The Real Cost of Beauty Ideals

The real cost
of beauty ideals
The staggering economic and social cost of body dissatisfaction
and appearance-based discrimination in the United States
Prepared with
Let’s Change Beauty | October 2022 Deloitte Access Economics
We acknowledge the assistance Deloitte
Access Economics and our Expert Advisory
Panel led by Dr Bryn Austin from STRIPED at
the TH Chan Harvard School of Public Health
provided in compiling this report.
The real cost of beauty ideals 2

Contents
Glossary 4
Definitions 5
Acknowledgments 8
Preface 9
Foreword 12
Executive summary 17
1 Introduction 23
2 Approach 29
3 Prevalence 39
4 The economic and social cost of body dissatisfaction 49
5 T
he economic and social cost of appearance-based 68
discrimination
6 Discussion 96
Appendices 103
Appendix A : Costing methodology 104
Appendix B : Sensitivity testing 133
Endnotes 135

Glossary
ACRONYM FULL NAME
BASS Body Areas Satisfaction Subscale
BLS Bureau of Labor Statistics
BMI Body mass index
CDC Centers for Disease Control
CPI Consumer Price Index
CROWN Creating a Respectful and Open World for Natural Hair
DALYs Disability adjusted life years
GBD Global Burden of Disease
GDP Gross domestic product
MBSRQ Multidimensional Body-Self Relations Questionnaire
NIEHS National Institute of Environmental Health Sciences
OR Odds ratio
PAF Population attributable fraction
RR Relative risk
UK United Kingdom
US United States
VSLY Value of a statistical life year
WHO World Health Organization
YLD Years of healthy life lost due to disability
YLL Years of life lost due to premature death

Definitions
TERM DEFINITION
Harmful beauty ideals are socially constructed notions of ideal
beauty. Beauty ideals can vary significantly across the population
(e.g., by age, gender, ethnicity, etc.), however, the most accept-
ed beauty standards in the United States (US) tend to idealize
Harmful beauty ideals predominantly white features and thinness. By imposing narrow
standards of beauty, harmful beauty ideals create an unrealistic
norm against which people compare their appearance and the
appearance of others. In this report, ‘harmful beauty ideals’ is used
interchangeably with ‘idealized beauty’.
Body dissatisfaction is defined as having a severe negative attitude

towards one’s own physical appearance. It originates from a per-
Body dissatisfaction ceived discrepancy between an individual’s ideal state of appear-
ance (i.e., the beauty ideal) and their actual
physical appearance.
Refers to the way in which different aspects of a person’s identity

Intersectionality (such as race, gender, class, disability, sexuality and more) interact
in overlapping forms of discrimination or disadvantage.
The differential unfair or prejudicial treatment of someone on the

basis of their appearance. This study considers appearance-based
discrimination on the basis of three physical features: natural hair,
skin shade and weight. However, we note that other forms of ap-
pearance-based discrimination exist (e.g., discrimination on the
basis of one’s height, physical disabilities, the shape of one’s nose
Appearance-based
and mouth, the shape and size of one’s breasts, among others). It
discrimination
should be acknowledged that beauty ideals, race and gender are
intersectional, meaning that discrimination on the basis of appear-
ance, race and gender intersect or overlap for marginalized com-
munities. Many of the strongest influences on the development of
body image are due to sociocultural factors such as gender, race,
ethnicity, and sexual orientation.1
The unfair or prejudicial treatment of someone on the basis of nat-

Natural hair ural hair texture and styles associated with the Black community.
discrimination These textures are typically kinky and coily, and include afros, locs,
and braids.

TERM DEFINITION
The unfair or prejudicial treatment of someone on the basis of skin
shade (or color). This is also referred to as colorism or shadeism,
Skin shade however the term ‘skin shade discrimination’ has been adopted
discrimination throughout this study. This study costed skin shade discrimination
for only the Black community in the US, as further research is
required to understand its impacts within other racial groups.
The unfair or prejudicial treatment of someone on the basis of body

Weight
weight. For the purpose of this study, an individual with a BMI over
discrimination
30kg/m2 has been classified as having a ‘high weight.’
The unfair or prejudicial treatment of someone on the basis of race

or ethnicity.
Note: Skin shade and hair type are observable, socially assigned
Racial indicators of race. Race therefore plays a key role in the discrimina-
discrimination tion of an individual on the basis of these features. In this study, the
focus is on understanding how appearance-based discrimination
differs for people of the same race, but with different skin shades
and hairstyles, by relying on studies that controlled for race.
Note: This study doesn’t consider discrimination based on gender identity.

For example, it doesn’t account for the discrimination faced by transgender or
nonbinary individuals who don’t present within the traditional gender binary.

TERM DEFINITION
Health system costs
Costs associated with the provision of medical services for health
Medical services conditions/illnesses attributable to body dissatisfaction or appear-
ance-based discrimination, such as inpatient and outpatient costs.
Costs associated with the provision of pharmaceuticals (i.e.,
Pharmaceuticals prescription drugs) for health conditions/illnesses attributable to
body dissatisfaction or appearance-based discrimination.
Productivity costs
Costs associated with increased absences from work due to a
Absenteeism health condition developed as a result of body dissatisfaction or
appearance-based discrimination.
Lost productivity at work due to a health condition developed was a
Presenteeism
result of body dissatisfaction or appearance-based discrimination.
Unpaid care provided to someone by a friend or family member, for
Informal care a health condition developed as a result of body dissatisfaction or
appearance-based discrimination.
Lost annual income due to appearance-based discrimination in
employment and/or incarceration. Annual earnings are derived
Wage losses
from median wages and fringe costs, by age group, gender, and
race or ethnicity.
Costs associated with the reduction in employment, or reduced par-
Reduced employment ticipation in the labor-market, due to a health condition developed as
a result of body dissatisfaction or appearance-based discrimination.
Other financial costs
The reduction in economic efficiency associated with the need to

levy additional taxation to fund the provision of services (e.g., addi-
tional healthcare) and recoup lost taxation revenue due to condi-
tions attributable to body dissatisfaction or appearance-based dis-
Efficiency losses
crimination. Efficiency losses are not the same as transfer payments,
which represent a redistribution of money and are not real costs to
society but instead reflect the reduction in economic efficiency asso-
ciated with a suboptimal allocation of resources in the economy.
Non-financial or loss of well-being costs
Years of healthy life lost Represents the reduction in quality of life due to conditions attribut-
due to disability (YLD) able to body dissatisfaction or appearance-based discrimination.
Represents the years of life lost due to premature death due to
Years of life lost due to
conditions attributable to body dissatisfaction or appearance-
premature death (YLL)
based discrimination.

Acknowledgments
Funding: This report was supported by the Dove Self-Esteem Project of Unilever PLC.
Expert Advisory Panel for this report: We offer a debt of gratitude to the members of the
Expert Advisory Panel for their extensive guidance on the preparation of this report:
• Dr. S. Bryn Austin, Sc.D from STRIPED at Harvard T.H. Chan School of Public Health
• Dr. Phillippa C. Diedrichs, PhD from the Centre for Appearance Research at the University
of the West of England Bristol
• Kayla A. Greaves, Executive Beauty Editor at InStyle magazine
• Dr Josiemer Mattei, PhD, at Harvard T.H. Chan School of Public Health
• Dr. Ayesha McAdams-Mahmoud Sc.D, MPH is a Social Scientists and researcher at Salesforce
• Dr Rebecca Puhl, PhD, is from the Rudd Center at the University of Connecticut
• Dr. Jaime Slaughter-Acey, PhD is at the School of Public Health at the University of Minnesota
• Professor Iyiola Solanke is from School of Law and Social Justice at the University of Leeds
• Dr Kendrin Sonneville, ScD, RD is from the School of Public Health at the University of Michigan
• Katrina Velasquez Esq, MA is the Founder and Managing Principal of Center Road Solutions
• Dr Davene R. Wright, PhD is from Harvard Pilgrim Health Care Institute and
Harvard Medical School.
Thank you to community members: We are deeply indebted to the individuals who shared
their personal stories with us on their struggles with body dissatisfaction and appearance-
based discrimination, including: Candace B., William L., and Tyra S., whose stories are
featured throughout the report, and Anitra R., Ashley G., Saad A., Grace M., Shirley K.,
and others, who also generously gave their time to be interviewed for this report.
Their courage and resilience are an inspiration to all of us.

Preface
Authors: S. Bryn Austin, ScD DSEP, and an international scientific advisory
Professor, Harvard T.H. Chan School of Public panel led by STRIPED. At the start of our study,
Health and Boston Children’s Hospital, we set out to uncover all that could be learned
Director, Strategic Training Initiative for the from the existing research literature and avail-
Prevention of Eating Disorders able data sources to quantify the psychological,
Jaime C. Slaughter-Acey, PhD, MPH health, and economic costs of racist and gen-
Assistant Professor, University of Minnesota dered societal appearance ideals in the United
School of Public Health States. We distilled the extant science base into
two hypothesized pathways:
The United Nation’s 2030 Sustainable Develop-
ment Goal 5 challenges all nations to achieve 1) body dissatisfaction, an intrapsychic phe-
gender equality and empower girls and women. nomenon that is heavily influenced by the
Reproductive health, gender-based violence, messages about and experiences of social
and economic opportunity are most often rec- hierarchies in the world around us; and
ognized as key domains in the struggle for gen- 2) appearance-based discrimination –
der equity. Each is understood to intersect with specifically, discrimination based on body
structural racism in profound ways. Noninclusive size, skin shade, and natural hair texture and
beauty ideals is another domain of life where style - which is interpersonally and structur-
gender inequities exist and intersect with struc- ally mediated injustice enacted in education,
tural racism; yet, this domain has received far employment, healthcare, and a myriad of
less attention from scientists, research funders, other settings.
and government leaders than have reproduc-
tive health, gender-based violence, and eco- In both cases, these pathways disproportion-
nomic opportunity. With this report, we take aim ately target girls and women, though all gen-
at racist and gendered societal appearance ders are impacted, and both have their histor-
ideals, bringing much-needed scrutiny to a ical roots and contemporary power in white
domain of inequity that for too long has been supremacy and patriarchy. Black, indigenous,
relegated to the periphery of economic and so- and other people of color (BIPOC) communities
cial inquiry, no doubt both a consequence and are each targeted by skin shade discrimination,
a cause of the comparatively small research while natural hairstyle discrimination is most
literature investigating this domain. often directed against Black girls and women.
Yet again, all genders are affected.
This report was conceived through a collabo-
ration of the Dove Self-Esteem Project (DSEP) Simply put, our findings on the costs of these
and the Harvard University-based Strategic twin pathways of harm, suffering, and injus-
Training Initiative for the Prevention of Eating tice are astronomical: Each year in the United
Disorders: A Public Health Incubator (STRIPED). States, body dissatisfaction incurs $84 billion in
The findings reported here were generated by a financial costs, with an additional $221 billion
diverse team of economists with Deloitte Access in loss of well-being; and appearance-based
Economics consulting firm, expert input from discrimination incurs $269 billion in financial

costs, with an additional $233 billion in well-be- society, we found that the depth and breadth of
ing losses. Nearly one-third of the financial costs research literature and data sources document-
of body dissatisfaction are borne by individuals ing their impact fell short in several disappoint-
and families (32%) and government (29%), while ing ways. We were not completely surprised by
employers also pick up a sizable portion of the this finding, given the historical and enduring
tab (14%). Our investigation indicates that the marginalization of research by and about BI-
impact of appearance-based discrimination is POC and gender-diverse communities. Yet we
even more profound, affecting most arenas of reject the idea that this knowledge gap in the
life and work, from unfair healthcare barriers, science is indelible, and we challenge funding
wage losses, and diminished employment and organizations and the scientific community to
education to incarceration. For weight discrim- close the gap by supporting scholars whose
ination, each year the financial costs amount work focuses on gendered and racist societal
to $206 billion and well-being losses to $224 appearance ideals, especially those from
billion; for skin-shade discrimination, the corre- BIPOC and gender-diverse communities.
sponding financial costs reached $63 billion and
well-being losses $8 billion. In 2019, the finan- Here are just a few examples of limitations of
cial cost of appearance-based discrimination our report:
was 1.3% of US gross domestic product (GDP).
Expressed in current dollars, the costs of body • Scientists have developed many different
dissatisfaction and appearance-based dis- measures of body dissatisfaction derived
crimination would be even higher, with inflation from varying conceptualizations of the con-
averaging 3.9% per annum between 2019 and struct and focusing on different aspects of the
2022. Our report represents the most com- physical body, which vary in salience in part as
prehensive assessment ever conducted on the a function of societal ideals and social group
pervasive and pernicious impact of body dissat- identity. While the research to date has been
isfaction and appearance-based discrimination rich and illuminating, the lack of consistency in
on the U.S. economy and society. measurement complicated our comparisons
across studies, population groups, and con-
While we gained a clearer understanding of texts and impeded our efforts to comprehen-
the historical roots and pervasiveness of racist sively quantify the social and economic costs
and gendered societal appearance ideals in U.S of body dissatisfaction for society as a whole.
• Skin shade discrimination or colorism in the

United States adversely affects all BIPOC
communities, yet to date, research has pri-
marily concentrated on the impacts on Black
Americans. The sparse literature on Indige-
nous, Latino/a/e, and Asian ethnic communi-
ties in the United States resulted in our team
having sufficient data to base estimates of the
economic impact of skin shade discrimination
for only Black Americans.

• Discrimination based on natural hairstyles is ance-based ideals. Rather, our goal is to inspire
widely documented in the news media and a new generation of scholarship and feder-
well-characterized in social sciences. Still, al and foundation research funding, building
pertinent economic research on this form of on the insights of all the pioneering scientists
discrimination lags far behind, thus preclud- whose work served as the basis for our report.
ing analysis of its economic impact. We aimed to synthesize what is known, illumi-
nate what is not yet known, and motivate
• Likewise, the adverse effects of appear- scholars and funders to pick up where our
ance-based discrimination and body dissatis- report leaves off.
faction for transgender and gender nonbinary
communities in the United States are widely For some of our readers, our findings may be
documented in the news media and are in- illuminating and shocking. For others, they may
creasingly being studied in the social sciences, simply underscore with novel data what was
but the requisite economic studies to inform already well known or experienced by them
our comprehensive analyses of the economic directly. Whether our findings are astounding,
impact are lacking. infuriating, or validating, we hope for all our
readers that this report inspires action to design
We strongly encourage research scientists to new studies, launch new research funding
pay heed to the gaps in the literature described opportunities, and initiate new policies and
above and other limitations we identify in our programs to redress the staggering economic
full report, where the breadth or depth of our and social costs of body dissatisfaction and
findings have been constrained by the dearth of appearance-based discrimination.
pertinent research. In addition, we urge the na-
tion’s preeminent funding organizations in gov-
ernment and foundation sectors, including the
National Institutes of Health, National Science
Foundation, Robert Wood Johnson Foundation,
and others, to dedicate funding to support
new studies and research scholars to redress
these deficiencies in the science base and illu-
minate promising policy and program interven-
tion strategies to eliminate appearance-based
discrimination and promote body confidence
and well-being. Our goal in undertaking this
report was not to produce a final definitive
assessment of the devastating economic
and social cost of harmful societal appear-

Foreword
Author: Alessandro Manfredi,
Dove Global Chief Marketing Officer
Women and girls are inundated with harmful based discrimination face poorer health out-
messages about their appearance every day – comes, labor market outcomes, educational
whether it’s in the form of toxic beauty advice outcomes, and discriminatory incarceration.
on social media or unrealistic representations of Moreover, body dissatisfaction and appear-
beauty on a billboard – it can have a negative ance-based discrimination can lead to severe
impact on their body confidence and self-es- outcomes like depression, anxiety, eating disor-
teem. At Dove, we are on a mission to make a ders and even suicide – all of which have been
positive experience of beauty accessible to all. exacerbated by the global COVID-19 pandemic
This is why we partnered with Deloitte Access and economic inflation. This report highlights
Economics and Dr. S. Bryn Austin, Founding the true impact of harmful beauty ideals – and
Director of the Strategic Training Initiative for the findings reveal that body dissatisfaction and
the Prevention of Eating Disorders (STRIPED): appearance-based discrimination are a pub-
A Public Health Incubator at the Harvard T.H. lic health crisis. Illuminating that the impact is
Chan School of Public Health on The Real Cost worse for women and girls – body dissatisfac-
of Beauty Ideals report. Together, we uncov- tion endangers more girls than toxic substances
ered the massive economic toll of $305 billion (underage alcohol abuse, smoking cigarettes,
through body dissatisfaction and $501 billion and illegal drug abuse).
through appearance-based discrimination that
harmful beauty ideals impose upon Since Dove launched the Campaign for Real
the US economy each year. Beauty nearly two decades ago – inspired sadly
by the insight that just 2% of women describe
The scale of the issues we face is beyond imagi- themselves as “beautiful” – Dove is deeply
nation, and we have seen first-hand how dis- committed to changing beauty for the better by
crimination exacts a terrible price. The Real Cost addressing harmful ideals that have an ad-
of Beauty Ideals report found the financial costs verse effect on self-esteem, mental wellness,
of appearance-based discrimination totaled and even ideals that limit access to employment
$269 billion in 2019 — close to 1.3% of US GDP. and educational opportunities. Our work in-
In addition, the loss of well-being from appear- cludes showing a more diverse representation
ance-based discrimination was estimated to be of beauty, zero digital distortion, investing in
$233 billion. It’s a human problem, impacting young people to build and nurture their self-
66 million individuals aged 10 years or older, esteem, and championing legislation to end
of whom it was estimated that 34 million faced race-based hair discrimination in the workplace
weight discrimination, 27 million faced skin tone and in schools. Dove’s actions have taken
discrimination, and 5 million faced natural hair many different forms.
discrimination. It’s critical to remember that
these 66 million lives encountering appearance-

• In 2004, we started the Dove Self-Esteem Our work over the years has taught us that
Project, the largest provider of body con- we can’t solve the problem if we don’t know
fidence education in the world. We have the scale of the challenge.
reached 82 million kids across 150 countries
with our no-cost, academically validated re- That’s why this report is such a vital
sources to-date, and are on track to positively contribution to the current conversa-
impact the body confidence and self-esteem tions around beauty – and hopefully,
in 250 million young people by 2030.
a catalyst for change.
• Dove co-founded The CROWN Coalition in This study demonstrates that the cost of harmful
2018 with partners such as such as the Na- beauty standards is not only measured in hap-
tional Urban League, Color Of Change, and piness and health, but also in losses of dollars
Western Center on Law & Poverty to ‘Create a and cents. We hope it will serve as a call to
Respectful and Open World for Natural Hair,’ action to reprogram our learned behaviors and
and will continue to support The CROWN Act denounce harmful beauty ideals, ensuring the
until race-based hair discrimination in work- world the next generation enters is one where
places and schools is illegal across the United all forms of beauty are seen, respected and cel-
States. To date, the CROWN Act is law in 18 ebrated. Simply, we can’t continue to ignore
US states and has passed in the US House of the price we’re paying for harmful beauty
Representatives. ideals.
• Through Project #ShowUs, Dove created the While we cannot make broad change alone,
first-ever global collection of inclusive beauty The Dove Self-Esteem Project is committed
images for media and advertisers to use. Since to working alongside likeminded individuals,
launching in 2019, we’ve grown the bank to experts, and organizations to change beauty
over 16,000 images, and more than 7,627 com- for the next generation. This means providing
panies across 39 countries have used images continued support for a multi-channel, long
from the bank to help us redefine beauty in term approach to disarming the complex influ-
media and advertising. Also in 2018, we deep- ences that lead to both body dissatisfaction and
ened our commitment to ensuring women are appearance-based discrimination that erode
portrayed with #NoDigitalDistortion, and a the self-esteem of kids and teens.
pledge to create a more positive experience
for the next generation on social media. Change doesn’t happen overnight, but we must
do our part to drive awareness for issues im-
pacting young people through our platforms
and campaigns, while also identifying small
actions we can all take that can lead to big re-
sults in the future. These actions can come in
the form of:

• Education & Mentorship: Support academ- • Advocating on a legislative level:
ically validated body-confidence education Advocate at the state and municipal level to
in schools and talk to young people in your action legislation that protects people from
life about body image and anxieties they may discrimination based on weight, skin tone and
have about their appearance. Download no- hair. The data in this report is currently being
cost, confidence-building resources at dove. used to support state legislation around body
com/selfesteem. size discrimination, which is presently legal
in 49 US states. You can write your local
• Supporting Inclusive, Diverse & Authentic legislators about these issues to advocate
Images in Media: Challenge companies, TV for change. You can also join our mission to
shows, films and advertisers that perpetu- make race-based hair discrimination illegal
ate narrow beauty standards. Media and ad by supporting the CROWN Act in states
industry leaders can promote authenticity by where legislation has not passed – visit
supporting diverse imagery in advertising like Dove.com/CROWN for updates.
the Project #ShowUs photography bank. We
also encourage consumers to purchase prod- Together, we have an obligation to take action
ucts from brands that celebrate diversity. to create a world where beauty is a positive
experience for everyone.
• Helping Young People Curate Positive
Social Media Feeds: When you allow your Visit Dove.com/costofbeauty for more
teen to sign up for a social media account, information and join us on our mission to
take time to help them identify positive ac- change beauty.
counts to follow, which can help ensure a
positive algorithm. For teens who are already
on social media, empower them to unfollow Sincerely,
or mute posts, videos or accounts that makes
them feel bad about themselves. Additionally, Alessandro
adults can demand popular platforms hold
safe spaces for kids online, including a safety
and awareness checklist at sign-on require-
ment. Learn more about how to help teens
detox their feed at dove.com/detoxify.

Beauty ideals are socially constructed notions of ideal
beauty. The report explores the impacts and costs of
harmful beauty ideals through the dual pathways of body
dissatisfaction and appearance-based discrimination.
In 2019, there were:
66 million
People affected by
appearance-based
discrimination
45 million
People affected by
body dissatisfaction
COST TYPES
Financial costs Non-financial costs
Health costs Productivity costs Other costs Loss of well-being

Medical services, Reduced employment, Efficiency losses, Years of life lost and
pharmaceuticals absenteeism, prison expenditure, years lived with a
presenteeism, societal impact disability
wage losses and of wage losses
informal care

ATIO N
I N
IS C RIM
E D D
E - B A S
APPE ARANC
Appearance-based discrimination
is defined as the unjust, prejudicial treatment of
somebody purely on the basis of their appearance.
$269 billion $233 billion

$ $
in financial in lost
costs well-being
Weight Skin shade Natural hair
discrimination discrimination discrimination
affected 34 million affected 27 million affected 5 million
people and cost people in the Black people in the Black
$206 billion. community and community
cost $63 billion. (not costed)
BODY DISSATISFACTION
Body dissatisfaction
is defined as having a severe and persistent negative
attitude towards one’s own physical appearance,
which has been caused by harmful beauty ideals.

$ $
in financial in lost
costs well-being
Beyond the immediate economic benefits, eliminating harmful beauty
ideals could also greatly improve societal well-being more broadly.

Executive Summary
There is a need for multi-level BOX I: DEFINITIONS
interventions to address harmful
BODY DISSATISFACTION is defined as
beauty ideals in the United States,
having a severe and persistent negative
which cost the economy $305 billion attitude towards one’s own physical appear-
through body dissatisfaction and $501 ance, which has been caused by harmful
billion through appearance-based beauty ideals. It originates from a perceived
discrimination in 2019. discrepancy between an individual’s ideal
state of appearance (i.e., the beauty ideal)
and their actual physical appearance.
Beauty ideals are socially constructed no-
tions of ideal beauty. They are communicated APPEARANCE-BASED DISCRIMINA-
through media, film, family, and other sociocul- TION is defined as the unjust, prejudicial
tural channels, creating a culturally accepted treatment of somebody purely on the basis
norm of what makes someone beautiful. of their appearance. Appearance-based
discrimination can be based on any physical
In the United States (US), the most accepted feature of a person. The three types of ap-
pearance-based discrimination considered
beauty norms reflect white standards. The lack
in this study include weight discrimination,
of diversity in body shapes, sizes, ages, abilities,
skin shade discrimination, and natural hair
hair types, and skin shades of people shown in
discrimination (see Definitions for further
the media sets a narrow and unrealistic beauty
details).
standard that is difficult (if not impossible) for
most to attain.
This has a profound impact on the way people anxiety and can realize their full potential. Dove
think and feel about themselves and the people commissioned Deloitte Access Economics to
around them. Yet, we still do not have a good estimate the economic and social cost of harm-
understanding of the impacts that are attribut- ful beauty ideals, for people aged 10 years and
able to harmful beauty ideals, nor the associat- older in the US in 2019.ii To our knowledge, this is
ed economic costs. the first study to attempt to cost harmful beauty
ideals and holistically identify the associated
Dove has made a commitment to portraying impacts.
real and diverse beauty in all of its advertis-
ing since 2004. The Dove Self-Esteem Project,
the educational arm of Dove, was established
in 2004 to help the next generation develop a
healthy relationship with the way they look, so
they are not held back by appearance-related ii The calendar year of 2019 was chosen to enable us to cal-
culate the costs of harmful beauty ideals while avoiding
any impacts caused by the COVID-19pandemic. All costs
in this report are in United States dollars ($USD).

This report explores the impacts of harmful Furthermore, as many as 66 million peopleiv
beauty ideals through the dual pathways of in the US aged10 years or older experienced
body dissatisfaction and appearance-based appearance-based discrimination in 2019. This
discrimination. Put simply, appearance-based includes anyone who experienced discrimina-
discrimination describes how beauty ideals tion based on their skin shade, weight or natural
change the way we treat others while body hair styles but does not include those who expe-
dissatisfaction indicates how beauty ideals can rienced other forms of appearance-based dis-
change the ways we think and feel about our- crimination (such as height discrimination). Of
selves. the 66 million, it was estimated that 34 million
faced weight discrimination, 27 million faced
Importantly, this study focuses on understanding skin tone discrimination, and 5 million faced
how appearance-based discrimination differs natural hair discrimination. For the purposes of
for people of the same race or gender but with the calculations in this report, it was assumed
different physical characteristics such as hair that someone could be counted towards only
type, skin shade and weight. However, it is noted one form of discrimination. However, this is not
that skin shade and hair type are observable, necessarily reflective of the true experiences
socially assigned indicators of race, and race of people facing discrimination. People who
therefore plays a key role in the discrimination experienced appearance-based discrimination
of an individual on the basis of these features. faced poorer health outcomes, labour market
Furthermore, appearance-based discrimination outcomes, educational outcomes and discrimi-
is driven by white standards of beauty, which natory incarceration.
means people with pre-dominantly white fea-
tures such as light skin shades or straight hair To estimate the costs of harmful beauty ideals,
are systematically and structurally privileged, this report adopted a prevalence approach,
while darker skin shades tend to be devalued. where costs are estimated for specific out-
comes that are attributable (such as depres-
This report conservatively estimates that as sion, eating disorders, anxiety, etc.) and applied
much as 16% of the US population aged 10 years to the proportion of the population that faces
or older – reflecting 45 million people – expe- these outcomes due to body dissatisfaction or
rienced body dissatisfaction in the US in 2019. appearance-based discrimination. These costs
People who experienced body dissatisfaction have been estimated based on the prevalence
faced poorer health outcomes, reduced en- of body dissatisfaction and appearance-based
gagement across social circles, school and work, discrimination for people aged 10 years and
and engaged in risky behaviours. This estimate older in the US.
is likely conservativeiii and focuses on individuals
with severe and persistent experiences of body
dissatisfaction, resulting in an array of serious
impacts such as depression, anxiety, eating
disorders, illicit drug use, among others. iv This estimate does not reflect the number of people who
also face appearance-based discrimination on the basis
iii F
or example, in a critical evaluation of research exam- of other physical features such as the shape of one’s nose
ining the population prevalence of body dissatisfaction and mouth, the shape and size of one’s breasts, height,
among US adults, Fiske et al. (2014) found that estimates and physical disabilities. Including all forms of discrimina-
of body dissatisfaction varied between 11-72% for women tion for all groups who experience it would likely result in
and between 8%-61% for men. a far larger estimate of prevalence.

