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In our second reply to the comments on our article (1) by Chua and Li, (2) we emphasise that our study indeed compared the difference in responses between junior college and medical school students. There are inherent differences in the ages of the two groups of participants. In trying to study the effect of education level on attitudes towards cosmetic surgery, it is difficult to completely eliminate the confounding effect of age, even with randomisation, which Chua and Li suggested. It is also artificial to attempt to do so, as in Singapore and most of the world, a higher education level is associated with older age. We are of the opinion that careful comparison of the results of our study with that of other studies is hypothesis generating, even though the designs of our studies may carry differences. We have pointed out the limitations of our study in our original article, some of which have been reiterated by Chua and Li in their comments. (2,3) Nonetheless, we hope that the hypotheses generated by our study will inspire other relevant research on this topic.

This is in response to the letter written by Chua and Li (1) regarding our article. (2) We would like to highlight that the Norwegian study by Javo and Sørlie (3) included a representative sample of 3,500 women aged 18-35 years. Therefore, unlike what is suggested by Chua and Li, there was a variation in age and maturity among the subjects in the Norwegian study. (3) In a country like Singapore, where education is almost universal among our youths, it is unfortunately impossible to compare two groups of subjects who are similar in age but have vastly different amount of education. In other words, it is inevitable that in studying Singaporean youths, older age would correspond with a higher level of education. However, we agree that future studies could aim to include a larger and more representative sample of youths. In the meantime, the lack of knowledge on cosmetic procedures even in this select group of youths makes our findings more startling.