1. Martin T Donohoe, MD, FACP
Ideals of Beauty
and Body Modification
Martin T Donohoe, MD, FACP

2. Historical Ideals of Beauty
Ancient Greeks valued symmetry
Contemporary definitions similar:
“Ideal woman”: small chin, delicate jaws, full lips, small nose, high cheek bones, large and widely spaced eyes, and waist:hip ratio of 0.7
“Ideal man”: taller, waist:hip ratio of 0.9, dominant/rectangular face/chin, deep-set eyes, heavy brow
Suggests strong supply of testosterone

3. “Ugly”
Common first name in Ancient Greece, parts of sub-Saharan Africa
Also derives from Old Norse word meaning “to be feared of dreaded.”
Idea: give children bad names so demons won’t find them
Other favorites: “Disagreeable,” “Crippled”

4. Historical Ideals of Beauty
Scarification – dates back at least 4,000 years
Chinese foot binding
pain, osteoporosis, falls/imbalance
Surgery to reshape women’s feet for stiletto heels increasingly popular
Ancient Greek newborn female baby wrapping

5. Historical Ideals of Beauty
Ancient Roman women colored their lips with red cinnabar stone, a type of mercury ore, lined their faces with white lead, and rouged their cheeks with red lead
Ancient Egyptians/Roman/Persians: antimony for conjunctival sparkle
Rome to medieval Europe: paleness preferred

6. Historical Ideals of Beauty
Renaissance women used leeches on their ears to drain blood from their faces for a fashionably pale complexion
Elizabethan hair plucking, ceruse makeup
Elizabethans used lard to set wigs, which could result in rat infestations

7. Historical Ideals of Beauty
Court of Louis XVI: blue veins drawn on neck and shoulders to emphasize noble blood
16th & 17th century: belladona eye drops

8. Historical Ideals of Beauty
18th Century: vermillion makeup (sulfur and mercury)
14th - 19th century: corsetting (whalebone and steel) – precursor to the girdle/Spanx
Making a comeback at both high- and low-end retailers (takes up to 30 minutes to lace up; requires an extra set of hands)

9. Historical Ideals of Beauty
Unibrow:
Sign of criminal tendencies in Victorian England; mark of beauty in contemporary Iran
19th Century: Vacuum pumps and vibration therapy for baldness/”flabby skin”; mercury-based freckle remover

10. Historical Ideals of Beauty
Efik people of the Nigerian coast, others: fattening rituals
Breast implants (since Charles Miller, MD)
First silicone breast enlargement 1962

11. Contemporary Ideals of Beauty
“Better Baby Contests” – Eugenic Movement / Social Darwinism
Today – “Baby Bangs,” toddler beauty contests, Barbie dolls (new models out)
Tapeworms (Maria Callas)
Rib removal (Cher?)
Prostitutes using diuretics (for weight loss), child sex workers forced to take dexamethasone (to look older, “curvier”)

13. Contemporary Ideals of Beauty
U.S.:
Women began shaving legs and armpits in 1920s
2014: nearly half of college students shave all their pubic hair; only 4% go “au naturel”

14. Contemporary Ideals of Beauty
Botox injections
Plastic surgery
Abusive subjugation of women through body modification – female genital mutilation
Cultural components

15. Ideals of Beauty Brass neck rings (Paduang people of Burma)
Lip and earlobe expanders (certain African tribes)
Tattoos, body piercings, wings
Ilizarov procedure (involves breaking, stretching leg bones) to make women taller

16. Ideals of Beauty
Wonderbra, Brava Bra ($2500, suction device worn overnight for 10 weeks, promises 1 cup increase (actual increase ½ cup size), can cause broken blood vessels, skin rash, discomfort)
Wonderbum pantyhose (DuPont Lycra) – promises a “perfectly peachy, pert bottom”
Music industry depictions of beauty

17. Ideals of Beauty Ancient Greeks – symmetry
Remains true
Familiarity, personality traits also important
Evolutionary adaptation for survival of human species
Size, muscle power, pathogen-free status, fertility

