‘You’re a pretty girl, but ...’: How the injectables industry preys on your insecurities

Jas Rawlinson never worried about the symmetry of her face until she visited a cosmetic nurse.

“She made me feel really bad about myself,” Rawlinson recalled. “She said, ‘You’re a very pretty girl, but this asymmetry is quite strong’.”

The comments at her 2023 appointment spurred Rawlinson to get Botox injected into the muscles above her right eyebrow – a treatment she’d never before contemplated.

The Botox was prescribed by a telehealth doctor who spoke to Rawlinson for a few minutes via a video call on the nurse’s phone.

Rawlinson, who has a history of body dysmorphic disorder, said the encounter made her hyper-aware of things that previously had not concerned her.

While doctors working in the fast-growing $4 billion cosmetic injectables industry should consider body dysmorphic disorder when assessing every patient before treatment, psychologists say this is not always happening.

With telehealth appointments driving the sector’s boom, there is concern the high turnover made possible by video appointments may put vulnerable patients at risk.

This masthead this week revealed video consultations lasting under 60 seconds, prompting the Australian Health Practitioner Regulation Agency (AHPRA) to say it was difficult to see how a consultation of that length met its guidelines.

National boards overseeing health professionals are also weighing new rules requiring other health practitioners, such as nurses, to also consider body dysmorphic disorder in patient assessments before non-surgical procedures such as injectables.

Body dysmorphic disorder is a debilitating condition that affects up to 20 per cent of patients seeking cosmetic procedures, says Toni Pikoos, a clinical psychologist who specialises in treating patients with the condition.

Pikoos said more regulation was needed to protect people particularly vulnerable to upselling and receiving unnecessary treatments.

“They become fixated on these perceived flaws in their appearance, and it’s something to them that is very distressing,” she said. “They tend to seek out cosmetic surgery to try to fix that perceived flaw and that can lead to them seeking excessive treatments they don’t necessarily need or will not resolve the underlying issue.”

Pikoos, who is also co-owner of a software company that screens patients for body dysmorphic disorder, said it’s unclear whether the responsibility for assessing the condition lies with the injector or the prescribing telehealth doctor.

“While body dysmorphic disorder screening is a quick process, discussing the results with the patient and referring them on to a mental health professional if needed can be a longer conversation,” she said. “The doctor may not have time for this in a short phone consult.”

An AHPRA spokesman said medical practitioners performing surgical and non-surgical procedures must consider body dysmorphic disorder as part of their broader assessment of a patient’s suitability.

“The guidelines also require the doctor to discuss the patient’s expectations of the procedure to ensure they are realistic,” he said.

If a patient appears to have significant underlying psychological issues making them an unsuitable candidate, the doctor must refer the patient to a psychologist, psychiatrist or GP for evaluation.

The spokesman said new guidelines were under development for non-medical practitioners such as nurses involved in non-surgical cosmetic procedures.

“It is expected these new guidelines will include appropriate patient assessment by non-medical practitioners that may include a body dysmorphic disorder assessment,” he said.

Author Lucinda Price, known online as Froomes, explored the role of body dysmorphic disorder in her book All I Ever Wanted Was To Be Hot, a memoir and investigation into the Australian cosmetic and beauty industry, published late last year.

Price has written about body dysmorphic disorder, although she believes her experience of it was influenced primarily by societal conditioning. “When I take into account the media diet I was raised on, my preoccupation with subtle flaws was likely the result of what I witnessed rather than a case of full-blown, pathological BDD,” she writes in her book.

Lucinda Price, who last year published All I Ever Wanted Was To Be Hot, a memoir and investigation into the Australian cosmetic and beauty industry.Credit: Steven Siewert

She was 19 when she first had lip filler and remembers her cosmetic surgeon suggesting she might benefit from more cosmetic work.

“He asked me – and I wasn’t asking – if my parents had sunken cheeks because it looked like I was losing volume under my eyes. I was 19. I thought that was kind of crazy.”

A few years later, the same doctor injected filler into Price’s lips again and she had an allergic reaction. Price’s mum, a nurse, sprang into action when her upper lip started expanding rapidly.

“Had I not had her, I would have definitely gone to the hospital,” the now 29-year-old said.

Price said she’s the perfect prey for cosmetic doctors because she has unrelenting standards. “That’s very attractive to them if you’re kind of vulnerable.”

She said women, influencers, models and stars such as Lindsay Lohan often get unfairly blamed for everything that’s wrong with the beauty industry.

“It’s a way of deflecting the blame away from the actual powerbrokers, which are plastic surgeons, the cosmetic injectables industry and beauty [sector] executives who need women to look a certain way.”

Price has noticed cosmetic injectable clinics popping up in shopping centres – which she notes is where teenage girls hang out in great numbers – and that this has made them mainstream. “It makes it seem much more normal than it used to be.”

Australian Association of Psychologists policy co-ordinator Carly Dober said while some body dysmorphic disorder screenings were taking place, there had been a slow uptake.

“They might not feel confident and they might be fearful of being fined or penalised in some way if they fail to pick up on what can be a very insidious psychological illness,” she said.

Dober said a key characteristic of body dysmorphic disorder was seeking out unnecessary dermatological or cosmetic procedures.

Griffith University body image expert Veya Seekis said even beyond body dysmorphic disorder, women faced intense societal pressures to remain youthful.

“We’re trying to treat the appearance of ageing as some kind of disease that needs to be stopped in its tracks,” said Seekis, who oversaw research asking young women if they feared the appearance of ageing.

“That really worries me because when we already have ageism in our society ... it stops people from simply experiencing the ageing process without feeling stigmatised or invisible.”

She said the injectables industry, which was once only available to the rich and famous, tapped into this insecurity by selling people a potential solution to ageing.

At the same time, filtered images on social media have made it hard for the brain “to start discerning what’s filtered and what’s real”, according to Seekis.

“People take shots of themselves, filter that shot, and then feel terrible about themselves because they don’t live up to the filtered image that they’ve created,” she said.

Research published in January by Griffith University of 365 undergraduate students studying there and aged between 17 and 25 showed 12 per cent were considering some form of cosmetic procedure in the near future. The most common procedures considered were lip fillers (58 per cent), Botox (19 per cent) and rhinoplasty (12 per cent). Just over a third of those polled had considered the risks of these procedures.

And the more pronounced potential symptoms for body dysmorphic disorder were, along with the fear of the appearance of ageing, the higher the likelihood that a cosmetic procedure was under consideration.

It follows research by Seekis published in 2023 that revealed young women watching just seven minutes of “beauty content” in one session on TikTok or Instagram were left feeling negative about their appearance.

Rawlinson would like to see more oversight of the booming injectables sector to ensure that people aren’t being taken advantage of.

“If you’ve grown up with body dysmorphia ... cosmetic injections may not be something that you need. That’s where there is danger,” said Rawlinson, who is a domestic violence survivor, motivational speaker and author.

Rawlinson now gets Botox twice a year from a more diligent and caring clinic. She has also had surgery to remove the puffy bags under her eyes, the insecurity which originally led her to the cosmetic clinic back in 2023.

While several nurses at different clinics recommended Rawlinson inject dermal filler into her tear troughs to remove her bags, Rawlinson did some research and discovered she had a genetic condition called orbital fat prolapse which could only be resolved with surgery.

She was pleasantly surprised by the strict safeguards around surgery, including a mandatory three-month cooling-off period before the operation took place and a surgeon sensitive to her insecurities.

“I wouldn’t want to have to wait three months to get Botox,” Rawlinson said. “But there needs to be some sort of balance, especially with fillers.”

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