NOTE: To view the article with Web enhancements,
Women's Health in Context Beauty and Body Modification
Martin Donohoe, MD, FACP Medscape Ob/Gyn & Women's Health. 2006;11(1) ?2006 Medscape
Since ancient times, human beings have attempted to modify their physical appearances to
conform to cultural ideals of beauty. Many characteristics of human appearance are also
considered to be evolutionary adaptations for survival of the human species. Beauty, size, and
muscularity advertise one's health and fertility. The ancient Greek ideal equated symmetry with beauty, and more recent scientific studies have shown that symmetry is still valued in both male
and female faces. The "ideal woman" is said to have a small chin, delicate jaws, full lips, a small
nose, high cheek bones, large and widely spaced eyes, and a waist-to-hip ratio of 0.7. The "ideal
man" is taller, with a waist-to-hip ratio of 0.9, and rugged features such as a dominant,
rectangular face and chin; deep-set eyes; and a heavy brow, suggesting a strong supply of testosterone.
As Christine Rosen points out, physical appearance has also been linked to moral worth. Those
considered good-looking are more likely to get married, be hired, get paid more, and be promoted
sooner. Height is associated with income and leadership positions. Strangers are more likely to
assist good-looking people in distress. The pretty/handsome are less likely to be reported, caught,
accused, or punished for minor and major crimes. On the other hand, attractiveness is recognized
as a special gift, and its misuse is not easily tolerated.
Today, women and men of many cultures diet, exercise, apply cosmetics, and undergo a
bewildering array of surgical procedures to achieve a desired look. Yet, many techniques of body
manipulation have had profound health effects on the individuals practicing them. Moreover,
some have been cultural practices designed to control the female sex, even when willingly
accepted by women. Others, such as female genital mutilation, again often accepted by women, involve the abrogation of women's right to bodily integrity and sexual fulfillment.
Most interventions have been practiced by women, rather than men, who, as a result of their
more privileged position in society, have been able to rely more upon their intellectual, political,
and military feats to achieve respectability and to woo prospective mates. Ageism has also
historically disproportionately discriminated against women. Whereas older men have been seen
as distinguished and sophisticated, women who have completed their childbearing years are
more often considered "past their prime" and older women have been the greatest consumers of
cosmetic procedures. However, this is changing in American culture particularly, in which
"youthfulness" dominates the popular cultural discourse on beauty, and older men comprise an increasingly larger proportion of the cosmetic surgery market.
"Youthfulness is a...desirable commodity, as Americans in the corporate world are learning. A
February 2004 report in the Wall Street Journal described a recent survey by ExecuNet that
asked senior-level corporate executives about attitudes toward aging. The result found that "82
percent consider age bias a 'serious problem,' up from 78 percent three years ago. And 94
percent of these respondents, who were mostly in their 40s and 50s, said they thought age 'had
cost them a shot at a particular job.' Many executives -- male and female -- are turning to  cosmetic surgery to help them stay competitive."
This article takes a brief historical look at some of the modifications people (mostly women) have
undertaken to try to achieve particular ideals of beauty, and then focuses on some currently
fashionable modifications -- namely cosmetics, tanning, body piercing, and botulinum toxin
(BOTOX) and dermal fillers. Future articles will consider cosmetic surgery and female genital
What Is Beautiful? A Brief Look Through History
In ancient China, the 4-inch "lotus foot" was considered a sign of perfect beauty. The practice of
foot-binding, uncommonly seen today, involved breaking the bones of the forefoot and folding them forward, then tying the misshapen appendage to prohibit growth. Foot-binding caused severe pain, imbalance, and falls, and eventually osteoporosis, because afflicted women were
unable to bear weight and ambulate correctly. Other consequences included hip and knee osteoarthritis, chronic pain, and even joint replacement surgery. Chinese foot binding was also a form of subjugation; as a class, women were even less able to take advantage of already limited
educational and economic opportunities.
For ancient Egyptians, Romans, and Persians, sparkling eyes were considered beautiful and they applied the heavy metal antimony to make their conjunctiva sparkle. A woman with a high forehead was considered beautiful during the Elizabethan era, and upper-class Elizabethan
women plucked or shaved their frontal hairs to achieve this look. These women also covered their
skin with ceruse (lead-based) makeup, which caused peripheral neuropathy, gout, anemia, chronic renal failure, and disfiguring scarring, requiring the application of more ceruse makeup.
