
==== Front
Discov Psychol
Discov Psychol
Discover Psychology
2731-4537
Springer International Publishing Cham

230
10.1007/s44202-024-00230-6
Research
Men’s use of cosmetic surgery and the role of traditional masculinity ideologies
Walther A. a.walther@psychologie.uzh.ch

1
Möllmann A. 2
Reppenhagen S. 3
Ehlert U. 1
Watzke B. 4
Drüge M. 4
Schneeberger M. 1
Eggenberger L. 56
1 https://ror.org/02crff812 grid.7400.3 0000 0004 1937 0650 Clinical Psychology and Psychotherapy, University of Zurich, Binzmühlestrasse 14, 8050 Zurich, Switzerland
2 https://ror.org/02hpadn98 grid.7491.b 0000 0001 0944 9128 Clinical Child and Adolescent Psychology and Psychotherapy, Bielefeld University, Bielefeld, Germany
3 https://ror.org/00r1edq15 grid.5603.0 0000 0001 2353 1531 Psychology, University of Greifswald, Greifswald, Germany
4 https://ror.org/02crff812 grid.7400.3 0000 0004 1937 0650 Clinical Psychology and Psychotherapy, University of Zurich, Zurich, Switzerland
5 https://ror.org/02crff812 grid.7400.3 0000 0004 1937 0650 Experimental Pharmacopsychology and Psychological Addiction Research, Department of Adult Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
6 https://ror.org/02crff812 grid.7400.3 0000 0004 1937 0650 Jacobs Center for Productive Youth Development, University of Zurich, Zurich, Switzerland
6 9 2024
6 9 2024
2024
4 1 1136 5 2024
28 8 2024
© The Author(s) 2024
2024
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In western countries, men are increasingly using cosmetic surgery. However, despite this trend, there remains a dearth of information on the prevalence, acceptance, and motivations behind men’s use of cosmetic surgery. Furthermore, the potential association between men’s use of cosmetic surgery and in particular male-specific cosmetic surgery procedures such as head hair transplant or penis enlargement and traditional masculinity ideologies (TMI) has not been investigated so far. For this purpose, a cross-sectional anonymous online survey was conducted among 241 self-identifying men aged 18 years or older from the German-speaking part of Europe. Participants responded to questions about cosmetic surgery use and experiences, and completed the Conformity to Masculine Norms Inventory—Short Form (CMNI-SF) and the Male Role Norms Inventory—Short Form (MRNI-SF) questionnaires to assess conformity with and endorsement of TMI. Of the 241 men investigated, 47 (19.5%) had undergone cosmetic surgery. The most common types of cosmetic surgeries reported were wrinkle treatment, eyelid correction, and head-hair transplant. Penis enlargement procedures were reported by three (6.4%) of the 47 men who had undergone cosmetic surgery. The main reasons for undergoing surgery were to feel better (72.3%) and look better (55.3%), while to increase sexual success (17.0%) and to increase manliness (14.9%) were also reported. Logistic regression models showed that higher conformity to TMI (CMNI-SF) was associated with higher odds of having undergone cosmetic surgery. The results highlight the overall increase in men’s cosmetic surgery use and its specific characteristics. The significant positive association between conformity to TMI and men’s use of cosmetic surgery suggests that men increasingly use cosmetic surgery as a means to assert power, success, dominance, and sexual success.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44202-024-00230-6.

Keywords

Men
Masculinities
Cosmetic surgery
TMI
Plastic surgery
http://dx.doi.org/10.13039/501100001711 Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung PZPGP1_201757 Walther A. issue-copyright-statement© Springer Nature Switzerland AG 2024
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pmcIntroduction

Plastic surgery and cosmetic surgery are two closely related branches of medical procedures aimed at improving or restoring the appearance or function of the body. Plastic surgery primarily focuses on reconstructing or repairing defects in the body resulting from birth disorders, trauma, burns, or disease. Its goal is to restore normal function and appearance, while cosmetic surgery, on the other hand, is a subset of plastic surgery that specifically deals with enhancing a person’s appearance by altering or reshaping the body’s features. It is typically performed on patients with no underlying medical issues, and the primary motivation is aesthetic improvement and indeed, most patients are generally satisfied with the outcome of their procedures [1].

Historically, cosmetic surgery has been dominated by women, as beauty and physical appearance have played a significant role in their ability to navigate societal expectations and achieve life goals [2, 3]. About 90% of all cosmetic surgery patients are women and they generally show higher acceptance and greater specific knowledge compared to men [4]. However, recent data from the Associations of American and German Aesthetic Plastic Surgery [5–8] reveals a sharp increase in the number of cosmetic surgeries performed on men. In line with that, men also increasingly use physical appearance modifications such as hair care products and makeup for men [9, 10]. Despite this trend, there remains a dearth of information on the prevalence, acceptance, and motivations behind men’s use of cosmetic surgery. In general, individuals undergo cosmetic surgery for various reasons, ranging from aesthetic enhancement and boosting self-confidence to relationship issues [11]. Some may seek to address perceived imperfections, while others may wish to reverse the signs of aging or enhance traditionally gender-specific features. Earlier studies implied different, potentially gender-specific motives, such as men often seeking to emphasize traditionally masculine features, while women focus on meeting societal standards of beauty [12–14].

Especially the influence of societal standards of beauty have become more important for men, as well. For men, traditional masculinity ideologies (TMI) may play a central role. TMI are socially defined sets of standards and norms how men are expected to be or behave [15–17]. Importantly, these aspects include features of ideal men’s bodies such as muscular and lean with little body fat [18]. As such, men who aim to uphold TMI, such as power, dominance, status, or playboy, report higher body dissatisfaction [19] and these TMI may drive men to seek cosmetic surgery as a means of conforming to societal expectations and enhancing their perceived attractiveness [17, 20]. By undergoing cosmetic procedures, men may aim to achieve a more youthful, manly, powerful, or successful appearance, which they may perceive as being linked to their overall status and desirability.

Commonly sought-after procedures in men include liposuction, rhinoplasty, male breast reduction (gynecomastia surgery), facelifts, but male-oriented procedures such as hair transplantation or penis enlargements are increasingly performed [5, 6, 8]. Head hair transplantation and penis enlargement are examples of cosmetic procedures that directly relate to TMI of power, dominance, playboy, and success [17, 20]. Hair loss is often associated with aging and a decline in attractiveness, whereas a full head of hair can symbolize youth, vitality, virility and strength [21–23]. Undergoing hair transplantation may thus help men conform to TMI and thereby fulfill societal expectations and enhance their perceived masculinity [20].

Similarly, penis size has long been linked to male sexual prowess, dominance, and masculinity [24]. Penis enlargement procedures may provide men with a sense of increased power, attractiveness, and status, adhering to TMI [17]. Men who undergo these surgeries may believe that these enhancements will positively impact their romantic and sexual relationships, as well as their overall self-esteem and social standing [25, 26].

As men become increasingly aware of the potential benefits of cosmetic surgery, they are investing more in male-tailored procedures. The growth of the male cosmetic surgery market signifies the rising importance of appearance and adherence to TMI in modern society. As a result, men are dedicating more financial resources to enhance and maintain their physical appearance, further fueling the expansion of this industry. The cost of these procedures can vary depending on location, but are in most cases several thousand dollar [7]. The global cosmetic surgery market size is currently valued around $70 billion, and is projected to reach around $200 billion by 2030 (Allied Market Research: https://www.alliedmarketresearch.com/cosmetic-surgery-market-A16492). The increase in men’s cosmetic surgery is therefore already factored in by the current market predictions.

It is crucial to acknowledge that cosmetic surgery is not without risks, and complications can arise from anesthesia, infection, or unsatisfactory results, potentially impacting an individual’s overall health [6]. Moreover, it is essential to consider the psychological factors behind the desire for cosmetic procedures. Body Dysmorphic Disorder (BDD), as defined by the DSM-5, is a mental health condition characterized by a persistent and excessive preoccupation with perceived flaws in appearance, leading to significant distress and impairment in daily functioning [27].

BDD affects approximately 1.9% of the general population, with a similar prevalence in both men and women. The prevalence of BDD is clearly higher in cosmetic surgery settings with 13–20% and, importantly, higher prevalences for men compared to women [28]. There is a fine line between seeking cosmetic surgery for personal enhancement and suffering from BDD. While all individuals may undergo cosmetic procedures to address specific concerns or boost self-esteem, irrespective of BDD status, those with BDD often find that surgery does not alleviate their distress [29], as the surgery does not target their biased perceptual body image [30]. Further symptoms of BDD include excessive grooming, social withdrawal, constant comparison to others, and frequent attempts to change the perceived flaw through various means, including cosmetic surgery [31].

