Pauline Rasset
email: pauline.rasset@unicaen.fr

Jessica Mange

Benoît Montalan

Sarah E Stutterheim

Towards a better understanding of the social stigma of facial difference

Keywords: Facial difference, facial disfigurement, stigma

. While demonstrating that FD is a public stigma, a self-stigma, a stigma by association, and a structural stigma, this overview stresses the need for the development of interventions, and how the social stigma literature could be helpful for that purpose.

Introduction

Researchers struggle to define Facial difference (FD). FD usually tends to be defined biomedically with emphasis placed on individual impairment [START_REF] Katz | Reliability and validity of an observer-rated disfigurement scale for head and neck cancer patients[END_REF][START_REF] Krishna | Disfigurement: Psychosocial impact and coping[END_REF][START_REF] Rakic | Development of a scale for evaluating the severity of disfigurements caused by injuries disease or surgery[END_REF]. However, FD is not only an individual experience [START_REF] Atkinson | Looking to the future: Priorities for translating research to impact in the field of appearance and body image[END_REF]. Rather, how FD is viewed and perceived is inherently social, reflecting interactions between social norms and individual attitudes [START_REF] Thompson | Adjusting to disfigurement: Processes involved in dealing with being visibly different[END_REF]. Therefore, we define FD as a face whose characteristics make it deviate significantly from what an individual who perceives it expects from a normal human face.

Often, but not always FD is stigmatized. [START_REF] Pescosolido | The stigma complex[END_REF] define stigmatization as a socially and culturally constructed process where a person is labelled as different and then devalued, resulting in status loss and discrimination, and [START_REF] Phelan | Stigma and prejudice: One animal or two[END_REF] claim that stigma serves three functions: 1) to keep people in via norm enforcement; 2) to keep people out through avoidance;

and 3) to keep people down through domination and exploitation.

In this paper, we employ a widely used stigma framework, namely the social stigma framework put forth by [START_REF] Pryor | HIV/AIDS in the Post-HAART Era: Manifestations, treatment[END_REF]see Fig. 1;[START_REF] Bos | Stigma: Advances in theory and research[END_REF], to unpack the stigma of FD. [START_REF] Pryor | HIV/AIDS in the Post-HAART Era: Manifestations, treatment[END_REF] framework is, in our opinion, the most comprehensive framework for understanding stigma. It brings together the broad range of stigma forms (e.g., public stigma, perceived stigma, enacted stigma, anticipated stigma, internalized stigma, structural stigma, stigma-by-association) in a cohesive and theoretically sound framework, which has demonstrated utility across a number of stigmatized identities, conditions, and behaviors, including sexual orientation (i.e., being lesbian; [START_REF] Leonard | Lesbian students' experiences of challenges faced at a south african university[END_REF], race and ethnicity (i.e., being Black; [START_REF] Pryor | The infection of bad company: Stigma by association[END_REF], marital status (i.e., being single; [START_REF] Ochnik | Do Polish never-married singles feel stigmatized? In Singlehood from Individual and Social Perspective[END_REF], adolescent motherhood [START_REF] Bermea | Students getting pregnant are not gonna go nowhere": Manifestations of stigma in adolescent mothers' educational environment[END_REF], weight [START_REF] Pryor | The infection of bad company: Stigma by association[END_REF], sex trafficking (i.e., being a victim of sex trafficking; [START_REF] Basu | A study on the rehabilitation mechanisms of the victims of trafficking with special focus on commercial sexual exploitation of women in West Bengal[END_REF], criminal offenders [START_REF] Moore | The effect of stigma on criminal offenders' functioning: A longitudinal mediational model[END_REF], noncommunicable neurological disease [START_REF] Elliot | Health-related stigma of noncommunicable neurological disease in rural adult populations: A scoping review[END_REF], Autism Spectrum Disorders [START_REF] Mazumder | Stigmatization of children and adolescents with autism spectrum disorders and their families: A scoping study[END_REF], Fetal Alcohol Spectrum Disorders [START_REF] Roozen | Understanding the social stigma of fetal alcohol spectrum disorders: From theory to interventions[END_REF], HIV [START_REF] Pryor | HIV/AIDS in the Post-HAART Era: Manifestations, treatment[END_REF]Stutterheim et al., 2022;[START_REF] Van Der Kooij | Role of self-stigma in pathways from hiv-related stigma to quality of life among people living with HIV[END_REF], menstruation [START_REF] Coleman | Menstruation in marketing (Issue January)The routledge companion to marketing and feminism[END_REF], and mental illness [START_REF] Shu | Perspectives on mental health difficulties amongst second-generation Chinese individuals in Germany: Stigma, acculturation, and help seeking[END_REF][START_REF] Van Der Sanden | Stigma by association among family members of people with a mental illness: A qualitative analysis[END_REF] including depression (Aziz &

Pryor and Reeder's social stigma framework

The social stigma framework put forth by [START_REF] Pryor | HIV/AIDS in the Post-HAART Era: Manifestations, treatment[END_REF] outlines four forms of stigma: Public stigma, self-stigma, stigma-by-association, and structural stigma (Fig. 1). Public stigma represents people's cognitive, affective, and behavioral reactions to people with a stigmatized condition, and manifests on an interpersonal level. Self-stigma is the anticipation and internalization of society's negative beliefs about the stigmatized condition, and occurs on an intrapersonal level.

Stigma-by-association entails social and psychological reactions to people associated with a stigmatized person (e.g., family and friends) as well as the impact of being connected to a person with a stigmatized identity or condition, and can be considered analogous to [START_REF] Goffman | Stigma: Notes on the management of spoiled identity[END_REF] courtesy stigma. Lastly, structural stigma is the legitimization and perpetuation of stigma by society's institutions and ideological systems through, for example, policy and legislation. This form of stigma occurs on organizational, institutional, or societal levels. The four types of stigmas are interrelated with public stigma being at the core of the other forms of stigma.

In what follows, we discuss the literature on FD in the context of each of the four forms of stigma put forth by [START_REF] Pryor | HIV/AIDS in the Post-HAART Era: Manifestations, treatment[END_REF].

Public stigma

From a social psychological perspective, public stigma comprises cognitions, affects, and behaviors. Cognitive reactions often reflect stereotypes, affective responses demonstrate prejudice, and behavioral reactions to a stigmatized condition like FD manifests as discrimination (often also termed enacted stigma; [START_REF] Bos | Stigma: Advances in theory and research[END_REF][START_REF] Stutterheim | Understanding and addressing stigma through qualitative research: Four reasons why we need qualitative studies[END_REF]. Because public stigma is the core form of stigma, this is where the majority of research on FD stigma occurs. Below, we outline the various cognitive, affective, and behavioral responses that occur in interactions with people with FD as reported in the literature. We then look specifically at ambivalent reactions and their implications.

Cognitive reactions

Research on cognitive reactions to people with FD has shown that people without FD hold stereotypical representations of people with FD, and that these manifest via attributions of less favorable characteristics to people with FD, resulting in an 'anomalous-is-bad' stereotype (Jamrozik et al., 2019;[START_REF] Stone | Evaluations of people depicted with facial disfigurement compared to those with mobility impairment[END_REF][START_REF] Workman | Morality is in the eye of the beholder: The neurocognitive basis of the "anomalous-is-bad" stereotype[END_REF]. This bias is contrary to the 'beauty is good' bias [START_REF] Dion | What is beautiful is good[END_REF], whereby attractive individuals are favored in terms of personality traits, as well as in life opportunities [START_REF] Eagly | What is beautiful is good, but.: A meta-analytic review of research on the physical attractiveness stereotype[END_REF]Fig. 1. Types of stigma adapted from [START_REF] Pryor | HIV/AIDS in the Post-HAART Era: Manifestations, treatment[END_REF]. [START_REF] Klebl | Beauty Goes Down to the Core: Attractiveness Biases Moral Character Attributions[END_REF]. The 'anomalous-is bad' bias would therefore work in the same way as the 'ugly-is-bad' bias [START_REF] Griffin | Stereotype directionality and attractiveness stereotyping: Is beauty good or is ugly bad?[END_REF]) but more dramatically. 1 Accordingly, people with FD have been rated as having significantly less positive personality traits (e.g., conscientiousness, emotional stability), less positive internal attributes (e.g., intelligence, 1 However, considering FD as an issue of unattractiveness is not always informative for considering the difficulties faced by people with FD [START_REF] Roberts | Children's experience of living with a craniofacial condition: Perspectives of children and parents[END_REF][START_REF] Stone | Emotional responses to disfigured faces: The influences of perceived anonymity, empathy, and disgust sensitivity[END_REF]. Moreover, considering FD as intrinsically rather than culturally un attractive is problematic (e.g., see the career of Winnie Harlow as a model while living with a vitiligo). honesty), less positive social attributes (e.g., likability, school success), and as less attractive [START_REF] Bull | The psychological significance of facial difformity[END_REF][START_REF] Collett | Laypersons' ratings of appearance in children with and without single-suture craniosynostosis[END_REF][START_REF] Jamrozik | More than skin deep: Judgments of individuals with facial disfigurement[END_REF]Masnari, Schiestl, Weibel, et al., 2013;[START_REF] Rankin | Perceived functional impact of abnormal facial appearance[END_REF][START_REF] Stone | Evaluations of people depicted with facial disfigurement compared to those with mobility impairment[END_REF]. These attributions have been made both on an individual level and in a group context [START_REF] Workman | Morality is in the eye of the beholder: The neurocognitive basis of the "anomalous-is-bad" stereotype[END_REF].