Chronic users, such as Queen Elizabeth I, acquired a misshapen appearance. Upset over her
grisly visage, the Queen banished all mirrors from her castle. Her servants sometimes painted a red dot on her nose, an inside joke mocking her clown-like appearance. In the court of Louis XVI, noblewomen drew blue veins onto their necks and shoulders to emphasize their exalted status ("bluebloods"). In the 16th and 17th centuries, the wealthy used belladonna eyedrops to dilate their pupils. Users acquired an "attractive" doe-like appearance,
but they also risked retinal damage, glaucoma, and blindness. During the 18th century, vermilion
rouge, concocted of sulphur and mercury, achieved popularity. Users lost teeth, suffered gingivitis,
and (unknowingly) risked kidney and nervous system damage from mercury -- not to mention their having to deal with the unpleasant smell of sulphur. Corseting, popular from the 14th to 19th centuries, originally involved compressing the bosom and constricting the waist with tightly wound whalebone on a steel frame. Shallow breathing, combined with inadequate venous return, produced fainting and swooning. Hiatal hernias caused
by overly tight corsets are termed "Sommerring's syndrome" -- after the 18th century physician who first warned of the dangers of tight lacing. Christina Larson points out, "the corset facilitated
a pernicious association between physical beauty and virtue, as upright posture and a slender
waist came to be regarded as evidence of discipline, modesty, rigor, and refinement. Ladies who abandoned their stays were scorned as both lazy and immoral." Ideal body weight and shape have fluctuated throughout history, from the rotund Venus of
Willendorf of antiquity, to the statuesque, leggy flappers of the 1920s, to the ultra-thin "Twiggy"-
inspired look of the 1960s and the "heroin chic" cachexia of the 1990s. In some cultures (eg,
Hawaiian royalty), women voluntarily consumed or were force-fed excessive quantities of food to maintain their corpulence, a sign of fertility and power. At other times, women, including those with and without anorexia and bulimia, have dieted, induced vomiting, abused laxatives, and
exercised excessively to lose weight. Famed opera singer Maria Callas deliberately infected  herself with tapeworms to produce a malabsorption syndrome to maintain her lithe figure.
Today, popular icons of beauty are found in music videos and on commercial television. Large
bust size and round, but not excessively large, posteriors are emphasized, for example. To help
the average woman achieve this look, a variety of products have become available, such as
Wonderbra, which elevates and compresses the breasts, and the Brava bra, a $2500 suction device designed to be worn overnight for 10 weeks. Brava bra makers promise a 1-cup size increase; side effects include skin rash and discomfort. In the United Kingdom, women can buy "Wonderbum" panty hose, made of DuPont lycra to mimic a "perfectly peachy, pert bottom."
Thoroughly routing the idea of a woman-only "beauty myth" is the very real fact that men are a
rapidly growing consumer niche in cosmetic surgery. They are getting procedures such as
botulinum toxin injections and chemical peels, although they are not yet as willing to admit to their
cosmetic habits as women are. One New York plastic surgeon told the Wall Street Journal that "17 percent of his patients undergoing eyelid surgery and about 11 percent choosing facelifts are
male, double the percentage of ten years ago." According to the American Academy of Cosmetic
Surgery, the most popular procedures for men are botulinum toxin injections, hair transplantation,
chemical peels, microdermabrasion, and liposuction. But more than 10,000 men have also had
cosmetic surgery to lengthen or widen their penises, as well as calf and pectoral implants to upsize their musculature.
Beauty Today -- Altered Appearances
Until the early 20th century, beauty aids were concocted at home, the recipes passed down from
mother to daughter and from neighbor to neighbor. The cosmetics industry was jump-started by
the mass popularity of anti-aging products in the 1920s, and grew over the next few decades as women entered the workforce and migrated to the cities in increasing numbers. In 1938, Congress passed the Pure Food and Drug Act, which extended the jurisdiction of the US Food
and Drug Administration (FDA). This measure was due in large part to renal failure from
polyethylene glycol contamination of elixir of sulfonamide, but also in response to a series of
disfigurements brought about by the use of products such as Kormelu, a depilatory that contained rat poison. Books such as American Chamber of Horrors, Skin Deep, and 100,000,000 Guinea Pigs spurred Congress to action.
