Body Image: Social Influences, Ethnic Differences and Impact on Self-esteem 9781634838702, 9781634839211, 163483870X

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PSYCHOLOGY RESEARCH PROGRESS

BODY IMAGE SOCIAL INFLUENCES, ETHNIC DIFFERENCES AND IMPACT ON SELF-ESTEEM

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PSYCHOLOGY RESEARCH PROGRESS

BODY IMAGE SOCIAL INFLUENCES, ETHNIC DIFFERENCES AND IMPACT ON SELF-ESTEEM

RAFAEL VARGAS EDITOR

New York

Copyright © 2016 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. We have partnered with Copyright Clearance Center to make it easy for you to obtain permissions to reuse content from this publication. Simply navigate to this publication‘s page on Nova‘s website and locate the ―Get Permission‖ button below the title description. This button is linked directly to the title‘s permission page on copyright.com. Alternatively, you can visit copyright.com and search by title, ISBN, or ISSN. For further questions about using the service on copyright.com, please contact: Copyright Clearance Center Phone: +1-(978) 750-8400 Fax: +1-(978) 750-4470 E-mail: [email protected]. NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers‘ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book.

Library of Congress Cataloging-in-Publication Data ISBN:  (eBook)

Published by Nova Science Publishers, Inc. † New York

CONTENTS Preface Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

vii Self-Esteem and Body Image: The Importance of Contingent Self-Esteem Amy E. Noser and Virgil Zeigler-Hill

1

From Body Dissatisfaction to Embodied Connection: Exploring Young Women‘s Body Experiences Satu Liimakka

15

Associations between Racism, Emotional Overeating, and Appearance Satisfaction among Black Women Christina M. Capodilupo and Kristin M. Smith

27

Ethnicity-Related Differences in Responses to ―In Favor of Myself‖ – A Wellness Program to Enhance Positive Self and Body Image among Adolescents Moria Golan, Rose Awidat and Shani Abutbul Body Image in Adolescent Pregnancy: A Comparison with the Adult Research Danusha Jebanesan, Leanna Isserlin and Megan E. Harrison Magazine Image Influence, Extraversion and Body Image in Fraternity and Non-Fraternity College Males Morgan Draxten and F. Richard Ferraro Body Image, Sociocultural Influences and Self-Esteem: The Case of Cyprus Marios Argyrides, Natalie Kkeli and Marianna Koutsantoni The Concept of the Body Image in Old People in Relation to Psychiatric Disorders Carmen M. Sarabia-Cobo

43

53

63

77

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vi Chapter 9

Chapter 10 Index

Contents The Impact of Gynecological Conditions on Body Image, Sexual Function and Quality of Life Ellery Greenberg,, Liel Navi and Lior Lowenstein Sociocultural Routes to Unhealthy Body Image Investment Eliana V. Carraça

101 119 137

PREFACE The relationship between self-esteem and body image has been well-established such that low levels of self-esteem have been found to be associated with body image concerns. The authors review previous research on the link between low self-esteem and body image concerns and then discuss more recent research concerning the importance of contingent selfesteem in this connection. The next chapter provides a discussion on the commonness of body dissatisfaction among contemporary Western young women and suggests re-embodiment as a means of transforming this experience. Chapter 3 explores the relationship between appearance satisfaction emotional overeating, experiences of racism and BMI among Black and African American women. Ethnic identity plays an important role in the self-concept related to feelings and attitudes. Chapter 4 explores the ethnic differences in self-esteem and body image among adolescents, as well as the need to address ethnicity in prevention programs. The remaining chapters of the book focus on body image in adolescent pregnancy; magazine image influence, extraversion and body image in college males; sociocultural factors, body image factors and self-esteem on school-age males and females, the perception of self-image in older people and how it changes throughout life; an examination of how the way woman perceive themselves influences the psychosexual impact on quality of life; and finally, how people can improve or develop a healthier investment in appearance. Chapter 1 – The relationship between self-esteem and body image has been wellestablished such that low levels of self-esteem have been found to be associated with body image concerns. Previous research provides some explanation for why individuals with low self-esteem tend to have body image concerns. However, the vast majority of this research has focused primarily on self-esteem level without addressing other features of self-esteem such as its contingencies (i.e., domains on which individuals base their feelings of worth), which may have limited the understanding of the connection between self-esteem and body image. The purpose of the present chapter is to gain a better understanding of the link between self-esteem and body image. This is accomplished by reviewing previous research on the link between low self-esteem and body image concerns and then discussing more recent research concerning the importance of contingent self-esteem in this connection. Chapter 2 – This chapter provides a discussion on the commonness of body dissatisfaction among contemporary Western young women and suggests re-embodiment as a means of transforming this experience. The chapter is based on a study exploring young Finnish women‘s body experiences as well as their possibilities for embodied agency as located in the socio-cultural context. The young women described experiences of body

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dissatisfaction and practices of body monitoring, and often related these to the standard created by the current Western body ideal. The young women engaged in cultural criticism towards the body ideal, yet they could not resist the impact the ideal had on their personal body relation. This caused feelings of dissatisfaction with their selves. However, finding a new body-mind connection as well as a body-world connection enabled a more positively experienced body relation for some young women. The chapter argues that mere strategies of the mind alone are inefficient in combating body dissatisfaction – in addition, a transformation on the level of the body is needed. Finding an embodied connectedness within oneself and in one‘s relation to the world can transform the young woman‘s self-critical and anxiety-laden body relation. Chapter 3 – The objective of the current study was to explore the relationships between appearance satisfaction, emotional overeating, experiences of racism, and BMI among Black and African American women. In this community-based sample (N = 404), women (mean age: 39) completed the Emotional Overeating Questionnaire, the Daily Life Experiences Questionnaire-Racial Hassles, and an appearance satisfaction and demographic questionnaire that were author created. Results indicate that women who were less satisfied with their appearance (a) engaged in more emotional overeating behavior, (b) had higher BMI‘s, and (c) indicated a greater influence of Black men‘s aesthetic preferences on their body image. When controlling for BMI, daily experiences of racism was a positive predictor of emotional overeating. Findings underscore the importance of including culturally-relevant variables in research and clinical work that explores women of color‘s body image and eating habits. Chapter 4 – Ethnic identity plays an important part in the self-concept related to feelings and attitudes. Despite decades of research into prevention programs for youth and their implementation nationwide, publications describing ethnic differences in the impact of prevention programs among adolescents are scarce. Programs may have different impacts on participants due to baseline exposure to different sociocultural values, different self-esteem and body image, as well as other individual characteristics related to participants‘ ethnic origin and values. This review explores the ethnic differences in self-esteem and body image among adolescents, as well as the need to address ethnicity in prevention programs. It further examines the current publications on ethnic differences in self-esteem and body image among Druze and Jewish adolescents, and presents data from a comparison of two randomized control trials which assessed the mediating influence of ethnicity on the impact of "In Favor of Myself,‖ a universal wellness prevention program, in Druze vs. Jewish adolescents. Data came from a school-based grouped randomized trial in Israel involving 204 Druze and Jewish adolescents, mostly 8th-graders, using a general linear model to assess the interaction between times (baseline and program conclusion), groups (intervention vs. control) and ethnicity (Druze vs. Jews). Results showed that acceptability and program implementation were higher among Druze compared to Jewish adolescents. The "In Favor of Myself" program was more effective when delivered to Druze adolescents with respect to media literacy—a greater reduction in feeling stressed about appearance due to media messages was found among Druze compared to the Jews; self-esteem declined during the assessment period among Jews (as expected at this age) but not among Druze. A greater improvement in the gap between current body image and ideal body image was also seen among Druze vs. Jews. The reasons for these differences are discussed. Chapter 5 – Women‘s responses to the physical changes of pregnancy vary greatly. Some research suggests that pregnancy weight and body shape changes result in a decline in body

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satisfaction in some adult women, whereas other research suggests that most women experience stable or improved body image during certain stages of pregnancy. Many factors are said to be involved in a pregnant woman’s perception of and feelings towards her body; for example, one’s pre-pregnancy body image, the trimester of pregnancy, as well as symptoms of depression. Research exploring the relationship between body image and pregnancy in adolescence is limited, both in quality and quantity, and shows inconsistent results. Some studies found an increase in body image disturbance and dissatisfaction during pregnancy in adolescents, whereas others demonstrated that the majority of pregnant adolescents reported a positive body image. Negative body image in pregnancy can be associated with unhealthy weight control behaviours (ie. dieting), as well as depressive symptoms in pregnancy and postpartum. Given the possible ramifications of both weight control behaviours and depression in pregnancy, it is imperative that researchers explore the potential risk factors for body dissatisfaction during pregnancy in both adults and adolescents. Chapter 6 – Previous research has shown that exposure to media images of physically fit males increase body dissatisfaction. Also, those high in extraversion will have low body dissatisfaction. In the present study fraternity (n = 37) and non-fraternity (n = 157) males were given the Eysenck Personality Questionnaire – Brief Version and the Male Body Attitudes Scale. The design was a 2 (Group: Fraternity, Non-Fraternity) x 2 (Image: physically fit males, neutral household objects). Extraversion scores in fraternity and nonfraternity males were not significantly different. There was no significant interaction between images viewed and the Male Body Attitudes Scale, there also no main effect in the scores on the Male Body Attitudes Scale between fraternity and non-fraternity males. The physically fit mages did not have a significant effect on male body dissatisfaction. Chapter 7 – Sociocultural influences and self-esteem have been found to have an impact on body image. The internalization of the thin ideal by the media, the large emphasis on appearance placed by society and the unrealistic, distorted media images are just some of the long list of the sociocultural factors that have been assessed in the past. Many of these variables have also been assessed cross-culturally indicating some contradicting information between Western and Non-Western cultures. The current chapter focuses mainly on Cyprus, an island country in the Mediterranean Sea with 320 days of sunshine per year. Cyprus is of great interest in the literature concerning body image, self-esteem and sociocultural issues if one takes into consideration five main factors: 1) There was a great boost in economy after the 1974 war and an emphasis was placed by the inhabitants on their social image as well as their body image 2) There is a very warm weather in Cyprus which causes lighter, more revealing clothing to be worn. Previous research has pointed out that this may lead to an emphasis being placed on body image 3) The presence of significant increase in body image and self-esteem concerns as compared to other countries and ethnicities 4) The minimal emphasis that is placed by the school curriculum on the above issues as the classes that address the issues have been reduced significantly and 5) The 2.4 million tourists visiting the country each year, wearing lighter clothing, which the 850,000 inhabitants inevitably compare themselves. The chapter focuses on recent findings of a countrywide, large sample (N = 2664) of school-age males and females. Data were collected on sociocultural factors, body image factors and self-esteem. Some findings reflect the literature on these constructs whereas other findings differ significantly from other northern and southern European countries (and other Western and Non-western countries). These findings are presented

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through the lens of the independent variables of gender, socioeconomic status, Body Mass Index category, age, and geographical location of one‘s upbringing and residence. The chapter concludes with conclusions and recommendations not only for Cyprus, but also for countries with similar demographics. Chapter 8 – The perception of the self-image changes throughout life, and it is important for people to adapt and accommodate to those changes. In particular for a population of elderly of more than 65 years, the author study the distortion of their perceived body image with regard to their actual and ideal images, and how psychiatric disorders may affect this relationship. The study was conducted on 457 elderly from seven nursing homes in Spain, who participated in the Body Shape Questionnaire (BSQ) and the Silhouettes Test. An additional systematic review of clinical history of patients was performed to detect psychiatric disorders like depression, anxiety or anorexia. The author found out that people with depression or anxiety had a higher dissatisfaction with their body image, and women were more dissatisfied than men, regardless of age. Chapter 9 – Body image is one of the major contributors to a woman‘s self esteem. The way a woman perceives herself has a profound impact on sexual function and thus quality of life. Over the last few decades, many researchers have focused on investigating different diseases that influence both quality of life and sexual function. This chapter will address the effects of various gynecological conditions that influence the psychosexual impact on quality of life. Many women‘s health and gynecological conditions are known to influence selfesteem and sexual function. This chapter will examine endocrinologic disorders, such as polycystic ovary syndrome, reproductive infertility, and premature ovarian failure. It will also explore the impact of gynecological malignancies, as well as breast cancer on body image and sexual function. Furthermore, pelvic floor disorders such as pelvic organ prolapse and urinary incontinence will be discussed, as well as other gynecological conditions such as fibroids, endometriosis and dyspareunia. Finally, the author will review the normal physiologic changes that occur in menopause, as well as normal anatomic variations in external genitalia that influence self esteem and sexual function in many women. Within these topics, the author will discuss how the reaction to these conditions affects women differently based on age, race, and ethnicity. Furthermore, the author will examine the impact of medical and surgical interventions in regard to their influence on changes in sexual health. According to the World Health Organization, when one measures the effects of health care, the author must not focus solely on the severity and frequency of disease but also on well-being, as assessed by one‘s quality of life. In gynecology, one of the major factors that influences quality of life is sexual function, which is highly correlated to both body image and self esteem. It is, therefore, important to focus women‘s health care not only on the medical efficacy of treatment, but also to emphasize the impact treatment should have on preservation of sexual function and thus optimization of quality of life. Chapter 10 – Body image investment refers to the psychobehavioral salience of one‘s body image evaluations, often reflected in the way they define them and function on a daily basis. The current social environment encourages the development of an unhealthy investment in appearance, due to the high emphasis placed on the pursuit of ultra-slender body ideals and concurrent depreciation of excess weight conditions. Appearance becomes central to many people‘s identity, and their self-esteem and well-being contingent on meeting the thin body ideals, almost impossible to achieve. Guided by the increased sociocultural

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pressure to conform, people end up engaging in unhealthy, often non-sustainable, behavioral efforts to lose weight and improve appearance. However, this type of reasons to engage in body image improvement efforts could be experienced as controlling and/or as a self-imposed pressure, possibly leading to a less autonomous functioning as well as less adaptive behaviors. The available evidence consistently supports the adverse consequences of an unhealthy body image investment on people‘s self-esteem, psychological and behavioral functioning. However, researchers have often ignored this body image facet. This chapter will describe the investment dimension of body image and explain how the sociocultural milieu contributes to the prevalence of an unhealthy (over a more adaptive) investment in appearance. Informed by self-determination theory, this chapter will also discuss the motivational routes underpinning people‘s decisions to engage in appearance management efforts, and the consequences of this unhealthy investment to their self-esteem, psychological functioning, and behaviors. To conclude, a reflection on how people can improve or develop a healthier investment in appearance will be presented.

In: Body Image Editor: Rafael Vargas

ISBN: 978-1-63483-870-2 © 2016 Nova Science Publishers, Inc.

Chapter 1

SELF-ESTEEM AND BODY IMAGE: THE IMPORTANCE OF CONTINGENT SELF-ESTEEM Amy E. Noser1 and Virgil Zeigler-Hill2,* 1

University of Kansas, Lawrence, KS, US Oakland University, Rochester, MI, US

2

ABSTRACT The relationship between self-esteem and body image has been well-established such that low levels of self-esteem have been found to be associated with body image concerns. Previous research provides some explanation for why individuals with low selfesteem tend to have body image concerns. However, the vast majority of this research has focused primarily on self-esteem level without addressing other features of self-esteem such as its contingencies (i.e., domains on which individuals base their feelings of worth), which may have limited the understanding of the connection between self-esteem and body image. The purpose of the present chapter is to gain a better understanding of the link between self-esteem and body image. This is accomplished by reviewing previous research on the link between low self-esteem and body image concerns and then discussing more recent research concerning the importance of contingent self-esteem in this connection.

INTRODUCTION Physical attractiveness has become increasingly important in contemporary Western societies. This emphasis on appearance often leads individuals to measure their value and worth by evaluating their appearance. Socially constructed standards of attractiveness are particularly evident for women and girls and are believed to develop as a result of external pressures that many individuals accept as normative and incorporate into their daily lives *

Virgil Zeigler-Hill e-mail: [email protected].

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(e.g., media, Birch and Fisher 1998). This is an important issue because individuals who personally identify with these social values often rely on them to evaluate their self-worth. Simply put, women and girls who value and accept societal standards of attractiveness as normative may rely on their perceived attractiveness as a means to evaluate their own worth (Costanzo 1992). It is not unreasonable to expect women and girls to value their appearance so highly given that physical attractiveness is associated with an array of important life outcomes for women including dating and marriage opportunities (see Frederick, Reynolds, Fales and Garcia 2012, for a review), higher educational and economic attainments (see Furnham and Swami 2012, for a review), and better physical health (see Langlois et al. 2000, for a review). These findings suggest that physical appearance is critical to the social and economic success of women which may explain, at least in part, why physical attractiveness is tied to women‘s feelings of worth. Numerous studies have shown that self-esteem is connected to how individuals feel about their appearance and more specifically their body weight and shape (e.g., Connors and Casey 2006, Davison and McCabe 2006, Tiggemann 2005, Wojtowicz and von Ranson 2012). The present chapter will begin by providing an overview of the empirical research concerning the link between self-esteem and physical appearance and discuss potential reasons for this connection. Next, the chapter will discuss the importance of considering the extent to which self-esteem is contingent on different domains such as one‘s appearance, when examining how individuals feel about their bodies. Finally, research concerning the associations among appearance-based contingencies of selfesteem, self-esteem level, and body image concerns will be reviewed.

SELF-ESTEEM Self-esteem is the evaluative component of self-knowledge that refers to the extent that individuals like themselves and believe they are competent (e.g., Brown and Marshall 2006). High levels of self-esteem refer to highly favorable views of the self, whereas low levels of self-esteem reflect feelings of worth that are either uncertain or negative (Campbell et al. 2006). It is important to note that because self-esteem reflects an individual‘s perception of the self it is not necessarily accurate or inaccurate. Therefore, high levels of self-esteem may correspond to an individual‘s attributes and accomplishment or these feelings of worth may be out of alignment with objective appraisals of the individual. Self-esteem is understood to be a relatively enduring characteristic that is comprised of both motivational and cognitive features (Kernis 2003). In general, individuals seek to possess high self-esteem so they adopt strategies to maintain and enhance their positive feelings of self-worth (Crocker and Park 2004). The level of self-esteem possessed by individuals often influences the strategies that are used to maintain or enhance their feelings of worth such that those who possess high levels of self-esteem tend to engage in strategies that will further boost their self-esteem (e.g., self-enhancement), whereas those with low selfesteem often focus on protecting their relatively scarce self-esteem resources (see Baumeister, Tice and Hutton 1989, for a review).

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In contrast to the self-promoting strategies employed by those with high levels of self-esteem, individuals with low levels of self-esteem are more inclined to use self-protective strategies characterized by reluctance to draw attention to themselves, attempts to conceal their bad qualities from being noticed, and effort to avoid potential risks of negative feedback or rejection. The behavior of individuals with low self-esteem is often described as cautious and conservative because these individuals tend to be reluctant to risk failure or rejection unless doing so is unavoidable (Josephs, Larrick, Steele and Nisbett 1992). As mentioned above, individuals show a preference for high levels of self-esteem. In fact, individuals who possess high levels of self-esteem have been shown to choose self-esteem boosts over other pleasant activities such as eating a favorite food or engaging in a favorite sexual activity (Bushman, Moeller and Crocker 2011). One underlying reason that individuals desire to possess high self-esteem may be that it serves as a resource that buffers individuals from negative experiences (e.g., failure, rejection). That is, individuals who possess high levels of self-esteem are thought to be less impacted by negative experiences and to recover from these experiences more quickly than individuals with low self-esteem. This basic idea has been referred to as the stress-buffering model of high self-esteem as well as the vulnerability model of low self-esteem (see Zeigler-Hill 2011, for a review). The rationale for these models is that high self-esteem serves as a buffer against negative experiences due to enhanced coping resources (Arndt and Goldenberg 2002) and clarity regarding their positive characteristics (Campbell 1996). For example, the stress-buffering model proposes that selfesteem and stress interact such that high self-esteem protects against the deleterious consequences of stress, whereas low self-esteem increases vulnerability to the effects of stress. Ample research concerning the stress-buffering model has shown that individuals who possess high self-esteem are more resilient than individuals who possess low self-esteem when faced with stressful or negative experiences (e.g., Brown 2010, Brown, Cai, Oakes and Deng 2009, Brown and Dutton 1995). For example, a series of studies conducted by Brown (2010) found that individuals with high levels of self-esteem experienced less distress than individuals with low levels of self-esteem when confronted with negative feedback following a social encounter or an achievement task. However, it is important to note that individuals with high self-esteem do not report feeling less sad or disappointed than individuals with low self-esteem when experiencing negative outcomes, rather these individuals feel less bad about themselves following negative experiences. That is, individuals with high self-esteem are not inclined to allow failures to detract from their feelings of self-worth.

SELF-ESTEEM AND BODY IMAGE The link between self-esteem and body image concerns has been well established such that individuals who possess low levels of self-esteem have often been found to have more body image concerns (e.g., Connors and Casey 2006, Davison and McCabe 2006, Tiggemann 2005, Wojtowicz and von Ranson 2012). Although most prominent during adolescence and early adulthood, the importance of physical appearance for feelings of worth is evident across the lifespan which may be due, at least in part, to the fact that physical appearance is highly consequential from a very young age. For example, individuals who are perceived as physically attractive receive more positive attention beginning at infancy and children as

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young as three-years-old show a preference for attractive versus unattractive playmates (see Smolak 2012, for a review). The importance of physical appearance for self-evaluations becomes increasingly salient during middle childhood (i.e., 5-12 years of age) which may be due to that individuals begin to incorporate external feedback, such as social feedback, into their self-evaluations during this period (Harter 2003). This suggests that the emphasis on appearance from external influences (e.g., societal, peer, family) in contemporary society is first incorporated into individuals understanding of themselves during middle childhood (Tiggemann 2012). That is, middle childhood may be the time when individuals begin to internalize external feedback about their appearance in such a way that this information begins to influence their feelings of self-worth. For example, studies have shown that negative feedback from peers such as appearance-related and weight-related teasing is associated with low self-esteem starting during middle childhood (Kutob, Senf, Crago and Shisslak 2010). Although the importance of appearance for women‘s feelings of self-worth generally does not increase with age following adolescence, women with low self-esteem continue to report relatively high levels of dissatisfaction with their bodies compared to women with high self-esteem or men (e.g., Grogan 2012). This is most likely explained by constant exposure to appearance ideals that are simply unrealistic (e.g., airbrushed or digitally enhanced bodies) or unattainable (e.g., extreme thinness) for most women. Further, the appearance of women tends to move further away from appearance ideals as they age. Thus, while body image concerns may differ for women and girls across the lifespan (e.g., breast size, hip-to-waist ratio, body fat distribution), individuals with low self-esteem persistently report discontent with their body size or shape (O‘Dea 2012). Researchers examining the association between low self-esteem and body image concerns have considered both evaluative (i.e., body satisfaction or dissatisfaction) and investment (i.e., appearance) components of body image. Evaluative components of body image concern subjective feelings about the body or its constituent parts. Research concerning evaluative components of body image examines the extent to which individuals are satisfied or dissatisfied with their body. However, the vast majority of this research has focused on body dissatisfaction (Paxton, Eisenberg and Neumark-Sztainer 2006, Tiggemann 2005, Wojtowicz and von Ranson 2012). Body dissatisfaction refers to negative selfevaluations of the shape, size, and/or appearance of one‘s body (Stice and Shaw 2002) and is considered to be a gendered experience that is more common among women than men (Frederick, Peplau and Lever 2006, Maphis, Martz, Bergman, Curtin and Webb 2013). Studies examining the relationship between self-esteem and body dissatisfaction have consistently demonstrated that self-esteem is negatively correlated with body dissatisfaction such that higher levels of self-esteem are associated with lower levels of body dissatisfaction (e.g., Paxton et al. 2006, Tiggemann 2005, Wojtowicz and von Ranson 2012). For example, a recent prospective study conducted by Wojtowicz and von Ranson (2012) examined potential risk factors of body dissatisfaction (i.e., self-esteem, body mass index, thin-ideal internalization, weight-related teasing, and perfectionism) among adolescent females. Results of the study revealed that low self-esteem was the strongest predictor of increased body dissatisfaction one year later. Research regarding the relationship between self-esteem and body satisfaction is more limited. However, available findings have suggested that self-esteem and body satisfaction are positively associated such that individuals with high self-esteem report high levels of

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body satisfaction (e.g., Connors and Casey 2006). Body appreciation – which refers to the degree to which individuals accept, hold favorable opinions toward, and respect their body while also rejecting media-promoted appearance ideals (Avalos, Tylka and Wood-Barcalow 2005) – has also been shown to be associated with high self-esteem. Studies that have examined the association between self-esteem and body appreciation have found that individuals who possess high self-esteem are more likely to show appreciation for their bodies even after accounting for other aspects of body image such as body dissatisfaction (Tylka and Wood-Barcalow 2015). Taken together, findings concerning evaluative components of body image suggest that individuals with low self-esteem tend to have more negative and fewer positive feelings about their body than those individuals with high selfesteem. This is a potential concern because body dissatisfaction has been shown to be pervasive among women (Rodin, Silberstein and Striegel-Moore 1984) and found to be associated with a variety of negative outcomes such as engagement in risky activities (e.g., early sexual activity, self-harm behaviors; Cook, MacPherson and Langille 2007), negative affect (Stice and Bearman 2001), and the development of eating disorders (Stice and Shaw 2002). Appearance investment is another important component of body image that considers the cognitive-behavioral domain of appearance (Cash, Melnyk and Hrabosky 2004). That is, appearance investment refers to the investment that individuals make in certain beliefs or assumptions about the importance, meaning, and influence of their appearance in their everyday lives and is expressed as an overvaluation of appearance and excessive effort devoted to the management of appearance (Cash et al. 2004). For example, women with high appearance investment spend a great deal of time attending to their appearance and attempting to maintain or enhance it (Cash et al. 2004). Interest in the importance of appearance investment has grown because a great deal of research has supported the idea that external pressures for attractiveness contribute to body image concerns (e.g., Cafri et al. 2005, Grabe et al. 2008, Myers and Crowther 2009) but individual factors (e.g., beliefs) determine how and to what extent these external pressures influences thoughts, feelings, and behaviors (Cash et al. 2004). Researchers interested in appearance investment have identified two distinct features of the construct that are referred to as self-evaluative salience and motivational salience. Selfevaluative salience reflects the extent to which appearance is important to an individual‘s feelings of worth and beliefs about the degree to which appearance is instrumental in causing social and emotional experiences (Cash et al. 2004). In contrast, motivational salience reflects the degree to which one attends to and manages one‘s own appearance (Cash et al. 2004). For example, individuals with high levels of motivational salience spend a great deal of time or money improving or maintaining a certain level of attractiveness (Ledoux, Winterowd, Richardson and Clark 2010). It is important to note that one crucial difference between the two domains of appearance investment is that self-evaluative salience reflects dysfunctional attitudes, whereas motivational salience may not necessarily be problematic if the goal is simply to maintain a certain level of attractiveness. That is, the desire to care for one‘s appearance and/or actually caring for appearance may not be associated with problematic outcomes (e.g., disordered eating attitudes and behaviors) if these efforts are relatively independent of individuals‘ feelings of worth. For example, a recent study interested in the link between fear of negative evaluation (i.e., distress over being negatively evaluated and avoiding situations where one may be evaluated) and dietary restraint found that after

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controlling for body mass index, self-evaluative salience fully mediated – and motivational salience partially mediated – the relationship between negative evaluations and dietary restraint (Chang, Jarry and Kong 2014). Broadly, these findings suggest that women who are highly anxious about others‘ negative evaluations may be inclined to process interpersonal cues through appearance schemas (i.e., self-evaluative salience) and engage in appearance corrective behaviors (i.e., motivational salience) which, in turn, may translate into restrictive eating behaviors. More specifically, the study showed that fear of negative evaluation had a significantly stronger association with self-evaluative salience than with motivational salience. This suggests that individuals who fear being negatively evaluated by others may be overly concerned about receiving negative appearance feedback which may naturally increase their focus on the importance and instrumentality of appearance. In line with previous research concerning the association between self-esteem and body image, appearance investment has been shown to be associated with self-esteem such that high levels of self-esteem are associated with low levels of appearance investment (e.g., Cash et al. 2004, Ip and Jarry 2007). For example, Cash et al. (2004) found individuals with low self-esteem reported higher appearance investment. However, closer examination of these constructs revealed that low self-esteem was negatively associated with self-evaluative salience but it was unrelated to motivational salience. This suggests that individuals with low self-esteem believe that their appearance is important and instrumental in their everyday lives but they do not necessarily engage in a high degree of appearance management. These findings may be explained by the fact that self-evaluative salience is associated with more pathology (e.g., depression, quality of life) than motivational salience (e.g., Cash et al. 2004, Chang et al. 2014, Ip and Jarry 2007).

