1. Should there be a cosmetic surgical ban for adolescent women aged 13 to 19 years of age in the
province of Ontario
Abstract
Cosmetic surgical procedures have steadily been on the rise in North American adolescents. This rise is
related to the influence of the mass media. Mass media influence body dissatisfaction through the
promotion of ideal images of beauty. Common procedures among adolescents include rhinoplasty (nose
reshaping), otoplasty (ear surgery), correction of breast asymmetry, breast augmentation, liposuction, and
breast reduction. Adolescent girls that undergo major surgery, that is, breast augmentation and liposuction
are particularly vulnerable to the complications that arise from these procedures. The risks and
complications from these surgeries warrant strong governmental action as well as health promotion to
decrease the demand for cosmetic surgery in adolescent girls.

2. 2
Background
Cosmetic surgical procedures among adolescents in the United States and Canada have steadily been on the
rise. Common procedures among adolescents include rhinoplasty (nose reshaping), otoplasty (ear surgery),
correction of breast asymmetry, breast augmentation, liposuction, and breast reduction (see American Society
of Plastic Surgeons, 2011; Zuckerman & Abraham, 2008). Adolescents now account for 2 percent of all
cosmetic procedures in the United States and Canada (CBC Radio, 2011). 333, 000 of these procedures were
performed in adolescents 18 years of age and younger in the United States in 2005 (Zuckerman & Abraham,
2008). In 2003, 85 percent of all cosmetic procedures in Canada were performed in women, 42 percent of
them in Ontario (Medicard Finance, 2005). 24, 337 of the procedures were liposuction, and 16, 973 breast
augmentation (Medicard Finance, 2005). While no official figures are available on the rates of surgical
procedures in adolescents in Canada, experts reveal that they have been on the rise with growth rates
mirroring that of adolescents in the United States (see Smith, quoted in Kelly, 2010; Kelly, 2010; Blackwell,
2011).
The following discussion focuses on two of the most popular cosmetic procedures in adolescents,
breast augmentation and liposuction. In what follows, I will discuss the factors contributing to the demand
for cosmetic surgery. I will argue that the rise in cosmetic surgery is problematic given the physiological
complications that accompany these procedures (see Zuckerman & Abraham, 2008; Zuckerman &
Nagelin-Anderson, 2009).i This will be followed a discussion of an intervention at the systems level. I will
conclude with a discussion of the ethical issues, the opportunities, limitations, and barriers to the adoption of
the proposed intervention.
Cosmetic surgery in Canada
The most common invasive procedures in Canada are breast augmentation, liposuction and and
rhinoplasty (Flood, Thomas, & Harrison-Wilson, 2010; also see Medicard, 2005). Ontario leads the
provinces and territories in proportion of cosmetic surgical procedures with 42 percent of all cosmetic

3. 3
procedures being performed in the province (Medicard, 2005). This is followed by British Columbia (26
percent), Alberta (11 percent), and the rest of Canada (a combined 20 percent) (Medicard, 2005).
Interestingly women undergo 85.5 percent of all cosmetic procedures with the most popular surgical
procedures being liposuction, and breast augmentation (Medicard, 2005). From 2002 to 2003, rates of
liposuction in Ontario rose from 8, 846 to 10, 022, and from 6, 074 to 7, 129 for breast augmentation
(Medicard, 2005).ii
Cosmetic surgery vis-a vis reconstructive surgery
Cosmetic surgery differs from reconstructive surgery in a number of ways. Zuckerman and
Abraham (2008) define reconstructive surgery as a “procedure to correct a clear abnormality" Examples of
this include surgeries to correct a cleft lip or palate, a surgery that they argue can provide “enourmous benefit
to children and teenagers” (p. 2). They contrast this with cosmetic surgery which they assert is a “surgery to
improve a ‘normal’ appearance, such as reshaping a nose or augmenting breasts” (p. 2). Sullivan (2004) also
indentifies a number of features of cosmetic surgery that distinguish it from non-commercial medical care:
Cosmetic surgery reshapes healthy anatomical structures, the appearances of which fall within the normal
range of variation…[and is usually not] covered by health insurance because it is considered an elective
procedure without merit for physical health (p. 13). [This is in contrast to reconstructive surgery] which aims
to improve the function and sometimes the appearance of abnormal body structures. The abnormalities
addressed include those caused by congenital defects, developmental aberrations, trauma, infection, tumors,
or disease. Reconstructive surgery usually is not considered elective … is covered by health insurance...
[and] is part of the much larger noncommercial sector of medicine (pp. 13-14).
Cosmetic surgery in Ontario: The state of “the practice”
In Ontario, invasive and non-invasive surgeries can be performed by any medical doctor (doctors are
not necessarily surgeons) without the doctor being registered with the "Royal College of Physicians and
Surgeons of Canada (RCPSC) as a specialist in surgery or plastic surgery" (Flood, Thomas &
Harrison-Wilson, 2010, p. 37). Invasive surgeries Flood, Thomas and Harrison-Wilson (2010) note, are
generally "performed in public or private settings or in a private ‘cosmetic surgery’ clinic” (Flood, Thomas &
Harrison-Wilson, 2010, p. 37). Interestingly, while provinces monitor care provided in public facilities, they

4. 4
do not always do so for private facilities such as those providing cosmetic procedures (Fierlback, 2011).
Only Alberta and British Columbia have comprehensive regulatory and monitoring systems that oversee
among other things procedures that are performed in public and private clinics (National Post, n.d.).
Similarly, Alberta doctors that provide cosmetic surgery are prohibited from advertising themselves as
cosmetic surgeons unless they hold specialized training as cosmetic surgeons (National Post, n.d.). Yet in
Ontario, which has over 600 clinics providing 'invasive procedures," regulatory systems are negligible
(Fierlbeck, 2011). In 2008, a spokesperson for the provincial College of Physicians and Surgeons revealed
that they did not have authority to approve a facility before it opened, nor did they have the authority to shut
it down if there were any problems (Fierlbeck, 2011; also see Lett, 2008b). Exacerbating this is the fact that
many family physicians have been performing cosmetic surgical procedures and advertising themselves as
cosmetic surgeons (Lett, 2008a). This is problematic as the performance, particularly of invasive surgical
procedures such as liposuction and breast augmentation requires many years of specialized training (see Lett,
2008a). Despite this, aggressive advertising by cosmetic surgeons attempts to convince prospective patients
that procedures are simple and risk free (Lett, 2008a).
Furthermore, “Alberta doctors who perform cosmetic procedures are prohibited from advertising
themselves as cosmetic surgeons unless they hold a specialty in plastic surgery” (National Post, n.d.). In
short, the lack of regulations provide the impetus for a ban (and subsequently a stricter regulatory regimes for
major surgical procures, liposuction and breast augmentation) in the province. But even with strict
regulation, there can be instances when physicians that are not qualified to perform surgical procedures
sometimes do so in home-based cosmetic surgery (Lett, 2008), hence the need for interventions at the
individual, community, and systems level.
Body dissatisfaction: The conflict within
Body dissatisfaction in adolescent girls is related to number of outcomes. Girls who have
depression tend to have higher body dissatisfaction (Presnell, Bearman, & Stice, 2004; McCreary & Sasse,

