The role of media and peer influences in Australian women’s attitudes towards cosmetic surgery

The study aimed to examine the influence of media and peers on attitudes towards cosmetic surgery using a sociocultural framework. A sample of 351 Australian women aged 18–69 years completed measures of media exposure, friend conversations, internalisation of appearance ideals, appearance comparison, body dissatisfaction, and attitudes towards cosmetic surgery. Correlational analysis showed that almost all media and friend variables were significantly correlated with positive attitudes towards cosmetic surgery. A structural equation model based on the sociocultural model showed a good level of fit to the data. The effects of media exposure and friend conversations on body dissatisfaction and attitudes towards cosmetic surgery were mediated by internalisation. We concluded that media exposure and friend conversations affected attitudes towards cosmetic surgery both directly and indirectly. Our results contribute to the understanding of the sociocultural mechanisms underlying women’s motivations for cosmetic surgery.

There has been a rapid increase in the demand for cosmetic surgery over the last ten years (American Society for Aesthetic Plastic Sugery [ASAPS], 2013). For example, in 2013, there were over 11 million surgical and non-surgical cosmetic procedures performed in the United States which represents a 279% increase in the number of procedures performed since 1997 (ASAPS, 2013). Surgical procedures accounted for 16.5% of the total number of procedures and non-surgical procedures (e.g., Botox) represented 83.5% of the total. Ninety-one percent of these procedures were performed on women, with those aged 35–50 years being the most likely to seek a cosmetic procedure. The five most commonly conducted surgical procedures for women were breast augmentation, liposuction, abdominoplasty, breast lift and eyelid surgery (ASAPS, 2013). Despite the growing popularity of cosmetic surgery, the social and psychological factors which influence attitudes towards cosmetic surgery are yet to be fully explored.

In the available literature, body dissatisfaction is unequivocally reported as a major motivator for cosmetic surgery. In their model of cosmetic surgery intentions, Sarwer, Wadden, Pertschuk, and Whitaker (1998) postulated that individuals who are both highly dissatisfied with their bodily appearance and highly invested in their appearance are the most likely to desire cosmetic surgery interventions. Indeed, elevated body dissatisfaction has been reported in a number of studies of preoperative cosmetic surgery patients (e.g., Bolton, Pruzinsky, Cash, & Persing, 2003; Didie & Sarwer, 2003; Sarwer et al., 2003; Sarwer, Wadden, & Whitaker, 2002; Von Soest, Kvalem, Skolleborg, & Roald, 2011). Similarly, in non-surgical samples, greater body dissatisfaction has been associated with positive attitudes towards cosmetic surgery (Henderson-King & Henderson-King, 2005; Sarwer et al., 2005; Slevec & Tiggemann, 2010). However, body image concerns do not develop in isolation, but are a result of broader sociocultural influences (Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999). Thus, sociocultural models may provide an appropriate framework to study influences on attitudes towards cosmetic surgery. Sociocultural models (Tiggemann, 2012) that were originally developed to explain body image concerns and disordered eating have since been applied to other phenomena, such as tanning behaviour (Cafri, Thompson, Jacobsen, & Hillhouse, 2009). One particularly useful sociocultural model, the Tripartite Influence Model (Keery, van den Berg, & Thompson, 2004; Thompson et al., 1999), proposes that beauty ideals are reinforced and transmitted by three

