Introduction

In 2007, almost 12 million cosmetic surgery procedures were performed, a 59% increase since 2000 (American Society of Plastic Surgeons [ASPS] 2008a). This trend may be cause for concern given these procedures are not risk-free and they are now performed on hundreds of thousands of young women who are simultaneously undergoing the vast physical, social, and psychological changes associated with adolescence and young adulthood (Sarwer 2001). Specifically, according to the ASPS (2008a), 224,658 13–19 year olds underwent cosmetic surgery procedures in 2007. Although the majority of cosmetic surgery patients are women (90%) over the age of 19 (95%), this still represents an increase in cosmetic surgery procedures among youths in the last decade (ASPS 2008a). Cosmetic surgery patients are increasingly ethnically and socioeconomically diverse (ASPS 2008b) and the appeal of cosmetic surgery is international (International Society for Aesthetic Plastic Surgery [ISAPS] 2008; Suissa 2008). One recent account of these trends went as far as to suggest that cosmetic surgery is “breezily” compared to fashion accessorizing in the media because individuals can now readily “choose” how to shape their appearance (Bordo 2003, p. 247). Unfortunately, is spite of the growing number of young cosmetic surgery patients, there is a paucity of research examining predictors of young people’s (i.e., U.S. college undergraduates’) desire to alter their bodies via cosmetic surgery.

The present study was designed to examine potential predictors of young women’s (i.e., U.S. undergraduate women’s) interest in obtaining cosmetic surgery to alter their bodies including their weight status, body dissatisfaction, experiences of teasing about their bodies, and internalization of media messages about physical appearance issues. The focus of the present study is women’s interest in obtaining cosmetic surgery to alter their body (i.e., not their face) and the relative importance of personal versus sociocultural factors in predicting women’s pursuit of cosmetic surgery. This survey-based design extends past research by considering multiple predictors of young women’s interest in cosmetic surgery and by considering body image as a potential mediator of other predictors.

It may be good advice for young women to wait to alter their bodies surgically until they are done “growing up” (Sarwer 2001), but patience may be hard to come by with an apparent remedy for physical appearance concerns readily available (Zuckerman and Abraham 2008). According to Harter (1990), youths’ perceptions of their physical appearance is the primary contributor to their global self-esteem (see also Sarwer et al. 2004). This is especially true of young women who are less likely than men to view their bodies positively (Striegel-Moore and Franko 2002; Markey and Markey 2005). Weight gain associated with puberty, increasing pressures from peers to maintain an attractive body according to sociocultural standards, and young women’s greater realization that they are susceptible to body surveillance and objectification negatively affects body image and contributes to the desire for body modification (McKinley and Hyde 1996; Polivy et al. 1990). The recent flood of media messages suggesting that appearance-enhancing surgical transformations are not only increasingly accessible to but appropriate for young people, likely exacerbates youths’ inclination to want to improve their physical appearance (Henderson-King and Henderson-King 2005; Ogden 2003).

Past research clearly suggests that body dissatisfaction motivates individuals to pursue cosmetic surgery (Henderson-King and Henderson-King 2005; Sarwer 2001; Sarwer et al. 2005, 2006; von Soest et al. 2006). Further, extreme dissatisfaction with a particular body part often precedes seeking surgical modification of that body part (Sarwer 2001). The extent to which this body dissatisfaction is rooted in “objective” body concerns (e.g., body size or weight) or reflects individuals’ perceptions of their bodies is not clear. Some past research suggests that both American girls’ and women’s perceptions of their bodies are more predictive of their weight concerns and desire to change their bodies than are more objective assessments of their body or weight (Davison et al. 2000). Further, body dissatisfaction has successfully been conceptualized as a mediator of relations between objective measures of young adult women’s bodies and their concerns about and attempts to change their bodies (Markey and Markey 2005). In these models, body size or weight is positively associated with body dissatisfaction, which in turn is associated with weight concerns and dieting behaviors. Thus, in this study we aim to examine both objective weight status and body dissatisfaction (as an independent predictor and as a mediator) as correlates of young women’s interest in cosmetic surgery.

