body image and social media research paper

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Social Media Use and Body Image Disorders: Association between Frequency of Comparing One’s Own Physical Appearance to That of People Being Followed on Social Media and Body Dissatisfaction and Drive for Thinness

Barbara jiotsa.

1 Addictology and Liaison Psychiatry Department, Nantes University Hospital, 44000 Nantes, France; [email protected] (B.J.); [email protected] (B.N.); [email protected] (B.R.)

Benjamin Naccache

Mélanie duval.

2 Public Health Department, Nantes University Hospital, 44000 Nantes, France; [email protected]

Bruno Rocher

Marie grall-bronnec.

3 Inserm UMR 1246, Nantes and Tours Universities, 44200 Nantes, France

Associated Data

The data presented in this study are available on request from the corresponding author.

(1) Summary: Many studies have evaluated the association between traditional media exposure and the presence of body dissatisfaction and body image disorders. The last decade has borne witness to the rise of social media, predominantly used by teenagers and young adults. This study’s main objective was to investigate the association between how often one compares their physical appearance to that of the people they follow on social media, and one’s body dissatisfaction and drive for thinness. (2) Method: A sample composed of 1331 subjects aged 15 to 35 (mean age = 24.2), including 1138 subjects recruited from the general population and 193 patients suffering from eating disorders, completed an online questionnaire assessing social media use (followed accounts, selfies posted, image comparison frequency). This questionnaire incorporated two items originating from the Eating Disorder Inventory Scale (Body Dissatisfaction: EDI-BD and Drive for Thinness: EDI-DT). (3) Results: We found an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and body dissatisfaction and drive for thinness. Interestingly, the level of education was a confounding factor in this relationship, while BMI was not. (4) Discussion: The widespread use of social media in teenagers and young adults could increase body dissatisfaction as well as their drive for thinness, therefore rendering them more vulnerable to eating disorders. We should consequently take this social evolution into account, including it in general population prevention programs and in patients’ specific treatment plans.

1. Introduction

Body image is defined as one’s perception, thoughts, and emotions revolving around one’s own body. It is the depiction of one’s body representation, including their mirror reflection, and it reflects social constructs, which depend on a society’s culture and norms. This conception is created using body ideals, substantially communicated via media, family, and peers.

For the last 30 years, media have been over-exposing people to thinness ideals, starting from a young age [ 1 ], turning this ideal into a new reference standard [ 2 ]. Young women, who are most sensitive to thinness ideals, tend to liken them to beauty and success [ 3 ]. Thus, etiologic models incorporating environmental factors consider social pressure about physical appearance to be a determining factor in developing eating disorders (EDs) [ 4 , 5 ].

However, even though this social pressure is indisputable, not all people are vulnerable to it. It is the degree with which they will relate to these thinness standards, namely how they internalize this ideal, that will help to predict the risk of developing an ED [ 6 ]. Indeed, internalizing thinness standards can lead to an alteration in body image, resulting in body dissatisfaction and exaggerated concerns about body and weight [ 4 ]. Body dissatisfaction is characterized by an inconsistency between one’s real body and the idealized body. It is one of the most studied psychological constructs in body image disorders literature [ 4 , 7 , 8 , 9 ]. According to the literature, it is often linked to psychological distress [ 10 , 11 ] and is a proven risk factor for developing an ED [ 12 , 13 ], through, in particular, the implementation of food restriction that can lead to anorexia nervosa (AN) [ 14 , 15 ] or to the onset of binge eating episodes (with or without compensatory behaviors to prevent weight gain). According to several authors, body dissatisfaction found in AN patients differs from that of control subjects by a greater feeling of inconsistency between their actual body and the desired body [ 16 ]. Indeed, in addition to overestimating the size of their actual shape, AN patients seek to resemble an ideal significantly thinner than subjects without EDs do. People with AN and bulimia nervosa share the same body image obsession, with the pervasive fear of gaining weight [ 4 ]. Finally, subjects with binge eating disorders tend to be overweight, or even obese, which can reinforce body dissatisfaction [ 17 ].

Social comparison, combined with the internalization of ideals, is one of the main mechanisms participating in one’s body image perception. These two mechanisms are instrumental in developing body dissatisfaction [ 1 , 18 , 19 ]. Several studies have shown that individuals who compare their physical appearance to that of others they considered to be more attractive than them, such as models or celebrities, had a higher chance of being dissatisfied with their body image and developing an ED [ 20 , 21 , 22 , 23 ].

Although historically speaking, body norms have been mainly conveyed through traditional media (TV, radio, newspaper, magazines), the last few years have borne witness to the rise and expansion of social media use. The term “social media” refers to every website and online mobile app with user-generated content. They enable their users to participate in online exchanges, broadcast self-made content, and join virtual communities. They are mostly used by teenagers and young adults, and the most common ones are Facebook, Instagram, Snapchat, and Twitter. Several studies have suggested that social media exposure could foster body dissatisfaction and result in risky eating behaviors by broadcasting thinness ideals individuals thus long for [ 18 , 24 , 25 ]. Among the identified mechanisms that explain this outcome, the most common ones are social comparison based on physical appearance and thinness ideals’ internalization through daily exposure to idealized bodies. Indeed, physical appearance holds a central place in social media today [ 26 ].

There is, to this day, a lack of scientific data, and in particular French data, about the association between the use of social media and risky eating behaviors [ 27 ]. In this context, this study’s main objective was to study the association between, on one hand, daily exposure to idealized bodies through social media and, on the other hand, the presence of two dimensions fostering body image disorders: body dissatisfaction and drive for thinness. A secondary objective was to compare two populations, one with a risk of suffering from ED, and the other one free of that risk, using different variables. The hypothesis was that at-risk participants were more dissatisfied with their physical appearance, had a higher drive for thinness, and compared themselves more often to social-media-conveyed images.

2. Materials and Methods

2.1. study design and ethics statements.

This is a transversal observational study. Participants had to answer a questionnaire available online. Since it was an investigation involving the health field, but with an objective that did not involve the developing of biological or medical knowledge, it not fit in the French Jardé legal framework (and thus, approval from an ethics committee was not required). Data collection was made anonymously, was digitalized, and was realized outside of a care setting. Answering the questionnaire was interpreted as consent for data use, as it displayed that the results would be used in a survey, but that the participation would be anonymous, and that there were no data that would lead them to be recognized should they decide to participate.

2.2. Participants Recruitment

The study’s general population participants were enlisted via a social media publication (Facebook, Instagram, Twitter) and via posters in gyms. These posters were also sent to health workers with a practice in Nantes and in different French cities (psychiatrists, GPs, psychologists, etc.), who were tasked with informing their ED patients about this study. The Fédération Française Anorexie Boulimie (FFAB, French Federation for Anorexia and Bulimia), which is an association regrouping professionals working in the ED field, helped to broadcast the questionnaire using mailing lists, social media, and websites. Recruitment occurred between September 2019 and December 2019.

The inclusion criteria were as follows: using their Facebook and/or Instagram account daily and being 15 to 35 years old. This age range was chosen in light of the current literature, which shows that use of social media and body image concerns involved mainly teenagers and young people [ 28 , 29 ]. Moreover, participants recruited via a health professional had to register their ED diagnosis for which they were treated.

2.3. Evaluation

2.3.1. general data.

The questionnaire’s first part was designed to register sex, age, degrees, and current height and weight to measure body mass index (BMI).

2.3.2. Social Media Use

The questionnaire’s second part interrogated the participants about their use of social media: platform, frequency (number of uses per day), time spent (hours per day), frequency of comparing one’s physical appearance to that of people followed on social media, and the frequency of posting “selfies” (a photograph that you take of yourself).

2.3.3. Body Image

The questionnaire’s third part evaluated body image perception, using the Eating Disorder Inventory-2 (EDI-2) scale, translated and adapted in French [ 30 , 31 ]. It is a self-rated questionnaire evaluating psychological characteristics and symptoms associated with ED, using 11 subscales. We used the “Drive for Thinness” subscale (EDI-DT), composed of 7 questions (score of 0 to 21), and “Body Dissatisfaction” subscale (EDI-BD), composed of 9 questions (score of 0 to 27). The subscales are presented in Table 1 .

Drive for Thinness and Body Dissatisfaction subscales of Eating Disorder Inventory-2.

2.3.4. ED Screening

The questionnaire’s last part aimed at screening ED, using the Sick-Control-One Stone-Fat-Food (SCOFF) self-questionnaire. It is a simple survey of 5 questions used to screen eating disorders in general population [ 32 ]. The French validation depicted this questionnaire to be as efficient and relatable as the original, with a great sensitivity and specificity in diagnosing ED when a patient has a score of 2 or over [ 33 ]. It enabled us to sort the population sample into two groups depending on their risk of having an ED: when their score was ≥2, they were sorted in the “SCOFF positive” group, and when their score was <2, in the “SCOFF negative” group. The SCOFF questionnaire is presented in Table 2 .

Sick-Control-One Stone-Fat-Food (SCOFF) questionnaire.

Yes = 1 point; score of ≥2 suggests an eating disorder.

2.4. Statistical Analysis

A descriptive statistical analysis was conducted for the entire sample. Continuous variables are described by means and standard deviations, while categorical variables are presented as numbers and percentages.

We asked all participants to complete the SCOFF questionnaire, so that they were sorted into two groups depending on their results: the “SCOFF+” group gathering all participants with a SCOFF score of 2 or over, and therefore with the risk of suffering from an ED, and the “SCOFF−” group gathering all participants with a SCOFF score under 2. These two groups were then compared based on all collected variables. We applied a Student’s t -test for quantitative variables (“age”, “EDI-BD”, “EDI-DT”, and “average BMI”), a Chi-squared test for qualitative variables (“sex”, “level of education”, “social media use frequency”, “time spent”, “body comparison”, “groups of BMI”), and Fisher exact test for multimodal qualitative variables whose theoretical headcount did not allow the use of the Chi-squared test (“posting selfies”).

Then, we looked for an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and the scores measured using the EDI Body Dissatisfaction and Drive for Thinness subscales. We thus performed two linear regressions with adjustment for two potential confounding factors (BMI and level of education). Confounding factor status was assessed by searching for an association of the two variables with EDI subscores on the one hand and with the frequency of comparing one’s own physical appearance to that of people followed on social media on the other hand.

The significance threshold for all these analyses was set at p = 0.05 (α risk of 5%).

Statistical analyses were done using the SPSS software (Statistical Package for Social Science, IBM, Armonk, NY, USA).

3.1. Population Description

In total, 1407 questionnaires were completed, and 1331 were analyzed. A total of 1138 subjects were from the general population, and 193 were ED patients recruited via health workers. Seventy-six completed questionnaires (5.4%) were excluded from the analysis because they did not match the age criteria or because their ED diagnosis was not communicated (for ED patients recruited via health workers). Figure 1 represents the study’s flowchart.

Flow chart of subjects’ inclusion.

The participants’ age ranged from 15 to 35 (M = 24.2, σ = 4.2). Most were women (97.7%). They had, for the most part, a Bachelor’s degree. Mean BMI was 22.3 (σ = 4.2).

Table 3 presents the final sample’s characteristics.

Final sample characteristics and comparison between SCOFF+ and SCOFF− groups.

Note. BDI: body mass index; EDI-IC: Eating Disorder Inventory—Body Dissatisfaction; EDI-RM: Eating Disorder Inventory—Drive for Thinness. *: p < 0.05; **: p < 0.01; ***: p < 0.001. According to the International Classification of Diseases, anorexia nervosa is associated with a BMI < 17.5.

Most participants declared using Facebook (93%) and Instagram (92.8%). Other social media were less frequently used: Snapchat (68.4%), Twitter (29.1%), and Tiktok (2.5%).

In total, 57.3% of participants had a private account and 42.7% an account open to the public. Users declared that they used social media mainly to “like posts” (82.7%) and to “observe content, as ghost followers (bots or inactive accounts)” (65.4%). In total, 92.7% said that they used social media to “follow friends and acquaintances”, “follow healthy food content” (68%), “follow the news” (67%), and “follow fitness content” (61.2%).

Regarding participants recruited via health workers for whom data were analyzed (N = 193), the most frequently reported ED was anorexia nervosa restricting type (41%), followed by anorexia nervosa purging type (28%), binge eating disorder (16%), bulimia nervosa (12%), and unspecified feeding or eating disorder (9%).

3.2. Comparing Participants Based on Their ED Screening

The final sample was sorted into two groups according to the SCOFF’s results ( n = 953 in the SCOFF+ group; n = 378 in the SCOFF− group). These groups were compared using all described variables, and the results are showcased in Table 3 .

SCOFF+ group subjects had a significantly higher social media use (regarding both frequency and time spent), a significantly higher frequency of comparing their physical appearance to that of people they followed, and of posting selfies.

In addition, they declared having significantly higher EDI-BD and EDI-DT scores than SCOFF− subjects ( p < 0.001), and they more frequently had BMI both in the lower and higher ranges.

3.3. Association between the Frequency of Comparing One’s Own Physical Appearance to That of People Followed on Social Media and EDI Body Dissatisfaction and Drive for Thinness

In the search for confounding factors associated with both the frequency of comparing one’s own physical appearance to that of people followed on social media and EDI-BD and EDI-DT scores, we found a significant association between the level of education and the frequency of comparing one’s own physical appearance to that of people followed on social media ( Table 4 ). Similarly, we observed an association between the modality “Level of education ≥12” and EDI-BD: participants with a level of education ≥12 had a mean EDI-BD score 2.5 points lower compared to that of participants with a level of education <12 ( Table 5 ). We also found a similar association between the modality “Level of education ≥12” and EDI-DT: participants with a level of education ≥12 had a mean EDI-DT score 3 points lower compared to that of participants with a level of education <12 ( Table 6 ).

Association between level of education and frequency of comparing one’s own physical appearance to that of people followed on social media.

Note. **: p < 0.01.

One-way ANOVA results looking for a link between EDI-BD score and level of education.

Global p -value = 0.1338. Note: The modality “Less than level 12” was chosen as the reference modality for this analysis. *: p < 0.05; ***: p < 0.001.

One-way ANOVA results looking for a link between EDI-DT score and level of education.

Global p -value = 0.0016. Note: The modality “Less than level 12” was chosen as the reference modality for this analysis. ***: p < 0.001.

Furthermore, we did not find any significant association between BMI and the frequency of comparing one’s own physical appearance to that of people followed on social media ( Table 7 ). A significant but very weak correlation (<0.3) was found between the BMI and the two EDI subscores ( Table 8 ). In view of these results, we did not retain BMI as a confounding factor for the following analysis.

One-way ANOVA results looking for a link between BMI and frequency of comparing one’s own physical appearance to that of people followed on social media.

Global p -value = 0.4368. Note: The modality “Never” was chosen as the reference modality for this analysis. ***: p < 0.001.

Results of association between BMI and EDI scores.

Note. EDI-BD: Eating Disorder Inventory—Body Dissatisfaction. **: p < 0.01; ***: p < 0.001.

The results of the search for an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and EDI Body Dissatisfaction and Drive for Thinness scores are presented in Table 9 and Table 10 . As showcased in Table 9 , the “Sometimes”, “Often”, and “Always” frequency of comparing modalities were significantly associated with the EDI-DT score. Participants who sometimes compared their own physical appearance to that of people followed on social media had a mean EDI-DT score 2.0 points higher than that of those who never compared themselves; those who often compared themselves had a mean EDI-DT score 5.3 points higher; and those who always compared themselves had a mean EDI-DT score 8.4 points higher.

Linear regression looking for a link between EDI-DT score and frequency of comparing one’s own physical appearance to that of people followed on social media.

Global p -value <2.2 × 10 −16 ***. Note: Modalities “Less than level 12” and “Never” were chosen as the reference modalities for this analysis. *: p < 0.05; **: p < 0.01; ***: p < 0.001.

Linear regression looking for a link between EDI-BD score and frequency of comparing one’s own physical appearance to that of people followed on social media.

Global p -value <2.2 × 10 −16 ***. Note: Modalities “Less than level 12” and “Never” were chosen as the reference modalities for this analysis. *: p < 0.05; ***: p < 0.001.

In addition, according to Table 10 , the “Often” and “Always” frequency of comparing modalities were significantly associated with the EDI-BD score. Participants who often compared their own physical appearance to that of people followed on social media had a mean EDI-BD score 5.6 points higher than that of those who did not, and those who always compared themselves to social media images had an average EDI-BD score 9.2 points higher than that of those who never did.

4. Discussion

4.1. discussing the main results.

Our survey aimed to study the links between social media use, body image disorders, and ED prevalence in a teenage and young adult population.

First, we found that ED or at-risk of ED subjects presented significantly different results concerning all social media use parameters. Using platforms such as Facebook and Instagram has been particularly associated with a higher body dissatisfaction and the appearance of ED symptoms [ 27 , 34 ]. As was expected, in ED or at-risk of ED patients, Body Dissatisfaction rates were higher, as was their Drive for Thinness. A common ED assumption is that ED patients develop a cognitive structure that focalizes on weight, combined with, most of the time, a mistaken perception of their own body image, especially in anorexia nervosa. These subjects tend to yearn for a thinner body ideal than the general population, thus creating a substantial inconsistency between what they think they look like and what they yearn to look like [ 35 ]. Leahey and her colleagues in 2011 [ 36 ] found that, in addition to increasing body dissatisfaction, social comparisons have an influence on negative effects, guilt, as well as diets and physical-activity-centered thoughts.

Participants in general were seldom prone to posting selfies. Ridgway and her colleagues [ 37 ] conducted in 2018 a study on Instagram and posting selfies, which showed that a higher body image satisfaction was associated with an increase in posting selfies. This could explain the low percentage of self-promoting subjects found in this study.

Second, we confirmed the existence of a significant association between, on one hand, the frequency of comparing one’s own physical appearance to that of people followed on social media and, on the other hand, Body Dissatisfaction and Drive for Thinness scores measured using the EDI scale. It seems that the more the subjects compared themselves to the images, the more they increased their body dissatisfaction and their drive for thinness. However, this association can work two ways. Indeed, it could be that the depth of body dissatisfaction and the drive for thinness increase the inclination to compare oneself to images. Our results are in accordance with those found in the literature, which identified a link between social media use and body image disorders [ 26 , 38 , 39 ]. It has also been found that subjects who often compared their physical appearance to that of idealized images were more dissatisfied with their body and had a higher drive for thinness than those who compared themselves less often [ 40 , 41 ]. Interestingly, the level of education was a confounding factor in this relationship, while BMI was not. Indeed, the relation between frequency of comparing one’s own physical appearance to that of people followed on social media on the one hand and EDI DT and BD subscores on the other hand is modified by the level of education, starting from a level corresponding to a Bachelor’s degree (>12 + 3 years).

Self-assessment is a fundamental reflexive analysis tool [ 42 ]. It plays an essential part in self-positioning among others and oneself. This self-evaluation must resort to social comparisons, which have a direct link to self-esteem. Body image’s sociocultural construct takes shape using body ideals that are broadcasted through, in particular, media, family, and peers and are thereafter internalized by individuals [ 43 ]. Reaching these body norms is usually perceived as proof of self-control and success, which leads one to stand out from the crowd in a positive way [ 44 ]. Internalizing body ideals thus creates an authentic concern for one’s physical appearance, which will be observed and judged by others [ 45 ]. This can trigger body dissatisfaction, which usually involves feeling inadequate in one’s body, estranged from the ideal one pursues [ 43 ]. Fear of gaining weight can be exacerbated when thinness is one of narcissism’s only tools. It can lead to behaviors such as food restriction, excessive physical activity, with the aim of modifying one’s appearance and thus fit into social standards. This excessive self-surveillance can bring about emotional and psychological consequences, including shame about one’s own body, self-bashing, anxiety, and depression, up to ED [ 46 ].

