Pretty privilege, surgery stigma and the cosmetic procedure paradox

Sana Qadar:
If you've been on social media at all recently, you might have noticed something unsettling.
Professor Gemma Sharp:
We used to be able to differentiate people's ages a little bit more easily and now it's quite homogenous.
Sana Qadar:
From big name celebrities to your friends from high school, people are looking increasingly ageless. They're smoother, they're a bit more plump, more perfect. You might have also heard the term Instagram face coined in 2019 to describe the homogenous beauty standards populating our online feeds. Obviously, we've got access to filters and photo editing, but there is something else on the rise too, and that's cosmetic procedures.
Professor Gemma Sharp:
And even during times like the pandemic, it was an industry that was not hit. In fact, it actually flourished.
Sana Qadar:
So in a world where we can change our faces and bodies easier than ever, how does this impact the way we think about ourselves and others?
Dr Sarah Bonell:
Aging is now almost seen as a medical condition.
Professor Gemma Sharp:
What does that mean for our sense of belonging to our heritage, to our families?
Dr Sarah Bonell:
Across the board, we found that people who were described as considering having plastic surgery were perceived as less warm, competent, moral and human.
Sana Qadar:
I'm Sana Qadar and from ABC Radio National, this is All in the Mind. And producer Rose Kerr has this story today and she joins me in the studio. Hey, Rose.
Rose Kerr:
Hi, Sana.
Sana Qadar:
Are you chronically online, Rose?
Rose Kerr:
(Laughs) I would like to say no, but I really think that I am. And sometimes things sneak into my algorithm that I never even asked for. And cosmetic surgery content is absolutely one of those things. I don't know if it's having recently turned 30 or just what's trendy, but I see endless videos about plastic surgeons describing the types of procedures they do and then celebrities and influencers telling me what they get done. Is this something that you see as well?
Sana Qadar:
Oh my gosh, so much. So much of my Instagram, if I go to the For You page, is yes, those surgeons being like, this person's had this that done. But also a lot of face comparison composite photos like this person in 2015 versus now. Yeah, there's a lot of it around.
Rose Kerr:
And it can make you feel a bit weird because those faces don't necessarily reflect what we see in the mirror. And I have to admit, the more content like this that I see, the more I've been thinking about how it impacts our mental health, our psychology, how we think about aging, how we see other people, things that I'm excited to say we're going to get into in this episode. But before we get too deep into it, I do want to say there is no moral judgment on whether or not people get these procedures. Full disclosure, I don't have a whole lot of interest in them, but that's mostly because I'm kind of scared of needles.
Sana Qadar:
Yeah, yeah, I'll mimic that. You do you, whatever you've had done, cool. Although we will also talk about body dysmorphia in this episode.
Rose Kerr:
Yeah, there will be some discussions of mental health and mental illness that are related to body image throughout this episode.
Sana Qadar:
And so, Rose, do we know how common cosmetic procedures actually are in Australia?
Rose Kerr:
Like so many things that we talk about on the show, Sana, it is hard to pin down because of limited reporting. But in 2023, the injectables industry was valued at $4.1 billion in Australia. And if we look globally, there are some surveys that have shown that nearly one in four people who get Botox were between the ages of 18 and 34.
Professor Gemma Sharp:
So it is a huge and boomy industry.
Rose Kerr:
This is clinical psychologist Gemma Sharp. She's a professor of psychology at Adelaide University, who's done research in the body image space.
Professor Gemma Sharp:
Surgery has always been pretty popular, but it's not growing as much as injectables are.
Rose Kerr:
How much do you think social media has influenced the popularity of cosmetic procedures?
Professor Gemma Sharp:
People were always interested in cosmetic procedures. I think what social media has done is made it seem very accessible through marketing, whether that be an influencer talking about what they've had done and they feel like it's benefited them. But also direct marketing, which we all know happens on social media. I think there's a couple of pathways there. I think it's really normalised getting procedures done.
