Negative plastic surgery effect: Women seeking plastic surgery were perceived less favorably than those planning to complete control activities across all outcome variables (warmth, competence, morality, & humanness)

Bonell S, Murphy SC, Griffiths S (2021) Under the knife: Unfavorable perceptions of women who seek plastic surgery. PLoS ONE 16(9): e0257145, Sep 7 2021. https://doi.org/10.1371/journal.pone.0257145

Abstract: Plastic surgery is growing in popularity. Despite this, there has been little exploration to date regarding the psychosocial consequences of seeking plastic surgery. Our study investigated how women seeking plastic surgery are perceived by others. We presented a random sample of 985 adults (men = 54%, Mage = 35.84 years, SDage = 10.59) recruited via Amazon’s Mechanical Turk with a series of experimental stimuli consisting of a photographed woman (attractive versus unattractive) and a vignette describing an activity she plans to engage in (plastic surgery versus control activity). Participants rated stimuli on perceived warmth, competence, morality, and humanness. We ran linear mixed-effect models to assess all study hypotheses. There was a negative plastic surgery effect; that is, women seeking plastic surgery were perceived less favorably than those planning to complete control activities across all outcome variables (warmth, competence, morality, and humanness). These relationships were moderated by physical attractiveness; while attractive women planning to undergo plastic surgery were perceived less favorably than attractive women planning to engage in control activities, perceptions of unattractive individuals remained unchanged by plastic surgery status. We theorized that empathy toward unattractive women seeking plastic surgery mitigated the negative plastic surgery effect for these women. In sum, our results suggest that perceptions of attractive women are worsened when these women decide to seek cosmetic surgery. Perceptions of warmth and competence have implications for an individual’s self-esteem and interpersonal relationships, while perceptions of morality and humanness can impact an individual’s ability to fulfil their psychological needs. As such, we concluded that attractive women seeking plastic surgery are potentially subject to experience negative psychosocial outcomes. Future research ought to examine whether perceptions and outcomes differ for women seeking reconstructive plastic surgery (versus cosmetic plastic surgery) and whether they differ across different types of surgeries (i.e. face versus body).

Discussion

Hypothesis 1 (primary hypothesis): The negative plastic surgery effect

The present study built on existing literature by examining whether women seeking plastic surgery are systematically perceived differently to other women. We hypothesized that there would be a negative plastic surgery effect; that is, women planning to have plastic surgery would be considered less warm, competent, moral, and human than those planning to complete control activities. Results largely supported this hypothesis. Importantly, this study was the first of its kind in which perceptions of women planning to undergo plastic surgery were explored (where focus has previously been on perceptions of women who had already undergone plastic surgery). As such, the present study demonstrates that negative attitudes toward plastic surgery extend specifically to plastic surgery itself, and not just to its associated outcomes; that is, negative attitudes toward plastic surgery are not dependent on how women look or feel after surgery, but rather pertain simply to the decision to undergo plastic surgery in the first place. Implications for women seeking plastic surgery are discussed below.

Low warmth and competence: A recipe for contempt.

The Stereotype Content Model proposes that we form impressions of others by assessing them across two fundamental dimensions: warmth and competence [38, 54]. In this model, individuals are perceived as belonging to one of four quadrants: High Warmth-Low Competence, High Warmth-High Competence, Low Warmth-High Competence, or Low Warmth-Low Competence. Correlational and experimental evidence has demonstrated that the way in which people relate to members of each quadrant is unique [54]. For instance, the Low Warmth-Low Competence quadrant is said to house ‘free-loaders’ who induce contempt [37, 38]. In line with our hypothesis, plastic surgery stimuli were considered both less warm and less competent than non-plastic surgery stimuli in the present study. As such, we infer that by choosing to undergo plastic surgery, women might be subject to contempt. In work contexts, receiving contemptuous feedback has been associated with decreased self-esteem and increased interpersonal aggressiveness toward colleagues [55]. Likewise, feelings of contempt are one of the primary predictors of marital breakdown [56, 57]. As such, women seeking plastic surgery (and, by extension, inducing contempt) may face implications both interpersonally and professionally.

