Introduction and Literature Review

Acne is the most common skin disease of the human race. Approximately 85% of adolescents and 45% of adults experience acne breakouts to various degrees at some time during their lives. Although acne usually starts at puberty or adolescence, it can last in many people through adulthood. While acne can afflict many areas of the body, such as the shoulders or back, the current research was only concerned with acne that afflicted the face. This paper examines the social relevance of facial acne. For instance, how are persons with facial acne perceived by others? What is the social-perception of facial acne?

While existing research does not focus on the social perception of facial acne per se, a significant portion of research has been devoted to the social relevance of skin diseases and physical deformities. For example, people react negatively to those whose facial appearance is not in accordance with cultural standards of beauty (Berscheid & Walster, 1974; Landy & Sigall, 1974; Mercer, Andrews, & Mercer, 1983). Nadelson (1978) established the social significance of the skin and concluded that highly visible skin (such as face, neck, hands) are of particular social significance. Facial acne manifests itself on this highly visible, and therefore, socially significant skin. Furthermore, several studies have revealed that skin diseases are stigmatized (Jowett & Ryan, 1985; Landy and Sigall, 1974). These studies revealed that many skin diseases (i.e. eczema, psoriasis) resulted in an impaired appearance, which the researchers dubbed "cosmetic disfigurement". These findings support the notion that facial acne, like eczema, is a "cosmetic disfigurement." The current study intends to verify that facial acne is a skin disease that is stigmatized.

Erving Goffman, in his classic work Stigma (1963), distinguishes between stigmata that are discrediting and those that are discreditable. Discreditable stigma refers to attributes that are not readily apparent to others, such as being an ex-convict. Discrediting stigma, however, refers to attributes that are immediately apparent to others, such as obesity, physical abnormalities, and blindness. According to Goffman, these attributes fall outside the range of what is considered ordinary or natural and generally "spoil" the social identity of the stigma possessor. Jowett and Ryan (1985) reported that 70% of acne-sufferers (n=30) experienced shame and embarrassment as a result of their acne. Furthermore, this shame/embarrassment was described by a majority of respondents as the worst aspect of their condition. Facial acne is an attribute that is immediately apparent to others, and the current study intends to demonstrate how facial acne qualifies as a discrediting stigma.

Becker (1963) stated that possession of one deviant trait might have a generalized symbolic value, so that people automatically assume that its bearer possesses other undesirable traits allegedly associated with it. The possession of one deviant trait (i.e. facial acne) might be associated with other undesirable traits (i.e. being irresponsible, lacking self-control). For example, acne myths (Krawczuk, 1997) exist that stigmatize the acne-sufferer. One very common myth is that acne is the result of poor hygiene. Another typical myth is that acne is caused by a poor diet (i.e. eating greasy foods, chocolate, etc.). Contrary to popular opinion, there is no evidence correlating acne and diet (Leyden, 1997). In fact, a strict diet by itself will not clear one's skin of acne. Likewise, acne is not caused by dirt or poor hygiene (Leyden, 1997; Rothman & Lucky, 1993). Acne is actually formed by one or more of the following conditions: stress, fluctuating hormone levels, genetic predisposition, and/or bacteria. Cleansing the face will not prevent acne, and washing too often can actually exacerbate one's condition. Acne myths imply that the acne-sufferer is personally responsible for his or her condition. These myths attack the individual's integrity and suggest that the acne-sufferer lacks proper hygiene and/or diet. One goal of the current study is to confirm the prevalence of these acne myths.

In addition to verifying the prevalence of acne myths, this study examines how the "general public" perceives individuals possessing facial acne. Bosse (1976) completed a study that dealt with the social-perception of skin diseases. In Bosse’s study, subjects evaluated slides depicting a person with a visible skin disease and a slide showing the same person with healthy skin (a retouched copy). The results revealed that, overall, the "healthy" slides were preferred over the "unhealthy" slides. Bosse’s study also revealed a significant gender difference between men and women; men had a much stronger preference for the healthy slides in areas such as erotic appeal and physical attractiveness.