CONTINGENT SELF-ESTEEM Studies exploring the relationship between self-esteem and body image have clearly demonstrated that low self-esteem is associated with more body image concerns (e.g., Connors and Casey 2006, Davison and McCabe 2006, Tiggemann 2005, Wojtowicz and von Ranson 2012). However, this research has focused primarily on self-esteem level (i.e., whether self-esteem is high or low) without attending to other features of self-esteem such as its fragility. This exclusive focus on self-esteem level may have limited the ability of researchers to fully understand the connection that self-esteem has with body image because indicators of self-esteem fragility have been found to moderate the associations that selfesteem level has with outcomes in other domains (see Jordan and Zeigler-Hill 2013, for a review). One important marker of self-esteem fragility is contingent self-esteem which reflects what an individual believes he or she must do or be in order to have value and worth as a person (Crocker and Wolfe 2001, Deci and Ryan 1995). That is, individuals who possess contingent self-esteem stake their feelings of self-worth on domains they deem important such that success or failure in these domains has tremendous influence on their selfevaluations. According to self-determination theory (Deci and Ryan 1995), contingent selfesteem develops when individuals rely on introjected standards –typically represented by the internalization of significant others‘ approval – to regulate their behavior and goals which, in turn, leads them to become preoccupied with meeting or exceeding these external standards in

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order to maintain their feelings of self-worth. As a result, these individuals‘ feelings of selfworth are continually ―on the line‖ such that failure to meet self-imposed or external standards may result in intense feelings of shame, incompetence, or worthlessness. In contrast, non-contingent self-esteem reflects feelings of self-worth that are secure and do not depend on external reinforcement. That is, individuals who possess non-contingent self-esteem (i.e., secure self-esteem) have feelings of self-worth that that do not depend upon the attainment of specific outcomes and do not require continual validation (Deci and Ryan 1995). Self-determination theory proposes that non-contingent self-esteem develops when an individual‘s actions are self-determined and congruent with his or her inner self (Deci and Ryan 1995). As a result, individuals with non-contingent self-esteem select activities and undertake goals that are important to the individual and build relationships with others characterized by mutual acceptance, intimacy, and understanding. Contingent self-esteem was originally conceptualized as a global construct such that the self-esteem of some individuals is contingent whereas for others self-esteem is relatively noncontingent (Deci and Ryan 1995). However, recent research suggests that contingent selfesteem may actually represent a domain-specific construct because individual differences have been found in the areas of life that serve as a basis for feelings of self-worth (e.g., Crocker and Park 2004, Crocker and Wolfe 2001). According to the domain-specific approach to contingent self-esteem, few individuals possess non-contingent self-esteem (Crocker and Wolfe 2001, Pyszczynski, Greenberg and Goldenberg 2003). Rather, individuals differ with regard to the domains upon which they stake their feelings of selfworth. Crocker, Luhtanen, Cooper and Bouvrette (2003) have identified seven important domains of contingent self-esteem which include appearance, others‘ approval, outperforming others, academics, family support, virtue, and religious faith. Additional research has also examined the extent to which people base their feelings of self-worth on friendships (Cambron, Acitelli and Steinberg 2010), body weight (Clabaugh, Karpinski and Griffin 2008) and romantic relationships (Knee, Canevello, Bush and Cook 2009). Domains of contingent self-esteem are based primarily on either external factors (e.g., appearance) or internal factors (e.g., virtue). Identifying whether self-esteem contingencies are based on external or internal factors is important given that external self-esteem contingencies have been found to be more problematic than internal contingencies because they often lead to a continual self-evaluation process that is associated with more negative mental health outcomes (e.g., Crocker 2002, Crocker and Wolfe 2001).

APPEARANCE-BASED CONTINGENT SELF-ESTEEM One common domain upon which self-esteem may be based is on one‘s physical appearance. Appearance-based contingencies of self-worth refer to high levels of concern for meeting standards of attractiveness that are closely connected to how individuals feel about themselves (Crocker and Park 2010). Therefore, possessing appearance-based contingent selfesteem may cause fluctuations in feelings of self-worth that are reliant on physical appearance (Crocker, Sommers and Luhtanen 2002). More simply, individuals who possess appearancebased contingent self-esteem rely on successfully meeting self-prescribed or external

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standards of attractiveness to elevate or maintain their feelings of worth such that failure to meet these appearance standards are likely to result in a decline in their feelings of self-worth. Appearance-based contingent self-esteem is considered to be an external contingency of self-worth because approval of one‘s appearance is often reliant on external feedback. Studies that support this idea show that individuals with appearance-based contingent self-esteem experience a decline in feelings of self-worth when they receive negative interpersonal feedback about their physical appearance (e.g., Patrick, Neighbors and Knee 2004). Similarly, it has been shown that the way interpersonal feedback is interpreted impacts feelings of selfworth (Forand, Gunthert, German and Wenze 2010). That is, women who possess appearance-based contingent self-esteem experienced fluctuations in their feelings of selfworth when they interpreted interpersonal feedback as being related to their appearance. For example, one study found that women who possess appearance-based contingent self-esteem showed a heightened sensitivity to the perceived level of communion in their interpersonal relationships. More specifically, these women experienced greater decreases in their selfesteem and mood when they perceived social partners (e.g., romantic partners, close friends) to be emotionally distant as well as greater boosts in their self-esteem and mood when they perceived more closeness with their social partners (Forand et al. 2010). These findings suggests that low levels of communion may be interpreted by women with appearance-based contingent self-esteem as containing implicit criticism that are directly related to their appearance, whereas high levels of communion may be perceived as conveying acceptance and praise about one‘s appearance. These women also experienced fluctuations in their selfworth when they thought that others saw them in a negative light because these negative views were perceived to be a result of their failure to be physically attractive. Studies interested in the relationship between appearance-based contingent self-esteem and body image concerns have consistently demonstrated that individuals with high appearance-based contingent self-esteem report numerous body image concerns (e.g., Noser and Zeigler-Hill 2104, Overstreet and Quinn 2012, Patrick et al. 2004, Thøgersen-Ntoumani, Ntoumanis, Cumming and Chatzisarantis 2011, Zeigler-Hill and Noser 2015). For example, individuals with high levels of appearance-based contingent self-esteem have been shown to objectify their bodies (e.g., Noser and Zeigler-Hill 2014, Overstreet and Quinn 2012), have low levels of appearance self-esteem (i.e., the degree to which an individual is satisfied with his or her appearance, independent of actual attractiveness or self-esteem in other domains; Noser and Zeigler-Hill 2014), experience low body satisfaction (Overstreet and Quinn 2012), and engage in disordered eating behaviors (Thøgersen-Ntoumani et al. 2011). Taken together, these findings suggest that individuals who base their value and on their physical appearance may be at an increased risk for body image concerns. Interest in appearance-based contingent self-esteem has led to closer examination of appearance contingences by considering specific aspects of appearance such as body weight (e.g., Clabaugh et al. 2008). Weight-based contingent self-esteem refers to the extent to which an individual bases their self-worth on their weight. Thus, the self-esteem of individuals with weight-based contingent self-esteem relies on successfully meeting or exceeding selfprescribed or external standards of body weight such that failure to meet these standards are likely to result in a decline in feelings of self-worth. Research has identified important similarities between weight-based contingent self-esteem and appearance-based contingent self-esteem such that individuals who base their self-worth on their appearance in general or their body weight more specifically report low appearance self-esteem and body satisfaction

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(e.g., O‘Driscoll and Jarry 2015, Overstreet and Quinn 2012). However, weight-based contingent self-esteem has demonstrated unique associations with outcomes directly related to body weight such as restrained eating, bulimic symptoms, and subjective weight estimates (Clabaugh et al. 2008). Taken together, these findings suggest that weight-based contingent self-esteem complements research on appearance-based contingent self-esteem by allowing researchers to examine specific appearance contingencies such as one‘s perceived weight.

APPEARANCE-BASED CONTINGENT SELF-ESTEEM, SELF-ESTEEM LEVEL, AND BODY IMAGE Although the relationship between appearance-based contingent self-esteem and body image concerns has been well-established (e.g., Noser and Zeigler-Hill 2104, Overstreet and Quinn 2012, Patrick et al. 2004), research has often failed to consider the interaction between self-esteem level and appearance-based contingencies of self-worth. More recently, researchers have started to examine how the interaction between self-esteem level and appearance-based contingencies of self-worth projects onto body image concerns (e.g., Zeigler-Hill and Noser 2015). Taking this approach is important because individuals with different combinations of self-esteem level and appearance-based contingencies may experience different body image concerns. For example, individuals who possess high levels of self-esteem in combination with appearance-based contingent self-esteem may engage in behaviors such as dieting or exercise that lead to increased body satisfaction and that may enhance or help maintain their feelings of self-worth. However, these individuals may experience a dramatic decline in their self-esteem when they fail to meet self-prescribed appearance standards (e.g., receive negative feedback about their appearance). Conversely, individuals who possess high levels of self-esteem that are not contingent upon their appearance may engage in diet and exercise behaviors for other reasons (e.g., health benefits, stress reduction) which may also result in high levels of body satisfaction (Connors and Casey 2006). However, unlike individuals with high appearance-based contingent selfesteem, these individuals would be less likely to experience a decline in their feelings of selfworth when they receive negative feedback about their appearance because their feelings of self-worth are not overly reliant on external validation about their appearance. Appearancebased contingent self-esteem may be especially problematic when combined with low selfesteem level. Individuals who possess low self-esteem and base their feelings of self-worth on their appearance may experience an increase in self-esteem when they feel attractive but these improvements are only likely to be maintained as long as they continue to feel positively about their appearance. Not surprisingly, women who possess high self-esteem tend to be more satisfied with their appearance than those women with low self-esteem (Connors and Casey 2006, Davison and McCabe 2006, Tiggemann 2005, Wojtowicz and von Ranson 2012). Interestingly, this relationship appears to be particularly true for women who possess high self-esteem in combination with appearance-based contingent self-esteem. For example, a recent study found that women with high levels of self-esteem that were contingent on their physical appearance reported higher levels of well-being when they objectified their bodies (Breines et al. 2008). These results are consistent with previous research that demonstrates contingencies

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of self-worth may lead to increases in well-being when individuals feel successful in a domain of contingency their self-worth is based. More specifically, the results of this study suggest that for women with high self-esteem that is contingent on their appearance, objectification of their bodies may be validating, whereas for others (i.e., individuals with high self-esteem that is not contingent on their appearance or individuals with low selfesteem) it may be more threatening. Notably, this study highlights the importance of appearance-based contingent self-esteem in understanding the connection between selfesteem and appearance-related outcomes. In contrast, the association between appearance-based contingent self-esteem and body image for women with low self-esteem level and high appearance-based contingent selfesteem appears to be of particular concern because these individuals have been found to report relatively high levels of body image concerns (Zeigler-Hill and Noser 2015). That is, individuals possessing low levels of self-esteem and who base their self-worth on their appearance are often dissatisfied with their physical appearance. For example, Zeigler-Hill and Noser (2015) found that women who possessed low levels of self-esteem that was contingent on their appearance reported large body image discrepancies (i.e., discrepancy between one‘s actual and ideal body size) which, in turn, predicted more disordered eating symptoms. This suggests that women who possess low levels of self-esteem and base their feelings of self-worth on their appearance may be at risk for the development of body image discrepancies and, in turn, more disordered eating symptoms. One possible explanation of these findings is that women who possess this combination of low self-esteem and appearance-based contingent self-esteem are especially vulnerable to experiencing body image concerns and related negative outcomes (e.g., disordered eating) because they may be acutely aware of their failures to meet the standards of attractiveness that they have established for themselves.

CONCLUSION The important connections between self-esteem and individuals‘ perceptions and concerns about their bodies have been the focus of numerous empirical studies. The general pattern that has emerged from these studies is that low self-esteem is often linked with more body image concerns (e.g., body dissatisfaction, body preoccupations, low levels of body appreciation). However, more recent researchers have recognized that there is more to selfesteem than simply whether it is high or low which has led to studies that have addressed other features of self-esteem such as its contingencies. Findings from these studies have highlighted the importance of appearance-based contingent self-esteem in how individuals evaluate and treat their bodies (e.g., Noser and Zeigler-Hill 2014, Overstreet and Quinn 2012, Patrick et al. 2004, Thøgersen-Ntoumani et al. 2011, Zeigler-Hill and Noser 2015). However, it is important to note that these studies have focused primarily on samples of White women in young adulthood so relatively little is known about how appearance contingencies may impact women or girls in other periods of life, men and boys, or individuals from different racial/ethnic backgrounds. Future research should aim to explore these relationships, given that important differences in preferred body image exist among these groups of individuals (e.g., men show a preference for muscular physiques; Daniel and Bridges 2010). Research

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should also aim to examine potentially important contingencies other than general appearance-based contingencies such as those based on body shape and muscularity.

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Grabe, S., Ward, L. M. and Hyde, J. S. (2008). The role of the media in body image concerns among women: a meta-analysis of experimental and correlational studies. Psychological Bulletin, 134, 460-476. Grogan, S. (2012). Body image development-Adult women. In: T. Cash (Ed.), The encyclopedia of body image and human appearance (pp. 201-206). Norfolk, VA: Elsevier. Harter, S., 2003. The development of self-representations during childhood and adolescence. In: M. R. Leary and J. P. Tangney (Eds.), Handbook of self and identity. (pp. 610-642). New York, NY: Guilford Press. Ip, K. and Jarry, J. L. (2008). Investment in body image for self-definition results in greater vulnerability to the thin media than does investment in appearance management. Body Image, 5, 59-69. Jordan, C. H. and Zeigler-Hill, V. (2013). Fragile self-esteem: The perils and pitfalls of (some) high self-esteem. In: V. Zeigler-Hill (Ed.), Self-esteem (pp. 80-98). London: Psychology Press. Josephs, R. A., Larrick, R. P., Steele, C. M. and Nisbett, R. E. (1992). Protecting the self from the negative consequences of risky decisions. Journal of Personality and Social Psychology, 62, 26-37. Kernis, M. H. (2003). Toward a conceptualization of optimal self-esteem. Psychological Inquiry, 14, 1-26. Kutob, R. M., Senf, J. H., Crago, M. and Shisslak, C. M. (2010), Concurrent and longitudinal predictors of self-esteem in elementary and middle school girls. Journal of School Health, 80, 240-248. Josephs, R. A., Larrick, R. P., Steele, C. M. and Nisbett, R. E. (1992). Protecting the self from the negative consequences of risky decisions. Journal of Personality and Social Psychology, 62, 26-37. Knee, C. R., Canevello, A., Bush, A. L. and Cook, A. (2008). Relationship-contingent selfesteem and the ups and downs of romantic relationships. Journal of Personality and Social Psychology, 95, 608-627. Langlois, J. H., Kalakanis, L., Rubenstein, A. J., Larson, A., Hallam, M. and Smoot, M. (2000). Maxims or myths of beauty? A metaanalytic and theoretical review. Psychological Bulletin, 126, 390-423. Ledoux, T., Winterowd, C., Richardson, T. and Clark, J. D. (2010). Relationship of negative self-schemas and attachment styles with appearance schemas. Body Image, 7, 213-217. Maphis, L. E., Martz, D. M., Bergman, S. S., Curtin, L. A. and Webb, R. M. (2013). Body size dissatisfaction and avoidance behavior: How gender, age, ethnicity, and relative clothing size predict what some won‘t try. Body Image, 10, 361-368. Myers, T. A. and Crowther, J. H. (2009). Social comparison as a predictor of body dissatisfaction: A meta-analytic review. Journal of Abnormal Psychology, 118, 683-698. Noser, A. and Zeigler-Hill, V. (2014). Investing in the ideal: Does objectified body consciousness mediate the association between appearance contingent self-worth and appearance self-esteem in women? Body Image, 11, 119-125. O‘Dea, J. A. (2012). Body image and self-esteem. In: T. Cash (Ed.), The encyclopedia of body image and human appearance (pp. 141-147). Norfolk, VA: Elsevier.

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O‘Driscoll, L. M. and Jarry, J. L. (2015). Interpersonal rejection results in increased appearance satisfaction for women who rely on body weight for self-worth. Body Image, 12, 36-43. Overstreet, N. M. and Quinn, D. M. (2012). Contingencies of Self-Worth and Appearance Concerns Do Domains of Self-Worth Matter? Psychology of Women Quarterly, 36, 314325. Patrick, H., Neighbors, C. and Knee, C. R. (2004). Appearance-related social comparisons: The role of contingent self-esteem and self-perceptions of attractiveness. Personality and Social Psychology Bulletin, 30, 501-514. Paxton, S. J., Eisenberg, M. E. and Neumark-Sztainer, D. (2006). Prospective predictors of body dissatisfaction in adolescent girls and boys: a five-year longitudinal study. Developmental Psychology, 42, 888-899. Pyszcynski, T., Greenberg, J. and Goldenberg, J. L. (2003). Freedom versus fear: On the defense, growth, and expansion of the self. In: M. R. Leary and J. P. Tangney (Eds.), Handbook of self and identity (pp. 314-343). New York, NY: Guilford Press. Rodin, J., Silberstein, L. and Striegel-Moore, R. (1984). Women and weight: A normative discontent. In: T. B. Sondregger (Ed.), Psychology and gender: Nebraska symposium on motivation (pp. 267-307). Lincoln, NE: University of Nebraska Press. Shea, M. E. and Pritchard, M. E. (2007). Is self-esteem the primary predictor of disordered eating? Personality and Individual Differences, 42, 1527-1537. Stice, E. and Bearman, S. K. (2001). Body-image and eating disturbances prospectively predict increases in depressive symptoms in adolescent girls: A growth curve analysis. Developmental Psychology, 37, 597-607. Stice, E. and Shaw, H. E. (2002). Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. Journal of Psychosomatic Research, 53, 985-993. Thøgersen-Ntoumani, C., Ntoumanis, N., Cumming, J. and Chatzisarantis, N. L. (2011). When feeling attractive matters too much to women: A process underpinning the relation between psychological need satisfaction and unhealthy weight control behaviors. Motivation and Emotion, 35, 413-422. Tiggemann, M. (2005). Body dissatisfaction and adolescent self-esteem: Prospective findings. Body Image, 2, 129-135. Tiggemann, M. (2012). Sociocultural perspectives on body image. The encyclopedia of body image and human appearance (pp. 758-765). Norfolk, VA: Elsevier. Tylka, T. L. and Wood-Barcalow, N. L. (2015). The Body Appreciation Scale-2: Item refinement and psychometric evaluation. Body Image, 12, 53-67. Wojtowicz, A. E. and von Ranson, K. M. (2012). Weighing in on risk factors for body dissatisfaction: A one-year prospective study of middle-adolescent girls. Body Image, 9, 20-30. Zeigler-Hill, V. (2013). Self-esteem. London: Psychology Press. Zeigler-Hill, V. (2011). The connections between self-esteem and psychopathology. Journal of Contemporary Psychotherapy, 41, 157-164. Zeigler-Hill, V. and Noser, A. (2015). Will I ever think I‘m thin enough? A moderated mediation study of women‘s contingent self-esteem, body image discrepancies, and disordered eating. Psychology of Women Quarterly, 39, 109-118.

In: Body Image Editor: Rafael Vargas

ISBN: 978-1-63483-870-2 © 2016 Nova Science Publishers, Inc.

Chapter 2

FROM BODY DISSATISFACTION TO EMBODIED CONNECTION: EXPLORING YOUNG WOMEN’S BODY EXPERIENCES Satu Liimakka, PhD Department of Social Research, University of Helsinki, Helsinki, Finland

ABSTRACT This chapter provides a discussion on the commonness of body dissatisfaction among contemporary Western young women and suggests re-embodiment as a means of transforming this experience. The chapter is based on a study exploring young Finnish women‘s body experiences as well as their possibilities for embodied agency as located in the socio-cultural context. The young women described experiences of body dissatisfaction and practices of body monitoring, and often related these to the standard created by the current Western body ideal. The young women engaged in cultural criticism towards the body ideal, yet they could not resist the impact the ideal had on their personal body relation. This caused feelings of dissatisfaction with their selves. However, finding a new body-mind connection as well as a body-world connection enabled a more positively experienced body relation for some young women. The chapter argues that mere strategies of the mind alone are inefficient in combating body dissatisfaction – in addition, a transformation on the level of the body is needed. Finding an embodied connectedness within oneself and in one‘s relation to the world can transform the young woman‘s self-critical and anxiety-laden body relation.

INTRODUCTION Experiences of body dissatisfaction are common among girls and women in the Western world (Grogan, 2008). Body dissatisfaction is more commonly reported by girls and women 

Email: [email protected]

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than by boys and men (Grogan, 2008). In Finland, as well, girls and young women commonly express feeling dissatisfied with their bodies (Oksanen, 2005; Ålgars et al. 2009). Body dissatisfaction is experienced by women of all ages, throughout their lifespan (Johnston, Reilly, & Kremer, 2004; Tiggemann & Lynch, 2001; Tiggemann, 2004). Young women particularly are prone to experience dissatisfaction with their bodies and habitually engage in body monitoring practices (Frost, 2001; Grogan, 2008; Tiggemann & Lynch, 2001). Young women in their 20s and 30s report higher levels of body monitoring, appearance anxiety and disordered eating practices than older women (Greenleaf, 2005; Tiggemann & Lynch, 2001). Further, in comparison to older women, young women attach more importance to their body weight and appearance (Johnston et al. 2004; Tiggemann, 2004) and are less likely to forget their self-consciousness during exercise (Greenleaf, 2005). Scholars have argued that the experiences of body dissatisfaction and body anxiety have their roots in the contemporary highly visualized and consumerist Western culture, driven by beauty imperatives targeting particularly women (Bordo, 1993; Fredrickson & Roberts, 1997). In this cultural context, the self is a continuous bodily project (Shilling, 1993), lived to a great extent as a bodily representation (Turner, 1996), a spectacle (Tseëlon, 1995). This creates an ―externally‖ focused body experience. Young women particularly are ushered towards experiencing and moulding their bodies as visual representations. Thus, young women‘s bodies become lived visual spaces presented to an outside audience (Frost, 2005; Tseëlon, 1995). One‘s own body is constantly compared to the cultural body ideal. The standard created by the cultural body ideal has real social and material consequences for those whose bodies resemble the ideal as well as for those whose bodies differ from the ideal. For example, in Finland, overweight women receive a considerably smaller income than thin women (Kauppinen & Anttila, 2005; Sarlio-Lähteenkorva, Silventoinen, & Lahelma, 2004). Similar income differences were not found among men (Sarlio-Lähteenkorva et al. 2004). Experiencing one‘s body as a representation, a lived visual space, may impact the individual young woman‘s relation to her body and surroundings in several ways. Objectification theory proposes that women learn to internalize their societal bodily objectification as self-objectification. This can lead to habitual body monitoring, feelings of shame and anxiety, and an increased risk for eating disorders as well as reduced opportunities for experiencing peak motivational states and a diminished awareness of internal bodily states (Fredrickson & Roberts, 1997). Young (2005) presents female bodily comportment and motility in an objectifying society as being characterized by three modalities: an ambiguous transcendence, an inhibited intentionality and a discontinuous unity with its surroundings. Her phenomenological analysis implies that a woman‘s body relation is linked to her world relation, impacting her ability to function in and unite with her surroundings. Yet not every young woman reports experiencing body dissatisfaction (Wood-Barcalow, Tylka, & Augustus-Horvath, 2010). Further, an individual‘s body image may change within time (Tiggemann, 2004). Could the common experience of body dissatisfaction among young women be transformed into a more empowering body relation? Based on my study (Liimakka, 2013), this chapter ponders the possibility to transform one‘s body experience within or despite one‘s socio-cultural surroundings. My study explored qualitatively young Finnish women‘s body experiences as well as their possibilities for embodied agency as located in the socio-cultural context. By focusing on agency, I aimed to explore the possibilities of individuals to change their learnt body habit(us), that is, their learned habitual way of being as inscribed in their bodies (Bourdieu, 1977, 1990, 2000;

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Merleau-Ponty, 1945/2003). The study draws from the phenomenological perspectives presented by Merleau-Ponty and Bourdieu. They argued that since we are our bodies (Merleau-Ponty, 1945/2003), what is learned by our bodies becomes something that we are (Bourdieu, 1990, p. 73). Thus embodiment forms the fundamental basis for one‘s self. Our bodies bring our history to all our present-day experiences, framing the range of options and experiences that are available to us (Bourdieu, 1977, 1990, 2000). Since social order is inscribed in the body, simply changing how one thinks is not enough to change a bodily habitus – a bodily countertraining is needed (Bourdieu, 2000). As argued by Merleau-Ponty (1945/2003), our bodies carry the potential for agency and change.

