© Springer International Publishing Switzerland 2015Neelam A. Vashi (ed.)Beauty and Body Dysmorphic Disorder10.1007/978-3-319-17867-7_5
5. Body Image and Body Image Dissatisfaction
Department of Dermatology, Boston University School of Medicine, Boston Medical Center, 609 Albany St, J602, 02118 Boston, MA, USA
Department of Dermatology, Cosmetic and Laser Center, Boston University, 609 Albany Street, J602, 02118 Boston, MA, USA
KeywordsBody imageSelf-imageBody dissatisfactionMedia influenceSelf-esteemCosmetic surgeryDermatologySkin agingPatient satisfaction
Introduction: Conceptualizing Self and Body Image
The concept of self and body image has been explored to great depths in the psychological and medical literature. It is broadly defined as “an internal mental representation of the bodily self .” That is to say, the body image is formulated by one’s collective cognitive and emotional experiences relating to the perceptive awareness of one’s body in relation to its physical environment, and it is ever changing in the face of new sensory inputs. The body image is, therefore, a phenomenon of a lifetime of ongoing subjective experiences, including memories and emotions that combine with tangible sensory data that are unique to the individual within a broader social and cultural context [2, 3].
It is proposed that the hypothetical body image is demonstrably influenced by the prejudices, expectations, and beliefs of the individual in addition to societal and cultural standards of desirable body features. Indeed, a multitude of external influences and information—including family, peers, and the media—may combine and become internalized into an individual’s measurement of the ideal body form. Body image is manifestly linked to an individual’s emotional state, and such emotions are often evoked by one’s self-judgment of his or her image in comparison to this ideal. In this way, one’s body image functions as a component of the broader self-image. Any degree of dissonance between one’s self-image and his or her ideal may lead to body image dissatisfaction. As such, we may conceptualize the body image as a dynamic cognitive process of self-appraisal that incorporates an individual’s current summative percept of his or her own physical form.
Remarkable in its complexity, body image and body image dissatisfaction are believed to motivate and influence human behavior in innumerable, and often, striking ways. The desire to alter one’s physical appearance is widely acknowledged and commonplace in society today: cosmetics, hairstyles, wardrobe, and exercise are all examples of everyday attempts to effect change of one’s own body image. The majority of research examining the construct of bodily self-image examines its relationship to body weight and size, yet there are innumerable facets of our physical appearance that comprise our internal representation. Dermatologists are fundamentally tasked with correcting undesired and highly visible physical features by methods ranging from medical treatment of clinical skin diseases to cosmetic enhancement and reconstruction, often in an effort to restore or advance an individual’s body image closer to his or her ideal. The extent to which individuals pursue such methods varies widely and exemplifies the variability in one’s perception and prioritization of visible bodily features. Physicians who evaluate and treat patients who desire cosmetic enhancement or reconstruction will reasonably encounter a diverse range of body image concerns and dissatisfaction; consequently, they must remain vigilant for individuals who exhibit extreme degrees of body image distortion and dissatisfaction.
External Influences on Body Image
Fundamental to the development of body image are innumerable external sources of information that continuously enter an individual’s conscious and subconscious awareness. Visual representations of body forms and features; peer and expert opinions on the worthiness of certain physical attributes and appearance; and established societal and cultural norms exemplify these pervasive sources of internalized ideals. The impact of this myriad of external influences is profound and forges an inerasable foundation in the ongoing construction of our bodily self-image.
