safeguard patient mental health and create a safer, more compassionate industry.
To every aesthetic practitioner reading this: your role is so much more than just technical skill. You have the power to change lives in ways that go far beyond physical appearance. Please, take a moment to ask the right questions, use the tools at your disposal, and refer to mental health professionals when needed. It might feel like a small step, but to patients like me, it’s everything.
Learn more about the patients desperately asking for mental health safeguards in the medical aesthetics industry.