primary sociocultural influences, namely peers, parents, and the media (Thompson et al., 1999). These sociocultural influences have both direct and indirect effects on body dissatisfaction and eating disturbance. The indirect pathway involves two mediators: internalisation of appearance ideals and appearance comparison (Keery, van den Berg, et al., 2004; Thompson et al., 1999). Here we examined two of the specific sociocultural influences, namely media (television and advertising) and peers (friend conversations). The influence of parents was deemed to be less relevant for adult women. There is no doubt that the media have increasingly featured cosmetic surgery. For example, cosmetic surgical procedures are the focus of a number of reality television programmes such as Extreme Makeover and Embarrassing Bodies. Several studies have shown that exposure to this type of programme is predictive of women’s consideration of cosmetic surgery (e.g., Markey & Markey, 2010; Sperry, Thompson, Sarwer, & Cash, 2009). Nevertheless, other types of television programmes may also influence women’s attitudes towards cosmetic surgery by affecting their level of body dissatisfaction, a major motivator for cosmetic surgery. For example, Slevec and Tiggemann (2011) reported that the viewing of a range of appearance-focused television programmes was associated with body dissatisfaction in a sample of middle-aged women. Along with the increased focus on cosmetic surgery in television programmes, there has recently been a marked increase in the volume of advertising for cosmetic surgery (Hennink-Kaminski, Reid, & King, 2010). Research suggests that the vast majority of women have been exposed to advertisements for cosmetic surgery (Brown, Furnham, Glanville, & Swami, 2007; Delinsky, 2005), but how these advertisements potentially influence women’s body dissatisfaction and attitudes towards cosmetic surgery has not yet been investigated. We also sought to investigate a specific form of peer influence, namely appearance conversations with friends, on attitudes towards cosmetic surgery. Jones, Vigfusdottir, and Lee (2004) have suggested that appearance conversations with friends serve to direct attention to appearance as an issue, reinforce its importance and advocate appearance ideals. Several studies have found that more frequent appearance-related conversations with friends are associated with elevated body dissatisfaction (e.g., Clark & Tiggemann, 2006; Jones et al., 2004; Shroff & Thompson, 2006) and we proposed that this would lead to more favourable attitudes towards cosmetic surgery. To our knowledge, only one published study has explicitly tested the Tripartite Influence Model of attitudes towards cosmetic surgery. Menzel et al. (2011) examined the effect of perceived pressure to have cosmetic surgery from media, peers, partners and parents on attitudes towards cosmetic surgery in a sample of male and female college students. In support of the proposed Tripartite Influence Model, Menzel et al. (2011) found that perceived pressures to undergo cosmetic surgery were both directly and indirectly related to positive attitudes towards cosmetic surgery. Perceived pressures worked indirectly by increasing internalisation and decreasing body satisfaction. However, variables like perceived pressure assess an individual’s perception of the extent of the influence of the media, family and peers. Thus, perceived pressure may reflect more the characteristics of the individual, rather than serving as a measure of exposure to these influences (Tiggemann, 2006). The present study aimed to extend Menzel et al.’s (2011) findings by examining reported exposure to media and peer influences. In addition, we included the second proposed sociocultural mediator, namely appearance comparison. The model postulates that when women compare their appearance to idealised images in the media, they almost always find themselves lacking and they become dissatisfied.

