This article discusses the unexpected relationship between cosmetic breast implants and suicide that has been found in six epidemiological investigations completed in the last several years.

METHOD: The epidemiological studies are reviewed.

The American Society of Plastic Surgeons reported that 329,396 women underwent cosmetic breast augmentation in the United States in 2006. This represents an increase of 55% since 2000 and over 300% in the past decade. These numbers, while substantial, may underestimate the number of women who receive breast implants in the United States each year for several reasons. First, they do not account for women who receive breast implants as part of surgical breast reconstruction following mastectomy. (This article will focus solely on women who receive breast implants for cosmetic purposes.) Second, these statistics do not capture breast augmentation procedures being performed by physicians who are not plastic surgeons. Furthermore, the number of American women who undergo cosmetic breast augmentation is expected to increase, given the Food and Drug Administration’s (FDA’s) November 2006 decision to reapprove silicone gel-filled breast implants for general cosmetic use.

The growth in the popularity of cosmetic breast augmentation is all the more remarkable considering that in 1992 the FDA issued a moratorium on the use of silicone gel-filled implants. Then-FDA Commissioner Dr. David Kessler called for further study of the physical safety and psychological benefits of breast implants. Comprehensive reviews have concluded that silicone breast implants are not associated with significant long-term health problems. Since that time, six epidemiological studies have found an unexpected relationship between cosmetic breast augmentation and suicide.

Possible Explanations of the Relationship Between Cosmetic Breast Implants and Suicide

The six epidemiological studies produced few clues to the nature of the relationship between cosmetic breast implants and suicide. These studies primarily were designed to investigate all-cause mortality. They were not prospectively planned to investigate the unexpected association with suicide and, as a result, provide only limited information on the potential causal relationship between breast implants and suicide.

There are several possible explanations for the relationship between breast implants and suicide that, while not yet specifically investigated, have some support from related literatures. These explanations include the role of preoperative personality characteristics and psychopathology, motivations and expectations for surgery, and the impact of postoperative complications.

Demographic and descriptive characteristics
The stereotypical breast augmentation patient is widely believed to be a single Caucasian woman in her early to mid-20s who is interested in breast augmentation surgery as a way to facilitate the development of a romantic relationship. Reviews, however, have suggested that the typical patient differs from this stereotype. She is most often Caucasian but is frequently in her late 20s or early 30s, is married, and has children. Although these characteristics may describe the “typical” patient, women from their late teens to mid-40s of varying ethnic backgrounds and relationship status present for breast augmentation surgery. As found in several of the epidemiological studies, women age 40 years and older who undergo breast augmentation appear to be at increased risk of suicide.

Several studies have found that women who receive breast implants differ from other women on a variety of unique characteristics. Women with breast implants are more likely to have had more sexual partners, report a greater use of oral contraceptives, be younger at their first pregnancy, and have a history of terminated pregnancies compared to other women. They have been found to be more frequent users of alcohol and tobacco and have a higher divorce rate. Women with breast implants have been found to have a below average body weight, leading to concern that some may be experiencing eating disorders. Finally, they have been found to report more frequent use of psychotherapy than physically similar women not interested in breast augmentation, and they have been found to have a history of more psychiatric hospitalizations than other plastic surgery patients.

Many of these characteristics have been found to be risk factors for suicide in psychiatric and community samples. For example, previous psychiatric hospitalization constitutes a major risk factor for suicide. Alcohol consumption and tobacco use also have been associated with an increased risk of suicide. Moreover, women with anorexia nervosa who were referred to medical or psychiatric departments are approximately 23 times more likely to die from suicide in comparison with the overall population.

Considering these and other characteristics, including age, ethnicity, and marital status, Joiner argued that the suicide rate among women with breast implants could be almost five times the rate for the general population of women. He further suggested that postoperative improvements in body image following breast augmentation may produce a “protective effect” from the otherwise increased risk. Additional prospective epidemiological and psychological studies involving valid and reliable methodologies are needed to further investigate this hypothesis.

RESULTS: Across the six studies, the suicide rate of women who received cosmetic breast implants is approximately twice the expected rate based on estimates of the general population.

Although the first study of this issue suggested that the rate of suicide among women with breast implants was greater than that of women who underwent other forms of cosmetic surgery, the largest and most recent investigation in this area found no difference in the rate of suicide between these two groups of women.

CONCLUSIONS: The higher-than-expected suicide rate among women with cosmetic breast implants warrants further research. In the absence of additional information on the relationship, women interested in breast augmentation who present with a history of psychopathology or those who are suspected by the plastic surgeon of having some form of psychopathology should undergo a mental health consultation before surgery.

David B. Sarwer, Ph.D., Gregory K. Brown, Ph.D. and Dwight L. Evans, M.D.

Am J Psychiatry 164:1006-1013, July 2007
doi: 10.1176/appi.ajp.164.7.1006
American Psychiatric Association
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