As with other disabilities, there seems to be a "spread" of FD to people's identity (see Nario-Redmond, 2020) whereby FD is perceived as an essential element of the person explaining his or her other characteristics (e.g., "he/she is not self-confident probably because of her FD"; see also [START_REF] Rumsey | The psychology of appearence[END_REF]. However, research has shown that people with FD are more negatively evaluated than other people with visible physical disabilities [START_REF] Bogart | Born that way or became that way: Stigma toward congenital versus acquired disability[END_REF][START_REF] Stevenage | Model applicants: The effect of facial appearance on recruitment decisions[END_REF][START_REF] Stone | Evaluations of people depicted with facial disfigurement compared to those with mobility impairment[END_REF].

In fact, some studies suggest that faces with FD are actually processed differently than faces without FD. For example, studies using eye-tracking have shown that visual attention is drawn to the part of the face where FD is apparent (for a review, see [START_REF] Asaad | Eye-tracking technology in plastic and reconstructive surgery: A systematic review[END_REF]. At the same time, FD diverts attention away from internal facial features like the eyes, which plays an important role in social interactions (Rasset et al., 2022a). Clearly, FD affects the allocation of overt visual attention, and not only because of its saliency [START_REF] Ackerman | A pox on the mind: Disjunction of attention and memory in the processing of physical disfigurement[END_REF][START_REF] Boutsen | Differential impact of disfiguring facial features on overt and covert attention[END_REF][START_REF] Boutsen | Do facially disfiguring features influence attention and perception of faces? Evidence from an antisaccade task[END_REF]. In fact, research has shown that faces with FD are not better memorized; people tend to confuse different faces with FD with each other more than different faces without FD [START_REF] Ackerman | A pox on the mind: Disjunction of attention and memory in the processing of physical disfigurement[END_REF]. Differential attention to faces with FD has also been explored using neuroimaging techniques.

In a study by [START_REF] Hartung | Behavioural and neural responses to facial disfigurement[END_REF], faces with FD evoked lower neural responses in the anterior cingulate and medio-prefrontal cortex. As these networks are important in social cognition, notably for inferring feelings and mental states, this particular way of processing faces with FD is likely to have implications for social interactions as well (e.g., dehumanization [START_REF] Harris | Dehumanizing the Lowest of the Low[END_REF], 2007, 2009;[START_REF] Hartung | Behavioural and neural responses to facial disfigurement[END_REF][START_REF] Workman | Morality is in the eye of the beholder: The neurocognitive basis of the "anomalous-is-bad" stereotype[END_REF]. Additionally, research using event-related potentials (ERP) showed alterations in the configural processing of faces with FD (i.e., the default mode of processing for 'normal' faces) [START_REF] Huffmeijer | Changes in facespecific neural processing explain reduced cuteness and approachability of infants with cleft lip[END_REF][START_REF] Parsons | Minor structural abnormalities in the infant face disrupt neural processing: A unique window into early caregiving responses[END_REF].

Affective reactions

A general preference for people showing no FD appears to arise early in child development [START_REF] Harper | Social psychology of difference: Stigma, spread, and stereotypes in childhood[END_REF]Masnari, et al., 2013;[START_REF] Richardson | Handicap, appearance and stigma[END_REF][START_REF] Sigelman | The early development of stigmatizing reactions to physical differences[END_REF]. Even at an implicit level, research has shown that people are quicker to associate FD with negatively valenced words than with positively valenced ones [START_REF] Grandfield | An attitudinal study of responses to a range of dermatological conditions using the Implicit Association Test[END_REF] yet not replicated by [START_REF] Roberts | Implicit attitudes towards people with visible difference: findings from an Implicit Association Test[END_REF][START_REF] Hartung | Behavioural and neural responses to facial disfigurement[END_REF][START_REF] Stone | Negative perceptions of people with facial disfigurement depend on a general attitude rather than on specific concerns[END_REF].

Beyond a global negativity towards people with FD [START_REF] Madera | Facial stigmas in dyadic selection interviews[END_REF], specific affective reactions to FD have also been documented, with the emotion of disgust drawing specific interest (e.g., [START_REF] Shanmugarajah | The role of disgust emotions in the observer response to facial disfigurement[END_REF]. Indeed, research shows that FD elicits significant activations in the amygdala and anterior insula, both of which are regions that react to disgust-inducing stimuli [START_REF] Krendl | The good, the bad, and the ugly: An fMRI investigation of the functional anatomic correlates of stigma[END_REF][START_REF] Workman | Morality is in the eye of the beholder: The neurocognitive basis of the "anomalous-is-bad" stereotype[END_REF]. Also, in a study by Ryan and colleagues (2012), participants were asked to touch props that had been allegedly used by someone either with a birthmark or an infectious disease, and the results showed similar levels of behavioral avoidance and disgust for both conditions.

From an evolutionary perspective, disgust serves the function of avoiding disease [START_REF] Kurzban | Evolutionary origins of stigmatization: The functions of social exclusion[END_REF][START_REF] Oaten | Disgust as a disease-avoidance mechanism[END_REF]. However, disgust is especially prone to false alarms, and is frequently instinctively activated in perceivers when faced with a stigmatized condition [START_REF] Oaten | Disgust as a disease-avoidance mechanism[END_REF]. This suggests that FD is misinterpreted as a disease [START_REF] Ackerman | A pox on the mind: Disjunction of attention and memory in the processing of physical disfigurement[END_REF][START_REF] Kurzban | Evolutionary origins of stigmatization: The functions of social exclusion[END_REF][START_REF] Ryan | Facial disfigurement is treated like an infectious disease[END_REF][START_REF] Shanmugarajah | The role of disgust emotions in the observer response to facial disfigurement[END_REF]. However, disgust reactions to FD are not universal. Recent research shows that biases towards faces with a scar vary based on exposure to Western culture [START_REF] Workman | Evidence against the "anomalous-is-bad" stereotype in Hadza hunter gatherers[END_REF].

In addition to disgust, research has demonstrated that FD also elicits threat reactions. In [START_REF] Blascovich | Perceiver threat in social interactions with stigmatized others[END_REF] study, participants interacting with a made-up confederate exhibiting a port wine stain had increased cardiovascular activity, which is consistent with a feeling of threat. Also, in a study by [START_REF] Jones | Perceived discomfort associated with working with persons with varying disabilities[END_REF], participants reported more discomfort towards people with FD than towards people living with other physical disabilities.

Additional affective reactions have been demonstrated by [START_REF] Stone | Emotional responses to disfigured faces: The influences of perceived anonymity, empathy, and disgust sensitivity[END_REF]. In their study, participants were asked to report their subjective emotional experience when shown faces that were attractive, unattractive, or presenting a FD. The results showed that, when high anonymity was guaranteed, participants reported more sorrow and curiosity, less positive and more negative emotions. Based on this, a six-dimension typology describing a wide array of possible affective states experienced by perceivers of people with FD emerged [START_REF] Rasset | Un)veiling distinct feelings: A typology of affective reactions while meeting people with facial disfigurement for the first time[END_REF]. The dimensions are surprise, anxiety and embarrassment, disgust, hostility, sympathy, and neutral affective states.

Behavioral reactions

There is significant literature showing that people with FD experience enacted stigma or discrimination (for reviews, see [START_REF] Macgregor | Facial disfigurement: Problems and management of social interaction and implications for mental health[END_REF][START_REF] Rumsey | Body image and disfigurement: Issues and interventions[END_REF][START_REF] Thompson | Adjusting to disfigurement: Processes involved in dealing with being visibly different[END_REF][START_REF] Wali | People living with facial disfigurement after having had noma disease: A systematic review of the literature[END_REF] across the life course [START_REF] Feragen | Peer harassment and satisfaction with appearance in children with and without a facial difference[END_REF][START_REF] Holland | Rate and frequency of bullying victimization in school-age children with neurofibromatosis type 1 (NF1)[END_REF][START_REF] Lawrence | Comparing parent and child perceptions of stigmatizing behavior experienced by children with burn scars[END_REF][START_REF] Magin | Experiences of appearancerelated teasing and bullying in skin diseases and their psychological sequelae: Results of a qualitative study[END_REF][START_REF] Masnari | Self-and parent-perceived stigmatisation in children and adolescents with congenital or acquired facial differences[END_REF][START_REF] Strauss | Stigma experiences in youth with facial differences: A multi-site study of adolescents and their mothers[END_REF][START_REF] Strobel | Quality of life and adjustment in children and adolescents with Moebius syndrome: Evidence for specific impairments in social functioning[END_REF] with the most detrimental impacts occurring in formative periods of life (e.g., adolescence; [START_REF] Bogart | People are all about appearances": A focus group of teenagers with Moebius Syndrome[END_REF][START_REF] Crerand | Sex differences in perceived stigmatization, body image disturbance, and satisfaction with facial appearance and speech among adolescents with craniofacial conditions[END_REF].

