Motivation and emotion/Book/2014/Cosmetic surgery motivation

Case study
My name is Roxy and I am a 27 year old woman. I have spent over $80,000 to look 'more attractive'. I have had four rhinoplasties (nose jobs), my forehead shortened (facelift), two rounds of very expensive (and extremely painful) cosmetic dentistry, my  cheeks augmented  (made more pronounced), countess  botox   and collagen filler procedures and countless laser and peel procedures. I know the cosmetic surgery industry inside out and could rattle off the best doctors in Australia for most procedures and the cost and physical benefits involved.

I have always felt like the motivation behind why I chose to undergo these procedures was something that I needed to do. I feel as though I have had to undergo these procedures so I can be the person I am on the inside. To me this motivation is logical. I also know that the motivation to undergo these procedures is not exactly 'normal' and would probably be behaviour motivated by unhealthy mental health. I compare myself to others constantly and before undergoing these procedures, I used to avoid public situations because I felt I was unattractive and unworthy.

At the end of this chapter we will revisit this case study. When reading this chapter, keep in mind Roxy's story and see if you can pick the motivation types that apply to her situation.

Overview
One of the major aims of this book it to help you, the reader, better understand and improve your motivational life. With this in mind, the aim of this chapter is help you understand the motivations that may drive an individual (or even yourself) to seek out and to undergo cosmetic surgery. As a result of understanding these motivations, it is hoped that your motivational life may improve.

In this chapter, you can expect to:
 * Understand cosmetic surgery and its history
 * Understand how being considered attractive or unattractive could impact your life
 * Refresh your knowledge on the basic principals of motivation (if you have skipped to this chapter)
 * Discover the different motivations which may drive an individual to seek and undergo cosmetic surgery
 * Understand when undergoing plastic surgery may be right, or not right for you

What is cosmetic surgery
Cosmetic surgery is a medical discipline focused on enhancing the physical appearance of a person (American Board of Cosmetic Surgery, 2014) to increase self-esteem and confidence (Ericksen & Billick, 2012). As a sub discipline of plastic surgery (along with hand surgery, reconstructive surgery, trauma surgery and congenital defect repair (American Board of Cosmetic Surgery, 2014), cosmetic surgery encompasses both surgical and non surgical procedures.

Australian statistics are currently not collected on cosmetic surgery rates (Australian Society of Plastic Surgeons Inc., 2014), however in 2013, over 11 million surgical and nonsurgical cosmetic procedures were performed in the United States of America (The American Society for Aesthetic Plastic Surgery, 2013). The top five surgical procedures were liposuction followed by  breast augmentation,  blepharoplasty,   abdominoplasty and lastly  rhinoplasty (The American Society for Aesthetic Plastic Surgery, 2013). These figures, reported by members of the American Society of Plastic and Reconstructive Surgeons (ASPRS) is an estimation of the figure, as cosmetic surgery can also be performed by general surgeons and doctors from other medical areas (Sarwer, Wadden, Pertschuk, & Whitaker, 1998).



History of cosmetic surgery
Western cosmetic surgery was first described in American literature around the late 1800s, when papers such as “The Deformity Termed Pug Nose, and Its Correction by a Simple Operation”, were published to describe cosmetic rhinoplasties (Rogers, 1971). Before regulation early procedures were performed by ‘quacks’ and others who advertised in newspapers (Rogers, 1971).

During the world wars, large numbers of soldiers needed reconstructive surgery and through this avenue, surgeons greatly developed reconstructive techniques, which were applied to the cosmetic domain (Costhetics, 2013). The prosperity of post-World War II, coupled with the more readily available media of movies and television helped to influence the modern era of cosmetic surgery (Donohoe, 2006). Advances in technology have made cosmetic surgery safer, less invasive, lower cost and less recovery times (Furnham & Levitas, 2012)

Why cosmetic surgery?
Why is it that 11 million people last year in the United States of America had surgical or non surgical cosmetic surgery? Given the increase in popularity of cosmetic surgery (The American Society for Aesthetic Plastic Surgery, 2013). What are the motivations behind these behaviours? Are certain people driven to undergo cosmetic surgery because they suffer from low self-esteem or a more serious psychological illness like Body Dysmorphic Disorder? Western culture is a society that places an importance on beauty. This beauty is good stereotype, theorises that attractive people are perceived and treated more positively than those who are considered less attractive (Mahajan, 2007). Let us look at an example that should get you thinking about how you would react two to different people. How would you react if the female in Figure 3. was standing next to you on a train? What would your perceptions of this person be? Would you act differently if instead the person in Figure 4. was standing next to you on a train and what would your perceptions of the person in Figure 4. be? You are most likely to have said that the person in Figure 3. was more attractive than the person in Figure 4. (this is however dependant on your culture, gender and background). It is probably also likely you said that you wouldn't have treated these people any differently, however research indicates that the answer to this question is that you would.

