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Purpose: Assessment of the symptoms of body image disorder (BID) is crucial in anorexia nervosa (AN). Recent technological advancements such as virtual reality (VR) have improved the visual perception with 3D avatars and the feeling to be the avatar with the immersive conditions. This retrospective study examines the hypothesis that VR with standardized 3D avatars would improve body image perception and then body image evaluation by adolescents with AN, compared to the paper-based figure rating scales (FRS)., Methods: Data of 31 female adolescents with AN were retrospectively studied. Paired data of perceived and desired body forms in addition to body perception index (BPI) (p = 0.2) and body dissatisfaction (p = 0.6), obtained by both VR and FRS were compared. Furthermore, correlation with validated psychometric questionnaires was also studied. Head-tracking technology allowed for the implicit measurement of explicit choices of patients., Results: Participants with AN overestimated own body size regardless of the assessment tool used. BPI and body dissatisfaction did not differ significantly between FRS and VR. VR-based evaluation was correlated with the psychometric parameters BID and body dissatisfaction. Head tracking revealed significantly longer participant engagement with avatars representing malnutrition and underweight states, while those least engaged corresponded to obesity., Conclusions: Results of BID evaluation by VR standardized 3D avatars are comparable to those obtained by paper-based FRS. These findings suggest that comparable results obtained by both tools of evaluation reflect primarily the role of affective-cognitive perturbation in BID. The perceptive component could be better evaluated using biometric-enhanced assessment tools., Level of Evidence: Level V, cross-sectional descriptive study (evaluation data retrospectively studied).

Online data collection is becoming increasingly common and has some advantages compared to traditional paper-and-pencil formats, such as reducing loss of data, increasing participants' privacy, and decreasing the effect of social desirability. However, the validity and reliability of this administration format must be established before results can be considered acceptable. The aim of this study was to evaluate the validity, reliability, and equivalence of paper-and-pencil and online versions of the Weight Concerns Scale (WCS) when applied to Brazilian university students. A crossover design was used, and the Portuguese version of the WCS (in both paper-and-pencil and online formats) was completed by 100 college students. The results indicated adequate fit in both formats. The simultaneous fit of data for both groups was excellent, with strong invariance between models. Adequate convergent validity, internal consistency, and mean score equivalence of the WCS in both formats were observed. Thus, the WCS presented adequate reliability and validity in both administration formats, with equivalence/stability between answers.

Objective: Disrupted interoception has been found in individuals with body image concerns and related psychiatric conditions (i.e., eating disorders, body dysmorphic disorder). However, few studies have explored the role of interoception in the relationship between body image concern and self-objectification (SO). As components of the bodily self, interoception and body image may also contribute to the fostering of self-consciousness., Methods: The current study estimated the network model of body image concern, adaptive and maladaptive interoceptive sensibility (IS), self-consciousness, and SO, with data from 743 neurotypical adults. The centrality of nodes and the robustness of the network were verified., Results: Our network showed that interoception correlated with certain characteristics of body image concern (BIC) with varying strength and different directions. The most central node described beliefs of BIC, namely, negative evaluation toward appearance. Self-objectification and maladaptive IS presented the highest bridge centrality. Interoception also linked BICs with SO and self-consciousness., Conclusion: Findings suggested that SO, adaptive and maladaptive interoception might be the targets of intervention for individuals with BIC, specifically for those with high levels of appearance-related negative self-evaluations., (© 2024 Wiley Periodicals LLC.)

People with CF (pwCF) are at high risk for malnutrition, making nutritional management a critical aspect of CF care. Over the past several decades, optimal nutritional status for pwCF has been defined by body mass index (BMI) based on evidence linking suboptimal BMI to decreased lung function and life expectancy, although more recent changes in CF care may also bring changes to how nutritional health is defined. The historical focus on weight, BMI, and nutrition as key parts of multidisciplinary CF care starting at an early age places pwCF at increased risk for body image concerns and disordered eating. The landscape of CF care is evolving with the approval of highly effective modulator therapies (HEMT) and resulting improvements in growth; however, issues related to body image and eating remain important to consider, especially as past difficulties gaining weight may shift to discomfort with one's weight gain and/or physical appearance. This review aims to describe how body image concerns and disordered eating occur in pwCF across the lifespan; to discuss evidence-based approaches to addressing these concerns; and to identify future directions for research and clinical practice in assessing and treating eating disorders and body image concerns in this population., (© 2024 Wiley Periodicals LLC.)