5. 5
2000; Stice & Bearman, 2001), and body dissatisfaction is often a precursor to anorexia and bulimia anervosa
(Smolak & Striegel-Moore, 2002; also see Spettigue & Henderson, 2004; Durkin & Paxton, 2002; van den
Berg, Thompson, Obremski-Brandon, & Coovert, 2002; Stice, Schupak-Neuberg, Shaw, & Stein, 1994).
High levels of body dissatisfaction are also associated with cosmetic surgery (Sarwer, Wadden, Pertschuk &
Whitaker, 1998; Slevec & Tiggerman, 2010; Markey & Markey, 2009; Muhlan, Eisenmann-Klein, & Schmidt,
2007; von Soest et al., 2006; Henderson-King & Henderson-King, 2005; Didie & Sarwer, 2003; Sarwer,
Nordman, & Herbert, 2000). In other words, body dissatisfaction motivates individuals to pursue cosmetic
surgery. Adolescent girls women who undergo cosmetic surgical procedures have greater dissatisfaction with
specific body parts as well as a heightened concern about their general appearance (Zuckerman & Abraham,
2008; also see Muhlan, Eisenmann-Klein, & Schmidt, 2007).iii Cosmetic surgery is "body image therapy"
(Muhlan, Eisenmann-Klein, & Schmidt, 2007, p. 747) so that unlike eating disorders or mental health issues,
which have a stigma attached to them, “cosmetic surgery is a culturally sanctioned means of coping with body
dissatisfaction ... [so that i]increasingly, people turn to cosmetic surgery to feel better about their bodies”
(Smolak & Striegel-Moore, 2002, p. 205; also see Delinski, 2005).
“The medium is the message”: The media and body image
The majority of studies have shown that young women’s body dissatisfaction is highly associated
with exposure to thin-ideal images that are highly prevalent in the media (Tiggeman, 2003; Posovac, Posovac,
Weigel, 2001; Posavac, Posavac, & Posavac, 1998; Stice & Shaw, 1994; Stice, Spangler, & Agras, 2001; also
see studies on body dissatisfaction cited above). While the root causes of adolescent girls’ decisions to
undergo cosmetic surgery are hard to isolate, ideals of feminine beauty portrayed in the mass media are a
major factor correlated with many women’s decisions to undergo cosmetic surgery (Flood, Thomas, &
Harrison-Wilson, 2010; Cash, 1998). As Cash (1998) succinctly notes, recent decades in Western culture have
“heralded a thinner, not-so-curvaceous body type as the standard of feminine beauty” (p. 387), body types
that are primarily advocated in the media. It is not the media per se that influences decisions to undergo

6. 6
cosmetic surgery, but the internalization of the media ideals of feminine beauty (Brown, Furnham, Glanville,
& Swami, 2007). [This internalization is mediated through the process of social comparison (Tiggemann &
McGill, 2004; Hausenblas et al., 2004; Posavac, Posavac, & Weigel, 2001; Wood, 1989)]. Social comparison
theory suggests that individuals have an innate nature to compare themselves to other and often compare
themselves to others when objective standards are not available to them (Lew, Mann, Myers, Taylor, &
Bower, 2007).] Markey and Markey (2009), for example, found that women that had higher rates of body
dissatisfaction and a greater internalization of media ideals were more likely to “desire cosmetic surgery
compared to women who internalized media messages to a lesser degree” (p. 163). In addition, the “type of
exposure … is correlated with negative body image so that exposure to soap operas, movies, and music
videos are associated with higher rates of body dissatisfaction and drive for thinness” (Derenne & Beresin,
2006, Effects on health). These factors taken along with the media messages that suggest that appearance
enhancing surgical transformations are accessible and appropriate for young people, increase their
“inclination to want to improve their physical appearance” (Markey & Markey, 2009, p. 159). In essence, it is
through these “pathways” that the mass media propagate unrealistic standards of beauty which can only be
attained through cosmetic surgical procedures (Swami, Arteche, Chamorro-Premuzic, Furnham, Steiger et al.,
2008).
Whither cosmetic surgery: The evidence against cosmetic surgery
A number of scholars have argued that adolescents are good candidates for cosmetic surgery as they
have “have high satisfaction rates for …surgical and psychosocial results of the operation” (Kamburoglu &
Ozgur, 2007, p. 744), and “benefit from plastic surgery with improvements not accounted by ‘natural’
development, …[with the] improvement being ‘stronger in those undergoing corrective surgery’ ” (Simis,
Houvius, de Beaufort, Vethulst, Koot, et al., 2002, p. 17). While cosmetic surgery might improve some
adolescents’ self esteem in the short-term, from a medial and ethical viewpoint, there are a number of
short-term and long-term consequences that warrant a ban for major surgeries such as breast augmentation

