Original Article
Facial disfigurement is treated like an infectious disease

https://doi.org/10.1016/j.evolhumbehav.2012.04.001Get rights and content

Abstract

The behavioral avoidance of people with facial disfigurement is well documented, but its psychological basis is poorly understood. Based upon a disease avoidance account of stigmatization, we conducted the first empirical test of whether facial disfigurement—naevus flammeus (a port wine stain) here—can trigger the same set of emotional and behavioral responses as a contagious disease (influenza). Ninety-eight participants contacted props, which they had seen used either by a healthy confederate or by a confederate simulating medical conditions affecting the face—birthmark and influenza. Behavioral avoidance (e.g., willingness to handle the prop) and facial display of disgust were recorded across five levels of prop contact varying from no contact to contact with the mouth. Behavioral avoidance and disgust displays, especially with oral contact, were equivalent in the birthmark and influenza conditions, with both significantly exceeding reactions to the healthy confederate. These results support the theory that humans have an evolved predisposition to avoid individuals with disease signs, which is mediated by the emotion of disgust. This implicit avoidance occurs even when they know explicitly that such signs—the birthmark here—result from a noncontagious condition.

Introduction

Individuals with acne, psoriasis, or eczema, as well as people with cleft palates, facial birthmarks, or other disfiguring facial lesions, have all reported being avoided by others (Clarke, 1999, Hill & Kennedy, 2002, Hong et al., 2008, Papadopoulos et al., 2000). This avoidance may take many forms, including difficulties in forming and maintaining interpersonal relationships (Clarke, 1999), as well as inequities in employment, education, and health care settings (Lanigan & Cotterill, 1989). Several authors have claimed that avoidance of people with facial lesions and disfigurement, amongst others, arises because such individuals trigger an innate disease avoidance system, which is primed to detect “disease-like” signs irrespective of their veracity (Kurzban & Leary, 2001, Oaten et al., 2011, Park et al., 2003). This disease-based account of avoidance makes one central prediction, which has yet to been tested. Specifically, people's reaction to an individual with a facial lesion should be the same as their reaction to an individual with a visible contagious disease. The experiment reported here tested this prediction (Crocker, Major, & Steel, 1998).

It has been suggested that behavioral avoidance may reflect the activation of a disease avoidance system that is predisposed to respond to signs of disease, irrespective of their accuracy (Kurzban & Leary, 2001). Disease can impact on an individual in a number of different ways, many of which may lead to deviations from the species-typical norm (Kurzban & Leary, 2001). For example, some diseases may disturb an individual's symmetry, creating marks, lesions, or discoloration of body parts, while others may produce behavioral anomalies as a consequence of damage to muscles or muscle control systems (Ewald, 1993). The human face may be a particularly important point of display for disease signs. The 25 diseases that currently (and historically) impose the highest human mortality and morbidity were recently identified (Wolfe, Dunavan, & Diamond, 2007). Of these 25 diseases, 16 present with readily visible facial lesions (rashes, bleeding under the skin, changes in color of the sclera), 20 present with fever (which will also include abnormal facial coloring and perspiration), 6 with a cough or nasal discharge, 5 with abnormal movement or behavior that extends beyond illness-related malaise (muscle spasms, torpor, psychosis), and 5 with changes to the physical structure of the body (swollen neck, cachexia, lipodystrophy). In total, all 25 diseases demonstrate one or more of these signs, with most (23/25) visible on the face (i.e., skin lesions, jaundice, fever, cough/nasal discharge).

While the face may be a useful indicator of a person's health status, it is far from perfect. Not all diseases manifest in clearly visible facial (or other) symptoms. Not all rashes, sores, and disfigurements indicate an active infection (Ewald 1993). Moreover, all humans deviate to some degree from the species-typical norms because of injury or genetics (Kurzban & Leary, 2001). Together, this “noise” makes it difficult to tell whether or not a particular facial sign is truly indicative of infection—a signal detection problem. A disease avoidance module functions to process a given type of stimuli or inputs—e.g., correlates of parasite infestation. These inputs constitute the “proper domain” of the module (Sperber, 1994). To recognize inputs belonging to its proper domain, a module uses formal conditions that an input has to meet in order to be accepted and processed. All inputs meeting the input conditions of a module constitute its actual domain. These input conditions can never be perfectly adequate. Some items belonging to the proper domain of the module may fail to satisfy them—a genuine illness may not exhibit detectable disease signs (false negative or “miss”; Haselton & Buss, 2000). Some items not belonging to the proper domain of a module may nevertheless satisfy its input conditions—a benign disease sign such as a birthmark (false positive or “false-alarm”; Haselton & Buss, 2000). Faced then with an ambiguous disease sign, a person can err by a false alarm (a healthy person is erroneously perceived to be sick) or a miss (a sick person is erroneously perceived to be healthy). Error Management Theory (Haselton & Buss, 2000, Haselton & Nettle, 2006) suggests that, in such cases, people will act to reduce the error that poses the greatest threat to one's fitness. Thus, humans should be biased toward false alarms because false rejections are potentially fatal (Haselton et al., 2005, Kurzban & Leary, 2001). Accordingly, we are likely to be particularly reactive to signs of disease, especially if the threat of disease is highly salient or if we feel particularly vulnerable to disease (Functional Flexibility; Schaller & Duncan, 2007, Schaller & Park, 2011).