In the present study, we aimed to explore the prevalence of cosmetic surgery in the male population, identify the most common procedures and the satisfaction with the performed procedures, the potential influence of TMI, and the distinction between cosmetic surgery use with and without BDD. By examining these factors, we hope to provide a better understanding of the evolving dynamics of cosmetic surgery and its intersection with gender norms in contemporary society. Our a priori preregistered hypotheses examining the relationship between conformity with TMI (CMNI-30) and cosmetic surgery are presented below. Relationships between the endorsement with TMI (MRNI-SF) and cosmetic surgery (H4-H6) are presented only in the supplementary Material.H1: Higher conformity to TMI (CMNI-30) is associated with a higher likelihood of performing cosmetic surgery (all forms).

H2: Higher conformity to TMI (CMNI-30) is associated with a higher likelihood of performing penis enlargement procedures (enlargement/lengthening/thickening).

H3: Higher conformity to TMI (CMNI-30) is associated with a higher likelihood of performing head hair transplantation.

Methods

Study design

Data for the present study were obtained through an anonymous online survey investigating the use of cosmetic surgery among men, which was hosted by Unipark (EFS Release 21.2; Tivian XI GmbH; Cologne, Germany, https://www.unipark.com). The link to the survey was distributed via social media platforms, the study’s website www.andromind.ch, and paid advertising on Facebook. The paid advertisements were age- and geo-restricted for adult men living in German-speaking parts of Europe. In order to take part in the survey, participants needed to provide informed consent, accept a data privacy agreement, and self-report adequate proficiency in the German language. The survey lasted about 30 min and consisted of multiple questionnaires assessing men’s experience with plastic surgery, mental and physical health variables, endorsement of and conformity to TMI, as well as sociodemographic information. Recruitment for the present sample started on October 28, 2022, and ended on March 4, 2023. This study was preregistered on OSF [https://doi.org/10.17605/OSF.IO/FB6D3] and was performed in accordance with the open-science guidelines “Guidelines for Transparency and Openness Promotion (TOP) in Journal Policies and Practices [https://osf.io/ud578]”. The study was approved by the ethical review board of the Ethics Committee of the Philosophical Faculty of the University of Zurich (EK-number: #22.10.15).

Sample

Out of an initial 6413 individuals who visited the survey’s website, 364 continued past the welcoming page and 327 gave informed consent, accepted the privacy agreement, and indicated proficiency in German. Out of these 327 individuals, 247 completed the basic questionnaires relevant for the present study. Five individuals were excluded because they reported their biological sex as female, and one individual was excluded because this person reported being unsure of their gender identity. This resulted in a primary sample of N = 241 adult cisgender men. Because some analyses required participants to have filled out additional questionnaires, a secondary, slightly smaller sample consisted of n = 190 adult cisgender men. As this study was a voluntary, anonymous online survey, participants could discontinue the survey at any time. As a result, some participants (n = 51) ended the survey before completing the measure for TMI, meaning that no analysis of the relationship between TMI and cosmetic surgery could be carried out for these men.

Instruments

Sociodemographic information

Participants were asked about their birth-assigned sex, gender identity, age (in years), weight and height, nationality, ethnicity, race, marital status, relationship status, self-identified sexual orientation, highest completed educational attainment, yearly household income (in CHF), and subjective social status (once in relation to their environment and once in relation to their country). Additionally, participants were asked about their general physical health, whether they are psychologically burdened, diagnosed with a psychiatric disorder, using psychotherapy, and whether they are using any form of psychiatric medication. Lastly, participants were also asked questions regarding the self-image of their body to assess whether they potentially fulfill the criteria for BDD according to the DSM-5. The sociodemographic information obtained is described in more detail in the supplementary (Appendices 1, 2, and 3).

Cosmetic surgery

Participants were also asked whether they underwent cosmetic surgery in the past and, if so, how many, and what type (e.g., head-hair transplant, liposuction, etc.). Participants were then asked if they were content with the results of the surgery and if they felt more comfortable, more beautiful, more self-confident, and more manly since the surgery. Additional questions asked about the reasons for undergoing cosmetic surgery (e.g., to remove blemishes, to increase self-esteem, to feel more manly, etc.), how much time has passed since their last surgery, whether they are considering another cosmetic surgery, and whether they feel ashamed of their decision to undergo cosmetic surgery. Lastly, participants were asked how much money they have paid for cosmetic surgeries so far.

Conformity to Masculine Norms Inventory-30

The Conformity to Masculine Norms Inventory-30 (CMNI-30, [32] consists of 30 items and assesses conformity to TMI on ten dimensions. For each item, participants have to indicate their degree of agreement with a statement about conforming to TMI (e.g., “It bothers me when I have to ask for help”) on a six-point Likert scale (0 = strongly disagree; 5 = strongly agree). For the German-language version used in the present study, internal consistencies between ω = 0.63 and ω = 0.94 have been reported and the use of a total score was supported for heterosexually identified cisgender men [33]. The present study therefore used the total score of the CMNI-30, with higher values indicating stronger conformity to TMI. In the present sample, an internal consistency α = 0.87 and ω = 0.90 was found.

Male role norms inventory–short form

The male role norms inventory–short form (MRNI-SF, [34]) consists of 21 items and assesses endorsement of TMI on six dimensions. For each item, participants indicate how strongly they agree with a statement about endorsing TMI (e.g., “When going gets tough, men should get tough”). Answers are given on a seven-point Likert scale (1 = strongly disagree; 7 = strongly agree). The German-language version used in the present study has been found to possess internal consistencies between α = 0.73 and α = 0.89 [35]. The present study used a total score of the MNRI-SF, with higher values indicating stronger endorsement of TMI. In the present sample, an internal consistency of α = 0.93 and ω = 0.95 was found.

Statistical analysis

The statistical analysis consisted of three parts, as described below. In a first part, the sample composition was analyzed by calculating summary statistics for all sociodemographic variables, stratified by whether or not men had conducted any type of cosmetic surgery. These groups were compared by using two-samples t-tests for continuous and Chi-square tests for categorical variables. In a second part, the subsample of men who underwent cosmetic surgery was further analyzed in relation to the questions pertaining to their experience with cosmetic surgery. However, these analyses were purely descriptive because of the small subsample sizes. In a third part, binomial logistic regression analyses were used to estimate the association between TMI and the odds of undergoing cosmetic surgery, controlled for the covariates age, education, and income.

For all analyses, an initial α-level of 0.05 was used to test statistical significance, subsequently applying a step-down Holm correction for multiple testing [36]. All analyses were conducted with the statistical software R (version 4.2.2; [37]) and the additional packages psych ([38]; estimating psychometric properties and implementation of the Holm correction), rcompanion ([39]; estimating effect sizes) car ([40]; assessment of regression models), and ggpplot2 ([41]; data visualizations).

Results

Sample composition

As shown in Table 1, the sample’s mean age was 45.1 years (SD = 16.7) and ranged from 18 to 80 years. The majority of men were from Germany and Switzerland, and almost all men were of European race and ethnicity. The majority of men reported to be in an exclusive relationship, identified as heterosexual or gay, and finished a secondary or tertiary education. Additionally, the majority reported a yearly household income over 75,000 CHF and a subjective social status above both the average of their social environment and their country. Regarding physical and mental health, the majority estimated their general health to be good or above, while about one-sixth experienced a psychological burden, and one-tenth each self-reported a psychiatric diagnosis, current psychotherapeutic treatment, and use of psychiatric medication. Lastly, three men (1.2%) were suspected to match the criteria of a BDD-diagnosis according to the DSM-5.Table 1 Descriptive statistics for the sample

