Gender, Culture, and Social Constructs in Body-Focused Repetitive Behaviors

Lustre Art Group/AdobeStock

ADAA Partner

Unrealistic beauty standards and perfectionistic expectations of physical appearance have been long-standing norms in our society and are reflected across contemporary life, transcending cultural boundaries. They can be seen in our families, communities, work cultures, leisure activities, and other aspects of daily living. The ideals promoted by social media regarding the way individuals view themselves and others are consequential. From digital tools that alter images and augmented reality beauty filters, to Tik Tok and Reel makeup tutorials, individuals are constantly bombarded with images of quixotic beauty. These ideals are perpetuated and capitalized on by the beauty industry, as exemplified by what is a $374.18 billion dollar beauty industry that is projected to grow to $758.05 billion dollars by 2032.¹

When individuals are experiencing body-focused repetitive behaviors (BFRBs), such as hair pulling, skin picking, or nail biting, the promotion of such ideals can have a profoundly negative impact on self-concept and present challenges to treatment and recovery. Moreover, the value placed on hair, skin, and nails vary across ethnic groups, gender identities, and sexual orientations, and may present additional challenges to care. Careful consideration of the complex interplay between cultural identities, their associations with beauty, and the experience of BFRBs, may improve case conceptualization and treatment outcomes.

The Symbolic Meaning of Hair, Skin, and Nails

Throughout history, the appearance of hair, skin, and nails have held symbolic meaning. There are many examples in which hair cutting served as a means of social control, dehumanization and humiliation, such as in Nazi hair-taking or in military cultures. Long, flowing hair; smooth, clear skin; and manicured nails have been associated with sexuality and beauty. In lesbian and gay culture, hair has been used to communicate sexual identity, practices, and preferences.“Many members of the queer community have historically utilized clothing and style choices as a way to express their identity and signal to others who they are, especially throughout history when more people remained closeted, people could provide subtle hints via their clothing, style, and hair… Now, it can be a way to signal boldly and be unapologetically who you are.”² One individual described their experience: “I 100% used my hair to appear more queer and to feel like I fit in more in queer spaces.”³

In African American culture, afros and dreadlocks have been worn as a symbol of racial pride. For example, hair braiding has been a celebrated art form among African women since at least 3500 BCE, holding cultural and personal significance within Black communities, and continues to signify shared experience and solidarity among many Black women in the context of historic and present-day oppression.⁴ In indigenous North American tribes, hair has represented cultural identity and played a role in socialization and cultural celebrations. One indigenous American writes of the significance of hair, “Our hair is considered sacred and significant to who we are as an individual, family, and community. In many tribes, it is believed that a person’s long hair represents a strong cultural identity. This strong cultural identity promotes self-esteem, self-respect, a sense of belonging, and a healthy sense of pride. As part of the practice in self-respect, we are taught to take good care of our hair through proper grooming. In preparation for ceremonies, we take great care in the grooming, styling, and ornamentation of our hair. Our hairstyle and ornamentation are guided by the values of our family and tribe. It is a form of creative self-expression that reinforces our connection to our family, tribe, and Creation.”⁵ Hair has also been used to convey messages about marital commitments, lifestyles, group identity, and self-expression across cultures.

Hairdressing or cutting of the hair is often associated with rites of passage. In Asian cultures, hair has traditionally been a symbol of social status, religious beliefs, womanhood, and political affiliation. In Orthodox and Hasidic Jewish culture, hair may demonstrate rites of passage (eg, upsherin/chalakah), and group identity or marital status (eg, wigs, tichel, shpitzel, sheitel, sudra). Orthodox and Hasidic Jewish men may wear payes (ie, earlocks) or shave their face in a certain manner. In Islamic culture, the mustache is seen as a sign of masculinity and virility, and Islamic women may wear head coverings (eg, hijab, burka, keffiyeh) as a symbol of modesty.