Finally, although estimating ED prevalence in a young adult population was not an objective determined beforehand, we must point out that most participants had a SCOFF+ result (71%), suggesting they might suffer from an ED. This questions whether a more systematic ED screening should be done in teenage and young adult populations, which are ED’s main targets. Several studies in which teenagers were interviewed have shown that they often are dissatisfied with their bodies, feeling like they are “too fat”, and most of them have already followed a diet [ 47 , 48 , 49 ]. These diets can include ingesting smaller portions, eating healthier food, up to major food restrictions and complete removal of some types of food, which can be found in ED.

4.2. Study’s Strengths and Weaknesses

There are several limits to this study. First, it is a transversal study, which cannot prove the existence of a causal relationship between the studied variables. Therefore, longitudinal studies are necessary in finding out how this association works. Second, the online questionnaire was not designed to collect data that could be considered as indicators of individual or family vulnerabilities for ED, which did not allow for stratified analyses. Third, measuring the time spent on social media and how often participants used it was done through self-reported data, which could induce a declaration bias, thus limiting the data’s precision. Future studies could use technologies such as data tracking (virtual counter measuring connection frequency and time spent) in order to have more precise data and thus be more confident in the data’s reliability. Fourth, the participants’ recruitment induced a selection bias. Indeed, having used daily use of social media as an inclusion criterion leads to selecting a certain type of population and renders irrelevant any extrapolation to the general population. Moreover, recruiting via gyms may have led to selecting individuals with a specific concern for their body image. We can assume that these subjects, who paid specific attention to their physical appearance, might have certain demands concerning themselves, which might involve body dissatisfaction and an exaggerated drive for thinness. The daily use of social networks could also be a reflection of excessive body concerns, which could lead to more body dissatisfaction and a more pronounced drive for thinness compared to subjects who are less exposed to these kinds of media. Fifth, our participants recruited via health workers may not be representative of all ED patients for several reasons: ED diagnosis was self-reported, anorexia nervosa restricting type was overrepresented in our sample, and the most severe patients may not be psychologically available to participate in a study like this one. Finally, the SCOFF questionnaire is a screening tool and not a diagnostic one. It does not enable discriminating between anorexia nervosa, bulimia nervosa, or binge eating disorder among participants, but we can assume that all types of ED were present in the SCOFF+ group, as the participants in this group more frequently had BMI both in the lower and higher ranges.

However, these limits are balanced by the study’s strengths. First, the sample rallied a significant number of participants, and their sorting into two groups after ED screening was quite proportionate, which ensured the statistical analyses’ power. Second, EDs were screened using a validated tool for the general population, and the Body Dissatisfaction and Drive for Thinness dimensions were evaluated using a self-questionnaire whose psychometric characteristics have been validated in clinical populations. Finally, to the extent of our knowledge, this type of study had never been conducted in France, thus bringing forth unprecedented data.

4.3. Perspectives

This study’s results open new avenues for clinicians to explore social media use and cognitive pathways in ED. Indeed, social media exposure and, in particular, exposure to edited and idealized images could contribute to inaccurate thought processes about body image, internalizing what is socially valued on social media as a personal goal. Since we know that cognitive pathways play an important part in ED development and continuation [ 50 ], it seems relevant to explore patients’ use of social media and the cognitions associated. This could contribute to increasing psychotherapy’s efficacy, enriching prevention programs using cognitive dissonance, therapies that have been proven to be effective in reducing ED symptoms’ intensity [ 51 ]. A way to implement this could be to encourage the development of the ability to question social media, encouraging patients to think of arguments that go against posting idealized photos on social media [ 27 ].

When considering the general population, when we see how important social comparison based on physical appearance is in developing body dissatisfaction, prevention programs could be useful. It seems relevant to encourage teenagers, particularly those with the tendency to compare themselves to their peers, to evaluate their body using health criteria instead of using other peoples’ bodies as a standard. Additionally, it would be interesting to intervene by deconstructing the “ideal body” myth, with the goal of diminishing the comparison to “idols”. Finally, it seems relevant to inform people that some role models’ BMI and body type are not representative of those of most of the population and that trying to reach their body type could be harmful. ED screening in this population should thus be more systematic.

5. Conclusions

To summarize, we found an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and body dissatisfaction and drive for thinness. Interestingly, the level of education was a confounding factor in this relationship, while BMI was not. The widespread use of social media in teenagers and young adults could increase body dissatisfaction as well as their drive for thinness, therefore rendering them more vulnerable to eating disorders.

Acknowledgments

The authors would like to thank the French Federation for Anorexia and Bulimia (Fédération Française Anorexie-Boulimie (FFAB)), who allowed the broadcasting of the questionnaire to its members, ED-specialized health workers.

Author Contributions

Study concept and design: B.J., B.R., and M.G.-B. Analysis and interpretation of data: B.J., B.N., B.R., and M.G.-B. Statistical analysis: M.D. Study supervision: B.R. and M.G.-B. Investigation (data collection): B.J., B.R., and M.G.-B. Writing—original draft: B.J. and B.N. Critical revision: M.D., B.R., and M.G.-B. Writing—revised version of the manuscript: B.J., M.D., and M.G.-B. All authors have read and agreed to the published version of the manuscript.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Institutional Review Board Statement

Since the study was an investigation involving the health field, but with an objective that did not involve the development of biological or medical knowledge, it not fit in the French Jardé legal framework. The approval from an ethics committee was not required according to the current French legislation.

Informed Consent Statement

Data collection was made anonymously. According to the current French legislation, answering the questionnaire was interpreted as consent for data use.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

ORIGINAL RESEARCH article

Processing body image on social media: gender differences in adolescent boys’ and girls’ agency and active coping.

• School of Psychology, Trinity College Dublin, Dublin, Ireland

Although scholars continue to debate the influence of social media on body image, increased social media use, especially engaging in appearance-related behaviors may be a potential risk factor for body dissatisfaction in adolescents. Little research has investigated how adolescents process appearance-related content and the potential strategies they use to protect body image perceptions on social media. To investigate coping strategies used by adolescents, four qualitative focus groups were conducted with 29 adolescents (23 girls) aged 15–16 years ( M = 15.31, SD = 0.47) in mixed-gender Irish secondary schools. Thematic analysis revealed that adolescents employed many different behavioral strategies such as avoiding negative content and selecting positive content. Cognitive processing strategies such as critically evaluating body-related content, psychologically distancing from and positively reframing challenging content were also used, although less frequently. Boys appeared to exhibit greater positive agency over their bodies and social media use and tended to use more active coping styles than girls. Efforts to promote body image on social media such as body positive pages and exposing artificial social media content were considered limited in their effectiveness.

Introduction

Body dissatisfaction, defined as “a person’s negative thoughts and feelings about his/her body” ( Grogan, 1999 , p. 2) is a leading cause of eating disorders, disordered eating, low self-esteem and poor psychological wellbeing ( Stice and Shaw, 2002 ; Paxton et al., 2006 ; Cruz-Sáez et al., 2018 ). Relatively high prevalence rates of body weight dissatisfaction have been reported cross culturally among adolescent girls [Mean = 48%, Range (26–62%)] and boys [Mean = 31%, Range (15–44%)] in 26 countries ( Al Sabbah et al., 2009 ). Social media is extensively used by adolescents ( Pew Research Center, 2018 ; Rodgers et al., 2020 ) and has received a lot of research attention as a possible risk factor for body dissatisfaction ( Rodgers and Melioli, 2016 ).

While the causes of body dissatisfaction are considered multifaceted, and include biological, evolutionary, psychological and sociocultural factors ( Polivy and Herman, 2002 ; Ferguson et al., 2011 ; Fitzsimmons-Craft, 2011 ), social media is a sociocultural factor that has been suggested by some to be linked to body dissatisfaction. However, the extent to which social media influences body dissatisfaction is debated and the evidence is inconsistent; some studies find associations between social media use and body dissatisfaction ( Fardouly et al., 2017 ; Scully et al., 2020 ), others find that social media use is associated with positive body image ( Cohen et al., 2019 ), some observe no direct relationships ( Ferguson et al., 2014 ; Cohen et al., 2017 ) and others suggest that social media may indirectly influence body dissatisfaction by increasing opportunities for other predictors of body dissatisfaction such as peer competition ( Ferguson et al., 2014 ). Furthermore, the inferences that can be drawn regarding social media effects may also be limited by methodological issues in the literature, such as the inability to capture the dynamic, interactive, and personalized nature of social media within a controlled environment or failure to use appropriate controls and procedures to account for demand characteristics ( Fardouly and Vartanian, 2016 ).

Nonetheless, concurring with previous systematic reviews (e.g., Holland and Tiggemann, 2016 ), a recent meta-analysis of 63 independent samples observed a small, positive, significant relationship between social media use and body image disturbance ( Saiphoo and Vahedi, 2019 ). It should be noted that the meta-analysis’ conclusions are constrained by the literature on which they are based, which as mentioned, has its limitations (i.e., demand characteristics, single-responder bias, common method variance, lack of preregistration, and the fact that many studies report simple bivariate correlations). These limitations may result in an over-estimate of the effect size; consequently, the small effects in this meta-analysis do not necessarily confirm the existence of effects and therefore must be considered as suggestive. 1 Even though the effect size was small, the authors noted that it is important to further explore the relationship between social media use and body dissatisfaction because social media is extensively used by adolescents. Adolescence is also a particularly vulnerable time for body image ( Voelker et al., 2015 ), and it is important to identify risk/protective factors for body dissatisfaction on social media to help foster more favorable body image during this sensitive developmental period.

Sociocultural theories of body image, such as the Tripartite model ( Thompson et al., 1999 ), propose that social media, influences body image perceptions by conveying messages that emphasize the importance of appearance and pressurize the attainment of unrealistic body ideals. These body-related messages are proposed to give rise to body dissatisfaction directly and indirectly via two mediating mechanisms: internalization of and appearance comparisons with body ideals. Body ideal internalization involves endorsing and pursuing body ideals as a personal body standard ( Thompson and Stice, 2001 ), while appearance comparisons involve evaluating one’s appearance relative to others ( Jones, 2001 ). Because the body ideals that individuals internalize are largely unrealistic and unattainable, failure to exemplify these ideals becomes a source of body dissatisfaction when these ideals are valued as a personal goal ( Thompson et al., 1999 ). Upward comparisons, comparisons with “superior” others highlight discrepancies between one’s own body and body ideals thereby giving rise to body dissatisfaction ( van den Berg et al., 2002 ).

Social media are highly visual, appearance focused platforms that extend opportunities to engage in these body dissatisfaction-inducing behaviors ( Rodgers and Melioli, 2016 ). Popular social media platforms used by adolescents such as Instagram and Snapchat ( Pew Research Center, 2018 ), contain a profusion of idealized body related content, which tend to endorse muscular ideals (characterized by a v-shaped torso, visible abs, large biceps, and low body fat,) and lean/athletic ideals (characterized by a toned body with low body fat,) for men/boys. Thin ideals (characterized by a lean physique with low body fat and a narrow waist), fit/athletic ideals (characterized by a lean and muscular physique), and curvy ideals (characterized by a thin waist and large bosom/bottom) are generally more relevant for women/girls ( Betz and Ramsey, 2017 ). Adolescents have been found to endorse and strive for these ideals, despite acknowledging the unrealistic nature of these bodies ( Edcoms and Credos, 2016 ; Burnette et al., 2017 ; Bell et al., 2019 ).

Consistent with the Tripartite model, comparisons with celebrities, sports stars, and peers who embody these ideals on social media have been reported by adolescents to give rise to feelings of body dissatisfaction ( Edcoms and Credos, 2016 ; Burnette et al., 2017 ). Additionally, posting and editing “selfies” (self-portraits of one’s face/body) on social media amplify adolescents’ tendencies to compare and critically evaluate their appearance ( Chua and Chang, 2016 ; Bell, 2019 ). Adolescent girls tend to engage more in these self-presentation behaviors than boys and tend to be far more invested and influenced by the feedback indices such as “likes” and “comments” received on these posts. Although boys tend not to be greatly affected by the number of “likes” they receive, they are concerned about receiving negative commentary from peers on social media ( Kenny et al., 2017 ).

Some studies suggest that girls’ body image perceptions are more strongly and negatively impacted by social media because they engage with and invest more in body-related content than boys ( Frisén and Holmqvist, 2010 ; McAndrew and Jeong, 2012 ; Chua and Chang, 2016 ). Boys have also been found to perceive social media as a more positive, motivating influence on their body image vs. girls who tend to report that social media exerts more negative effects on their body image ( Bell et al., 2019 ). Boys are also thought to be protected somewhat from exposure to aesthetic body ideals, because they value body functionality over aesthetics ( Grogan and Richards, 2002 ). However, recent meta-analyses suggest that the magnitude of social media’s influence on body image is the same for girls and boys ( Holland and Tiggemann, 2016 ; Saiphoo and Vahedi, 2019 ). It has also been suggested that social media’s impact on male body image may be underestimated because of boys’ tendencies to disclose or downplay body image issues because of stigma surrounding male body image ( Griffiths et al., 2014 ). However, given the methodological issues mentioned previously, the strength of relationship between social media and body image requires more robust examination.

Although appearance-related behaviors on social media have been suggested as a risk factor for body image ( Saiphoo and Vahedi, 2019 ), little research has investigated ways that adolescents manage challenging social media content or strategies they use to buffer the negative effects of these behaviors. It is important to understand the ways that users interact with social media, because the possible body-related outcomes arising from social media use are likely to be the result of complex, reciprocal transactions between the media content and the social media user ( Valkenburg and Peter, 2013 ; Perloff, 2014 ).

Additionally, while studies have investigated ways to protect and promote adolescent body image in general, social media is a unique sociocultural context that may require specific strategies to help improve body image ( Perloff, 2014 ). Existing approaches to addressing body-dissatisfaction on social media involve teaching social media literacy in order to reduce the credibility of media messages and subsequent body ideal internalization and appearance comparison behaviors ( McLean et al., 2017 ). Although one study found a social media literacy program to be effective in producing gains in body image outcomes in adolescent girls ( McLean et al., 2016b ), similar improvements were not observed in adolescent boys ( Tamplin et al., 2018 ); this is surprising because it would be anticipated that adolescent boys, who are largely unaware of photo-manipulation/editing of male bodies on social media ( Edcoms and Credos, 2016 ), would benefit from enhanced social media literacy. Although these findings are preliminary, meta-analyses from traditional media literacy interventions indicate that although media literacy programs are effective in increasing knowledge about the media, they do not substantially change body image outcomes ( McLean et al., 2016a ). This suggests that increasing knowledge about body ideals may not alone be sufficient to address body dissatisfaction and that other strategies/coping tools are required for adolescents to effectively manage problematic appearance-focused social media. Understanding the strategies (if any) that adolescents use can inform the design of interventions such that they target self-protective skills that are in need of cultivation or further development among adolescents. Probing adolescents’ self-protective strategies can also help identify the approaches that might be most effective in improving adolescent body image and can focus intervention efforts toward these.

Only one qualitative study (to the authors’ awareness) with 38 female adolescents aged 12–14 years has explored protective and promotive coping strategies used by adolescents on social media ( Burnette et al., 2017 ). While adolescents in this sample endorsed behaviors associated with body dissatisfaction on social media, including using photo-based platforms, engaging in appearance-related behaviors and making appearance comparisons ( Rodgers and Melioli, 2016 ), they identified several factors that helped protect their body image when using social media. Girls reported that they consciously avoided undesirable social media posts that invoked appearance comparisons or body image concerns as a way of protecting their body image. While this gave adolescents a sense of personal agency over social media use, it was not regarded as a wholly effectual strategy because it was difficult to avoid unsolicited body related content on social media. Participants also evinced high social media literacy levels as they were critical of the body ideals encountered on social media, regarding them as edited, photoshopped, and unrealistic. Participants were also aware of the concerted efforts that peers went to, to capture and post a “perfect” photo of themselves. The authors posited that adolescents’ skepticism and avoidance of idealized body-related content and their appreciation of diverse beauty standards was indicative of protective filtering.

Protective filtering is an aspect of positive body image that involves selectively internalizing messages that promote positive body image and rejecting negative body-related information ( Andrew et al., 2015 ). Protective filtering has been found to buffer the negative effects of exposure to idealized body-related content in the media in adults ( Andrew et al., 2015 ). Protective filtering also appeared to provide promotive benefits to adolescents’ body image in sample of Burnette et al. (2017) . However, it is unclear whether the findings of these focus groups are generalizable across adolescents because the sample was relatively small and came from a single-sex, private school that taught social media literacy and critical thinking skills and encouraged an ethos of body appreciation, diversity, and confidence, which was reported to facilitate this protective filtering of social media content. Outside of this study, little research has investigated if adolescents use protective filtering strategies on social media and whether these filtering skills can be fostered in adolescents, including those with negative body image.

It is also not known whether aspects of social media content may help encourage protective filtering; “body acceptance” and “body positive” messages have recently propagated the social media space and have been lauded by adult women as a promising way to buffer against problematic idealized content and decrease body dissatisfaction ( Convertino et al., 2019 ; Rodgers et al., 2019 ). It is not known whether adolescents engage with this content and whether it exerts protective effects on their body image perceptions ( Bell et al., 2017 ).

Furthermore, little is known about the strategies that adolescent boys use to protect and promote body image. To the authors’ awareness no study has investigated self-protective strategies used by adolescent boys on social media. This reflects a traditional research focus on female body image, as men/boys were thought to be less impacted by body-related issues ( Parent, 2013 ). However, body image has been recognized an increasingly important issue for boys ( Parent, 2013 ), and has been found to be influenced by social media to a similar extent in both boys and girls ( Saiphoo and Vahedi, 2019 ). Boys and girls may face different body-related challenges and pressures on social media ( Kenny et al., 2018 ; Rodgers et al., 2020 ), and subsequently may employ different strategies to manage these pressures.

This qualitative study explored adolescents’ processing and protective filtering of social media content and whether these strategies were perceived to provide protective benefits for body image. Both adolescent boys and girls were included in the study because little is known about coping or management strategies used, especially by boys, to address gender-specific issues on social media. This study aimed to inform intervention and prevention efforts in the area of body image on social media.

Materials and Methods

Focus groups investigated how adolescents managed challenging body-related content and promoted positive body image on social media. Focus groups were used because they provide a rich and ecologically valid insight into the opinions and lived experiences of participants in their own words and from their own perspectives ( Greene and Harris, 2011 ). Focus groups were favored over one-to-one interviews for this kind of exploratory work because they facilitate greater elaboration of ideas and provide a vocabulary to discuss topics ( Heary and Hennessy, 2006 ; Greene and Harris, 2011 ). In accordance with guidelines ( Heary and Hennessy, 2002 ), single sex focus groups consisting of 6–9 participants were conducted as adolescents have been found to be more comfortable about opening up and discussing sensitive issues in single rather than mixed sex groups.