MATERIAL AND METHOD The participants of the study are young, white, Finnish women who are studying in upper secondary school or university. The study is comprised of three sub-studies, each targeting a different sub-group of young women and partly utilizing different methods in data collection and analysis. In order to locate individual body experiences within socio-cultural surroundings I utilized in the study both collectively and individually produced accounts of body experience, that is, focus group discussions and individually written accounts. The participants of the first sub-study were 19 young Finnish women, aged between 17 and 18 years, studying in upper secondary schools in Helsinki. The data consists of three focus group discussions and 22 individually written accounts. The research material was collected in 2001. The group discussions focused on the themes of physical appearance, cultural body ideals, the body within social relations and everyday embodiment in general. To facilitate the group discussions, at the beginning of each discussion I showed five images of women cut out of magazines and asked the young women to comment on them. The length of the focus group discussions ranged from 45 to 90 minutes. The group discussions were transcribed verbatim. After the group discussion I asked the young women to write about their body experiences and gave them 13 topics to choose from. Most young women wrote on one topic, but three of them wrote two separate pieces about different topics. The length of the written accounts varied from a few sentences to two pages. The participants of the second sub-study were 16 Finnish first and second year students studying social sciences, most with a major in social psychology, in a university in southern Finland. Their age ranged from 19 to 23 years. The data is comprised of four focus group discussions. Of the 16 participants, 14 were women and 2 men. Two focus groups were comprised of women only, and two groups included one man. The focus groups were conducted in 2004 in the university facilities. The focus group participants were presented ten statements focusing on embodiment and spatiality in order to provoke lively discussion and debate. They were asked to comment on the statements. The length of the focus group discussions ranged from one to two hours. The focus group discussions were transcribed verbatim. The participants of the third sub-study were 13 students of women‘s studies from three different Finnish universities. They were all young women aged between 23 and 28 years. The data consists of 13 written accounts about body experience. The major disciplines of the young women ranged from the humanities and social sciences to theology – at the time,

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women‘s studies could not be studied as a major subject in Finland. All of the young women had been studying women‘s studies to some extent, and the majority of them had completed the basic courses or more in women‘s studies. The written accounts were collected at a twoday national meeting of students of women‘s studies as part of a workshop on body experience, which I directed in 2002. I utilized the workshop as a context for collecting data, yet the workshop was not originally organized for research purposes. I began the workshop with a short presentation, in which I discussed different perspectives on women‘s embodiment. After this, the participants engaged in a reflective activity of writing accounts of bodily experience, followed by a general discussion. The participants were asked to write under the title ―My experience of my body.‖ The participants had the choice of keeping their written accounts to themselves or allowing them, anonymously, to be included in my study. Slightly more than half of the participants permitted me to use their accounts. The study includes my own written account from the workshop. The length of the written accounts ranged from one to three pages. The data analysis in the first and second sub-study utilized grounded theory–inspired coding, as conceptualized by Willig (2008). I followed the grounded theory approach developed by Strauss and Corbin (Strauss & Corbin, 1998), but only utilized their suggested techniques of coding and categorizing. This choice of analysis method allowed me to contextualize the produced verbal and written accounts within the group dynamics emerging in the social contexts of focus groups. In the third sub-study the data consisted of individually written accounts only. I analysed these written accounts using interpretative phenomenological analysis (IPA) (Smith, Flowers, & Larkin, 2009). This method allowed a detailed phenomenological analysis of individually produced experiential accounts. It further allowed a focus on both the shared and particular aspects of the experiential accounts. In this chapter, the study participants are mostly referred to as a group termed ―young women,‖ as the chapter mostly focuses on issues that were reported by the participants in all three sub-studies. Particular sub-groups of young women (e.g., students of women‘s studies) are only referred to when necessary. All the data excerpts in this chapter are from the written accounts, as this chapter focuses on personal accounts of body experiences. Similar themes were often discussed in the focus group discussions, but the tone and content of expression was more personal in the individually written accounts. Next, I present the main results of the study: the anxiety-laden body relation of many young women, consisting of body dissatisfaction and self-critical body surveillance; the young women‘s attempts at agency and resistance in overcoming these feelings and their consequent feelings of dissatisfaction with the self when resistance failed; and a newly-found embodied connection with one‘s body and the surrounding world, as reported by a few young women.

BODY DISSATISFACTION AND SELF-CRITICAL BODY SURVEILLANCE A central part of the young women‘s accounts in the study was their personal relation to the socio-cultural ideal of a beautiful, slim and fit body. For many, this relation contained experiences of dissatisfaction with the body and attempts to shape their bodies to fit the

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cultural norm. Some young women described contextual fluctuations in their body relation. In some situations the young woman might feel satisfied with her body, while in other situations and contexts feelings of dissatisfaction with her body dominated. Some young women had set themselves an aim: they wanted to overcome the feelings of dissatisfaction with their bodies and learn to accept their bodies. When I spend a day with my boyfriend, for example, I feel I am good-looking, but as soon as I watch television or read magazines I feel again I am somehow inadequate. (Ella, upper secondary school) When my breasts have fully developed, I have decided to be satisfied with my body, even though I don‘t like my crooked knees, thick thighs, large buttocks, skinny arms and slouch. This is because only I notice all this in myself, the others notice only my small breasts. (Anita, upper secondary school)

The social surroundings were described a multiple role in impacting a young woman‘s body relation (Liimakka, 2008). Through their comments and attention, other people could enhance a young woman‘s positive or negative feelings about her body. Even positive comments about one‘s body were sometimes reported having negative consequences, as they highlighted the importance of physical appearance and increased the already high awareness of one‘s physical appearance. Many of the young women described themselves as engaging in self-critical surveillance of their bodies, either momentarily, in particular situations, or even continuously. For some young women, their self-critical body surveillance severely intervened with their daily lives. Most of the time my body is about appearance, I walk on the street and try to hide that I am not thin. It takes a lot of energy. I think about it too much. (Helena, university, women‘s studies) I myself am not able to ‗forget‘ about my body even in bed, though that is supposed to be a place where issues of appearance are forgotten, and the contact between two people and tenderness have a higher priority. Even if I had sex with a familiar and safe boyfriend, I cannot help but to think ―how do I look like in this and this position,‖ and ―how much cellulite does my boyfriend see.‖ And still I know that he does not care about my extra kilograms or my bulges. (Taru, upper secondary school, quotes in the original)

The young women‘s self-critical body surveillance was based on their expectations, assumptions and fears about how other people might perceive their bodies. Even though the young woman might know that other people do not perceive and judge her body critically, her fear remained. Thus, many young women lived their bodies as visual spaces (Frost, 2005), presented to an outside ―audience‖ (Tseëlon, 1995).

CULTURAL CRITICISM AND SELF CRITICISM The young women also described attempts to resist the pressures to comply with the cultural body ideal and experiences of dissatisfaction with the self when resistance failed. The young women defined the current cultural body ideal of a slim, fit and beautiful female body

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as unrealistic and even unhealthy. The current cultural body ideal and the practices of trying to acquire the ideal body were mostly criticized in the focus group discussions. In the individually written accounts, the young women often ―confessed‖ to trying to achieve the ideal body or feeling that they should try to achieve it, despite their criticism of the ideal. The young women engaged in several strategies of resisting the cultural body ideal: They highlighted the individuality of their own bodies in opposition to the cultural ideal as a mass product, defined the culturally ideal womanhood as a spectacle, laughed together as a group at the cultural ideal and at their own attempts to achieve the ideal and posed the cultural body ideal as a marketing strategy as well as a gendered ideal rooted in societal power relations. However, criticising the body ideal did not seem to free the young women from pressures to comply with the ideal. Consequently, the young women criticised themselves for not being able to resist the cultural body ideal. Overall, cultural criticism and self criticism intertwined in the young women‘s accounts. The intertwining of cultural criticism and self criticism produced an experience of a faulty self. The faulty self is perceived as ―vain‖ and having problems ―between her ears.‖ In addition to the standard created by the cultural body ideal, acceptance of one‘s body the way it is had become another body norm to adhere to. ―One must feel good about one‘s body and accept it, especially in spite of the temptation of the contrary view offered by the media.‖ I am aware of this and I have tried to do that even though the statement is naïve. I can decide to be self-confident and unconstrained, but if it were that simple… (Kerttu, university, women‘s studies, quotes in the original) I am still so vain that I see it as a problem that over the past two years I have gained 4–5 kilos of weight, which I cannot get rid of just like that. --- I don‘t see that as a woman I should submit to beauty ideals, but they just easily have an influence, even though one tries to be aware of it. (Jonna, university, women‘s studies) Always, if I have to eat in a public place (for example, a train), I feel that people are thinking, ―Is she eating again, you can already see from her that she has been at home at dinnertime.‖ I know I am not fat, and I have no other problem with weight but the one between my ears. And even though I know it is crazy to think the way I just explained above, that is just the way it is. (Minna, upper secondary school, quotes and parenthesis in the original)

The young women‘s accounts seemed to draw from an ideology of collective or individual resistance to objectifying body practices: one should not surrender or comply with the cultural body ideal. This ideology produced a continuous moral self-evaluation in terms of the amount of one‘s resistance or surrender (Liimakka, 2011a). It further produced a critical evaluation of one‘s own and other people‘s motives for engaging in body projects (Liimakka, 2014). The ideology of resistance is based on the ideal of individual autonomy and agency in relation to the cultural body ideal. This individualistic understanding of agency, defined by me as Cartesian agency (Liimakka, 2011a), emphasizes the young woman‘s independence from culture, other people and her own body. Cartesian agency lies within the assumed superiority and activity of the mind in relation to the inferior passivity of the body: the young woman needs to change the way her mind perceives her body. This was something that many

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of the young women expressed that they attempt to do. However, this study, as well as other studies (Markula, 1995; Rubin, Nemeroff, & Russo, 2004), shows that changing one‘s thinking does not necessarily change one‘s feelings about the body. Instead, it is likely that the attempts at Cartesian agency work to maintain – or even enhance – the state of bodily alienation that apparently characterizes many young women‘s body relations. Overall, the young women were prone to experience both dissatisfaction with their bodies for not being thin and beautiful enough and dissatisfaction with their selves for not being resistant and strong enough in relation to the cultural body ideal.

EMBODIED CONNECTIONS Some of the young women also described empowering experiences of embodied connection, that is, experiences of living their bodies as connected to their minds and/or the surrounding world. These descriptions consisted of experiences of overcoming the mind/body dichotomy and experiences of bodily connection or merging with the surrounding world. In these descriptions, the body was a source of empowerment, pleasure and connection instead of appearing mainly as a problem. These accounts were produced by the students of women‘s studies. Some of the students of women‘s studies described their realization of ―I am my body‖ as a key to a better self-body relation (Liimakka, 2011b). Their previous, rather dualist experience of a separate, problematic body was replaced with the experience of mind-body wholeness. My most important insight about my body, gained after I had started to do sport and exercise, concerned the feeling that I am my body: thus a replacement of a dichotomized Cartesian subjectivity by an over-all self-identity as a unity. (Kerttu, university, women‘s studies) Strangely, when I was at the deepest state of my illness I sometimes felt I could overcome the mind/body dichotomy: the question is not that ―my body is this and that‖ and I relate to it like this and I do this to it, but that, my body is me and I am my body. Maybe my recovery began from that experience. (Anni, university, women‘s studies, quotes in the original)

Some of the women‘s studies students also described positive experiences in which there was no clear dividing line between their bodies and the world around them. It [my body] is me. --- But the way I experience other people‘s bodies and beings becomes part of me all the time. It is linked to my experience and feeling of myself, I long to be close to other bodies, people, animals, plants, the earth, the body of the sea. (Sini, university, women‘s studies) During dance lessons I am so merged with everything and myself, and tears come to my eyes. Then I am the most satisfied with myself, I am myself. --- my body is like an instrument among all the saxophones, trumpets, piano, bongo drums, flutes, and violins, I am being looked at, but most of all I look at myself --- (Helena, university, women‘s studies)

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In the young women‘s accounts, the body-self relation seemed to be intimately linked to the body-world relation. In these descriptions, something changed in the way the young women typically inhabit their bodies and the way they inhabit the world as embodied agents. Their self experience was transformed, at least momentarily, from an experience of ―what I should be‖ or ―what I should look like‖ to an experience of ―I am,‖ I exist. The described experiences of embodied connection lacked the dimension of a normative standard created by the cultural body ideal: the young woman was not focusing on what she should look like when she experienced herself as being connected with her body and/or bodily merged with her surroundings. The experiences of mind-body connection and bodyworld connection formed a counter experience to what Young (2005, pp. 36–38) calls a typical feminine bodily orientation: an experience of a bodily ―I cannot‖ and the body‘s discontinuous unity with itself and its surroundings. They further enabled the young women to experience peak motivational states (Fredrickson & Roberts, 1997).

CONCLUSION The traditional Cartesian mind/body –dichotomy formed an implicit frame for all the young women‘s accounts in the current study. Further, the students of women‘s studies discussed this dichotomy explicitly. The mind/body –dichotomy is a culturally available discursive resource in describing physical experience (Gillies et al. 2004). As such, it forms a potential frame for experiencing one‘s body. Many of the young women in this study described experiences of being dissatisfied with their bodies and engaging in body monitoring practices. Often the young women related their body dissatisfaction to the normative standard produced by the current cultural body ideal. In current Western culture, the potential body as described by the cultural imagery has become the criterion for one‘s own body (Bordo, 1993). Cultural body norms pose a continuous threat of one‘s body appearing as faulty and in need of correction (Bordo, 1993, Fredrickson & Roberts, 1997). Body dissatisfaction arises out of striving to reach the impossible body standards. The typically suggested solution to the problem of constant body dissatisfaction and body monitoring, also sought by many of the young women in the current study, is cultural criticism in relation to the dominant cultural body ideal. The young women aimed to resist the cultural body ideal and its influence on their personal body relation. Yet, when their resistance failed, the young women experienced dissatisfaction with their selves. Another solution to the problem of body dissatisfaction and body surveillance, as described by some of the students of women‘s studies, was finding a new bodily connectedness. In their accounts, the key to a better body relation seems to have been becoming more embodied – a positively experienced re-embodiment. They described finding a better body-mind connection as well as a bodily connection to the surrounding world or even a state of bodily merging with their surroundings. Finding a new embodied connection can happen in many ways, such as through physical activity or nature experience. The empowering body experiences described by some of the students of women‘s studies likely result from a combination of new experiences of physicality and their previous familiarization with feminist ideas. Feminism might enable women to identify and problematize their bodily alienation as a gendered experience, and consequently, seek out ways to redefine and

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reconnect with their bodies (Scott & Derry, 2005). Yet critical feminist awareness as such is not enough to combat feelings of body dissatisfaction arising in relation to the cultural body ideal (Murnen and Smolak, 2009; Rubin, Nemeroff, & Russo, 2004) – a bodily countertraining is needed (Bourdieu, 2000). For example, physical activity can provide young women with possibilities to restructure their bodily habituality (Grimshaw, 1999), creating a new sense of actively being ―in‖ one‘s body (Scott & Derry, 2005). In their habitual body relation, many young women constantly compare their bodies to the normative cultural body ideal and find their own bodies lacking in comparison to the body perfection, thus producing experiences of dissatisfaction. Many young women are further attuned to self-critically monitoring their bodies in the way they expect the (assumedly critical) others to be looking at their bodies. The experiences of a body-mind connection and of bodily merging with one‘s surroundings form a ―counter experience‖ to the experiences of body dissatisfaction and the practices of body surveillance. During the moments of embodied connection the habitual experience of body dissatisfaction and body monitoring, consisting of looking at one‘s body from the outside, is replaced by an experience of being in one‘s body. Instead of one‘s mind critically evaluating the body, as if being outside the body, the young woman can experience herself and her surroundings from within the body (Scott & Derry, 2005). In this study, the explicit descriptions of body-mind connection and body-world connection appeared only in the written accounts by the students of women‘s studies. This may be partly due to their background in women‘s studies as well as to the informal context and open formulation in the collection of their accounts. Due to their likely familiarity with feminist theories of the body, the students of women‘s studies might have had a more conscious and reflexive relation to their own embodiment. The mind/body –dichotomy is explicitly discussed and problematized in the feminist theories of the body. Consequently, the dichotomy might have been more readily available for the students of women‘s studies than for other young women as an explicit frame for describing body experiences. Whether other young women would provide similar accounts if prompted with the mind/body –dichotomy remains a topic for further studies. This study suggests that a negatively experienced habitual body relation consisting of body dissatisfaction and body monitoring can be modified, yet mere strategies of the mind alone are insufficient to effect this change. With mere critical reflexivity its transformative potential remains in the sphere of the mind, leaving the individual‘s embodied feelings and dispositions (Bourdieu, 2000) as well as embodied perceptions about the self and the world (Merleau-Ponty, 1945/2003) intact. Embodied experience may include dimensions that remain beyond articulation and conscious processes of reflexive self-monitoring (McNay, 2000). Instead, finding a new body-mind connection as well as a new body-world connection can transform a young woman‘s habitual body relation. Though experienced by many and produced collectively, the experience of body dissatisfaction as such is a rather individualistic state, as the young woman‘s mind is focused on the faults and inadequacies of her individual body. In comparison, experiencing an embodied connection to the surrounding world enables the young woman to stretch out to the world with her body. This study highlights the importance of the body itself in combating feelings of body dissatisfaction and habitual practices of self-critical body monitoring. In developing educative and/or therapeutic body image interventions and empowerment programs, a more bodily based approach should be utilized, in combination with providing tools for cultural criticism.

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Body image interventions and empowerment programs could incorporate a combination of encouraging embodied connections (e.g., physical activity, dance, nature walks) and cultural criticism (e.g., workshops, facilitated group discussions). Physical activities should offer enough ―flow‖ experiences to allow the young women momentarily to forget to carry out body surveillance. Instead of focusing on measures and ideals directly linked with external physical appearances, such as body weight, health professionals and other professional working with young women could focus on enabling young women to find positive corporeal experiences of being in their bodies and bodily connecting with the world. Leisure time practices emphasizing body-mind wholeness, such as yoga, may further provide possibilities for young women to find an embodied connection to their own bodies and the surrounding world.

REFERENCES Ålgars, M., Santtila, P., Varjonen, M., Witting, K., Johansson, A., Jern, P., & Sandnabba, N. K. (2009). The adult body: How age, gender, and body mass index are related to body image. Journal of Aging and Health, 21(8), 1112–1132. Bordo, S. (1993). Unbearable weight: Feminism, western culture, and the body. Berkeley: University of California Press. Bourdieu, P. (1977). Outline of a theory of practice. Cambridge: Cambridge University Press. Bourdieu, P. (1990). The logic of practice. Stanford: Stanford University Press. Bourdieu, P. (2000). Pascalian meditations. Cambridge: Polity. Fredrickson, B. L., & Roberts, T.-A. (1997). Objectification theory: Toward understanding women‘s lived experiences and mental health risks. Psychology of Women Quarterly, 21(2), 173–206. Frost, L. (2001). Young women and the body: A feminist sociology. London: Palgrave. Frost, L. (2005). Theorizing the young woman in the body. Body & Society, 11(1), 63–85. Gillies, A., Harden, A., Johnson, K., Reavey, P., Strange, V., & Willig, C. (2004). Women‘s collective constructions of embodied practices through memory work: Cartesian dualism in memories of sweating and pain. British Journal of Social Psychology, 43(1), 99–112. Greenleaf, C. (2005). Self-objectification among physically active women. Sex Roles, 52(1/2), 51–62. Grimshaw, J. (1999). Working out with Merleau-Ponty. In J. Arthurs & J. Grimshaw (Eds.), Women’s bodies: Discipline and transgression (pp. 91–116). London: Cassell. Grogan, S. (2008). Body image: Understanding body dissatisfaction in men, women and children. London: Routledge. Johnston, O., Reilly, J., & Kremer, J. (2004). Women‘s experiences of appearance concern and body control across the lifespan: Challenging accepted wisdom. Journal of Health Psychology, 9(3), 397–410. Kauppinen, K., & Anttila, E. (2005). Onko painolla väliä: hoikat, lihavat ja normaalipainoiset naiset työelämän murroksessa? [Does body weight matter? Thin, fat and normal weight women in the changing work life]. Työ ja ihminen, 19(2), 239–256. Liimakka, S. (2008). The influence of cultural images and other people on young women‘s embodied agency. Young – Nordic Journal of Youth Research, 16(2), 131–152.

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Liimakka, S. (2011a). Cartesian and corporeal agency: Women‘s studies students‘ reflections on body experience. Gender and Education, 23(7), 811–823. Liimakka, S. (2011b). ―I am my body‖: Objectification, empowering embodiment, and physical activity in women‘s studies students‘ accounts. Sociology of Sport Journal, 28(4), 441–460. Liimakka, S. (2013). Re-embodied: Young women, the body quest and agency in the culture of appearances. Doctoral thesis. Department of Social Research, University of Helsinki, Finland. Liimakka, S. (2014). Healthy appearances – distorted body images? Young adults negotiating body motives. Journal of Health Psychology, 19(2), 230–241. Markula, P. (1995). Firm but shapely, fit but sexy, strong but thin: The postmodern aerobicizing female bodies. Sociology of Sport Journal, 12(4), 424–453. McNay, L. (2000). Gender and agency: Reconfiguring the subject in feminist and social theory. Cambridge: Polity Press. Merleau-Ponty, M. (2003). Phenomenology of perception. London: Routledge. (Orig. Phénoménologie de la perception, 1945). Murnen, S. K., & Smolak, L. (2009). Are feminist women protected from body image problems? A meta-analytic review of relevant research. Sex Roles, 60(3–4), 186–197. Oksanen, A. (2005). Bodies in chains: Consumer culture as black pedagogy and body dissatisfaction among Finnish, Swedish and Norwegian children. In T. Hoikkala, P. Hakkarainen, & S. Laine (Eds.), Beyond health literacy – Youth cultures, prevention and policy (pp. 63–88). Helsinki: Finnish Youth Research Network. Rubin, L. R., Nemeroff, C. J., & Russo, N. F. (2004). Exploring feminist women‘s body consciousness. Psychology of Women Quarterly, 28(1), 27–37. Sarlio-Lähteenkorva, S., Silventoinen, K., & Lahelma, E. (2004). Relative weight and income at different levels of socioeconomic status. American Journal of Public Health, 94(3), 468–472. Scott, B. A., & Derry, J. A. (2005). Women IN their bodies: Challenging objectification through experiential learning. Women’s Studies Quarterly, 33(1/2), 188–209. Shilling, C. (1993). The body and social theory. London: Sage. Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis: Theory, method and research. London: Sage. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory. London: Sage. Tiggemann, M. (2004). Body image across the adult life span: Stability and change. Body Image, 1(1), 29–41. Tiggemann, M., & Lynch, J. E. (2001). Body image across the life span in adult women: The role of self-objectification. Developmental Psychology, 37(2), 243–253. Tseëlon, E. (1995). The masque of femininity: The presentation of woman in everyday life. London: Sage. Turner, B. S. (1996). The body and society: Explorations in social theory. London: Sage. (Orig. 1984). Willig, C. (2008b). Introducing qualitative research in psychology: Adventures in theory and method (2nd ed.). Maidenhead: Open University Press / McGraw Hill.

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Wood-Barcalow, N. L., Tylka, T. L., & Augustus-Horvath, C. L. (2010). ―But I like my body‖: Positive body image characteristics and a holistic model for young-adult women. Body Image, 7(2), 106–116. Young, I. M. (2005). On female body experience: “Throwing like a girl” and other essays. Oxford: Oxford University Press.

In: Body Image Editor: Rafael Vargas

ISBN: 978-1-63483-870-2 © 2016 Nova Science Publishers, Inc.

Chapter 3

ASSOCIATIONS BETWEEN RACISM, EMOTIONAL OVEREATING, AND APPEARANCE SATISFACTION AMONG BLACK WOMEN Christina M. Capodilupo1 and Kristin M. Smith2 1

Teachers College, Columbia University, NY, US 2 University of Hartford, West Hartford, CT, US

ABSTRACT The objective of the current study was to explore the relationships between appearance satisfaction, emotional overeating, experiences of racism, and BMI among Black and African American women. In this community-based sample (N=404), women (mean age: 39) completed the Emotional Overeating Questionnaire, the Daily Life Experiences Questionnaire-Racial Hassles, and an appearance satisfaction and demographic questionnaire that were author created. Results indicate that women who were less satisfied with their appearance (a) engaged in more emotional overeating behavior, (b) had higher BMI‘s, and (c) indicated a greater influence of Black men‘s aesthetic preferences on their body image. When controlling for BMI, daily experiences of racism was a positive predictor of emotional overeating. Findings underscore the importance of including culturally-relevant variables in research and clinical work that explores women of color‘s body image and eating habits.

Keywords: Race, body image, binge eating, racism, African American women

LITERATURE REVIEW Black Women, Body Image, and Binge Eating To date, most empirical research of eating pathology has looked at theoretical models that were originally developed to explain eating problems among White women (Kelly et al., 2011). The focus has primarily been on variables such as internalization and pursuit of a thin

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ideal, body dissatisfaction that may result from a discrepancy between the thin body ideal and one‘s own body, and cultural pressure to be thin (Harrington, Crowther, Payne Henrickson, & Mickelson, 2006). However, research has suggested that compared to White women, AfricanAmerican women tend to exhibit a greater flexibility in the appraisal of the ideal body image and report more often that ―looking good‖ is more related to personality and public image than to body weight (Russell & Cox, 2003). Hence, the definition of attractiveness for African American women is multifactorial and may include factors such as attitude, how one carries herself, hair and skin tone, extending beyond a small body size (Davis, Sbroco, OdomsYoung, & Smith, 2010). Research shows that approximately 50% of African American adult women are obese as indicated by the Body Mass Index (BMI) measure (Center for Disease Control and Prevention [CDC], 2010). The rates of obesity as measured by a BMI of equal to 40 or greater are substantially higher in African American women than in all other racial or ethnic groups (Mazzeo, Saunders, & Mitchell, 2005). Research has shown that higher BMI is associated with greater binge eating pathology (Napolitano & Hines, 2010). Furthermore, StriegelMoore and Smolak (2000) found that Black women were significantly more likely to engage in the behavior of recurrent binge eating than their White counterparts. Therefore, although eating pathology has customarily been studied under the theoretical models that pertain to pathology in relationship to the thin ideal, African American women may be overeating or binge eating in pathological ways that have gone unnoticed and have been understudied. Binge eating behaviors may play a role in contributing to or maintaining obesity and Black women may be less likely to receive treatment for binge eating disorder which creates a significant public health concern (Pike, Dohm, Striegel-Moore, Wilfley, & Fairburn, 2001). Therefore, it is of paramount importance for researchers and clinicians to study and understand the underlying factors that may contribute to overeating and eating pathology for African American women. It has been postulated that emotional distress may contribute to overeating and weight gain in women of all racial and ethnic backgrounds (Fitzgibbon et al., 1998). An investigation of binge eating pathology in Black, White and Hispanic women and found a trend for all ethnic groups, such that more depressed women exhibited more severe binge eating. Interestingly, research has shown that Black women who meet the criteria for binge eating disorder have reported lower levels of anxiety prior to binge eating (Napolitano & Hines, 2010). However, Harrington, Crowther, and Shipherd (2010) found that Black women who more intensely internalized the cultural ideology of the ―Strong Black Woman‖ (i.e., being an individual that is capable of handling all challenges with minimal acknowledgment of emotional weakness) were found to have an increased rate of binge eating as a culturally and socially acceptable means of emotional avoidance and selfmedication. Hence, it is possible that the binge eating episodes alone may be more culturally accepted for Black women and their anxiety levels are not recognized prior to overeating. However, Mazzeo et al., (2005) suggest that anxiety is a direct predictor of binge eating in African American women and is a likely pathway and mechanism for a binge-eating episode.

