This post is a part of our Bioethics in the News series
By Devan Stahl, PhD
When I was in my mid-twenties I went to my physician to have a mole on my face removed. Before my dermatologist began the procedure, however, she suggested I consider another procedure: Botox. Botox for someone my age was “preventative,” she explained; if I could not move my facial muscles, I was less likely to develop wrinkles. To add insult to injury, she held up a mirror and pointed out all the lines on my face when I frowned (which I was doing at that moment, irked that my doctor was trying to push Botox on me). The experience was unsettling. Our culture is saturated with impossible beauty standards for women, but I did not expect my doctor to perpetuate these standards or to try to make money off of my potential insecurities.
I had nearly forgotten about this experience until last month, when my social media and online streaming services were inundated with advertisements for Botox® and Juvéderm® fillers that smooth wrinkles and plump lips. The advertisements were clearly geared toward millennial women such as myself. The ads push messages of personal empowerment. “My lips are my vocal advocates for self-acceptance,” one model says. “Command it, boss it, #juvedermit,” reads the tagline.
The drug company Allergan produces both Botox and Juvéderm, which some have deemed “cosmeceuticals” or cosmetic pharmaceuticals. According to news reports, Allergan’s aim over the next year is to increase sales to millennials as more products come on the market. According to a spokesperson for the company, they aim to “educate and empower consumers to do what is right for them when it comes to aesthetic treatments.” This push means that millennials are likely to see an increasing number of targeted ads that play upon social norms of beauty and youth to sell injectable toxins that have unknown long-term side effects. And although the short term risks might be seen as minimal (including pain at injection site, trouble breathing or swallowing, double vision, drooping eyelids, and more), studies have shown that when advertisements rely upon idealized forms of beauty to market cosmeceuticals, the social and psychological risks of not using the product detract from its known physical risks.
Botox and fillers are part of a multibillion dollar beauty and anti-aging industry in the U.S. According to a 2017 report by the American Society of Plastic Surgeons, 7.2 million Botulinum Toxin Type A procedures are performed in the U.S., which is up almost 800% since 2000. Although Botox and fillers have traditionally been used by an older demographic, millennials (ages 20-34) make up a fast growing demographic of Botulinum users. This means big money for companies like Allergan. The effects of Botox only last 4-6 months and cost around $300 to $400 a session. Their consumer potential means millennials are now being aggressively targeted by doctors (both dermatologists and dentists) as well as pharmaceutical companies. The pitch to these mostly wrinkle-free patients is that Botox will prevent wrinkles from forming, “it is best to clean your room before it gets dirty,” claims one dermatologist.
Beauty expectations for women have always been high, but some have speculated the turn to cosmeceuticals by young women has likely increased as a result of celebrity endorsements (Kylie Jenner famously announced she is a frequent user of lip fillers) and social media platforms such as Instagram that allow users to filter pictures. As Botox and other cosmeceuticals become more mainstream (and Allergan hopes they will by producing not only advertisements, but also blogs and podcasts), social norms are beginning to change such that young women are feeling increasing pressure to use biomedical technologies to preserve and enhance their youth. Cosmeceuticals increase the pressure on women to look young and cultivate feelings of inadequacy, according to Dana Berkowitz, author of Botox Nation: Changing the Face of America. Young women begin Botox because of their fear of looking older, even before they begin seeing major age-related changes in their faces.
The appeal of the technological fix is powerful to both men and women, young and old, in a culture that prizes youth and attractiveness. The reasons people use Botox and other anti-aging procedures are multi-faceted and should not simply be reduced to mere vanity. According to Berkowitz, young women claim Botox helps them get ahead in the workforce, helps them to feel good about themselves, and is common place in certain sectors of society. Whatever the reasons, however, the result of the normalization of cosmeceuticals is that aging is becoming increasingly pathologized, and our anxieties surrounding the natural aging process are likely to increase. “It is really up to you,” one Botox ad proclaims: “You can choose to live with wrinkles. Or you can choose to live without them.” Those who refuse to use cosmeceuticals are thus complicit in the dreadful aging process. Pharmaceutical companies and even some doctors are keen to encourage and capitalize on our aging insecurities.
Devan Stahl, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Pediatrics and Human Development in the Michigan State University College of Human Medicine.