In addition to the symbolic meaning of hair, there are also values and practices involving skin and nails across cultures. In Jewish culture, circumcision of baby boys (ie, bris/brit milah) has been carried out for thousands of years in accordance with the Tanakh (ie, Hebrew Bible) symbolizing religious affiliation.⁶ Skin painting, tattooing (eg, Austronesian groups, Indigenous North American tribes), scarification (eg, West African tribes), piercing (eg, African and American tribal cultures), and amount of skin exposure in view of others (eg, Jewish and Islamic cultures) may also convey meaning and group affiliation. Nail manicuring, painting, and accessorizing also have cultural and societal meanings (eg, Asian, European, and American cultures). The longstanding history of value placed on nails began in ancient Egypt in 3200 BC, where manicures and pedicures were symbols of luxury and status; and, in China where the first nail polish was created and considered a symbol of femininity, wealth, and power.⁷ Nail fashion continues to have significance in contemporary societies. A recent study of African American college students found that nail fashion represented a form of creative self-expression.⁸

Hair, Skin, Nails, and Physical/Mental Health

The appearance of health of hair, skin, and nails may serve as an indication of one’s health status. Alterations of these physical attributes may suggest heart disease, anemia, thyroid dysfunction, diabetes, malnutrition, eating disorder, or BFRB. Approximately 1 in 20 individuals experience a BFRB, behaviors that involve biting, pulling, picking, or scraping one’s own hair, skin, or nails that result in damage to the body. BFRBs are not just an American phenomenon; they occur at similar rates across cultures and demographics.^9,10 There has been very little attention on the cultural impacts of BFRBs or discussion of the ways in which damage to the hair, skin, or nails impacts how individuals experience their culture. Some faiths, including Christians, believe that our bodies are not our own and are believed to be a temple of the Holy Spirit.¹¹ Damage to the body is seen as sinful.

It is important to explore the impact of beauty-centered culture on individuals experiencing BFRBs and the ways in which cultural and religious beliefs may deepen shame and limit participation in meaningful events and milestones. Although a paucity of research has examined the experience of shame, a very common and significant experience in BFRBs, existing data suggests that the emotional toll of living with a BFRB is similar across cultures, including shame, low self-esteem, sadness, and feelings of unattractiveness.^12,13

The Impact in Intersectionality

Only recently has there been an examination of the impact of intersectional stigma in individuals who report experiencing a BFRB. Research suggests that stigma may combine when individuals are part of 2 or more identities that experience prejudice which results in emotional damage (O Deerin, J Stevenson, University of Glasgow, written communication, April 2024). An initial study regarding the experience of mental illness stigma in the LGBTQ+ community demonstrated that BFRB symptomatology may be more prevalent in the LGBTQ+ community compared to a cisgender population (N Pokorna, J Stevenson, University of Glasgow, written communication, April 2024). The LGBTQ+ group also experienced greater levels of negative emotional states, discrimination, intersectional stigma, and family rejection. Transgender participants with BFRBs reported greater dysmorphic appearance concern. Overall, the study suggests that individuals in the LGBTQ+ community may experience an increase in symptomatology because of these intersectional factors.

The Role of Emotion in BFRBs

Emotions play a vital role in the cycle of BFRBs. Individuals with a BFRB may be more vulnerable to intense emotional experiences, difficulties in regulating those emotions, and emotion-driven impulsivity.^14,15 Sensitivity to shame is associated with BFRBs and is identified as a key emotional experience prior to and following a BFRB episode. Furthermore, shame is positively correlated with BFRB symptom severity, distress, and body dissatisfaction.¹⁶

The emotion regulation model of BFRBs posits that BFRBs serve the function of immediate self-regulation. BFRBs are often associated with increased feelings of pleasure, relief, and decreased boredom in the initial stages of the behavior cycle, but trend toward negative emotions, such as anger and anxiety over time.¹³ As a result, individuals report that the long-term emotional impact of experiencing BFRBs include feelings of shame, sadness, frustration, low self-esteem, feelings of unattractiveness, depression, and decreased levels of calmness.^12,13 These longer-term consequences may thus be perpetuated by serving as internal discomforts which are met with a BFRB in an attempt to self-regulate.

Research further suggests that shame and maladaptive cognitive emotion regulation strategies predict BFRB symptoms, and shame mediates the relationship between perfectionism and BFRB symptoms, suggesting that interventions targeting shame may be useful for treatment.¹⁷

The BFRB Reinforcement Cycle can be seen in the Table.