Variable	Total (N = 241)	Cosmetic surgery	t / χ2 (df)	Effect (d / V)	p-value	p (adj.)	
No (n = 194)	Yes (n = 47)	
Age, mean (SD)	45.1 (16.7)	44.1 (17.4)	49.7 (12.7)	− 2.52 (93)	0.34	0.014*	0.041*	
BMI, mean (SD)	26.2 (4.3)	26.4 (4.4)	25.6 (3.5)	1.12 (239)	− 0.18	0.266	0.266	
Nationality, n (%)				0.60sim	0.05	0.908	1	
Swiss	91 (37.8)	72 (37.1)	19 (40.4)					
German	117 (48.5)	96 (49.5)	21 (44.7)					
Austrian	21 (8.7)	16 (8.2)	5 (10.6)					
Other	12 (5.0)	10 (5.2)	2 (4.3)					
Race, n (%)				0.16sim	0.03	1	1	
European	233 (96.7)	188 (96.9)	45 (95.7)					
Non-European	8 (3.3)	6 (3.1)	2 (4.3)					
Ethnicity, n (%)				1.75sim	0.09	0.353	1	
European	234 (97.1)	187 (96.4)	47 (100.0)					
Non-European	7 (2.9)	7 (3.6)	0 (0.0)					
Marital status, n (%)				20.93sim	0.29	0.011**	0.015*	
Unmarried (single)	74 (30.7)	63 (32.5)	11 (23.4)					
Unmarried (in a relationship)	75 (31.1)	64 (33.0)	11 (23.4)					
Married	66 (27.4)	52 (26.8)	14 (29.8)					
Registered partnership	10 (4.1)	3 (1.5)	7 (14.9)					
Divorced	12 (5.0)	10 (5.2)	2 (4.3)					
Widowed	4 (1.7)	2 (1.0)	2 (4.3)					
Relationship status, n (%)				0.98sim	0.06	0.651	1	
Yes (exclusive)	151 (62.7)	119 (61.3)	32 (68.1)					
Yes (non-exclusive)	14 (5.8)	11 (5.7)	3 (6.4)					
No	76 (31.5)	64 (33.0)	12 (25.5)					
Sexual orientation, n (%)				14.09sim	0.24	0.007**	0.067	
Heterosexual	111 (46.1)	98 (50.5)	13 (27.7)					
Gay	92 (38.2)	63 (32.5)	29 (61.7)					
Bisexual	35 (14.5)	30 (15.5)	5 (10.6)					
Asexual	1 (0.4)	1 (0.5)	0 (0.0)					
Other	2 (0.8)	2 (1.0)	0 (0.0)					
Education, n (%)				2.16sim	0.09	0.322	1	
None completed	0 (0.0)	0 (0.0)	0 (0.0)					
Secondary education	128 (53.1)	104 (53.6)	24 (51.1)					
Tertiary education	98 (40.7)	76 (39.2)	22 (46.8)					
Other	15 (6.2)	14 (7.2)	1 (2.1)					
Yearly income (CHF), n (%)				8.80 (2)	0.19	0.012*	0.098	
< 25,000	64 (26.6)	59 (30.4)	5 (10.6)					
25,000–75,000	71 (29.5)	57 (29.4)	14 (29.8)					
> 75,000	106 (44.0)	78 (40.2)	28 (59.6)					
Social status (environment), n (%)				0.28 (1)	0.05	0.597	1	
< Average	34 (14.1)	29 (14.9)	5 (10.6)					
> Average	207 (85.9)	165 (85.1)	42 (89.4)					
Social status (country), n (%)				0.12 (1)	0.04	0.726	1	
< Average	48 (19.9)	40 (20.6)	8 (17.0)					
> Average	193 (80.1)	154 (79.4)	39 (83.0)					
General health, n (%)				6.12sim	0.16	0.054	0.109	
< Good	23 (9.5)	21 (10.8)	2 (4.3)					
Good	121 (50.2)	102 (52.6)	19 (40.4)					
> Good	97 (40.2)	71 (36.6)	26 (55.3)					
Mental health, n (%)								
Psychological burden, n (%)	43 (17.8)	37 (19.1)	6 (12.8)	0.64 (1)	0.07	0.423	1	
Psychiatric diagnosis, n (%)	28 (11.6)	22 (11.3)	6 (12.8)	0.00 (1)	0.02	0.984	1	
Psychotherapy use, n (%)	27 (11.2)	20 (10.3)	7 (14.9)	0.40 (1)	0.06	0.525	1	
Psychiatric medication, n (%)	24 (10.0)	21 (10.8)	3 (6.4)	0.83sim	0.06	0.421	1	
Body dysmorphia, n (%)	3 (1.2)	1 (0.5)	2 (4.3)	4.30sim	0.13	0.090	0.452	
p-values were adjusted for multiple testing using the Holm-method while bootstrapped 95% confidence intervals (95% CI) are unadjusted

SD = standard deviation; n = number of participants; t = t-statistic; χ2 = Chi-squared-statistic; df = degrees of freedom; d = Cohen’s d; V = Cramer’s V; 95%-CI = bootstrapped 95% confidence interval for the respective effect; CHF = Swiss Francs

sim = test statistic obtained using Monte-Carlo simulation

*p < 0.05, **p < 0.01

Out of the total 241 men, 47 (19.5%) have undergone cosmetic surgery. Those who underwent cosmetic surgery were on average older, more often married or in a registered partnership, more often gay, and disproportionately often in the highest income category. Notably, group differences regarding sexual orientation and income did not persist when controlling for multiple testing. Nonetheless, because sexual orientation is related to TMI (e.g., non-heterosexual oriented individuals have lower scores on the heterosexual self-presentation dimension and thus overall lower TMI levels) [42], a sensitivity analysis was conducted that additionally controlled for sexual orientation in the analyses (Tables S3–S6).

Experiences with cosmetic surgery

As presented in Fig. 1, the majority of men who underwent cosmetic surgery did either wrinkle treatment, eyelid correction, or head-hair transplant, followed by liposuction and nose correction. No cosmetic surgeries on glutes, thighs, sixpack, penis lengthening, or penis glans enlargements were reported. The most frequently mentioned reason for a cosmetic surgery was to feel better, followed by wanting to look better, feel more comfortable, remove blemishes, and to be more attractive (Fig. 2). Wanting to satisfy a partner was never mentioned as a reason for cosmetic surgery. Most men’s experience after the surgery left them feeling more comfortable, more beautiful, and more self-confident (Fig. 3). Only a minority reported to feel more manly after their surgery, with the majority reporting to feel as manly as before the surgery. Overall, almost all men reported comparable or improved sentiments after their surgery.Fig. 1 Frequencies of men’s cosmetic surgeries by type

Fig. 2 Frequencies of men’s reasons for cosmetic surgery

Fig. 3 Experienced changes after cosmetic surgery

As summarized in Table 2, half of the men underwent only one cosmetic surgery, and very few underwent four or more. Similarly, most men reported their last surgery to have been more than two years ago, with only seven men reporting their last surgery as having been more recent than three months ago. Almost all men would consider getting another surgery, and the majority reported positive feedback from their environment regarding the results of their surgery. Most men did not know whether they experienced shame because of their surgery, and few more reported yes (19.1%) compared to no (8.5%). The amount of money spent in CHF for cosmetic surgeries ranged from 500 to 35,000, with a median of 8000 and a mean of 9572 (SD = 7945).Table 2 Further questions about men’s cosmetic surgeries

A) How many cosmetic surgeries have you undergone?	
	1	2	3	4	> 4	
n (%)	20 (42.5)	13 (27.7)	8 (17.0)	3 (6.3)	3 (6.3)	
B) How recent was your last cosmetic surgery?	
	< 3 months	< 6 months	< 1 year	< 2 years	< 5 years	> 5 years	
n (%)	7 (14.9)	3 (6.4)	6 (12.8)	6 (12.8)	9 (19.1)	16 (34.0)	
C) Would you consider getting cosmetic surgery again?	
	Definitely not	Probably not	Unsure	Probably	Definitely	
n (%)	–	5 (10.6)	2 (4.3)	19 (40.4)	21 (44.7)	
D) What was the reaction of your environment to the results of the cosmetic surgery?	
	Negative	Mostly negative	Mixed	Mostly positive	Positive	Did not tell	
n (%)	–	–	12 (25.5)	8 (17.0)	17 (36.2)	10 (21.3)	
E) Was your decision to get cosmetic surgery associated with shame?	
	No	Don’t know	Yes	
n (%)	4 (8.5)	34 (72.3)	9 (19.1)	
F) How much money have you spent on cosmetic surgery so far?	
	Min	Max	Median	Mean	SD	
CHF	500	35,000	8000	9572.3	7945.5	
n = number of mentions, CHF = Swiss Francs, min = minimum value, max = maximum value, SD = standard deviation

TMI and cosmetic surgery

To test hypothesis 1, stepwise binomial logistic regression models were used to estimate the association between conformity to TMI and the odds of having undergone cosmetic surgery when controlling for the covariates age, education, and income (Table 3). Notably, these analyses were conducted with a smaller sample consisting of only n = 190 men (of which n = 35 underwent cosmetic surgery). Men who conform more strongly to TMI showed higher odds of having undergone cosmetic surgery. Regarding the effect size, an increase of one standard-deviation in the CMNI-30 (i.e., 7.8 points) was found to increase the odds of having undergone cosmetic surgery by a factor of 2.29, conditional on all covariates being at reference level (i.e., men with an average age of 43.8 years, no tertiary education, and an average yearly household income of about 86,900 CHF). Back-transforming this effect yields an increase by a factor of 1.04 in the odds of having undergone cosmetic surgery per one-point increase in the CMNI-30.Table 3 Association between conformity to TMI and cosmetic surgery

Predictor	Model 1	Model 2	
OR	95% CI	p (adj.)	OR	95% CI	p (adj.)	
Intercept	0.20	[0.13, 0.29]	< 0.001***	0.14	[0.08, 0.25]	< 0.001***	
CMNI-301	2.03	[1.39, 2.96]	< 0.001***	2.29	[1.51, 3.49]	< 0.001***	
Covariates							
 Age1				2.04	[1.28, 3.25]	0.008**	
 Tertiary education				1.44	[0.64, 3.23]	0.373	
 Income1 (CHF)				1.47	[1.03, 2.10]	0.066	
Fit and performance							
χ2 (df)	14.59 (1)	14.04 (3)	
ΔR2 (in %)	12.0***	10.7**	
AIC (BIC)	170.9 (177.4)	162.9 (179.1)	
p-values were adjusted for multiple testing using the Holm-method while 95% Wald confidence intervals (95% CI) are unadjusted. OR = odds ratio; CI = Wald confidence interval; ΔR2 = difference in Nagelkerke’s pseudo-R2; CMNI-30 = Conformity to Masculine Norms Inventory—30; CHF = Swiss Francs

1Variable was z-standardized

*p < 0.05; **p < 0.01; ***p < 0.001

It was not possible to test hypothesis 2, since only three men indicated having undergone penis enlargement procedures. Such a small number of men with penis enlargement procedures did not allow for any meaningful statistical analysis regarding the association between penis enlargement procedures and conformity to TMI.