Focus groups were guided using an interview schedule, which asked adolescents about their experiences and perceptions of body image on social media, the appearance-related challenges they faced on social media and the ways they manage these challenges. The results presented below will focus on adolescents’ management of challenging appearance-related content on social media, however; a brief outline of adolescents’ perceptions/experiences of social media will be provided to contextualize adolescents’ coping strategies. Given the exploratory nature of the research, conversations were allowed to flow freely, and the researcher was free to pursue related topics if they were mentioned.

Participants

A convenience sample of 29 participants, 23 girls, and 6 boys, aged between 15 and 16 years ( M = 15.31, SD = 0.47) were recruited from two mixed sex Irish secondary schools, one urban private school and one rural community school for a study investigating adolescents’ experiences and perceptions of body image on social media. The study was only open to fourth year students who used social media and who received parental consent to participate. Participants’ ethnicity and other sociodemographic information were not recorded. Four focus groups were conducted, three with girls only and one with boys only (see Table 1 ).

Table 1 . Composition and duration of adolescent focus groups.

Focus groups were audio recorded using an Olympus WS853 voice recorder and qualitative analysis software, MAXQDA (Version 2018.1) was used to analyze the data. The interview schedule included questions such as; (1) What social media activities/behaviors do you think help/harm body image perceptions? (2) What characteristics of social media platforms promote positive body image/negatively impact body image? and (3) How do you manage challenging appearance-focused content on social media?

Full ethical approval was received from the ethics committee at Trinity College Dublin. Permission from school principals was obtained to allow the study to be hosted in schools and for students to participate in the study. Informed consent from parents and informed assent from participants was obtained prior to study commencement. Focus groups were conducted on the school premises and participants were assigned to focus groups based on their class group. Participants’ gender, age, and school attended were obtained in demographic questionnaires that participants completed prior to the focus groups. Focus groups were conducted by two female researchers; the primary researcher led the discussion, while the secondary researcher took notes and kept track of time. Focus groups lasted approximately 30–50 min and participants were offered refreshments, thanked and debriefed afterward.

Data Analysis

Focus group discussions were transcribed verbatim by the primary researcher (CM) and were analyzed using thematic analysis. The analysis was guided by six step procedure of Braun and Clarke (2006) , which involved firstly becoming familiar with the data by transcribing data, reading transcripts and listening to audio recordings (Step 1). Then, initial semantic codes were generated and assigned to the data using MAXQDA software (Step 2). Semantic coding, which involves characterization of explicit, surface meaning of content was deemed the most appropriate form of coding of the personal experiences pertinent to the research question. Data was also coded according to an essentialist/realist perspective, which assumes a unidirectional relationship between meaning and experience. This approach allows for a straightforward exploration of motivations, experiences, and meaning, which were the focus of the research questions. These codes were organized into a coding frame containing concise labels and descriptions for codes was established. Related codes were grouped together to form themes and subthemes (Step 3). An inductive approach, which allows themes to emerge from the data rather than being informed by pre-existing literature, was applied to generate themes ( Thomas, 2006 ). These themes were refined by reviewing the data at the level of the coded extracts and entire data sets to ensure that distinct, coherent themes were generated (Step 4). Themes and subthemes were assigned names and definitions (Step 5).

To verify whether these themes characterized the data, inter-rater agreement was conducted both on codes within the coding frame and final themes identified in the data. As recommended by Breen (2006) , an independent researcher (not involved in hosting focus groups) used MAXQDA to review the coded transcriptions and indicate their agreement or disagreement with each of the pre-existing codes and themes; they could also suggest additional codes and themes. The primary researcher reviewed the additional codes/themes suggested by the independent researcher and adjusted coding schemes where appropriate, in consultation with the project lead (DH). According to Breen (2006) , to attain adequate consistency (reliability), code-to-sentence matches should occur for at least 80% of cases. Agreement between coders was calculated using the Kappa Coefficient ( Brennan and Prediger, 1981 ) was high, K = 0.92, indicating good inter-rater agreement. Finally, themes were described and contextualized within relevant literature on social media and body image in adolescents (Step 6). These steps were conducted in an iterative, recursive manner.

The researcher adopted a reflexive approach and acknowledged that their own biases and backgrounds shaped the data obtained and the way it was interpreted. The researcher recognized that as a white, Irish, educated woman in her mid-twenties, she could resonate with the struggles of body image and social media pressures to pursue body ideals (insider position) and could recognize that the body-related pursuits and pressures of men/boys and adolescents may differ from her own, and that adolescents’ experience of social media content and affordances may also be divergent (outsider position; Berger, 2015 ). She also recognized that her adult and female status may have affected adolescents’ interactions and the ways they disclosed information about body image and social media ( Berger, 2015 ; Dodgson, 2019 ).

Adolescents reported that they were prolific, habitual users of social media, showing preferences for appearance focused platforms; adolescents, especially girls explicitly reported that they felt social media exerted a mostly negative influence on their body image. Girls strove to attain female body ideals, while boys largely endorsed functionality ideals; appearance comparisons tended to induce body dissatisfaction when these appearance-related goals were not met. Adolescent girls were perceived to invest more in appearance-related behaviors on social media and to experience greater levels body-related pressure, dissatisfaction and self-criticism than boys. Appearance comparisons with peers, social media influencers, and celebrities were identified as the main sources of body dissatisfaction on social media. Thematic analysis revealed two key themes, and various subthemes pertaining to the management of body image on social media by adolescents.

Theme 1: Behavioral Strategies Used to Manage Problematic Social Media Content

Avoidant strategies.

Adolescents reported using avoidant strategies and unfollowing content that contained body-ideals and reducing their social media use. Female 22 “ stopped using [social media as much] ,” while Female 21 “ unfollowed all the celebrities and people with unrealistic body goal standards ” and it was commonly reported that “ not seeing it [social media] as much helped ” (Female 21).

Avoiding social comparisons was emphasized as a core strategy to protect body image. However, some participants felt that avoidance strategies were limited in their effectiveness because it was difficult evade appearance comparisons as body-related images “ were always just popping up ” (Female 2) and body-related content was “ kind of pushed at [them] sometimes ” (Female 2) irrespective of whether they were interested in it or not.

Active Selection of Positive Content

Boys believed that they could control the outcomes of social media use by selecting content that promoted their self-image. Boys reported that they “ [did not] really get negative thoughts from looking at [social media], usually [they] just look[ed] at positive stuff ” (Male 4).

However, girls reported that they did not actively select positive content as they felt that all body-related content on social media was damaging. Even content designed to improve body image, such as body-positive content, was viewed skeptically by girls. While girls acknowledged and lauded increased efforts to promote body-acceptance, they held reservations about the effectiveness of these efforts. Participants felt that there was a huge disparity between “ the picture ,” which “ portrays a different message to what it’s captioned ” (Female 22). Participants noted that while a picture may be accompanied by a wholesome caption advocating ostensibly positive messages, the picture itself, which was often appearance/body-focused and objectified, was sending the opposite message.

Female 16 “I think that, what people say when they post something, like what they say might be positive and well-meaning but nearly the pictures themselves speak for themselves and maybe what they are promoting in the pictures isn’t healthy even though they are saying ‘self-love’.”

Participants also found it difficult to endorse messages of body acceptance when they were delivered by individuals who embodied body ideals. Participants found it difficult to reconcile “ See[ing] a very skinny woman and she says ‘love your imperfections’ ” (Female 23) because they felt that it was easy for individuals who had perfect bodies to promote the notion of body acceptance as they seemingly had reason to be happy with their bodies. Participants found it difficult to believe that these individuals struggled with body image concerns and thus were reluctant to buy into the notions of acceptance that these individuals were promoting.

Female 7 “A lot of influencers do promote like body confidence and all that but that’s kind of easy for them to say at the same time because they do have the perfect body say for Instagram and all that sort of stuff.”

Other self-acceptance content was recently noted to contain diverse body types including “ plus size models rather than just the really stick thin skinny ones ” (Female 5), which was lauded because it provided a more realistic representation of body image and body types on social media. However, body ideal content with “ skinnier ones [sic: individuals] ” was observed to “ get more positivity back than the plus size ones [individuals] would ” (Female 2) and body ideals were the main attentional draw that influenced bodily self-perceptions. Furthermore, some participants still felt that this body-diversity content reflected extreme body types such as overweight bodies and therefore failed encompass “normal” bodies such as their own.

Female 3 “Nothing’s like normal if you know what I mean.”

Researcher “Right ok, so it’s extremes of all of them kind of?”

Female 3 “Yeah, yeah.”

Researcher “So, nothing in the middle?”

Female 3 “Yeah.”

Active Selection of Alternative Platforms

Although girls felt limited in their ability to engage in positive body-related content, especially on Instagram, some girls actively chose to engage with VSCO, an alternative social media platform that was considered less damaging for body image. VSCO was favored because it was not considered to be as “serious” as Instagram and did not contain feedback indices “likes,” “comments” or hierarchical structures such as “followers,” which were problematic features of Instagram. Girls felt that they “did not feel pressure ” and could post “ a picture on VSCO with no makeup on … but would not put [the same photo] up on Instagram ” (Female 2). Female 1 noted that on “ Instagram ‐ you have to look perfect because you can see how many likes you get and people feel pressured into, they want more likes and that, but you cannot see that on VSCO .”

VSCO appeared to provide an alternative venue for girls to safely explore their body image without fears of overt judgment from others. However, its use was mentioned by girls in one school, and even among this group Instagram surpassed VSCO in terms of popularity despite the negative effects associated with Instagram.

Theme 2: Cognitive Strategies

Psychological distancing strategies.

Psychologically distancing oneself from comparison targets was a common strategy utilized by both boys and girls. Focusing on differences between the goals and values of comparison targets vs. themselves served to increase the psychological distance from these targets in boys and lessen their desire or drive to attain these bodies. Male 1 reconciled that “ They’re [celebrities/sports stars/social influencers] kind of devoting their whole life to it ,” while Male 4 concurred “ Yeah that’s their job like .” Boys felt that they too could attain these ideals if they devoted themselves to this extent but felt secure in their own bodies because they did not hold the same investment or commitment as individuals who possessed body ideals.

Some girls attained psychological distance from targets by focusing on the manipulated, edited nature of the images. Female 10 noted that celebrities/social influencers on social media “use filters ” and reconciled that “ if [she] used them[filters] [she] would look way better . ” “Know[ing] that they [celebrities/social influencers] are photoshopped ” helped her to be less affected by them because she knew they were “ unrealistic looking .” Some girls also attempted to distance themselves from comparison targets by acknowledging that although they often liked the appearance of these individuals, they felt that their features were too extreme and ill-suited to their own appearance.

Female 10 “I like the way they look but I don’t think I’d like to look as … extreme as they do. I don’t think it looks normal. But I think it looks normal with them because they all look like that, but if I walked in like them, I’d look weird, I’d look like an alien.”

While this distancing strategy worked for some, most girls noted that idealized images negatively affected them regardless of the knowledge of their manipulation and this limited the effectiveness of psychological distancing.

Reframing Strategies

Both boys and girls reported that reflective practices such as taking a step back, conducting reality checks and looking at the bigger picture enabled them to reassure themselves. Other strategies mentioned by adolescents involved reframing or putting a positive spin on challenging content. One boy suggested that focusing on goals and achievement rather than focusing on discrepancies and feeling self-pity enabled him to process social media content in a healthier way.

Male 4 “Depends on what way you view it really. If you look at it like, saying they’re this and they’re that and I’m just here, you’re not – you’re always just going to be feeling shite like. You are not going to move forward at all. If you just take – just watch whoever, take inspiration, try work yourself, if you want to be like them, work yourself towards being like them.”

In addition, accepting one’s uniqueness and viewing difference as a good rather than negative thing was identified by a female participant as a way of framing body image in a positive light.

Female 21 “I think the problem overall is that we are looking at difference as if it were a problem, we are saying “Why don’t I look like that? Why can’t I be that person?” But I think we all just have to learn to accept that we are all different and we know these facts, but we chose to ignore them!”

Ceasing to judge others and oneself was also mentioned by a few participants, however, it was acknowledged that this was difficult to achieve. Although boys appeared to be less judgmental and more accepting of their bodies with Male 4 noting “ I am grand just the way I am ,” girls struggled to accept their bodies and avoid negative critical self-evaluations, with Female 5 stating “ You have to get a certain amount of likes … or else it’s not like good enough .”

Female 19 “The more you look at the photo you’re like ‘God I hate it’ you see things that other people wouldn’t see and you’re like ‘I hate everything about it’.”

One girl stressed the value of maintaining a compassionate mindset and endorsed the notion that everyone struggles with the same issues and not to be so harsh and critical toward oneself.

Female 21 “I think we always compare ourselves to the people we see on social media, so we don’t see their flaws, because we are busy pointing out our own in comparison to theirs. We don’t realise that not everyone is perfect as well. And because of that we are kind of blind.”

Female 21 “I just think that young girls need to stop comparing themselves and to take a minute to realise that we are all the same, we are all doing the exact same thing; We are all sitting at home, scrolling. And all the likes we receive, it’s just a double tap of the finger, that person probably doesn’t probably even look at it for more two seconds, we need to stop overthinking everything.”

However, these reframing strategies were only mentioned by a few individuals in focus groups and did not typically reflect the whole groups’ responses to body-related content on social media.

Some participants, particularly girls, reported that they felt social media negatively influenced their body image perceptions. Aligning with the literature, adolescents reported that appearance-focused activities like photo sharing/editing practices and appearance comparisons with celebrities, social media influencers, and peers led to feelings of body dissatisfaction ( Edcoms and Credos, 2016 ; Rodgers and Melioli, 2016 ; Burnette et al., 2017 ).

Limiting their social media use and avoiding, unfollowing, or ignoring problematic body related content were the strategies most used by adolescents to protect their body image on social media. However, as found by Burnette et al. (2017) , these strategies were considered limited in their effectiveness because of the difficulty in avoiding ubiquitous body-related content on social media. Adolescents were aware of targeted advertising and the fact that their newsfeeds were often propagated with content that they did not necessarily want or chose to see; this limited their perceived control over social media use, especially among girls.

Aligning with these control beliefs, girls tended to report more passive responses to social media such as “putting up” with problematic content. Some boys, on the other hand, reported that they actively sought out and selected positive content that inspired them to exercise or helped them improve in some way. It should be noted that the number of boys in the present study was relatively small. Adolescent girls did not appear to engage in such active selection strategies as they felt that any content related to body image exerted negative effects on them, including content designed to promote positive body image. Adolescent girls’ reservations about body positive/acceptance content is notable as it contrasts with the endorsement of the protective effects of this content for body image in the literature (e.g., Convertino et al., 2019 ; Rodgers et al., 2019 ); given the recency of its emergence, the limitations of body positive content may not have been extensively documented in the literature or it may be the case that this kind of content resonates with adult women but not adolescents. Although the influence of body positive content on adolescent body image perceptions requires further research, these findings indicate that adolescent girls experienced social media as a largely negative and disempowering space for body image.

However, VSCO was a photo-sharing platform that was preferred by some girls to Instagram because it did not contain feedback indices such as likes, comments, followers and subsequently did not put as much appearance-related pressure on girls. VSCO has not previously featured in body image research and is worthy of further research attention because it represents a platform that may contain protective features for body image, namely the lack of hierarchical popularity structures or feedback indices.

Some girls distanced themselves from body ideals by reminding themselves that body ideals were not attainable – a strategy also noted by Burnette et al. (2017) . However, most girls reported that their knowledge of unrealistic body ideals did little to protect their body image perceptions and they continued to compare despite this awareness. Girls also achieved psychological distance from body ideals by reasoning that while they admired certain body features on others, they did not desire them themselves because these features would be incompatible with their own appearance. Adolescent boys in this sample reported deprioritizing the importance of the muscular ideal and distancing themselves from comparison targets as a way of protecting body image perceptions. This low investment in body-related content was also identified by Holmqvist and Frisén (2012) as a feature that supported adolescent boys’ body image.

Adolescents exhibited a repertoire of strategies to protect and promote body image. The use of these strategies by adolescents and their perceived effectiveness varied. Passive and avoidance strategies were most commonly used but were limited in terms of perceived effectiveness, while active and acceptance strategies were considered effective but were least commonly employed, especially by girls. As these active and acceptance-focused strategies are considered components of positive body image ( Holmqvist and Frisén, 2012 ), enabling adolescents to employ more active cognitive processing and reframing strategies may enhance their resilience to social media content.

Adolescents in this sample did exhibit aspects of protective filtering (as observed by Burnette et al., 2017 ), in that they were critical of the extreme natures of body ideals and attempted to psychologically distance from and reduce comparisons with these ideals. They also expressed an appreciation of body diversity on social media. However, protective filtering involves both the rejection of negative body-related messages and the endorsement of positive messages ( Andrew et al., 2015 ). Contrasting with the findings of Burnette et al. (2017) , high social media literacy levels did not always serve protective effects for body image and adolescent girls in this sample were largely unable to internalize positive body-related messages and struggled to accept/appreciate their own bodies.

Boys appeared to hold more positive perceptions of social media’s influence on body image, processed body-related content in “protective ways” and exhibited higher levels of body-acceptance than girls. Mirroring the findings of the national study of adolescent boys in the United Kingdom of Edcoms and Credos (2016) , boys in this sample were less aware of photo-editing and manipulation of images of male bodies on social media and viewed body ideals as attainable with sufficient hard work and effort. It may be the case that social media is experienced as a less pressurizing and more motivating space for boys, encouraging them to hold these more positive evaluations of social media. Alternatively, boys may have deemed it acceptable to report beliefs that body ideals were attainable and that they were not negatively affected by social media in order to adhere to masculine gender roles of self-reliance and dominance ( Gattario and Frisén, 2019 ). Boys may also be less aware of manipulation/editing strategies or less critical in perceptions of body ideal attainability and this might protect them from feelings of disempowerment and dissatisfaction when exposed to body-related content.

Nonetheless, some boys and girls reported self-criticism, self-blame, and body-dissatisfaction from social media comparisons and for perceived failures to adhere to desired body standards. Knowledge/information about body ideals did not always appear to change how individuals felt about their body image. This suggests that enhancing social media literacy and knowledge is not alone sufficient to mitigate tendencies to engage in appearance comparison and body ideal internalization behaviors and help individuals to internalize positive body-related messages. Furthermore, relying on body positive/body acceptance content to promote positive body image is also not sufficient given adolescent girls’ skepticism of this content and its ability to improve their body image perceptions.

Self-compassion approaches are purported to target and change how individuals feel about their bodies by addressing self-criticism and shame at the root of body dissatisfaction ( Gilbert and Irons, 2005 ; Gilbert, 2010 ). Instead of trying to inhibit appearance comparisons like media literacy approaches, compassion focused approaches (e.g., Neff, 2003 ; Gilbert, 2009 , 2014 ) try to reduce the self-criticism arising from comparisons – an approach, which may be particularly beneficial in light if the highly self-critical attitudes held particularly by adolescent girls about their bodies. Compassion focused approaches have been found to be effective in reducing body dissatisfaction and disordered eating, in addition to promoting body appreciation and positive body image in adults ( Braun et al., 2016 ; Rahimi-Ardabili et al., 2018 ). However, the ability of compassion-focused approaches to improve body image outcomes has not been investigated in adolescents ( Rahimi-Ardabili et al., 2018 ).