Modelling for this report found the financial For both body dissatisfaction and appearance-
costs of body dissatisfaction in the US was $84 based discrimination, women bore the major-
billion in 2019, equivalent to 0.4% of total US ity of costs (58% or $177 billion and 63% or $317
gross domestic product (GDP) each year. While billion respectively.).
the financial and economic costs are substan-
tial, they do not tell the full story. There is also For context, the financial costs of body dissat-
a considerable impact on quality of life. Loss isfaction would cover tuition, fees, room and
of well-being or non-financial costs from body board costs for 2.9 million college students in
dissatisfaction were estimated to be $221 billion the US for one academic year,v reflecting 17% of
in 2019. all students enrolled in a postsecondary insti-
tution in 2019.1,2 The financial costs of appear-
These costs are bigger still for appearance- ance-based discrimination would cover two-
based discrimination, with the financial costs thirds (66%) of the total national out-of-pocket
totalling $269 billion in 2019 or close to 1.3% of spending on healthcare in the US (estimated
US GDP. In addition, the loss of well-being from to be $406.5 billion in 2019).3
appearance-based discrimination was esti-
mated to be $233 billion. Weight discrimination Collectively, the combined financial and
was responsible for $206 billion of the financial well-being costs was $305 billion for body
costs attributable to appearance-based dis- dissatisfaction and $501 billion for appear-
crimination, while skin shade discrimination was ance-based discrimination.
responsible for $63 billion.
COST OF APPEARANCE-BASED COST OF BODY DISSATISFACTION

DISCRIMINATION IN 2019
IN 2019
financial costs financial costs
non- financial costs non- financial costs
Beyond the immediate economic benefits, eliminating harmful beauty ideals
could also greatly improve societal well-being more broadly.
v Based on average costs in a four-year institution in the United States.

While the costs of appearance-based discrimi- There are a range of evidence-backed inter-
nation and body dissatisfaction can be consid- ventions that could help to address harmful
ered collectively, they cannot be summed. This beauty ideals such as promoting safer digital
is due to likely crossovers between the pathways spaces, encouraging diversity in advertising,
themselves. For example, some people who regulating the sale of harmful products, tax
face appearancebased discrimination or stigma incentives and laws to end appearance-based
might internalize these experiences and subse- discrimination, education at schools to promote
quently be dissatisfied with their appearances, body confidence, mental health support servic-
creating an overlap with body dissatisfaction.vi es, and social media literacy, among others.
Given the indicative costs of body dissatisfaction Of course, a key starting place to address
and appearance-based discrimination on indi- harmful beauty ideals is to ensure that initi-
viduals, government and broader society, there atives are backed by robust research and to
is a need for multi-level interventions to address deepen our understanding of harmful beauty
harmful beauty ideals. Beyond the immediate ideals more broadly. This report identifies a
economic benefits associated with reducing range of limitations in the existing literature,
healthcare costs and improving productive summarized in Box ii (next page).Vii
output, initiatives aimed at encouraging body
confidence and reducing bias, underpinned by
research, have the potential to greatly improve
societal well-being more broadly.
vi F
or example, it is estimated that approximately 44% of
adults in the US might be internalizing weight bias,
which captures the negative perception one feels towards
themselves because of weight stereotypes in society.
vii Further detail is provided in Chapter 6.

BOX II: BUILDING THE EVIDENCE-BASE • More research is needed to inform estimates
AROUND HARMFUL BEAUTY IDEALS of the financial and non-financial costs of
body dissatisfaction and appearance-based
• Further research is needed around specific discrimination experienced by transgender
forms of appearance-based discrimination and gender nonbinary communities in the US.
that were not quantified (e.g., hair discrim- Body dissatisfaction and weight, skin shade,
ination) or which were not included in this and hair discrimination affect transgender
report (e.g., height discrimination, discrimi- and gender nonbinary communities, but how
nation against people with visible disabilities, these experiences are patterned by age, sex
etc.), to better understand their impacts and assigned at birth, and other important factors
costs. Furthermore, it would be valuable to is not yet known. In addition, discrimination
gain a better understanding of the intersec- targeting transgender and gender nonbina-
tionality between different forms of appear- ry communities for their gender expression
ance-based discrimination, for example, is widespread and likely to profoundly affect
experiencing both skin shade and hair dis- employment and other economic indicators,
crimination. but more research is needed to help inform
costing analyzes like those presented in this
• The majority of research in the US of skin report for cisgender women and men.
shade discrimination is focused on the Black
community. More research is needed to un- • Some of the studies used in this report were
derstand the prevalence and impacts of skin based on non-US samples and, as a result,
shade discrimination for other communities of lack generalizability to the US population.
color, for whom this form of discrimination is For example, the odds ratio adopted for
also likely to be relevant. anxiety is based on an Irish sample. To obtain
more precise estimates, more US-specific
•T
here are also many different definitions of research is needed. Further, for some of the
body dissatisfaction in the literature, and impacts that were costed, the estimates could
different ways it is measured. Adopting a con- be improved. For example, the odds ratio for
sistent definition and measure of body dis- eating disorders for men was based on
satisfaction would help enable comparisons disordered eating behaviors as opposed to
to be made across studies and improve the clinically diagnosed eating disorders.
quality of research.
• For outcomes related to skin shade and hair
• Certain impacts in this report were discussed discrimination, controls for race were care-
qualitatively and as such their costs are not fully considered to understand how appear-
well understood. For body dissatisfaction this ance-based discrimination differs for peo-
includes certain behavioral disorders, low ple of the same race, but with different skin
self-esteem, risky sexual behavior, worse shades and hair types. However, more work
educational outcomes and professional is needed to enable researchers to further
engagement, alongside the use of risky cos- disentangle the effects of appearance-based
metic products and procedures. For appear- discrimination from other forms of racial and
ance-based discrimination, this includes gender discrimination and identify the
employment and health outcomes associated incremental costs.
with discrimination.

1 Introduction.
The report explores the impacts
and costs of harmful beauty ideals
through two pathways:
BODY APPEARANCE-BASED
DISSATISFACTION DISCRIMINATION

1 Introduction
Beauty ideals are socially constructed notions anxiety and can realize their full potential. As
of optimal physical attractiveness. They can part of the development of a program of evi-
exist for a combination of physical features of dence-based resources, Dove commissioned
the human body, such as facial features, hair, Deloitte Access Economics to estimate the eco-
weight, height, body shape and skin shade, nomic and social cost of harmful beauty ideals
among others. in the US for people aged 10 years and older.
There is no one definition of the ideal standard To our knowledge, this is the first report to ho-
of beauty. Indeed, beauty ideals can vary by listically consider a wide range of impacts asso-
age, gender, race or ethnic group and even ciated with harmful beauty ideals and attempt
personal preference. They can also evolve over to estimate attributable costs. In doing so, this
time. What was once idealized fifty years ago report aims to shed light on the severity of the
may no longer be idealized today. issue while highlighting the need for interven-
tions to address the underlying cause.
Yet, regardless of how the beauty ideal is de-
fined, the fact that it exists is problematic. This
is because beauty ideals inherently represent 1.1 How are beauty ideals created?
only a fraction of the population. For most peo- Harmful beauty ideals are created and com-
ple, realizing these ideals would not be possible municated through several different sociocul-
without significant time, money, and resources, tural channels. Media is one of the key channels
and even then, may still remain out of reach. through which beauty ideals are conveyed and
reinforced. This can include both digital forms
By imposing narrow and unrealistic standards of media (such as social media) alongside tra-
of beauty, harmful beauty ideals create a norm ditional formats (such as TV and newspapers).
against which people compare their appear- Beauty ideals portrayed in the media are typi-
ance and the appearance of others. Pressure cally not representative of the average person
to meet these standards can lead to a range of in US society. These ideals have been further
negative impacts. Some individuals may be- distorted by the rise of body-altering apps. For
come dissatisfied with their appearance, while example, based on findings from a survey of
others may be discriminated against because 175 women or nonbinary people aged 18-30
they do not meet society’s ideals of what it in the UK, Gill (2021) found that approximately
means to be beautiful. 90% use a filter or edit their photos before post-
ing online.4
Dove has made a commitment to portraying
real and diverse beauty in all of its advertis- Media use in the US is growing. On average,
ing since 2004. The Dove Self-Esteem Project, people in the US spent just over 11 hours on av-
the educational arm of Dove, was established erage consuming media (both traditional and
in 2004 to help the next generation develop a digital formats) every day in 2011. In 2019, this
healthy relationship with the way they look, so had increased to 12.5 hours – and is expected
they are not held back by appearancerelated to continue to grow.5

Increasing use of media means people are The impacts of normative beauty ideals are not
more exposed than ever before to unrealistic just felt within the US. In a study of more than
beauty ideals. This is particularly concerning 3,000 women across 10 countries, 90% said
for younger generations, who are the highest they wanted to change at least one aspect of
users of digital media.6 Indeed, research has their physical appearance, suggesting this is
found that girls who regularly share photos of a global phenomenon.11 Importantly, this does
themselves online are significantly more likely not mean beauty standards themselves are the
to internalize societal beauty ideals and criti- same but can vary significantly across cultur-
cally evaluate their shape and weight, relative al and historical boundaries. This variation is
to those who do not.7 important because it demonstrates that beauty
ideals are socially constructed.
In addition to media, family and peers can also
influence the propagation of beauty ideals. Because they are socially constructed, norma-
Peers and family can convey harmful body tive beauty ideals can perpetuate disadvan-
ideals both directly (for example, through com- tages already faced by particular groups in the
ments about weight, shape, skin tone or hair US.12 For example, people with predominantly
styles), or indirectly (for example, by modeling white features such as lighter skin shades and
dieting behavior). Certain products such as skin straight hair are systematically and structurally
bleach used by Black girls and women to light- privileged, while darker skin shades or natural
en their skin can also reinforce beauty ideals. hair styles tend to be devalued.13
1.1.1 Beauty ideals, race and gender 1.2 Impacts of harmful beauty ideals
It should be acknowledged that beauty ideals, Beauty ideals that are internalized can cause
race and gender are intersectional. Indeed, harm through two distinct pathways:
most researchers agree that the strongest
influences on the development of body image • beauty ideals can cause someone to judge
are sociocultural factors such as gender, race, their own appearance negatively, leading to
ethnicity, sexual orientation, among others.8 body dissatisfaction.14 15 16
• beauty ideals can also change the way
In the US, the most accepted norms reflect people view others based on their appear-
white beauty standards. While other racial ance, leading to appearance-based
groups may have a different set of norms, they discrimination.
are often still subjected to white standards in
the US. This reflects the underlying discourses This report explores the impacts of harmful
of race and power in societies in which the ra- beauty ideals through these two pathways
cial group with institutional and social privilege (see Figure 1.1).
makes their racial features the norm.9 Similarly,
beauty norms can reinforce existing inequalities
between men and women. Some researchers
suggest beauty norms are used as a tool to op-
press women, by basing women’s value in socie-
ty on how conventionally attractive they are.10

Figure 1.1: Framework for understanding how harmful beauty ideals manifest and impact society
Sociocultural Internalization of Impacts of harm-

channels beauty ideals ful beauty ideals
MEDIA Judgment of Body

Harmful
one’s own dissatisfaction
beauty
PEERS AND appearance
ideals
FAMILY
Bias formation Appearance-
EDUCATION based on based
others’ discrimination
OTHERS appearance
Source: Deloitte Access Economics.
The definitions of body dissatisfaction and appearance-based discrimination are provided in Box 1.1.
BOX 1.1: DEFINITIONS
•B
ODY DISSATISFACTION is defined as having •A
PPEARANCE-BASED DISCRIMINATION is
a severe and persistent negative attitude to- defined as the unjust, prejudicial treatment
wards one’s own physical appearance, which of somebody purely on the basis of their ap-
has been caused by harmful beauty ideals. It pearance. Appearance-based discrimination
originates from a perceived discrepancy can be based on any physical feature of a
between an individual’s ideal state of ap- person. This can occur in a number of differ-
pearance (i.e., the beauty ideal), and their ent settings including in education, employ-
actual physical appearance. ment and in the provision of government or
other services, such as healthcare. The three
types of appearance-based discrimination
considered in this study include weight dis-
crimination, skin shade discrimination, and
natural hair discrimination
(see Definitions for further details).

It should be noted that while the costs of ap- 1.3 This report
pearance-based discrimination and body The remainder of this report is structured as
dissatisfaction can be considered collectively, follows:
they cannot be summed. This is due to likely
crossovers between the pathways themselves. • Chapter 2 provides an overview of the ap-
For example, some people who face appear- proach taken to cost harmful beauty ideals,
ance-based discrimination or stigma might covering the method framework, prevalence,
internalize these experiences and subsequently impacts, cost types, cost estimation method,
be dissatisfied with their appearances, creating and the method limitations
an overlap with body dissatisfaction.Viii This in
turn leads to personal and societal costs. • Chapter 3 details the prevalence of body
dissatisfaction and appearance-based
discrimination
• Chapter 4 details the impacts and estimated

costs of body dissatisfaction in 2019
• Chapter 5 details the impacts and estimated

costs of appearance-based discrimination in
2019
• Chapter 6 provides a discussion of the main

findings of this report, their implications, and
recommends a number of areas for future
research.
viii F
or example, it is estimated that approximately 44% of
adults in the US might be internalizing weight bias,
which captures the negative perception one feels to-
wards themselves because of weight stereotypes
in society

2 Approach.
Harmful beauty ideals were costed
using a prevalence approach, where
costs of impacts were applied to the
population facing the impacts.

2 Approach
The costs of harmful beauty ideals were estimated for the pathways of body
dissatisfaction and appearance-based discrimination using a prevalence
approach. At a high-level, this involves identifying the costs associated with
the impacts of each pathway and applying them to the proportion of the
population that faces these due to body dissatisfaction or appearance-based
discrimination.
Two approaches were used to attribute costs:
• For most impacts, costs were attributed to • However, for appearance-based discrimina-
body dissatisfaction or appearance-based tion only, some costs were estimated using an
discrimination by applying the population at- outcome approach. This involved comparing
tributable fraction (PAF) to the total costs as- specific outcomes for people impacted by
sociated with an impact (such as depression, appearance-based discrimination to those
anxiety, etc.). The PAF represents the pro- that are not and applying the gap between
portional reduction in population disease the two groups to the total number of people
or mortality that would occur if exposure to facing appearance-based discrimination. This
beauty ideals (either from body dissatisfaction method was used to quantify wage and em-
or appearance-based discrimination) were ployment losses attributable to labor market
reduced to zero. outcomes and discriminatory incarceration.

The cost framework for this study is illustrated in Figure 2.1.
Further detail on cost estimation is provided in the sections following.
Figure 2.1: Overall cost framework

PATHWAYS PREVALENCE DISCRIMINATORY ECONOMIC
OUTCOMES AND COSTS
QUANTIFIABLE IMPACTS
IMPACTS Financial costs:

Number of Cost of
-H ealth system
people who - Depression body
costs
report being - Eating disorders dissatis-
Body - Productivity losses
body dissatisfied, - Smoking faction
dissatisfaction - Efficiency losses
by gender and - Suicide attempts
age - Anxiety Non-financial costs: =
- Alcohol and drug abuse - Loss of well-being Cost of
x appearance-
based
Population attrib- discrimina-
Number of OUTCOMES IMPACTS utable fraction tion
people - Poorer labor - Depression
experiencing:
Appearance- - Weight
market - Anxiety +
outcomes - Drug abuse
based discrimination - Discrimina- - Smoking Labor market
discrimination - Skin shade tory incar- - Obesity cost:
discrimination ceration - Hypertension
- Hair - Wage gap
discrimination - Employment gap
x
Wage losses
While the costs of appearance-based discrimi- The following sections detail the various com-
nation and body dissatisfaction should be con- ponents of the methodology used to cost harm-
sidered collectively, they cannot be summed. ful beauty ideals. Further detail on the costing
This is due to likely crossovers between the methodology and sensitivity analysis are pro-
pathways themselves. For example, some peo- vided in Appendix A and B respectively.
ple who face appearancebased discrimination
or stigma might internalize these experiences
and subsequently be dissatisfied with their
appearances, creating an overlap with body
dissatisfaction.iX This in turn leads to personal
and societal costs. ix For example, it is estimated that approximately 44% of
adults in the US might be internalizing weight bias, which
captures the negative perception one feels towards
themselves because of weight stereotypes in society.

Furthermore, as part of this project, Edelman to arrive at the one-year prevalence among
USA facilitated 11 interviews with people in the the population aged 10 years or older.
US who had experienced body dissatisfaction
and/or appearance-based discrimination. Estimates for appearance-based discrimination
Each interview sought to understand the im- were calculated by aggregating the prevalence
pact of harmful beauty ideals on the individ- of weight, skin shade, and natural hair discrim-
ual, their families, and society more broadly. ination. Skin shade, weight, and hair type have
Interviewees were selected to capture a broad been considered because they are some of the
range of experiences (across different types of most common forms of appearance-based
appearance-based discrimination and body discrimination occurring in the US, with a large
dissatisfaction), for people of different ages, body of empirical evidence surrounding their
genders, and races/ethnicities. impacts. However, appearance-based discrimi-
nation is in no way restricted to these forms.x
Interviews were provided to Deloitte to be Further work is needed to understand the costs
synthesized in the report. These case studies attributable to other forms of appearance-
have been integrated throughout the report to based discrimination not included in this study.
help demonstrate the lived experience of body
dissatisfaction and appearance-based discrim- Further detail on the prevalence of body dissat-
ination, particularly for those areas where the isfaction and appearance-based discrimination
empirical evidence was not as well established is provided in Chapter 3.
(e.g., hair discrimination) or where evidence
was only available for particular groups in US
society. All names in the case studies have been
changed for anonymity.
2.1 Prevalence
Prevalence estimates for body dissatisfaction
and appearancebased discrimination were
drawn from nationally representative preva-
lence studies identified through a systematic
literature review (see Appendix A). Population
data for both pathways was derived from the
Bureau of Labor Statistics (BLS) and the Centers
for Disease Control and Prevention (CDC) as
relevant. Estimates for body dissatisfaction
were drawn from Fallon et al. (2014),17 which
sampled roughly 2,000 adults in the US. These x For example, some literature looks at the impacts associ-
estimates were adjusted for age differentials ated with being perceived as simply ‘unattractive’, which
might be driven by any combination of physical features.
and applied to the age-sex population in 2019
Appearance-based discrimination may also occur against
people with visible disabilities, people with physical disfig-
urements, those that show signs of ageing, among many
others.

2.2 Impacts anxiety, and alcohol and drug abuse. For ap-
Body dissatisfaction and appearance-based pearance-based discrimination, health impacts
discrimination are linked to an array of nega- including anxiety, depression, smoking, obesity,
tive impacts. A broad literature review was un- drug abuse and hypertension were costed. In
dertaken to determine the full scope of impacts addition to health impacts, labor market differ-
attributable to these pathways (a detailed de- entials and discriminatory incarceration were
scription of the attributable impacts is provided also considered. Labor market differentials in-
in Chapter 4 and Chapter 5). cluded wage and employment losses. Discrim-
inatory incarceration incurred wage losses and
Evidence was assessed using the guiding prin- government expenditure on prisons.
ciples of the Grading of Recommendations
Assessment, Development and Evaluation Impacts were excluded if they risked double
(GRADE) approach (see Appendix A for further counting, if there was inadequate cost data, or
detail).18 Key factors considered in the evalua- if the empirical evidence was sparse. For exam-
tion of evidence include: ple, hair discrimination was not costed due to
lack of available empirical data, illustrating the
• the risk of bias need for further research in this space to un-
• the precision of effect estimates derstand its prevalence and associated costs.
• the consistency of individual study results
• how directly the evidence answers the Second order impacts were also not costed. In
question of interest the context of this report, second order impacts
• the risk of reporting bias. are those conditions/illnesses which can be
caused by an impact of body dissatisfaction or
For body dissatisfaction, a range of health appearance-based discrimination but are not
impacts were costed, including depression, directly attributable. Examples of second order
eating disorders, suicide attempts, smoking, impacts include lung cancer attributable to
smoking, or diabetes associated with having a
BMI over 30 kg/m2.
Future impacts of conditions attributable to

discrimination were also not costed. For exam-
ple, the costs of future labor market outcomes
due to the impact of worse educational out-
comes today.
Further detail around quantified outcomes and

the population groups they apply to are provid-
ed in Appendix A.

2.3 Cost types
The modeling in this report estimates both the Typically, six groups bear costs and pay or
financial and nonfinancial costs associated with receive transfer payments, including: (1) people
harmful beauty ideals. Financial costs include directly affected by beauty ideals; (2) friends
health and productivity costs, the societal im- and family (including informal caregivers); (3)
pact of wage losses, government expenditure employers; (4) governments; (5) other payers
on prison, and the loss in economic efficiency (e.g., private health insurers); and (6) the rest of
associated with lost taxes or government ex- society.
penditure (compared to a counterfactual where
harmful beauty ideals do not exist). Non-finan- Another group that may bear costs is the chil-
cial costs, or loss of well-being costs, represent dren of parents who have been discriminated
the reduction in quality of life due to impaired against. But the costs of appearance-based
functioning or death that results from the im- discrimination in this study include the impact
pacts of harmful beauty ideals. Costs estimated on only the individual directly, not the subse-
in this report relate to the 2019 calendar year, quent impact of the disadvantage on future
prior to the COVID-19 pandemic. generations of children.
These costs are borne by different individuals Further descriptions of the costs, and a break-
or sectors of society. It is important to under- down of costs by cost component and the
stand how costs are shared in order to make bearers of cost, are provided in Table 2.1.
informed decisions regarding interventions.

Table 2.1: Breakdown of costs by cost types and bearers
COST COST BEARERS DESCRIPTION

COMPONENTS OF COST
• Individuals A financial cost that captures the associated
•M edical services,
• Government health costs of illnesses and conditions at-
Health including hospital
• Health tributable to body dissatisfaction or appear-
system inpatient and
insurance ance-based discrimination. Includes the
costs outpatient services
providers costs of medical services (such as inpatient
• Pharmaceuticals
• Rest of society and outpatient costs) and pharmaceuticals.
A financial cost capturing reduced produc-

tivity (presenteeism), increased absences
• Individuals (absenteeism), and reduced participation
• Reduced employment • Employers in the labor market. This may also include
• Absenteeism • Government wage penalties and lost future earnings
Productivity
• Presenteeism (forgone due to premature death.
costs
• Wage losses taxation)
• Informal care • Friends and Informal care captures the opportunity cost
family of a caregiver’s time for conditions attrib-
utable to body dissatisfaction and appear-
ance-based discrimination.
Efficiency losses comprise the reduced eco-

nomic efficiency associated with the need
to levy taxes to fund the provision of govern-
ment services and replace lost employment
taxes attributable to body dissatisfaction
and discrimination. Efficiency losses are
not the same as transfer payments, which
• Efficiency losses represent a redistribution of money and are
• Prison expenditure • Rest of society not real costs to society. It is noted that some
Other costs
•S ocietal impact of • Government scholars caution against including efficiency
wage losses losses; further detail is provided in
Appendix A.
The societal impact of wage losses reflects

the reduction in economic efficiency from
a suboptimal allocation of talent with the
labor market, causing a reduction in output.
Further detail is provided in Appendix A.
A non-financial cost which captures the re-

• Years of healthy life
duction in quality of life (measured through
Loss of lost due to disability
YLDs) and premature death (measured
well-being (YLD) • Individuals
through YLLs) for people experiencing body
costs • Years of life lost due to
dissatisfaction or appearance-based
premature death (YLL)
discrimination.

The financial costs related to spending on cos- • Where available, existing cost estimates for
metic products and procedures have not been each impact have been sourced directly from
included in the main estimates for body dissat- the literature. Per person or per unit costs
isfaction or appearance-based discrimination. for each impact were updated based on the
This is because these costs are typically seen as number of people affected in 2019.
a transfer between groups and not a net cost
to society. For example, spending on cosmetic • Where existing cost estimates were not avail-
products may represent a cost to the individual, able, or where particular costs are missing
but would generate revenue for sellers of these from the literature, cost components were
products. Of course, there may still be distribu- estimated by sourcing and aggregating raw
tional impacts associated with these transfers. data inputs.
For example, 92% of cosmetic procedures are
undertaken by women,19 whereas there are Occasionally, a combination of the two ap-
many more male compared to female plastic proaches has been used. For example, there
surgeons in the US.20 Similarly, one study found are no existing estimates of the total societal
that men in the US spend roughly $2,900 every labor market costs from appearance-based
year on beauty treatments and services, while discrimination, so these were estimated sep-
women spend $3,700. Across a consumer’s arately for each group affected. Similarly, the
lifetime, this is equivalent to women spending study estimating the cost of depression includes
an additional $50,000 on these products and both health and productivity costs, but does not
services, relative to men. consider broader loss of well-being, efficien-
cy losses, and informal care costs, which were
estimated using supplementary evidence.
2.4 Cost estimation
To our knowledge, this is the first study to holis- Generally, existing cost estimates were able to
tically consider and cost the impacts of harm- be sourced for direct health costs and absen-
ful beauty ideals. This means it differs from a teeism and presenteeism costs. Costs asso-
typical cost study in that it spans multiple out- ciated with the value of informal care, loss of
comes. While a typical cost study might capture well-being, efficiency losses and other pro-
costs associated with a single health condition ductivity losses were estimated from raw data
such as depression, this study costs multiple inputs. The methodology used to estimate these
health conditions attributable to harmful beau- costs type is described in Appendix A.
ty ideals, alongside other outcomes such as
wage losses due to labor market discrimination. The costs identified for each impact were then
estimated to body dissatisfaction and/or ap-
Two main approaches were adopted to esti- pearance-based discrimination using PAFs or
mate each cost component (e.g., health system, direct cost estimation (see Box 2.1).
productivity, loss of well-being, etc. as outlined
in Section 2.3) associated with each impact of
discrimination:

BOX 2.1: COSTING EACH IMPACT
METHOD 1: METHOD 2:
Population attributable fractions (PAFs) Direct cost estimation
To attribute the costs of conditions to the Labor market discrimination differed from the
pathways of beauty ideals (as opposed to other other outcomes in that it presented as a cost in
causes), this study relies on estimatesof the PAF itself. That is, labor market discrimination that
for each impact. manifested in a wage loss was costed as the
wage loss itself. To estimate the wage loss for a
THE PAF CAN EITHER BE: person who faced labor market discrimination,
• Multiplied by the total costs of the conditions the median annual income (including an al-
attributable to body dissatisfaction and ap- lowance for employee fringe benefits) for that
pearance-based discrimination in 2019, or person was estimated using Bureau of Labor
• Multiplied by the total prevalence of the relat- Statistics (BLS) earnings data by race, age and
ed condition, and then multiplied the resulting gender. Then, the wage penalty due to appear-
attributed cases by the average cost per case. ance-based discrimination was applied to this
income, assuming that no wage gap implied
As explored in the following chapter, body full earnings. For example, a person with an es-
dissatisfaction can lead to depression, anxiety timated annual wage plus benefits of $100,000
and a range of other impacts. The evidence in facing a 10% wage penalty due to their weight
Appendix A shows that women who are body would instead earn $90,000. This results in a
dissatisfied are more than 1.8 times more likely wage loss of $10,000 due appearance-based
to become clinically depressed compared to discrimination. These losses were aggregated
those who are not. When combined with the for every individual who faced a penalty due to
prevalence of the condition, the PAF formula appearance-based discrimination.
can be used to estimate body dissatisfaction
leads to 13% of total cases of depression in Employment losses were estimated in a similar
women. To put that another way, the preva- way to estimate the number of people unem-
lence of depression could be reduced by this ployed due to appearance-based discrimina-
amount in the absence of body dissatisfaction. tion. To cost this, the median wages for a cate-
A similar process is repeated for each possible gory by race, age and gender were applied to
impact of both body dissatisfaction and ap- the number of people unemployed to estimate
pearance-based discrimination. the total wage loss due to unemployment.
A summary of the PAFs and the inputs underly- The wage losses due to labor market discrimi-
ing them are further described in Appendix A, nation had associated efficiency losses due to
along with further detail regarding the selec- lost taxation revenue for the government and
tion of study inputs. also the reduction in societal output from an
inefficient use of labor resources (i.e. because
This method was applied to estimate costs of the appearance-based discrimination, those
associated with poorer health outcomes and workers are more likely to be in lower paying
discriminatory incarceration. jobs that may not use their skills).
A summary of the relevant inputs used to esti-

mate the direct costs of labor market discrim-
ination are presented in Table A.16 and Table
A.18 in Appendix A.

