BPS response to the Health and Care Committee’s call for evidence on the impact of body image on physical and mental health

The BPS is the representative body for psychology and psychologists in the UK, and is responsible for the promotion of excellence and ethical practice in the science, education, and application of the discipline.

As a society we support and enhance the development and application of psychology for the greater public good, setting high standards for research, education, training and knowledge, and disseminating our knowledge to increase public awareness.

With contributions from:

• Dr Deborah Auer, DCPsych (CPsychol),CSAccred.
• Dr Anna Sedda, CPsychol, Associate Professor in Psychology, Heriot-Watt University
• Dr Olivia Donnelly, Consultant Clinical Psychologist at North Bristol NHS Trust
• Professor Andrew Thompson, Consultant Clinical Psychologist, Trustee for Changing Faces and a member of the All Party Parliamentary Group on Skin Disease

For enquiries regarding this this submission, please contact:

Eilidh Wilson, Public Affairs Officer

British Psychological Society
48 Princess Road East Leicester
LE1 7DR

Introduction

1. Both psychological practice and research has clearly demonstrated an observable association between body image and physical and mental health. Issues with self-esteem, shame, stigmatisation and anxiety can lead to negative body image. Further, individuals affected by these issues have high service utilisation in both NHS and private sectors, seeking both mental health and physical health interventions (including cosmetic surgery and aesthetic procedures).

2. Throughout the course of this submission, we will make the following key recommendations:

• The Department for Health and Social Care should work with colleagues in the Department for Digital, Cultural, Media and Sport to ensure that the Online Safety Bill is strengthened in scope so that duties on platforms to take measures to mitigate risk are extended to include exposure to content that is legal but harmful.

• That the Department of Health and Social Care should lead a cross-Government approach working with colleagues in the Department for Education to implement more campaigns within schools where an understanding of the development of body image is a topic that is frequently discussed.

• That frontline staff, including in the NHS and the education sector, need to be up-skilled to better understand body image development, the impact of language of patients, and the diversity of body image conditions and available therapies.

• That public health campaigns need to address the wording used in the media about body image, to help society understand that decisions to focus on beauty are not only driven by internal factors but are strongly influenced by external factors and experience.

• That patients proceeding with cosmetic surgery and aesthetic procedures, from both NHS and private sectors, should have specialised psychological support preoperatively and postoperatively to ensure more realistic expectations for surgery and, hopefully, a better outcome for patients.

What is the relationship between people's perception of their body image and their physical and mental health?

1. There is significant psychological evidence which suggests there is a relationship between discrimination and/or negative reactions of others in relation to appearance and the later development of distress[1]. Further, studies have also shown that weight stigma and weight-based teasing can be associated with greater weight and fat gain[2]- due to an increased likelihood of engaging in unhealthy eating patterns and avoidance of physical activity[3].

2. People with eating disorders may value body image perfectionism more than the norm, which may include being influenced by and orientated towards slim imagery, and develop a tendency to take restraint from eating certain foods, or all foods, to the extremes, at the expense of physical and mental health[4].

3. There is also psychological evidence that indicates that perception of body image can have a detrimental impact on physical health as it can be a deterrent in an individual's choice to engage with certain healthcare treatments. For example, for women considering breast surgery for reducing risk of cancer, there is research which indicates that a key factor in their decision is body image (generally, but especially where the main request relates to symmetrisation i.e. to be symmetrical after the surgery to remove a breast as part of cancer treatment)[5].

How can the Department of Health and Social care and its arms' length bodies work collaboratively across Government to tackle the health impacts of a negative perception of body image?

1. The Department for Health and Social Care should work with colleagues in the Department for Digital, Cultural, Media and Sport to ensure that the Online Safety Bill is strengthened in scope so that duties on platforms to take measures to mitigate risk are extended to include exposure to content that is legal but harmful. Psychology research from the University of Durham has demonstrated a link between exposure to content depicting risky behaviour- including disordered eating- and users' own offline risky behaviour[6]. Additionally, body image can be impacted by extensive screen use, and media fixation with young, slim, attractive people, worsened by social media and manipulation of one's online visual presentation of self[7].

2. The Department of Health and Social Care should also lead a cross-Government strategy and work collaboratively with colleagues in the Department for Education to implement more campaigns in secondary schools that promote a greater understanding of body image development among adolescents. Psychological evidence has shown that behaviours such as conversations among peers that focus attention towards appearance issues, reinforce the importance of appearance and advocating for appearance ideals and frequent appearance-related conversations with friends is associated with elevated body dissatisfaction[8]. Campaigns which challenge prevalent narratives about body in the media and online can help adolescents develop a more realistic understanding of the variety of body types in the real world and promote a greater emphases on health rather than aspiring to an ideal depicted on social media. These campaigns can also raise awareness with adolescents of the potential outcomes of having a negative body image, including increased likelihood of seeking cosmetic procedures, in school settings means we give those seeking these procedures more understanding and informed choice.

3. When it comes to procedures that may cause profound changes to the body, such as risk-reducing breast surgery, the healthcare bodies should work more collaboratively with psychologists by applying psychology within health care settings, and integrating it as part of clinical teams. For instance, psychologists should be embedded in breast care services.