Rose Kerr:
So at a population level, it seems non-surgical cosmetic procedures are on the rise. But why is that the case? What is driving individual people to seek out these surgeries and treatments? As you can probably imagine, the motivations are hugely varied and personal. But Gemma says there are a few common themes that pop up.
Professor Gemma Sharp:
People might think that people who seek cosmetic procedures have poor body image in general, but that's not the case. The body image distress is usually very focused on the area that they want to change. So thinking of people who have always thought their nose is too big, people may have teased them throughout their lives.
Rose Kerr:
Other reasons might include wanting to improve self-confidence or to overcome physical discomfort.
Professor Gemma Sharp:
People will talk about relationship concerns as well.
Rose Kerr:
And when it comes to personality traits and cosmetic procedures, Gemma says there needs to be more research to properly understand the relationship between the two.
Professor Gemma Sharp:
We've always found that if anyone tries to publish a profile, the next study kind of refutes it. So what we do know is that the person usually has a body image concern. Sometimes we do see people who are a bit more perfectionistic and people who maybe they value their appearance more than the norm. And we often get people saying that it will help them in life, help them get jobs, help them get partners, those kinds of things. So that appearance value is linking into other parts of their lives.
Rose Kerr:
Do we know from research if being attractive actually does improve your life?
Professor Gemma Sharp:
The pretty privilege question.
Rose Kerr:
Yes.
Professor Gemma Sharp:
There is research to show that people who are more conventionally attractive do tend to earn more money, they get further ahead in their jobs, they're more likely to attract partners.
Rose Kerr:
This is thought to be in part due to the halo effect. The halo effect is a cognitive bias where one positive aspect of a person influences your whole picture of them. For example, if you like someone, you might assume they are more competent at their job than they are. And in the case of someone's appearance…
Professor Gemma Sharp:
People who are more attractive are perceived to have other positive attributes like being intelligent and things like that.
Rose Kerr:
That is horrifying to hear, but also like pretty validating.
Professor Gemma Sharp:
It's pretty sobering, isn't it? Yeah, it's a thing. And I suppose if we think of our evolutionary roots, attractiveness came along with health and ability to reproduce. So we are hardwired to look for attractiveness.
Rose Kerr:
And it does kind of make you go, this is the world we live in and it's rooted in our evolution. Like, it's kind of fair enough that people would go, well, this is what I got to do.
Professor Gemma Sharp:
Exactly right. And I think, you know, and that's why the cosmetic industry is worth an absolute fortune. And even during times like the pandemic, it was an industry that was not hit. In fact, it actually flourished. So it shows that people will invest in this even in really difficult times.
Rose Kerr:
Part of Gemma's clinical work is seeing patients before they go ahead with a cosmetic procedure.
Professor Gemma Sharp:
So these are patients who are considering cosmetic procedures, but their surgeons, their cosmetic practitioners feel they may benefit from extra consultation with a clinical psychologist, mostly to discuss their motivations and their expected outcomes.
Rose Kerr:
Through this work, she comes across a lot of different reasons why someone is seeking a particular treatment.
Professor Gemma Sharp:
I will say that no two people's stories are the same. And I suppose one particular instance really sticks out to me because it was a male patient and they are a bit less frequent. And he was interested in a penile augmentation. And this was a non-surgical penile augmentation. So basically increasing the girth through filler.
Rose Kerr:
He was referred to Gemma because he had recently gone through a breakup.
Professor Gemma Sharp:
And he was quite convinced that the reason for the breakdown was his penis size. And he thought that that would really solve his relationship issues. It was really clear with speaking with him that he had a sort of understanding that the cosmetic procedure really wasn't going to solve these relationship issues and that other pathways needed to be taken. And I was, I suppose I'm always remembering that one because it was just so clear that something else was going on and that the cosmetic procedure probably wouldn't have benefited him that much.
Rose Kerr:
Do you remember what he ended up deciding to do?
