Implications and recommendations for policy and action
Everyone, whatever their age and background, has the right to feel comfortable and confident in their own body. Yet, as evidenced by our review and the YouGov survey we commissioned for Mental Health Awareness Week 2019, a substantial number of women, LGBT+ people, and, to a lesser extent, men are far from feeling this comfort and confidence.
This includes feelings connected to one of the most natural human processes: pregnancy. Of the 66% of women in our YouGov survey who had been pregnant, 18% said they felt ‘much more negative’ about their bodies after being pregnant than before, and 23% said they felt ‘slightly more negative’.
Overall, the main picture that emerges from our survey is one of societal pressures on body image, driven by the commercial sector, particularly the fashion and cosmetic industries, which predominantly use ‘idealised’ images to sell their products. This is having serious limiting effects on the day-to-day lives of millions and cannot be ignored. Action is needed in many areas; below, we set out the priorities, as we see them, for regulation, policy and practice.
1. Regulatory action
The literature shows that one of the primary drivers of body dissatisfaction is comparing oneself negatively to others based on appearance (40). Exposure to idealised bodies in the media and social media provides significant risk of this (1,20) and of internalising an ‘ideal’ body image that is unrealistic or unattainable.
This social harm has been allowed to develop largely unchecked. Despite some positive initiatives from individual companies, poor practice persists in advertising, and social media companies have been unwilling to take the necessary steps to protect their users from harmful content. Of the 21% (12% of men and 30% of women) of respondents to our survey who said that images used in advertising had caused them to worry about their body image, 72% cited adverts for fashion brands, 46% adverts for weight-loss products/programmes and 31% adverts for cosmetic surgery.
All such industries with the capacity to cause harm need structured regulation. If left unregulated, advertising is driven by incentives to present unattainable ‘idealised’ bodies as aspirational in order to increase the desirability of products or lifestyles. Social media use also carries social incentives for users to present themselves in a positive way, including through photo selection or even image manipulation, which can encourage unhealthy and unrealistic appearance-based comparisons.
Of the respondents to our survey, 59% said that the government needs to do more to protect the public from unhealthy body images in advertising and social media. It is now time for the government to improve regulation to prevent the promotion of harmful body images.
1b. Advertising regulation
The Advertising Standards Authority should consider pre-vetting high reach broadcast adverts from high-risk industries – such as cosmetic surgery companies and weight-loss products and services – to ensure that all advertising that reaches the public abides by its codes. It should also make greater use of its ability to proactively instigate investigations.
Advertising, both online and offline, is regulated by the Advertising Standards Authority (ASA). The ASA is a strong example of industry self-regulation and the vast majority of advertisers abide by its codes and rulings. Last year, the ASA upheld the Mental Health Foundation’s complaint in connection with cosmetic surgery adverts during ITV’s Love Island programme (165). Application of the ASA’s social responsibility code prevents advertisers from using models in a way that makes them look unhealthily thin or from presenting unhealthy body images as aspirational (166). This avoids some of the pitfalls of using a BMI-based approach, which has been taken in some other countries, and captures the use of photo editing and lighting. However, our YouGov survey finding that 21% of UK adults worried about their body image because of images used in advertising shows that there is still room to improve.
While the ASA has existing codes and guidelines on body image, adverts can be in circulation for a long time before the ASA receives complaints and makes a ruling. This means that harmful adverts can achieve significant reach and therefore spread significant harm before they are taken down. The ASA should make greater use of its ability to pre-vet advertising and proactively instigate investigations. The ASA should also consider extending its power to pre-vet non-broadcast advertising to broadcast advertising, and pre-vet all adverts from high-risk industries, such as cosmetic surgery companies and weight-loss products and services, to ensure all advertising that reaches the public abides by its codes.
2. Industry action
In order to achieve meaningful cultural change, industry has a responsibility to work together to find solutions that go beyond regulatory efforts to minimise the negative consequences of advertising and social media.
2a. Diversity in media
Social media companies should sign the Be Real Campaign’s Body Image Pledge and investigate innovative ways of using their platforms to promote positive body image and to ensure that a diversity of body types is presented positively to their users.