To test hypothesis 3, the same model was estimated as for hypothesis 1 for the odds of having undergone a head-hair transplant surgery (Table 4). Again, men who conform more strongly to TMI had higher odds of having undergone a head-hair transplant surgery. Regarding the effect size, an increase of 7.8 points in the CMNI-30 was found to increase the odds for head-hair transplant by a factor of 3.84, conditional on all covariates being at reference level. Back transformation yielded a multiplicative effect of 1.07 per one-point increase in the CMNI-30 for having undergone head-hair transplant surgery. Comparable results were found for the association between men’s endorsement of TMI (MRNI-SF) and cosmetic surgery, which can be found in the supplementary materials (Table S1, Table S2). Finally, our sensitivity analyses showed conformity to and endorsement of TMI remained significant explanatory variables for cosmetic surgery even when accounted for men’s sexual orientation (Table S3–S6). Notably, self-reported non-heterosexual orientation was associated with a higher likelihood of cosmetic surgery but not with head hair transplant.Table 4 Association between conformity to TMI and head-hair transplant

Predictor	Model 1	Model 2	
OR	95% CI	p (adj.)	OR	95% CI	p (adj.)	
Intercept	0.03	[0.01, 0.08]	< 0.001***	0.01	[0.01, 0.06]	< 0.001***	
CMNI-30	3.49	[1.91, 6.37]	< 0.001***	3.84	[1.96, 7.52]	< 0.001***	
Covariates							
 Age1				1.50	[0.68, 3.30]	0.465	
 Tertiary education				2.85	[0.67, 12.08]	0.465	
 Income1 (CHF)				1.45	[0.79, 2.64]	0.465	
Fit and performance							
χ2 (df)	19.45 (1)	4.27 (3)	
ΔR2 (in %)	27.2***	5.6	
AIC (BIC)	68.6 (75.1)	70.3 (86.6)	
p-values were adjusted for multiple testing using the Holm-method while 95% Wald confidence intervals (95% CI) are unadjusted. OR = odds ratio; CI = Wald confidence interval; ΔR2 = difference in Nagelkerke’s pseudo-R2; CMNI-30 = Conformity to Masculine Norms Inventory—30; CHF = Swiss Francs

1Variable was z-standardized

*p < 0.05; **p < 0.01; ***p < 0.001

Discussion

Summary of results

The aim of this cross-sectional anonymous online survey was to assess men’s use, motives and thoughts regarding cosmetic surgery. Furthermore, this study is the first to examine cosmetic surgery use in men in the context of TMI. The most common types of cosmetic surgeries reported were wrinkle treatment, eyelid correction, and head-hair transplant. Penis enlargement procedures were reported by three (6.4%) of the 47 men that underwent cosmetic surgery procedures. The main reasons for undergoing surgery were to feel better (72.3%) and look better (55.3%), while to increase sexual success (17.0%) and to increase manliness (14.9%) were also reported. Logistic regression models showed that higher conformity to TMI was associated with higher odds of having undergone cosmetic surgery. Specifically, an increase of one standard-deviation in the CMNI-SF increased the odds of having undergone cosmetic surgery by a factor of 2.29, and the odds of having undergone head-hair transplant surgery by a factor of 3.84.

Integration of findings

A clear association between the use of cosmetic surgery and conformity to TMI was observed. Given the rapidly increasing number of cosmetic surgeries performed on men, it is important to understand their underlying motivations and reasons for seeking cosmetic surgery. In the present study, 19.5% participants reported having undergone cosmetic surgery. In 2021, the Association of German Aesthetic Plastic Surgery recorded a total of 93853 cosmetic surgeries with 13.2% (12389) of all surgeries being performed in men (VDÄPC—Behandlungsstatistik, 2022). Although in Germany the number of performed cosmetic surgeries has increased by approximately 15% compared to the year 2020, it is still a relatively small percentage of the adult male population that uses cosmetic surgery. For Germany—based on the adult male population of around 33 million and the annually performed cosmetic surgeries in men—a lifetime prevalence of cosmetic surgery use of 3–5% can be estimated. It is important to note here, that not all men perform their cosmetic surgeries in Germany and thereby are not recorded by the VDÄPC and that some men perform two or more cosmetic surgeries within one year and thus only approximations of the lifetime cosmetic surgery prevalence can be performed.

Much higher lifetime prevalence rates for men’s cosmetic surgery use stem from an Iranian survey suggesting 16.5% of men having ever undergone a cosmetic surgery [43]. However, such high prevalence rates need to be interpreted with caution and might indicate a selection bias for participants with an increased interest for cosmetic surgery. Indeed, this lifetime prevalence of 16.5% would be very similar to our percentage of 19.5% of all men in the study having undergone a cosmetic surgery at least once in their life, although our study explicitly recruited men with an interest in the topic of cosmetic surgery. Therefore, we conclude that the actual prevalence of cosmetic surgery use in men in Germany, Switzerland, and Austria, but also in other industrialized western countries must be much lower and that the estimate of 3–5% based on the annual surgery statistics might be accurate.

The top five procedures in men recorded by the Association of German Aesthetic Plastic Surgery were upper eyelid lift, botulinum treatment, liposuction, hyaluron treatment and tummy tuck. In our study, we found some degree of overlap in that wrinkle treatment, eyelid correction, head-hair transplant, liposuction and nose correction were the five most reported surgeries (Fig. 1). Since both, botulinum and hyaluron treatment are used for wrinkle treatment, it confirms that younger appearance seems to be desirable for many men who opt for cosmetic surgery. Regarding experienced changes after the cosmetic surgery, almost exclusively all men report to feel more or much more comfortable, while also the majority reports to feel more or much more beautiful and also self-confident (Fig. 3). Also, about a third of men report to feel more manly after the cosmetic surgery. Thus, the men in the present study reported to feel better after a performed cosmetic surgery, which is in line with previous research [44].

Regarding hypothesis 1, we were able to show that higher conformity to TMI was associated with a higher likelihood of having performed cosmetic surgery (all forms). This suggests that conformity to TMI such as success, competition, power, dominance, status, or playboy may lead men to undergo cosmetic surgery to meet societal expectations and increase their perceived attractiveness and fitness [17, 20]. Men seem to want to appear younger, more dynamic, physically strong and more successful through cosmetic surgery. Since only four men in the sample underwent penis enlargement procedures, no sound conclusion can be made regarding the second hypothesis. Whether the hypothesized association between conformity to TMI and cosmetic surgery in the genital area is confirmed needs to be investigated in future studies. Nevertheless, the findings further support hypothesis three stressing that full hair fits the social image of a successful and dominant man or a playboy and therefore men opting for a head hair transplant also often intend to increase their perceived attractiveness and fitness.

The discrepancy between one’s own appearance and the societal and internalized ideal image of a man, as well as the stress caused by the perceived discrepancy, could explain why the self-reported main reasons for cosmetic surgery were to feel better (n = 34 [72.3%]), to look better (n = 26 [55.3%]), and to feel more comfortable (n = 23 [48.9%]) (Fig. 2). In total, 7 (14.9%) of the 47 men reported that they opted for cosmetic surgery to feel more masculine. This percentage is rather low compared to other motives, probably because TMI and the ideas of an ideal man attached to it have a rather subliminal influence and men may not be aware of it directly before deciding to undergo cosmetic surgery. This interpretation is supported by the discrepancy of motive versus effect, with an almost doubled percentage of men (n = 13; 27.7%) who reported to feel more masculine as a result of the surgery.

