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Health Psychology

‘Hirsutism’: A Psychological Analysis

Anna Keegan, Lih-Mei Liao and Mary Boyle
J Health Psychol 2003 8: 327
DOI: 10.1177/13591053030083004

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Hirsutism: A Journal of Health Psychology

Copyright 2003 SAGE Publications
London, Thousand Oaks and New Delhi,
Psychological Analysis [13591053(200305)8:3]
Vol 8(3) 327345; 031674

Abstract
Hirsutism, i.e. excess body hair
in the male distribution, is a
medical term applied only to
women. Although associated with
social and psychological
ANNA KEEGAN difficulties including anxiety,
Ambrose King Centre, Royal London Hospital, London,
social avoidance and a confusion
UK
of gender identity and although it
raises important gender issues,
LIH-MEI LIAO there has been little systematic
Sub-Department of Clinical Health Psychology, University
study. No prior research has
College London, UK
focussed on the relationship
between womens perceived
MARY BOYLE degree of hirsutism and
Department of Psychology, University of East London, UK
psychological distress.
A survey of 53 women with
polycystic ovary syndrome
(PCOS), which often produces
A N NA K E E G A N completed this work as part of her excess hair growth, was carried
doctoral degree in clinical psychology. She now works out to assess any psychological
as a clinical psychologist in HIV and sexual health at consequences of perceived
the Royal London Hospital, UK. She is also involved hirsutism. Results indicated
in research that investigates the impact of HIV on raised levels of psychological
womens sexual functioning. distress overall, but no significant
relationships between perceived
L I H - M E I L I AO is Consultant Clinical Psychologist and
hirsutism and distress.
Honorary Senior Lecturer at the Sub-Department of Four semi-structured interviews
Clinical Health Psychology, University College were then conducted to facilitate
London. Her current clinical and research interests are more in-depth exploration of
in the psychological aspects of atypical genitalia. hirsute womens experience.
M A RY B OY L E is Professor of Clinical Psychology at
Analysis suggested idealized
cultural norms for hair growth
the University of East London where she is Course
prevail and excess hair growth
Director of the Doctoral Degree in Clinical
contributes to gender
Psychology. She has published extensively in the field
inconsistencies and feelings of
of mental health, abortion and sexual dysfunction. deviance and stigma. Effective
concealment of hair growth and
passing for normal appear to
AC K N OW L E D G E M E N T S . We are grateful to the women who shared
facilitate relatively high levels of
their valuable information with us and to Professor Howard Jacobs for
functioning and allows idealized
facilitating this study.
cultural norms to be maintained.
COMPETING INTERESTS: None declared.

ADDRESS. Correspondence should be directed to: Keywords

A N NA K E E G A N ,
Clinical Psychology Service, The Ambrose King
Centre, The Royal London Hospital, London, E1 1BB, UK. [email: gender, hirsutism, polycystic ovary
anna.keegan@bartsandthelondon.nhs.uk] syndrome, psychology
327

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04 Keegan (jr/t) 3/31/03 1:31 PM Page 328
JOURNAL OF HEALTH PSYCHOLOGY 8(3)
Introduction
A LT H O U G H body hair is characteristic of both
men and women, hirsutism as a medical term is
applied only to women. Two commonly used
definitions are an excess of sexual hair in the
female (Keye, 1982) and an excess of body hair
in the male distribution (Conn & Jacobs, 1997).
Sexual hairas opposed to asexual hairrefers
to terminal hair1 growth in response to andro-
gens, in regions supposedly characteristic of
masculine hair growth, i.e. upper lip, chin, side-
burns, chest, upper pubic triangle and abdomi-
nal regions (Lunde, 1984).
In general women tend not to have the same
amount of facial and body hair as men.
However, even if we were to accept the idea of
hirsutism as a medical problem for women, the
distinction between normal and excess female
hair growth is not as clear-cut as it is generally
assumed. Womens customary removal or
concealment of hair growth makes it difficult to
determine the normal distribution in the general
population. Furthermore, women tend to
present more hair growth as they get older
(Lunde, 1984; Lunde & Grottum, 1984), there-
fore what is considered normal for one age
group may be different from what is considered
normal for another. There are also ethnic differ-
ences; for example Far Eastern women tend to
have less sexual hair compared to Mediter-
ranean women (Keye, 1982; Lunde, 1984). As
for differences between men and women,
anthropological studies indicate that women
have the potential to develop sexual hair growth
in the same regions of the face and body as men.
Thus, contrary to popular belief, differences
between men and women in relation to the
development of the type of hair growth in ques-
tion are quantitative rather than qualitative
(Beek, 1950; Ferriman & Gallwey, 1961; Peder-
sen, 1942), though the size of the difference
remains unquantified.
Be that as it may, extreme negative emotional
reactions by women towards hirsutism have
been documented by physicians for a consider-
able time (Baum, 1912; Coulam, 1974; Gara,
1936; Hatch, Rosenfield, Moon, & Tredway,
1981; Lunde, 1984; Lunde & Grottum, 1984;
Lux, 1982; McCafferty, 1923). Ferrante (1988) in
a review article reports hirsutism to be
associated with increased anxiety, depression,
328
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self-consciousness and embarrassment, dimin-
ished self-confidence and body dissatisfaction.
More severely affected women have been
described as experiencing shame, ridicule and
social rejection and as developing a morbid
preoccupation with hair growthalthough
adverse psychological reactions are found even
with what appears to an observer to be clinically
insignificant levels of hair growth. These obser-
vations concord with our own psychological
work with women presenting hirsutism and are
generally supported by the small number of
social and psychological studies available. All of
these used the Ferriman and Gallwey Scale
(1961), a semi-quantitative measure based on
clinicians ratings of hair growth at nine key sites
to assess the degree of hirsutism present.
Rabinowitz, Cohen and Le Roith (1983)
found significantly higher levels of both state
and trait anxiety in their group of 15 hirsute
women, compared to their non-hirsute control
group of 20. Interestingly the level of anxiety
was unrelated to the degree of hair growth
present. Barth, Catalan, Cherry and Day (1993)
assessed 69 women with hirsutism for psychi-
atric morbidity. They found that 27 per cent of
the women met the criteria for caseness as
measured by the General Health Questionnaire
(Goldberg, 1978), which is comparable to other
general hospital outpatient samples. Again,
caseness was not associated with the degree of
hair growth. Just over two-thirds of their sample
avoided some social situations and one-third
had never discussed their hirsutism. Likewise a
study by Sonino, Fava and Mani (1993) found in
a sample of 50 hirsute women significantly
higher levels of anxiety and psychotic symptoms
as well as interpersonal fears, reduced quality of
life and some avoidance of social situations,
compared to a control group of women.
In their sample of 15 hirsute women, Zerssen
and Meyer (1960) identified two common
themes to the emotional disturbances:
comprised gender identity and a tendency to
social and behavioural withdrawal. The former,
they suggest was linked to the womens belief
that they possessed a male characteristic and
were therefore defective as females. This belief
was accompanied by an intense concern that this
perceived abnormality would be noticed by
others, a fear of ridicule and social rejection, and
a desire to appear completely hairless.
04 Keegan (jr/t) 3/31/03 1:31 PM Page 329
Behavioural measures to conceal hair in this
sample included covering the lower part of the
face with the hands, staying in shade, maintain-
ing physical distance from others, moving
quickly to avoid close observation, wearing
concealing clothes and an avoidance of physical
contact.
Ross, Richard, Mastrodonato, Cassall, Moses,
Fischer, Steckler, Radin, Kaplan and Dubey
(1965) proposed that women have difficulties
with superfluous hair because body hair is one
of the symbolic characteristics that differentiate
them from men. They might equally have
argued that our culture has difficulty with
superfluous hair in women because possession
of such hair represents a confusion of symbolic
categories, which blurs the boundaries between
women and men. It is not surprising, then, that
claims about the existence of superfluous hair,
or threats that it would grow, together with
claims about its association with lesbianism or
rejection of marriage and femininity, were
prominent in controversies over womens
suffrage and womens place in public life
(Jeffreys, 1985). And although such associations
may not now be made so directly, it is notable
that womens increasing prominence in public
life has if anything been paralleled by increased
demands or expectations that they be free from
superfluous hair. Thus hirsutism appears to
owe its status as a medical symptom worthy of
treatment to the gender issue that it exposes.
Any psychological explanation for womens
distress would therefore need to address the role
of gendered social context in the production of
such distress.
