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Another look at facial disfigurement.

In a now classic article entitled, "What is beautiful is good," Dion, Berscheild and Walster (1972) outlined the existence of a "physical attractiveness stereotype." This stereotype works so that people who are seen to be physically attractive are also seen to be more socially desirable, likely to secure more prestigious jobs, have happier marriages, be better parents and more competent spouses, more likely to find an acceptable spouse, and marry earlier.

Further studies and reviews of physical attractiveness (e.g. Rumsey and Bull, 1986; Cunningham, 1986; Rumsey, Bull & Gahagan, 1982) have found that physical attractiveness influences heterosexual dating, peer acceptance, teacher behavior, attitude change, employment interviews, and jury decisions, and that attractive people are less likely to be judged to be mentally ill, are liked and helped more, and judged to have higher social skills and greater opportunities for social interaction than unattractive people.

The appearance stereotype also operates for clients of rehabilitation services. For example, students in rehabilitation counseling and social work, after hearing an audiotape of an initial interview, rated the attractive female more positively than the unattractive female on all factors including friendliness, employability, prognosis, motivation, severity of presenting problem, and adjustment (Mercer, Andrews & Mercer, 1983).

College students attribute greater psychological disturbances to target persons (persons alleged to have been confined to a psychiatric hospital or be in counseling) who are unattractive, even when warned that attractiveness is unimportant (Jones, Hansson & Philips, 1978), and are significantly more likely to attribute epilepsy to unattractive persons than attractive persons (Hansson and Duffield, 1976).

Similarly, Bordieri, Sotolongo and Wilson (1983) had subjects view a picture and listen to a tape recording giving a brief account of a victim's automobile accident which left the victim paralyzed through spinal cord injury. Results showed that the attractive victim's paralysis was perceived as significantly less permanent and would take less time to recover than the unattractive victim. Interestingly, the attractive person was seen as having more responsibility for his or her accident, perhaps also indicating that attractive people are perceived to have greater control over themselves and their actions than do unattractive persons.

The Significance of the Face

Simon (1972) considers the face to be "the site of our beauty and attractiveness, and which, more than any other part of the body, distinguishes one human being from another" (p. 67). Indeed it is hard to downplay the importance of the face in human interactions and in forming social judgements, especially in the beginning phases. For example, in initial encounters, people generally focus on the face as it is the most specialized area of communications in the body, and provides information on how the encounter should proceed (Argyle, 1983).

In an ingenious study, Cunningham (1986) investigated the relation between specific adult female facial features and the attraction, attribution, and altruistic responses of adult males. He found that higher and wider eyes, greater distance between the eyes, smaller chin, smaller overall nose size, prominent cheekbones and narrower cheeks, higher eyebrows, larger smile and dilated pupils were all associated with higher ratings of attractiveness. These types of measures, which are measured in millimeters, also influence perceptions of intelligence, sociability, assertiveness, modesty, fertility, likelihood of an extramarital affair, whether the person is likely to be a beneficiary of self-sacrificial actions (such as loaning money) and desirability for job hiring, sexual intercourse and childbearing.

Similarly, McArthur and Apatow (1984) showed the importance of specific facial features- namely that of having a "baby-face" (defined as having large eyes, low vertical placement of features, and short features). They found that having the above facial features led to a decrease in perceivers' impressions of a stimulus person's physical strength, social dominance, and intellectual astuteness.

Thus, not only is the face judged to be extremely important by persons in making evaluative judgements about other persons, but human beings are particularly discerning in noting and evaluating even slight differences from the prevailing norm or "ideal."

Facial Disfigurement


There is one feature that is both necessary and sufficient in defining facial disfigurement, namely the strength of negative reaction by the possessor, and others, to a particular facial feature, or set of features. Without this negative reaction, a facial deviation is simply a difference and not a disfigurement. It is thus possible to define facial disfigurement by the degree of negative reaction it causes. MacGregor (1953) lists four degrees of facial disfigurement:

1. Slight. A mild deviation which is neither conspicuous nor apt to attract attention; requires having attention called to it before it is noticed, but may be a source of distress to some individuals.

2. Moderate. Noticeable. May elicit remarks, teasing, questioning, or staring, but usually no violent reaction.

3. Marked. Definitely noticeable. Likely to evoke strong reactions from others; repulsion, jokes, pity, curiosity, deliberate avoidance, or undue staring.

