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Self-esteem is a person's beliefs about themselves that can create high anxiety in individuals, these beliefs can be about personal and physical factors. Nose beauty surgery in Iran ranks first in the world and 30% of people who undergo beauty surgery are not satisfied with the operation and complain afterwards. Therefore, the aim of this research was to investigate the relationship between self-esteem and anxiety in women seeking beauty surgery in 1400. The present research method was descriptive correlational and the statistical population of this research included all female students seeking beauty surgery at Islamic Azad University, Karaj branch in 1400, and the sample included 200 applicants for beauty surgery who were randomly selected. The data collection tool in this research was the self-esteem and anxiety questionnaires. The research hypotheses were evaluated using Pearson correlation test and regression analysis. The research results showed a positive and significant correlation between anxiety and self-esteem in female students seeking beauty surgery (0.442). It is worth mentioning that in this research, a higher score in self-esteem dimension means a more negative attitude towards oneself in the individual. Women seeking beauty surgery have high negative self-esteem scores and therefore higher anxiety scores. Therefore, by examining the results of this research and identifying motivating factors for women to undergo beauty surgeries, it can be used to improve and develop women's health and prevent unnecessary surgeries.
Keywords: Self-esteem, Anxiety, Beauty surgery, Women's health, Nose surgeryNose beauty surgery in Iran ranks first globally, and 30% of individuals undergoing beauty surgery are dissatisfied with the results and complain afterwards. Despite the minimal risks and side effects, these surgeries have become a social status symbol for many women. Considering the necessary time for postoperative recovery ranging from at least one week to three months and its exorbitant costs, the annual demand for beauty surgery by over 10,000 Iranian women is thought-provoking [4]. Since beauty surgeries are performed to enhance visibility, all beauty surgery applicants will experience anxiety. Anxiety is an unpleasant feeling and excitement arising from an individual's perception of bodily tension and changes [5].
Anxiety is the feeling of fear and apprehension in response to internal and external stimuli, which can manifest in behavioral, emotional, cognitive, and physical symptoms. It is the most common psychological reaction to stress, experienced by all individuals and often perceived as a threat to identity and self-confidence before new experiences [6].
Self-esteem is each person's beliefs about themselves that can create high anxiety in situations of evaluation. For example, a student who has small self-esteem about their abilities and competencies will undoubtedly experience test anxiety when taking exams and will not be able to meet the performance standards they have set for themselves compared to others, perceiving the situation as unpleasant and lowering their self-esteem [7]. Having a desirable self-perception has a positive impact on mental health and self-esteem ([8,9,10]. Based on this, this research will focus on the relationship between self-esteem and anxiety in applicants for beauty surgery.
In today's societies, due to excessive emphasis on beauty and the images presented in fashion magazines, cinema, and the media, this attention has become excessively focused, especially among women. They defined beauty surgery as a type of surgery to change the appearance of the body, in the absence of illness, injury, and congenital deformity, which can be a factor in improving the quality of life. These surgeries are mostly done to eliminate body dysmorphic disorder, dissatisfaction with one's appearance, and sometimes to increase self-esteem [11].
The presence of anxiety is a very unpleasant feeling and often accompanied by autonomic nervous system symptoms, such as shortness of breath, palpitations, sweating, headaches, stomach discomfort, and restlessness, which is manifested by the inability to sit or stand. Also, the presence of negative self-esteem and particularly negative perfectionism can cause significant psychological pressure on an individual, which can manifest as anxiety, and using specific strategies is a suitable way to alleviate anxiety [12].
