Appearance-related bullying and skin disorders
Introduction
Bullying is a complex construct encompassing elements of verbal aggression, physical aggression, and social exclusion.1 It is proposed as being aggressive behavior or intentional “harm-doing” that is carried out repeatedly and over time.1 A defining feature is that it occurs in an interpersonal relationship characterized by an imbalance of power in which the victim finds it difficult to defend himself or herself.1, 2 Distinction can be made between bullying that is “direct,” “indirect,” and “relational.”1, 3, 4 Direct bullying involves physical or verbal attacks or aggression. Indirect bullying involves rumor-spreading and gossiping and will often rely on a third party, whereas relational bullying (sometimes considered a subcategory of indirect bullying) involves behaviors such as hurtful manipulation of peer relationships through social exclusion and ignoring.1, 3, 4 Bullying is particularly common and problematic among children and adolescents.2, 4, 5, 6, 7, 8, 9, 10, 11
Teasing is often characterized as a specific form of bullying12 but “can have a milder connotation of verbal and possibly playful aggression.” 1 Thus, the construct of teasing may not necessarily meet common definitions of bullying in that it can be “playful” or “pro-social.”13 “Peer victimization” is a further term that is used in connection to, or interchangeably with, bullying and encompasses bullying and teasing,8 as well as other elements such as harassment. Harassment is similar to bullying, but this term is often used to describe adult or adolescent rather than child behaviors, as in sexual harassment.14
A particular variant of bullying, cyberbullying, has been identified. Definitions of cyberbullying are similar to traditional bullying definitions but include “using electronic forms of contact.”15 Cyberbullying can be via text message, e-mail, phone call, and picture or video clip.16 Research about cyberbullying is still in its early stages,17 but similar patterns of bullying (and similar patterns of harm arising from this form of bullying) are emerging.15, 16, 17
Section snippets
Bullying research
Studies of teasing and bullying have often been of bullying in general. Studies of particular circumstances have often been of weight-related bullying and teasing, usually in children and adolescents.8, 11, 14, 18, 19
Teasing and bullying have also been documented in a wide range of medical conditions. Bullying has been shown to be associated with suffering from a chronic medical condition11, 20, 21 and with somatic illness.17 Specific medical conditions in which teasing or bullying of sufferers
Bullying in skin diseases
A feature of bullying, both in nonmedical (including weight-related bullying)8, 14, 18, 38 and in these particular health-related settings23, 24, 29, 36 is that it is frequently appearance-related. Thus, it would be surprising if bullying were not associated with skin diseases, given the high visibility of skin diseases. Other aspects of skin diseases that render sufferers particularly vulnerable to teasing and bullying are their age distribution and common misconceptions regarding contagion.
Prevalence of bullying in skin diseases
There is limited literature on bullying in skin diseases; therefore, it is difficult to compare the prevalence of bullying in skin disease sufferers with prevalence in other situations. In a schools-based cross-sectional study of Norwegian 15-year-olds,39 dermatitis was significantly associated with being bullied in boys, with an odds ratio of 1.3 (95% confidence interval, 1.1–1.7), but not in girls. The absolute prevalence of bullying was not reported. Several other studies have, however,
The nature of bullying in skin diseases
Alternative approaches have attempted to explore the topic of bullying in more depth. One approach has been to present children with video clips of individual children with and without a (false) facial port wine stain and then assess their attitudes to the children depicted in the videos.46 Participants were significantly more likely to think that the children portrayed with port wine stains would attract teasing from their peers.
Three qualitative studies have explored bullying and teasing in
What can clinicians do about bullying in their patients?
The position paper of the Society for Adolescent Medicine on bullying and peer victimization states:
Health care providers should be familiar with the characteristics of youth that may be involved in bullying, either as aggressors or victims. They need to be sensitive to signs and symptoms of bullying, victimization, their influences and their sequelae.4
This advice may be especially pertinent in the case of skin disease where doctors (both family physicians and dermatologists) have been reported
Conclusions
Bullying and teasing are recognized as major problems in children and adolescents. Despite limited evidence, it is reasonable to conclude that children and adolescents with skin diseases are especially prone to bullying and teasing on the basis of their condition. Dermatologists and other clinicians should be aware of this and of the potential for bullying and teasing to effect their patients' psychological well-being.
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