Discriminatory responses tend to reflect a lack of social tolerance [START_REF] Lawrence | Comparing parent and child perceptions of stigmatizing behavior experienced by children with burn scars[END_REF] and can manifest as unfriendly behaviors, avoidance, and ostracism [START_REF] Bogart | Social interaction experiences of adults with Moebius Syndrome: A focus group[END_REF][START_REF] Bonanno | Mapping out the social experience of cancer patients with facial disfigurement[END_REF][START_REF] Ryan | Facial disfigurement is treated like an infectious disease[END_REF]. Additionally, people with FD have reported staring and unsolicited attention as behavioral responses [START_REF] Bogart | Social interaction experiences of adults with Moebius Syndrome: A focus group[END_REF][START_REF] Bonanno | Mapping out the social experience of cancer patients with facial disfigurement[END_REF][START_REF] Halioua | Feelings of stigmatization in patients with rosacea[END_REF][START_REF] Lawrence | The reliability and validity of the Perceived Stigmatization Questionnaire (PSQ) and the Social Comfort Questionnaire (SCQ) among an adult burn survivor sample[END_REF][START_REF] Rossi | Cultural meaning of quality of life: Perspectives of Brazilian burn patients[END_REF][START_REF] Strauss | Stigma experiences in youth with facial differences: A multi-site study of adolescents and their mothers[END_REF][START_REF] Strobel | Quality of life and adjustment in children and adolescents with Moebius syndrome: Evidence for specific impairments in social functioning[END_REF][START_REF] Threader | Cancer-related trauma, stigma and growth: the 'lived' experience of head and neck cancer[END_REF].

Research shows that people with FD may not experience the "civil inattention" that others commonly experience [START_REF] Macgregor | Facial disfigurement: Problems and management of social interaction and implications for mental health[END_REF], particularly when they are singled out [START_REF] Kornhaber | Adult burn survivors' personal experiences of rehabilitation: An integrative review[END_REF]. Visible difference may also elicit questions, comments, and other privacy intrusions [START_REF] Bogart | Social interaction experiences of adults with Moebius Syndrome: A focus group[END_REF][START_REF] Bonanno | Mapping out the social experience of cancer patients with facial disfigurement[END_REF][START_REF] Rossi | Cultural meaning of quality of life: Perspectives of Brazilian burn patients[END_REF][START_REF] Strauss | Stigma experiences in youth with facial differences: A multi-site study of adolescents and their mothers[END_REF].

Furthermore, people with FD experience social rejection, which can be subtle or blatant [START_REF] Ginsburg | Psychosocial consequences of rejection and stigma feelings in psoriasis patients[END_REF]. In terms of hostile behaviors, people with FD have reported teasing as a common experience, as well as harassment [START_REF] Bogart | People are all about appearances": A focus group of teenagers with Moebius Syndrome[END_REF][START_REF] Bogart | Social interaction experiences of adults with Moebius Syndrome: A focus group[END_REF][START_REF] Bonanno | Mapping out the social experience of cancer patients with facial disfigurement[END_REF][START_REF] Feragen | Peer harassment and satisfaction with appearance in children with and without a facial difference[END_REF][START_REF] Griffiths | The romantic experiences of adolescents with a visible difference: Exploring concerns, protective factors and support needs[END_REF][START_REF] Halioua | Feelings of stigmatization in patients with rosacea[END_REF][START_REF] Holland | Rate and frequency of bullying victimization in school-age children with neurofibromatosis type 1 (NF1)[END_REF][START_REF] Lawrence | Comparing parent and child perceptions of stigmatizing behavior experienced by children with burn scars[END_REF][START_REF] Magin | Experiences of appearancerelated teasing and bullying in skin diseases and their psychological sequelae: Results of a qualitative study[END_REF][START_REF] Nishikura | Difficulties with employment: Understanding the experiences of people with visible differences[END_REF][START_REF] Strauss | Stigma experiences in youth with facial differences: A multi-site study of adolescents and their mothers[END_REF][START_REF] Turner | Psychological outcomes amongst cleft patients and their families[END_REF][START_REF] Visram | Qualitative study to identify issues affecting quality of life in adults with craniofacial anomalies[END_REF].

Teasing and, to a greater extent, bullying have a detrimental impact on psychological well-being, especially with regard to self-esteem, self-image, and self-consciousness, but also in terms of body image and satisfaction with facial appearance [START_REF] Crerand | Sex differences in perceived stigmatization, body image disturbance, and satisfaction with facial appearance and speech among adolescents with craniofacial conditions[END_REF][START_REF] Feragen | Peer harassment and satisfaction with appearance in children with and without a facial difference[END_REF][START_REF] Magin | Experiences of appearancerelated teasing and bullying in skin diseases and their psychological sequelae: Results of a qualitative study[END_REF]. It is also important to note that social interactions are not always antisocial; sympathetic reactions have also been reported, but these are sometimes considered stigmatizing, particularly when expressed in public, manifested as unsolicited help, or when they show pity [START_REF] Bonanno | Mapping out the social experience of cancer patients with facial disfigurement[END_REF].

The various behavioral reactions to people with FD occur across a number of contexts, both private (e.g., at the swimming pool, at the hairdresser's, on the street; [START_REF] Ginsburg | Psychosocial consequences of rejection and stigma feelings in psoriasis patients[END_REF][START_REF] Koster | Public-and self-stigma attached to physical versus psychological disabilities[END_REF] and professional (e.g., at work; [START_REF] Porter | Psychosocial effect of vitiligo: A comparison of vitiligo patients with "normal" control subjects, with psoriasis patients, and with patients with other pigmentary disorders[END_REF][START_REF] Stevenage | Model applicants: The effect of facial appearance on recruitment decisions[END_REF]Stone & Wright, 2012a, 2013;[START_REF] Stone | Stigmas in organizations: Race, handicaps, and physical unattractiveness[END_REF].

It is noteworthy that most of the literature on behavioral responses to people with FD focus on the experiences of people with FD, rather than on the behavior of people interacting with people with FD (i.e., the perceiver). However, there are a few experimental studies that have shown that FD affects recruitment decisions (e.g., intention to hire, especially for jobs with high levels of customer contact; [START_REF] Stevenage | Model applicants: The effect of facial appearance on recruitment decisions[END_REF][START_REF] Stone | When your face doesn't fit: Employment discrimination against people with facial disfigurements[END_REF], interpersonal distance [START_REF] Albrecht | Social distance from the stigmatized[END_REF][START_REF] Pausch | Psychosocial acceptance of cleft patients: Has something changed?[END_REF], and willingness to help [START_REF] Knapp-Oliver | Visibility and the stigmatization of cancer: Context matters[END_REF]. Also, there are a few behavioral studies that have provided evidence that discrimination does occur (e.g., aversion to interaction, avoidance). Notably, [START_REF] Houston | Do people avoid sitting next to someone who is facially disfigured[END_REF] demonstrated that people avoided sitting next to a person with a FD, and [START_REF] Rumsey | The effect of facial disfigurement on the proxemic behavior of the general public[END_REF] showed that people stood significantly further away from people with FD on the streets of London. Both real-life and laboratory setting results consistently show that FD elicits avoidance behaviors [START_REF] Miller | Sick body, vigilant mind: The biological immune system activates the behavioral immune system[END_REF].

In order to synthesize the stigma experiences of people with FD, Partridge (1998) developed, based on testimonies and his own experience of FD, the acronym "SCARED" (Fig. 2) which summarizes the various cognitive, affective, and behavioral reactions experienced by people with FD, and also refers to the uncertainty and fear felt in a social situation between two people where one has FD.

Ambivalent reactions

Stigmatized conditions like FD do not only evoke negative reactions. They also, like other stigmatized conditions, elicit ambivalent reactions (e.g., mixed affective reactions ranging from sympathy to hostility). This can be explained by the dual-process model of stigmatization [START_REF] Pryor | A dual-process model of reactions to perceived stigma[END_REF] which postulates that reactions to people with a stigmatized identity or condition rely on two processes, namely a 'reflexive system' and a 'rule-based system'. The former engenders automatic and immediate responses which can then be counterbalanced by a more controlled and thoughtful reaction, which occurs slightly later. For this reason, reactions to people with FD often comprise a mixture of negative and positive feelings [START_REF] Dovidio | Stigma: Introduction and overview[END_REF]Rasset et al., 2022a[START_REF] Rasset | Un)veiling distinct feelings: A typology of affective reactions while meeting people with facial disfigurement for the first time[END_REF].

