body satisfaction literature review

Self-Compassion and Body Image

• First Online: 24 March 2023

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• Tracy L. Tylka 5 &
• Katarina L. Huellemann 6  

Part of the book series: Mindfulness in Behavioral Health ((MIBH))

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The study of self-compassion holds great relevance for body image theory, research, and practice. In this chapter, we review the various theoretical frameworks (i.e., tripartite influence model, objectification theory, social mentalities theory, and weight stigma theory) and research designs (meta-analytic, cross-sectional, prospective, and diary-based) researchers have used to explore the connection between self-compassion and body image. Evidence for self-compassion’s role as a predictor, moderator, and mediator has emerged. Specifically, self-compassion helps build and maintain positive body image and counteracts the development and persistence of body dissatisfaction. Next, we review various self-compassion interventions (i.e., meditations, writing tasks, a mobile application) and the research showing how these interventions improve participants’ positive body image and reduce their body dissatisfaction. We end the chapter with a discussion of opportunities for the next generation of research exploring self-compassion and body image.

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Tylka, T.L., Huellemann, K.L. (2023). Self-Compassion and Body Image. In: Finlay-Jones, A., Bluth, K., Neff, K. (eds) Handbook of Self-Compassion. Mindfulness in Behavioral Health. Springer, Cham. https://doi.org/10.1007/978-3-031-22348-8_11

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ORIGINAL RESEARCH article

Body dissatisfaction, importance of appearance, and body appreciation in men and women over the lifespan.

• 1 Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Osnabrück University, Osnabrück, Germany
• 2 Department of Research Methodology, Diagnostics & Evaluation, Institute of Psychology, Osnabrück University, Osnabrück, Germany
• 3 Clinical Psychology and Psychotherapy, Institute of Psychology, University of Münster, Münster, Germany

Body image disturbance is associated with several mental disorders. Previous research on body image has focused mostly on women, largely neglecting body image in men. Moreover, only a small number of studies have conducted gender comparisons of body image over the lifespan and included participants aged 50 years and older. With regard to measurement, body image has often been assessed only in terms of body dissatisfaction, disregarding further aspects such as body appreciation or the importance of appearance. The aim of this cross-sectional study was to explore different aspects of body image in the general German-speaking population and to compare men and women of various ages. Participants completed an online survey comprising questionnaires about body image. Body dissatisfaction, importance of appearance, the number of hours per day participants would invest and the number of years they would sacrifice to achieve their ideal appearance, and body appreciation were assessed and analyzed with respect to gender and age differences. We hypothesized that body dissatisfaction and importance of appearance would be higher in women than in men, that body dissatisfaction would remain stable across age in women, and that importance of appearance would be lower in older women compared to younger women. Body appreciation was predicted to be higher in men than in women. General and generalized linear models were used to examine the impact of age and gender. In line with our hypotheses, body dissatisfaction was higher in women than in men and was unaffected by age in women, and importance of appearance was higher in women than in men. However, only in men did age predict a lower level of the importance of appearance. Compared to men, women stated that they would invest more hours of their lives to achieve their ideal appearance. For both genders, age was a predictor of the number of years participants would sacrifice to achieve their ideal appearance. Contrary to our assumption, body appreciation improved and was higher in women across all ages than in men. The results seem to suggest that men’s and women’s body image are dissimilar and appear to vary across different ages.

Introduction

Many people are concerned about at least one part of their body ( 1 ). A negative cognitive evaluation of one’s body can be an expression of a negative body image ( 2 ). Body image is conceptualized as a multidimensional construct, which encompasses a behavioral component involving body-related behaviors (e.g. checking behaviors), a perceptual component involving the perception of body characteristics (e.g. estimation of one’s body size or weight), and a cognitive-affective component involving cognitions, attitudes, and feelings toward one’s body ( 3 – 6 ).

Negative thoughts and feelings about one’s body are defined as body dissatisfaction ( 7 ), which is considered to be the most important global measure of stress related to the body ( 4 ). Body dissatisfaction has been found to be a predictor for the development of an eating disorder ( 8 ) and occurs in individuals with different mental disorders, such as binge eating disorder or social anxiety disorder (e.g. 6 , 9 ), as well as in healthy persons (e.g. 10 – 12 ). It represents one of the two poles of the satisfaction-dissatisfaction continuum of body image disturbance ( 4 ), which encompasses measures of satisfaction (e.g. being satisfied with particular body areas; e.g. 13 ) and dissatisfaction (e.g. weight or muscle dissatisfaction; e.g. 14 , 15 ).

Another construct which is related to both the cognitive-affective and the behavioral component is the importance of appearance, also termed appearance orientation, which reflects the cognitive-behavioral investment in one’s appearance as an expression of the importance people place on their appearance ( 16 , 17 ). This construct was shown to be distinguishable from the construct of appearance evaluation ( 18 ), which also represents a measure of body satisfaction/dissatisfaction.

Besides negative body evaluation and the importance of appearance, a positive appraisal of one’s body also forms part of the cognitive-affective component. For instance, body appreciation is defined as accepting, respecting, and having a favorable opinion of one’s own body, as well as rejecting unrealistic body ideals portrayed by the media ( 19 ). Body appreciation was shown to predict indices of well-being beyond other measures of body image ( 19 ) and occurred simultaneously with body dissatisfaction, highlighting the independence of the two concepts ( 20 ).

In the past, studies have investigated the impact of gender and age on body features related to the cognitive-affective component. Specifically, research on body dissatisfaction has shown that girls and female adolescents (e.g. 21 – 24 ), and women of all ages (e.g. 12 , 25 , 26 ) report body dissatisfaction. While some studies revealed that the level of body dissatisfaction varied across different age groups ( 27 , 28 ), others found that body dissatisfaction remained quite stable across the adult lifespan in females ( 20 , 25 , 29 , 30 ). Studies examining other aspects of the satisfaction-dissatisfaction continuum, such as weight dissatisfaction ( 15 , 31 ) or satisfaction with particular body parts ( 13 , 32 ), also found body dissatisfaction in women. Frederick and colleagues ( 33 ) estimated that 20% to 40% of women are dissatisfied with their bodies. Nevertheless, body dissatisfaction is also reported in men, suggesting that 10% to 30% of men show body dissatisfaction ( 33 ) or 69% of male adolescents to be dissatisfied with their bodies in terms of their weight ( 34 ). Frederick and colleagues ( 14 ) even reported that 90% of male US students in their sample described themselves as being dissatisfied with respect to muscularity. In terms of body evaluation, striving for increased muscularity, referred to as drive for muscularity ( 35 ), has emerged as a central issue for boys and men (e.g. 35 – 38 ). It was shown to be distinct from body dissatisfaction ( 39 ). However, although previous studies reported that body dissatisfaction does not differ across age in women, it remains unclear whether the level of body dissatisfaction changes across age in men.

While body dissatisfaction seems to remain stable across age in women, studies suggest that the importance of appearance appears to decrease with age ( 40 ). In line with Pliner and colleagues, Tiggemann and Lynch ( 41 ) found in a group of females aged 20 to 84 years that the importance of appearance was lower in older than in younger women. For men, only one study has examined the importance of appearance, and found that it varied between age groups and reached a peak at age 75 years and older ( 42 ). To our knowledge, no other study has examined the importance of appearance in men over the lifetime. Thus, it remains relatively unclear whether the importance of appearance remains stable or changes over the lifetime in men.

With respect to body appreciation, Tiggemann and McCourt ( 20 ) demonstrated higher body appreciation in older than in younger women. Furthermore, high body appreciation was found to be protective against the negative effects of media exposure to thin models in women ( 43 ). Other studies reported that body appreciation in men and women was associated with a low level of consumption of Western and appearance-focused media ( 44 ) and correlated negatively with internalization of sociocultural ideals ( 45 ). However, studies focusing on age differences regarding body appreciation in males are lacking.

Previous studies on body image have mostly considered age-related changes in either men or women, or in particular age groups (e.g. college students, adolescents). Only a limited number of studies have compared men and women with respect to the aforementioned aspects of body image. These studies generally found greater body dissatisfaction in females than in males (e.g. 29 , 30 , 46 – 49 ). Men (vs. women) seem to place less importance on their appearance ( 42 , 50 , 51 ) and report slightly higher levels of body appreciation (e.g. 45 , 52 – 54 ). Tylka and Wood-Barcalow ( 55 ) also reported higher body appreciation in college men (vs. college women), but were unable to replicate this effect in a community sample. In contrast to this latter result, Swami and colleagues ( 53 ) reported higher body appreciation in men than in women in a sample from the general Austrian population. However, these studies comparing men and women did not analyze their data with respect to the impact of age.

Only a small number of studies have investigated the effect of age and gender on body dissatisfaction, importance of appearance and body appreciation. In a two-year longitudinal study, Mellor and colleagues ( 56 ) found that body dissatisfaction was higher in females than in males and higher in younger than in older participants. In another longitudinal study, Keel and colleagues ( 15 ) examined men and women over a period of 20 years. As men aged, the authors observed increasing weight and increasing weight dissatisfaction, while weight dissatisfaction decreased in women despite analogous increases in weight. The authors concluded that women appear to be more accepting of their weight as they age ( 15 ). Unfortunately, the mean age at the 20-year follow-up was only 40 years, meaning that conclusions could not be drawn about the whole adult lifespan. Similarly, in a large sample of men and women aged 18 to 49 years, Ålgars et al. ( 46 ) found that overall body dissatisfaction was higher in women than in men, but that only in women was age associated with decreasing body dissatisfaction, while in men, body dissatisfaction changed across the different age groups ( 46 ). However, these results have to be interpreted with caution, as the sample consisted of twins and was thus not representative of the general population.

Other studies found higher levels of body dissatisfaction ( 28 ) and lower levels of satisfaction with certain body areas ( 29 ) in women than in men. However, the latter study did not find any gender- or age-related effect on overall body dissatisfaction ( 29 ). Concerning the importance of appearance, Öberg and Tornstam ( 42 ) found that women placed more importance on their appearance than did men, and that this factor remained stable across different age groups in women but varied in men. These results are contrary to the findings of Tiggemann and Lynch ( 41 ) and Pliner et al. ( 40 ), who found that the importance of appearance decreased with age in women. However, this discrepancy may be due to the assessment method in the study by Öberg and Tornstam, as they used a single item to evaluate the importance of appearance. Hence, the development of importance of appearance in men and women across the lifespan remains unclear.

Although, as mentioned above, some studies have found that women place less importance on their appearance as they age ( 40 , 41 ), this aspect has not been examined in a large population sample comprising different age groups in relation to the impact of gender and age. Furthermore, studies comparing body appreciation between men and women across different age groups are lacking. To our knowledge, no previous study has examined body dissatisfaction, importance of appearance and body appreciation in the general population including men and women aged 16 to 50 years and older. Therefore, the present study aims to fill this research gap by analyzing these negative and positive aspects of body image in a general population sample considering gender and age.

First, based on the previous findings outlined above, we predicted that body dissatisfaction would be higher in women than in men (Hypothesis 1) and would remain stable across age in women (Hypothesis 2). As no previous study has investigated body dissatisfaction across the whole lifespan in men, we aimed to examine a potential influence of age on body dissatisfaction in men.

Second, we hypothesized that women would place more importance on their appearance than men (Hypothesis 3), but that in line with the aforementioned studies, across age, older women would report lower levels of importance than younger women (Hypothesis 4). Given the lack of corresponding studies in men, we intended to investigate the importance of appearance and its relation to age in men in an exploratory analysis. Furthermore, appearance orientation assesses the importance of appearance in terms of the extent of investment in one’s appearance (e.g. grooming behaviors) and in terms of the attention one pays to one’s appearance. However, it does not quantify how many hours or years people would be willing to invest in their appearance to look the way they want to. Therefore, as a measure of the importance of appearance, we additionally assessed the number of hours men and women would be willing to invest per day to achieve their ideal appearance, and the number of years of their life they would sacrifice to achieve their ideal appearance.

Third, we predicted that body appreciation would be higher in men than in women (Hypothesis 5). As the aforementioned studies examined gender differences without analyzing the impact of age, we aimed to investigate potential changes in body appreciation across age in an exploratory manner.

