Between 2014 and 2015, 15.9 million surgical and minimally invasive procedures were performed in the United States; 226,000 of those procedures were performed in 13- to 19-year-olds.1 Rates of cosmetic surgery are similarly increasing in the United Kingdom2 and across the globe.3 As the prevalence of cosmetic procedures has risen, so too has an interest in the drivers that lead people to desire a change in their appearance. Drivers examined so far include individual factors (e.g., sex),4–7 psychological factors (e.g., body image),5,8–17 sociocultural factors (e.g., media influences),5,18–22 and interpersonal factors (e.g., peer influences).11,18,19,23–26 Some21 have found that peers have a strong influence on body image, and several studies have found that a large proportion (approximately 50 percent) of adults seeking cosmetic surgery report a history of teasing or bullying.5,11,24–26 Bullying, defined as an imbalanced relationship characterized by intended and repeated aggression,27 can have a range of adverse effects on children and adolescents.28–32 For bullying victims, the negative effects may be similar to those caused by adult abuse or maltreatment.33
There are several gaps in knowledge regarding the relationship between cosmetic surgery and bullying. First, most studies have used a retrospective design in adult samples. Retrospective studies have generally found that cosmetic patients or candidates report appearance teasing more frequently than controls.11,13,24,26,34 However, retrospective studies are problematic because current or prior psychological problems can lead to biased recall.35,36 In young adults (e.g., undergraduate students), teasing history can uniquely predict interest in cosmetic surgery.5,25 Most bullying occurs during childhood and adolescence,24 but there has been little concurrent investigation of the extent to which adolescents currently involved in bullying desire cosmetic surgery.
Second, it is unknown whether all of those involved in bullying are more likely to desire cosmetic surgery or particularly those who are bullied. Adolescents who are purely bullied (i.e., victims) and those who are bullied but also bully others (i.e., bully-victims) tend to suffer the poorest outcomes.37,38 We might therefore expect that victims and bully-victims will have an increased desire for cosmetic surgery because of poorer psychological functioning (e.g., low self-esteem or body-esteem, or high depressive symptoms). Those who purely perpetrate bullying (i.e., bullies) tend to have good psychological functioning and suffer few negative long-term consequences.37,38 Some suggest that bullies harm others as a means of achieving dominance and social status, which may increase romantic and sexual opportunities.39 We therefore hypothesized that bullies may also have an increased desire for cosmetic surgery as another strategy to achieve their status goals, irrespective of psychological functioning.
Third, the majority of research has focused on female subjects, which is understandable considering that the sex ratio of cosmetic procedures is highly skewed (e.g., over 90 percent of procedures are performed on female patients).1 However, boys, and especially those who have experienced bullying, may want to increase their muscle bulk and appear stronger, through body building or potentially cosmetic surgery.31 In adolescents, bullying and victimization among boys and girls is approximately equal: boys tend to be bullies and bully-victims more often than girls, but there are few sex differences in victimization.40–42
This study addressed the following research questions: (1) Do adolescents in all bullying roles (i.e., bullies, victims, and bully-victims) have a greater desire for cosmetic surgery than adolescents uninvolved in bullying? (2) Are any effects of bullying on desire for cosmetic surgery sex-specific? (3) Is the relationship between bullying role and desire for cosmetic surgery direct or is it mediated by psychological functioning?
PATIENTS AND METHODS
Design and Participants
Approval for the study was obtained from the University of Warwick’s ethical committee. A two-stage sampling process was used. In stage 1, pupils from all year groups (i.e., grades 7 to 11; ages 11 to 16 years) of five secondary schools in the United Kingdom were approached (n = 3883). As shown in the Strengthening the Reporting of Observational Studies in Epidemiology diagram43 (Fig. 1), 2782 (71 percent) agreed to take part and were screened for bullying involvement. All those who screened positive for bullying others (bullies) were invited to take part in stage 2 alongside a sample of adolescents who were identified as victims, bully-victims, or uninvolved. As there were many uninvolved adolescents, a random subgroup of subjects balanced by sex were selected using the random number generator in Microsoft Excel (Microsoft Corp., Redmond, Wash.). In total, 1088 pupils were selected for stage 2. After dropouts and exclusions, data were collected from 752 (69.1 percent). Just over half (53.3 percent) were female, and the mean age was 13.6 ± 1.4 years.