Professor Gemma Sharp:
Yeah. So, I mean, I don't know what happened to him all these years hence, but he decided not to have the penile augmentation at that time and pursued his own individual therapy with my support, which I thought was a really great outcome.
Rose Kerr:
I just want to pause here and talk about men and cosmetic surgery, because it's a topic that doesn't come up as often as it does for women. Although generally motivations for surgery do cross over a lot between men and women, there seems to be a difference in the way men talk about it.
Professor Gemma Sharp:
From my own research and the broader literature, we do see that men will often talk about overall self-confidence, overall self-esteem, sense of self as motivations more commonly than women will. And I think it's often phrased as like an improvement rather than managing a deficit or an appearance concern. And I wonder if that just maybe how males communicate their concerns. Like it's just, oh, there's nothing wrong, but I just want to feel better.
Rose Kerr:
And Gemma's noticed that the types of surgeries men seek out are expanding.
Professor Gemma Sharp:
It used to be more kind of hair replacement, removement of man boobs, penile augmentation, liposuction, abdominoplasty, pectoral muscles. And just thinking more recently, seeing more kind of chin implants, people wanting that very chiseled chin look.
Rose Kerr:
I imagine it's shaped by social media similarly to women.
Professor Gemma Sharp:
Yeah, I think so. With men, they're looking for those, I suppose, very strongly masculine features. And those are things that are often enhanced and emphasised when people post on social media.
Rose Kerr:
Okay, back to Gemma's work with people seeking out cosmetic procedures. She says overall, she'd like to see more involvement of psychologists in the cosmetic industry.
Professor Gemma Sharp:
I should say I'm not trying to promote my business here at all. I just think that cosmetic practitioners are sometimes a little bit cautious about referring to a psychologist. They don't want the patient to think they're quote unquote crazy or something like that, which is unfortunately a common response by patients. I think people often mistake the goal of the mental health professional as the gatekeeper to the procedure. And that's definitely not the case. It's more that we are helping to assist in the decision making for the best treatment moving forward.
Rose Kerr:
Currently in Australia, registered health professionals that perform non-surgical cosmetic procedures are required to assess their patient's mental health.
Professor Gemma Sharp:
Cosmetic practitioners must screen for body dysmorphic disorder, which I think is a great start.
Rose Kerr:
Body dysmorphic disorder, or BDD, is a mental health condition where someone has a fixation on an aspect of their appearance, often believing that it's defective. It has a significant effect on someone's day-to-day life and is often associated with anxiety, depression, and even suicidal behaviour. The reason BDD is named specifically in the guidelines for these patient assessments is because it's the most studied psychiatric illness in cosmetic settings. And research suggests that BDD has a higher prevalence in people seeking cosmetic procedures compared to the general population.
Professor Gemma Sharp:
So we know that body dysmorphic disorder has a prevalence about 1-2% in the general community, but it's been estimated anywhere between 15% and 50% of people who seek cosmetic procedures. So they're very much overrepresented in terms of those seeking this kind of intervention. And it makes complete sense because people with body dysmorphic disorder don't necessarily think it is a mental disorder. They will think that there is an issue with their appearance. And so why wouldn't you go to a cosmetic clinic to get an appearance issue fixed than go talk about it with a psychologist? So often BDD cases are picked up at the cosmetic clinics rather than the psychology clinics.
Rose Kerr:
This begs the question, does surgery help people with BDD? Gemma says we need more research to fully understand the outcomes.
Professor Gemma Sharp:
So even in my own research, in my own team's research, we have seen that when people have a very specific concern focused on one part of their body where the surgery has a definitive outcome, that body dysmorphic disorder symptoms can reduce.
Rose Kerr:
But it's unclear whether someone's concerns about their appearance will be redirected to another part of the body.
Professor Gemma Sharp:
And that's how you can end up having lots and lots of cosmetic procedures and still not feeling satisfied.