Other studies show that college men rank "good looks" and "good body" as first and second factors in date selection, while college women listed intelligence as the most important characteristic sought in a boyfriend (Bersheid, Dion, Walster, & Walster, 1981). Schulman and Hoskins (1986) studied the perceptual processes in rating the appearance of male versus female faces. Findings revealed that the female faces were judged with more scrutiny and discrimination. The results from these studies demonstrate that women are more likely to be judged by their physical appearance. Physical appearance is a central feature of role expectations for women (Freedman, 1984), and attractiveness stereotypes are stronger for females than for males (Wallston & O'Leary, 1981). Emphasis on appearance is especially strong among women because an attractive appearance is deemed essential to the feminine gender role. If women are more likely to be judged by their physical attractiveness, then facial acne on females might be judged with more scrutiny than facial acne on males.

The current study examines the social relevance of facial acne by asking, "what is the social-perception of facial acne?" This paper hypothesizes that facial acne is a skin disease that is stigmatized. This study intends to confirm the prevalence of acne myths. Thus, facial acne should fit the definition of Goffman’s discrediting stigma. Our culture places a premium on beauty, especially on the physical attractiveness of women. The current study will explore how gender affects the social-perception of acne. This paper hypothesizes that facial appearance is a more heavily weighted element of a female’s (versus a male’s) social identity. Facial acne on females will be judged with more scrutiny than facial acne on males, regardless of a respondent's gender. It is predicted that both male and female respondents will not tolerate high levels of acne severity in the female photo series. Meanwhile, male and female respondents will tolerate higher levels of acne severity in the male photo series.

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Methodology

Ninety-seven Montclair State University students (n=97) were surveyed in 1997 during the spring semester. Respondents completed self-administered questionnaires. The age of respondents ranged from 18-24 years and the mean age was 20. 47 of the respondents were male and 50 of the respondents were female. The questionnaires were administered over a two-week period in the Student Center and in Bohn Hall at Montclair State University. In order to achieve a relatively balanced male-female ratio, questionnaires were administered by alternating between males and females. However, the questionnaires were not distributed randomly; only students who didn't look too busy were approached. Each prospective respondent was informed that the survey was completely anonymous. A large envelope was given to each respondent in which he or she could place the survey upon its completion. All respondents sat at a table and had a large photographic display placed before them.

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Instrument design

The photographic display was a vital instrument for this study. The photo display possessed two series of photographs. Each series was comprised of seven photographs. One photo series was mounted on the front of the display; one photo series was mounted on the back. The first series of photographs depicted a woman with steadily increasing degrees of facial acne. Photograph #1 depicted a very mild case of acne, while photograph #7 depicted a severe case of facial acne. Each photograph in the series was clearly numbered. The second photo series was identical to the first except that it depicted a man with varying degrees of acne. Six questions on the survey referred specifically to the photo display. Respondents were instructed to check the number of the photograph that best fit their answer.

An assistant who was very skilled in Adobe Photoshop 3.0 was integral to the creation of each series of photographs. I worked closely with the assistant as we selected and manipulated the images. The Bosse (1976) study used slides depicting both "healthy" and "unhealthy" skin. In order to create slides depicting unhealthy skin, Bosse "touched up" the healthy slides to simulate unhealthy skin. Bosse’s technique of "touching up" photographs was employed in the present study to simulate facial acne.

Both the male model and the female model were obtained from magazines ("W" and "Details"). An attempt was made to pick two average looking faces. The intention was to portray each face as generically as possible. I tried to choose models that were expressionless, since the Schulman and Hoskin (1986) research mentioned that facial expressions significantly influenced the responses. The images were reduced in size until they were proportionate to each other. Then the images were cropped to ensure that the composition of the male and female photos would be identical.

Although the photographs could have been printed in color, it would have introduced too many variables (i.e. hair, lip, and eye color) which could have potentially influenced the results. For instance, suppose a respondent was partial to brown hair and blue eyes. Printing black and white photographs eliminated these variables and helped make the two series uniform with each other. The contrast and brightness of each photo was adjusted until they matched. In fact, we even cropped the male's hair so it would not appear overly prominent. The goal was to remove all distracting elements from the photos so that the only variable would be the sex of the model.