Today the cosmetics industry is one of the largest in the United States. In 2004, Americans spent
$12.4 billion on cosmetics, an amount of money that is 33% larger than the amount needed each
year (in addition to current expenditures) to provide water and sanitation for all people in
developing nations, and, ironically, since cosmetics are often advertised as symbols of women's
rights and independence, just slightly larger than the amount needed each year (in addition to current expenditures) to provide reproductive healthcare for all women in developing countries.
Women devote an average of 19 minutes per day to treating and altering their faces. The average American adult uses 9 personal care products each day, with 126 unique chemical ingredients. Yet despite the 1938 law, and subsequent amendments, cosmetics are produced,
tested, labeled, marketed, and sold with little FDA supervision beyond the banning of 9 ingredients (such as mercury and chloroform) and certain color additives. Cosmetic companies are essentially free to make exaggerated claims regarding their products, and those producing
anti-aging creams frequently do, using celebrity and/or physician spokespersons and scientific-
sounding names. The toxicity of product ingredients is scrutinized almost exclusively by a self-
policing industry safety committee, the Cosmetic Ingredient Review (CIR) panel. Eighty-nine
percent of the 10,500 ingredients used in personal care products have not been evaluated for
 Many products contain ingredients linked to cancer, pregnancy safety by the CIR nor the FDA.problems, and other important health issues. Because of underfunding and a greater focus on pharmaceuticals, the FDA only steps in when cosmetics and "cosmeceuticals" manufacturers
grossly overstep legal bounds; fines are considered by larger manufacturers to be simply a cost of doing business.
Tanning represents the skin's response to ultraviolet light injury; thus, there is no such thing as a
"safe tan." Yet, while 95% of Americans understand that sunburns are dangerous, 81% still think they look better with a tan. Tanning is especially popular among the young. A 2002 study found
that 61% of college students had used a tanning lamp -- women more than men -- even though
more than 90% of users were aware that tanning lamps can lead to premature aging and skin cancer. One study examining 145 beachgoers on Galveston Island evaluated tanning as a type
of substance-related disorder. Researchers found that 26% of subjects met the modified CAGE
(Cut down, Annoyed, Guilty, Eye-opener) criteria, and 53% met the American Psychiatric
Association's diagnostic criteria for a substance abuse disorder with regard to ultraviolet light and related sun tanning. Perhaps this may be explained in part by the fact that sunlight interacts
with the skin to produce endorphins, chemicals that produce a "natural" high. While the United
States, Canada, Australia, the United Kingdom, and New Zealand prohibit minors from buying
tobacco products, only in rare instances do they prevent youths from visiting tanning parlors, despite the skin cancer risk. Wearing (and frequently reapplying) sunscreens with skin
protection factor (SPF) of at least 15 can help prevent sun damage.
Suncare product sales in the United States represent about $4 million per year. Another $1
million is spent annually on spray-on tans, which average $15 per application session and last about a week. One company is currently seeking FDA approval to market a new drug dubbed Melanotan II, which augments tanning and promotes sexual arousal (at least in male rats).
The word tattoo comes from the Tahitian word tatau, meaning "to mark something." Tattooing's
roots reach back to all ancient cultures. Tattooing reached its apogee among the Maori of New
Zealand, who often adorned their entire bodies and faces with exotic pigmented tendrils.
Tattooing was popularized in the West by sailors returning from voyages to Tahiti, New Zealand, and other Polynesian islands.
For some, tattooing is an aesthetic choice, for others an initiation rite, and for some disabled
individuals, a time-saving way to overcome difficulties in applying regular temporary makeup.
Some obtain tattoos as an adjunct to reconstructive surgery, particularly of the face and breast, to
simulate natural pigmentation; others to camouflage vitiligo. A bizarre phenomenon akin to
tattooing is anal bleaching, once practiced only by sex workers and porn stars, but now being
performed on a small but increasing number of other women for about $75, despite the risk of eczema.