One potential way to lessen the impact of advertising on body image is to achieve greater exposure to diversity in media and advertising. This is an area where industry collaboration could be particularly meaningful.
We recommend that DCMS convenes roundtable meetings with advertisers, broadcasters, and body image campaigners to explore ways to promote diversity in advertising and media and to widen sign-up to the Be Real Campaign’s Body Image Pledge (152).
The Online Harms White Paper should be an opportunity for government to engage with social media companies that have so far been reluctant to acknowledge their role in causing and preventing harm online. It is a welcome first step to compel companies to recognise that they have a duty of care to their users, but change will be most effective if social media companies are fully engaged in the process.
The causes of body image dissatisfaction are multifactorial and complicated, and regulation is not going to be able to capture all the drivers of poor body image. Social media carries the potential to deliver some innovative solutions to the problem above and beyond what is possible through the application of sanctions alone. Social media companies should investigate positive and innovative ways of promoting healthy body image and protecting their users from body-image-related harm.
2b. Discrimination and stigma
Social media companies should have clear systems for users to report bullying and discrimination and targets for action to be taken. Social media platforms should give users greater control over the content they see and create accessible tutorials to show users how to exercise this control.
Our review of the literature found that stigma and shaming, including through appearance-based bullying, puts people at greater risk of experiencing body dissatisfaction. Discrimination, stigma and shaming disproportionately affect people from minority ethnic groups, LGBT people, people in later life, people with disabilities, and people who are overweight and obese. Stigma and shaming can take direct forms, such as bullying and appearance-based teasing, as well as more indirect forms, such as unaccommodating environments and isolating behaviour.
The growth of online life, and particularly social media, has increased exposure to experiences of bullying and discrimination. As digital citizens, people have a right to expect freedom from bullying and discrimination online, as well as a responsibility to treat others well. As part of the Online Harms White Paper process, social media companies should be expected to have clear systems for users to report bullying and discrimination and effective means to take down offending content. Users should have greater control over the content they see and should be able to hide likes and comments, as well as filter content that they consider undesirable.
3. Healthcare and public health action
3a. Training of frontline practitioners
Training for GPs, health visitors, dietitians and other frontline practitioners advising parents and carers on both parenting and healthy eating should include information about how parents and carers can, from a very early age, positively influence their children’s feelings about their bodies through the behaviours and attitudes they express when they are with them. Training on this issue should also be given to the early years childcare workforce, including childminders, nursery nurses, nannies and others who care for young children in loco parentis, whose comments and behaviours are also strongly likely to influence young children’s developing sense of their bodies.
Our survey found that ‘things my family have said’ were the third most likely factor to have caused teenagers to worry in relation to their body image. Overall, 29% of teenagers aged 13–19 said this. The figure was much higher for girls (37%), but it also affected 21% of boys. Our internalised feelings about our body develop from a very early age, and, as our report shows, parents’ behaviours and attitudes in relation to diet, weight and body shape have a powerful influence on their children’s feelings about their bodies and themselves.
The advice parents receive should focus on using simple evidence-based phrases, techniques and behaviours that have been shown to increase body esteem and reduce the potential for harm and can be built into their everyday interactions with their children, starting from an early age and continuing through their childhood and adolescence (153). A public health approach to promoting positive body image therefore needs to start early in life. It must recognise that our body image and body esteem is formed, to a large extent, by the attitudes to food, weight and body shape of those closest to us, and their associated behaviours. The influence of those closest to us can be both direct (in comments they make to and about us), and indirect (in comments made about themselves and others, and associated behaviours) and this influence continues in later childhood and adolescence.
3b. Supporting those in crisis and distress
Children and adults in distress should receive fast and empathetic support when they need it, regardless of where they live in the country.
Research suggests that young adults with negative body image concerns are more likely to self-harm and/or experience depression, anxiety and suicidal feelings (33,167). We know that people often face barriers in receiving the right support when they need it. All parts of the UK should learn from the Distress Brief Intervention model currently being piloted in five sites across Scotland, which enables front line services to provide a consistent, compassionate response to people presenting in distress (168). While this is an adult service, we support efforts to lower the age criteria with a view to widening access.