Sociocultural influences likely contribute significantly to women’s interest in surgically altering their bodies. The aforementioned statistics regarding the recent increase in popularity of cosmetic surgery procedures speak to the growing cultural acceptance of obtaining cosmetic surgery in the U.S. and internationally. Further, as research has documented links between U.S. girls’ and women’s body dissatisfaction and their exposure to media messages (Cafri et al. 2005; Markey 2004), it is unlikely that young women are impervious to messages about cosmetic surgery presented in the mass media (Delinsky 2005). Growing evidence has accumulated in the past decade or so indicating that young women’s exposure to and internalization of media messages about physical appearance issues is linked to their body dissatisfaction and behavioral attempts to alter their bodies via dieting (Harrison and Hefner 2006; Levine and Harrison 2004). Of course, this is not to say that all recipients of physical appearance media messages respond similarly to these messages; the extent to which young women internalize these messages has been deemed important in past research (Knauss et al. 2007). Thus, in the present study, the extent to which young women internalize media messages about physical appearance issues will be examined as a predictor of their interest in cosmetic surgery.

In addition to personal and sociocultural factors that may prompt individuals to pursue cosmetic surgery, it seems likely that direct social feedback about physical appearance issues may prompt interest in cosmetic surgery. In particular, it seems likely that negative feedback, or teasing, about one’s body would contribute to a desire to change one’s body (Keery et al. 2006). Research has documented the deleterious effects of physical appearance teasing on the development of a healthy self-concept (Davison and Birch 2002) and one report suggests a modest link (albeit not significant) between physical appearance teasing and women’s pursuit of breast augmentation in a patient sample (Didie and Sarwer 2003). Adolescents and adults who report experiencing teasing during their childhood also report greater overall body dissatisfaction (Grilo et al. 1994). Jones and colleagues (2004) further suggest that adolescent girls’ residing in the U.S. have conversations about physical appearance issues that serve as a mechanism for learning about social standards and expectations, with the feedback they receive from their peers becoming particularly salient as they reach adolescence. Thus, it seems likely that the extent to which young women are motivated to change their physical appearances may result in part from the feedback they have received from others about the appearance of their bodies. This study will extend past research investigating the effects of teasing by examining young women’s reports of being teased about their bodies as a predictor of their interest in cosmetic surgery.

Aims of the Present Study

In spite of the growing popularity of cosmetic surgery, research is needed to help explain the predictors of interest in cosmetic surgery, particularly among young women. Thus, there are three main aims of this research. First, we will attempt to replicate past research linking body dissatisfaction and cosmetic surgery among a late adolescent-young adult sample of undergraduates. Consistent with past research examining older samples, we hypothesize that women’s body dissatisfaction will be related to their interest in cosmetic surgery and that this relationship will remain significant even when their actual body size (i.e., weight status) is taken into account (Hypothesis 1). Such a finding would suggest that the correlation between body dissatisfaction and the desire to obtain plastic surgery does not exist simply because heavier women tend to desire plastic surgery more than relatively thin women.

Second, we will examine women’s sociocultural experiences as predictors of their interest in cosmetic surgery (Hypothesis 2). In particular, we will examine whether or not the extent to which women internalize media messages about their appearance is predictive of their desire to obtain cosmetic surgery. We anticipate that women who internalize these messages to a greater degree than their peers will be more likely to indicate an interest in pursuing cosmetic surgery to change their bodies. We will also examine the social feedback that women receive in the form of teasing in relation to women’s interest in cosmetic surgery. We anticipate that women who report having been teased about their bodies will be more likely to express an interest in cosmetic surgery. We expect that both of these predictors will remain significant when taking into account women’s actual weight status (i.e., women’s weight status cannot fully account for the relations between these sociocultural experiences and their interest in cosmetic surgery).

Third, given the previously documented link between body dissatisfaction and cosmetic surgery, we will examine body dissatisfaction as a mediator of weight status, women’s internalization of media messages, and teasing in predicting women’s interest in cosmetic surgery (Hypothesis 3; see Figs 1 and 2). In other words, we believe that women’s internalization of media messages, parent-peer teasing, and weight status will be predictive of women’s body dissatisfaction which, in turn, will be predictive of their desire to pursue plastic surgery.