There are more than 50 different pigments and shades used in tattooing today. None, including the hair dye henna, are actually approved by the FDA for skin injection. Some tattooists even use industrial grade printer ink or automobile paint. Direct risks of tattooing include infections, such as hepatitis B and C and HIV, particularly when needles are inadequately sterilized. The American Association of Blood Banks requires a 1-year wait between getting a tattoo and donating blood. Allergic reactions, granulomas, keloids (more common in African Americans), local swelling, and burns are not uncommon.
Practitioners' skill levels vary widely. Blurring may occur when injections are given too deep. The
appearance of tattoos and permanent makeup may become distorted following cosmetic surgery.
Because the human body changes with time, styles come and go, and tattoos can fade over the
years, and many seek tattoo removal. Techniques involve laser dermabrasion, salabrasion,  All procedures are associated with scarification, direct surgical removal, and camouflaging.potentially disfiguring cosmetic complications. Finally, tattooing has also been associated with a number of risky behaviors in adolescents.
Temporary tattoos, an alternative to permanent tattoos, fade after several days. These are also associated with allergic reactions, particularly with products made overseas. Another type of
temporary tattoo is formed when a cutout is laid over the skin during tanning, leaving a
hypopigmented area underneath with the desired design. This "tan-too" carries the risks of
tanning described previously.
Body piercing has been practiced since ancient times, as seen in art and antiquities. In the
United States, the most common sites of piercing include the earlobe, ear cartilage, eyebrow,
tongue, lips, nose, umbilicus, nipples, and external genitalia. Ear piercings are particularly common in the United States, while nose piercings are popular in Southern Asia. The prevalence of body piercing among undergraduates is as high as 50%. Complications of piercing are similar to those of tattooing and include poor healing, pain, edema, scar formation,
allergic reactions to metal, tooth and gum damage from oral or tongue piercing, and infections, including hepatitis B and C and HIV. The Association of Professional Piercers has produced a
guide for safe piercing, available at www.safepiercing.org. Botulinum Toxin and Dermal Fillers
Injectable botulinum toxin (the cause of botulism food poisoning and a potential
biowarfare/bioterror agent) has achieved unprecedented popularity for the treatment of facial
wrinkles. Its more conventional medical uses include treatment of blepharospasm, spasmodic torticollis, axillary hyperhidrosis, and achalasia. Potential future medical uses include treatment for migraines, back spasms, and a variety of types of chronic pain. Botulinum toxin can temporarily reduce or erase wrinkles due to normal aging; it does not work well on sun- or smoking-induced wrinkles.
BOTOX is manufactured by Allergan. According to the 2005 National Plastic Surgery Statistics
compiled by the American Society of Plastic Surgeons, 3,839,387 botulinum toxin treatments were performed in 2005, totaling almost $1.4 billion. Sales in 2001 were $310 million (including $100 million for cosmetic uses). More than one and one-half million patients were treated that
year, but clearly many have since climbed aboard the bandwagon in response to a $39 million direct-to-consumer ad campaign. At $80 per dose, plus a physician's fee (ranging from $300 to
$1000), a single treatment session can cost between $2000 and $5000; re-treatments are required every 3 to 4 months. Most users are white and age 30 to 35; 88% are women. Side
effects include a mask-like face, jaw slackness, drooling, and, in rare cases, more severe allergic [28,33]or paralytic reactions. Many Hollywood actors use botulinum toxin before filming. Some
dermatologists, to augment their income, have sponsored in-home BOTOX parties, over the objections of the American Academy of Dermatology. Johns Hopkins Medical Center narrowly avoided national disgrace in 2002 by calling off an offer of discounted botulinum toxin injections to
all students, faculty, and staff at an industry-sponsored (but university-supported) "BOTOX Night." More troubling BOTOX scams have proliferated underground and through the Internet,
sometimes using impure and/or adulterated toxin, which increase the risk of adverse reactions, [36,37]including botulism.