2.5 Limitations
There are a range of limitations associated with
the modeling undertaken in this report. These are
noted below.
•M
any of the impacts considered in this study enable researchers to further disentangle the
are comorbid, meaning one impact is relat- effects of appearance-based discrimination
ed to another (for example, depression and and identify the incremental costs.
smoking). This means there is a risk of double
counting, as some of the costs included may • Additionally, the estimated prevalence of
already be captured through the costs of body dissatisfaction adopted in this study is
related impacts. To help minimize the risk of a conservative measure, with other research
double counting, estimates have been drawn suggesting it could be as high as 72% for
from research which controls for comorbid women and 61% for men, contingent on how
conditions where possible, to help isolate the body dissatisfaction is defined and meas-
main impact. ured.21 It is recommended that a consistent
approach to measuring body dissatisfaction
• An important consideration is whether a be adopted in the literature to help reduce
causal relationship was evident in the litera- this uncertainty and enable more accurate
ture, between the impact being studied and comparisons to be made across studies and
the pathways of appearance-based dis- over time.
crimination and body dissatisfaction. Studies
were reviewed to determine whether they • Our review identified various gaps in the
controlled for a range of confounding factors, literature around the impacts of body dissat-
such as race or ethnicity, gender, age, and isfaction and appearance-based discrimina-
other variables. This was done to reduce the tion. For example, while there is a large body
chance of bias impacting on the estimated of evidence surrounding the impact of body
PAFs in the costing study. Further, longitudinal dissatisfaction on disordered eating in men,
studies, rather than crosssectional, were used there is less evidence linking body dissatisfac-
where possible. While these measures are tion to clinical diagnoses of eating disorders
indicative of the strength of the evidence, they in men. Furthermore, there are gaps in the
do not guarantee causality. literature regarding outcomes across all racial
or ethnic groups. As a result, some impacts in
•S
kin shade and hair type are key indicators this study, such as incarceration, are based
of race. Race therefore plays a key role in the largely on studies with the Black community.
discrimination of an individual on the basis Where gaps exist the best available estimate
of these features. In this study, the focus is from the literature has been used in sensitivity
on understanding how appearance-based testing – for example, to demonstrate what
discrimination differs for people of the same the cost might be if skin shade discrimination
race but with different skin shades and hair- leads to a wage gap for all workers of color.
styles, by relying on studies that controlled
for race. However, more work is needed to

• Skin shade, weight, and hair have been • Finally, it is noted that this report is reliant on
considered because they are some of the other studies for information about individ-
most common forms of appearance-based uals’ race or ethnicity as it relates to experi-
discrimination occurring in the US. However, ences of appearance-based discrimination
appearance-based discrimination is in no and body dissatisfaction. However, the racial
way restricted to these forms.xi Further work is and/or ethnic identity of certain communities
needed to understand the costs attributable in the US is complex, and source data often
to other forms of appearance-based dis- lacks more detailed information about indi-
crimination not included in this study. viduals’ race or ethnicity. A key example of
this is people who identify as being Hispanic
• Another limitation of this study is that it could or Latino. Standards issued by the Office of
not capture the financial and non-financial Management and Budget specify that race
costs of body dissatisfaction and appear- and Hispanic origin (i.e., ethnicity) are two
ance-based discrimination for transgender separate and distinct concepts.22 In other
and gender nonbinary communities in the words, people who identify as being Hispan-
US due to insufficient research on which to ic or Latino can be of any race (e.g., white,
base these estimates. Body dissatisfaction Black, Asian, etc.), and are identified as such
and weight, skin shade, and hair discrimina- in the US Census. Unfortunately, this level of
tion affect transgender and gender nonbinary detail is often not included in source literature
communities, but how these experiences are and as such this report is limited to describing
patterned by age, sex assigned at birth, and people of Hispanic or Latino origin by their
other important factors is not yet known. In ethnicity only and not by their ethnicity and
addition, discrimination targeting transgender race. It is recommended that future research
and gender nonbinary communities for their separately identifies race and ethnicity, to
gender expression is widespread and likely to enable researchers to understand how out-
profoundly affect employment and other eco- comes differ for these different subgroups
nomic indicators, but more research is need- and to ensure individuals’ racial and ethnic
ed to help inform costing analyzes like those backgrounds are accurately represented in
presented in this report for cisgender women the underlying data.
and men.
More broadly, as this is the first time this type
• This study costed skin shade discrimination of costing exercise has been undertaken, there
for only the Black community in the US due are inherently limitations associated with the
to a lack of empirical evidence around its analysis. In raising awareness of the harms of
impacts within other racial groups (such as beauty ideals, this report also seeks to build
Latino or Asian groups). Due to this restricted interest and motivation for studying the impacts
focus, the prevalence and costs of skin shade of harmfulbeauty ideals to help broaden the
discrimination are likely understated in this evidence base for future research.
study. It is recommended that future research
xi For example, some literature looks at the impacts as-
focuses on different racial or ethnic groups to sociated with being perceived as simply ‘unattractive’,
help inform future quantitative analysis. which might be driven by any combination of physical
features. Appearance-based discrimination may also
occur against people with visible disabilities, people with
physical

3 Prevalence.
BODY APPEARANCE-BASED
DISSATISFACTION DISCRIMINATION
affected affected
45 million 66 million
people in the US people in the US
in 2019 in 2019

3 Prevalence
Key findings
• This report conservatively estimates that 45 million or 16% of people in the US

aged 10 years and older were severely affected by body dissatisfaction in 2019.
• In addition, 18% or 66 million people experienced appearance-based discrimination.
3.1 Body dissatisfaction

It is estimated that 45 million people or 16% of justed for age differentials and multiplied by
the population aged 10 years or older were the US age-sex specific population in 2019 to
severely affected by body dissatisfaction in determine the total prevalence of body dissat-
2019 (Chart 3.1). For context, the prevalence of isfaction (see Appendix A for more detail).
body dissatisfaction in the US is estimated to It is likely that experiences of body dissatisfac-
be higher than the prevalence of smoking (34 tion vary significantly, ranging from lapses in
million people).23 body confidence, to more severe and persistent
experiences. This research focuses on more
The estimates of the prevalence of body dissat- severe and persistent experiences, but further
isfaction were drawn from Fallon et al (2014), work is needed to understand differences in
which uses a sample of roughly 2,000 adults in experiences and severity of body dissatisfaction
the US.24 Body dissatisfaction was measured across the population. Furthermore, the preva-
using the Body Areas Satisfaction Subscale lence estimates adopted in this study are likely
(BASS) of the Multidimensional Body-Self conservative, with prior research indicating the
Relations Questionnaire (MBSRQ; see Box 3.1). prevalence of body dissatisfaction could be as
Estimates from Fallon et al. (2014) were ad- high as 72% for women and 61% for men.26
Chart 3.1: Prevalence of body dissatisfaction in the US, by gender and age group
3.0
2.5
Prevalence (millions)
2.0
1.5
1.0
0.5
0 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+
Source: Deloitte Access Economics based on Fallon et al (2014).25 FEMALE MALE

While it is generally accepted that the preva- As such, in this report the prevalence of body
lence of bodydissatisfaction is higher among dissatisfaction by age has been kept consistent
women than it is for men, empirical evidence with Fallon et al (2014) (see Appendix A for fur-
around the prevalence of body dissatisfaction ther details). Because Fallon et al (2014) con-
by age is inconclusive. For example, there are sidered only US adults aged 18 and above, the
some studies that suggest body dissatisfaction prevalence for younger age groups is based on
is higher among adolescents and gets lower the average prevalence across the population
as people age.27 In contrast, using US data, more broadly (i.e., no age adjustment has been
Wang et al (2019) found that 95% of individuals made for ages 10 to 14).
experienced relatively stable body dissatisfac-
tion from adolescence through to adulthood.28 The prevalence of body dissatisfaction can also
Further, Quittkat et al (2019) found that only vary by race/ethnicity. According to Fallon et al.
in men did older age predict a lower level of (2014), the prevalence of body dissatisfaction
importance of appearance.29 Another study for women is highest among Black women and
by Bucchianeri et al. (2013) found that body lowest among white men.32 It is noted that to
dissatisfaction increased from adolescence to cost body dissatisfaction, prevalence was held
young adulthood, however this trend became constant across all racial and ethnic groups
non-significant when BMI was controlled.30 i.e., only age- and gender-specific parameters
Karazsia et al. (2017) find that changes in body were used; see Appendix A.
dissatisfaction over time vary for different
dimensions of body dissatisfaction.31
Chart 3.2: Prevalence of body dissatisfaction by race/ethnicityxii
Other
Native American/
Native Hawaiian/
Pacific Islander
Latin American
Asian
Black*
White
0 5 10 15 20 25
FEMALE MALE
Source: Deloitte Access Economics based on Fallon et al. (2014).33

*Note: The prevalence of body dissatisfaction among Black men in the sample was estimated to be 0% (n=9).
xii It is noted that the sample size for certain races was less than n=10. As such, care should taken when relying on these results,
and it is recommended that further research is undertaken to understand how body dissatisfaction varies by race/ethnicity.

BOX 3.1: MEASURING THE PREVALENCE
OF BODY DISSATISFACTION
There are various instruments noted in the BASS is also used in studies looking at the
literature that are commonly used to measure relationship between body dissatisfaction and
body dissatisfaction. various impacts included in our study, such as
in Crow et al (2008)37 and Stice et al (2016).38
Fallon et al (2014), from which the prevalence
estimates from this study are adapted, uses the Other measures commonly used in the litera-
Body Areas Satisfaction Subscale (BASS) of the ture to measure body dissatisfaction include:
Multidimensional Body-Self Relations Ques-
tionnaire (MBSRQ).34 BASS uses a five-point • The appearance evaluation subscale of the
scale ranging from (1) very dissatisfied to (5) MBSRQ, which captures feelings of physical
very satisfied to measure participants’ satis- attractiveness on a 7-point scale.
faction with nine specific areas of their bodies
(i.e., face, hair, lower torso, mid-torso, upper • The Stunkard (figure rating) scale. This pro-
torso, muscle tone, weight, height, and vides participants with nine body shapes from
overall appearance). which they are asked to select their current
and ideal body shapes. Differences between
Scores are averaged across the nine areas to the chosen and ideal body shape are consid-
yield a single body dissatisfaction score, where ered to represent body dissatisfaction.
lower scores represent greater dissatisfaction.
While there are various cut-off points in the Across the various measures of body dissat-
literature for classifying people as being body isfaction, estimates typically reflect current
dissatisfied, this report conservatively uses a attitudes and feelings towards one’s body, as
cut-off score of 2.75, based on Frederick et al opposed to capturing retrospective body
(2007).35 In sensitivity analysis, we test the im- dissatisfaction.
pact of varying the cut-off score to 3 based on
Cash & Henry (1995),36 see Appendix B.
3.2 Appearance-based discrimination purposes of the calculations in this report, it

It is estimated at least 66 million people in the was assumed that someone could be counted
US experienced appearance-based discrimi- towards only one form of discrimination. How-
nation in 2019, representing approximately 18% ever, this is not necessarily reflective of the true
of the total population aged 10 years or older. experiences of people facing discrimination.
This was estimated by aggregating the number Estimates on the prevalence of hair discrimi-
of people affectedby weight, skin shade, and nation was found only for women, however it is
hair discrimination.xiii Of the 66 million, it was possible it is experienced by all genders.
estimated that 34 million faced weight discrimi-
nation, 27 million faced skin tone discrimination, The prevalence of appearance-based discrimi-
and 5 million faced hair discrimination. For the nation in this report does not reflect the number

of people who also face appearance-based The prevalence for appearance-based dis-
discrimination on the basis of other physical crimination varied by type of discrimination
features such as the shape of one’s nose and and impact. As such, a range of different data
mouth, the shape and size of one’s breasts, sources have informed these estimates. Health
height, and physical disabilities. Including all outcomes were applied to people ever having
forms of discrimination for all groups who perceived discrimination in their lifetime, which
experience it would likely result in a far larger in turn was applied to the relevant population
estimate of prevalence. This study also doesn’t in 2019. Labor market outcomes and incarcer-
consider discrimination based on gender ation were based on physical characteristics,
identity. For example, it doesn’t account for the such as skin shade and weight, which were
discrimination faced by transgender or nonbi- derived for the population in 2019.
nary individuals who don’t present within the
traditional gender binary.
3.2.1 Weight discrimination

Weight discrimination can occur against people in every weight category, but is higher on average
for people of a higher body weight (Chart 3.3).
Estimates of perceived weight discrimination were applied to the entire US population, with out-
come differentials captured by race or ethnic group and gender. Where these prevalence es-
timates or their associated outcomes were specific to people in a certain weight category, the
weight distribution for the population was derived from CDC.39
Chart 3.3: Prevalence of weight discrimination in the US, within each weight category
50
40
Proportion of total
population (%)
30
20
10
0
≤24.9 25.0-29.9 30-34.9 ≥35.0
BMI category (kg/m^2)
Spalholz et al. (2016) Robinson et al. (2017) Population distribution (2017)(2016)
Source: Deloitte Access Economics based on Spalholz et al (2016)40, Robinson et al (2017)41, CDC42

Weight discrimination can also be an intersectional issue, varying by race, gender, socioeconomic
status, sexual orientation and other factors.43 For example, estimates from Dutton et al. (2014)
show that white women with a BMI greater than 35 kg/m2 were more likely to report experiencing
weight discrimination than any other group studied (Chart 3.4). In fact, 100% of white women with
a BMI greater than 35 kg/m2 report experiencing weight discrimination, compared to 60-66% of
African Americans and white men of a similar weight.44 It is noted that to cost weight discrimination,
prevalence was held constant across all racial and ethnic groups i.e., only age- and gender-
specific parameters were used; see Appendix A.
Chart 3.4: Prevalence of weight discrimination, by BMI category,

relative to white women with a BMI over 35kg/m2 in the US.
100%
Proportion of total
80%
population (%)
60%
40%
20%
0%
18.5-24.9 25.0-29.9 30.0-34.9 ≥35.0
BMI category (kg/m^2)
African American men African American women White men White women
Source: Deloitte Access Economics based on Dutton et al. (2013).45

Note: Estimates were not available for other racial/ethnic groups.
3.2.2 Skin shade discrimination

Costs associated with skin shade were restrict- To derive costs associated with skin shade
ed to the Black population in the US due to a discrimination, the population was segmented
lack of empirical research currently available into various ‘shades’ on a scale from ‘very light’
for other communities such as Asian Americans, to ‘very dark’ (see Chart 3.5). Since outcomes
Native Americans, and Latin Americans. The in literature were presented for people based
impacts faced by some of these communities on their skin shade, the number of people in a
have been qualitatively explored in this study given skin shade category informed the prev-
(see section 5.1). alence for the modelling. However, prevalence
ultimately varied by outcome.

For example, if Black people in the darkest skin
category had 15% lower wages than those in the
lightest skin category holding all else constant,
then wage penalties of 15% of the median wage
were multiplied by the proportion of Black
people in darkest skin category.
Chart 3.3: Prevalence of skin shade discrimination in the US, within each skin shade category
50%
40%
Proportion of Black
population
30%
20%
10%
0
Very dark Dark Somewhat Medium Somewhat Light Very light
dark light
Skin tone
Monk, E. P (2015) Kreisman and Rangel (2015)
Source: Deloitte Access Economics based on Monk, E. P (2015)46 , Kreisman and Rangel (2015)47 .
The seven point distribution (very dark to very light) for Kreisman and Rangel is estimated by aggregating
the proportions from the 10-point scale presented in the study.
3.2.3 Natural hair discrimination

As with skin shade discrimination, the bulk of women, and more work is needed to under-
empirical evidence relating to hair discrimina- stand the prevalence of natural hair discrim-
tion was associated with the Black population ination among men as well as across other
in the US, and as such our analysis has been ethnic and racial groups in the US. As an ex-
restricted to this group. Based on self-report- ample, anecdotal evidence suggests the Jewish
ed experiences of discrimination, previous community in the United States may experience
research estimates that one-quarter of wom- judgement and discrimination based on their
en identifying as being of African descent are hair, however there is insufficient empirical
affected by natural hair discrimination.48 The evidence to cost this.49
evidence contained experiences of only

Case study: Lived experiences of natural hair discrimination
Viola is a 31-year-old mixed race woman Decades later as an adult, Viola still expe-
working as an information security analyst riences stigma around her hair. Her experi-
in Texas, of Black and white heritage. Viola ences are everyday micro-aggressions she
feels beauty ideals in the United States have describes facing everywhere, including her
evolved over her lifetime, from the ‘blonde workplace. Viola shares an experience she
hair, thin figured Barbie look’, to more cur- had at her workplace, where she decided
vaceous figures. But while curves and dark to wear her hair naturally one day to let it
hair have become more accepted, they are breathe and felt eyes on her and faced neg-
still limiting. ative comments.
Viola’s introduction to beauty ideals coincid- Alongside hair discrimination, Viola has also
ed with an experience of hair discrimination had experiences surrounding her skin shade,
at her daycare when she was only four years that she attributes to her being of mixed
old. The barrette and hair tie her mother race. She remembers walking around with
clipped on to hold down her Afro broke off her mother who had blonde hair and blue
while Viola was playing at daycare, causing eyes, and having people ask her “Who is this
the other kids to question what was ‘wrong’ girl following you around?”, despite Viola
with her hair and refuse to play with her any being her biological child and having very
longer. During sleepovers with friends who similar facial features. She notes that peo-
did not have similar hair to her, Viola would ple could never look past the skin shade and
often be barraged with questions when hair and that her stepsister who isn’t a bio-
wrapping her hair at night. logical child of her mother’s but has blonde
hair and blue eyes was more accepted as a
“What’s going on here? Can we daughter by society.
touch your hair? Can you wrap our
Viola’s experiences with natural hair stigma
hair? Is this necessary? I mean, just
led to her relaxing her hair frequently, up
all these questions and I’m like, ‘I’m until the age of 22, after which she decid-
six. I don’t know what to tell you ed to embrace her natural curls. Her hair
guys, wrap your hair if you want to treatments included hair straightening kits
but why are we touching my hair? she used as a child, which would sometimes
burn her scalp.
I’m not touching your hair.’ It was
very weird.”

Natural hair stigma has also impacted the Being tired of the dependency on chemical
life of Layla, a 43-year-old woman who treatment, and due to the damage it was
works as a psychotherapist in Manhattan, causing to her hair texture, Layla decided
New York. Layla has a “big, luscious Afro” to embrace her natural hair. Despite the
she wears in a variety of styles now, but was burdens associated with having to constant-
met with curiosity and discomfort at her ly manipulate hair textures to conform to
workplace when she first transitioned from societal standards, Layla says hair relaxing
chemically relaxed hair to natural hair. remains a common practice in her family
and in her community.
“I would have non-Black
coleagues, even superiors asking
lots of questions about my hair.
How do I manage it? How do I
touch it? Can I blow it out? Or
expressing preferences for styles
I wore before [going natural],
just comments that I found really
uncomfortable and inappropriate
in the workplace.”

4 The economic
and social cost of
body dissatisfaction.
$305 billion
$
$ $84 billion $221 billion
Financial Loss of
costs well-being
POOR REDUCED RISKY RISKY COSMETIC

HEALTH ENGAGEMENT BEHAVIOUR PRODUCTS AND
OUTCOMES PROCEDURES

4 The economic
and social cost of
body dissatisfaction
Key findings
• The combined financial and well-being costs of severe body dissatisfaction in the
US was estimated to be $305 billion in 2019. This includes $84 billion in financial costs
and $221 billion in non-financial costs. The financial costs of body dissatisfaction
comprised 0.4% of total US GDP in 2019.
• There is an array of serious impacts that are attributable to body dissatisfaction.
The four main categories of impacts identified include poorer health outcomes, risky
behavior, reduced engagement at school and work, and use of risky cosmetic products
and procedures.
• The costs of body dissatisfaction are shared by many different groups. Individuals
directly impacted by body dissatisfaction bore roughly one-third (32%) of the financial
costs. However, government (29%) and employers (14%) also bore a large share.
4.1 Impacts of body dissatisfaction

The impacts of body dissatisfaction can be risky behavior (e.g., drug and alcohol abuse),
devastating. It can trigger impacts ranging and use of risky beauty products or procedures
from low self-esteem and anxiety to high-risk (i.e., products or procedures that are associat-
drinking and even suicide. It can also cause ed with potential health risks such as cancer or
individuals to undertake more extreme meas- surgical complications) (see Figure 4.1). Further
ures to achieve harmful, narrow ideals, such as detail on the search strategy underpinning the
cosmetic surgery. identification of these impacts is provided in
Appendix A.
Four broad categories of impacts that are typi-
cally associated with body dissatisfaction were
identified including poorer health outcomes,
reduced engagement (at school and work),

Figure 4.1: Impacts of body dissatisfaction
POOR HEALTH REDUCED

OUTCOMES ENGAGEMENT
- Eating disorders - Avoiding school or
- Depression work
- Anxiety - Lower academic
- Other behavioural achievement
problems - Avoiding social
- Low self-esteem interactions
- Self-harm
- Suicide
RISKY RISKY COSMETIC

BEHAVIOUR PRODUCTS AND
PROCEDURES
- Drug and alcohol
abuse - Cosmetic surgery
- Smoking - Figure altering
- Risky sexual substances
behaviour - Indoor tanning
- Skin bleaching
- Chemical hair
straightening
4.1.1 Poorer health outcomes

Body dissatisfaction is associated with a range to those who are not.50,51,52 For example, in a
of negative health outcomes. While there is systematic literature review of 22 studies, body
an extensive body of literature covering these dissatisfaction was identified as a possible pro-
health impacts, existing studies tend to focus spective associations of eating disorders were
on a single condition/illness in isolation (i.e., identified.53 Stice et al. (2016) find that the risk
depression). This section attempts to provide a of developing bulimia nervosa or binge eating
more holistic view of the attributable impacts, disorder is 2.1 times higher among women who
drawing on evidence from a range of sources. are body dissatisfied, relative to those who
were not.54 Additionally, Neumark-Sztainer et al.
Body dissatisfaction is associated with poorer (2006) find that even after controlling for BMI,
mental health outcomes. In particular, the risk body dissatisfaction predicts unhealthy weight
of developing an eating disorder is much higher control behaviors and binge eating for both
for those who are body dissatisfied, compared men and women.55

Body dissatisfaction is also associated with a There is some, albeit limited, evidence that
greater risk of developing depression.56 Born- body dissatisfaction could lead to worse phys-
ioli et al (2021) found that men who are body ical health outcomes. Although generally this
dissatisfied are 2.9 times more likely to experi- research focuses on broad definitions of physi-
ence severe depressive episodes while women cal health such as mobility as opposed to being
are 1.8 times more likely, relative to those who linked to any one attributable condition or
are not body dissatisfied.57 Similarly, Paxton et illness.67
al. (2006) find that body dissatisfaction pro-
spectively predicts depressive mood in both
girls and boys, but in different phases of ado- 4.1.2 Risky behavior
lescence.58 The risk of developing moderate or The likelihood of undertaking risky behavior is
severe anxiety is also higher for those with body higher among people who are body dissatis-
dissatisfaction, for both sexes.59 Body dissat- fied, compared to those who are not. Bornioli
isfaction can lead to lower self-esteem60 and et al. (2019) demonstrate that body dissatisfac-
increases the risk of self-harm and suicide.61 tion in adolescence predicts the occurrence of
Using longitudinal data, Mars et al. (2019) find several risky health behaviors. They found that
that among those who had experienced suicid- women who were body dissatisfied were 1.4
al ideation, those who had attempted suicide times more likely to engage in high-risk drink-
were more likely to report being body dissatis- ing, 1.5 times more likely to take illicit drugs, and
fied.62 1.4 times more likely to smoke, relative to wom-
en who were not body dissatisfied.68 Among
There is some research that body dissatisfac- men, they found that body dissatisfaction pre-
tion can worsen during pregnancy, which, in dicted smoking.69
turn, may cause maternal mental health to
deteriorate. For example, body dissatisfaction While Bornioli et al. (2019) did not find signifi-
has been associated with antenatal anxiety cant associations between body dissatisfaction
and postpartum depression.63,64 Not only do and illicit drug use/high-risk drinking among
such conditions severely impact a mother’s men, other studies have found significant rela-
quality of life, they can also have a multigener- tionships when using proxy measures for body
ational effect, worsening the health outcomes dissatisfaction. For example, Field et al (2014)
of her child. found that males with high concerns about
muscularity and thinness were 2.1 times more
It is noted that much of the research looking at likely than their peers to use drugs. They also
mental health impacts of body dissatisfaction find males with high concerns about muscu-
focus on symptoms of mental distress, rather larity and who use muscle-building dietary
than the clinical diagnosis. Mond et al (2013) supplements, were twice as likely to start binge
examine the relationship between body dis- drinking frequently.70
satisfaction and various mental health indica-
tors, such as feeling ‘blue/sad’, which in turn is The relationship between body dissatisfaction
associated with depression.65 Similarly, Regis et and risky behavior is supported by a range of
al (2018) explore whether body image dissat- other prospective studies. For example, Howe
isfaction is associated with symptoms of social et al. (2017) found that body dissatisfaction was
anxiety disorder.66

associated with increased odds of late-onset Body dissatisfaction is associated with poorer
regular smoking among both men and wom- mental healthoutcomes. In particular, the risk of
en,71 while Stice & Shaw (2003) found that body developing an eating disorder is much higher
dissatisfaction was associated with increased for those who are body dissatisfied, compared
odds of smoking initiation in a sample of ad- to those who are not.50,51,52 For example, in a
olescent girls.72 When estimating the costs of systematic literature review of 22 studies, body
smoking attributable to body dissatisfaction in dissatisfaction was identified as a possible pro-
this report, only direct costs were included i.e., spective associations of eating disorders were
productivity costs associated with taking smok- identified.53 Stice et al. (2016) find that the risk
ing breaks. The costs of conditions associated of developing bulimia nervosa or binge eating
with smoking (e.g., lung cancer, heart disease, disorder is 2.1 times higher among women who
stroke, etc.) were not included as these reflect are body dissatisfied, relative to those who
second order impacts (see Section 2.2). were not.54 Additionally, Neumark-Sztainer et al.
(2006) find that even after controlling for BMI,
body dissatisfaction predicts unhealthy weight
4.1.1 Poorer health outcomes control behaviors and binge eating for both
Body dissatisfaction is associated with a range men and women.55
of negative health outcomes. While there is
an extensive body of literature covering these Body dissatisfaction is also associated with a
health impacts, existing studies tend to focus greater risk ofdeveloping depression.56 Bornioli
on a single condition/illness in isolation (i.e., et al (2021) found that menwho are body dis-
depression). This section attempts to provide a satisfied are 2.9 times more likely to experience
more holistic view of the attributable impacts, severe depressive episodes while women are
drawing on evidence from a range of sources. 1.8 times more likely, relative to those who are
not body dissatisfied.57 Similarly, Paxton et al.
(2006) find that body dissatisfaction prospec-
tively predicts depressive mood in both girls
and boys, but in different phases of adoles-
cence.58 The risk of developing moderate or
severe anxiety is also higher for those with body
dissatisfaction, for both sexes.59 Body dissat-
isfaction can lead to lower self-esteem60 and
increases the risk of self-harm and suicide.61
Using longitudinal data, Mars et al. (2019) find
that among those who had experienced suicid-
al ideation, those who had attempted suicide
were more likely to report being body dissatis-
fied.62

