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Introduction
Interest in cosmetic surgery has risen in recent decades. According to the American Society for Aesthetic Plastic Surgery statistics (ASPS), 13.5 billion cosmetic procedures were performed in 2020, while women undertook more than 12.4 million cases [1]. These statistics indicate that women received 92% of cosmetic procedures.
Although cosmetic surgery can result in complications for women’s health, many women accept to undergo various cosmetic surgeries. So, the question of why women use cosmetic surgery to enhance their appearance arises. 
The literature shows that society forces women to follow beauty standards. Even in some cultures, gender roles define beauty as a feminine trait and dictate certain beauty standards to women. These standards, which usually are unrealistic, can lead to body dissatisfaction in women. In this regard, Cash et al. [2] investigated traditional gender role attitudes and body image in women′s students. They found a positive relationship between gender role attitudes and body dissatisfaction. This finding is important because body image is a main factor for cosmetic surgery. Most research has shown that body dissatisfaction is related to cosmetic surgery, and people with body dissatisfaction are more interested in cosmetic surgery [3, 4, 5, 6, 7, 8, 9, 10]. Standards of beauty that women try to attain and can lead to body dissatisfaction may originate from traditional gender roles. Although a relationship exists between traditional gender role attitudes and body image, the nature of this relationship is complicated. Therefore, it is necessary to clarify how traditional gender role attitudes can lead to body dissatisfaction and cosmetic surgery. We hypothesized that this process is based on a cognitive behavioral (CB) perspective on body image. This perspective elucidates the multidimensional definition of body image. From this perspective, body image is not an isolated phenomenon; rather refers to several interrelated variables. The model emphasizes social learning and conditioning processes and the cognitive mediation of behaviors and emotions [11]. It also supposes that body image has cognitive, emotional, and behavioral dimensions. Thus, we should investigate all body image dimensions to understand body dissatisfaction and related phenomenon like acceptance of cosmetic surgery. Accordingly, we suppose that the cognitive process can stimulate body dissatisfaction as an emotional dimension. Finally, the behavioral dimension determines how people select cosmetic surgery. In this regard, some studies have shown that women are dependent on traditional gender roles and invest in their appearance and their bodies more than other women [12, 13]. These women organize dysfunctional attitudes around appearance and beauty.
Consequently, traditional gender role attitudes may affect the development of dysfunctional appearance schemas in women. Dysfunctional appearance beliefs define the importance of appearance in achievement, self-concept, and interpersonal relationships and cause more body dissatisfaction [14]. Spangler [15] investigated the importance of dysfunctional appearance beliefs for eating disorders and showed beliefs about appearance predicted dietary restriction and body dissatisfaction. Based on the CB model, in the final step, people manage body dissatisfaction through coping strategies. These strategies include avoidance, appearance fixing, and acceptance. Avoidance is an attempt to escape or avert stressful body-image situations [16]. Appearance fixing is directed at altering appearance by covering, camouflaging, or correcting the perceived defect, and positive rational acceptance entails strategies emphasizing acceptance of the challenging event and positive self-care or rational self-talk about one’s appearance [16]. So, cosmetic surgery encompasses appearance-fixing strategies. Research also confirms that appearance-fixing strategies are associated with more maladaptive body image strategies like eating disorders, dieting, excessive exercise, and interest in cosmetic surgery [17, 18, 19]. Albeit, choosing cosmetic procedures can depend on women’s expectations about cosmetic surgeries. Some women imagine cosmetic surgery always results in positive outcomes and more beauty. Women may believe they are not at risk because their friend has undergone cosmetic surgery without complications. Most women think they are less likely to experience health or beauty problems.
Accordingly, it seems that acceptance of cosmetic surgery is a process that can influence cosmetic surgery and has not been investigated adequately. The present study aims to investigate this process and the relationship between traditional gender roles and emotional, cognitive, and behavioral variables based on the CB model. 
Considering that cosmetic surgeries have dramatically increased in Iranian women, we investigate factors affecting the acceptance of cosmetic surgery as a health risk behavior in Iranian women. This model proposes that gender role attitudes can facilitate cosmetic surgery in women. In this model, traditional gender role attitudes are considered latent variables, and dysfunctional appearance belief, fixing strategies, and outcome expectancies as mediating variables. The conceptual model of the study is shown in Figure 1.