Ambivalence can lead to nervousness caused by pressures to express kindness and compassion, while actually feeling anxious and uncomfortable [START_REF] Dey | The social penalty of facial lesions: New evidence supporting high-quality reconstruction[END_REF]. Further, with the knowledge that people should not judge based on appearance, people interacting with someone with FD may attempt to compensate by displaying more controlled sympathetic behaviors and willingness to help [START_REF] Nario-Redmond | Hostile, benevolent, and ambivalent ableism: Contemporary manifestations[END_REF] but not fully succeed leading to awkward interactions [START_REF] Hebl | Awkward moments in interactions between nonstigmatized and stigmatized individuals[END_REF]. For example, Rumsey et al.'s (1982) on how FD impacts proxemic behavior in the street was not replicated twenty years later in Australia by [START_REF] Roberts | The effect of visible facial differences on personal space during encounters with the general public[END_REF]. This may be because stigma towards people with FD has evolved into something less overt. This contention is further supported by [START_REF] Knapp-Oliver | Visibility and the stigmatization of cancer: Context matters[END_REF] work showing that discrimination against people with FD may be stronger when the context allows the stigmatization to be subtle. Indeed, as normative pressures increasingly encourage people to be kind to people with disabilities (Nario-Redmond et al., 2019), self-presentation biases are likely to occur, and this is reinforced by research showing that negative emotions were only reported when anonymity was guaranteed [START_REF] Stone | Emotional responses to disfigured faces: The influences of perceived anonymity, empathy, and disgust sensitivity[END_REF]; see also [START_REF] Jewett | Factors associated with negative observer responses towards individuals with visible differences: A scoping review[END_REF].

To further explore this ambivalence, researchers have ingeniously employed methodologies that reach beyond the explicit measurement of stigmatizing reactions (e.g., self-reported questionnaires such as the Measure of Disease-Related Stigma; [START_REF] Stump | The Measure of Diseaserelated stigma: Construction, validation, and application across three disease contexts[END_REF] to include more implicit measures (e.g., Implicit Association Test; [START_REF] Grandfield | An attitudinal study of responses to a range of dermatological conditions using the Implicit Association Test[END_REF][START_REF] Stone | Evaluations of people depicted with facial disfigurement compared to those with mobility impairment[END_REF]. Also, physiological measures have been helpful in establishing affective reactions [START_REF] Blascovich | Perceiver threat in social interactions with stigmatized others[END_REF] and circumventing social desirability bias. These include eye-tracking measures for gaze behavior (see [START_REF] Asaad | Eye-tracking technology in plastic and reconstructive surgery: A systematic review[END_REF]Rasset et al., 2022a[START_REF] Rasset | Un)veiling distinct feelings: A typology of affective reactions while meeting people with facial disfigurement for the first time[END_REF], and fMRI for cognitive processes and their neural correlates (e.g., [START_REF] Hartung | Behavioural and neural responses to facial disfigurement[END_REF][START_REF] Krendl | Does context matter in evaluations of stigmatized individuals? An fMRI study[END_REF].

Summary

Evidently, there is abundant research showing that public stigma in the form of cognitive, affective, and behavioral reactions, occurs and impacts the lives of people with FD. Some of this research, predominantly research on cognitive and affective responses, focuses on the perspectives of 'perceivers' thus those without FD that engage with some with FD. Other research, particularly research focusing on behavioral responses to FD, hones in on the lived experiences of people with FD across various contexts. Ambivalent reactions to people with FD are also present, demonstrating that stigma is often subtle. Also, it is interesting to note that, although researchers often focus on one type of FD (e.g., clefts), reactions of perceivers to different FD are often very similar. This suggests that we should be studying reactions to various FD in a unitary manner.

Self-stigma

Self-stigma entails the anticipation of stigma (i.e., anticipated stigma) and the internalization of the negative beliefs about people with FD reflected in public stigma, (i.e., internalized stigma; [START_REF] Pryor | HIV/AIDS in the Post-HAART Era: Manifestations, treatment[END_REF][START_REF] Bos | Stigma: Advances in theory and research[END_REF]. The experience of self-stigma is prevalent and widespread among people with FD (for reviews, see [START_REF] Dimitrov | Stigmatization in dermatology with a special focus on psoriatic patients. 0-0 Postępy Higieny i Medycyny Doświadczalnej[END_REF][START_REF] Germain | Stigma in visible skin diseases -a literature review and development of a conceptual model[END_REF][START_REF] Reynolds | Stigma in the face of cancer disfigurement: A systematic review and research agenda[END_REF], as is also reflected in the development and validation of standardized scales for measuring self-stigma, such as the Feelings of Stigmatization Questionnaire [START_REF] Ginsburg | Feelings of stigmatization in patients with psoriasis[END_REF], the Questionnaire on Experience with Skin Complaints [START_REF] Schmid-Ott | Dimensions of stigmatization in patients with psoriasis in a 'questionnaire on experience with skin complaints[END_REF], and the Shame and Stigma Scale [START_REF] Kissane | Preliminary evaluation of the reliability and validity of the Shame and Stigma Scale in head and neck cancer[END_REF].

Various manifestations of self-stigma have been reported, including the anticipation of rejection, feelings of being flawed, sensitivity to the opinions of others, feelings of guilt and shame, and feeling the need to be discrete about one's FD [START_REF] Ginsburg | Feelings of stigmatization in patients with psoriasis[END_REF]. These manifestations of self-stigma lead to fear of negative evaluations, fear of intrusive behaviors and even fear of provoking disgust in others, which, in turn, can lead people to conceal their FD when possible [START_REF] Clarke | Appearance concerns and psychosocial adjustment following head and neck cancer: A cross-sectional study and nine-month follow-up[END_REF][START_REF] Keys | The psychosocial impact of losing an eye through traumatic injury and living with prosthetic restoration: A thematic analysis[END_REF][START_REF] Leary | Interpersonal concerns and psychological difficulties of psoriasis patients: Effects of disease severity and fear of negative evaluation[END_REF][START_REF] Reynolds | Stigma in the face of cancer disfigurement: A systematic review and research agenda[END_REF][START_REF] Sharratt | Becoming known: Disclosure and exposure of (in)visible difference[END_REF][START_REF] Tiemens | Living with difference: Experiences of adolescent girls with cleft lip and palate[END_REF].

People with FD also internalize negativity and have reported considering themselves to be dirty, ugly, or flawed [START_REF] Bradbury | Meeting the psychological needs of patients with facial disfigurement[END_REF][START_REF] Brown | The hidden cost of skin scars: Quality of life after skin scarring[END_REF][START_REF] Crerand | Sex differences in perceived stigmatization, body image disturbance, and satisfaction with facial appearance and speech among adolescents with craniofacial conditions[END_REF][START_REF] Halioua | Feelings of stigmatization in patients with rosacea[END_REF][START_REF] Lanigan | Psychological disabilities amongst patients with port wine stains[END_REF][START_REF] Visram | Qualitative study to identify issues affecting quality of life in adults with craniofacial anomalies[END_REF]. Accordingly, there has been substantial research attention to the role of shame in appearance related issues (for a review, see [START_REF] Halioua | Feelings of stigmatization in patients with rosacea[END_REF][START_REF] Keys | The psychosocial impact of losing an eye through traumatic injury and living with prosthetic restoration: A thematic analysis[END_REF][START_REF] Kissane | Preliminary evaluation of the reliability and validity of the Shame and Stigma Scale in head and neck cancer[END_REF][START_REF] Rumsey | The psychology of appearence[END_REF]. For some conditions, such as head and neck cancers that are related to lifestyle risk factors (e.g., tobacco use; [START_REF] Threader | Cancer-related trauma, stigma and growth: the 'lived' experience of head and neck cancer[END_REF], shame is amplified by perceptions that one may be responsible for one's FD [START_REF] Goyal | Assessment of shame and stigma in head and neck cancer: A meta-analysis[END_REF][START_REF] Kissane | Preliminary evaluation of the reliability and validity of the Shame and Stigma Scale in head and neck cancer[END_REF].

Research has consistently demonstrated that enacted stigma (e.g., bullying) can lead to felt stigma (e.g., fear of rejection) and internalized stigma (e.g., feeling unattractive; [START_REF] Griffiths | The romantic experiences of adolescents with a visible difference: Exploring concerns, protective factors and support needs[END_REF].

For instance, in a qualitative study conducted with adolescents with cutaneous leishmaniasis, the reactions of others were related to subsequent lower self-concept [START_REF] Bennis | Psychosocial impact of scars due to cutaneous leishmaniasis on high school students in Errachidia province, Morocco[END_REF]. At the same time, anticipated stigma and internalized stigma can occur even in the absence of enacted stigma, and research has indeed shown discrepancies between the perception that stigma is present and actual discrimination, also for FD [START_REF] Kleck | Perceptions of the impact of negatively valued physical characteristics on social interaction[END_REF]. This is termed stigma consciousness [START_REF] Pinel | Stigma consciousness: The psychological legacy of social stereotypes[END_REF].