A review of the literature suggests that first,
there is a dearth of systematic studies of
hirsutism. Second, those that are available have
tended to ignore womens own perception of
their degree of hirsutism, even though the pres-
ence and reporting of this symptom largely
owe themselves to self-definitions. Third, the
meanings which women themselves ascribe to
their hair growth and its management, and their
relationship to a gendered social context, have
yet to be analysed in any detail. The present
study sought to address each of these issues.
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KEEGAN ET AL.: HIRSUTISM
Methods
The study of perceived hair growth was
approached in two ways, via a cross-sectional
survey to provide principally quantitative data
followed by semi-structured interviews to
collect qualitative information.
The rationale underlying such a triangulation
design (Robson, 1993) was that quantitative
survey methods would provide an efficient
means of gathering substantial information on
problem perception. These data would also
enable us to evaluate the extent to which such
perceptions are associated with psychological
distress while providing anonymity for partici-
pants (such anonymity was considered import-
ant due to the taboos surrounding facial and
body hair in women).
Alone, however, this quantitative data would
not facilitate exploration of the meanings of
body hair, their relationship to social contexts or
the development of a theoretical framework
from which to view perceived hirsutism in
women. Following the quantitative data collec-
tion phase, qualitative data were therefore
obtained via semi-structured interviews. The
methods and results from the two parts of the
study are reported sequentially, in order to
provide a clear account of what was done. We
will argue, however, that interpretation of the
results of the quantitative study is enhanced by
consideration of the qualitative analysis (and
vice versa) and we will synthesize the two sets of
results in the final section.
Quantitative phase
Participants
Seventy-one women diagnosed as having poly-
cystic ovary syndrome (PCOS) and attending an
outpatient reproductive endocrinology clinic
were approached to take part in our survey and
53 participated. This sample was drawn from
this group of women as studies using clinician
ratings suggest excess hair growth to be present
in 61 per cent (Jacobs, 1986) to 90 per cent
(Adams, Polson, & Franks, 1990) of women with
the diagnosis of PCOS. Other aspects of PCOS
include amenorrhea or oligomenorrhea, and
sometimes acne and/or being overweight and/or
sub-fertility. In order to avoid the potentially
confounding effects of weight and fertility
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JOURNAL OF HEALTH PSYCHOLOGY 8(3)
problems on psychological well-being, women
with a body mass index of 25 or more, women
undergoing fertility treatment and women in the
postmenopause were excluded from the survey.
Procedure
Participants were recruited over a 12-week
period as they waited for routine outpatient
appointments at the clinic. Potential participants
were identified through screening the medical
notes of clinic attenders within this time frame.
All women with a diagnosis of PCOS attending
the clinic (except for those women who met the
exclusion criteria above) were approached by
one of the researchers, AK, and asked if they
would be interested in participating in this study.
If they agreed, AK described the study,
provided information sheets, obtained written
consent and gave out assessment packs. Those
who consented could either complete the
research pack at the clinic or return it by post.
Measures
The assessment pack given to each participant
had a number of components whose content was
derived from several sources. These included
psychological literature, clinical practice and
discussion with women attending a support
group for women with PCOS who were known
to the first two authors. The assessment pack
included general questions about PCOS; a picto-
rial scale to measure self-perceived hair growth;
questions aimed at assessing any impact of hair
growth and standardized measures of psycho-
logical distress. These are detailed below.
Questions about PCOS Questions were
included about a number of aspects of PCOS
including symptoms, treatment history, medi-
cation and time since diagnosis.
Self-perceived hirsutism In previous studies,
the degree of hirsutism was assessed by clinicians
using the Ferriman and Gallwey Scale (1961).
This scale lists nine sites of the face and trunk:
lip, chin, chest, upper back, sacro-iliac region,
upper abdomen, lower abdomen, upper arm and
thigh. The ratings from 0 to 4 for each site are
verbally described. A score of 0 represents
absence of hair and 4 the highest rating of hair
growth. The maximum total score for the scale is
36 for all nine sites.
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This earlier scale was subsequently redevel-
oped by Hatch et al. (1981). The only difference
is that in the new scale, the gradings of hair
growth were represented pictorially instead of
verbally. Using the same scoring method, Hatch
et al. (1981) suggested a total score of 8 or more
as indicative of hirsutism, as only 5 per cent of
premenopausal women would score 8 or above.
In the absence of any validated self-report
measures of perceived hirsutism, Hatch et al.s
(1981) scale was incorporated into this study.
The important difference here, however, is that
scores were based on womens own ratings of
hair growth at each of these sites, rather than
clinicians ratings. Furthermore, participants
were asked to rate their self-perception of
current levels of hair growth at each site without
physical depilation (to give a current score)
and again their perception of their hair growth
at each site at its most prolific (giving a worst
ever score). This is important, as many women
who attended the clinic have had medical and
cosmetic treatments that would have altered
their levels of hair growth (e.g. electrolysis). The
same summed score of 8 was adopted in this
study to indicate self-perceived hirsutism.
Impact of self-perceived hirsutism Ques-
tions were also included to assess the impact of
self-perceived hair growth on participants lives,
negative social reactions, social avoidance and
openness to discussion of hair growth.
Hospital Anxiety and Depression Scale
(HADS) (Zigmond & Snaith, 1983) The
HADS has two sub-scales measuring anxiety
(HADA) and depression (HADD). There are
seven items in each sub-scale. Each item is
scored from 0 to 3 with higher scores reflecting
higher levels of distress. The sub-scale score is
the sum of the scores of the seven items and
therefore ranges from 0 to 21. Sub-scale scores
are popularly categorized as normal (07);
mild (810); moderate (1114) and severe
(1521) (Milne, 1992).
The internal consistency of the two sub-scales
provided a Cronbachs alpha of .93 for anxiety
and .90 for depression (Moorey, Greer,
Watson, Gorman, Rowden, Tunmore, Robert-
son, & Bliss, 1991). Concurrent validity as
assessed by comparison with five-point psychi-
atric scales of anxiety and depression for 100
04 Keegan (jr/t) 3/31/03 1:31 PM Page 331
psychiatric outpatients (Zigmond & Snaith,
1983) showed the HADS sub-scales correlated
significantly with these ratings (anxiety r = .54;
depression r = .79).
Rosenberg Self-esteem Scale (RSES)
(Rosenberg, 1989) The RSES is a 10-item
Likert scale. Each item is scored 1 to 4 in the
direction of low self-esteem. The overall RSES
score is the total for all the items and hence
ranges from 10 to 40. Lower scores reflect higher
self-esteem and vice versa. Normative data
suggest that scores are negatively skewed, i.e.
tending towards low self-esteem for the general
population (Johnson, 1995). Although the
RSES is the most widely used measure of self-
esteem in psychological research, few data are
available on its psychometric properties.
Ingham, Kreitman, Miller, Sashidharan and
Surtees (1986) describe an alpha figure of .69
and Silber and Tippett (1965) found testretest
reliabilities of .85 over a two-week period and
also reported good concurrent validity (correla-
tions ranging from .56 to .83).
Social Avoidance and Distress Scale (SADS)
(Watson & Friend, 1969) The SADS may be
used as a measure of social anxiety or inter-
personal difficulties and is widely used in clinical
practice as it is brief and easy to complete
(Milne, 1992). It consists of 28 items rated as
true or false. Items are scored either 0 or 1,
with a maximum score of 28. Higher SADS
scores are taken to indicate higher levels of
distress.
There are no validation studies available
using clinic outpatients. However, Watson and
Friend (1969) reported a mean score of 9.1 (SD
8.0) for a sample of 205 Canadian undergradu-
ates. These figures are used to provide a base
rate against which to compare scores, with a
figure of 9 taken to represent a degree of distress
that may be found in a non-clinical sample.
Testretest reliability for the SAD Scale over a
one-month period was .68 with a sample of 154
undergraduates.
Watson and Friend also conducted concurrent
validations of the SAD Scale. Highly significant
correlations were obtained with appropriate
comparators (e.g. Taylors Manifest Anxiety
Scale; Taylor, 1953), but the fact that these were
in the order of .60 suggests that the SAD Scale
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KEEGAN ET AL.: HIRSUTISM
measures something additional (see Milne, 1992
for further discussion).
Body Satisfaction Scale (BSS) (Slade,
Dewey, Newton, Brodie, & Gundi, 1990)
This scale consists of 16 Likert items, which
participants rate from 1 to 7 in the direction of
increasing dissatisfaction. Total BSS scores
range from 16112 with higher scores indicating
a greater degree of body dissatisfaction. The
scale can also yield three separate measures of
body dissatisfaction: (a) a general measure (all
16 items); (b) a head measure (seven items);
and (c) a body measure (seven items). As well
as the general measure, the head measure was
also used as clinical practice suggested that
facial hair growth might be especially problem-
atic.
