A partiality to beauty has long existed in humans (Yarosh, 2019). Today, those who feel more dissatisfied with their bodies and have a negative body image are likely to seek a more ‘beautiful’ appearance (Sheikh et al, 2019). Appearance dissatisfaction is a phenomenon that affects one's personal life. In cultures that value physical attractiveness, there is an increased demand to eliminate what is deemed unattractive by various societies (Walker et al, 2019).
The advancements in surgical and non-surgical cosmetic treatments are the latest human achievements in creating beauty. When applied ethically (for example, achieving natural results and using screening tools), they can improve the patient's quality of life. These treatments are referred to as cosmetic as they are carried out in the absence of disease, injury or congenital and genetic abnormalities (Borujeni et al, 2020; Kasmaei et al, 2020). In general, cosmetic surgeries are those that are performed without special medical necessity and only for beauty purposes (Nejadsarvari et al, 2016).
Cosmetic surgeries are one of the most common surgeries in the world and the number of patients undergoing such treatments is increasing. The American Society for Aesthetic Plastic Surgery reported an increase of 446% in cosmetic procedures since 1997 and an overall increase of 8% in 2007, with a 17% increase in men undertaking cosmetic surgery (Furnham and Levitas, 2012). This increase is similar in the UK. The American Society of Plastic Surgeons Report (2016) showed that there were approximately 1.9 million cosmetic surgeries in the US in 2016 (Bidkhori et al, 2021). This growth has been very significant in developing countries, especially among young people.
According to reports, Iran ranks first in the world in terms of the ratio of cosmetic surgeries performed to the total population (Niya et al, 2019). In Iran, the demand for cosmetic surgery has had an 80-point increase since the 1970s, which is still increasing (Bidkhori et al, 2021). Furthermore, one study suggests that the tendency to undergo cosmetic surgery has become fashionable and is a determinant of social status (Niya et al, 2019).
Researchers have shown that the types of motivation behind why people undergo cosmetic surgeries include social and intrapersonal factors (Niya et al, 2018). Additionally, some studies have revealed that intrapersonal factors, such as self-assessment, attractiveness, appearance-based rejection sensitivity and negative body image, are the primary stimulants for cosmetic surgery. Socio-cultural factors can also increase a person's interest in cosmetic surgery, as they are increasingly exposed to it and peers who have undergone treatments via social networks (Niya et al, 2018).
Few studies have investigated patients’ motivations and attitudes toward such surgeries, which vary in different societies and even in different strata of a society and various patients (Niya et al, 2019). One study aimed to assess self-esteem and attitude toward physical appearance before and after rhinoplasty. It reported an increase in attitude score after surgery. In addition, body image and self-esteem were significantly improved after surgery. Although not statistically significant, quality of life was also improved (Borujeni et al, 2020). Sex, race, culture and social media are all factors related to a positive attitude towards cosmetic surgery (Alotaibi, 2021).
In one study on older students with a history of previous cosmetic procedures and students with engineering specialities, participants had more acceptance scores in both cosmetic surgeries and procedures. On the other hand, male students with middle class backgrounds who perceived themselves to be aware of the risk associated with cosmetic procedures had less acceptance scores. The most reported barrier to undergoing cosmetic surgeries and procedures was feeling that they do not want or need it (AlShamlan et al, 2021).
The results of another study showed that viewing images of women who have undergone cosmetic enhancements affected young women's desire for cosmetic procedures, especially if they spent a significant amount of time on social media, followed many accounts and were less satisfied with their appearance (Walker et al, 2019).
Although cosmetic procedures have become prevalent in societies, more comprehensive research from a psychological perspective is needed, as most studies have been based on the consequences of cosmetic procedures with no control group. Therefore, this study aimed to compare the attitudes toward cosmetic procedures in its applicants and their relative non-applicants in Rafsanjan, Iran.
Method
This descriptive cross-sectional study aimed to compare attitudes toward cosmetic procedures in its applicants and non-applicants in Rafsanjan, Iran. The study population included all applicants referred to cosmetic clinics and non-applicants who were relatives of the applicants. The sample size was 220 people by using the following formula, taking into account the study variables of Ardakan et al (2011). In total, 200 participants (applicants and non-applicants) completed the self-report questionnaires and information was collected through interviews in case participants could not complete the questionnaire for any reason.
Participants who met inclusion criteria were selected by using convenience sampling. Informed consent was taken from the participants. Inclusion criteria were those who definitely underwent cosmetic surgery by a specialist 15 days after passing medical procedures, did not have a medical and necessary reason to undergo cosmetic surgery and underwent cosmetic surgery in the operating room and not as outpatients. Exclusion criteria were the history of cosmetic procedures and no tendency to undergo cosmetic surgery in the future in non-applicants.
