Facial disfigurement

The last bastion of discrimination

Facial disfigurement and deformity are common causes of human suffering, much more common than a walk down the high street may suggest as many afflicted will choose to hide from public gaze. Accurate figures do not exist, but–given the known incidences of congenital, traumatic, and malignant facial conditions, together with skin diseases–every general practitioner will frequently encounter this problem.1 At the root of the patient's distress lies the pressure in modern cosmopolitan society to confirm to an idealised appearance.2 Image and beauty are marketing tools portraying a particular “supermodel” as the desired “look,” diminishing the value of individuals who deviate from the face or form of the moment.

Stigmatisation by appearance is reinforced at every stage in education, from characters children's books such as Big Ears or Mr Nosey. Pantomime Ugly Sisters equate ugliness with evil, and film and video villains such as Freddy (in Nightmare on Elm Street) reinforce this definition. Were film makers to tackle race or sex in the way that they tackle beauty or ugliness they would be subject to prosecution. Yet incitement to pick on the disfigured is widespread–Chris Evans' “Ugly Bloke” feature in his TFI Friday television programme is a gross example. More subtle judgments based on appearance are widespread; recent media attention to the hairstyle of Tony Blair, leader of the Labour party, is an example. This obsession with appearance devalues and marginalises those who do not match the perceived ideal, and those with a visible disfigurement, being furthest down the ladder of beauty, are challenged most.

An interesting twist in this tale has been the suggestion that symmetry of body or facial form implies attractiveness3; symmetrical men have more sexual partners than asymmetrical people, and more satisfactory relationships. There must be doubt, however, about the measurement of symmetry.

Victims of society's cultural attack may simply adopt a defensive style of behaviour.4 Alternatively, they may approach their general practitioner with a complaint that is clearly directed towards a specific anatomical or pathological facial feature, or the true problem may be obscured as part of a depressive or anxiety state. It should be appreciated that the impact on a patient is not proportional to the magnitude of the disfigurement but depends on other psychological parameters, family adaption, and how much it interferes with his or her life. These are not frivolous complaints, and as many tears may be shed in the doctor's surgery as when confronting a fatal illness.

Negative coping strategies may include avoidance of social contact, alcohol misuse, and aggression, but these patients are not “psychiatric.” It is as dangerous for the doctor to dismiss a complaint of this type as it would be to ignore haemoptysis, as both may ultimately result in fatality; dissatisfaction with appearance seems to be a factor in many suicides. As with other conditions–such as heart disease–some patients may imagine that they have a problem where none exists, and minor degrees of pathology may require no action other than reassurance.

However, to take the stance, as some purchasers have done, that “cosmetic” (a term open to all sort of definitions) treatments will not be provided seems an extreme view that may deprive patients of an improved quality of life. It is difficult to categorise problems in to the morally worthy and the unworthy; even removal of a facial tattoo may return a patient to gainful employment. Having diagnosed a disfigurement, the doctor should assess its impact on the patient. The patient's general practitioner will generally be more successful at this than a specialist relying on a brief consultation. It is then appropriate to consider what sorts of help may be available. Referral to a plastic surgeon may be appropriate, not with a promise to remove the blemish or scar (in fact, contrary to suggestions in soap operas, scars cannot be removed) but to consider in a balanced way whether surgery can offer a physical improvement.

It is becoming clear, however, that surgery alone is not sufficient: such patients also require informed supportive counselling. At this point there is often a vacuum in the provision of service, which has been partly filled by a plethora of patient support groups. One such group, Changing Faces, provides training in social skills and a useful range of publications for patients and health professionals.5 A more extensive booklet, Counselling People with Disfigurement, informs doctors about the psychological management of this problem.6

The challenge now is to audit and scientifically evaluate various forms of counselling and to lobby politicians to ensure that resources are made available. Research is required in all aspects of patient care, from healing of the wound to coming to terms with the result. Society at large must also be educated to understand disfigurement and deformity. To achieve all of these aims, the various interest groups should be encouraged to unite their strengths in a foundation that works towards the healing of the whole patient.