Media and Advertising
It is impossible to discuss body image in the present day without acknowledging the impact of various forms of media on body image. Extensive research links consumption of the media body ideals—that is, ultra-attractive and ultrathin or muscular images—with body dissatisfaction, negative self-esteem, and disordered eating beginning as early as preadolescence . Even brief periods of viewing photographs of thin and round body images demonstrated an impact on viewers’ judgments of body shapes. Specifically, viewing images of thin bodies subsequently decreased viewers’ quality ratings of rounder bodies, whereas viewing images of fuller figures relatively increased ratings of round body shapes . In men, for whom the media promotes a muscular body ideal, continuous exposure to images of ideal muscular bodies in advertisements is linked to increased body dissatisfaction . In a more practical sense, women of average attractiveness are rated less beautiful when viewed after an attractive female in print media, and women underrate their own attractiveness immediately after viewing images of highly attractive women [7, 8]. Viewing frequency of reality television programs depicting cosmetic surgery not only correlates with body dissatisfaction but also increases willingness and perceived pressure to undergo cosmetic procedures . Notwithstanding these potentially negative psychological effects to consumers induced by the depiction of unattainable body ideals, it is nevertheless naive to expect that a cultural vehicle as pervasive as the mass media impact will change considerably in the near future .
From another perspective, one might request cosmetic enhancement with the specific aim to reproduce the physical features of a particular celebrity. Familiarity is posited to correlate with a more positive or favorable body image ideal. In one study, subjects rated the mirror image of his or her self as superior to the true image as one would appear in a photograph . As most individuals viewed their reflection with far greater frequency than photographs of oneself at the time of the study, this suggests that visual familiarity may more closely equate physical features with a favorable body image. When extended to friends and lovers, the individual’s true image is more often preferred over the mirror, lending authenticity to the concept of familiarity as desirable beyond that of one’s self-image. It is plausible that physical features from frequently viewed celebrities may be internalized into the ideal body image in a similar manner.
In addition, research reveals that we find composite facial photographs that merge the features of several different people more attractive than individual photographs . This suggests that the cognitive “averaging” of facial features contributes more heavily to the framework of an ideal face than any one face alone. When considering that the frequencies of ideal facial features and body types are inarguably higher among celebrities and models across many forms of media than the general population, we begin to appreciate the extent to which mass media contributes to the individual’s body image and internalization of ideals.
Family and Peers
Parents may contribute to the development of body image in various ways. Direct parental comments about their child’s body size or appearance in clothing, for example, may heighten a child’s awareness of physical features from an early age. Males may be less affected by parental comments than their female counterparts . Children may also learn to be dissatisfied about their bodies and looks by modeling parental concerns perceived through comments or weight-loss behaviors .
Peer influence on body image begins in childhood when young girls appear to be impacted at an earlier age and develop more dissatisfaction as a result of peer comments compared to boys . This extends to adolescence and young adulthood, when females routinely outnumber males in body dissatisfaction. Further, peer evaluations of a third party’s physical attractiveness can subsequently influence an individual’s own judgment of beauty and may thus become internalized into one’s own self-image ideal . While verbal communication is clearly influential, it is worth noting that congenitally blind individuals report significantly less body dissatisfaction than individuals blinded later in life, and all visually impaired individuals are more satisfied than their full-sighted peers .
Conventional Variances in Body Image
To remark that men and women internalize markedly different body ideals would be an understatement. Relative to women, men internalize a larger and more muscular ideal and are generally more satisfied with body size and weight, although men are more likely to feel dissatisfied by being too thin than women . Along the similar vein, women associate a lower facial adiposity with higher attractiveness than do their male counterparts, and the degree of facial adiposity deemed ideal for attractiveness by women is lower than that considered ideal for health . Women are also more likely than men to be dissatisfied with skin tone and color, and this is illustrative of a recurring theme of greater overall body dissatisfaction in females . Perhaps due to this relatively lower prevalence of body image dissatisfaction, men may bear more of a stigma when it comes to seeking out cosmetic procedures, and historically are considered a more psychologically disturbed subset of patients. However, more contemporary views highlight that the majority of men pursuing cosmetic plastic surgery endorse no more global self-image dissatisfaction or attention to appearance than their peers, and rate significantly lower than that of females of the same age .
The awareness of one’s body begins early in childhood, and body dissatisfaction (particularly pertaining to weight) is well documented in girls and boys with prevalence increasing through the elementary years . There exists an important link between the physical changes of puberty, body dissatisfaction, and clinical depression; and adolescent females with a negative body image are particularly at risk for future struggles with depression .
