Not all purveyors of injectables start their anti-wrinkle injection (aka Botox) sermons the way I’m about to. Truly, though, it was only after five days of completely caning it at Glastonbury that I realised just how magical Botox is. While I may have spent the weekend accumulating a 275,000 step count, consuming an ungodly amount of canned margaritas and passing out in my make-up, you wouldn’t know it from my appearance.
You see, alongside a well-honed skincare routine, having Botox injected into my face every five months for the past two years has meant that, unlike some of my peers, I came out looking miraculously unscathed. In my experience, Botox doesn’t just hide a multitude of partying sins; on an average day, it fights against the long shadow that everyday tiredness casts. A demanding job and sleep-refusing small children are no match for its face-freshening abilities. After each top-up, my brows don’t furrow like a Klingon’s, my crow’s feet don’t protrude in unforgiving light and my elevenses lines no longer suggest I’m permanently incensed. So, it might surprise you to learn that I’ve let my regular appointment lapse.
I’ve not suddenly evolved past all vanity, nor shed my susceptibility to the myriad aesthetic pressures society places on women as we age. It’s a choice made with my relationships in mind, catalysed one afternoon in the office when I came across a study. It showed how, after having Botox, people’s brains responded differently when looking at images of faces showing emotion, in a way that meant they found it harder to interpret other people’s feelings. The researchers posited that this happens because the toxin disrupts signalling between participants’ facial muscles and their brains.
Feeling more than a little disturbed, I promptly closed my browser and pushed the research to the back of my mind. But the seed of doubt had been planted. Commuting home that evening, I reflected on my recent interactions with loved ones. Did I misinterpret my eldest’s feelings over coming second in a sports competition? Had I overlooked my friend’s anguish about a tricky work colleague? Wasn’t it ironic that the thing I use to, in no small part, function better in social situations (via the confidence boost that comes from a well-rested, line-free appearance) could actually end up blunting my social skills?
The prospect of ghosting Botox felt harder than giving up coffee, wine and sex all at once. But – with the study authors’ findings ringing in my ears – I cancelled my repeat appointment with my injector and dived face-first into the research with two questions in mind. What does it mean for society that we’ve embraced a beauty treatment that goes against the normal transmission of emotion? And what does it mean for my face?
A shot at fame
My search began in the 1800s when a Belgian scientist discovered that botulinum toxin (aka Botox), found in sausages, had triggered a life-threatening food poisoning outbreak that led to paralysis. By the 1940s, scientists were studying it in a lab, but much like super glue, pacemakers and LSD, the discovery of the toxin’s cosmetic virtues was a happy accident. In 1987, Canadian eye specialist Jean Carruthers was using Botox to treat blepharospasm (involuntary eye twitching) in a female patient; when her patient didn’t get injected in the forehead, she complained, saying, ‘When you treat me there, I get this beautiful, untroubled expression.’
Together with her dermatologist husband, Dr Carruthers spent five years investigating their wrinkle-busting breakthrough, publishing their first study in 1992. A decade later, Botox was approved for cosmetic use in the UK. Already the norm among Hollywood actors, Botox was added to the treatment menus of aesthetic doctors on these shores. Today, an estimated 900,000 Botox injections are carried out in the UK each year, with the UK injectables market predicted to reach a value of £11.7bn by 2026.
Its popularity has soared in recent years, thanks in part to influencers extolling its merits online and those hours we spent staring at our faces on pandemic-era video calls. But also because, despite a wealth of other aesthetic treatments hitting the market, nothing else compares.
‘While peptide-based skincare can provide a micro Botox-type effect with consistent use, it isn’t an equivalent to the type of effects Botox can achieve,’ explains aesthetic doctor Sophie Shotter. ‘Fillers, lasers – these can play a role in addressing concerns, but if you’re looking to treat lines related to movement in the face, Botox is the only treatment that effectively addresses these – and it takes minutes, with no downtime.’ When administered by a qualified medic, it’s also believed that Botox confers minimal physical risks.