Importantly, many earlier studies have linked cosmetic surgery to BDD, especially in male cosmetic surgery samples [28]. However, in the present study, only 1.2% met the DSM-5 criteria for BDD reflecting no increased point prevalence in this adult male group as compared to the general population [45], adolescents [46] or female college students [47]. This further underscores the importance of motives related to internal belief systems such as TMI for cosmetic surgery use. Still, a screening for BDD in men seeking cosmetic surgery might be as important as in women, given the higher risk for adverse effects of cosmetic surgery in individuals with BDD [29]. Of further interest is that in the study by Möllmann et al. [46] identified regions of concern for male youth were predominantly related to the breasts/pectorals (20.5%) and having insufficient muscles (17.9%), while in adult males the body parts rated as especially unattractive were head hair (10.3%), nose (5.3%), ears (4.7%), skin (3.7%) and stomach (3.5%) [45]. Corroborating these findings and showing that many men also decide to use cosmetic surgery to correct blemishes, in the present study, head hair (n = 12 [4.8%]), wrinkle treatment (n = 12 [4.8%]), eyelid correction (n = 12 [4.8%]), liposuction (n = 11 [4.4%]) and nose correction (n = 8 [3.2%]) were the most performed surgeries. Also, men did rarely perform surgeries in the regions with which male youth was primarily preoccupied (gynecomastia: n = 3 [1.2%], breast implant: n = 1 [0.4%]). On the one hand, interventions related to these regions tend to be more invasive in nature than others. On the other hand, it can be assumed that men have the aspiration to achieve satisfactory musculature through training and effort—in general and in men suffering from BDD of the muscle dysmorphia form. Such an attitude would in turn reflect conformity with TMI dimensions such as success, power, competition, and self-reliance.

However, Drüge et al. [48] report for a male-only sample of Swiss military recruits, which are known to rely more heavily on TMI [49, 50], that the areas of most preoccupation were muscles with 42% and genitals with 33% highlighting the relevance of these areas for TMI and masculinity. The TMI dimensions of strength and power might be reflected by a muscular body, while the TMI dimension of playboy or power over women might be reflected by a large penis. Thus, corroborating and extending the findings by Drüge et al. [48], many men in the present study did perform cosmetic surgeries in areas that are generally associated with TMI dimensions and masculinity in general. In addition to head hair, musculaturity, and genitals, two men for example also underwent chin correction procedures, which is also associated with dominance and strength, as a broad and pronounced chin is commonly considered masculine and associated with physical strength and assertiveness [51, 52].

In addition, group comparisons between men who have had cosmetic surgery and those who have not showed that men who have had cosmetic surgery are significantly older and are significantly less often single and more often in committed relationships. As possible explanations for these findings, it is conceivable that men who have had cosmetic surgery tend to be older, because they are more likely to have the financial resources and stability required for elective procedures. Furthermore, as these men age, they may feel the pressure to maintain a youthful appearance in order to remain competitive in both personal and professional settings and conform to still upholding TMI of power, success and competitiveness [53–55]. This is also supported by the finding that the most reported cosmetic surgeries may serve as cosmetic rejuvenation procedures such as wrinkle treatment, eyelid correction, and head-hair transplant. Additionally, being in a committed partnership could provide emotional support and encouragement to undergo cosmetic surgery, as partners may discuss and mutually agree upon the decision. Men in committed relationships might thus undergo cosmetic surgery to enhance their self-esteem and maintain their attractiveness within the partnership, which corresponds to the TMI dimension of importance of sex and maintaining sex and vitality [54, 56].

To a lesser extent, so that the significance levels do not survive correction for multiple testing, the analysis revealed that men, who have had cosmetic surgery are more likely to be gay or bisexual than heterosexual and that men who have had cosmetic surgery have significantly higher incomes. As higher incomes enable a more costly lifestyle, men with higher incomes naturally have more resources to perform cosmetic surgeries, what is in line with the argumentation, that older men are also more likely to have more financial resources to perform cosmetic surgery. However, men who identify as gay or bisexual may be more likely to undergo cosmetic surgery due to the heightened emphasis on physical appearance and attractiveness within some LGBTQ + social circles [57, 58] and higher perceived discrepancy between the actual and ideal body compared to heterosexual men [59]. The desire to fit in and be perceived as attractive within these communities could lead to a higher likelihood of pursuing cosmetic procedures [60] as has previously been shown for gay men [61]. Additionally, LGBTQ + individuals may face unique pressures to conform to certain beauty standards, which can encourage them to seek surgical enhancements [62]. Furthermore, the LGBTQ + community has historically been more open to self-expression and body modification [63–66], making cosmetic surgery a more socially accepted choice within these groups. In our sensitivity analysis controlling for sexual orientation, we did indeed find that self-reported non-heterosexual orientation was associated with higher odds of having undergone cosmetic surgery, which is consistent with the aforementioned findings. However, the absence of a significant association between non-heterosexual orientation and head hair transplant is most likely attributable to the small sample size of men having undergone a head hair transplant surgery (n = 12), which is also reflected in the large confidence intervals for the estimated effects.

Historically, there has been much investigation of the effects of body satisfaction in female samples, but not as much in male samples. Previous work examining body satisfaction in mixed-sex individuals has found that body satisfaction is more related to appearance for women (particularly heterosexual women), whereas men focus more on body function to determine their levels of body satisfaction [67]. However, the current study calls this finding into question, as it seems that appearance was a major motivating factor for men’s engagement in cosmetic surgery. It is interesting that men seem to be motivated to engage in cosmetic surgery in order to a TMI-conform appearance, which implies a certain degree of approval-seeking. However, need for approval or dependency is generally regarded as a component of a traditional feminine ideology [68]. In fact, the need for approval has been linked to disordered eating in both men and women [69], another behavior that focuses on acceptance through appearance, similar to cosmetic surgery. The current study suggests that the need for approval may be less gendered than previously thought and that this approval can be achieved by conforming to TMI with one’s own masculine appearance and using cosmetic surgery to achieve this.

The investigation of the connection between traditional femininity and cosmetic surgery is also of interest. Women may have even stronger traditional femininity ideologies surrounding youth and beauty and a strong need for acceptance through appearance [70–73], which may lead disproportionally more women to seek cosmetic surgery than men [4, 8]. Therefore, future research on the connection between traditional ideologies and cosmetic surgery should examine both men and women in parallel shedding light on gender similarities and differences.

Limitations

When interpreting the results, some limitations must be considered. Most importantly, the cross-sectional nature of the study does not allow for any causal inferences. The men were not surveyed before and after a cosmetic surgery and so we must rely on retrospective assessments. A longitudinal study with time points before and after a cosmetic surgery to measure potential changes in TMI and other variables would be of much interest for the field. Also, most participants were from Germany and Switzerland, and almost all men were of European race and ethnicity. For this reason, the sample is only representative of the general male adult population to a limited extent, despite the large age range (18–80). It needs to be emphasized that the composition of the sample with almost all men self-identifying as European race and ethnicity, might reflect only a specific cultural group of men as there is data from South Korea showing that cosmetic surgery among men is much more prevalent [74]. Ideally, future studies might conduct surveys in different cultural regions across the globe, to better understand cultural differences in men’s cosmetic surgery use. Relatedly, around 50% of men self-identified as non-heterosexual, which is comparably higher as in the general male population. Another limitation of the study is that a portion of men (n = 51) did not complete the CMNI-30 reducing the sample size from 241 to 190 participants for analysis of the association between TMI and cosmetic surgery. Furthermore, the listed prevalence of cosmetic surgery should be considered in the context of the study. Based on the statistics released by the Association of German Aesthetic Plastic Surgery, it is not realistic that Penis enlargements represent 6.4% of cosmetic surgeries performed on men. It was explicitly stated that the study was about cosmetic surgery, so it is most likely that a selection bias towards men with an existing interest in the subject of cosmetic surgery participated in the study. Future studies should aim for longitudinal study designs with more diverse samples.

Conclusion

In cisgender men, undergoing cosmetic surgery is clearly associated with conformity to TMI. Many men strive towards achieving success, establishing dominance, and nurturing competitiveness. This aspiration can foster the belief that projecting an appropriate appearance can enhance these desired achievements. Such an idealized appearance consists of full head hair, a young-looking face without blemishes, prominent facial features, a lean muscular body and a large penis. Cosmetic surgery offers many possibilities to achieve such an appearance. Since women have already been extensively targeted in recent decades through advertising and social expectations, it is now apparent that providers are increasingly trying to recruit men for cosmetic surgeries by framing cosmetic surgery as necessary to obtain the appearance that enables one to be successful, dominant, and competitive. Outreach efforts to make men aware of increased targeting for cosmetic surgery advertising, on the one hand, but also of the link between conformity to TMI and cosmetic surgery use, on the other, would therefore be important. In this way, men are empowered to decide for themselves whether it is their own personal desire to undergo cosmetic surgery or whether it is clever advertising strategies highlighting idealized traditional masculine body images that trigger this feeling in them.