The Role of Black Men Mazzeo et al. (2005) postulate that African American women who experience body dissatisfaction are at an increased risk for binge eating through the mechanism of negative

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affect. Therefore, if research suggests that Black women may binge eat in response to anxiety or negative affect, it is imperative to identify sources of anxiety that are specific to the lives of Black women. One possible source of anxiety for Black women that may increase the risk of developing a maladaptive relationship with food is the role of Black men. Calogero (2004) found that women may be deeply affected by the way in which they feel they are perceived by men; at minimum, the anticipation of even a simple look from a male was found to elicit body anxiety and appearance concerns for women. Although researchers suggest that Black women are protected from body image dissatisfaction due to the lack of internalization of the thin ideal (Davis et al., 2010), Poran (2006) suggests that Black women do feel pressure to meet body image standards, partially based on the role of Black men. Poran (2006) found that young African American women were concerned about their looks, and felt frustrated about the pressure to meet physical preferences of Black men. The young African American women in this study further expressed that they felt the need to fit the criteria of what Black men perceive as attractive with regard to body size, skin tone and hair, and this pressure was directly related to perceived sexism and oppression of women. Therefore, Black women may experience anxiety and stress related to perceptions of Black men, which could play role in appearance dissatisfaction and overeating behaviors.

Racism in the Lives of Black Women Negative affect in the lives of Black women can also be related to racism and discrimination based on race. Striegel-Moore, Dohm, Pike, Wilfely, and Fairburn (2002) reported that ethnic discrimination has been found in studies of health and psychological problems among African Americans, as an identified and important risk for binge-eating. In a study conducted by Striegel-Moore et al. (2002), the researchers observed that Black women with binge eating disorder reported higher rates of discrimination than women with other psychiatric diagnoses. However, because rates of discrimination were not significantly different, these researchers suggest that self-reported discrimination may not be a general risk factor for binge eating, or even a specific risk factor. Therefore, Striegel-Moore et al. (2002) found a trend for increased discriminatory events in Black women with binge eating disorder, but did not find statistically significant findings to support previous research. However, research does suggest that women of color have consistently linked a high rate of stressful life events (inclusive of racist and sexist events) and trauma to the onset of problematic eating and the maintenance of undesirable eating behaviors (Harrington et al., 2006).Of interest, Striegel-Moore et al. (2005) found within a sample of White and Black women with binge eating disorder, Black women exhibited the first clinically significant binge eating behavior at a later age in life than White women. This finding may be related to the negative life events and racial discrimination that Black women are exposed to as they get older and may alter the trajectory of the disordered eating pattern usually seen in White individuals. Therefore, it is important that the effects of racism in relationship to eating patterns in Black women are investigated, in order to provide more information on the possible reciprocal or predictive role that racism or discrimination may play in the lives of Black women, eating habits and appearance satisfaction.

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THE CURRENT STUDY The purpose of the current study is to explore the relationships between appearance satisfaction, experiences of racism, emotional overeating, and BMI among African American and Black women. An additional purpose is to examine predictors of emotional overeating and BMI in this population and to test for within group differences based on (a) weight status and (b) the influence of Black men.

METHOD Participants A total of 404 women participated in this study. 301 women identified as African American while 54 identified as West Indian/Caribbean, and 49 as African American and Other. For this reason, participants will be referred to as African American and Black women, because though all the women identified racially as Black, they did not all identify an African American ethnicity. Their ages ranged from 18 to 77 years old, with a mean age of 39. With regard to level of education, 43% had a graduate degree, 31% completed college, 14% completed some college, 3% completed high school, and 9% indicated ―other.‖ Body Mass Index (BMI) was calculated for each participant using her self-reported height and weight.

Figure 1. Participants BMI.

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Figure 2. Participants Self- and Other-Perception of Weight.

The definition provided by The CDC (2010) was used to determine weight status among participants: An adult with a BMI between 18.5 and 24.9 is considered in a normal and healthy weight range. Those between 25 and 29.9 are considered overweight. An adult with a BMI over 30 is considered obese (CDC, 2010). In this sample, 68% of the participants were either overweight or obese. The CDC (2010) published data suggesting that 78% of African American women are overweight or obese; the largest of any ethnic group in the country. A pie chart depicting participants‘ BMI‘s is provided in Figure 1. Despite the high incidence of overweight and obese status in the sample, participants perceived themselves to be mostly normal or slightly overweight, and mostly believed that others perceived them to be normal weight. These results can be seen in Figure 2.

Procedure Upon receiving IRB approval for the study, participants were recruited via online sampling. Individuals were invited to participate through listservs, message boards, online groups, and site announcements. A snowball method was also used whereby participants were encouraged to send the survey on to eligible women who they believed may be interested in the study. No compensation was provided for participation. Surveys were confidential and secure and an informed consent was provided before moving on to the first surveys. Participants were made aware that they could end their participation at any time by exiting the survey. An answer to every question was required; therefore a participant could not skip any part of the survey. Participants took an average of 20 minutes to complete the survey. Once finished, participants were provided with a list of further reading and national counseling resources.

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Measures Demographic Questionnaire A brief measure looking at demographic data was created for this study. This questionnaire assessed for race, ethnicity, gender, age, level of education, self-report weight and height (from which BMI was calculated), and racial composition of school, work, neighborhood, and friendship group. In addition, participants were asked two questions regarding perception of weight. They were asked if (a) they perceived themselves to be and (b) if others perceived them to be: underweight, normal weight, somewhat overweight, or very overweight. Daily Life Experiences/Racial Hassles (DLER) (Harrell, 1997). Racial Hassles is a twenty-item subscale of the DLER which investigates people's everyday experiences of racism. Participants were asked to indicate (a) how often incidents occurred because of race and (α=.93), and (b) how much it bothered them when they did occur (α=94). An example of an item is ―How often have you been treated suspiciously because of your race?‖ Higher scores indicate a greater number of racist incidents and stronger feelings of being bothered by said incidents. Appearance Satisfaction Questionnaire (ASQ) (Author Created). The ASQ is a two-part, 34 item scale which was created for this study. The first 20 items measure participants' satisfaction with specific body parts, facial features, and appearance characteristics. An EFA revealed three factors: Body, Face, and Hair (α=.89), which accounted for 54.77% of the variance. Higher scores indicate a higher level of satisfaction with these features. The second 14 items measured the influence of Black men's perceptions on the participants‘ satisfaction. An EFA revealed two factors: Body and Face, and Hair (α= .95), which accounted for 75.49% of the variance. Higher scores indicate a higher influence of Black men‘s perceptions on satisfaction. Emotional Overeating Questionnaire (EOQ) (Masheb & Grilo, 2006). The EOQ is a 14 item self-report questionnaire that assesses overeating in response to emotions over the past 28 days. An example of an item is: ―On how many days have you eaten an unusually large amount of food given the circumstances in response to feelings of: Anxiety, Sadness, Boredom.‖ Five items were added for the purposes of this study in order to capture (a) eating in response to racism (e.g., Anxiety/Sadness/Anger that was race related), (b) eating to attain a larger shape and size, and (c) eating to increase sex appeal. Higher scores reflect more frequent overeating in response to emotions. The overall alpha was .91 and the alpha for the three added items was .95.

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RESULTS The Relationship between Appearance Satisfaction, BMI, Emotional Overeating, and Appearance Satisfaction due to the Influence of Black Men The sample was split into two groups: participants who scored above the median of 74 were categorized into the high appearance satisfaction group while those who scored 74 and below were classified into the low satisfaction group. Independent t-test procedures were conducted to test the relationship between appearance satisfaction, BMI, emotional overeating, and appearance satisfaction due to the influence of Black men. The means and standard deviations for BMI, emotional overeating, and appearance satisfaction due to the influence of Black men are presented in Table 3 while the independent t-test results are summarized in Table 4. The findings reveal that BMI varied significantly across satisfaction groups (t (303) = 5.88, p = .000). Respondents with low appearance satisfaction scores (M = 31.76, SD = 8.14) had higher BMI values (with the mean falling into the obese category) than respondents with high appearance satisfaction (where the mean was in the overweight category) (M = 27.12, SD = 6.28). Emotional overeating scores also differed significantly across satisfaction groups (t (204) = 5.78, p = .000). Respondents with low appearance satisfaction scores (M = 1.67, SD = .87) had higher emotional overeating scores than respondents with high appearance satisfaction (M = 1.25, SD = .33). Lastly, appearance satisfaction due to the influence of Black men also varied significantly across satisfaction groups (t (297) = 6.56, p = .000). Respondents with low appearance satisfaction scores (M = 27.17, SD = 10.87) indicated a greater influence of Black men on their satisfaction than respondents with high appearance satisfaction (M = 20.35, SD = 8.08). Table 3. Means and Standard Deviations for BMI, Emotional Overeating, and Satisfaction Due to the Influence of Black Men across Appearance Satisfaction Groups Variable BMI Emotional overeating Satisfaction due to male Black influence

Low (N = 190) Mean SD 31.76 8.14 1.67 .87 27.17 10.87

High (N = 214) Mean SD 27.12 6.28 1.25 .33 20.35 8.08

Table 4. Independent t-test Results for BMI, Emotional Overeating, and Satisfaction Due to the Influence of Black Men across Appearance Satisfaction Groups Variable

t

BMI Emotional overeating Satisfaction due to male Black influence Note. Because variances were not equal, t-values and degrees unequal variances.

df 5.88 303 5.78 204 6.56 297 of freedom that appear

Sig. .000 .000 .000 are those for

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Emotional Overeating Across BMI Groups To check for within group differences based on BMI, participants were categorized into one of three groups: Underweight and Normal Weight, Overweight, and Obese. The categories were informed by the standards set forth by The CDC (2010) as previously mentioned. Analysis of variance (ANOVA) procedures were conducted to test the relationship between BMI category and emotional overeating. The findings reveal that total emotional overeating scores varied significantly across BMI categories (F (2,340) = 4.18, p = .016). Post-hoc Tukey test results reveal that respondents in the underweight and normal weight category (M = 1.35, SD = .69) had significantly lower total emotional overeating scores than respondents in the obese category (M = 1.59, SD = .78).

Predictors of BMI A linear regression procedure was conducted to test for predictors of BMI in the sample. These findings are summarized in Table 5.Results reveal that Appearance Satisfaction negatively predicted BMI (Beta = -.10, p = .039). Self-perceptions of weight positively predicted BMI (Beta = .12, p = .035) as did other‘s perceptions of respondents‘ weight (Beta = .53, p = .000). Emotional overeating also positively predicted BMI (Beta = .11, p = .025). Table 5. Linear Regression Findings for BMI Variable Appearance satisfaction Appearance satisfaction – Men Perceived invisibility Self-perception of weight Other perception of weight Frequency of daily racism Emotional overeating

B -.06 -.03 .81 1.08 5.05 -.38 1.14

SE .03 .03 .50 .51 .56 .45 .51

Beta -.10 -.04 .08 .12 .53 -.04 .11

F 4.27 .90 2.56 4.47 81.95 .75 5.09

Sig. .039 .342 .110 .035 .000 .389 .025

Tol. .70 .79 .65 .46 .46 .67 .62

Table 6. Stepwise Regression Findings for Emotional Overeating Variable B SE BMI .02 .01 Appearance Satisfaction -.01 .00 Appearance Satisfaction – Men .01 .00 Self-perception of weight .04 .06 Other perception of weight -.19 .07 Frequency of daily racism .10 .05 Note. First step: R square = .051, Second Step: R Square = .191.

Beta .23 -.18 .17 .05 -.22 .12

F 12.56 9.47 9.49 .45 7.41 4.08

Sig. .000 .002 .002 .501 .007 .044

Tol. .55 .72 .81 .45 .38 .69

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Predictors of Emotional Overeating A hierarchical regression procedure was conducted. In the first step, BMI (i.e., the control variable) was entered into the equation. In the second step, the main predictors were entered into the equation. The findings of the second and final step are summarized in Table 6.After controlling for BMI, Appearance Satisfaction negatively predicted emotional overeating scores (Beta = -.18, p = .002). However, Appearance Satisfaction due to Black Men‘s Influence positively predicted emotional overeating scores (Beta =.17, p = .002).Frequency with which respondents experienced racism on a daily basis was also a positive predictor of emotional overeating (Beta = .12, p = .044).Finally, others‘ perception of respondents‘ weight negatively predicted emotional overeating scores (Beta = -.22, p = .007).

DISCUSSION Appearance Satisfaction Although research has suggested that there may be a cultural preference for a larger body size resulting in less body dissatisfaction among African American women (Lynch et al., 2009; Gilliard, Lackland, Mountford, & Egan, 2007; Fitzgibon, Blackman, & Avellone, 2000; Pike et al., 2001; Rogers & Petrie, 2010; Perez & Joiner, 2003), the present study found that Black women with higher BMI‘s experienced increased rates of appearance dissatisfaction, challenging the notion of a cultural protection or buffer. This finding is aligned with qualitative studies that have suggested that Black women do, in fact, experience feelings of discontentment about their appearance (Poran, 2006; Capodilupo, 2014; Capodilupo & Kim, 2014). A major difference between the current investigation and the vast majority of previous studies of Black women‘s body image is that our measure of body satisfaction included aspects of appearance such as hair texture, length and color as well as skin tone and complexion. On this measure, items related to the physical feature of hair (i.e., texture, color, etc.) and face (e.g., skin tone, size of lips, etc.) loaded onto their own statistically significant factors, strengthening the assertion that appearance characteristics such as hair and skin tone need to be considered when assessing Black women‘s body image (Capodilupo, 2014; Capodilupo & Kim, 2014; Falconer & Neville, 2000; Root, 2001). As our study demonstrates, when we query beyond weight and shape, a significant finding emerges that challenges the idea of cultural protection. Williamson (1998) suggested that the dominant culture‘s social construct of beauty denigrates African American features (e.g., dark skin, curly or kinky hair), which can create dissatisfaction among African American women and impact the overall perception of body image. Falconer and Neville (2000) found that the racially relevant feature, skin color satisfaction, accounted for a significant amount of the variance among African American women college students in their evaluation of appearance and satisfaction with specific body parts. In our study we find a significant relationship between appearance satisfaction and emotional overeating as well, suggesting that Black women may overeat as a method for coping with feelings about their global appearance. In other words, discontentment over hair or skin may play as big or bigger

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of a role in contributing to negative body image and subsequent coping behaviors such as overeating for Black women.

BMI and Weight Perception It has been suggested that Black women, regardless of socioeconomic status, engage in behaviors that lead to larger body sizes, which may be perpetuated by social and cultural preferences for heavier figures (Malpede et al., 2007). Our study supports this finding such that 74% of study participants had obtained at least a college degree and 68% of this highly educated sample was overweight or obese. Of note, there was a large discrepancy between participants‘ actual weight and how they believed others perceived them. Nearly half the sample (48%) indicated that others perceived them as normal weight, despite that 68% of the sample was actually overweight or obese (only 7% believed others perceived them to be very overweight). Self-perceptions of weight were in line with reality, with only 25% perceiving themselves to be normal weight and half identifying as somewhat overweight (17% identified as very overweight). Black women have reported that they receive conflicting messages about weight and shape from members of their own racial/ethnic community: at times being encouraged to eat a lot, while simultaneously being encouraged to lose weight (Befort, Thomas, Daley, Rhode, & Ahluwalia, 2006). Similarly, recent qualitative work states that Black women receive contradictory messages to maintain a strong cultural identity and thus reject the mainstream U.S. thin ideal, while also attending to familial pressure to attain a slender body shape as a means of protection against discrimination beyond that of darker skin tone (Hess-Biber et al., 2010). Perhaps participants in our study felt that in the eyes of their community or culture (i.e., ―others‖), they represent a normal weight, but compared to the mainstream U.S. ideal, they are overweight (constituting the self-perception). These findings need to be further studied, as they have implications for weight status among African American and Black women. For example, if Black women who are overweight and obese believe that their weight is in a normal range from a racial/cultural perspective, they may be less inclined to believe that their weight poses as a real and serious health risk with major consequences such as diabetes and hypertension.

The Role of Black Men The present study found that Black women who reported being more strongly influenced by Black men‘s preferences engaged in more emotional overeating and also had higher BMI‘s than their peers who indicated a lesser influence of Black men. Further, participants who indicated a stronger influence of Black men had lower global scores of appearance satisfaction. Previous research has suggested that Black women may be protected from body dissatisfaction because Black culture, more specifically Black men, have a preference for larger body sizes (Molloy & Herzberger, 1998; Poran, 2006; Cunningham, Roberts, Barbee, Druen, & Wu, 1995). However, our study suggests that Black men‘s preferences play an important role in the development of appearance dissatisfaction for Black women and may contribute to overeating behaviors as well as weight status.

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In our study, Black women who were more influenced by the preferential standards of Black men engaged in higher rates of emotional overeating and also had higher BMI‘s. One potential explanation of our findings is that Black women who are more influenced by Black men‘s aesthetic preferences could engage in overeating behavior purposefully to achieve a large body size (and thus a resultant higher BMI) in an effort to be more sexually appealing. Perhaps this relationship becomes even stronger for women who feel a need to overcompensate for other areas of appearance such as hair and skin that are not in line with cultural ideals. Recall that our measure of appearance satisfaction included items related to hair and skin and so women who scored lower on this measure indicated a lessened satisfaction with these features. Future studies should consider including the variable of Black men‘s influence when studying body image and eating habits among Black women.

Emotional Overeating and Racism The present study found that participants who experienced a greater incidence of daily racial hassles reported higher levels of emotional overeating. This finding suggests that there may be a relationship between the emotional consequences of experiencing racism and overeating behavior. It is important to remember that our measure of racism captured subtle, every day exchanges that were racial in nature. This is a phenomenon that has been referred to by some researchers as racial microggressions (Sue, 2010) and it has been shown to be a pervasive and negative stressor in the lives of African Americans (Sue, 2010; Sue, Nadal, et al., 2008). Black women may eat in response to negative feelings experienced throughout the course of the day, specifically, negative interpersonal interactions that are perceived to be racial discrimination. Qualitative investigations have suggested that Black women eat in response to experiences as a means of coping with multiple oppressions (Capodilupo, 2014; Kempa & Thompson, 2000; Thompson, 1992). Currently, researchers recognize the relationship between negative affect and emotional overeating or binge eating (Harrington et al., 2010; Hrabosky & Grilo, 2007); however, very few studies have looked at negative affect precipitated by racism and the role that racism may play in the development of eating pathology. Vines et al. (2006) found that, in response to perceived racism, 41% of Black women experienced feeling: very angry, anxious, sad, and/or frustrated. Furthermore, these researchers found that 20% of Black women reported feeling powerless or hopeless in response to perceived racism. Harrington et al. (2006) found a significant, positive relationship between binge eating and discriminatory stress. Atlas et al. (2002) suggest that African American women use eating as a way to regulate emotions. Our study supports the idea that racism is significantly related to emotional overeating for Black and African American women. Future studies with this population should consider including a variable of racism (whether subtle or more overt) as a potential risk factor for disorders that involve binge eating such as bulimia nervosa and binge eating disorder.

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Strengths and Limitations The current study possesses both strengths and limitations worth highlighting. First, all measures were self-report, relying on participants‘ authentic responses to questionnaires. However, the study was conducted electronically, securing confidentiality and eliminating any person to person contact with the researchers. There is increasing support for the use of online methodology to collect data, especially among racial/ethnic minorities (CITE). Another limitation is with regard to participant composition. Namely, our sample represents a highly educated grouping of women, with over 40% having obtained an advanced degree. Thus, external validity is limited. However, the participant pool also represents a major strength of this study: Over 400 Black and African American women from the community completed all of our measures and the mean age is nearly 40 years old. Older African American and Black women from the community are drastically underrepresented in the literature on body image and eating disorders and the majority of findings that exist are with college populations. There are several strengths and limitations as they relate to the measurement of constructs in this study. First, it would have been helpful to have an additional measure of overeating behavior, as the current questionnaire only captures overeating in response to emotions and does not include many of the characteristics of binge eating in the DSM-IV-TR (e.g., eating in secrecy, feeling a loss of control). Second, a measure of actual skin and hair characteristics (similar to the idea of asking for self-report height and weight) would have been helpful to look at within group differences based on these features. It also would have been helpful to explore the discrepancy between those features actually possessed and appearance satisfaction. However, that our appearance satisfaction measure takes into consideration hair and facial features with as much consideration as weight and shape is a strength of our study. The majority of other research with Black women continues to utilize measures that centralize the thin ideal. Our study included other culturally relevant variables as well, namely the influence of Black men and daily experiences of racism. Finally, the variable that measured Other‘s perception of weight, while interesting, raises more questions than answers as we do not know who the reference population was for participants. Were they thinking of the Black community or Black men in particular? Could they have been thinking Others referred to society at large, or the White community?

Clinical Implications Our findings highlight the importance of including culturally relevant variables when working with body image and eating habits among women of color. Clinicians in particular want to be mindful that eating behaviors (in either direction) are not necessarily linked to the pursuit of a thin ideal and may in fact represent a coping mechanism for dealing with feelings about other aspects of appearance such as hair, skin, and facial features. Gender and racial discrimination can also be significant sources of stress that lead to overeating behaviors in women of color. It would behoove clinicians to remain mindful that subtle, everyday experiences that are tinged with racial undertones (such as those captured in the current study) can be of major significance in the lives of their clients of color and are worth exploring. In fact, it has been

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suggested that the more ambiguous and covert forms of oppression are more stressful than blatant racism because they cause the recipient to question the intention and meaning of the incident (Sue, 2010). While it is recognized that overeating may result from stressful emotions and adverse experiences such as trauma, there is far less acknowledgment in the field that experiences of gender and racial discrimination can also be significant sources of stress that lead to maladaptive eating behaviors in women of color. Finally, clinicians want to remain aware that Black women are likely to be differentially influenced by both Black culture and Black men‘s aesthetic preferences, and that these varied influences probably play an important role in their weight perceptions and global self- and body-images.

REFERENCES Atlas, J. G., Smith, G. T., Hohlstein, L. A., McCarthy, D. M. & Kroll, L. S. (2002). Similarities and differences between Caucasian and African American college women on eating and dieting expectancies, bulimic symptoms, dietary restraint, and disinhibition. International Journal of Eating Disorders, 32, 326–334. doi: 10.1002/eat.10081. Befort, C. A., Thomas, J. L., Rhode, P. C., Daley, C. M. & Ahluwalia, J. S. (2008). Perceptions and beliefs about body size, weight, and weight loss among obese African American women: A qualitative inquiry. Health Education and Behavior, 35(3), 410-426. Calogero, R. M. (2004). A test of objectification theory: The effect of the male gaze appearance concerns in college women. Psychology of Women Quarterly, 28, 16-21. doi:10.1111/j.1471-6402.2004.00118.x. Capodilupo, C. M. (2014). One size does not fit all: Using variables other than the thin ideal to understand Black women‘s body image. Cultural Diversity and Ethnic Minority Psychology, 21(2), 268-278. Capodilupo, C. M. & Kim, S. (2014). Gender and race matter: The importance of considering intersections in Black women‘s body image. Journal of Counseling Psychology, 61(1), 37-49. Centers for Disease Control and Prevention (2010). Nutrition. Retrieved from http://www.cdc.gove/nutrition. Cunningham, M. R., Roberts, A. R., Barbee, A. P., Druen, P. B. & Wu, G. (1995). Their ideas of beauty are on the whole the same as ours: Consistency and variability in the crosscultural perception of female physical attractiveness. Journal of Personality and Social Psychology, 68, 261-279. doi: 10.1037/0022-3514.68.2.261. Davis, D. S., Sbrocco, T., Odoms-Young, A. & Smith, D. M. (2010). Attractiveness in African American and Caucasian women: Is beauty in the eyes of the observer? Eating Behaviors, 11, 25-32. doi:10.1016/j.eatbeh.2009.08.004. Falconer, J. W. & Neville, H. A. (2000). African American college women‘s body image: An examination of body mass, African self-consciousness, and skin color satisfaction. Psychology of Women Quarterly, 24(3), 236-243. Fitzgibon, M. L., Spring, B., Avellone, M. E., Blackman, L. R., Pingitore, R. & Stolley, M. R. (1998). Correlates of binge eating in Hispanic, Black, and White Women. International Journal of Eating Disorders, 24, 43-52.

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Fitzgibon, M. L., Blackman, L. R. & Avellone, M. E. (2000). The relationship between body image discrepancy and body mass index across ethnic groups. Obesity Research, 8, 582589. doi:10.1038/oby.2000.75. Gilliard, T. S., Lackland, D. T., Mountford, W. K. & Egan, B. M. (2007). Concordance between self-reported heights and weights and current and ideal body image in young adult African American men and women. Ethnicity & Disease, 17, 617-623. Harrell, S. P. (1997). The Racism and Life Experiences Scales (RaLES). Unpublished manuscript, California School of Professional Psychology, Los Angeles. Harrington, E. F., Crowther, J. H., Payne Henrickson, H. C. & Mickelson, K. D. (2006). The relationships among trauma, stress, ethnicity, and binge eating. Cultural Diversity and Ethnic Minority Psychology, 12, 212-229. Doi: 10.1037/1099-9809.12.2.212. Harrington, E. F., Crowther, J. H. & Shipherd, J. C. (2010). Trauma, binge eating, and the ―Strong Black Woman‖ Journal of Consulting and Clinical Psychology, 78, 469-479. doi:10.1037/a0019174. Hesse-Biber, S., Livingstone, S., Ramirez, D., Barko, E. B. & Johnson, A. L. (2010). Racial identity and body image among Black female college students attending predominately White colleges. Sex Roles, 63, 697-711. Hrabosky, J. I. & Grilo, C. M. (2007). Body image and eating disordered behavior in a community sample of Black and Hispanic women. Eating Behaviors, 8, 106-114. doi: 10.1016/j.eatbeh.2006.02.005. Kelly, N. R., Mitchell, K. S., Gow, R. W., Trace, S. E., Lydecker, J. A., Bair, C. E. & Mazzeo, S. (2011). An evaluation of the reliability and construct validity of eating disorder measures in White and Black women. Psychological Assessment, Dec 12, 2011. doi:10.1037/a0026457. Kempa, M. L. & Thomas, A. J. (2000). Culturally sensitive assessment and treatment of eating disorders. Eating Disorders, 8, 17-30. Lynch, E., Liu, K., Wei, G. S., Spring, B., Kiefe, C. & Greenland, P. (2009). The relation between body size perception and change in body mass index over 13 years. American Journal of Epidemiology, 169, 857-866. doi: 10.1093/aje/kwn412. Malpede, C. Z., Greene, L. F., Fitzpatrick, S. L., Jefferson, W. K., Shewchuk, R. M., Baskin, M. L. & Ard, J. D. (2007). Racial influences associated with weight-related beliefs in African American and Caucasian Women. Ethnicity and Disease, 17, 1-5. Mazzeo, S. E., Saunders, R. & Mitchell, K. S. (2005). Binge eating among African American and Caucasian bariatric surgery candidates. Eating Behaviors, 6, 189-196. doi:10.1016/j.eatbeh.2004.12.001. Molloy, B. L. & Herzberger, S. D. (1998). Body image and self-esteem: A comparison of African-American and Caucasian Women. Sex Roles, 38, 631-643. doi: 0.1023/A:1018782527302. Napolitano, M. A. & Hines, S. (2010). Race, weight, and correlates of binge eating in female college students. Eating Behaviors, 12, 29-36. doi:10.1016/j.eatbeh.2010.09.003. Perez, M. & Joiner, Jr. T. E. (2003). Body image dissatisfaction and disordered eating in Black and White women. International Journal of Eating Disorders, 33, 342-350. doi: 10.1002/eat.10148. Pike, K. M., Dohm, F., Striegel-Moore, R. H., Wilfely, D. E. & Fiarburn, C. G. (2001). A comparison of Black and White women with binge eating disorder. American Journal of Psychiatry, 158, 1455-1460. doi:10.1176.appi.ajp.158.9.1455.