Guess who
But, back to those psychological repercussions and that study. It was authored last year by a team at the University of California, who found that when Botox inhibits muscle contractions and decreases facial movement (by blocking acetylcholine, the parasympathetic nervous system’s primary neurotransmitter), it affects people’s ability to relate to others. ‘Using botulinum toxin injections, we induced temporary paralysis in the female participants’ glabellar muscles (responsible for frowning),’ explains one of the study’s authors, Shauna Stark.
The participants underwent two brain-imaging scans – one before the injection, one after – in which their functional brain activity was monitored as they were shown a series of happy and angry faces. After the injections, the brain scans showed that activity in the amygdala (the major processing centre for emotion) and fusiform gyrus (part of the brain that processes visual information) had changed. ‘Consistent with our predictions, preventing frowning altered the way the amygdala processes emotional faces,’ she explains – adding that the changes in the aforementioned brain regions may indicate that Botox injections force the brain to engage in ‘compensatory processes’ when facial feedback through the primary, frown-activated emotional processing system is impaired.
Her hypothesis is based on the facial feedback loop theory, first presented by psychologist William James in the 1840s and used later by Charles Darwin in the 1870s. Since then, many different studies have been done to test the idea that recognising and mimicking others’ faces (in microscopic ways) allows us to read and respond to each other’s feelings. The idea is that when we see an angry, worried or happy face, we contract or flex the relevant muscles to recreate the expression to assist in identifying and experiencing the emotion reflected.
While it remains unclear how facial feedback works, what researchers do know is that Botox essentially disrupts the mechanism. Such was the finding of a study by researchers from the University of Southern California and Duke University’s Fuqua School of Business. For the 2011 study, the team compared people who’d had Botox with a control group who had another cosmetic procedure that doesn’t reduce muscular feedback. They found that those who had Botox struggled more than the others to interpret what people were thinking and feeling. ‘This failure to mirror the faces of those they’re watching or talking to robs them of the ability to understand what people are feeling,’ the study’s authors concluded.
It’s not just your ability to read other people’s faces that Botox could be affecting, either. Italian researchers found those who had been administered with Botox rated emotionally provocative sentences as less emotionally resonant than those who didn’t receive the treatment. That said, it’s worth noting that while all studies show a consistent pattern, they’re small in scale – meaning outcomes are more variable and conclusions less reliable than those on larger, randomised controlled trials.
Lost connections
The reality that the demographic over-represented among Botox patients – women in their thirties and forties – are those most affected by the current connection crisis adds another dimension. While my WhatsApp groups are popping, face-to-face hangs aren’t. I’m not alone; millennials have been dubbed the loneliest generation, with 51% reporting that they regularly feel lonely – markedly higher than older generations – and those whose friendships were affected by the pandemic have reportedly shed an average of four pals since 2020. Could our fondness for anti-wrinkle injections be making this worse?
Psychologist Ravi Gill cautiously endorses the argument. ‘The long-term effects of not reading someone’s emotions could include challenges in building and maintaining healthy relationships,’ she explains – adding that if you come off as apathetic, people may be reluctant to socialise or engage with you. ‘Our facial expressions influence our emotional experience when connecting with others. So, it follows that if you dilute the emotional intensity of these interactions, then social experiences may decrease in quality.’
Every day, Dr Gill explains, we respond to thousands of non-verbal cues – facial expressions, postures and gestures. ‘This type of communication reveals who we are and impacts how we relate to other people. In the perceived absence, the connection crisis may be exacerbated.’ If you’re thinking that you wouldn’t miss those bonding moments as much as the effects of regular injections, Martha Laham wouldn’t be surprised.
The US-based marketing lecturer and author of Made Up tells me that the societal pressures women face to hold on to youth are so strong, they may override any concerns about losing their ability to empathise with others. ‘As aesthetic trends such as injectables continue to dictate beauty ideals, this could lead women to forsake the appearance of physical empathy for a flawless, wrinkleless, affectless face.’ We discuss the fact that Gen Z, who are also reported to feel disconnected (YouGov stats show that 46% of those aged 18 to 24 say they experience some difficulty making new friends), are facing increasing pressures to stay youthful, posting intense youth-preserving routines – using retinol and blocking out sunlight – while they’re still going through puberty.