Objective: Theoretical models highlight body image disturbances as central to the maintenance of eating disorders, with empirical evidence finding negative body image to be a robust predictor of treatment nonresponse, relapse and symptom persistence. Accessible, scalable, and inexpensive interventions that can effectively target negative body image across the eating disorders are needed. We developed an online single session intervention (SSI) for negative body image and evaluated its acceptability and efficacy in a randomized controlled trial in individuals with recurrent binge eating., Method: Participants with recurrent binge eating were randomly assigned to the SSI (n = 99) or a waitlist (n = 101). Assessments were conducted at baseline, 4 week follow-up, and 8 week follow-up., Results: 81% of participants accessed the SSI, demonstrating reasonable uptake. However, issues with attrition were apparent; a 32% study dropout rate was observed at posttest, while a 58% dropout rate was observed at follow-up. 87% of participants who completed satisfaction measures would recommend the SSI. SSI participants experienced greater improvements in negative body image at both 4 (d = -0.65) and 8 week (d = -0.74) follow-up. Significant between-group effects were also observed on most other secondary symptom measures, though no differences were found for motivations and help-seeking beliefs and intentions., Conclusion: Body image-focused self-guided SSIs for recurrent binge are largely accepted by those who are retained in the trial, but are associated with significant attrition. Although SSIs are not intended to replace standard treatment, they may help with short-term symptom management and could play an important role in eating disorder care., Public Significance: Single session interventions (SSI) are a potentially accessible, scalable, and cost-effective way to deliver evidence-based treatment content to people with eating disorders. This study shows that an online (SSI) designed to target body image among people with recurrent binge eating is accepted and produced short-term symptom relief., (© 2024 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

The objectives of this study were (a) to explore the preliminary cross-cultural validity of a visual-perceptual method to assess body image; (b) to examine potential differences and similarities in body image phenomena between women from two Western countries (i.e., Canada and Spain). 201 self-identified women participated in this cross-sectional study. Ideal, normal, and self-perceived body sizes were assessed using a visual-perceptual method, whereas body dissatisfaction was measured using both a visual-perceptual method and a questionnaire. Visual-perceptual body dissatisfaction was significantly correlated with questionnaire body dissatisfaction, suggesting a preliminary convergent validity between the two assessment methods. Women in both countries were dissatisfied with their bodies. Compared to their self-perceived body, all women chose a significantly thinner visual representation of their "normal" and ideal body. These results may suggest a shift towards the "thin" body as not only ideal, but also normative. This study provides the first evidence for the cross-cultural validity of a visual-perceptual body image assessment tool. The results of the current study confirm the presence of "normative discontent", and suggest more cross-country similarities than differences among women from these two Western societies., (© 2024 The Authors. European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd.)

The current study uses a mixed method design to investigate Kenyan and Ghanaian adolescents' experiences of puberty, and the relations between gender, country of origin, pubertal status, and body image appraisals (N = 86; Ghana = 46, Kenya = 40, 52.9% female aged 13 and 14). Qualitative results revealed seven major themes; puberty means a universal period of growth and transition into adulthood but also evokes negative emotions of shame, anxiety, and embarrassment, being in sync with peers during puberty is important and knowing that others in their lives similarly experience puberty is reassuring. Quantitative results revealed significant gender and country differences in pubertal status and body image. Ghanaian adolescents had more advanced pubertal status and more positive body image appraisals compared to Kenyan adolescents. Moderation analysis results revealed that for the Kenyan sample, post-pubertal males had less favorable body image appraisals than their counterparts who were still pre pubertal whilst for females, post-pubertal girls had more favorable body images than their counterparts. No such effects were observed with the Ghanaian sample. The findings highlight the need for context considerations in understanding body image during the pubertal transition to help identify relevant protective factors for possible interventions. The results affirm the importance of positive body image promotions for adolescents within the African context and suggest the need for much more comprehensive sex education with gender-specific components to help allay fears about puberty, thus preventing the development of possible adaptation problems., (© 2024 Society for Research on Adolescence.)

An introduction is presented in which the author discusses articles within the issue on topics including the role of visual experiences and sociocultural pressures in the shaping of body images of people diagnosed with blindness, feasibility and acceptability of using videoconferencing tools to present an adapted job-search intervention, and low vision rehabilitation of optometrists providing services in the Pubjab, Pakistan.

Purpose: In this study, we investigate whether individuals' BMI categories are associated with being dissatisfied with one's life, how this association is affected by the social comparison that individuals make, and what the role of the overall BMI levels in this process is., Methods: We use data for 21,577 men and 27,415 women, collected in 2016 by the European Bank for Reconstruction and Development, from 34 countries in Europe, the Middle East, and Central Asia. To understand the moderating effect of contextual environment, we use multilevel mixed effect logistic regression models and data for national, regional, and cohort-specific BMI levels., Result: We find that the association of BMI and dissatisfaction with life differs by gender, with overweight men being less likely to be dissatisfied with life than men with normal weight and obese women being more likely to be dissatisfied with life compared to women with normal weight. For contextual effects, we find that obese women in regions with low BMI levels are more likely to be dissatisfied with life. The effect of obesity on female life dissatisfaction is not observed in regions with high BMI levels. As for men, regional BMI levels affect the levels of life dissatisfaction but only for underweight men., Conclusions: Our study adds additional nuance to the quality-of-life research by showing that the association between BMI and decreased life satisfaction is, at least partially, moderated by the contextual environment, and that the character of these effects differs by gender., (© 2021. The Author(s).)