Fig. 1
figure 1

The unmediated model: Weight status, media influence, and physical appearance teasing predicting interest in obtaining cosmetic surgery. Values in parentheses represent standardized regression weights

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Fig. 2
figure 2

The mediated model displaying how the effects of weight status, media influence, and physical appearance teasing on interest in obtaining cosmetic surgery are mediated by body dissatisfaction. Values in parentheses represent standardized regression weights

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Method

Participants and Procedures

One hundred and one women (M age = 19.99, SD = 4.79) participated in this study. Participants were all students from a Northeastern university in the Philadelphia metropolitan area and they represent a diverse group in regards to ethnicity and other demographic traits. Approximately half (55%) of the sample self-identified as Euro-American, 15% of the sample was African American, 15% Asian American, 12% Hispanic/Latina and 3% indicated that they were of an “other” ethnic background. The majority of the participants (86%) reported personal incomes of less than 20 thousand dollars a year. However, given the age of the participants, most did not reside alone and/or support themselves. Eleven percent reported residing in homes (i.e., with parents and/or a spouse) where the household income was $20,000 per year or less, 30% reported residing in homes where the household income was $20,000–$49,000 per year, 31% reported residing in homes where the household income was $50,000–$75,000, and 28% reported household incomes greater than $75,000 per year. Approximately half of the women (51%) reported having some vocational school experience and a little less than half (49%) reported having already completed some college (i.e., they were not college freshman in their first semester).

Participants were recruited for a study investigating “physical appearance issues” and completed the measures used in this study along with other measures assessing personality and health issues. Administration of the questionnaire was performed by trained research assistants in a private laboratory setting. Small groups (i.e., 1–5) of women came to the lab to complete a survey about how people feel about themselves, their appearance, and options available to alter their appearance. All procedures were designed in accordance with the American Psychological Association’s guidelines for the ethical treatment of human subjects and participants were compensated with research credit towards their Introductory Psychology course.

Measures

Weight Status

Participants’ weight status was operationalized using Body Mass Index scores [BMI; (weight(kg)/height2(m)]. Because self-reported weight and height information has been shown to correlated significantly with researcher-measured anthropometric information (correlations of .90+; Brooks-Gunn et al. 1987; Castro-Markey and Gesner 1999), participants were asked to report their weight in pounds and their height in feet/inches. This information was then used to calculate their BMIs. Women’s average BMI was 24.52 (range = 16.10 – 44.63; see Table 1), with approximately 30% of the sample maintaining a BMI of 25 or greater indicating that they were overweight or obese. According to the Centers for Disease Control and Prevention (CDC 2008, see “Obesity Trends”), approximately 34% of American adults over 20 are obese and approximately 32% of children and adolescents are overweight or obese, with the average adult woman’s BMI being 26. Thus, it appears that this sample does not differ significantly from the general population in terms of the likelihood of being overweight or obese.

Table 1 Means, standard deviations, and correlations among the variables investigated.
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Body Dissatisfaction

The female version of the Contour Drawing Rating Scale (CDRS; Thompson and Gray 1995) was used to assess participants’ perceptions of their bodies and their body dissatisfaction. Participants were asked to indicate which picture (range from 1 = very thin to 9 = very overweight) they thought looked like them and which picture they would like to look like. Body dissatisfaction was calculated using discrepancy scores: the “figure they would like to look like” minus the “figure most like them.” Scores could range from -8 to +8; however, none of the women in this sample indicated that they wanted to gain weight (see Table 1). The obtained mean from this sample was within 1 SD of previous research utilizing this instrument (e.g., Markey et al. 2008). Thus, scores could be used in a linear fashion with higher scores indicating greater body dissatisfaction. In previous research, the test-retest reliability for this measure was .79 (Thompson and Gray 1995).