18. Fashion Industry
Big business: $1.2 trillion annual revenue globally ($250 million in U.S.)
Employs large numbers of individuals (including children) in unsafe workplaces in developing world, pay low
Large environmental footprint: 15.1 million tons of textile waste (2013), 12.8 million tons discarded
Increasing with trend toward “fast fashion” (frequent turnover of “hot” styles)

19. The Perks of Beauty
The good-looking are more likely to have higher self-esteem, date more, get higher grades, graduate from college, get married, be hired, get paid more (including tips), and be promoted sooner
Lifetime earnings difference between the typical “good-looking” and “below average-looking” worker = $230,000

20. The Perks of Beauty
Height is associated with income and leadership positions
Ironically, 50 years ago some women were treated with estrogen to prevent them from growing too tall and becoming un-marriable
This impaired their fertility, among other consequences
Strangers are more likely to assist good-looking people in distress

21. The Perks of Beauty
The pretty/handsome are less likely to be reported, caught, accused, or punished for a minor or major crime
Role of ageism (more important for women)
The responsibility:
Attractiveness is recognized as a special gift, and its misuse is not tolerated

22. The Adonis Complex
38% of men want bigger pectorals; 34% of women want bigger breasts
Each year, men spend over $2 billion on health club memberships and $2 billion for home exercise equipment
Tommy John surgery
To enhance elbow strength and improve pitching velocity

23. Anabolic Steroid Abuse
Supplement industry booming
3 million American men have swallowed or injected anabolic steroids since they became widely available in the 1960s
Some female athletes use anti-estrogens

24. Anabolic Steroid Abuse
% of current middle and high school students have used anabolic steroids (100% increase over last 6 years); rates higher among boys
Use associated with increased risk for thrombosis (heart attack and stroke) and violent behavior
35% use protein powders/shakes to build muscle

25. Adonis Complex of the Middle Aged and Elderly
“Low T (testosterone) Syndrome”
Hypogonadism is a real disorder, but “Low T Syndrome” manufactured by drug companies to treat those with stunted libidos and depressed mood
“Treatment” carries increased risk of cardiovascular disease, BPH, prostate cancer

26. Cosmetics Concocted at home prior to 20th Century Industry spawned by:
“Allure” of prostitutes/sexuality
Mass popularity of anti-aging products in 1920s
Women entering workforce
Migrations to cities
Food, Drug and Cosmetic Act (1938)

27. Cosmetics
Worldwide cosmetics market $462 billion in 2014 ($62 billion in U.S )
33% more than the amount needed each year (in addition to current expenditures) to provide water and sanitation for all people in developing nations
Slightly more than the amount needed each year (in addition to current expenditures) to provide reproductive healthcare for all women in developing countries

28. Cosmetics
Average American adult uses 9 personal care products/day (with 126 unique chemical ingredients)
89% of the over 10,500 ingredients used in personal care products never tested for toxicity
Little FDA oversight

29. Cosmetics
Most contain carcinogens and/or endocrine disruptors (see
Unusual/dangerous ingredients include:
Mercury – skin creams
Lead – lipstick and kohl (decorative black eyeliner, alleged to help children’s eyes develop and protect them against curses)
Arsenic, Cadmium, Copper, aluminum
Triphenyl phosphate (endocrine disruptor) – nail polishes (mani/pedicurists higher exposures)
Bacteria – mascara

30. Cosmetics Unusual/dangerous ingredients include:
Mica (lung-damaging particles)
Cow colostrum
Gold
Foreskin
Placenta/Fetal cells
Paint stripper and varnish - eyeliner

31. Cosmetics and Hair Coloring
Women devote average of 19 minutes per day to treating and altering their faces
55% of American women between 13 and 70 color their hair
1/8 American men between 16 and 60

32. Hair Care Products
African-American “hair relaxers” contain endocrine disruptors (also found in some soaps and shampoos)
Use increases risk of uterine fibroids, cancers
Brazilian Blowout hair straightening products contain formaldehyde (possible carcinogen)

