IntroductionHistorically, the social value given to women has been inseparable from their bodies. Their social role has been identified and expressed through them, for example, by having children or satisfying others’ sexual, emotional and physical needs. When body size and shape are regarded as essential because of their social value, women learn to focus their attention on their physical appearance, which becomes a requirement for obtaining both internal satisfaction and social success (Brown & Jasper, 1993). In the particular case of Western society, where slenderness and youth are equated with the concepts of beauty and health, most women –including middle-aged ones– have some degree of dissatisfaction with their bodies. To understand this, we need to consider two concepts: body image and body dissatisfaction. Body image is defined as “the image of our body that we form in our minds, that is, the way in which our body represents us” (Schilder, 1994, p. 15), while body dissatisfaction is defined as a person's dissatisfaction with their weight and shape, which translates into a pathological concern with their appearance (Cooper, Taylor, Cooper, & Fairburn, 1987; Devlin & Zhu, 2001). Body dissatisfaction can arise as a result of the influence of one's culture, family or peer group, and may constitute a risk factor in the adoption of strategies to alter one's figure and weight (Midlarsky & Nitzburg, 2008) such as extreme methods for reducing or controlling body weight (Heinberg, Thompson, & Matzon, 2001) and thus trigger an eating disorder (ED).Several authors have studied middle-aged women, addressing issues such as the development of body image and its possible alterations and consequences (Lev-Ari, Baumgarten-Katz, & Zohar, 2014; Muhlbauer & Chrisler, 2007; Paquette, Leung, & Raine, 2002; Paquette & Raine, 2004; Peat, Peyerl, & Muehlenkamp, 2008; Runfola et al., 2013; Stokes & Frederick-Recascino, 2003; Whitbourne & Skultety, 2002). Reviews such as those by Brandsma (2007) and Harris and Cumella (2006) state that the transition between childhood and adolescence, adolescence and youth, and youth and adulthood are associated with an increased risk of developing alterations in one's body image or ED. Meanwhile, Zerbe and Domnitei (2004) point out that it is essential to recognize the existence of the problem, observe the triggers, and pay attention to other aspects of body experience beyond physical appearance (Tiggemann, 2004).In Mexico, research on body image and eating behaviors in middle-aged women is recent. Most of the studies are based on surveys or group interviews and explore different directions. Bojorquez, Mendoza, Tolentino, Morales, and De-Regil (2010) evaluated the link between risky eating behaviors (REB) and vitamin deficiency and certain nutrients in a sample of women of reproductive age. Although the authors found no association between the variables studied, they did find a high prevalence of REB and obesity in this population. Bojorquez, Unikel, Mendoza, and De-Lachica (2013) focused on the experience of pregnancy in Mexican women in relation to their body image. Although the researchers found widespread acceptance of the ideal of slenderness, the women they studied felt “protected” from body dissatisfaction because of the fact that they were mothers and ended up focusing on looking after their children's bodies rather than their own. These authors suggest that health campaigns aimed at adult women should emphasize their care and well-being and consider other aspects of their lives. Kimoto et al. (2014) explored the experiences of eating in rural areas of Querétaro, where obesity ends up being a desirable state for women, due to the limited availability –for economic reasons– of healthy food choices as a factor limiting the ability to access and consume diets compatible with the promotion of good health. These authors propose continuing studies on these populations with the aim of designing interventions for Mexican rural women that are sensitive to their cultural and environmental context.As we can see, there are aspects related to Mexican middle-aged women's body image that have yet to be addressed, that is why this study is interested in exploring the experiences of this population in greater depth, both to intervene in body dissatisfaction in the future and to prevent any eating pathology that could go unnoticed since this population is not regarded as being at risk. We therefore asked: What are the aspects that have influenced middle-aged women throughout their lives in constructing their body image and the decision whether or not to adopt body modification strategies?Since body image construction is a continuous process throughout a person's life, for this research, it was decided to identify “epiphanies” (Denzin, 1989a, 1989b), defined as events that transformed women's lives, and use them as a tool that allows us to understand the participants’ behavior. The purpose of this study was therefore defined as the exploration of experiences that have influenced the development of middle-aged women's body image and their adoption of body modification strategies.MethodParticipantsThe participants were eight women aged between 35 and 50 years based in Mexico City, who were receiving psychotherapy at a non-profit institution.Methodological approachThe biographical method (Bertaux, 1993) was used. This perspective makes it possible to study and compile personal documents, which involves examining people's lives through their experiences, simultaneously directing