Materials and Methods
The study participants were 600 female students aged 18 to 35, selected from Kharazmi University using random cluster sampling. Determining sample size for structural equation modeling (SEM) is a challenge for researchers because SEM requires a “sufficient” sample size to produce plausible results. Various rules of thumb have been proposed, including: A) A minimum sample size of 100 or 200, B) 5 or 10 observations per estimated parameter, and C) 10 cases per variable [20]. We have used the last rule (10 cases per variable) to determine sample size. The participants were in three levels: Bachelor 50%, master 30%, and doctorate 20%. First, we randomly selected 5 girls′ dormitory from various departments of Kharazmi University. Then, every building of the girls′ dormitory was considered a cluster, and participants were randomly selected within each building. Research data were collected over two months. The data were completed through a paper-pencil questionnaire. Psychology experts as investigators distributed the questionnaires among students. All students participated voluntarily in the research, and the investigator provided the necessary help. The average time for answering questions was 30 minutes. The questionnaires were the short version of the attitude toward women scale (AWS), the beliefs about appearance scale (BAAS), the body areas satisfaction scale (BASS), the body image coping strategies inventory (BICSI), rhinoplasty outcome evaluation (ROE), and the Acceptance of Cosmetic Surgery Scale (ACSS).

The gender role attitudes (AWS) 
We used the short version of AWS developed by Spence and Helmreich (1978). This scale assesses a person’s beliefs about women’s rights, roles, and responsibilities in society. In this study, the 15-item short version of the scale was used. The items on this scale are rated on a 5-point scale ranging from 0 (disagree strongly) to 4 (agree strongly). These items consist of statements about the roles and behaviors of women in a wide range of areas, including vocational, educational, freedom and independence, sexual behavior, and marital roles and responsibilities in society. Indeed, the AWS measures attitudes concerning the fights, roles, obligations, and privileges that women should have in modem society. It provides scores along a continuum, ranging from the endorsement of traditional sex roles to an egalitarian view of the roles of women and men [21]. Therefore, the high scores on the scale indicate modern attitudes about women’s societal roles, and the low scores reflect traditional gender role attitudes. The scale was used in some studies about gender, and its validity and reliability were reported as adequate [22, 23, 24]. The Cronbach α of the scale in this study was 0.60.

Dysfunctional appearance beliefs
The BAAS was constructed by Spangler and Stice (2001) to measure dysfunctional beliefs about physical appearance. BAAS measures dysfunctional attitudes about bodily appearance, particularly the perceived importance of appearance for achievement, self-view, and relationships [25]. The scale has 20 items rated on a 5-point Likert scale. Spangler and Stic [26] reported the reliability of BAAS using internal consistency and test-retest reliability. The Cronbach α in three samples was between 0.94 and 0.96. Also, the test-retest reliability coefficient attains 0.83. The scale was used in several studies, and its validity and reliability were reported as desirable [27, 28, 29, 30]. In the present study, Cronbach α was 0.91.

Body dissatisfaction
Body image satisfaction was measured using the BASS of the multidimensional body-self relations questionnaire (MBSRQ-AS). The BASS subscale consists of 9 items assessing how people are satisfied with different body areas such as the face, hair, lower body, middle body, upper body, height, weight, and overall satisfaction with their body. The items are rated on a 5-point Likert scale. Cash has reported the test re-test reliability of BASS between 0.74 and 0.86 [31]. This scale is widely used, and its validity and reliability have been established [32, 33, 34, 35, 36, 37]. In the present study, the Cronbach α was 0.80.