Sana Qadar:
From ABC Radio National, this is All In The Mind, I'm Sana Qadar. Today, producer Rose Kerr has been investigating cosmetic procedures, why we might want to change the way we look and what it might mean for our mental health. So Rose, I've noticed an increasing transparency in people talking about the procedures that they've gotten and, you know, sort of listing what they've gotten done to achieve the look that they have. Have you noticed this?
Rose Kerr:
Oh yeah. And a massive one in my world was 11 years ago in 2015, after years of speculation, Kylie Jenner finally admitted to getting lip filler, like it wasn't just really great makeup.
Sana Qadar:
Yes. OK. I remember that. I mean, to me, it was a surprise that it was even the newsflash. But yeah, OK (both laugh).
Rose Kerr:
And despite this increased awareness and more normalisation of cosmetic procedures, there is kind of still a stigma. A recent example for me was when the final season of Stranger Things came out. People were kind of making fun of Millie Bobby Brown's lips because it looked like she had had filler done.
Sana Qadar:
Ah, OK. I miss that. But the names and events, I suppose, I remember are Renee Zellweger, when she had work done to her face and she was at a premiere and everyone was like, who is this person? And it got pretty mean after that. But also more recently, Mandy Moore, that like 90s pop singer who, similarly to Renee, got some work done and looks quite different now.
Rose Kerr:
Yeah. It's like an elephant in the room, right? You can tell someone's face looks different and then seemingly people can react in quite a negative way. And seeing these conversations play out online got me interested in how we view other people who've had cosmetic procedures. So I spoke to a researcher who's done work looking at just that.
Dr Sarah Bonell:
I am Dr. Sarah Bonell. I'm a research fellow at the Bolton Clark Research Institute here in Melbourne.
Rose Kerr:
In 2021, Sarah and her team published a paper in PLOS One titled Under the Knife, Unfavourable Perceptions of Women Who Seek Plastic Surgery.
Dr Sarah Bonell:
We took photos of women, kind of a standardised database of photos of women who were considered conventionally attractive and women who were considered conventionally unattractive.
Rose Kerr:
The photos were paired with descriptions of activities that the women were doing.
Dr Sarah Bonell:
So we either describe them as doing sort of everyday boring activities, walking their dog, whatever it might be. But then for some of the photos, we included the description that they were planning to undergo plastic surgery.
Rose Kerr:
They presented these images and descriptions to nearly a thousand adults, asking them to rate the women based on various traits.
Dr Sarah Bonell:
And we were also looking at whether that effect was influenced by the conventional attractiveness of the woman pictured as well. And we sort of measured that on a whole bunch of different traits. So we were looking at whether the plastic surgery description made women seem more or less moral, but we also looked at competence and warmth and humanness as well, which was an interesting one.
Rose Kerr:
You'd be like, come on humanity. We're really going to get in deep here.
Dr Sarah Bonell:
Yeah, exactly. Like surely they won't be seen as less human, we would hope. That's where maybe the line is drawn. But yeah.
Rose Kerr:
What were some of the trends that you saw?
Dr Sarah Bonell:
So across the board, we found that people who were described as having or considering having plastic surgery were perceived as less warm, competent, moral and human. But interestingly, we only found that effect for photographs where the woman pictured was conventionally attractive. So when a conventionally unattractive woman was described as undergoing plastic surgery, there wasn't really any stigma associated with that for her. But for the conventionally attractive woman, it was kind of heavily stigmatized. And yeah, as I said, all the way down to like she was seen as less human for making that choice.
Rose Kerr:
Wow. But then, unless you're not attractive, because then it's fair enough.
Dr Sarah Bonell:
Yeah, exactly. And I think interestingly, like it's almost, I mean, and we didn't test this, to be fair, this is just my conjecture. But I feel like that is a testament to the empathy that people feel, right? Because they know that pretty privilege is so prevalent. So in the context of a woman being conventionally unattractive, it's like they can understand more readily why she quote unquote needs to have plastic surgery. Whereas for an attractive woman, obviously that empathy isn't really there. And it's interesting to me how both empathy and stigma can exist within the same space as well.