4. Gross. Definitely shocking and repellent to others. Evokes violent reactions or horror, repulsion, pity. Effects of Facial Disfigurement

The prominence and centrality of the face in influencing others' judgements of one's attractiveness means that persons with facial disfigurements experience the negative effects of the appearance stereotype outlined above, namely negative judgements regarding employability, marriageability, etc. A great deal of research has been done on the effects of facial disfigurement. Recent studies and reviews such as Rumsey and Bull (1986), Rumsey, Bull and Gahagan (1982) describe the following findings:

1. Severely burned adults object to the pity and curiosity of strangers. Female patients are reluctant to go out in public because of stares and rude remarks.

2. Persons with facial paralysis frequently complain of difficulties making friends, lack of opportunities for marriage, problems in obtaining jobs, and the disgust or horror in the expressions of others.

3. Subjects with cleft palate have more difficulty meeting new people than sibling controls.

4. Patients awaiting plastic surgery describe major problems with heterosexual effectiveness.

5. Passers-by waiting at street comers stand significantly further away, and on the non-disfigured side, of a stationary pedestrian.

Interestingly, these later research findings tell substantially the same story as that of MacGregor (1953), one of the earliest researchers on facial disfigurement, who concluded:

More often than not, such individuals discover that they are regarded as social inferiors, and in some instances, they are assigned a marginal or minority status, or both. Opportunities available to the non-disfigured are often denied them; social participation, matters of employment, prestige, role and status, interpersonal relationships, personality organization, and a variety of cultural activities are affected or altered in some way (p.64).

Causes and Forms of Facial Disfigurement

Converse (1963) divides the causes of facial disfigurement into three groups: congenital, acquired, and those resulting from treatment for deformities. Each of these causes is described below.

1. Congenital. These disfigurements represent congenital malformations from events in pre-natal life. Feingold and Pashayan (1983) describe 25 congenital syndromes with known incidence rates which involve facial dysmorphia. These range from Down Syndrome (1 in 660 live births) to Hutchinson-Gilford Syndrome (1 in 250,000 live births).

Forms of congenital facial disfigurements include: facial atrophy (e.g. Romberg's disease), excessive facial height, lop ears, cleft lip/palate, buck tooth deformity, anopthalmos and micropthalmos, anencephaly, "frog face" (Crouzon's disease), mocrotia, and colombomata of the lower eyelids.

2. Acquired. These represent deformities acquired from various sources of trauma during one's lifetime, such as automobile accidents, fires, frostbite, and wars. Schultz (1977) reports seven causes of facial injury and their relative frequency of occurrence including: automobile 54%); home accidents 17%); athletic injury (11%); animal bite 6%); intended injury such as fist fights 4%); and work injuries such as falling from scaffolding (3%). Home injuries can include lawnmower accidents, burns from stoves or burning Halloween masks worn on the face (Simon, 1972), petrol lamp explosions, and falling into an open fire during epilepsy crisis (Zellner, 1972). Intended injuries include those resulting from fist fights, crimes of passion such as self-mutilation, child maltreatment, and gunshot wounds.

Forms of acquired facial disfigurements include burns, scarring, and deflected nose. Of particular importance because of their severity are burns. Simon (1972) describes the effects of facial burns in the following terms:

A burn to the face is a terrifying and devastating injury. No other trauma, if one includes chemical and radiation injury, can cause such rapid and total destruction.... Even sophisticated repair and reconstruction leave a patina of scar distortion and grotesquerie which is well nigh impossible to prevent or disguise (p. 67).

3. Treatment Sequelae. These represent disfigurements resulting from treatment of other disfigurements, for example, surgical loss of a portion of the face from the eradication of malignant disease, and post-operative asymmetry. Forms include skull depressions, nasal misalignments, skin graft distortions, scarring, etc.

Facial Disfigurement as a Cultural


Most authors in the field acknowledge the existence of a cultural overlay to facial disfigurement which they believe adds to the negative impact of the initial disfigurement. For example, MacGregor (1953) believes that prevailing prejudices and misunderstandings in our society "further complicate" (p. 64) the situation of someone with a facial disfigurement. Similarly, Jones, Farina, Hastorf, Markus, Miller and Scott (1984) regard the reactions and evaluations elicited from other people to be "disproportionately" negative (p. 111). Such views assume that disfigurement (i.e., negative judgement) is an intrinsic aspect of some facial differences, and that cultural factors interact with this initial disfigurement thereby adding to, or amplifying it.

MacGregor (1953) outlines five social forces operating to add to the already negative judgements of persons with facial deformities:

1. A social premium on physical attractiveness in which attractiveness is seen as both a symbol of success and a saleable commodity. Today's western values, for example, negatively value the aging process and its consequences to the face. These values place a premium on youth and beauty and define any evidence of age (such as wrinkles) as being ugly.

2. Prejudice against certain minorities such as Negroes and Jews which creates a demand for cosmetic alteration of certain facial features.