Appearance fixing strategies
The fixing subscale from BICSI was developed by Cash, (2005) [31]. This scale assesses cognitive and behavioral activities for managing of threats or challenges to body image. It consists of 3 subscales: Avoidance, appearance fixing, and positive rational acceptance. The avoidance subscale has 8 items assessing ignoring stressful situations for body image. The acceptance subscale has 11 items that evaluate the acceptance of self and appearance, and the fixing subscale has 10 items that measure fixing strategies. Cash et al. [38] reported the reliability of BICSI using internal consistency. The Cronbach α in 3 subscales were between 0.74 and 0.91 in women: Avoidance (0.74), appearance fixing (0.91), and positive rational acceptance (0.80). In the present study, the appearance fixing subscale was used. This scale has been shown to have desirable validity and reliability [39, 40, 41, 42]. The Cronbach α for this subscale was 0.70.

Outcomes expectancies
We used ROE that was created by Alsarraf. This scale assesses the satisfaction of individuals from Rhinoplasty surgery. Satisfaction includes 3 areas: Physical, emotional, and social. In this study, participants were asked to imagine that if they underwent cosmetic surgery with Rhinoplasty procedures, they would have to respond. The ROE questionnaire has 6 questions, scored on a 5-point scale from 0 to 4. The scoring can vary between 0 to 24, and the scores have to divide by 24 and multiplied by 100, which leads to a score varying between 0 and 100. The higher scores indicate a person’s satisfaction with the rhinoplasty. REO has been shown desirable validity and reliability in many studies [43, 44, 45, 46]. In my research, internal consistency was 0.65.

The acceptance of cosmetic surgery
The ACSS was developed by Henderson-King and Henderson-King (2005) [47]. It has 15 items that evaluate different aspects of cosmetic surgery attitudes and consists of 3 subscales: Social, intrapersonal, and consider. The social subscale (5 items) indicates social motivations for deciding to have cosmetic surgery (if a simple procedure made me more attractive to others, I would try it). The intrapersonal subscale (5 items) indicates self-oriented reasons for choosing cosmetic surgery (cosmetic surgery is good because it can help people feel better about themselves). Consider subscale (5 items) assesses the likelihood of having cosmetic surgery in the future (I have sometimes thought about having cosmetic surgery). The items ranged from 1 (strongly disagree) to 7 (strongly agree) on a 5-point Likert scale, with higher scores indicating more positive attitudes toward cosmetic surgery. Henderson-King and Henderson-King. [47] calculated the Cronbach α coefficients and means for the 3 subscales across the 4 studies. The Cronbach α values for consider subscale were between 0.82 and 0.96, the social subscale between 0.84 and 0.88, and the interpersonal subscale between 0.88 and 0.91. In the present study, ACSS had an overall α value of 0.91. This scale is widely used in research and various cultures and has been shown to have desirable validity and reliability [48, 49, 50, 51, 52, 53].

Results
In this research, first, data were screened for normality of distribution. There are all variables between 2 and -2 in skewness and kurtosis. So, the data were normally distributed. Also, the Mean±SD for all variables are presented in Table 1.

Second, a structural model was formulated to predict acceptance of cosmetic surgery in Iranian females based on a body image model that explains body image and its problems from a cognitive behavioral perspective. SEM with maximum likelihood estimation was conducted using LISREL software, version 8.8. Path analysis revealed that all of the coefficients are significant. According to these results, gender role attitude significantly predicts dysfunctional appearance beliefs. Also, body dissatisfaction, coping strategies, and outcomes expectancies mediated the relationship among gender role attitudes, dysfunctional appearance beliefs, and cosmetic surgery in women. Beta and gamma coefficients for the model are shown in Figure 2.

Consequently, a set of fit indices was used to evaluate the model. These indices are shown in Table 2 and include minimum fit function chi-square, root mean square error of approximation (RMSEA), root mean square residual (RMR), absolute fit indices (GFI, CFI), normed fit index (NFI), comparative fit index (CFI), incremental fit index (IFI), and relative fit index (RFI). According to Maccallam et al. [54], values lower than 0.05 for RMSEA indicate a good fit to data, and higher than 0.1 shows a weak fit. Also, values between 0.05 and 0.08 indicate an acceptable fit to the data.