33. Scented Products
Many cosmetics, perfumes, colognes, air freshener sprays, candles, oils, and gels contain fragrances
Fragrance industry sales $40 billion/yr (projected, 2016)
Some fragrances toxic
Many contain allergens
30% of Americans report skin irritation or headaches with at least some scented products

34. Feminine Care Products
Fragranced products contain phthalates
Tampons contain dioxins (byproducts of bleaching process)

35. Cosmetics
FDA does not require premarket testing of cosmetics or scented products
Personal Care Safety Act stuck in Congress
2013: EU bans sale of all cosmetics tested on animals

36. Tanning The skin’s response to ultraviolet light injury
No such thing as a “safe tan”
95% of Americans understand that sunburns are dangerous, but 81% still think they look better with a tan.

37. Tanning UVA and UVB dangerous
Ozone damage allows greater UV radiation exposure
Estimated lifetime risk of melanoma 1/54
Clouds filter out only 20% of sun’s UV rays
Snow reflects up to 80% of UV rays (sand 17%)
White T-shirt has SPF 7 (min 15 recommended); darker shirts have higher SPFs

38. Tanning High sun exposure during childhood increases risk of melanoma
High sun exposures during adulthood increases risk for nonmelanoma skin cancers (squamous and basal cell)

39. Artificial Tanning
36% of adults, 25% of teens, and 55% of college students use a tanning lamp each year (females more than males)
More than 90% of users are aware that premature aging and skin cancer are possible complications of tanning lamp use (melanoma and basal cell)

40. Artificial Tanning WHO: tanning beds cause cancer
450,000 cases of basal and squamous cell skin cancer and 11,000 cases of melanoma each year attributable to indoor tanning in the U.S., Australia, and Europe
Melanoma rate up 200%

41. Skin Cancers – Other Estimates
Skin cancers of all types rising dramatically: 1/5 Americans will get during their lifetimes
Increased lifetime melanoma risk
1/1500 – 1930; 1/68 – today
Due mostly to ozone destruction, which is reversing due to Montreal Protocol (phaseout of CFCs)
Other studies show decreasing risks in younger patients due to phase-out of early 20th Century practice of heliotherapy (high dose UV light exposure thought to prevent rickets and provide other health benefits)

42. Tanning Facilities
Over 50,000 in US (more than the number of Starbucks or McDonalds)
Found at 50% of colleges
Generate revenues of over $5 billion/yr

43. Tanning Facilities
Most countries do not limit access of youths to tanning parlors (Australia and Brazil have banned them altogether)
Most US states limit access of youths (bans; parental consent)
Indoor 10% tanning tax implemented in 2010 as part of PPACA (Obama Health Care Plan)

44. Tanning Facilities
FDA regulates as moderate risk devices, requires black box warning for minors (but does not outlaw or restrict use by minors)
2016: FDA proposes restriction of sunlamp products to people ages 18 and over; requirement for adults to sign risk acknowledgement every 6 months; require sunlamp manufacturers to provide better eye protection, have easy-to-read warnings and install emergency shut-off switches

45. Tanning Tanning as a substance abuse-like disorder
Associated with other addictions
Excessive indoor tanning associated with depression, suicide attempts
Tanning produces endorphins
some contain fragrances – can cause allergic reactions
Sprays may damage lungs
Many UV filtering chemicals endocrine disruptors, affect sperm cells

46. Tanning
Mineral sunscreens best (Zn or Titanium); lotions and creams do not necessarily protect against UVA)
Use SPF of at least 15 and re-apply frequently
Avoid benzophenone (aka oxybenzone, estrogenic); avobenzone is safer
2016: Consumer Reports’ study shows 40% of sunscreens don’t live up to their promised SPF levels