There was a 33% increase in the use of dermal fillers, alternatives to botulinum toxin, from 2001  Examples include cow collagen, liquid silicone, plastic microbeads, and even synthetic to 2002.bone and ground-up human cadaver skin, often supplied by for-profit tissue banks that divert the skin away from burn units, where it is needed to treat critically ill patients. Cow collagen may carry the prions associated with bovine spongiform encephalopathy (mad cow disease), possibly putting recipients at risk for variant Jacob-Creutzfeldt disease.
Treatments with dermal fillers cost between $700 and $900 and last just a few months. Poor
technique increases wrinkling; many products have not yet been approved by the FDA, but are
available through clinical trials and through an underground cosmeto-economy. Plastic surgeons
argue that compared with a $4000 to $6000 face lift (which lasts 10 to 15 years before requiring touch-ups), treatment with botulinum toxin and dermal fillers is not cost-effective.
Ideals of beauty are a constantly changing product of culture, religion, visual appeal, genetic
response, marketing, and social mores. Historically and presently, those whose appearance is
out of step with some perceived norm, which is usually defined by the majority or those in power,
suffer discrimination. Those who have felt that their appearance (whether a result of age or
genetic endowment) is unattractive or otherwise limits their options sometimes resort to extreme
and potentially dangerous procedures to modify their appearance.
Of course, for many, "beauty is in the eye of the beholder," and familiarity breeds fondness, rather
than contempt. Children who have good relationships with the parent of the opposite sex often
seek out characteristics of that partner in future mates. Personality traits also affect how one is
perceived by potential suitors. A "perfect" physiognomy can turn "ugly" if its possessor exhibits
arrogance, immaturity, or lack of intelligence. Conversely, physically unattractive individuals with warm and outgoing ("radiant") personalities can appear "beautiful." Perhaps one day we as a society can change our minds about the relevance of external appearance, rather than feeling the need to change our bodies. And maybe, the aged will echo the words of the French playwright Racine, and value their wrinkles as "the imprints of exploits," evidence of a life fully lived.
1. Alam M, Dover JS. On beauty: Evolution, psychosocial considerations, and surgical
enhancement. Arch Dermatol. 2001;137:795-807. Abstract
2. Slater L. Love. National Geographic 2006:32-39, 44-49.
3. Rosen C. The Democratization of Beauty. The New Atlantis. Number 5, Spring 2004, pp.
19-35. Available at: http://www.thenewatlantis.com/archive/5/rosen.htm. Accessed April
4. Adams KE. What's "normal": female genital mutilation, psychology, and body image. J
American Medical Womens Assn. 2004;59:168-170.
5. Henig RM. The price of perfection. Civilization 1996;:56-61.
6. Cummings SR, Ling X, Stone K. Consequences of foot binding among older women in
Beijing, China. Am J Public Health. 1997;87:1677-1679. Abstract
7. Newman C. The enigma of beauty. National Geographic 2000;January:94-121.
8. Fee E, Brown TM, Lazarus J, Theerman P. The effects of the corset. Am J Publ Health.
9. Larson C. Of corset matters. A review of Valerie Steele's The Corset: A Cultural History.
The Washington Monthly January/February 2002. Available at:
http://www.washingtonmonthly.com/features/2001/0201.larson.html. Accessed April 12,
10. Klarreich K. Did busts boom? TIME June 3, 2002. Available at:
http://www.time.com/time/archive/preview/0,10987,1002578,00.html. Accessed March 3,
11. Hodge RD. Harper's Weekly Review 2001 (Oct. 16). Available at:
http://www.harpers.org/weekly-review/. Accessed October 16, 2001. 12. Kawalek E. Artfully made up. Legal Affairs 2005;Nov/Dec:54-57. 13. Staff. Matters of Scale: Spending priorities. Worldwatch Institute 1999 (Jan/Feb).