There is some research that body dissatisfac- 4.1.2 Risky behavior
tion can worsen during pregnancy, which, in The likelihood of undertaking risky behavior is
turn, may cause maternal mental health to de- higher among people who are body dissatis-
teriorate. For example, body dissatisfaction has fied, compared to those who are not. Bornioli
been associated with antenatal anxiety and et al. (2019) demonstrate that body dissatisfac-
postpartum depression.63,64 Not only do such tion in adolescence predicts the occurrence of
conditions severely impact a mother’s quality several risky health behaviors. They found that
of life, they can also have a multigenerational women who were body dissatisfied were 1.4
effect, worsening the health outcomes of her times more likely to engage in high-risk drink-
child. ing, 1.5 times more likely to take illicit drugs, and
1.4 times more likely to smoke, relative to wom-
It is noted that much of the research looking at en who were not body dissatisfied.68 Among
mental health impacts of body dissatisfaction men, they found that body dissatisfaction pre-
focus on symptoms of mental distress, rather dicted smoking.69
than the clinical diagnosis. Mond et al (2013)
examine the relationship between body dis- While Bornioli et al. (2019) did not find signifi-
satisfaction and various mental health indica- cant associations between body dissatisfaction
tors, such as feeling ‘blue/sad’, which in turn is and illicit drug use/high-risk drinking among
associated with depression.65 Similarly, Regis et men, other studies have found significant rela-
al (2018) explore whether body image dissat- tionships when using proxy measures for body
isfaction is associated with symptoms of social dissatisfaction. For example, Field et al (2014)
anxiety disorder.66 found that males with high concerns about
muscularity and thinness were 2.1 times more
There is some, albeit limited, evidence that likely than their peers to use drugs. They also
body dissatisfaction could lead to worse phys- find males with high concerns about muscu-
ical health outcomes. Although generally this larity and who use muscle-building dietary
research focuses on broad definitions of physi- supplements, were twice as likely to start binge
cal health such as mobility as opposed to being drinking frequently.70
linked to any one attributable condition or
illness.67

Case study: Lived experiences of body dissatisfaction
Max is a 33-year-old white man, current- socially. Max has suffered anxiety in social
ly managing a hotel in Indianapolis. Max situations, anticipating negative comments
spends a lot of time facing customers, often about his appearance. Max has also spent
in large groups, when organizing events over $2,000 on orthodontic aligners; money
in his hotel. This isn’t always easy, and Max he says he would have rather spent on other
has to often muster courage to face his items such as bills. He also avoids social
customers day in and day out, due to expe- settings where he might have to interact
riences he had growing up. with large groups of people, even if he really
wants to attend these events.
Growing up, Max was the tall, skinny kid
who always got made fun of. He would have
to deal with judgmental questions about his “I have a lot of friends that are into
weight - “Oh, why don’t you eat enough? Do comedy, so we’d go out to open mic
you have an issue with eating?” which made nights, and I have always wanted
him lose body confidence.
to so bad get up there and just do
something or acting… I just steer
“I always felt like I was under an away from that because I feel like
ideal weight, so I would always try people would just be looking at my
and be snacking on things, and teeth.”
eating as much as I possibly could,
and trying to eat in front of people
so they didn’t get this perception
that I never ate.”
Max’s experience of body dissatisfaction

goes beyond his weight, with low confidence
also surrounding his teeth. His experience
has impacted him mentally, financially, and

Spending on cosmetic products to achieve “You see me as a woman, you see
a beauty ideal is something Max has in me as your auntie, you see me as
common with Marlene, a 51-year-old trans-
gender African American woman living in
your sister. You don’t see me as a
Indiana. drag queen...”
As a transgender woman, Marlene’s atti-

“It was just so many different tudes towards beauty ideals are complex.
things that was necessary, or that And while she feels satisfied with her ap-
pearance since her transition, she feels there
we were led to believe were neces-
is always more that can be done to change
sary in order to achieve this portion the way her body looks – “I want a tummy
of beauty… Let me tell you, thou- tuck. I want to get lipo. I want these love
sands and thousands of dollars handles gone.”
later, I’ve never achieved what all
Importantly, Marlene views her experiences
of these products said that I would as strengthening for her character and her
potentially achieve.” resilience. She describes herself as a social
justice warrior and activist. Her resilience
helps her to help others through her work in
In fact, Marlene describes how body dissat- public health, where she has been working
isfaction led her to use risky products to help for the last 15 years. For Marlene, the key to
her achieve a beauty ideal, including illegal reducing the consequences associated with
injection of liquid silicone and skin bleaches. harmful beauty ideals is to diversify what
Despite the risks, Marlene says adhering to beauty looks like, not only through racial
beauty standards have provided her with a diversity, but also by embracing flaws and
sense of safety as she moved through the imperfections that people have.
world, knowing that she would be perceived
by others as a cisgender woman.

4.2 Costs of body dissatisfaction 4.2.2 Financial costs
The economic and social cost of body dissatis- The financial costs of severe body dissatis-
faction was estimated to be $305 billion in the faction totaled $84 billion, or 28% of the total
US in 2019. Of this total, $84 billion is attributed costs of severe body dissatisfaction (see Table
to financial costs and $221 billion is attributed to 4.1). This represents nearly $1,900 per person in
non-financial costs, reflecting the loss in well- the US with severe body dissatisfaction. Of the
being associated with body dissatisfaction. financial costs, productivity costs contributed
Women bore the majority (58% or $177 billion) the largest proportion of costs, comprising 63%
of the total financial and non-financial costs of of the financial costs.
body dissatisfaction.
By condition, the largest share of these costs
was accounted for by anxiety due to body
Figure 4.2: Economic and social costs of dissatisfaction ($34 billion; 41%), followed by
body dissatisfaction, 2019 (billions) depression ($15 billion; 18%). This is a conserv-
ative estimate because the modelling in this
$ $84 billion report has focused on severe depressive ep-
Financial isodes only, which contributes approximately
cost 10% of all major depression disorder cases.91 It
does not account for mild or moderate forms of
depression which can also impact day-to-day
$ $221 billion engagement.
Loss of
well-being
Table 4.1: Financial costs due to body
Source: Deloitte Access Economics. dissatisfaction in 2019
COST TOTAL COST PER PROPOR-

COMPO- COST PERSON TION OF
The financial costs of body dissatisfaction were NENT ($M) WITH BODY TOTAL
DISSATIS- COST (%)
equivalent to 0.4% of the total US Gross Do-
FACTION ($)
mestic Product (GDP) in 2019 (equal to $21.4
Health
trillion). For context, the financial costs of body system 9,060 204 11%
dissatisfaction would cover tuition, fees, room costs
and board costs for 2.9 million college students Productiv-
in the US for one academic year,xiv reflecting ity losses
68,566 1,545 81%
17% of all students enrolled in a postsecondary
institution in 2019.89,90 Efficiency
losses
6,464 146 8%
Total 84,090 1,895 100%
Source: Deloitte Access Economics. Note: components

may not sum to totals due to rounding.
xiv Based on average costs in a four-year institution in the United States.

Individuals impacted by body dissatisfaction
bore roughly one third (32%) of the total finan- Chart 4.1: Financial costs of body
cial costs. Government and employers also dissatisfaction by payer in 2019 ($ millions)
bore a significant share, estimated at 29% and
$26,684
14% respectively (see Chart 4.1). Individuals
$24,478
Governments
Overall, the costs of body dissatisfaction by age
$11,363
tend to be consistent with its prevalence, with a Employers
few exceptions. The costs of body dissatisfac- Friends and $11,124
tion for people aged 10 to 14 are relatively small family (carers)
compared to what would be expected based $6,464
Society
on prevalence (see Chart 4.2), but this repre-
sents the lack of attributable employment costs Healthcare $3,977
payers
for this age group. In comparison, the costs for
some other age groups exceeded what would Source: Deloitte Access Economics analysis.
be expected based on the number of people
impacted – in particular, for ages 20 to 24. This
is likely due to the higher prevalence of depres-
sion, suicide, and suicide attempts for people
within thisage bracket.
Chart 4.2: Financial costs of body dissatisfaction by attributed condition and age group
(in years), $ billions (left axis) and prevalence of body dissatisfaction by age group (right axis)
$10 5
Prevalence (millions of people)
$8 4
Cost ($billions)
$6 3
$4 2
$2 1
$0 0
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+
Age group (years)
Depression Suicide Eating Anxiety Smoking Alkohol and Prevalence
attempt disorder drug abuse
Source: Deloitte Access Economics

4.2.2.1 Health system costs Health costs for smoking were not estimated,
The total expenditure on health services due as these costs are not directly attributable to
to body dissatisfaction in 2019 was estimated smoking but instead reflects costs of conditions
to be $9 billion. This is equivalent to a cost of and illnesses associated with smoking (e.g.,
$204 per person with body dissatisfaction (see lung cancer, heart disease, etc.) i.e., second or-
Table 4.2). der impacts. Second order impacts were not in
the scope of this report so were not estimated.
The distribution of these costs varies by health If included, they would increase the estimated
condition. Anxiety, as well as drug and alcohol costs of harmful beauty ideals.
abuse, were the main drivers, accounting for
39% and 34% of the total attributed health ex- Furthermore, it is likely there are costs associ-
penditure respectively. Depression was another ated with government-funded tobacco control
major contributor to health system expenditure, efforts in the US. These costs have not been in-
comprising 10% of the total cost. However, as cluded in the main results, but its inclusion was
mentioned this is likely underestimated due to tested in the sensitivity analysis, see section 4.2.4.
the focus on severe major depressive disorder
only.
Table 4.2: Annual health system costs attributable to body dissatisfaction in 2019 ($, millions)
HEALTH MEDICAL PHARMACEU- TOTAL COST PER

IMPACT COSTS TICAL COSTS PERSON
WITH BD ($)
Depression 715 190 905 20
Suicide attempts 576 302 878 20
Eating disorders 679 15 695 16
Anxiety 2,408 1,138 3,546 80
Drug and alcohol
2,668 368 3,036 68
abuse
Total 7,046 2,014 9,060 204
Cost per person
159 45 204
with BD ($)
Source: Deloitte Access Economics analysis.

Note: Components may not sum to totals due to rounding; Second round impacts such as respiratory
conditions and lung cancer associated with smoking are not included in this study (see Appendix A)

Medical costs contributed 78% ($7 billion) of
total health system cost, with pharmaceuticals
contributing the remaining 22% ($2 billion) (see
Chart 4.3). Government bore the majority of
health costs (45%), followed by private health
insurers (44%).
Chart 4.3: Health system costs attributable to body dissatisfaction in 2019,

by health condition and cost type (first panel) and cost bearer (second panel) ($ million)
Drug and
alcohol abuse
Anxiety
Eating
disorders
Suicide
attempts
Medical costs
Depression
Pharmaceuticals
$0 $2,000 $4,000
Costs ($ millions)
Drug and
alcohol abuse
Anxiety
Eating
disorders
Suicide Individuals
attempts
Government
Depression Private health insurers
$0 $2,000 $4,000
Costs ($ millions)

BOX 4.1: COMPLICATIONS OF COSMETIC SURGERY AND INDOOR TANNING
COSMETIC SURGERY
According to data from the American Society cosmetic surgery were estimated to cost the US
of Plastic Surgeons, there were over 2.6 million economy $986 million in 2019.xv The majority of
cosmetic surgery procedures done in 2019 (an health system costs are for women ($858 mil-
increase of 44% on the year prior) and it is esti- lion;87%) rather than men ($128 million; 13%).
mated that approximately $16.7 billion is spent
on cosmetic procedures in the US each year.92 In rare cases, cosmetic surgery can also lead to
There are a range of reasons people undertake death. While it can vary significantly by proce-
cosmetic surgery. Sometimes, it is performed dure, it is estimated that 0.002% of all cosmetic
for reconstructive reasons. For example, a surgeries result in death, or 200 deaths per
breast reconstruction following a mastecto- every 100,000 cosmetic procedures.95 For
my. However, evidence suggests many people context, the observed mortality rate for coro-
undertake cosmetic surgery because they are nary artery bypass grafting between 2000-09
dissatisfied with how they look.93 in the US was 1.9%.96
Not every cosmetic procedure has complica- Of course, only a portion of these costs are
tions associated with it. Based on Wimalawansa related to body dissatisfaction (as opposed to
et al (2014), it is estimated that 3.6% of all other reasons for undertaking cosmetic sur-
cosmetic surgery procedures on average lead gery). Furthermore, the health costs attributa-
to complications, such as infection and hemor- ble to complications of cosmetic surgery were
rhage.94 There may also be future health prob- not included in the main estimates, as they
lems that are attributable to these procedures. represent a second order impact and are not
The health costs of complications related to directly attributable to body dissatisfaction.
INDOOR TANNING
According to Guy et al (2017), roughly 5.2% of A 2018 study by Waters & Adamson found that
women and 2.2% of men use indoor tanning de- more than 9,000 incident cases of melanoma,
vices in the US. This is equivalent to 9.9 million alongside 86,600 cases of SCC and 168,000
people in the US every year.97 cases of BCC were attributable to the use of
tanning devices in the US in 2015.101
There is some evidence to suggest body dis-
satisfaction could be linked to higher indoor The same study estimated that skin cancers at-
tanning use.98 This, in turn, is associated with tributable to indoor tanning cost the US economy
an increased risk of skin cancer. Indeed, one $343.1 million.102 Again, this cost is a second order
study found that use of indoor tanning before impact and so was not included in the main
the age of 35 doubles the risk of melanoma.99 estimates of the costs of body dissatisfaction.
Other types of skin cancers, including basal cell
carcinomas (BCC) and squamous cell carcino-
mas (SCC),100 have also been found to be linked
to indoor tanning.
xv Based on the median charge of complications related to

cosmetic surgeries from Wimalawansa et al (2014).
This was converted to a health cost figure based on a
charge-to-cost ratio of 24% and inflated to 2019 dollars. The real cost of beauty ideals 61
4.2.2.2 Productivity losses
Productivity losses associated with body dissat- costs for smoking relate to the need to leave
isfaction occur for various reasons but include the workspace when smoking (presenteeism)
productivity losses from attributable health and excess absenteeism.
impacts such as depression and anxiety, as well
as reduced engagement in the labor market Productivity losses due to body dissatisfaction
more broadly. Productivity losses also include were estimated to cost $68.6 billion. By condi-
loss of future earnings due to premature mor- tion, the largest share of productivity losses was
tality and the estimated costs of informal car- caused by anxiety attributable to body dissat-
egiving from conditions attributable to body isfaction ($28 billion; 41% of total productivity
dissatisfaction. Depression, anxiety, and other losses). This was followed by depression (19% of
attributed conditions may also lead to presen- total productivity losses) and suicide attempts
teeism and absenteeism costs. Productivity (16% of total productivity losses) (see Table 4.3).
Table 4.3: Annual productivity losses due to body dissatisfaction in 2019 ($, millions)
PRODUCTIVITY ABSENTEEISM PRESENTEEISM REDUCED INFORMAL PREMATURE TOTAL COST PER

LOSSES EMPLOY- CARE MORTALITY PERSON
MENT WITH BD ($)
Depression 723 1,826 3,094 3,128 4,037 12,808 289
Suicide
485 1,637 8,319 214 - 10,655 240
attempts
Eating
974 2,778 2,208 1,026 1,300 8,287 187
disorders
Anxiety 1,429 1,323 13,269 11,634 437 633
Smoking 853 4,454 - - - 5,307 120
Drug and
22 - - - 3,394 3,417 77
alcohol abuse
Total 4,488 12,017 26,889 16,002 9,169 1,545
Cost per person

101 271 606 361 207 1,545
with BD ($)
Source: Deloitte Access Economics analysis. Note: Components may not sum to totals due to rounding.
Of the productivity losses, reduced participation in the labor market accounted for the largest
share at $27 billion, representing 39% of total productivity costs (see Chart 4.4). In comparison,
informal care and presenteeism accounted for $16 billion (23%) and $12 billion (18%) respectively.
A detailed breakdown of the hours spent providing informal care for each health condition is
provided in Appendix A. By cost bearer, 38% is borne by individuals with body dissatisfaction.
Additionally, 17% of productivity losses are borne by employers and 16% by family and friends
of people with body dissatisfaction (due to the provision of informal caregiving).

Chart 4.4: Productivity costs due to body dissatisfaction in 2019, by health condition and
cost component (first panel) and cost bearer (second panel)
Anxiety
Depression
Suicide
Absenteeism
attempts
Eating Presenteeism
disorders
Reduced employment
Smoking
Informal care
Drug and
alcohol abuse Premature mortality
$0 $15,000 $30,000
Costs ($ millions)
Anxiety
Depression
Suicide
attempts
Individuals
Eating
disorders Family and friends
Smoking
Employers
Drug and
alcohol abuse Government
0% 20% 40% 60% 80% 100%

Costs ($ millions)

4.2.2.3 Loss of economic efficiency and The loss in economic efficiency due to body
other costs dissatisfaction reduced potential US output by
In addition to the health expenditure and as much as $6.5 billion in 2019, which stems
productivity impacts, there was also a loss in from reduced taxation including lost caregiver
economic efficiency due to the health outcomes taxes ($5.1 billion) and government expendi-
attributable to body dissatisfaction. The loss of tures on services ($1.3 billion) (see Table 4.4).
efficiency arises due to the need to levy taxes
to fund government expenditure and replace By condition, efficiency losses were largest
lost tax revenue (when compared to a situa- for anxiety ($2.8 billion; 44% of total efficiency
tion where body dissatisfaction does not exist). losses due to body dissatisfaction). This was
Further detail on efficiency losses is provided in followed by depression (17%) and attempted
Appendix A. suicide (13%). These losses are borne by society.
Table 4.4: Annual productivity losses due to body dissatisfaction in 2019 ($, millions)
EFFICIENCY REDUCED GOVERNMENT TOTAL COST PER

LOSSES TAXATION EXPENDITURES PERSON
WITH BD ($)
Depression 966 135 1,101 25
Suicide attempts 727 131 858 19
Eating disorders 568 103 672 15
Anxiety 2,305 528 2,833 64
Smoking 309 - 309 7
Drug and alcohol abuse 239 452 691 16
Total 5,115 1,348 6,464 146

Cost per person with
115 30 146
BD ($)

4.2.3 Non-financial costs
4.2.3.1 Loss of well-being be estimated (e.g., lung cancer), these are not
In 2019, there were roughly 718,000 disabil- attributable to smoking directly. Similarly, YLDs
ity-adjusted life years (DALYs) due to body were not estimated for drug and alcohol abuse.
dissatisfaction. This represents the sum of years While certain conditions related to alcohol and
of life lost due to premature mortality (YLL) and drug abuse (such as substance use disorder)
years lived with disability (YLD) associated with do certainly impact quality of life on an ongo-
conditions attributable to body dissatisfaction. ing basis, this study considered only the direct
Converting the DALYs to a dollar estimate using impacts (such as hospitalizations or deaths
the value of a statistical life year (VSLY),xvi the that are directly attributable, for example due
total reduction in well-being was estimated to drug overdoses). YLLs were not estimated
to be $220.6 billion in 2019 (see Table 4.5), ap- for suicide attempts as this cost only considers
proximately equivalent to every American pay- attempts that did not result in loss of life.xvii Sui-
ing $670. DALYs were not estimated for smok- cides resulting in loss of life attributable to body
ing. Although smoking is a risk factor for various dissatisfaction are captured through depres-
conditions and illnesses for which DALYs could sion and anxiety.
Table 4.5: Loss of well-being due to body dissatisfaction in 2019
CONDITION YLLS YLDS DALYS DALYS ($M) DALYS PER

(DIS- PERSON
COUNTED) ($)
Depression 74,669 225,198 299,867 92,109 2,076
Suicide attempts - 3,551 3,551 1,091 25
Eating disorders 34,861 137,651 172,512 52,990 1,194
Anxiety 10,628 162,198 172,826 53,086 1,196
Drug and alcohol abuse 69,466 - 69,466 21,338 481
Total 189,624 528,598 718,221 220,614 4,972
Per person (number, $) 0.004 0.012 0.016 4,972
Source: Deloitte Access Economics analysis. Note: components may not sum to totals due to rounding.
xvi For this report a VSL of $307,167 was used. This was cal- xvii Suicides resulting in loss of life attributable to body
culated based on the mid-point of the Office of Man- dissatisfaction are captured through depression and
agement and Budget recommendation in 2003 (a VSL of anxiety.
$5.5 million) and

DALYs were estimated to be higher in women than for men (see Chart 4.5), consistent with the
higher prevalence of body dissatisfaction among women in the US. On a per person basis, the loss
of well-being is highest for people with body dissatisfaction aged between 20 to 29 years of age.
This is due to the devastating impacts of depression and the relatively high prevalence of suicide
among this age group.
Chart 4.5: Financial costs of body dissatisfaction by attributed condition and age group
(in years, $ billions (left axis) and prevalence of body dissatisfaction by age group (right axis)
$25 4,500
4,000
$20
(thousands of people)
3,500
Cost ($billions)
$15 3,000
Prevalence
2,500
$10 2,000
1,500
$5 1,000
500
$0
0
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+
Age group (years)
Woman Men Prevalence

Note: prevalence is shown on the right axis while the other series are shown on the left axis.

4.2.4 Sensitivity analysis
Sensitivity analysis was performed to test how Three additional scenarios were considered:
variations in certain parameters impacts over-
all results. Sensitivity analysis helps identify tudies do not always include efficiency
01. S
how responsive the model is to changes in key losses – the costs associated with the act of
parameters. One-way sensitivity analyzes were taxation and transfers, which distorts incen-
conducted on prevalence, the VSLY, PAFs (and tives and results in a loss of economic effi-
therefore the underlying risk of developing a ciency. Excluding efficiency losses, the total
condition), and estimated unit costs (health sys- social and economic cost of body dissatis-
tem and productivity costs). Input values have faction was estimated to be $298.2 billion,
been varied by a consistent amount across instead of $305 billion.
model inputs to show how sensitive the results
are to particular inputs. 02. T
he evidence for risky behavior from body
dissatisfaction does not tell the complete
The results of the sensitivity analysis showed picture of the possible impacts associat-
that varying the PAF had the largest impact on ed with drug and alcohol use or smoking.
the results, with total costs – economic and non When including possible long-term ef-
financial – ranging between $189.3 billion and fects and risk for future loss of healthy
$407.5 (see Appendix Table B.1). life from smoking as an example, the total
social and economic cost of body dissatis-
faction was estimated to be $328 billion.
03. C
osts of government programs – such as
prevention or awareness programs – asso-
ciated with conditions/illnesses attributable
to body dissatisfaction were not explicitly
considered in this analysis. The inclusion of
these costs was tested using tobacco con-
trol program funding for smoking as an
example. Under a scenario where tobacco
control program funding is included, the to-
tal social and economic cost of body dissat-
isfaction was estimated to be $306.4 billion.

5 The economic and social
cost of appearance-
based discrimination.
$501 billion
$ $269 billion $ $233billion
Financial Loss of
costs well-being
HEALTH LABOR OTHER LIFE

OUTCOMES MARKET OUTCOMES
OUTCOMES

5 The economic and social
cost of appearance-
based discrimination
Key findings
• The total cost of appearance-based discrimination was $501 billion in 2019. This
includes $269 billion in financial costs, and $232 billion in lost well-being. The financial
costs are equivalent to 1.3% of US GDP in 2019.
• The total costs associated with weight discrimination were $430 billion in 2019, which
included $206 billion in financial costs and $224 billion in lost well-being. Skin shade
discrimination costed $71 billion in total, which included $63 billion in financial costs
and $8 billion in lost well-being.
• Experiencing appearance-based discrimination can lead to a range of poorer out-

comes for the individual. This includes poorer health outcomes (by leading to an in-
creased risk of particular conditions such as anxiety, depression, obesity, among oth-
ers), as well as poorer labor-market outcomes by lowering wages and employment
opportunities. More broadly, it can also cause a deterioration in other life outcomes
such as increasing the risk of school suspension and increasing the probability of
receiving a prison sentence.
• The cost of appearance-based discrimination in 2019 was primarily borne by
individuals and their families (58%), and the US government (30%).
5.1 Impacts of appearance-based

discrimination Appearance-based discrimination is captured
Appearance-based discrimination has far in two ways:
reaching impacts on the individual experienc- • By comparing differences in outcomes for
ing discrimination as well as on broader society. people that have experienced appearance-
These impacts can occur in a variety of settings, based discrimination, compared to those that
such as at school or the workplace, and can be have not. Differences in health, labor market,
experienced by anyone such as by employees and other life outcomes (e.g., educational at-
or someone seeking medical care. The forms tainment and justice system) were explored.
of appearance-based discrimination costed in • Through the health impacts attributable to
this report are weight discrimination and skin experiences of appearance-based discrimi-
shade discrimination. In addition, this report nation (e.g., depression or anxiety).
also provides a qualitative discussion of the These are summarized in Figure 5.1.
impacts of natural hair discrimination.