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Poran, M. A. (2006). The politics of protection: Body image, social pressures, and the misrepresentation of young Black women. Sex Roles, 55, 739-755. doi: 10.1007/s11199006-9129-5. Rogers Wood, N. A. & Petrie, T. A. (2010). Body dissatisfaction, ethnic identity, and disordered eating among African American women. Journal of Counseling Psychology, 57, 141-153. doi:10.1037/a0018922. Root, M. P. P (2001). Future considerations in research on eating disorders. The Counseling Psychologist, 29, 754-762. doi: 10.1177/ 0011000001295007. Russell, W. D. & Cox, R. H. (2003). Social physique anxiety, body dissatisfaction and selfesteem in college females of differing exercise frequency, perceived weight discrepancy and race. Journal of Sport Behavior, 26, 298-318. Striegel-Moore, R. H. & Smolak, L. (2000). The influence of ethnicity on eating disorders in women. Handbook of gender, culture, and health. Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers. Striegel-Moore, R. H., Dohm, F., Pike, K. M., Wilfely, D. E. & Fairburn, C. G. (2002). Abuse, bullying, and discrimination as risk factors for binge eating disorder. American Journal of Psychiatry, 159, 1902-1907. doi: 10.1176/appi.ajp.159.11.1902. Striegel-Moore, R. H., Fairburn, C. G., Wilfely, D. E., Pike, K. M., Dohm, F. & Kraemer, H. C. (2005). Toward an understanding of risk factors for binge-eating disorder in Black and White women: a community-based case-control study. Psychological Medicine, 35, 907917. doi:10.1017/ s0033291704003435. Sue, Derald Wing [Ed]. (2010). Microaggressions and marginality: Manifestation, Dynamics, and impact. (3-22). xiii, 360 pp. Hoboken, NJ, US: John Wiley & Sons Inc. Sue, D. W., Nadal, K. L., Capodilupo, C. M., Torino, G. C., Lin, A. & Rivera, D. (2008). Racial microaggressions against Black Americans: Implications for counseling. Journal of Counseling and Development, 86(3), 330-338. Thompson, B. (1992). ―A way outa no way‖: Eating disorders among African-American, Latina and White women. Gender & Society, 6(4), 546-561. Vines, A. I, Baird, D. D., McNeilly, M., Hertz-Picciotto, I., Light, K. C. & Stevens, J. (2006). Social correlates of the chronic stress of perceived racism among Black women. Ethnicity and Disease, 16, 101-107. Williamson, L. (1998). Eating disorders and the cultural forces behind the drive for thinness: Are African-American women really protected. Social Work in Health Care, 28, 61-73.

In: Body Image Editor: Rafael Vargas

ISBN: 978-1-63483-870-2 © 2016 Nova Science Publishers, Inc.

Chapter 4

ETHNICITY-RELATED DIFFERENCES IN RESPONSES TO “IN FAVOR OF MYSELF” – A WELLNESS PROGRAM TO ENHANCE POSITIVE SELF AND BODY IMAGE AMONG ADOLESCENTS Moria Golan1,2,3,, Rose Awidat2 and Shani Abutbul2 1

Shahaf, Community Services for the Management of Weight-Related Problems 2 Tel Hai College, Upper Galilee and School of Nutritional Sciences, Israel 3 The Hebrew University of Jerusalem, School of Nutritional Sciences, Israel

ABSTRACT Ethnic identity plays an important part in the self-concept related to feelings and attitudes. Despite decades of research into prevention programs for youth and their implementation nationwide, publications describing ethnic differences in the impact of prevention programs among adolescents are scarce. Programs may have different impacts on participants due to baseline exposure to different sociocultural values, different selfesteem and body image, as well as other individual characteristics related to participants‘ ethnic origin and values. This review explores the ethnic differences in self-esteem and body image among adolescents, as well as the need to address ethnicity in prevention programs. It further examines the current publications on ethnic differences in selfesteem and body image among Druze and Jewish adolescents, and presents data from a comparison of two randomized control trials which assessed the mediating influence of ethnicity on the impact of "In Favor of Myself,‖ a universal wellness prevention program, in Druze vs. Jewish adolescents. Data came from a school-based grouped randomized trial in Israel involving 204 Druze and Jewish adolescents, mostly 8th-graders, using a general linear model to assess the interaction between times (baseline and program conclusion), groups (intervention vs. control) and ethnicity (Druze vs. Jews). Results 

Author for correspondence and reprints: Moria Golan, PhD, Tel Hai College, Upper Galilee, Israel, Tel: 972548240330, Fax: 97289348798, e-mail: [email protected]

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Moria Golan, Rose Awidat and Shani Abutbul showed that acceptability and program implementation were higher among Druze compared to Jewish adolescents. The "In Favor of Myself" program was more effective when delivered to Druze adolescents with respect to media literacy—a greater reduction in feeling stressed about appearance due to media messages was found among Druze compared to the Jews; self-esteem declined during the assessment period among Jews (as expected at this age) but not among Druze. A greater improvement in the gap between current body image and ideal body image was also seen among Druze vs. Jews. The reasons for these differences are discussed.

Keywords: Wellness program, adolescent, self-image, body image

INTRODUCTION Body dissatisfaction and low self-esteem are affected by at least four factors during adolescence, namely, age, gender, body weight, and race/ethnicity. Ethnic identity plays an important part in self-concept as it relates to feelings and attitudes about ethnic affiliation )Phinney & Rosenthal, 1992; Phinney & Alipuria, 1996(. A person‘s ethnic identity is likely to be stronger when their ethnic affiliation is obvious to the outsider observer, such as with people of color. A strong ethnic identity is more likely to contribute to one‘s self-concept )Phinney & Rosenthal, 1992(. Despite decades of research on prevention programs for youth and their nationwide implementation, publications about ethnic differences in the impact of prevention programs among adolescents are scarce. Programs may have different impacts on participants due to baseline exposure to different sociocultural values, different risk factors, variations in selfesteem and body image, as well as other individual characteristics stemming from participants‘ ethnic origin and values. Studies have explored whether universal programs work equally well among youth from Caucasian, Black and Hispanic ethnic groups (Shin et al., 2005; Kulis, Yabiku, Marsiglia, Nieri, & Ashley, 2007; Stice, Marti, & Cheng, 2014). However, no prevention programs have been tested for their efficacy across ethnic Druze, Arabs and Jews. This study explored the ethnic differences in the efficacy of "In Favor of Myself,‖ a universal prevention program for adolescents.

ETHNIC DIFFERENCES IN SELF-ESTEEM AND BODY IMAGE AMONG ADOLESCENTS The influence of cultural norms on self- and body image in a multiethnic society has been widely examined. Bachman, O‘Malley, Freedman-Doan, Trzesniewski, and Donnellan (2011) performed a large-scale representative survey of 8th-, 10th-, and 12th-grade students in the United States, and found that African-American students score highest for self-esteem, in comparison to Whites' scores, which were slightly higher than Hispanics and AsianAmericans, who scored lowest. With respect to body image, Mikolajczyk, Iannotti, Farhat, and Thomas (2012) reported substantial differences in perceived appearance and body satisfaction across the three largest ethnic groups of school-age children in the United States:

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whereas non-Hispanic Whites and Hispanics had similar perceptions of body image, both groups differed from the African-Americans. The latter youth had much better perceived body appearance at the youngest age. Perceived appearance remained high in AfricanAmerican girls over the age range, but dropped dramatically in African-American boys. There was also a non-negligible drop in positive perception of appearance among non-Hispanic White and Hispanic girls toward late adolescence. Non-Hispanic White and Hispanic boys had similar perceptions of body weight in relation to their BMI, compared to AfricanAmerican boys, who were less likely to perceive themselves as too fat at higher BMI percentiles. Girls in all three ethnic groups considered themselves to be too fat at substantially lower age- and gender-specific BMI percentiles than boys. However, there was a substantial difference across all three ethnic groups, with Non-Hispanic White girls substantially more likely to perceive themselves as too fat at a given BMI percentile, followed by Hispanics and African-Americans. Van den Berg, Mond, Eisenberg, Ackard, and Neumark-Sztainer (2010) examined the cross-sectional association between body dissatisfaction and low self-esteem among 4,746 adolescents aged 11–18 years. Among girls, the relationship between body dissatisfaction and self-esteem was strong. It was higher among Black, Asian, and lowsocioeconomic-status girls (all P < 0.0001) in comparison to White and high-socioeconomicstatus girls. Among boys, the association did not differ significantly across demographic groups (P values of 0.18–0.79). In longitudinal analyses, the strength of the association did not change significantly, as adolescents got older. Gitau, Micklesfield, Pettifor, and Norris (2014) found significant differences in perception of silhouettes by ethnicity. Most Black girls chose a silhouette with a higher BMI to be the ‗best‘ and to receive more ‗respect‘ than the BMI chosen by the White girls (P < 0.05). The latter perceived a higher BMI silhouette to be ‗clumsier‘ than did the Black girls (P < 0.05), and the Black girls perceived a low BMI silhouette as deserving of less respect than the White girls. Black girls perceived that their family and friends desired them to have a higher BMI than that indicated to be the perceptions of family and friends of their White counterparts. There was no significant association between body-image perceptions and the type of school (indicator of socioeconomic status) they attended. Ethnic differences also significantly affected adolescent boys‘ self-esteem and body image. White boys had higher self-esteem, BMI and normal eating attitudes than the Black boys did. BMI was positively associated with self-esteem (P = 0.01, r = 0.134) and negatively associated with dieting behavior in White boys (P = 0.004, r = −0.257), and with lower EAT-26 (Eating Attitudes test, bulimic and oral control subscales scores in Black boys. Overall, these findings highlight ethnic differences and a need to better understand the cultural differences that influence adolescent attitudes and behavior.

ETHNICITY AND PREVENTION Gaps in health as well as prevention programs remain widespread among racial and ethnic minority groups. A recurring question surrounding prevention programs is how much their effectiveness depends on participants‘ ethnicity and acculturation. Amico (2005) studied factors that affect adolescents‘ intentions to utilize alcohol-related prevention services. She found that youth with strong positive beliefs about the provider and the program process reported stronger intentions to use alcohol-related prevention services. Girls reported greater

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intentions to use these services than boys did, and Whites reported greater intentions to use these services compared to youth of mixed ethnicity. Liu et al. (2012) suggested that evidence from available guidelines, systematic reviews and empirical studies is insufficient to draw conclusions about the clinical effectiveness or cost-effectiveness of non-adapted compared to adapted health-promotive interventions for smoking cessation, increasing physical activity and improving healthy eating. However, the overall body of adapted interventions suggests that careful consideration of target-group needs and contextual factors can enhance planning, engagement, implementation and retention. Griner and Smith (2006) reported that mental health prevention programs for groups of same-race participants who were culturally adapted were four times more effective than interventions provided to groups consisting of mixed-race participants (Cohen's d size effect 0.49 vs 0.12). Two studies examining the effects of prevention programs on diverse samples of adolescents and young adults (aged 13–20 years) did not find differential effects among groups (Franko et al., 2005; Rodriguez, Marchand, & Stice, 2008). Recently, Stice, Marti, and Cheng (2014) reported that although there was some variation in risk-factor scores across ethnic groups, ethnic minority participants did not demonstrate consistently higher or lower risk relative to American participants of European descent. Intervention effects did not differ significantly for participants from minority groups versus American participants of European descent in either trial. Given the limited number of studies comparing the impact of prevention programs on different ethnic groups, our study adds important data.

ETHNIC DIFFERENCES IN SELF-ESTEEM AND BODY IMAGE AMONG DRUZE VS. JEWISH ADOLESCENTS Published empirical research on the differences between Druze and Jewish adolescents‘ self-esteem and body image is scarce. Umaña-Taylor (2005) found that micro and macrocontexts have an effect on the relationship between ethnicity and self-esteem, and that minority members are able to maintain higher levels of self-esteem when there are intragroup social connections. Together with family and peer support, ethnic-group identification can serve as a buffer against institutional racism or prejudice that would otherwise lower minority youths' self-esteem (Crocker, 1999). Previous research has suggested that, in general, IsraeliArab students have lower self-esteem than Israeli-Jewish ones (Hofman, 1982). Abu-Saad (1999) examined the level of global self-esteem among a group of 1,560 12th-grade IsraeliArab adolescents using the Rosenberg Self-Esteem Scale (Rosenberg, 1965). He found that Arab high-school students exhibit intermediate to high self-esteem, with a tendency to agree with positive self-evaluations and to reject negative ones. Self-esteem can be strongly influenced by appearance. Global self-esteem, satisfaction with appearance, and self-reported dieting are interrelated (Markland & Oliver, 2008). Apter et al. (1994) examined eating attitudes and body image among 783 females aged 15–18 years, including Jews (n = 270) and Arabs (n = 489). The Arab sample was made up of five ethnically distinct groups: Muslim (n = 204), Christian (n = 91), Druze from a village in the Galilee (n = 77), Bedouin (n = 67) from the Middle Eastern desert tribes, and Circassian (n = 50), who are Sunni Muslims. All Jewish and Arab females reported a desire to lose weight. This is not surprising in light of food's central role in Jewish and Arab/Druze ethnics. While

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the Israeli-Jewish population lives according to social codes and norms of modern Western society, the Druze minority maintains more traditional norms and social customs (Becker, Burwell, Gilman, Herzog, & Hamburg, 2002). However, as the Arab society becomes exposed to Western civilization, which is opposed to traditional Arab mores, fissures have begun to form in the set of traditional values. This exposure has led to many changes in education, the role of women, and family structure (Mahajna, 2007). Nevertheless, nonreligious adolescents (Jewish and Druze) do not identify with traditional religious rules and values and thus are exposed to Western media messages and are not immune to Western ideals of female body shape. In these societies, females may receive dual messages: one that celebrates food and eating, and another that celebrates thinness and restraint. Still, in Israel, there is some evidence to suggest that the Arab population has a lower representation among referrals to eating-disorder clinics in Israel (Latzer, Witztum, & Stein, 2008). This low incidence may reflect different attitudes toward beauty in the Arab culture, where plumpness is considered attractive and a symbol of feminine nurturance (Nasser, Katzman, & Gordon, 2001). Latzer, Tzischinsky, and Geraisy (2007) examined the prevalence of disordered eating attitudes and behaviors among 1,131 Arab schoolgirls (Muslem, Druze, and Christian) in Israel. The Christian subgroup had a significantly lower total eating disorder inventory-2 (EDI-2) score than the Druze or Muslem subgroups, which had similar total EDI-2 scores. A total of 154 (13%) Arab school girls scored higher than the cut-off point of 14 on the EDI-DT (Eating Disorders Inventory, drive for thinness subscale( .

"IN FAVOR OF MYSELF" – ETHNIC DIFFERENCES IN PROGRAM OUTCOME The term ―cultural adaptation‖ is widely recognized in the field of prevention, and various stage models have been described that specify the process of adapting interventions to specific cultural groups (Castro, Barrera, & Holleran Steiker, 2010; Okamoto, Kulis, Marsiglia, Steiker, & Dustman, 2015). In light of this approach, we modified the Hebrew program ―In Favor of Myself,‖ which is an empirically supported intervention (Golan, Hagay, & Tamir, 2013, 2014), and tailored its contents and visualizations to the Druze culture in Israel. The program was delivered in a school-based setting, in the north of Israel, using a group-randomized clinical trial to assess its efficacy. "In Favor of Myself" is an interactive educational program that focuses on discussing the myriad changes that take place during adolescence and their impact, awareness of media strategies, and literacy among youth as a way to help lower unrealistic expectations and decrease concerns with appearance. It teaches participants to identify and counter prejudice and sociopolitical structures that contribute to the development of body dissatisfaction and preoccupation. By helping youth gain the skills necessary to critically evaluate strong societal messages for both males and females with respect to self-esteem, happiness, and ideal body type or image, the program aims to help mitigate the effects of these messages. The program includes eight 1.5-hour-long structured sessions (plus introductory and baseline assessment sessions), with interactive activities to engage the mixed-gender group participants, both verbally and nonverbally. The results of the first 50 Druze participants and 50 Jewish participants compared to a similar-sized control sample were surprising. At baseline, there were no statistically significant differences

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between the four subgroups (Druze and Jews, control and intervention) with respect to the measured variables. Mean participant age was 13.9 ± 0.5 years. Participants filled out the same questionnaire on three occasions (0, 3 and 6 months); the results presented here are from the first two occasions. Satisfaction rate was similar among Jewish and Druze pupils, with more than 85% of participants declaring their intention to recommend the program to their friends. ANOVA with repeated measures demonstrated that overall, the program had a larger effect size for Druze than for Jews. A statistically significant interaction was found for time x group x ethnicity [F (3, 204) = 7.34, P < 0.05, η2 = 0.035]. When the impact of the intervention was calculated for each ethnic group separately, the Druze demonstrated a large effect size for reduction in pressure due to media exposure [F (0, 58) = 31.1, P < 0.000, η2 = 0.35], whereas the change among Jews was not statistically significant [F (0, 50) = 1.6, NS, η2 = 0.03]. These results were confirmed by an analysis that made use of the pressure subscale of SATAQ-3 (Markland & Oliver, 2008). A statistically significant interaction was found for time x group x ethnicity [F (3, 204) = 13.36, P < 0.000, η2 = 0.06, medium effect size]. When the impact of the intervention with time was calculated for each ethnic group, Druze demonstrated a large effect size for thin-ideal internalization [F (0, 58) = 30.3, P < 0.000, η2 = 0.35], whereas Jews demonstrated only a medium effect size for this variable [F (0, 50) = 5.8, P < 0.05, η2 = 0.11]. With respect to self-esteem (measured by the Rosenberg Self-Esteem Scale), a statistically significant interaction was found for time x group x ethnicity [F (3, 204) = 12.13, P < 0.001, η2 = 0.06, medium effect size]. When the impact of the intervention with time was calculated for each ethnic group, Druze demonstrated stability (no significant change) [F (0, 58) = 1.4, NS, η2 = 0.02], whereas Jews demonstrated a statistically significant reduction in self-esteem as is commonly observed in this age group [F (0, 50) = 4.2, P < 0.04, η2 = 0.08] (Davis, Robins, & Trzesniewski, 2005). As concerns the gap between concurrent and ideal body image, which was measured using The Figure Body Images (FBG) (Collins, 1991), a statistically significant interaction was found for time x group x ethnicity [F (3, 204) = 6.43, P < 0.005, η2 = 0.03]. A statistically significant reduction was only found among Druze girls [(F (0, 50) = 4.43, P < 0.05, η2 = 0.008], whereas no significant change was observed with the Jewish girls. A few hypotheses can explain the better effect of "In Favor of Myself" on Druze compared to Jews. First, the Druze group leaders faced significantly less behavioral problems when delivering the program to Druze adolescents, in contrast to medium and high degrees of behavioral problems faced by the Jewish group deliverer. Patterns of behavior among Druze adolescents are friendlier when it comes to preventive programs, possibly due in part to their hunger for such enrichment. Secondly, there are indications that new programs are better accepted among minorities when members from the same ethnic minority group deliver them, as was the case in our study (Maramba & Hall, 2002; Shin et al. 2005). This is in contrast to Stice et al. (2014) who found no evidence of significantly larger intervention effects if participants from a minority group have at least one facilitator who matches their ethnicity. However, the setting described in our study is different, since the program was delivered in a Druze city with a Druze deliverer, which might differ from measuring the impact of a program delivered in a mixedethnicity setting.

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A third assumption that was investigated is the similarity in baseline status of each of the studied groups with respect to drive for thinness and body dissatisfaction, because one might assume that adolescents from societies in transition are more bound to their conservative cultural norms than adolescents from Western cultures (Warren, Gleaves, Cepeda-Benito, Fernandez, & Rodriguez-Ruiz, 2005). In our study, there were no significant differences between the groups in their baseline levels of body dissatisfaction or drive for thinness.

CONCLUSION Druze participants, which belong to a culture in transition, might gain more from prevention programs that are delivered locally with a facilitator from their ethnic minority than Jewish participants, who received the same program in a similar setting (their local school and a facilitator from their ethnic group). The predictors of less or better outcomes of preventive programs which are delivered to different ethnic populations are not yet clear, although some effort has been made to identify such factors (Franko & Edwards George, 2008; Rodriguez et al. 2008; Stice et al. 2014; Awidat, Tamir, & Golan, 2015). Prevention programs should be culturally sensitive for various ethnic groups. Given the limited number of studies, research is needed to develop and test the efficacy of prevention programs designed to address the concerns of diverse youth.

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Nasser, M., Katzman, M. A., & Gordon, R.A. (2001). Eating disorders and cultures in transition. London: Brunner-Routledge. Okamoto, S. K., Kulis, S., Marsiglia, F. F., Steiker, L. K. H., & Dustman, P. (2015). A continuum of approaches toward developing culturally focused prevention interventions: From adaptation to grounding. Journal of Primary Prevention, 35 (2), 103–112. Phinney, J., & Alipuria, L. (1996). At the interface of culture: Multiethnic/multiracial high school and college students. Journal of Social Psychology, 136, 139–158. Phinney, J. S., & Rosenthal, D. A. (1992). Ethnic identity in adolescence: Process, context, and outcome. In G. R. Adams, T. R. Gullota, & R. Monternighter (Eds.), Advances in adolescent development: Adolescent identity formation (vol. 4, pp. 145–172). Newbury Park, CA: Sage. Rodriguez, R., Marchand, E., & Stice E. (2008). Effects of a cognitive-dissonance-based eating disorder prevention program are similar for Asian American, Hispanic, and White participants. International Journal of Eating Disorders, 41, 618–625. Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press. Shin, S. M., Chow, C., Camacho-Gonsalves, T., Levy, R. J., Allen, I. E., & Leff, H. S. (2005). A meta-analytic review of racial-ethnic matching for African American and Caucasian American clients and clinicians. Journal of Counseling Psychology, 52, 45–56. Stice, E., Marti, C. N., & Cheng, Z. H. (2014). Effectiveness of a dissonance-based eating disorder prevention program for ethnic groups in two randomized controlled trials. Behaviour Research Therapy, 55, 54–64. Umaña-Taylor, A. G. (2005). Ethnic identity and self-esteem examining the role of social context. Journal of Adolescent Research, 27 (2), 139–146. Van den Berg, P. A., Mond, J., Eisenberg, M., Ackard, D., & Neumark-Sztainer, D. (2010). The link between body dissatisfaction and self-esteem in adolescents: Similarities across gender, age, weight status, race/ethnicity, and socioeconomic status. Journal of Adolescent Health, 47 (3), 290–296. Warren, C. S., Gleaves, D. H., Cepeda-Benito, A., Fernandez, Mdel C., & Rodriguez-Ruiz, S. (2005). Ethnicity as a protective factor against internalization of a thin ideal and body dissatisfaction. International Journal of Eating Disorders, 37 (3), 241–249.

In: Body Image Editor: Rafael Vargas

ISBN: 978-1-63483-870-2 © 2016 Nova Science Publishers, Inc.

Chapter 5

BODY IMAGE IN ADOLESCENT PREGNANCY: A COMPARISON WITH THE ADULT RESEARCH Danusha Jebanesan1, BSc, Leanna Isserlin2,3, MD and Megan E. Harrison3,4,5,, MD 1

Faculty of Medicine, University of Ottawa, Canada Department of Psychiatry, Children‘s Hospital of Eastern Ontario, Ottawa, Canada 3 Children‘s Hospital of Eastern Ontario, Eating Disorders Program, Ottawa, Canada 4 Department of Pediatrics, Division of Adolescent Medicine, Children‘s Hospital of Eastern Ontario, Ottawa, Canada 5 Children‘s Hospital of Eastern Ontario Research Institute, Ottawa, Canada 2

ABSTRACT Women‘s responses to the physical changes of pregnancy vary greatly. Some research suggests that pregnancy weight and body shape changes result in a decline in body satisfaction in some adult women, whereas other research suggests that most women experience stable or improved body image during certain stages of pregnancy. Many factors are said to be involved in a pregnant woman’s perception of and feelings towards her body; for example, one’s pre-pregnancy body image, the trimester of pregnancy, as well as symptoms of depression. Research exploring the relationship between body image and pregnancy in adolescence is limited, both in quality and quantity, and shows inconsistent results. Some studies found an increase in body image disturbance and dissatisfaction during pregnancy in adolescents, whereas others demonstrated that the majority of pregnant adolescents reported a positive body image. Negative body image in pregnancy can be associated with unhealthy weight control behaviours (i. e., dieting), as well as depressive symptoms in pregnancy and postpartum. Given the possible ramifications of both weight control behaviours and depression in

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Correspondence to Megan Harrison, MD, FRCPC, Department of Paediatrics, Children‘s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa Ontario, Canada K1H 8L1. Tel 613-737-7600 x 2571 Fax 613-738-4878 Email [email protected]

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Danusha Jebanesan, Leanna Isserlin and Megan E. Harrison pregnancy, it is imperative that researchers explore the potential risk factors for body dissatisfaction during pregnancy in both adults and adolescents.