Compassion-focused approaches may be particularly useful for improving adolescent body image on social media, as they can provide individuals with the skills to reframe self-critical thoughts and enhance their resilience to negative body-related messages on social media. Self-compassion may also enable adolescents, especially girls, to internalize positive body-related messages and foster greater levels of body appreciation ( Andrew et al., 2016 ). They therefore represent a new and potentially promising alternative for tackling body image concerns in adolescents.

Limitations

Although this study sought to capture a diversity of viewpoints by recruiting from heterogenous schools that differed in terms of school status (private vs. public) and school size (medium-large and small), the sample size of this study was small which limits the transferability of the findings. Furthermore, very few boys participated in the study, which further limits the conclusions that can be made about social media’s influence on their body image perceptions. Due to study, time pressures a pragmatic decision was made to proceed with the analysis and write-up with the imbalanced gender split. This difficulty in recruiting male participants has been noted in the research in this area, and it may be indicative of male stigma around body image and a reluctance among adolescents to discuss it as a topic ( Griffiths et al., 2014 ; Edcoms and Credos, 2016 ). Future research needs to identify ways of circumventing this stigma and encouraging boys to discuss body image and social media, because far less is known about adolescent boys’ experiences of social media and body image vs. girls, despite the finding that body dissatisfaction is a prevalent and problematic issue among boys and one that is influenced by social media use ( Saiphoo and Vahedi, 2019 ).

The focus group design may have influenced participant’s responses such that they may have provided socially desirable answers that may not have reflected personal opinions, or their opinions may have been swayed by or suppressed because of dominant members of the group. 2 This may be particularly true of boys, who are less likely to disclose body image concerns because of social norms, which dictate that body image is not an issue for males ( Hargreaves and Tiggemann, 2006 ; Yager et al., 2013 ). Furthermore, as the focus groups were conducted by female researchers only, boys may have been reluctant to discuss gender differences related to body image ( Allen, 2005 ), while girls, may have been more expressive of their concerns because they tend to prefer same-sex female facilitators ( Yager et al., 2013 ).

Some adolescents, especially girls, indicated that social media led them to feel dissatisfied with their bodies. Boys and girls appeared to employ different strategies to manage to address the gender-specific challenges they encountered online. Boys appeared to exhibit more agency and active coping strategies, which contrasted with girls who were less optimistic about their ability to control social media outcomes and who struggled to interpret body-related information in a positive, self-protective way. Future research should examine these gender differences in larger samples across diverse contexts.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by School of Psychology, Trinity College Dublin. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.

Author Contributions

CM conceived, planned, and carried out the study, analyzed the data, and wrote the manuscript with input from DH, who was involved in the planning and supervision of the study. Both the authors contributed to the article and approved the submitted version.

This research did not receive any specific grant from funding agencies in the public, commercial and not-for-profit sectors.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We would like to acknowledge colleagues Ms. Selin Akkol-Solakoglu who assisted with focus groups and Ms. Molly Light who assisted with inter-rater agreements and the School of Psychology, Trinity College Dublin for their support.

1. ^ We wish to thank a reviewer of the paper for highlighting this issue.

2. ^ We would like to thank the reviewer for highlighting that demand characteristics may have influenced participant responses such that respondents are likely to just go with the theme of the questions, rather than spontaneously come to the conclusion that social media influences them in negative ways.

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Keywords: body image, adolescent(s), social media, body dissatisfaction, positive body image, coping strategies

Citation: Mahon C and Hevey D (2021) Processing Body Image on Social Media: Gender Differences in Adolescent Boys’ and Girls’ Agency and Active Coping. Front. Psychol . 12:626763. doi: 10.3389/fpsyg.2021.626763

Received: 06 November 2020; Accepted: 19 April 2021; Published: 21 May 2021.

Reviewed by:

Copyright © 2021 Mahon and Hevey. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Ciara Mahon, [email protected]

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• Open access
• Published: 27 June 2022

“Why don’t I look like her?” How adolescent girls view social media and its connection to body image

• Alana Papageorgiou 1 , 2 ,
• Colleen Fisher 2 &
• Donna Cross 1 , 3  

BMC Women's Health volume  22 , Article number:  261 ( 2022 ) Cite this article

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Adolescent girls appear more vulnerable to experiencing mental health difficulties from social media use than boys. The presence of sexualized images online is thought to contribute, through increasing body dissatisfaction among adolescent girls. Sexual objectification through images may reinforce to adolescent girls that their value is based on their appearance. This study explored how sexualized images typically found on social media might influence adolescent girls’ mental health, in positive and/or negative ways.

In-depth interviews were conducted with girls aged 14–17 years (n = 24) in Perth, Western Australia. Data were analyzed using thematic analysis.

Participants identified body image as a major concern, reporting negative appearance comparisons when viewing images on social media. Appearance comparisons were perceived to exacerbate adolescent girls’ appearance-based concerns. Comparisons also influenced adolescent girls’ efforts to change their appearance and seek validation on social media. The importance of awareness and education from a younger age about social media and its influence on body image was emphasized, as was the need for strategies to promote positive body image and counteract negative body image.

The findings of this study have important implications for professionals working with adolescent girls and for the development of health promotion programs addressing social media use and body image concerns.

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Adolescence is an important period of development, with major physical, social, cognitive and emotional changes, and identity formation occurring [ 1 ]. Adolescence is also a time when young people begin to use social media, online platforms enabling social interaction through the creation of individualized online profiles and sharing of photos, videos and other media on sites or apps such as Instagram, Snapchat and Facebook [ 2 , 3 ]. Social media has been found to have both positive and negative impacts on the lives of adolescents. Positive aspects of social media use include increased peer connection and support, and opportunities to learn [ 4 , 5 , 6 ]. However, research has largely reported adverse influences from adolescents’ social media use, contributing to mental health difficulties including increased depression, anxiety, and self-harm behaviors, decreased socio-emotional wellbeing, low self-esteem and negative body image [ 7 , 8 , 9 , 10 ]. For girls, the combination of reaching puberty, their body changing, and the importance of approval from peers and romantic relationship formation can increase vulnerability to negative body image and research suggests social media may have a greater influence on their body dissatisfaction compared to boys’ [ 2 , 11 , 12 ].

Body image encompasses the thoughts, feelings, beliefs and attitudes one has about their body and appearance [ 13 ]. Body dissatisfaction is an important element of body image and can range in severity from having a preference for different body characteristics to the uptake of extreme action to change one’s body [ 14 ]. Body dissatisfaction has been linked to low self-esteem, decreased mental health and wellbeing, and the development of eating disorders among adolescent girls [ 14 , 15 , 16 , 17 ]. The potential harms associated with body dissatisfaction highlight negative body image as an important public health concern [ 18 ].

Time spent on the Internet has been associated with increased body dissatisfaction among adolescent girls, with the interaction allowed by social media and appearance-focused content influencing body image concerns through negative social comparisons and peer normative processes [ 11 , 19 , 20 , 21 , 22 ]. Images of attractive thin females, often photo-shopped with filters, feature frequently on social media platforms such as Instagram, promoting stereotyped beauty ideals subsequently affecting viewers’ body image and dissatisfaction [ 9 , 23 ]. The females in images on social media are more commonly peers rather than celebrities like those included in mass media, which may influence body image related attitudes and concerns more significantly, given peers’ relatability and relevance to girls’ daily lives [ 19 , 24 , 25 ]. A study investigating the effect of manipulated Instagram selfies on adolescent girls’ body image found such images resulted in poorer body image perception, especially among those with high levels of social comparison [ 24 ]. Given the increasing prevalence of image-sharing online, young people may need support to improve their self-esteem and become more informed consumers of digital images (e.g. being able to identify enhanced or photo-shopped images as unrealistic and unattainable).

While social media can also counteract negative body image messages with positive body image accounts, even these accounts have been identified as commonly featuring appearance focused content [ 26 , 27 ]. It seems the overwhelming message to adolescent girls is that their value is largely derived from their appearance [ 28 , 29 ]. Girls can now easily and frequently compare themselves to those they follow on Instagram, whether they are peers or celebrities. The role of social media on body image is also an important issue for consideration among adolescent boys; however, existing research suggests girls are more likely to report negative body image [ 29 , 30 ].

An increased level of female sexual objectification has been identified through images on social media, where gender inequality is reinforced through the depiction of girls and women as sexually available and objectified [ 31 , 32 , 33 , 34 ]. Sexual objectification through social media may then lead to adolescent girls’ internalization of conventional ideas of femininity, with subsequent effects on their mental health and wellbeing [ 34 , 35 , 36 , 37 , 38 ]. For body image development, sexually objectified images on social media provide ample opportunity for girls to evaluate themselves against such images which emphasize appearing ‘sexy’ as critical to identity and that their worth is based on constant observation and evaluation of their appearance [ 36 , 39 ]. Additionally, while masculinity ideals are featuring more frequently in the media, including social media, the sexualization of females remains pervasive compared to males [ 40 ].

Previous research conducted on the influence of sexualized media on females’ body image as an indicator of mental health has largely focused on the impact of conventional mass media [ 41 , 42 ], employed quantitative research methods [ 21 , 34 , 43 , 44 , 45 ], analyzed sexualized content in various forms of media [ 46 ], focused on pre/early adolescent girls [ 29 , 47 , 48 ] or young women [ 32 , 49 , 50 , 51 , 52 ]. There are few qualitative studies exploring the influence of sexualized images on social media or the role of social media use in body image development from the perspective of adolescent girls themselves. Of these, the focus has either been on sexualized content only [ 53 , 54 ], image-sharing practices on social media [ 31 , 33 , 55 ], or the influence of social media use broadly (without a focus on sexualized images) on body image [ 11 , 56 , 57 ]. To the best of the authors’ knowledge, there are no qualitative studies exploring adolescent girls’ perceptions of the influence of sexualized images on social media on their mental health, or body image, as referred to in the present study. Nonetheless, these studies illuminate the ubiquity of appearance-focused and objectified images girls encounter when using social media and the challenges they experience navigating sexualized ideals of femininity [ 31 , 53 , 54 ]. Focus groups with girls and boys found the importance of appearing attractive on social media [ 33 , 55 , 56 ] and the perception that social media negatively impacted one’s body image [ 57 ] were more prominent for girls. Additionally, focus groups with only girls reported they frequently use social media to engage in appearance-focused social comparisons and some girls in the study indicated they were dissatisfied with their appearance [ 11 ]. These findings, in combination with their limitations related to focus group methodology whereby participants may have provided socially desirable responses, warrant further in-depth exploration with adolescent girls. Therefore, the aim of this study was to explore how sexualized images of females’ bodies typically found on social media might influence adolescent girls’ mental health, in positive and/or negative ways. A generic qualitative approach [ 58 ] utilizing in-depth interviews with adolescent girls was used for this study. The findings reported here are part of a broader study that included interviews with parents of adolescent girls, secondary school staff in a support service role such as school psychologists and those on pastoral care teams, and youth mental health service providers. Only the findings from girls are reported in this paper.

A generic qualitative research design was used for this study, an approach which is not informed by any one known qualitative methodology and its explicit or established set of philosophical assumptions [ 58 ]. A constructivist epistemology [ 59 , 60 ] guided the study to explore the unique perspectives of adolescent girls using one-on-one in-depth interviews to elicit their thoughts, knowledge and experiences [ 61 , 62 ].

Theoretical framework

Objectification Theory has been used to better understand the impacts of being female in a culture that sexually objectifies the female body [ 34 ] and suggests this leads to self-objectification whereby females internalize an observer’s perspective as a primary view of themselves and their bodies [ 63 ]. Adolescent girls may be particularly susceptible to self-objectification as adolescence is a developmental period of increased self-awareness, self-consciousness, and preoccupation with image and a time when identity is established [ 64 ]. When girls encounter sexualized images while using social media, they may self-objectify as they observe and view such content [ 65 ]. Additionally, the dual pathway model [ 66 , 67 ] provides a framework for understanding the mechanisms in which adolescent girls’ social media use can influence their body image. The dual pathway model suggests sociocultural appearance pressures and the internalization of appearance ideals lead to body dissatisfaction and subsequent risk factors for eating disorder development such as disordered eating behaviors [ 68 ]. Pressure to conform to appearance ideals through adolescent girls’ social media use and the extent to which they internalize these ideals may contribute to body dissatisfaction [ 9 ] and consequently, their likelihood of engaging in disordered eating behaviors with impacts on their mental health [ 68 ].

Participants

A purposive sample of twenty-four adolescent girls aged 14–17 years (Grades 9–11) was recruited for the study from the Student Edge (an Australian student membership organization) youth research panel (n = 13, 54.17%), non-government schools (n = 6, 25%) and through snowball sampling techniques (n = 5, 20.83%) in Perth, Western Australia between 2016 and 2018. Inclusion criteria to participate in the study included active use (i.e., one hour or more per day) of at least one social media platform (i.e., Instagram, Snapchat, Facebook). Most participants were 16–17 years of age (n = 14), spoke English as their first language, and attended a non-government school. One of the participants spoke English as a second language and seven of the participants attended two different all girls’ schools.

Full ethical approval to conduct this research was obtained from the University of Western Australia Human Research Ethics Committee. Student Edge emailed the relevant target audience from their membership base (girls aged 14–17 years in the Perth metropolitan area) and provided a link on their website to a screening survey. The screening survey explained the research project and what participation involved, asked students their age and gender, and if they would like to participate. Those who responded ‘yes’ and met the inclusion criteria for participation (n = 45) had their name, phone number and email address captured based on their Student Edge membership details. These details were then sent to the first author who made contact via phone and/or email to arrange an interview.

To recruit students from non-government schools, approval was first sought from the Catholic Education Office of Western Australia and the Association of Independent Schools of Western Australia then school principals, who were contacted by phone and email seeking their approval for project information to be distributed within their schools via email, newsletter items and flyers. Parents and students were provided with an information sheet describing the research and asked to contact the research team via phone or email if they were interested in participating. School principals were asked to nominate a school-coordinator to assist in arranging student interviews. Additionally, girls were recruited through snowball sampling methods, with those who participated in the study asked to distribute project information to other girls aged between 14 and 17 years.

Prior to participation in the study, written informed consent was obtained from both parents or guardians and adolescent girls. For those recruited from the Student Edge youth research panel, parent or guardian consent was required for students under 15 years to be eligible to become a member.

Adolescent girls participated in one-on-one semi-structured interviews with open-ended questioning undertaken by the first author between October 2016 and February 2018. During the interviews, girls were asked questions in relation to publicly available images of celebrities from Instagram using third person disclosures. These methods were used to enable discussion without participants having to reveal personal experiences which may have caused discomfort, and as a requirement of the study’s ethical approvals. The images were selected from celebrities with some of the largest numbers of female followers on Instagram at the time of data collection (Selena Gomez, Gigi Hadid, Kylie Jenner and Kendall Jenner), and for variation in parts of the body that were emphasized, and the presence of a sexually suggestive pose as used in previous studies [ 24 , 46 ]. Participants were shown each image and asked what girls their age looking at Instagram might think about the images and why, how the images might make them feel about themselves and why, and how the images might influence mental health (in both positive and negative ways). Participants were also asked for their opinions about the sexualization of girls through images on social media, and in what ways this could be positive or negative. Interviews concluded with asking girls what they thought might help or prevent any of the negative influences on body image they identified. Participants were also asked demographic questions, how often they used social media, and what types of social media they used.

Prior to data collection, the interview protocol was pilot tested with a convenience sample of two adolescent girls aged between 16 and 17 years to provide feedback on question development and types of responses received, as well as the skills of the interviewer. No changes were made to the protocol as a result of the pilot testing.

Ten of the interviews were conducted in person (at their school or a public location) and the remaining fourteen interviews via phone (by participant request). Interviews lasted between thirty minutes and one hour.

Data analysis

All interviews were audio recorded and professionally transcribed verbatim and imported into qualitative data management software NVivo 11 (QSR International Pty Ltd, 2018) for management, retrieval, and interrogation. Data were analyzed by the first author using thematic analysis as described by Braun and Clarke [ 69 ]. This involved immersion in the data through reading and re-reading interview transcripts, followed by the generation of initial codes from features of the data, with some of these forming repeated patterns across the data set. During the initial coding phase, full and equal attention was given to each data item. These codes were then collated into potential themes. Themes were reviewed at the level of the coded extracts to ensure they were coherent, with a candidate thematic ‘map’ created. These themes were then refined to ensure they accurately reflected the data set as a whole, with recoding occurring as required. The thematic ‘map’ of the analysis was then further refined to formulate clear definitions and names for each theme. Throughout analysis the first author discussed the generated codes and themes with the co-authors to ensure accuracy of meaning and interpretation.

The coding frame for thematic analysis included both inductive codes generated from the data itself and deductive codes present in the existing research literature [ 59 ]. Codes that did not reflect the data were amended to fit the data. Data were not molded to fit predetermined codes or discarded. To maintain confidentiality, each participant and other entity or institution was allocated a pseudonym during data analysis.

Data collection and analysis procedures were recorded in an audit trail by the first author to document comments, decisions and observations, and to demonstrate and clarify decision-making to ensure any interpretations made accurately reflected the data. This documentation maintains rigor in qualitative research by strengthening the dependability and confirmability of the study [ 62 , 70 ]. To increase credibility of the research, responses were checked during and on completion of interviews to ensure the representations of participants’ viewpoints were accurate [ 62 ].

As an introduction to participant interviews, adolescent girls were asked about their social media use. These questions related to the different types of social media they used most often, how many hours a day they spent using these (on both a weekday and weekend day), and the device used to access social media.

The most used social media among participants were Instagram, Facebook and Snapchat. An equal number of participants reported they either spent less than two hours, or more than three hours, using social media on a weekday. On a weekend day, most participants spent more than four hours using social media. Delineation between passive use such as scrolling social media app feeds or viewing stories, and active use involving liking, commenting, and sharing posts was not collected as part of this study. Mobile phones were the most commonly used device to access social media. Daily use of social media reported by participants in this study was greater than has been previously reported among Australian females aged between 14 and 24 years, who on average in 2018 spent close to fourteen hours each week, or about two hours per day, on social media [ 71 ]. Additionally, time spent on social media by girls in this study is outside of the Australian 24-h movement guidelines for children and young people aged 5–17 years which recommend limiting sedentary recreational screen time to no more than two hours per day [ 72 ].

Participants identified body image as a major concern in relation to adolescent girls’ social media use and its influence on mental health, reporting girls felt insecure and self-conscious about their appearance when using Instagram specifically. This was not necessarily related to content participants considered as sexualized. Images were identified as sexualized depending on the amount of skin exposed rather than a females’ pose in an image. Four overarching themes emerged from the data and provided an in-depth understanding of the ways in which the girls in the study described how social media use influences body image: ‘expectation’, ‘comparison’, ‘striving’, and ‘validation’. Participants also referred to ‘counteracting negative body image and influence of social media’. Additional quotes to support each theme described below are included as a supplementary file (see Additional file 1 ).