The original validation study found the
scales internal consistency to be acceptable
(alpha figures of .87, .88 and .89) for the three
sample groups. The scale has been found to
discriminate well between a combined control
group (nurses, female volunteers and students)
with a mean of 45.38 and standard deviation of
14.71; eating disorder patients (M 61.42, SD
18.39) and overweight women (M 63.57, SD
17.44).
Results
Sample characteristics
Fifty-three out of a total of 71 women
approached completed and returned their
questionnaires, giving a response rate of 74.6
per cent. The mean age of the sample was 30.37
years (SD = 8.56). Most (71.7%) were employed
or students, with 60.4 per cent having graduate
or postgraduate level qualifications. Approach-
ing two-thirds of the sample (60.7%) were
in relationships and 79.2 per cent categor-
ized themselves as White British or White Euro-
pean.
Ten women (19.2%) said that they had known
about their PCOS for less than one year, 20
women (38.5%) between two and five years, 14
(26.9%) between six and 10 years and eight
(15.4%) for 11 or more years.
Arising from their PCOS, 45 women (84.9%)
reported current menstrual problems; 24
(47.2%) skin problems; 13 (24.5%) fertility
problems; 45 (84.9%) hair growth problems; and
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JOURNAL OF HEALTH PSYCHOLOGY 8(3)
15 (28.3%) reported other non-specific hair
growth problems including alopecia.
Descriptive statistics
The distribution of scores obtained for each of
the psychometric measures included (i.e.
HADS, RSES, SAD, BSS) is shown in Table 1.
Comparisons of mean scores with those in the
original validation samples for each of these
measures was carried out using Students t-tests.
Compared to a clinic sample of 573 patients
with cancer (Moorey et al., 1991), the mean
HADA score from the present study is signifi-
cantly higher (t = 3.45, p < .05). Furthermore, 47
per cent of the sample reach case status for
anxiety (i.e. scored 8 or above) compared to
Moorey et al.s 24 per cent.
The mean HADD score in the present study
is also significantly higher than in Moorey et al.s
sample (t = 3.19, p < .01); 15.1 per cent of this
sample reach caseness for depression (that is
scored 8 or above) compared to Moorey et al.s
8.7 per cent.
A comparison of mean RSES scores from the
present study with scores available from a
community sample of 1345 women (Milne,
1992) indicated that the current sample
generally had significantly lower RSES scores (t
= 18.5; p < .01) and therefore higher self-esteem.
However this finding is in the context of a
sample that was socio-demographically skewed
in terms of employment and educational attain-
ment.
The mean SADS scores of the current sample
were not significantly different from those of the
standardization sample of 205 Canadian under-
graduates (Watson & Friend, 1969).
The mean BSS scores from the present
sample were significantly higher than those of
the combined control group of the original
Table 1. Measures of central tendency and t-values for comparisons of the current sample with relevant stan-
dardization samples
Present sample
M SD
HADA (N = 53) 7.45 4.22
HADD (N = 53) 4.43 3.95
RSES (N = 53) 21.60 6.93
SADS (N = 47) 10.37 8.45
BSS (N = 53) 51.35 18.70
(*p < .05; **p < .01)
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validation sample of Slade, Dewey, Newton,
Brodie and Gundi (1990) (t = 2.18, p < .05) and
a group of women with premature menopause (t
= 1.98; p < .05) (Liao, Wood, & Conway, 2000).
However, the mean scores of the current sample
were considerably lower than the eating
disorder group also reported in Slade et al.s
(1990) original validation study (N = 84, M =
61.42, SD = 18.39).
Impact of hair growth
Half the sample (51%) reported that they
avoided some activities as a result of their excess
hair growth. These included: activities involving
exposure of the body such as swimming and
sunbathing; activities involving social contact
such as meeting people; activities involving inti-
mate contact such as physical or sexual contact;
and activities that interrupted depilatory
routines.
When asked if they worried about their hair
growth being noticed, 41.2 per cent of the
sample reported often or always, 31.3 per cent
reported never or only occasionally.
Forty-one per cent of the sample reported
that they had never had their hair growth
remarked upon; 43.2 per cent reported they had
occasionally and 15.7 per cent reported some-
times or often. These comments included refer-
ences to hair growth (e.g. youre growing a
beard), references to the need to depilate (e.g.
you need a shave) and name-calling (e.g. hairy
monkey).
Sixty per cent of respondents thought hair
growth had an impact on their view of them-
selves, 30 per cent thought it had not and 7.7
per cent were unsure. When asked to qualify
this, responses fell into four categories: feelings
of being unfeminine or unwomanly, feelings
of being unattractive or ugly, reduced
Standardization sample
M SD t
5.44 4.07 3.45*
3.02 2.98 3.19**
34.52 4.91 18.50**
9.10 8.00 NS
45.38 14.71 2.18*
04 Keegan (jr/t) 3/31/03 1:31 PM Page 333
self-confidence and worry about others noticing
hair growth. Fifty-six per cent indicated they
were able to discuss their hair growth to some
extent, although only two people (3.8%) stated
that they were able to discuss this freely.
Relationships between aspects
of self-perceived hirsutism and
psychological distress
Maintaining the cut-off point of 8 in our adap-
tation of Hatch et al.s (1981) pictorial scale as
indicative of self-perceived hirsutism, measures
of central tendency were calculated for the self-
perceived non-hirsute (i.e. those who scored
< 8) and the self-perceived hirsute groups
(scores > 8). Twenty-four respondents fell into
the self-perceived non-hirsute and 29 into the
self-perceived hirsute groups, categorized on
the basis of participants perceived levels of
their current hair growth (see Table 2).
Differences between the self-perceived
hirsute and the self-perceived non-hirsute
groups on these psychometric measures were
calculated using the Mann-Whitney test. Spear-
mans rho was also calculated to test for degree
of association. No significant differences
emerged for any of the measures of psycho-
logical distress between those whose self-
perceived hair growth was rated as hirsute
compared to those whose self-perception was
rated non-hirsute. None of the correlation
coefficients obtained achieved levels of statisti-
cal significance. A similar analysis carried out
with respect to past self-perceived levels of hair
growth at worst ever levels. This also revealed
no significant differences or associations.
The overall scores for self-perceived levels of
hair growth were achieved by summing scores
from a total of nine hair growth sites. Conse-
quently, a score of 8 could be achieved in a
Table 2. Measures of central tendency of current levels of perceived hair growth: perceived non-hirsute and
perceived hirsute sub-groups
Perceived non-hirsute (N = 24)
M SD
HADA 3.96 3.84
HADD 7.58 4.15
RSES 21.87 6.13
SADS 10.21 9.38
BSSG 49.87 20.14
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KEEGAN ET AL.: HIRSUTISM
number of ways, for example by a score of 1
from eight different sites or two scores of 4 from
two hair growth sites. It is possible that differing
distributions of hair growth have different
meanings, as both clinical practice and
responses to questions in the assessment tool
suggest that facial hair growth was generally
most problematic.
To explore this idea, analyses of self-
perceived facial hair scores (current and worst
ever) and all of the standardized measures of
psychological distress included (i.e. HADS,
SADS, RSES, BSS) were also carried out. As we
could not establish scores on which to divide the
sample into self-perceived hirsute and self-
perceived non-hirsute categories for facial hair
growth, only measures of association were
calculated (i.e. scattergrams and Spearmans
rho). Again no association was found between
self-perceived facial hair growth and any of the
measures of psychological distress for current or
worst ever levels.
Discussion of quantitative
results
The response rate of 74.6 per cent is considered
high for a psychological study. However, it is
important to note that the sample is skewed
towards higher socio-economic status with 60
per cent of the women having completed
graduate education. Thus the results have to be
interpreted with this in mind.
In line with our clinical observations, a
considerable number of the women avoided
some activities, over half reported having
received negative comments about their hair
growth, and many of the women reported
feeling unfeminine. Although half of the
women indicated that they could confide to
Perceived hirsute (N = 29)
M SD
4.83 4.07
7.34 4.34
21.38 7.62
10.52 7.71
52.59 17.68
333
04 Keegan (jr/t) 3/31/03 1:31 PM Page 334
JOURNAL OF HEALTH PSYCHOLOGY 8(3)
someone about their hair growth, very few indi-
cated that they could do so freely.
The psychometric data in this study are
mixed. Overall, anxiety scores were found to be
high, with close to half of the current sample
reaching the cut-off score for caseness.
However, there was no significant association
between degree of anxiety and degree of
perceived hirsutism. One explanation is that the
diagnosis of PCOS rather than self-perceived
hirsutism per se, is associated with raised
anxiety in this sample. Rabinowitz et al. (1983)
and Sonino et al. (1993) also found significantly
raised levels of anxiety in clinical samples of
women with (clinically assessed) hirsutism and
likewise psychological distress was not signifi-
cantly related to degrees of hair growth.