Physical appearance is one of the first pieces of information that guides social interaction with others (Sarwer, Wadden, Pertschuk, & Whitaker, 1998). Over the last few decades, researchers have found that people link physical attractiveness to positive factors like intelligence and desirability (Sarwer, Wadden, Pertschuk, & Whitaker, 1998). Whilst there is evidence to suggest that we are guided by innate symmetry and evolutionarily adaptive preference of beauty (Markey,& Markey, 2010), societal norms dictate the standards by which appearance, physicality and grooming is measured (Mahajan, 2007).

How do we measure physical appearance?
To get a measure of physical attractiveness, researches most commonly use judges, with each judge asked to provide a rating of physical attractive of a person. For example a judge may be asked 'on a scale of 1 to 10 how attractive do you find this person?'. These rating are then averaged out between judges to give an attractiveness score (Feingold, 1992). These rating are then used to compare attractiveness to the factor(s) being measured.

To succeed?
Many academics have researched physical attractiveness and the advantages it may offer to individuals in society. For example, a longitudinal study (Biddle & Hamermesh, 1998) of graduating lawyers in the 1970s, looked at attractiveness ratings (averages scores of beauty assessments) as they grew and developed in their industries. Those lawyers with higher attractiveness scores earned signifigantly more than those with lower scores, in the proceeding 5 year period. Similarly, a recent study (Rule & Ambady, 2008) which looked at the link between attractiveness of chief executive officers and the the earnings of their companies, researchers found that  chief executive officers rated higher in attractiveness measures earned more profit for their companies. Some studies even suggest that unattractive criminals receive longer penalties then their more attractive counterparts (Frevert & Walker, 2014). Even though these studies are focused on specific populations, can not be generalised and are not making casual conclusions about attractiveness, is its still interesting, never the less, to understanding the link between attractiveness and success and how being attractive may be an advantage.

For psychological well-being?
Does physical attractiveness contribute to well-being? You may expect that the values you hold would lead you to believe our inner qualities and not just our appearance cause life satisfaction (Diener, Wolsic, & Fujita, 1995). Umberson & Hughes (1987), looked at the relationship between an individual’s physical attractiveness and psychological well being. Psychological well being was measured on affect, satisfaction and strain dimensions. The research found that higher attractiveness scores were significantly linked with lower stress and higher life satisfaction. A more recent study found that among college students, physical attractiveness only had a marginal effect (improvement) on happiness and life satisfaction (Diener, Wolsic, & Fujita, 1995).

What is motivation?
To be motivated means to be moved to do something and when someone is energised or activated towards an end (Ryan & Deci, 2000). Most theories view motivation on a spectrum, from very little to a lot of motivation, which means they fall into a unitary category. But reflect on the construct of motivation shows that people have different amounts, but also different kinds of motivation (Ryan & Deci, 2000). As we will see in the remainder of this chapter, the motivation behind a person seeking cosmetic surgery is complex, from very little to a lot of motivation and even when motivation overlaps between factors.

Extrinsic motivation vs Intrinsic motivation


Extrinsic and extrinsic motivations are the basic split in motivation types. Intrinsic motivation, means someone is driven to do something because they are inherently interested or enjoy it (Ryan & Deci, 2000). More specially it means that a person is performing or engaging in a behaviour for its own sake rather than to obtain an external reward (Cherry, 2014). Extrinsic motivation means that someone is doing something because it leads to a distinct outcome (Ryan & Deci, 2000). More specifically extrinsic motivation occurs when we are motivated to perform or engage in a behaviour to earn a reward of avoid a punishment (Cherry, 2014). (see oppernant and classic conditioning for more information)

It could be argued that cosmetic surgery seeking behaviour is always going to be driven by extrinsic motivation. The person undergoing the cosmetic surgery is seeking cosmetic surgery because they are avoiding punishment, for example the effects of low self esteem, or because they are seeking rewards, for example improved social status. For someone to be intrinsically motivated to undergo cosmetic surgery would mean they would enjoy the act of undergoing cosmetic surgery without seeking the rewards that go with it.

