BACKGROUND: Transgender women suffer a great deal of self-reported anxiety and concern about their facial appearance as they may readily be identified by observers as "trans" when they would prefer to be interpreted solely as women. Little is known about the psychological distress that transgender individuals experience in their decision to undergo major aesthetic plastic surgery as a result of their appearance concern. As such, it remains unknown whether transgender individuals experience improved appearance anxiety and a greater quality of life following facial feminization surgery. AIMS: The objective of this study is to determine, using the Derriford Appearance Scale 24, whether any improvement can be seen among transgender patients in their level of appearance anxiety following facial feminization surgery. We also aim to look at whether additional improvements can be seen in the quality of life of transgender patients. METHODS: A prospective study was conducted on patients undergoing facial feminization surgery. The outcome measure used was the Derriford Appearance Scale 24. The Derriford Appearance Scale 24 was given to transgender patients to fill out at the end of their pre-operative visit before their schedule facial feminization surgery. The scale was then also administered three weeks following surgery and three months following surgery, via the Internet. RESULTS: Twenty-four patients were enrolled. Of these, fourteen patients completed at least one of the surveys, post-operatively; twelve patients completed all three surveys. Of those patients who completed at least two out of the three surveys, scores revealed that 85% of transgender patients displayed higher levels of psychological distress when completing the first survey, preoperatively, than in subsequent post-operative surveys. CONCLUSIONS: Transgender individuals enrolled in the study showed decreased levels of distress both three weeks after surgery and three months after surgery. These results were promising in displaying amelioration of appearance anxiety following facial feminization surgery. Though results show increased quality of life, the degree of impact that gender confirming facial features may have on quality of life for transgender patients has yet to be assessed.

The aims of the studies were to assess body image perceptions, the role of stress and other possible associated psychopathologies within a non-clinical sample. The prevalence of body image concern is increasing and is widely considered as secondary to evolving socio-cultural trends. Negative self-perceptions about body image can be manifest as measurable indicators of physiological stress, or even psychopathology. This thesis describes two quantitative studies into the role and relevance of various causative factors in the development of negative body image in cohorts of volunteers drawn from the general population of the University of Bradford in West Yorkshire, UK. In Study One, subjects (n=360) completed a self-directed questionnaire that psychometrically measured satisfaction/dissatisfaction with personal appearance, queried which external sources influenced those opinions, and correlated these with demographic information. In particular, we sought to examine how a subject's opinion about their personal appearance varied with age, gender, ethnicity, mental health, relationship status, sexual orientation and Body Mass Index (BMI). Subjective views regarding personal appearance were determined by answers given to specific body image questions that revealed a subject's day-to-day appearance concerns, all preoccupations, and the extent to which these concerns resulted in distress, all social impairment. Overall, the results demonstrated that BMI values were positively correlated with personal appearance concerns. High BMI values correlated with greater dissatisfaction with personal appearance. Self ratings of appearance values were negatively correlated with BMI scores. Subjects who gave themselves high appearance ratings were relatively unaffected by media influence with regard to their image, compared to subjects rating themselves less attractive. These latter subjects also showed higher peer pressure scores in terms of both the amount of time they compared themselves to peers, and the degree to which peer comparisons affected their self-appearance ratings. Based on responses to the body image questions specifically, the entire cohort of subjects were categorised into principal clusters: those largely unaffected by any body image concerns; and those profoundly distressed by their self assessed body image. Perhaps the most interesting aspect of these findings is that the scores for this latter (n=17) group of subjects on the body image questions revealed a degree of personal distress this is almost identical to the scores expected from those people diagnosed with body dysmorphic disorder (BDD). Collectively, these results suggest that high BMI values in subjects negatively impact on self-appearance ratings, render subjects more prone to media messages that portray body image ideals, and elicit frequent comparisons with peers to validate self-image concerns. Furthermore, severely affected subjects with high BMI scores may show similar psychopathology to that of BDD sufferers. In Study Two, a small cohort of subjects (n=60) were given questionnaires and were interviewed to further investigate self-appearance ratings and mood/depressive traits. The body image questions used in Study One to assess image concerns and the magnitude of distress were repeated in Study Two. Mood and depressive state were measured using the validated Beck's Depression Inventory (BDI). In parallel, subjects completed the Derriford Appearance Scale 59 (DAS 59), which is a valid psychometric indication of an individual's perception of their appearance as 'normal' or 'disfigured', and used as a tool by plastic surgeons to inform decisions regarding the necessity for surgery to correct an individual's appearance. Physiological markers were recorded before and after exposure of subjects to a physical and a psychological stressor: these were saliva concentrations of cortisol and sIgA (an immune marker), blood glucose and blood pressure. The results of Study Two revealed no changes in scores for any of the physiological measures following stressors. BDI scores for most subjects fell within normal ranges, although females scored higher than males, but not at a pathological level. Those subjects with a history of mental illness or those who reported feeling a high degree of stress on a daily basis, or those who expressed greater self-appearance concerns, all had significantly elevated BDI values. Perhaps the most intriguing finding from Study Two, as in Study One, was that subjects again tended to fall within specific categories for body image concerns: those unaffected or minimally affected by body image concerns, and those (n=6) greatly and deleteriously affected by body image concerns. This subsection of subjects also scored very high on the DAS 59 for disfigurement. On the basis of these findings it would seem that body image concerns may be severe enough for some individuals for them to perceive themselves as actually being disfigured, or that the DAS 59 (a widely used assessment tool in plastic surgery), may not be entirely appropriate for assessment of an individual's need for surgery because it cannot distinguish between those genuinely disfigured and those merely expressing severe body image concerns.

