Written evidence submitted by YoungMinds (MISS0033)

1.0)            I am writing on behalf of YoungMinds to provide a written submission to your Committee’s inquiry into body image. We welcome the attention that you are giving to this important issue.

1.1)            YoungMinds is the leading children and young people’s mental health charity in the UK, and we put the experiences of children, young people and families at the heart of everything we do. This submission will draw on the insights and lived experiences of the children, young people, parents, carers and professionals that we work and wider research.

1.2)            To inform our response to this submission, we consulted with 15 young people during June 2020 through a virtual insight workshop, one-to-one calls and the YoungMinds’ online participation platform.

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Young people’s body image, self-esteem

2.0)            The term body image is used to describe how we think and feel about our bodies, and how we believe others see us. The use of the term is varied and is often used in association with having a ‘positive’ and ‘negative’ body image. Historically, body image has been associated with the ‘extent to which an individual has an accurate perception of their body size, shape and weight’[1]. However, how we feel about our bodies extends much further than this to include how our body functions, our skin tone and how we see ourselves physically more generally.

2.1)            Body image is also intrinsically linked with self-esteem, which refers to a person’s overall sense value or worth[2]. Young people can perceive themselves differently in different areas of life, such as physical activity, education, physical appearance, relationships, or overall. For example, our self-esteem may be strong educationally but less so in terms of how we feel about our bodies. Together, those views add up to create our self-image and can influence the way we behave and interact with other. We will use these definitions of body image and self-esteem throughout our submission.

3.0)            Body image and how we think of ourselves is influenced by a broad range of socio-cultural influences, including our families, our peers, the media and the narratives that are presented about bodies in society[3]. For example, our ideas about bodies may be influenced by how our friends and families talk about bodies and appearance[4], either in the context of themselves or others.

3.1)            Simultaneously, the representation of idealised beauty or physicality in the media can influence or reinforce stereotypes[5].  This can lead to young people having negative feelings about their size, the colour of their skin or other physical features. Additionally, the dominant perceptions of ideals related to body image are not fixed and differences can be identified between them at different points in time and within different cultures[6]. The young people that we work with also identified that messages about what does and does not constitute a ‘healthy body’ in campaigns or PHSE lessons at schools can impact on how they feel about themselves. We discuss this further later in the submission.

3.2)            Adolescence is also a period of significant change and development for young people. As young people experience puberty, their bodies change and they may experience acne or other conditions that impact how they feel about themselves[7]. Equally, adolescence is an important period for young people to develop views about themselves, their identities and how they relate to the world around them. It may also be a period when young people start to compare themselves to their peers to a much greater extent[8] .  However, it is important to note that concerns about body image can start at a much earlier age[9].

4.0)            Evidence indicates that discontent concerning the body is particularly prominent during the adolescent period, with young people reporting higher levels of body dissatisfaction[10]. Research by YMCA through its Be Real Campaign has shown that body image is an important issue for young people. YMCA’s research suggests that the majority of young people often worried about the way they look, with four in five young people (79%) reporting that how they look is important to them, and  more than half (52%) reporting that they often worry about the way they look[11].

5.0)            It is important to consider that young people’s experiences of body image and how they relate to the world can differ. As has been identified previously, body image extends beyond weight, shape and body size. Young people may experience intersecting and compounding pressures related to different aspects of their identity or characteristics that impact on how they feel about themselves.

6.0)            During our insight work with young people, they identified young people with disabilities and long-term health conditions as a group that may be particularly affected by concerns related to body image, which the Committee should consider during the inquiry. Importantly, they identified that living with a disability or long-term health condition can impact on how young people feel about their body’s abilities and appearance in relation to others. Notably, research has found that people with visible physical impairments may perceive their body as devalued, which in turn impacts on their feelings of self-worth[12]. For both young people with visible and invisible disabilities, these feelings may be compounded with feelings of shame that have been perpetuated by historic representations of disability as ‘outside of the norm’[13]. As we will discuss later in the submission, increasing representation of people including those with disabilities is important when considering the influences of media on young people’s body image and self-esteem.