47. Artificial Tanning Many lotions, creams, and sprays available
Most contain dihydroxyacetone (DHA) – can damage DNA and lungs and cause allergic reactions
International Smart Tan Network– PR campaign opposing the “sun scare industry”
“Natural” does not necessarily mean safe
See EWG database

48. Artificial Tanning
Increased (but not excessive) carotenoid-containing fruit and vegetable consumption can improve skin color
Tanning pills (not approved for use) containing canthaxanthin dangerous
Skin lightening creams may contain mercury, hydrocortisone, vitamin A, and hydroquinine (used to develop photographs)

49. Tattooing
Roman Empire used to brand convicts, slaves, and army deserters
Tattoo from Tahitian word “tatau” (“to mark”)
Reached apogee among Maori
Popularized in West by sailors returning from Polynesia

50. Tattooing Aesthetic choice Initiation rite
Time-saving way for disabled to overcome difficulties of applying makeup
Adjuvant to reconstructive surgery (particularly face and breast, to simulate natural pigmentation)

51. Tattooing 120 million people worldwide have tattoos
24-29% of American adults have at least one permanent tattoo (12% of Europeans)
Ancient practice: Otzi the iceman (3300 BCE), Egyptian mummies, Maori tribesmen, Thracian women of 5th Century Greece, Moors)
Tattooing still illegal in South Carolina and Oklahoma
Sometimes used in lieu of Medic-Alert bracelet

52. Tattooing More than 50 different pigments and inks employed
Many contain heavy metals,formaldehyde, phthalates, other endocrine disruptors and carcinogens
Some contain industrial grade printer’s ink or automobile paint
Red dyes most allergenic

53. Tattooing
FDA considers inks to be cosmetics (premarketing safety evaluation required)
FDA considers pigments to be “color additives” (no premarketing safety evaluation required)

54. Risks of Tattooing
Tattooing associated with risky behaviors in adolescents
Infection (5%)
e.g., Staph, Strep, Mycobacteria, hepatitis B, C, syphilis, leprosy, and HIV (HIV risk theoretical – no cases identified to date)
Am Assn Blood Banks requires one-year wait between getting tattoo and donating blood
Allergic reactions (6%)

55. Risks of Tattooing Granulomas Keloid formation MRI complications
Swellings/burns
Flareups of psoriasis

56. Risks of Tattooing Difficulty detecting later skin cancers
Pigments and toxic particles migrate to lymph nodes, may cause later cancer
Image quality suffers (particularly with permanent mascara)
Removal problems

57. The Most Common Problem: Dissatisfaction
11% of those getting tattoo experience adverse reactions (infections, allergies, etc.)
> 1/3 of those tattooed later regret it
Chief reason = the person’s name in the tattoo
Practitioners’ skill levels vary widely
Fading with time
Blurring when injections too deep

58. The Most Common Problem: Dissatisfaction
Human body changes with time
Styles come and go
With facial cosmetic surgery, appearance of tattoos and permanent makeup may become distorted

59. Tattoo Removal Techniques (average cost $600+)
Laser treatments (photothermolysis)
Requires multiple treatments; can disperse toxic chemicals throughout body
Dermabrasion
Salabrasion
Scarification
Surgical Removal
Camouflaging
No method perfect; immunosuppression interferes with healing process post-removal

60. Temporary Tattoos Fade after several days Allergic reactions
FDA alert re risks with foreign-made products
Freedom-2 Ink, Infinitink: Biodegradable dye capsules – when zapped by laser, dyes absorbed by body and tattoo disappears

61. Risks of Henna Tattoos Henna products risky
Henna approved for use as a hair dye, not for injection into the skin
Produces a reddish-brown tint, raising questions about what ingredients are added to produce the varieties of colors labeled as henna (e.g., “black henna,” “blue henna”
Color can last for more than a week

62. Body Piercing 36% of Americans Women > Men Complications: 20-40%
Skin irritation and infections most common

63. Body Piercing Complications
Other complications include auricular chondritis, nasal cartilage destruction, abscesses, contact dermatitis, bleeding, bladder infections, dental trauma, and other secondary trauma
Death rare
Avoid shopping mall kiosks
Unclear if prophylactic antibiotics helpful