Procedure and Measures
First, school head teachers were approached and were asked to participate in The Bullying, Appearance, Social Information Processing, and Emotions Study (The BASE study). After consent to school participation, written information sheets were sent to pupils and their parents. Passive consent was obtained from parents, and pupils gave their informed consent before any data collection. At both stages, electronic questionnaires were completed in a school classroom on a personal computer, laptop, or tablet, with at least one investigator present. All pupils who completed stages 1 and 2 from each school were entered into a prize draw to win a £50 voucher. Stage 2 was conducted approximately 1 to 2 months after stage 1.
Stage 1 Measures
Sex, age, ethnicity, and parent education were included as covariates based on previous research indicating an association with cosmetic surgery.6,7,18,23,44,45 Parents’ highest level of education—that is, did not complete school (<11 years), school (11 years), college (1 to 13 years), or university (>13 years)—was used as a proxy for socioeconomic status46 and was dummy coded: 0 = 13 years or less (≤13) and 1 = more than 13 years (>13) of education. As there was a low proportion of adolescents whose ethnicity was not white British (e.g., the next highest prevalence was Asian at 6.1 percent), the ethnicity variable was dummy coded (0 = white British, 1 = other).
We used two measures of bullying: self-report and peer nominations. For self-reported bullying, we used the validated Bullying and Friendship Interview schedule.47–49 The schedule included 13 behavioral descriptions that relate to direct, relational, and cyber-victimization (Table 1). The items were repeated with slight wording adaptions to assess bullying perpetration (At no point was the term bullying used.). Adolescents were asked the frequency of each behavior during the past 6 months, and responses of “quite a lot” or “a lot” indicated bullying involvement.48,49
For the peer nominations, adolescents were given a list of names of all peers in their tutor group and asked to nominate up to three pupils (excluding themselves) who perpetrated or were a victim of bullying behaviors (Table 1). Using the total number of nominations received and the total number of peers in the tutor group, z-scores were computed. Adolescents were identified as involved in bullying if their z-score was 1 SD above (>1) the tutor group mean on the bullying items (bullies), victimization items (victims), or both (bully-victims) (Table 2). Adolescents were identified as uninvolved if they received zero nominations.
We constructed a latent variable of psychological functioning from three scales: self-esteem,50 body-esteem,51 and emotional problems (subscale of the Strengths and Difficulties Questionnaire).52,53 Differences in scale scores for each bullying role are listed in Table 3. Self-esteem and emotional problems were self-reported at stage 1 and body-esteem was self-reported at stage 2. The latent variable measures total psychological functioning: higher scores indicate higher functioning and well-being, and lower scores indicate poorer functioning and distress.
Stage 2 Measure
Desire for Cosmetic Surgery.
We used three items adapted from the Acceptance of Cosmetic Surgery Scale8 to assess desire for cosmetic surgery. These were as follows: (1) “I would like to have cosmetic surgery so that others would find me more attractive”; (2) “I would consider having cosmetic surgery as a way to change my appearance so that I would feel better about myself”; and (3) “If I was offered cosmetic surgery for free, I would consider changing a part of my appearance that I do not like.” Responses were on a five-point scale (1 = not at all, 5 = very much). These items have been used previously to assess overall and current interest in cosmetic surgery in a sample of undergraduate students.25
Between-group comparisons were conducted using chi-square tests, t tests, analysis of variance, and analysis of covariance. The analysis of variance tested the unadjusted associations between bullying roles and desire for cosmetic surgery, and the analysis of covariance adjusted for covariates (age, parent education, and ethnicity) and included sex as a factor. A bullying × sex interaction term was added to the model to test whether any effects were moderated (i.e., sex-specific). These analyses were performed using IBM SPSS Version 22.0 (IBM Corp., Armonk, N.Y.). To examine the potential mechanisms between bullying role and desire for cosmetic surgery, path analyses were performed by means of Mplus Version 7.4 (Muthén & Muthén, Los Angeles, Calif.) using full information maximum likelihood, which can handle missing data.54 We first estimated the psychological functioning variable using the scale scores of self-esteem, body-esteem, and emotional problems (reverse scored). Dummy variables were created (e.g., uninvolved = 0, victim = 1) to examine the direct effect of each bullying role on desire for cosmetic surgery and the indirect (mediated) effect by means of psychological functioning. Paths adjusted for covariates were computed for each bullying role separately. To assess model fit, the root-mean square error of approximation, the Comparative Fit Index, and the Tucker-Lewis index were used. Root-mean square error of approximation values less than 0.06 and Comparative Fit Index and Tucker-Lewis index values greater than 0.90 indicate an acceptable model.55–57 Model results are expressed as standardized regression coefficients (β).