Figure 5.1: Outcomes of appearance-based discrimination
HEALTH OUTCOMES LABOR MARKET OTHER LIFE

- Healthcare avoidance OUTCOMES OUTCOMES
- Lower quality of care - Wage losses - Incarceration
- Employment losses - Lower educational
H
ealth impacts attainment
resulting from an - School
experience of suspensions
appearance-based
discrimination
HEALTH IMPACTS
- Depression
- Anxiety
- Obesity
- Hypertension
- Mortality
- Psychotic experiences
- Risky drug use
- Mood disorders
- Physiological dysregulation
- Social phobia
- Post-traumatic stress disorders
- Sensory dysfunction
- Cardiovascular and cardiometabolic disorders

The following sections discuss these impacts in The current body of evidence does not allow
further detail, drawing on the relevant litera- for these mechanisms to be disentangled – for
ture. Various factors can affect the impacts that example, facing weight stigma when consulting
are attributable to appearance-based discrim- a medical professional may result in healthcare
ination, such as type of discrimination, individ- avoidance and also cause anxiety.
ual characteristics, perpetrator characteristics,
and research design. It has not been possible to
explore all these factors in detail, however key 5.1.1.1 Mental health outcomes
differences are noted in the sections below. Skin shade discrimination can lead to poorer
mental health outcomes. For example, evi-
Furthermore, the use of controls also varied dence suggests that those who selfrate their
across the research. Typically, studies con- skin as the darkest shade are 1.54 times more
trolled for key demographic variables, such likely to report being depressed, compared
as age, gender, education, and income.xviii For to those who rate themselves as being of the
skin shade discrimination, only those studies lightest skin shade, within the same race.113
that controlled for race were included. Again, Another study found there was a greater odds
we have not attempted to list controls for each of lifetime suicidal ideation and suicide at-
study but instead focus on key confounding tempts resulting from skin shade discrimination
factors and their controls where relevant. when perpetrated by members of the same
community.114 More broadly, skin shade dis-
crimination can lead to differences in overall
5.1.1 Health outcomes health outcomes, with evidence from Puerto
Appearance-based discrimination can lead Rico suggesting those with lightest skin shades
to poorer health outcomes through various fare better on a measure capturing overall
mechanisms: health, compared to those with the darkest
skin shades.115 Another study focused on Puer-
• Healthcare providers might deliver a poorer to Ricans revealed that it is major instances of
quality of care to someone based on their discrimination, as opposed to acts of everyday
appearance.103 discrimination, that have severe physiological
• Discriminatory experiences in the health- health consequences, such as allostatic load.116
care system can lead to distrust, health-
care avoidance or low engagement from a The likelihood of depression is also greater for
patient, which can impact their treatment people who perceive weight discrimination.
through delayed diagnoses and substandard Robinson et al (2017) show that even after con-
care.104,105,106,107 Patients may also blame them- trolling for risk factors of depression, those who
selves for their stigmatized identity, which can have perceived weight discrimination are 1.5
have consequences for their mental health.108 times more likely to suffer from clinically signifi-
• Discriminatory experiences can also lead to cant depression than those who do not.117
negative health impacts such as depression,
anxiety, weight gain and even premature
mortality.109,110,111,112 xviii One potential confounder is the wealth and network
effects associated with Black people with lighter skin
shades having one white parent. Controls for income
and education help to control for this effect.

The mental health impacts of weight discrimi- 5.1.1.2 Physical health outcomes
nation also tend to be more severe for people Alongside poorer mental health outcomes are
of a higher weight. For example, people who poorer physical health outcomes, such as hy-
experienced weight discrimination and were pertension, premature mortality, and having a
of a high weight were almost three times more body mass index (BMI) of 30kg/m2 or higher.xix
likely to suffer from any anxiety disorder, com- On average, Black people with the darkest skin
pared to those who were not a high weight.118 shade are 14 percentage points more likely to
develop hypertension compared to Black peo-
Among children, weight-based bullying and ple with the lightest skin shade.124 Skin shade
teasing at school is one of the most common has also been found to be a significant deter-
reasons for youth victimization in the US, and minant of mortality among Black people, where
can cause disordered eating, suicidal idea- respondents with medium and dark brown skin
tion, and a range of other poor health out- had significantly higher rates of all-cause mor-
comes.119,120,121,122 Hair discrimination has also tality than those with lighter skin.125
been shown to lead to poorer mental health
outcomes. The “Good Hair” Study by Percep- Weight discrimination can also lead to a higher
tion Institute measured the level of anxiety that likelihood of having and maintaining a BMI of
women faced about their hair, finding that 30kg/m2 or higher. Sutin and Terracciano (2013)
Black women were on average 13 percentage show that people who experienced weight dis-
points more anxious about their hair than white crimination were 1.72 times more likely to devel-
women.123 op a BMI of 30kg/m2 or higher, and 1.69 times
more likely to maintain a BMI of 30kg/m2 or
higher (if they already had a BMI in this range),
compared to those who did not perceive weight
discrimination.126
Weight discrimination also leads to increased

risk of mortality, higher inflammatory mark-
ers, engaging in risky health behaviors, de-
mentia, and physical inactivity, among oth-
ers.127,128,129,130,131,132 These studies controlled for
BMI to help isolate the impact of weight dis-
crimination as distinct from an individual’s
current weight status.
Weight stigma is also associated with a host of

negative impacts, such as greater risk of diabe-
tes, higher cortisol levels, higher oxidative stress
levels, and disordered eating.133,134,135
xix An adult with a body mass index (BMI) of 30kg/m2 or

higher is classified by CDC as falling within the obesity
range.

Weight stigma differs from weight discrimina- also have broader societal costs such as
tion in that it captures the negative attitudes in lost or lower income and efficiency losses.
society surrounding weight, which can manifest Skin shade discrimination can lead to wage
in forms that may not result in an act of dis- penalties, with some estimates suggesting
crimination (e.g., societal prejudices and stere- males with dark skin shades face wage pen-
otypes).136 alties as high as 6.3% compared to males with
light skin shades, within the same race or ethnic
There is some evidence pointing to the health group.140 A study focusing on the immigrant
risks associated with the use of particular hair population in the United States showed that
products, which may be more likely to be used non-Black Latin American immigrants with dark
or used more frequently by those facing hair skin shades face a wage penalty, across all
discrimination. For example, a study by Nation- genders.141 Skin shade discrimination can also
al Institute of Environmental Health Sciences affect occupation, with one study showing that
(NIEHS) found that women who used chemical Mexicans and Cubans with darker skin shades
hair straighteners at least every five to eight face lower occupational prestige scores than
weeks were 30% more likely to develop breast Mexicans and Cubans with lighter skin shades,
cancer.137 Another study found that the Black even after controlling for factors that can
community is more likely to be exposed to influence labor market performance.142
dangerous chemicals in hair products than the
white community, leading to a greater risk of Weight discrimination can also lead to wage
developing health conditions associated with penalties, but these tend to vary by gender. The
exogenous estrogen and endocrine disruptors. wage penalty for women tends to increase as
A number of factors play into the greater expo- their weight increases, whereas men face wage
sure, including frequency of use, product pur- penalties if they have a high or a low weight.143
pose and the hair styles they are targeted to,
and the proportion of the community using the Appearance-based discrimination can also in-
products.138 fluence jobrecruitment. An examination of four
studies demonstrated that Black women with
Further, the pressure that black women feel to natural hairstyles were perceived to be less
maintain their hair can lead to them avoiding professional, less competent, and less likely to
exercise at far higher rates than white women. be recommended for job interviews than both
In fact, one in three black women report that white women with curly or straight hair and
their hair is the reason that they haven’t exer- Black women with straight hair.144
cised, compared to one in ten white women.139
This can lead to serious health outcomes in the Importantly, while this study focuses on natu-
long run as exercise plays a key role in avoiding ral hair bias against Black women, there are
illnesses like heart disease, cancer, etc. numerous examples of hair discrimination af-
fecting other groups. For example, Black male
students have been suspended and denied
5.1.2 Labor market outcomes participation in school sports on the grounds
Appearance-based discrimination can lead to that their locs are too long.145 Waitresses wear-
poorer labor market outcomes such as lower ing blonde wigs received more tips from male
wages, fewer employment opportunities and patrons than the same waitresses wearing red,
being perceived as less professional. But it may brown or dark colored wigs.146

5.1.3 Other life outcomes
Beyond poorer health and employment out- • It may lead to increased frequency of being
comes, appearance-based discrimination can stopped and arrested by police. Black and
lead to a host of other life consequences in- Latino people with darker skin shades are
cluding in the justice and education systems. more likely to be perceived as being danger-
Experiences of appearance-based discrimina- ous by the police than people with lighter skin
tion can also impact behavior. shades, increasing their odds of being arrest-
ed.154 xx
5.1.3.1 Justice system
• Appearance-based discrimination can lead to Members of the public might also be more
an increased likelihood of receiving a prison likely to report people with darker skin shades
sentence.147 As an example, one study found to the police or judge them more harshly when
that a one-unit increase in the darkness of serving on juries. A study conducted with un-
an individual’s skin shade has been shown to dergraduate students found that Black people
correspond with a 15% increase in the likeli- with dark skin shades were more often per-
hood of receiving a prison sentence.148 ceived to be aggressive than Black people with
lighter skin shades.155 Given undergraduates
• It can also affect the length of a prison sen- can go on to become members of a jury, this
tence.149,150,151,152 For example, one study esti- might have implications for the outcome of
mated that Black people with medium and legal trials.
dark-skin shades receive prison sentences
that are 4.8% longer than the sentences re-
ceived by white people, but found no signifi-
cant differences in sentence length between
Black people with light skin shades and white
people.153
xx This study presented results for Blacks and Latinos only

and did not ask Latinos to separately identify their race
(see Section 2.5).

5.1.3.2 Education system Lower test scores are not limited to skin shade
Appearance-based discrimination can impact discrimination. Weight-based victimization has
educationalattainment,156,157,158 test scores,159,160 also been linked to higher odds of skipping
school suspensions,161,162 school attendance,163 school and receiving lower grades by 5% per
and participation in extracurriculars.164 These teasing incident.167
can pose future costs for an individual through
income instability in the future or poor health. 5.1.3.3 Risky behavior
Appearance-based discrimination can also
Asian-American males with light skin shades impact people’s behavior. People who have
are 32% more likely to have a college education perceived weight discrimination are more than
than Asian-American males with darker skin twice as likely to engage in risky sexual or drug
shades, even after controlling for parental in- use behaviors than those who have not.168 They
come, parental educational attainment, school are also twice as likely to drive while intoxicat-
level standardized scores, and other relevant ed.169
factors that might affect college education.
The result is even greater for Asian-Ameri-
can females with light skin shades, who are
60% more likely to get a college education
than Asian-American females with darker skin
shades.165 The proportion of these impacts that
are a direct result of appearance-based
discrimination is unclear.
Furthermore, students with dark skin shades

are more likely to be suspended than students
with light skin shades within the same race or
ethnic group. A 2013 study estimated that the
likelihood of suspension for African American
male students of the darkest skin shades was
45% higher than the rate for African American
male students of the lightest skin shades. For
African American female students, the likeli-
hood of suspension was 107% higher for the
darkest skin shade compared to the lightest
shade.166 This additional risk is above and be-
yond the already disparate targeting of African
American children for suspension.

Case study: Lived experiences of skin shade discrimination
Chris is a 39-year-old Black Latino man represented in media, to celebrate different

working for the New York City Fire Depart- body types and cultures.
ment. He first became aware of beauty ide-
als as a young child who loved superheroes, Chris’s philosophy is shared by Layla, a
but found the hero was always a “blonde 43-year-old African American woman with
haired, blue eyed, white American.” Chris some Afro-Caribbean lineage. Layla is a
has been treated differently due to his skin psychotherapist in Manhattan and has
shade in clothing stores, electronic shops, on noticed narrow beauty ideals represented
the road, at the car dealership, on his job. in advertising of beauty products, social
media, fairy tales for children and even
song lyrics.
“Of course, when you have mela-
Like Chris, Layla first became aware of
nin in your skin, you’re going to be
beauty ideals as a young child in the 1980s,
treated different, looked at, you’re when she would notice while shopping with
going to be followed in the store. her parents, that store shelves were stacked
Happens to this day. You go into with dolls that were predominantly white.
a dealership and the salespeople “It was a bit disheartening and confus-
ing because I wasn’t a white little girl. And
treat you a little different… They
wanted to know why they didn’t have any
think you don’t have a down pay- dolls that looked like me.” To find dolls who
ment or have horrible credit.” represented people of color, Layla’s parents
sought out special vendors and distributors
who sold dolls with Afro-textured hair or
Of major concern to Chris is when he gets darker skin shades.
treated differently while performing his job
as a paramedic. He recounts examples of “It was extraordinarily important
people not wanting to be treated by him in that I had dolls with coily, Afro-tex-
emergency situations, waiting instead for
tured hair, brown skin, because my
someone they’re comfortable with to take
care of them. Chris feels it is because of his dad and I would play with the dolls
skin shade, along with religious and cultur- and create little scenarios and
al differences. This impacts how Chris can narratives. And it was important
perform patient care as a paramedic, where for me as a little girl to see what I
timely medical attention can make a sig-
could be or what I could look like
nificant impact on patient safety. To reduce
the impact of beauty ideals in society, Chris as an adult.”
believes in increasing the diversity of people
Layla believes beauty ideals in the United for vacations for the same reason, without
States are improving over time, but Layla still checking the proportion of people of color
faces skin shade discrimination in her day- in the communities she intends to visit. Her
to-day life. experiences have also impacted her self-es-
teem and caused her to feel low on several
“I’ve been in stores and I’ve been occasions. Layla says that while once she
followed around, I’ve been passed was more extroverted and felt free to travel,
overtime she has become more reclusive.
by cabs…or I’ve gotten into cabs
Layla has also compromised her career ad-
and they asked my l ocation, my vancement by leaving a job on account
destination, and they made of skin shade discrimination. For Layla, so-
assumptions around my destina- ciety will be able to embrace diversity when
tion and their safety…I have more it moves away from centering whiteness as
the standard.
examples than I could possibly
count or recount here today.”
Layla says her experiences are exhausting

and have led to her being hypervigilant
wherever she’s going to assess the level of
danger around her. She finds it hard to plan

5.2 Costs of appearance-based
discrimination Figure 5.2: Economic and social costs of
Modelling for this report finds that the eco- appearance-based discrimination,
2019 (billions)
nomic and social cost of appearance-based
discrimination in 2019 was $501.3 billion. This is
made-up of $268.7 billion in financial costs, and
$ $269 billion
$232.5 billion in non-financial costs, reflecting Financial
the loss in well-being associated with appear- cost
ance-based discrimination from worse health
outcomes. Women bore more than two-thirds
$ $233 billion
(63% or $317 billion) of the costs of appear- Loss of
ance-based discrimination. well-being
The financial costs of appearance-based Source: Deloitte Access Economics.
discrimination made up approximately 54% of
the total costs of appearance-based discrim-
ination, at $268.7 billion. The financial costs of
appearance-based discrimination were equiv-
alent to 1.3% of the US GDP in 2019 ($21.4 trillion)
and would have covered two-thirds (66%) of
the total national out-of-pocket spending on
healthcare in the US (estimated to be $406.5
billion in 2019).170
By type of discrimination, the financial costs

of weight discrimination totaled $205.9 bil-
lion, while for skin shade discrimination it
was $62.8 billion. Financial costs were largest
for labor market outcomes ($181.6 billion) and
health outcomes ($84.5 billion). The breakdown
by type of discrimination and outcome is pro-
vided in Table 5.1.

Table 5.1: Financial costs of weight discrimination and skin shade discrimination
by outcome type in 2019 ($ millions)
OUTCOME TOTAL COST PER PROPORTION OF

FINANCIAL COST PERSON ($) TOTAL FINANCIAL
COST (%)
Weight discrimination
Health outcomes 82,837 1,261 31
Labor market outcomes 123,082 1,874 46
Subtotal 205,919 3,135 77
Skin shade discrimination
Health outcomes 1,627 25 1
Labor market outcomes 58,503 891 22

Other life outcomes –
2,686 41 1
incarceration
Subtotal 62,816 956 24
Total 268,735 4,091 0.016
Source: Deloitte Access Economics analysis. Note: cost per person refers to cost per person that experiences
appearance-based discrimination. Components may not sum to totals due to rounding.
It was estimated that individuals and their fam-

ilies and friends bore 58% of total financial and Chart 5.1: Financial costs of appearance-
based discrimination by payer in 2019
economic costs, while government, employers,
($ millions)
and the rest of society each bore 30%, 3% and $1,43,560
9% of total financial and economic costs respec- Individuals
tively, as shown on the right. $81,911
Governments
$13,855
When the non-financial cost capturing the loss Society/Other
of well-being is added to these financial costs, Friends and $11,012
the health costs for individuals increase signif- family (carers)
icantly. Together, the financial costs and loss Healthcare $9,622
of well-being costs form the total societal cost payers
of appearance-based discrimination. A break- $8,774
Employers
down of the total cost by outcome category and
five-year age group is shown in Chart 5.2. Source: Deloitte Access Economics analysis.

Chart 5.2: T
otal cost of appearance-based discrimination by outcome category and age group
(in years), ($ billions)
$60
$50
Cost ($ billions)
$40
$30
$20
$10
$0
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+
Age group (years)
Health outcomes Labor market outcomes Other life outcomes
The cost of appearance-based discrimination is highest for people between the ages to 25 and
54. This is due to the employment and wage differentials faced by this group, in addition to poorer
health outcomes. Further, the rate of incarceration is also highest for people aged 20 to 54 years
further increasing the costs for this age category through prison outcomes. The following sections
provide further detail regarding the costs across health outcomes, labor market outcomes and
other life outcomes.
5.2.1 Health outcomes

The total social and economic cost associated with the health outcomes of appearance-based
discrimination were estimated to be $317 billion in 2019. This was made up of health system costs
($21.9 billion), productivity losses ($39.3 billion), informal care costs ($15.8 billion), efficiency losses
($7.5 billion) and loss of well-being ($232.5 billion).

Table 5.2: Costs of health outcomes attributable to weight and skin shade discrimination in 2019
($, millions)
HEALTH PRODUC- INFORMAL EFFICIEN- LOSS OF TOTAL COST PER

SYSTEM TIVITY CARE CY WELL- PERSON
COSTS LOSSES COSTS LOSSES BEING ($)
Skin shade
210 995 296 126 8,417 10,044 153
discrimination
Weight
21,708 38,300 15,484 7,345 224,116 306,953 4,673
discrimination
Total 21,919 39,294 15,780 7,471 232,534 316,997 4,826
Cost per
334 598 240 114 3,540 4,826
person ($)
5.2.1.2 Health system costs

The total 2019 expenditure of $21.9 billion on ($9.5 billion) and drug abuse ($7.2 billion) were
health services was equivalent to a cost of the primary drivers of health system expendi-
$334 per person who experienced appearance ture attributable to appearance-based discrim-
based discrimination in 2019. By type of discrimination. Consistent with all other costs reported
ination, the total health system costs attributa- in this study, costs for obesity relate to those
ble to skin shade discrimination was $0.21 billion which are attributable to appearance-based
from depression and hypertension, and that discrimination (i.e., causing someone to gain
attributable to weight discrimination was $21.7 weight or maintain a high weight). Notably,
billion from depression, anxiety, obesity and obesity due to weight discrimination accounted
drug abuse (see Appendix Table A.24). for 44% of the total health system costs resulting
By health impact, anxiety ($4.6 billion), obesity from appearance-based discrimination.
Table 5.2: Costs of health outcomes attributable to weight and skin shade
discrimination in 2019 ($, millions)
HEALTH IMPACT MEDICAL PHARMACEUTI- TOTAL COST PER

COSTS CAL COSTS PERSON ($)
Anxiety 3,119 1,474 4,593 70
Obesity 6,491 3,052 9,542 145
Drug abuse 6,380 859 7,239 110
Hypertension 66 33 99 2
Total 16,393 5,525 21,919 334
Cost per person ($) 250 84 334 114

Chart 5.3: Health system costs attributable to appearance-based discrimination in 2019,
by health condition and cost bearer, ($ millions)
Obesity
Drug
Health condition
abuse
Anxiety
Depression
Hyperten-
sion
Smoking
0 2000 4000 6000 8000 10000
Individuals Government Others
Black women with natural hair report greater might lead to reduced engagement of work-
levels of hair-related anxiety than white wom- ers, leading them to take days off work or find
en.171 This was not costed because it is unclear themselves unable to perform as well as they
what proportion is due to appearance-based otherwise would while at work.
discrimination, and the extent to which these
feelings progress into clinical anxiety. However, Finally, where a condition that developed as a
if a portion is attributable to hair discrimination, result of the discrimination required informal
it might pose notable implications for impacts care, this resulted in further losses under the
and costs, given the significant burden of dis- assumption that there is an opportunity cost of
ease associated with anxiety. More research the caregiver’s time (i.e. they may have other-
is needed to estimate the portion of hair-re- wise been earning a wage). A detailed break-
lated anxiety that is due to natural hair style down of the hours spent providing informal
discrimination. care for each health condition is provided in
Appendix A. The productivity losses associat-
ed with health conditions developed were $55
5.2.1.3 Productivity losses billion. Of this, reduced employment accounted
The productivity losses associated with the for $19.0 billion (34.6%), loss of lifetime earnings
health consequences of appearance-based cost $7.5 billion (13.6%), absenteeism cost $3.4
discrimination capture premature mortality, billion (6.3%) and presenteeism cost $9.3 billion
lower productivity at work (absenteeism and (16.9%). Further, the productivity losses of in-
presenteeism) and costs that arise when a fam- formal caregiving due to appearance-based
ily member or friend provides care to someone discrimination was $15.8 billion in 2019. By type
because of their condition. Both premature of discrimination, productivity losses associated
mortality and lower productivity at work stem with weight discrimination totaled $53.7 billion,
from the health conditions developed by work- while for skin shade discrimination they were
ers as a result of appearance-based discrim- $1.3 billion (see Appendix A).
ination. For example, depression and anxiety

Overall, the productivity losses were mostly due to anxiety attributed to appearance-based
discrimination (see Chart 5.4). It is noted that obesity and hypertension are associated with
other conditions (such as diabetes and heart failure). However, costs attributable to second
order impacts were not included in this analysis, resulting in a relatively low cost for obesity
and hypertension. Despite also being a risk factor for other conditions, smoking presents a
high cost due to the need to leave the workspace when smoking (presenteeism).
Chart 5.4: Proportion of productivity losses associated with health outcomes, by outcome, 2019
56.3%
Anxiety
16%
Smoking
13%
Drug abuse
10.5%
Depression
4.1%
Obesity
0.2%
Hypertension
Table 5.4: A
nnual productivity losses due to health outcomes of appearance-based discrimination,
in 2019 ($ millions)
PRODUCTIVITY REDUCED ABSEN- PRESEN- PREMA- INFOR- TOTAL COST

LOSSES EMPLOY- TEEISM TEEISM TURE MAL PER
MENT MOR- CAR- PERSON
TALITY EGIVING ($)
Anxiety 17,755 1,760 1,630 960 14,328 555
Depression 1,294 353 963 1,508 1,451 5,569 85
Smoking - 804 5,501 - - 6,304 96
Obesity - 478 1,141 - - 1,618 25
Drug abuse - 52 - 5,038 - 5,090 77
Hypertension - 4 58 - - 61 1
Total 19,049 3,450 9,291 7,506 15,780 838
Cost per person ($) 290 53 141 114 240 838

5.2.1.3 Productivity losses
In addition to the health expenditure and productivity impacts, there was also a loss in economic
efficiency due to the health outcomes attributable to appearance-based discrimination. The
loss of efficiency arises due to the need to levy taxes to fund government expenditure and replace
lost tax revenue (when compared to a situation where appearance-based discrimination does
not exist). The loss in economic efficiency from the health impacts of appearance-based discrimi-
nation reduced potential US output by as much as $7.5 billion in 2019, representing 54% of the
total loss in economic efficiency across all outcome categories (health, labor market and other
outcomes). Of the total $7.5 billion, individual income, caregiver tax, and company tax revenue
forgone accounted for $4.2 billion, and government expenditures accounted for $3.3 billion.
These losses are borne by society.
Table 5.5: Annual reduction in economic efficiency due to health outcomes of appearance-based
discrimination in 2019 ($ millions)
HEALTH REDUCED GOVERNMENT TOTAL COST PER

OUTCOME TAXATION EXPENDITURES PERSON ($)
Anxiety 2,968 684 3,652 56
Smoking 367 - 367 6
Obesity 94 1,420 1,514 23
Risky drug use 355 1,077 1,433 22
Hypertension 4 15 19 0.3
Total 4,208 3,262 7,471 114
Cost per person ($) 64 50 114
Of the total $7.5 billion in efficiency losses, $7.3 cost was associated with anxiety, at $98.9 billion
billion were due to the health impacts associat- (42.5%), which was followed by obesity at
ed with weight discrimination and $126 million $53.6 billion (23.1%), depression at $41.4 billion
were due to the health impacts associated with (17.8%) and drug abuse at $38.6 billion (16.6%)
skin shade discrimination (see Appendix Table (Table 5.6).
A.26).
The total loss of well-being associated with
5.2.1.5 Loss of well-being weight discrimination was $224.1 billion, re-
More than 757,000 years of healthy life were flecting lost well-being from depression ($32.9
lost due to the health impacts of appearance- billion), anxiety ($98.9 billion), obesity ($53.6
based discrimination in the US in 2019. Con- billion) and drug abuse ($38.6 billion). The total
verting the DALYs to a dollar estimate using the loss of well-being associated with skin shade
value of a statistical life year (VSLY), the total discrimination was $8.4 billion, reflecting lost
reduction in well-being was valued at $232.5 well-being from depression ($8.4 billion) (See
billion in 2019. The greatest loss of well-being Appendix, Table A.27).

Table 5.6: Loss of well-being due to appearance-based discrimination in 2019
CONDITION YLLS YLDS DALYS DALYS ($M) DALYS PER

(DISCOUNTED) PERSON ($)
Anxiety 21,685 300,355 322,040 98,920 1,506
Depression 33,947 100,883 134,830 41,415 631
Obesity - 174,574 174,574 53,623 816
Drug abuse 125,583 - 125,583 38,575 587
Total 181,215 575,812 757,027 232,534 3,540
Per person
0.003 0.009 0.012 3,540
(number, $)
Source: Deloitte Access Economics analysis. Note: components may not sum to totals due to rounding. Discounting
means that YLLs will sum with YLDs to undiscounted DALYs, but in converting using the VSLY future YLLs are
discounted so the result is not a simple multiplication of DALYs and the VSLY. Missing values for the YLLs for
obesity and the YLDs for drug abuse reflect that there are none associated with these conditions.
As in the case for body dissatisfaction, DALYs were not estimated for smoking or hypertension,
as DALYs are not directly attributable to these impacts but are instead attributable to risk factors
associated with these conditions.xxi Similarly, YLDs were not estimated for drug abuse. Suicides
resulting in loss of life attributable to appearance-based discrimination are captured through
depression. On average, the loss of well-being for men and women were similar, but this varied
slightly by age group, as shown in the Chart below.
Chart 5.5: Loss of well-being for appearance-based discrimination in 2019, by age group
and gender ($ billions)
$25
$20
Cost ($ billions)
$15
$10
$5
$0
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+
Age group (years)

Women Men
Source: Deloitte Access Economics
xxi Second order impacts were not costed in this report.