Fourth, to take into account the well-documented increase in BMI over the lifetime (e.g. 46 , 57 , 58 ) and its potential association with the outcome variables, we examined these relations as a control analysis by calculating correlations between the subjective evaluations of body image and BMI.

Materials and Methods

Participants.

Inclusion criteria were age 16 years and older, sufficient German-language skills, and internet access. Data were collected from N = 1,338 persons. From the original data set, n = 4 participants had to be excluded due to ambiguous details about their age or invalid responses to questions. Moreover, n = 7 persons were excluded as they did not fit into the binary gender categories male or female. The final study sample comprised n = 942 women and n = 385 men, aged 16 to 88 years (total sample: n = 1,327).

Demographic Data

All participants completed a questionnaire assessing demographic data such as gender, age, height and weight, educational level, relationship status, sexual orientation, and number of children. The item on sexual orientation was optional. Self-reported weight and height were used to calculate the body mass index (BMI, kg/m 2 ).

Multidimensional Body-Self Relations Questionnaire–Appearance Scales

The Multidimensional Body-Self Relations Questionnaire–Appearance Scales [MBSRQ-AS; ( 16 ); German-language version: ( 17 )] is a self-report questionnaire consisting of 34 items and five subscales to assess different appearance-related aspects of body image. The MBSRQ-AS has been validated for participants aged 15 years and older and for both men and women ( 16 ). For the purpose of this study, the Appearance Evaluation Scale (seven items) and Body Areas Satisfaction Scale (nine items) were used to assess body dissatisfaction, and the Appearance Orientation Scale (12 items) was applied to examine the importance people place on their appearance. According to Cash ( 16 ), the Appearance Evaluation Scale measures overall satisfaction/dissatisfaction with one’s appearance and physical attractiveness, with high scores indicating body satisfaction and low scores indicating body dissatisfaction. Furthermore, the Body Areas Satisfaction Scale (nine items) assesses satisfaction/dissatisfaction with particular body areas; high and low scores are analogous to the Appearance Evaluation Scale. The Appearance Orientation Scale (12 items) evaluates the investment in one’s appearance, with low scores indicating that people do not place importance on or invest much effort into being “good-looking”. All items are rated on a 5-point Likert scale with different response labeling ( Appearance Evaluation Scale and Appearance Orientation Scale : 1 = definitely disagree to 5 = definitely agree; Body Areas Satisfaction Scale : 1 = very dissatisfied to 5 = very satisfied). While the English-language version has been validated in both men and women ( 16 ), the German-language version has only been validated for females ( 17 ). In the German validation, all subscales showed good internal consistency (α = .78–.90; 17 ). In the current sample, high internal consistencies were found ( Appearance Evaluation Scale : α = .88; Appearance Orientation Scale : α = .85; Body Areas Satisfaction Scale : α = .81), both for men ( Appearance Evaluation Scale : α = .87; Appearance Orientation Scale : α = .85; Body Areas Satisfaction Scale : α = .80) and women ( Appearance Evaluation Scale : α = .89; Appearance Orientation Scale : α = .86; Body Areas Satisfaction Scale : α = .81).

Body Appreciation Scale-2

The Body Appreciation Scale-2 (BAS-2; 55 ; German-language version: Steinfeld, unpublished manuscript) assesses body appreciation in a gender-neutral manner using 10 items rated on a 5-point Likert scale (1 = never to 5 = always). High internal consistency (α = .96) was found for the BAS-2 in an English-speaking sample of men and women ( 55 ). In our sample, internal consistency was high (α = .94), both in males (α = .92) and females (α = .94).

Investment in One’s Appearance

To investigate the amount of time which men and women would be willing to invest in and sacrifice for their own appearance, participants were asked the following two questions: “How many years of your life would you be willing to sacrifice if you could look the way you want?”, “How many hours a day would you invest in your appearance if you could look the way you want?”

Single-Item Self-Esteem Scale

The Single-Item Self-Esteem Scale (SISE; 59 ) measures self-esteem using the item “I have high self-esteem,” which is rated on a 5-point Likert scale (1 = not very true of me to 5 = very true of me). It has shown high correlations with the Rosenberg Self-Esteem Scale and a high test-retest reliability after four years ( r tt = .75) ( 59 ).

Depression Anxiety Stress Scales–Depression Subscale

The Depression Anxiety Stress Scales–Depression Subscale (DASS-D) ( 60 ; German-language version: 61 ) consists of seven items assessing depressive mood over the past week on a 4-point Likert scale (0 = never to 3 = always). For the German version of the DASS-D, high internal consistency has been found (α = .88) ( 61 ). In the present study, internal consistency ranged from α = .89 for men to α = .91 for women (total sample: α = .90).

Study Procedure

Participants were recruited via social media, mailing lists, press releases, advertisements, and flyers and were asked to take part in a short online survey comprising different questionnaires about body image. To access the study website, they could either scan a barcode or use a web link. The online survey was set up using the software Unipark (Version EFS Winter 2018; 62 ). Participants were informed about the purpose of the study and were asked to provide their informed consent by clicking a button next to a declaration asserting that they agree to the processing of their personal data according to the given information. The survey began once participants had provided consent and took approximately 10 min to complete. Participants were offered no financial compensation for study participation. The research project was conducted in accordance with the Declaration of Helsinki and was approved by the ethics committee of Osnabrück University.

Data Analysis

Data analysis was performed using the software SPSS Statistics (version 25; IBM 63 ) for descriptive statistics, correlation analysis, and general linear models and the software R (version 3.5.3; R 64 ) with the DHARMa package (version 0.2.4; 65 ), the glmmTMB package (version 0.2.3; 66 ), and the MASS package (version 7.3–51.3; 67 ) for generalized linear models. As we intended to explore homogenous hypotheses in terms of body dissatisfaction, the power was set at a significance level of p = .10 for the variable age.

For group comparisons on demographic and descriptive variables ( Table 1 ), we calculated Mann-Whitney U Tests, as our data were not normally distributed (except BMI). Since inferential statistics for simple comparisons are massively overpowered in such large samples, we additionally report effect sizes. For better interpretability, U -values were converted into correlation coefficients r ( 68 , 69 ). For correlations between BMI and the body image variables ( Table 3 ), Spearman’s rank correlations were calculated due to non-normally distributed data.

Table 1 Descriptive statistics and group comparisons regarding age, height, weight, BMI, depression, and self-esteem.

For linear and generalized linear models, gender was dummy-coded, with men as the reference category. Age was centered to simplify the interpretation of the model coefficients. Due to missing data on single items within the questionnaires, the sample sizes for the initial model estimations varied, since participants were only included in the respective data analysis if they answered all items of a scale. To examine the individual impact of gender and age for each dependent variable, we started with the general linear model and inspected the residual distributions, tested statistically and by visual inspection for normality, and tested for homogeneity of variance as well as for skewness, kurtosis, and outliers (Mahalanobis and Cook’s distance, Leverage). While Cook’s distance should be smaller than 1 ( 70 ) and Leverage for large samples <3 k / N ( 71 ), a value was identified as an outlier if the Mahalanobis distances were above the critical χ 2 value exceeding the probability of 0.01 ( 72 ) and if studentized deleted residuals were larger than 3 standard deviations. The highest number of outliers was detected for the Body Areas Satisfaction Scale, with 3.36%. Comparisons of the models with and without outliers revealed no substantial differences; hence, we report the models without potential outliers, as power issues were not expected for such a large sample size and precision of estimates was prioritized. Final sample sizes are reported for each model ( Tables 4 and 5 ).

For the Body Areas Satisfaction Scale, the assumption of homogeneity was violated. Therefore, a general linear model was calculated, using the HC3 method for robust estimation of the standard errors. Furthermore, due to skewness and non-normal distribution of the data, responses to the Body Appreciation Scale-2 were inverted and a generalized linear model with a gamma distribution and identity link function was used. The analyses of hours people would invest in their appearance and years people would sacrifice from their lives indicated severe violations of the assumptions of the general linear model, since their distributions were similar to zero-bounded count data. Therefore, the numbers of hours and years were rounded to integer values to enable us to calculate several Poisson and negative binomial regression models, which are suitable for count data. The fit of each model was assessed by tests for overdispersion and zero inflation, as well as by tests of residual fit using the DHARMa package. As a final model for the analyses of the years people would sacrifice from their lives, we used a negative binomial regression with a log-link and linearly increasing variance ( 73 ) and adjustment for zero inflation for the intercept using the glmmTMB package. For the analyses of the hours people would spend on their appearance, we used a negative binomial regression with the log-link function using the MASS package.

Sample Characteristics

Descriptive statistics and group differences are shown in Table 1 . Men and women differed significantly in terms of age, height, weight, BMI, and self-esteem. Compared to women, men were slightly older, taller, and heavier and had a higher BMI. This is in line with data from the German Federal Statistical Office ( 57 ), which reported a mean weight of 68.7 kg, a mean height of 166 cm and a mean BMI of 25.1 in German women, and a mean weight of 85.0 kg, a mean height of 179 cm and a mean BMI of 26.1 in German men. As indicators of psychopathology, men and women did not differ regarding depressive mood over the past week ( p = .152), whereas self-esteem was higher in men than in women.

Information about educational level, relationship status, number of children, and sexual orientation is reported in Table 2 . Of the total sample, n = 29 participants (of whom n = 23 were female) refused to answer the question regarding sexual orientation, and n = 3 participants (of whom n = 1 was female) did not state whether they had children. A recent study on the proportion of Lesbian, Gay, Bisexual, and Transgender (LGBT) persons in Europe reported that 7.40% of the German population identify themselves as LGBT ( 74 ). In our sample, 10.17% reported a sexual orientation other than heterosexuality, which is slightly higher than the reported value for the German population, but can be still considered as representative.

Table 2 Numbers and percentages regarding educational level, relationship status, and sexual orientation for total sample, women, and men.

The Spearman’s rank correlations of BMI with body dissatisfaction, importance of appearance, the number of hours per day participants would invest and years they would sacrifice to achieve their ideal appearance, and body appreciation are displayed in Table 3 .

Table 3 Spearman’s correlations between BMI and the scores on the scales Appearance Evaluation, Body Areas Satisfaction, Appearance Orientation, the number of hours per day participants would invest to achieve their ideal appearance, and the number of years participants would sacrifice to achieve their ideal appearance and Body Appreciation for total sample, women, and men.

General and Generalized Linear Models

Table 4 presents the descriptive statistics for appearance evaluation, body areas satisfaction, appearance orientation, hours of investment, and years of sacrifice, as well as body appreciation, separated for total sample, men, and women. The results of the general and the generalized linear models are displayed in Table 5 . Regarding body dissatisfaction, gender emerged as the only significant predictor of appearance evaluation ( t = −2.012, p = .044) and body areas satisfaction ( t = 4.282, p < .001), indicating lower appearance evaluation and lower body areas satisfaction in women than in men. Age (appearance evaluation: t = −1.489, p = .137; body areas satisfaction: t = −1.605, p = .109) and the interaction of age × gender (appearance evaluation: t = 1.630, p = .103; body areas satisfaction: t = 1.257, p = .209) did not reach statistical significance. In terms of the importance of appearance, gender ( t = 6.597, p < .001), age ( t = −3.636, p < .001), and the interaction of gender × age ( t = 3.194, p < .001) significantly predicted appearance orientation, revealing that women placed more importance on their appearance than did men, whereas age only influenced the importance of appearance in men. The number of hours which participants would spend on their appearance if they could achieve their ideal appearance was predicted by gender ( z = 2.037, p = .042) and age ( z = −4.654, p < .001), indicating that women would invest more hours than men, but that with higher age, both genders would invest fewer hours in their appearance. The interaction of gender × age ( z = 0.428, p = .67) was not significant. Age was the only predictor of the number of years participants would be willing to sacrifice to achieve their ideal appearance ( z = −5.828, p < .001), revealing that with higher age, men and women would sacrifice fewer years for their ideal appearance. Neither gender ( z = −0.526, p = .60) nor the interaction of gender × age ( z = 1.015, p = .310) had a significant impact on the number of years. Furthermore, gender ( t = 2.828, p = . 005) and the interaction of gender × age ( t = −2.186, p = . 029) were significant predictors of body appreciation, insofar as with higher age, women reported higher body appreciation than men, while body appreciation in men remained stable with higher age. Age ( t = 0.127, p = . 899) did not reach statistical significance.