In sum, the present study aimed to test a more elaborate sociocultural model for attitudes towards cosmetic surgery. Specifically, we predicted that greater media exposure (cosmetic surgeryrelated and appearance-related television and cosmetic surgery advertising) and peer influence (friend conversations) would be associated with greater body dissatisfaction and, in turn, with more favourable attitudes towards cosmetic surgery. In accord with the Tripartite Influence Model, internalisation of appearance ideals and appearance comparison were predicted to mediate the relationships between media exposure/peer influence and body dissatisfaction and attitudes towards cosmetic surgery. Method Participants Participants were 351 women from the general Australian community aged 18–69 years (M = 29.7 years, SD = 12.2 years), recruited through Facebook, survey sharing websites, and undergraduate psychology classes. Characteristics of this sample have been previously described in Sharp, Tiggemann, and Mattiske (in press). The greatmajority of participants (94.6%) identified as Caucasian/White (Asian 3.1%, Indigenous Australian 0.6%, African 0.3%, 1.4% Other). Measures Participants completed a questionnaire entitled ‘Cosmetic Surgery Attitudes’. The questionnaire measured, in order, demographic information, media exposure (television and advertising), friend conversations, proposed mediators (internalisation of appearance ideals and appearance comparison), and consequences (body dissatisfaction and attitudes towards cosmetic surgery). Demographic information. Participants were asked to report their age, ethnicity, relationship status, and number of children. Participants were also asked to provide details of any prior cosmetic procedures they had undertaken and the number of people they personally knew who had undergone cosmetic surgery. Consideration of nine popular cosmetic procedures (liposuction, abdominoplasty, face lift, rhinoplasty, eye lift, breast augmentation, labiaplasty, Botox and facial fillers) was also measured. Participants rated how likely they were to undergo each procedure on a scale ranging from 0% (not likely at all) to 100% (absolutely certain). As financial expense could potentially be a prohibitive factor, participants were also asked to indicate percentage likelihood if money was no object in a separate measure. Exposure to television. Participants were provided with a list of 12 high rating programmes showing on Australian television at the time of the study. Four of these programmes featured cosmetic surgery (“Extreme Makeover”, “Embarrassing Bodies”, “The Doctors”, “How to Look Good Naked”). Four were programmes with a focus on physical appearance and ideal body types (“Desperate Housewives”, “Next Top Model”, “Sex and the City”, “Bold and the Beautiful”). The remaining four (“Big Bang Theory”, “MasterChef”, “The Voice”, “My Kitchen Rules”) were programmes with a non-appearance focus, and served as filler items. The categorisation of programmes was determined by three independent female raters aged 25–53 years. The order of the 12 programmes was randomised and participants were asked to record the frequency with which they viewed each television programme on a 5-point Likert scale from 1 (never) to 5 (every time it’s on). Separate scores for cosmetic surgery-related and appearance-related programmes were calculated to produce total scores for each programme type which ranged from 4 to 20, with higher scores indicating greater exposure to cosmetic or appearance-related programmes. Reliability for the cosmeticsurgery-related (˛= .64) and appearance-related programme items (˛= .50) were considered adequate for scales with only a few items. Exposure to advertising. Participants were asked how many advertisements they had seen for any type of cosmetic surgery on a scale ranging from 1 (none) to 5 (over 50). Friend conversations. The frequency of conversations with friends about body appearance was measured using the five-item Appearance Conversations with Friends Scale (Jones et al., 2004). Participants were asked how often each item (e.g., “My friends and I talk about the size and shape of our bodies”) occurred on a 5-point Likert scale ranging from 1 (never) to 5 (very often). Scores were summed to produce a total score which ranged from 5 to 25. Higher scores indicated more frequent conversations about body appearance. Jones et al. (2004) reported high internal consistency (˛= .85). Reliability for the present sample was high (˛= .91). Internalisation of appearance ideals.Internalisation of societal appearance standards was measured using the five-item Sociocultural Internalisation of Appearance Questionnaire-Adolescents (SIAQ-A; Keery, Shroff, Thompson, Wertheim, & Smolak, 2004). The SIAQ-A was chosen because, in contrast to other available measures, it does not contain any items specifically addressing appearance comparison. Participants rated their level of agreement with each item (e.g., “I would like my body to look like the bodies of people in the movies”) on a 5-point Likert scale ranging from 1 (definitely disagree) to 5 (definitely agree). Scores were summed to produce a total score which ranged from 5 to 25. High scores indicated greater internalisation of the ideal. Keery, Shroff, et al. (2004) reported high internal consistencies (˛= .83 to .92). Reliability for the present sample was slightly higher (˛= .94). Appearance comparison. The extent of body appearance comparison was assessed using a measure based on the comparison targets subscale of the Social Comparison Questionnaire (Schutz, Paxton, & Wertheim, 2002). Participants rated how often they compared the appearance of their body with five social targets (e.g., “friends” and “fashion models”) on a 5-point Likert scale ranging from 1 (never) to 5 (very often). Scores were summed to produce a total score which ranged from 5 to 25. Higher scores indicated more frequent body appearance comparison. Reliability for the present sample was adequate (˛= .86). Body dissatisfaction. The Body Areas Satisfaction Subscale of the Multidimensional Body-Self Relations Questionnaire (Cash, 2000; Giovannelli, Cash, Henson, & Engle, 2008) was used to measure body dissatisfaction. The nine-item measure covers the full body. Participants rated their degree of satisfaction using a 5-point Likert scale ranging from 1 (very dissatisfied) to 5 (very satisfied). All items were reverse scored for ease of interpretation. Scores were summed to produce a total score which ranged from 9 to 45. Higher scores indicated greater body dissatisfaction. Slevec and Tiggemann (2010) reported acceptable internal consistency in an Australian sample (˛= .81). Reliability for the present sample was adequate (˛= .86). Attitudes towards cosmetic surgery. The Acceptance of Cosmetic Surgery Scale (Henderson-King & Henderson-King, 2005) was used to examine participant attitudes towards cosmetic surgery. The 15-item scale consists of three five-item subscales: Intrapersonal, Social, and Consider. The Intrapersonal subscale is an other-oriented measure, which assesses attitudes about cosmetic surgery for people in general (e.g., “People who are very unhappy with their physical appearance should consider cosmetic surgery as one option”). The other two subscales, Social and Consider, are selforiented measures. The Social subscale examines personal social motivations for having cosmetic surgery (e.g., “I would seriously consider having cosmetic surgery if my partner thought it was a good idea”), while the Consider subscale assesses the likelihood that the respondent would consider having cosmetic surgery in the future (e.g., “I have sometimes thought about having cosmetic surgery”).

Article info Article history:

Received 31 March 2014 Received in revised form 19 June 2014 Accepted 22 July 2014 Keywords: Cosmetic surgery Body dissatisfaction Sociocultural Media Peers Tripartite Influence Model

article info Article history: Received 31 March 2014 Received in revised form 19 June 2014 Accepted 22 July 2014 Keywords: Cosmetic surgery Body dissatisfaction Sociocultural Media Peers Tripartite Influence Model