The instruments used in this study included two questionnaires of demographic information and attitudes toward cosmetic procedures. The demographic questionnaire contained nine items, including age, sex, marital status, education, job, type of surgery, date of surgery, postoperative satisfaction and monthly income. The self-made attitude questionnaire consisted of 22 items on a five-point Likert scale, ranging from one (strongly disagree) to five (strongly agree). The lowest score was 22 and the highest was 88. The questions were obtained by using the review of literature, and the opinions of professors related to attitude measurement research. The validity of the instrument was estimated by using face and content validities; the validity of the items was 0.89–1.0. The reliability of the instrument was estimated by conducting a pilot study on 30 eligible individuals, which was 0.90 using the Cronbach's alpha coefficient.
Data were analysed by SPSS-18. The research characteristics were described by using frequency, percentage, mean and standard deviation. Owing to the fact that the quantitative variables of the study (attitude and age scores) did not follow the normal distribution, the Mann-Whitney U test was used to compare the two groups in terms of these variables. A Chi-square test was used to determine the relationship between qualitative variables and being the applicant for cosmetic surgery. For the confounding effect of the variables to be determined, the variables that had a significant relationship with being the applicant for cosmetic surgery were included in the univariate and multivariate logistic regression model. The goodness-of-fit of the logistic regression model was checked by using the Hosmer-Lemeshow goodness-of-fit test. The significance level was considered to be 0.05.
Results
Table 1 shows sociodemography of the sample. The mean (SD) age of the applicants and non-applicants for cosmetic surgery were 25.07 ± 5.74 and 27.74 ± 8 years, respectively. Some 79% of the procedures were related to rhinoplasty, 7% were related to liposuction, 6% were related to mammoplasty and 8% were related to botulinum toxin injections.
Table 1. Distribution of demographic characteristics of applicants and non-applicants for cosmetic procedures in Rafsanjan, Kerman, Iran (2021)
| Variable | Applicants (n=100) (%) | Non-applicants (n=100) (%) | |
|---|---|---|---|
| Sex | Male | 26 | 41 |
| Female | 74 | 59 | |
| Marital status | Single | 71 | 64 |
| Married | 29 | 35 | |
| Divorced | 0 | 1 | |
| Education | Middle/high school | 7 | 8 |
| Diploma | 15 | 26 | |
| Associate degree | 78 | 66 | |
| Student | 65 | 42 | |
| Job | Self-employed | 13 | 23 |
| Employed | 8 | 21 | |
| Unemployed | 14 | 14 | |
| Monthly income | < 500000 Tomans | 31 | 52 |
| 500000–1000000 Tomans | 41 | 20 | |
| > 1000000 Tomans | 28 | 28 | |
The mean (SD) scores of attitudes towards cosmetic procedures in applicants and non-applicants were 64.93 ±14.84 and 63.08 ±11.66, respectively, but this difference was not statistically significant (p=0.259). Table 2 shows the comparison between the attitude items.
Table 2.
| Row | Items | Applicant for cosmetic surgery (n=100) | Non-applicant for cosmetic surgery (n=100) | Mann-Whitney U | P value |
|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | ||||
| 1 | It is better for a person to have a small cosmetic procedure rather than have a bad feeling about him/herself | 3.12 ± 1.32 | 2.82 ± 1.33 | − 1.64 | 0.101 |
| 2 | Cosmetic surgery is positive because it can help a person feel good | 3.23 ± 1.17 | 2.91 ± 1.16 | − 2.11 | 0.039 |
| 3 | People who are unhappy with their appearances should choose cosmetic surgery as an important task | 3.04 ± 1.13 | 2.80 ± 1.02 | − 1.55 | 0.123 |
| 4 | If cosmetic surgery makes a person happy, he/she should undergo it | 3.42 ± 1.03 | 3.01 ± 1.10 | − 2.77 | 0.006 |
| 5 | I sometimes think about having cosmetic surgery | 3.05 ± 1.32 | 2.92 ± 1.28 | − 0.82 | 0.414 |
| 6 | If I knew that cosmetic surgery has no side effects (for example, pain), I would undergo it | 3.11 ± 1.28 | 3.00 ± 1.29 | − 0.74 | 0.461 |
| 7 | I would seriously consider reconstructive surgery if my spouse and those around me thought it was a good idea | 2.82 ± 1.25 | 2.69 ± 1.19 | − 0.88 | 0.381 |
| 8 | I will never undergo cosmetic surgery | 2.74 ± 1.21 | 3.02 ± 1.10 | − 1.94 | 0.051 |
| 9 | Cosmetic surgery can be a great help to a person's mental image of himself/herself | 3.18 ± 1.17 | 3.17 ± 1.12 | − 0.21 | 0.842 |
| 10 | If cosmetic surgery would make me more attractive to other people, I will undergo it | 2.89 ± 1.21 | 2.75 ± 1.07 | − 0.93 | 0.349 |
| 11 | If my spouse or people around me think that I look more attractive with surgery, I will definitely undergo it | 2.99 ± 1.31 | 2.77 ± 1.10 | − 1.37 | 0.172 |
| 12 | If I know that I will look younger with surgery, I will undergo it | 3.11 ± 1.28 | 2.78 ± 1.16 | − 2.07 | 0.039 |
| 13 | Cosmetic surgery gives the most hope to life | 2.63 ± 1.28 | 2.51 ± 1.14 | − 0.63 | 0.532 |