Expectation

Images of other females were perceived to add an expectation for adolescent girls to look a certain way in their own social media posts to obtain what they deem an acceptable number of ‘likes’ and positive commentary. Although this is often influenced by images of celebrities, girls interpreted these as less realistic and attainable, with sexualized images posted by peers and other girls their age having a greater influence on their likelihood to make negative appearance comparisons;

I guess, you know they’re celebrities, so something must have gone into it [a photo]. It’s not just a photo, but I think if it’s someone you know or someone your age, it’s like, “Wow, that really could be me,” or “People my age are looking like this or doing this kind of stuff.” So, I think it would have a worse effect. (Sana, 17 years)

This expectation was perceived to make girls feel pressured to look attractive in their social media posts, even if it meant not being themselves as described in the participant quote below;

Some girls try to look like that [the images shown] and then they’re probably not being themselves, but they’re being what they think they’re expected to be kind of, which is not very good. (Candice, 15 years)

Girls also talked about how expectations experienced from viewing sexualized images on social media would vary between girls, depending on how they already felt about their appearance;

I guess it depends on how the girls feel about themselves first because depending on how they feel about themselves will depend on how they view the photo. (Daisy, 16 years) I think in general it depends on the mood that you're in when you open your phone. If you're already in a vulnerable mindset or if you've been out all day at the beach or something and you'd come home, you'd probably take more notice of that and be like, "Oh, I wish I looked like that." (Charlotte, 17 years)

While asked about both potential positive and negative influences of sexualized images of females featured within social media, girls could not identify any positives and continually spoke of the negative influences;

I think it would definitely have a negative impact on their mental health because they’d probably really be upset if they can’t achieve those unrealistic body expectations. (Sophie, 17 years)

Expectations related to social media use and body image were also discussed in relation to the normalization of following certain types of Instagram accounts, such as those that are appearance-focused and of attractive females with many followers, and how this could then lead to appearance-based expectations;

I think it [following appearance-focused and popular attractive female Instagram accounts] becomes more accepted and it becomes okay. It’s almost like a visual effect I guess if one particular group of teenage girls follow celebrities or whatever, begin to follow those sort of things [appearance-focused and popular attractive female Instagram accounts] and all people follow them, their friends, it [trying to look like the females in those accounts] becomes more of an expectation. (Brooke, 16 years)

While encouraged to use third person disclosures during interviews, participants reported they made negative appearance comparisons when viewing images on social media. Negative appearance comparisons were made irrespective of whether images were considered sexualized. As in the discussions among girls related to expectation, both images of celebrities and peers influenced comparisons, however, the influence of peers was considered more prolific;

When I see girls my age [on Instagram], I just compare myself to them ‘cause I know it’s kind of reality, if that makes sense, to know that someone my age can look like that and then why don’t I look like that? I think that’s what a lot of girls would see. (Olivia, 16 years)

While images of peers were considered to have a greater influence on negative appearance comparisons among the majority of girls, not all shared this viewpoint;

I think they [girls] would still to a certain extent be like, “Oh, I still want to be them,” but I feel it would be less, because if they see, “Oh, they're just like a regular person, they’re not a celebrity,” then they’re not really worth looking up to. But some people might say, “Oh, I want that kind of life,” for a regular person, like, “Why can she have just such a great life but I don’t?” (Amelia, 16 years)

All four images shown in interviews were perceived by participants to influence girls their age in making negative appearance-based comparisons. Reasons included the celebrities’ current popularity among their age group and the perception that all were attractive. For some participants, the number of likes was considered to play a role in comparisons, with a higher number equating to level of attractiveness. For others, the negative comparison was considered irrespective of the number of ‘likes’. All but one of the images was considered sexualized (where the least amount of skin was exposed), but it was noted that when using Instagram, girls would be unlikely to pause and make this distinction while scrolling through images.

All participants acknowledged the editing behind photos on social media but this did not counteract them making negative appearance comparisons;

A lot of them [photos] are edited and things like that but you don't really think about that when you look at someone's profile, you just compare that to yourself and then, that just makes you feel really bad about yourself. (Emma, 17 years)

Similarly, an awareness of images on social media usually featuring someone at their best did not ameliorate negative comparisons;

‘Cause if they constantly see it – and especially if you’re scrolling, some people might be in bed or on the couch, kind of not looking their best, they compared themselves at maybe their worst, compared to them at their very best and immediately, they go, “Oh, wow, okay.” And they see themselves as so much lower because of the comparison. (Candice, 15 years)

Even when prompted, girls struggled to identify any potential positive comparisons with the images to which they are exposed on social media. Females on social media who post photos of themselves were considered confident and empowered by their appearance, but girls did not agree on whether this would make girls their age feel good about their own appearance.

The expectation perceived by participants and the comparisons made from viewing images on social media was seen to influence girls’ striving to look a certain way, portray an enviable lifestyle and obtain many followers, ‘likes’ and comments;

You’re constantly thinking about aspiring to be something that I know 90% of girls aren’t going to be that way. It’s not possible and people need to realize that you’ve got to be happy with who you are and that you're beautiful in your own way. (Matilda, 16 years)

Participants particularly spoke about the influence of images on girls wanting to change their bodies;

You just think, “Oh, that's possible” and then you try and shape your body to be like that, so you eat less and eating disorders occur. (Zoe, 16 years) Just seeing [images on social media] all the time and it can get you down and girls could think, “Oh, I need to have my body like that.” People are always saying, “Oh, I want to get a summer body,” all the time. (Madeleine, 14 years)

For some girls, fitness accounts on Instagram, in addition to celebrities and peers, were also perceived as influential in girls’ striving to change their bodies;

I think it [images of females on fitness accounts] just puts this really unrealistic vision of what you should look like, and what you should do with your body to girls my age. (Abbey, 17 years)

When discussing the images shown of two popular and attractive models, it was well known among girls that both had been, and were currently, Victoria’s Secret models. This led to considering the type of influence such images have on adolescent girls’ body image;

I do know that a lot of my friends follow [on Instagram] a lot of models and celebrities, especially like Victoria Secret models for instance. I mean I’ve never been into that and that’s just never been my thing but I think that a lot of girls my age are following models. I guess it [is] sort of a way for them to almost, like to see what they aspire to be, which is really sad. (Matilda, 16 years)

Intersecting with the themes of expectation, comparison and striving, participants frequently spoke about validation when discussing the influence of social media on body image. A currency of ‘likes’, comments and followers where girls are validated on their Instagram posts and accounts was evident throughout discussions with participants;

I feel that when people post photos of them in their bikini, they want that positive feedback and say, “Oh, you look so amazing.” And that's why they do it because they want the compliments. It's kind of a false representation of themselves because they're just doing it for the likes and the compliments. (Tahlia, 16 years)

This validation was perceived to reinforce to girls that their value is largely placed on their appearance and influenced the types of images they would consider posting of themselves.

Although not frequently identified by participants, some discussed behaviors of possible concern among girls regarding the influence of social media likes, as described by Charlotte (17 years):

If you went to a birthday or something and everyone is eating cake and heaps of food, I think you probably would restrict yourself a little bit more than you would have otherwise. And think, "Oh, they got these many likes and this, maybe I should stop eating a little bit.”

Counteracting negative body image and influence of social media

Participants discussed the importance of awareness and education from a younger age among girls about social media and its influence on body image. Year six (11–12 years of age) was identified by the girls as an optimal range for this to occur, when girls are starting to use social media and many are experiencing pubertal changes and becoming more aware of their bodies and appearance. Schools, parents, peers and online sources including apps were all perceived by girls as having the potential to play a helpful role in counteracting negative body image messages, particularly when awareness and education can be delivered by all of these sources.

A form of awareness and education commonly identified by girls included critiquing images on social media within the school curriculum, to improve ‘social media literacy’;

Just to be reminded that these things aren’t what they look like. Maybe videos or something that show how edited these photos get. Like, I've seen one and it was about magazine covers, and it was just the beginning of a woman, and then two hours of makeup and things like that later, the end of her. And then she got put on the magazine cover. So, maybe similar things for social media. (Sana, 17 years)

Although it was apparent throughout the interviews with the girls that they were already aware of the editing and enhancement of images on social media, as well as the tendency for images to portray females at their best, they struggled to apply this knowledge. This was especially the case when viewing images of their peers.

It was highlighted that messages to counteract negative body image were needed, including focusing on girls’ strengths rather than their appearance, diversity of physical appearance and that idolized physiques, such as those of celebrities are not the norm;

I think for me the thing that I would like to see is saying yes, this person might be really pretty and this person might not be, but that intelligence and sort of physical [ability] is just as important. I mean, trying to say, “Oh, don’t worry [not] everyone looks good all [the] time.” That’s not helpful ‘cause nobody really believes it. (Brooke, 16 years)

Participants discussed the use of social media to counteract negative body image and promote positive body image, with body positive and acceptance messages including imagery and quotes considered helpful;

There’re a lot of body positive pages, so they post photos of normal people, not like Kendall [Jenner] but people with stretch marks and not like that at all. And then you get quotes and all these amazing things, like people's stories. So you just have to balance it out, I think, which took me awhile to do because, at first, I was just following people like her [Kendall Jenner], which didn't make me feel too good, and then now, I just go half and half. (Ava, 14 years)

While identified by the majority of girls as helpful to counteract negative body image, only a few said they followed such profiles or accounts and some were not aware of any these.

Girl-focused support and programs were discussed as needed to help girls counteract negative body image and the influence of social media, as exemplified by Grace (15 years):

I would just say there needs to be more support directly aimed at girls. I mean just bringing awareness to the fact that social media isn’t the point of your value and your worth, and that people might think that’s stupid but it is really such a big thing and I noticed it with so many people. It’s not the epitome of who you are. There’s way more substance to your person than how many followers you have and just raising awareness and bringing a lot of support and teaching girls self-love and self-worth is important so that you don’t have to have a boy validate that or you don’t have to have ‘likes’ to validate that.

The role of apps in providing girl-focused support was also discussed by participants, although some expressed concern that girls may not seek out such an app;

If it was just like [a] ‘girls only’ app. Like little ways to de-stress. Where you like breathe and stuff like that, I think that it needs to be something like that, but the thing is I don’t know if many girls would use it, I guess. They’d be like, “Why do I need this? This isn’t a necessity for me.” I don’t think many girls know that it’s harmful for them to be comparing themselves to these girls. (Amelia, 16 years)

Both school and other sources such as online environments were identified as settings where such support could be provided. However, girls also stressed the importance of schools not just providing talks about body image or advising them to simply stop engaging with social media that is influencing them negatively, as described in detail by Rachel (17 years):

We have heaps of body image talks, but it’s like, okay, they’re good for the first one, and then they’re sort of repeating themselves and it’s not going in anymore. It’s just your natural instinct to look at someone [and compare yourself]. They’ve told us to go unfollow anyone on Instagram who’s making you upset or whatever. [Its] a lot easier said than done. ‘Cause you don’t really know what’s making you upset. You can be following lots of supermodels and them as a collective are making you upset, but you’re so intrigued on where they’ve got to in their life that you don’t wanna unfollow them.

The current study utilized in-depth interviews to better understand how sexualized images typically found on social media might influence adolescent girls’ mental health, in positive and/or negative ways. Body image was the only aspect of mental health highlighted by participants in this study, attesting to its importance in the minds of participants.

While studies have found sexualized images to influence body image among females [ 34 , 43 , 49 ], participants in this study did not highlight sexualization as a specific concern in relation to body image. The pervasiveness and normalization of sexualized images within social media may help explain why girls participating in this study did not consider such images as distinct from others [ 34 , 52 ]. However, the four overarching themes of expectation, comparison, striving and validation reported in this study highlighted that adolescent girls largely view their body in relation to their appearance, and suggests self-objectification is a prominent issue when exploring the relationship between social media use and body image. Previous studies have also found a connection between self-objectification on girls’ appearance concerns [ 40 , 51 , 52 ]. Consequently, preventing appearance concerns and negative body image among girls may be facilitated by the development of strategies from a young age to counteract self-objectification, appearance concerns and comparisons in relation to social media use [ 11 , 21 , 73 ].

Consistent with previous research, the influence of social media on adolescent girls’ body image was perceived as negative by the participants in this study [ 12 , 24 , 29 , 57 , 74 ]. Girls found it difficult to identify positive influences of social media on body image, with little to no discussion among participants, even when prompted during interviews. Participants perceived girls who posted photos of themselves on social media as confident and empowered by their appearance and were unsure whether this would have a positive influence on the body image of other girls their age or those who posted the images. While some existing literature suggests adolescents are unaware and naïve to negative influences associated with social media [ 2 , 23 , 75 ], this study found girls were well aware of how the experiences of expectation, comparison, striving and validation led to negative thoughts and feelings related to their body image. Girls were also able to suggest strategies to counteract negative body image and were able to apply critical thinking when viewing images of celebrities. These findings align with previous research that found adolescents to be critical users and generators of social media, with high media literacy and the ability to identify strategies that may help mitigate social media’s negative effects on body image [ 11 , 76 , 77 ].

Adolescent girls in this study identified the importance of peers in relation to making appearance-based comparisons, with differences in the comparisons made to peers or celebrities, suggesting body image may be more negatively influenced by viewing images of peers on social media. This finding aligns with previous studies identifying peers as having a significant influence on body image concerns among girls [ 11 , 24 , 73 ]. Participants perceived peers as more relatable than celebrities, who they considered as less realistic and attainable. With images on social media more frequently featuring girls’ peers (although images of celebrities are also prominent), this finding adds to existing research highlighting peer appearance comparisons as an important component to address when developing programs aimed at the prevention and early intervention of body dissatisfaction and appearance-based concerns among girls [ 21 , 73 , 78 ]. Additionally, this study found girls were not able to apply critical thinking skills when viewing images of peers, suggesting girls need support to apply these cognitive skills to prevent or minimize peer appearance-related comparisons.

Participants also suggested that some adolescent girls may be more at risk than others of making negative appearance comparisons. This was discussed in relation to how girls already felt about their own appearance and their mood when using social media and viewing images. In relation to how girls already feel about their own appearance, positive body image could play a protective role in influencing the likelihood of making negative appearance comparisons while using social media. Positive body image refers to love and respect of one’s body and emphasizes acceptance and appreciation of its functions irrespective of whether it meets dominant societal appearance ideals [ 79 ]. An important characteristic of positive body image pertinent to the influence of girls’ social media use on their body image is protective filtering, whereby positive-body related information is accepted while negative information is rejected, maintaining positive body image [ 79 , 80 ]. Among a sample of adolescents with positive body image, expressing strong criticism against appearance ideals was found to foster protective filtering and thus helped to uphold positive body image [ 81 ], whilst in another study of adolescent girls, protective filtering also suggested benefits to body image [ 11 ]. Conversely, a recent qualitative study exploring adolescents’ processing and protective filtering of social media content and perceived protective benefits of these strategies for body image found that although girls in the study displayed aspects of engaging in protective filtering, this did not necessarily translate to protective effects to their body image and they experienced difficulty internalizing positive body-related messages and accepting and appreciating their own bodies [ 57 ]. While the present study did not collect data about participants’ own body image, findings support the importance of girls’ varying levels of body image when developing interventions aimed at reducing negative appearance comparisons when using social media.

Participants in this study also considered that a girls’ mood when using social media and viewing images may place some girls at greater risk of making negative appearance comparisons. This finding suggests that body dissatisfaction could be state-based and mediate the influence of viewing images on social media and body image, with the immediate impact of exposure to such images influencing body dissatisfaction. Research conducted with women who had trait-level appearance ideal internalization and body dissatisfaction found appearance comparisons, and in particular upward comparisons (to those deemed more attractive) predicted increased state body dissatisfaction [ 82 ]. Adolescent girls who internalize appearance ideals and those with elevated trait body dissatisfaction may be at greater risk of making negative appearance comparisons when using social media and thus may be an important sub-group to consider for intervention. Previous research has also found that girls with higher social comparison tendencies [ 24 ] and those focused on gaining approval from others about their appearance, experience more negative effects on their body image as a result of using social media [ 29 ]. Gaining approval from others when using social media through ‘likes’ and comments was mentioned frequently among girls in this study and was perceived to provide validation of one’s appearance and thus, reinforcing a focus on appearance. At the time of this study, Instagram had not yet begun its trial of no longer displaying the amount of ‘likes’ on posts. Further research with adolescent girls could explore their views on this change and its influence on appearance-based comparisons and social media activity among this group.

The role of schools, parents, peers and online sources in counteracting negative body image was highlighted by participants in this study, with emphasis placed on body image awareness, education and support being delivered by each of these sources. This finding supports existing research recommending an ecological approach to adolescent body image development, where all interactions in a girls’ environment can be influenced to prevent body dissatisfaction related to social media use [ 83 ]. Parents are a key influence on girls’ body image [ 84 , 85 ], and research has found they can play a protective role in preadolescent and adolescent social media appearance comparisons and body dissatisfaction [ 86 , 87 ]. Schools provide a setting in which content can be delivered in the classroom and whereby families, peers, teachers and other school staff can be engaged and involved in the implementation of health promotion interventions with a focus on body image [ 88 ]. When planning such interventions, it is important to consider girls’ age and developmental stage, as well as the influence and interaction of individual, family, peer, online, community, and school environments on their body image to counteract negative body image.

Congruent with research investigating social media literacy interventions as an emerging approach to address specific challenges to body image posed by social media [ 89 ], participants in this study perceived improved social media literacy among adolescent girls from a younger age, taught within the school curriculum, as important to counteracting negative body image. Social media literacy focuses on the interactions among users of social media, whether friends, other peers or celebrities, as well as developing the skills to examine the messages underlying commercial media advertising, including health and fitness, seen on social media [ 78 ]. This finding aligns with previous research which has observed favorable effects on body dissatisfaction, internalization of the thin ideal, appearance comparison, and self-esteem among girls following a pilot social media literacy intervention adapted from the ‘Happy Being Me’ program [ 90 ]. However, a recent randomized controlled trial found less effectiveness as a stand-alone intervention, with the appearance-comparison component found to be more effective [ 78 ]. Participants in the present study also identified appearance-based comparisons as a topic of concern to them, suggesting the need to include both social media literacy and appearance-comparison content in body dissatisfaction prevention interventions.

When discussing strategies for counteracting negative body image and the influence of social media, participants also referred to the importance of promoting positive body image through messaging focused on girls’ strengths rather than their appearance, body acceptance and ways to challenge unrealistic societal appearance ideals. This finding aligns with sociocultural theories such as the dual pathway model [ 68 ] suggesting the pressure among girls to conform to appearance ideals and the extent to which they internalize such ideals are important factors to target in interventions aimed at this group. To this effect, cognitive dissonance intervention the Body Project has a strong body of evidence supporting its effectiveness in increasing body appreciation and reducing thin-ideal internalization and body dissatisfaction among adolescent girls when implemented in schools [ 91 , 92 , 93 , 94 , 95 ]. The theoretical premise of the Body Project is that when there is a discrepancy between an individual’s beliefs and actions, they experience discomfort i.e. cognitive dissonance, which they then try to avoid, becoming motivated to re-assess their beliefs to align with their actions [ 96 ]. In the intervention, this is facilitated by group discussions and activities with adolescent girls where girls actively challenge appearance ideals with subsequent decreases in thin-ideal internalization and body dissatisfaction [ 91 ]. Additionally, research indicates acceptability of the intervention among adolescent girls, with the group setting contributing to their sense of belonging, particularly when facilitators are considered relatable, such as undergraduate female university students [ 95 , 97 ].

The finding that any negative influence of social media on body image was not necessarily in relation to sexualized content highlights the importance of undertaking research with girls to better understand the mechanisms of social media’s influence on their body image. In this study, participants made negative comparisons with images of females on social media regardless of whether they were considered sexualized, with the influence of peer appearance comparisons more prominent. Research with adolescent girls will also enable them to inform and co-develop interventions to support their body image development and prevent or reduce harms experienced from their social media use in relation to body image, targeted to the needs and interests of their age group.