Table 4 Descriptive statistics regarding the scores on the scales Appearance Evaluation, Body Areas Satisfaction, Appearance Orientation, hours of investment, and years of sacrifice, as well as Body Appreciation for total sample, women and men used in the final models.

Table 5 General linear models for the prediction of Appearance Evaluation, Body Areas Satisfaction and Appearance Orientation as well as generalized linear models for the prediction of Body Appreciation, the number of hours per day participants would invest to achieve their ideal appearance, and the number of years participants would sacrifice to achieve their ideal appearance, with gender and age as predictors.

The aim of the present study was to investigate potential gender differences and the impact of age on body dissatisfaction, importance of appearance, the number of hours per day participants would invest and the number of years they would sacrifice to achieve their ideal appearance, and body appreciation in the general population.

As predicted in our first hypothesis, we found an effect of gender on the Appearance Evaluation Scale and the Body Areas Satisfaction Scale, suggesting that women were significantly more dissatisfied with their bodies than men. This is in accordance with the results of several studies (e.g. 28 , 30 , 46 , 56 ), which likewise reported higher levels of body dissatisfaction in women than in men. In line with our results, Fallon and colleagues ( 29 ) found that women (vs. men) reported higher levels of body dissatisfaction on the Body Areas Satisfaction Scale, but contrary to our study, the authors did not find an effect of gender on the Appearance Evaluation Scale. Keel et al. ( 15 ) even found higher weight dissatisfaction in men than in women, which is also in contrast to previous findings. Therefore, it might be possible that women may be more satisfied with their weight while still reporting more body dissatisfaction.

Additionally, we found that body dissatisfaction on the Appearance Evaluation Scale and on the Body Areas Satisfaction Scale was not influenced by age or by the interaction of gender and age, indicating that body dissatisfaction remains stable across all ages for both genders. For women, this finding confirms our second hypothesis, which assumed that body dissatisfaction would not be influenced by age, and also supports previous findings (e.g. 20 , 25 , 29 , 30 ). One study by Öberg and Tornstam ( 42 ) found that body satisfaction was higher in older than in younger women, which is also in contrast to our findings, as we found no influence of age on body dissatisfaction. For men, our results indicate that body dissatisfaction remains stable across different ages. This is in contrast to Ålgars and colleagues ( 46 ), who found that body dissatisfaction varied across different age groups in men. However, the latter finding might be attributable to artificial grouping strategies, as the authors investigated the impact of the continuous variable age as a categorical variable through the use of age groups. Moreover, Ålgars and colleagues ( 46 ) only assessed participants between the age of 18 and 49 years. The present study included men and women aged from 16 to 88 years, thus covering a broader proportion of the lifespan in Germany; according to the German Federal Statistical Office ( 75 ), the average life expectancy lies at 78.4 years for men and 83.2 years for women. To sum up, body dissatisfaction seems to remain relatively stable across different ages, both for men and for women.

In line with our third hypothesis that women would place more importance on their appearance than men, we found a significant effect of gender on the Appearance Orientation Scale, indicating that women indeed place more importance on their appearance compared to men. This finding corroborates previous studies ( 42 , 50 , 51 ). Moreover, age was a significant predictor of appearance orientation, as was the interaction of gender and age. Although age and the interaction of gender and age reached statistical significance, only in men did higher age bring about a lower importance of appearance. For women, the regression weights of age and the interaction of gender and age cancelled each other out. Therefore, gender was the only factor to impact appearance orientation in women, and the importance of appearance was not affected by age in women. This is in contrast to our fourth hypothesis that older women would report lower levels of importance of appearance than younger women. It also conflicts with previous findings ( 40 , 41 ), as we found that appearance orientation remained stable across all ages in women. In line with our finding, Öberg and Tornstam ( 42 ) also reported that the importance of appearance remained stable in women of different ages. They further found a small variation of the importance of appearance across different age groups in men, with the level of importance being more pronounced from the age of 45 years and older ( 42 ). However, we observed that older men seem to place less importance on their appearance than do younger men.

As the construct of importance of appearance does not reflect the extent to which people are willing to invest time in order to reach their ideal appearance, we additionally assessed the amount of hours per day participants would invest, and the number of years of their lives they would sacrifice, in order to achieve their ideal appearance. We found an effect of gender and age on the number of hours spent on appearance, but only an effect of age on the number of years which participants would sacrifice for their appearance. Women were more likely to spend more hours per day on their ideal appearance than men. However, older men and women would invest fewer hours than their younger counterparts. Concerning the number of years people would be willing to sacrifice to achieve their ideal appearance, we found no effect of gender, but found age to be a significant predictor, meaning that older men and women would sacrifice fewer years from their lives for the sake of their ideal appearance. This indicates that in terms of their behavioral investment regarding the importance of appearance, men and women may be more similar than hitherto assumed. Apparently, women might find it easier to relinquish a small number of hours per day to be invested in their appearance compared to men, but regarding lifetime investment, both genders might be unwilling to sacrifice years of their lives for the sake of their appearance.

Furthermore, we examined the impact of gender and age on body appreciation, and found gender and the interaction of gender and age to be significant predictors. The significant effect of gender suggested that women showed less body appreciation than did men. This is in line with our fifth hypothesis that women would show lower levels of body appreciation than men, and is also in accordance with other studies ( 45 , 53 , 76 ). However, the significant interaction of gender and age indicates that with higher age, women report higher levels of body appreciation compared to men. This is in contrast to the aforementioned studies (e.g. 45 , 53 , 76 ), but may provide an explanation for the lack of a gender effect in an English-speaking community sample in the study by Tylka and Wood-Barcalow ( 55 ). Interestingly, compared to our study, Tylka and Wood-Barcalow ( 55 ) reported slightly higher values (from 3.22 to 3.97) for their samples for both genders. Furthermore, the significant interaction in our study suggested that body appreciation also improves in women across age, and older (vs. younger) women report higher levels of body appreciation. This is in line with Tiggemann and McCourt ( 20 ), who found greater body appreciation in older than in younger women. Regarding men, as pointed out above, no previous study has investigated the impact of age on body appreciation. In our study, the level of body appreciation remained quite stable across different ages in men, and was lower compared to that of women. An explanation might be that men are possibly more affected by restrictions of their body’s functionality due to aging processes ( 27 ), whereas women may cherish their body and the remaining functionality.

With respect to the associations between BMI and the aspects of body image, we found significant negative correlations between BMI and the Appearance Evaluation Scale and Body Areas Satisfaction Scale for men and women, insofar as with increasing BMI, values on both scales decreased (= higher body dissatisfaction). This is in line with previous research, which found that BMI was positively associated with body dissatisfaction in both genders (e.g. 77 – 81 ). Body appreciation was found to be negatively correlated with BMI for both genders, which is partially in line with previous research: One study found this association for women but not for men ( 53 ), while other studies yielded mixed findings, reporting either a negative association between BMI and body appreciation (e.g. 82 , 83 ) or no significant results (e.g. 44 ). Concerning the importance of appearance, we found no significant association with BMI for either gender. In line with our results, some previous studies found no association between the importance of appearance and BMI in both men and women ( 13 , 84 ), while others reported a positive correlation for women but no significant association for men ( 85 ). The latter may be explained by the differentiation between the importance of appearance and the investment of time in appearance, as we found that BMI was positively associated with the number of invested hours for both genders, but was only associated with the number of years participants would sacrifice to achieve their ideal appearance in women. These findings emphasize the distinction between the evaluative perspective of the importance of appearance (How essential are my looks to me)? and the behavioral perspective of the extent of investment in appearance (How many hours/years am I willing to invest in my appearance)?. For instance, a person may place importance on his or her appearance, but as appearance is less important than years of his or her life, he or she is unwilling to invest much effort in appearance. As shown in our study, women reported quite stable, higher levels of importance across age than did men. Consequently, it might be assumed that they have to invest more time in order to achieve their ideal appearance. Nevertheless, as older men and women would invest fewer hours and sacrifice fewer years, the extent of investment or sacrifice is evidently not expressed by the importance of appearance. These results underline the need to differentiate between the importance of appearance and the investment of time in one’s appearance.

Although in the present study, women reported a higher degree of body dissatisfaction than did men, men’s and women’s responses on average lay slightly above the value of 3 on the 5-point Likert scale ( Table 4 ). This indicates, on average, neither agreement nor disagreement on the two scales (3 = I neither agree nor disagree) and possibly reveals a more neutral to slightly positive evaluation of one’s body. These results are in line with those of Cash ( 16 ) and Fallon et al. ( 29 ), who reported similar values on both scales for men and women. Therefore, on average, men and women may be neither particularly dissatisfied nor particularly satisfied with their bodies.

In consideration of all of the aforementioned research, one has to raise the more general question of whether the absence of body dissatisfaction is synonymous with the presence of body satisfaction in terms of a continuum model as proposed by Thompson et al. ( 4 ). Another possibility lies in an alternative model, in which body satisfaction and body dissatisfaction coexist alongside one another. For instance, it may be possible for a person to report high levels of overall body dissatisfaction, while simultaneously reporting high levels of body satisfaction with certain areas (e.g. “In general, I am dissatisfied with my body, but I like my legs, my cheeks and my hair.”). This could result in neither agreement nor disagreement on a continuum scale. Further research is needed to investigate a possible coexistence of both concepts.

Some limitations have to be mentioned when interpreting the results of the present study. Although several coefficients turned out to be significant, they contribute only a minimum of change to the dependent variables. In addition, according to the conventions of Cohen ( 86 ), we found very small values for the R 2 s, as the R 2 s in the present study explained only 0.5% (appearance evaluation) up to 5.2% (appearance orientation) of the total variance. Due to our total sample size of N = 1,327, the significance of the coefficients therefore might be attributed to the study’s power. Moreover, as was the case for most of the previous studies (except for 15 and 56 ), we did not investigate age effects in a longitudinal design. Therefore, it is not possible to disentangle the effects of age and birth cohorts. The effects found in this study may be related to different birth cohorts, the way in which people were brought up and socialized, or different ideals of beauty and fashion. Longitudinal studies including different age cohorts of men and women are therefore required.

Another limitation may lie in the assessment method. As younger people use the internet more frequently than older people ( 87 ), it cannot be excluded that this could have led to a stronger selection bias in older participants. Further, the online assessment may not be representative for the general population ( 88 ). Thus, there was no control regarding the implementation conditions of participation (e.g. whether there were distractions while participating) or regarding who was participating ( 88 ). False answers on variables such as weight, height, and age seem to be easier to notice in the laboratory. However, false statements concerning the variables of body image may be just as difficult to detect in the laboratory or in paper-and-pencil examinations as in online assessments. Our calculation of correlations between BMI and the outcome variables may be seen as a control analysis, as the participants’ answers on BMI were associated with our dependent variables, in line with aforementioned research.

Furthermore, our sample included more women than men. This may reflect the fact that women are more likely to participate in studies than men (e.g. 89 , 90 ). Although general and generalized linear models are able to control for different sample sizes, men and women differed significantly regarding age, height, weight, and self-esteem. While the differences in weight and height could be explained by natural gender differences, men were slightly older than women. As a further limitation, the assessment was restricted to certain body-related aspects and omitted other concepts such as the drive for muscularity ( 35 ) or drive for thinness ( 91 ). We only included appearance-related aspects of body image and body appreciation in order to shorten the length of our study and to decrease the burden of our survey on respondents. Therefore, we concentrated on more general aspects related to the cognitive-affective component of body image. Future studies need to investigate the impact of gender and age on other components of body image, such as perceptual estimation of body size (e.g. 92 ) or checking behaviors (e.g. 93 ). Although some studies have already investigated body image regarding genders other than the distinct categories of male and female (e.g. 94 , 95 ), we did not analyze these persons in the present study due to the insufficient sample size ( N = 7). Moreover, we did not investigate the relation between sexual orientation and body image, although previous studies have found indications of an influence of sexual orientation on body image ( 96 – 99 ). Therefore, future research should investigate the impact of age on body image for different sexual orientations.