7. 7
and liposuction. It should be noted however, that arguments about the efficacy of cosmetic surgery are
primarily advanced by cosmetic surgery providers who have greatly benefited from the medicalization of
appearance (see Sullivan, 2004).
Adolescent girls who undergo cosmetic surgical procedures have greater dissatisfaction with specific body
parts as well as a heightened concern about their general appearance (Zuckerman & Abraham, 2008; also see
Smolak & Striegel-Moore, 2002; Muhlan, Eisenmann-Klein, & Schmidt, 2007), a factor that raises questions
about the extent to which they have Body Dysmorphic Disorder (BDD) (Zuckerman & Abraham, 2008).ivv,vi
Adolescents and individuals who suffer from BDD do not require cosmetic surgery as a treatment
for BDD, but instead require psychiatric interventions (Crerans, Menard, & Phillips, 2010). This is because
cosmetic surgery only improves preoccupation with the treated body part but fails to treat BDD (Crerand,
Menard, & Phillips, 2010). BDD can be more effectively addressed through pharmocological approaches, and
cognitive behavioual therapy (Phillips, 2011; also see Neziroglu & Khemlani-Patel, 2002; Phillips, 2005)
instead of cosmetic surgery which approximates a "band-aid" approach to addressing the problem. For
example, “[i]n a study of 17 patients that received 20 daily sessions of 90 minutes CBT over one month, 12
patients had a 50% or greater reduction in BDD symptom severity” (Phillips, 2011, p. 197).
Similarly, because the objective of cosmetic surgery is self improvement due to poor body image,
individuals that undergo cosmetic procedures often fail to be satisfied with their appearances following
surgery. In fact, as Suissa (2008) notes, "plastic surgery may not prove beneficial in the medium term for
some people since it is never seen as being good enough...[so that] patients continue to be obsessed with
other body parts that must be changed and transformed" (pp. 625-626). Lorenc and Hall (2005; quoted in
Suissa, 2008, p. 627) identify at least three social factors that are influential in promoting obsession in
individuals with body dissatisfaction, as follows:
1. Exposure to television, special programming, such that patients require less representations, and fashion;
2. The huge technological strides in medical procedures, such that patients require less anesthetic and

8. 8
postoperative recovery is much faster;
3. The socialization process that increases the acceptability and desirability of surgery in a society that has
become more and more tolerant of the idea.
Breast augmentation and liposuction should be banned for adolescent girls also due to the
physiological and psychological changes that occur during this period (Zuckerman & Abraham, 2008). For
many adolescent girls, Zuckerman and Abraham (2008) breast size increases with weight gain which typically
occurs between the ages of 18 and 21. Weight gain that is associated with body development, they note,
reduces many adolescent girls concerns with breast size and can also increase fat deposits in areas that are
considered for liposuction. These developmental changes warrant a transformation in the acceptability of
liposuction and breast augmentation for adolescent girls so that they should be banned.
Finally, breast augmentation and liposuction should be banned for adolescent girls as body
dissatisfaction decreases with age through adolescence so that many adolescents report greater body
satisfaction after age 18 even among those that have not undergone cosmetic surgery (Zuckerman &
Abraham, 2008). For example, in a longitudinal study that assessed satisfaction with various parts of the
body in adolescent boys and girls when they were 11, 13, 15 and 18 years old, Rauste-von Wright (1989)
found the body satisfaction was highest at age 18 years old. On the other hand, increasing rates of cosmetic
surgery can exacerbate adolescent girls’ body dissatisfaction through the perpetuation of “an increasingly
stringent ideal of attractiveness” (Markey & Markey, 2009, p. 164; also see Bordo, 2003; Brumberg, 2000).
These issues, in combination, warrant interventions that address the demand for cosmetic surgery in
adolescent girls, chief of which is body dissatisfaction. In fact, several scholars have stressed the need for the
psychoeducational empowerment of women in order to reduce the “victimization of women by the mass
media” and to “enhance body acceptance… [These include the need for] social change, preventative
education, and effective therapies” (Cash, 1998, p. 390). Effectively addressing the demand for cosmetic
surgery in adolescent girls thus requires an intervention that employs a model/theory that recognizes the

9. 9
influence of structural factors. One such model is the ecological model.
Ecological models propose that factors outside of individuals influence their health behaviours
(Sallis, Owen & Fisher, 2008). A number of key features of ecological models are discussed by Sallis, Owen
and Fisher (2008). The first of these is that multi-level interventions are often the most effective in achieving
health behaviour change as policy and environmental changes affect “virtually entire populations in contrast
to interventions that reach only individuals” (p. 479). Because interventions that target individuals work best
when there are policies and environments that support the targeted behaviour changes, cosmetic surgical
prevention in adolescent girls will require a comprehensive strategy to address the health behaviour change.
Second, ecological models recognize the interplay of influences at the different environmental levels on health
behaviour so that interaction across the different levels, the individual, community, organization, policy, and
system influence health behaviour. Finally, the ecological model also maintains that influences at the various
ecological levels interact with one another (Sallis, Owen, & Fisher, 2008). In this regard, body dissatisfaction
among adolescent girls caused by media and adverting industry portrayals of the ideal body creates demand
for cosmetic surgical procedures. The profitability of cosmetic surgery drives the cosmetic surgical providers
who oppose a ban on major cosmetic surgery (breast augmentation and liposuction) for adolescent girls aged
13 to 19 years (adapted from Sallis, Owen, and Fisher, 2008). These factors taken together, require a systems
approach to addressing the cosmetic surgery problem in adolescent girls.
Ban on breast augmentation and liposuction for adolescent girls aged 13 to 19 years in the province
of Ontario
Firstly, in order to reduce the demand for non-medically necessary surgical cosmetic procedures,
liposuction and breast augmentation, in adolescent girls aged 13 to 19 years of age, a ban is recommended.
In doing so, Ontario will join Queensland, Australia in banning unnecessary cosmetic procedures for minors
(see Queensland Government, 2008). This ban will protect adolescent girls from the dangers of undergoing
major cosmetic surgical procedures, as well, as from the issues that arise from poor regulation of such

10. 10
cosmetic surgical procedures in the province. This intervention is predicated on the ecological models which
purport that healthy behaviours can be maximized when policies and environments support healthful choices
(Sallis, Owen, & Fisher, 2008, p. 467; also see WHO Commission on the Social Determinants of Health,
2008; Ottawa Charter for Health Promotion, 1986). This translates into a comprehensive strategy for
addressing the demand for cosmetic surgery in adolescent girls and women more generally. The ban,
alongside existing interventions that promote healthy body image, and subsequently, stronger regulatory
controls of the cosmetic surgical industry are all expected to promote long term health behaviour change
thereby reducing the demand for medically unnecessary cosmetic surgical procedures once these adolescent
girls become adults.
Secondly, it is recommended that a secondary measure facilitating long-term health behaviour change
at the systems level involves the introduction of stronger regulations on advertising standards for providers of
cosmetic surgical procedures (Flood, Thomas & Harrison-Wilson, 2010). These should move beyond the
existing College and Physicians of Ontario’s (CPSO) ban on the misleading use of the term ‘cosmetic
surgeon’ (Flood, Thomas & Harrison-Wilson, 2010).vii Advertisements from cosmetic surgical providers
should also provide patients with the potential risks associated with cosmetic surgery, as well as information
on their training and competence (Flood, Thomas & Harrison-Wilson, 2010).
Thirdly, it is recommended that the Ontario government make it a priority to repeal or amend the
legislation governing the provision of care in public and private hospitals. This is imperative as existing
legislation in Ontario are such that public hospitals and private hospitals have different regulations governing
the provision of health care in these facilities (see Flood, Thomas & Harrison-Wilson, 2010).viii This creates
an environment where patient safety is not prioritized in the private sector as it is in the public sector (Flood,
Thomas & Harrison-Wilson, 2010). While the right to health primarily applies to preventative and curative
health care, Article 35 of General Comment 14 states that:
Obligations of [States parties to the International Covenant on Economic, Social, and Cultural Rights

