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Eleanor Roosevelt once said, No one can make you feel inferior without your consent 39 Some would have us believe that the cosmetics and toiletries industry makes a valiant attempt In fact, there are those who would characterize the advertising of the billion-dollar beauty industry as an outright assault Although a near-consensus regarding beauty standards seems to have emerged, the judgment of attraction is heavily influenced by mass media, art, literature, television, movies, and other media40 Unless one is
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able to steadfastly avoid television, the Internet, billboards, bus advertisements, magazines, and the like, it is virtually impossible not to encounter the plethora of beauty images virtually omnipresent in our culture today Scanning the magazine racks, paying attention to advertisements, and watching television can leave a person feeling bombarded with what society seems to deem the ideal images of a healthy, beautiful person Through art history, beginning with the classical images of beauty, particularly female beauty, as depicted in ancient times, through the Medieval and Baroque periods, especially the generously-proportioned figures painted by Peter Paul Rubens, the Renaissance and on into contemporary times, it is clear that beauty ideals wax and wane This is more patently clear when one considers the apparent changes in modern female iconography as represented by so-called supermodels, pin-up models, or centerfolds Larger, more curvaceous women, such as Marilyn Monroe and Jayne Mansfield, were considered ideal a half century ago, while considerably thinner models, such as Kate Moss, are more typical now Changes have also been noted and quantified regarding centerfolds during the last half century A recent study by Seifert that considered the height, weight, breast, waist, and hip measurements of 559 Playboy centerfold models over the last 50 years revealed a subtle, gradual trend toward slimness, with very thin models rarely seen until this century41 Greater specificity was achieved in a fascinating study that included economic conditions as a variable in facial and body feature preferences Pettijohn and Jungeberg explored the relationships of United States social and economic factors to facial and body characteristics of Playboy Playmates of the Year from 1960 to 2000 They found that older, heavier, taller models with a larger waist and waist-to-hip ratio, smaller bust-to-waist ratio, smaller body mass index (BMI), and smaller eyes were chosen during periods when social and economic conditions were measurably difficult, and concluded that environmental security conditions can influence perceptions of attractiveness42 In a broader study considering idealized female body images represented by Playboy Playmates of the Year, Miss America Pageant winners, fashion models, and young women in general spanning eight decades, Byrd-Bredbenner et al reported that the general trend in all groups changed from a less curvaceous figure during the early 20th cen-
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COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE
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tury to a more curvaceous shape by midcentury, returning to a less curvaceous body by the end of the century In addition, they found a significant decline in BMI in the idealized groups over time, with an opposite trend in young women, and a markedly wider divergence between the typical body sizes of young women and the idealized images depicted in the media43 A smaller previous study by Katzmaryzyk and Davis that considered the changes in body weight and shape of 240 Playboy centerfolds from 1978 to 1998, a cohort tacitly understood as ideal, found that 70% of the models were underweight, which underscores the nature of the social pressures for thinness that women face and helps to explain their body dissatisfaction and increased risks for eating disorders44 Currently, the idealized female profile is tall and thin but sporting an hourglass figure, large eyes, prominent cheek bones, and large forehead Other features associated with attractiveness for females include a smaller than average chin, smaller than average nose, and higher than average forehead45 The typical male image is also tall, muscular with little body fat, and features large eyes, prominent cheekbones, and a large chin46 When juxtaposed, the female has lighter hair than the male, who typically has dark hair, to match documented preferences40 However, negative self-esteem or body image effects on both women and men are seen more often as increasingly narrow and nearly unattainable gender stereotypes are emphasized with ideal images of physical beauty47 Although women have long been described as victims of this onslaught of idealized images of feminine beauty, there is evidence to suggest that men are even starting to feel the implied pressure of such masculine imagery Purchases of fitness equipment and even pectoral and other implants may very well be manifestations of Western cultural norms for presentations of the ideal male body that are growing increasingly muscular48 It is generally accepted that men spend significantly more money now than 10 to 15 years ago on aesthetic surgery, cosmetics, fitness equipment, and hair products, including dyes, weaves, and transplants Nevertheless, 90% of the patients who underwent cosmetic surgery or minimally-invasive procedures in 2006, as tracked by the American Society of Plastic Surgeons (which measures procedures performed by physicians of all disciplines), were women1 This suggests
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that women remain more drastically and measurably influenced by beautification pressures In a study of 246 medical students in Austria, answers to a questionnaire on weight and attitudes toward personal body weight indicated that both men and women, but women in particular, characterize their weight according to current beauty ideals as opposed to the BMI definition49 Researchers observed significant body dissatisfaction among women, much more than among men, and concluded that the females in the study group were more profoundly influenced by current ideals of slenderness Further evidence of the effects of body image on individual self-esteem is found from a study by Pinhas et al in which 51 female subjects were shown slides of fashion models and 67 control subjects were shown slides with no human figures The researchers found that the study group members were more depressed and angry following exposure to the slides of female fashion models, indicating that such images have an immediate negative impact on women s moods50 These findings are particularly noteworthy because body dissatisfaction is considered a potent risk for the development of eating disorders and can contribute to depression A more recent meta-analysis also supports these results regarding female body image In considering data from 25 studies, Groesz et al observed that body image of female subjects was significantly worse after subjects saw media images of thin women as compared to average-size models, plus-size models, or inanimate objects51 Although the beauty industry is frequently blamed for stimulating women s desire to appear younger and more attractive, the industry itself might not be culpable Instead, these longings may be a reflection of preferences hard-wired into human brain circuitry through evolution The billion-dollar beauty industry exists because women want to attract men, and men are often attracted to younger women Etcoff argues that this attraction has occurred because of evolutionary pressure Men remain attracted to nulliparous women who abundantly exhibit signs of fertility because this leads to propagation of the species52 The beauty industry, represented by the physical fitness branch, aesthetic surgery, cosmetics, and advances in beauty technology, allows people to indulge in the illusion of an extended youth and continued membership in the visually preferred age group
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Nevertheless, the advertising branch of the business might still be presenting a skewed view of what most people find desirable or acceptable In a study on acceptable body sizes, 303 children, 427 adolescents, 261 young adults, and 326 middle-aged adults were shown several line drawings of human figures ranging in age grouping and size53 Participants were instructed to evaluate sets of drawings that were divided by age group infant, children, young adult, middleaged adult, and older adults Each subject group preferred similar ideal body sizes across all arrays, choosing the midrange of fatness, and eschewing both the obese and very thin body sizes Although a medically healthy range for a particular height for adults would translate to four or five of the nine body sizes depicted in the study, participants demonstrated acceptance for an average of three or fewer body sizes This suggests that the ideal imagery exhibited in various media may filter into people s internal ideations and that midrange models might better reflect what people typically find acceptable or desirable Further, very different images of the ideal body form continue to exist in non-Western cultures such as the Inuit, Maori, Tibetans, and Bushmen of the Kalahari Desert54 The notion of the power of visual media is reinforced by a study on body dissatisfaction and abnormal eating attitudes among congenitally blind women, women who were blinded later in life, and sighted women Baker et al found that congenitally blind women had the lowest body dissatisfaction scores and the most positive eating attitudes while sighted women exhibited the highest level of body dissatisfaction and the most negative eating attitudes55 The external pressures exerted on the psyche are inestimable and provide an important backdrop for consultation with a physician prior to any decision for cosmetic alteration
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