Medical pages on the Internet (http://biomed.nus.sg/nsc/acne.html, http://www.aad.org/acnepamp.html) provided pictures of "mild," "moderate," and "severe" facial acne. Using these pictures and classifications as a guide, a series of seven stages of acne severity were developed. We created acne "templates" for each severity of acne. We then placed these acne templates on both the male and female photos. Therefore, for each degree of acne severity, the male and female have exactly the same type of acne in the identical locations. The only difference between the two photo series is sex; the pattern of acne is identical.

Measures

The self-administered survey was comprised entirely of close-ended questions. In order to measure the prevalence of acne myths, the following two questions were asked: 1. Do you think facial acne is caused by poor hygiene (i.e. getting dirty, not washing your face, etc.)? and 2. Do you think facial acne is caused by a poor diet? (i.e. eating greasy food, chocolate, etc.). In addition, there were six questions specifically designed for the photo display. When answering the following three questions, the respondent was always referring to a same-sex series of photographs. These questions were designed for same-sex appraisal only. For instance, if a male was completing the survey, the male photo series was facing towards him. The same-sex appraisal measured how males viewed other males and how males viewed themselves. Similarly, if the respondent was a female, the same-sex appraisal would measure how females viewed females and how females viewed themselves. Sex is the independent variable and same-sex appraisal is the dependent variable. The same-sex appraisal questions were: 1. At what degree would you become concerned about facial acne?, 2. At what degree would you consider the acne to be a "serious" case? and, 3. At what degree would you seek professional treatment (i.e. dermatologist)?

After answering the preceding three questions, respondents were instructed to flip the photo display over; thus revealing a series of photos depicting the opposite sex. The opposite-sex appraisal questions measured how the respondent perceived the opposite sex. These questions were designed to tap into the physical and sexual realm. If a man was answering, the questions gauged how that man viewed women. If a woman was answering, the questions gauged how that woman viewed men. Again, sex was the independent variable and opposite-sex appraisal was the dependent variable. The questions which measured opposite-sex appraisal were: 1. At what degree would you not be physically attracted to someone?, 2. At what degree would you hesitate to kiss a person?, and 3. At what degree would you not go on a date with someone?

Respondents were also asked "Do you have facial acne now?" Possessing facial acne was treated as an independent variable, since acne-sufferers might be sympathetic to the condition in others. Another question, Have you ever had acne?, was also asked and treated as another possible independent variable. Perhaps previously experiencing facial acne would influence the way an individual currently perceives acne.

In addition to the previous questions, the survey contained two sections that were purely exploratory. In an attempt to measure the extent to which a person would go to treat their acne, a range of treatments was created starting with "topical" (i.e. medicated creams, "Oxy pads", soaps) and ending with "plastic surgery." This ordinal series begins with a relatively mild form of treatment (topical) and ends with the most serious form of treatment (plastic surgery). The final two questions on the survey ("Does facial acne influence a first impression?" and "Does facial acne seriously affect one’s life?") were intended to reveal the extent to which acne is believed to be influential. Again, these questions were merely exploratory in nature.

Results and Discussion

86.6% of the sample (n=97, females=50,males=47) answered "yes" to the question "Is facial acne caused by poor hygiene?" Sex did not affect the response to this question, with 85.1% of males and 88.0% of females answering "yes." For the next question, Is facial acne caused by a poor diet?, 82.5% of the sample responded "yes." Again, there were no gender differences in response to this question (80.9% of males and 84.0% of females answered "yes"). Only 16.5% of the respondents presently suffered from acne (9 women, 7 men). However, roughly 49% of the sample had suffered from acne previously. An overwhelming 92.8% of the respondents answered "yes" to the exploratory question "Does acne influence first impressions?" However, only 12.4% believed that acne could "seriously affect one's life."