Immorality, dehumanization, and psychological needs.

Results indicated that plastic surgery stimuli were rated lower on morality and humanness traits than non-plastic surgery stimuli, supporting our hypothesis. Literature has suggested that ‘feeling moral’ ought to be categorized as a basic psychological need. Specifically, Prentice and colleagues [58] found that having a positive perception of one’s own morality was uniquely predictive of wellbeing over and above the effect of fulfilling traditional psychological needs (i.e. autonomy, relatedness, and competence). In line with socialization theory (whereby the beliefs of those around us heavily inform our own), we induce that women considering plastic surgery may struggle to ‘feel moral’ if others perceive them to be morally questionable [59]. In turn, they may experience worsened wellbeing relative to if they were not seeking plastic surgery. Similarly, our results suggest that plastic surgery is dehumanizing. While existing literature has extensively explored the motivations preceding dehumanization, relatively less attention has been paid to the consequences of dehumanization for victims. That said, there is some evidence to suggest that being dehumanized negatively impacts one’s ability to meet four psychological needs: perceived control, meaningful existence, sense of belonging, and self-esteem [45]. Further, dehumanized people may experience less empathy from others and be targets for aggression [46]. Therefore, we conclude that dehumanized plastic surgery recipients may face negative psychosocial outcomes.

Hypothesis 2: Justice sensitivity and disgust sensitivity as moderators for the negative plastic surgery effect

Beyond simply establishing the existence of a negative plastic surgery effect, the present study also sought to explain for whom this effect was strongest. Specifically, we hypothesized that the negative plastic surgery effect would be greater for participants higher in justice sensitivity and disgust sensitivity; that is, those more sensitive to injustice and disgust would perceive women intending to have plastic surgery less favorably. This hypothesis was not supported by results. Firstly, contrary to existing literature, these findings do not support the theory that the negative plastic surgery effect is driven by concerns pertaining to recipients reaping ‘unearned’ rewards from plastic surgery (i.e. the concern that plastic surgery is ’cheating’) [11]. Further, also in contrast with existing literature, these findings do not support the theory that the negative plastic surgery effect is driven by stigmatization toward individuals with non-normative bodies [31, 33, 60, 61]. We note, however, that in the present study, stimuli described as having had plastic surgery did not necessarily look non-normative (i.e. they did not look different to control stimuli). As such, we cannot definitively conclude that perceptions of disgust do not drive the negative plastic surgery effect in cases where women have visibly undergone surgery (e.g., they look ‘artificial’); rather, only in cases where plastic surgery status becomes known via vignette.

Hypothesis 3: ‘What is beautiful is good’

Existing literature demonstrates that the social consequences of being attractive are overwhelmingly positive [22–26]. As such, we hypothesized unattractive stimuli would be perceived as less warm, competent, moral, and human than attractive stimuli. This hypothesis was supported by results. These findings contributes to an extensive and growing body of literature that demonstrates that ‘what is beautiful is good’.

Hypothesis 4: Exploratory hypotheses

Hypothesis 4a.

Next, we assessed the exploratory hypothesis that the negative plastic surgery effect would be moderated by patient attractiveness; that is, we examined whether attractive and unattractive women planning to have plastic surgery were both subject to similar negative plastic surgery effects. Results indicated that the negative plastic surgery effect applied exclusively to attractive plastic surgery recipients. To elaborate, person perception for unattractive individuals remained unchanged by plastic surgery status (e.g., an unattractive woman planning to have a conversation and an unattractive woman planning to have plastic surgery were perceived similarly), while attractive plastic surgery stimuli were perceived as less warm, competent, moral, and human than attractive non-plastic surgery stimuli.