The current study contributes new knowledge from the perspective of adolescent girls to the existing literature on adolescent girls’ social media use and its influence on their body image. The findings of this study suggest that social media can have a negative influence on girls’ body image through negative appearance comparisons when viewing images on social media, exacerbating appearance-based concerns and body dissatisfaction. While negative comparisons were made irrespective of whether images were considered sexualized, findings suggested a level of self-objectification among adolescent girls whereby they viewed themselves in relation to their appearance. The important role of peers in appearance comparisons was also evident in this study. Participants also identified strategies to prevent and counteract negative body image, which have important implications for the development of health promotion programs addressing social media use and body image concerns among adolescent girls for prevention and early intervention that can minimize potential harms. For parents and professionals working with adolescent girls, particularly in the school setting, the findings can be applied in their work by providing education about social media and its influence on body image and strategies to prevent and counteract negative body image to support girls.

Limitations

This study has several limitations that should be considered when interpreting its findings. This study was exploratory and limited by a small number of self-selected participants (n = 24). Therefore, its findings cannot be used to make assumptions about the population of girls aged between 14 and 17 years in Perth, Western Australia and does not claim to be representative of the broader population of girls. Findings may vary in other areas of Western Australia, Australia and internationally. However, qualitative research often uses smaller samples enabling the collection of in-depth information and providing direction for further research.

Additionally, participants’ own body image concerns/body dissatisfaction were not assessed as part of this study. The participating girls’ feelings about their body image may have influenced their perceptions of how social media influences body image among other girls.

The interpretation of this study’s findings may also be influenced by the characteristics of the participating girls. There were slightly more participants in this study aged between 16–17 years old, and these girls may have been using social media for longer compared to younger participants. Age and more years of experience using social media may have influenced participants’ interest in issues related to social media and thus their interest in participating in the study. In addition, all but one of the girls were from an English-speaking background and findings may differ among girls from culturally and linguistically diverse backgrounds, as they may not feel they meet Western appearance ideals and may also experience different perceived sociocultural appearance-related pressures depending on their cultural background. Another limitation of this study was that most participants attended non-government and co-educational schools. It is possible that findings may be different among samples where girls largely attend government or all girls’ schools. As most participants attended non-government schools and were from higher socioeconomic backgrounds, they may have had increased access to digital technology and therefore use of social media. Additionally, girls from high socioeconomic backgrounds may experience differences in perceived appearance ideals compared to girls from different backgrounds. It would be useful for future research to explore further the perceptions of girls in government schools and all girls’ schools to allow for comparisons, especially in relation to peers and sexualized images with those in non-government and co-educational schools.

This study provides some insight into the influence of social media on adolescent girls’ body image from the perspective of girls in Perth, Western Australia. Further research should engage with adolescent girls to identify and investigate the impact of strategies to prevent and counteract negative body image related to social media utilizing an ecological approach to encompass all aspects of girls’ lives.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available to protect the anonymity and confidentiality of the participants. Requests to obtain datasets can be made to the corresponding author.

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Acknowledgements

The authors thank Student Edge and the schools and students involved in this research.

Alana Papageorgiou was supported by a Western Australian Health Promotion Foundation (Healthway) Scholarship (file number: 24235) and an Australian Government Research Training Program Scholarship at the University of Western Australia. Donna Cross’ contribution to this paper was supported by a National Health and Medical Research Council Research Fellowship (GNT1119339). The funders had no role in the design of the study, the collection, analysis or interpretation of data, in the writing of the manuscript, or the decision to submit the manuscript for publication.

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Papageorgiou, A., Fisher, C. & Cross, D. “Why don’t I look like her?” How adolescent girls view social media and its connection to body image. BMC Women's Health 22 , 261 (2022). https://doi.org/10.1186/s12905-022-01845-4

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• Review Article
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Mechanisms linking social media use to adolescent mental health vulnerability

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• Adrian Meier   ORCID: orcid.org/0000-0002-8191-2962 2 ,
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Research linking social media use and adolescent mental health has produced mixed and inconsistent findings and little translational evidence, despite pressure to deliver concrete recommendations for families, schools and policymakers. At the same time, it is widely recognized that developmental changes in behaviour, cognition and neurobiology predispose adolescents to developing socio-emotional disorders. In this Review, we argue that such developmental changes would be a fruitful focus for social media research. Specifically, we review mechanisms by which social media could amplify the developmental changes that increase adolescents’ mental health vulnerability. These mechanisms include changes to behaviour, such as sharing risky content and self-presentation, and changes to cognition, such as modifications in self-concept, social comparison, responsiveness to social feedback and experiences of social exclusion. We also consider neurobiological mechanisms that heighten stress sensitivity and modify reward processing. By focusing on mechanisms by which social media might interact with developmental changes to increase mental health risks, our Review equips researchers with a toolkit of key digital affordances that enables theorizing and studying technology effects despite an ever-changing social media landscape.

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Introduction.

Adolescence is a period marked by profound neurobiological, behavioural and environmental changes that facilitate the transition from familial dependence to independent membership in society 1 , 2 . This critical developmental stage is also characterized by diminished well-being and increased vulnerability to the onset of mental health conditions 3 , 4 , 5 , particularly socio-emotional disorders such as depression, and eating disorders 4 , 6 (Fig. 1 ). Notable symptoms of socio-emotional disorders include heightened negative affect, mood dysregulation and an increased focus on distress or challenges concerning interpersonal relationships, including heightened sensitivity to peers or perceptions of others 6 . Although some risk factors for socio-emotional disorders do not necessarily occur in adolescence (including genetic predispositions, adverse childhood experiences and poverty 7 , 8 , 9 ), the unique developmental characteristics of this period of life can interact with pre-existing vulnerabilities, increasing the risk of disorder onset 10 .

Meta-analytic proportion of age of onset of anxiety (red), obsessive-compulsive disorder (purple), eating disorders (orange), personality disorders (green), schizophrenia (grey) and mood disorders (blue). The peak age of onset (dotted lines) is 5.5 and 15.5 years for anxiety, 14.5 years for obsessive-compulsive disorder, 15.5 years for eating disorders and 20.5 years for personality disorders, schizophrenia and mood disorders. Adapted from ref. 258 , CC BY 4.0 ( https://creativecommons.org/licenses/by/4.0/ ).

Over the past decade, declines in adolescent mental health have become a great concern 11 , 12 . The prevalence of socio-emotional disorders has increased in the adolescent age range (10–24 years 2 ) 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , leading to mounting pressures on child and adolescent mental health services 16 , 21 , 22 . This increase has not been as pronounced among other age groups when compared with adolescents 20 , 22 , 23 (measured in ref.  20 , ref.  22 and ref.  23 as age 12–25 years, 12–20 years and 18–25 years, respectively), even if some studies have found increases across the entire lifespan 24 , 25 . Although these trends might not be generalizable across the world 26 or to subclinical indicators of distress 15 , similar trends have been found in a range of countries 27 . Declines in adolescent mental health, especially socio-emotional problems, are consistent across datasets and researchers have argued that they are not solely driven by changes in social attitudes, stigma or reporting of distress 28 , 29 .

Concurrently, adolescents’ lives have become increasingly digital, with most young people using social media platforms throughout the day 30 . Ninety-five per cent of UK adolescents aged 15 years use social media 31 , and 50% of US adolescents aged 13–17 years report being almost constantly online 32 . The social media environment impacts adolescent and adult life across many domains (for example, by enabling social communication or changing the way news is accessed) and influences individuals, dyads and larger social systems 33 , 34 , 35 , 36 . Because social media is inherently social and relational 37 , it potentially overlaps and interacts with the developmental changes that make adolescents vulnerable to the onset of mental health problems 38 , 39 (Fig. 2 ). Thus, it has been intensely debated whether the increase in social media use during the past decade has a causal role in the decline of adolescent mental health 40 . Indeed, rapid changes to the environment experienced before and during adolescence might be a fruitful area to explore when examining current mental health trends 41 .

During adolescence, the interaction between genetic programming (yellow), social determinants (red) and environmental factors (blue), as well as the developmental changes discussed in this Review, increases the risk for onset of mental health conditions. Digital environments, mediated behaviours and experiences, and the impact that this technology has on society and economy more generally, are one aspect of the complex forces that might lead to the declines in adolescent mental health observed in the last decade. Adapted from ref. 259 , Springer Nature Limited.

Although there are many environmental changes that could be relevant, a substantial body of research has emerged to investigate the potential link between social media use and declines in adolescent mental health 42 , 43 using various research approaches, including cross-sectional studies 44 , longitudinal observational data analyses 45 , 46 , 47 and experimental studies 48 , 49 . However, the scientific results have been mixed and inconclusive (for reviews, see refs. 43 , 50 , 51 , 52 , 53 ), which has made it difficult to establish evidence-based recommendations, regulations and interventions aimed at ensuring that social media use is not harmful to adolescents 54 , 55 , 56 , 57 .

Many researchers attribute the mixed results to insufficient study specificity. For instance, the relationship between social media use and mental health varies notably across individuals 45 , 58 and developmental time windows 59 . Yet studies often examine adolescents without differentiating them based on age or developmental stage 60 , which prevents systematic accounts of individual and subgroup differences. Additionally, most studies only rely on self-reported measures of time spent on social media 61 , 62 , and overlook more nuanced aspects of social media use such as the nature of the activities 63 and the content or features that users engage with 52 . These factors need to be considered to unpack any broader relationships 35 , 64 , 65 , 66 . Furthermore, the measurement of mental health often conflates positive and negative mental health outcomes as well as various mental health conditions, which could all be differentially related to social media use 52 , 67 .

This research space presents substantial complexity 68 . There is an ever-increasing range of potential combinations of social media predictors, well-being and mental health outcomes and participant groups of varying backgrounds and demographics that can become the target of scientific investigation. However, the pressure to deliver policy and public-facing recommendations and interventions leaves little time to investigate comprehensively each of these combinations. Researchers need to be able to pinpoint quickly the research programmes with the maximum potential to create translational and real-world impact for adolescent mental health.

In this Review, we aim to delineate potential avenues for future research that could lead to concrete interventions to improve adolescent mental health by considering mechanisms at the nexus between pre-existing processes known to increase adolescent mental health vulnerability and digital affordances introduced by social media. First, we describe the affordance approach to understanding the effects of social media. We then draw upon research on adolescent development, mental health and social media to describe behavioural, cognitive and neurobiological mechanisms by which social media use might amplify changes during adolescent development to increase mental health vulnerability during this period of life. The specific mechanisms within each category were chosen because they have a strong evidence base showing that they undergo substantive changes during adolescent development, are implicated in mental health risk and can be modulated by social media affordances. Although the ways in which social media can also improve mental health resilience are not the focus of our Review and therefore are not reviewed fully here, they are briefly discussed in relation to each mechanism. Finally, we discuss future research focused on how to systematically test the intersection between social media and adolescent mental health.

Social media affordances

To study the impact of social media on adolescent mental health, its diverse design elements and highly individualized uses must be conceptualized. Initial research predominately related access to or time spent on social media to mental health outcomes 46 , 69 , 70 . However, social media is not similar to a toxin or nutrient for which each exposure dose has a defined link to a health-related outcome (dose–response relationship) 56 . Social media is a diverse environment that cannot be summarized by the amount of time one spends interacting with it 71 , 72 , and individual experiences are highly varied 45 .

Previous psychological reviews often focused on social media ‘features’ 73 and ‘affordances’ 74 interchangeably. However, these terms have distinct definitions in communication science and information systems research. Social media features are components of the technology intentionally designed to enable users to perform specific actions, such as liking, reposting or uploading a story 75 , 76 . By contrast, affordances describe the perceptions of action possibilities users have when engaging with social media and its features, such as anonymity (the difficulty with which social media users can identify the source of a message) and quantifiability (how countable information is).

The term ‘affordance’ came from ecological psychology and visuomotor research, and was described as mainly determined by human perception 77 . ‘Affordance’ was later adopted for design and human–computer interaction contexts to refer to the action possibilities that are suggested to the user by the technology design 78 . Communication research synthesizes both views. Affordances are now typically understood as the perceived — and therefore flexible — action possibilities of digital environments, which are jointly shaped by the technology’s features and users’ idiosyncratic perceptions of those features 79 .

Latent action possibilities can vary across different users, uses and technologies 79 . For example, ‘stories’ are a feature of Instagram designed to share content between users. Stories can also be described in terms of affordances when users perceive them as a way to determine how long their content remains available on the platform (persistence) or who can see that content (visibility) 80 , 81 , 82 , 83 , 84 . Low persistence (also termed ephemerality) and comparatively low visibility can be achieved through a technology feature (Instagram stories), but are not an outcome of technology use itself; they are instead perceived action possibilities that can vary across different technologies, users and designs 79 .

The affordances approach is particularly valuable for theorizing at a level above individual social media apps or specific features, which makes this approach more resilient to technological changes or shifts in platform popularity 79 , 85 . However, the affordances approach can also be related back to specific types of social media by assessing the extent to which certain affordances are ‘built into’ a particular platform through feature design 35 . Furthermore, because affordances depend on individuals’ perceptions and actions, they are more aligned than features with a neurocognitive and behavioural perspective to social media use. Affordances, similar to neurocognitive and behavioural research, emphasize the role of the user (how the technology is perceived, interpreted and used) rather than technology design per se. In this sense, the affordances approach is essential to overcome technological determinism of mental health outcomes, which overly emphasizes the role of technology as the driver of outcomes but overlooks the agency and impact of the people in question 86 . This flexibility and alignment with psychological theory has contributed to the increasing popularity of the affordance approach 35 , 73 , 74 , 85 , 87 and previous reviews have explored relevant social media affordances in the context of interpersonal communication among adults and adolescents 35 , 88 , 89 , adolescent body image concerns 73 and work contexts 33 . Here, we focus on the affordances of social media that are relevant for adolescent development and its intersection with mental health (Table  1 ).

Behavioural mechanisms

Adolescents often use social media differently to adults, engaging with different platforms and features and, potentially, perceiving or making use of affordances in distinctive ways 35 . These usage differences might interact with developmental characteristics and changes to amplify mental health vulnerability (Fig.  3 ). We examine two behavioural mechanisms that might govern the impact of social media use on mental health: risky posting behaviours and self-presentation.

Social media affordances can amplify the impact that common adolescent developmental mechanisms (behavioural, cognitive and neurobiological) have on mental health. At the behavioural level (top), affordances such as permanence and publicness lead to an increased impact of risk-taking behaviour on mental health compared with similar behaviours in non-mediated environments. At the cognitive level (middle), high quantifiability influences the effects of social comparison. At the neurobiological level (bottom), low synchronicity can amplify the effects of stress on the developing brain.

Risky posting behaviour

Sensation-seeking peaks in adolescence and self-regulation abilities are still not fully developed in this period of life 90 . Thus, adolescents often engage in more risky behaviours than other age groups 91 . Adolescents are more likely to take risks in situations involving peers 92 , 93 , perhaps because they are motivated to avoid social exclusion 94 , 95 . Whether adolescent risk-taking behaviour is inherently adaptive or maladaptive is debated. Although some risk-taking behaviours can be adaptive and part of typical development, others can increase mental health vulnerability. For example, data from a prospective UK panel study of more than 5,500 young people showed that engaging in more risky behaviours (including social and health risks) at age 16 years increases the odds of a range of adverse outcomes at age 18 years, such as depression, anxiety and substance abuse 96 .

Social media can increase adolescents’ engagement in risky behaviours both in non-mediated and mediated environments (environments in which the behaviour is executed in or through a technology, such as a mobile phone and social media). First, affordances such as quantifiability in conjunction with visibility and association (the degree with which links between people, between people and content or between a presenter and their audience can be articulated) can promote more risky behaviours in non-mediated environments and in-person social interactions. For example, posts from university students containing references to alcohol gain more likes than posts not referencing alcohol and liking such posts predicts an individual’s subsequent drinking habits 97 . Users expecting likes from their audience are incentivized to engage in riskier posting behaviour (such as more frequent or more extreme posts containing references to alcohol). The relationship between risky online behaviour and offline behaviour is supported by meta-analyses that found a positive correlation between adolescents’ social media use and their engagement in behaviours that might expose them to harm or risk of injury (for example, substance use or risky sexual behaviours) 98 . Further, affordances such as persistence and visibility can mean that risky behaviours in mediated and non-mediated environments remain public for long periods of time, potentially influencing how an adolescent is perceived by peers over the longer term 39 , 99 .

Adolescence can also be a time of more risky social media use. For most forms of semi-public and public social media use, users typically do not know who exactly will be able to see their posts. Thus, adolescents need to self-present to an ‘imagined audience’ 100 and avoid posting the wrong kind of content as the boundaries between different social spheres collapse (context collapse 101 ). However, young people can underestimate the risks of disclosing revealing information in a social media environment 102 . Affordances such as visibility, replicability (social media posts remain in the system and can be screenshotted and shared even if they are later deleted 39 ), association and persistence could heighten the risk of experiencing cyberbullying, victimization and online harassment 103 . For example, adolescents can forward privately received sexual images to larger friendship groups, increasing the risk of online harassment over the subject of the sexual images 104 . Further, low bandwidth (a relative lack of socio-emotional cues) and high anonymity have the potential to disinhibit interactions between users and make behaviours and reactions more extreme 105 , 106 . For example, anonymity was associated with more trolling behaviours during an online group discussion in an experiment with 242 undergraduate students 107 .

Thus, social media might drive more risky behaviours in both mediated and non-mediated contexts, increasing mental health vulnerability. However, the evidence is still not clear cut and often discounts adolescent agency and understanding. For example, mixed-methods research has shown that young people often understand the risks of posting private or sexual content and use social media apps that ensure that posts are deleted and inaccessible after short periods of time to counteract them 39 (even though posts can still be captured in the meantime). Future work will therefore need to investigate how adolescents understand and balance such risks and how such processes relate to social media’s impact on mental health.

Self-presentation and identity

The adolescent period is characterized by an abundance of self-presentation activities on social media 74 , where the drive to present oneself becomes a fundamental motivation for engagement 108 . These activities include disclosing, concealing and modifying one’s true self, and might involve deception, to convey a desired impression to an audience 109 . Compared with adults, adolescents more frequently take part in self-presentation 102 , which can encompass both realistic and idealized portrayals of themselves 110 . In adults, authentic self-presentation has been associated with increased well-being, and inauthentic presentation (such as when a person describes themselves in ways not aligned with their true self) has been associated with decreased well-being 111 , 112 , 113 .

Several social media affordances shape the self-presentation behaviours of adolescents. For example, the editability of social media profiles enables users to curate their online identity 84 , 114 . Editability is further enhanced by highly visible (public) self-presentations. Additionally, the constant availability of social media platforms enables adolescents to access and engage with their profiles at any time, and provides them with rapid quantitative feedback about their popularity among peers 89 , 115 . People receive more direct and public feedback on their self-presentation on social media than in other types of environment 116 , 117 . The affordances associated with self-presentation can have a particular impact during adolescence, a period characterized by identity development and exploration.

Social media environments might provide more opportunities than offline environments for shaping one’s identity. Indeed, public self-presentation has been found to invoke more prominent identity shifts (substantial changes in identity) compared with private self-presentation 118 , 119 . Concerns have been raised that higher Internet use is associated with decreased self-concept clarity. Only one study of 101 adolescents as well as adults reviewed in a 2021 meta-analysis 120 showed that the intensity of Facebook use (measured by the Facebook Intensity Scale) predicted a longitudinal decline in self-concept clarity 3 months later, but the converse was not the case and changes in self-concept clarity did not predict Facebook use 121 . This result is still not enough to show a causal relationship 121 . Further, the affordances of persistence and replicability could also curtail adolescents’ ability to explore their identity freely 122 .