These results illustrate that an overwhelming majority of the respondents believed in the two acne myths. 80%+ of the respondents accept that facial acne is a product of poor hygiene and poor diet. These results confirm the prevalence of acne myths and reveal that a majority of the respondents blame the acne-sufferer for his/her condition. Acne myths attack the individual's integrity and suggest that the acne-sufferer lacks self-control and is irresponsible. These myths are based on the false assumption that poor diet and poor hygiene cause facial acne. In fact, there is no conclusive evidence that correlates facial acne with hygiene and/or diet (Leyden, 1997; Rothman & Lucky, 1993).

It was hypothesized that acne myths reflected the discrediting nature of acne. Indeed, acne myths function to stigmatize the acne-sufferer. Possession of one deviant trait (facial acne) might have a generalized symbolic value, so that people automatically assume that its bearer possesses other undesirable traits allegedly associated with it (poor hygiene, poor diet) (Becker, 1963). This process of labeling allows the acne-sufferer to be labeled as an "irresponsible" individual who has poor hygiene and a poor diet. Facial acne, since it can detract from a person's physical attractiveness and can result in negative labeling, qualifies as a discrediting stigma capable of tarnishing a person’s social identity.

For the same-sex appraisals, men and women differed considerably on the first question, "At what degree would you become concerned about facial acne?" The mean male rating was 4.0, while the mean female rating was 2.0. (These ratings refer to the degree of facial acne severity, which corresponds with the number of the photograph on the photo display. A rating of "1" refers to the mildest depiction of acne, whereas a rating of "7" refers to the most severe depiction of acne. When reading the results and discussion, please refer to the photo display.) Female respondents became concerned with their complexion sooner than the males. While males became concerned at a mean rating of 4.0, females became concerned at a mean rating of 2.0. The fact that females became concerned with acne severity 2.0 degrees sooner than males suggests that beauty remains a strong role expectation for women.

For the next question, both males and females agreed that a "serious" case of facial acne was a mean rating of 5.0. However, gender differences emerged again for the final question, "At what degree would you seek professional treatment (i.e. dermatologist)?" The mean male response was 5.6. However, the mean female response was only 3.0, indicating that females would seek professional treatment for acne much sooner than their male counterparts.

Overall, the results from the same-sex appraisals revealed that males and females agreed on what a "serious" case of acne was. However, significant gender differences developed in response to the other questions. Female respondents became concerned with their acne 2.0 degrees sooner and would seek professional treatment 2.6 degrees sooner than their male counterparts. Perhaps, as Bosse (1976) suggested, "those for whom appearance is a highly salient feature of self-identity are more likely than others to be threatened by a disease that causes cosmetic impairment" (p. 25). Indeed, if physical attractiveness is a key role expectation for women, then it follows that the female respondents would become concerned and seek professional treatment sooner than their male counterparts. The significant difference between the male and female responses reveals the burden placed on women to be physically attractive and beautiful. The results suggest that males are not subject to the same degree of pressure to be physically attractive. If beauty is a basic dimension of the feminine gender role, then females are more likely to develop a knowledge and familiarity with cosmetic maintenance. In addition, certain activities, such as cosmetic maintenance, would be more socially acceptable for females to engage in. Beauty stereotypes, coupled with the familiarity and encouragement to engage in cosmetic maintenance, might help explain why female respondents became concerned with their acne and would seek professional treatment sooner than their male counterparts.

Recall that respondents were asked "Do you have facial acne now?" Possessing facial acne was treated as a possible independent variable. Data analysis revealed that male acne-sufferers would not seek professional treatment (i.e. dermatologist) until a mean severity of 6.4. In comparison, acne-free males would seek professional treatment at a mean severity of 5.4. Perhaps male acne-sufferers, as a result of their condition, are more tolerant of facial acne. This higher tolerance for facial acne might explain why male acne-sufferers had a mean response that was 1.0 degree higher than the acne-free males. Data analysis also revealed that female acne-sufferers would seek professional treatment at a mean rating of 2.2. Acne-free females, though, would seek professional treatment at a mean rating of 3.4. Curiously, possessing acne seemed to have a reverse effect in females. Perhaps female acne-sufferers, as a result of their condition, are less tolerant of acne.