To what extent does people's perception of their body image, and stigma around particular body images, hinder them from accessing NHS services and what could be done to address this? What training is needed about body image for frontline public health staff?

1. Concerns and stigma around body image can deter individuals from seeking out certain NHS services. As previously mentioned, for women considering breast surgery for reducing risk of cancer, there is research which indicates that a key factor in their decision is body image (generally, but especially where the main request relates to symmetrisation i.e. to be symmetrical after the surgery to remove a breast as part of cancer treatment)[9].

2. Frontline staff, including in the NHS and the education sector, need to be up-skilled to understand how one develops a body image and the various factors that can contribute to body image development. This will then help them to understand how important the language they use impacts on the experiences patients have especially those with a negative body image. Terms like 'nip and tuck', 'boob job', 'nose job', and 'freshening up' (for facelift and eyelid surgery) seem rather benign, but what they do is minimise the perceived risks of surgery so that individuals are unaware of the invasive nature of some procedures[10].

3. Psychological evidence-based training, aimed at health care professionals and people working in the fitness and nutrition industries, which covers the impact of weight stigma and outlines best practice, would improve clinical practice and service delivery. This should be provided by health education bodies as part of undergraduate training as well as being offered by professional bodies as part of continuing professional development (CPD) and vocational training. Health professionals delivering weight management initiatives should have regular supervision sessions with a practitioner psychologist to increase their awareness of how mental health conditions and psychological factors can contribute to obesity and the success of treatment. This would also help professionals understand and address their own unconscious biases within their practice, language and behaviour[11].

4. Public Healthcare staff should also be provided with further training about body image problems related to visible difference in appearance, due to visible congenital conditions as well as acquired disfiguring conditions such as burns and diseases such as skin conditions. Furthermore, more service providers should be trained in therapies which have proven to be effective in supporting this group, such as Acceptance and Commitment Therapy (ACT)[12].

5. There should also be increased training and awareness of Body Integrity Identity Disorder (BIID)[13], which is a condition in which individuals experience an intense desire for amputation of a healthy limb. This is important in order to prepare professionals to identify and support individuals affected by the condition and address the stigma surrounding the condition so that more can be understood on the condition itself and effective treatments and support can be developed.

How best can public health campaigns tackle negative perceptions of body image?

1. In the case of public health campaigns targeting weight management, it could be more effective to avoid framing obesity as a simple 'choice' and using psychological evidence and expertise to design such campaigns.  Body image and obesity should be approached with the "biopsychosocial model", an inter-disciplinary model that looks people within the context they live in- their social influences and networks, cultural and societal norms, as well as the physical environment and psychological factors. By focusing attention on the determinants of behaviour, and not simply the behaviour itself, biopsychosocial approaches to obesity integrate the many complex influences on obesity within a single framework.

2. Public health campaigns can raise awareness about how requests for cosmetic procedures are not just an exercise in freedom of choice, but a complex interdependent decision. Evidence demonstrating the scale of the pressure on women to conform to society's ideal standards of beauty makes it doubtful whether it is truly a freedom of choice to have cosmetic surgery, or perhaps more a reflection of society's dominance on how women's and, more recently, men's bodies should look[14]. Campaigns need to address the wording that is out in the media about body image, helping society understand that decisions to focus on beauty are not only driven by internal factors but strongly influenced by external factors and experience.

To what extent are people who have a negative body image drawn to cosmetic procedures, and how do cosmetic procedures affect their body image?

1. Higher anxiety means levels can make an individual more vulnerable to being negatively affected by beauty ideals portrayed in the media, and to negative cultural, parental and peer influences[15]. Research indicates that there is overwhelming pressure on women and more recently men, to conform to a particular beauty ideal that is portrayed by the media and magazines[16]. Additionally, an individual with low self-esteem is more susceptible to being impacted by conversations with friends and family about their body and the media's normalisation of cosmetic surgery[17]. These factors then have a further impact by causing a favourable attitude towards cosmetic procedures[18] and may undermine the extent to which cosmetic procedures are truly a reflection of freedom of choice.[19]

2. Marketing campaigns within the cosmetic industry which portrays procedures as something that helps people love themselves again can unconsciously tap into the individual's shame, and cause the individual to feel that cosmetic procedures are the way in which to change what it is they feel ashamed of[20]. The risks of aesthetic procedures are also often minimised by the way it is portrayed in the media. This causes patients to think it may be a 'quick fix' to more deep-seated psychological issues[21]. 

3. It is important to differentiate between body shame and body dissatisfaction. Body shame is about self-worth and will often be described by patients in terms of inferiority, embarrassment, vulnerability and feeling inadequate and is about more than just dissatisfaction with a particular body part[22]. A patient with a high level of body shame is unlikely to be a suitable candidate for cosmetic surgery. The patient's expectation from surgery is likely to be more invested in shifting the shame than the actual physical outcome of surgery.

Is there sufficient support and advice for people who are considering cosmetic procedures?