Rose Kerr:
What do you think this kind of tells us about society's attitudes towards cosmetic procedures broadly?
Dr Sarah Bonell:
I mean, I think it suggests that everybody has body image issues, ultimately. I mean, maybe there's someone out there who doesn't and kudos to them. But we all go through it. And I think that means that everyone to a degree can really empathise and understand with the desire to have surgery done. But the interesting part is when they decide that for them, that's a step too far, for whatever reason. And so then that stigma sort of comes in.
Rose Kerr:
Sarah has continued her research in this area through interviewing women about their experiences of cosmetic surgery stigma. Some of these were worked on with Professor Gemma Sharp, and we'll link to them and others we've mentioned on our website. But through these studies, Sarah has found that women who have had work done to their appearance were very aware of the stigma they may face.
Dr Sarah Bonell:
Essentially, all of them described, you know, after I had this procedure done or even when I was talking about having cosmetic surgery, I received negative reactions from people, really sort of centralising the idea that cosmetic surgery was somehow the wrong thing to do. And interestingly, you know, these were women who had then gone on to have the procedure. And a lot of the time they ended up internalising that stigma. So they would kind of express that they felt glad that they did it. But then also in the same breath, they'd be like, oh, but I had to do surgery because I'm lazy. So I couldn't do it through diet and exercise like I should have. Like there was almost this self-shaming that went on.
Rose Kerr:
Sana, I'm keen to get your thoughts on something we've not mentioned yet, which is how the popularity and normalisation of cosmetic procedures impacts our view of ageing. Like so many treatments are focused on lifting the face or reducing wrinkles. Like I want to know do all these things impact how we view our own faces when they do start looking older? What do you reckon? How does all this content make you feel?
Sana Qadar:
Yeah, it definitely makes me feel like can I be 50 and wrinkle-free? Because lots of these women who are actresses and models seem to be. It's a bit ridiculous, but it has made me newly obsessed with skincare. I'll say like I'm definitely with the retinol and the vitamin C serums and all that kind of stuff.
Rose Kerr:
Exactly. And it's not that far of a step to then picture someone going, I'll get the cosmetic procedure as well. I wanted to put this question to Professor Gemma Sharp. So I asked her if she thinks the popularity of cosmetic procedures has changed the way we think about ageing at a broader scale, at more of a societal level.
Professor Gemma Sharp:
So I think when we look at the cosmetic surgery and cosmetic intervention statistics for the last, I suppose, 10, 20 years, there's this group, usually 35 to 50 year olds, who are the biggest consumers. And some would say that that is potentially when signs of ageing start to kick in. And you'll hear people saying, well, I don't want to be discriminated against because of my age. I need to be able to keep up a job. I want to have access to certain relationships. And so you'll think, well, why wouldn't they go and seek cosmetic procedures in order to not look 35 to 50? I think what we have seen a bit more recently, though, is that younger people come in saying, well, I don't want to age at all. I want to remain looking 18. I want to prevent ageing as much as I can. So we're seeing this shift in a younger demographic seeking some of the same procedures that we're usually only seen in 35 to 50 year olds. And so what it does seem to be doing is that we have this sort of, I suppose, 18 to 50 all getting the same procedures and all looking of a similar age, which is an incredibly weird time in society because we used to be able to differentiate people's ages a little bit more easily. And now it's quite homogenous.
Dr Sarah Bonell:
I think I would best describe it as ageing is now almost seen as a medical condition in the sense that it's no longer, I guess, appropriate to look old.
Rose Kerr:
Here's Dr. Sarah Bonell again.
Dr Sarah Bonell:
We almost see it as a signifier of someone not taking care of themselves if they've aged to a certain degree. Now, I think the paradox exists in older people as well. Society wants to see older people looking older. And if people, you know, take a facelift to the extreme or whatever it might be, and they look far younger than they are, I think there's a lot of sort of stigma associated with that. And we sort of see that with celebrities and with everyday people.