INTRODUCTION Body image is defined as one‘s internal representation of his or her own physical appearance. Negative body image is common among women and social pressures regarding thinness can contribute significantly to high levels of body dissatisfaction (Loth, Bauer, Wall, Berge, & Neumark-Sztainer, 2011). Body dissatisfaction is thought to be even more prevalent in adolescent females, as body image is an important aspect of self-evaluation during adolescence (Jones, 2001). The period of adolescence is characterized by many developmental, biological, and psychological changes that exist within the realm of established sociocultural standards. Pregnancy complicates this existing situation, as there is a large discrepancy between societal ideals of physical appearance and the reality of the developing pregnant body. Body dissatisfaction, which is already heightened in the normal adolescent female population (Clay, Vignoles, & Dittmar, 2005; Jones, 2001), is potentially at increased risk for escalation among the pregnant adolescent population. Research in the area of body image in adolescent pregnancy, however, is limited and has shown inconsistent results (Zaltzman, Falcon, & Harrison, 2014). Some studies suggest that pregnant adolescents (maternal age at pregnancy under 19 years) have greater body dissatisfaction (Figueiredo, Tendais, & Dias, 2014) and a less positive perception of their bodies (Windridge & Berryman, 1996) as compared to older mothers. Other studies have found that the majority of adolescents express positive attitudes toward pregnancy weight gain and have more positive body image than their non-pregnant peers (Matsuhashi & Felice, 1991; Stevens-Simon, Nakashima, & Andrews, 1993). In adults, the literature exploring body image in pregnancy is more extensive than in adolescents. As with adolescents, current evidence supports the occurrence of both body image dissatisfaction and satisfaction among women during the time of pregnancy (Clark, Skouteris, Wertheim, Paxton, & Milgrom, 2009a; Davies & Wardle, 1994; Duncombe, Wertheim, Skouteris, Paxton, & Kelly, 2008; Skouteris, Carr, Wertheim, Paxton, & Duncombe, 2005). This discrepancy in body image appraisal among different women may be attributed to the extent by which certain influencing factors are applicable to individual women during pregnancy. Research suggests that a variety of factors are associated with body dissatisfaction in pregnancy such as low mood, eating behaviours, perceived socio-cultural pressure, and intention to breastfeed (Fuller-Tyszkiewicz, Skouteris, Watson, & Hill, 2013). Several of these factors will be explored in greater detail in this chapter, with a particular focus on the adolescent research where possible.

DEPRESSION AND BODY IMAGE IN PREGNANCY The relationship between body image and depression in pregnancy is complex. Body image dissatisfaction in early pregnancy is not uncommon, and is thought to be caused by distress related to the early body changes in pregnancy, which can be comparable to women who have gained weight due to lifestyle, rather than to women who are further along in

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pregnancy. As the pregnancy progresses and becomes more physically apparent, many women are better able to adapt to their changing bodies through understanding that these changes are necessary for a successful pregnancy (Davies & Wardle, 1994; Duncombe et al., 2008). Some research has found, however, that body image dissatisfaction in early pregnancy (trimester 1 and 2) may be an important psychological determinant of depressive symptoms in later pregnancy (trimester 2 and 3) and postpartum (Duncombe et al., 2008; Rauff & Downs, 2011). Several studies have also found associations between body image and depression in the postpartum period, generally after six to twelve months (Clark, Skouteris, Wertheim, Paxton, & Milgrom, 2009b; Downs, DiNallo, & Kirner, 2008; Hill, Skouteris, McCabe, & Fuller-Tyszkiewicz, 2013; Silveira, Ertel, Dole, & Chasan-Taber, 2015). In the postpartum period, women often feel they no longer have an ―excuse‖ to have ―excess weight‖ which leads to increased perceived pressure to lose weight and subsequent body image distress (Clark et al., 2009b; Rallis, Skouteris, Wertheim, & Paxton, 2007). In the adolescent population, similar trends are seen. In non-pregnant youth, body dissatisfaction has been linked with depression (Kostanski & Gullone, 1998; Stice, Hayward, Cameron, Killen, & Taylor, 2000). Research evidence in the adolescent pregnant population in regards to the relationship between body image and depression, however, is very limited (Zaltzman et al., 2014). One retrospective self-report study found that concerns around weight gained and body shape were predictors of postpartum depression among adolescents in the post-partum period; other stressors connected to postpartum depression in this study were social isolation and maternal self-efficacy (Birkeland, Thompson, & Phares, 2005). Positive body image during pregnancy, on the other hand, may be a protective factor for pregnancy – related depression in adolescents. One prospective study found that adolescents who expressed positive attitudes toward pregnancy weight gain prenatally also scored lower on a depression scale while pregnant (Stevens-Simon et al., 1993). As such, it is possible that, during adolescent pregnancy, depression and body image may have bi-directional effects where negative attitudes toward pregnancy weight gain can be seen among depressed adolescents and where adolescents with pre-existing poor body image may be more likely to develop depressive symptoms (Stevens-Simon et al., 1993). This potential bidirectional relationship between body image and depression is especially significant in adolescent pregnancy because of the reported high prevalence of antenatal depression in adolescence of between 16 to 44% (Hodgkinson, Colantuoni, Roberts, Berg-Cross, & Belcher, 2010), with some studies reporting even greater ranges of 28 to 67% (Birkeland et al., 2005). Delineating the relationship between depression and body image during adolescent pregnancy is also important, due to its role as a key determinant of depressive symptoms during the postpartum period and later in adulthood (Birkeland et al., 2005; Duncombe et al., 2008; Rauff & Downs, 2011). Unfortunately, without larger prospective studies in adolescent pregnancy, it is not possible to comment on whether depression leads to decreased body image or vice versa.

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EATING BEHAVIORS AND BODY IMAGE IN PREGNANCY In the adult pregnancy population, there seems to be a stasis in concerns surrounding body weight, shape and dieting during pregnancy (Clark et al., 2009b; Duncombe et al., 2008). Body image dissatisfaction, negative self-esteem and drive for thinness are often reduced or stable during pregnancy which is also reflected in lower levels of eating restraint and dieting among normal pregnant women (Davies & Wardle, 1994; Kazmierczak & Goodwin, 2011). Women with pre-existing eating disorders prior to pregnancy may also experience protection with improvements in eating disorder symptomatology (extreme dieting; bingeing; vomiting; use of laxatives, diuretics, slimming pills; and excessive physical exercise) during most of their pregnancy. However, many women who are unsatisfied with their body image and weight at conception will experience worsening of these feelings in late pregnancy and early postpartum and are likely to return to pre-pregnancy symptom levels after delivery (Baker, Carter, Cohen, & Brownell, 1999; Fairburn, Stein, & Jones, 1992; Rocco, Orbitello, Perini, Pera, Ciano, & Balestrieri, 2005). A small proportion of women who self-report dieting pre-pregnancy have been identified to be at an increased risk of continuing to diet during pregnancy and are even more likely to experience body dissatisfaction in the post partum period (Baker et al., 1999). Given that dieting is not traditionally seen or advised during pregnancy, these findings suggest that screening for individuals that were active dieters pre-pregnancy, and continued to diet, during pregnancy would help identify a niche of individuals at high-risk for eating problems after delivery. Additionally, pregnant adult women who do experience negative body satisfaction, are at increased risk of engaging in extreme methods of weight and appearance modification such as dieting, fasting, and purging during pregnancy (Duncombe et al., 2008; Loth et al., 2011). The relationship between disordered eating habits and body dissatisfaction in pregnancy is much less clearly defined in the adolescent pregnant population. It is unclear whether pregnancy is also protective for eating disorders in adolescents, as it is in adults, or whether pregnancy related weight gain exacerbates pre-pregnancy eating disorders in adolescents. One case study found the physical and psychological changes of pregnancy and motherhood could be triggers for anorexia nervosa, which was surmised to be a conduit the patient used to manage identity formation and to relate herself with her peer group (Benton-Hardy & Lock, 1998). Other studies have also suggested that eating disorders can first present in pregnant adolescents, even though this is not typical among adult pregnant women (Rand, Willis, & Kuldau, 1987; Rocco et al., 2005). However, these studies presented cases of adolescent girls who had other predisposing factors such as weak support systems, emotional distress, and drastic shifts in social structures among peers. Therefore it is difficult to draw definitive correlations between eating disorders and body image during pregnancy with the current literature. Body image is a key player in understanding the interplay between eating behaviours and pregnancy. The extent to which women are comfortable with their body image even before becoming pregnant can determine their risk for engaging in inappropriate eating behaviours or for triggering a relapse in pre-existing eating disorders once the protective social acknowledgement of pregnancy weight gain and psychological stability incurred by

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pregnancy is no longer in effect. Much more research is needed in this area in both the adult and adolescent population.

SOCIOENVIRONMENTAL FACTORS AND BODY IMAGE IN PREGNANCY Sociocultural influences can impact the way women perceive themselves, and self-esteem and body image are highly reflective of what is accepted as desirable traits within cultural and social groups (Loth et al., 2011; Molloy & Herzberger, 1998). Pregnancy is a transient time in a woman‘s life when her body deviates from the thin ideal valued by western society (Clark et al., 2009b), but nevertheless, for most pregnant adult women, body image seems to often be protected from socially constructed ideals of thinness, likely due to the pregnant body being viewed as having a functional and mothering identity (Hodgkinson, Smith, & Wittkowski, 2014). This notion that women experience improved body image during pregnancy, when emphasis on their reproductive role undermines societal pressure surrounding physical appearance, is supported widely in the literature (Duncombe et al., 2008; Hodgkinson et al., 2014; Kazmierczak & Goodwin, 2011; Loth et al., 2011). However, the reprieve from the sociocultural ideal of thinness is not ubiquitous, and may differ throughout trimesters. In several studies women actually reported poorer body image during the first to mid-second trimester when their waist was larger but pregnancy was not yet identifiable (Hodgkinson et al., 2014; Skouteris et al., 2005), and less body image dissatisfaction during later pregnancy (Goodwin, Astbury, & McMeeken, 2000; Skouteris et al., 2005). Moreover, body image during pregnancy may be differentially affected depending on the part of body that is being considered. For example, in one study added weight to areas such as the arms or face was considered ―fatness‖ whereas weight around the abdomen and pregnancy related weight was attributed to the growing fetus and therefore more easily accepted (Earle, 2003). This vulnerability of women to body image dissatisfaction in the earlier stages of pregnancy may be explained by the extent to which women internalize social norms of idealized appearance, and their flexibility in accepting changes that deviate from their pre-pregnancy self-image (Silveira et al., 2015). Research has also identified that women feel societal pressure to reclaim control of their body quickly after their babies were born (Clark et al., 2009a), and that many women feel that this pressure was even greater in the postpartum period than before pregnancy (Upton & Han, 2003). This ―relief‖ during pregnancy from the socially constructed ideal of thinness may unfortunately be shifting with time, as the gap between the pregnant body‘s ―imperfections‖ and the societal ideal are widening (Hodgkinson et al., 2014). For example, one study found that women had increased body satisfaction when their breast increased in size during pregnancy (moving them closer to the ―ideal‖) whereas acne and stretch marks moved them away from the ideal (Bondas & Eriksson, 2001; Chang, Chao, & Kenney, 2006). Currently, there are gaps in literature that explore the social context in which pregnant adolescents evaluate their body image. Social comparison, avoidance of social disapproval, media and fashion all exert added pressures for adolescent girls to be thin (Wertheim, Paxton, Schutz, & Muir, 1997). It is unclear whether social pressures to maintain a particular body type are relaxed during pregnancy in adolescence or whether pregnant youth continue to

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evaluate their self image under a persisting pressure. It is also unclear whether the internalization of the new maternal role is ranked higher than the need to maintain a specific physical appearance standard as it occurs with adult women. One study did find that adolescent pregnant girls felt more productive as a family member, which contributed to higher overall self-esteem and positive body image (Matsuhashi & Felice, 1991). Lack of social support from family and friends has been found to have a small negative correlation with body dissatisfaction in adult pregnant women (Chou, Lin, Cooney, Walker, & Riggs, 2003). Similarly, negative attitudes toward pregnancy weight gain was seen among adolescents whose families were not perceived by them to be supportive (Stevens-Simon et al., 1993). Further research should explore the extent to which support systems and relationships such as with family, peer-groups and partners affect body image appraisal.

FUTURE RESEARCH CONSIDERATIONS Understanding how pregnancy related body changes affect body image has important clinical implications for both the mother and the baby, among adult and adolescents females alike. Body dissatisfaction during pregnancy is a concern because of the potential association with negative behaviours, such as unhealthy dieting or dieting and purging behaviours, which have been linked to poor pregnancy outcomes like premature delivery and low infant birth weight (Conti, Abraham, & Taylor, 1998; Franko & Walton, 1993; Loth et al., 2011). Additionally, maternal eating disorders (such as anorexia nervosa) have been associated with anemia, delayed fetal growth, premature contractions, very premature birth, small for gestational age, low birth weight, and perinatal death (Linna, Raevuori, Haukka, Suvisaari, Suokas, & Gissler, 2014). The relationship between poor body image and depression is also important given that depression can have significant effects on young mothers and their children, including an increased risk of early repeat pregnancy (Black, Fleming, & Rome, 2012), a decrease sense of maternal confidence (Cox, Buman, Valenzuela, Joseph, Mitchell, & Woods, 2008), an increased risk for development of insecure infant-maternal attachment (Moran, Pederson, & Krupka, 2005) and poor cognitive developmental outcomes in children of depressed teen mothers (Grace, Evindar, & Stewart, 2003). To more fully explore body image in pregnancy, diverse prospective studies that assess women from pregnancy throughout the postpartum period could help to understand how the various stages of pregnancy differentially affect body image appraisal. More specifically, tools that link very specific pregnancy-related changes (in addition to the obvious weight gain) to body image satisfaction could identify how specific pregnancy changes affect body image. Further, these studies should be conducted in both the adult and adolescent populations using standardized measures so a direct comparison can be made between these two populations, as well as, with their non-pregnant counterparts. It has been noted that some traditionally used body image scales are inaccurate during pregnancy, and as such, further research is required to develop more applicable measures and ways of evaluating body image in pregnancy (Hodgkinson et al., 2014). The existing literature on pregnancy and body image is highly skewed to focus on the adult population and there are major limitations in the literature concerning body image during adolescent pregnancy. Conclusions are difficult to illicit given that study methods and

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designs (i.e., different measures to assess body image) vary significantly, as do the demographics of the research samples. There is a particular need for further research to determine what risks, if any, the adolescent developmental period pose for pregnant teenagers in terms of negative body image and other associated factors such as depression and selfesteem.

CONCLUSION The rapid changes pertaining to weight and body shape associated with pregnancy can potentially lead to significant reappraisal of self-image by both adults and adolescents. The relationship between body image and pregnancy, especially in adolescents, is poorly understood and the paucity of present research begs the need for further studies. From the adult literature, it appears that pregnancy body shape and weight changes are socially accepted and are, therefore, protective against developing a negative body image. In the instances where pregnancy negatively impacts body image, it is usually post-partum (when social constructs of idealized beauty become applicable again) or pre-pregnancy to early pregnancy (when pre-existing psychological factors persist into pregnancy or women have not positively adapted to their pregnant bodies). Modulating cultural factors, such as emphasis on social and gender roles, early detection of pre-existing psychological conditions such as depression, and eating disorders could help protect women against negative body image brought forth by pregnancy-related body changes. Further understanding of body image development, adjustment and/or change during pregnancy and post-partum has the potential to prevent negative sequelae such as struggling to integrate with the mothering identity, eating disordered behaviours, and mood changes that will have long-lasting effects on both mother and baby.

REFERENCES Baker, C., Carter, A., Cohen, L., & Brownell, K. (1999). Eating attitudes and behaviors in pregnancy and postpartum: Global stability versus specific transitions. Annals of behavioral medicine, 21(2), 143–148. Benton‐Hardy, L., & Lock, J. (1998). Pregnancy and Early Parenthood: Factors in the Development of Anorexia Nervosa? International Journal of eating disorders, 24(2), 223–6. Birkeland, R., Thompson, J. K., & Phares, V. (2005). Adolescent Motherhood and Postpartum Depression. Journal of Clinical child and adolescent psychology, 34(2), 292– 300. Black, A.Y., Fleming, N.A., & Rome, E.S. (2012). Pregnancy in adolescents. Adolescent Medicine State of the Art Reviews, 23, 123-38. Bondas, T., & Eriksson, K. (2001). Women‘s lived experiences of pregnancy: A tapestry of joy and suffering. Qualitative Health Research, 11(6), 824–840.

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Chang, S., Chao, Y. Y., & Kenney, N. J. (2006). I Am a Woman and I‘m Pregnant: Body Image of Women in Taiwan During the Third Trimester of Pregnancy. Birth, 33(2), 147– 153. Chou, F.-H., Lin, L.-L., Cooney, A., Walker, L. O., & Riggs, M. (2003). Psychosocial factors related to nausea, vomiting, and fatigue in early pregnancy. Journal of Nursing Scholarship, 35(2), 119–125. Clark, A., Skouteris, H., Wertheim, E. H., Paxton, S. J., & Milgrom, J. (2009a). My baby body: A qualitative insight into women‘s body‐related experiences and mood during pregnancy and the postpartum. Journal of Reproductive and Infant Psychology, 27(4), 330–345. doi:10.1080/ 02646830903190904. Clark, A., Skouteris, H., Wertheim, E. H., Paxton, S. J., & Milgrom, J. (2009b). The relationship between depression and body dissatisfaction across pregnancy and the postpartum: a prospective study. Journal of health psychology, 14(1), 27–35. doi:10.1177/1359105308097940. Clay, D., Vignoles, V., & Dittmar, H. (2005). Body image and self‐esteem among adolescent girls: testing the influence of sociocultural factors. Journal of research on adolescence, 15(4), 451–477. Conti, J., Abraham, S., & Taylor, A. (1998). Eating behavior and pregnancy outcome. Journal of Psychosomatic Research, 44(3-4), 465–477. Cox, J.E., Buman, M., Valenzuela, J., Joseph, N.P., Mitchell, A., & Woods, E.R. (2008). Depression, parenting attributes, and social support among adolescent mothers attending a teen tot program. Journal of Pediatric and Adolescent Gynecology, 21, 275-81. Davies, K., & Wardle, J. (1994). Body image and dieting in pregnancy. Journal of Psychosomatic Research, 38(8), 787–99. Downs, D. S., DiNallo, J. M., & Kirner, T. L. (2008). Determinants of pregnancy and postpartum depression: prospective influences of depressive symptoms, body image satisfaction, and exercise behavior. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, 36(1), 54–63. doi:10.1007/s12160-008-9044-9. Duncombe, D., Wertheim, E., Skouteris, H., Paxton, S., & Kelly, L. (2008). How well do women adapt to changes in their body size and shape across the course of pregnancy? Journal of health Psychology, 13(4), 503–515. doi:10.1177/1359105308088521. Earle, S. (2003). ―Bumps and Boobs‖: Fatness and Women‘S Experiences of Pregnancy. Women’s Studies International Forum, 26(3), 245–252. doi:10.1016/S02775395(03)00054-2. Fairburn, C., Stein, A., & Jones, R. (1992). Eating habits and eating disorders during pregnancy. Psychosomatic Medicine, 54(6), 665–672. Figueiredo, B., Tendais, I., & Dias, C. C. (2014). Maternal adjustment and maternal attitudes in adolescent and adult pregnant women. Journal of pediatric and adolescent gynecology, 27(4), 194–201. doi:10.1016/j.jpag. 2013.09.014. Franko, D. L., & Walton, B. E. (1993). Pregnancy and Eating Disorders: A Review and Clinical Implications. Journal of Eating Disorders, 13(1), 41–47. Fuller-Tyszkiewicz, M., Skouteris, H., Watson, B. E., & Hill, B. (2013). Body dissatisfaction during pregnancy: a systematic review of cross-sectional and prospective correlates. Journal of health psychology, 18(11), 1411–21. doi:10.1177/1359105312462437.

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Goodwin, A., Astbury, J., & McMeeken, J. (2000). Body image and psychological well-being in pregnancy: A comparison of exercisers and non-exercisers. Australian and New Zealand Journal of Obstetrics and Gynaecology, 40(4), 442–447. Grace, S.L., Evindar, A., & Stewart, D.E. (2003). The effect of postpartum depression on child cognitive development and behavior: a review and critical analysis of the literature. Archives of Women's Mental Health, 6, 263-74. Hill, B., Skouteris, H., McCabe, M., & Fuller-Tyszkiewicz, M. (2013). Body image and gestational weight gain: a prospective study. Journal of midwifery & women’s health, 58(2), 189–94. doi:10.1111/j.1542-2011.2012.00227.x. Hodgkinson, E. L., Smith, D. M., & Wittkowski, A. (2014). Women‘s experiences of their pregnancy and postpartum body image: a systematic review and meta-synthesis. BMC pregnancy and childbirth, 14(330), 1–11. doi:10.1186/1471-2393-14-330. Hodgkinson, S. C., Colantuoni, E., Roberts, D., Berg-Cross, L., & Belcher, H. E. (2010). Depressive symptoms and birth outcomes among pregnant teenagers. Journal of Pediatric and Adolescent Gynecology, 23, 16–22. Jones, D. (2001). Social comparison and body image: Attractiveness comparisons to models and peers among adolescent girls and boys. Sex roles, 45, 645–664. Kazmierczak, M., & Goodwin, R. (2011). Pregnancy and body image in Poland: Gender roles and self-esteem during the third trimester. Journal of Reproductive and Infant Psychology, 29(4), 334–342. doi:10.1080/02646 838.2011.631179. Kostanski, M., & Gullone, E. (1998). Adolescent body image dissatisfaction: relationships with self-esteem, anxiety, and depression controlling for body mass. Journal of Child Psychology and Psychiatry, 39(2), 255-62. Linna, M. S., Raevuori, A., Haukka, J., Suvisaari, J. M., Suokas, J. T., & Gissler, M. (2014). Pregnancy, obstetric, and perinatal health outcomes in eating disorders. American journal of obstetrics and gynecology, 211(4), 392.e1–8. doi:10.1016/j.ajog.2014.03.067. Loth, K., Bauer, K., Wall, M., Berge, J., & Neumark-Sztainer, D. (2011). Body satisfaction during pregnancy. Body image, 8(3), 297–300. doi:10.1016/j.bodyim.2011.03.002.Body. Matsuhashi, Y., & Felice, M. (1991). Adolescent body image during pregnancy. Journal of adolescent health, 12(4), 313–315. Molloy, B., & Herzberger, S. (1998). Body Image and Self-Esteem : A Comparison of African-American and Caucasian Women. Sex Roles, 38(718), 631–643. Moran, G., Pederson, D.R., & Krupka, A. (2005) Maternal unresolved attachment status impedes the effectiveness of interventions with adolescent mothers. Infant Mental Health Journal, 26, 231-49. Rallis, S., Skouteris, H., Wertheim, E., & Paxton, S. (2007). Predictors of Body Image During the First Year Postpartum : A Prospective Study. Women & health, 45(1), 87–104. doi:10.1300/J013v45n01. Rand, C., Willis, D., & Kuldau, J. (1987). Pregnancy after anorexia nervosa. International Journal of eating disorders, 6(5), 671–674. Rauff, E. L., & Downs, D. S. (2011). Mediating effects of body image satisfaction on exercise behavior, depressive symptoms, and gestational weight gain in pregnancy. Annals of behavioral medicine: a publication of the Society of Behavioral Medicine, 42(3), 381–90. doi:10.1007/s12160-011-9300-2.

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Rocco, P. L., Orbitello, B., Perini, L., Pera, V., Ciano, R. P., & Balestrieri, M. (2005). Effects of pregnancy on eating attitudes and disorders: a prospective study. Journal of psychosomatic research, 59(3), 175–9. doi:10.1016/j.jpsychores.2005.03.002. Silveira, M. L., Ertel, K. a, Dole, N., & Chasan-Taber, L. (2015). The role of body image in prenatal and postpartum depression: a critical review of the literature. Archives of women’s mental health, 18(3), 409–421. doi:10.1007/s00737-015-0525-0. Skouteris, H., Carr, R., Wertheim, E. H., Paxton, S. J., & Duncombe, D. (2005). A prospective study of factors that lead to body dissatisfaction during pregnancy. Body image, 2(4), 347–61. doi:10.1016/ j.bodyim.2005.09.002. Stevens-Simon, C., Nakashima, I., & Andrews, D. (1993). Weight gain attitudes among pregnant adolescents. Journal of adolescent health, 14(5), 369–372. Stice, E., Hayward, C., Cameron, R.P., Killen, J.D., & Taylor, C.B. (2000). Body-image and eating disturbances predict onset of depression among female adolescents: a longitudinal study. Journal of Abnormal Pscyhology, 109(3), 438-44. Upton, R. L., & Han, S. S. (2003). Maternity and Its Discontents: ―Getting The Body Back‖ After Pregnancy. Journal of Contemporary Ethnography, 32(6), 670–692. doi:10.1177/0891241603257596. Wertheim, E., Paxton, S., Schutz, H., & Muir, S. (1997). Why do adolescent girls watch their weight? An interview study examining sociocultural pressures to be thin. Journal of psychosomatic research, 42(4), 345–355. Windridge, K. C., & Berryman, J. C. (1996). Maternal adjustment and maternal attitudes during pregnancy and early motherhood in women of 35 and over. Journal of Reproductive and Infant Psychology, 14(1), 45–55. doi:10.1080/02646839608405858. Zaltzman, A., Falcon, B., & Harrison, M. E. (2014). Body Image in Adolescent Pregnancy. Journal of Pediatric and Adolescent Gynecology, 28(2), 102–108. doi:10.1016 /j.jpag.2014.06.003.

In: Body Image Editor: Rafael Vargas

ISBN: 978-1-63483-870-2 © 2016 Nova Science Publishers, Inc.

Chapter 6

MAGAZINE IMAGE INFLUENCE, EXTRAVERSION AND BODY IMAGE IN FRATERNITY AND NON-FRATERNITY COLLEGE MALES Morgan Draxten and F. Richard Ferraro* University of North Dakota, North Dakota, US

ABSTRACT Previous research has shown that exposure to media images of physically fit males increase body dissatisfaction. Also, those high in extraversion will have low body dissatisfaction. In the present study fraternity (n = 37) and non-fraternity (n = 157) males were given the Eysenck Personality Questionnaire – Brief Version and the Male Body Attitudes Scale. The design was a 2 (Group: Fraternity, Non-Fraternity) x 2 (Image: physically fit males, neutral household objects). Extraversion scores in fraternity and non-fraternity males were not significantly different. There was no significant interaction between images viewed and the Male Body Attitudes Scale, there also no main effect in the scores on the Male Body Attitudes Scale between fraternity and non-fraternity males. The physically fit mages did not have a significant effect on male body dissatisfaction.