BOX 5.1: SKIN BLEACHING AND HAIR STRAIGHTENING
HAIR STRAIGHTENING
Black women spend more time and money While it is unclear how much of the styling is
styling and straightening their hair than women due to appearance-based discrimination com-
of any other racial or ethnic group. They spend pared to other factors such as styling prefer-
in the order of three times as much by some ences, the Dove hair study shows that Black
estimates,172 and nine times as much on beauty women are 80% more likely to alter their hair
and grooming products than the average for to meet social or work expectations than non-
women across all racial or ethnic groups.173 Black women.174
SKIN BLEACHING
In 2020, the US market for skin lighteners was nation directly. Further, while the financial costs
estimated at $2.3 billion.175 Many women of are considerable for some groups, this has also
color seek chemical products to lighten their been excluded from the total costs as they are
complexion, however women of all skin shades an income transfer and do not represent a net
may use skin lighteners to fade age spots. cost to society.
This is significant, considering the range of It is important to consider the intersections

negative impacts associated with cosmetic between those who acquire skin bleaching
bleaching, such as hyperpigmentation, car- services and segments of the society. Outside
cinoma, and bacterial, fungal and viral skin of the United States, skin bleaching is common
infections.176 Skin bleaching products some- in sub-Saharan Africa, the Middle East, Asia,
times include ingredients that are not approved and Latin America. A quarter of the adult fe-
for use in humans, and some are banned for male population in Bamako (Mali) and 67% of
use, such as mercury. Skin creams and soaps the adult female population in Dakar (Senegal)
containing mercury, hydroquinone and steroids are estimated to be using skin lightening prod-
are associated with an additional set of health ucts.179 Within the United States, a large portion
problems such as mercury poisoning and kidney of the immigrant communities is found to be
damage.177 Uses of these products is a major using skin-lightening compounds for cosmet-
source of mercury exposure for Caribbean-born ic purposes, even though these are made for
Blacks and Dominicans in New York City.178 medical use.180 Skin bleaching in these commu-
nities is likely a response to widespread skin
Health conditions resulting from exposure to shade discrimination.181
chemical skin-lighteners can present signifi-
cant costs for the individual and society. They Mercury-containing skin bleaching products
incur well-being losses, cost time and money, are a public health crisis according to the World
and can impact overall mental and physical Health Organization,182 given the vast health
health. While these costs can be significant, implications of these products. Recognizing the
they have not been incorporated into this study role of body dissatisfaction and skin shade dis-
because they are second order impacts associ- crimination in propagating bleaching is crucial
ated with skin bleaching, rather than from body to addressing this public health concern.
dissatisfaction or appearance-based discrimi-

5.2.2 Labor market outcomes
Labor market discrimination on the basis of appearance cost the society $181.6 billion in 2019.
This was in the form of lower wages, lower employment, and their associated efficiency losses.
Weight discrimination cost the society $123.1 billion and skin shade discrimination cost $58.5 billion
(see Table 5.7).
Table 5.7: Costs of labor market outcomes attributable to weight and skin shade discrimination
in 2019 ($ millions)
PRODUCTIVITY EFFICIENCY TOTAL COST PER

LOSSES LOSSES PERSON ($)
Skin shade discrimination 56,436 2,067 58,503 891
Weight discrimination 118,977 4,106 123,082 1,874
Total 175,412 6,173 181,585 2,765
Cost per person ($) 2,671 94 2,765
Wage losses made up 58% of this cost and are 5.2.2.2 Productivity losses
partly due to Black people with darker skin The productivity losses associated with weight
shades (as opposed to lighter) and individuals and skin shade discrimination in the labor mar-
of a higher weight holding lower paying jobs ket cost the society $175.4 billion in 2019, which
because of appearance-based discrimination. included reduced employment costs of $73.2
It is also due to these individuals receiving less billion and wage gaps leading to an economic
compensation for otherwise equal work in the loss of $102.2 billion (see Table 5.8).
same roles compared to those who are not dis-
criminated against.
Employment losses made up 42%, reflecting the

lower rate of employment faced by individuals
who might have faced discriminatory hiring due
to their appearance.
While the exact mechanisms driving these gaps

are unclear, controls for common determinants
of wages and employment such as race or
ethnic group, the level of education, experience,
gender, and age indicate the differentials are
likely driven by appearance-based discrimina-
tion.

Table 5.8: Annual productivity losses due to poorer employment outcomes in 2019 ($ millions)
PRODUCTIVITY WAGE LOSS REDUCED TOTAL COST PER

LOSSES SOCIETAL EMPLOYMENT PERSON ($)
IMPACT
Skin shade discrimination 28,505 27,931 56,436 859
Weight discrimination 73,703 45,273 118,977 1,811
Total 102,208 73,204 175,412 2,671
Cost per person ($) 1,556 1,115 2,671
These costs are substantial, but they do not 5.2.2.3 Efficiency losses
capture the full extent of the difference in out- The efficiency losses associated with labor
comes individuals facing appearance-based market outcomes make up 45% of the total
discrimination. For example, hair discrimina- efficiency losses across the three outcome
tion might also affect labor market outcomes, categories. The estimated annual reduction in
with Black women with natural hairstyles being economic efficiency due to the labor market
viewed as less professional, less competent, and outcomes of weight discrimination was $4.1 bil-
less likely to be recommended for an interview lion, while for skin shade discrimination it
than Black women with straight hairstyles.183 was $2.1 billion.
This can influence the likelihood of someone
with natural hair getting a job, especially in These are composed of lower wages and
markets where interview referrals play a major lower employment resulting in losses in taxa-
role. Approximately 2% of interviews will result in tion revenue for the government of $6.2 billion
a job offer,184 so there could be a considerable which would not occur in the absence of ap-
social and economic cost of hair discrimination pearance-based discrimination (Table 5.9).
as there are currently 0.9 million Black women Efficiency losses associated with labor market
(aged 20 years and over) who are in the labor outcomes do not include government expendi-
force but who are unemployed.185 However, it is tures.
not possible to estimate the cost of this accu-
rately, as more research is needed to document
patterns and consequences of wearing natural
versus straightened hair styles in employment
and other settings.

Table 5.9: Annual reduction in economic efficiency due to labor market outcomes
of appearance-based discrimination in 2019 ($ millions)
OUTCOMES REDUCED TOTAL

TAXATION
Wage gap 2,807 2,807
Employment gap 3,367 3,367
Total 6,173 6,173
Cost per person ($) 94 94
5.2.3 Other life outcomes

Individuals also experience worse outcomes While the cost of incarceration is relatively
in other areas of their life due to appearance- small compared to the other outcome catego-
based discrimination. Two additional areas ries, incarceration can impose large future costs
where these impacts occur are in the justice for an individual in the form of worse mental
system and within educational settings. This health,186 housing instability187 and long-term
study quantified the costs associated with dis- employment instability,188 among others, which
crimination in the justice system attributable are not captured in this analysis. Incarcerat-
to skin shade discrimination. ed members of the Black community are more
likely to face unemployment once released from
In the justice system, discriminatory incarcer- prison, than the non-Black community on aver-
ation on the basis of skin shade discrimination age.
was modelled for members of the Black com-
munity, as there is not enough research for The expenditure on prisons includes expendi-
other groups. ture on correctional services to cover the aver-
age cost of incarceration for federal inmates,190
Discriminatory incarceration on the basis of skin and is similar to the other estimates that cover
shade cost society $2.7 billion in 2019, which expenses such as personnel, utilities and health
includes additional expenditure on prisons ($1.4 care.191 Educational outcomes are harder to cost
billion), forgone earnings due to incarceration due to them largely presenting in the future.
($1 billion) and a loss of economic efficiency Nonetheless, these outcomes have major im-
from government expenditure and forgone pacts on people who face discrimination
taxation revenue ($211 million). (see Box 5.2).

BOX 5.2: THE IMPACT OF SKIN SHADE
AND HAIR DISCRIMINATION ON SCHOOL
SUSPENSIONS
Appearance-based discrimination may lead to payers) loss of $82,900 per student over a life-
poorer educational outcomes, which can pose time, in 2019 dollars.194 The punitive measures
future costs for an individual through income against schoolchildren has contributed to the
instability or poor health. ‘School-to-Prison Pipeline,’ referring to children
being forced out of schools due to a collective
School suspensions are more likely for those of punishment policies and into the juvenile and
who have darker skin shades than for those criminal justice system.195
with lighter skin shades within the same racial/
ethnic group. School suspensions are also more According to the National Center for Education
common for Black people who wear their hair Statistics, there are approximately 2.3 million
naturally than for those who wear it chemi- Black Americans enrolled in public secondary
cally straightened, because dress codes treat schools in the US (increasing to 2.5 million when
natural hairstyles as de facto violations.192 accounting for private school enrolments).196
Hannon et al (2013)193 found that for every unit We estimate that 34% fewer suspensions would
increase in the darkness of one’s skin shade on occur if all African Americans were suspended
a 10-point scale, the likelihood of suspension at the same rate as those with the lightest skin
increased by 12.7%. The study used a sample of shade. If skin shade discrimination were elim-
1,797 African American students aged between inated, there would be an estimated 379,000
12-16 years. The increased likelihood of suspen- fewer suspensions of Black schoolchildren each
sion was robust to the inclusion of controls such year, which would lead to an estimated 49,000
as socioeconomic status, academic perfor- more Black school-children graduating from
mance, and adolescent behavior. high school each year in the US. The future
costs (e.g., lost income and employment)
The impacts could be substantial; each sus- associated with additional school suspensions
pension has been shown to increase a student’s and subsequent school leaving each year are
odds of dropping out of school by 13%, which is estimated to be approximately $4.09 billion
associated with a future social and fiscal (eco- each year.
nomic impact on local, state, and federal tax-
5.2.4 Sensitivity analysis

One-way sensitivity analysis was conducted Input values have been varied by a consistent
on prevalence, the VSLY, PAFs (and therefore amount across model inputs to show how
the underlying risk of developing a condition), sensitive the results are to particular inputs.
and estimated unit costs (health system and
productivity costs), along with the direct effects The results of the sensitivity analysis showed
of appearance-based discrimination (i.e. the that varying the PAFs had the largest impact
impact on wage and employment outcomes). on the results, with total costs – financial and

non-financial – ranging between $338.4 billion Similarly, while there are no population wide
and $652.8 billion (see Appendix Table B.2). estimates of the effect of skin shade discrimi-
nation, estimates do exist for immigrants to the
The costs considered here are almost certain- US. Hersch (2008)198 used data from the New
ly an underestimate; for example, costs of skin Immigrant Survey to show that each 1-unit in-
shade discrimination have not been considered crease in the darkness of skin shade on a scale
for other races or ethnic groups beyond the from 0 to 10 reduces average hourly earnings
Black community, due to the lack of research by 1.7% for immigrants, controlling for educa-
conducted for other communities. Similarly, it is tion, English language proficiency, occupation
possible that weight discrimination may occur in source country, family background, race,
for people of a high weight who do not feel ethnicity, and country of birth. When the mean
comfortable reporting it in surveys intended to skin shade rating for Latin Americans, Asians
capture total prevalence. and Black people is compared to white (Chart
5.6), it is possible to estimate that the wage gap
To test the effects of broader weight discrimina- for these groups due to skin shade discrimina-
tion on the results, the employment and wage tion is in the order of 4.5%.xxii Of course, this as-
effect of weight discrimination was applied to sumes that the skin shade of new immigrants to
all people of a higher weight (with a BMI of the US matches the broader population, which
25kg/m2 or higher), rather than only for those is unknown. Despite this, under this scenario,
groups where statistically significant results the costs of labor market discrimination due to
were observed (see Appendix Table A.18). For an individual’s skin shade would increase from
this scenario, an employment gap of 1.5% and a $181.6 billion to $240.2 billion. Another study fo-
wage gap of 2.5% was used, where these values cusing on Latino immigrants showed that those
represent the average of the negative results with darker skin shades earned $2,500 less per
reported in Han et al (2008).197 Under this sce- year on average, than those with lighter skin
nario, the costs of labor market discrimination shades.199 Studies focusing immigrants are not
due to an individual’s appearance would captured in main estimates due to the com-
plexity of the US immigration system. For ex-
icrease from $181.6 billion to $217.9 billion (in- ample, the skin shade of an applicant applying
cluding weight and skin shade discrimination). for a H-1B work visa might be correlated with
These costs capture wage losses, employment their socioeconomic status in their home coun-
losses, and efficiency losses corresponding to try, which in turn might be correlated with the
lost wage and employment. underlying race/ skin shade distribution in that
country.
xxii Racial/ethnic sub-groups among immigrant study participants were rated on a skin shade scale of 1 (lightest) to 10
(darkest). The mean skin shade for Latin Americans, Asian, Black and white was 4.3, 4.1, 7.0 and 2.5, respectively.
Each of these groups was compared to white to obtain the wage gap due to skin shade discrimination, and the
resulting figures were then weighted by their respective number of workers in the general population.

Chart 5.6: Skin shade scale of new immigrants to the US
30%
25%
20%
Proportion
15%
10%
5%
0%
0 1 2 3 4 5 6 7 8 9 10
Skin colour
Latin American Asian Black White
Source: Adapted from Hersch et al (2008).200
As with body dissatisfaction, a final scenario excluding efficiency losses was considered (see
Section 4.2.4) under this scenario the total social and economic cost of skin shade discrimination
would be $487.4 billion.

Case study: Lived experiences of weight discrimination
Trish is a 27-year-old African American “If you’re not one of those girls,
woman living in Maryland. Trish believes then you can expect to be treated
that beauty ideals are something that ap-
peals to the masses and helps to sell prod-
a lot differently. And even when
ucts. In the United States, she describes this it comes to paying for things, like
as, “lighter skin tones, thinner figures, tall they’ll make exceptions for them.
frames, … being flawless, no flaws, without And for you, it’s full price.”
imperfections.” Trish believes that people
who fit typical beauty ideals are given op-
As a result of her experiences, Trish has
portunities in industries such as entertain-
skipped meals to restrict her calorie in-
ment, advertising, and modelling, while
take, sometimes eating only once a day
those who don’t are excluded. Trish, who
or chewing gum from 8:00am to 8:00pm.
describes herself as being ‘heavy’, has
These habits resulted in her struggling to get
experienced this herself while modelling
through the day. Trish also found comfort in
for a store.
going out with a mask during the COVID-19
pandemic, because she didn’t have to spend
Trish and her friend were visiting a store
long hours of the day on makeup to conform
owned by someone Trish knew on a day the
to societal standards.
store was photographing models for ad-
vertisements. While waiting for the models,
she was asked if she wanted to jump in and “Well now, I don’t put on makeup, I
model. But when she did, Trish noticed that save so much time. I think it’s more
most clothes were cut small to fit women
mental than anything, and I’ll
with a smaller size and shape. When she did
put on something to model, she was asked say this for the most part - I can
to angle herself in ways that would hide her navigate without feeling like I’m
stomach. Trish was strongly opposed to this, not worthy.”
wanting to role model bodies that many
people have but feel ashamed of due to the Overtime, Trish has sought therapy and fo-
unrealistic standards set by certain indus- cused on self-acceptance and self-worth to
tries. derive a better understanding of who she is,
and how to best navigate triggering situ-
Trish also recounts she has been treated dif- ations. Through this, she has been able to
ferently in lounges and clubs to other women embrace her own beauty for herself.
around her who sport the “perfect curls” and
“hourglass body” she sees on Instagram.

Case study: Lived experiences of weight discrimination
Sophie shares Trish’s belief about beauty “Before, I wouldn’t even catch a
standards being set by entertainment. glance or whatever. Now it was like
Sophie is a 26-year-old white woman
working as a nurse assistant in California.
I was somebody that he had never
seen before.”
Sophie felt stigma around her weight when
she played softball for her high school team,
with people assuming she couldn’t run bases When Sophie gains weight she feels stigma,
as quickly without assessing her abilities. But even from people she did not know, includ-
Sophie’s weight has fluctuated over different ing grocery shoppers who would judge
stages of her life, and she has noticed being the food items in her grocery cart. Feeling
treated differently when she loses weight by judged physically, rather than for the person
the same set of people, including her ex- she is, makes Sophie feel depressed, anxious
spouse: about pursuing new relationships, seek re-
assurance during existing relationships, and
look at herself as being less beautiful than
others. The acceptance and support Sophie
receives from her family regardless of
her weight has kept her going through
her experiences of weight discrimination.

95 The real cost of beauty ideals
6 Discussion.
It will take a range of initiatives,
underpinned by robust research and
supported by multi-sector partnerships,
to help drive broader social change.
RESEARCHERS EMPLOYERS INDIVIDUALS FAMILY AND

FRIENDS
Tackling
harmful
beauty ideals
GOVERNMENT EDUCATION INDUSTRY

AND AND MEDIA
HEALTH CARE
PROVIDERS

6 Discussion
Key findings
• The findings in this report indicate there is a need to address harmful beauty ideals in
the US to help reduce attributable economic and social costs.
• The combined financial and well-being costs of severe body dissatisfaction in the US
was estimated to be $305 billion in 2019, while for appearance-based discrimination
it was $501 billion. This includes $71 billion associated with the cost of skin shade
discrimination, and $430 billion for weight discrimination.
• Tackling harmful beauty ideals will likely require a range of interventions, supported by
multi-sector partnerships, and underpinned by evidence, to help drive broader social
change. Potential interventions include promoting safer digital spaces, encouraging
diversity in advertising, regulating the sale of harmful products, tax incentives and laws
to end appearance-based discrimination, education at schools to promote body
confidence, mental health support services, and social media literacy.
• Importantly, there are several areas where further research is required to deepen our
understanding of harmful beauty ideals. Targeting these research gaps will help to
ensure interventionsimplemented are effective and remain fit-for-purpose over time.
Harmful beauty ideals impact at least 45 million bigger still for appearance-based discrimina-
people in the US through severe body dissatis- tion, with the financial costs totaling $269 billion
faction every year and 66 million through expe- in 2019 or close to 1.3% of US GDP. In addition,
riences of appearance-based discrimination. the loss of well-being from appearance-based
discrimination was estimated to be $233 billion.
Yet, despite how pervasive the issue is, the
collective impacts of harmful beauty ideals Collectively, the combined financial and well-
(and associated costs) are generally not well being costs was $305 billion for body dissatis-
understood. This report attempts to fill this gap faction and $501 billion for appearance-based
by estimating the economic and social costs discrimination. For both body dissatisfaction
of harmful beauty ideals in 2019 for malesand and appearance-based discrimination, women
females aged 10 years and older in the US. bore most of the impact and costs (58% or $177
billion and 63% or $317 billion respectively).
Modelling for this report found that the financial
costs of body dissatisfaction in 2019 were $84
billion, while the associated well-being costs
were $221. These costs are

COST OF APPEARANCE-BASED COST OF BODY DISSATISFACTION
DISCRIMINATION IN 2019
IN 2019
financial costs financial costs
non- financial costs non- financial costs
Beyond the immediate economic benefits, eliminating harmful beauty ideals
could also greatly improve societal well-being more broadly.
This report highlights that the impacts of body Despite what is now known about the impacts
dissatisfaction and appearance-based discrim- of body dissatisfaction and appearance-based
ination are far reaching – from poorer mental discrimination, there are several areas where
health, to worse employment and education future research is required to improve our un-
outcomes, and even premature mortality. derstanding of the total costs associated with
harmful beauty ideals (see Box 6.1).
The costs of harmful beauty ideals affect every-
one. While the majority of costs related to body
dissatisfaction and appearance-based discrim-
ination were borne by individuals impacted by
them, a large proportion of the costs – up to
54% of the total financial costs for body dissat-
isfaction and 33% for appearance-based dis-
crimination – are borne by every tax payer. This
includes family and friends, employers, private
health insurers, government, and the rest of
society.

BOX 6.1: BUILDING THE EVIDENCE-BASE
AROUND HARMFUL BEAUTY IDEALS
• Further research is needed around specific • More research is needed to inform estimates
forms of appearance-based discrimination of the financial and non-financial costs of
that were not quantified (e.g., hair discrim- body dissatisfaction and appearance-based
ination) or which were not included in this discrimination experienced by transgender
report (e.g., height discrimination, discrimi- and gender nonbinary communities in the US.
nation against people with visible disabilities, Body dissatisfaction and weight, skin shade,
etc.), to better understand their impacts and and hair discrimination affect transgender
costs. Furthermore, it would be valuable to and gender nonbinary communities, but how
gain a better understanding of the intersec- these experiences are patterned by age, sex
tionality between different forms of appear- assigned at birth, and other important factors
ance-based discrimination, for example, is not yet known. In addition, discrimination
experiencing both skin shade and hair dis- targeting transgender and gender nonbina-
crimination. ry communities for their gender expression
is widespread and likely to profoundly affect
• The majority of research in the US of skin employment and other economic indicators,
shade discrimination is focused on the Black but more research is needed to help inform
community. More research is needed to un- costing analyzes like those presented in this
derstand the prevalence and impacts of skin report for cisgender women and men.
shade discrimination for other communities of
color, for whom this form of discrimination is • Some of the studies used in this report were
also likely to be relevant. based on non-US samples and, as a result,
lack generalizability to the US population.
• There are also many different definitions of For example, the odds ratio adopted for
body dissatisfaction in the literature, and anxiety is based on an Irish sample. To obtain
different ways it is measured. Adopting a con- more precise estimates, more US-specific
sistent definition and measure of body dis- research is needed. Further, for some of the
satisfaction would help enable comparisons impacts that were costed, the estimates could
to be made across studies and improve the be improved. For example, the odds ratio
quality of research. for eating disorders for men was based on
disordered eating behaviors as opposed to
• Certain impacts in this report were discussed clinically diagnosed eating disorders.
qualitatively and as such their costs are not
well understood. For body dissatisfaction • For outcomes related to skin shade and hair
this includes certain behavioral disorders, discrimination, controls for race were care-
low self-esteem, risky sexual behavior, worse fully considered to understand how appear-
educational outcomes and profession- ance-based discrimination differs for people
al engagement, alongside the use of risky of the same race, but with different skin shades
cosmetic products and procedures. For ap- and hair types. However, more work is needed
pearance-based discrimination, this includes to enable researchers to further disentangle
employment and health outcomes associated the effects of appearance-based discrimina-
with discrimination. tion from other forms of racial and gender dis-
crimination and identify the incremental costs.

Deepening our understanding of harmful beau- Businesses also play an important role in how
ty ideals, by focusing on key gaps identified in they market their products to consumers, with
this report, will be key to helping to tackle harm- some research exploring tax cuts and other
ful beauty ideals moving forward. But what else business incentives as a way to prevent digitally
can be done to address the underlying forces altered and highly unrealistic advertising.208
that promote and propagate harmful beauty Furthermore, raising awareness around the
ideals? role of certain consumer products, such as skin
bleaching, in perpetuating harmful beauty
The media is an important channel through ideals could also help to disincentivize busi-
which harmful beauty ideals are created and nesses from producing and marketing these
consumed by the general public. By removing products.209 Workplaces could also tackle ap-
harmful advertisements and promoting diver- pearance-based discrimination through imple-
sity, the media can help to break down narrow menting unconscious bias training alongside
beauty ideals. For example, in 2021, Pinterest inclusivity programs.
became the first major media platform to ban
all advertisements with weight loss language Similarly, unconscious bias training could be
and imagery, including those that glamorize used to educate those working in the criminal
or diminish particular body types.201 justice system on how appearance-based dis-
crimination leads to unfair outcomes for mar-
Research has shown that the media can be ginalized groups. While some law enforcement
used as a tool to help – not hinder – people’s officers, judges and prosecutors have been
attitudes towards their own appearance and exposed to unconscious bias training, it has
the appearance of others. For example, expo- mostly focused on racial bias overall and is yet
sure to self compassion quotes on social media to explore specifically skin shade or other ap-
has been shown to help improve young wom- pearance-based forms of bias.210
en’s body dissatisfaction.202 Other research has
shown that promoting positive and non-stere- Helping to raise awareness around appear-
otypical portrayals of people of a higher weight ance-based discrimination among health care,
in the media can reduce weight stigma, weight education and other government service pro-
discrimination and their associated negative viders could help to reduce its prevalence in
health outcomes.203,204,205,206 particular settings. For example, the quality of
healthcare provided could be improved through
Educating people about the unrealistic nature ethics training among medical and nursing
of images shown in the media can also help students to reduce weight or skin shade dis-
to prevent people from internalizing harmful crimination.211 This could also enable health care
beauty ideals. For example, McLean et al (2016) providers to have important conversations with
find that media literacy – that is, the ability to their patients around the attributable health
think critically about media – is a protective risks. Stigma in design systems also needs to be
factor against body dissatisfaction after viewing tackled to facilitate inclusiveness of all bodies.
thin-ideal media images.207 This might include expanding seat sizes and
door frames and updating medical equipment

to suit people with large bodies.212 It could also dence suggests the impacts of body dissatisfac-
include correcting bias in some medical tech- tion and appearance-based discrimination may
nologies (such as medical oximeters which have increased during the COVID-19 pandemic.
measure people’s oxygen saturation levels), A recent study published by Sutin et al. (2021)
which have been shown to be more effective found that compared to pre-COVID-19 times,
on lighter skin shades compared to darker skin weight discrimination during the pandemic was
shades.213 associated with a two-fold increased risk
of depression.217 Further, the stress induced by
Many researchers have also called for strong- COVID-19 lockdowns has been linked to wors-
er legislation targeting appearance-based ening body image and maladaptive eating
discrimination.214 For example, the Creating a practices.218,219
Respectful and Open World for Natural Hair
(CROWN) Act prohibits schools and workplaces This is only a snapshot of potential interventions
from discriminating against people based on for what is a very broad and pervasive issue. In
their natural hair styles and has been passed in reality, it will take a range of initiatives, under-
twelve states in the US as of July 2021.215 Further, pinned by robust research and supported by
only one state and six cities in the country have multi-sector partnerships, to help drive broader
enacted legislation that prohibits discrimination social change (see Figure 6.1).
on the basis of weight.216
Importantly, indicators for both body dissatis-

faction and appearance-based discrimination
need to be developed and monitored over time
in national data collections. For example, evi-

Figure 6.1: Tackling harmful beauty ideals
FAMILY AND
RESEARCHERS EMPLOYERS INDIVIDUALS FRIENDS
•B
roaden the •R
eview workplace • Follow social media • Promote positive body
evidence base around grooming policies to accounts that promote image through healthy
the impacts ofharmful limit appearance-based positive and diverse beauty. conversations about
beauty ideals. discrimination. •S eek help if you feel you appearance.
ocus on key limitations
•F • Implement unconscious are experiencing body • Avoid criticising others
identified in this report. bias training to help dissatisfaction or appear- about the way they look.
• Continue to evaluate address appearance bias, ance-based discrimination.
evidence-based alongside comprehensive • R
espect, accept and
interventions to inclusivity programs. appreciate your body for
improve body • Introduce a zero toler- everything it can do and
satisfaction. ance policy for appear- how it looks.
ance-based discrimina- • Get involved in civic
tion. advocacy to enact antidis-
crimination legislation
and company policies.
Tackling
harmful
beauty ideals
EDUCATION AND
HEALTH CARE INDUSTRY
GOVERNMENT PROVIDERS AND MEDIA
• Implement interventions that • I mprove training for health • Stop digital distortion and
are underpinned by a strong practitioners and teachers to promote appearance
evidence base. mitigate bias in service delivery. diversity in advertising.
•E
valuate interventions over • Implement checks for equipment, • Ensure there are a variety of
time to ensure they remain seating, clothing, etc. to ensure it creators behind the camera.
fit-for-purpose. is inclusive of all body sizes. •E
ducate minors, especially
• I mprove data collection • Ensure medical devices are with social media literacy, to
around the prevalence and effective for all skin shades; create safer digital spaces.
impacts of body dissatisfaction ensure training in dermatology • Develop products which meet
and appearance-based covers all skin shades. hygiene and personal care
discrimination. • Teach evidenced-based body needs and do not reinforce
•E
xpand anti-discrimination image lessons in schools and harmful beauty ideals.
statute to prohibit discrimination have explicit anti-bullying • Advance social media policies
based on weight, height, skin policies that address appear- to create safer digital spaces.
shade, and natural hairstyle. ance-based discrimination.