Missing and Descriptive Data
Missing data on desire for cosmetic surgery (2.5 percent) and the covariates (1.1 percent) were low. Missing data were highest on the body-esteem scale (15.4 percent) (Table 3) and were related to age (OR, 0.88; 95 percent CI, 0.79 to 0.99; p = 0.034); the odds of missing data were lower in older adolescents.
Descriptive data for each bullying role are reported in Table 3. The majority of the sample were bully-victims (39.1 percent), and victims were most likely to be girls (67.6 percent). Victims and bully-victims had significantly poorer psychological functioning than bullies and uninvolved adolescents. Victims had the lowest body-esteem and self-esteem and had the highest emotional problem scores. Overall, mean interest in cosmetic surgery was low (mean ± SD, 1.79 ± 1.06; range, 1 to 5).
Do Adolescents in All Bullying Roles Have a Greater Desire for Cosmetic Surgery Than Adolescents Uninvolved in Bullying?
Bullies, victims, and bully-victims were significantly more interested in cosmetic surgery than uninvolved adolescents. In the unadjusted model (analysis of variance), bullying role significantly predicted desire for cosmetic surgery (F3,748 = 17.57, p < 0.001). Table 3 lists the means and standard errors. In the adjusted model (analysis of covariance), bullying role (F3,738 = 16.99, p < 0.001), sex (F1,738 = 28.46, p < 0.001), age (F1,738 = 16.61, p < 0.001), and parent education (F1,738 = 3.87, p < 0.049) were significant. Desire for cosmetic surgery was highest in victims (Table 3), in girls (1.98 ± 1.16) compared to boys (1.56 ± 0.89), and increased as age increased (β = 0.11) and as parent education decreased (β = −0.16). When sex was included as a factor, the bullying × sex interaction was not significant (F3,735 = 1.18, p = 0.32), which means that regardless of whether bullies, victims, and bully-victims were girls or boys, they were more interested in cosmetic surgery than uninvolved peers (Fig. 2).
Is the Relationship between Bullying and Cosmetic Surgery Direct or Mediated by Psychological Functioning?
All possible coefficients were estimated, meaning the model was saturated (root-mean square error of approximation = 0.000, Comparative Fit Index = 1.000, Tucker-Lewis index = 1.000); these fit indices represent neither a perfect nor a problematic model.58 Factor loadings were high for self-esteem (0.885), body-esteem (0.705), and emotional problems (0.702), suggesting they were strong indicators of total psychological functioning.
The model fits for bullies (root-mean square error of approximation = 0.028, Comparative Fit Index = 0.985, Tucker-Lewis index = 0.975), victims (root-mean square error of approximation = 0.057, Comparative Fit Index = 0.973, Tucker-Lewis index = 0.954), and bully-victims (root-mean square error of approximation = 0.045, Comparative Fit Index = 0.978, Tucker-Lewis index = 0.963) were excellent. Figure 3 shows the hypothetical mediation model and Table 4 shows the total, direct, and indirect effect of bullying role on desire for cosmetic surgery. There were both direct and indirect effects in victims and bully-victims; that is, there was a direct relationship between being bullied and a desire for cosmetic surgery, and another part of the relationship was mediated by poorer psychological functioning. In victims, the indirect effect was stronger than the direct effect, suggesting that being victimized resulted in poorer psychological functioning, which was driving their desire for cosmetic surgery. In bullies, desire for cosmetic surgery was direct and not related to psychological functioning. Desire for cosmetic surgery in victims was over double that of bullies (i.e., total effect). Examining the top 25th percentile of desire for cosmetic surgery scores revealed that 6.6 percent (n = 50) of the sample had extreme scores, the majority of which were victims (11.5 percent) and bully-victims (8.8 percent).