Keywords: Extraversion, body image, fraternity

The subject of body dissatisfaction has been extensively studied in females but now the focus has started to shift to male body dissatisfaction. Research has also shown that the factors playing a role in female body dissatisfaction are not exactly the same as the factors in male body dissatisfaction (Van den Berg, Paxton & Keery et. al. 2007). This helps to explain the expanding research of male body dissatisfaction. Body dissatisfaction has been shown to *

Address all correspondence to: F. Richard Ferraro, Ph.D. Chester Fritz Distinguished Professor, Editor-in-Chief, Current Psychology; https://www.editorialmanager.com/cups), Director, General/Experimental PhD Program (2003-2013), Fellow, National Academy of Neuropsychology, Dept. Psychology - University of North Dakota, Corwin-Larimore Rm. 215,319 Harvard St., Stop 8380, Grand Forks, ND 58202-8380, 701-777-2414 (O)/701777-3454 (FAX); [email protected].

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be perceived by males as the extent to which they differed from their ideal body image. The inconsistency between the ideal body image and body dissatisfaction has been managed by reducing the significance of the ideal body image (Adams, Turner & Bucks, 2005). Previous research suggested that there are many environmental factors influencing male body dissatisfaction such as negative comments, messages from society and media images (Adams et al., 2005; Arbour et al., 2006; Blond 2008; Diedrichs et al., 2010; Nowell et al., 2008; Van den Berg et al., 2007). Research has also suggested that individual factors, such as body checking behaviors, body comparison, self-esteem, mood, mindfulness and personality traits play a role in body dissatisfaction. Many researchers have studied different groups of males to find diversity between group participant‘s body dissatisfaction and many of the differences are significant. Body dissatisfaction in males has been shown to be correlated with eating disorders, to reduce eating disorders, researchers have to find and change the specific factors that play a role in body dissatisfaction (Daniel et al., 2010; Fink et al., 2005; Grammas et al., 2009; Gunnare et al., 2013; Kakizaki et al., 2008; Lavender et al., 2012; Lukaszewski et al., 2011; Walker et al., 2009). The growing literature of male body dissatisfaction has found many environmental factors that are major influences. One of the factors is negative comments towards a male‘s muscularity and strength. These negative comments have been shown to increase body dissatisfaction while positive comments have shown to decrease body dissatisfaction (Nowell & Ricciardelli, 2008). Thus, if an individual were to make a negative comment on a male‘s muscularity, that male‘s body dissatisfaction would increase, especially if the negative comments were continuous. Internalized messages from society have also been shown to affect body dissatisfaction in males. The more a male internalizes or interprets societal messages about ideal body physique, the more dissatisfied he is with his body (Grammas & Schwartz, 2009). People are exposed to many societal messages every day, therefore, depending on how extreme societal messages are about ideal body physiques; body dissatisfaction could increase significantly in males. Last but not least, media images which are a large portion of societal messages have been found to effect body dissatisfaction in males. According to a study conducted by Arbour and Ginis (2006), included 74 males from a southern university and hypothesized that males with higher muscularity would be negatively affected by exposure to muscular media images than males who were less muscular. The null hypothesis was rejected in that males with higher body dissatisfaction prior to viewing media images of muscular males were more affected after exposure while males who were exposed to hypermuscular media images did not show a relationship between body dissatisfaction either before or after exposure to the images. A male who is highly dissatisfied with his body image and who views media images of the ―ideal‖ body physique will demonstrate an increase in body dissatisfaction. However, if this male views media images of the non-ideal body physique his dissatisfaction stays at a constant. A meta-analysis supports these results as well by showing increases in body dissatisfaction as exposure to ideal male body images increased (Blond, 2008). In the meta-analysis, all accounts of increased body dissatisfaction followed the exposure of ideal male images but even though exposure to ideal male images increased body dissatisfaction, studies support that it can be changed by altering the ideal body image in the media to portray an average size male. One study found that the ideal body image in the media can be changed to an average size body image and it would not have an effect on the perception of the product being advertised. Dietrichs and Lee (2010) conducted

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a study that included 619 men and women from universities in Australia. The study hypothesized that media images containing muscular males would be rated as equally effective in advertising a product as average-sized males. The study supported this statement by exposing participants to advertisements with either ideal male models or average male models. It was found that the male participants rated advertisements that included ideal male models as equally effective as advertisements that included average male models. Moreover, if the marketers want to sell more products, sales could increase if there were no male model incorporated. When male participants were shown advertisements that included ideal male models versus advertisements without any models, participants rated advertisements with ideal male models as less effective than the ones that did not include models. This means that the media can either add average size male models or eliminates and either increase sales or equate them. Even though there are many environmental factors that may play a role in body dissatisfaction, there are also many individual factors. Internal factors such as body checking behaviors which are defined as thoughts or feelings of increasing muscle mass, strength and overall size, were found to influence body dissatisfaction in normal weight males by maintaining eating and body psychopathology. These behaviors also were significantly correlated with depression, symptoms of muscle dysmorphia, aspiration to increase body mass index and weight and shape concerns (Walker, Anderson & Hildebrandt, 2006). Each of the correlations is detrimental to a male‘s mental health. Internalization and BMI have been found to be the two strongest predictors of a male‘s drive for muscularity (Daniel & Bridges, 2010). Internalization of media ideals has been defined as setting goals or comparing oneself to others based on the ideal body image set by the media. An increased internalization of media ideals was found to be positively correlated with body dissatisfaction. Therefore, when a male sets goals and/or compares himself to others based on the ideal body image, he will likely have higher body dissatisfaction than a male who does not internalize media ideals. Body mass index is another strong predictor of a male‘s drive for muscularity for example, one study supported that 37 percent of males overestimated their weight due to their body mass index (Gunnare, Silliman & Morris, 2013). When males have a lower BMI some may tend to overestimate their weight in order to conform to the ideal body image set by society. Another internal factor is called dispositional mindfulness. Dispositional mindfulness is defined as the propensity to be distracted and preoccupied at the present moment while completing tasks or engaging in behaviors with little awareness (Lavender, Gratz & Anderson, 2012). Interestingly, dispositional mindfulness was negatively correlated with the drive for muscularity and body dissatisfaction in males and positively correlated with appearance evaluation. This means that when a male is prone to being more distracted than usual, his desire for muscularity is decreased. It also means that when he is prone to being more attentive than usual, his desire for muscularity is increased. To explain this further, a male who is more distracted will have lower body dissatisfaction while a male who is less distracted will have a higher body dissatisfaction. Finally, another large internal influence of body dissatisfaction is a male‘s personality. More specifically, extraversion has been shown to influence body dissatisfaction. First, levels of extraversion have been found to attune with levels of physical strength and attractiveness (Lukazweski & Roney, 2011). This means that high levels of extraversion will mean high levels of physical strength and attractiveness and low levels of extraversion will mean low levels of physical strength and attractiveness. The attuning of extraversion and physical

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strength and attractiveness is important in understanding a large source of body dissatisfaction. In a study conducted by Kakizaki et. al. (2008), 30,722 middle age males from only western countries participated. The researchers hypothesized that extraversion and psychoticism would have a positive association with being overweight. The study found that extraversion was negatively associated with underweight and positively associated with overweight in males. These results suggest that if a male has high extraversion it is likely that he is muscular, and if a male has low extraversion, it is likely that he is hypomuscular. Extraversion has also been positively correlated with facial symmetry, which has been viewed as healthy and therefore attractive. When a male is more facially symmetrical, he is more likely to have higher extraversion because he is viewed as more attractive in society (Fink, Neave, Manning & Grammer, 2005). Another study that supports the relationship between body dissatisfaction and extraversion found that extraversion was positively related to a higher body appreciation (Swami, Hadji-Micheal & Furnham, 2008). An explanation of this result is that higher extraversion is associated to higher body satisfaction and higher body satisfaction means lower body dissatisfaction. Therefore, when a male values his body image rather than internalizing ideal body image standards, he is less likely to be dissatisfied with his physique. Through extensive research, it has been shown that external and internal factors play a role in male body dissatisfaction. However, little research has been done on different subgroups of males. Previous research, although minimal, has defined differences between homo- and heterosexual males and between male athletes and non-athletes. Differences between homo- and heterosexual males have shown that homosexual males have a significantly higher drive to be thin along with higher appearance-related anxiety. However, homosexual males did not identify physical attractiveness as any more essential than heterosexual males. Homosexual males have also been found to feel more pressure from media images to imitate the ideal physique portrayed in them (Carper, Negy & TantleffDunn, 2010). A study conducted by Morgan and Arcelus (2009), included 15 men from a university and wanted to expand on research that included differences in sexual orientation and body image attitudes. The researchers found that homosexual males experience more pressure from peers and media to conform to the ideal body image and because of this pressure, homosexual males are more likely to experience body dissatisfaction along with eating disorders. It was also noted that other sub-groups of males are more likely to experience body dissatisfaction as well such as athletes. Therefore, by a changing the media‘s ideal male image, normal weight males, no matter what sub-group, may discontinue engaging in many of the factors that increase body dissatisfaction. An example of how extraversion and body dissatisfaction are related was found between athletic and non-athletic males. Extraversion and body satisfaction along with introversion and social physique anxiety has been found to be related in both athletic and non-athletic males. However, this relationship is much more prevalent in non-athletic males (Tok, Tartar & Morali, 2010). Since there are differences among personality, body dissatisfaction and different groups of males, there can be a vast array of research topics in this area. Since extraversion can have an effect on body dissatisfaction in men, it is logical to suggest that fraternity males have lower body dissatisfaction than regular college males due to a higher extraversion score. A study conducted by Cole, Field and Giles (2003), found that sorority and fraternity membership was positively associated with extraversion. This means that fraternity members have higher extraversion scores than college students who are not

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involved in extracurricular activities. It has also been reported that fraternity members may engage in more high risk behaviors than non-fraternity members because of their high levels of extraversion (Raynor & Levine, 2009). This supports that fraternity members have higher extraversion scores than non-fraternity college males and can suggest that body dissatisfaction is also affected by the high levels of extraversion fraternity males‘ possess.

THE PRESENT STUDY The main area of interest of this study is the relationship between extraversion and body dissatisfaction in fraternity and non-fraternity males after viewing magazine images of physically fit males. Many differences among groups of males that support body dissatisfaction have been found. Previous research has linked high body dissatisfaction with more exposure to media images of physically fit males. It has also been supported that body satisfaction is positively correlated with extraversion in athletes, homosexuals, and heterosexuals (Adams et al., 2005; Daniel et al., 2010; Diedrichs et al., 2010). Many subgroups of males have significantly different scores on body dissatisfaction based on extraversion/introversion scores as well. Therefore, being that some sub-groups of males are more extraverted than others, different groups of males may have lower extraversion and higher body dissatisfaction after being exposed to magazine images of physically fit males. Being able to find a connection between extraversion and body dissatisfaction among fraternity and non-fraternity males will build on the knowledge already known about subgroups of males. It will also help to explain how extraversion interacts with body dissatisfaction after exposure to media images. Therefore, the first hypothesis of this study is that fraternity males will have significantly higher extraversion scores than non-fraternity males. The second hypothesis is that non-fraternity males will have significantly higher body dissatisfaction scores on the Male Body Attitude Scale than fraternity males.

METHOD Participants A total of 194 (M age = 20 years, 77% European American, 96% heterosexual, 48% freshmen) male participants were recruited from a large upper Midwest university. A total of 157 were non-fraternity members and 37 were fraternity members.

Procedure Participants logged onto SONA Systems and signed-up for the study. The study consisted of a survey which asked age, race, and class level. Next, participants took the Eysenck Personality Inventory Questionnaire – Brief Version (Sato, 2005). They then viewed a series of neutral media images and images of physically fit male images which were obtained from various websites. The physically images were rated on a Likert scale 1 (not fit at all) to 5

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(extremely physically fit) by three graduate student males. The most physically fit images were chosen if the mean rating of the image was 4 or higher. These images were shown one at a time to half of the fraternity and non-fraternity participants. The other half of the fraternity and non-fraternity participants viewed the neutral images one at a time which did not include people and included pictures of household items, animals, and nature scenery. Finally, participants took the Male Body Attitude Scale (MBAS; Tylka, 2005).

RESULTS An independent sample t-test was run and there was not a significant difference in extraversion between the fraternity member (M = 43.91, SD = 8.34), and non-fraternity member (M = 41.98, SD = 8.69) conditions, t(192) = 1.25, p = .22, power = .113. A 2 (Membership: Fraternity, Non Fraternity) x 2 (Image: Neutral, Physically Fit) ANOVA was conducted on Male Body Attitudes Scale (MBAS) scores. The main effect for Membership was not significant [F(1, 193 = .000, p = .988, power = .050], nor was the main effect for Image [F(1, 193) = 1.58, p = .21, power = .239]. The interaction was also not significant [F(1, 193) = .81, p = .37, power = .146]. Extraversion scores were negatively associated with MBAS scores (r = -.276, p < .01).

DISCUSSION The results show that extraversion in fraternity males is not significantly different than non-fraternity males and that after viewing magazine images of physically fit males, nonfraternity males do not have significantly higher body dissatisfaction than fraternity males. There was no main effect in body dissatisfaction between fraternity males and non-fraternity. The hypothesis was not supported and therefore does not support that different sub-groups of men have significantly different body dissatisfaction when compared to extraversion scores after exposure to magazine images of physically fit males. The study does not support previous research results in that significant differences in body dissatisfaction were not shown. The study retains the null hypothesis in which there is no effect on male body dissatisfaction in this sub-group of males due to the exposure to media. Future research could include samples from many different colleges while still studying the same age group along with a much larger sample size. This would make the sample more diverse and help the results become more generalizable. Future research could also employ a cross-sectional research design to see at what age body dissatisfaction is hindered by media images the most. Increasing the variety of ideal male body images would increase the likelihood that the significance in the results is due to the images rather than an outlying factor. Another idea for future research would have participants view the same images but have one control group, which would include neutral images, and two experimental groups, which would include images that are at the extreme ends of physical fitness and fatness. After viewing these images each group would be asked multiple questions about their body dissatisfaction. This experiment would reinforce the idea that body image ideals in the media increases body dissatisfaction. A third improvement future research could implement is

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extraversion survey should be used before and after the images are viewed in order to see if there is any significant change in scores after viewing images. Since extraversion has been supported to be effected by media in previous research, participants should view other types of media that include physically fit male images (Swami, Michael & Furnham, 2008). The next step, after correcting the limitations, would be to apply the results to the population who views the media. Finding the root of the problem, ideal body media images, and correcting it by banning or reducing this type of media images may decrease body dissatisfaction and improve extraversion. A limitation to the study is that the results reduce generalizability and validity due to the small sample size. Another limitation is that the images did not have the same background or pose which may have affected the perception of physical fitness. In summary, body dissatisfaction in males is an expanding area of research. The results showed there was no significant difference in extraversion scores between the two groups along with no main or interaction effects between images viewed and body dissatisfaction scores. Results also showed no main effect in body dissatisfaction scores between fraternity and non-fraternity males.

Figure 1. (Continued).

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Figure 1. Neutral Images.

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Figure 2. (Continued).

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Figure 2. (Continued).

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Figure 2. (Continued).

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Figure 2. Physically Fit Images.

REFERENCES Adams, G., Turner, H., & Bucks, R. (2005). The experience of body dissatisfaction in men. Body Image, 2, 271-283. Arbour, K. P., & Martin Ginis, K. A. (2006). Effects of exposure to muscular and hypermuscular media images on young men‘s muscularity dissatisfaction and body dissatisfaction. Body Image, 3, 153-161. Blond, A. (2008). Impacts of exposure to images of ideal bodies on male body dissatisfaction: a review. Body Image, 5, 244-250. Cole, M., Field, H., & Giles, W. (2003). What can we uncover about applicants based on their resumes?: A field study. Applied HRM Research, 8, 51-62. Daniel, S., & Bridges, S. K. (2010). The drive for muscularity in men: media influences and objectification theory. Body Image, 7, 32-38. Diedrichs, P. C., & Lee, C. (2010). GI joe or average joe? the impact of average-size and muscular male fasion models on men‘s and women‘s body image and advertisement effectiveness. Body Image, 7, 218-226. Fink, B., Neave, N., Manning, J. T., & Grammer, K. (2005). Facial symmetry and the ‗bigfive‘ personality factors. Personality and Individual Differences, 39, 523-529. Grammas, D. L., & Schwartz, J. P. (2009). Internalization of messages from society and perfectionism as predictors of male body image. Body Image, 6, 31-36. Gunnare, N. A., Silliman, K., & Morris, M. N. (2013). Accuracy of self-reported weight and role of gender, body mass index, weight satisfaction, weighing behavior, and physical activity among rural college students. Body Image, doi: 10.1016/j.bodyim.2013.01.006 Kakizaki, M., Kuriyama, S., Sato, Y., Shimazu, T., Matsuda-Ohmori, K., Nakaya, N., Fukao, A., Fukudo, S., & Tsuji, I. (2008). Personality and body mass index: a cross-sectional analysis from the Miyagi cohort study. Journal of Psychosomatic Research, 64, 71-80. Lavender, J. M., Gratz, K. L., & Anderson, D. A. (2012). Mindfulness, body image, and drive for muscularity in men. Body Image, 9, 289-292. Lukaszewski, A. W., & Roney, J. R. (2011). The origins of extraversion: joint effects of facultative calibration and genetic polymorphism. Personality and Social Psychology Bulletin, 37, 409-421.

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Marino Carper, T. L., Negy, C., & Tantleff-Dunn, S. (2010). Relations among media influence, body image, eating concerns, and sexual orientation in men: a preliminary investigation. Body Image, 7, 301-309. Morgan, J.F., & Arcelus, J. (2003). What can we uncover about applicants based on their resumes? A field study. Applied HRM Research, 8, 51-62. Nowell, C., & Ricciardelli, L. A. (2008). Appearance-based comments, body dissatisfaction and drive for muscularity in males. Body Image, 5, 337-345. Raynor, D., & Levine, H. (2009). Associations between the five-factor model of personality and health behaviors among college students. Journal of American College Health, 58, 73-81. Sato, T. (2005) The eysenck personality questionnaire brief version: factor structure and reliability. The Journal of Psychology, 6, 545-552. Swami, V., Hadji-Michael, M., & Furnham, A. (2008). Personality and individual difference correlates of positive body image. Body Image, 5, 322-325. Tok, S., Tartar, A., & Morali, S. L. (2010). Relationship between dimensions of the five factor personality model, body image satisfaction and social physique anxiety in college students. Studia Psychologica, 52, 59-67. Tylka, T. L., Bergeron, D., & Schwartz, J. P. (2005). Development and psychometric evaluation of the male body attitudes scale. Body Image, 2, 161-175. Van den Berg, P., Paxton, S. J., Keery, H., Wall, M., Guo, J., & Neumark-Sztainer, D. (2007). Body dissatisfaction and body comparison with media-images in males and females. Body Image, 4, 257-268. Walker, D. C., Anderson, D. A., & Hildebrandt, T. (2009). Body checking behaviors in men. Body Image, 6, 164-170.

In: Body Image Editor: Rafael Vargas

ISBN: 978-1-63483-870-2 © 2016 Nova Science Publishers, Inc.

Chapter 7

BODY IMAGE, SOCIOCULTURAL INFLUENCES AND SELF-ESTEEM: THE CASE OF CYPRUS Marios Argyrides1, PhD, Natalie Kkeli2, MSc and Marianna Koutsantoni2, MSc 1

Neapolis University Pafos, Paphos, Cyprus 2 University of Cyprus, Cyprus

ABSTRACT Sociocultural influences and self-esteem have been found to have an impact on body image (Thompson et al., 2004; Argyrides, 2013). The internalization of the thin ideal by the media, the large emphasis on appearance placed by society and the unrealistic, distorted media images are just some of the long list of the sociocultural factors that have been assessed in the past. Many of these variables have also been assessed crossculturally indicating some contradicting information between Western and Non-Western cultures (Bakhshi, 2011). The current chapter focuses mainly on Cyprus, an island country in the Mediterranean Sea with 320 days of sunshine per year. Cyprus is of great interest in the literature concerning body image, self-esteem and sociocultural issues if one takes into consideration five main factors: 1) There was a great boost in economy after the 1974 war and an emphasis was placed by the inhabitants on their social image as well as their body image (Katsounari, 2009) 2) There is a very warm weather in Cyprus which causes lighter, more revealing clothing to be worn. Previous research has pointed out that this may lead to an emphasis being placed on body image (Sloan, 2002) 3) The presence of significant increase in body image and self-esteem concerns as compared to other countries and ethnicities (Argyrides, 2013; Katsounari, 2009) 4) The minimal emphasis that is placed by the school curriculum on the above issues as the classes that address the issues have been reduced significantly (Ministry of Education, 2015) and 5) The 2.4 million tourists visiting the country each year, wearing lighter clothing, which the 850,000 inhabitants inevitably compare themselves. The chapter focuses on recent findings of a countrywide, large sample (N = 2664) of school-age males and females. Data were collected on sociocultural factors, body image factors and self-esteem. Some findings reflect the literature on these constructs whereas other findings differ significantly from other northern and southern European countries (and other Western and Non-western countries). These findings are presented through the lens of the

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Marios Argyrides, Natalie Kkeli and Marianna Koutsantoni independent variables of gender, socioeconomic status, Body Mass Index category, age, and geographical location of one‘s upbringing and residence. The chapter concludes with conclusions and recommendations not only for Cyprus, but also for countries with similar demographics.

INTRODUCTION Sociocultural influences and self-esteem have been found to have an impact on body image (Argyrides, 2013; Thompson, van den Berg, Roehrig, Guarda, & Heinberg, 2004). The internalization of the ideal body presented by the mass media, the large emphasis on appearance placed by society and the unrealistic, distorted media images are just some of the long list of the sociocultural factors that have been assessed in the past. Many of these variables have also been assessed cross-culturally indicating some contradicting information between Western and Non-Western cultures (Bakhshi, 2011). The current chapter focuses mainly on Cyprus, an island country in the Mediterranean Sea with 320 days of sunshine per year. Cyprus is of a great interest in the literature concerning body image, self-esteem, and sociocultural issues if one takes into consideration five main factors: (a) There was a great boost in economy after the 1974 war, which resulted, among many other issues, in a significant emphasis placed by the inhabitants on their social image as well as their body image (Katsounari, 2009); (b) There is a very warm weather in Cyprus which causes lighter, more revealing clothing to be worn, therefore more emphasis is placed on body image (Sloan, 2002); (c) The presence of significant increase in body image and self-esteem concerns as compared to other countries and ethnicities (Argyrides, 2013; Katsounari, 2009; Zeeni, Gharibeh, & Katsounari, 2013); (d) The minimal emphasis that is placed by the school curriculum on the above issues as the classes that address the issues have been reduced significantly (Ministry of Education and Culture, 2015) and (e) As compared to the 850,000 local inhabitants, there are 2.4 million tourists that visit the country each year, wearing lighter clothing, resulting in an inevitable comparison of locals to tourists (Argyrides, 2013; Katsounari, 2009). The chapter will focus on recent findings of a countrywide, large sample (N = 2664) of school-age males and females. Data were collected on sociocultural factors, body image, and self-esteem. Some findings reflect the literature on these constructs whereas other findings differ significantly from other northern and southern European countries (and other Western and Non-Western countries). These findings are presented through the lens of the independent variables of gender, socioeconomic status (SES), Body Mass Index (BMI) categories, age, and geographical location of one‘s residence and upbringing. The chapter concludes with conclusions and recommendations not only for Cyprus, but also for countries with similar demographic information.

SOCIOCULTURAL INFLUENCES AND SELF-ESTEEM ON BODY IMAGE Body image. Body image is a multidimensional concept including one‘s thoughts, feelings, and behaviors towards one‘s body and physical appearance (Grogan, 1999; Muth & Cash, 1997). This concept consists of three facets: (a) evaluation; (b) affect; (c) investment

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(Cash, 1994a). Evaluation refers to the degree a person is satisfied or dissatisfied with his/her physical appearance and self-evaluations of his/her body (Muth & Cash, 1997). Affect relates to emotional experiences concerning the self-evaluations of his/her body that are elicited in specific situations (Cash, 1994b; Szymanski & Cash, 1995). Investment is the degree of focus on one‘s attention on his/her physical appearance as well as one‘s behaviors towards appearance (Cash, 1994a; Cash & Labarge, 1996). In females, body dissatisfaction is expressed as the desire to lose weight, but in males is expressed as the wish to gain weight (Furnham, Badmin, & Sneade, 2002). There are conflicting results concerning body image and gender. Females are more dissatisfied with their bodies than males (Furnham & Calnan, 1998). On the contrary, Silberstein, StriegelMorre, Timko, and Rodin (1988) found that there was no significant difference between males and females regarding body and weight dissatisfaction. Gender appears to play a significant role in the relationship between body image and Body Mass Index (BMI) categories (Hudson, 2008). The BMI categories have been found to be associated with body image and in particular with body dissatisfaction (Wilson, Tripp, & Boland, 2005). Previous studies concluded that female college students with high BMI are dissatisfied with their bodies (Burger & Doiny, 2002; Hudson, 2008; Schwarts, & Brownell, 2004; Yates, Edman, & Aruguete, 2004). Additionally, obese adolescents were more dissatisfied with their bodies than their overweight counterparts, who in turn had higher body dissatisfaction than normal weight adolescents (Goldfield et al., 2010). In contrast, Bearman, Presenell, Martinez, and Stice (2006) did not find any association between body dissatisfaction and BMI categories. Specifically, no relationship was found between body dissatisfaction and BMI in overweight and obese women (Hill & Williams, 1998). Besides BMI categories, previous studies have also assessed and found a difference between ethnic groups regarding body satisfaction, dieting, and disordered eating behaviors (Franko & Striegel-Moore, 2002; Sarwer, Thompson, & Cash, 2005). It was found that Black females were less dissatisfied with their bodies than their White counterparts (Adams et al., 2000; Celio, Zabinski, & Wiffley, 2002; Crago, Shisslak, Estes, 1996). Non-Black women (i.e., White, Asian, Hispanic, and other ethnicities) reported less positive evaluation than nonBlack men and Black women. Moreover, Black women and non-black women experienced greater appearance investment as compared to non-Black men. In addition, Black women scored higher in appearance investment than non-Black women (Cash, Morrow, Hrabosky, & Perry, 2004). Sociocultural influences. A significant amount of body image attitudes and behaviors is affected by culture (Rudd & Lennon, 2001). The male ideal body is defined as a V-shaped body with muscular upper-body, flat stomach, and narrow hips (Leit, Pope, & Gray, 2001). On the other hand, the female ideal body is defined as an unrealistically thin body (Trampe, Stapel, & Siero, 2007). These attitudes and behaviors are reinforced through appraisal and comparisons by family, peers, and the mass media including conventional media, such as magazines and television, and social networking sites, such as Facebook, Instagram, and Twitter (Cohen & Blaszczynski, 2015; Thompson & Stice, 2001). Parents seem to play a predominant role in transmitting messages to adolescents, in accordance to sociocultural standards (Stice, 1994). Particularly, mothers appear to have the greatest influence on their children‘s body image (Pike & Rodin, 1992). Adolescents engage in conversations about their physical appearance, encompassing weight, shape, dieting, clothes, look, and attractiveness (Jones, 2004; Levine, Smolak, Moodey, Shuman, & Hessen, 1994). The mass media appear

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to have the greatest influence on adolescents regarding the sociocultural standards (Heiberg, 1996). The messages about ideal body are usually communicated via television and magazines. Sociocultural influences on body image. Parents‘ comments about body shape were found to have an impact on body dissatisfaction. Specifically, the feedback of both parents has the greatest influence on heavier adolescents (McCabe & Ricciardelli, 2001). In addition, the influence of mothers‘ feedback was greater for female adolescents than for males in regards to losing weight and increasing muscles (McCabe & Ricciardelli, 2001). Similarly, the comments from male friends also have an influence on heavier adolescents regarding losing weight and increasing muscles (McCabe & Ricciardelli, 2001). Additionally, the feedback from female friends was greater for females than for males (McCabe & Ricciardelli, 2001). In a study of similar influences in Black and White females, Mikula, Argyrides, and Ross (2004) found that White female students seemed to value their best male friend‘s opinion more than Black female students and Black female students seemed to value their best female friend‘s opinion more than White female students. The mass media were found to have an influence on body image and particularly on body dissatisfaction. In detail, exposure to the media seems to lead to an internalization of the ideal body, which results in an inevitable comparison and in turn results in body dissatisfaction and symptoms of disordered eating in both sexes (Hobza & Rochlen, 2009; Stice, SchupakNeuberg, Shaw, & Stein, 1994; Tucci & Peters, 2008). Specifically, the mass media have been found to influence females‘ drive for thinness (Ahern, Bennett, & Hetherington, 2008) and males‘ drive for muscularity (Giles & Close, 2008). The total hours of television watching per week was found to be correlated with greater body image dissatisfaction (Gonzalez-Lavin & Smolak, 1995). Similarly, television advertisements associated with appearance, led to body dissatisfaction in girls aged 13-15 years old (Hargreaves & Tiggemann, 2003) and in girls aged 15-17 (Hargreaves & Tiggemann, 2002) as well as those 18 years and older (Cattarin, Thompson, Thomas, & Williams, 2000; Lavine, Sweeney, & Wagner, 1999). In contrast, the frequency of television watching did not have an impact on body image in female college students (Kim & Lennon, 2007). However, commercial viewing did not have an impact on males‘ body dissatisfaction (Hargreaves & Tiggemann, 2003). In general, females were affected in a greater degree by the mass media than males (McCabe & Ricciardelli, 2001). In addition, the exposure to photographs of thin models on women‘s magazines resulted in body image dissatisfaction as compared to exposure of photographs of average-sized models (Kim & Lennon, 2007; Stice & Shaw, 1994). A recent study compared the effects of exposure to conventional media thin-ideal images and Facebook thin-ideal images. It was found that social comparison was a significant predictor of body image dissatisfaction for female university students who were exposed to Facebook thin-ideal images than those who were exposed to conventional media thin-ideal images (Cohen & Blaszcynski, 2015). This finding further supports Trampe, Stapel, and Siero‘s (2007) study that suggests that females who were exposed to a physically attractive target had lower self-evaluations in comparison with their counterparts who were exposed to an attractive female model. Self-esteem. Sociocultural standards appear to influence one‘s self-esteem (Martin & Kennedy, 1993). Self-esteem is defined as positive and negative attitudes toward one‘s self (Rosenberg, 1965). Self-esteem is associated with emotions, behaviors, and psychological adjustment (Berk, 2001; Mann, Hosman, Scaalma, & de Vries, 2004).

