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Cosmetic medical treatments have become mainstream, and images of beauty surround us on television, in magazines, and in advertising. It is no wonder that the quest for beauty has become so prevalent. This paper explores why individuals choose to undergo cosmetic procedures, and looks at the nature versus nurture debate surrounding this phenomenon. It is important for nurses, physicians, nurse practitioners, or other healthcare professionals involved in the cosmetic surgery field to understand the underlying motivations for choosing to undergo elective cosmetic procedures in order to make appropriate choices about their patients' care. The first theory in this article is rooted in the "nature" school-of-thought and explores the evolutionary basis behind the quest for beauty. It shows that we may be 'hardwired' to think that our appearance signals our reproductive capability (D. B. Sarwer, L. Magee, & V. Clark, 2004) and that human physical attractiveness is merely a collection of physical traits that signal fecundity and health (V. Swami, C. Greven, & A. Furnham, 2007). The "nurture" concept focuses on the second theory, the sociocultural theory, which implies that people who choose to use cosmetic medical treatments to enhance their appearance may be attempting to increase their self-image or self-perception, improve their social relationships, and increase their probability of success across a variety of social situations. Other minor theories such as the estrogen theory and the psychological theory are discussed, along with implications for practice. All of these theories are valuable to the healthcare professional and allow a deeper understanding of the psyche of their patients.
There is no doubt that the cosmetic industry is booming. Once taboo, cosmetic treatments are becoming mainstream and the public and media alike are talking about it. Reality TV shows like Extreme Makeover, Skin Deep, and The Swan have added to the visibility of cosmetic treatments and the evolution of the Internet has put vast amounts of knowledge about these procedures at people's fingertips. Now that the phenomenon of cosmetic treatments is so visible and information regarding treatments is so available, how is this impacting the population?
The psychology surrounding the cosmetic surgery industry is of particular interest. Why do people get cosmetic treatments? The answer is not simple, but it is important. Many men and women are choosing to get cosmetic treatments: some believe that they are quick fixes. Literally, some patients believe that they can have a lunch hour facelift!! However, many patients forget that these procedures are medical treatments that carry some degree of risk and warrant proper thought and consideration before proceeding. Because these treatments are elective, understanding the patient's motivation for choosing a certain procedure is of particular interest to the healthcare professional. The psychological state of the patient is important in screening which patients are appropriate for cosmetic treatment, which is important in managing their expectations. When a psychological illness is present, it can impede the patient's satisfaction postprocedure, even in the presence of a successful outcome (Sarwer & Crerand, 2004). There is a significant number (about 15%) of cosmetic patients who have some degree of psychopathology, and it is part of the healthcare professionals' job to be sure that their patients are appropriate, mentally and physically, for treatment before prescribing it to them (Metules, 2005).
In this paper, I will explore some of the theories that may influence why patients are electing to undergo cosmetic procedures. The evolutionary theory and the psychosocial theory (Sarwer, Magee, & Clark, 2004) are two of the major theories that will be discussed, although they are not the only theories that apply.
The evolutionary theory can help us understand why people may subconsciously choose to have cosmetic procedures. It shows that we may be "hardwired" to think that our appearance signals our reproductive capability, which, according to Darwin (1900), is all species' ultimate goal (Sarwer et al., 2004). Sarwer et al. (2004) discuss the importance of physical appearance in their evolutionary theory. Characteristics of beauty, such as lustrous hair, clear skin, and bright eyes, are physical traits that serve as markers for less obvious beauty traits such as youthfulness, pathogen resistance, symmetry, body ratios, and averageness. They argue that our prominent use of less invasive appearance enhancing modalities such as makeup and lotions may be explained by the evolutionary theory. Human physical attractiveness, then, is a collection of physical traits that signal fecundity and health (Swami, Greven, & Furnham, 2007). Physical characteristics are an important factor in selecting a romantic and sexual partner, but based on the evolutionary theory of beauty, perhaps physical characteristics are even a more important factor in selecting a mate, or someone with whom a person will produce an offspring. According to this theory, choosing to engage in cosmetic medical treatments aimed at altering the physiological markers of beauty such as a clear, wrinkle-free complexion, fits nicely within this framework. However, Sarwer et al. (2004) add that patients are probably not thinking about the evolutionary aspects of their cosmetic treatments, yet it gives the practitioner a chance to recognize the relationship between the patient's expectations and physiological influences and therefore a better understanding of a patient's motivations for treatment.