Fewer women scored above caseness on the
depression measure, though the HADD scores
here are higher compared to the British vali-
dation sample (Moorey et al., 1991). Moorey et
al.s sample comprised both men and women
who had recently been diagnosed as having
cancer, while the current sample comprised only
women. As women tend to report higher levels
of depression than men (Stoppard, 1989), the
higher levels of depression found here may
represent a methodological artefact. The only
previous study to measure depression in women
assessed clinically as hirsute found no significant
differences in levels of depression between
hirsute participants and a community control
group of women (Sonino et al., 1993).
The comparisons with the original validation
samples in Slade et al. (1990) indicated that the
current sample experience significantly lower
body satisfaction than the community sample
though higher satisfaction than the sample of
women with eating disorders. Body satisfaction
in the current sample is also low compared to a
recent sample of women attending the same
clinic with the diagnosis of premature
menopause (Liao et al., 2000). While this finding
may be somewhat predictable, what is surprising
is that body satisfaction is not significantly
related to the degree of self-perceived hirsutism.
Thus body dissatisfaction may be related to
having PCOS and not to self-perceived
hirsutism per se.
The current sample reported a higher level of
self-esteem compared to the female standard-
ization sample (Rosenberg, 1989). Higher than
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average educational attainment and being in
paid employment might have contributed to the
high levels of self-esteem identified in the
current sample. No difference in self-esteem was
found between self-perceived hirsute and self-
perceived non-hirsute women.
Interestingly, none of the 71 women
approached to participate in the study presented
any apparent signs of hirsutism, even though
this number included women who defined them-
selves as having excess hair growth. This
suggests that through various hair removal
strategies, hair growth is concealed and the
women are able to pass for normal (Goffman,
1963). The success of passing might have
enabled these women to maintain relatively
higher levels of functioning, though high socio-
economic status may also be a factor. The high
levels of functioning found in this sample are
similar to earlier reports (Zerssen & Meyer,
1960). The rationale and utility of passing as a
strategy for managing problematic body hair is
explored more explicitly in the analysis and
discussion of the qualitative interview data.
Over half of this sample avoided some activi-
ties, particularly activities that involved expo-
sure of the body. This finding was not necessarily
suggested by the SADS scores, which did not
differ from those of the original validation
sample. This lack of relationship between self-
perceived hirsutism and SADS scores contradict
to some previous findings. For example, Sonino
et al. (1993), using the Social Situations Ques-
tionnaire (SSQ) found a significant difference
between their hirsute sample and the validation
sample. This could be a reflection of either
methodological or sampling differences.
Summary of quantitative
results
On the whole, it would seem that experience of
PCOS, independent of potential complications
such as obesity and fertility treatment, is associ-
ated with a mixed pattern of raised distress,
avoidance of some activities and feelings of
being unfeminine. Self-perceived hirsutism
per se does not appear to be obviously related
to these psychological constructs.
This study was carried out on a socio-
demographically skewed sample of women,
who, one could speculate, would enjoy
04 Keegan (jr/t) 3/31/03 1:31 PM Page 335
advantages such as greater access to services and
treatment. In general, there are complex inter-
actions between social status, age, employment,
relationship status and health outcomes. A
larger sample would have enabled an analysis of
different sub-groups, providing greater possi-
bilities for the exploration of the different
impact of perceived hirsutism for different
social groups.
It would seem that the relationship between
self-perceived hirsutism and psychological well-
being is neither straightforward nor easily
measurable. There may be complex interactions
with intervening variables that are not easily
quantified at this stage. The analysis and
consideration of the qualitative interview data
within this triangulation design may provide a
basis to explain some of the complexities and
contradictions suggested by the quantitative
data analysis and enhance our understanding of
their relationships.
An understanding of these mechanisms and
placing these within a social context is particu-
larly important since hair growth in itself is not
life threatening, nor is it painful, yet treatment
of hair growth is not a pre-requisite of the
medical management of PCOS. Interesting
questions are therefore raised as to why hair
growth for women is treated like an illness.
Given the widespread nature of depilatory prac-
tices, such an explanation would need to take
account of the social significance of a prescribed
and enforced level of acceptable facial and body
hair growth in women. These issues were
addressed via the interviews with a small
number of the research participants.
Qualitative phase
Participants
Participants in the quantitative part of the
research were also informed in the introduction
to the study and again on the consent form that
some participants would be contacted subse-
quently and asked to take part in a taped inter-
view. Women were considered suitable for
interview if they had self-perceived hirsutism
scores of at least 8 (but in practice all those
interviewed achieved scores of 13 or more) and
had indicated that hair growth had impacted on
their view of themselves.
Practical considerations limited the number
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KEEGAN ET AL.: HIRSUTISM
of interviews we were able to undertake to four.
Again for practical reasons, two were inter-
viewed individually and two in a research dyad.
Brief biographical information is given below
(all names are pseudonyms and identifiable
details have been changed):
Lisa is 42, married with one child and works
as an administrator. She reports thick hair
growth over a number of body sites. She
waxes extensively to manage this. She also
had weekly electrolysis for 15 years to reduce
her facial hair growth.
Susan is 27, married and does not have
children. She works as an administrator. Her
hair growth is quite fine and began to appear
when she was about 19. Her depilatory regime
is varied but bleaching and waxing are the
methods most commonly used.
Lorna is 39, has a regular male partner but
lives alone. Originally from the United States,
she has lived here since childhood. She has
recently completed a postgraduate qualifi-
cation and is about to start her first post in her
field of study. She reports extensive, coarse
dark hair growth and also uses a variety of
methods to manage this including plucking
(chin), waxing (legs). Some methods such as
electrolysis have caused problems for her
such as burning and scarring. In the past she
has tried medical treatments (the contracep-
tive pill, anti-androgens) but suffered badly
from side effects and found them generally
ineffective.
Carol is 34, lives with her regular male partner
and has no children. She works in arts
administration. She has heavy dark hair
growth. She covers her face by wearing heavy
make-up as this hides the scarring from hair
removal about which she feels self-conscious.
She also engages in a range of depilatory prac-
tices such as shaving (chin, legs), waxing (legs
and abdomen) and plucking (chest). She has
also tried a number of medical treatments and
found the anti-androgen cyproterone acetate
to be most effective in reducing her hair
growth, but was unable to tolerate side
effects. She now takes a less powerful drug
(spironolactone) but finds this less effective.
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JOURNAL OF HEALTH PSYCHOLOGY 8(3)
Procedure
The interviews took place in the clinic over a
two-week period subsequent to the collection of
the survey data. They were audio taped and
lasted between 45 and 75 minutes. These taped
interviews were subsequently transcribed for
analysis.
Interview schedule
The interview schedule was designed to seek
information not easily obtained by conventional
survey methods. Questions in the interview
were derived from a number of sources includ-
ing therapeutic dialogues with women referred
for psychological help in relation to their hair
growth; the psychological literature and
discussion with other women about hair growth.
The questions of particular interest were:
1. How the women came to construe their hair
growth as problematic?
2. What are perceived as acceptable levels of
facial and body hair growth for women?
3. What are the collective ideas about female
hair growth that construct womens experi-
ences of unwanted hair growth?
Analysis
A discourse analytic approach was chosen to
make sense of the interview data. It is assumed
within such a framework that lives, selves,
experiences and their significance are
constructed through culturally available ideas
and practices. In particular, language is
considered not as a transparent medium
describing some underlying real entity, but is a
medium through which the individual is actively
structuring and constructing the world (Potter &
Wetherell, 1987). Meaning is suppressed or
expressed as a consequence of its effects on the
subjective experience of vulnerability and
power. Thus a discourse analytic approach can
be useful in highlighting issues of power and in
particular, genderpower relations (Hollway,
1989).
The product of a discursive analysis is a
reading of the text. Meanings in any text change
over time and according to context. Any reading
of the text must be regarded as provisional and
profoundly influenced by both the authors and
the readers assumptions and understanding
(Parker, 1989). Theory is seen not as simply
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emerging from data, because all observation is
pre-interpreted in terms of existing theory and
concepts. Henwood and Pidgeon (1992) suggest
that researchers should have a perspective (e.g.
substantive interests that guide research ques-
tions, or a philosophical stance) from which
actively to build analyses, without merely
applying these. They further suggest that these,
and also the researchers own personal experi-
ences, priorities and values, provide a store of
sensitizing concepts through which the emer-
gent account arises as a result of the constant
interplay between data and conceptualization, a
flip-flop between ideas and research data.