7.0)            Body image has historically been associated with young women and until recently empirical studies tended to focus on body dissatisfaction among women[14]. Research by the Mental Health Foundation has shown that young women report higher rates of dissatisfaction with their bodies in comparison to young men[15]. It is therefore important to consider young women in discussions around body image and the impact that poor body image might have on their mental health.

7.1)            However, it is also important to stress that concerns around body image are not limited to young people that identify as women. Young men, non-binary, non-gender conforming and transgender people can also be significantly impacted by feelings of body dissatisfaction, low self-esteem and mental health concerns related to how they feel about their body. Importantly, there are differences in the pressures amongst young people related to their gender identity which should be considered in your inquiry.

7.2)            For example, some young transgender people, whose gender identity differs from the male or female designation given at birth, may feel distress resulting from the differences between the gender that they identify with and their physical appearance[16]. This may be particularly pertinent for young transgender people who have not received gender confirmation treatments (GCT)[17]. For young transgender people, this distress can be compounded by their experiences of discrimination, harassment and bullying. Recent research by Stonewall reports 75 per cent of trans young people report experiencing name-calling, and 28 per cent physical abuse[18].

7.3)            Additionally, young men report that they feel pressures on their body image with 43% responding to a Be Real survey that they are often worried about the way they look and 74% reporting that the way they look is important to them. However, in the same study, men were twice as likely as women to say that they wouldn’t discuss body confidence with their friends (11%), with a theme identified that it was not considered ‘masculine’ to speak about body image concerns and the need to maintain a façade of strength[19]. This stigma and shame has been identified in further research focusing on men with eating disorders and body image issues where it was found that as a result, men have been significantly neglected in diagnosis and treatment[20].

8.0)            In addition to the above, ethnicity has been shown to have an impact on the way that young people feel about their body image. For example, research by the Mental Health Foundation has shown that Black British girls are more likely to have higher satisfaction with their body image than their white British counterparts, and are less likely to display disordered eating behaviours[21]. However,  Boothroyd et al have argued that by focusing predominantly on weight when discussing body image, the discussion can unwittingly miss key risk factors for BAME young people. These include things like being bullied or discriminated against due to hair style and texture, colourism within BAME communities and the impact of lack of representation in the media leading to increased dissatisfaction with being of non-white ethnicity[22].

Impact of body image on young people’s mental health

9.0)            Having positive body image or feelings of satisfaction, acceptance and appreciation for our bodies[23], may be a protective factor for psychological well-being[24]. Conversely, whilst having negative body image is not in and of itself a mental health problem and young people do not necessarily need to have a mental health condition for concerns about their body to impact on their mental health. The young people that we spoke to identified that having poor body image may lead to increased anxieties around people seeing body parts or contribute to existing anxieties with socialising with peers. However, concerns about body image and how young people think about their bodies can be a risk factor for mental health concerns and increase anxiety, depression and unhealthy behaviours[25] [26]. Additionally, low self-esteem is associated with an increased risk of depression[27].

10.0)        Body Dysmorphic Disorder is a mental health condition that is characterised by a ‘preoccupation with one or more perceived defects of flaws in appearance’ which can have a significant impact on a young person’s quality of life[28]. It may cause a young person to worry a lot about a specific area of their body or develop compulsive behaviours such as excessive use of mirrors[29]. The 2017 prevalence survey on children and young people’s mental health by NHS Digital that 1.0% of young people aged 5-19 years has the condition[30].

11.0)        Despite this, discussions around body and mental health are often related to young people’s attitudes and relationship with food and eating. Young people’s attitudes to eating are affected by a range of factors including the attitudes and behaviours of parent and peers towards food, nutrition and body image, trauma, stress, and bullying. Young people’s problems with food can begin as a coping strategy for times when they are bored, anxious, angry, lonely, ashamed or sad. Food becomes a problem when it is used to help cope with painful situations or feelings, or to relieve stress, perhaps without even realising it[31]. Therefore, it is important to consider a range of environmental factors when discussing problems with eating behaviours among young people.

11.1)        Equally, poor body image is often linked with eating disorder such as Anorexia Nervosa or Binge Eating Disorders due to the relationship that these mental health conditions have with food and eating. However, eating disorders are complex disorders and there is no singular reason why someone may develop an eating disorder. They may develop as the result of genetic, psychological, environmental, social and biological factors[32]. Eating disorders are serious mental illnesses that often develop in adolescence, with studies estimating that 75% of anorexia nervosa and bulimia nervosa cases and 50% of binge eating disorder and eating disorder not otherwise specified (EDNOS) cases onset before the age of 22[33] [34].