us to an inner world of thought and an outside world of the events surrounding them (Denzin, 1989a). This method provides methodological strategies of conversation and narration as well as a documentary review of autobiographies, biographies, personal narratives, letters, diaries and pictures. It combines oral sources with documentary ones, with the twofold purpose of first, identifying the mechanisms underlying the processes used by individuals to give sense and meaning to their own lives, and second, of providing a descriptive, interpretive and necessarily systematic and critical analysis of life documents (Sanz, 2005).In order to obtain a biographical account of each respondent, several methodological tools were used that make it possible to understand the chain from the history of the group to which they belong to family history, and from this history to the shaping of their own identity. In this regard, work on the life history is a method that attempts to locate the evolution of social relations through individual stories, since participants are encouraged to use this knowledge to better understand the significance they give their bodies on the basis of their experiences.This research used the tools proposed by Vincent de Gaulejac (cited in Saldaña, 2009), who suggests a combination of techniques involving verbal and nonverbal exploration (drawings, dramatizations, role playing, family tree, lifeline, masks, etc.) that make it possible to gain access to expression forms not linked to spoken language rules in which one tends to rationalize.Methodological devicesSemi-structured individual interview. An interview guide was constructed on the basis of the main topics identified in the research reviewed that have addressed body image issues (Barthalow, Kernoff, Thurau, & Carey, 2005; Harris & Cumella, 2006; Johnston, Reilly, & Kremer, 2004; Kally & Cumella, 2008; Paquette et al., 2002; Paquette & Raine, 2004; Patrick & Stahl, 2009; Peat et al., 2008). The guide covered the following topics: the experience of being a woman, the body, being the target of criticism, body image, body dissatisfaction, natural body changes, losses (deaths, separations, divorces, job losses), body weight history, health problems, strategies and attempts to control body weight (diet and/or exercise, etc.), interpersonal relationships, sexual experiences and pregnancy (see Appendix A).Life line. This tool involved drawing three horizontal lines on a sheet of bond paper. On the top line, called social events, each respondent wrote down the macro events that were significant in her country or the world, in other words, events such as an earthquake or a strike. On the second line, called biography, they described everything they considered significant from the moment of birth until the present, both individually and in their families (school, birth of siblings, marriages, major diseases, parental divorce, losses, achievements, meetings, jobs, etc.). On the third line, called membership groups, they were asked to include the groups to which they had belonged in their lifetime, an important person who had had an influence on them, and the messages about being a woman, their bodies and beauty they had experienced at each life-stage.Family tree. Graphic representation of at least three generations of relatives. In addition, they had to include critical events in the family history, social mandates regarding the body, beauty and the gender stereotypes followed in their families; important people, and comments about the body. They were also asked to mention family members who had implemented a strategy to change their body shape, from frequent personal grooming through restricted diets to surgeries.Analytical frameworkIn order to perform the analysis, emphasis was placed on epiphanies, defined as experiences that leave marks on people's lives. Epiphanies happen when the subject experiences and copes with a crisis. They have the potential to create a transformative experience and are commonly interpreted as breaking experiences, because after these experiences, a person changes the perception of the world around her, which leads her to make substantial changes in her behavior (Denzin, 1989a, 1989b). There are four types of epiphanies proposed by Denzin (1989b), called: (1) Major epiphany: a situation that touches a person's life to such an extent that he is no longer the same person; one talks of a before and after the event; (2) Cumulative epiphany or representative event: this is a sudden reaction, resulting from a series of events that have been taking place over a long period of time; (3) Minor or illuminating epiphany: this is a problematic moment in a relationship or a person's life. These epiphanies highlight the underlying tensions or problems in a situation or relationship; and (4) Relived epiphany: in this type of epiphanies, a person experiences a situation that triggers the memory and feelings of other similar experiences, due to the occurrence of an event. These situations can trigger the feelings and thoughts that surrounded previous events.ProcedurePermission was requested from the directors of the institution to allow its population to participate in the project. The therapists identified possible participants who were contacted to explain them about the goal and the dynamics of participating in the project. The inclusion criteria were: being within the established age range, agreeing to participate and being Mexican.The study was conducted on the premises of the civil association, with the exception