11. 11
(ICESCR)] to protect include, inter alia, the duties of States to adopt legislation or to take other measures
ensuring equal access to health care and health-related services provided by third parties; to ensure that
privatization of the health sector does not constitute a threat to the availability, accessibility, acceptability and
quality of health facilities, goods and services; to control the marketing of medical equipment and medicines
by third parties; and to ensure that medical practitioners and other health professionals meet appropriate
standards of education, skill and ethical codes of conduct.
Based on this, Canadian governments, federal and provincial, have the moral obligation to ensure that
individuals receiving elective surgeries in private clinics receive similar protections as individuals that receive
general care in the public health care system.ix
Fourthly, it is recommended that Ontario join Alberta and British Columbia in instituting
accreditation requirements for the providers of cosmetic surgery which will consist of a residency program in
plastic surgery. Such a regulatory regime will have the effect of controlling general practitioners and
surgeons whose specialties are not in plastic surgery, from performing invasive procedures.x
Ethical issues and consequences
Public health codes of conduct have been influenced by four principles inherent in biomedicine
namely: bioethics, beneficence, non-malfeasance, and justice (see Kirch, 2008; Birn, Pillay & Holtz, 2009).
There are instances however, when these principles might be violated due to the functions of public health
(see Mann et al, 1994). The functions of public health according to Mann et al. (1994) include “assessing
health needs and problems; developing policies designed to address priority health issues; and assuring
programs to implement strategic health goals” (p. 13). A government's public health actions therefore must
protect population health while simultaneously upholding basic human rights and social values of a
population (Boggio, Zignol, Jaramillo, Nunn, Pinet et al., 2008). As such, "the protection afforded to an
individual's human rights is subject to limitation, and international human rights law authorizes restricting
rights to protect public health, when necessary" the legal standards of which are spelled out in the Syracusa
Principlesxi (Boggio, Zignol, Jaramillo, Nunn, Pinet et al., 2008, Public Health and Human Rights Laws). Due to
these issues, the ban might be challenged on the grounds that it is unethical and violates ethical values of

12. 12
public health, namely liberty and autonomy (see Have et al., 2010 ), or more specifically, adolescent girls’
autonomy and their right to choose. Ethically however, it is important to ensure that there are harm
reduction strategies in place once adolescent girls become adults. In the interest of harm reduction
therefore, a regulation is proposed.
The regulation will ensure that once adolescent girls reach adulthood, there will be more stringent
harm reduction strategies in place. A related issue is whether the ban might cause harm, or endanger certain
individuals. To ensure that the ban does not violate the principle of malfeasance, in this case, "doing the
least harm possible to the least number of people" (Kirch, 2008, p. 365), the ban applies only to breast
augmentation and liposuction for purely cosmetic purposes. Adolescent girls that require breast
augmentation and liposuction as a medical necessity on the other hand will not be prevented from
undergoing these procedures. Finally stemming from the core principles of public health, the
recommended interventions are based on evidence-based information which is required for the
implementation of effective programs and policies to promote health (see Kirch, 2008). Moreover, in
discussing the public health code of ethics, Kirch (2008) notes that “public health should address principally
the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes”
(p. 366). Based on this reasoning, the ban and subsequent regulation address these core values of public
health.
Challenges, opportunities, and implementation issue
According to Sullivan (2004) beauty has increasingly become a medical business and because
“cosmetic surgery is a business enterprise aimed at generating profit by selling a product for more than the
cost of providing it” (p. 9) the ban will encounter strong opposition from the cosmetic surgery industry.
Opposition could challenge the constitutionality of the law by demanding a repeal of the law, a process that
could stall its implementation. This is exemplified by Bill 141. Despite the fact that the bill would provide
the College of Physicians and Surgeons Ontario (CPSO) the power to inspect clinics where cosmetic surgeries

13. 13
were being performed, it took 5 months for the passing of the bill from the time that it was introduced
(CPSO, 2011). As such, interventions that challenge the “status quo”, such as a ban, could be met with
strong opposition from the College arguing that a ban might subvert patients’-consumers rights to choice
(examples include the removal of out of pocket payments in the early 1980s in Canada, and “Obamacare” in
the United States) thereby making implementation difficult.
The ban should be followed by the introduction of greater regulatory measures for surgical cosmetic
procedures. Regulation will be required to ensure that cosmetic surgery is safe more generally. This is a not
a dichotomous approach as the two interventions are complimentary. Furthermore, the implementation of
greater regulatory measures is an ethical way of addressing the issue, particularly from a human rights
framework. In discussing harm reduction related to drug use, the Commission on Narcotic Drugs (2008)
notes that there is not a contradiction between “prevention and treatment on one hand, and ...reducing the
adverse health and social consequences ...on the other hand” (p. 18). It argues that harm reduction that does
not address enforcement, prevention, and treatment will perpetuate drug use. In the same way, banning
cosmetic surgery for adolescent girls aged 13 to 19, without the introduction of greater regulatory controls
inadvertently perpetuates harm. In other words, effectively reducing harm and designing interventions that
can achieve this requires complimentary policies at various levels, such as the systems and individual levels,
for example.
While adolescent girls have greater body dissatisfaction compared to adolescent boys (Markey &
Markey, 2009), these interventions provide the opportunity to address body dissatisfaction in adolescent boys,
as well as in the population more generally. More specifically, stronger regulatory measures will benefit
boys and the Ontario population more generally by protecting them from the inadequacies of the existing
regulations around the cosmetic surgical industry in the province.
Conclusion
The past decade has witnessed a rise in cosmetic surgery among adolescents in Canada and the

14. 14
United States. The rising demand for cosmetic procedures, namely breast augmentation and liposuction, in
adolescent girls is linked to body dissatisfaction which is in part a consequence of their internalization of
media ideals of feminine beauty. These procedures have major physiological complications that are
detrimental to health and well-being of these girls. Instituting legislative changes such as a ban and the
introduction of greater regulatory measures will help to address the rising demand for cosmetic surgery in this
population. While these measures are not a panacea for addressing the root of the cosmetic surgery
problem, they provide a major starting point for addressing this complex problem.