Maslow's hierarchy of needs
Maslow believed that we are motivated to achieve certain needs and when one of those needs is for fulfilled, we seek to fulfil the next one and so on (McLeod, 2007). Maslow proposed a five stage hierarchical model of needs. They are made up of physiological, safety and security, belongingness, esteem, and self-actualisation (Lester, 2013). The lower needs (for example eating) are more powerful than higher needs (for example having high self esteem).Whilst the theory helps us to understand basic ideas of need motivations it does not take into account the importance of factors to a person and how this may affect the motivational hierarchy. For example to one person, belongingness might be lower down the pyramid than safety and security.

Our self-concept
Our self-concept is just that, the concept of ourselves and who we are. Our self-concept is a collection of images, self-schemas, prototypes, theories, goals or tasks which are now understood to be dynamic and a significant regulator of behaviour (Markus, 1987). Who am I? Am I tall, short, thin, fat, blonde or bad at writing chapters for books? Our self concept also includes the ongoing process of perceiving and organisation information about ourselves (Oosterwegel & Oppenheimer, 2013)

Self-enhancement
The self-enhancement motive is a fundamental part of human nature and involves taking a favourable view of one-self through self-evalution (Sedikides & Gregg, 2008). Self-enhancement is made up of an observed effect, An ongoing process, A personality trait, an underlying motive. There are four levels of self-enhancement:


 * Self-enhancement through self advancing or self protecting. This is done through either changing the positivity or reducing the negativity of the self concept.
 * Self-enhancement either publicly or privately. Self-enhancement publicly involves favourable self presentation. Self-enhancement privately involves more internal psychological processes.
 * How much a particular factors matters most.
 * Self-enhancement can be candid or tactical. Candid self-enhancement is seizing an opportunity for immediate self-advancement, where as tactical self-enhancement forges emendate advancement for delayed self-enhancement (Sedikides & Gregg, 2008).



Self-esteem
Self-esteem is an individuals subjective evaluation of that individuals worth (positive or negative) (Orth & Robins, 2014). The construct of self-esteem does not always reflect the individuals abilities or talents or evaluation from others. It is generally conceptualised as the feeling that one is ‘good enough' (Orth & Robins, 2014).

Self-discrepancy theory
Self-discrepancy theory is one of the major theories that is researched in reference to the motivations for cosmetic surgery. The basic idea of self-discrepancy is focused on the difference between the acutal self, the attributes that you or someone else believes you actually possess, and the ideal self of a individual, the attributes that you or someone else believes you should ideally posses (ideal self) or the attributes that you ore someone else believes you ought to possess (ought self) (Higgins, 1987). Similar to dissonance theory, which suggests that psychological discomfort arises when an individual holds incompatible and conflicting beliefs, self discrepancy theory hypothesises that we are motivated to reach a state where our self-concept matches our personally relevant self-guides (Higgins, 1987). Our self-guides are made up of our idea self and our ought self.

The discrepancies between the self and the self-ideal is said to relate to different types of emotional issues (Higgins, 1987). The differences types of emotional issues stem from how much the discrepancy between the actual and ideal mean to you (based on your experiences).

Taylor & Pentina, (2009) examined the relationship between self-discrepancy and young women, aged 17 to 29 years old, wanting to undergo cosmetic surgery. Through self-report, Taylor & Pentina, (2009), found that a perceived difference between the individuals actual and ideal-self can influence the choice to undergo cosmetic surgery procedures to cope and reduce discomfort associated with the self-difference.

Social comparison theory
Social comparison theory is focused on when we compare ourselves to others, when we are driven to self evaluate and to use that self evaluation to compare ourselves to others (Festinger, 1954). The theory detailed possible (untested) rules (also called hypothesises) to go with the theory. For example if someone is quite different from you, you are less likely to compare yourself to that person (Festinger, 1954). There are a number of different areas of research which focus on the psychosocial motivations behind cosmetic surgery.