Reality check
The future looks pretty bleak – at least in my mind, which conjures visions of a Black Mirror-coded future, full of ageless-looking octogenarians, interacting with as much warmth as a robot. When I discuss this with Elena Touroni, a consultant psychologist and co-founder of The Chelsea Clinic, she interrupts my spiralling. ‘The idea that cosmetic treatments will make women less empathetic is a false concern,’ she argues. ‘Ultimately, there are many ways to understand emotions beyond facial expressions. And if people are aware that their facial muscles are impeded, they might focus on being clearer in their verbal communication,’ she says, ‘which isn’t necessarily a bad thing.’
Injectables specialist Dr Shotter agrees, pointing out that most of her patients report feeling more positive post-treatment. Longer term, there’s even evidence that the substance can help treat depression. Scientists are unsure of the mechanism, but the way the toxin reduces frowning is one suggested explanation. It’s also been mooted that Botox could be transported to central nervous system structures involved in regulating mood and emotion, easing depressive symptoms, regardless of where it’s injected.
Even Dr Stark, co-author of the latest research, doesn’t believe the findings are cause for major alarm. That’s because while there were changes in brain activity, these didn’t impede the participants’ classification of emotions – ie, they could still identify a face as happy or sad. But she welcomes more nuanced studies to identify subtle changes – and track what happens in the brain when the visible effects of the treatment tail off.
Indeed, in the time that I’ve given up Botox, I’ve not observed any meaningful improvement in my relationships. But I’m certainly more conscious of reading people’s facial expressions – and those I’m making now my forehead moves again – which has made me feel more present and engaged in someone’s company. (And that can’t be a bad thing.)
Face forwards
So, will I be ghosting Botox for good? It’s complicated. While reporting on this piece has largely quelled my fears about it making me emotionally inept, it’s underlined my concerns about perpetuating ‘Botox culture’ and adding my face to the bank of evidence – which my generation and younger will draw on – that suggests getting injections is as normal as applying foundation or going for a pedicure.
And it’s just not. Injectables are medical procedures and this one has been shown to have a knock-on effect on the brain. And yet, I’d be lying if I said I had the energy to rail against the beauty ideals of our patriarchal society. When it comes to appearance, I think people should be able to make their own choices.
It feels fitting to end where we started: my face. One month after my lapsed appointment with my injector, I chastised my appearance in the mirror and poured scorn on my knackered-ness. But, six months on, my frown lines returning has been... a non-event. That no one has batted an eyelid has made me question if I ever really needed it. So, presently, the answer is no. Next month? Who knows.
Botox up close
Time to straighten out key questions on the anti-wrinkle treatment that just won’t quit:
Straight up, is it safe?
No procedures are risk-free but, broadly, the answer is yes. ‘Studies indicate there are no long-term or life-threatening adverse effects related to Botox for cosmetic purposes,’ notes Dr Shotter. ‘The low risk of possible complications can be reduced by thorough analysis of the patient’s medical history and the use of the appropriate dose and technique for the injection.’
So, who you choose to administer it matters?
It’s paramount. While there are few safety issues with the substance itself, seeing a qualified health professional – doctor, nurse, dentist – is essential for safe results (they’ll be on a register to show they meet certain standards). If your beautician offers cheap injections alongside waxes and manicures? That’s not illegal – although the botulinum toxin is a prescription medicine, anyone can legally administer it in the UK – but booking is ill-advised.
And what’s the deal with the terminology?
Botulinum toxin is generally, but often wrongly, referred to as Botox. Botox is the trade name of just one of the seven forms of botulinum toxin. Others include Xeomin, Azzalure, Dysport, Vistabel and Bocouture. Confusion happened because Botox, made by Allergan, is by far the best-known brand of botulinum toxin, as it was the first on the market in 1994.
Perdita Nouril is the Beauty Editor for Women’s Health UK. She has worked in the beauty industry for 15 years since graduating from the University of Nottingham. Adept at exploring the colossal world of beauty, she loves to scratch beneath the surface to debunk the myths, decode the science and challenge traditional notions of beauty. You can always find her preaching sermons on the power of a red lip, extolling the virtues of a decent serum and championing the very best female beauty founders.
You can find Perdita on Instagram on @perditanouril