15. 15
Bibliography
Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs,
NJ: Prentice-Hall.
Alagna, M. (2002). Dangers of cosmetic surgery. New York: The Rosen Publishing Group.
American Society of Plastic Surgeons (2011). Plastic surgery for teenagers briefly paper. Retrieved January 13, 2012
from http://www.plasticsurgery.org/news-and-resources/briefing-papers/plastic-surgery-for-teenagers.html
Bank, B. J., Biddle, B. J., Anderson, D. S., Hauge, R., Keats, D. M., Mariin, N. N. and Valantira, S. (1985)
Comparative research on the social determinants of adolescent drinking. Social Psychology Quarterly, 48,
164—177.
Birn, A. E., Pillay, Y., & Holtz, T. H. (2009). Textbook of international health: Global health in a dynamic
world. New York: Oxford University Press.
Blackwell, T. (2011). Demand for plastic surgery growing among Canada ’s youth. Retrieved
October 15, 2011 from http://news.nationalpost.com/2011/09/10/demand-for-plastic-
surgery-growing-among-canadas-youth/
Boggio, A., Zigol, M., Jaramillo, Nunn, P., Pinet, G., et al. (2008). Limitations on human rights: Are they
justifiable to reduce the burden of TB in the era of MDR-and XDR-TB. Health and Human Rights: An
International Journal, 10(2).
Bordo, S. (2003). Unbearable weight: Feminism, Western culture, and the body. Berkeley, CA: University of
California Press.
Brook, J. S.,, Whiteman, M., Gordon, A. S., Nomura, C., & Brook, D. W. (1986) Onset of adolescent
drinking: A longitudinal study of intrapersonal and interpersonal antecedents. Advances in Alcohol and
Substance Abuse, 5, 91-110.
Brown, A., Furnham, A., Glanville, L., & Swami, V. (2007). Factors that affect the likelihood of undergoing
cosmetic surgery. Aesthetic Surgery Journal, 27, 501–508.
Brumberg, J. J. (2000). Fasting girls: The history of anorexia nervosa. New York: Vintage Books.
Cash, T.F. (1998). The emergence of negative body images. In E. Blechman & K. Brownell (Eds.), Behavioral
Medicine for Women: A Comprehensive Handbook, pp. 386-391. New York: Guilford.
CBC Radio. (May 18, 2011). Kid’s cosmetic surgery. Retrieved October 14, 2011 from
http://www.cbc.ca/thecurrent/episode/2011/05/18/kids-cosmetic-surgery/
Childress, J. F., Faden, R. R., Gaare, R. D., Fostin, L. O., Kahn, J., et al. (2002). Public health ethics: Mapping
the terrain. Journal of Law, Medicine & Ethics, 30, 170-178.
Clark, N. M., & Houle, C. R. (2008). In S. A., Shumaker, J. K, Ockene, and K. A. Riekert (Eds.), The

16. 16
handbook of health behavior change, pp. 39-58. New York: Springer Publishing Company.
Commission on Narcotic Drugs. (2008). Making drug control ‘fit for purpose’: Building on the UNGASS
decade. Retrieved November 12, 2011 from
http://www.unodc.org/documents/commissions/CND-Session51/CND-UNGASS-CRPs/ECN72008CRP
17.pdf
Constitution of the World Health Organization.
http://www.who.int/governance/eb/who_constitution_en.pdf
Convention on the Elimination of All Forms of Discrimination against Women. Retrieved January 12, 2012,
from http://www.un.org/womenwatch/daw/cedaw/text/econvention.htm
Convention on the Rights of the Child. Retrieved January 12, 2012,
http://www2.ohchr.org/english/law/crc.htm
Crerand, C. E., Menard, W., & Phillips, K. A. (2010). Surgical and minimally invasive cosmetic procedures
among persons with body dysmorphic disorder. Annals of Plastic Surgery, 65(1), 11–16.
Delinsky, S. S. (2005). Cosmetic surgery: A common and accepted form of selfimprovement. Journal of
Applied Social Psychology, 35, 2012–2028.
Derenne, J. L., & Beresin, E. V. (2006). Body image, media, and eating disorders. Academic Psychiatry, 30,
257-261.
Didie, E. R., & Sarwer, D. B. (2003). Factors that influence the decision to undergo cosmetic breast
augmentation surgery. Journal of Women’s Health, 12, 241–253.
Doyal, L. (1995). What makes women sick: Gender and the political economy of health. New Brunswick:
New Jersey: Rutgers University Press, 1995.
Durkin, S., & Paxton, S. (2002). Predictors of vulnerability to reduced body image satisfaction and
psychological wellbeing in response to exposure to idealized female media images in adolescent girls. Journal
of Psychosomatic Research, 53, 995-1005.
Eakin, J., Robertson, A., Poland, B., Coburn, D., & Edwards, R. (1996). Towards a critical social science
perspective on health promotion research. Health Promotion International, 11 (2), 157-165.
Family Health International. (2002). Behavior change -- A summary of four major theories. Retrieved
November 12, 2011 from
http://www.fhi360.org/nr/rdonlyres/ei26vbslpsidmahhxc332vwo3g233xsqw22er3vofqvrfjvubwyzclvqjcbdg
exyzl3msu4mn6xv5j/bccsummaryfourmajortheories.pdf
Fierlbeck, K. (2011). Health care in Canada : A citizen’s guide to policy and politics. The University of
Toronto Press.
Fishbein, M., & Ajzen, I. (1975).. Belief, attitude, intention, and behavior. Reading, MA: Addison-Wesley.