Although stigma consciousness has been studied among people with physical disabilities [START_REF] Koster | Public-and self-stigma attached to physical versus psychological disabilities[END_REF], to our knowledge, to date, no studies have looked at stigma consciousness specifically among people with FD.

For FD, it is often difficult to disentangle the negative psychological and well-being impacts of stigma from the impact of impairment or trauma, which is notably present in individuals whose condition is acquired [START_REF] Bogart | The role of disability self-concept in adaptation to congenital or acquired disability[END_REF]. Nonetheless, self-stigma does have detrimental effects for the psychological and social well-being of people with FD. Self-stigma in general is associated with decreased hope, lower self-esteem, poorer self-efficacy, and reduced quality of life (see [START_REF] Mittal | Empirical studies of selfstigma reduction strategies: A critical review of the literature[END_REF]. Accordingly, people with FD may have decreased self-confidence, increased self-consciousness, and they may be dissatisfied with their facial appearance [START_REF] Hunt | The psychosocial effects of cleft lip and palate: A systematic review[END_REF][START_REF] Sharratt | Becoming known: Disclosure and exposure of (in)visible difference[END_REF][START_REF] Turner | Psychological outcomes amongst cleft patients and their families[END_REF].

Additionally, research has demonstrated negative associations between self-stigma and both self-esteem and self-confidence [START_REF] Griffiths | The romantic experiences of adolescents with a visible difference: Exploring concerns, protective factors and support needs[END_REF][START_REF] Katz | Reliability and validity of an observer-rated disfigurement scale for head and neck cancer patients[END_REF][START_REF] Porter | Racial variation in reaction to physical stigma: A study of degree of disturbance by vitiligo among black and white patients[END_REF]. In a qualitative study, adolescents with various visible FD reported experiencing fear of being negatively evaluated, which hampered confidence in initiating relationships and even fears of becoming intimate [START_REF] Griffiths | The romantic experiences of adolescents with a visible difference: Exploring concerns, protective factors and support needs[END_REF]. Furthermore, research has shown that people with FD have higher rates of depression or anxiety than people without FD [START_REF] Gibson | The association of affective disorders and facial scarring: Systematic review and metaanalysis[END_REF][START_REF] Halioua | Feelings of stigmatization in patients with rosacea[END_REF][START_REF] Hunt | The psychosocial effects of cleft lip and palate: A systematic review[END_REF], and depression and anxiety are related to self-stigma. For instance, in a study on rosacea, people who reported feelings of stigmatization also reported more depressive symptoms [START_REF] Halioua | Feelings of stigmatization in patients with rosacea[END_REF].

More generally, self-stigma impacts quality of life [START_REF] Germain | Stigma in visible skin diseases -a literature review and development of a conceptual model[END_REF][START_REF] Jankowiak | Stigmatization and quality of life in patients with psoriasis[END_REF]Masnari, et al., 2013;[START_REF] Strobel | Quality of life and adjustment in children and adolescents with Moebius syndrome: Evidence for specific impairments in social functioning[END_REF][START_REF] Topolski | Quality of life: How do adolescents with facial differences compare with other adolescents? The Cleft PalateCraniofacial[END_REF][START_REF] Visram | Qualitative study to identify issues affecting quality of life in adults with craniofacial anomalies[END_REF]. In a study conducted among people with psoriasis, [START_REF] Jankowiak | Stigmatization and quality of life in patients with psoriasis[END_REF] showed that the more sensitive individuals were to the opinions of others and the worse their attitudes about their psoriasis, the worse their quality of life was.

Summary

Overall, there is some research on self-stigma and its effects, but little research has directly measured the consequences of self-stigma and even less has explored the mediating role of stigma on quality of life outcomes (see, e.g., [START_REF] Van Der Kooij | Role of self-stigma in pathways from hiv-related stigma to quality of life among people living with HIV[END_REF] for an example of an application to HIV stigma).

Stigma by association

Stigma can also affect people who do not have FD themselves but are, in some way, associated with someone with FD through stigma by association [START_REF] Pryor | HIV/AIDS in the Post-HAART Era: Manifestations, treatment[END_REF]. Indeed, stigma can spread to people (i.e., companions) that are arbitrarily and closely related to individuals with FD, and this is especially the case in highly intolerant individuals [START_REF] Neuberg | When we observe stigmatized and "normal" individuals interacting: Stigma by association[END_REF][START_REF] Pryor | The infection of bad company: Stigma by association[END_REF][START_REF] Sigelman | Courtesy stigma: The social implications of associating with a gay person[END_REF]. Having a family member with a stigmatized condition or identity can lead to feelings of shame regarding the relationship, blame regarding the onset of the stigma, and fear of being contaminated by the stigma [START_REF] Corrigan | Shame, blame, and contamination: A review of the impact of mental illness stigma on family members[END_REF]Roozen et al., 2020). This can have severe implications as people are apt to be reluctant to build relationships with people with FD for fear of stigma. This clearly jeopardizes social opportunities [START_REF] Crocker | Stigma and the social basis of the self. A synthesis[END_REF]. In terms of research, stigma by association can be studied either from the perspective of the companions (e.g., family, relatives, and/or partner) or from the perspective of the person who stigmatizes someone associated with a person with FD (i.e., the perceiver).

In the FD literature, most studies exploring stigma by association focus on families with a specific attention to the perspective of parent(s) or sibling(s) of a child with FD [START_REF] Lehna | Stigma perspective of siblings of children with a major childhood burn injury (n/a-n/a[END_REF][START_REF] Strauss | Stigma experiences in youth with facial differences: A multi-site study of adolescents and their mothers[END_REF]. That research shows that parents may feel 'different' because of their child's FD (Nelson et al., 2012) and that they experience discrimination in their social environment (for a review, see Nelson, et al., 2012). Similar to their child, they experience staring [START_REF] Rossi | The stigma of burns[END_REF], questions and comments [START_REF] Kerr | Memorable messages parents of children with vascular birthmarks receive from others: Implications for stigma and identity[END_REF], and rejection (Nelson, et al., 2012). At the same time, family members may also feel 'unseen' when relatives act with neutrality as this can be (mis)interpreted as a lack of interest [START_REF] Johansson | Parents' experiences of having a child with cleft lip and palate[END_REF].

Research on the perspectives of other associates such as friends or intimate partners has also been conducted. Although controversial, studies on dating people living with disabilities have shown that one reason why individuals prefer dating people without disability is because they fear the reactions of their friends [START_REF] Fichten | Reactions toward dating peers with visual impairments[END_REF]; for an alternative explanation in terms of relationship satisfaction and inequity, see [START_REF] Collisson | Perceived satisfaction and inequity: A survey of potential romantic partners of P. Rasset[END_REF]. Research has also shown that stigma by association is detrimental for companions (Dako-Gyeke, 2018). For example, in a qualitative study by Nelson et al., (2012) on parent's emotional and social experiences of caring for a child through cleft treatment, mothers reported worrying and feeling blamed for their child's condition, leading to feelings of guilt (Nelson et al., 2012). They also reported concerns about their child not being accepted or even bullied (Nelson et al., 2012). In another study, parents of children with vascular birthmarks reported having to deal with questions and comments that sought to ascertain the extent to which they may be responsible for their child's condition, which can be hurtful and upsetting [START_REF] Kerr | Memorable messages parents of children with vascular birthmarks receive from others: Implications for stigma and identity[END_REF]. Clearly, parents of children with FD have to navigate both stigmatizing reactions directed at themselves and stigmatizing reactions directed at their child with FD. Generally, these stigmatizing reactions emphasize abnormality and the undesirability of FD, or question the extent to which that child can meet beauty ideals [START_REF] Kerr | Memorable messages parents of children with vascular birthmarks receive from others: Implications for stigma and identity[END_REF].

To our knowledge, there is no research conducted on stigma by association from the perceivers' perspective. However, given evidence that attitudes towards people with visible stigmas contaminate their companions [START_REF] Pryor | The infection of bad company: Stigma by association[END_REF], and research showing that stereotypes towards people living with disabilities 'spread' to their partners [START_REF] Goldstein | Stigma by association: Perceptions of the dating partners of college students with physical disabilities[END_REF][START_REF] Nieweglowski | Relationship depth and associative stigma of disability[END_REF], it is likely that this phenomenon also occurs in interactions with associates of people with FD such as families, partners, and friends.

Summary

There is clear evidence that the stigma of FD can 'spread' to companions, and that companions grapple with both witnessing stigma towards their loved one and being stigmatized themselves because of their association with someone, often a child, with FD.

Structural stigma

Structural stigma encompasses the ways in which society perpetuates and legitimizes the stigmatization of FD, notably by promoting ideal (face) shape in general, and, more specifically, by neglecting FD. The predominant source of structural stigma for FD is media. Media representations are important because they contribute to the beliefs and stereotypes about people with FD held by consumers of media [START_REF] Garrisi | Appearance, discrimination and the media[END_REF][START_REF] Gunter | The role of the media[END_REF].

