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Adolescent Desire for Cosmetic Surgery: Associations with Bullying and Psychological Functioning

Lee, Kirsty M.Sc.; Guy, Alexa M.Res.; Dale, Jeremy Ph.D., M.B.B.S., F.R.C.G.P.; Wolke, Dieter Ph.D., Dr. rer. nat. h.c.

Plastic & Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1109–1118
doi: 10.1097/PRS.0000000000003252
Cosmetic: Special Topics
Press Release
Video Discussion

Background: Adolescent bullying may be a key driver of interest in cosmetic surgery. This study examined the extent of such interest and whether any effect was sex-specific, and examined psychological functioning as a potential mechanism through which bullying involvement may lead to a wish for cosmetic surgery.

Methods: A two-stage design was used. In the first stage, 2782 adolescents (aged 11 to 16 years) were screened for bullying involvement using self-reports and peer nominations. In the second stage, 752 adolescents who were bullies, victims, bully-victims, or uninvolved in bullying reported their desire for cosmetic surgery. Psychological functioning was constructed as a composite of self-esteem and emotional problems (assessed at stage 1) and body-esteem scores (assessed at stage 2).

Results: Adolescents involved in bullying in any role were significantly more interested in cosmetic surgery than uninvolved adolescents. Desire for cosmetic surgery was greatest in adolescents who were bullied (victims and bully-victims) and girls. Desire for cosmetic surgery was highest in girls, but sex did not interact with bullying role. Being victimized by peers resulted in poor psychological functioning, which increased desire for cosmetic surgery. In contrast, desire for cosmetic surgery in bullies was not related to psychological functioning, which was in the normal range.

Conclusions: Bullying victimization is related to poor psychological functioning, and both are related to a greater desire for cosmetic surgery in adolescents. Cosmetic surgeons should screen candidates for psychological vulnerability and may want to include a short screening questionnaire for a history of peer victimization.

Coventry, United Kingdom

From the Department of Psychology and the Warwick Medical School, University of Warwick.

Received for publication August 1, 2016; accepted October 24, 2016.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. Kirsty Lee and Alexa Guy were supported to undertake this research by a departmental fellowship.

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www.PRSJournal.com).

A Video Discussion by David Sarwer, Ph.D., accompanies this article. Go to PRSJournal.com and click on “Video Discussions” in the “Digital Media” tab to watch.

Dieter Wolke, Ph.D., Dr. rer. nat. h.c., Department of Psychology, University of Warwick, Coventry CV4 7AL, United Kingdom, d.wolke@warwick.ac.uk

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?

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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.

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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.

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Stage 1 Measures

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Individual Characteristics.

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).

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Bullying Role.

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.

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Psychological Functioning.

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.

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Stage 2 Measure

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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

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Statistical Analysis

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).

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RESULTS

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).

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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).

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Is the Relationship between Bullying and Cosmetic Surgery Direct or Mediated by Psychological Functioning?

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.

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Mediation Analyses

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.

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DISCUSSION

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

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CONCLUSIONS

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.

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ACKNOWLEDGMENTS

The authors would like to express sincere thanks to the schools and pupils who took part in this study.

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