Because empathy plays a crucial role in reducing stigmatization, we theorize that empathy might explain the revealed interaction between plastic surgery status and stimuli attractiveness [62–67]. Intuitively, individuals may feel that it is more ‘understandable’ that unattractive women might seek plastic surgery. Given that both the present study’s results and existing literature suggest that unattractive women are perceived to be less warm, competent, moral, and human than attractive women, it may seem reasonable for these women to want to undergo plastic surgery to reduce their experiences of appearance-based stigmatization [9, 22]. Conversely, participants may have less empathy for attractive women who do not stand to face the same stigmatization with or without surgery. In line with this theory, existing literature has demonstrated that people feel more empathy toward unattractive individuals (versus attractive individuals) across a variety of situations because they are more easily able to believe that unattractive individuals are suffering or in need of help [66, 67]. As such, we propose that there unattractive stimuli in the present study were not subject to the negative plastic surgery effect because participants were more easily able to empathize with them.

Hypothesis 4b.

Given that our hypothesis 4a was supported, we subsequently examined whether participant justice sensitivity and/or disgust sensitivity would influence the interaction between plastic surgery status and attractiveness. This exploratory hypothesis, however, was not supported by results. As such, we concluded that neither justice sensitivity nor disgust sensitivity influenced the phenomenon whereby solely attractive individuals were subject to the negative plastic surgery effect.

Limitations

There were some limitations for the present study. Firstly, we note that the plastic surgery vignette used in our study (“this woman is planning to have plastic surgery”) neither specified the nature of the plastic surgery the woman was planning to have, nor the specific surgery performed. We assumed (but did not ensure) that participants would respond to our measures with regard to cosmetic plastic surgery as opposed to reconstructive plastic surgery, given that the faces presented in our stimuli did not look disfigured in any way. We also did not specify whether the plastic surgery in question was for the face (e.g., rhinoplasty) or body (e.g., abdominoplasty), nor provide any other information pertaining to the surgery (e.g., whether she was planning to have one surgery or multiple). As such, the biggest limitation for the present study is that we cannot say with certainty whether the perceptions measured are in relation to cosmetic plastic surgery or reconstructive plastic surgery (or both), and/or whether different specific surgeries would elicit different attitudes from participants (e.g., face vs body).

We also note limitations in the generalizability of our conclusions. The means on all outcome measure scales used in the present study were consistently above the mid-point, regardless of plastic surgery condition, and our effect sizes were consistently small. In other words, while there were statistically significant differences between perceptions of women who seek surgery and women who do not across all outcome measures, the absolute difference in perceptions of these women were minimal. As such, negative outcomes faced by women seeking plastic surgery may ultimately be small, though still significant and important. Speaking further to the generalizability of the study, we note that only White plastic surgery stimuli were used. These findings therefore cannot be generalized to people of color; specifically, we are unable to establish whether plastic surgery recipients who are people of color are subject to the negative plastic surgery effect. Given that plastic surgery has historically attempted to produce more stereotypically White features (e.g., surgeries for the ‘Jewish nose’ or ‘Black nose’), it is especially important that we acknowledge the limited applicability of our findings [32, 68].

Implications, conclusions, and future directions

The present study demonstrates the existence of a negative plastic surgery effect, specifically for attractive women. In planning to undergo plastic surgery, these women are perceived as less warm, moral, competent, and human. As such, we contend that attractive women seeking plastic surgery may find themselves experiencing negative psychosocial outcomes (e.g., being subject to contempt). However, we note that at present these outcomes are purely speculative, and that future research is needed to test these associations. As per our limitations section, future research also ought to examine the negative plastic surgery for cosmetic plastic surgeries and reconstructive plastic surgeries separately, and for different types of surgeries (e.g., face vs body). Future research might also explore additional consequences that women subject to the negative plastic surgery effect are likely to face. For example, might this worsened person perception result in social exclusion or prejudicial treatment? Finally, future research need address whether these results are generalizable to non-White plastic surgery recipients. Overall, our study was the first to examine the negative plastic surgery effect experimentally. We provide a fundamental starting point from which future literature can further investigate negative plastic surgery attitudes in order to inform both women seeking plastic surgery and plastic surgeons themselves.