By contrast, qualitative research has highlighted that social media enables adolescents to broaden their horizons, explore their identity and identify and reaffirm their values 123 . Social media can help self-presentation by enabling adolescents to elaborate on various aspects of their identity, such as ethnicity and race 124 or sexuality 125 . Social media affordances such as editability and visibility can also facilitate this process. Adolescents can modify and curate self-presentations online, try out new identities or express previously undisclosed aspects of their identity 126 , 127 . They can leverage social media affordances to present different facets of themselves to various social groups by using different profiles, platforms and self-censorship and curation of posts 128 , 129 . Presenting and exploring different aspects of one’s identity can have mental health implications for minority teens. Emerging research shows a positive correlation between well-being and problematic Internet use in transgender, non-binary and gender-diverse adolescents (age 13–18 years), and positive sentiment has been associated with online identity disclosures in transgender individuals with supportive networks (both adolescent and adult) 130 , 131 .

Cognitive mechanisms

Adolescents and adults might experience different socio-cognitive impacts from the same social media activity. In this section, we review four cognitive mechanisms via which social media and its affordances might influence the link between adolescent development and mental health vulnerabilities (Fig.  3 ). These mechanisms (self-concept development, social comparison, social feedback and exclusion) roughly align with a previous review that examined self-esteem and social media use 115 .

Self-concept development

Self-concept refers to a person’s beliefs and evaluations about their own qualities and traits 132 , which first develops and becomes more complex throughout childhood and then accelerates its development during adolescence 133 , 134 , 135 . Self-concept is shaped by socio-emotional processes such as self-appraisal and social feedback 134 . A negative and unstable self-concept has been associated with negative mental health outcomes 136 , 137 .

Perspective-taking abilities also develop during adolescence 133 , 138 , 139 , as does the processing of self-relevant stimuli (measured by self-referential memory tasks, which assess memory for self-referential trait adjectives 140 , 141 ). During adolescence, direct self-evaluations and reflected self-evaluations (how someone thinks others evaluate them) become more similar. Further, self-evaluations have a distinct positive bias during childhood, but this positivity bias decreases in adolescence as evaluations of the self are integrated with judgements of other people’s perspectives 142 . Indeed, negative self-evaluations peak in late adolescence (around age 19 years) 140 .

The impact of social media on the development of self-concept could be heightened during adolescence because of affordances such as personalization of content 143 (the degree to which content can be tailored to fit the identity, preferences or expectations of the receiver), which adapts the information young people are exposed to. Other affordances with similar impacts are quantifiability, availability (the accessibility of the technology as well as the user’s accessibility through the technology) and public visibility of interactions 89 , which render the evaluations of others more prominent and omnipresent. The prominence of social evaluation can pose long-term risks to mental health under certain conditions and for some users 144 , 145 . For example, receiving negative evaluations from others or being exposed to cyberbullying behaviours 146 , 147 can, potentially, have heightened impact at times of self-concept development.

A pioneering cross-sectional study of 150 adolescents showed that direct self-evaluations are more similar to reflected self-evaluations, and self-evaluations are more negative, in adolescents aged 11–21 years who estimate spending more time on social media 148 . Further, longitudinal data have shown bidirectional negative links between social media use and satisfaction with domains of the self (such as satisfaction with family, friends or schoolwork) 47 .

Although large-scale evidence is still unavailable, these findings raise the interesting prospect that social media might have a negative influence on perspective-taking and self-concept. There is less evidence for the potential positive influence of social media on these aspects of adolescent development, demonstrating an important research gap. Some researchers hypothesize that social media enables self-concept unification because it provides ample opportunity to find validation 89 . Research has also discussed how algorithmic curation of personalized social media feeds (for example, TikTok algorithms tailoring videos viewed to the user’s interests) enables users to reflect on their self-concept by being exposed to others’ experiences and perspectives 143 , an area where future research can provide important insights.

Social comparison

Social comparison (thinking about information about other people in relation to the self 149 ) also influences self-concept development and becomes particularly important during adolescence 133 , 150 . There are a range of social media affordances that can amplify the impact of social comparison on mental health. For example, quantifiability enables like or follower counts to be easily compared with others as a sign of status, which facilitates social ranking 151 , 152 , 153 , 154 . Studies of older adolescents and adults aged, on average, 20 years have also found that the number of likes or reactions received predict, in part, how successful users judge their self-presentation posts on Facebook 155 . Furthermore, personalization enables the content that users see on social media to be curated so as to be highly relevant and interesting for them, which should intensify comparisons. For example, an adolescent interested in sports and fitness content will receive personalized recommendations fitting those interests, which should increase the likelihood of comparisons with people portrayed in this content. In turn, the affordance of association can help adolescents surround themselves with similar peers and public personae online, enhancing social comparison effects 63 , 156 . Being able to edit posts (via the affordance of editability) has been argued to contribute to the positivity bias on social media: what is portrayed online is often more positive than the offline experience. Thus, upward comparisons are more likely to happen in online spaces than downward or lateral comparisons 157 . Lastly, the verifiability of others’ idealized self-presentations is often low, meaning that users have insufficient cues to gauge their authenticity 158 .

Engaging in comparisons on social media has been associated with depression in correlational studies 159 . Furthermore, qualitative research has shown that not receiving as many positive evaluations as expected (or if positive evaluations are not provided quickly enough) increases negative emotions in children and adolescents aged between age 9 and 19 years 39 . This result aligns with a reinforcement learning modelling study of Instagram data, which found that the likes a user receives on their own posts become less valuable and less predictive of future posting behaviour if others in their network receive more likes on their posts 160 . Although this study did not measure mood or mental health, it shows that the value of the likes are not static but inherently social; their impact depends on how many are typically received by other people in the same network.

Among the different types of social comparison that adolescents engage in (comparing one’s achievements, social status or lifestyle), the most substantial concerns have been raised about body-related comparisons. One review suggested that social media affordances create a ‘perfect storm’ for body image concerns that can contribute to both socio-emotional and eating disorders 73 . Social media affordances might increase young people’s focus on other people’s appearances as well as on their own appearance by showing idealized, highly edited images, providing quantified feedback and making the ability to associate and compare oneself with peers constantly available 161 , 162 . The latter puts adolescents who are less popular or receive less social support at particular risk of low self-image and social distress 35 .

Affordances enable more prominent and explicit social comparisons in social media environments relative to offline environments 158 , 159 , 163 , 164 , 165 . However, this association could have a positive impact on mental health 164 , 166 . Initial evidence suggests beneficial outcomes of upward comparisons on social media, which can motivate behaviour change and yield positive downstream effects on mental health 164 , 166 . Positive motivational effects (inspiration) have been observed among young adults for topics such as travelling and exploring nature, as well as fitness and other health behaviours, which can all improve mental health 167 . Importantly, inspiration experiences are not a niche phenomenon on social media: an experience sampling study of 353 Dutch adolescents (mean age 13–15 years) found that participants reported some level of social media-induced inspiration in 33% of the times they were asked to report on this over the course of 3 weeks 168 . Several experimental and longitudinal studies show that inspiration is linked to upward comparison on social media 157 , 164 , 166 . However, the positive, motivating side of social comparison on social media has only been examined in a few studies and requires additional investigation.

Social feedback

Adolescence is also a period of social reorientation, when peers tend to become more important than family 169 , peer acceptance becomes increasingly relevant 170 , 171 , 172 and young people spend increasing amounts of time with peers 173 . In parallel, there is a heightened sensitivity to negative socio-emotional or self-referential cues 140 , 174 , higher expectation of being rejected by others 175 and internalization of such rejection 142 , 176 compared with other phases in life development. A meta-analysis of both adolescents and adults found that oversensitivity to social rejection is moderately associated with both depression and anxiety 177 .

Social media affordances might amplify the potential impact of social feedback on mental health. Wanting to be accepted by peers and increased susceptibility to social rewards could be a motivator for using social media in the first place 178 . Indeed, receiving likes as social reward activated areas of the brain (such as the nucleus accumbens) that are also activated by monetary reward 179 . Quantifiability amplifies peer acceptance and rejection (via like counts), and social rejection has been linked to adverse mental health outcomes 170 , 180 , 181 , 182 . Social media can also increase feelings of being evaluated, the risk of social rejection and rumination about potential rejection due to affordances such as quantifiability, synchronicity (the degree to which an interaction happens in real time) and variability of social rewards (the degree to which social interaction and feedback occur on variable time schedules). For example, one study of undergraduate students found that active communication such as messaging was associated with feeling better after Facebook use; however, this was not the case if the communication led to negative feelings such as rumination (for example, after no responses to the messages) 183 .

In a study assessing threatened social evaluation online 184 , participants were asked to record a statement about themselves and were told their statements would be rated by others. To increase the authenticity of the threat, participants were asked to rate other people’s recordings. Threatened social evaluation online in this study decreased mood, most prominently in people with high sensitivity to social rejection. Adolescents who are more sensitive to social rejection report more severe depressive symptoms and maladaptive ruminative brooding in both mediated and non-mediated social environments, and this association is most prominent in early adolescence 185 . Not receiving as much online social approval as peers led to more severe depressive symptoms in a study of American ninth-grade adolescents (between age 14 and 15 years), especially those who were already experiencing peer victimization 153 . Furthermore, individuals with lower self-esteem post more negative and less positive content than individuals with higher self-esteem. Posted negative content receives less social reward and recognition from others than positive content, possibly creating a vicious cycle 186 . Negative experiences pertaining to social exclusion and status are also risk factors for socio-emotional disorders 180 .

The impact of social media experiences on self-esteem can be very heterogeneous, varying substantially across individuals. As a benefit, positive social feedback obtained via social media can increase users’ self-esteem 115 , an association also found among adolescents 187 . For instance, receiving likes on one’s profile or posted photographs can bolster self-esteem in the short term 144 , 188 . A study linking behavioural data and self-reports from Facebook users found that receiving quick responses on public posts increased a sense of social support and decreased loneliness 189 . Furthermore, a review of reviews consistently documented that users who report more social media use also perceive themselves to have more social resources and support online 52 , although this association has mostly been studied among young adults using social network sites such as Facebook. Whether such social feedback benefits extend to adolescents’ use of platforms centred on content consumption (such as TikTok or Instagram) is an open question.

Social inclusion and exclusion

Adolescents are more sensitive to the negative emotional impacts of being excluded than are adults 170 , 190 . It has been proposed that, as the importance of social affiliation increases during this period of life 134 , 191 , 192 , adolescents are more sensitive to a range of social stimuli, regardless of valence 193 . These include social feedback (such as compliments or likes) 95 , 194 , negative socio-emotional cues (such as negative facial expressions or social exclusion) 174 and social rejection 172 , 185 . By contrast, social inclusion (via friendships in adolescence) is protective against emotional disorders 195 and more social support is related to higher adolescent well-being 196 .

Experiencing ostracism and exclusion online decreases self-esteem and positive emotion 197 . This association has been found in vignette experiments where participants received no, only a few or a lot of likes 198 , or experiments that used mock-ups of social media sites where others received more likes than participants 153 . Being ostracized (not receiving attention or feedback) or rejected through social media features (receiving dislikes and no likes) is also associated with a reduced sense of belonging, meaningfulness, self-esteem and control 199 . Similar results were found when ostracism was experienced over messaging apps, such as not receiving a reply via WhatsApp 200 .

Evidence on whether social media also enables adolescents to experience positive social inclusion is mostly indirect and mixed. Some longitudinal surveys have found that prosocial feedback received on social media during major life events (such as university admissions) helps to buffer against stress 201 . Adult participants of a longitudinal study reported that social media offered more informational support than offline contexts, but offline contexts more often offered emotional or instrumental support 202 . Higher social network site use is, on average, associated with a perception of having more social resources and support in adults (for an overview of meta-analyses, see ref. 52 ). However, most of these studies have not investigated social support among adolescents, and it is unclear whether early findings (for example, on Facebook or Twitter) generalize to a social media landscape more strongly characterized by content consumption than social interaction (such as Instagram or TikTok).

Still, a review of social media use and offline interpersonal outcomes among adolescents documents both positive (sense of belonging and social capital) and negative (alienation from peers and perceived isolation) correlates 203 . Experience sampling research on emotional support among young adults has further shown that online social support is received and perceived as effective, and its perceived effectiveness is similar to in-person social support 204 . Social media use also has complex associations with friendship closeness among adolescents. For example, one experience sampling study found that greater use of WhatsApp or Instagram is associated with higher friendship closeness among adolescents; however, within-person examinations over time showed small negative associations 205 .

Neurobiological mechanisms

The long-term impact of environmental changes such as social media use on mental health might be amplified because adolescence is a period of considerable neurobiological development 95 (Fig.  3 ). During adolescence, overall cortical grey matter declines and white matter increases 206 , 207 . Development is particularly protracted in brain regions associated with social cognition and executive functions such as planning, decision-making and inhibiting prepotent responses. The changes in grey and white matter are thought to reflect axonal growth, myelination and synaptic reorganization, which are mechanisms of neuroplasticity influenced by the environment 208 . For example, research in rodents has demonstrated that adolescence is a sensitive period for social input, and that social isolation in adolescence has unique and more deleterious consequences for neural, behavioural and mental health development than social isolation before puberty or in adulthood 206 , 209 . There is evidence that brain regions involved in motivation and reward show greater activation to rewarding and motivational stimuli (such as appetitive stimuli and the presence of peers) in early and/or mid adolescence compared with other age groups 210 , 211 , 212 , 213 , 214 .

Little is known about the potential links between social media and neurodevelopment due to the paucity of research investigating these associations. Furthermore, causal chains (for example, social media increasing stress, which in turn influences the brain) have not yet been accurately delineated. However, it would be amiss not to recognize that brain development during adolescence forms part of the biological basis of mental health vulnerability and should therefore be considered. Indeed, the brain is proposed to be particularly plastic in adolescence and susceptible to environmental stimuli, both positive and negative 208 . Thus, even if adults and adolescents experienced the same affective consequences from social media use (such as increases in peer comparison or stress), these consequences might have a greater impact in adolescence.

A cross-sectional study (with some longitudinal elements) suggested that habitual checking of social media (for example, checking for rewards such as likes) might exacerbate reward sensitivity processes, leading to long-term hypersensitization of the reward system 215 . Specifically, frequently checking social media was associated with reduced activation in brain regions such as the dorsolateral prefrontal cortex and the amygdala in response to anticipated social feedback in young people. Brain activation during the same social feedback task was measured over subsequent years. Upon follow-up, anticipating feedback was associated with increased activation of the same brain regions among the individuals who checked social media frequently initially 215 . Although longitudinal brain imaging measurements enabled trajectories of brain development to be specified, the measures of social media use were only acquired once in the first wave of data collection. The study therefore cannot account for confounds such as personality traits, which might influence both social media checking behaviours and brain development. Other studies of digital screen use and brain development have found no impact on adolescent functional brain organization 216 .

Brain development and heightened neuroplasticity 208 render adolescence a particularly sensitive period with potentially long-term impacts into adulthood. It is possible that social media affordances that underpin increased checking and reward-seeking behaviours (such as quantifiability, variability of social rewards and permanent availability of peers) might have long-term consequences on reward processing when experienced during adolescence. However, this suggestion is still speculative and not backed up by evidence 217 .

Stress is another example of the potential amplifying effect of social media on adolescent mental health vulnerability due to neural development. Adolescents show higher stress reactivity because of maturational changes to, and increased reactivity in, the hypothalamic–pituitary–adrenal axis 218 , 219 . Compared with children and adults, adolescents experience an increase in self-consciousness and associated emotional states such as self-reported embarrassment and related physiological measures of arousal (such as skin conductance), and heightened neural response patterns compared with adults, when being evaluated or observed by peers 220 . Similarly, adolescents (age 13–17 years) show higher stress responses (higher levels of cortisol or blood pressure) compared with children (age 7–12 years) when they perform in front of others or experience social rejection 221 .

Such changes in adolescence might confer heightened risk for the onset of mental health conditions, especially socio-emotional disorders 6 . Both adolescent rodents and humans show prolonged hypothalamic–pituitary–adrenal activation after experiencing stress compared with conspecifics of different ages 218 , 219 . In animal models, stress during adolescence has been shown to result in increased anxiety levels in adulthood 222 and alterations in emotional and cognitive development 223 . Furthermore, human studies have linked stress in adolescence to a higher risk of mental health disorder onset 218 and reviews of cross-species work have illustrated a range of brain changes due to adolescent stress 224 , 225 .

There is still little conclusive neurobiological evidence about social media use and stress, and a lack of understanding about which affordances might be involved (although there has been a range of work studying digital stress; Box  1 ). Studies of changes in cortisol levels or hypothalamic–pituitary–adrenal functioning and their relation to social media use have been mixed and inconclusive 226 , 227 . These results could be due to the challenge of studying stress responses in adolescents, particularly as cortisol fluctuates across the day and one-point readings can be unreliable. However, the increased stress sensitivity during the adolescent developmental period might mean that social media use can have a long-term influence on mental health due to neurobiological mechanisms. These processes are therefore important to understand in future research.

Box 1 Digital stress

Digital stress is not a unified construct. Thematic content analyses have categorized digital stress into type I stressors (for example, mean attacks, cyberbullying or shaming) and type II stressors (for example, interpersonal stress due to pressure to stay available) 260 . Other reviews have noted its complexity, and categorized digital stress into availability stress (stress that results from having to be constantly available), approval anxiety (anxiety regarding others’ reaction to their own profile, posts or activities online), fear of missing out (stress about being absent from or not experiencing others’ rewarding experiences) and communication overload (stress due to the scale, intensity and frequency of online communication) 261 .

Digital stress has been systematically linked to negative mental health outcomes. Higher digital stress was longitudinally associated with higher depressive symptoms in a questionnaire study 262 . Higher social media stress was also longitudinally related to poorer sleep outcomes in girls (but not boys) 263 . Studies and reviews have linked cyberbullying victimization (a highly stressful experience) to decreased mental health outcomes such as depression, and psychosocial outcomes such as self-esteem 103 , 146 , 147 , 264 , 265 . A systematic review of both adolescents and adults found a medium association ( r  = 0.26–0.34) between different components of digital stress and psychological distress outcomes such as anxiety, depression or loneliness, which was not moderated by age or sex (except for connection overload) 266 . However, the causal structure giving rise to such results is still far from clear. For example, surveys have linked higher stress levels to more problematic social media use and fear of missing out 267 , 268 .

Thus, the impact of digital stress on mental health is probably complex and influenced by the type of digital stressor and various affordances. For example, visibility and availability increase fear of negative public evaluation 269 and high availability and a social norm of responding quickly to messages drive constant monitoring in adolescents due to a persistent fear of upsetting friends 270 .