It is well documented that media influences body image through, for example, the mere exposure to socially imposed standards of appearance, or by inviting individuals to evaluate selfimages posted on social media (for a review, see [START_REF] Jarman | Critical measurement issues in the assessment of social media influence on body image[END_REF]. Media content overwhelmingly praises ideal bodies and faces (e.g., thinspiration and fitspiration social media content; [START_REF] Griffiths | How does exposure to thinspiration and fitspiration relate to symptom severity among individuals with eating disorders? Evaluation of a proposed model[END_REF] and scrutinizes less ideal ones [START_REF] Frith | Appearance and society[END_REF]. This idealization is particularly detrimental for people with FD for several reasons. First, it can lead to substantial body dissatisfaction, particularly among vulnerable populations [START_REF] Ferguson | In the eye of the beholder: Thin-ideal media affects some, but not most, viewers in a meta-analytic review of body dissatisfaction in women and men[END_REF][START_REF] Puhl | Weight stigma, policy initiatives, and harnessing social media to elevate activism[END_REF][START_REF] Rodgers | A biopsychosocial model of social media use and body image concerns, disordered eating, and musclebuilding behaviors among adolescent girls and boys[END_REF]. Second, by promoting ideal body shapes, media contributes to the denigration of visible differences, thus shaping how people think about FD and framing visible difference as inherently negative and necessarily troubling [START_REF] Rumsey | The psychology of appearence[END_REF].

On the whole, FD in the media is either not present or not well represented (Garrisi et al., 2018). There is a gross underrepresentation of visible differences, which contributes to a lack of public awareness, especially for rare conditions (see [START_REF] Riklin | The effects of society on the psychosocial functioning of those with a facial difference[END_REF]. When represented, the content tends to present a sensational or tragic depiction of FD (Garrisi et al., 2018). Indeed, most representations of FD in the media come either from reports on crimes or incidents that have led to FD through 'before and after' stories (Garrisi et al., 2018) or from entertainment (e.g., evil cinematic characters). Media attention to some rare diseases occurs occasionally but very little attention is paid to more frequent forms of FD (e.g., acne vulgaris; [START_REF] Gunter | The role of the media[END_REF]. Furthermore, visible difference is almost completely absent in advertising which can lead people with FD to feel ignored and underrepresented (Changing Faces, 2021).

With regard to entertainment, almost all representations of FD in entertainment media frame the person with FD as evil [START_REF] Partridge | Changing faces: The challenge of facial disfigurement[END_REF][START_REF] Reese | Dermatology in the cinema[END_REF]. [START_REF] Croley | Dermatologic features of classic movie villains[END_REF] compared the dermatologic characteristics of heroes and villains in the top ten American films and found that, in six of ten movies, villains had one or more skin disease, but none of the heroes had FD. This highlights how FD is used to illustrate moral depravity.

Clearly, media has significant impact in perpetuating structural stigma but structural stigma is also reflected in policy and legislation. Discrimination against, and human rights violations towards, people with FD are still neglected [START_REF] Swift | A hidden community: Facial disfigurement as a globally neglected human rights issue[END_REF]. In many contexts, the rights of people with FD are not sufficiently protected [START_REF] Saunders | Difficult distinctions in anti-discrimination law: Disfigurement, appearance and disability[END_REF]. This lack of protection concerns financial, medical, educational and other societal domains [START_REF] Swift | A hidden community: Facial disfigurement as a globally neglected human rights issue[END_REF]. This is often because FD is seen as an individual issue, and as an individual problem that needs to be fixed. In this context, the propagation of surgery as the only viable avenue for living with FD is another reflection of structural stigma. Indeed, surgery is put forth as the ideal, and an almost mandatory obligation, for people with FD. There are several possible reasons for this. First, unrealistic beauty standards have led to the medicalization of beautification and popularization of cosmetic surgery [START_REF] Bonell | The cosmetic surgery paradox: Toward a contemporary understanding of cosmetic surgery popularisation and attitudes[END_REF][START_REF] Wu | Body image and acceptance of cosmetic surgery in China and the Netherlands: A qualitative study on cultural differences and similarities[END_REF], which offers the promise of an immediate and permanent solution to psychological distress. Second, reconstructive surgery has benefited from considerable technological progress offering an ever-expanding array of solutions. One example is the hope offered by the development of facial transplantation [START_REF] Rifkin | Facial disfigurement and identity: A review of the literature and implications for facial transplantation[END_REF], alongside the fact that medical and surgical solutions often also provide a functional gain, thus lowering the stress elicited by disability and impairment [START_REF] Bemmels | Psychological and social factors in undergoing reconstructive surgery among individuals with craniofacial conditions: An exploratory study[END_REF][START_REF] Roberts | Children's experience of living with a craniofacial condition: Perspectives of children and parents[END_REF]. However, focusing 'only' on these solutions can lead individuals with FD to think that they must 'fix' the FD, and that the problem, and solution, lies with them. Beyond the significance of this therapeutic focus, people may also be dissatisfied with surgery, especially if the surgery has spillover effects (e.g., school absences), the social difficulties remain unchanged, or their post-operative look does not appear as "normal" as they had hoped [START_REF] Bemmels | Psychological and social factors in undergoing reconstructive surgery among individuals with craniofacial conditions: An exploratory study[END_REF][START_REF] Myhre | The need to belong: Subjective experiences of living with craniofacial conditions and undergoing appearance-altering surgery[END_REF]. Thus, the social pressure for people with FD to undergo surgery is problematic, especially for individuals for whom surgery is either not possible, not sufficient, or not wanted.

Summary

Society plays an important role in the perpetuation of FD stigma, by promoting what people with FD are not, by not adequately representing people with FD in media and advertising, by negatively representing FD in media, by inadequately addressing human rights violations, and by perpetuating surgery as only viable avenue for dealing with FD.

Coping with the social stigma of facial difference

Evidently, in the context of facial difference, there is public stigma, self-stigma, stigma by association, and structural stigma, and each of these has detrimental social and psychological impacts. This necessitates coping on the part of people with FD and their associates like parents and siblings.

People with FD may also benefit and improve coping with help of others [START_REF] Griffiths | The romantic experiences of adolescents with a visible difference: Exploring concerns, protective factors and support needs[END_REF][START_REF] Habib | Perceptions and experiences of female burn survivors with facial disfigurement[END_REF]. For instance, family members of people with FD can facilitate social participation [START_REF] Bonanno | Cancer and facial disfigurement: Reducing survivors' stigma in social interaction[END_REF].

Link and colleagues [START_REF] Link | A modified labeling theory approach to mental disorders: An empirical assessment[END_REF]; see also [START_REF] Link | Labeling and Stigma[END_REF] identified three main coping orientations to face public stigma: secrecy, withdrawal, and education. Although FD is undoubtedly visible, many people with FD engage in measures to conceal their FD (e.g., cosmetic cream, prosthesis, surgery), often to ease outings in public places [START_REF] Keys | The psychosocial impact of losing an eye through traumatic injury and living with prosthetic restoration: A thematic analysis[END_REF][START_REF] Thompson | Cancer and changes in facial appearance: A meta-ethnography of qualitative studies[END_REF] and in social interactions [START_REF] Bemmels | Psychological and social factors in undergoing reconstructive surgery among individuals with craniofacial conditions: An exploratory study[END_REF][START_REF] Myhre | The need to belong: Subjective experiences of living with craniofacial conditions and undergoing appearance-altering surgery[END_REF]. Their stigma is thus partially concealed, because it may not be readily apparent to others. However, the mere presence of a 'mask' provokes reactions on the part of the perceivers [START_REF] Yaron | Recognizing difference: In/visibility in the everyday life of individuals with facial limb absence[END_REF]. As such, disclosure is frequently challenging for people with FD [START_REF] Sharratt | Becoming known: Disclosure and exposure of (in)visible difference[END_REF].

In addition to concealment, people with FD may also adopt avoidant behaviors and social withdrawal, in order to prevent stigma. However, this reduces opportunities to socialize and access social support [START_REF] Griffiths | The romantic experiences of adolescents with a visible difference: Exploring concerns, protective factors and support needs[END_REF][START_REF] Halioua | Feelings of stigmatization in patients with rosacea[END_REF][START_REF] Lanigan | Psychological disabilities amongst patients with port wine stains[END_REF][START_REF] Magin | Experiences of appearancerelated teasing and bullying in skin diseases and their psychological sequelae: Results of a qualitative study[END_REF][START_REF] Thompson | Cancer and changes in facial appearance: A meta-ethnography of qualitative studies[END_REF].