In conclusion, the present study is one of the first to examine body dissatisfaction, importance of appearance, the number of hours participants would be willing to invest per day to achieve their ideal appearance and the number of years they would sacrifice to achieve their ideal appearance, and body appreciation in relation to gender and age. Body appreciation was higher in older than in younger women and women reported higher levels of body appreciation compared to men. While the importance of appearance was lower in older than in younger men and remained stable in women, neither gender was willing to relinquish a large amount of time for the sake of their appearance. Although we found higher body dissatisfaction for women than for men, both genders seem to be neither satisfied nor dissatisfied with their bodies on average. Eating disorder prevention programs, or therapeutic approaches for several mental disorders, could benefit from a more functional perspective on the absence of body satisfaction, as this does not necessarily equate with the presence of body dissatisfaction.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Ethics Statement

The studies involving human participants were reviewed and approved by Ethics committee of Osnabrück University. Written informed consent from the participants’ legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.

Author Contributions

HQ, SV, AH, and UB planned and conducted the study. RD and HQ analyzed the data. HQ wrote the first draft of the manuscript. All authors contributed to the compilation of the manuscript and read and approved the submitted version.

We acknowledge support by Deutsche Forschungsgemeinschaft (DFG) and the Open Access Publishing Fund of Osnabrück University for the publication of the article.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: body image, body dissatisfaction, body appreciation, importance of appearance, gender comparison, age, lifespan

Citation: Quittkat HL, Hartmann AS, Düsing R, Buhlmann U and Vocks S (2019) Body Dissatisfaction, Importance of Appearance, and Body Appreciation in Men and Women Over the Lifespan. Front. Psychiatry 10:864. doi: 10.3389/fpsyt.2019.00864

Received: 14 July 2019; Accepted: 04 November 2019; Published: 17 December 2019.

Reviewed by:

Copyright © 2019 Quittkat, Hartmann, Düsing, Buhlmann and Vocks. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Hannah L. Quittkat, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Body image dissatisfaction among males across the lifespan: a review of past literature

Affiliation.

• 1 School of Psychology, Deakin University, 221 Burwood Highway, Burwood, Victoria 3125, Australia. [email protected]
• PMID: 15193964
• DOI: 10.1016/S0022-3999(03)00129-6

Objective: Most past research has focused on body dissatisfaction among females. This paper provides a review and evaluation of studies that have examined body dissatisfaction among males. Body dissatisfaction in males has been associated with poor psychological adjustment, eating disorders, steroid use, exercise dependence, as well as other health behaviors. It is therefore important to understand the level of body dissatisfaction, as well as the factors that are related to this construct.

Method: The review is divided into three sections: body dissatisfaction among children, adolescents and adults. Within each section, levels of body dissatisfaction are examined, as well as the research that relates to sociocultural influences on body dissatisfaction. Difficulties in drawing valid conclusions from the data due to methodological problems are highlighted.

Results: From the current data, it would appear that there are strong similarities in the levels of body dissatisfaction of male and female children, with most children demonstrating high levels of body satisfaction. During adolescence, boys are about equally divided between wanting to lose weight and increasing weight, but there are few studies that have examined a desire for increased muscle size. In adulthood, men evidence a stronger desire to lose weight as they get older.

Conclusion: Overall, past studies have primarily focused on questions that are relevant to females, and there is a need to conduct studies that evaluate areas of body dissatisfaction that have greater relevance for males. This will then allow a better understanding of the relationship between body dissatisfaction and psychological and behavioral problems experienced by males at all stages of the lifespan.

Copyright 2004 Elsevier Inc.

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• Adolescent Behavior*
• Age Factors
• Body Composition
• Body Image*
• Self Concept*
• Sex Factors
• Weight Loss

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• Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: a systematic review
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• http://orcid.org/0000-0001-5898-0900 Jo Taylor ,
• Alex Mitchell ,
• Ruth Hall ,
• Claire Heathcote ,
• Trilby Langton ,
• Lorna Fraser ,
• http://orcid.org/0000-0002-0415-3536 Catherine Elizabeth Hewitt
• Department of Health Sciences , University of York , York , UK
• Correspondence to Dr Jo Taylor, Health Sciences, University of York, York, North Yorkshire, UK; dohs-gender-research{at}york.ac.uk

Background Treatment to suppress or lessen effects of puberty are outlined in clinical guidelines for adolescents experiencing gender dysphoria/incongruence. Robust evidence concerning risks and benefits is lacking and there is a need to aggregate evidence as new studies are published.

Aim To identify and synthesise studies assessing the outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence.

Methods A systematic review and narrative synthesis. Database searches (Medline, Embase, CINAHL, PsycINFO, Web of Science) were performed in April 2022, with results assessed independently by two reviewers. An adapted version of the Newcastle-Ottawa Scale for cohort studies was used to appraise study quality. Only moderate-quality and high-quality studies were synthesised. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were used.

Results 11 cohort, 8 cross-sectional and 31 pre-post studies were included (n=50). One cross-sectional study was high quality, 25 studies were moderate quality (including 5 cohort studies) and 24 were low quality. Synthesis of moderate-quality and high-quality studies showed consistent evidence demonstrating efficacy for suppressing puberty. Height increased in multiple studies, although not in line with expected growth. Multiple studies reported reductions in bone density during treatment. Limited and/or inconsistent evidence was found in relation to gender dysphoria, psychological and psychosocial health, body satisfaction, cardiometabolic risk, cognitive development and fertility.

Conclusions There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment. More recent studies published since April 2022 until January 2024 also support the conclusions of this review.

PROSPERO registration number CRD42021289659.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/archdischild-2023-326669

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Increasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services.

National and international guidelines have changed over time and outline that medications to suppress puberty can be considered for adolescents experiencing gender dysphoria/incongruence.

Several systematic reviews report a limited evidence base for these treatments, and uncertainty about the benefits, risks and long-term effects.

WHAT THIS STUDY ADDS

No high-quality studies were identified that used an appropriate study design to assess the outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence.

There is insufficient and/or inconsistent evidence about the effects of puberty suppression on gender-related outcomes, mental and psychosocial health, cognitive development, cardiometabolic risk, and fertility.

There is consistent moderate-quality evidence, although from mainly pre-post studies, that bone density and height may be compromised during treatment.

HOW THIS STUDY MIGHT AFFECT RESEARCH, POLICY OR PRACTICE

There is a lack of high-quality evidence to support the use of puberty suppression in adolescents experiencing gender dysphoria/incongruence, and large well-designed research is needed.

Introduction

Over the last 10-15 years, increasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist paediatric gender services. 1 2

Gender dysphoria/incongruence in childhood is associated with high rates of co-occurring mental health and psychosocial difficulties, which can affect health and well-being. 3 Clinical guidelines recommend psychosocial care to alleviate gender-related distress and any co-occurring difficulties. For pubertal adolescents, medications to suppress or lessen effects of puberty are also outlined. Gonadotropin-releasing hormone analogues (GnRH-a) are used as first-line treatment, although other drugs with anti-androgenic properties including progestins and spironolactone are used in this population. 4 5 The effects differ depending on whether they are initiated in early puberty or mid-puberty, as well as the type of intervention used, with GnRH-a suppressing puberty when started early or suspending further progression when initiated in mid-puberty, and anti-androgens instead blocking specific downstream effects of sex hormones. 4

Rationales for puberty suppression in the Dutch treatment protocol, which has informed practice internationally, were to alleviate worsening gender dysphoria, allow time for gender exploration, and pause development of secondary sex characteristics to make passing in the desired gender role easier. 6 Practice guidelines propose other indications for puberty suppression, including allowing time and/or capacity for decision-making about masculinising or feminising hormone interventions, and improving quality of life. 4 7 8

Criteria in early treatment protocols for puberty suppression specified adolescents be at least age 12 years, at Tanner stage 2 in puberty, experienced gender dysphoria in childhood which persisted and intensified during puberty and met criteria for diagnosis of gender dysphoria. 6 It was also expected that any psychosocial difficulties that could interfere with treatment were managed. 6 The World Professional Association for Transgender Health standards of care 4 and other practice guidelines 5 8 9 have broadened these criteria, for example, removing minimum age. However, other recent guidelines have taken a more cautious approach and restricted inclusion criteria in response to uncertainties in the evidence base. 7 10

Systematic reviews have consistently found mainly low-quality evidence, limited data on key outcomes or long-term follow-up. 11–16 These reviews report that while puberty suppression may offer some benefit, there are concerns about the impact on bone health, and uncertainty regarding cognitive development, psychosocial outcomes and cardiometabolic health. They conclude there is insufficient evidence to support clinical recommendations.

The proliferation of research in this area and lack of evidence to support practice means there is an ongoing need to aggregate evidence. This systematic review aims to synthesise evidence published to April 2022 that reports outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence.

The review forms part of a linked series examining the epidemiology, care pathways, outcomes and experiences for children and adolescents experiencing gender dysphoria/incongruence and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 17 The protocol was registered on PROSPERO (CRD42021289659. 18

Search strategy

A single search strategy was used to identify studies comprising two combined concepts: ‘children’, which included all terms for children and adolescents and ‘gender dysphoria’, which included associated terms such as gender-related distress and gender incongruence, and gender identity terms including transgender, gender diverse and non-binary.

MEDLINE ( online supplemental table S1 ), EMBASE and PsycINFO through OVID, CINAHL Complete through EBSCO, and Web of Science (Social Science Citation Index) were searched (13–23 May 2021 and updated on 27 April 2022).

Supplemental material

Reference lists of included studies and relevant systematic reviews were assessed for inclusion. 11–16 19 20

Inclusion criteria

The review included published research that reported outcomes of interventions used to suppress puberty for children and/or adolescents experiencing gender dysphoria/incongruence ( table 1 ).

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Inclusion and exclusion criteria

Selection process

The results of database and other searches were uploaded to Covidence 21 and screened independently by two reviewers. Full texts of potentially relevant articles were retrieved and reviewed against inclusion criteria by two reviewers independently. Disagreements were resolved through discussion and inclusion of a third reviewer.

Data extraction

Data on study characteristics, methods and reported outcomes were extracted into prepiloted data extraction templates by one reviewer and second-checked by another.

Study quality

Critical appraisal was undertaken by two reviewers independently, with consensus reached through discussion and involvement of a third reviewer where necessary.

Quality was assessed using a modified version ( online supplemental file 1 ) of the Newcastle-Ottawa Scale for cohort studies, a validated scale of eight items covering three domains: selection, comparability and outcome. 22 Scale modification included not scoring certain question(s) for cross-sectional and single-group designs, or particular outcomes; specification of key confounders to assess comparability of cohorts; guidance regarding sufficiency of follow-up and use of numerical scores for items and overall (maximum score 9 for cohorts, 8 for pre-post and cross-sectional studies with comparator). Total scores were calculated as percentages to account for different total scores (≤50% low quality, >50%–75% moderate quality, >75% high quality).

Narrative synthesis methods were used because of heterogeneity in study design, intervention, comparator, outcome and measurement. Due to high risk of bias in low-quality studies, these were excluded from the synthesis.

When synthesising results by outcome domains, care was taken to differentiate between different study designs, comparators and interventions. Where possible, potential differences in effects by birth-registered sex, treatment duration or treatment in early puberty versus late puberty were examined.

The database search yielded 28 147 records, 3181 of which were identified as potentially relevant for the linked systematic reviews and full texts reviewed. From these, 50 studies met inclusion criteria for this review ( figure 1 ).

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Study flow diagram.

Study characteristics

Studies were published from 2006 to 2022 with the majority published in 2020–2022 (n=29). Studies were conducted in the Netherlands (n=17), 23–39 the US (n=15), 40–54 the UK (n=6), 55–60 Canada (n=4), 61–64 three in Belgium 65–67 and Israel 68–70 and one in Brazil 71 and Germany 72 ( online supplemental table S2 ).

The 50 studies included 11 cohorts comparing adolescents experiencing gender dysphoria/incongruence receiving puberty suppression with a comparator, 35 39–42 45 49 50 52 56 72 8 cross-sectional with a comparator 23 33 37 47 51 53 60 71 and 31 pre-post single group studies. 24–32 34 36 38 43 44 46 48 54 55 57–59 61–70 More than half of studies (n=29) used retrospective chart review.