Supplementary Information

Below is the link to the electronic supplementary material.Supplementary file1 (PDF 234 KB)

Author contributions

Study conception and design were performed by AW, AM, SR, UE, MS, and LE. Material preparation and data collection were performed by AW, SR, MS and LE. Data analysis and visualization was performed by AW and LE. The first draft of the manuscript was written AW, SR and LE and all authors (AW, AM, SR, UE, BW, MD, MS, LE) reviewed and edited previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

This work was funded by a Grant of the Swiss National Science Foundation [PZPGP1_201757] awarded to Andreas Walther. The funders had no role in the study design; collection, analyses, or interpretation of data; or writing of the manuscript.

Data availability

Research data supporting the results of this manuscript is publicly available on OSF: https://osf.io/eqs4t/.

Declarations

Competing interests

The authors declare no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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References

1. Honigman RJ Phillips KA Castle DJ A review of psychosocial outcomes for patients seeking cosmetic surgery Plast Reconstr Surg 2004 113 4 1229 10.1097/01.PRS.0000110214.88868.CA 15083026
Honigman RJ, Phillips KA, Castle DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004;113(4):1229.15083026 10.1097/01.PRS.0000110214.88868.CA
2. Wolf N. The beauty myth: How images of beauty are used against women. New York: William Morrow and Company Inc, vol. 348, p. 5, 1991.
3. Bordo S. Unbearable weight: Feminism, Western culture, and the body. Univ of California Press, 2004.
4. Alotaibi AS Demographic and cultural differences in the acceptance and pursuit of cosmetic surgery: a systematic literature review Plast Reconstr Surg Glob Open 2021 9 3 e3501 10.1097/GOX.0000000000003501 33777604
Alotaibi AS. Demographic and cultural differences in the acceptance and pursuit of cosmetic surgery: a systematic literature review. Plast Reconstr Surg Glob Open. 2021;9(3):e3501.33777604 10.1097/GOX.0000000000003501
5. Vereinigung der Deutschen Ästhetisch-Plastischen Chirurgen, “Behandlungsstatistik 2022,” 2022. Accessed: Apr. 14, 2023. [Online]. Available: https://vdaepc.de/wp-content/uploads/2022/09/2022_VDAEPC_Behandlungsstatistik_Fokus_Gesichtaesthetik.pdf.
6. International Society of Aeshetic Plastic Surgery. Aesthetic / Cosmetic Procedures performed in 2021. 2022. [Online]. Available: www.isaps.org.
7. American Society of Plastic Surgeons. American Society of Plastic Surgeons. 2018 Plastic Surgery Statistics Report. Plastic Surg. 2017;25.
8. Aesthetic Plastic Surgery National Databank Aesthetic Plastic Surgery National Databank: Statistics 2020–2021 Aesthet Surg J 2022 42 Suppl 1 1 18
Aesthetic Plastic Surgery National Databank. Aesthetic Plastic Surgery National Databank: Statistics 2020–2021. Aesthet Surg J. 2022;42(Suppl 1):1–18.
9. Shimpi SS, Sinha DK. A factor analysis on attitude characteristics of consumer buying behaviour for male cosmetics products in Pune City. International Journal of Marketing, financial Services and Management Research. vol. 1, 2012.
10. Batres C Robinson H Makeup increases attractiveness in male faces PLoS ONE 2022 17 11 e0275662 10.1371/journal.pone.0275662 36327222
Batres C, Robinson H. Makeup increases attractiveness in male faces. PLoS ONE. 2022;17(11): e0275662.36327222 10.1371/journal.pone.0275662
11. Milothridis P Pavlidis L Haidich A-B Panagopoulou E A systematic review of the factors predicting the interest in cosmetic plastic surgery Indian J Plastic Surg 2016 49 03 397 402 10.4103/0970-0358.197224
Milothridis P, Pavlidis L, Haidich A-B, Panagopoulou E. A systematic review of the factors predicting the interest in cosmetic plastic surgery. Indian J Plastic Surg. 2016;49(03):397–402.10.4103/0970-0358.197224
12. Sarwer DB Crerand CE Body image and cosmetic medical treatments Body Image 2004 1 1 99 111 10.1016/S1740-1445(03)00003-2 18089144
Sarwer DB, Crerand CE. Body image and cosmetic medical treatments. Body Image. 2004;1(1):99–111.18089144 10.1016/S1740-1445(03)00003-2
13. Sarwer DB Wadden TA Pertschuk MJ Whitaker LA Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients Plast Reconstr Surg 1998 101 6 1644 1649 10.1097/00006534-199805000-00035 9583501
Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. 1998;101(6):1644–9.9583501 10.1097/00006534-199805000-00035
14. Crerand CE Franklin ME Sarwer DB Body dysmorphic disorder and cosmetic surgery Plast Reconstr Surg 2006 118 7 167e 180e 10.1097/01.prs.0000242500.28431.24 17102719
Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg. 2006;118(7):167e–80e.17102719 10.1097/01.prs.0000242500.28431.24
15. Levant RF, Richmond K. The gender role strain paradigm and masculinity ideologies. in APA handbook of men and masculinities. American Psychological Association, 2016, pp. 23–49.
16. Gerdes ZT Alto KM Jadaszewski S D’Auria F Levant RF A content analysis of research on masculinity ideologies using all forms of the Male Role Norms Inventory (MRNI) Psychol Men Masc 2018 19 4 584 10.1037/men0000134
Gerdes ZT, Alto KM, Jadaszewski S, D’Auria F, Levant RF. A content analysis of research on masculinity ideologies using all forms of the Male Role Norms Inventory (MRNI). Psychol Men Masc. 2018;19(4):584.10.1037/men0000134
17. Levant RF Wong Y The psychology of men and masculinities 2017 American Psychological Association
Levant RF, Wong Y. The psychology of men and masculinities. American Psychological Association; 2017.
18. Komlenac N Hochleitner M Heterosexual-identified men’s endorsement of masculinity ideologies moderates associations between pornography consumption, body satisfaction and sexual functioning Psychol Sex 2022 13 4 880 900
Komlenac N, Hochleitner M. Heterosexual-identified men’s endorsement of masculinity ideologies moderates associations between pornography consumption, body satisfaction and sexual functioning. Psychol Sex. 2022;13(4):880–900.
19. Gattario KH How is men’s conformity to masculine norms related to their body image? Masculinity and muscularity across Western countries Psychol Men Masc 2015 16 3 337 10.1037/a0038494
Gattario KH, et al. How is men’s conformity to masculine norms related to their body image? Masculinity and muscularity across Western countries. Psychol Men Masc. 2015;16(3):337.10.1037/a0038494
20. Connell RW Masculinities 2020 Routledge
Connell RW. Masculinities. Routledge; 2020.
21. Szymczak JE, Conrad P. Medicalizing the Aging Male Body: Andropause. Medicalized Masculinities. p. 89, 2006.
22. Ricciardelli R Masculinity, consumerism, and appearance: a look at men’s hair Can Rev Sociol/Revue canadienne de sociologie 2011 48 2 181 201 10.1111/j.1755-618X.2011.01261.x 21879522
Ricciardelli R. Masculinity, consumerism, and appearance: a look at men’s hair. Can Rev Sociol/Revue canadienne de sociologie. 2011;48(2):181–201.21879522 10.1111/j.1755-618X.2011.01261.x
23. Cash TF The psychosocial consequences of androgenetic alopecia: a review of the research literature Br J Dermatol 1999 141 3 398 405 10.1046/j.1365-2133.1999.03030.x 10583042
Cash TF. The psychosocial consequences of androgenetic alopecia: a review of the research literature. Br J Dermatol. 1999;141(3):398–405.10583042 10.1046/j.1365-2133.1999.03030.x
24. Lever J Frederick DA Peplau LA “Does size matter? Men’s and women’s views on penis size across the lifespan Psychol Men Masc 2006 7 3 129 10.1037/1524-9220.7.3.129
Lever J, Frederick DA, Peplau LA. “Does size matter? Men’s and women’s views on penis size across the lifespan. Psychol Men Masc. 2006;7(3):129.10.1037/1524-9220.7.3.129
25. Wylie KR Eardley I Penile size and the ‘small penis syndrome’ BJU Int 2007 99 6 1449 1455 10.1111/j.1464-410X.2007.06806.x 17355371
Wylie KR, Eardley I. Penile size and the ‘small penis syndrome.’ BJU Int. 2007;99(6):1449–55.17355371 10.1111/j.1464-410X.2007.06806.x
26. Walther A Rice T Eggenberger L Precarious manhood beliefs are positively associated with erectile dysfunction in cisgender men Arch Sex Behav 2023 52 7 3123 3138 10.1007/s10508-023-02640-4 37351710