Path diagrams that include the covariates for bullies, victims, and bully-victims can be found in Supplemental Digital Content 1, 2, and 3, respectively. (See Figure, Supplemental Digital Content 1, which shows a path diagram for bullies, http://links.lww.com/PRS/C126. See Figure, Supplemental Digital Content 2, which shows a path diagram for victims, http://links.lww.com/PRS/C127. See Figure, Supplemental Digital Content 3, which shows a path diagram for bully-victims, http://links.lww.com/PRS/C128.) Age contributed to the models for victims (β = 0.117, SE = 0.051, p = 0.022) and bully-victims (β = 0.157, SE = 0.042, p < 0.001): as age increased, so did desire for cosmetic surgery.
This study found that involvement in bullying in any role was associated with an increased desire for cosmetic surgery. The mechanisms were different for those who bully others and those who are bullied (victims and bully-victims). Bullies want to look better independent of their psychological functioning, whereas being bullied was related to reduced psychological functioning and that partly mediated the effect between being victimized by peers and desire for cosmetic surgery. Victims had the greatest desire for cosmetic surgery and the most extreme scores.
The findings of this study offer several new contributions to knowledge. First, previous research indicated that approximately 50 percent of adults seeking cosmetic surgery were teased or bullied, mostly during adolescence.24 Results here suggest that the relationship between bullying and cosmetic surgery is not limited to adult samples and is present in adolescents who are currently being victimized by their peers. The desire for cosmetic surgery in bullied adolescents is thus immediate and long lasting. Second, our findings highlight that being bullied is related to reduced psychological functioning (i.e., reduced body-esteem and self-esteem and increased emotional problems), which in turn increases the desire for cosmetic surgery. This supports previous research suggesting that poor body image is one of the key drivers of desire for cosmetic surgery,5,9,10 and adds to the literature by showing that bullying involvement during adolescence is an important driver of reduced body-esteem and emotional functioning. There is now ample evidence that peer victimization is a childhood trauma that negatively affects psychological functioning, both concurrently and longitudinally.28,32,33,59,60 Childhood trauma has been associated with poor postoperative outcomes (despite a technically good result) and an increased rate of recurrent cosmetic procedures.61 Thus, those who are victims of bullying are at increased risk of seeking cosmetic surgery and, we speculate, less likely to be satisfied with the outcome because of poorer psychological functioning related to symptoms of body dysmorphia,12,31 which are present in approximately one-fifth of cosmetic surgery candidates.62 Third, this study showed that adolescents who bully others also have an increased desire for cosmetic surgery, which was unrelated to psychological functioning. Pure bullies generally have good psychological and physical health, are well known, and are often popular in the peer group.37,38,63 Thus, for bullies, cosmetic surgery may simply be another tactic to increase social status (i.e., another strategy to look good and achieve dominance).30
Another new contribution is the lack of sex differences in the pathway from being bullied to cosmetic surgery desire. Although desire for cosmetic surgery was greater in girls than in boys, bullied boys and girls are both at increased risk of body dysmorphic symptoms as adults12,31 and therefore may equally want to change their appearance through cosmetic surgery. The lower prevalence of cosmetic surgery among male subjects might suggest that they alter their body in other ways, such as body building31 or disordered eating.30 When male subjects do undergo cosmetic surgery, they are more likely to have poorer outcomes,4 and this might be explained by poorer psychological functioning before surgery as a result of peer victimization. Further research is needed to test this empirically.
Longitudinal research is now needed to determine whether adolescents involved in bullying undergo cosmetic procedures more often than adolescents uninvolved in bullying, to determine whether the age at which they have their first procedure is earlier, and to determine whether peer victimization has adverse effects on long-term postoperative outcomes. Our findings already suggest that screening tools for cosmetic candidates should include assessments of bullying in all roles to better counsel candidates for cosmetic surgery and potentially reduce risks to the candidate and surgeon.64 An adapted version of the bullying interview questionnaire,47–49 as used in a study of adult male bodybuilders,31 could be administered to cosmetic surgery candidates. The brief questionnaire asks about six types of victimization behaviors (i.e., been kicked, had belongings taken or damaged, been called names, been made fun of, been socially excluded, or been the subject of rumors being spread) in childhood or adolescence, and asks the age at which this first occurred. Responses include “never/hardly ever,” “occasionally,” “quite a lot” (at least two or three times per month), or “a lot” (at least once a week). Victims are those who experience any of the six victimization behaviors at least two or three times per month. The items can be reworded to assess bullying perpetration.