If a patient is not thinking of what he or she looks like in terms of evolutionary advantage, what else could motivate him or her to choose cosmetic treatments? Another theory on the influences affecting patients who choose to undergo cosmetic treatments is the sociocultural theory. We are all aware of the presence of media and the strong influences it can have. Over the years, cultural ideals of beauty have changed and the media has reflected this continuum. These ideals of beauty range from voluptuous figures like Marilyn Monroe in the 1950s, to today, when thinness coupled with height and muscularity is the desired body type (Sarwer et al., 2004). Kreyden (2005) states that the media is omnipresent, with magazines, television, and even flat screens in public places that are all projecting dynamic, youthful, good-looking people who all happen to be successful in life.
This idea-that with attractive looks you have an edge over someone who is less attractive, and you are more likely to receive favorable treatment-is well-studied (Boyatzis, Baloff, & Durieux, 1998; Langlois et al., 2000; Marlowe, Schneider, & Nelson, 1996). Bombarded with media images of beauty and with real-life examples of the beautiful getting preferential treatment, people are beginning to latch on to the idea that, with money, the ideal image can be transposed onto oneself in the hopes of benefiting from the "beauty advantage." The possibility of improving social interactions may indeed be the motivation for many to undergo cosmetic treatments, despite certain drawbacks, such as medical complications and cost. It is plausible to think that people are willing to pay the cost of treatment upfront, in the hopes that they will make their money back down the road when they receive preferential treatment, such as getting that bonus at work, or that coveted promotion over their less-attractive counterpart.
The current cultural ideal of beauty is pervasive; if a person does not fit into the mould of what society says is beautiful, the psychological aspect of being inadequate can negatively affect one's body image. A negative body image has been revealed to be one of the main psychological variables in the decision to undergo cosmetic medical treatments (von Soest, Kvalem, Skolleborg, & Roald 2006). Thompson and Hirschman (1995) state that body image is conditioned by social relationships, cultural ideals, normative prescriptions, and moralistic meanings regarding self-control and discipline. In today's society, the consumer is heavily inspired to be thinner, more toned, and less wrinkled, and to hide imperfections and all deviations of cultural norms of appearance. Our culture and socialization undermine our acceptance of ourselves and our body image. According to the sociocultural theory, people who choose to use cosmetic medical treatments to enhance their appearance may be attempting to increase their self-image or self-perception, improve their social relationships, and increase their probability of success across a variety of social situations.
Both theories discussed have valid, logical arguments regarding the reasons why people might choose to undergo cosmetic medical treatments; however, neither one can stand alone as being the greatest motivator to have cosmetic treatment. The evolutionary theory takes into account the biological aspects of physical attractiveness, and why it exists. However, beauty may be more than skin deep, according to Swami et al. (2007), as nonphysical factors play an important role in attractiveness. Kniffin and Wilson (2004) argue that our ancestors probably related to each other in a small-group setting where physical attributes of the group members were roughly average, and they were familiar with each other's nonphysical attributes (e.g., personality, intelligence), which could have played an important role in mate selection and, therefore, reproduction. Building on this idea, Swami et al. (2007) imply that such a scenario suggests that nonphysical traits may have been important components of interpersonal relations and selecting a mate in human evolutionary history, which directly refutes the evolutionary theory's purely physical standpoint.
There have also been studies refuting specific portions of the evolutionary theory, such as the claim that symmetry equals beauty. Springer et al. (2007) agree that overall symmetry is perceived as attractive across cultures; however, there may be exceptions to this rule, such as moles or "beauty marks" on the face. The further an irregularity, such as a mole, is from the midline, the less it affects perceived attractiveness. Springer et al. (2007) showed that there can be very attractive asymmetries and very unattractive symmetries. The term beauty mark itself supports this idea that certain asymmetrical features can be considered beautiful.