All but 4 studies selected adolescents experiencing gender dysphoria/incongruence from specialist gender or endocrinology services: 43 from single services (in Belgium, Israel, the Netherlands and the UK these were large regional or national services) and 3 from multiple US services. 48–50 The other four included three US studies (national survey recruiting via community settings, 53 clinical and community settings, 51 US Military Healthcare Data Repository 54 ) and a study from Brazil recruiting via Facebook. 71

Overall, studies included 10 673 participants: 9404 were adolescents experiencing gender dysphoria/incongruence (4702 received puberty suppression, 4702 did not) and 1269 other comparators. Comparator groups included adolescents or adults experiencing gender dysphoria/incongruence who had not received puberty suppression, 35 39 40 42 51–53 60 71 72 untreated adolescents not experiencing gender dysphoria/incongruence, 36 47 50 both of these comparators 23 33 37 56 or adolescents receiving treatment for a different medical reason. 41 45 49

Most studies (n=39) assessed GnRH-a. In one, some participants received GnRH-a and some (birth-registered males) spironolactone. 62 In another, GnRH-a or progestins/anti-androgens were used but numbers taking each were not reported. 40 Among the other 11 studies, 5 assessed effects of progestins (cyproterone acetate, 66 67 lynestrenol, 65 66 medroxyprogesterone 44 and levonorgestrel-releasing intrauterine system 41 ) as alternatives to GnRH-a, 41 44 65–67 1 assessed bicalutamide 46 and 5 did not specify. 43 52–54 71

Of the 50 studies, 29 reported outcomes for feminising or masculinising hormones as well as for puberty suppression, either by including a mixed sample of those receiving the two different interventions or by assessing those who progressed to hormones following puberty suppression.

The most frequently measured outcomes were puberty suppression (n=30) and physical health outcomes (n=27) ( figure 2 , online supplemental table S3 ). Gender-related outcomes and body image were measured in five and four studies, respectively. Psychological health was measured in 13 studies, psychosocial in 9 studies and cognitive/neurodevelopmental outcomes in 3 studies. Side effects were reported in six, bone health in nine, and one study measured fertility.

Outcome categories by study quality and design.

One cross-sectional study was rated high quality, 37 25 moderate quality 23 24 29–32 34–36 39 48–51 54–59 64 65 67–69 and 24 low quality. 25–28 33 38 40–47 52 53 60–63 66 70–72 Of the 11 cohort studies, which were the only studies to include a comparator and assess outcomes over time, only 5 were rated moderate quality ( figure 2 , online supplemental table S4 ). 35 39 49 50 56

In most studies, there were concerns about sample representativeness due to single site recruitment, inclusion of a selected group and/or poor reporting of the eligible population. In studies including a comparator, most did not report or control for key differences between groups and only four used matched controls. 23 33 41 47 Most studies presented results for birth-registered males and females separately or controlled for this. Few studies controlled for age or Tanner stage or co-interventions that could influence outcomes.

Overall, studies used appropriate methods to ascertain exposure and assess outcomes. Adequacy of follow-up was evident in 18 studies, with multiple studies not reporting treatment duration, including participants receiving treatment at baseline, and not aligning follow-up with treatment initiation. Missing data at follow-up/analysis or poor reporting of this affected many studies.

Four studies did not report separate outcome data for adolescents receiving puberty suppression or masculinising/feminising hormones. 39 54 60 71 Two of these were of moderate quality and not included in the synthesis, 39 54 one of which was the only study to assess fertility outcomes. 39 One moderate-quality study assessed amplitude of click-evoked otoacoustic emissions. 23 This was excluded from the synthesis on the basis of not being clinically relevant.

Synthesis of outcomes

Gender dysphoria and body satisfaction.

Two pre-post studies measured gender dysphoria and body satisfaction (with primary and secondary sex or neutral body characteristics) and reported no change before and after receiving treatment 24 55 ( table 2 ).

Gender-related, body image, psychological, psychosocial, and cognitive/neurodevelopmental outcomes

Psychological health

One cross-sectional 37 and two pre-post studies 24 55 measured symptoms of depression (n=1), anxiety (n=1), anger (n=1), internalising and externalising symptoms (n=3), suicide and/or self-harm (n=2) and psychological functioning (n=2).

Three studies assessed internalising and externalising symptoms with one reporting improvements in both (pre-post 24 ), one improvement in internalising but not externalising symptoms when compared with adolescents under assessment by a gender service (cross-sectional 37 ) and one observed no change in either (pre-post). 55

For other psychological outcomes, there was either a single study, or two studies showing inconsistent results, with studies reporting either a small to moderate significant improvement or no change ( table 2 ).

Psychosocial outcomes

One cohort 56 and two pre-post 24 55 studies measured psychosocial functioning, one pre-post study assessed quality of life 55 and one cross-sectional study measured peer-relations ( table 2 ). 37

For psychosocial functioning, both pre-post studies reported no clinically significant change at follow-up. 24 55 The cohort study compared adolescents who were not immediately eligible for puberty suppression and received psychological support only, and adolescents who additionally received GnRH-a after 6 months. 56 Improvements were seen in both groups after 6 months of psychological support. This improvement was maintained over time for those receiving psychological support only. For those receiving GnRH-a, further improvements were observed at 12 and 18 months. At 18 months, psychosocial functioning in this group was considerably higher than in those still waiting for puberty suppression, and similar to adolescents not experiencing gender dysphoria/incongruence. However, there were considerably fewer participants included at final follow-up.

There was no change in quality of life pre-post, 55 and treated adolescents had better peer-relations compared with adolescents under assessment at a gender service but poorer peer-relations than adolescents not experiencing gender dysphoria/incongruence. 37

Cognitive/neurodevelopmental outcomes

One cross-sectional study measured executive functioning and found no difference between adolescents who were treated for <1 year compared with those not treated, but worse executive functioning in those treated for >1 year compared with those not treated. 51 A pre-post study found no differences in features typically associated with autism spectrum condition after treatment ( table 2 ). 59

Physical health outcomes

Bone health.

Five studies found decreases in bone mineral apparent density and z-scores pre-post treatment; however, absolute measures generally remained stable or increased/decreased slightly. 29 32 34 55 58 Results were similar across birth-registered males and females. 29 32 55 58 One study considered timing of treatment, and found similar decreases among those starting GnRH-a in early or late puberty ( table 3 ). 32

Physical health outcomes and side effects

Cardiometabolic health

Twelve pre-post studies measured body mass index (BMI), and in 10 studies there was no evidence of a clinically significant change in BMI and/or BMI SD score. 29 30 32 34 55 57 65 67–69 In one study, BMI increased for birth-registered males but not females. 58 Another study found BMI increased for birth-registered females who started GnRH-a in early puberty or mid-puberty, and birth-registered males in early puberty. 36

Three studies assessed cholesterol markers, one after GnRH-a (no changes), 34 one after cyproterone acetate (decrease in high-density lipoprotein (HDL) and triglycerides) 67 and one after lynestrenol (decrease in HDL, increase in low-density lipoprotein). 65 Three studies assessing GnRH-a reported blood pressure: two found similar systolic and diastolic blood pressure before and after treatment, 34 68 and one found a non-clinically significant increase in diastolic but not systolic blood pressure. 69 Two studies measured markers of diabetes (fasting glucose, HbA1c and/or insulin) and noted no changes. 65 67

Other physiological parameters

Five pre-post studies assessed other parameters from blood tests undertaken at baseline and follow-up, 30 31 34 65 67 three in those treated with GnRH-a, 30 31 34 one lynestrenol 65 and one cyproterone acetate. 67 Measurements included haemoglobin count (n=3), haematocrit percentage (n=3), creatinine (n=4), aspartate aminotransferase (n=3), alanine aminotransferase (n=3), γ-glutamyl transferase (n=1), alkaline phosphatase (n=2), prolactin (n=2), free thyroxin (n=3), thyroid-stimulating hormone (n=3), sex hormone binding globulin (n=3), vitamin D levels (n=1), dehydroepiandrosterone sulfate (n=3) and androstenedione (n=2). For most outcomes, no changes were reported. Where there were changes, these were not consistent in direction across studies.

One pre-post study assessing GnRH-a reported QTc prolongation, 64 and found no change in mean QTc, with no participants outside normal range.

Side effects

A cohort study of GnRH-a reported side effects including mild headaches or hot flushes (~20%) and moderate/severe headaches or hot flushes, mild fatigue, mood swings, weight gain and sleep problems (<10%) ( table 3 ). 55

Two studies assessed other medications and reported headaches and hot flushes as common and an increase in acne in a sample of birth-registered females receiving lynestrenol, 65 and complaints of fatigue in birth-registered males receiving cyproterone acetate. 67

Puberty suppression

Hormone levels.

Hormone levels were reported in nine studies of GnRH-a (two cohort, 49 50 seven pre-post 30 34 36 48 55 68 69 ), two in birth-registered females, 34 69 one in birth-registered males 68 and six including both ( table 4 ). 30 36 48–50 55

Puberty suppression outcomes

Five studies reported decreases in luteinising hormone, follicle-stimulating hormone, oestradiol and testosterone after receiving GnRH-a. 30 34 48 68 69 Another study, which reported luteinising and follicle-stimulating hormones, also found decreases in both pre-post. 55 One study reported that where baseline levels were high due to puberty starting, decreases were reported in testosterone and oestradiol. 36 One cohort study reporting pre-post data found smaller decreases in luteinising hormone, follicle-stimulating hormone, oestradiol and testosterone compared with other studies; however, it included a younger population, some of who were likely prepubertal. 50 The other cohort study included a comparator of adolescents with precocious puberty and found similar decreases in luteinising hormone and oestradiol. 49

One pre-post study of lynestrenol (birth-registered females) found a decrease in luteinising hormones but not follicle-stimulating hormone, oestradiol or testosterone. 65 One study of cyproterone acetate (birth-registered males) found no changes in luteinising hormone, follicle-stimulating hormone or oestradiol, but a decrease in total testosterone. 67

Pubertal progression

Puberty development was reported in four studies (two cohort, two pre-post). 30 35 49 67 One only included birth-registered males, 67 and three included both birth-registered males and females. 30 35 49

A cohort study assessing GnRH-a reported clinical pubertal escape in 2/21 adolescents treated for gender dysphoria/incongruence, in the form of breast enlargement or testicular enlargement together with deepening of voice, compared with no children treated for precocious puberty. 49 A pre-post study reported a decrease in testicular volume in birth-registered males, but unclear results with regard to breast development in birth-registered females (most started treatment at Tanner stage 4–5). 30 A pre-post study of birth-registered males using cyproterone acetate reported decreases in facial shaving and spontaneous erections. 67

A cohort study assessed whether secondary sex characteristics differed depending on receipt or timing of GnRH-a, and whether this affected which surgical interventions/techniques were later used. 35 The study found breast size was smallest in birth-registered females who received GnRH-a in Tanner stage 2/3 and largest in untreated participants. Those treated early in puberty were less likely to require a mastectomy and when surgery was required it was less burdensome. In birth-registered males, penile length was greater in those who received GnRH-a at Tanner stage 4/5 compared with Tanner stage 2/3, and greatest in untreated participants. 35 Those who received GnRH-a early required more invasive vaginoplasty techniques than those who received it later or not at all.

Menstrual suppression

Three studies (one cohort, two pre-post) measured menstrual suppression in birth-registered females, and found full suppression at follow-up, 30 49 55 which was similar to the effect seen in those with precocious puberty in the cohort study. 49

Height/Growth

Eleven studies (1 cohort, 50 10 pre-post 29 30 32 34 36 55 57 58 65 67 ) reported height, nine after GnRH-a, 29 30 32 34 36 50 55 57 58 one lynestrenol 65 and one cyproterone acetate. 67 The cohort study found a similar height velocity between the GnRH-a group and adolescent controls. 50 Six studies reported height Z or SD score 29 30 34 55 57 67 with two studies finding no change, 34 55 two a decrease for birth-registered males but not females, 29 57 one a decrease across birth-registered males and females 30 and one a decrease in birth-registered males with cyproterone acetate. 67 Absolute measures of height generally increased slightly or remained the same. 29 30 32 34 36 58 65 67

Body composition

Two studies reported changes in body composition pre-post, 30 57 reporting a significant decrease in lean mass SD score 57 and percentage 30 in males and females. One also measured body fat percentage and reported significant increases in both groups. 30

Bone geometry

One pre-post study measured the subperiosteal width and endocortical diameter of the hip bone and found that in birth-registered males these increased in those starting GnRH-a in early puberty and mid-puberty, but only in the early puberty group for birth-registered females. 36

This systematic review identified 50 studies reporting outcomes relating to puberty suppression in adolescents experiencing gender dysphoria/incongruence. No high-quality studies using an appropriate design were identified, and only four measured gender dysphoria as an outcome. Only 5 of the 11 cohort studies, which were the only studies to compare groups over time, were rated as moderate quality. 35 40 49 50 56

There was evidence from multiple mainly pre-post studies that puberty suppression exerts its expected physiological effect, as previously demonstrated in children with precocious puberty. 73 In adolescents experiencing gender dysphoria/incongruence, puberty suppression is initiated at different stages of puberty, 74 and two studies found that the effects on secondary sex characteristics may vary depending on whether treatment is initiated in early puberty versus mid-puberty, with potentially different outcomes for birth-registered males and females. 30 35 Multiple studies also found that bone density is compromised during puberty suppression, and gains in height may lag behind that seen in other adolescents. High-quality research is needed to confirm these findings; however, these potential risks should be explained to adolescents considering puberty suppression.