Media Influence

Participants’ perceptions of media messages about appearance issues were assessed using three scales from the Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ-3; Thompson et al. 2004). Each scaled used a 5-point response scale. The first 9-item scale assesses internalization of general media messages with items such as, “I would like my body to look like the models who appear in magazines.” The second 9-item scale assesses perceptions of the media as a source of information about appearance issues with items such as, “TV programs are an important source of information about fashion and ‘being attractive.’” The final 7-item scale assesses the extent to which participants view the media as a source of “pressure” to look a certain way with items such as, “I’ve felt pressure from TV or magazines to lose weight.” In this sample, these three scales were significantly correlated (rs = .57 to .86), and a subsequent factor analysis of the three scales revealed a single factor as indicated by a first to second eigenvalue ratio of 2.21 to .59. As suggested by methodologists (e.g., Cohen and Cohen 1983), because it appears these scales define a common factor, the scale items were averaged together to create a single measure of overall media influence (see Table 1). The resulting 25-item measure of media influence had high internal reliability with a Cronbach’s Alpha of .94, which indicates that these items reliably assess a single construct.

Physical Appearance Teasing

In order to assess participants’ feedback about their bodies from individuals in their social environments (i.e., as opposed to more distal sociocultural influences such as media influences), they completed a measure assessing the extent to which they had ever been teased about their appearance. This measure was adapted from a measure of physical appearance teasing developed by Davison and Birch (2002) to assess young girls’ experiences of teasing. Specifically, participants were asked to rate the extent to which (1 = not at all to 5 = all the time) they have ever been teased about 11 different body parts (arms, stomach, breasts, waist, butt, hips, legs, chest, weight, being fat, body shape). Given our focus on body dissatisfaction, all of the body parts queried about pertained to the body and not the face (i.e., body parts such as “nose” and “hair” were not included). A composite score of teasing experiences was created by averaging the scores for all 11 items (see Table 1); Cronbach’s alpha = .86. The relatively high reliability of this measure suggests that women who recalled being teased about one body part also tended to report being teased about other body parts. This may have occurred because some women had less socially-desirable/attractive bodies and were teased more often than their peers. Consistent with this notion, we found that teasing was moderately correlated with women’s weight status (r = .37, p < .05).

Interest in Cosmetic Surgery

Women’s interest in obtaining cosmetic surgery was assessed using a measure created for the purpose of this study. A list of 7 cosmetic surgery procedures was presented to participants and they were asked to rate, using a 5-point Likert scale (1 = I would never consider this procedure to 5 = I would definitely consider this procedure), the extent to which they were interested in obtaining the procedures. This list of procedures was derived from information provided by the American Society of Plastic Surgeons’ web page (ASPS 2008) and Sarwer’s (2001) discussion of the cosmetic surgery procedures youths obtain (i.e., procedures associated with aging are not likely to be relevant to late adolescent/early adult women). Because of the focus of this research on body dissatisfaction, each of the cosmetic surgery procedures pertained to the body (e.g., liposuction, buttock lift, thigh lift, tummy tuck, upper arm lift, breast augmentation, breast lift) and did not include facial procedures. Participants’ overall interest in cosmetic surgery was determined by averaging their responses to all the items (see Table 1; Cronbach’s alpha = .86). The relatively high reliability of this measure suggests that some women were generally interested in a variety of different surgeries whereas other women were not interested in these procedures. Forty-three percent of the participants indicated that they would definitely or probably consider at least one of the cosmetic surgery procedures queried. The two most popular procedures were tummy tucks and liposuction; 26% of the sample reported being interested in liposuction and 27% reported being interested in obtaining a tummy tuck.

Results

We first examined whether or not body dissatisfaction was related to participants’ interest in obtaining cosmetic surgery. Consistent with Hypothesis 1, women who were dissatisfied with their bodies were more interested in pursuing cosmetic surgery to alter their bodies than were women who were relatively satisfied with their bodies (see Table 1). This relationship remained significant even when weight status was statistically controlled (partial r (98) = .44, p < .001). Consistent with Hypothesis 2, media influences and teasing about physical appearance were related to women’s interest in cosmetic surgery (see Table 1). Next, a multiple regression analysis was used in order to simultaneously examine the unique importance of these variables and women’s weight status in predicting women’s desire to obtain cosmetic surgery. Consistent with the second hypothesis, weight status, media influence, and teasing about physical appearance were all found to uniquely predict women’s desire to obtain cosmetic surgery to alter their bodies (i.e., links between media influences, teasing, and interest in cosmetic surgery cannot be explained by women’s weight status; see Table 2).