Clinicians need to have a better understanding of the motivation of this patient group to be able to offer the appropriate psychological support. Awareness also needs to be raised with surgeons, to help them better understand how the surgery they perform can have a psychological impact. Patients proceeding with cosmetic surgery could benefit from having specialised psychological support preoperatively and postoperatively. This would contribute to more realistic expectations for surgery and, hopefully, a better outcome for the patient[23].

Conclusion

The psychological evidence informs us that body impact can impact both physical and mental health. Physical health can be impacted as a result of disordered eating and aversion from physical exercise, or because individuals can be discouraged from important health treatment due to concerns about its impact on body image. Additionally, there are identifiable links between body image and mental health issues such as experiences of distress and low self-esteem. There is also a wealth of psychological evidence which suggests that those with a negative body image may be more drawn to cosmetic surgery.

The BPS believes that there are a number of measures that can be taken to mitigate the impact of body image on health, including: ensuring that those working in the NHS and in education are equipped with the information they need to understand body image development, the impact of language of patients, and the diversity of body image conditions and available therapies.

With respect to cosmetic treatments, the BPS believes that: public health campaigns need to address the wording that is out in the media about body image; and that patients proceeding with cosmetic surgery should have specialised psychological support preoperatively and postoperatively. This will create better outcomes for those who receive cosmetic treatments.

References

[1] The All Party Parliamentary Group on Skin (2020). Mental Health and Skin Disease. Accessed 18/01/2021, 

[2] Schvey, NA, Marwitz, SE, Mi, SJ, et al. (2019) Weight-based teasing is associated with gain in BMI and fat mass among children and adolescents at-risk for obesity: A longitudinal study. Pediatric Obesity.

[3] BPS (2019) Psychological perspectives on Obesity: Addressing policy, practice and research priorities.

[4] BPS (2021) Clinical Psychology Forum Special Issue: Eating Disorders; Reid & Wicksteed Beyond eating disorders: Towards a formulation-based approach

[5] BPS (2018). Guideline for the role of practitioner psychologists in the assessment and support of women considering risk-reducing breast surgery. Leicester: BPS.

[6] Branley & Covey (2017) Is exposure to noline content depicting risky behaviour related to viewers' own risky behaviour offline?

[7] Pauli, D. (2019). Body cult, pressure of beauty, obsession with slenderness. Effects on the physical and mental health of contemporary women. Gynakologe, 52(3), 237–244. 

[8] Auer, D.N. (2018) The experience of female patients seeking elective rhinoplasty surgery: A narrative inquiry. Doctor of Counselling Psychology and Psychotherapy by Professional Studies. Middlesex University and Metanoia Institute.

[9] BPS (2018). Guideline for the role of practitioner psychologists in the assessment and support of women considering risk-reducing breast surgery. Leicester: BPS.

[10] Sharp, G., Tiggemann, M. and Mattiske. J. (2014) The role of media and peer influences in Australian women's attitudes towards cosmetic surgery. Body Image Journal, 11, pp. 482-487.

[11] BPS (2019) Psychological perspectives on Obesity: Addressing policy, practice and research priorities.

[12] https://actnow-erasmusproject.eu/training-resources/

[13] Sedda A. Body integrity identity disorder: from a psychological to a neurological syndrome. Neuropsychol Rev. 2011

[14] Wijsbek, H. (2000) The pursuit of beauty: the enforcement of aesthetics or a freely adopted lifestyle? Journal of Medical Ethics, 26, pp.454–458

[15] Hardit, S.K. and Hannum. J.W. (2012) Attachment, the tripartite influence model, and the development of body dissatisfaction. Body Image, 9, pp.469-475

[16] Auer, D.N. (2018) The experience of female patients seeking elective rhinoplasty surgery: A narrative inquiry. Doctor of Counselling Psychology and Psychotherapy by Professional Studies. Middlesex University and Metanoia Institute.

[17] Menzel, J.E., Sperry, S.L., Small, B., Thompson, J.K., Sarwer, D.B. and Cash, T.F. (2011) Internalization of Appearance Ideals and Cosmetic Surgery Attitudes: A Test of the Tripartite Influence Model of Body Image. Sex Roles Journal, 65, pp.469-477.

[18] Ibid

[19] Wijsbek, H. (2000) The pursuit of beauty: the enforcement of aesthetics or a freely adopted lifestyle? Journal of Medical Ethics, 26, pp.454–458

[20] Northrop, M.J. (2012) Reflecting on Cosmetic Surgery: Body image, shame and narcissism. London: Routledge.

[21] Auer, D.N. (2018) The experience of female patients seeking elective rhinoplasty surgery: A narrative inquiry. Doctor of Counselling Psychology and Psychotherapy by Professional Studies. Middlesex University and Metanoia Institute.

[22] Constantian M.B. Childhood Abuse, Body Shame, and Addictive Plastic Surgery: The Face of Trauma. New York and London; Routledge, 2019

[23] Auer, D.N. (2018) The experience of female patients seeking elective rhinoplasty surgery: A narrative inquiry. Doctor of Counselling Psychology and Psychotherapy by Professional Studies. Middlesex University and Metanoia Institute.