In summary, female acne-sufferers would seek professional treatment much sooner than any other group, suggesting they felt most threatened. In stark contrast, male acne-sufferers were the least likely group to seek professional treatment. While these results are interesting, they are also suspect. This was the only question on the entire survey where "possessing facial acne" appeared to affect the response. Therefore, it is highly unlikely that possessing facial acne is a valid or useful independent variable, suggesting that "possessing facial acne" should not be treated as an independent variable.

With the opposite-sex appraisals, male and female responses continued to differ. For the question, "At what degree would you not be physically attracted to someone?", female respondents had a mean rating of 5.9. Male respondents, in contrast, had a mean rating of only 4.2. This trend continued with the next question, "At what degree would you hesitate to kiss a person?" The mean female response to this question was 5.8, while the mean male response was 4.0. The final question in this series was "At what degree would you not go on a date with someone?" The mean female rating was 5.5, in contrast with the much lower mean male response of 3.1.

The results from the opposite-sex appraisal section reveal that females had a higher tolerance for facial acne on males in all three scenarios. The mean female responses were at least 1.7 degrees higher than the male responses, thus females were consistently more tolerant of facial acne on males. The last question revealed the most significant difference between the sexes: women were 2.4 degrees more tolerant than men in regards to "going out on a date." Overall, the results of the opposite-sex appraisal supported the hypothesis that male respondents would not tolerate high levels of acne severity in the female photo series. In addition, female respondents did tolerate higher levels of acne severity in the male photo series, providing further confirmation of the hypothesis. These results also corroborate the Schulman and Hoskins study (1986) that showed that female faces were judged with more scrutiny and discrimination than male faces.

The exploratory results to "which acne treatments would you use" were also interesting. Both males and females would equally try topical treatments (approximately 98% for both sexes) and oral treatments (approximately 66% for both sexes). Similarly, both males and females were unwilling to try chemical peels (8% males, 15% females). However, very few males were willing to try the other treatments. Laser surgery had a 78% approval with females and a low 11% approval with males. For plastic surgery, 47% of women said "yes," but only 14% men said "yes." Society is still very divided along gender lines as far as cosmetic surgery is concerned. The results indicate that women are much more likely to have serious cosmetic surgery. Again, it is socially acceptable, even encouraged, for women to spend time and energy working on their physical appearance. Women might be more familiar with cosmetic procedures, perhaps explaining why so many women would be willing to undergo laser and plastic surgery. Men’s ignorance of cosmetic procedures might prevent them from considering the chemical peel, laser surgery, or plastic surgery as an option. Men might want to treat their facial acne but are afraid to undergo such procedures for fear of being stigmatized. Not surprisingly, these results suggest that certain activities, such as cosmetic maintenance, are more socially acceptable for females to engage in.

The current study had several goals. First, this study intended to verify the prevalence of acne myths. The results confirmed that two acne myths (acne is caused by poor hygiene, acne is caused by a poor diet) were, in fact, commonly held beliefs among this sample. 80%+ of the respondents in this study believed in both of these myths. It was proposed that acne myths attack the integrity of the acne-sufferer and are a reflection of the discrediting nature of facial acne. These myths are based on the false assumption that facial acne is caused by poor diet and poor hygiene; that, ultimately, facial acne is the result of being irresponsible.

In addition to validating the prevalence of acne myths, this paper confirmed that facial acne qualifies as a discrediting stigma. According to Goffman (1963), discrediting stigma refers to attributes that are immediately apparent to others, such as obesity, physical abnormalities, etc. These attributes fall outside the range of what is considered ordinary or natural and generally "spoil" the social identity of the stigma possessor. Our culture places a premium on beauty and facial acne is an affliction that is immediately apparent to others. Facial acne detracts from a person’s beauty and can be considered a "cosmetic disfigurement." Consider the following questions and results: At what degree would you not be physically attracted to someone?, At what degree would you hesitate to kiss a person? Both questions had a mean response of approximately 5.0. At what degree would you not go on a date with someone? This question had a mean response of 4.3. These results clearly illustrate the discrediting nature of facial acne. However, the level of stigmatization varies depending upon gender and acne severity. Higher degrees of acne severity appear to be related to higher degrees of stigmatization. For example, as the acne severity increased, respondents were less likely to kiss, go on a date, or be physically attracted to an acne-sufferer. Concerning gender, respondents were more tolerant of facial acne on males.