of two sessions, which were held at another institution providing psychological care under the same conditions, in other words, a large, private space. The first author was responsible for performing the field work. The participants’ informed consent was obtained in accordance with the Ethical principles for medical research in human beings of the Helsinki Declaration and the protocol that informed this research was approved by the tutors’ committee of the Masters and Doctoral Program of the National Autonomous University of Mexico Psychology Faculty. The informed consent form guaranteed the confidentiality and anonymity of the information (synonyms were used), and respondents were asked to authorize the audio recording of the sessions. Their participation was completely voluntary and there was no financial or any other type of compensation. Information was gathered in four two-hour meetings. The first meeting consisted of a semi-structured interview, with individual sessions for each participant. For the next three meetings, groups of two were formed whose members were chosen randomly and the life lines and the family trees were drawn. This dynamic was chosen because these are the most productive methodological devices for small groups.Data analysisThe analysis involved categorizing the information in three stages (Monje, 2011): (a) verbatim transcript of the audio formats; (b) categorization, which involves identifying key topics in the transcripts, retrieving textual data segments that share a common code; and (c) the identification of recurrent and divergent issues. Each transcribed document was independently reviewed in order to identify the topics that arose. The first author classified the corresponding fragments in order to subsequently draw up a list of categories per participant and identify what they had in common.ResultsThe results are shown as follows. First the demographic profile of the participants, showing the population studied and the body modification used by each participant (Table 1). This is followed by the dissatisfaction with a particular part of the body which they mentioned, and the modification methods used. Lastly, the epiphanies found in the participants’ accounts are presented.Participants’ profileThe participants’ age range is 35–50. Five of the participants receive low, sporadic financial remuneration, three of them work in family businesses, one has temporary jobs, and another is engaged in formal employment, for which she earns a low wage and payments can be delayed by up to a month. Three of the remaining women have permanent jobs, one as a sales manager, another at a government agency, and another as a mortgage broker, a position she secured through one of her sisters, since she had been unable to find work on her own. Table 1 shows the participants’ demographic data.The study found that 87.5% of the participants had implemented a strategy to modify their bodies and engaged in REB, mainly involving restricted diets. They also reported other weight control strategies, such as engaging in physical activity (running, walking, jogging); having injections and taking burn fat capsules, and support from nutritionists or other alternative practitioners (acupuncturists) that offer options for weight control. Moreover, some of the participants reported that there were some parts of their bodies they disliked, which is classified as dissatisfaction with their bodies. This dissatisfaction is associated with their skin, face, height and in one case, breast size. It is important to note that, in the latter case, the participant said that this dissatisfaction is due to the fact that this part of the body is attractive to men, a situation that has made her feel uncomfortable throughout her life.Analysis of the storiesOn the basis of the reading of the material produced by the participants, the analysis focused on the epiphanies that have influenced the development of the women's body image.Major epiphaniesThroughout the accounts, five major epiphanies were identified, which constituted situations that significantly changed the participants’ lives. In four of the five accounts, the common factor was the presence of a male figure (the participant's father or partner). The period when these situations emerge varied from childhood and adolescence to middle age.The following is a testimonial of an epiphany that occurred in childhood, in which the male figure is personified by the father. The participant was taken to the doctor, because the father thought she was an overweight child. Although both parents attended the consultation, the father was usually the only one to make decisions.“When I was girl, I was still at elementary school…my dad took me to a doctor…(my father) told him to put me on a diet, but he (the doctor) refused because I was beginning to develop and um…he couldn’t put me on a diet”. (Mapi, 38 years old)This event is remembered as the first in her life where she was told that overweight is something that should not be present, and should be treated as a disease to be cured.In the second major epiphany, her father made a momentous decision for the participant's life when he decided to move her from a public to a private school. In this new context, she began to feel different from the other students:“…they moved me to the south to a private school that was full of preppy girls and boys. I did not feel I was on the same level as them. They all had nice houses, decent dads, with good degrees, nice families, everything was nice…I did not want to introduce them to my dad, who was a cabbie”. (Zapatita, 38 years old)This was the first time that Zapatita had placed importance on the appearance required to belong to her new social group and thus establish interpersonal relationships that would facilitate her inclusion.The third epiphany is linked to the previous one, and occurred at the time of a surgical operation that would initially improve her health, but also had esthetic benefits.