There is no one single method of discourse
analysis; rather, the framework refers to a prolif-
eration of approaches each with different
emphases and analytic styles. The analysis was
informed by two particular techniques, thematic
analysis (Burman & Parker, 1994) and thematic
decomposition (Stenner, 1994). Thematic analy-
sis has been described as a coherent way of
organizing and reading interview materials in
relation to specific research questions. These
readings are then organized in ways that attempt
to address the concerns identified by the
research questions, and also to the preoccupa-
tions of the intervieweesin this case, women
who are affected by their conceptualization of
themselves as hirsute. Stenner (1994) describes
thematic decomposition as a close reading that
attempts to separate a given text into coherent
themes or stories. This approach is informed by
the idea that discourse does not simply reflect
meanings, but that meanings are constructed
through discourse. The aim is not to ascertain if
a story is true but to examine what may be
achieved by its use.
Following Burman and Parker (1994), the first
stage of the analysis involved reading and re-
reading the transcript of the interviews. Then,
the themes from each transcript were noted
down. Under these headings, the instances of
text from which each theme was extrapolated
were also annotated with many pieces of text
coming under a number of different headings.
This enabled the process of collapsing these
themes into more general themes, e.g. hair as
sexing men and women. Following Burman and
Parker (1994) these themes remained close to
the preoccupations of the interviewees rather
than higher-level theoretical speculations. Then,
04 Keegan (jr/t) 3/31/03 1:31 PM Page 337
using Stenners thematic decomposition frame-
work, the functions of these themes or stories
were explored, i.e. what was being achieved
through their use and also the subject positions
(i.e. the part allocated to the women by the use
of these). The use of subject position helps to
explore how the subject is constructed, the
effects of taking up different positions in
discourses, the meanings they confer, and the
different values these have for different
categories of people.
Themes
The abnormal norm and its
regulation
Historically, ideas relating to the correct and
desirable amount of facial and body hair for
both men and women have varied. The current
feminine ideal of head hair, eyebrows, eyelashes
and a defined pubic triangle has been in circu-
lation since the turn of the century (Stratz,
1901). However, perhaps it is within the context
of contemporary consumer culture, in which
body attributes are regarded as plastic or infi-
nitely malleable (Featherstone, 1982) that such
an ideal is transformed from the status of
statistical rarity that is desirable, to the status of
normality. The capacity to approximate to such
an idealwith diligent depilatory practicesis
propagated through the mass media. In every-
day discourse, womens bodies are constructed
as naturally (and normally) smooth-skinned
and hairless; and the only available creditable
images of normal women are those portraying
smoothness and hairlessness.
Thus, while normal patterning of facial and
body hair growth in women (and men) has never
been determined, the following accounts indi-
cate how these women came to position them-
selves in relation to this abnormal norm. From
this reading of these texts, constructions of
normality and abnormality take place in the
context of what is communicated by other
people, by the amount of hair growth generally
displayed by women, and by media images:
Lorna: I never saw ladies with armpit hair and
when I first came to Europe (from the USA),
I almost fell off my chair. There was a lady
with armpit hairoh, whats that! because
Id never seen it, you always shaved. Even
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KEEGAN ET AL.: HIRSUTISM
before I was old enough to shave, ladies had
smooth legs, ladies had no armpit hair and
they had no hair on their faces. I think its just
what you see, the females you live with, the
images you see on TV, the things you read. I
was always (.)2 you were aware from an early
age that daddy might have, or a man might
have a moustache or a beard, but the bearded
lady was a freak.
Susan: We were at his (boyfriends) flat one
night and one of his friends came round and
said, Susan youre getting a few hairs on your
upper lip. That was me done, that was totally,
oh my God, some guy has noticed it.
AK: How did you come to determine that
your hair growth was abnormal?
Carol: Initially it was the fact that someone
else had pointed it out to me, I mean, I didnt
know whether, Id never really looked at
womens faces when I was 14 or 15 and
thought oh, theyve got hair on their face it
just wasnt anything Id ever really thought
about, but when someone pointed it out to me
I immediately thought oh, theres something
not right here.
AK: What did they point out to you?
Carol: Oh, they just said something like
youre developing a proper beard and mous-
tache.
Lisa: I did know whats normal from school,
from other people and my mum had hairy legs
and one of my aunts didnt. My grandparents
didnt have hairy legs.
The womens accounts of what is normal were
invariably tied up with the cultural ideal with
which their views concur, i.e. women have head
hair, eyebrows and lashes, and a defined pubic
triangle. However, their accounts of what was
acceptable were more varied. Lisa was able to
accept only hair growth equivalent to the classic
ideal. Carol, on the other hand, said that she did
not mind having hair, even facial hair, as long as
it was of a fine quality. Lorna considered that
her patterning of hair growth (excluding the hair
on her chin) could in fact be normal but stated
that it was unacceptable to others.
Within a social constructionist framework,
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JOURNAL OF HEALTH PSYCHOLOGY 8(3)
the internalization of such norms is seen as part
of the productive nature of the operation of
modern disciplinary power, which produces
and normalizes bodies, particularly womens
bodies, and maintains relations of dominance
and subordination (Foucault, 1979). Through
self-surveillance and correction to such norms,
and the regulation of bodies through body prac-
tices such as depilatory regimes, women are
rendered less socially oriented and more
focused on self-modification. They therefore
remain vulnerable to outside approval and
reliant on the approval of others (Bordo, 1993).
Having come to position themselves as
abnormal, a position clearly achieved (or
imposed) through relations with others, these
women have been described within clinical
literature as developing a morbid preoccu-
pation with hair growth (in Ferrante, 1988), or
an intense and exaggerated concern that their
perceived deviation will be noticed (Zerssen &
Meyer, 1960). However, such psychological
accounts, which focus on the individual women
as a site of psychological pathology, fail to take
into account the role of social context in the
production of such concerns, particularly the
enforcement of norms in line with prevailing
genderpower relations.
These ideas of exaggerated concern and
morbid preoccupation also fail to take account
of the enforcement of this cultural norm by
others. Indeed, what is notable about the
contemporary enforcement of norms with
respect to womens facial and body hair, is the
stringency with which such standards are
enforced:
Carol: Its interesting the hostility it provokes
(not removing armpit hair), it provoked quite
a hostile reaction from my mother and some
of my friends, they said yeuk, what are you
doing? and I said look, I dont feel like
removing it and then you change and another
time decided to, but (.) my mum really didnt
think it was right.
Lisa: Once, I dont even know who it was,
someone passing said oh you need a shave, I
was walking along, the wind caught my hair.
Lorna: I mean I come from (place name in the
USA) where its absolutely taboo to walk
around with leg hair, or underarm hair, and I
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remember being told in no uncertain terms
that I had to shave my legs.
AK: By whom?
Lorna: By my female relatives when we were
visiting the States. And then, at the age of 21,
I had a little bit of hair growth under my arms,
because Id been to University, where I didnt
see it as a problem, it was the era of feminism
and it was considered OK, and I got hauled to
one side by my aunt and told that it was
absolutely obscene and I needed to shave
right away or dont expose my arms and so it
shamed me into it.
Not only are women affected by the imposition
of this norm, but they too judge others in
relation to it. When asked about their reactions
to obvious superfluous hair growth on other
women. They said:
Lorna: I have mixed feelings. My first feeling
is one of absolute empathy and sympathy,
thinking God, I know what its like and
phew, Im not alone, but then sometimes, I
almost feel a sense of disgust that theyre not
looking after it and theyre not removing it. I
wish I didnt have to say that, its not very
right on, not very PC (politically correct) and
I guess Im not but I sort of think yuk, well
why dont you deal with it?
AK: And if you see a hairier person, how do
you feel? Do you think oh good?
Lisa: No I dont. I want to tell them how
electrolysis can help.
AK: What if you saw somebody wandering
around who had it, say facial hair, moustache
and chin hair, very obviously a woman, who
didnt remove it?
Carol: To be honest, I havent really. You
maybe associate it with older ladies, I was
almost on the verge of saying who let them-
selves go a bit, which is an interesting
comment.
Two points are of particular interest here. First
is the way in which removal of hair is seen as
looking after yourself, a striking example of
the process discussed by Foucault (1986) in
which regulation of the body comes to be seen
by us as self-care, rather than as a process
04 Keegan (jr/t) 3/31/03 1:31 PM Page 339
which may reflect gender or economic power
relations. The second point (illustrated in more
detail below) is that for these women, a display
of facial or body hair is only acceptable in
women who in some way represent the other.
Two such categories of other emerge from this
reading of these texts: older women (i.e. past the
need to be sexually attractive) and foreigners.