These findings add to other systematic reviews in concluding there is insufficient and/or inconsistent evidence about the effects of puberty suppression on gender dysphoria, body satisfaction, psychological and psychosocial health, cognitive development, cardiometabolic risk and fertility. 11–16 Regarding psychological health, one recent systematic review 14 reported some evidence of benefit while others have not. The results in this review found no consistent evidence of benefit. Inclusion of only moderate-quality to high-quality studies may explain this difference, as 8 of the 12 studies reporting psychological outcomes were rated as low-quality.

The lack of representativeness of samples and comparability of selected control groups were key concerns across studies. Only one study attempted to compare puberty suppression with psychosocial care, which is the only other treatment offered for gender dysphoria/incongruence in childhood, and this included a small sample, limited analyses, and little detail about the intervention. 56 Other studies lacked information about any psychological care provided to participants, and in studies that included a comparator there was limited information about any differences between groups. Large, well-designed studies with appropriate comparators that enable long-term outcomes of puberty suppression to be measured are needed.

Many studies reported effects of both puberty suppressants and hormones used in later adolescence for feminisation/masculinisation. In adolescents, GnRH-a often continues during hormone treatment, 74 or for adolescents who do not receive puberty suppression, GnRH-a or other anti-androgens may be offered at initiation of hormones. 66 This makes long-term follow-up of puberty suppression difficult to assess, including any differences between the types of interventions that are offered and when these are initiated, and the few studies reporting long-term outcomes either did not control for this or reported overall effects for both interventions. Although recent studies suggest nearly all adolescents who receive puberty suppression go on to feminising/masculinising hormones, 74–76 research is still needed to assess whether suppression will have any lasting effects for those who do not. Aggregation of studies reporting proportions of adolescents who progress to hormones and reasons for discontinuation would also offer useful insights.

Included studies assessed different outcomes across various outcome domains and employed multiple different measures. Agreement about the primary aim and related core outcomes of puberty suppression in this population would help to ensure studies measure key outcomes and facilitate future aggregation of evidence. Expert consensus recommendations to guide the methods and domains for assessing the neurodevelopmental effects of puberty suppression have been developed 77 ; however, there is currently no agreement across other outcome domains.

Strengths and limitations

Strengths include a published protocol with robust search strategies, use of PRISMA guidelines and comprehensive synthesis of moderate and high quality studies. Poor reporting across studies may have resulted in moderate-quality studies being rated low-quality and excluded from synthesis. As searches were conducted up to April 2022, this review does not include more recently published studies. However, the findings are in line with previous reviews despite the inclusion of numerous additional studies. In an update of the National Institute for Health and Care Excellence evidence review of GnRH-a performed in April 2023, 78 nine additional studies were identified, two of which they felt might materially affect their conclusions. 72 74 One was already included in this review, 72 and the other examined treatment trajectories which was not an outcome of interest. 74

Of other studies that we are aware have been published since April 2022 until January 2024, very few used a cohort design or an appropriate comparator and were of a similar low quality to moderate quality as the studies summarised in this review. Of those likely to contribute new data for synthesis, five examined physical growth and development, 79–83 one cardiometabolic health 84 and one psychological health. 85 The latter, a study from the US, found that adolescents who received puberty suppression before assessment for masculinising or feminising hormones had fewer symptoms of depression, anxiety, stress and suicidal thoughts compared with those who had not received puberty suppression. A sensitivity analysis found similar results, although no difference in suicidal thoughts. 85 Adding this study would provide no further clarity about whether puberty suppression improves psychological health due to the inconsistency of results between studies, and the limited high-quality research measuring these outcomes.

Two studies from the Netherlands found that height growth and bone maturation both decelerated during GnRH-a treatment, 80 81 and a third assessing only bone health found the same. 83 A Belgian study found stable height growth in birth-registered females but deceleration in birth-registered males. 82 These studies add strength to the conclusion that bone health and adult height may be compromised during GnRH-a, although like in previous studies the participants went on to receive masculinising or feminising hormones, and therefore the long-term outcomes of puberty suppression alone were not possible to determine.

Another new study, also from the Netherlands, assessed changes in body composition. 79 This found that in both birth-registered males and females lean mass z-scores decreased during puberty suppression and fat mass z-scores increased, although the rate and duration of change differed by birth-registered sex. These changes were also found in the two studies synthesised, 30 57 but as all three included no comparator uncertainty continues about the effect of puberty suppression on body composition.

A large study of adults in the US examined whether receipt of hormone interventions during adolescence was associated with cardiometabolic-related diagnoses, and for GnRH-a found no statistically significant differences for any diagnosis. 84 However, the study uses a retrospective cross-sectional design and is the only study to have examined cardiometabolic diagnoses, so no conclusions can be drawn about these outcomes.

To our knowledge, there are no additional moderate-quality or high-quality studies that have measured psychosocial or fertility outcomes, and only a single study assessing cognitive effects which measured a different outcome (white matter microstructure) to those included in this review. 86

Conclusions

There are no high-quality studies using an appropriate study design that assess outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the effect on gender-related outcomes, psychological and psychosocial health, cognitive development or fertility. Bone health and height may be compromised during treatment. High-quality research and agreement on the core outcomes of puberty suppression are needed.

Ethics statements

Patient consent for publication.

Not applicable.

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Supplementary materials

Supplementary data.

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• Data supplement 1
• Data supplement 2
• Data supplement 3
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• Data supplement 5

Contributors LF, CEH, RH, TL and JT contributed to the conception of this review. RH, CEH, CH, AM and JT contributed to screening and selection. AM and JT completed data extraction. CEH, RH, AM and JT contributed to critical appraisal. CEH, AM and JT completed the synthesis and drafted the manuscript. All authors contributed to interpretation and reviewed and approved the manuscript prior to submission. CEH accepts full responsibility for the finished work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

Funding This work was funded by NHS England to inform the Cass Review (Independent review of gender identity services for children and young people). The funder and Cass Review team had a role in commissioning the research programme but no role in the study conduct, interpretation or conclusion.

Competing interests None declared.

Provenance and peer review Commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Social Media Use and Body Dissatisfaction in Adolescents: The Moderating Role of Thin- and Muscular-Ideal Internalisation

An t. vuong.

1 College of Health and Biomedicine, Victoria University, Melbourne, VIC 8001, Australia; [email protected]

2 School of Psychology & Public Health, La Trobe University, Melbourne, VIC 3086, Australia; [email protected]

Hannah K. Jarman

Jo r. doley.

3 Institute for Health and Sport, Victoria University, Melbourne, VIC 8001, Australia; [email protected]

Siân A. McLean

Associated data.

Data are available from authors upon reasonable request.

Internalisation of appearance ideals moderates the relationship between exposure to media images and body dissatisfaction. To date, the role of thin- and muscular-ideal internalisation in the context of social media remains under explored, particularly for boys. As such, we aimed to explore how social media use (Instagram and Snapchat) was related to body dissatisfaction, and whether thin- and muscular-ideal internalisation would moderate this relationship in a sample of 1153 adolescent boys and girls (55.42% males; M age = 13.71, SD = 1.14). As hypothesised, social media use, and thin- and muscular ideal internalisation were positively correlated with body dissatisfaction in both genders. In moderation analyses, thin-ideal internalisation emerged as the only variable that had a significant effect on body dissatisfaction in both genders. Additionally, the influence of social media use on body dissatisfaction was moderated by muscular-ideal internalisation in boys, whereby for boys with high muscular-ideal internalisation, greater social media use was associated with greater body dissatisfaction. The two-way (muscular x thin-ideal internalisation) and three-way interaction (social media use x thin-ideal internalisation x muscular-ideal internalisation) effects on body dissatisfaction were non-significant. These findings emphasise the importance of considering the sociocultural environment (i.e., new media influences) as frameworks for understanding body dissatisfaction and suggest targeting of internalisation of appearance ideals in body dissatisfaction prevention programs.

1. Introduction

Body dissatisfaction, the negative self-evaluation of one’s appearance [ 1 ], is experienced across the lifespan, but adolescence is a period of particular vulnerability [ 2 ]. An emerging factor relevant to body dissatisfaction in adolescence is social media use, which has been found to predict increases in body dissatisfaction among girls and boys [ 3 ]. However, social media does not affect body dissatisfaction to the same degree in all young people and individual characteristics may affect the extent to which social media use is associated with body dissatisfaction. One such factor is the internalisation of appearance ideals that promote thinness in females and muscularity in males [ 4 , 5 ]. Emerging evidence suggests that mass media can be highly influential as it may lead adolescents to internalise Western societal ideals about physical attractiveness and beauty, resulting in dissatisfaction with their own appearance when they are unable to mirror these standards [ 6 , 7 ], yet this remains unexamined in the context of social media. Despite being active social media users as well as undergoing a critical period that puts them at greater risk for body dissatisfaction [ 8 , 9 ], there is presently a lack of research of this nature among adolescents. Therefore, this study aims to fill this gap by examining how social media use (Instagram and Snapchat) is related to adolescents’ body dissatisfaction, and whether thin- and muscular-ideal internalisation would moderate this relationship.

Adolescence is an important period for body dissatisfaction. Many adolescents are highly invested in their appearance and are vulnerable to the development of body image concerns [ 8 , 10 ]. Adolescents begin to demonstrate declines in body esteem (i.e., appearance and weight satisfaction) at 13 years of age [ 11 ] and this persists throughout mid-adolescence [ 12 , 13 ]. A high proportion of boys (50%) and girls (74%) at age 14 have been found to want to modify something about their body [ 14 ]. The prevalence of body dissatisfaction in adolescents is concerning given that it has been found to prospectively predict negative physical and psychological health outcomes such as depression, poor self-esteem, and eating disorders [ 2 , 15 ]. Body dissatisfaction has also been shown to predict engagement in risky body-change behaviours such as supplement use, excessive exercise, muscle-gaining strategies, and restrictive dieting practices among adolescents [ 16 , 17 ].

Although body dissatisfaction has been observed to be more normative and profound in adolescent girls compared to boys [ 18 , 19 ], new evidence suggests that it is becoming a considerable issue among both genders [ 20 , 21 ]. However, the nature of body dissatisfaction experienced by girls and by boys tends to differ in that concerns expressed by girls typically focus on attaining a thin appearance ideal, whereas boys’ appearance ideal tends to be lean and muscular [ 22 ]. Similarly, boys tend to place more value on their functional abilities (e.g., physical qualities and strength) whereas girls tend to be more invested in the aesthetic qualities of their outward appearance [ 23 ]. Thus, it follows that weight gain has been frequently reported as a body change strategy among adolescent boys while weight reduction strategies such as dieting are more common among adolescent girls [ 24 , 25 ]. As a result, external influences on body dissatisfaction and personal characteristics that may mitigate those influences could differ for boys and for girls, so more research is required to discern the factors that contribute to body dissatisfaction in both groups.