For some people with FD, coping takes the form of educating people about their condition in order to ease social interactions [START_REF] Bogart | Social interaction experiences of adults with Moebius Syndrome: A focus group[END_REF]. To do this, resilience in dealing with negative reactions and comments is necessary [START_REF] Thompson | Adjusting to disfigurement: Processes involved in dealing with being visibly different[END_REF]. Some individuals develop a more positive perspective by focusing on positive aspects of their FD, giving less importance to appearance, or accepting their condition as part of themselves [START_REF] Bogart | People are all about appearances": A focus group of teenagers with Moebius Syndrome[END_REF][START_REF] Cash | Coping with body-image threats and challenges: Validation of the Body Image Coping Strategies Inventory[END_REF][START_REF] Clarke | Appearance concerns and psychosocial adjustment following head and neck cancer: A cross-sectional study and nine-month follow-up[END_REF][START_REF] Griffiths | The romantic experiences of adolescents with a visible difference: Exploring concerns, protective factors and support needs[END_REF][START_REF] Habib | Perceptions and experiences of female burn survivors with facial disfigurement[END_REF][START_REF] Visram | Qualitative study to identify issues affecting quality of life in adults with craniofacial anomalies[END_REF]. These strategies can be particularly useful for reducing self-stigma. One channel through which education takes place is through blogs. Blogs (e.g., https://katiemeehan.co.uk; see Garrisi & Johanssen, 2018) offer opportunities to broadcast one's experience of living with FD, which both tackles negative representations of FD conveyed in the mainstream media, and replaces self-stigma with personal empowerment [START_REF] Corrigan | The stigma effect[END_REF]. Indeed, there is research highlighting positive aspects of living with FD [START_REF] Eiserman | Unique outcomes and positive contributions associated with facial difference: Expanding research and practice[END_REF]. Some of this work shows how FD makes its bearer unique, special, and recognized, which may be perceived as particularly positive in societies that value individuality [START_REF] Kerr | Memorable messages parents of children with vascular birthmarks receive from others: Implications for stigma and identity[END_REF][START_REF] Strauss | Only skin deep": Health, resilience, and craniofacial care[END_REF]. Other studies have shown that, despite stigma, a traumatic event -which may have led to an acquired FDcan bring about psychological growth and personal development, and actually increase well-being [START_REF] Threader | Cancer-related trauma, stigma and growth: the 'lived' experience of head and neck cancer[END_REF]. Accordingly, there is research showing that optimism is associated with reduced fear of negative appearance evaluation (Costa et al., 2021). A perspective whereby FD is studied and viewed as a strength rather than a weakness is clearly desirable, both because it fosters optimism in those affected and their relatives, and because it better enables us to develop innovative treatments, psychological interventions, and ways to promote well-being and healthy relationships [START_REF] Broder | Using psychological assessment and therapeutic strategies to enhance well-being[END_REF][START_REF] Kerr | Memorable messages parents of children with vascular birthmarks receive from others: Implications for stigma and identity[END_REF][START_REF] Meyerson | Resiliency and success in adults with Moebius Syndrome[END_REF][START_REF] Mouradian | Deficits versus strengths: Ethics and implications for clinical practice and research[END_REF][START_REF] Roberts | Children's experience of living with a craniofacial condition: Perspectives of children and parents[END_REF].

Coping with FD stigma can also be leveraged through body positivity movements. Body positivity movements often use social media as a mass communication tool to share information and to elevate attention to rights activism [START_REF] Puhl | Weight stigma, policy initiatives, and harnessing social media to elevate activism[END_REF]. Given that people with FD use social media to find information and to access emotional and social support from others with FD [START_REF] Stock | #CleftProud: A content analysis and online survey of 2 cleft lip and palate facebook groups[END_REF], the body positivity movement is an integral part to coping with FD stigma and developing a positive social identity. Moreover, social media allows us to target structural stigma of FD by, for example, revaluing FD as an asset, reclaiming disability labels as positive subcultural signifiers, and establishing new norms, values, or dimensions of comparison [START_REF] Nario-Redmond | Hostile, benevolent, and ambivalent ableism: Contemporary manifestations[END_REF].

With respect to stigma by association, families may respond in ways similar to people with FD, such as withdrawal or concealment [START_REF] Bonanno | The social limits of reconstructive surgery: Stigma in facially disfigured cancer patients[END_REF][START_REF] Kerr | Memorable messages parents of children with vascular birthmarks receive from others: Implications for stigma and identity[END_REF]Nelson et al., 2012). Stigma is distressing and thus often a motivation for parents to seek medical or surgical advice [START_REF] Williams | A psychological profile of children with hemangiomas and their families[END_REF]. Research has shown that this differs for mothers and fathers. Fathers tend to be less concerned about being judged by others, while mothers tend to experience more social support [START_REF] Nidey | Psychosocial wellbeing of parents of children with oral clefts[END_REF]. It is also possible that parents acknowledge positive impacts of their child's condition (for a review, see Nelson et al., 2012). For example, the experience of being a parent of a child with FD can offer an opportunity to recognize one's own personal strengths and the strengths of one's child, which can lead to stronger relationships, or can increase a sense of community (Nelson et al., 2012).

Summary

People with FD cope with stigma using various approach and avoidance strategies including concealment, withdrawal, and education. Body positivity movements have also been leveraged to cope and empower people with FD. Associates of people with FD cope in similar ways as well.

Addressing the stigma of facial difference: How to intervene

There is a significant evidence base for stigma reduction interventions (Stutterheim et al., 2022;[START_REF] Stutterheim | Understanding and addressing stigma through qualitative research: Four reasons why we need qualitative studies[END_REF] that have been tested and demonstrated efficacy across various stigmatized identities and conditions including sexual orientation [START_REF] Bartoş | Interventions to reduce sexual prejudice: A studyspace analysis and meta-analytic review[END_REF], mental illness in general [START_REF] Corrigan | Challenging the public stigma of mental illness: A meta-analysis of outcome studies[END_REF], eating disorders more specifically [START_REF] Doley | Interventions to reduce the stigma of eating disorders: A systematic review and meta-analysis[END_REF], weight [START_REF] Rubino | Joint international consensus statement for ending stigma of obesity[END_REF], tuberculosis [START_REF] Sommerland | Evidence-based interventions to reduce tuberculosis stigma: A systematic review[END_REF], HIV [START_REF] Mak | Meta-analysis and systematic review of studies on the effectiveness of HIV stigma reduction programs[END_REF], and health-related stigma more generally [START_REF] Stangl | The health stigma and discrimination framework: A global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas[END_REF]; for a review see [START_REF] Paluck | Prejudice reduction: Progress and challenges[END_REF]. As such, the broader stigma literature can offer insight on how to best tackle stigma related to FD (for a review, see [START_REF] Stutterheim | Understanding and addressing stigma through qualitative research: Four reasons why we need qualitative studies[END_REF].

With regard to FD, much research focusing on the social difficulties encountered by people living with FD provide practical implications (for a review, see [START_REF] Rumsey | Body image and disfigurement: Issues and interventions[END_REF]). Yet, we believe that bridging together social stigma and the FD literatures can foster the development of innovative intervention strategies and/or the improvement of already existing ones. To this end, we detail, below, interventions addressing the different types of stigma in parallel to interventions targeting FD difficulties.

Interventions for public stigma

Interventions are needed in order to tackle the public stigma of FD and its accompanying cognitive (e.g., stereotypes; Jamrozik et al., 2019), affective (e.g., disgust;[START_REF] Shanmugarajah | The role of disgust emotions in the observer response to facial disfigurement[END_REF], and behavioral reactions (e.g., avoidance; [START_REF] Ryan | Facial disfigurement is treated like an infectious disease[END_REF]. These interventions should aim to reduce automatic negative reactions, while promoting more deliberate and positive ones [START_REF] Pryor | A dual-process model of reactions to perceived stigma[END_REF], regardless of the context.

Strategies that have been developed to reduce and prevent the public stigma of FD have mostly focused on information provision and contact with affected groups (see [START_REF] Topp | Strategies to reduce stigma related to visible chronic skin diseases: A systematic review[END_REF]. The provision of information can be important (e.g., through education campaigns, notably for rare diseases) [START_REF] Bogart | Looking beyond the face: A training to improve perceivers' impressions of people with facial paralysis[END_REF], but, generally, strategies promoting contact are more effective than information-based ones [START_REF] Corrigan | Reducing physical illness stigma: Insights from the mental illness arena[END_REF][START_REF] Topp | Strategies to reduce stigma related to visible chronic skin diseases: A systematic review[END_REF]. Contact interventions lead to the disconfirmation of stereotypes and are particularly effective when the contact is between people of equal status, when the interactions are one-on-one, and when the interaction involves an activity that is rewarding or includes a shared goal [START_REF] Corrigan | Measuring the impact of programs that challenge the public stigma of mental illness[END_REF]. However, indirect contact through videos can also improve social judgments of individuals with FD [START_REF] Edwards | What difference can a minute make? Social skills and first impressions of youth with craniofacial differences[END_REF][START_REF] Stone | Changing negative perceptions of individuals with facial disfigurement: The effectiveness of a brief intervention[END_REF].