Table. The BFRB Reinforcement Cycle

Cultural Considerations in BFRB Assessment and Case Conceptualization

Experiences within the various cultural groups in which a given individual spends time send messages about what is acceptable, what is not acceptable, and a range of the attitudes in between. Individuals learn the meaning and values their cultural groups assign through their encounters in a range of cultural contexts. In considering potential cultural factors that are relevant to an individual’s BFRB experience, it may be helpful to inquire about the cultural groups with which the individual identifies (eg, family, friends, community, religion, ethnicity, nationality, sexuality, gender, etc) and about the messages received within these contexts. Factors to consider include:

• Messages about beauty, attractiveness, femininity/masculinity
• Messages about hair, skin, or nails
• Messages about what is right vs wrong
• Messages about what it means to have a habit behavior
• Messages about what it means to have a mental health disorder
• Messages about help-seeking behaviors for psychological well-being
• Messages about locus of control
• Negative feedback from others or more subtle interactions about BFRBs, the overt and covert consequences of BFRBs, and any misunderstandings others may have had about the behavior
• Self-judgment and negative self-talk resulting from difficult thoughts, emotions, or unwanted behaviors associated with the BFRB experience
• The reinforcing nature of avoidance and isolation in an attempt to protect oneself from emotional pain
• Accessibility to evidence-based health care and appropriate support
• Potential impact of intersectional stigma

Treatment Considerations

At the outset of treatment, it is critical for the clinician to have a foundation of clinical competency and approach each clinical encounter with curiosity, respect, and cultural humility. Providing psychoeducation regarding BFRBs in general, and a discussion about the individualized conceptualization of behavior and its reinforcement at the beginning of treatment may promote rapport and an open, therapeutic, working relationship. Depending on the individual’s circumstances, it may also be useful to provide psychoeducation to support persons and significant others in the context of a family (ie, multi-person) therapy session with the identified patient present. This may serve to address any misunderstandings, review educational information, and provide guidance regarding how to most appropriately support the individual.

With attention to information gleaned from self-monitoring and the exploration of a comprehensive functional behavioral analysis, strategizing interventions focused on experiential avoidance which results in the maladaptive BFRB is then planned. (As the scope of this article is focused on cultural considerations and the impact thereof, the breadth and depth of describing this treatment approach is limited to highlighting cultural considerations.) Interventions to consider based upon the individual’s relevant cultural factors may include, but are not limited to:

• Examination of the experience of shame in the individual’s life and its relationship to the BFRB
• Examination of the willingness to experience shame and other difficult emotions
• Examination of how the individual responds to shame and other difficult emotions
• Examination of the concept of acceptance as the willingness to experience each moment fully, without attempts to avoid or push away unwanted internal experiences
• Development of a mindfulness practice
• Development of emotion regulation skills
• Development of distress tolerance skills
• Development of self-compassion and other intrapersonal effectiveness skills
• Development of self-care practices and the minimization of BFRB vulnerabilities
• Development of interpersonal effectiveness skills
• Identification of personal values and values-oriented behaviors
• Connection with community, including those who have a shared experience, both culturally and an individual living with a BFRB

Concluding Thoughts

The pervasive and often unrealistic beauty standards that saturate contemporary society play a significant role in the experience and treatment of BFRBs. These standards, perpetuated by social media and a booming beauty industry, exacerbate feelings of inadequacy and shame among individuals with BFRBs. The symbolic meanings attached to hair, skin, and nails across various cultures further complicate these experiences, influencing how individuals perceive themselves and their behaviors. Effective treatment must therefore consider these cultural dimensions. By addressing the emotional underpinnings of BFRBs, particularly shame, and promoting adaptive emotion regulation strategies, therapists can enhance treatment outcomes. Integrating a culturally sensitive approach that acknowledges and respects the diverse experiences of individuals with BFRBs is crucial for meaningful recovery and the promotion of psychological well-being.

Dr Deibler is a licensed clinical psychologist and executive director of The Center for Emotional Health of Greater Philadelphia. She is an author of The BFRB Recovery Workbook: Effective Recovery from Hair Pulling, Skin Picking, Nail Biting, and Other Body-Focused Repetitive Behaviors. Dr Reinardy is a licensed clinical psychologist and director of the Lakeside Center for Behavioral Change. She is an author of The BFRB Recovery Workbook: Effective Recovery from Hair Pulling, Skin Picking, Nail Biting, and Other Body-Focused Repetitive Behaviors.

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