Sociocultural models of the development of body dissatisfaction and eating disorders, such as the tripartite influence model [ 26 ] and the dual pathway model [ 27 ] provide a framework to guide understanding of factors relevant to the development of body dissatisfaction. According to these models, appearance pressures that emanate from peers, family, and media (the latter being the focus of the present study) and psychological processes (e.g., appearance-ideal internalisation and social comparisons) contribute to the emergence and maintenance of body dissatisfaction. Subsequently, body dissatisfaction leads to risk factors for disordered eating (e.g., dieting and negative affect) and in turn, the onset of bulimic pathology. In relation to media, social media use is becoming highly relevant for young adolescents compared with traditional media, with Instagram and Snapchat used more frequently than other platforms [ 28 ]. Over the past decade, the total number of hours per day that early adolescents devoted to social media had risen and the percentage of those who used social media on a daily basis had almost doubled [ 29 ]. Therefore, investigating the influence of social media, rather than traditional media, on body dissatisfaction may be more reflective of the media environment in which adolescents are engaged.

Social media sites, particularly Instagram and Snapchat, allow opportunities for users to share and view visual content that can be digitally retouched to reflect beauty ideals [ 30 ]. Given that these platforms involve behaviours such as commenting and liking, adolescents can become fixated on how they present themselves and are enticed to post pictures that conform to appearance ideals in hopes of gaining approval from others [ 31 , 32 ]. Thus, the highly visual nature of social media stimuli means that adolescents are constantly exposed to unrealistic appearance ideals when engaging with peers and celebrities, which may heighten their body dissatisfaction levels [ 33 , 34 ]. As cultivation theory suggests [ 35 ], frequent engagement with social media content may prompt negative behaviours and attitudes about society’s ideal appearance due to regular and repeated exposure [ 31 , 34 ]. Empirical evidence supports this contention whereby positive relationships between social media use (especially highly visual platforms) and body dissatisfaction have been identified in pre to late adolescent boys and girls [ 36 , 37 ]. Interestingly, specific online behaviours (e.g., “likes” received and selfie-posting) had no significant impact on body dissatisfaction even when controlling for BMI and gender [ 37 ]. Thereby, narrowing the focus of general social media use to appearance-focused platforms seems appropriate [ 21 , 38 ]. Despite gender differences regarding social media behaviours (posting, commenting, and liking), boys are equally prolific users who are also subject to idealised imagery [ 28 , 39 ]. Social media use also heightens opportunities for boys to make appearance comparisons, subsequently increasing their levels of body dissatisfaction [ 40 ]. Notably, these recent observations stress that boys who use social media are just as vulnerable as girls to negative body image.

In addition, sociocultural models also specify a role for internalisation of appearance ideals, that is, the endorsement of and aspiration to achieve Western appearance standards (e.g., thinness in females and muscularity in males), in the transmission of sociocultural appearance pressures to body dissatisfaction. In this manner, individuals who internalise appearance ideals, such as those presented in social media, are more likely to experience body dissatisfaction when they find they cannot attain the typically unrealistic appearance ideals promoted by these sources [ 41 ]. Meta-analytic work has illustrated that media exposure reinforces appearance-ideal internalisation and this can affect both genders of all ages, although adolescents were the most at risk [ 42 ]. Similarly, the association between appearance-ideal internalisation and body dissatisfaction does not significantly differ across gender but the magnitude of this relationship was more profound in younger than older individuals [ 43 ]. Such findings allude to the importance of mixed-gender studies and research in adolescents who are most vulnerable, hence the focus of this study.

There are two ways internalisation has been conceptualised in the relationship between media exposure and body dissatisfaction; baseline trait internalisation as a moderator and change in trait internalisation as a mediator [ 5 ]. Recently, considerable research has examined internalisation as a mediator in adults [ 44 , 45 , 46 ] and adolescents [ 47 ] but fewer studies have examined internalisation as a moderator in the context of social media use. In this regard, internalisation (baseline) as a moderator will be the focus of this paper in that higher internalisation is expected to strengthen the negative influence of media imagery on body image and this detrimental effect is expected to diminish with lower internalisation levels [ 48 , 49 ].

As described, appearance ideals may reflect either the thin or muscular body type. Traditionally, thin-ideal internalisation has been examined in the domain of female body image and empirical findings have demonstrated well-established associations between these concepts among girls. For example, greater thin-ideal internalisation has been associated with greater body dissatisfaction in adolescent girls [ 7 , 50 ] and has also been recognised as a prospective predictor of body dissatisfaction among young adolescent girls [ 51 ]. Although thin-ideal internalisation could also be relevant to adolescent boys given research indicating that they desire to look lean with low body fat [ 52 , 53 ], research among boys is somewhat limited to date and findings are conflicting. Some studies found that thin-ideal internalisation did not predict body dissatisfaction in boys [ 54 , 55 ]. However, one study found that internalised thin ideals in the media increased men’s body dissatisfaction [ 56 ].

In parallel to thin-ideal internalisation, muscular-ideal internalisation has commonly been perceived as more relevant to males than females. This relevance is demonstrated in research findings among adolescent boys whereby those who highly internalised the muscular/athletic ideal were more dissatisfied with their bodies than those who did not [ 55 , 57 ]. There is also empirical support for muscular-ideal internalisation as a moderator between media exposure and body dissatisfaction. Boys who highly endorsed masculine gender roles regarding muscularity and strength were more vulnerable to negative mass media effects (magazines and advertisements) as inferred by their higher body-change desires and drives for muscularity [ 58 , 59 ].

Despite the traditional focus on males, research has also begun to explore muscular-ideal internalisation among females. Initial evidence suggested that muscular-ideal internalisation was not detrimental to women’s body image [ 60 ]. However, with the advent of social media movements such as ‘fitspiration’, whereby thin and toned images are accompanied by text that motivates acquisition of the fit ideal appearance, an unrealistically muscular appearance is now an element of the female appearance ideal [ 61 , 62 ]. Thus, muscular-ideal internalisation may be more relevant and potentially be associated with body image in both girls and boys. Emerging evidence has indicated that media exposure to muscular ideal imagery predicts greater body dissatisfaction and drives for both thinness and muscularity in females [ 55 , 63 ]. Furthermore, muscular-ideal internalisation has also been found to be positively associated with muscle building behaviours in boys and girls, indicating the relevance of this form of internalisation for adolescents regardless of gender [ 47 ]. In light of the changing social media environment promoting both thin and muscular ideals, further research examining both thin- and muscular-ideal internalisation may provide a more complete picture of the underlying mechanisms that shape body dissatisfaction in both girls and boys.

Taken together, much of the existing research on internalisation as a moderator has been confined to adult samples and revolves around typical appearance attributes (i.e., thin-ideal internalisation in females and muscular-ideal internalisation in males) [ 48 , 58 , 59 , 64 ]. Therefore, the overarching aim of the current study was to add to past research and explore the relationships between social media use (Instagram and Snapchat), thin-ideal internalisation, muscular-ideal internalisation, and body dissatisfaction in adolescents. In both girls and boys, it was hypothesised that (1) social media use, thin-ideal internalisation, and muscular-ideal internalisation would be positively associated with body dissatisfaction, and (2) thin- and muscular-ideal internalisation would individually moderate the relationship between social media use and body dissatisfaction. Specifically, a stronger association between social media use and body dissatisfaction would be demonstrated for those with high levels of internalisation compared to those with low levels. In exploratory moderation analyses, we aimed to test the effects of a 2-way interaction (between thin- and muscular-ideal internalisation) and a 3-way interaction (between thin-ideal internalisation, muscular-ideal internalisation, and social media use) on body dissatisfaction. No specific assumptions were formed for these exploratory aims.

2.1. Participants

The initial sample comprised 1200 adolescents from grades 7 to 10 in two independent, co-educational high schools in Melbourne, Australia, who were recruited to take part in a longitudinal study of body dissatisfaction and well-being in adolescence over 1-year. For the present study, data from the first wave of data collection were analysed. Inclusion criteria were that participants had a social media account or profile and identified as either male or female. Following exclusion, data from 1153 (males n = 665; females n = 488) participants were included in analyses ( n = 306, n = 266, n = 405, and n = 176 in grades 7, 8, 9, and 10, respectively). Participants’ ages ranged from 11 to 17 years ( M age = 13.71, SD = 1.14). Their BMI (kg/m 2 ) ranged from 11.02 to 57.81 ( M BMI = 19.89, SD = 3.68) and, in line with World Health Organization cut-offs for BMI-for-age z-scores [ 65 ], the BMI of the majority of participants was classified as ‘normal’ weight (80.22%), with 9.89% ‘overweight’, 8.27% ‘underweight’, and 1.62% ‘obese’. Most participants were born in Australian/New Zealand (83.5%), followed by Asia (9.2%), Europe (4.7%), and other (2.6%).

2.2. Measures

2.2.1. demographic information.

Participants were asked to indicate their age, gender, and country of birth.

2.2.2. Social Media Use

To assess social media use, respondents were asked to specify how often they used two appearance-related social media sites (Snapchat and Instagram) on a 5-point scale (1 = never to 5 = always ). A mean score was calculated, with higher scores indicating greater frequency of social media use. Another study used a similar approach to measure the frequency of social media use [ 66 ]. Use of Snapchat and Instagram were included in analyses due to high popularity amongst adolescents in western cultures, being highly image-centric, and having been associated with body image concerns [ 67 ].

2.2.3. Thin-Ideal Internalisation

The Thin/Low Body Fat subscale of the Sociocultural Attitudes Towards Appearance-4 Scale (SATAQ-4) was used to assess thin-ideal internalisation [ 68 ]. This measure assesses the degree to which individuals endorse or strive towards the thin body ideal. On a 5-point Likert scale (1 = definitely disagree to 5 = definitely agree ), participants rated how much they agreed with five items (e.g., “I want my body to look very lean (e.g., like celebrities and models)”). Mean scores were calculated with higher scores indicating greater thin-ideal internalisation. In this study, the internal consistency was high for boys (α = 0.89) and girls (α = 0.92).

2.2.4. Muscular-Ideal Internalisation

The Internalisation-Muscular subscale of the SATAQ-4 assessed muscular-ideal internalisation [ 69 ]. This subscale measures the extent to which individuals internalise or strive towards the muscular body ideal. On a 5-point Likert scale (1 = definitely disagree to 5 = definitely agree ), participants rated how strongly they agreed with four statements (e.g., “I think a lot about looking muscular (e.g., like sports stars and fitspiration posts)”). The mean score was calculated whereby higher scores indicate greater internalisation of the muscular body ideal. For this sample, the internal consistency was high for boys (α = 0.93) and girls (α = 0.93).

2.2.5. Body Dissatisfaction

The appearance subscale of the Body Esteem Scale for Adolescents and Adults (BESAA) was used as an index of body dissatisfaction [ 70 ]. Although it traditionally assesses an individual’s global appraisal of their outward appearance, it has been empirically linked to body dissatisfaction [ 71 ] and has been used as a broad indicator of body dissatisfaction elsewhere [ 72 , 73 ]. Participants were asked to indicate how true ten statements were for them on a 5-point scale (1 = never to 5 = always ). Example items include, “I wish I looked like someone else” and “I feel ashamed of how I look”. Positively-worded items (e.g., “I like what I look like in pictures”) were reverse scored. The mean score was calculated with higher scores indicating greater body dissatisfaction. For the current study, the internal consistency was high for boys (α = 0.88) and girls (α = 0.92).

2.3. Procedures

The study was approved by the university’s Human Ethics Committee (approval number: HED18424). Written informed consent procedures were implemented in which parents had the option to opt their child out of participation. Prior to the commencement of the survey, the research team gave verbal instructions and written informed active assent was obtained from all participants. Participants completed the online survey independently in classroom settings, supervised by researchers. The survey took approximately 30 min to complete and contained approximately 150 items. At the end of the questionnaire, students were invited to provide height and weight measurements. If students wished to provide their measurements, they could either provide an estimate, or use height and weight equipment which had been set up and facilitated in a private area by a member of the research team.

2.4. Data Analysis

SPSS 26 (IBM Corp: Armonk, NY, USA) and Mplus 8.0 (Muthen & Muthen: Los Angeles, CA, USA) were used for data analyses. Consistent with research in adolescents of a similar nature [ 67 ], missing data across each outcome variable was moderate (8–12%). Little’s missing completely at random (MCAR) test [ 74 ] indicated that the data were missing completely at random ( p > 0.05). Data were not normally distributed so non-parametric alternatives were used for preliminary analysis. Mann-Whitney U Tests were conducted to examine gender differences on study variables and Spearman correlations were performed to determine zero-order relationships between variables. Effect sizes were evaluated according to recommendations by Khalilzadeh and Tasci [ 75 ]. Preliminary frequency and descriptive analyses were also performed.