Often, young people’s existing support networks – their families, schools and peers – will provide the most effective support and a nurturing environment. However, we need new thinking and innovation, alongside investment, to revolutionise how young people, who are struggling but fall below the threshold for the specialist mental health treatment provided by CAMHS are supported by people in youth and community settings. More must be done to lessen the impact of early experiences of poor mental health and help those who are struggling to adopt positive help-seeking strategies.
3c. Obesity campaigns
Public campaigns focusing on nutrition, obesity and being overweight should avoid the potential to create stigma and indirectly contribute to appearance-based bullying by not making weight the main focus of their messages. Instead, they should focus on healthy eating and exercise for all members of the population, regardless of weight.
The prevalence of obesity in the population is a major public health concern (169,170) and we support efforts to improve the physical health of people with mental health problems, who, according to research, will die, on average, 20 years younger than the rest of the population. However, much less attention has been paid to the psychological and cultural impact of this increasing focus on people’s weight and size. The NHS, national governments and public health bodies across the UK should actively consider these effects when developing their campaigns and other messaging on obesity (71,72).
This should include consideration of the psychological effects on children of child measurement programmes in schools, and their influence on how parents respond to and interact with their children about their weight.
3d. Education, schools and media literacy
A body image and media literacy toolkit, co-produced by young people, should be a compulsory element of what children learn in schools. This should include the development of a charter for achieving a healthy and positive body image. In England, we recommend that this is used within the new Health Education Curriculum being introduced in September 2020. In Scotland, the Scottish Government should implement this as part of its ongoing personal and social education (PSE) review.
Our education system must do more to address some of the root causes of emotional distress in children and young people, and we know that body image is a concern, with 35% of 13–19- year-olds telling us that it always or often causes them to worry. We previously highlighted this as part of our Make it Count campaign.
Media literacy can help young people critically explore the influences of popular culture on everyday life. For example, pupils could be encouraged to discuss and question the objectives of media products such as adverts or magazines, considering the techniques that are used, their target audiences and commercial ambitions. The image of perfection that is often portrayed by advertising and social media platforms can be challenged by exposing their hidden motivations and helping young people identify the overt and more coded messages that might be detrimental to their self-esteem, especially on how genders are objectified and stereotyped.
A body image and media literacy toolkit could also address the negative consequences of comparing ourselves to idealised, often ‘perfected’, images, as well as unhealthy comparisons with peers. In our survey, over half (53%) of 18–24-year-olds reported that they compared themselves negatively to others because of their body image – a statistic that is higher than in any older age group. Pupils could be shown how to become more aware of when they are comparing themselves to others, both online and offline, and consider the length of time they spend doing it and whether the content is an accurate portrayal of reality. The PSHE Association, Be Real Campaign, and National Citizen Service have all created toolkits and guidance on teaching about body image (3, 171–173). We have created a body image module to add to our UK Peer Education Project (174) and our Scottish Stress Less programme, which run in secondary schools (175).
In addition to developing pupils’ media literacy through the curriculum, it’s also important to embed a range of mental health support workers, including counsellors and family liaison workers, in every school to provide children and young people with a safe and trusted space in which to discuss their feelings. Encouraging young people to express concerns about their body image and the way that they look is an important first step in valuing who they are as a person and acknowledging the importance of their non-appearance-based traits as a way to boost their self-esteem.
As bullying often starts early in life, early intervention in schools can be an effective way to reduce the impact of appearance-based bullying on people’s body image and wider mental health, and this should be an explicit focus of programmes to tackle bullying. Schools should also seek to identify the root causes of bullying behaviour, which can often present as a result of a bully’s own unmet needs.
Beyond the school gate, while it’s crucial that we continue to invest in specialist service provision, we also need to prioritise the right early intervention services for young people who begin to struggle. We need to do more to lessen the impact of early experiences of poor mental health and help those who are struggling to adopt positive help-seeking strategies.