The evolutionary theory is also limiting when it comes to patients who are seeking cosmetic medical treatments clearly for reasons other than reproductive purposes. There is a large population, about 22%, of cosmetic patients who are over the age of 55 and past their reproductive years (American Society of Plastic Surgeons, 2006). These patients cannot be trying to signal their fertility to others by using cosmetic treatments in order to make them look youthful. They may, however, be looking for a companion, so the theory may have some validity in this perspective.
On the other hand, the sociocultural theory does not take into account that humans may be "hardwired" to be attracted to certain characteristics, and places more emphasis on images that are created in the media and societal ideals. However, the issue is complex. Is the media creating these images, or are they merely reflecting our natural evolutionary preferences?
There is another possible motivation that is not accounted for by either theory. From my personal experience as a practicing nurse in a cosmetic surgery clinic, a sentiment that I hear time and time again from my patients is that they have a conflicting sense of their mind-body connection. They feel young inside, but they do not look young on the outside, and they would like to bridge that gap. They often state that using cosmetic treatment helps make them look on the outside how they feel on the inside. I do not know if this statement is used to cover up vulnerability resulting from a patient's true motivation, such as a possibly more embarrassing explanation of having low self-esteem, or if they are truly intrinsically motivated. If the latter is true, then the sociocultural as well as the evolutionary model has no bearing on their impetus for cosmetic enhancement.
The evolutionary and sociocultural theories are not the only two perspectives that seek to explain the desire to alter one's aesthetic appearance. There are other theories that build on, or extend from, the evolutionary theory, for example, the estrogen theory. Draelos (2007) explains that perceived attractiveness is related to an estrogen-rich state. For example, images of beautiful people often have similar characteristics, such as high cheekbones, which is the single most sensitive indicator of an estrogen-rich state and also signals fertility. Without estrogen, Draelos (2007) states that women would have the same angular jawline and cheekbones as a male. In the fertility aspect, it is similar to the evolutionary theory but differs by relating the theory directly to the female sex hormone, estrogen. This brings up an interesting quandary, however. If the estrogen theory is a driving factor in motivations for cosmetic treatments, are treatments such as hormone replacement therapy, common in postmenopausal women, parallel to using cosmetic treatments to bring one's appearance back to the estrogen-rich state? Furthermore, are hormone therapies, such as birth control, antithetic to our human instincts to reproduce? Perhaps this is one situation in which sociocultural influence overpowers our evolutionary instincts. Men who receive cosmetic medical treatments are also not explained by this theory.
Other theories focus more on the psychological aspects of those who undergo cosmetic medical treatments. Some suggest that body image disturbances, such as body dysmorphic disorder (BDD), may play a significant role in many cosmetic patients' psyche (Castle, Phillips, & Dufresne, 2004). It has been shown that between 10% and 15% of all cosmetic patients have underlying BDD (Castle et al., 2004; Metules, 2005).
The theories discussed in this paper serve to assist the healthcare provider in obtaining a deeper understanding of some of the possible motivations for elective cosmetic treatments. Doing so can provide the physician or nurse with insight, and perhaps it may help manage expectations. In terms of underlying psychological illness, it is important for physicians and nurses to watch for signs of BDD when assessing their patients for cosmetic treatment suitability. A word of caution can also be offered. Kreyden (2005) speaks of a disturbing trend resulting from the popularity of cosmetic medical treatments, many physicians who have attended an aesthetic conference or workshop turnaround and offer their patients cosmetic procedures. The danger of this occurrence is twofold: (1) cosmetic dermatology may lose its scientific relevance and (2) patients may be at risk from improperly trained practitioners, physician, or otherwise. Kreyden (2005) finishes by stating that evidence-based medicine should be applied not only in medical procedures but also in cosmetic treatments. Cosmetic medical treatments appear to be here to stay, but why they are here remains a complex and multifaceted topic. Are they really motivated by nature, such as the evolutionary theory suggests, or are we nurtured by our societal and cultural ideals?
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