17. 17
Flood, C. M., & Choudhry, S. (2002). Strenghtening the foundations: Modernizing the Canada Health Act.
Retrieved February 11, 2012 from http://www.law.utoronto.ca/healthlaw/docs/romanow_report.pdf
Flood, C. M., Thomas, B., & Harrison-Wilson, L. (2010). Cosmetic surgery regulation and regulation
enforcement in Ontario. Queen's Law Journal, 36. ,
Foster-Fishman, P.G., Nowell, B., & Yang, H. (2007). Putting the system back into systems change: a
framework for understanding and changing organizational and community systems. American
Journal of Community Psychology, 39, (3/4) 197-215.
General Comment No. 14 (2000) on the right to health.
Gillmore, M.R, Archibold, M.E., Morrison, D.M., Wilsdon, A., Weels, E.A., et al. (2002) Teen sexual
behaviour: applicability of the theory of reasoned action. Journal of Marriage and
Family, 64, 885–889.
Hausenblas, H. A., Janelle, C. M., Gardner, R. E., & Focht, B. C. (2004). Viewing physique slides: Affective
responses of women at high and low drive for thinness. Journal of Social and Clinical Psychology, 23, 45–60.
Hayden, J. (2009). Introduction to health behavior theory. Sudbury, Massachusetts: Jones and Bartlett
Publishers.
Henderson-King, D., & Henderson-King, E. (2005). Acceptance of cosmetic surgery: Scale development and
validation. Body Image, 2, 137–149.
Hersey, J. C., Niederdeppe, J., Evans, W. D., Nonnemaker, J., Blahut, S.,Farrelly, M. C., et al. (2003). The
effects of state counterindustry media campaigns on beliefs, attitudes, and smoking status among teens and
young adults. Preventive Medicine, 37, 544–552.
International Covenant on Economic, Social and Cultural Rights (1976).
Kamburoglu, H. O., & Ozgur, F. (2007). Postoperative satisfaction and the patient's body image, life
satisfaction, and self-esteem: A retrospective study comparing adolescent boys and girls after cosmetic
surgery. Aesthetic Plastic Surgery, 31, 739-745.
Kandel, D. B. (1985) On processes of peer influences in adolescent drug use: a developmental perspective.
Advances in Alcohol and Substance Abuse, 4, 139—163.
Kelly, D. (2010, June 18). Teens undergo cosmetic surgery in record numbers. Globe and Mail.
Retrieved October 10, 2011 from http://www.theglobeandmail.com/life/health/teens-
undergo-cosmetic-surgery-in-record-numbers/article1609439/
Kirch, W. (2008). Encyclopedia of public health. New York: Springer Science + Business Media, LLC.
Lennon, S. J., Lillethun, A., & Buckland, S. S. (1999). Attitudes toward social comparison as a function of
self-esteem: Idealized appearance and body image. Family and Consumer Sciences Research Journal, 27(4),

18. 18
379–405.
Lett, (2008a). The search for integrity in the cosmetic surgery market. CMAJ, 178(3), 274–275.
---. (2008b). Private health clinics remain unregulated in most of Canada . CMAJ, 178(8), 986-987.
Lew, A., Mann, T., Myers, H., Taylor, S., & Bower, J. (2007). Thin-ideal media and women’s body
dissatisfaction: Prevention using downward social comparisons on non-appearance dimensions. Sex Roles: A
Journal of Research, 57, 543–556.
Mabry, P. L., Marcus,S. E., Clark, P. I., Leischow, S. J., & Mendez, D. (2010). Systems science: a revolution in
public health policy research. American Journal of Public Health, 100(7), 1161-1163.
Madden, T. J., Ellen, P. S., & Ajzen, I. (1992). A comparison of the theory of planned behavior and the
theory of reasoned action. Personality and Social Psychology Bulletin, 18, 3-9.
Malchiodi, C. A. (2005). Expressive therapies: History, theory and practice. In C. A. Malchiodi (Ed),
Expressive therapies, (pp. 1-15). New York: The Guilford Press.
Mann, J., Goskin, L., Gruskin, S., Brennan, T., Lazzarini, Z., & Fineberg, H. V. (1994). Health and human
rights. Health and Human Rights: An International Journal , 1(1), 6–23.
Marcoux, B. C., & Shope, J. T. (1997). Application of the theory of planned behavior to adolescent use and
misuse of alcohol. Health Education Research: Theory & Practice, 12(3), 323-331.
Mackey, E. R., & La Greca, A. M. (2008). Does This Make Me Look Fat? Peer Crowd and Peer Contributions
to Adolescent Girls’ Weight Control Behaviors Journal of Youth and Adolescence, 37( 9), 1097-1110.
Markey, C.N. & Markey, P.M. (2009). Correlates in young women’s interest in obtaining cosmetic
surgery. Sex Roles, 61, 158-166.
Martin, L. R., Haskard-Zolnierek, K. B., & DiMatteo, M. R. (2010). Change and treatment adherence. New York:
Oxford University Press.
McCreary, D. R., & Sasse, D. K. (2000). Exploring the drive for muscularity in adolescent boys and girls.
Journal ofAmerican College Health, 48, 297–304.
Medicard Finance (2005). Plastic Surgery Statistics. Retrieved October 5, 2011 from
http://www.plasticsurgerystatistics.com
Montano, D., & Kasprzyk, D. (2008). Theory of reasoned action, theory of planned behavior, and the
integrated behavioral model. In K. Glanz, B. Rimer, & K. Vizwanath (Eds.), Health behavior and health
education: Theory, research, and pactice, pp. 67–96. San Francisco: Jossey-Bass.
Mühlan, H., Eisenmann-Klein, M., & Schmidt, S. (2007). Psychological features in a German sample of
female cosmetic surgery candidates. Aesthetic Plastic surgery, 31(6), 746-751.