To be happy about the presence of superfluous
hair is also the prerogative of women regarded
socially as deviant, e.g. lesbians. One impli-
cation of this, which is not directly spoken, is
that sexually attractive heterosexual women
cannot display facial and body hair:
Lorna: Thinking about older women, I dont
feel such a sense of disgust with older women
if I see facial hair and also, I get the impres-
sion that theyre not so bothered and my
feeling is that when Im older, its not going to
bother me so much, perhaps because Im not
a sexual being, or at least Im not perceived as
that in society and therefore the pressures
less.
Lisa: Even if you go to France theyve all
(women) got their hair hanging out their arms
and I find it disgusting.
Lorna: I met someone once who had this
really big clump on her chin, it was like
witches hair, long, thick. She had a name for
it, it was hilarious because we were talking
about facial hair and she was perfectly happy
with her little clumpette. I dont know what
she called it. She had a name for it, and she
was perfectly happy and she wasnt going to
remove it. She was a lesbian by the way and
she was perfectly happy with it.
Not surprisingly, the same strictures are not in
place for men. As we have seen, the presence of
body hair in men is normal and part of what
separates them from women:
Lisa: The thought of men being waxed I find
nauseating.
AK: If you see a really hairy man, do you sort
of think yuk, get rid of it or do you think
anything apart from hes hairy?
Carol: Yeah, my instinct is a bit like you do
hes a bit hairy, but my dads got the full
chest hair, sprouting out here. It doesnt
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KEEGAN ET AL.: HIRSUTISM
bother me on my dad, but other men, Ive
been out with very hairy men and Ive been
out with men who are completely, practically,
hairless, so I dont think Ive got any view.
Interestingly, Carol suggests that the removal of
body hair is an issue for several gay male friends
of hers. This implies that for body hair to be an
issue for men, they must also be part of a group
that in some way is regarded as other. As such,
she suggests they may also be subject to the
pursuit of an aesthetic ideal, manipulating their
bodies in ways that may be similar to women.
Hair as sexing men and women
Hair is seen to demarcate genderwomen are
prescribed a different distribution of facial and
body hair in relation to men. Hair in certain
sites, such as the face and thoracic regions, is
regarded as the domain of the masculine male:
Lorna: Because the way I see it, hairiness in
most of the body apart from your head and
long eyelashes maybe, is the domain of the
male man, its the masculine thing.
Carol: Men should have facial hair, women
shouldnt and a woman who does is peculiar.
Carol: Your average heterosexual man
expects to have plenty of body hair he can
shave off in the morning and so if a women
starts portraying similar characteristics, its
regarded as being rather strange.
The presence of such facial and body hair has
different meanings for men and women. Men
are seen as normally virile and the presence of
facial and body hair symbolizes virility for them.
For women, however, the presence of such
hairand perhaps still symbolizing virilityis
associated with being base and repulsive:
Lorna: Well, its a sign of virility, isnt it, I
mean, Samson and Delilah, where the mans
hair was a sign of his virility and it still is, this
idea of a hairy chest.
Lorna: Well not a woman, or a kind of base
woman, not sexual, not sexy, not attractive at
all and almost like careless, a woman that
doesnt look after herself and therefore is
quite repugnant, really because she doesnt
look after herself.
Gender is represented in society as a entity,
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JOURNAL OF HEALTH PSYCHOLOGY 8(3)

mediated by social constructs and scientific preoccupation with hair as a focus of the regu-
classificatory schema (Turner, 1992). The rigid lation of anatomical difference between men
classification of human beings into the two and women is also evident in the proliferation of
mutually exclusive categories of males and depilatory products in recent years that promise
females has important functions for the main- women relief from superfluous hair. Further-
tenance of social relations within societies more, as the entire female body becomes
(Douglas, 1970). This rigidity is evident in the increasingly available as an object of public
insistent assignment of gender-ambiguous indi- display, the number of areas for hair removal
viduals (e.g. hermaphrodites) into one gender, have correspondingly increased (Ferrante,
even if it requires invasive medical interventions 1988).
aiming at a purely cosmetic outcome (Kessler,
1998). In most circumstances, however, gender
Unwanted hair as dirt
classification is maintained through social
Hair growth in places where it is not wanted is
discourses and regulatory practices. Ferrante
also associated with dirt. Douglas suggests that
(1988) proposed that a woman confronted with
a contravention of order by any object which is
the masculine hair referred to above is
likely to confuse or contradict cherished classi-
presented with a biographical inconsistency,
fications (1970, p. 48) becomes, dirt, much like
which threatens her gender identity and social
an unwanted flower is classified as a weed. She
position. This confusion of symbolic categories
also maintains that social deviance is important
and impairment of gender identity is echoed in
for the purpose of re-affirming blurred, ambigu-
the earlier findings of Ross et al. (1965) and
ous or somehow threatened social structures:
Zerssen and Meyer (1960).
This effort to differentiate the sexes on an Susan: When Im hairy, I feel dirty, but when
anatomical level gained momentum prior to the Im waxed and Im de-furred, I feel clean and
onset of the Industrial Revolution, when smooth.
barriers and stratification between the sexes on
Lisa: Yes, you feel dirty (with hair). Thats the
an economic and social level were beginning to
only way to describe it.
crumble. Concerns about the transgression of
social barriers increased in importance during AK: You say when youve taken all the hair
the Victorian era. Firth (1973) suggests that off you feel different. How?
prior to this, facial and body hair in women
Carol: Oh, I feel clean, like Ive had a wash or
might have been considered a disadvantage, but
something.
not a serious problem.
As the Industrial Revolution developed,
boundaries between men and women became
Deviance, stigma and passing
increasingly unclear. Over time, the regulation
As suggested in the discussion of the quantita-
of many aspects of physical difference (e.g. head
tive data, Goffmans (1963) conceptualization of
hairstyles, clothing) between men and women
deviance and stigma may shed light on some of
has become more blurred. In addition, the
the feelings that arise from this gender
mechanisms through which power operates to
confusion. He proposed that social categories
maintain gender relations has become focused
are differentiated by attributes considered ordi-
on more subtle physical and psychological
nary and natural for their members and
mechanisms (Foucault, 1979). It is possible to
defines as a stigma3 an attribute that is deeply
speculate that this enforcement is still stringent
discrediting. He suggests that those bearing such
around superfluous hair because such hair
stigmatizing characteristics are constructed as
growth represents one of the few visible demar-
inferior and as a threat. How the women express
cators of gender that remain. And it is certainly
feelings of stigmatization is illustrated below:
the case that institutional preoccupation with
hair growth in men has always been greatest in Carol: Well it was just that freak type of idea,
those areas where women have been marginal- you know, you get the circus spectacle of the
ized, such as the military and the police, which bearded woman, every time I hear someone
have demanded very short male head hair. The mention anything like that Id cringe.
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Susan: I just want to feel female. I just want to
feel pretty. I just want to feel normal and I
dont.
Lisa: Yeah, its mainly my face . . . Ive had
really rude comments. You feel a freak.
Here, in their use of language, these women
position themselves as freaks, and therefore as
other. According to Tajfels Social Identity
Theory (1981), individuals faced with such a
position will be motivated to remain within a
group that contributes positively and distinctly
to their identity. When this is not possible,
options are assimilation and accommodation
and/or insulation. The former refers to attempts
to pass (Goffman, 1963), that is, the adoption
of measures aimed at correcting the basis of any
perceived failing by reducing visible stigmata,
enabling passage into mainstream society.
Goffman suggests that because of the great
rewards attached to being considered normal,
almost all individuals who are in a position to
pass will do so (1963, p. 95). Not unsurprisingly,
therefore, this is the strategy adopted by all of
the interviewees and perhaps more generally, as
indicated by the absence of visible hair growth
in women approached for the study as a whole:
Lorna: I became aware at an early age of the
incessant, the continuously vigilant fight you
had to maintain against hair growth.
Carol: . . . but, Ive spent a lot of money on
skin, special skin preparations to cover the
areas and whatever, and so I feel my camou-
flage has been developed pretty well by now,
so Im not as insecure or fearful as I was. But
in my private life, at home, I still feel bad
about it.
Goffman also suggests that in passing, indi-
viduals have to consider aspects of their situ-
ation that maintain the facade of normality.
For these women, lives are re-arranged to
accommodate depilatory regimes and wherever
possible, disruption to these is avoided. For
example:
Susan: When someone is talking to me, I feel
like theyre looking at my upper lip. I start
covering my face or talking to somebody else
and then go back to them. I just feel so self-
conscious and I dread the summer, the light
nights.