There are some limitations to the study. First, the cross-sectional design means we cannot determine causality. However, a meta-analysis has shown that the effects of bullying on poor psychological functioning are stronger than vice versa65 and that bullying is an environmental trauma, as shown in studies of discordant monozygotic twins.66 Second, we reported on general bullying, but it is possible that specific types of bullying may be more or less likely to increase desire for cosmetic surgery. For example, relational bullying is often used in intrasexual competition by adolescent girls and is particularly damaging to body-esteem;67 it is also possible that the effects of several types of bullying may be cumulative.5 Third, the outcome measure focused on cosmetic surgery and not minimally invasive procedures (e.g., botulinum toxin type A), which are increasingly prevalent, even among 13- to 19-year-olds (up 1 percent between 2014 and 2015).1 The outcome measure was also broad and did not ask about specific types of procedures (e.g., evidence suggests those who are bullied may particularly seek rhinoplasty).12,24
Adolescents involved in bullying have an increased desire for cosmetic surgery compared with their noninvolved peers. For bullies, their desire appears to be driven by a need for status and admiration; for the bullied, it is partly related to their reduced psychological functioning. Addressing the mental health of bullied adolescents may reduce their desire for cosmetic surgery. Cosmetic surgeons should screen candidates for psychological vulnerability as recommended by the Royal College of Surgeons of England,68 and may want to include a short screening questionnaire31 for a history of peer victimization.
The authors would like to express sincere thanks to the schools and pupils who took part in this study.
3. Holliday R, Bell D, Jones M, et al. Beautiful face, beautiful place: Relational geographies and gender in cosmetic surgery tourism websites. Gender Place Culture 2015;22:90–106.
4. Honigman RJ, Phillips KA, Castle DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004;113:1229–1237.
5. Markey CN, Markey PM. Correlates of young women’s interest in obtaining cosmetic surgery. Sex Roles 2009;61:158–166.
6. Swami V, Campana AN, Coles R. Acceptance of cosmetic surgery among British female university students: Are there ethnic differences? Eur Psychol. 2012;17:55–62.
7. Swami V, Chamorro-Premuzic T, Bridges S, Furnham A. Acceptance of cosmetic surgery: Personality and individual difference predictors. Body Image 2009;6:7–13.
8. Henderson-King D, Henderson-King E. Acceptance of cosmetic surgery: Scale development and validation. Body Image 2005;2:137–149.
9. Pertschuk MJ, Sarwer DB, Wadden TA, Whitaker LA. Body image dissatisfaction in male cosmetic surgery patients. Aesthetic Plast Surg. 1998;22:20–24.
10. Sarwer DB, Crerand CE. Body image and cosmetic medical treatments. Body Image 2004;1:99–111.
11. Javo IM, Sørlie T. Psychosocial predictors of an interest in cosmetic surgery among young Norwegian women: A population-based study. Plast Reconstr Surg. 2009;124:2142–2148.
12. de Brito MJ, Nahas FX, Cordás TA, Tavares H, Ferreira LM. Body dysmorphic disorder in patients seeking abdominoplasty, rhinoplasty, and rhytidectomy. Plast Reconstr Surg. 2016;137:462–471.
13. Sarwer DB, LaRossa D, Bartlett SP, Low DW, Bucky LP, Whitaker LA. Body image concerns of breast augmentation patients. Plast Reconstr Surg. 2003;112:83–90.
14. Sarwer DB, Zanville HA, LaRossa D, et al. Mental health histories and psychiatric medication usage among persons who sought cosmetic surgery. Plast Reconstr Surg. 2004;114:1927–1933; discussion 1934.
15. Sarwer DB, Spitzer JC. Body image dysmorphic disorder in persons who undergo aesthetic medical treatments. Aesthet Surg J. 2012;32:999–1009.
16. Crerand CE, Infield AL, Sarwer DB. Psychological considerations in cosmetic breast augmentation. Plast Surg Nurs. 2007;27:146–154.
17. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg. 2006;118:167e–180e.
18. Delinsky SS. Cosmetic surgery: A common and accepted form of self-improvement? J Appl Soc Psychol. 2005;35:2012–2028.
19. Henderson-King D, Brooks KD. Materialism, sociocultural appearance messages, and paternal attitudes predict college women’s attitudes about cosmetic surgery. Psychol Women Q. 2009;33:133–142.