Discussion
The current study aims to design a model for accepting cosmetic surgery in Iranian females, emphasizing traditional gender roles. Hence, a model was formulated and tested. According to this model, gender role attitudes result in dysfunctional appearance attitudes in women. Thus, these attitudes that usually originate in culture may increase women’s vulnerability to body image dissatisfaction. In this regard, it is believed that in most Asian cultures, there is much more pressure on women than men regarding physical appearances. Parents may exert pressure on their daughters through explicit comments about appearances or via implicit expectations to keep up appearances, while for men, the focus of attention is more on educational and occupational attainment. Parents may also exert additional pressure on their daughters to be beautiful enough to attract a suitable partner, as a married daughter is the desired social norm. For some Asian American women, not finding a marriage partner can damage their self-image, even if they are academically or occupationally successful, as they are told that failure to marry is a serious deficiency on their part [55]. So, women and men more concerned with adherence to gender-stereotyped roles are more susceptible to ideal body messages, but women are generally more vulnerable due to their subordinate societal position. The social processes related to gender role stereotyping lead to societal expectations that women are better suited to ‘feminine’ roles and men to ‘masculine’ roles [56]. The results are consistent with previous studies that have indicated gender role attitudes are related to appearance investment [12, 13, 57]. Also, they have revealed that women with dysfunctional appearance attitudes reported body dissatisfaction and adherence to body modification strategies [58, 59, 60, 61, 62, 63, 64, 65, 66]. 
In the second step, we must consider that not all women with body dissatisfaction use cosmetic surgeries to enhance their appearance. It seems that coping strategies and outcome expectancies are the important factors influencing women’s decision to undergo cosmetic surgeries. Only women who have positive expectations from cosmetic surgery accept it. Correspondingly, negative expectations can inhibit acceptance of cosmetic surgery. According to the result, women with more positive expectancies about cosmetic surgery are more likely to select surgery procedures to enhance their appearances, especially in societies where cosmetic surgery is prevalent, and many women experience cosmetic surgery and report satisfaction with cosmetic surgery without considering its risks and real outcomes.
Consequently, in this study, we had several limitations. First, our sample was limited to Iranian women, which can cause problems with the generalization of results, especially regarding variables that depend on culture, such as traditional gender role attitudes and body image. Second, research about gender produces sensitivities in societies where speaking about all dimensions of gender is Taboo. As a result, some women do not reflect real ideas in questionnaires, which can influence results. Third, the present study was carried out in a student sample, and it is one of the research limitations because the views of students about gender roles and even body image can be different from other women. So, it is suggested that research related to the gender domain carry out with various samples.

Conclusion 
In societies where traditional gender roles are powerful for men and women, appearance investment for women is more common because, in these societies, gender role attitudes send the message that beauty is a feminine trait and is part of feminine roles. Thus, women try to attain beauty even through cosmetic surgery, especially in countries where cosmetic surgery is frequent and inexpensive. The present study also showed that body image is a key factor in understanding cosmetic surgery in women, and the concept is multidimensional. Therefore, we should consider the roles of cognitive, emotional, and behavioral dimensions of body image. Also, the role of outcome expectancies as an important variable has not been investigated sufficiently, and future research should focus on the field. Finally, the effective factors influencing cosmetic surgery should be explored together with other variables, 

Ethical Considerations
Compliance with ethical guidelines
All ethical Issues were considered in this article. The research meets all applicable standards concerning the ethics of survey research throughout the processes of data collection, data analysis, and reporting. Informed written consent has beenobtained from individuals.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
Conceptualization and supervision: Negar Sadeghi, Jafar Hasani, Ali Reza Moradi; Methodology: Negar Sadeghi; Investigation, data collection, data analysis and writing the original draft: Negar Sadeghi; Review and editing: Jafar Hasani, Ali Reza Moradi and Shahram Mohammadkhani.

Conflict of interest
The authors declared no conflict of interest. 

Acknowledgments
We thank all students for their contribution to this study.


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