Moderated multiple regression analyses were run to test whether thin- and muscular-ideal internalisation moderated the relationship between social media use and body dissatisfaction. A Maximum Likelihood Robust estimator was used which adjusts the standard errors and chi-square statistic for non-normality [ 76 ]. Continuous two-way and three-way interaction terms were calculated using mean-centred variables and were included as predictors of body dissatisfaction. To interpret the moderating effects, simple slopes were then plotted for significant interactions for the relationship between the independent variable (social media use) and the dependent variable (body dissatisfaction) when the levels of the moderator variable (thin-ideal and/or muscular-ideal internalisation) was one standard deviation above and below the mean. Finally, the significance of the slopes was tested [ 77 ] which denotes the simple effect of social media use on body dissatisfaction at two levels (high and low) of thin- and muscular-ideal internalisation. All analyses were performed separately for girls and boys.

3.1. Descriptive Statistics

Descriptive statistics for all measures are reported in Table 1 . Both girls and boys reported moderate levels of social media use, thin- and muscular-ideal internalisation, and body dissatisfaction. However, girls reported significantly higher social media use, thin-ideal internalization, and body dissatisfaction, and lower muscular-ideal internalization than boys. The majority of participants used Instagram (90.89%) and Snapchat (90.72%). As shown in Figure 1 , both girls and boys predominantly used Instagram and Snapchat “often”. A low proportion of participants “never” or “rarely” used Instagram. Similarly, a low proportion of participants “rarely” used Snapchat.

Frequency of social media site use among adolescent girls and boys.

Means (M), Standard Deviations (SD) and Gender Differences in Social Media and Body Image Variables.

Note . Girls n = 488, boys n = 665.

3.2. Correlations

As shown in Table 2 , Spearman correlations indicated that social media use, thin-ideal internalisation, and muscular-ideal internalisation were positively and significantly correlated with body dissatisfaction. There were also positive correlations between social media use and thin- and muscular-ideal internalisation, except for the relationship between social media use and muscular-ideal internalisation in girls. In both girls and boys, correlations between all variables were small, apart from the large correlation between thin-ideal internalisation and body dissatisfaction in girls.

Spearman Correlations between Social Media Use, Thin-Ideal Internalisation, Muscular-Ideal Internalisation and Body Dissatisfaction, in Boys and Girls.

Note . Correlations above the diagonal line are for girls (n = 488). Correlations below the diagonal line are for boys (n = 665). * p < 0.05 (two-tailed), ** p < 0.01 (two-tailed).

3.3. Moderation Analyses

Moderated multiple regression analyses examined cross-sectional predictors of body dissatisfaction and tested whether thin- and muscular-ideal internalisation moderated the relationship between social media use and body dissatisfaction. For girls, there was a positive main effect of thin-ideal internalisation on body dissatisfaction (β = 0.600, p < 0.001) but there was no main effect of muscular-ideal internalisation on body dissatisfaction (β = 0.020, p = 0.642). There was also no main effect of social media use on body dissatisfaction (β = 0.054, p = 0.267). None of the interaction terms were significant (social media use x muscular-ideal internalisation: β = 0.001, p = 0.984; social media use x thin-ideal internalisation: β = −0.044, p = 0.385; muscular-ideal internalisation x thin-ideal internalisation: β = −0.017, p = 0.694; and social media use x thin-ideal internalisation x muscular-ideal internalisation: β = 0.015, p = 0.761).

For boys, thin-ideal internalisation had a positive main effect on body dissatisfaction (β = 0.240, p < 0.001) but there was no main effect of muscular-ideal internalisation on body dissatisfaction (β = −0.021, p = 0.707). There was also no main effect of social media use on body dissatisfaction (β = 0.037, p = 0.384). The interaction between social media use and muscular-ideal internalisation was positively associated with body dissatisfaction (β = 0.124, p = 0.006), however the interaction between social media use and thin-ideal internalisation was not significant (β = −0.020, p = 0.654), nor was the interaction between muscular- and thin-ideal internalisation (β = 0.018, p = 0.734). The three-way social media use x thin-ideal internalisation x muscular-ideal internalisation interaction was not significant and demonstrated a small effect among boys (β = 0.100, p = 0.055).

Simple slopes tests were conducted in boys to follow-up the significant interaction effect which revealed that muscular-ideal internalisation moderated the effect of social media use on body dissatisfaction for boys, such that a relationship between social media use and body dissatisfaction was evident only at high levels of muscular-ideal internalisation, but not low levels (see Figure 2 ). Specifically, for boys with high muscular-ideal internalisation, higher social media use was associated with greater body dissatisfaction (β = 0.116, p = 0.005). For boys with low muscular-ideal internalisation, there was no relationship between social media use and body dissatisfaction (β = −0.063, p = 0.202). These results provide partial support for our hypotheses.

The two-way interaction effect of muscular-ideal internalisation and social media use on body dissatisfaction in boys.

4. Discussion

The aim of the present study was to broaden current understandings of relationships between social media use, thin- and muscular-ideal internalisation, and body dissatisfaction. The first hypothesis, that appearance-related social media use would be positively and significantly associated with body dissatisfaction in girls and boys, was supported. This is consistent with previous findings in Western samples [ 36 , 67 ] and consolidates the small body of literature that has examined this relationship in boys [ 38 ]. Additionally, thin- and muscular-ideal internalisation were positively and significantly correlated with body dissatisfaction in girls and boys which is consistent with prior research [ 78 , 79 , 80 ]. As adolescents are now faced with the unhealthy standard of the ‘strong’ and ‘skinny’ paradox on social media [ 81 ], it is unsurprising that those who endorse such ideals also experience body dissatisfaction. Furthermore, these results underscore the importance of athletic-ideal internalisation, a novel construct that entails both muscularity and thinness [ 68 ], in the prediction of body concerns (regarding weight/shape and muscularity) in both males and females [ 55 ].

In the multiple regression models in girls, thin-ideal internalisation emerged as the only variable that was significantly associated with body dissatisfaction. This adds to the mounting evidence that thin–ideal internalisation is problematic for girls’ body image [ 50 , 57 , 82 , 83 ]. Unexpectedly, neither thin- or muscular-ideal internalisation moderated the relationship between social media use and body dissatisfaction among girls. This latter finding conflicts with literature that has highlighted a moderation effect through thin-ideal internalisation in women [ 48 , 64 ]. Given that these studies were conducted in relation to effects from traditional media and in older samples, moderation may perhaps be stronger under those circumstances rather than when tested in younger individuals in the social media environment. Nevertheless, the absence of muscular-ideal internalisation as a cross-sectional predictor of body dissatisfaction and moderation via muscular/athletic-ideal internalisation supports some work in women [ 60 , 84 , 85 ], so it is possible that internalising the muscular/athletic physique does not have as strong an effect on body dissatisfaction as thin-ideal internalisation. Further investigation is needed to clarify these mixed findings.

In the multiple regression models in boys, thin-ideal internalisation emerged as the only variable that had a positive main effect on body dissatisfaction. This is in line with previous findings where thin-ideal internalisation has been shown to be related to body dissatisfaction in boys, as well as girls [ 86 ]. It should be emphasised that the measure of thin-ideal internalisation used in this study reflects endorsement of both thinness and leanness that is espoused in males currently and may be more relevant than previous measures of thin-ideal internalization that did not reflect the leanness component [ 54 , 87 ]. Notably, muscular-ideal internalisation but not thin-ideal internalisation moderated the relationship between social media use and body dissatisfaction in boys which partially supports our hypotheses. This extends previous research with traditional forms of media which found that those who highly endorsed the muscular ideal were more negatively affected by mass media portrayals compared to those who did not highly endorse the muscular ideal [ 58 , 59 ]. The relevance of muscular-ideal internalisation reflects modern appearance trends on social media (e.g., fitspiration posts) that emphasise hyper-muscular ideals in males [ 88 ]. As such, it may be more important for boys in the current social media environment to look muscular rather than thin, which may explain the lack of moderation through thin-ideal internalisation. Based on the findings, it appears that the interaction between social media use and internalisation is highly relevant for body dissatisfaction. For example, one study found that the internalisation-body satisfaction relationship was conditional upon the use of photo-editing apps in young adult women [ 89 ]. Further investigation is required to provide a deeper understanding of these associations in adolescents particularly in relation to temporal sequencing.

Additionally, the two-way interaction (muscular x thin-ideal internalisation) was non-significant in effect on body dissatisfaction for both girls and boys. This is similar to past research in women and suggests that incorporating thinness into that of the muscular ideal (e.g., fit-ideal internalisation) does not alter body dissatisfaction levels [ 90 ]. As previously posited [ 90 ], moderation may not have occurred because thin- and muscular-ideal internalisation are only related to body image outcomes when analysed independently rather than concurrently. More research is warranted to support these claims. Likewise, the three-way interaction (social media use x thin- x muscular-ideal internalisation) was non-significant in both girls and boys. That is, body dissatisfaction scores did not vary across the levels of these factors in their interaction, they were equivalent regardless of the interaction between frequency of social media use and tendencies of thin- and muscular-ideal internalisation. Despite approaching significance in boys at the p < 0.05 level, the effect was small relative to the other effects in boys (e.g., comparison to beta coefficients for thin-ideal internalisation and the social media use x muscular-ideal internalisation interaction). These preliminary findings offer important avenues for future research to help elucidate the conditions and personal characteristics that elevate risk and could thus be targeted in interventions to prevent the detrimental impact of social media engagement on body dissatisfaction.

Despite the contributions of this study to our knowledge of the role of social media use and internalisations in explaining body dissatisfaction, there are several limitations. First, although our narrow focus on the use of appearance-related platforms (Instagram and Snapchat) was informed by previous findings [ 37 ], it fails to address relevant photo-based behaviours such as commenting, liking, and posting pictures that have been previously associated with body dissatisfaction [ 91 , 92 , 93 ]. Future research in this direction could be valuable. Second, causality cannot be established due to the cross-sectional nature of the study and thus, experimental and longitudinal studies are warranted to identify whether combinations of social media use and internalisation of appearance ideals constitute risk for body dissatisfaction. Although this study contributes to the growing field of body image research, inclusion of other potential risk factors in sociocultural models of body image concerns such as social comparisons may also serve as an important direction for future research [ 94 , 95 ]. Finally, considering the wide age range of adolescents in our study (11–17 years), future research could incorporate age as a potential moderator.

Given the relevance of muscular-ideal internalisation as a moderator, particularly in the case for boys, there is a need for prevention programs targeted towards adolescents who may be more sensitive to the negative effect of muscularity focused appearance-related media on body dissatisfaction. Similarly, boys engaged in muscularity-focused activities, such as sports, may benefit from such intervention. In particular, dissonance-based approaches have demonstrated effectiveness in minimising appearance-ideal internalisation and body dissatisfaction levels [ 96 , 97 ]. Furthermore, media-literacy programs offering education on forming critical arguments against unrealistic body ideal images in the media have demonstrated some benefits [ 49 ].

5. Conclusions

Findings from this study build upon existing research on the positive relationships between social media use and body dissatisfaction, and between thin- and muscular-ideal internalisation and body dissatisfaction in adolescent boys and girls. This underscores the importance of mixed gender studies and extends the literature to adolescents. These findings also support consideration of the sociocultural environment as a framework for understanding body dissatisfaction in the new media environment and emphasise the importance of thin-ideal internalisation as a significant cross-sectional predictor of body dissatisfaction in both genders. Additionally, muscular-ideal internalisation moderated the relationship between social media use and body dissatisfaction in boys highlighting the centrality of muscularity to boys’ body dissatisfaction. Results suggest the need to focus on relevant concerns for boys and girls and support the use of intervention and prevention efforts that aim to lessen appearance-ideal internalisation, thereby reducing the detrimental effects of appearance-related media exposure on body dissatisfaction.

Author Contributions

Authors A.T.V., S.A.M. and H.K.J. contributed to the study conception and design. Formal analysis and investigation were performed by A.T.V. and H.K.J. with contribution from S.A.M. and J.R.D. The original draft was written by A.T.V. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

The study was approved by the institutional ethics committee (Approval number: HED18424).

Informed Consent Statement

Written, informed, opt-out parental consent and active participant assent was obtained.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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