Self-esteem, as a theoretical term, has multiple synonyms and definitions. In research literature, it is sometimes defined as "self-concept," "self-perception," "self-image," "self-awareness," and "self-esteem" [13] assessment of a person's personality is called self-esteem or self-perception. This evaluation arises from mental assessments that we usually make about our behavioral traits. As a result, self-esteem can be positive or negative. In short, self-perception is a cognitive framework through which we organize what we know about ourselves and process information related to ourselves based on it. Self-esteem is an individual's perception of themselves and their physical and personal characteristics that form based on feedback from others since childhood. Many individuals who repeatedly undergo beauty surgeries in adulthood have issues with their body image [14]. One of the concepts in the field of psychology of growth and personality is self-esteem, which, in a general sense, is an individual's perception of themselves and their physical and personal characteristics. As a child grows naturally, they gradually form an image of their physical characteristics based on feedback received from others, which is called body image [15]. Negative self-esteem reflects feelings of worthlessness and lack of self-respect and abilities. In the process of personality development, the active self (as the doer of actions) plays a role in the child's mind, which is called self-image from a psychological perspective, and self-image is the main basis for determining whether a person sees themselves as good or bad. Self-image is influenced by parenting styles and interactions with children to the extent that the more positive interactions parents have with an individual, the more positive their self-image becomes, preventing them from engaging in negative actions in the future. Such cases necessitate a deeper psychological look at applicants for beauty surgery, so that the effective psychological phenomena related to this social behavior can be identified and examined, increasing the need for such research. Hosseini [16] showed in their study that applicants for beauty surgery have lower self-esteem [17]. The fundamental question raised here is whether there is a relationship between self-esteem and anxiety in applicants for beauty surgery?
MATERIALS AND METHODS
This research is considered a fundamental study in terms of its objective and a descriptive correlational model in terms of data collection methods. The study population included all students who were seeking cosmetic surgery without medical reasons and had visited cosmetic surgery centers in Karaj during the year 2021. The sample size, based on Plant's formulas (N>50+8m), was 200 students who were selected as convenience samples from students seeking cosmetic surgery. Questionnaires were distributed among them, and they were asked to answer the questions.
Following the test guidelines and considering the inclusion criteria, including: 1) age between 15 to 45 years old. 2) No history of psychiatric disorders. 3) No history of any physical disorders in the past or present. 4) Visiting Karaj cosmetic surgery centers in 2021 and the criterion of non-tampered questionnaires. After obtaining permission from the university, researchers identified 280 applicants for cosmetic surgery by visiting all classes in all faculties of the Islamic Azad University, Karaj campus during the academic year 2021-2020. They provided detailed explanations to individuals who were willing to participate in the study and examined the entry criteria for them. Then, 200 of them were randomly selected and asked to complete self-esteem and anxiety questionnaires.
Research tools consisted of:
- Beck Self-Concept Test
Beck [18] is a self-report measure of negative self-perception. It's a cognitive component of depression that Beck mentioned. The SCT differs from self-esteem and self-concept questionnaires as it asks the respondent to compare themselves with people they know, not with vague standards. Scores range from 1 to 5, with lower or higher scores depending on the individual's self-perception value, ranging from 25 to 125. The reliability of the Beck Self-Concept Test was examined through internal consistency and retesting methods, with a reliability of 0.80 in internal consistency and 0.88 in retesting, indicating its validity. Additionally, the validity of the test was confirmed with a correlation coefficient of 0.55, indicating its statistical validity.
- Beck Anxiety Questionnaire
Aaron Beck and colleagues introduced the Beck Anxiety Inventory (BAI), which specifically measures clinical anxiety symptoms in individuals. The Beck Anxiety Questionnaire is a self-report questionnaire designed to measure anxiety severity in adolescents and adults. This 21-item scale requires respondents to choose one of four options indicating their level of anxiety for each item. Each question's four options are scored on a four-point scale from zero to three. Each item describes one of the common anxiety symptoms (cognitive, physical, and fear). Therefore, the total score of this questionnaire ranges from zero to 63. Studies have shown that this questionnaire is highly reliable and valid. Its internal consistency (alpha coefficient) is 0.92, its test-retest reliability after one week is 0.75, and the correlation between its items ranges from 0.30 to 0.76. Five types of validity, content, concurrent, structural, diagnostic, and comprehensive, have been evaluated for this test, all indicating its high efficiency in measuring anxiety severity [18]. Some studies in Iran have been conducted on the psychometric properties of this test. For example, Gharaii reported its reliability coefficient through retesting after a two-week interval as 0.80. Additionally, Kavyani and Mousavi reported the validity characteristics of this test in the Iranian population with a validity coefficient of approximately 0.72, a test-retest reliability coefficient after a one-month interval of 0.83, and a Cronbach's alpha of 0.92 [19].