Body dissatisfaction intuitively increases with the transformative forces of time . Physical signs of aging can have a significant impact on one’s body image and, for many people, may provoke more general feelings of insecurity about advancing age. Longstanding deformities or chronic dermatologic conditions (e.g., vitiligo, psoriasis) may eventually become incorporated into the body image with subsequent acceptance as being part of the self. However, self-image concerns related to aging skin may contribute to social isolation, anxiety, and extreme or ill-advised pursuits of a youthful appearance [22, 23]. In contrast, body image concerns related to weight might, at least temporarily, diminish in women as they progress further into adulthood. Men, however, demonstrate nearly the opposite; the majority report higher dissatisfaction and dieting frequency later in adulthood .
Cultural and Ethnic Groups
A great deal of research has examined the physical features most closely aligned with beauty, resulting in “ideal” ratios, shapes, and even favorable personality characteristics . However, much of this early research included predominantly Caucasian subjects, and such facial features or proportions deemed attractive in Caucasians may not naturally exist or correlate with average features in non-white individuals. Culture and ethnicity are formative to the body image, and so one’s ideal image and future cosmetic enhancement will naturally fit within these parameters .
Body dissatisfaction is also variable among different ethnic groups. During formative childhood and teenage years, black females generally report less weight-related body dissatisfaction than their white counterparts. This is attributed, in part, to the overall tendency for black females to weigh more than white females and communal acceptance of larger body proportions . Hair concerns are a significant source of body dissatisfaction in nearly half of African-American females. Hair loss and breakage are the predominant clinical concerns, and these have far-reaching impacts on self-esteem, physical activity, and even doctor–patient rapport . Skin color is also an important feature of one’s self-image and degree of attractiveness. Darker-skinned individuals tend to find darker skin more attractive and likewise among fair-skinned counterparts, but both groups favor an intermediate brown tone over darker brown [18, 28]. We can presume then that skin color may have more of an impact on self-image for individuals at both ends of the skin color spectrum, and dissatisfaction may motivate behaviors intended to bring skin tone closer to the ideal.
Though not a distinct cultural group in the traditional sense, tattooed individuals are of great interest when considering the body image and behaviors effecting change on one’s appearance. Tattoo art in the present day is no longer strictly aligned with the male gender, criminal behavior, or social outliers and is seen by many as a form of artistic self-expression. Early research on body image in tattooed individuals revealed them to have stronger positive feelings about their bodies than nontattooed peers , and contemporary research reports improvement in body image after obtaining one’s first tattoo .
Defining “Normal” vs. “Abnormal” Body Dissatisfaction
Essentially, every person experiences a time when one’s beliefs about his or her current physical state do not perfectly match with the internally constructed body ideal. The conscious acknowledgement of this discrepancy may, thereby, induce a highly variable degree of emotional distress broadly termed “body dissatisfaction.” The degree of dissonance does not simply correlate with the degree of stress in a similar manner for every person. Likewise, the motivations to undergo procedures that effect change in one’s appearance are unique to each individual and often unpredictable, though modern views of beauty and aesthetic medicine posit that routine, appropriately selected cosmetic interventions “may be no more psychologically deviant than the resolution to brush one’s teeth .”
By report, body dissatisfaction is common and perhaps normal among adults in developed countries. In general, more women than men report body dissatisfaction, particularly as it pertains to body weight and the feeling that one is too heavy. The point prevalence of body dissatisfaction was reported in one study to be around 11 % in men to 21 % in women across all ages; this increased by an additional 5–10 %, respectively, when including the avoidance of wearing one’s bathing suit in public . However, baseline estimates of body dissatisfaction range widely—from 11 to 72 % for women, and 8–61 % for men—given the tendency for ideals and dissatisfaction to vary across lifespan, gender, and cultural backgrounds . Weight-specific body dissatisfaction exists in the majority of young adults in the USA ; and in one study, 75 % of women reported an ideal body image as smaller than one’s own . More broadly, both men and women tend to rate themselves significantly less attractive than their own romantic partners do , implying that internal representations of bodily ideals and interpretation of disparities differ for oneself compared to others, but a measurable deviation from the ideal exists at baseline.