Education-based strategies have also been developed in order to ease social interactions between people with FD and people without FD that they see on a regular basis (e.g., caregivers, professors, colleagues; [START_REF] Hlongwa | People look and ask lots of questions": Caregivers' perceptions of healthcare provision and support for children born with cleft lip and palate[END_REF][START_REF] Rumsey | Body image and disfigurement: Issues and interventions[END_REF]. For instance, reintegration programs for children with burns are improved when they also help teachers to manage the situation, including their own reactions [START_REF] Pan | School reintegration of pediatric burn survivors: An integrative literature review[END_REF].

Specifically with respect to cognitive reactions to people with FD, strategies enabling people to challenge their beliefs or biases towards FD are imperative. [START_REF] Bogart | Looking beyond the face: A training to improve perceivers' impressions of people with facial paralysis[END_REF] showed the beneficial impact of a training to 'look beyond' FD. In their study, participants who were informed, trained, and provided with feedback on cues for interacting with people with facial paralysis displayed better performances in impression formation [START_REF] Bogart | Looking beyond the face: A training to improve perceivers' impressions of people with facial paralysis[END_REF]. Other strategies include cognitive training, which aims to alter particular cognitive associations (e.g., FD with villains; see [START_REF] Paluck | Prejudice reduction: Progress and challenges[END_REF]. Cognitive training can be applied to emotional reactions, and lower associations between FD and negative attributes [START_REF] Bilici | Normalizing Anomalies with Mobile Exposure (NAME): Reducing implicit biases against people with facial anomalies[END_REF]. Furthermore, strategies fostering empathy, such as perspective-taking [START_REF] Todd | Perspective-taking as a strategy for improving intergroup relations: Evidence, mechanisms, and qualifications[END_REF], have been found to be effective [START_REF] Batson | Empathy, attitudes, and action: Can feeling for a member of a stigmatized group motivate one to help the group[END_REF]. Perspective taking also has beneficial behavioral outcomes, fostering approach-oriented action tendencies and smoother interactions.

Interventions for self-stigma

Strategies that can effectively address self-stigma include cognitive behavioral therapy (CBT) and skills building [START_REF] Topp | Strategies to reduce stigma related to visible chronic skin diseases: A systematic review[END_REF]. Indeed, the provision of psychological services can be beneficial for the reduction of both anticipated and internalized stigma. By training individuals to identify and modify negative beliefs and interpretations, CBT addresses not only internalized negative beliefs about FD; it also helps people with FD deal with consequences of self-stigma and develop coping skills (e.g., behavioral therapy) [START_REF] Heijnders | The fight against stigma: An overview of stigmareduction strategies and interventions[END_REF][START_REF] Mittal | Empirical studies of selfstigma reduction strategies: A critical review of the literature[END_REF].

Strategies that seek to develop social skills or provide tools for social interactions can also serve to manage enacted stigma (e.g., training conversation skills, identifying others' reactions, using compensatory strategies; Clarke, 1999;[START_REF] Jenkinson | Systematic review: Psychosocial interventions for children and young people with visible differences resulting from appearance altering conditions, injury, or treatment Effects[END_REF][START_REF] Robinson | An evaluation of the impact of social interaction skills training for facially disfigured people[END_REF]. Furthermore, self-help interventions that have been designed to lower appearance-related distress may also lower self-stigma [START_REF] Muftin | A systematic review of self-help for disfigurement: Effectiveness, usability, and acceptability[END_REF]. This includes interventions that target stress reduction with mindfulness, or resilience with self-compassion. Additionally, peer support can enable people with FD to find new ways to manage self-stigma by sharing experiences [START_REF] Bogart | Rare place where I feel normal": Perceptions of a social support conference among parents of and people with Moebius syndrome[END_REF]Bogart & Hemmesch, 2016).

Research on other stigmas can also provide insights for the development of new strategies and the refinement of existing strategies for addressing FD self-stigma (for a critical review on self-stigma reduction strategies, see [START_REF] Mittal | Empirical studies of selfstigma reduction strategies: A critical review of the literature[END_REF]. For example, there is substantial evidence showing that Acceptance and Commitment Therapy (ACT) can successfully reduce internalized stigma, both when employed in isolation [START_REF] Luoma | Reducing selfstigma in substance abuse through acceptance and commitment therapy: Model, manual development, and pilot outcomes[END_REF] and when combined with CBT [START_REF] Pearl | Effects of a cognitive-behavioral intervention targeting weight stigma: A randomized controlled trial[END_REF]. More generally, ACT is a psychological flexibility-based intervention, which can lessen self-stigma by increasing psychological acceptance and lowering self-conscious emotions (e.g., shame; [START_REF] Masuda | A psychological flexibilitybased intervention for modulating the impact of stigma and prejudice: a descriptive review of empirical evidence[END_REF].

Interventions for stigma by association

Strategies aimed at counselling families and helping them to deal with their family member's FD have proven to be valuable in reducing stigma by association (e.g., Positive Parenting Program, parental training; Costa, et al., 2021). For instance, the Early Family Intervention Program was designed to support parents of a child with a disability and has demonstrated evidence for better adaptation, including reduced emotional distress [START_REF] Pelchat | Longitudinal effects of an early family intervention programme on the adaptation of parents of children with a disability[END_REF]. More generally, providing peer support to close relatives is advantageous, especially for mothers [START_REF] Nidey | Psychosocial wellbeing of parents of children with oral clefts[END_REF].

To be effective, strategies targeting stigma by association should aim to help relatives build resilience and coping skills. As such, strategies for addressing public stigma or self-stigma can also be employed to reduce stigma by association. More broadly, there is a substantial need to support relatives of people with a stigmatized identity or condition, as demonstrated by a study conducted with family members of people with mental illness. This study showed that emotional support (e.g., discussing feelings), instrumental support (e.g., information, advice) and organizing support systems (e.g., networks) can be life-changing [START_REF] Van Der Sanden | Coping with stigma by association and family burden among family members of people with mental illness[END_REF].

Interventions for structural stigma

Several approaches can be used to prevent structural stigma and to protect people with FD against the impacts of structural stigma. Given the important work conducted by the charity Changing Faces, we draw heavily on their work in our recommendations for reducing structural stigma. First, we recommend changes to policy and laws, and the recognition of the rights of people with FD. Changing Faces has lobbied for 'disfigurement' to be covered by the Disability Discrimination Act 1995 and the Equality Act 2010 (Changing Faces, 2017) and we support this. More generally, advocacy is needed in order to support the interests of people with FD.

Second, in order to improve knowledge and generate more positive attitudes towards FD in society, increased awareness and positive exposure to facial conditions is needed. This has, to some extent, been done. For example, in an effort to tackle the 'disfigured is bad' stereotype, there have been public awareness campaigns that focus on positive exposure (e.g., see Changing faces' campaign 'I am not your villain' in the UK, or Corasso's campaign 'Quoi ma gueule ?' in France). Increased awareness also requires educating and training the media on best practices for addressing FD (Garrisi et al., 2018). For instance, Face Equality International (2021) provides resources on how to present, interview, and talk about FD. Furthermore, we suggest explicitly calling on the media to produce and commit in non-stigmatizing portrayals of FD (see [START_REF] Rubino | Joint international consensus statement for ending stigma of obesity[END_REF].

Third, because structural stigma causes social exclusion, we need inclusive efforts that remove the barriers that reduce people with FD's opportunities to participate in social life (e.g., discrimination at work, school). These efforts should also seek to increase the visibility of people with FD. For instance, the Changing Faces' (2021) campaign 'pledge to be seen' aims at representing more people with a visible difference in communication.

Summary

We have a broad toolbox for addressing public stigma, self-stigma, stigma by association, and structural stigma. These strategies can be derived from not only previous experience and efforts to reduce FD stigma, but also efforts to reduce stigmatization related to other identities and conditions.

Conclusion

In this paper, we set out to employ the social stigma framework put forth by [START_REF] Pryor | HIV/AIDS in the Post-HAART Era: Manifestations, treatment[END_REF] to unpack the stigma of facial difference (FD). By describing relevant literature on public stigma including the cognitive, affective, and behavioral reactions to people with FD; self-stigma including anticipated and internalized stigma; stigma by association experienced predominantly by parents of children with FD, and structural stigma embedded in media and in legislation, we have shown the utility of [START_REF] Pryor | HIV/AIDS in the Post-HAART Era: Manifestations, treatment[END_REF] framework for understanding FD stigma. We then followed up by discussing how people with FD cope with the various forms of stigma. Lastly, we outlined a number of evidence-based strategies for addressing FD stigma. In doing so, we hope to have shed light on future avenues for intervention and the improvement of well-being for people with FD.

Funding

This work was supported by the Normandy Region [grant RIN 100%, 2018; grant RIN tremplin 19E00851, 2019], the Foundation Gueules Cassées 2020]. Data Availability No data was used for the research described in the article.