11.2)        As the eating disorder charity Beat outlines[35], as with all mental health concerns, receiving early treatment is crucial for someone with an eating disorder. Despite this, people with eating disorders face barriers to early intervention, among them a lack of public awareness about early signs and symptoms, misconceptions among GPs, and limited funding for treatment.

12.0)        Over the past few years, there has been a significant increase in the resources provided to children and young people’s eating disorder services. Notably, in 2014 the government announced an additional £30 million in recurrent funding over five years to improve support, care and treatment options for children and young people through community eating disorder teams[36]. Further to this, we welcome the commitment in the NHS Long Term Plan to continue the investment in community provision for children and young people’s eating disorder services[37].

12.1)        Currently, due to the COVID-19 pandemic, young people with mental health concerns including those with eating disorders may face difficulties accessing support for their mental health. Mental health professionals across all sectors deserve enormous credit for responding to the challenges the pandemic brings.

12.2)        However, many young people who were receiving some form of mental health treatment before the crisis are now receiving reduced support. Among respondents to a YoungMinds’ survey[38] during the COVID-19 pandemic who were accessing mental health support in the lead-up to the crisis (including from the NHS, private providers, school counsellors, charities and helplines), 26% said that they were no longer able to access any support. In some cases, this is due to services being withdrawn; in others, young people feel unable to access remote support that has been offered or face practical barriers to doing so.

12.3)        Additionally, there is emerging evidence of a reduction in new referrals to Child and Adolescent Mental Health Services[39]. This is likely to be because normal referral routes, including through schools and GPs, are severely restricted, and because young people and parents are choosing not to seek support during the crisis. It is therefore expected that there will be an increase in the demand for young people’s mental health services as we recover from the pandemic.

12.4)        To meet the needs of young people as we recover from the vast economic and social repercussions of the COVID-19 pandemic, we need a new and systematic approach to mental health support. This must strengthen mental health support in the NHS and prioritise early intervention in our communities. Therefore, through our Beyond Tomorrow campaign[40], we are calling for to take urgent action to make sure that, as we emerge from this pandemic, all young people can get the help they need when they need it.

The effect of companies, media and social media on young people’s body image

13.0)        As we have previously identified, body image is impacted by a number of external influences including how society constructs ideas of physical attractiveness, beauty, and gender alongside ideals about how bodies should function. This in turn impacts on how young people perceive themselves and expectations around how they should look and behave. Alongside personal relationships and interactions, companies, the media and social media play a significant role in the communication of these societal constructions to young people and are therefore important to consider when understanding what impacts body image among young people.

The media, campaigns and body image

14.0)        During the insight work that we conducted with young people during June 2020 to inform this submission, young people highlighted that what they see in the media influences how they perceive themselves and how they relate to the world around them.

15.0)        A key theme that emerged related to the representation of people that were deemed to be ‘aspirational’ or ‘desirable’ in the media. One young person referred to this in the context of the ITV television programme Love Island, where it was noted that many of the contestants look very similar in terms of their ethnicity, body shape and physicality. The interpretation of this and the show‘s response to this criticism amongst the young people that we spoke to, was an underlying message that if you don’t look like the contestants, people would not find you desirable to watch on television. Importantly, young people in our workshop outlined their perception that some of the contestants had previously had cosmetic survey but this wasn’t necessarily clear to viewers. In their view, this contributed to unachievable standards of beauty, as well as a normalisation of surgery to achieve ‘ideal features’.

15.1)        The lack of diversity of people represented in the media and the negative impact that this can have on body image and mental health was noted more widely in our work with young people As one young person told us:

‘Negative representation in the media can have a bad impact - models only being shown in one size creates ideals that young people look up to setting unrealistic targets which can be really damaging to mental health’.

15.2)        This concern was extended to some campaigns or companies that claim to be part of the body positivity movement. As one young person noted, some of these campaigns still lack representation of people with visible disabilities and people of colour, as well as using models whose frame is larger than the models typically used but still lack genuine diversity of shapes and sizes. They told us that this lack of diversity within a movement that is supposed to be celebrating diversity can further marginalise young people who do not feel that they align with the dominant constructions of beauty and physicality.