After completing the execution stages and scoring, data analysis was performed based on descriptive statistics, including measures of central tendency and dispersion. In inferential statistics, Pearson correlation coefficient and multiple variable regression analysis using a step-by-step method were utilized for inferential analysis.
Findings
In this section, the information and data obtained from the research are examined in two parts, including descriptive findings and analysis test questions. In the first part, data from questionnaires regarding central tendency and dispersion indexes related to the variables of interest were investigated in tabular form. In the second part, research hypotheses were tested based on descriptive findings using statistical tests such as Pearson correlation and multiple variable regression analysis in a step-by-step approach, leading to conclusions. Three questionnaires were used for data collection. After gathering data using SPSS computer software, the data were analyzed within the range of descriptive and inferential statistics. Specifically, Pearson correlation and regression tests using a step-by-step method were employed.
Descriptive Statistics
60% of evaluated individuals fall into the age group of 20 to 25 years, 34% in the age group of 26 to 30 years, and 6% in the age group over 30 years. Central tendency and dispersion indexes related to research variables were used to describe the obtained data in the following tables (Table 1).
Table 1 values for the research variables in cosmetic surgery applicants are presented. Examination of the table results shows that the average anxiety score of the evaluated individuals is 29.14 with a minimum score of 25 and a maximum score of 25, and the average self-esteem score of the evaluated individuals is 88.43 with a minimum score of 25 and a maximum score of 96.
Inferential Statistics
Based on the results of the extracted data from the questionnaires and the descriptive findings obtained from them to examine and test the research hypotheses, Pearson correlation and step-by-step regression analysis tests were used. Therefore, using the mentioned tests, analyses related to each hypothesis have been presented separately as follows.
Checking the normality of the data
Initially, Kolmogorov-Smirnov tests were conducted to examine the normality of the frequency distribution of each calculated item, and the results are presented in the table below. Then, each of the research questions was investigated.
Based on the results of the Kolmogorov-Smirnov test in Table 2 for the characteristics under study and considering a significance level greater than 0.05, it can be said that all evaluated characteristics have a normal distribution. Therefore, appropriate parametric tests can be used for data analysis.
Table 3 shows the results of the multiple regression test for predicting the tendency to undergo cosmetic surgery in students. This table indicates that the regression is significant at the 0.001 level (P<0.001).
Examination of the research hypothesis
There is a significant relationship between anxiety and self-esteem in individuals seeking cosmetic surgery.
The results of correlation Table 4 indicate a significant positive correlation between anxiety and self-esteem in students (r=0.442). It is worth mentioning that in this study, higher scores in the self-esteem dimension indicate a more negative self-perception in individuals.
DISCUSSION
The correlation results regarding the relationship between self-esteem and anxiety in the evaluated individuals demonstrate a significant positive correlation between anxiety and self-esteem in applicants for cosmetic surgery. It is important to note that in this study, higher scores in the self-esteem dimension indicate a more negative self-perception in individuals.
The current research findings are consistent with the results of many researchers, including [20] who examined the relationship between anxiety, self-esteem, and stress. The results indicated that anxiety and stress explain 39% of the variance in self-esteem scores.
The research results of Nilforooshan [20] with the title "Early Maladaptive Schemes and General Health in Women Seeking Cosmetic Surgery" showed that with an increase in positive self-esteem, their social adaptation also increases, and as a result, their anxiety decreases. Additionally, Sohrabi [21] stated in his research that there is a significant positive and effective relationship between anxiety and improvement in quality of life indicators. A high percentage of cosmetic surgery demand in Iran comes from women, with 95% of applicants being women and girls up to the age of 45 for nose and body surgeries, and 5% being men for nose and hair transplant surgeries. Currently, there is a trend occurring worldwide that no country is immune to - the commercialization and individualization of beauty. While in the past, the beauty of individuals was considered as a whole, today it is being broken down and each part of the body is being emphasized in the media world, with specific trends emerging, even in cosmetic.