“I had a nose job, that was a before and after. It was as though I had been born again. As sure as my name's Z…I used to have a large, hooked nose and that made me feel very bad”. (Zapatita, 38 years old)The fourth epiphany occurred with the divorce of one of the participants. This situation resulted in the woman having mainly negative thoughts and feelings about her appearance and her self-concept in general.“…I was a real mess, I felt ugly and bad. I felt like a failure and had an economic, professional, emotional slump all at the same time”. (Mary, 41 years old)The last epiphany occurred as a result of the comments of the partner of one of the participants about her body weight. This occurred during her high school studies. In her own words, it was the first time someone had pointed out her build and made her engage in weight loss strategies.“My first boyfriend kept saying that I was very fat and that my clothes didn’t fit right…that I was fat…I felt fat at the time because the trend of being too skinny was starting but I was not fat. I had curves but not because I was fat but because I had a womanly figure”. (Zapatita, 38 years old)In addition to the comments that can be made by those close to a person, which have consequences on their habits or self-perception, we can see the influence that the ideal of beauty can have on these women's self-appraisal.Cumulative epiphaniesThe central feature of this type of epiphanies is that after the presence of events of the same kind that have accumulated over an indefinite period of time, a sudden reaction occurs, a decision is taken and as a result, there is a significant change in people's lives.Six cumulative epiphanies were found in this study. The common factor was concern and pressure regarding one's weight. The pressure, comments and insinuations about the participants’ body weight were made by the women's mothers, grandmothers or sisters, which led to them having a great interest in keeping thin. It is important to recall that cumulative epiphanies are a chain of events that gather during people's lives and at the end of each chain there is one last epiphany that triggers a sudden reaction to this series of accumulated experiences. For this analysis, we only report the last epiphany in the chain, which left an important mark on the participants’ lives.1.Negative remarks about their bodies (Mapi, 38 years old)In the first case, events accumulated from childhood to youth. During this period, she received a number of negative comments regarding her body, mainly focused on her being overweight, by relatives and male classmates. The negative comments upset her and made her think she should have a different body from the one she had, a perfect body, described by these men in her life story, although she thought this would be impossible to achieve:“I started to be really affected by…the remarks I heard from my uncle and my dad… the newspapers they brought home nearly always had a girl on the front…and whenever they got to that page…they almost fainted. Wow! They would make comments…mostly about her physique and how beautiful she was…it made me feel that I was never going to achieve that.”2.Comments about her appearance (Natacha, 39 years old)In another story, the respondent mentions having heard positive comments about slenderness since childhood, because she always had a bigger build than that of her classmates. Although she did not regard them as important at the time of receipt, she now realizes that they recurred throughout her life, becoming more important when she went to live at New York. Her partner's comments were usually summarized in the following phrases:“You have to be slim, you have to look good, you have to be pretty”.“You’re fat and ugly and I don’t find you attractive any more, I don’t fancy you any more”.After having received all these negative comments, she made a sudden decision on his birthday, which constituted a cumulative epiphany.“…and then I looked for information and started to diet, after about six months I said”.“I do not want to be fat, because I didn’t feel good … I said: I’ve had it”.3.Comments received throughout her life about the value of slim women (Coco, 50 years old)Throughout her life, C has received comments, emphasizing the importance of thinness as a prerequisite in people's worth. Although she is aware that this message had to do with her mother, this has not prevented her from feeling dissatisfied with her body image to date. Her younger sister has also been influenced by these stereotypes, which still persecute C. This sister is very interested in maintaining an image of youth and thinness, which reinforces the participant's desire to be thin:“How is that possible? Where do you put all that food? Humans have to eat to live, not live to eat. Just look at yourself!”