Walther A, Rice T, Eggenberger L. Precarious manhood beliefs are positively associated with erectile dysfunction in cisgender men. Arch Sex Behav. 2023;52(7):3123–38.37351710 10.1007/s10508-023-02640-4
27. A. P. A. APA. DSM 5 diagnostic and statistical manual of mental disorders. in DSM 5 Diagnostic and statistical manual of mental disorders, 2013, pp. 947-p.
28. Veale D Gledhill LJ Christodoulou P Hodsoll J Body dysmorphic disorder in different settings: a systematic review and estimated weighted prevalence Body Image 2016 18 168 186 10.1016/j.bodyim.2016.07.003 27498379
Veale D, Gledhill LJ, Christodoulou P, Hodsoll J. Body dysmorphic disorder in different settings: a systematic review and estimated weighted prevalence. Body Image. 2016;18:168–86.27498379 10.1016/j.bodyim.2016.07.003
29. Bowyer L Krebs G Mataix-Cols D Veale D Monzani B A critical review of cosmetic treatment outcomes in body dysmorphic disorder Body Image 2016 19 1 8 10.1016/j.bodyim.2016.07.001 27517118
Bowyer L, Krebs G, Mataix-Cols D, Veale D, Monzani B. A critical review of cosmetic treatment outcomes in body dysmorphic disorder. Body Image. 2016;19:1–8.27517118 10.1016/j.bodyim.2016.07.001
30. Möllmann A, Heinrichs N, Herwig A. A conceptual framework on body representations and their relevance for mental disorders. Front Psychol. 2024;14:1231640.
31. Veale D, Neziroglu F. Body dysmorphic disorder: a treatment manual. John Wiley & Sons, 2010.
32. Levant RF McDermott R Parent MC Alshabani N Mahalik JR Hammer JH Development and evaluation of a new short form of the Conformity to Masculine Norms Inventory (CMNI-30) J Couns Psychol 2020 67 5 622 636 10.1037/cou0000414 32011153
Levant RF, McDermott R, Parent MC, Alshabani N, Mahalik JR, Hammer JH. Development and evaluation of a new short form of the Conformity to Masculine Norms Inventory (CMNI-30). J Couns Psychol. 2020;67(5):622–36. 10.1037/cou0000414.32011153 10.1037/cou0000414
33. Komlenac N Eggenberger L Walther A Maresch F Lamp E Hochleitner M Measurement invariance and psychometric properties of a German-language Conformity to Masculine Norms Inventory among cisgender sexual minority and heterosexually identified women and men Psychol Men Masc 2023 10.1037/men0000429
Komlenac N, Eggenberger L, Walther A, Maresch F, Lamp E, Hochleitner M. Measurement invariance and psychometric properties of a German-language Conformity to Masculine Norms Inventory among cisgender sexual minority and heterosexually identified women and men. Psychol Men Masc. 2023. 10.1037/men0000429.10.1037/men0000429
34. Levant RF Hall RJ Rankin TJ Male role norms inventory-short form (MRNI-SF): development, confirmatory factor analytic investigation of structure, and measurement invariance across gender J Couns Psychol 2013 60 2 228 238 10.1037/a0031545 23421776
Levant RF, Hall RJ, Rankin TJ. Male role norms inventory-short form (MRNI-SF): development, confirmatory factor analytic investigation of structure, and measurement invariance across gender. J Couns Psychol. 2013;60(2):228–38. 10.1037/a0031545.23421776 10.1037/a0031545
35. Komlenac N Hochleitner M Internal structure and invariance analyses across gender of the German-language version of the Male Role Norm Inventory-Short Form Psychol Men Masc 2022 23 1 86 98 10.1037/men0000356
Komlenac N, Hochleitner M. Internal structure and invariance analyses across gender of the German-language version of the Male Role Norm Inventory-Short Form. Psychol Men Masc. 2022;23(1):86–98. 10.1037/men0000356.10.1037/men0000356
36. Holm S A simple sequentially rejective multiple test procedure Scand J Stat 1979 6 2 65 70
Holm S. A simple sequentially rejective multiple test procedure. Scand J Stat. 1979;6(2):65–70.
37. R Core Team. R: A language and environment for statistical computing. 2020, R Foundation for Statistical Computing, Vienna, Austria: 4.0.3. [Online]. Available: https://www.r-project.org/.
38. Revelle W. psych: Procedures for personality and psychological research. 2020, Northwestern University, Evanston, Illinois, USA: 2.1.3. [Online]. Available: https://cran.r-project.org/package=psych.
39. Mangiafico S. rcompanion: Functions to support extension education program evaluation. 2021. 2.4.0. [Online]. Available: https://cran.r-project.org/package=rcompanion.
40. Fox J, Sanford W. An {R} Companion to Applied Regression, Third Edition. 2019, Sage, Thousand Oaks CA. [Online]. Available: https://socialsciences.mcmaster.ca/jfox/Books/Companion/.
41. Wickham H ggplot2: Elegant graphics for data analysis 2016 New York Springer-Verlag
Wickham H. ggplot2: Elegant graphics for data analysis. New York: Springer-Verlag; 2016.
42. Eggenberger L Komlenac N Ehlert U Grub J Walther A Association between psychotherapy use, sexual orientation, and traditional masculinity among psychologically distressed men Psychol Men Masc 2022 23 4 384 10.1037/men0000402
Eggenberger L, Komlenac N, Ehlert U, Grub J, Walther A. Association between psychotherapy use, sexual orientation, and traditional masculinity among psychologically distressed men. Psychol Men Masc. 2022;23(4):384.10.1037/men0000402
43. Ghorbani A Prevalence of elective cosmetic surgery and its relationship with socioeconomic and mental health: a cross-sectional study in west of Iran Health Sci Rep 2022 10.1002/hsr2.872 36268461
Ghorbani A, et al. Prevalence of elective cosmetic surgery and its relationship with socioeconomic and mental health: a cross-sectional study in west of Iran. Health Sci Rep. 2022. 10.1002/hsr2.872.36268461 10.1002/hsr2.872
44. Castle DJ Honigman RJ Phillips KA Does cosmetic surgery improve psychosocial wellbeing? Med J Aust 2002 176 12 601 604 10.5694/j.1326-5377.2002.tb04593.x 12064961
Castle DJ, Honigman RJ, Phillips KA. Does cosmetic surgery improve psychosocial wellbeing? Med J Aust. 2002;176(12):601–4.12064961 10.5694/j.1326-5377.2002.tb04593.x
45. Rief W Buhlmann U Wilhelm S Borkenhagen ADA Brähler E The prevalence of body dysmorphic disorder: a population-based survey Psychol Med 2006 36 6 877 885 10.1017/S0033291706007264 16515733
Rief W, Buhlmann U, Wilhelm S, Borkenhagen ADA, Brähler E. The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med. 2006;36(6):877–85.16515733 10.1017/S0033291706007264
46. Möllmann A Dietel FA Hunger A Buhlmann U Prevalence of body dysmorphic disorder and associated features in German adolescents: a self-report survey Psychiatry Res 2017 254 263 267 10.1016/j.psychres.2017.04.063 28482195
Möllmann A, Dietel FA, Hunger A, Buhlmann U. Prevalence of body dysmorphic disorder and associated features in German adolescents: a self-report survey. Psychiatry Res. 2017;254:263–7.28482195 10.1016/j.psychres.2017.04.063
47. Sarwer DB Female college students and cosmetic surgery: an investigation of experiences, attitudes, and body image Plast Reconstr Surg 2005 115 3 931 938 10.1097/01.PRS.0000153204.37065.D3 15731697
Sarwer DB, et al. Female college students and cosmetic surgery: an investigation of experiences, attitudes, and body image. Plast Reconstr Surg. 2005;115(3):931–8.15731697 10.1097/01.PRS.0000153204.37065.D3
48. Drüge M Rafique G Jäger A Watzke B Prevalence of symptoms of body dysmorphic disorder (BDD) and associated features in Swiss military recruits: a self-report survey BMC Psychiatry 2021 21 1 294 10.1186/s12888-021-03288-x 34098932
Drüge M, Rafique G, Jäger A, Watzke B. Prevalence of symptoms of body dysmorphic disorder (BDD) and associated features in Swiss military recruits: a self-report survey. BMC Psychiatry. 2021;21(1):294.34098932 10.1186/s12888-021-03288-x
49. O’Loughlin JI, Cox DW, Ogrodniczuk JS, Castro CA. Traditional masculinity ideology and psychotherapy treatment outcome for military service veteran men. Psychol Men Masc. 2022.
50. Richard K Molloy S An examination of emerging adult military men: masculinity and US military climate Psychol Men Masc 2020 21 4 686 10.1037/men0000303
Richard K, Molloy S. An examination of emerging adult military men: masculinity and US military climate. Psychol Men Masc. 2020;21(4):686.10.1037/men0000303