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KEEGAN ET AL.: HIRSUTISM
Lorna: I mean I dread doing things like going
camping if I cant have access to a mirror,
because how am I going to be able to remove
the hair and I have to be able to do it on a
daily basis.
Carol: If Im going to the gym or going for a
swim and so I have to go and take all my war-
paint off and then I sort of creep out thinking
Oh God my face is all red, everybody is
going to be looking at me thinking I look a bit
strange.
The power of passing as a strategy which
enables these women to function socially at a
relatively high level, is illustrated by the
womens responses to a question about the
consequences of not having access to depilatory
products or medical treatments, i.e. if this option
of passing were no longer available:
Lorna: I would feel utterly ashamed. I cant
even envisage being in that situation because
Im so controlling about circumstances and
making sure everythings dealt with. I would
be ashamed. I would feel like I was a freak. I
would feel that I could not possibly walk out
and let anybody see me, certainly not
anybody that I knew or was likely to see again
. . . Id be very, very self-conscious, extremely
uncomfortable, embarrassed and ashamed.
Carol: No, that is my idea of absolute hell . . .
It would be horrible because it would be like
sort of, its almost like Jekyll and Hyde, thats
going a bit far, but someone believes youre
one way and then suddenly this thing happens
and the idea of heavy hair sprouting out of
your face. I cant even put into words quite
how it would be so horribleits just, I just
dont know because men, now thats interest-
ing talking about men, or just people would-
nt, arent used to dealing with women who
look like that. It would be like Id grown a
third arm or something.
On the one hand, the participants felt stigma-
tized while on the other, they successfully
adopted the strategy of passing. However,
these women must also negotiate between their
public and their private realities. This is
reflected in being unable to talk openly about
their hair growth. This provides an interesting
link with the quantitative data, whereby half of
341
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JOURNAL OF HEALTH PSYCHOLOGY 8(3)
the women there reported being unable to speak
to even close relatives about their hair growth,
and as few as 3.8 per cent reported being able to
discuss their hair growth freely:
Lorna: I sort of feel in this society, its some-
thing thats acknowledged by nearly all
women, most women must have a feeling
about this I should think and yet they dont
share it with other women, hardly ever, its
sort of kept secret, its kept alone and you do
it on your own.
Carol: Ive said Ive never spoken to anyone
about it unless they were my doctor or until I
said something to this friend.
This secrecy stands in contrast to the more
public nature of sexual hair removal by men,4
which is represented by a difference in the stan-
dards for men and women displayed in depila-
tory advertising. In advertisements for products
aimed at the removal of male sexual hair
growth, e.g. shaving products, prior hair growth
is often visible and depilation may be witnessed
(often by a beautiful girlfriend). In contrast,
advertisements for womens depilatory products
show only smooth skineven when represent-
ing pre-depilationand any depilatory activity
featured is private, with perhaps the exception
of a woman drawing a razor over an already
hairless leg.
One consequence of passing and the associ-
ated secrecy for these women, is the fear that
their true status, i.e. of freak, will be dis-
coveredthis is what Goffman (1963) refers to
as the fear of discreditationa fear of being
inadvertently found to be fulfilling an illegiti-
mate status. This fear of being found out can be
seen as inseparable from the social and cultural
context of its experience and expression. That is,
such fear can be conceived of as not originating
solely within the minds of these women, but as
a complex social production mediated by
culturally available knowledge.
Through the internalization of the cultural
ideal by these women, through the positioning
of the self as deviant and through adopting the
strategy of passing (i.e. camouflaging their hair
growth), the extent of these womens hair
growth is never seen. Thus the idea of the
proper amount and distribution of female hair
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growth remains unchallenged and the status quo
is maintained.
General discussion
Hair growth, though physically benign, is a
symptom worthy of medical treatmentbut
only for women. Treatment given by specialist
physicians is made available not so much for the
potential of hair growth to threaten health but
for its capacity to threaten gender classification
and such treatment illustrates how gender is
treated as a biological given, with certain
exclusive characteristics for men and women.
Although common to men and women, hair in
certain sites is deemed to be the prerogative of
the male sex, with the responsibility for demar-
cating gender falling on women. Women who
have hair growth on these sites face a bio-
graphical inconsistency that is not tolerated by
themselves or others. In both the quantitative
and qualitative parts of this study, women have
expressed feelings of being unfeminine or
unwomanly resulting from the presence of
sexual hair.
Characteristics differentiating men and
women have become more elusive as ideas
about womanhood have shifted, as women have
more varied social roles. The regulation of
womens bodies and in particular enforcement
of differentiating anatomical characteristics can
be seen to represent a contemporary form of
social regulation to help maintain the status quo.
The success of regulation through social
discoursesevident in everyday talk and media
representationswas illustrated by the unques-
tioned acceptance throughout. No participant at
any stage in the research process viewed the
extensive work involved in maintaining an
abnormal norm as bizarre or unreal. On the
contrary, the interviewees appeared to have
internalized the cultural norms regarding the
proper distribution of facial and body hair for
women and judged themselves as deviant. Their
continuing attempts to regulate themselves, via
depilatory practices and/or medical treatments
to meet the prescribed criteria for proper
womanhood is communicated as conceptually if
not practically unproblematic.
The success of passing as a strategy is import-
ant in accounting for the relatively high levels
04 Keegan (jr/t) 3/31/03 1:31 PM Page 343
of psychological functioning found in both
parts of the study. It may also account for the
lack of relationship between perceived
hirsutism and current distress. However,
associated with passing is a fear of discredita-
tion, i.e. of being found to be fulfilling an ille-
gitimate status. For some, this fear of
discreditation results in the avoidance or dread
of certain activities, particularly those involving
exposure of the body or social contact and
regulation of activities around depilatory
routines, with a reluctance to have these
disrupted. This was found within both the
quantitative and qualitative data. The power of
this strategy was tested to some extent in the
interview situations by asking women to
consider how they would feel if such strategies
were no longer available. This provoked reac-
tions of absolute horror, with respondents
invoking images of hell and the suggestion that
living a normal life would be impossible. What
this suggests is the existence of a great deal of
potential distress among these women, which is
kept under control by measures available to
manage their superfluous hair growth.
In this study, multiple methods were in-
corporated into the design to facilitate the
development of a more holistic picture than
would have been possible by using any one
alone. A consideration of the information
gathered suggests that overall, using multiple
methods in this case did achieve this aim of
providing a fuller picture of the womens experi-
ence of hirsutism.
The quantitative data provided useful
descriptive data, challenged the notion of simple
linear relationships between aspects of
perceived hirsutism and a number of psycho-
logical constructs in this sample and pointed to
the issues of gender identity and social avoid-
ance as being important for some women in
relation to their hair growth. However, the
quantitative data would have offered limited
understanding in the absence of the womens
accounts. These accounts have permitted a
much more in-depth exploration, highlighting
issues of deviance, stigma and the necessity to
work persistently to conform to an abnormal
social norm, which is propagated in our society
and internalized by women. The analysis has
also highlighted the inappropriateness of
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KEEGAN ET AL.: HIRSUTISM
individualizing any distress as perfectionism or
morbid preoccupation.
Perhaps the most important message that
integrates our multiple data sets is that while
unwanted hair growth can be extremely distress-
ing for women, the ability to keep this sense of
shame private through hair removal, can enable
the women to function much more highly than
their professed adverse reactions would suggest.
In using a mixed methodology, this study
represents one of the first attempts to incorpo-
rate contemporary qualitative methods into the
study of womens experiences of hirsutism,
thereby facilitating an exploration of the contri-
bution of social context to their experience.
Notes
1. After birth, human body hair is divided into two
principal types, vellus and tertiary or terminal hair.
Vellus are short, fine and soft and generally display
no pigment or medulla. Terminal hair is longer,
coarser, stiffer and has both pigment and a well-
developed medulla. The growth of vellus is stimu-
lated by growth hormone and is dependent on
body region. The growth of what is known
medically as asexual hair, corresponding to scalp
hair, eyebrows and lashes, is influenced by growth
hormone. At puberty, androgens lead to the
replacement, in both men and women, of vellus
hair by terminal hair in the axillary regions, the
armpits, pubes and lower arm and leg. This is
known as ambo-sexual hair. Sexual hair is terminal
hair produced by exposure of vellus to androgens
in those regions considered characteristic of
masculine hair growth, i.e. lip, chin, sideburns,
chest, upper pubic triangle and abdominal regions
(Lunde, 1984).
2. Notation used in quotations: (.) indicates brief
pause; . . . indicates longer pause; (non-italicized
text) indicates something inferred by context, not
explicitly included within this quotation.