20. Swami V, Taylor R, Carvalho C. Acceptance of cosmetic surgery and celebrity worship: Evidence of associations among female undergraduates. Pers Individ Dif. 2009;47:869–872.
21. Ferguson CJ, Muñoz ME, Garza A, Galindo M. Concurrent and prospective analyses of peer, television and social media influences on body dissatisfaction, eating disorder symptoms and life satisfaction in adolescent girls. J Youth Adolesc. 2014;43:1–14.
22. de Vries DA, Peter J, Nikken P, de Graaf H. The effect of social network site use on appearance investment and desire for cosmetic surgery among adolescent boys and girls. Sex Roles 2014;71:283–295.
23. Brown A, Furnham A, Glanville L, Swami V. Factors that affect the likelihood of undergoing cosmetic surgery. Aesthet Surg J. 2007;27:501–508.
24. Jackson AC, Dowling NA, Honigman RJ, Francis KL, Kalus AM. The experience of teasing in elective cosmetic surgery patients. Behav Med. 2012;38:129–137.
25. Park LE, Calogero RM, Harwin MJ, DiRaddo AM. Predicting interest in cosmetic surgery: Interactive effects of appearance-based rejection sensitivity and negative appearance comments. Body Image 2009;6:186–193.
26. von Soest T, Kvalem IL, Skolleborg KC, Roald HE. Psychosocial factors predicting the motivation to undergo cosmetic surgery. Plast Reconstr Surg. 2006;117:51–62; discussion 63.
28. Stapinski LA, Bowes L, Wolke D, et al. Peer victimization during adolescence and risk for anxiety disorders in adulthood: A prospective cohort study. Depress Anxiety 2014;31:574–582.
29. Fox CL, Farrow CV. Global and physical self-esteem and body dissatisfaction as mediators of the relationship between weight status and being a victim of bullying. J Adolesc. 2009;32:1287–1301.
30. Copeland WE, Bulik CM, Zucker N, Wolke D, Lereya ST, Costello EJ. Does childhood bullying predict eating disorder symptoms? A prospective, longitudinal analysis. Int J Eat Disord. 2015;48:1141–1149.
31. Wolke D, Sapouna M. Big men feeling small: Childhood bullying experience, muscle dysmorphia and other mental health problems in bodybuilders. Psychol Sport Exerc. 2008;9:595–604.
32. Wolke D, Lereya ST, Fisher HL, Lewis G, Zammit S. Bullying in elementary school and psychotic experiences at 18 years: A longitudinal, population-based cohort study. Psychol Med. 2014;44:2199–2211.
33. Lereya ST, Copeland WE, Costello EJ, Wolke D. Adult mental health consequences of peer bullying and maltreatment in childhood: Two cohorts in two countries. Lancet Psychiatry 2015;2:524–531.
34. Veale D, Eshkevari E, Ellison N, et al. A comparison of risk factors for women seeking labiaplasty compared to those not seeking labiaplasty. Body Image 2014;11:57–62.
35. Richters JE. Depressed mothers as informants about their children: A critical review of the evidence for distortion. Psychol Bull. 1992;112:485–499.
36. Mackinger HF, Pachinger MM, Leibetseder MM, Fartacek RR. Autobiographical memories in women remitted from major depression. J Abnorm Psychol. 2000;109:331–334.
37. Juvonen J, Graham S, Schuster MA. Bullying among young adolescents: The strong, the weak, and the troubled. Pediatrics 2003;112:1231–1237.
38. Wolke D, Copeland WE, Angold A, Costello EJ. Impact of bullying in childhood on adult health, wealth, crime, and social outcomes. Psychol Sci. 2013;24:1958–1970.
39. Volk AA, Camilleri JA, Dane AV, Marini ZA. Is adolescent bullying an evolutionary adaptation? Aggress Behav. 2012;38:222–238.
40. Salmivalli C, Lagerspetz K, Björkqvist K, Österman K, Kaukiainen A. Bullying as a group process: Participant roles and their relations to social status within the group. Aggress Behav. 1996;22:1–15.
41. Reulbach U, Ladewig EL, Nixon E, O’Moore M, Williams J, O’Dowd T. Weight, body image and bullying in 9-year-old children. J Paediatr Child Health 2013;49:E288–E293.
42. Nansel TR, Overpeck M, Pilla RS, Ruan WJ, Simons-Morton B, Scheidt P. Bullying behaviors among US youth: Prevalence and association with psychosocial adjustment. JAMA 2001;285:2094–2100.