3. Folklore and superstitions implying that a deformity is the result of "sins of the fathers" or punishment for wrong doing (or even because the mother saw an accident while she was pregnant).

4. Social stereotypes and expectancies which endow the appearance of the face with personality and character traits. For example, a high forehead is indicative of superior intelligence (and vice versa); a prominent nose may be indicative of Jewishness; large ears and noses remind people of cartoon caricatures and clowns, which evoke laughter and ridicule; and certain features evoke associations of cancer, leprosy, syphilis and other dread diseases.

5. Belief about the genesis of a deformity such that a deformity that is caused by a disease is viewed with disapproval in the culture, whereas a prize fighter's saddlenose or veteran's war wound may not only be more acceptable, but may even carry prestige value.

Forms of congenital, acquired, or treatment caused facial disfigurements which may be regarded as cultural include "oriental eyelid," non-caucasian nose, double chin, absence of a second cheek dimple, pigmentation problems such as freckles or port wine stain, wrinkles, cheek furrows, flaring of nostrils, other unwanted nasal features such as tips, humps, hanging columella, etc., large lips, Machiavellian ear, protruding ear, alopecia (baldness), facial sag, and loose neck skin.

Recent studies further exemplify the role of culture in reinforcing the negative connotations of certain physical differences. For example, much of the way the media portrays persons with disabilities is particularly negative in that such persons are consistently portrayed as monsters, freaks or violent, vengeful, and evil madmen (see Bogdan, Biklen, and Shapiro, 1982; Longmore, 1985; Zola, 1987).

Hahn (1987) has looked at the effects of advertising media in shaping people's attitudes toward personal appearance which works against persons with disabilities and devalued facial differences. He has devised a "disability continuum" that proposes a correlation between the visibility of disabilities and the amount of discrimination which they may elicit in employment and other areas of society. In his largely historical analysis he describes how powerful industrialists in the 19th and 20th centuries promoted pervasive messages about acceptable forms of human appearance that encouraged consumers to try to imitate these images. These standards excluded the disabled, who could not possibly compete, from many areas of community life, including entrance to the labor force and to social activities. He concludes:

Clearly, mass communications played a prominent role in molding an environment in which consumers were encouraged, both by the prevalence of certain images and by the comparative absence of other models, to strive relentlessly to satisfy unachievable standards of personal appearance. One of the consequences of this process has been to render people with disabilities, who may differ most noticeably from the normative prescriptions of this imagery, virtually invisible (Hahn, 1987, p. 562).

These studies on the social meaning and significance of having a negatively valued appearance point to the possibility that the cultural component in "disfigurement" may be so large as to define all disfigurement as a cultural phenomenon, and that the assumption that there is such a thing as an intrinsic disfigurement, to which cultural factors only further complicate or exaggerate, maybe incorrect. The term "facial disfigurement" locates the cause of the problems of social interaction, self-concept, etc. within the individual's particular facial features and implies that there is "disfigurement" intrinsic to the particular facial difference. However, given the fact that it is the culture that defines beauty and not any particular individual, it would seem that any problems with "beauty" may just as easily lie within the culture of the individual.

If there are certain facial features that have been seen to be ugly or grotesque at all times in all cultures, then some weight could be given to the intrinsic disfigurement conceptualization-but just what might such a universal, intrinsic deformity be? History shows that concepts of beauty have and do vary considerably to the point where physical "disfigurements" have sometimes been considered attractive and appealing, such as in cultures that practice scarification, mutilation, tattooing, resculpting and painting (Hahn, 1988).

The problem of facial disfigurement, when seen from a cultural perspective, becomes very similar to other social problems such as racism and sexism, but in this case, negative judgements are made on the basis of physical appearance rather than gender or race. Facial prejudice (or "morphism") may thus be defined as the making of negative social judgements on the basis of a person's facial characteristics, over which the person has little or no control, either because the features are congenital or are otherwise unintentionally acquired. Moreover, rather than define the degree of disfigurement by the degree of negative social judgement a facial difference produces, one could define the degree of prejudice by the same criteria. Thus, gross morphism could be defined as the presence of violent reaction, horror, repulsion or pity to the facial difference(s) of another; marked morphism as definitely noticeable reactions from others such as repulsion, jokes, pity; and so on.

Traditional approaches to the problem of facial disfigurement have revolved around prevention or alleviation of the offending facial differences themselves. A broad range of techniques of cosmetic surgery (such as blepharoplasty, facelift, chemabrasion and dermabrasion, silicone injection therapy, rhinoplasty, otoplasty, prognathism and mentoplasty) have now progressed to a stage where dramatic results can be achieved (e.g. see Rees and Wood-Smith, 1973). However, from a cultural perspective, changing the facial feature(s), rather than societal attitudes (unless there are other reasons to do so, such as physical pain or health) amounts to blaming the victim. Why should someone with facial scars, for example, have to endure multiple operations or be forever stigmatized by society's appearance stereotype? A cultural perspective, on the other hand, emphasizes programs and treatments aimed at altering the beliefs, prejudices and values which are embodied in the appearance stereotype.