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More Bioethics in the News from Dr. Stahl: Making Martyrs of Our Children: Religious Exemptions in Child Abuse and Neglect Cases; Mass Shootings, Mental Illness and Stigma; Disability and the Decisional Capacity to Vote
References
- Allergan Launches New Juvederm ® IT Campaign Designed to Reach the Next Generation of Consumers. Cision PR Newswire. October 3, 2018. https://www.prnewswire.com/news-releases/allergan-launches-new-juvederm-it-campaign-designed-to-reach-the-next-generation-of-consumers-300723447.html.
- American Society of Plastic Surgeons. Plastic Surgery Statistics Report. 2017. https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf.
- Berkowitz D. Why are Young Women without Wrinkles Using Botox? The Conversation. December 15, 2016. http://theconversation.com/why-are-young-women-without-wrinkles-using-botox-65309.
- Botox Markets to Millennials. Hagerstown Dermatology and Skincare Blog. December 27, 2018. https://www.hagerstownderm.com/botox-markets-to-millennials/.
- Cronkleton E, Wells D. Is Botox Poisonous? Here’s What You Need to Know. Health Line. February 23, 2018. https://www.healthline.com/health/botox-poison.
- Fine J. Millennials are Buying Facial Aesthetics. Are You Selling? The Fine Company. April 19, 2017. https://finecompany.com/millennials-buying-facial-aesthetics-selling/.
- Gant M. ‘Preventative Botox’ Rising Trend Among Millennials. Fox News. April 19, 2018. https://www.foxnews.com/lifestyle/preventative-botox-rising-trend-among-millennials.
- Juvederm It: Christie Ferrari Juvederm Volbella ® XC. YouTube. October 3, 2018. https://youtu.be/IgHWMZRqwGE.
- Juvederm It: Juvederm ®. YouTube. October 2, 2018. https://youtu.be/5u-uQMJxP0c.
- Mello S. Selling a super Cosmeceutical: Contextualizing Risk in Direct-to-Consumer Advertising of Botox® Cosmetic. Health, Risk & Society 2012;14(4): 385-398. https://doi.org/10.1080/13698575.2012.680951.
- Milioulis C. Why More Millennials are Getting Lip Injections a La Kylie Jenner. Splash. January 18, 2016. http://www.chicagosplash.com/2016/01/18/why-more-millennials-are-getting-lip-injections-a-la-kylie-jenner.
- Rock L. Is America Developing a ‘Crack-like Addiction’ to Botox Beauty? The Guardian. January 7, 2017. https://www.theguardian.com/lifeandstyle/2017/jan/08/botox-nation-america-addiction-crack-like-cosmetic-procedures.
- Wellington E. How Botox is Becoming a Part of Millennials’ Basic Beauty Regimen. The Philadelphia Inquirer. July 19, 2017. http://www.philly.com/philly/columnists/elizabeth_wellington/botox-millennials-filler-twenty-somethings-elizabeth-wellington-20170719.html.
MSU Bioethics 
You provide a nice starting point to discuss the fear and pathology of aging, which seems to be strongly embedded in a primarily middle- to -upper-middle-class white American context. What thoughts do you have about the perception of aging in non-whites and the use of Botox in millennial non-whites?
This is a great point Karen. There is no doubt that the majority of women (young and old) who receive Botox and fillers are white women in a certain socio-economic class. According to the American Society for Aesthetic Plastic Surgery, among persons who receive cosmetic treatments, 76% are Caucasian, 10% are Hispanic, 8% are African-American, 5.5% are Asian, and 2% are other. And although the numbers for African-Americans may seem low given the demographics of our country, that number is double what is was in 1997. When it comes to Botox and fillers, however, the numbers are slightly lower for non-whites (Hispanics represent 9% of the procedures, African Americans 5% and Asian/Pacific Islanders 5%). There likely many reasons non-whites do not undergo as many of these procedures. According to Berkowitz (Botox Nation) many of the Botox providers she talked to said part of the reason for this is that people with more pigment in their skin get less sun damage and do not lose the elasticity in the same ways that white skin does. Of course, there are likely many cultural reasons why these procedures may be more taboo for certain women, particularly African American women. On the other hand, plenty of Botox providers trying to tap into the non-white market (see for example, http://www.brownskin.net/dermalfillers.html) so only time will tell if the anti-aging craze will become more universal among all segments of our society.