19. 19
National Post. (n.d). Cosmetic surgery rules to get tougher. Retrieved October 18, 2011 from
http://www.nationalpost.com/news/toronto/story.html?id=bfcc45b4-4092-4a79-8e72-
d34f8ab19ac2&p=1
Needle, R., McCubbin, H., Wilson, M., Reineck, R., Lazar, A., & Mederer, H. (1986) Interpersonal influences
in adolescent drug use. The role of older siblings, parents, and peers.
International Journal of Addiction, 2, 739—766.
Neziroglu, F., & Khemlani-Patel, S. (2002). A review of cognitive and behavioural treatment for body
dysmorphic disorder. CNS Spectrums, 7, 464-471.
Oppong, J. R., & Kalipeni, E. (2004). Perceptions and misperceptions of AIDS in Africa .In E. Kalipeni, S.
Craddock, J. R. Oppong, & J. Ghosh (Eds.), HIV and AIDS in Africa: Beyond epidemiology (pp. 47-58).
Malden, MA: Blackwell.
Packard, R. M., & Epstein, P. (1991). Epidemiologists, social scientists, and the structure of medical research
on AIDS in Africa. Social Science and Medicine, 33 (7), 771-794.
Phillips, K. A. (2005). The broken mirror: understanding and treating body dysmorphic disorder. New York:
Oxford University Press.
---. (2011). Body dysmorphic disorder. In R. Hudak, and D. Dougherty, Clinical obsessive- compulsive
disorders in adults and child, pp. 191-206. Cambridge : Cambridge University Press.
Posavac, H. D., Posavac, S. S., & Posavac, E. J. (1998). Exposure to media images of female attractiveness
and concern with body weight among young women. Sex Roles, 38, 187–201.
Posavac, H. D., Posavac, S. S., & Weigel, R. G. (2001). Reducing the impact of media images on women at
risk for body image disturbance: Three targeted interventions. Journal of Social and Clinical Psychology, 20,
324–340.
Presnell, K., Bearman, S. K., & Stice, E. (2004). Risk factors for body dissatisfaction in adolescent boys and
girls: A prospective study. The International Journal of Eating Disorder, 36(4), 389-401.
Queensland Government. (April 17, 2008). QLD to ban underage cosmetic surgery in Australian- First.
Retrieved November 12, 2011 from
http://www.cabinet.qld.gov.au/mms/StatementDisplaySingle.aspx?id=57628
Rauste-von Wright M. (1989). Body image satisfaction in adolescent girls and boys: a longitudinal study.
Journal of Youth and Adolescence, 18(1),71– 83.
Rogers, A. (2000). Subjective norms, attitudes, body mass indices, and self esteem as influences on women’s
body image behavior. Retrieved October 25, 2011 from
http://wvuscholar.wvu.edu:8881//exlibris/dtl/d3_1/apache_media/L2V4bGlicmlzL2R0bC9kM18xL2FwY
WNoZV9tZWRpYS80OTc2.pdf

20. 20
Rubin, J. A. (2010). Introduction to art therapy : Sources and resources. New York: Routledge.
Sallis, J.F., Owen, N. & Fisher, E.B. (2008). Ecological Models. In K. Glanz, B.K. Rimer, and K. Viswanath
(Eds.,) Health Behavior and Health Education, pp. 465-485. San Francisco , CA : Jossey-Bass.
Sarwer, D. B., Wadden, T. A., Pertschuk, M. J., & Whitaker, L. A. (1998). The psychology of cosmetic
surgery: A review and conceptualization. Clinical Psychology Review, 18, 1–22.
Sarwer, D. B., Nordmann, J. E., & Herbert, J. D. (2000). Cosmetic breast augmentation surgery: A critical
overview. Journal of Women’s Health & Gender-Based Medicine, 9, 843–856.
Schachter, D., Kleinman, I., Harvey , W. (2005). Informed consent and adolescents. Canadian Journal of
Psychiatry, 50(9), 534-540.
Selvan, M.S., Ross, M.W., Kapadia, A.S., Mathai, R., & Hira, S. (2001). Study of perceived norms, beliefs and
intended sexual behaviour among higher secondary school students in India.
AIDS Care, 13, 779–788.
Simis, K., Hovius, S., de Beaufort, I., Verhulst, F., Koot, H. et al. (2002). After plastic surgery:
Adolescent-reported appearance ratings and appearance-related burdens in patient and general population
groups. Plastic & Reconstructive Surgery, 109(1), 9–17.
Slevec, J., & Tiggemann, M. (2010). Attitudes towards cosmetic surgery in middle-aged women: Body image,
aging, anxiety, and the media.Psychology of Women Quarterly, 34, 65–74.
Smolak, L., & Striegel-Moore, R. H. (2002). Body image concerns. In J. Worell, (Ed.), Encyclopedia of
women and gender: sex similarities and differences and the impact of society on gender. Orlando, Florida:
Academic Press.
Spettigue, W., & Henderson, K. A. (2004). Eating disorders and the role of the media. Canadian Child and
Adolescent Psychiatry, 13 (1), 16-19.
Stice, E., Schupak-Neuberg, E., Shaw, H. E., & Stein, R. I. (1994). Relation of media exposure to eating
disorder symptomatology: An examination of mediating mechanisms. Journal of Abnormal Psychology,
103(4), 836-840.
Stice, E., & Shaw, H. (1994). Adverse effects of the media portrayed thin-ideal on women, and linkages to
bulimic symptomatology. Journal of Social and Clinical Psychology, 13, 288–308.
Stice, E., & Bearman, S. K. (2001). Body image and eating disturbances prospectively predict growth in
depressive symptoms in adolescent girls: A growth curve analysis. Developmental Psychology, 37, 597-607.
Stice, E., Spangler, D., & Agras, W.S. (2001). Exposure to media-portrayed thin-ideal images adversely affects
vulnerable girls: A longitudinal experiment. Journal of Social and Clinical Psychology, 20, 271–289.

21. 21
Stice, E., Chase, A., Stormer, A., & Appel, A. (2001). A randomized trial of a dissonance-based eating
disorder prevention program. Journal of Eating Disorders, 29 (3), 247–262.
Suissa, J.A. (2008). Addiction to Cosmetic Surgery : Representations and Medicalization of the Body.
International Journal of Mental Health & Addictions. 26, 3.
Swerissen, H. and Crisp, B. (2004) The sustainability of health promotion interventions for different levels of
social organisation. Health Promotion International, 19 (1), 123–130.
Sullivan, D. A. (2004). Cosmetic surgery: the cutting edge of commercial medicine in America. New
Brunswick , NJ : Rutgers University Press.
Swami, V., Arteche, A., Chamorro-Premuzic, T., Furnham, A., Stieger, S., Haubner, T., et al. (2008). Looking
good: Factors affecting the likelihood of having cosmetic surgery. European Journal of Plastic Surgery, 30,
211–218.
Swerissen, H., & Crisp, B. R. (2004). The sustainability of health promotion interventions for
different levels of social organization. Health Promotion International, 19 (1), 123-130.
Syu, Φ. Κ., Yii-Huang, Μ. Υ., & Huang, Ξ. Ξ. (2010). A successful intervention to reduce cigarillo use among
Baltimore youth. Fooyin Journal of Health Sciences, 2(3), 72-84.
.
The College of Physicians and Surgeons Ontario . (2011). Cosmetic procedures initiative. Retrieved
December 23, 2011 from
http://www.cpso.on.ca/uploadedFiles/policies/positions/cosmetic/timeline4pointplan.pdf
Tiggemann, M. (2003). Media exposure, body dissatisfaction and disordered eating: Television and magazines
are not the same! European Eating Disorders Review, 11, 418–430.
Tiggemann, M., & McGill, B. (2004). The role of social comparison in the effect of magazine advertisements
on women’s mood and body dissatisfaction. Journal of Social and Clinical Psychology, 23, 23–44.
van den Berg, P., Thompson, J. K., Obremski-Brandon, K., & Coovert, M. (2002). The tripartite influence
model of body image and eating disturbance: A covariate structure modeling investigation testing the
mediational role of appearance comparison. Journal of Psychosomatic Research, 53, 1007-1020.
VanderPlaat, M., & Teles, N. (2005). Mainstreaming social justice: human rights and public health.
Canadian Journal of Public Health, 96(1), 34-36.
von Soest, T., Kvalem, I., Skolleborg, K., & Roald, H. (2006). Psychosocial factors predicting the motivation
to undergo cosmetic surgery. Plastic & Reconstructive Surgery, 117(1), 51-62.
Wong, F., Huhman, M., Heitzler, C., Asbury, L., Bretthauer-Mueller, R. et al. (2004). VERB™ - a social
marketing campaign to increase physical activity among youth. Preventing Chronic Disease, Retrieved January