. (Sister)C has obviously received constant violent remarks about her image and not only from her family of origin, but also her partner:“…he is always telling me that I’m fat, that I’m not smart and he also always tells me: ‘Your face has gone like that now’, in other words, it sags…because he is a misogynist, yes, he just criticizes me and doesn’t see how he has aged”.Previous experiences have contributed to C's body image, resulting in insecurity, dissatisfaction and the rejection of her body as well as the adoption of strategies throughout her life, ranging from restrictive diets to overeating.4.Comments about keeping slim and emphasizing the importance of appearance (Ana, 45 years old)The main character in this cumulative epiphany is the mother, who strove to ensure that the family was not overweight, but focused on Ana, perhaps because she was the only girl.“…my mom was always very, very careful about our weight and controlling our diet. We never had dessert at home…or chocolate, or mayo…so I was always very slim, I was always the right weight, I always had a good figure”.She constantly received comments about her appearance, which made her dissatisfied with herself. Ana nearly always lived under the care of her mother, even during her marriage.“My mom told me, ‘You have an ugly nose and spots on your face’…she made me feel ugly for many years”.We can see from this pair of testimonials the idea that Ana's mother introjected into her, that slenderness is perfection. At the same time, her husband continually made comments about her overweight:“He says I’m very fat and that he’ll leave…because of me, he had an affair with a secretary, it's all my fault, the fact that I’m fat is my fault, the fact that I don’t stick to my diet is all my fault”.5.The power of the body (Denisse, 41 years old)Unlike the previous cases, one of the participants experienced a positive cumulative epiphany, which she refers to as the power of the body. At the end of high school, when she had emerged from puberty, there were some facts that meant she had a positive relationship with her body. We specifically discussed the events that had made her feel she was an attractive woman. She remarked that when her mother measured her to make her a skirt in high school, she breathed in so that it would be tighter and she would look more attractive:“I remember that my mum made me a skirt and it looked like a tube, and I felt very sexy in my skirt”.Moreover, the participant expressed acceptance of her body and does not link the concept of attractiveness to thinness. Later on in her life, the idea of power that a woman can have over men as a result of her body, was confirmed by the experiences of one of her friends. When she had these experiences, the participant had the following reflections showing that she had a positive relationship with her body:“…it depends on you, you determine whether you look nice and attractive”.6.Recovering after a divorce (Mary, 41 years old)A second and final positive cumulative epiphany began when one of the participants divorced, and was created by a series of subsequent favorable events reflecting her recovery. This epiphany concludes with the fact of being recognized by other men and being regarded as an attractive woman, a situation that restored her confidence in her appearance and herself.“…I met a lot of people…I also got to know myself better…this stage helped me to recover, and get myself back. I felt ugly, I felt bad, a failure, and I had a hard time financially, professionally and emotionally, all in one go”.“…I realized I was an interesting woman that I was an attractive woman and that men liked my figure…which helped me recover and regain my self-esteem”.Minor epiphaniesLastly, there are the minor epiphanies. This is a problematic moment in a person's life. These epiphanies highlight the latent tensions or problems in a situation or relationship. This one occurred at the time of a separation, caused by the unfaithfulness of the respondent's husband. The epiphany triggered the idea that she was not a valuable person and could only acquire value by being slim. When he left and I realized that he had gone off with someone else, I felt traumatized and said to myself:“You put on weight’ and so I started doing exercise and tried to get slim”. (Mariana, 39 years old)DiscussionThe aim of this paper was to explore the experiences that have influenced the development of middle-aged women's body image. The main findings of this research were the ways in which messages about slenderness reached each of the participants and how they are linked to significant life events (epiphanies). For most of these women, the epiphanies related to the perception of their body image and the desire to modify their bodies were associated with moments when their relationship with others was altered, and messages about slenderness became important in the context of this changed relationship.There is strong evidence that both peers and family can influence the onset of disordered eating or ED, through comments on a person's weight or appearance (Neumark-Sztainer et al., 2010; Quiles, Quiles, Pamies, Botella, & Treasure, 2013), and most participants have received messages about slenderness being a means of achieving both personal and professional success since their childhood. Research has shown that dissatisfaction with weight and body shape can be transmitted from one generation to another (Quiles et al., 2013), as borne out by several of the accounts in our sample. This influence may be more significant when it occurs in conjunction with life events. As in our study, other authors have noted that concerns about the body begin at significant times of transition throughout life (Anderson-Fye, 2004; Berge, Loth, Hanson, Croll, & Neumark-Sztainer, 2012; Brandsma, 2007; Carter & McGoldrick, 1989; Harris & Cumella, 2006; Keel, Leon, & Fulkerson, 2001; Zerbe & Domnitei, 2004). Transitions can be stressful periods, which may trigger negative symptoms in physical and mental health. The way people cope with them depends partly on the social support available, since it requires an enormous capacity to adapt to successfully advance through the critical moments of life.For most of the participants, the events associated with body modification strategies in adult life were the physical changes that occurred after childbirth, including sagging abdominal skin, cellulite, excess body weight and a larger stomach. Even those who had not had children so far declared that as they reached middle age, overweight and its consequences caused them to feel extremely dissatisfied with their bodies. In both cases, they have resorted to body modification strategies, ranging from walks, restrictive diets (most participants are familiar with a wide range of options) and exercise, through capsules and injections to burn fat. Some have already gone to clinics to lose weight or seen endocrinologists or dieticians yet have always been dissatisfied with these methods and given up after a short time. Another important aspect for these women were their partners’ comments about their bodies, criticizing them for being overweight. These experiences have affected their body image, eliciting great concern and sadness, which led them to employ strategies to modify their bodies. It is striking that these kinds of comments are almost regarded as normal.Another key moment was when couples separated, since women immediately blamed their bodies for the separation, and most of them tried to alter them in order to embark on a new relationship. This was the case of one participant, who used a nose lifter when she went out with a new partner after her divorce, even though it was extremely painful.Something we found in these women's stories is their constant fear of gaining weight, growing old and no longer finding ways to feel good about themselves. Researching this type of problem in greater depth could provide knowledge that would enable us to intervene earlier in the middle-aged Mexican female population, as well as those already at this stage, by working with their stories to improve their quality of life. In particular, the burden they place on their bodies and the difficulties women experience at times of transition, point to the importance of providing tools to address these issues.Among the limitations of this study is the fact that the information provided by the respondents was not totally confidential, since it was shared with their therapists. The topics addressed may vary by socioeconomic group and among populations that do or do not seek treatment, educational attainment or type of family, which would be interesting to study in the future. Lastly, the coding was only performed by the first author. It would be useful for future research to include two or more researchers to improve the reliability of the analysis.Attempts to please and be accepted by others do not disappear with age. On the contrary, most of these women have been perfecting their ways to maintain a low body weight; and some of them, despite their failure to achieve this, continue with this idealization of beauty that society demands today, which has been required of them from the time they were small. The findings of this research show that body dissatisfaction not only affects teenagers and young women, but also middle-aged women.Continuing with this type of research will also make it possible to define the elements that contribute to the prevention of REB and body dissatisfaction. It even makes it possible to identify ED symptoms in this population, and therefore stop the transmission of this type of dissatisfaction from generation to generation as happened to them, because although it is a well-known fact that this is a key factor for the occurrence of this type of diseases in young women, literature on the subject is still scarce.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).Confidentiality of dataThe authors declare that no patient data appear in this article.Right to privacy and informed consentThe authors declare that no patient data appear in this article.Conflict of interestThe authors declare no conflict of interest.SponsorsThe research was financed by a scholarship (No. 229174) to the first author by Consejo Nacional de Ciencia y Tecnología.AcknowledgementsThis research was supported by the “Cenyeliztli A.C.” donee institution which provided support for the use of methodological tools with the people in its facilities. This study was conducted as part of the first author's doctoral dissertation on the Ph.D. Psychology Program of the Universidad Nacional Autónoma de México.Appendix AInterview guide1.Welcome.2.Purpose of the research and the interview.3.What were the ways you were taught or how did you learn about being a woman? Messages, games, sayings, songs, body, religion, treatment.4.Tell me about your body.Thoughts, perceptions, desires and behaviors.5.What have people said about your body?Rules, roles, gender stereotypes, etc., related to the body.Social mandates (comments, explicit and implicit messages).Reference groups.6.The middle-aged body.Expectations.Physical changes in the body.Pregnancy, menopause, illness.7.What do people say about beauty, slenderness, youth?Parents.Friends, peers.8.Body modification strategies.Family, friends, group.Wish to be different.Wish to be transformed.Desire for resistance.9.End of interview.