15.3)        More generally, some of the young people that we spoke to told us that it would be useful to promote ‘body neutrality’ alongside ‘body positivity’, to reduce pressure on young people to feel positive about their bodies, when this is not always appropriate or accessible. As one of our Youth Activists wrote in a recent YoungMinds blog[41];

‘For me, the body positivity movement seemed too daunting to even try. It felt very all or nothing - a lot of the language people use made it seem like you either love your body or you hate it… This is where the body neutrality movement is so helpful. Body neutrality, for me, is a more attainable way of making peace with the way I look and the things I don’t like about my body’.

16.0)        More broadly, when discussing the influence of media and campaigns on body image, some young people identified that adverts that placed an emphasis on limiting numbers of calories or types of food may be harmful to young people and encourage restrictive eating. Public Health England’s Change 4 Life campaign in 2018, which encourages parents to look for ‘100 calorie snacks, two a day max’ for their children, was identified as an example of this. As Beat wrote at the time, focusing on calories rather than on a healthy and balanced diet is unhelpful, given that the calories in a snack are not a direct indicator of their impact on health[42]. Therefore, campaigns that seek to promote healthy eating must be conscious of the impact that their messaging may have on young people who may be struggling with mental health or with feelings about their body.

17.0)        Through our work and that of others, it is clear that there needs to be more diversity in the media to ensure that young people feel represented and can relate to the people that they see on television, social media and in marketing campaigns. Therefore, YoungMinds supports Be Real’s Body Image pledge[43], which calls for a commitment from companies in the advertising, fashion, media and music industries to responsible portrayals of body image.

17.1)        Additionally, to avoid presenting harmful campaigns and messaging young people with lived experience of concerns related to body image and their mental health should be able to actively participate in campaigns and marketing for public health campaigns.

Social media and body image

18.0)        Social media allows young people to connect with others with similar experiences, identities and interests.  Young people tell us that this can have a positive impact on their mental health.  Notably, social media can play an important role in young people feeling less lonely[44] through the connection with like-minded peers. It is also important to recognise in discussions about social media, that children and young people are not just passive consumers of online material generated by adults[45]. Instead, they are active generators of content which can form an important part of their self-expression which can be positive in building their sense of self.

18.1)        However, the young people that we work with often tell us that social media can simultaneously have positive and negative impacts on their lives and how they feel about themselves. During July 2019, YoungMinds worked with Instagram to understand how young people use social media, with a particular emphasis on 14-25-year-olds that had lived experience of self-harm, self-injury, suicidal thoughts and/ or eating disorders. For some of the young people that had lived experience of eating disorders, making comparisons between themselves and other users, or viewing their lives as being ‘better than theirs’ was highlighted as a concern. A systematic review[46] of the impact of social media on body image and disordered eating outcomes explored this further. The review presented evidence to suggest that the use of social media platforms is associated with increased body dissatisfaction and disordered eating and that these results held across gender.

18.2)        Research suggests this is more prominent in young people with diagnosable mental health conditions. In the 2017 NHS Digital prevalence survey of children and young people’s mental health[47], children aged 11-19 with a mental disorder were more likely than their peers to agree that they compared themselves to others on social media (41.9% to 25%) and report that the number of likes, comments or shares that they received on social media had an impact on their mood (27.2% vs 13.9%).

19.0)        Additionally, misinformation about diet tips from eating disorder recovery accounts was a concern that was highlighted in our research with Instagram, and particularly when it feels at odds with dieticians. A general feeling of confusion about who to trust was identified. The young people that were involved with the project told us that social media is designed to show the 'best and not the rest' and young people are at a loss for what’s real, what's not, and what they should be expecting from their own lives and journeys of recovery. When combined with the culture of competition on social media platforms, this can make young people hold themselves to unattainable standards and as a result impact on their self-esteem. As one young person told us;

‘I see lots of adverts about tummy teas and different diets and I hear advice from people [online] about dieting that doesn’t sound healthy for me’.