A range of relevant evidence from qualitative and quantitative studies documents that adolescents often ruminate about online interactions and messages. For example, online salience (constantly thinking about communication, content or events happening online) was positively associated with stress on both between-person and within-person levels in a cross-sectional quota sample of adults and three diary studies of young adults 271 , 272 . Online salience has also been associated with lower well-being in a pre-registered study of momentary self-reports from young adults with logged online behaviours. However, this study also noted that positive thoughts were related to higher well-being 273 . Furthermore, although some studies found no associations between the amount of communication and digital stress 272 , a cross-sectional study found that younger users’ (age 14–34 years and 35–49 years) perception of social pressure to be constantly available was related to communication load (measured by questions about the amount of use, as well as the urge to check email and social media) and Internet multitasking, whereas this was not the case for older users aged 50–85 years 274 . By contrast, communication load and perceived stress were associated only among older users.

Summary and future directions

To help to understand the potential role of social media in the decline of adolescent mental health over the past decade, researchers should study the mechanisms linking social media, adolescent development and mental health. Specifically, social media environments might amplify the socio-cognitive processes that render adolescents more vulnerable to mental health conditions in the first place. We outline various mechanisms at three levels of adolescent development — behavioural, cognitive and neurobiological — that could be involved in the decline of adolescent mental health as a function of social media engagement. To do so, we delineate specific social media affordances, such as quantification of social feedback or anonymity, which can also have positive impacts on mental health.

Our Review sets out clear recommendations for future research on the intersection of social media and adolescent mental health. The foundation of this research lies in the existing literature investigating the underlying processes that heighten adolescents’ risk of developing socio-emotional disorders. Zooming in on the potential mechanistic targets impacted by social media uses and affordances will produce specific research questions to facilitate controlled and systematic scientific inquiry relevant for intervention and translation. This approach encourages researchers to pinpoint the mechanisms and levels of explanation they want to include and will enable them to identify what factors to additionally consider, such as participants’ age 60 , the specific mental health outcomes being measured, the types of social media being examined and the populations under study 52 , 228 . Targeted and effective research should prioritize the most promising areas of study and acknowledge that all research approaches have inherent limitations 229 . Researchers must embrace methodological diversity, which in turn will facilitate triangulation. Surveys, experience sampling designs in conjunction with digital trace data, as well as experimental or neuroimaging paradigms and computational modelling (such as reinforcement learning) can all be used to address research questions comprehensively 230 . Employing such a multi-method approach enables the convergence of evidence and strengthens the reliability of findings 231 .

Mental health and developmental research can also become more applicable to the study of social media by considering how studies might already be exploring features of the digital environment, such as its design features and perceived affordances. Many cognitive neuroscience studies that investigate social processes and mental health during adolescence necessarily design tasks that can be completed in controlled experimental or brain scanning environments. Consequently, they tend to focus on digitally mediated interactions. However, researchers conceptualize and generalize their results to face-to-face interactions. For example, it is common across the discipline to not explicitly describe the interactions under study as being about social processes in digital environments (such as studies that assess social feedback based on the number of ‘thumbs up’ or ‘thumbs down’ received in social media 232 ). Considering whether cognitive neuroscience studies include key affordances of mediated (or non-mediated) environments, and discussing these in published papers, will make studies searchable within the field of social media research, enabling researchers to broaden the impact of their work and systematically specify generalizations to offline environments 233 .

To bridge the gap between knowledge about mediated and non-mediated social environments, it is essential to directly compare the two 233 . It is often assumed that negative experiences online have a detrimental impact on mental health. However, it remains unclear whether this mechanism is present in both mediated and non-mediated spaces or whether it is specific to the mediated context. For instance, our Review highlights that the quantification of social feedback through likes is an important affordance of social media 160 . Feedback on social media platforms might therefore elicit a greater sense of certainty because it is quantified compared with the more subjective and open-to-interpretation feedback received face to face 151 . Conducting experiments in which participants receive feedback that is more or less quantified and uncertain, specifically designed to compare mediated and non-mediated environments, would provide valuable insights. Such research efforts could also establish connections with computational neuroscience studies demonstrating that people tend to learn faster from stimuli that are less uncertain 234 .

We have chosen not to make recommendations concerning interventions targeting social media use to improve adolescent mental health for several reasons. First, we did not fully consider the bidirectional interactions between environment and development 35 , 235 , or the factors modulating adolescents’ differential susceptibility to the effects of social media 45 , 58 . For example, mental health status also influences how social media is used 47 , 58 , 59 , 236 , 237 (Box  2 ). These bidirectional interactions could be addressed using network or complexity science approaches 238 . Second, we do not yet know how the potential mechanisms by which social media might increase mental health vulnerability compare in magnitude, importance, scale and ease and/or cost of intervention with other factors and mechanisms that are already well known to influence mental health, such as poverty or loneliness. Last, social media use will probably interact with these predictors in ways that have not been delineated and can also support mental health resilience (for example, through social support or online self-help programmes). These complexities should be considered in future research, which will need to pinpoint not just the existence of mechanisms but their relative importance, to identify policy and intervention priorities.

Our Review has used a broad definition of mental health. Focusing on specific diagnostic or transdiagnostic symptomatology might reveal different mechanisms of interest. Furthermore, our Review is limited to mechanisms related to behaviour and neurocognitive development, disregarding other levels of explanation (such as genetics and culture) 34 , and also studying predominately Western-centric samples 239 . Mechanisms do not operate solely in linear pathways but exist within networks of interacting risk and resilience factors, characterized by non-linear and complex dynamics across diverse timescales 9 . Mechanisms and predisposing factors can interact and combine, amplifying mental health vulnerability. Mental health can be considered a dynamic system in which gradual changes to external conditions can have substantial downstream consequences due to system properties such as feedback loops 240 , 241 , 242 . These consequences are especially prominent in times of change and pre-existing vulnerability, such as adolescence 10 .

Indeed, if social media is a contributing factor to the current decline in adolescent mental health, as is commonly assumed, then it is important to identify and investigate mechanisms that are specifically tailored to the adolescent age range and make the case for why they matter. Without a thorough examination of these mechanisms and policy analysis to indicate whether they should be a priority to address, there is insufficient evidence to support the hypothesis that social media is the primary — or even just an influential and important — driver of mental health declines. Researchers need to stop studying social media as monolithic and uniform, and instead study its features, affordances and outcomes by leveraging a range of methods including experiments, questionnaires, qualitative research and industry data. Ultimately, this comprehensive approach will enhance researchers’ ability to address the potential challenges that the digital era poses on adolescent mental health.

Box 2 Effects of mental health on social media use

Although a lot of scientific discussion has focused on the impact of social media use on mental health, cross-sectional studies cannot differentiate between whether social media use is influencing mental health or mental health is influencing social media use, or a third factor is influencing both 51 . It is likely that mental health status influences social media use creating reinforcing cycles of behaviour, something that has been considered in the communication sciences literature under the term ‘transactional media effects’ 58 , 236 , 237 . According to communication science models, media use and its consequences are components of reciprocal processes 275 .

There are similar models in mental health research. For example, people’s moods influence their judgements of events, which can lead to self-perpetuating cycles of negativity (or positivity); a mechanism called ‘mood congruency’ 276 . Behavioural studies have also shown that people experiencing poor mental health behave in ways that decrease their opportunity to experience environmental reward such as social activities, maintaining poor mental health 277 , 278 . Although for many people these behaviours are a form of coping (for example, by avoiding stressful circumstances), they often worsen symptoms of mental health conditions 279 .

Some longitudinal studies found that a decrease in adolescent well-being predicted an increase in social media use 1 year later 47 , 59 . However, other studies have found no relationships between well-being and social media use over long-term or daily time windows 45 , 46 . One reason behind the heterogeneity of the results could be that how mental health impacts social media use is highly individual 45 , 280 .

Knowledge on the impact of mental health on social media use is still in its infancy and studies struggle to reach coherent conclusions. However, findings from the mental health literature can be used to generate hypotheses about how aspects of mental health might impact social media use. For example, it has been repeatedly found that young people with anxiety or eating disorders engage in more social comparisons than individuals without these disorders 281 , 282 , and adolescents with depression report more unfavourable social comparisons on social media than adolescents without depression 283 . Similar results have been found for social feedback seeking (for example, reassurance), including in social media environments 159 . Specifically, depressive symptoms were more associated with social comparison and feedback seeking, and these associations were stronger in women and in adolescents who were less popular. Individuals from the general population with lower self-esteem post more negative and less positive content than individuals with higher self-esteem, which in turn is associated with receiving less positive feedback from others 185 . There are therefore a wide range of possible ways in which diverse aspects of mental health might influence specific facets of how social media is used — and, in turn, how it ends up impacting the user.

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Acknowledgements

A.O. and T.D. were funded by the Medical Research Council (MC_UU_00030/13). A.O. was funded by the Jacobs Foundation and a UKRI Future Leaders Fellowship (MR/X034925/1). S.-J.B. is funded by Wellcome (grant numbers WT107496/Z/15/Z and WT227882/Z/23/Z), the MRC, the Jacobs Foundation, the Wellspring Foundation and the University of Cambridge.

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The International Journal of Indian Psychȯlogy

The Influence of Social Media on Adolescent Body Image Perception, Self-Esteem

| Published: May 12, 2024

This study investigates the complex interactions between adolescents’ use of Social Media (SM) and their perceptions of their bodies and esteem. The research examines how the pervasiveness of SM in modern culture impacts the cognitive processes and emotional responses of adolescents through a thorough examination of the body of current literature and empirical analysis based in social psychology. Using multiple regression analysis and a cross-sectional correlational methodology, the study investigates the associations between SM use, self-esteem (SE), and body image assessment in 128 adolescents selected using quota sampling. The results of this study show a strong negative relationship between teenage SM use and SE, suggesting that higher involvement levels are associated with lower SE. Nonetheless, SM impact on how people perceive their bodies is less pronounced and not statistically significant. These results emphasize the intricacy of SM influence on teenage mental health and the necessity for more investigation to fully comprehend its underlying mechanisms.

SM , Adolescents , Body Image Perception , SE , Social Psychology , Digital Natives , Mental Health , Correlation Analysis , Regression Analysis , Literature Review

This is an Open Access Research distributed under the terms of the Creative Commons Attribution License (www.creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any Medium, provided the original work is properly cited.

© 2024, Fatima, S.

Received: April 29, 2024; Revision Received: May 08, 2024; Accepted: May 12, 2024

Sameena Fatima @ [email protected]

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Published in   Volume 12, Issue 2, April-June, 2024

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

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[2] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[3] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk ; Kimmelman, J., Hyun, I., Benvenisty, N.  et al.  Policy: Global standards for stem-cell research.  Nature   533 , 311–313 (2016). https://doi.org/10.1038/533311a

[4] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk

[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research.  The New England journal of medicine ,  351 (3), 207–209. https://doi.org/10.1056/NEJMp048145 ; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos . The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos ; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy , 38 (2/3), 264–284. http://www.jstor.org/stable/24439776 ; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells.  The New England journal of medicine ,  351 (3), 209–211. https://doi.org/10.1056/NEJMp048147 ; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality.  Bosnian journal of basic medical sciences ,  4 (1), 5–14. https://doi.org/10.17305/bjbms.2004.3453

[6] Vazin, T., & Freed, W. J. (2010). Human embryonic stem cells: derivation, culture, and differentiation: a review.  Restorative neurology and neuroscience ,  28 (4), 589–603. https://doi.org/10.3233/RNN-2010-0543

[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells.  Social Research ,  73 (3), 819–834. http://www.jstor.org/stable/40971854

[12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics . 22. 10.1186/s12910-021-00678-4.

[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

[15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324

[16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa.  Stem Cell Res Ther   4 , 54 (2013). https://doi.org/10.1186/scrt204 ; Pew Research Center. (2014, May 1). Public health a major priority in African nations . Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/

[17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024 . National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf

[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia . UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html

[20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction.  Frontiers in pharmacology ,  13 , 1013740. https://doi.org/10.3389/fphar.2022.1013740

[25] Li, X.-T., & Zhao, J. (2012). Chapter 4: An Approach to the Nature of Qi in TCM- Qi and Bioenergy. In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech.

[26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine , 12 (6), 647–656. https://doi.org/10.2217/rme-2017-0035

[29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[30] Chen, H., Wei, T., Wang, H.  et al.  Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017.  BMC Public Health   22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

[31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan.  Curr Stem Cell Rep   1 , 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6

[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work.  Nature . https://doi.org/10.1038/nature.2012.10565

[34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned.  Accountability in research ,  13 (1), 101–109. https://doi.org/10.1080/08989620600634193 .

[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52.  https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation.  Journal of Religion and Health ,  30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law).  Journal of assisted reproduction and genetics ,  25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

[66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet) . Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en

[67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[68] Gert, B. (2007). Common morality: Deciding what to do . Oxford Univ. Press.

[69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association .; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979).  The Belmont report: Ethical principles and guidelines for the protection of human subjects of research . U.S. Department of Health and Human Services.  https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html

[70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes.  Journal of assisted reproduction and genetics ,  35 (7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine , 10 (12), 1715–1716. https://doi.org/10.1002/sctm.21-0234

[71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA.  Reproductive biomedicine online ,  18 (5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8

[72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa.  Clinical trials (London, England) ,  3 (3), 306–313. https://doi.org/10.1191/1740774506cn150oa

[73] Veatch, Robert M.  Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict . Georgetown University Press, 2012.

[74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity.  Research Ethics ,  14 (3), 1-17.  https://doi.org/10.1177/1747016117739939

[75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry.  Voices in Bioethics ,  8 . https://doi.org/10.52214/vib.v8i.9894

[76] Stem Cell Tourism: False Hope for Real Money . Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism , See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis.  Voices in Bioethics ,  3 . https://doi.org/10.7916/vib.v3i.6027

[77] Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation,  New Genetics and Society , 30:2, 141-153, DOI:  10.1080/14636778.2011.574375

[78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[79] International Society for Stem Cell Research. (2024). Standards in stem cell research . International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research

[80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier . Stanford University Press.

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

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About Down Syndrome

• Down syndrome is a genetic condition where a person is born with an extra chromosome.
• This can affect how their brain and body develop.
• People diagnosed with Down syndrome can lead healthy lives with supportive care.

Down syndrome is a condition in which a person has an extra copy of chromosome 21. Chromosomes are small "packages" of genes in the body's cells, which determine how the body forms and functions.

When babies are growing, the extra chromosome changes how their body and brain develop. This can cause both physical and mental challenges.

People with Down syndrome often have developmental challenges, such as being slower to learn to speak than other children.

Distinct physical signs of Down syndrome are usually present at birth and become more apparent as the baby grows. They can include facial features, such as:

• A flattened face, especially the bridge of the nose
• Almond-shaped eyes that slant up
• A tongue that tends to stick out of the mouth

Other physical signs can include:

• A short neck
• Small ears, hands, and feet
• A single line across the palm of the hand (palmar crease)
• Small pinky fingers
• Poor muscle tone or loose joints
• Shorter-than-average height

Some people with Down syndrome have other medical problems as well. Common health problems include:

• Congenital heart defects
• Hearing loss
• Obstructive sleep apnea

Down syndrome is the most common chromosomal condition diagnosed in the United States. Each year, about 5,700 babies born in the US have Down syndrome. 1

There are three types of Down syndrome. The physical features and behaviors are similar for all three types.

With Trisomy 21, each cell in the body has three separate copies of chromosome 21. About 95% of people with Down syndrome have Trisomy 21.

Translocation Down syndrome

In this type, an extra part or a whole extra chromosome 21 is present. However, the extra chromosome is attached or "trans-located" to a different chromosome rather than being a separate chromosome 21. This type accounts for about 3% of people with Down syndrome.

Mosaic Down syndrome

Mosaic means mixture or combination. In this type, some cells have three copies of chromosome 21, but other cells have the typical two copies. People with mosaic Down syndrome may have fewer features of the condition. This type accounts for about 2% of people with Down syndrome.

Risk factors

We don't know for sure why Down syndrome occurs or how many different factors play a role. We do know that some things can affect your risk of having a baby with Down syndrome.

One factor is your age when you get pregnant. The risk of having a baby with Down syndrome increases with age, especially if you are 35 years or older when you get pregnant. 2 3 4

However, the majority of babies with Down syndrome are still born to mothers less than 35 years old. This is because there are many more births among younger women. 5 6

Regardless of age, parents who have one child with Down syndrome are at an increased risk of having another child with Down syndrome. 7

Screening and diagnosis

There are two types of tests available to detect Down syndrome during pregnancy: screening tests and diagnostic tests. A screening test can tell you if your pregnancy has a higher chance of being affected Down syndrome. Screening tests don't provide an absolute diagnosis.

Diagnostic tests can typically detect if a baby will have Down syndrome, but they carry more risk. Neither screening nor diagnostic tests can predict the full impact of Down syndrome on a baby.

The views of these organizations are their own and do not reflect the official position of CDC.

Down Syndrome Resource Foundation (DSRF) : The DSRF supports people living with Down syndrome and their families with individualized and leading-edge educational programs, health services, information resources, and rich social connections so each person can flourish in their own right.

GiGi's Playhouse : GiGi's Playhouse provides free educational, therapeutic-based, and career development programs for individuals with Down syndrome, their families, and the community, through a replicable playhouse model.

Global Down Syndrome Foundation : This foundation is dedicated to significantly improving the lives of people with Down syndrome through research, medical care, education and advocacy.

National Association for Down Syndrome : The National Association for Down Syndrome supports all persons with Down syndrome in achieving their full potential. They seek to help families, educate the public, address social issues and challenges, and facilitate active participation.

National Down Syndrome Society (NDSS) : NDSS seeks to increase awareness and acceptance of those with Down syndrome.

• Stallings, E. B., Isenburg, J. L., Rutkowski, R. E., Kirby, R. S., Nembhard, W.N., Sandidge, T., Villavicencio, S., Nguyen, H. H., McMahon, D. M., Nestoridi, E., Pabst, L. J., for the National Birth Defects Prevention Network. National population-based estimates for major birth defects, 2016–2020. Birth Defects Research. 2024 Jan;116(1), e2301.
• Allen EG, Freeman SB, Druschel C, et al. Maternal age and risk for trisomy 21 assessed by the origin of chromosome nondisjunction: a report from the Atlanta and National Down Syndrome Projects. Hum Genet. 2009 Feb;125(1):41-52.
• Ghosh S, Feingold E, Dey SK. Etiology of Down syndrome: Evidence for consistent association among altered meiotic recombination, nondisjunction, and maternal age across populations. Am J Med Genet A. 2009 Jul;149A(7):1415-20.
• Sherman SL, Allen EG, Bean LH, Freeman SB. Epidemiology of Down syndrome. Ment Retard Dev Disabil Res Rev. 2007;13(3):221-7.
• Olsen CL, Cross PK, Gensburg LJ, Hughes JP. The effects of prenatal diagnosis, population ageing, and changing fertility rates on the live birth prevalence of Down syndrome in New York State, 1983-1992. Prenat Diagn. 1996 Nov;16(11):991-1002.
• Adams MM, Erickson JD, Layde PM, Oakley GP. Down's syndrome. Recent trends in the United States. JAMA. 1981 Aug 14;246(7):758-60.
• Morris JK, Mutton DE, Alberman E. Recurrences of free trisomy 21: analysis of data from the National Down Syndrome Cytogenetic Register. Prenatal Diagnosis: Published in Affiliation With the International Society for Prenatal Diagnosis. 2005 Dec 15;25(12):1120-8.

Birth Defects

About one in every 33 babies is born with a birth defect. Although not all birth defects can be prevented, people can increase their chances of having a healthy baby by managing health conditions and adopting healthy behaviors before becoming pregnant.

For Everyone

Health care providers, public health.