Popular media
The media plays a large role in most of our lives. We spend a significant amount of time in front of the television or on the internet, so its not suprosing that media may have an affect on our motivation to undergo cosmetic surgery. Furnham & Levitas (2012) looked at the effect of (general) media on motivations for cosmetic surgery by asking participants questions such as ‘In general, how often would you say you currently read magazines’. The study found that those who consumed more media believed that cosmetic surgery brought more benefits but the consumption of media did not drive the increase of the likelihood of undergoing cosmetic surgery.

Markey, & Markey (2010) investigated the effects of watching reality television focused on cosmetic surgery, found that randomly assigned participants with an average age of 19 years, who watch the reality television show focused on cosmetic surgery, were more likely to report the desire to get cosmetic surgery. This may be because reality television shows suggest that dramatic physical appearance change will be the catalyst for positive dramatic changes in life (Markey, & Markey, 2010)

Social and cultural conformity
From data collected in the 40s and 50s, Macgregor (1967) looked at the motivations of 89 New York residents undergoing a rhinoplasty (nose job). The study found that the participants viewed the nose as a distinctive mark of identity and when the nose represented ethnic or religious stereotypes, the patients wanted to get rid of their ethnic visibility to look more American. Patients were also emotionally affected by reactions of others to their nose, such as staring and remarks and believed that having the surgery would help them to conform (not being identified as a foreigner) and as a result be more socially successful.

Bullying and stigmatisation
Bullying and teasing are often cited as motivational factors for a person getting cosmetic surgery (e.g Markey & Markey, 2009). A recent Australian study (Jackson, Dowling, Honigman, Francis & Kalus, 2012) which looked at the prevalence of bullying and teasing in 459 patients undergoing elective cosmetic surgery and dentistry, found that patients reported high rates of appearance-related teasing and bullying and had lower levels of general psychological functioning.

Bullying case study
Nadia is a 14 year old from Georgina in the United States. She has been bulled at school and has undergone plastic surgery to stop the bullying from her class mates. "When Nadia Isle returns to school she won't just be toting a new bag, or uniform. The high school pupil is preparing to return to classes with a new-look nose, chin and ears after undergoing plastic surgery, aged 14" (Goddard, 2012). "The teenager from Georgia, who has been haunted by taunts of "Dumbo" and "Elephant Ears" since the age of six, had the surgical treatment in an attempt to curtail the abuse and end her misery" (Goddard, 2012).

 American teenagers resort to plastic surgery to beat bullies 



Psychopathology
The use and definition of psychopathology is often debated (Bergner, 1997). However, speaking in general terms, psychopathology can be described as the study of mental illness. It seems obvious that an individual seeking cosmetic surgery will likely be affected by psychological issues, considering the goal of cosmetic surgery is to change the appearance and or physical attribute of a individual and as as result change the way the individual perceives that particular physical attributive (Ericksen & Billick, 2012) and cosmetic surgery populations often have higher levels of psychothology (e.g, Mulkens, Bos, Uleman, Muris, Mayer & Velthuis, 2012; Vargel & Uluşahin, 2001).

Extreme case study
When you think of cosmetic surgery, you may also think of the extremes associated with it and those individuals who may take it to the 'next level'. Chelsea Charms has a 164XXX breast cup. Why? Chelsea "wanted to be a professional exotic dancer, "It was a way to get myself out there and noticed. It’s can be powerful and beautiful. It’s a girlyy feminine thing. You don’t want to feel like everyone else." (Chelsea Charms). Watch this video interview with Chelsea and see if you can spot the motivations behind why she underwent cosmetic surgery and now has a 164XXX breast cup.

 Chelsea Charms Interview (8.42 mins.) 

Body dysmorphic disorder
Body Dysmorphic Disorder is classified as the preoccupation with an imagined or exaggerated defect in physical appearance (American Psychiatric Association, 2000). An individual with Body Dysmorphic Disorder either imagines the defect in physical appearance, or, if a slightly physical anomaly is present the individuals concerns are excessive (American Psychiatric Association, 2000). Suffers often check their appearance in reflective surfaces, for example building windows and mirrors. The preoccupation with appearance is debilitating and causes significant distress to the individual. In cosmetic surgery and dermatology, reported rates of Body Dysmorphic Disorder are between 6% to 15% (American Psychiatric Association, 2000).

 Too ugly for love: body dysmorphic disorder (56.22 mins.)  "They say mirrors never lie, what happens when they do?"