22. 22
16, 2012, from http://www.cdc.gov/pcd/issues/2004/jul/04_0043.htm.
Woolfolk, R. L., & Allen, L. A. (2011). Somatoform and physical disorders. In D. H. Barlow, & P. E. Nathan
(Eds.,) The oxford handbook of clinical psychology, pp-334-358.
World Health Organization. (2003). WHO Framework Convention on tobacco control.
http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf
World Health Organization.. (2008). Closing the gap in a generation. Commission on social determinants of
health. World Health Organization.
Wood, J. (1989). Theory and research concerning social comparison of personal attributes. Psychological Bulletin,
106, 231–248.
Yamamiya, Y., Cash, T. F., Melnyk, S. E., Posavac, H. D., & Posavac, S. S. (2005). Women’s exposure to
thin-and-beautiful media images: body image effects of media-ideal internalization and impact-reduction
interventions. Body Image, 2, 74–80.
Zuckerman, D. & Abraham, A. (2008). Teenagers and cosmetic surgery: Focus on breast augmentation
and liposuction. Journal of Adolescent Health, 43 (4), 318-324.
Zuckerman, D., Nagelin-Anderson, E., & Santoro, E. (2009). What you need to know about breast implants.
Retrieved January 15, 2012 from http://20www.breastimplantinfo.org/pdfs/implantfacts.pdf

23. 23
Endnotes
i
While cosmetic surgery has negative psychological effects in addition to those that are physiological, the
former will not be discussed here.
ii
Rates for adolescents are not readily available but estimates from the grey literature reveals
that cosmetic surgical procedures are also increasing in adolescents. Similarly, Medicard (2005)
which provides cosmetic surgery financing reports that only 11 percent of practices in Canada
have clients aged 19 to 34 years
(http://www.plasticsurgerystatistics.com/value_by_age_group.html).
iii
Although both women and men possess "dysfunctional" body image, dysfunctional body
image is greater in women and the adolescent years are associated with greater concerns with
appearances and negative body image Cash (1999). Moreover a number of studies suggest that
cosmetic surgery is associated with feature specific dissatisfaction compared to “global” body
dissatisfaction (see Delinsky, 2005; Didie & Sarwer, 2003).
iv
BDD is a psychological disorder that is “characterized by a preoccupation with an imaged defect in appearance"
(Woodfolk & Allen, 2011, p. 345.
v
Estimates suggest that individuals with BDD are estimated to be 3.2 percent to 16.6 percent
of cosmetic surgery patients (Crerand, Menard, & Phillips, 2010).

24. 24
vi
Although both women and men possess "dysfunctional" body image, dysfunctional body
image is greater in women and the adolescent years are associated with greater concerns with
appearances and negative body image Cash (1999). Moreover a number of studies suggest that
cosmetic surgery is associated with feature specific dissatisfaction compared to “global” body
dissatisfaction (see Delinsky, 2005; Didie & Sarwer, 2003).
vii
While under:
CPSO rules, a member cannot communicate any information that is false, misleading, or
deceptive by the inclusion or omission of information, [and under] the Canadian Society of
Plastic Surgeons’ Code of Ethics, a member must not make a 'misrepresentation of fact or [omit]
to state any material fact necessary to make the statement, considered as a whole, not deceptive
or misleading’ [t]hese regulations do not appear to be strictly enforced, perhaps because there is
no specific requirement that advertisements fairly present the risk of cosmetic surgery” (Flood,
Thomas & Harrison-Wilson, 2010, p. 56).
viii
According to Flood, Thomas and Harrison-Wilson, 2010, “Ontario has enacted the Public Hospitals
Act, the Private Hospitals Act, and the independent Health Act to regulate distinct categories of instructions
that deliver health services ... [with p]rovisions on patient safety is different for the category of institutions
that deliver health services” (Flood, Thomas & Harrison-Wilson, 2010, p. 41).
ix
Governments that have ratified the ICESCR are required to institute the provisions of the covenant in
their domestic policies subject to progressive realization and the availability of resources.
x
11 Surgeons whose specialties are not in plastic surgery, but who meet the Ontario College of Physicians
and Surgeons (OCPS) requirements can perform invasive procedures, and work in certified facilities (see
Flood, Thomas & Harrison-Wilson, 2010; also see Lett, 2008 a, b).
xi
According to Boggio, Zignol, Jaramillo, Nunn, Pinet et al. (2008), "These principles hold
that measures restricting human rights should be legal, neither arbitrary nor discriminatory,
proportionate, necessary, the least restrictive means that are reasonably available under the
circumstances, and based on sound science. Specifically, for a restriction of a human right to be
considered legitimate, a government has to address the following five criteria: 1) the restriction is
provided for and carried out in accordance with the law; 2) the restriction is in the interest of a
legitimate objective of general interest; 3) the restriction is strictly necessary in a democratic

25. 25
society to achieve the objective; 4) there are no less intrusive and restrictive means available to
reach the same objective; and 5) the restriction is based on scientific evidence and not drafted or
imposed arbitrarily — that is, in an unreasonable or otherwise discriminatory manner" (Public
Health and Human Rights Laws).