43. Vandenbroucke JP, von Elm E, Altman DG, et al; STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): Explanation and elaboration. Epidemiology 2007;18:805–835.
44. Nassab R, Harris P. Cosmetic surgery growth and correlations with financial indices: A comparative study of the United Kingdom and United States from 2002-2011. Aesthet Surg J. 2013;33:604–608.
45. Prendergast TI, Ong’uti SK, Ortega G, et al. Differential trends in racial preferences for cosmetic surgery procedures. Am Surg. 2011;77:1081–1085.
46. Lien N, Friestad C, Klepp KI. Adolescents’ proxy reports of parents’ socioeconomic status: How valid are they? J Epidemiol Community Health 2001;55:731–737.
47. Griffiths LJ, Wolke D, Page AS, Horwood JP; ALSPAC Study Team. Obesity and bullying: Different effects for boys and girls. Arch Dis Child. 2006;91:121–125.
48. Schreier A, Wolke D, Thomas K, et al. Prospective study of peer victimization in childhood and psychotic symptoms in a nonclinical population at age 12 years. Arch Gen Psychiatry 2009;66:527–536.
49. Wolke D, Woods S, Bloomfield L, Karstadt L. The association between direct and relational bullying and behaviour problems among primary school children. J Child Psychol Psychiatry 2000;41:989–1002.
50. Rosenberg M. Society and the Adolescent Self-Image. 1965.Princeton, NJ: Princeton University Press.
51. Mendelson BK, Mendelson MJ, White DR. Body-esteem scale for adolescents and adults. J Pers Assess. 2001;76:90–106.
52. Goodman R. The Strengths and Difficulties Questionnaire: A research note. J Child Psychol Psychiatry 1997;38:581–586.
53. Goodman R, Ford T, Simmons H, Gatward R, Meltzer H. Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. Br J Psychiatry 2000;177:534–539.
54. Muthén LK, Muthén BO. Mplus User’s Guide. 1998–2015.7th ed: Los Angeles, Calif: Muthén & Muthén.
55. Hooper D, Coughlan J, Mullen M. Structural equation modelling: Guidelines for determining model fit. Electronic J Bus Res Methods 2008;6:53–60.
56. Browne MW, Cudeck R. Alternative ways of assessing model fit. Sociol Methods Res.1992;21:230–258.
57. Hu LT, Bentler P. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling 1999;6:1–55.
59. Lereya ST, Copeland WE, Zammit S, Wolke D. Bully/victims: A longitudinal, population-based cohort study of their mental health. Eur Child Adolesc Psychiatry 2015;24:1461–1471.
60. Takizawa R, Maughan B, Arseneault L. Adult health outcomes of childhood bullying victimization: Evidence from a five-decade longitudinal British birth cohort. Am J Psychiatry 2014;171:777–784.
61. Constantian MB, Lin CP. Why some patients are unhappy: Part 2. Relationship of nasal shape and trauma history to surgical success. Plast Reconstr Surg. 2014;134:836–851.
62. Veale D, Gledhill LJ, Christodoulou P, Hodsoll J. Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image 2016;18:168–186.
63. de Bruyn EH, Cillessen AH, Wissink IB. Associations of peer acceptance and perceived popularity with bullying and victimization in early adolescence. J Early Adolesc. 2010;30:543–566.
64. Paraskeva N, Clarke A, Rumsey N. The routine psychological screening of cosmetic surgery patients. Aesthetics 2014:28–32.
65. Arseneault L, Milne BJ, Taylor A, et al. Being bullied as an environmentally mediated contributing factor to children’s internalizing problems: A study of twins discordant for victimization. Arch Pediatr Adolesc Med. 2008;162:145–150.
66. Silberg JL, Copeland W, Linker J, Moore AA, Roberson-Nay R, York TP. Psychiatric outcomes of bullying victimization: A study of discordant monozygotic twins. Psychol Med. 2016;46:1875–1883.
67. Lereya ST, Eryigit-Madzwamuse S, Patra C, Smith JH, Wolke D. Body-esteem of pupils who attended single-sex versus mixed-sex schools: A cross-sectional study of intrasexual competition and peer victimization. J Adolesc. 2014;37:1109–1119.
Supplemental Digital Content
©2017American Society of Plastic Surgeons