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Self-esteem on body image. Previous studies on the association of body satisfaction and self-esteem in males and females have produced different findings (Furnham, Badmin, Sneade, 2002). Some researchers have found an association between body satisfaction and self-esteem in both genders (Lerner, Karabenick, & Stuart, 1973; Lerner, Orlos, & Knapp, 1976). However, Silberstein et al., (1988) found a significant relationship between body dissatisfaction and self-esteem only in males. In contrast, a significant correlation between self-esteem and body dissatisfaction has been found only in females (Furnham, Badmin, & Sneade, 2002; Lowery et al., 2005). Moreover, increased susceptibility to body dissatisfaction can be predicted by low selfesteem (Frost & McKelvie, 2004; Markham, Thompson, & Bowling, 2005; Newman, Sontag, & Salvato, 2006; Tiggemann & Williamson, 2000). In turn, low self-esteem is related to disturbance in eating attitudes in students (Baş, Aşçi, Karabudak, & Kiziltan, 2004; Hudson, 2008). In addition, self-esteem and Body Mass Index (BMI) are significantly correlated. Overweight participants have been found to experience low self-esteem (Hesketh, Wake, & Waters, 2004; Sarwer et al., 2005). In addition, obese participants had higher scores on negative self-esteem than overweight and normal weight counterparts (Goldfield et al., 2010). Contrary to the above finding, several studies did not find a significant relationship between self-esteem and BMI (Geller, et al., 1998; Hudson, 2008; Palmer, 2003). Sociocultural influences and self-esteem. There is a relationship between sociocultural influences and self-esteem (Kim & Lennon, 2007). Comparisons with family members, peers, and the mass media are likely to cause low self-esteem (Martin & Kennedy, 1993). Selfesteem was related to the mass media in both males and females (Fernandez & Pritchard, 2012). Males were found to have lower self-esteem after viewing pictures of muscular men (Hobza & Rochlen, 2009; Hobza, Walker, Yakushko, & Peugh, 2007).

The Case of Cyprus Geography. Cyprus is the third largest island located in the Mediterranean Sea. It has the warmest climate as compared to other islands in the Mediterranean Sea. Cyprus is part of the European Union since 2004 and is characterized by hot and dry summers and very mild winters (Argyrides & Kkeli, 2014). Interestingly, summers are prolonged through eight months of the year. Due to this weather, Cyprus is a well-known tourist destination in Europe and Russia, with 2.4 million tourist arrivals per year and only 850,000 local inhabitants. History. Due to its geographic location (in the center of Europe, Asia and Africa), Cyprus was occupied by several invaders throughout the years. In contemporary era, two countries had the most significant impact on the history of the island; Great-Britain and Turkey. Cyprus was an ex-colony of Great Britain and in 1960, the island gained its independence. Fourteen years later, Turkey invaded Cyprus, and as a result the island is divided in two parts; the Northern part, which is inhabited mainly by Turkish Cypriots and the Southern part, mainly inhabited by Greek Cypriots. Culture. Cyprus combines Western ideas and attitudes, as well as traditional characteristics (Katsounari, 2009). This island country places a great emphasis on extended family, religion, and the importance of food in family life (Zheeni, Gharibeh, & Katsounari, 2013).

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Demographics. The two official languages in Cyprus are Greek and Turkish. The majority of Greek Cypriot citizens are Greek Orthodox. The educational system, consists of primary and secondary education, and is highly developed. Taking into consideration the above brief description of Cyprus, as well as the information presented in the introduction section, it is worthwhile investigating body image, self-esteem and sociocultural issues in this context. Interestingly, after the war in 1974, there was an economic development, which resulted, among others, in a greater emphasis placed by Greek Cypriots on their social and physical appearance. Further emphasis on body image was given due to the warm weather as Cypriots usually wear more revealing and lighter clothes. In addition, local Greek Cypriots are exposed to a lot of tourists that are usually dressed in lighter clothing throughout the year as they visit Cyprus from countries with colder weather. Consequently, concerns about body image and self-esteem are increased in comparison to other countries and ethnicities. Despite the increase of these concerns, the school curriculum gives minimal emphasis on the above issues. This can be supported by the reduction of the weekly academic hours of the related lesson in primary and secondary education. Economic situation. After the end of the war in 1974, a non-steady economic development was observed in Cyprus. As a result, and as compared to the pre-war trends and tendencies, inhabitants adopted a more Western lifestyle, including food consumption and clothes (Katsounari, 2009). Specifically, their lifestyle was characterized by wealth, such as wearing designer clothes and buying expensive properties (Argyrides & Kkeli, 2014). Therefore, this economic boost, together with the changes in inhabitants‘ lifestyle, influenced body image and disordered eating as well. Weather. Sloan‘s (2002) research aimed to investigate the relationship between warm weather climate, disordered eating and body image concerns. The sample of this study consisted of female undergraduate students in Florida and Pennsylvania. The mean annual temperature in Florida is 23 degrees Celsius, and in Pennsylvania is 12 degrees Celsius. The findings of this study showed that females living in Florida had greater tendency to develop disordered eating in comparison to females living in Pennsylvania. Further, it was found that women from Florida had more concerns about their body shape than their counterparts from Pennsylvania. To sum up, this study demonstrated that disorder eating pathology and body shape concerns were greater in areas with warm climate, such as Florida. Cyprus‘ climate is comparable with Florida‘s, and therefore this study‘s findings could be applied to Cyprus as well. Comparison of Cyprus to other countries/ethnicities. Katsounari‘s study (2009) examined self-esteem and depression, as well as their association with disturbed eating in female undergraduate students from Cyprus and Great Britain. It was found that Cypriot females avoided fattening foods and were preoccupied with their physical appearance in a greater degree than British females. In summary, Cypriot females exhibited higher rates of disordered eating attitudes in comparison to their counterparts from Great Britain. Similarly, Zeeni et al., (2013) conducted a study regarding the correlation between eating behaviors and sociocultural influences regarding physical appearance and body image. This study compared Cypriot and Lebanese undergraduate female students. The findings showed that Lebanese females were engaged more in emotional and external eating. In addition, Lebanese females were affected by sociocultural influences to a greater extent than Cypriot females. Furthermore, emotional and external eating were positively correlated in both cultures. However, sociocultural influences correlated significantly with external eating only in

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Cypriot females. Concerning sociocultural impact on eating behaviors, it was found that female friends‘ feedback concerned Lebanese more than Cypriot students. Additionally, it was found that the impact of the mass media to become slimmer and more muscular was more important in the Lebanese in comparison to Cypriot female students. Further, the impact of mother and father on losing weight was more important in Lebanon than in Cyprus. Additionally, in Cypriot females, a positive relationship was found between external eating and mother‘s, male and female friend‘s opinion. Finally, the impact of sociocultural influences on body image and eating behavior was only significant in the Cypriot sample only. Health education curriculum. Cypriot students in pre-primary, primary and secondary education are educated about issues related to mental, physical, and social well-being through the health education curriculum. This curriculum consists of four thematic sections: (a) development and strengthening of self; (b) development of safe and healthy lifestyle; (c) establishment and improvement of social self; and (d) establishment of active citizen. Some issues related to body image, sociocultural influences, and self-esteem are the following: (a) to examine social stereotypes regarding masculine and feminine bodies and behaviors; (b) to elaborate cognitively healthy and unhealthy behaviors about food; (c) to elaborate economic and sociocultural factors that influence food attitudes and behaviors and (d) to develop positive attitudes concerning food. Despite the importance of these issues that are covered in the health education curriculum, the Ministry of Education and Culture suggested and is ready to implement a reduction of the already minimal weekly academic hours. Specifically, a reduction of 50% of the academic hours is suggested and will more than likely be implemented (Ministry of Education and Culture, 2015).

Recent Developments and Findings in Cyprus The purpose of the current chapter is to report recent developments and findings in Cyprus. Sociocultural and body image factors as well as self-esteem were investigated in a large countrywide sample. The findings of the studies will be presented based on the independent variables of the study, which included gender (male and female), socioeconomic status (SES) (low, medium, high), Body Mass Index (BMI) category (underweight, normal weight, overweight, obese), age, and geographic area of upbringing and residence (rural and urban). The dependent variables included five measures with all their subscales. Specifically, the Sociocultural Attitudes Towards Appearance Questionnaire – 3rd version (SATAQ-3; Thompson, van den Berg, Roehrig, Guarda, & Heinberg, 2004; Argyrides, Kkeli, & Kendeou, 2014 for the Greek version) was used which has four subscales: Internalization of the thin ideal, Internalization of the athletic ideal, Pressures from the media and the media as a good source of information. In addition, the Multidimensional Body Self-Relations Questionnaire – Appearance Scales (MBSRQ-AS; Cash, 2000; Argyrides & Kkeli, 2013 for the Greek version) was used which has five subscales: body image satisfaction, investment in appearance, weight-and body-related anxiety, satisfaction with specific body parts and selfclassified weight. Furthermore, the Rosenberg Self-Esteem Scale was used to assess for selfesteem (Rosenberg, 1965; Spanea, Anagnostopoulos, Kalatzi-Azizi, & Skarlos, 2005 for the Greek version). Body image-related dysphoria in social situations was assessed using the Situational Inventory of Body Image Dysphoria – Short Form (SIBID-S; Cash, 2002;

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Argyrides & Kkeli, 2015 for the Greek version). Finally, eating disturbances were assessed using the Eating Attitudes Test – 26 (EAT-26; Garner, Olmsted, Bohr, & Garfinkel, 1982; Varsou & Trikkas, 1991 for the Greek version). Participants consisted of a convenient sample of 2664 high school students (1119 males, 1545 females), fluent Greek speakers with no reported history of speech, attention, neurological, or sensory difficulties. Participants ranged in age from 13 to 18 years (M = 15.38, SD = 1.27 for females and M = 15.05, SD = 1.18 for males) and in Body Mass Index (BMI) from 12.77 to 49.59 for males (M = 21.63, SD = 3.63) and from 12.35 to 41.52 for females (M = 20.58, SD = 3.39). Participants‘ BMI Weight Category was also calculated using the teenage BMI scale (0-5th percentile = Underweight, 5th – 85th percentile = Normal Weight, 85th – 95th percentile = Overweight and Higher than 95th percentile = Obese) (Must & Anderson, 2006). Concerning males, this frequency distribution revealed that 172 participants (15.4%) fell in the Underweight category, 795 (71.0%) in the Normal Weight category, 119 (10.6%) in the Overweight category and 33 (2.9%) in the Obese category. Concerning females, the frequency distribution revealed that 424 participants (27.4%) fell in the Underweight category, 977 (63.2%) in the Normal Weight category, 115 (7.4%) in the Overweight category and 29 (1.9%) in the Obese category. The sample was Greek-Cypriots in its majority (87.6%) with a small percentage of non-Greek-Cypriots (12.4%), which overall reflects the demographic make-up of the Republic of Cyprus. Participants‘ self-reported answers also revealed that they came mostly from middle to upper-middle class families: 16.2% low SES; 64.3% middle SES; 19.5% high SES. Gender. Concerning the variables of gender and disordered eating in school-aged Cypriot girls and boys, it was found that disordered eating was predicted from discomfort with one‘s appearance in social situations, anxiety about one‘s appearance, and pressures from the media concerning one‘s physical appearance. Additionally, within girls, disordered eating was predicted from satisfaction with particular body parts, the internalization of the thin ideal, the mass media as a good source of information, and the discrepancy between actual and ideal body weight (Pepetsios & Argyrides, 2015). In boys, it was found that the internalization of the athletic body ideal was predicted by BMI, discomfort with one‘s appearance in social situations, satisfaction with one‘s appearance, investment in one‘s appearance, the internalization of the thin ideal and pressures from the media (Argyrides & Siafakas, 2015). In addition, it was found that there was a significant difference between overweight/obese males and females regarding satisfaction with their physical appearance, investment in appearance, satisfaction with particular body parts, anxiety about their physical appearance, internalization of the thin ideal, and the pressures from the mass media. Particularly, overweight males had better self-body image, however the overweight females had higher levels of pressure and anxiety about their physical appearance (Argyrides & Gregoriou, 2015). Adolescent females showed greater discrepancy between actual and ideal weight in comparison to males (Alexiou & Argyrides, 2014). Moreover, it was found that there were significant differences between boys and girls regarding satisfaction with the bottom part of their bodies, the waist, the upper part of their bodies, the muscle tone, weight, height, general physical appearance, and discrepancy between actual and ideal weight (Christodoulidou & Argyrides, 2014; Argyrides & Siafakas, 2014). In addition, females experienced greater dysphoria in social situations regarding their physical appearance in comparison to males. SES. Lower socioeconomic status was found to correlate with higher levels of internalization of the thin and athletic ideals. In addition, adolescents with low SES

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experienced greater pressure from the media regarding their physical appearance (Pepetsios & Argyrides, 2014). BMI categories. It was found that self-esteem of overweight/obese adolescents was predicted from satisfaction with physical appearance, investment in appearance, satisfaction with particular body parts and dysfunctional eating habits (Argyrides & Economidou, 2015). Additionally, it was found that overweight/obese adolescents were not taking into consideration body parts that are not weighed, such as face, hair or height. In contrast, in the underweight and normal weight adolescent groups, there was a significant correlation between body parts that are weighed and aspects of body image (Stylianou & Argyrides, 2015). Overweight adolescents demonstrated greater discrepancy between actual and ideal weight in contrast with the other BMI categories (Alexiou & Argyrides, 2014). In addition, BMI categories differed significantly regarding their levels of satisfaction with the lower body parts, their waist, their upper body parts, muscle mass, their weight and their general appearance. It was also found that participants in lower BMI categories were more satisfied with their bodies. Moreover, participants in higher BMI categories experienced greater pressure from the mass media (Argyrides, Parperis, & Economidou, 2014). Age. It was found that students in the third grade of high school (approximate age 15) showed higher levels of the internalization of the athletic body ideal, higher pressures from the mass media, and satisfaction with bottom parts of their bodies in comparison with students in the third grade of lyceum (approximate age 18). However, students in the third grade of lyceum had higher levels of self-esteem, satisfaction with appearance, investment in appearance, anxiety about appearance, internalization of the thin ideal, and satisfaction with their hair and face (Christodoulidou & Argyrides, 2015). Geographic area. It was found that overweight/obese adolescents from urban areas were more satisfied with their physical appearance as compared to their counterparts from rural areas (Argyrides & Pachtalias, 2015). In addition, adolescents from urban areas showed higher levels of self-esteem, satisfaction with their physical appearance, internalization of the thin ideal and investment in their appearance (Argyrides & Kotikas, 2014).

CONCLUSION AND RECOMMENDATIONS In summary, sociocultural influences and self-esteem appear to have an impact on body image. Regarding sociocultural influences, it was found that the mass media, peers and family members affect evaluations of one‘s body. Specifically, the mass media, including conventional media and social networking sites, have the greatest influence on body evaluation. In regards to the influence of self-esteem on body image, previous studies have found inconsistent results about gender and BMI categories. The current chapter focused on the country of Cyprus. After the war in 1974, Cyprus has experienced a great economic boost, which in turn resulted in changes in residents‘ lifestyle. The changes in lifestyle included alterations in food consumption, clothing and owning of properties. Moreover, the warm weather of Cyprus causes lighter, more revealing clothing to be worn, so more emphasis is placed on body image and physical appearance. Findings revealed differences between

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Cyprus and other countries and ethnicities such as Great Britain and Lebanon regarding body image and sociocultural influences respectively. Taking into consideration the significant body image concerns in Cyprus as compared to other countries and ethnicities, it is necessary not to reduce the weekly academic hours of the health education curriculum as suggested by the Ministry of Education and Culture. This recommendation is further supported by the recent developments and findings in Cyprus, as reported in this chapter. The findings are also suggesting the need for immediate prevention programs that should be implemented within the adolescent population. Future studies should consider examining differences and similarities between Cyprus and other Western and non-Western countries regarding body image, sociocultural influences and self-esteem. Additionally, it would be noteworthy to investigate the changes in body image after the economic crisis in 2013.

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In: Body Image Editor: Rafael Vargas

ISBN: 978-1-63483-870-2 © 2016 Nova Science Publishers, Inc.

Chapter 8

THE CONCEPT OF THE BODY IMAGE IN OLD PEOPLE IN RELATION TO PSYCHIATRIC DISORDERS Carmen M. Sarabia-Cobo, PhD University of Cantabria, Cantabria, Spain

ABSTRACT The perception of the self-image changes throughout life, and it is important for people to adapt and accommodate to those changes. In particular for a population of elderly of more than 65 years, we study the distortion of their perceived body image with regard to their actual and ideal images, and how psychiatric disorders may affect this relationship. The study was conducted on 457 elderly from seven nursing homes in Spain, who participated in the Body Shape Questionnaire (BSQ) and the Silhouettes Test. An additional systematic review of clinical history of patients was performed to detect psychiatric disorders like depression, anxiety or anorexia. We found out that people with depression or anxiety had a higher dissatisfaction with their body image, and women were more dissatisfied than men, regardless of age.

Keywords: Body image, depression, anorexia, elderly, nursing home

INTRODUCTION The self-image or the concept of how we see ourselves, is constantly changing throughout our life. The Body Image (BI), defined as the representation of the body that every person builds in their minds (Grogan, 2008), goes through many changes that require psychological adaptation and accommodation (Clarke & Korotchenko, 2011). The BI is the result of a subjective, multifaceted experience interrelated with self-consciousness, and is heavily influenced by the socio-cultural background and its values (Kotter-Grühn & Hess, 2012). 

Address: Nursing School, Avda Valdecilla s/n 39001 Santander, Spain, University of Cantabria. Research and Professional Experience: Lecturer, email: [email protected]

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Body image is made up of three components that comprise each individual's mental representation (Pruzinski & Cash, 1990):  



Perceptual image: provides information about the size and shape of the body and its various components. Cognitive picture: encompasses beliefs about the body, automatic thoughts, inferences, interpretations, comparisons and internal dialogues concerning social scrutiny, among others. Emotional picture: composed by the feelings about the degree of satisfaction or dissatisfaction that the individuals experience with their body.

The physical changes caused by aging can modify a person's BI, but whether gradually or not, it often creates a gap between the desired and the actual BI. This is due to the generalized concept of the image of the elderly (gray hair, wrinkles, body silhouette), commonly associated with negative stereotypes such as a loss of function (Slevec & Tiggemann, 2011) and a degradation of the aesthetic appearance (in a culture where beauty is synonymous with youth). These stereotypes can have an effect on the acceptance of their BI, and therefore the acceptance of themselves (Ferraro, Muehlenkamp, Paintner, Wasson, Hager, & Hoverson, 2008). Current research in the area of BI is focused on figure, body weight, and degree of satisfaction with the physical appearance. The studies show that approximately 50% of young women present great dissatisfaction with their appearance, a result also evident in older women (Mellor, Fuller-Tyszkiewicz, McCabe, & Ricciardelli, 2010). The BI has important consequences on health and quality of life. A positive BI reinforces a healthy state, adaptation to appropriate changes, and the ability to perform physical exercise and practice healthy behaviors. Conversely, a negative BI is related to psychological disorders, low self-esteem, lack of motivation, and poorer quality of life (E. Marshall, Lengyel, & H. Menec, 2014). The psychological changes associated with senescence may also imply significant changes in the perception of the self-image (Roy & Payette, 2012). The prevalence of depression in people aged 65 or over (1-4%) and anxiety disorders is high, and poses great difficulties to adapt to the changing perception of the self-image (Wild, Herzog, Lechner, Niehoff, Brenner, Müller et al., 2012). Dysphoria caused by a feeling of becoming more dependent and more reliant on aid, leads in many cases to a more distorted and negative selfimage that is often accompanied by a low self-esteem and lack of motivation (Wild et al., 2012). Sociological changes in recent years have transformed the standards of beauty to exploit the concept of eternal youth by claiming that "wrinkles are not beautiful" (Altschuler & Katz, 2010). Today, there is a social obsession to achieve an aesthetic appearance totally opposed to that of years ago. Elderly people are in a difficult position as they feel the need to adapt to these standards, and a direct consequence is that they seem more concerned about their aesthetic appearance that about their health. Women over 65 years are increasingly attending beauty centers and getting plastic surgery to overcome their dissatisfaction with their BI. The psychological concept of aging has been altered in a way that elderly people are at risk for disorders such as anorexia and bulimia nervosa.

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The BI is gaining importance in the study of psychological changes caused by aging. It is a useful tool for professionals to understand how elderly people face their physical changes and the strategies they develop to adapt to them. The number of studies of BI in the elderly has increased in recent years, although the results are so far inconclusive (Clarke, 2011; Roy et al., 2012). Some research works show that satisfaction with the BI does not vary significantly with age, but other works show that dissatisfaction increases as women get older (Marshall, Lengyel, & Utioh, 2012). It is thus interesting to examine more deeply and extensively the relationships between aging, BI, and satisfaction. The aim of this work is to study the association between the BI and the prevalence of psychiatric disorders such as depression and anxiety in adults of 65 years and over. It is not our intention to find conclusive answers, but to attempt to shed light on the subject of the selfimage, which has been a neglected area even though the ability of the elderly to successfully adapt to the changes experienced in their self-image may have important implications in the qualify of their lives.

METHODS Subjects. The study involved a total of 457 elderly from seven nursing homes in Spain with ages over 65 years. Prior to taking part in the study, all participants signed an informed consent. The study was also approved by a bioethics committee and by the board of directors of the seven participating nursing homes. Inclusion criteria were to be aged over 65 years, to present no alterations or physical or mental diseases preventing the completion of the tests, and to be taking no medication that could result in a physical or mental impairment and cause difficulties in participating in the study. Materials. Two tests were used: the Body Image test or BSQ (Body Shape Questionnaire, Cooper, Taylor, Cooper, & Fairburn, 1987), and the Scale of the Nine Silhouettes (Stunkard, Sorensen, & Schlusinger, 1983). The BSQ was developed by Cooper and others in 1987, and was adapted to the Spanish population. It consists of 34 questions scored on a Likert scale from 1 to 6, and yields an overall score (sum of direct item scores) and four subscales: body dissatisfaction, fear of becoming overweight, low self-esteem due to appearance and wish to lose weight. A sum score above a cutoff value of 105 indicates that the participant presents a pathology in the distortion of their BI. The higher the score, the greater degree of distortion. The satisfaction with the BI was verified by the Scale of the Nine Silhouettes which consists of nine sillhouettes exemplifying different degrees of body constitution, from thinness (sillhouette 1) to severe obesity (sillhouette 9). The participant chooses the one they consider most similar to their actual physical appearance (real BI), and the one they believe to be the ideal body appearance (BI ideal) for their age, and conclusions are drawn based on the choices. Both tests were performed by the investigators, individually, in a quiet and private room. An analysis of each subject was done by retrieving the following data from the participant and via medical history: age, sex, marital status, family relationships, years of schooling, medication, relevant diseases, prior history of depression, anxiety and anorexia nervosa,

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Barthel Index, Mini Mental Pfeiffer, participation in psychological therapy, and assistance to recreational activities and/or physical exercise in the residence. Data analysis. The sample characteristics were summarized as frequency and percentage for the categorical variables, and as mean and standard deviation for the continuous variables. A Wilcoxon signed-rank test for continuous variables and the chi-square test for categorical variables were used to examine the differences in the BSQ test and the variables of depression and anxiety (significant to p