64. The Fringes Snail slime facials to make skin soft (South America)
Nightingale dung facials to bleach and brighten skin (Japan, “The Geisha Facial”)
“Vampire Facelift”: patient’s own blood injected into face to smooth out wrinkles
Face slapping by massueses

65. The Fringes
Merkins (pubic hair wigs – used throughout history – allow male actors to play females; hide STDs; decorative; etc.)
Pubic hair implants (abundant pubic hair associated with fertility in South Korea)

66. The Fringes Anal bleaching Red labial dye (“My New Pink Button”)
Initially porn stars and sex workers
Now available to general public for $75/treatment
Can cause eczema
Red labial dye (“My New Pink Button”)

67. The Fringes
Money: Jim Nelson auctioned off his head on eBay for a corporate logo tattoo in 2003
Others sell tattoo space on their bodies

68. Botox Botulinum toxin:
Cause of botulism
potential biowarfare/bioterror agent
Medical Uses: blepharospasm, spasmodic torticollis, migraines, back spasms, chronic pain, axillary hyperhidrosis, BPH, autonomic disorders, wrinkles due to normal aging
Unlikely to work on sun- or smoking-induced wrinkles

69. Botox
Manufacturer = Allergan (Acquired by Actavis in 2014, merged with Pfizer in 2015)
Allergan also markets Latisse (bimatoprost, the same ingredient in the glaucoma treatment Lumigan) for topical “treatment” of “hypertrichosis of the eyelashes” (eyelash transplant alternative)
Myobloc, Dysport, and Xeomin (other botulinum neurotoxins)
-Limited standardization

70. Botox 6.8 million procedures in 2015
Large direct-to-consumer ad campaign
Olympians Mark Spitz, Nadia Comanici involved
$382 (physician’s fee; drug costs $300-$1,000/session)

71. Botox Most users white, age 35-50 12% are men
In-home Botox parties; Botox scams; counterfeit Botox (ineffective and/or dangerous)
Hollywood actors

72. Botox Retreatments required q 3-4 months
Side effects: muscle weakness, masklike facies, drooling, slurred speech, aspiration, dysphagia, dysnpnea, rare allergic reactions; may spread via neurons back to spinal cord or even CNS
87 hospitalizations, 16 deaths reported (unable to find numbers beyond this)
FDA boxed warning 2009

73. Rivals to Botox
Collagen injections (from cows, possible allergic responses)
Perlane (“natural” collagen alternative from human tissue)
Fat injections
Cold thermal injury
Face lift/eyelid surgery

74. Dermal Fillers Alternative to botox
Cow collagen, liquid silicone, plastic microbeads, synthetic bone and ground-up human cadaver skin (association with for-profit tissue banks)
Deoxycholic acid (Kybella) – destroys fat cell membranes (can also destroy skin cells, if injected into them)

75. Dermal Fillers $650-$1,800 per treatment (lasts a few months) Risks
Compare with $4000-$6000 for a facelift, which lasts yrs before requiring touch-ups
Risks
Include renal failure, retinal artery occlusion

76. Conclusions Ideals of beauty: some relatively constant, others change
Multiple methods of body modification: some dangerous, even abusive

77. Covered in Other Slide Shows
Cosmetic surgery
Female genital cutting
Body weight and the obesity epidemic
Ethical and policy issues

78. References
Donohoe MT. Beauty and body modification. Medscape Ob/Gyn and Women’s Health 2006;11(1): posted 4/19/06. Available at
Donohoe MT. Cosmetic surgery past, present, and future: scope, ethics and policy. Medscape Ob/Gyn and Women’s Health 2006;11(2): posted 8/28/06. Available at

79. Re Tanning
See slide show by Anuru and Salmon on risks and regulations related to indoor tanning at

80. Public Health and Social Justice Website
Contact Information
Public Health and Social Justice Website