This has obvious and far-reaching implications for social perception and behavior. Simply because people may display some superficial form of nonnormality, we may respond to them—even if they are perfectly-healthy—as though they are carriers of some contagious disease (Schaller & Duncan, 2007). A large literature suggests that facially disfigured people experience behavioral avoidance, and many of these findings are consistent with the operation of false-alarm biases. For example, Rumsey, Bull, and Gahagan (1982) conducted a naturalistic study that measured the personal space afforded to a disfigured or nondisfigured confederate by public pedestrians in a busy street. The study employed two types of disfigurement: a birthmark under the right eye (permanent disfigurement), and trauma scarring and bruising (temporary disfigurement). They found that members of the public stood further away from the confederate in the disfigured conditions than in the no disfigurement condition. Moreover, pedestrians tended to stand even further from the permanently disfigured confederate (birthmark) relative to the temporarily disfigured confederate (see Rumsey & Bull, 1986 and Houston & Bull, 1994, for similar findings).

While the data above provide a strong case that people with facial disfigurements are avoided and that this avoidance may result from “false alarms” generated by a disease avoidance system, this account has not been tested before. As we outlined in the opening paragraph, our central prediction is that participants will demonstrate the same reaction to an individual with a facial disfigurement as they will to a person with a visible contagious disease. A key component of this reaction is disgust, an emotion that seems to be selectively triggered by pathogen threats (Oaten, Stevenson, & Case, 2009). Moreover, the more intimate the contact with the pathogen threat and the more likely the prospect of oral incorporation of that “threat,” the greater the experienced level of disgust (Fallon & Rozin, 1983). If the pathogen threat contacts another object, this object may become “contaminated,” and it too may then engender disgust. This has been observed in laboratory settings by participants' reluctance, for example, to drink juice that had been in contact with a sterilized cockroach (Rozin, Millman, & Nemeroff, 1986) or to wear a laundered jumper previously worn by a person reported to have HIV/AIDS (Rozin, Markwith, & Nemeroff, 1992). Disgust-based disease avoidance should be both automatic and fairly impenetrable to cognition to ensure that all disease signals, false or real, are acted upon (Oaten et al., 2009). If genuine disease threats induce disgust and can contaminate other objects, which too can induce disgust and especially so if these objects come near the mouth, then these types of reactions should be common to both genuine disease threats and to apparent disease threats (i.e., false alarms).

The present study set out to test this prediction of reaction similarity by comparing participant responses to confederates feigning “real” disease signs (e.g., influenza symptoms) or “false alarms” (e.g., facial birthmark) and to a healthy control. Under the guise of an imitation study, participants handled three different props (e.g., towel, harmonica, snorkel mask) across five levels of proximity (e.g., no contact, contact with hand, contact with head, contact with face, and contact with mouth) and across three medical conditions (influenza, birthmark, healthy control). In accordance with the predictions of a disease avoidance account, we hypothesized that participants would make less contact with the props previously used by confederates displaying signs of disease—regardless of whether these signs were real (e.g., influenza) or “false alarms” (e.g., birthmark)—relative to the healthy control. In particular, we anticipated a greater number of facial and behavioral displays of disgust in the influenza and birthmark conditions relative to the healthy control, and especially as the level of prop contact became more intimate (e.g., oral).

Section snippets

Participants

Ninety-eight Macquarie University students (72 female, 26 male) participated for course credit. Age ranged from 18 to 50 years (M= 20.36, S.D.=4.87). The study was approved by the University Human Research Ethics Committee.

Overview and design

The aim of the study was to evaluate participants' reactions to the three experimental conditions: influenza, birthmark, and healthy control. Using a fully within-subject design, participants were asked to imitate tasks performed by three confederates each of whom was featured

Manipulation checks

In the trainer description, all participants described the healthy target using terms unrelated to health such as “male” (75/98), “brown hair” (66/98), and “blue shirt” (39/98). No participants used descriptors indicative of poor health. The birthmark target was described similarly to the healthy target but with a “birthmark on his left cheek” (82/98); however, all participants mentioned the birthmark when questioned during debrief. Participants described the influenza target as appearing sick

Discussion

This study is the first to test the prediction that facial disfigurement, in the form of a port wine stain, can trigger a disease-avoidance-like response. We predicted that both a birthmark and influenza would generate broadly the same reaction, characterized by facial expressions of disgust and avoidance of contact with items touched by the confederate, and that these effects would be most pronounced when they involved oral contact. Consistent with our prediction, participants demonstrated

Supplementary Materials

The following is the Supplementary data to this article.

. Experimental setup. The photograph on the left depicts the room from the perspective of entry, whereas the right photograph depicts the perspective of the participant during the imitation task.

. Screenshots of the three confederates in the three medical conditions.

. Levels of prop contact with the snorkel mask.

Acknowledgments

The authors would like to thank the Australian Research Council for their continued support and Georgia McClure and John Chalmers for assistance with this study.

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