To address this, Instagram introduced new policies last year aimed at reducing misinformation being published on their platform. This includes removing content that promotes weight loss products that make ‘miraculous claims’ and restricting posts for users under 18 years old that promote the use of certain weight loss products or cosmetic procedures and that have an incentive to buy or includes a price[48]. We would encourage other platforms to also consider how they manage misinformation around products that may impact on how young people see their bodies.

20.0)        The use of adverts and suggested content on social media platforms and the internet more widely was also highlighted in our most recent insight work with young people on body image. Several young people highlighted their experience with using the social media platform TikTok. They told us that following a search for content related to body image or eating disorders, either out of curiosity as to what is on the platform or when looking for supportive content, they noticed that they were being suggested more, and sometimes more extreme, content. As Beat’s media guidelines recognise, ‘people with eating disorders speak about being ‘triggered’ – how their eating disorder behaviour and negative mental state can be stimulated, encouraged or reinforced by certain words, images or situations’[49]. This potentially damaging characteristic of social media should be considered when thinking about young people’s mental health and the impact of content on body image and how young people see themselves. Therefore, we welcome steps taken by Instagram and others to include warnings when content may be triggering for young people.

21.0)        Our research has shown that it is impossible to fully limit young people’s exposure to harmful online content[50]. Therefore, to help young people navigate the online world safely, digital resilience should be embedded in children’s education so that young people can respond to the risks that social media and the internet can have. Importantly, the Government needs to build digital resilience by teaching children and young people to be safe and responsible online and to help them develop the emotional and social skills to mitigate online risks. 

Regulation and the Online Harms White Paper

22.0)        Last year, the Government consulted on the white paper on Online Harms[51]. The proposals included plans to create a regulatory framework for online safety alongside a statutory ‘duty of care’ to ensure that technology companies take action on cyberbullying and other harmful content. Alongside this, they outlined that an independent regulator would develop and publish a code of practice which sets out how companies are required to fulfil the requirements of the new legal duty and oversee and enforce the duty of care.

22.1)        We welcome this step and the greater responsibility that would be placed on online companies and social media platforms to take more responsibility for the safety of young people who use their platforms. It would cover ‘online harms’ like cyberbullying, fake news and material encouraging self-harm or suicide.

22.2)        Importantly, decisions that affect young people should be informed by their experiences and views and young people should be at the heart of internet safety policy development. Therefore, we recommend that there is meaningful and regular engagement with young people by social media companies and policymakers. This could take the form of a Youth Engagement Forum attached to UKCIS.

22.3)        Additionally, it is also important to recognise that the current research on the impact of social media on young people’s mental health had demonstrated an association, but studies have not been able to demonstrate a causal link. Prior  to the publication of the White Paper, we recommended to the Chief Medical Officer and others that more research need to be conducted on the relationship between social media and young people’s mental health, including its influence on body image and how young people think about themselves. Therefore, we support this recommendation and the commitment to increase the knowledge about social media’s impact on young people. The Government must ensure that funding is provided to understand the complex relationship between social media and young people’s mental health.

Our recommendations;

1. So that discussions around body image are including all young people, ensure that definitions extend beyond weight shape and size to include characteristics such as disability, gender identity, skin colour and any other aspects that might impact on how a young person thinks about themselves physically.

2. In order to improve representation of diverse bodies and characteristics, companies in the advertising, fashion, media and music industries should publicly commit to increasing diversity and demonstrate steps that they are taking to ensure that they are making responsible portrayals of body image.

3. Young people with lived experience of concerns related to body image and their mental health should be actively involved in public health campaigns and marketing to promote positive messages about body images and to void potentially harmful depictions.

4. The Government should further invest in and roll out tailored training programmes on digital resilience to cover the nature and consequences of online behaviour and to complement the focus on digital safety and literacy in RSHE. These programmes should utilise multiple channels including schools and youth programmes, with more targeted programmes and outreach for parents who have low digital literacy and resilience.

5. Bring forward legislation to introduce a new duty of care and independent regulator as outlined in the Online Harms White Paper.

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If you would like to discuss any of the points raised in this submission, then please do not hesitate to get in contact. Additionally, if you are holding any evidence sessions with people with that have lived experience of the impact of coronavirus on those with protected characteristics, we would be happy to discuss involvement from YoungMinds’ Youth Activists.

June 2020

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