The rate of Body Dysmorphic Disorder sufferers seeking cosmetic surgery is quite high. Body Dysmorphic Disorder suffers often seek cosmetic surgery treatments to improve their “flawed" appearance. A study (Biraben-Gotzamanis, Aouizerate, Martin-Guehl, Grabot & Tignol, 2009) which looked at Body Dysmorphic Disorder and cosmetic surgery patients over the 5 years post surgery, found that the majority of patients in the study received the cosmetic surgery procedures that they wanted and the patients were characteristically younger than the average cosmetic surgery patient. The study also found that the level of satisfaction with surgery at the 5 year follow up in Body Dysmorphic Disorder sufferers was high. However, the vast majority of literature indicates that cosmetic surgery will not help a Body Dysmorphic Disorder suffers and may even make the Body Dysmorphic Disorder worse following surgery (Veale, 2000).

Can cosmetic surgery improve your life?
Can cosmetic surgery improve your life, or can it negatively affect your life? in this chapter we have discussed the motivations that may drive a person to undergo cosmetic surgery, however we are yet to discover if these motivations actually serve a purpose. Does have bigger boobs or a smaller nose really help you to have better body image, be happier and healthier as a person?

In the short term, von Soest, Kvalem, Roald & Skolleborg (2009) compared body image, self-esteem, psychological problems ratings before surgery and 6 months after surgery in 160 people who underwent various types of body surgery. The results showed that patients body image evaluation improved after cosmetic surgery; likewise, self-esteem scores increased, even though the improvement was small in size. The increase in body image evaluation was such that, while being less satisfied with. The study also found, it didnt matter what type of body surgery (not facial) was completed, the change in ratings were the same. This study outines the shorter term effects of surgery not nessisiarly  the impacts that surgery could have over a life span. What happens long term? von Soest, Kvalem, Skolleborg & Roald (2011) looked at the same data set five years post surgery and found improvements in both general appearance satisfaction (related to the body part operate on). A small increase in self-esteem was also observed. Based on these studies, we can not concluded with any certainly that cosmetic surgery has a positive influence. To make these conclusions, research needs be completed across populations in experimental conditions and significant replicated.

As noted in Body Dysmorphic Disorder section, the vast majority of literature indicates that cosmetic surgery will not help a Body Dysmorphic Disorder suffers and may even make the Body Dysmorphic Disorder worse following surgery (Veale, 2000).

The medical field is interested in motivations behind a patient seeking cosmetic surgery to, improve patients outcomes and to screen patients for metal illness and prevent them from undergoing cosmetic surgery because they may be unhappy with the outcomes. In this regard it is also important for cosmetic surgeons to understand the motivations of patients so that positive outcomes and patient satisfaction can be obtained or where patients are potentially vulnerable, to ensure cosmetic surgeons meet ethical obligations (Brunton et al, 2014).

Revisiting the chapter case study
Lets revisit the case study involving Roxy. Do you have any ideas about the motivations that may be driving her to undergo cosmetic surgery?
 * 1) Roxy seems to be motivated by social comparison. Roxy compares herself to others and uses the term unworthy to describe herself before surgery.
 * 2) Dysmorphic types of symptoms appear to be present. Considering the amount of surgery Roxy has undergone and the age she is. Roxy also avoided public situations prior to surgery.

Did you come up with any other motivations?

Conclusion
Reflection on the content discussed in this chapter highlights just how complex motivation can be. However, at its core, motivation is the drive that directs behaviour at varying degrees.

By now, you should have an understanding of the general motivations in cosmetic surgery seeking behaviour and even if some of these motivations apply to you. It seems our social environments provides the strongest motivational factors for cosmetic surgery seeking behaviour. Human nature dictates we will compare ourself to others in order to (amongst other things) develop our self-concept and in comparing ourselves to others, we may discover things we are not happy with.

If you are thinking about undergoing cosmetic surgery, is it important that you recognise that certain motivations. For example, if you suffer from Body Dysmorphic Disorder or symptoms, may result in you being unsatisfied with surgery outcomes. Alternatively if you are undergoing cosmetic surgery purely to boost self esteem, it could yield positive outcomes.

Future chapter ideas
Given the popularity of cosmetic surgery, the following chapters could be explored in future motivation and emotion books.
 * The difference between male and females in cosmetic surgery seeking behaviour
 * The motivation behind plastic and reconstructive surgery
 * The motivation behind breast augmentation (or other specific surgery)
 * The motivation behind undergoing transgender surgery
 * Emotion and cosmetic surgery seeking behaviour