51. Waynforth D Delwadia S Camm M The influence of women’s mating strategies on preference for masculine facial architecture Evol Hum Behav 2005 26 5 409 416 10.1016/j.evolhumbehav.2005.03.003
Waynforth D, Delwadia S, Camm M. The influence of women’s mating strategies on preference for masculine facial architecture. Evol Hum Behav. 2005;26(5):409–16.10.1016/j.evolhumbehav.2005.03.003
52. Gangestad SW Thornhill R Facial masculinity and fluctuating asymmetry Evol Hum Behav 2003 24 4 231 241 10.1016/S1090-5138(03)00017-5
Gangestad SW, Thornhill R. Facial masculinity and fluctuating asymmetry. Evol Hum Behav. 2003;24(4):231–41.10.1016/S1090-5138(03)00017-5
53. Borgogna NC McDermott RC Is traditional masculinity ideology stable over time in men and women? Psychol Men Masc 2022 10.1037/men0000393 38250472
Borgogna NC, McDermott RC. Is traditional masculinity ideology stable over time in men and women? Psychol Men Masc. 2022. 10.1037/men0000393.38250472 10.1037/men0000393
54. Levant RF Webster BA Stanley JT Thompson EH The Aging Men’s Masculinity Ideologies Inventory (AMMII): dimensionality, variance composition, measurement invariance by gender, and validity Psychol Men Masc 2020 21 1 46 10.1037/men0000208
Levant RF, Webster BA, Stanley JT, Thompson EH. The Aging Men’s Masculinity Ideologies Inventory (AMMII): dimensionality, variance composition, measurement invariance by gender, and validity. Psychol Men Masc. 2020;21(1):46.10.1037/men0000208
55. Thompson EH Jr Bennett KM Measurement of masculinity ideologies: a (critical) review Psychol Men Masc 2015 16 2 115 10.1037/a0038609
Thompson EH Jr, Bennett KM. Measurement of masculinity ideologies: a (critical) review. Psychol Men Masc. 2015;16(2):115.10.1037/a0038609
56. Levant RF Hall RJ Weigold IK Mccurdy ER Construct validity evidence for the male role norms inventory-short form: a structural equation modeling approach using the bifactor model J Couns Psychol 2016 63 5 534 542 10.1037/cou0000171.supp 27598043
Levant RF, Hall RJ, Weigold IK, Mccurdy ER. Construct validity evidence for the male role norms inventory-short form: a structural equation modeling approach using the bifactor model. J Couns Psychol. 2016;63(5):534–42. 10.1037/cou0000171.supp.27598043 10.1037/cou0000171.supp
57. Peplau LA Frederick DA Yee C Maisel N Lever J Ghavami N Body image satisfaction in heterosexual, gay, and lesbian adults Arch Sex Behav 2009 38 713 725 10.1007/s10508-008-9378-1 18712469
Peplau LA, Frederick DA, Yee C, Maisel N, Lever J, Ghavami N. Body image satisfaction in heterosexual, gay, and lesbian adults. Arch Sex Behav. 2009;38:713–25.18712469 10.1007/s10508-008-9378-1
58. Bonell S Wilson MJ Griffiths S Rice SM Seidler ZE Why do queer men experience negative body image? A narrative review and testable stigma model Body Image 2023 45 94 104 10.1016/j.bodyim.2023.02.005 36867966
Bonell S, Wilson MJ, Griffiths S, Rice SM, Seidler ZE. Why do queer men experience negative body image? A narrative review and testable stigma model. Body Image. 2023;45:94–104.36867966 10.1016/j.bodyim.2023.02.005
59. Schmidt M Taube CO Heinrich T Vocks S Hartmann AS Body image disturbance and associated eating disorder and body dysmorphic disorder pathology in gay and heterosexual men: a systematic analyses of cognitive, affective, behavioral und perceptual aspects PLoS ONE 2022 17 12 e0278558 10.1371/journal.pone.0278558 36472982
Schmidt M, Taube CO, Heinrich T, Vocks S, Hartmann AS. Body image disturbance and associated eating disorder and body dysmorphic disorder pathology in gay and heterosexual men: a systematic analyses of cognitive, affective, behavioral und perceptual aspects. PLoS ONE. 2022;17(12): e0278558.36472982 10.1371/journal.pone.0278558
60. Atkins D Looking queer: body image and identity in lesbian, bisexual, gay, and transgender communities 2012 Routledge
Atkins D. Looking queer: body image and identity in lesbian, bisexual, gay, and transgender communities. Routledge; 2012.
61. Frederick DA Essayli JH Male body image: the roles of sexual orientation and body mass index across five national US studies Psychol Men Masc 2016 17 4 336 10.1037/men0000031
Frederick DA, Essayli JH. Male body image: the roles of sexual orientation and body mass index across five national US studies. Psychol Men Masc. 2016;17(4):336.10.1037/men0000031
62. Levesque MJ Vichesky DR Raising the bar on the body beautiful: an analysis of the body image concerns of homosexual men Body Image 2006 3 1 45 55 10.1016/j.bodyim.2005.10.007 18089208
Levesque MJ, Vichesky DR. Raising the bar on the body beautiful: an analysis of the body image concerns of homosexual men. Body Image. 2006;3(1):45–55.18089208 10.1016/j.bodyim.2005.10.007
63. Kaygalak-Celebi S Kaya S Ozeren E Gunlu-Kucukaltan E Pride festivals as a space of self-expression: tourism, body and place J Organ Chang Manag 2020 33 3 545 566 10.1108/JOCM-01-2019-0026
Kaygalak-Celebi S, Kaya S, Ozeren E, Gunlu-Kucukaltan E. Pride festivals as a space of self-expression: tourism, body and place. J Organ Chang Manag. 2020;33(3):545–66.10.1108/JOCM-01-2019-0026
64. Charmaraman L Hodes R Richer AM Young sexual minority adolescent experiences of self-expression and isolation on social media: cross-sectional survey study JMIR Ment Health 2021 8 9 e26207 10.2196/26207 34524107
Charmaraman L, Hodes R, Richer AM. Young sexual minority adolescent experiences of self-expression and isolation on social media: cross-sectional survey study. JMIR Ment Health. 2021;8(9): e26207.34524107 10.2196/26207
65. Pitts V. In the flesh: The cultural politics of body modification. Springer, 2003.
66. Wingate PR Trans bodies, trans speech Law & Ineq 2023 41 331
Wingate PR. Trans bodies, trans speech. Law & Ineq. 2023;41:331.
67. Halliwell E Dittmar H A qualitative investigation of women’s and men’s body image concerns and their attitudes toward aging Sex Roles 2003 49 675 684 10.1023/B:SERS.0000003137.71080.97
Halliwell E, Dittmar H. A qualitative investigation of women’s and men’s body image concerns and their attitudes toward aging. Sex Roles. 2003;49:675–84.10.1023/B:SERS.0000003137.71080.97
68. Levant R Richmond K Cook S House AT Aupont M The Femininity Ideology Scale: factor structure, reliability, convergent and discriminant validity, and social contextual variation Sex Roles 2007 57 373 383 10.1007/s11199-007-9258-5
Levant R, Richmond K, Cook S, House AT, Aupont M. The Femininity Ideology Scale: factor structure, reliability, convergent and discriminant validity, and social contextual variation. Sex Roles. 2007;57:373–83.10.1007/s11199-007-9258-5
69. Lakkis J Ricciardelli LA Williams RJ Role of sexual orientation and gender-related traits in disordered eating Sex Roles 1999 41 1 1 16 10.1023/A:1018829506907
Lakkis J, Ricciardelli LA, Williams RJ. Role of sexual orientation and gender-related traits in disordered eating. Sex Roles. 1999;41(1):1–16.10.1023/A:1018829506907
70. Fraser S. Cosmetic surgery, gender and culture. Springer, 2003.
71. Davis K Cosmetic surgery as feminist utopia? Eur J Womens Stud 1997 4 1 23 37 10.1177/135050689700400103
Davis K. Cosmetic surgery as feminist utopia? Eur J Womens Stud. 1997;4(1):23–37.10.1177/135050689700400103
72. Braun V The women are doing it for themselves’ the rhetoric of choice and agency around female genital ‘cosmetic surgery Aust Fem Stud 2009 24 60 233 249 10.1080/08164640902852449
Braun V. The women are doing it for themselves’ the rhetoric of choice and agency around female genital ‘cosmetic surgery. Aust Fem Stud. 2009;24(60):233–49.10.1080/08164640902852449
73. Leve M Rubin L Pusic A Cosmetic surgery and neoliberalisms: managing risk and responsibility Fem Psychol 2012 22 1 122 141 10.1177/0959353511424361
Leve M, Rubin L, Pusic A. Cosmetic surgery and neoliberalisms: managing risk and responsibility. Fem Psychol. 2012;22(1):122–41.10.1177/0959353511424361
74. Holliday R Elfving-Hwang J Gender, globalization and aesthetic surgery in South Korea Body Soc 2012 18 2 58 81 10.1177/1357034X12440828
Holliday R, Elfving-Hwang J. Gender, globalization and aesthetic surgery in South Korea. Body Soc. 2012;18(2):58–81.10.1177/1357034X12440828