Table 2 Multiple regression analysis predicting interest in obtaining cosmetic surgery.
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To addressed hypothesis 3 we examined whether or not body dissatisfaction mediated the relations between weight status, media influence, teasing, and women’s interest in cosmetic surgery. Baron and Kenny (1986) proposed three criteria for documenting mediation. First, the outcome variable (interest in obtaining cosmetic surgery) should be regressed on the predictor variables (weight status, media influence, and teasing about physical appearance) to show that the predictors are significantly related to the outcome (the paths labeled “C” in Fig. 1 are expected to be significant). Second, the mediator variable (body dissatisfaction) should be regressed on the predictor variables to show that the predictors are significantly related to the mediator (the paths labeled “A” in Fig. 2 are expected to be significant). Finally, the outcome variable should be regressed on both the predictor and mediator variables to show that the mediated variable is related to the outcome (the path labeled “B” in Fig. 2 is expected to be significant) and accounts for at least a portion of the direct relation between the predictors and the outcome (the paths labeled “C’ ” in Fig. 2 should no longer be significant).

Consistent with Baron and Kenny’s criteria, the first multiple regression analysis indicated that weight status, media influence, and teasing about physical appearance were all related to interest in cosmetic surgery (see Table 2; Fig. 1). A separate multiple regression analysis conformed Baron and Kenny’s second criterion revealing that weight status, media influence, and teasing about physical appearance were related to the mediator variable body dissatisfaction (see Table 3; see Fig. 2). To test the final requirement for mediation, interest in cosmetic surgery was regressed on body dissatisfaction with weight status, media influence, and teasing about physical appearance included in the equation (see Table 4; see Fig. 2). In this analysis, body dissatisfaction was related to women’s desire to obtain cosmetic surgery. The coefficient for the direct relation between weight status and interest in surgery dropped from .25 to .11 (and was no longer significant). The direct relation between media influence and interest in cosmetic surgery was reduced from .27 to .14 (and was no longer significant). Finally, the relation between teasing about physical appearance and interest in cosmetic surgery also dropped from .24 to .15 (and was no longer significant).

Table 3 Multiple regression analysis predicting body dissatisfaction.
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Table 4 Multiple regression analysis predicting interest in obtaining cosmetic surgery.
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In order to formally test if mediation occurred, MacKinnon and colleagues (2002) recommend examining the indirect effects of the predictor variables using Sobels z’ statistic (1982). This test examines the significance of the indirect relation between each predictor variable and interest in cosmetic surgery via the mediator variable of body dissatisfaction. This test further supported Hypothesis 3 indicating the effects of weight status (z’ = 2.00, p <.05), media influence (z’ = 2.12, p < .05) and teasing about physical appearance (z’=1.94, p = .05) and interest in cosmetic surgery were mediated by body dissatisfaction.

Discussion

In recent years, there has been a dramatic increase in the number of people pursuing cosmetic surgery for aesthetic (i.e., not reconstructive) purposes. Cosmetic surgery is no longer reserved for the rich, famous, or aging. Instead, patients are increasingly likely to come from all walks of life and are younger in age than ever before. In spite of clear data from the American Society of Plastic Surgeons (2008a) regarding cosmetic surgery trends in the U.S., research addressing predictors of interest in cosmetic surgery is needed; the primary psychological construct explored in past research is body dissatisfaction. In this study we attempted to extend these findings by examining a relatively young sample of women in their late adolescent and early adult years and by examining multiple personal (i.e., body dissatisfaction and weight status) and sociocultural influences (i.e., internalization of media messages about appearance issues and teasing about physical appearance) on young women’s desire to pursue cosmetic surgery to alter their bodies.

Consistent with our first hypothesis, we found that women’s body dissatisfaction significantly predicted their interest in cosmetic surgery. We further found that women’s objective weight status (i.e, BMI) was predictive of their interest in cosmetic surgery. However, when both of these constructs are examined simultaneously as predictors of women’s interest cosmetic surgery, it is clear that women’s object weight status cannot completely explain these relations. In other words, when weight status was statistically controlled, body dissatisfaction remained a significant predictor of interest in cosmetic surgery. This indicates that in order to understand women’s interest in changing their bodies it is important to not only consider how a woman may look (i.e., how much she actually weighs) but how she feels about her body (i.e., whether or not she is dissatisfied with her body).