Appendices.

Appendix A :
Costing methodology
Overview of literature review
This analysis was informed by a broad litera- Snowballing techniques were also used to
ture review, which helped inform the various expand on these terms and identify other
inputs required to understand the impacts of relevant sources. These were also combined
harmful beauty ideals and estimate the associ- with searches of specific data sources, such as
ated costs. publications from the BLS for general inputs to
the model and report.
Searches were conducted across a range of
different data-bases, such as Google Scholar Evidence was assessed using the guiding
and PubMed, JSTOR and EconLit. Key search principles of the Grading of Recommenda-
phrases included an interaction between the tions Assessment, Development and Evaluation
terms relating to body dissatisfaction, appear- (GRADE) approach.220 Key factors considered
ance, discrimination, and the possible out- in the evaluation of evidence include:
comes associated with these. Examples of key
words include: • the risk of bias
• the precision of effect estimates
• Body (dis)satisfaction, body image, • the consistency of individual study results
self-esteem • how directly the evidence answers the
• Attractiveness, beauty, beauty ideals, question of interest
appearance • the risk of reporting bias.
• Skin shade, skin color, colorism, skin tone

An important consideration is whether a caus-
• Weight discrimination, weight bias, weight al relationship was evident in the literature,
stigma, perceived discrimination between the impact being studied and the
• Natural hair, hair discrimination pathways of appearance-based discrimination
• Cost, impact, association, outcome, and body dissatisfaction. Further, studies were
risk,odds, effect reviewed to determine whether they controlled
for a range of confounding factors, such as
• Depression, anxiety, weight control, suicide,
race, gender, age, and other variables. This
suicidal thought, suicide attempt, eating dis-
was done to reduce the chance of bias impact-
orders, obesity, drug, alcohol, dieting, tan-
ing on the estimated PAFs in the costing study.
ning, smoking, substance abuse, mortality,
quality of life, skin bleaching, injury, cardio-
Importantly, not all impacts associated with
vascular, metabolic, diabetes, hypertension
• Wage, earnings, income, employment, ed- discrimination were costed. Impacts were ex-
ucation, attainment, crime, incarceration, cluded if they risked double counting, if there
arrests, healthcare, caregiving, care was inadequate cost data, or if the available
• Economic, social. empirical evidence was of low quality.

General modelling approach
As discussed in Chapter 2, our intent was to Not all health impacts were costed in the study.
cost the economic and social costs of harmful For example, impacts were discussed qualita-
beauty ideals. This was done by looking at the tively if they risked double counting (e.g., sui-
attributable costs of the outcomes associated cides and depression), if there was inadequate
with body dissatisfaction and harmful beauty cost data, or if empirical evidence was sparse.
ideals. Body dissatisfaction was associated with
poorer health outcomes in the form of a range Furthermore, this analysis does not consider
of health impacts. Appearance-based dis- possible future costs that may be attributed to
crimination was associated with poorer labor each health impact itself - for example, lung
market, health, and other life outcomes such as cancer costs attributable to the increased rate
incarceration. The health outcomes of appear- of smoking, or liver disease due to risky drink-
ance-based discrimination presented in the ing, among others. In part, this represents a
form of health impacts as in body dissatisfac- more conservative approach, but there is also
tion, but also in the form of healthcare avoid- some uncertainty about the longer-term out-
ance and poorer quality of care. comes of body dissatisfaction and appear-
ance-based discrimination (i.e. studies have
Outcomes for appearance-based discrimina- not linked body dissatisfaction, for example,
tion varied by type of discrimination and were to an increased risk of lung cancer).
not quantified for all population sub-groups
due to insufficient empirical evidence. A summary of the outcomes and groups affect-
ed is provided in Table A.1, and this is further
disaggregated by outcome and health impact
from either body dissatisfaction or appear-
ance-based discrimination in Table A.2.

Table A.1: Outcomes of body dissatisfaction and appearance-based discrimination,
and groups affected
PATHWAY FORM OUTCOMES GROUPS AFFECTED

Body N/A • Poor health outcomes
dissatisfaction
• (depression, anxie-
ty, eating disorders, • People aged 10 years and above,
smoking, suicide experiencing body dissatisfaction
attempts, alcohol and
drug abuse)
Appearance- Weight • Poor health outcomes
based discrimina- • People aged 10 years or above,
(depression, anxiety,
discrimination tion experiencing weight discrimina-
drug abuse, smoking,
tion
obesity)
• White working females with a
• Wage losses from
BMI of 25kg/m2 or higher
labor market
• Black working females with a
discrimination
• White working females with a
• Employment losses
• White working males with a
from labor market
BMI between 25-30kg/m2
discrimination
• Hispanic working females with a
Skin shade • Poor health outcomes • Black males and females aged 10
discrimina- (depression, hyper- years or above, of a ‘very dark’
tion tension) skin shade*
• Black working females and males

• Wage losses of a ‘dark’ or ‘very dark’ skin
shade*
• Black working females and males
• Employment losses of a ‘dark’ or ‘very dark’ skin
shade*
• Discriminatory incar- • Black males and females aged
ceration (prison costs, 10 years or above, of the darkest
wage losses) tercile**

*as categorized by Monk, E.P (2015)
**as derived from Kreisman and Rangel (2015) .

Table A.2: Cost types included by impact for body dissatisfaction and appearance-based
discrimination
IMPACT COST TYPE

Wage and
Absentee- Presentee- Informal
Medical Pharma employ-
ism ism care
ment
Depression
Eating disorders
Alcohol and drug

abuse
Suicide attempts
Smoking
Anxiety
Obesity
Hypertension
Direct effect of skin

shade
discrimination
Impacts of skin shade

discrimination
Direct effect of weight

discrimination
Impacts of weight
discrimination
Source: Deloitte Access Economics analysis

Table A.2 (continued): Cost types included by impact for body dissatisfaction and
appearance-based discrimination
IMPACT COST TYPE

Efficiency
Premature
and YLDs YLLs
mortality
other
Depression
Eating disorders
Alcohol and drug

abuse
Suicide attempts
Smoking
Anxiety
Obesity
Hypertension
Direct effect of skin

shade
discrimination

discrimination
Direct effect of weight

discrimination
Impacts of weight
discrimination

Table A.2 (continued): Cost types included by impact for body dissatisfaction and
appearance-based discrimination
IMPACT NOTES (IF APPLICABLE)
Depression
Eating disorders
Absenteeism costs relate to time spent away from work due to hospitali-
zations directly attributable to drugs and/or alcohol. In contrast, presen-
Alcohol and drug teeism, reduced employment and informal care costs are not applicable
abuse as alcohol and illicit drug use has not been costed as an ongoing condi-
tion. Similarly, YLDs have not been estimated but deaths that are directly
attributable to drugs and alcohol (e.g., overdoses) have been included.
This impact specifically focuses on suicide attempts and by definition ex-
Suicide attempts cludes all attempts that result in death. As such, YLLs and loss of lifetime
earnings associated with suicides are not included.xxiii
Smoking is a risk factor for other health conditions and illnesses (such
as lung cancer) but does not directly incur health costs. Similar to illicit
Smoking drugs and alcohol, there are no ongoing costs associated with reduced
employment, informal care, and loss of well-being. Presenteeism costs
relate to lost productivity from increased smoking breaks.
Anxiety
Obesity is a risk factor for other health conditions which can result in
premature mortality; however, these are not captured as they are be-
yond the direct cost of obesity included in this study. Similarly, informal
Obesity
care is associated with comorbidities for which obesity is a risk factor,
rather than obesity itself. The wage and employment effects of obesity
are those hat result from weight discrimination in the labor market.
The costs associated with hypertension are those that result from a
clinical diagnosis of hypertension. Costs in this study include the direct
Hypertension treatment costs (e.g., hypertensive medications) for the condition. The
conditions for which hypertension is a risk factor, such as stroke and
heart failure are not accounted for.
Direct effect of
Includes incarceration costs as well as the difference in wages and
skin shade
discrimination
employment.

Includes health impacts associated with skin shade discrimination.
discrimination
Direct effect of weight Includes differences in wages and employment due to perceived weight
discrimination discrimination.
Impacts of weight
Includes health impacts associated with weight discrimination.
discrimination

xxiii Costs associated with suicides are instead captured through the depression and anxiety pathways.

There are several general economic parameters and assumptions that inform the modelling for
this report. These include the discount rate, inflation data, employment and earnings and others
(see Table A.3).
Table A.3: Overall cost parameters

PARAMETER VALUE SOURCE
Base year 2019 n/a
Discount rate 3% Murray (1994)223
Females and males aged 10
Population of interest years and older. Varies by US Census data224
group.
Bureau of Labor Statistics
CPI inflation 1.8%
(BLS)225
Health inflation
Centers for Medicare and
(personal health care price 1.4%
Medicaid Services226
index)
Average weekly earnings Varies by group. BLS227
Fringe wages 1.46 BLS228
Employment rates Varies by group. BLS229
Source: As noted.
Prevalence of body dissatisfaction

The prevalence of body dissatisfaction, broken down by five-year age groups and gender, is
shown in Table A.4.
Table A.4: Prevalence of body dissatisfaction, % of population

AGE GROUP (IN YEARS) FEMALE MALE
10-24 19.2% 12.2%
25-34 13.2% 9.4%
35-44 19.8% 13.8%
45-54 24.8% 13.4%
55-64 24.6% 13.0%
65+ 14.6% 9.9%
Source: Deloitte Access Economics based on Fallon et al (2014).

Estimates of the prevalence of body dissatisfac- Estimates were adjusted by age based on the
tion have been drawn from Fallon et al (2014), breakdown in Fallon et al (2014). Age adjust-
representing the results from the Body Areas ments were based on the average deviations
Satisfaction Subscale (BASS) of the Multidi- across age groups, comparing a cut-off score
mensional Body-Self Relations Questionnaire of 2.75 and 3. The resulting age adjustments
(MBSRQ). Body dissatisfaction was constructed are shown in Table A.5. For ages 10-19, no ad-
as a binary variable based on average BASS justment has been made (as Fallon et al con-
scores. If someone received a score of 2.75 or sidered only adults in their study).
lower, they were classified as having body dis-
satisfaction, as per Frederick et al (2009).
Table A.5: Age adjustments for the prevalence of body dissatisfaction

10-19 1.00 1.00
20-24 0.63 1.30
25-34 0.69 0.77
35-44 1.03 1.13
45-54 1.29 1.10
55-64 1.28 1.06
65+ 0.76 0.81
Source: Deloitte Access Economics based on Fallon et al (2014).
Prevalence of appearance-based
discrimination
The overall prevalence of appearance-based
discrimination, broken down by five-year age
groups and gender, is shown in Table A.6. These
estimates were derived by aggregating the
number of people in the population experienc-
ing weight discrimination (based on prevalence
estimates in Table A.7), skin shade discrimina-
tion (based on prevalence estimates in Table
A.8) and hair discrimination.

Table A.6: Prevalence of appearance-based discrimination, % of population
10-14 25.9% 22.0%
15-19 25.7% 21.9%
20-24 26.0% 22.1%
25-29 26.7% 22.5%
30-34 25.6% 21.4%
35-39 25.1% 20.8%
40-44 26.8% 22.8%
45-49 26.5% 22.6%
50-54 26.1% 22.4%
55-59 25.5% 22.0%
60-64 22.5% 18.3%
65-69 21.6% 17.5%
70-74 20.5% 16.6%
70-74 20.0% 16.1%
80-84 19.8% 15.9%
85-89 22.6% 15.8%
90+ 14.3% 14.4%
Source: Deloitte Access Economics based on Spalholz et al (2016)230, Robinson et al (2017)231,
CDC.232, Monk (2015)233, Kreisman and Rangel (2015)234.
A limitation of this approach is the potential egory was derived from CDC235 and applied to
cross-over between those who experience skin the working age population as relevant. Health
shade discrimination, and those who experi- differentials were evidenced for people who
ence hair discrimination. This limitation might perceived weight discrimination. The preva-
overstate the overall prevalence of appear- lence of perceived weight discrimination by age
ance-based discrimination, but has no conse- and gender is shown in Table A.7. There was no
quence for cost estimation, as the cost of hair evidence of weight discrimination impacting
discrimination has been estimated separately incarceration.
from the total.
The prevalence rate for weight discrimina-

tion varied by outcome stream. Labor market
differentials were faced by the working age
population according to their BMI category.
The proportion of people in each weight cat-

Table A.7: Prevalence of weight discrimination, % of population
10-39 11.4% 11.5%
40-59 13.1% 13.7%
60+ 10.7% 10.5%
Source: Spalholz et al (2016)236
As in the case for weight discrimination, the prevalence rate for skin shade discrimination varied
by outcome stream (labor market outcomes, health outcomes and other life outcomes). Labor
market differentials were evidenced for the Black working population withmedium and dark skin
shades. Health outcome differentials were evidenced for the proportion of Black people with the
darkest skin shade on average. Other life outcomes capturing incarceration was evidenced for
Black people with the darkest skin shades. These estimates are presented in Table A.8.
Table A.8: Prevalence of skin shade discrimination, % of population

OUTCOME FEMALE MALE SOURCE
Labor market outcomes 69.9% i
69.9% i
Kreisman and Rangel (2015)237
Health outcomes 18.0%ii 18.0%ii Monk, E. P (2015)238
Other life outcomes 33.6% 33.6% Kreisman and Rangel (2015)239
Source: Calculated as approximate terciles of medium skin shade (rates 0 to 7) and dark skin shade
(rated 8 to 10) ii skin shade ‘very dark’ and ‘dark’.
The prevalence of hair discrimination is esti- P(RR - 1)

mated to be 25% of women identifying as being PAF =
P(RR -1) + 1
of African descent between 18-71 years of age,
per Johnson et al (2014).240 The population Where: P represents the prevalence of body
group captured in the study was Black women. dissatisfaction or appearance-based discrim-
No age breakdown was provided. ination, and RR represents the relative risk of
impact. As noted, the PAFs are derived based
Prevalence of impacts associated with body
dissatisfaction and appearance-based on the prevalence of body dissatisfaction or
discrimination appearance-based discrimination together
Costs were attributed to body dissatisfaction with the RR (or OR where this is not available).
and the health and incarceration outcomes of The RR was drawn from a range of sources
appearance-based discrimination using popu- in the literature, as summarized in Table A.9.
lation attributable fractions (PAFs). Where possible, inputs have been used that are
specific to men and women. Where this is not
The PAFs used in this analysis were calculated available, the same input has been used for
using the following formula: both sexes.

Table A.9: Prevalence and odds ratios/relative risks of impacts associated with
body dissatisfaction and appearance-based discrimination
PATHWAY IMPACT PREVA- ODDS RATIO/ SOURCE AND NOTES
LENCE HAZARD RATIO/
OF IMPACT RELATIVE RISK
(Crude rate, % of
population
aged 10+) FEMALE MALE
OR: Bornioli et al (2021)241
Based on severe episodes.
Body dissatisfaction Depression 1.0% 1.84 2.85 Prevalence: Hasin et al (2018)242; Global
Burden of Disease (GBD) (2019)243
HR: F: Bornioli et al (2019)244
Average across bulimia nervosa, binge
Eating eating disorder, and purging disorder.
disorders
1.9% 2.20 1.87 M: Neumark-Sztainer (2006)245
Prevalence: Deloitte Access Economics
(2020)246
OR: F: Bornioli et al (2019)247 Average
Alcohol and across high-drinking and illicit drug use.
drug abuse
7.4% 1.46 2.13 M: Field et al (2014)248
Prevalence: SAMSHA (2019)249
Suicide OR: Crow et al (2008)250

attempts
0.6% 2.23 1.81 Prevalence: SAMSHA (2019)251
OR: Bornioli et al (2019).252
Body dissatisfaction Smoking 12.7% 1.56 1.41 Prevalence: Centers for Disease Control
and Prevention (2020)253
OR: Dooley et al (2015)254
Based on moderate and severe anxiety.
Body dissatisfaction Anxiety 6.1% 1.87 1.87 Prevalence: Kessler et al (2012);255 GBD
(2019)256
OR: Robinson, Sutin and Daly (2017)257
Weight discrimination Depression 1.0% 1.50 1.50 Prevalence: Hasin et al (2018)258; Global
OR: Hatzenbuehler et al (2009)260
Weight discrimination Anxiety 6.1% 2.92 2.92 Prevalence: Kessler et al (2012);261 GBD
(2019)262
OR: Sutin and Terracciano (2017)263
Weight discrimination Smoking 12.7% 1.64 1.64 Prevalence: Centers for Disease Control
and Prevention (2020)264
Becoming OR: Sutin and Terracciano (2013)265
obese
50.6% i 1.72 1.72 Prevalence: See note i
Remaining OR: Sutin and Terracciano (2013)266
obese
49.4%ii 1.69 1.69 Prevalence: See note ii
OR: Sutin and Terracciano (2017)267
Weight discrimination Drug abuse 7.4% 2.01 2.01 Prevalence: SAMSHA (2019)268
OR: Monk, E. P (2015)269
Skin shade
discrimination
Depression 1.0% 1.54 1.54 Prevalence: Hasin et al (2018)270; Global
Skin shade OR: Monk, E. P (2015)272
discrimination
Hypertension 5.5% 1.94 1.94 Prevalence: CDC (2020)273
Source: As noted. i.% of population that is underweight or ‘normal’ weight (BMI < 30 kg/m2).
ii.% of population that is obese (BMI equal to
i. % of population with BMI < 30 kg/m2.

ii. % of population with a BMI equal or greater 30 kg/m2.
The PAFs are summarized in Table A.10
Table A.10: Summary of Population Attributable Fractions (PAFs)

PATHWAY IMPACT PAF
Female Male
Body dissatisfaction Depression 13% 17%
Body dissatisfaction Eating disorders 18% 9%
Alcohol and drug
Body dissatisfaction 2% 3%
abuse
Body dissatisfaction Suicide attempts 13% 12%
Body dissatisfaction Smoking 8% 4%
Body dissatisfaction Anxiety 22% 15%
Weight
Depression 5% 5%
discrimination
Weight
Anxiety 19% 21%
discrimination
Weight
Smoking 5% 3%
discrimination
Weight
Becoming obese 1% 0.4%
discrimination
Weight
Remaining obese 2% 2%
discrimination
Weight
Drug abuse 7% 4%
discrimination
Skin shade
Depression 1% 1%
discrimination
Skin shade
Hypertension 1% 1%
discrimination
Skin shade
Incarceration 4% 6%
discrimination
Labor market outcomes of appearance-based discrimination were estimated through a first

principles approach, where the wage andemployment gap resulting from appearance-based
discrimination was applied to the prevalence of appearance-based discrimination in the working
population. The approach for labor market outcomes is described further under the
productivity costs section.

Health costs
The health unit cost inputs for body dissatisfaction and appearance-based discrimination are
reported in Table A.11 and Table A.12 respectively.
Where unit health costs were not provided in 2019 dollars, they have been inflated using a rate of
1% per annum, based on the personal health care price index.274 Adjusted unit costs have then been
multiplied by the prevalence of the condition in 2019, to yield the total health cost by condition.
Table A.11: Health unit costs and data sources for body dissatisfaction
IMPACT MEDICAL SERVICES PHARMACEUTICALS SOURCE AND NOTES
Depression $1,754 $921 Greenberg et al (2021)275
Suicide attempts $2,834 $1,488 Shephard et al (2016)276

Deloitte Access Economics
Eating disorders $813 $18
(2020)277
Anxiety $1,288 $609 Shirneshan et al (2012)278
Smoking* n/a n/a n/a
Drugs & alcohol $23,256* $3,781* Quantified Ventures (2017)279
Source: As noted.
Note: Health costs for drugs and alcohol reflect the cost per hospitalization and emergency department visit,
as opposed to a per person cost.
*Not all costs are estimated for each impact, see Table A.2.
Table A.12: Health unit costs and data sources for appearance-based discrimination
Depression $1,754 $921 Greenberg et al (2021)280
Anxiety $1,288 $609 Shirneshan et al (2012)281
Smoking n/a* n/a* n/a*
Obesity $1,782 $838 Cawley et al (2021)282
Drug abuse $23,256 $3,781 Quantified Ventures (2017)283
Hypertension $519 $260 Heart Disease and Stroke

Statistics (2019)284
Source: As noted. *Not all costs are estimated for each impact, see Table A.2.

Productivity costs A wage inflation parameter of 2.5% was used
Productivity costs comprise a range of different to inflate values to 2019 dollars.285
cost types, including presenteeism costs, ab-
senteeism costs, reduced employment partici- Where productivity costs do not already incor-
pation, informal care costs, and loss of lifetime porate employee benefits, this has been added
earnings from premature mortality. in based on the ratio of wages and salaries to
total employee compensation from the BLS.286
Presenteeism and absenteeism
For presenteeism and absenteeism costs, unit A summary of presenteeism and absenteeism
costs have been taken directly from existing unit costs and their sources for body dissatis-
cost of illness studies where available and ad- faction and appearance-based discrimination
justed for changes in prevalence and inflation. are shown in the Tables below.
Table A.13: Productivity unit costs and data sources for body dissatisfaction
Depression $1,642 $4,146 Greenberg et al (2021)287
Suicide attempts $2,389 $8,056 Shephard et al (2016)288

Deloitte Access Economics
Eating disorders $1,166 $3,324
(2020)289
Anxiety $727 $673 Marciniak et al (2004)290
Smoking* $645 $4,414 Berman et al (2013)291
Drugs & alcohol $432 n/a Quantified Ventures (2017)292
Table A.14: Productivity unit costs and data sources for appearance-based discrimination
Depression $1,642 $4,146 Greenberg et al (2021)293
Anxiety $727 $673 Marciniak et al (2004)294
Smoking $645 $4,414 Berman et al (2013)295

F: $112 F: $331
Obesity Finkelstein et al (2010)296
M: $178 M: $347
Drug abuse $432 n/a Quantified Ventures (2017)297
Hypertension $28 $453 Heart Disease and Stroke

Statistics (2019)298

Reduced participation in the labor • An individual who perceives weight discrimi-
market nation compared to one who does not.
To calculate reduced employment participa-
tion, estimates of the reduction in employment In addition to a direct effect on employment
associated with an attributable condition or between groups, appearance-based discrim-
illness have been drawn from the literature. ination also leads to worse health outcomes
This reduction in employment have been mul- which in turn may reduce the likelihood of
tiplied by US general population employment being employed. (see Table A.17). In a simi-
rates and average weekly earnings by age and lar way, additional incarcerations due to skin
gender. Earnings were adjusted to incorporate shade discrimination also impose a reduction in
employment benefits as previously described. employment compared to a situation where the
discrimination does not exist.
For body dissatisfaction, the relative reduction
in employment associated with attributable The efficiency losses associated with the em-
conditions and illnesses is shown in Table A.15. ployment gap were derived under the assump-
tion that the people facing hiring discrimination
For appearance-based discrimination, the em- remain unemployed for duration of the year.
ployment gap was derived based on the lower This means the employment gap represents a
likelihood of employment for each of skin shade complete loss of output for society. That is, in
and weight discrimination when comparing: the absence of appearance-based discrimi-
nation, these individuals would otherwise be
• An individual who has darker skin shades employed at the same rate as in the general
(medium or dark skin shades) compared to population, and earning the same wage.
one with lighter skin shades, controlling for
race effects
Table A.15: Reduction in employment (%) and data sources for body dissatisfaction
IMPACT EMPLOYMENT (%) SOURCE
Luciano & Meara (2014)299, based on moderate
Depression 17%
mental illness
Various sources; based on the proportion of people
Suicide attempts 4% who are severely incapacitated or sustain a long-
term disability following a suicide attempt 300,301,302
Eating disorders 12% Deloitte Access Economics (2020)303
Luciano & Meara (2014)304, based on moderate
Anxiety 17%
mental illness
Smoking* n/a n/a
Drugs & alcohol n/a n/a

Table A.16: Reduction in employment (%) and data sources for employment outcomes
associated with appearance-based discrimination
IMPACT GROUP EMPLOYMENT GAP (%) SOURCE

White, female, obese 1.5% Han et al (2008)305
Hispanic, female, obese 4.5% Han et al (2008)
Black, women, obese Insignificant Han et al (2008)
White, female, overweight Insignificant Han et al (2008)
Hispanic, female, overweight 2.4% Han et al (2008)
Black, female, overweight Insignificant Han et al (2008)
White, male, obese Insignificant Han et al (2008)
Hispanic, male, obese Insignificant Han et al (2008)
Black, male, obese Insignificant Han et al (2008)
White, male, overweight 0.6% Han et al (2008)
Hispanic, male, overweight Insignificant Han et al (2008)
Black, male, overweight Insignificant Han et al (2008)
Black, female 15.0% Hersch, J. (2006)306
Black, male 15.0% Hersch, J. (2006)
Source: As noted. Employment rates for each group for weight discrimination are relative to the ‘normal’ weight
category. Employment rates for skin shade discrimination for each impact group are relative to lighter skin shades
in the same race or ethnic group.
Table A.17: R
eduction in employment (%) and data sources for health outcomes
associated with appearance-based discrimination
IMPACT EMPLOYMENT (%) SOURCE
Depression 17% Luciano & Meara (2014)307, based on moderate

mental illness
Anxiety 17% Luciano & Meara (2014)308, based on moderate
mental illness
Smoking n/a n/a
Obesity n/a n/a
Drug abuse n/a n/a
Hypertension n/a n/a
Source: As noted.
Social and economic costs from the
appearance-based discrimination wage
gap
Economic loss from labor market outcomes ing population were categorized into different
for appearance-based discrimination were weight segments using estimates from CDC.311
estimated by determining the average loss in The wage penalty for various weight segments
income due to the discrimination. These were of men and women were then applied to the
obtained for skin shade discrimination and relevant segments and aggregated to derive
weight discrimination. the total wage gap due to weight discrimination.
The wage penalties for both, skin shade and
To derive the wage gap associated with skin weight discrimination were those that persisted
shade discrimination, a skin shade distribution after holding constant the common determi-
was derived for the Black working population nants of income, such as education, experience
based on literature.309,310 The average wage and talent. A wage gap due to weight discrimi-
penalty for the relevant skin shade was then nation was only found for the proportion of
multiplied by the relevant portion of the working the population considered obese in Han et al
population that fits this distribution, and ag- (2008).312 The effects for the overweight or
gregated to derive the total wage gap due to underweight population wasinconclusive.
skin shade discrimination. Similarly, the work-
Table A.18: W
age gap (% reduction) and data sources for labor market outcomes associated
with appearance-based discrimination
IMPACT GROUP EMPLOYMENT (%) SOURCE
White, female, obese 7.5% Han et al (2008)313
White, male, obese Insignificant Han et al (2008)
Black, female, obese 4.9% Han et al (2008)
Black, male, obese Wage gain Han et al (2008)

Black, female 6.3% Kreisman and Rangel (2015)314
Black, male 6.3% Kreisman and Rangel (2015)
Source: As noted. The wage gap for weight discrimination is relative to the ‘normal’ weight category.
The wage gap for skin shade discrimination is relative to lighter skin shades in the same race or ethnic group.