Available at: http://www.worldwatch.org/pubs/mag/1999/121/mos/. Accessed February8,
14. Gorman C. Face lift in a jar. TIME August 14, 2000, 48-52. 15. Staff. Skin deep. Environmental Working Group 2004. Available at:
http://www.ewg.org/reports/skindeep2/. Accessed March 4, 2006. 16. McInerny V. Suntans sans sun. The Oregonian June 1, 2003, L9-10. 17. Knight JM, Kirincich AN, Farmer ER, Hood AF. Awareness of the risks of tanning lamps
does not influence behavior among college students. Arch Dermatol. 2002;138:1311-
18. Warthan MM, Uchida T, Wagner RF. UV light tanning as a type of substance-related
disorder. Arch Dermatol. 2005;141:963-966. Abstract
19. Dellavalle RP, Parker ER, Cersonsky N, et al. Youth access laws: In the dark at the
tanning parlor. Arch Dermatol. 2003;139:443-448. Abstract 20. Staff. No more baking: More seek spray-on tans. CNN.com/health. Available at:
http://www.cnn.com/2003/HEALTH/11/05/sprayon.tans.ap/index.html. Accessed April 12,
21. Robinson D. Hot for the Barbie drug. TIME August 26, 2002, 22. 22. Grobman P. Vital Statistics: An Amazing Compendium of Factoids, Minutiae, and
Random Bits of Wisdom. New York: Penguin, 2005.
23. Staff. Harper's Index. Harper's Magazine August, 2005. 24. US Food and Drug Administration, Center for Food Safety and Applied Nutrition, Office of
Cosmetics and Colors Fact Sheet (2001). Temporary tattoos and henna/mehndi.
Available at: http://www.cfsan.fda.gov/~dms/cos-tatt.html. Accessed April 12, 2006. 25. US Food and Drug Administration, Center for Food Safety and Applied Nutrition, Office of
Cosmetics and Colors Fact Sheet (2000). Tattoos and permanent makeup. Available at:
http://www.cfsan.fda.gov/~dms/cos-204.html . Accessed April 12, 2006. 26. Staff. Tattoo removal. Med Lett. 2003;45:95-96.
27. Roberts TA, Ryan SA. Tattooing and high-risk behavior in adolescents. Pediatrics
28. Staff. Body piercing. JAMA. 2004;291:1024.
29. Mayers LB, Judelson DA, Moriarty BW, Rundell KW. Prevalence of body art (body
piercing and tattooing) in university undergraduates and incidence of medical
complications. Mayo Clin Proc. 2002;77:29-34. Abstract 30. Noonan D, Adler J. The Botox boom. Newsweek May 13, 2002, 50-58. 31. Peck P. Nearly four million botox treatments performed in a year. Medpage Today, March
16, 2006. Available at: http://www.medpagetoday.com/Surgery/PlasticSurgery/dh/2874.
Accessed April 12, 2006.
32. Lemonick M. The pros and cons of botox. TIME April 29, 2002. Available at:
http://www.time.com/time/archive/preview/0,10987,1002330,00.html. Accessed April 12,
33. Staff. Botulinum toxin (Botox). Med Lett. 2004;46:76.
34. Staff. The Lawrence Summers Memorial Award to Allergan. 35. Multinational Monitor March 2002, 8.
36. Staff. It's Botox night at Hopkins. Public Citizen's Health Letter August 2002, 11, 12. 37. Peraino K. Beware the back-alley Botox scam. Newsweek August 5, 2002, 47. 38. Ford P. Harper's Weekly Review 2004 (December 7). Available at:
http://www.harpers.org/weekly-review/. Accessed December 7, 2004. 39. Kher U. Beyond Botox. TIME may 19, 2003, 58-59.
40. Cobain I, Luck A. The beauty products from the skin of executed Chinese prisoners. The
Guardian September 13, 2005. Available at:
http://www.guardian.co.uk/uk_news/story/0,3604,1568467,00.html. Accessed April 12,
41. Dreger AD. One of us: Conjoined Twins and the Future of Normal. Cambridge, Mass:
Harvard University Press; 2004.
42. Hruza GJ, Dover JS. Laser skin resurfacing. Arch Dermatol. 1996;132:451-455. Abstract
Martin Donohoe, MD, FACP, Adjunct Lecturer, Community Health, Portland State University, Portland, Oregon; Staff Physician, Department of Internal Medicine, Kaiser Sunnyside Medical
Center, Portland, Oregon
Disclosure: Martin Donohoe, MD, FACP, has disclosed no relevant financial relationships.
Public Health and Social Justice Website