Nevertheless, changing these social attitudes presents considerable challenges. For example, even though the physical appearance stereotype serves only a very small percentage of the population (the "beautiful people"), it does raise vast amounts of money for the fashion and cosmetic industry (both medical and non-medical) by the constant vigilance needed to maintain one's appearance to the required standard, and thereby avoid the stigma of a negatively valued appearance.

This constant vigilance is reflected, for example, in a recent television advertisement which portrays a woman determined not to succumb to wrinkles and grow old gracefully, but to "fight it every inch of the way" (a decision conveniently involving the purchase of a certain facial cream).

Fortunately there are some common social values (albeit rather buried) that one could use to appeal to change these attitudes. For example, Biblical injunctions that beauty should come from within, and not to look at the outward, but rather the inward appearance. Appeal could also be made on the grounds that facial differences can occur quite arbitrarily and not by any intent of the recipient, and that, therefore, the appearance stereotype is a completely unfair way to apportion negative judgements. There is a great deal of pain and suffering involved in being defined as "facially disfigured," but why should society inflict such punishment on persons who have done no wrong and based on such arbitrary criteria and spurious beliefs?

Of the three causes of facial disfigurement outlined by Converse (1963), congenital, acquired and treatment sequelae, how many can validly be associated with the negative social judgements we know are made of persons with such facial differences? Of all the possible forms and causes of facial differences, only in some of the congenital differences (such as Down Syndrome) may it be valid to make some judgements about mental characteristics from the physical appearance- but why should these judgements be negative? Even within the congenital category, what empirical evidence is there that, for instance, lop ears or excessive facial height can be associated with certain negative personality stereotypes? Such attempts to correlate physical appearance with mental capacities and characteristics, albeit a favorite activity of scientists, are fraught with difficulties and dangers.

Rehabilitation specialists need to be conscious of what assumptions they are making about "facial disfigurement" since their practice and attitudes will vary greatly depending on which of the two definitions (disfigurement as being intrinsic to certain facial differences, or culturally defined) they adhere to. Unless specialists are clear about which orientation they are subscribing to, and why, they may well be responsible for perpetuating certain beliefs and attitudes that in fact need to be radically altered.


Argyle, M. (1983). The psychology of interpersonal behavior, 4th ed. London: Penguin.

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Bordieri, J., Sotolongo, M., & Wilson, M. (1983). Physical attractiveness and attributions for disability. Rehabilitation Psychology,28(4), 207-215.

Converse, J.M. (1963). Discussion. In B.O. Rogers (Ed.) Facial disfigurements: A rehabilitation problem. A conference of the Institute of Reconstructive Plastic Surgery of the New York University Medical Center. March 21-22, 1963. New York, New York: U.S. Dept. of Health, Education and Welfare, Vocational Rehabilitation Administration, pp. xx-xxi.

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Jones, E.E., Farina, A., Hastorf, A.H., Markus, H., Miller, D.T., Scott, R.A. (1984). Social stigma: The psychology of marked relationships. New York: W.H. Freeman.

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MacGregor, F.C., Abel, T.M., Bryt, A., Lauer, E., & Weissmann, S. (1953). Facial deformities and plastic surgery: A psychosocial study. Springfield, Illinois: Charles C. Thomas.

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Mercer, J., Andrew, H., & Mercer, A. (1983). The effects of physical attractiveness and disability on client ratings by helping professionals. Journal of Applied Rehabilitation Counseling, 14(4), 41-45.

Rees, T.D., & Wood-Smith, D. (1973). Cosmetic facial surgery Philadelphia: W.B. Saunders.

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Schultz, R.C. (1977). Facial injuries. (2nd edition). Chicago: Year Book Medical Publishers.

Simon, B.E. (1972). Concepts in the treatment of burns of the face and neck. In J. Conley & J.T. Dickinson (Ed.). (1972). Plastic and reconstructive surgery of the face and neck, pp. 67-70. Proceedings of the First International Symposium, New York, 1970. Vol. 1, Aesthetic surgery, and Vol. 2, Rehabilitative surgery. New York: Grune & Stratton.

Zola, I.K. (1987). The portrayal of disability in the crime mystery genre. Social Policy, 17(3), 34-39.
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Author:Elks, Martin A.
Publication:The Journal of Rehabilitation
Date:Jan 1, 1990
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