3. Goffman (1963) proposed three types of stigma,
physical deformities, blemishes of character (e.g.
weak will) and what he refers to as the tribal
stigma of race, nation and religion. Within this
typology, hirsutism could be regarded as a physical
deformity.
4. Although there may be some hair growth that is
removed by men in private e.g. hair in the nostrils
or ears.
343
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JOURNAL OF HEALTH PSYCHOLOGY 8(3)
References
Adams, J., Polson, D. W., & Franks, S. (1986). Preva-
lence of polycystic ovaries in women with anovula-
tion and idiopathic hirsutism. British Medical
Journal, 293, 355359.
Barth, J. H., Catalan, C. A., Cherry, A., & Day, A.
(1993). Psychological morbidity in women referred
for treatment of hirsutism. Journal of Psychoso-
matic Research, 37(6), 615619.
Baum, H. C. (1912). The etiology and treatment of
superfluous hair. Journal of the American Medical
Association, 54, 104106.
Beek, C. H. (1950). A study on the extension and
distribution of human body-hair. Dermatologica,
101, 317337.
Bordo, S. (1993). Unbearable weight: Feminism,
western culture and the body. London: University of
California Press.
Burman, E., & Parker, I. (1994). Introduction
discourse analysisthe turn to the text. In E.
Burman & I. Parker (Eds.), Discourse analytic
research: Repertoires and readings of texts in action
(pp. 116). London: Routledge.
Conn, J. J., & Jacobs, H. S. (1997). Clinical manage-
ment of hirsutism. European Journal of Endocrinol-
ogy, 136(4), 339348.
Coulam, C. (1974). The hirsute person: A commen-
tary. Medical Clinics of North America, 58, 877884.
Douglas, M. (1970). Natural symbols. London: Tavis-
tock.
Featherstone, M. (1982). The body in consumer
culture. In The body: Social process and cultural
theory (pp. 170196). London: Sage.
Ferrante, J. (1988). Biomedical versus cultural
constructions of abnormality: The case of idiopathic
hirsutism in the United States. Culture, Medicine,
Psychiatry, 12(2), 219238.
Ferriman, D., & Gallwey, J. D. (1961). Clinical assess-
ment of body hair growth in women. Journal of
Endocrinology and Metabolism, 21, 14401447.
Firth, R. (1973). Hair as a public symbol. In Symbols,
public and private (pp. 262298). Ithaca, NY:
Cornell University Press.
Foucault, M. (1979). The history of sexuality vol. 1: An
introduction. London: Allen Lane.
Foucault, M. (1986). The history of sexuality vol. 3: The
care of the self. New York: Pantheon.
Gara, G. (1936). Hypertrichosis: The problem and
how to handle it as it appears in everyday practice.
Urologic and Cutaneous Review, 8, 771774.
Goffman, E. (1963). Stigma: Notes on the management
of a spoiled identity. Englewood Cliffs, NJ: Prentice
Hall.
Goldberg, D. (1978). The General Health Question-
naireGHQ 60. Windsor: NFERNELSON.
344
Downloaded from hpq.sagepub.com at NATIONAL CHUNG HSING UNIV on April 12, 2014
Hatch, R., Rosenfield, R. L., Moon, K., & Tredway, D.
(1981). Hirsutism: Implications, aetiology and
management. American Journal of Obstetrics and
Gynecology, 140(7), 815830.
Henwood, K. L., & Pidgeon, N. F. (1992). Qualitative
research and psychological theorising. British
Journal of Psychology, 83, 97111.
Hollway, W. (1989). Subjectivity and method in
psychology: Gender, meaning and science. London:
Sage.
Ingham, J. G., Kreitman, N. B., Miller, P., Sashidharan,
S. P., & Surtees, P. G. (1986). Self-esteem, vulnera-
bility and psychiatric disorder in the community.
British Journal of Psychiatry, 148, 373385.
Jacobs, H. S. (1987). Polycystic ovaries and polycystic
ovary syndrome. Gynecological Endocrinology, 1,
113131.
Jeffreys, S. (1985). The spinster and her enemies:
Feminism and sexuality 18801930. London: Rout-
ledge & Kegan Paul.
Johnson, M. (1995). Using the portfolio. In M.
Johnson, S. Wright, & J. Weinman (Eds.), Practical
measures in health psychology: A users portfolio.
Windsor: NFERNELSON.
Kessler, S. J. (1998). Lessons from the intersexed. New
Jersey: Rutgers University Press.
Keye, W. (1982). Evaluation and management of
hirsutism. Medical Aspects of Human Sexuality, 16,
190194.
Liao, K. L. M., Wood, N., & Conway, G. S. (2000).
Premature menopause and psychological well-
being. Journal of Psychosomatic Obstetrics and
Gynecology, 21, 167174.
Lunde, O. (1984). A study of body hair density and
distribution in normal women. American Journal of
Physical Anthropology, 64, 179184.
Lunde, O., & Grottum, P. (1984). A study of body hair
density and distribution: Normal or hirsute.
American Journal of Physical Anthropology, 64,
307313.
Lux, V. E. (1982). Die personlichkeitsund sozialbe-
deutung des hirsutism. Panminerva Medica, 23,
6974.
McCafferty, L. (1923). Hypertrichosis and its treat-
ment. New York Medical Journal and Medical
Record, 5 December, 685687.
Milne, P. (1992). Assessment: A mental health port-
folio. Windsor: NFERNELSON.
Moorey, S., Greer, S., Watson, M., Gorman, C.,
Rowden, L., Tunmore, R., Robertson, B., & Bliss, J.
(1991). The factor structure and factor stability of
the Hospital Anxiety and Depression Scale in
patients with cancer. British Journal of Psychiatry,
158, 255259.
Parker, I. (1989). The crisis in modern social psychol-
ogy, and how to end it. London: Routledge.
04 Keegan (jr/t) 3/31/03 1:31 PM Page 345
Pedersen, J. (1942). Hypertrichosis in women. Acta
Derm. Venereol. (Stockholm), 23, 113.
Potter, J., & Wetherell, M. (1987). Discourse and social
psychology. London: Sage.
Rabinowitz, S., Cohen, R., & Le Roith, D. (1983).
Psychological reports, 53, 827830.
Robson, R. (1993). Real world research: A resource for
social scientists and practitioner researchers. Oxford:
Basil Blackwell.
Rosenberg, M. (1989). Society and the adolescent self
image, reprint edn. Middletown, CT: Wesleyan
University Press.
Ross, J. R., Richard, A., Mastrodonato, N., Cassall,
W. A., Moses, A. A., Fischer, S., Steckler, P. P.,
Radin, S. S., Kaplan, E. A., & Dubey, J. (1965).
Psychological problems associated with hirsutism.
International Psychiatry Clinics, 2, 625640.
Silber, E., & Tippett, J. (1965). Self-esteem: Clinical
assessment and measurement validation. Psycho-
logical Reports, 16, 10711081.
Slade, P. D., Dewey, M. E., Newton, T., Brodie, D. A.,
& Gundi, K. (1990). Development and preliminary
validation of the Body Satisfaction Scale (BSS).
Psychology and Health, 4(3), 213220.
Sonino, N., Fava, G. A., & Mani, E. (1993). The quality
of life of hirsute women. Postgraduate Medical
Journal, 69(809), 186189.
Downloaded from hpq.sagepub.com at NATIONAL CHUNG HSING UNIV on April 12, 2014
KEEGAN ET AL.: HIRSUTISM
Stenner, P. (1994). Discoursing jealousy. In E. Burman
& I. Parker (Eds.), Discourse analytic research:
Repertoires and readings of texts in action (pp.
11434). London: Routledge.
Stoppard, J. M. (1989). An evaluation of the adequacy
of cognitive behavioural theories for understanding
depression in women. Canadian Psychology, 30(1),
3947.
Stratz, C. H. (1901). Die schoenheit des weiblichen
korpers. Stuttgart: Ferdian Enke.
Tajfel, H. (1981). Human groups and social categories.
Cambridge: Cambridge University Press.
Taylor, J. (1953). A personality scale of manifest
anxiety. Journal of Abnormal and Social Psychol-
ogy, 48, 285290.
Turner, B. S. (1992). Regulating bodies: Essays in
medical sociology. London: Routledge.
Watson, D., & Friend, R. (1969). Measurement of
social-evaluation anxiety. Journal of Consulting and
Clinical Psychology, 33, 448457.
Zerssen, D. V., & Meyer, A. E. (1960). Idiopathic
hirsutism. Journal of Psychosomatic Research, 4,
206235.
Zigmond, A. S., & Snaith, R. P. (1983). The Hospital
Anxiety and Depression Scale. Acta Psychiatrica
Scandinavia, 67, 361370.
345