Sana Qadar:
That's really fascinating to view ageing as a medical thing to fix. But it's also interesting, the stigma angle, because I will say when I saw Kris Jenner's new face, and she's like, what, 70, 70 plus, I actually felt viscerally angry. I was like, is this what we're expected to look like at 70? Like, 50 is one thing, but this is next level.
Rose Kerr:
Yeah, and there's so many elements to it, right? Because it's like, gosh, do I now need to adhere to that? And on top of that, Sarah did mention when we talked about how there can even be an annoyance with the money that is required to look that way. Yeah. And so not only is it unattainable because you have to get a surgery, it's also like, well, I can't afford that either, even if I wanted to.
Sana Qadar:
Yeah, exactly. And I guess the other aspect of all of this is also what it's doing to the diversity of the faces we see. I remember Bella Hadid a few years ago talked about her nose job and how she regretted getting her nose job because it meant she no longer had the nose of her ancestors. And actually, hearing that was really interesting and kind of made me feel better about my nose, because that's probably the one part of my body where I've always been like, could I get a nose job one day? And I never have, and I don't think I ever will. But hearing her say that she regretted not having the nose of her ancestors anymore was actually really helpful in a weird way to hear.
Rose Kerr:
Yeah, I can totally imagine that, especially in that interview with Vogue. I think she had the nose job at like 14. So it kind of goes to show, I mean, I'm just speculating here, but the pressure she must have felt so young to adhere to some kind of standard.
Rose Kerr:
In your opinion, how does the rise in cosmetic procedures impact the way we see other people?
Dr Sarah Bonell:
Oh, I mean, I think ultimately it's creating more of a divide. And obviously there are a lot of people who fall into the grey area, but you kind of have your pro procedure, anti-procedure camps. I also think obviously cosmetic procedures are creating body image issues, broadly speaking, like as beautification becomes more available within a society, people are going to be focusing more on beauty, which is maybe the more obvious answer. But then interestingly, and I don't know how to frame this, but I think there's been almost a nice silver lining, which has been like, with the rise of these cosmetic procedures, there's almost a resistance and a movement that's now celebrating something as simple as, you know, my wrinkles represent all of the experiences I've had in life, and like my body is a roadmap of where I've been and what's happened to me. I don't love when it then veers into stigma towards people who do have cosmetic procedures, but the celebration of the, I guess, natural aging process, so to speak, is quite nice to see.
Rose Kerr:
To finish up, I wanted to ask Gemma if she had any advice for people who are feeling unsure about whether or not to go ahead with a procedure.
Professor Gemma Sharp:
I think if someone is feeling conflicted about it, because I certainly know people who are very much, yep, this is what I'm going to do, and they just go and do it, which is a very easy situation, isn't it? As opposed to someone feeling quite conflicted, and I think that shows that this person is seeking more information and more consultation. And it might be that they speak with several cosmetic clinics. It might be that they go and speak with their general practitioner. They might speak with a psychologist as well, but it sounds to me like they're trying to sort out their thoughts and see where they lie on that decisional balance. But I tend to find that people who are quite convinced that they want this procedure and are committed to it do have better outcomes versus those who are, I suppose, feeling quite conflicted, unless the discussions can help the person resolve those conflicts and then they feel confident about their decision.
Sana Qadar:
That is clinical psychologist and researcher Professor Gemma Sharp from Adelaide University. You also heard from Dr. Sarah Bonell, Research Fellow at the Bolton Clarek Research Institute, and producer Rose Kerr reported on this episode. So thank you, Rose.
Rose Kerr:
Thank you, Sana.
Sana Qadar:
Additional thanks to Senior Producer James Bullen and Sound Engineer Roi Huberman. I'm Sana Qadar. I host and produce All in the Mind, and I'll be back next week with another episode. Catch you then. Bye.