Indeed, perhaps the most interesting element of this study concerned the role of gender in the social-perception of acne. It was hypothesized that facial appearance would be a more heavily weighted element in a female’s (versus male’s) social identity. Two previous studies (Bosse, 1976; Schulman Hoskins, 1986) had produced similar results and the current study introduced the dimension of facial acne. Facial acne, being a "cosmetic disfigurement", fitted nicely within the structure of this prior research. Both the results from the same-sex and opposite-sex appraisals confirmed that facial appearance is a more heavily weighted element in a female’s social identity. Males and females tend to judge the male face with low discrimination, while males and females tend to judge the female face with high discrimination. Men and women are clearly held to disparate standards of beauty, and these findings suggest that physical attractiveness remains a prominent role expectation for women.

Specifically, results of the opposite-sex appraisal revealed that females had a higher tolerance for facial acne in all three scenarios. These results supported the hypothesis that "women will tolerate higher levels of acne severity in the male photo series." The mean female responses were at least 1.7 degrees higher than the male responses, thus females were consistently more tolerant of facial acne. The final question in the section revealed the most significant difference between the sexes: women were 2.4 degrees more tolerant than men in regards to "going out on a date."

Furthermore, the results of the same-sex appraisal revealed that female respondents became concerned with their acne 2.0 degrees sooner and would seek professional treatment 2.6 degrees sooner than their male counterparts. Bosse (1976) suggested that "those for whom appearance is a highly salient feature of self-identity are more likely than others to be threatened by a disease that causes cosmetic impairment" (25). Indeed, if physical attractiveness is a key role expectation for women, then it follows that the female respondents would become concerned with and seek professional treatment of facial acne sooner than their male counterparts.

Unfortunately, there are several weak points of this study that need to be addressed. First, the entire research design is based upon a white, heterosexual foundation. For example, when choosing the two models for the photo series, non-white models were never considered. Light-skinned models possessed a complexion that amply contrasted with the acne, ostensibly allowing the facial acne to show up better. Still, the fact remains that non-white models were arbitrarily excluded from the design of this survey. Future research must carefully consider the selection of models in regard to race, class, age, gender, ethnicity, etc. Also, although care was taken to choose models that were expressionless, the male model appears to be smiling slightly. Prior research has shown that facial expressions can significantly influence the results (Schulman & Hoskins, 1986), and thus the male model’s slight smile may have tainted the integrity of the present study.

Another problem with this research concerned its sampling method. This survey relied upon convenience sampling, which is merely an available sample of people who are willing to complete a survey. Convenience sampling may skew the results of a survey because certain groups within a population might be under-represented in the sample. For example, assume that a significant majority of MSU students are white, middle-class, and 18-22 years of age. In this scenario, the results of the facial acne survey are more likely to represent the attitudes of this white, middle-class majority. The attitudes of minorities, lower income groups, and other age brackets would essentially be overlooked because of their under-representation in the sample. The results from this survey cannot be generalized to populations beyond that of the original sample.

Yet another colossal flaw with the design of this survey is that it assumes that all respondents are heterosexual. This survey is inflexible and does not adequately compensate for all forms of human sexuality. This problem could have been eliminated if respondents were asked to specify their sexuality. However, sexuality is an extremely sensitive topic that many respondents would be uncomfortable answering. Even if it were viable to obtain a respondent’s sexuality, questions arise as to how to compensate for various forms of sexuality. For example, how would bi-sexuality be handled? Unfortunately, rather than develop a more flexible survey, I opted for the generic, typical heterosexual model. Future research should be designed to accommodate all forms of sexuality. In addition, this paper employs the value-laden term "acne-sufferer." A more neutral term such as "acne-possessor" should be employed in future research. Ultimately, despite its numerous flaws, the present study has succeeded in providing a starting point for future explorations into the social perception of facial acne.