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 et al., 2003, Didie and Sarwer, 2003, Sarwer et al., 2003, Sarwer et al., 2002 and Von Soest et al., 2011). Similarly, in non-surgical samples, greater body dissatisfaction has been associated with positive attitudes towards cosmetic surgery (Henderson-King and Henderson-King, 2005, Sarwer et al., 2005 and Slevec and 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 et al., 2004b and 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 et al., 2004b and 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 and Markey, 2010 and Sperry et al., 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 et al., 2007 and 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 and Tiggemann, 2006, Jones et al., 2004 and Shroff and 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 surgery-related 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.