Our second set of hypotheses was also confirmed. Women who were more likely to internalize media messages about physical appearance issues were also more likely to desire cosmetic surgery than their peers who internalized these messages to a lesser degree. In other words, it seems that women who view media messages as informative and appropriate for learning about what their body should look like are also more likely to be interested in pursuing cosmetic surgery to change their body. Our results also revealed that women who recall being teased about their bodies were more likely to express an interest in changing their bodies surgically. It is possible that negative social feedback about their bodies may encourage young women to conform to culturally desirable standards of physical attractiveness so that they may receive positive feedback in the future (Brownell 1991; Feingold 1992; Sarwer et al. 2004). Because we found that women’s objective weight status could not completely account for the links between sociocultural predictors and women’s desire to obtain cosmetic surgery, it seems that women’s perceptions of what they should look like and their perceptions of what others think they look like are not completely overlapping with how they actually look.

Finally, because of the established role of body dissatisfaction in predicting young women’s desire to change their bodies and past research investigating mediational models, we examined body dissatisfaction as a mediator of the other influences examined in this study when attempting to predict interest in cosmetic surgery. We found that body dissatisfaction did successfully mediate the relations between weight status, internalization of media messages, women’s reports of teasing, and women’s interest in cosmetic surgery (see Fig. 2). Thus, the present findings concur with past research (e.g., Sarwer 2001) indicating the important role of body dissatisfaction and extends these findings by suggesting a new model linking personal and sociocultural factors to women’s pursuit of cosmetic surgery.

Although this study represents one of the first empirical examinations of young women’s interest in cosmetic surgery to alter their bodies and predictors of that interest, these findings should be tempered with an understanding of the limitations inherent in this research. The most significant limitation of this research is the cross-sectional and correlational nature of the design employed. It is hoped that future research will be able to follow individuals across time to better determine not just those who are interested in cosmetic surgery, but those who actually pursue and obtain surgery. The correlational findings presented here will be strengthened with replications that employ experimental manipulations. For example, experimental manipulation of media stimuli that participants are exposed to could be used to strengthen these findings indicating that media messages are influential in determining young women’s interest in cosmetic surgery. Although this sample was relatively diverse, replication of these results with a more heterogeneous sample in terms of age, gender, ethnicity, socioeconomic, and educational (i.e., non-student) background should further strengthen our understanding of predictors of interest in cosmetic surgery. Further, an exploration of women’s feminist ideology could provide researchers with an enhanced understanding of how cosmetic surgery may fit into women’s broader belief systems.

Conclusion

It is difficult to find fault with individuals interested in changing their bodies to enhance their appearance (Sarwer et al. 2004); research clearly indicates the important role individuals’ perceptions of their physical attractiveness has on their general sense of self-worth and evaluation by others (e.g., Feingold 1992; Harter 1990). Normative developmental concerns about physical appearance issues are likely exacerbate by sociocultural messages presented by the media and direct feedback from others (e.g., teasing), which conveys to young women the importance of their body’s appearance. Further, medical technology provides an ever-increasing number of approaches individuals can pursue in their attempts to improve their body. As more and more young girls and women alter their bodies surgically, it seems possible that beauty norms will begin to reflect an appearance that is nearly impossible to achieve without surgery (Bordo 2003). The question that research has yet to fully address is whether or not cosmetic surgery can actually improve the pervasive negative perceptions that young women have of their bodies (Cook et al. 2006; Rodin 1993; Rodin et al. 1985; Tiggemann 1994). Although some research suggests that cosmetic surgery may provide benefits to young women’s body image (Kamburoglu and Ozgur 2007), it is also possible that the increasing rates of cosmetic surgery will exacerbate young women’s body dissatisfaction by perpetuating an increasingly stringent ideal of attractiveness (Bordo 2003; Brumberg 2000). Some scholars have suggested that psychological screening should precede cosmetic surgery procedures (e.g., Zuckerman and Abraham 2008); our research could inform efforts to screen potential patients. Further, as we come to better understand the reasons underlying young women’s interest in cosmetic surgery, intervention efforts can be developed to target vulnerable audiences and educate them about the potential costs and benefits associated with cosmetic surgery.