On one hand, reference groups have failed to help young people in recognizing their identity. As a result, the most superficial layer of each individual's identity becomes so prominent that it pushes other existential dimensions to the margins. Psychologically, perfectionist types are individuals who tend to do all their work to the best of their ability, but usually, they are not satisfied with the results. This characteristic can intensify and transform into obsessive thinking in some cases. In this situation, the image these individuals have of themselves is more undesirable than their actual image.
Pursuing beauty through surgery is a psychological diversion from reality, and this multi-dimensional concept is particularly dependent on various factors, especially personality traits. These surgeries are mostly done to eliminate individuals' dissatisfaction with their appearance and sometimes to boost self-esteem.
Therefore, since cosmetic surgeries are performed to change individuals' appearance and increase their satisfaction and self-confidence, cosmetic surgery can be considered the outcome of a specific cognitive-behavioral pattern [22]. Extensive studies indicate that cosmetic surgery is common across all segments of society, and one of the reasons for this is the imbalance in personality traits. Personality-wise, individuals undergoing cosmetic surgery often exhibit prominent obsessive traits. In general, the five-factor personality traits, especially openness, body image, and particularly acceptance of cosmetic surgery, are influential. Furthermore, findings have shown that individuals' self-esteem is negatively related to the likelihood of accepting cosmetic surgery, meaning that individuals with low self-esteem use cosmetic surgery as a means to improve their overall self-image. Many individuals undergoing cosmetic surgeries suffer from personality disorders [23].
In these conditions, individuals feel negative about their body parts, especially if they feel bad about them, thinking these parts are inadequate. Personality disorders, obsessions, and anxiety are common issues in this group of individuals. In general, individuals with high positive self-perception have come to a clear view of themselves and are less influenced by daily events and evaluations of these events. Positive self-perception refers to beliefs about one's abilities to perform tasks and responsibilities. Cordeiro [24] stated that individuals with high positive self-perception are higher in terms of feelings of competence, inner motivation, power of choice, commitment to goals, and perseverance in the face of challenging tasks compared to individuals with high negative self-perception [24].
CONCLUSION
The results indicate that negative self-perception has a significant and positive correlation with anxiety, and women seeking cosmetic surgery have high scores of negative self-perception and consequently higher anxiety scores. Therefore, by examining the results of this study and identifying the motivating factors for women to undergo cosmetic surgeries, efforts can be made towards enhancing and developing women's health and well-being and preventing unnecessary surgeries.
LIMITATIONS
This research was conducted among students at the Islamic Azad University, Karaj branch, and caution should be exercised in generalizing it to other communities. One of the limitations of this research, which is specific to questionnaire-based studies, is the lack of interest and motivation to respond, which is sometimes seen among respondents. Also, sometimes individuals do not answer some questions correctly to present a better image of themselves. However, efforts were made to mitigate this limitation as much as possible by emphasizing the anonymity of the questionnaires and their use solely for research purposes. The present study was limited to girls seeking cosmetic surgery visiting cosmetic surgery centers in Karaj without medical reasons; therefore, the results cannot be generalized to all applicants for cosmetic surgery in other regions of the country. On the other hand, other potential mediating factors may influence the research results, which were beyond the researchers' control and measurement capacity.
SUGGESTIONS
It is suggested that the motivation for cosmetic surgery be carefully examined based on a combination of psychological, emotional, and personality factors, as well as the defense mechanisms and coping strategies adopted by these individuals. Therefore, it is recommended that psychological counseling be conducted to adjust more effective coping strategies before undergoing cosmetic surgery. Negative self-perception can lead to the perception of bodily unattractiveness and self-loathing and create a tendency to undergo cosmetic surgeries such as rhinoplasty. Accordingly, developing educational and intervention programs to modify and change personality traits and increase self-confidence can teach individuals skills and effective strategies to improve the quality of interpersonal relationships and boost self-confidence, leading to a reduction in individuals' inclination to undergo cosmetic surgery.
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