A key modelling assumption was then made higher by an amount approximately equal
in the analysis: The wage gap represents an to two-thirds (63%) of the wage gap. This as-
inefficient use of labor resources, and societal sumption was applied to the wage gap esti-
output would be higher in the absence of ap- mate derived in this study.xxiv
pearance-based discrimination. However, only
part of the gap would be closed. For example, Informal caregiving
someone with dark skin may be overlooked To estimate the costs of informal care for peo-
for a promotion and therefore may face lower ple in the US experiencing body dissatisfaction
wages than they otherwise would have if they and appearance-based discrimination, it was
were suitable for the position. However, the necessary to estimate the proportion of people
employer will most likely have filled the position receiving support from a caregiver for each
they were hiring for, even if they may not have attributable condition and the number of hours
chosen the most suitable applicant. of care provided.
As a result, it is necessary to consider the eco- Informal care costs were calculated using an
nomic costs of an inefficient allocation of labor opportunity cost approach. The opportunity
which is leading to the wage gap. To do this, lit- cost of an hour of care was estimated using
erature on the declining labor market discrimi- general population average weekly earnings
natory barriers faced by women and Black men and employment rates from the BLS. Earnings
was considered. Between 1960 and 2010, Hsieh were adjusted to incorporate employment ben-
et al (2018)315 found that reduced discrimination efits, using the ratio of wages and salaries to
and improved allocation of talent meant that total employee compensation. The opportunity
GDP in 2010 was 43.5% higher than it otherwise cost of a caregiver’s time was estimated to be
would have been in the absence of reducing $22.48 per hour.
discrimination. Further, Hsieh et al (2018) esti-
mated that GDP would be a further 9.9% higher The health outcomes associated with body
if the discriminatory barriers were completely dissatisfaction and appearance-based dis-
removed in 2010. Further analysis of the results crimination were not treated as risk factors for
of Hsieh et al (2018) indicatesthat close to 20% other conditions; thus, informal caregiving was
of the possible gain in GDP could be realized if not incorporatedfor associated conditions such
wage gaps did not persist in 2010.xxiv as lung cancer for smoking or cardiovascular
conditions for hypertension.
When this is compared to the size of the wage
gaps that existed in 2010 for women and Black
men,316 societal output can be estimated to be
xxiv The remaining gain in GDP would occur due to declining

barriers in the labor market, including increased labor
force participation, improved allocation of talent and
human capital accumulation.

Table A.19: Informal care hours and data sources for body dissatisfaction
IMPACT HOURS OF PROPORTION OF SOURCE AND NOTES

CARE PEOPLE WITH
CONDITION RE-
QUIRING CARE
Based on the incremental difference be-
tween care hours provided for people with
Depression 8.1 hours 100%
a mental illness,317 compared to the aver-
age hours spent by a primary caregiver.
Reflects the hours provided by a primary
caregiver.319 This is multiplied by the pro-
Suicide attempts 23.7 hours 4% portion of people who are severely inca-
pacitated or sustain a long-term disability
following a suicide attempt.320,321,322
Eating disorders 4.45 hours 100% Deloitte Access Economics (2020)323
Based on the incremental difference be-
tween care hours provided for people with
Anxiety 8.1 hours 100%
a mental illness,324 compared to the aver-
age hours spent by a primary caregiver.325
Smoking* n/a n/a n/a
Alcohol and
n/a n/a n/a
drug abuse*
Table A.20: Informal care hours and data sources for appearance-based discrimination
IMPACT HOURS OF PROPORTION OF SOURCE AND NOTES

CARE PEOPLE WITH
CONDITION RE-
QUIRING CARE
Based on the incremental difference
between care hours provided for
Depression 8.1 hours 100% people with a mental illness,326 com-
pared to the average hours spent by a
primary caregiver.327
Based on the incremental difference
between care hours provided for peo-
Anxiety 8.1 hours 100% ple with a mental illness,328 compared
to the average hours spent by a
primary caregiver.329
Smoking n/a n/a n/a
Obesity n/a n/a n/a
Drug abuse n/a n/a n/a
Source: As noted.

Loss of lifetime earnings
To estimate premature mortality, the discounted future value of lifetime earnings is multiplied by
deaths associated with attributable conditions and illnesses of body dissatisfaction and appear-
ance-based discrimination. Lifetime earnings are discounted at a rate of 3%,330 and incorporate
employment rates and average lifetime earnings based on the agegender distribution of deaths.
The crude rate of deaths associated with attributable conditions of body dissatisfaction and
appearance-based discrimination is provided below.
Table A.21: Mortality rates for health conditions associated with harmful beauty ideals,
and data sources
PATHWAY IMPACT MORALITY RATE SOURCE AND NOTES

BY IMPACT (crude
rate, ages 10+)
Based on prevalence of suicides from
Body
Depression 0.80% CDC Wonder (2020).331 Attribute 50%
dissatisfaction
of suicides to depression.332
Body Eating
0.19% Deloitte Access Economics (2020)333
dissatisfaction disorders
Body Alcohol and
1.55%* CDC Wonder (2020)334
dissatisfaction drug abuse
Body Suicide
n/a n/a
dissatisfaction attempts
Body
Smoking n/a n/a
dissatisfaction
Body
Anxiety 0.03% CDC Wonder (2020).335 Attributes 10%
dissatisfaction
of suicides to anxiety.336
Weight/skin Based on prevalence of suicides from
shade Depression 0.80% CDC Wonder (2020).337 Attributes 50%
discrimination of suicides to depression.338
Weight
Anxiety 0.03% CDC Wonder (2020).339 Attribute 10%
discrimination
of suicides to anxiety.340
Weight
Smoking n/a n/a
discrimination
Weight Becoming
n/a n/a
discrimination obese
Weight Remaining
n/a n/a
discrimination obese
Weight
Drug abuse 1.55%* CDC Wonder (2020)341
discrimination
Skin shade
Hypertension n/a n/a
discrimination
Source: As noted. *Mortality rate of drugs and alcohol is given as a proportion of the number of hospitalizations
and emergency departments visits attributable to drugs and alcohol in 2019.
Not all costs are estimated for each impact, see Table A.2.

Other costs
Incarceration
Incarceration costs included annual prison group. This was applied to the total estimat-
expenditure, wage losses for someone who ed number of people in prison in 2019 due to
spends one year in prison and the efficiency skin shade discrimination, to arrive at the total
losses associated with this loss. income loss attributable to appearance-based
discrimination.
Annual prison expenditure per person was
derived from the Federal register342 for 2017 Efficiency losses due to incarceration were for
($36,299) and inflated to 2019 ($37,969) using lost income taxes from lost wages and losses
the inflation rate derived from CPI growth. This associated with government expenditure on
was applied to the total estimated number prisons. These were estimated similarly to
of people in prison in 2019 due to skin shade efficiency losses associated with labor market-
discrimination, to arrive at the annual prison wage discrimination, and government expend-
expenditure attributable to appearance-based iture on health services, as explained in the
discrimination. No significant relationship was following sections.
found between weight discrimination and
incarceration. A summary of these inputs is provided in
Table A.22.
Wage loss per male or female inmate was
estimated as being the full-time annual wage
for Black males or females respectively, by age
Table A.22: Inputs to estimate the costs of incarceration due to appearance-based discrimination
INPUT VALUE SOURCE AND NOTES

Average odds of being
incarcerated due to skin shade 2.27 Monk, E.P. (2015)343
discrimination
Average cost of incarceration $37,969 Federal Register344
Total lost earnings while
$1,527 million BLS345
incarcerated
Source: As noted.

Efficiency losses
As noted in Chapter 2, a reduction in economic Including efficiency losses in this report is in line
efficiency has been included as a cost in this with best practice recommendations made by
study. The reduction in efficiency occurs when a number of studies, including Frick et al. (2010)
taxation is levied to fund services. Economic who argue that it is important for efficiency
theory suggests overall output is reduced com- losses associated with taxes and transfers be
pared to a included in societal cost-of-illness studies.346
counterfactual scenario where taxation does Further, Sindelar (1991, p.39) claims that “ig-
not need to be levied to fund services. noring the [efficiency loss] underestimates the
associated costs and the potential benefits of
When applied to the costs of body dissatisfac- prevention and treatment” associated with
tion and appearance-based discrimination, illnesses.347 Additionally, the inclusion of effi-
governments levy taxes to fund the provision of ciency losses is in line with the approach used
services, such as additional healthcare, beyond by other published cost-of-illness studies,348
what would be required in the absence of the although it is noted that not all cost-of-illness
condition. studies include these costs.
Similarly, governments also collect reduced

taxation revenue through lower employment Lost taxation revenue
and overall output, which is offset by a higher To estimate the efficiency loss due to lost tax-
marginal tax rate than would be required in the ation revenue (given an assumption of no
absence of costs imposed by body dissatisfac- change in spending), revenue was assumed to
tion and appearance-based discrimination. be maintained by taxing individuals more.
The higher marginal tax rates lead to reduced Reduced earnings from lower employment par-
economic efficiency as they induce a subopti- ticipation and lower output result in reduced
mal allocation of resources within the economy. taxation revenue collected by the government.
For example, an individual may choose to re- As well as forgone income taxation, there would
duce the amount of labor they supply for addi- also be a fall in indirect (consumption) taxes,
tional leisure time, which leads to a reduction in as those with lower incomes spend less on the
consumption of goods and services. Lost taxa-
overall output. The reduction in output is larger tion revenue was estimated by multiplying an
than the size of the tax itself, thereby creating average personal income tax rate and average
a net additional cost. indirect taxation rate to lost earnings.
There are a range of approaches discussed

in the literature, with some scholars including
efficiency losses in societal cost of illness and
others arguing that these costs should be ex-
cluded.

The average rates of taxation for personal The rate of efficiency loss was derived as the
income tax, indirect taxes and company taxes simple average of the following studies:
were derived based on Internal Revenue Ser-
vice tax statistics data. The respective tax rates • Blomquist & Simula (2010) adjusted for the
used in the calculation of efficiency losses were: non-linearity of US tax system to calculate
excess burden based on 2006 US data. They
• 23.8% average personal income tax rate, and found a $0.44 loss for every dollar of tax rev-
7.1% average indirect tax rate;349 and enue. This included state and federal income
• 25.7% average company tax rate.350 taxes, payroll tax and sales taxes.352
• Fullterton and Ta (2017) suggested that the
These tax rates were then multiplied by the marginal excess burden of income tax in the
total productivity impacts (including informal US is $0.21.353
care costs) and by the burden of taxation to
• Saez et al (2012) estimated that the marginal
derive efficiency losses.
excess burden per dollar of federal income
tax revenue levied is $0.195 under a scenario
Government expenditure where all income tax is proportionally in-
For this study, it was assumed that government creased.354
health expenditure associated with conditions • Baicker and Skinner (2011) examined the im-
and illnesses attributable to appearance- pact of continued growth in the Medicare and
based discrimination and body dissatisfaction Medicaid programs, finding that the cost of
is funded by taxing individuals more than they generating the revenue needed to finance the
otherwise would be in the absence of harmful additional health spending is $1.48 per dollar
beauty ideals. of revenue collected, implying the efficiency
loss is $0.48 per dollar of revenue collected.355
Based on data from the Centers of Medicare
and Medicaid Services, the federal government
pays for 29% of total health expenditure on av-
erage, while state and local governments fund
16.10%.351
This was multiplied by total health expenditure

and by the burden of taxation to derive effi-
xxv O
ther work in the US has indicated the excess burden
ciency losses. of levying taxation is highly variable and dependent on
a range of assumptions about the structure of the tax
system, and how the additional taxation is levied. For
the purposes of this analysis, we have focused on more
The burden of taxation conservative estimates of the efficiency loss associated
Based upon an average taken across multiple with levying additional taxation. For example, studies by
academic studies conducted in the US, income Feldstein in 1999 and 2006 estimated that the
efficiency loss is $0.76 per dollar of revenue raised, or
tax was estimated to impose a burden of $0.33 greater.
for every dollar of tax levied.xxv
Feldstein, M. (2006). The effect of taxes on efficiency and
growth (No. w12201). National Bureau of Economic Research.

Loss of well-being
The burden of disease methodology was de- The reduction in quality of life is estimated via
veloped by the World Health Organization and disability weights, which are assigned to various
is a comprehensive measure of mortality and health states. A disability weight of zero rep-
disability from conditions for populations around resents a year of perfect health and one rep-
the world. The burden of disease methodology is resents death. Other health states are given a
a non financial approach, where life and health weight between zero and one to reflect the loss
can be measured in terms of disability adjusted of well-being due to a particular condition. For
life years (DALYs). DALYs include both years of example, a disability weight of 0.2 is interpreted
life lost due to premature death (YLLs) and years as a 20% loss in well-being, relative to perfect
of healthy life lost due to disability (YLDs). health for the duration of the condition.
The burden of disease methodology was used A summary of the disability weights by condi-
to capture the non-financial costs of body tion, used to estimate the YLDs in this study, is
dissatisfaction and appearance-based dis- provided in the Table A.23.
crimination. This includes the reduced quality of
life due to the impacts of body dissatisfaction/
appearance-based discrimination, and the loss
of life from premature mortality.
Table A.23: Disability weights by condition for body dissatisfaction and appearance-based
discrimination
PATHWAY IMPACT DISABILITY SOURCE AND NOTES

WEIGHT
Body dissatisfaction Depression 0.658 GBD (2020),356 based on severe depression.
Deloitte Access Economics (2020),357
Body dissatisfaction Eating disorders 0.163 reflecting the weighted average across
various types of eating disorders.
Alcohol and drug
Body dissatisfaction n/a n/a
abuse*
Body dissatisfaction Suicide attempts 0.460 Spijker et al (2011)358
Body dissatisfaction Smoking* n/a n/a
Body dissatisfaction Anxiety 0.133 GBD (2020),359 based on moderate anxiety.
Weight discrimination Depression 0.658 GBD (2020),360 based on severe depression.
Weight discrimination Anxiety 0.133 GBD (2020),361 based on moderate anxiety^.
Weight discrimination Smoking* n/a n/a
Weight discrimination Obesity 0.047# Jia and Lubetkin (2005)362
Weight discrimination Drug abuse* n/a n/a
Skin shade
Depression 0.658 GBD (2020),363 based on severe depression.
discrimination
Source: As noted. #Utility change, impact of obesity on well-being.

*Not all costs are estimated for each impact, see Table A.2. ^Moderate anxiety is used as a proxy for the weighted
average across all severity levels, for all anxiety estimates.

A summary of the YLDs and YLLs by condition Costs by discrimination type
are provided in the main body of this report Within the appearance-based discrimination
(see Table 5.6 and Table 4.5). pathway, this study estimated costs for skin
shade and natural hair discrimination, across
These DALYs are then multiplied by the value health, labor market and other life outcomes.
of a statistical life year (VSLY) to calculate the
dollar value of the lost well-being. The VSL is For costs associated with health outcomes,
anestimate of the value society places on an the main body of this report provides a high-
anonymous life. The US Government collectively level breakdown of costs by discrimination type.
does not set a specified VSL dollar amount for However, this Appendix provides a more de-
use in policy and economic evaluations, with tailed breakdown of costs by type of discrimina-
heterogeneity across government departments tion and health impact.
and agencies.
For labor market outcomes, a breakdown of
For this report a VSL of $307,167 was used. This costs by impact and type of discrimination are
was calculated based on the mid-point of the already provided in the main body of this report
Office of Management and Budget recommen- (see Section 5.2.2). For other life outcomes, all
dation in 2003 (a VSL of $5.5 million) and inflat- costs estimated relate to skin shade discrimina-
ed to 2019 dollars using CPI inflation. tion only, and as such a more detailed break-
down of costs is not required.
A discount rate of 3% was used for future bur-
den of disease costs consistent with other costs
within this report. No discounting was applied to Health outcomes by discrimination
future DALY estimates (when presented in terms type and health impact
of DALYs) consistent with the current GBD study Health system costs
methods.364 Discounting of the VSLY reflects its The total health system costs were $21.9 billion.
lower future financial value due to positive time Of this, the total health system costs attributable
preference, risk and inflation. to skin shade discrimination was $0.21 billion
(from depression and hypertension) and that
To estimate the loss of well-being due to pre- attributable to weight discrimination was $21.7
mature mortality (the YLLs) from body dissatis- billion (from depression, anxiety, obesity and
faction and appearance-based discrimination, drug abuse).
YLLs were estimated based on the age of death,
the excess risk of mortality due to the condition,
and the corresponding difference between av-
erage life expectancy at the age of death minus
the age at death, where life expectancy was
based on the Standard Life Expectancy Table.365
A summary of mortality rates by condition is
provided in Table A.21.

Table A.24: A
nnual health system costs attributable to skin shade and weight discrimination
($ millions)
HEALTH IMPACT MEDICAL PHARMACEU- TOTAL COST PER

COSTS TICAL COSTS PERSON($)
Anxiety 3,119 1,474 4,593 70
Obesity 6,491 3,052 9,542 145
Drug abuse 6,380 859 7,239 110

Subtotal 16,254 5,454 21,708 331

Hypertension 66 33 99 2
Subtotal 139 71 210 3

*Not all costs are estimated for each impact, see Table A.2. Components may not sum due

Productivity costs
The productivity losses associated with health
conditions developed were $55 billion. Of this,
productivity losses associated with weight dis-
crimination totaled $53.7 billion, while for skin
shade discrimination they were $1.3 billion.
Table A.25: Annual productivity losses due to skin shade and weight discrimination in 2019
($ millions)
HEALTH REDUCED ABSEN- PRESEN- PREMA- INFOR- TOTAL COST

IMPACT EMPLOY- TEEISM TEEISM TURE MAL PER
MENT MORTAL- CARE- PERSON
ITY GIVING ($)
Anxiety 17,755 1,760 1,630 960 14,328 555
Depression 1,036 267 675 1,207 1,156 4,340 66
Smoking - 804 5,501 - - 6,304 96
Obesity - 478 1,141 - - 1,618 25
Drug abuse - 52 - 5,038 - 5,090 77
Subtotal 18,790 3,361 8,946 7,204 15,483 819

Cost per
286 51 136 110 236 819
person ($)
Depression 258 85 288 301 296 1,129 19
Hypertension - 4 58 - - 61 1
Subtotal 258 89 346 301 296 1,290 20

Cost per
4 1 5 5 5 20
person ($)

*Not all costs are estimated for each impact, see Table A.2. Components may not sum due to rounding.

Efficiency losses
The total efficiency loss associated with ap-
pearance-based discrimination was $7.5 billion,
of which $7.3 billion were due to the health im-
pacts associated with weight discrimination and
$126 million were due to the health impacts
associated with skin shade discrimination.
Table A.26: Annual efficiency losses due to skin shade and weight discrimination in 2019
($ millions)
TAXATION GOVERNMENT TOTAL COST PER

(INDIVIDUAL EXPENDITURE PERSON ($)
AND CAREGIVER)
Anxiety 2,967 684 3,651 56
Smoking 367 - 367 6
Obesity 94 1,420 9,542 23
Drug abuse 355 1,077 7,239 22
Subtotal 4,114 3,231 7,345 112

Hypertension 4 15 99 0.2
Subtotal 95 31 210 1.9
Cost per person ($) 1.4 0.5 1.9


Loss of well-being
The total loss of well-being associated with
weight discrimination was $224.1 billion, re-
flecting lost well-being from depression ($32.9
billion), anxiety ($98.9 billion), obesity ($53.6
billion) and drug abuse ($38.6 billion). The total
loss of well-being associated with skin shade
discrimination was $8.4 billion, reflecting lost
well-being from depression ($8.4 billion).
Table A.27: L oss of well-being due to skin shade and weight discrimination in 2019 ($ millions)
CONDITION DALYS ($M) DALYS PER TOTAL COST PER
PERSON ($) PERSON ($)
Anxiety 98,920 1,506 3,651 56
Depression 32,998 502 380 6
Smoking - - 367 6
Obesity 53,623 816 9,542 23
Drug abuse 38,575 587 7,239 22
Subtotal 224,116 3,412 7,345 112
Cost per person ($) 3,412 112

Depression 8,417 128 111 2
Hypertension - - 99 0.2
Subtotal 8,417 128 210 1.9
Cost per person ($) 128 1.9


Appendix B :
Sensitivity testing
This section will present the results of the sensitivity analysis, with changes in
key inputs such as prevalence, impacts, unit costs, etc., across both pathways.
Table B.1: Impact of one-way sensitivity analyzes on the cost of body dissatisfaction, 2019 ($ millions)
CASE HEALTH PRODUCTIVITY OTHER LOSS OF TOTAL

SYSTEM AND INFORMAL COSTS WELL-BEING
CARE
Base case $9,060 $68,566 $6,464 $220,614 $304,704
Prevalence
Lower bound based on
$6,665 $50,823 $4,783 $164,167 $226,439
Fallon et al (2014)366
Upper bound based
$14,700 $116,653 $10,880 $364,257 $506,490
on Fallon et al (2014)
VSLY
Lower (-20%) $9,060 $68,566 $6,464 $176,491 $260,581
Upper (+20%) $9,060 $68,566 $6,464 $264,737 $348,826
PAFs
Lower (-20%) $5,254 $40,329 $3,806 $139,955 $189,344
Upper (+20%) $12,450 $93,876 $8,842 $292,284 $407,451
Unit costs (health and productivity)
Lower (-20%) $7,449 $58,351 $5,445 $220,614 $291,859
Upper (+20%) $11,174 $78,782 $7,556 $220,614 $318,126
Effect of changing attributions
No efficiency losses $9,060 $68,566 $- $220,614 $298,240
No cost of risky
$6,024 $59,842 $5,464 $199,276 $270,606
behaviors
Future health costs
$19,422 $78,978 $8,967 $220,614 $327,982
from smoking
Tobacco control
$10,525 $68,566 $6,682 $220,614 $306,387
government funding
Source: Deloitte Access Economics calculations. Components may not sum to totals due to rounding.

Table B.2: I mpact of one-way sensitivity analyzes on the cost of appearance-based
discrimination, 2019 ($ millions)
CASE HEALTH LABOR OTHER TOTAL

OUTCOMES MARKET COSTS
Base case $316,997 $181,585 $2,686 $501,269
Prevalence
Lower (-20%) $255,440 $145,268 $2,191 $403,187
Upper (+20%) $377,937 $217,902 $3,183 $599,023
Wage and employment effect
Lower (-20%) $316,997 $145,268 $2,686 $464,951
Upper (+20%) $316,997 $217,902 $2,686 $537,586
PAFs
Lower (-20%) $154,944 $181,585 $1,825 $338,354
Upper (+20%) $467,743 $181,585 $3,512 $652,841
Unit costs (health and productivity)
Lower (-20%) $300,451 $181,585 $2,686 $484,723
Upper (+20%) $334,258 $181,585 $2,686 $518,530
Effect of changing attributions
No efficiency losses $309,527 $175,412 $2,475 $487,414
Broader weight-based
$316,997 $313,631 $2,686 $633,314
discrimination scenario*
$316,997 $240,221 $2,686 $559,904
scenario^
Source: Deloitte Access Economics calculations. Note: Components may not sum to totals due to rounding.
* describes a scenario where theaverage negative effect of weight discrimination for overweight and obese
within race/ethnic group is applied equally to all people with a BMI of 25kg/m2 or higher (see section 5.2.4). ^
describes a scenario where the

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The real cost

The real cost of beauty ideals 2

The real cost of beauty ideals 3

BLS Bureau of Labor Statistics

BMI Body mass index

CDC Centers for Disease Control

CPI Consumer Price Index

CROWN Creating a Respectful and Open World for Natural Hair

DALYs Disability adjusted life years

GBD Global Burden of Disease

GDP Gross domestic product

MBSRQ Multidimensional Body-Self Relations Questionnaire

NIEHS National Institute of Environmental Health Sciences

PAF Population attributable fraction

VSLY Value of a statistical life year

WHO World Health Organization

YLD Years of healthy life lost due to disability

YLL Years of life lost due to premature death

The real cost of beauty ideals 4

Body dissatisfaction is defined as having a severe negative attitude

Refers to the way in which different aspects of a person’s identity

The differential unfair or prejudicial treatment of someone on the

The unfair or prejudicial treatment of someone on the basis of nat-

The real cost of beauty ideals 5

The unfair or prejudicial treatment of someone on the basis of body

The unfair or prejudicial treatment of someone on the basis of race

Note: This study doesn’t consider discrimination based on gender identity.

The real cost of beauty ideals 6

The reduction in economic efficiency associated with the need to

Non-financial or loss of well-being costs

The real cost of beauty ideals 7

The real cost of beauty ideals 8

The real cost of beauty ideals 9

• Skin shade discrimination or colorism in the

The real cost of beauty ideals 10

The real cost of beauty ideals 11

The real cost of beauty ideals 12

The real cost of beauty ideals 13

The real cost of beauty ideals 14

In 2019, there were:

Financial costs Non-financial costs

Health costs Productivity costs Other costs Loss of well-being

The real cost of beauty ideals 15

$269 billion $233 billion

$84 billion $221 billion

The real cost of beauty ideals 16

The real cost of beauty ideals 17

The real cost of beauty ideals 18

COST OF APPEARANCE-BASED COST OF BODY DISSATISFACTION

v Based on average costs in a four-year institution in the United States.

The real cost of beauty ideals 19

The real cost of beauty ideals 20

The real cost of beauty ideals 21

The real cost of beauty ideals 23

The real cost of beauty ideals 24

The real cost of beauty ideals 25

Sociocultural Internalization of Impacts of harm-

MEDIA Judgment of Body

Source: Deloitte Access Economics.

BOX 1.1: DEFINITIONS

• Skin shade discrimination or colorism in the

• Chapter 4 details the impacts and estimated

• Chapter 5 details the impacts and estimated

• Chapter 6 provides a discussion of the main

• This report conservatively estimates that 45 million or 16% of people in the US

Chart 3.4: Prevalence of weight discrimination, by BMI category,