The aims of the studies were to assess body image perceptions, the role of stress and other possible associated psychopathologies within a non-clinical sample. The prevalence of body image concern is increasing and is widely considered as secondary to evolving socio-cultural trends. Negative self-perceptions about body image can be manifest as measurable indicators of physiological stress, or even psychopathology. This thesis describes two quantitative studies into the role and relevance of various causative factors in the development of negative body image in cohorts of volunteers drawn from the general population of the University of Bradford in West Yorkshire, UK. In Study One, subjects (n=360) completed a self-directed questionnaire that psychometrically measured satisfaction/dissatisfaction with personal appearance, queried which external sources influenced those opinions, and correlated these with demographic information. In particular, we sought to examine how a subject¿s opinion about their personal appearance varied with age, gender, ethnicity, mental health, relationship status, sexual orientation and Body Mass Index (BMI). Subjective views regarding personal appearance were determined by answers given to specific body image questions that revealed a subject¿s day-to-day appearance concerns, all preoccupations, and the extent to which these concerns resulted in distress, all social impairment. Overall, the results demonstrated that BMI values were positively correlated with personal appearance concerns. High BMI values correlated with greater dissatisfaction with personal appearance. Self ratings of appearance values were negatively correlated with BMI scores. Subjects who gave themselves high appearance ratings were relatively unaffected by media influence with regard to their image, compared to subjects rating themselves less attractive. These latter subjects also showed higher peer pressure scores in terms of both the amount of time they compared themselves to peers, and the degree to which peer comparisons affected their self-appearance ratings. Based on responses to the body image questions specifically, the entire cohort of subjects were categorised into principal clusters: those largely unaffected by any body image concerns; and those profoundly distressed by their self assessed body image. Perhaps the most interesting aspect of these findings is that the scores for this latter (n=17) group of subjects on the body image questions revealed a degree of personal distress this is almost identical to the scores expected from those people diagnosed with body dysmorphic disorder (BDD). Collectively, these results suggest that high BMI values in subjects negatively impact on self-appearance ratings, render subjects more prone to media messages that portray body image ideals, and elicit frequent comparisons with peers to validate self-image concerns. Furthermore, severely affected subjects with high BMI scores may show similar psychopathology to that of BDD sufferers. In Study Two, a small cohort of subjects (n=60) were given questionnaires and were interviewed to further investigate self-appearance ratings and mood/depressive traits. The body image questions used in Study One to assess image concerns and the magnitude of distress were repeated in Study Two. Mood and depressive state were measured using the validated Beck¿s Depression Inventory (BDI). In parallel, subjects completed the Derriford Appearance Scale 59 (DAS 59), which is a valid psychometric indication of an individual's perception of their appearance as ¿normal¿ or ¿disfigured¿, and used as a tool by plastic surgeons to inform decisions regarding the necessity for surgery to correct an individual's appearance. Physiological markers were recorded before and after exposure of subjects to a physical and a psychological stressor: these were saliva concentrations of cortisol and sIgA (an immune marker), blood glucose and blood pressure. The results of Study Two revealed no changes in scores for any of the physiological measures following stressors. BDI scores for most subjects fell within normal ranges, although females scored higher than males, but not at a pathological level. Those subjects with a history of mental illness or those who reported feeling a high degree of stress on a daily basis, or those who expressed greater self-appearance concerns, all had significantly elevated BDI values. Perhaps the most intriguing finding from Study Two, as in Study One, was that subjects again tended to fall within specific categories for body image concerns: those unaffected or minimally affected by body image concerns, and those (n=6) greatly and deleteriously affected by body image concerns. This subsection of subjects also scored very high on the DAS 59 for disfigurement. On the basis of these findings it would seem that body image concerns may be severe enough for some individuals for them to perceive themselves as actually being disfigured, or that the DAS 59 (a widely used assessment tool in plastic surgery), may not be entirely appropriate for assessment of an individual's need for surgery because it cannot distinguish between those genuinely disfigured and those merely expressing severe body image concerns.