| 14 | People with low self-esteem undergo cosmetic surgery | 3.07 ± 1.25 | 3.06 ± 1.21 | − 0.06 | 0.952 |
| 15 | Surgery is against what God has naturally created | 3.04 ± 1.14 | 3.00 ± 1.32 | − 0.35 | 0.728 |
| 16 | Cosmetic surgery raises a person's social class | 2.45 ± 1.21 | 2.61 ± 1.14 | − 1.05 | 0.301 |
| 17 | None of the applicants of cosmetic surgery is satisfied with their surgeries | 2.79 ± 1.07 | 2.56 ± 1.07 | − 1.55 | 0.124 |
| 18 | Cosmetic surgery is like any other surgery and should only be performed if necessary | 3.15 ± 1.18 | 2.85 ± 1.16 | − 1.73 | 0.082 |
| 19 | People who think about cosmetic surgery are unemployed | 2.71 ± 1.07 | 2.91 ± 1.02 | − 1.70 | 0.089 |
| 20 | Cosmetic surgery is for the rich | 2.56 ± 1.01 | 2.67 ± 1.04 | − 0.91 | 0.358 |
The Mann-Whitney test showed no significant difference between the age of applicants and non-applicants of cosmetic procedures (Z=-1.92 and p=0.054). Chi-square test showed a significant difference between sex and being an applicant for cosmetic procedures (χ2=5.05 and p=0.025), but there was no significant difference between marital status and being a cosmetic procedure applicant (χ2=1.92 and p=0.382). In addition, no significant difference was found between levels of education and being an applicant for cosmetic procedures (χ2=4.02 and p=0.134). However, a significant difference was observed between job, income and being an applicant for cosmetic surgery (χ2=13.55, p=0.004, χ2=12.54 and p=0.002, respectively). For the confounding effect of the variables to be determined, three variables that had significant differences between cosmetic surgery applicants and non-applicants were entered into univariate and multivariate logistic regression models. The results showed that, among the three variables of sex, job and level of education, sex had no significant relationship with being an applicant for a cosmetic procedure. The goodness-of-fit test of Hosmer and Lemeshow showed that the model was not very fitted (p=0.006, χ2=17.98). The sex variable was removed to correct the regression model. The Hosmer and Lemeshow (goodness-of-fit) test showed that the bivariate model of job and income was sufficiently fitted (χ2=7.36 and p=0.289). Therefore, job and income have a significant relationship with being a cosmetic procedure applicant. Employed people were less likely to undergo a cosmetic procedure compared with students. Self-employed people had 0.1 times more tendency and employees had 0.07 times lower tendency for cosmetic procedures compared with students.
Discussion
The results of the present study showed that the applicants’ mean score of attitudes toward cosmetic procedures was higher than that of the non-applicants, indicating that the applicants’ more positive attitude towards cosmetic procedures compared with the non-applicants, but this difference was not statistically significant. No other study has compared attitudes towards cosmetic surgery between applicants and non-applicants. People with negative attitudes towards themselves are more likely to have lower self-esteem, be isolated, have a sense of inadequacy and cognitively have inaccurate beliefs about their appearance. They usually evaluate their appearances more negatively and believe that they look unattractive to others (Baudson et al, 2016).
One study by Borujeni et al (2020) aimed to assess self-esteem and attitudes toward physical appearance before and after rhinoplasty. The authors reported an increase in attitude score after surgery, and body image perception and self-esteem were also significantly improved (p<0.005). Although not statistically significant, quality of life was also improved after surgery (Borujeni et al, 2020).
Cheraghian et al's (2020) study aimed to investigate the psychological and personality characteristics of the applicants for facial cosmetic surgery and reported that participants had abnormal health statuses. The openness, conscientiousness and agreeableness subscales were insignificantly lower than that of the general population and the extroversion subscale was significantly higher than that of the general population (Cheraghian et al, 2020).
Attention should be paid to the incredible rate of people undergoing cosmetic procedures, as well as the education and relevant psychological intervention affecting attitudes toward these.
Conclusions
The results of this study highlight the need for education in and psychological intervention, where necessary, in relation to cosmetic procedure patients.
Key points
- Cosmetic procedures are growing increasingly popular
- In this study, the attitude of participants who had undergone cosmetic procedures was not significantly more positive towards cosmetic procedures compared to those who did not undergo it
- Employed people had less tendency for cosmetic surgery compared with students
- High-income people were more eager to undergo cosmetic procedures in comparison with low-income people
- The results of this study highlight the need for education in and psychological intervention, where necessary, in relation to cosmetic procedure patients.