Aim: This study was planned to determine the relationship between social media addiction and orthorexia nervosa (ON), eating attitude and body image among adolescents., Method: This cross-sectional study was conducted with 1232 high school-going adolescents. Data were collected using the Social Media Addiction Scale for Adolescents, Eating Attitude Test-26 (EAT-26), Body Image Scale (BIS) and ORTO-11 questionnaire., Results: Social media addiction levels were higher in girls than in boys (p < 0.05). Multiple linear regression analysis showed that a better body image was associated with lower social media addiction scores (β =  - 0.268, p < 0.001). Social media addiction was significantly associated with a greater risk of eating behavior disorders (OR: 1.07, 95% Cl: 1.04-1.10) and ON tendency (OR: 1.02, 95% Cl = 1.00-1.04). Adolescents who stated that they always or often read nutrition-related posts on social media had an increased likelihood of eating behavior disorder risk (OR: 6.77, 95% CI: 3.84-11.94) and ON tendency (OR: 5.49, 95% CI: 3.39-8.88)., Conclusion: This study demonstrated that social media addiction was associated with a higher eating behavior disorder risk, ON tendency and lower body image. Moreover, frequent reading of posts about nutrition on social media was positively associated with ON tendency and eating behavior risk. These results highlight that adolescents should be educated about social media use and its content to minimize the negative effects of constant exposure to unrealistic body images and nutrition-related misinformation and reduce the risk of eating disorders and ON among adolescents. Level of evidence Level V, cross-sectional descriptive study., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Women with body image concerns are more likely to experience sexual difficulties (e.g., with arousal, lubrication, orgasm). However, the processes by which body image impacts sexual well-being are poorly understood. We theorized that women with negative body image are less likely to view sex in terms of reward, leading them to have weaker approach sexual motives (i.e., to pursue positive experiences such as pleasure). Rather, women with negative body image may have sex to avoid personal insecurities and negative emotions, leading them to have stronger avoidance sexual motives (i.e., to cope with negative affect or to avoid partner conflict). In turn, we theorized that stronger approach sexual motives may allow women to be more focused on erotic cues during sex, thereby enhancing sexual pleasure, whereas avoidance motives may lead to greater distraction, interfering with sexual pleasure. Women (N = 1619) were recruited from online venues and reported on their body image and most recent sex. We found that body dissatisfaction was associated with weaker self-focused approach motives and in turn more distraction. Additionally, body dissatisfaction was associated with stronger self- and partner-focused avoidance motives and in turn more distraction. In turn, more distraction was associated with less pleasure and worse sexual function. To the best of our knowledge, this is the first investigation of whether body image in women is associated with their sexual motives. Findings highlight the importance of sexual motives in explaining the link between body image and sexual pleasure and function., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Fashion models and athletes are considered at risk for eating disorders, but research has produced mixed findings and little insight into psychological risk factors. Body-focused performance is common to both occupations, but emotional risk factors like alexithymia and body-image particularities have not been compared between them. This study aimed to: (1) examine the levels of alexithymia and affective states among female fashion models and athletes as body-performing occupations, and a control group, and (2) compare multidimensional body image and disordered eating among these groups., Methods: Data from 351 females aged 16-30 were compared among three samples: fashion models (n = 88), student athletes (n = 84) and control students (n = 179), who completed measures for alexithymia, affective states, multidimensional body image, and disordered eating., Results: Fashion models had significantly lower alexithymia compared with the other groups, and lower negative affect than controls. Positive affect was significantly lower among controls than the other groups. Body image comparisons revealed significantly higher fitness evaluation and orientation in fashion models and athletes compared to controls. Fashion models had significantly higher appearance orientation than the other groups. Student athletes had significantly higher appearance evaluation than controls and higher fitness evaluation than fashion models. Disordered eating did not differ among groups., Conclusion: Lower alexithymia among fashion models is discussed in the context of emotional labor and artistic public performance. The findings suggest that body-focused performance may have emotional benefits and may drive higher body-image investment and satisfaction., Level of Evidence: Level III, case-control analytic study., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objective: Establishing factors that protect against the onset of eating disorder symptoms is needed to identify critical intervention targets to inform the design of more potent prevention programs. Knowledge of robust protective factors is lacking, which might account for the limited effectiveness of existing prevention programs. As positive body image, intuitive eating, and self-compassion show protective potential, the present study tested whether these factors protect against the onset of a range of different eating disorder symptoms., Method: Data were analyzed from 1,270 women who completed study measures at baseline and 8 months. Logistic regressions tested whether, among initially asymptomatic women, baseline and changes in positive body image components (body appreciation, body image flexibility, and functionality appreciation), intuitive eating, and self-compassion predicted the continued absence versus onset of seven core eating disorder symptoms at follow-up., Results: Each of the five factors at baseline was associated with a lower odds of symptom onset for each outcome in univariate analyses. Baseline body appreciation and intuitive eating scores remained consistent, unique predictors of a lower odds of experiencing symptom onset in multivariate models. Greater increases in intuitive eating and body appreciation over time were the two factors consistently associated with a lower odds of symptom onset across several outcomes., Discussion: This study provides strong evidence for the protective influence of positive body image components, intuitive eating, and self-compassion against several eating disorder symptoms. Building these factors within established prevention programs may, in the longer term, help reduce the incidence of eating disorder syndromes and symptoms., (© 2021 Wiley Periodicals LLC.)

Body image or how a person views their body and the way it functions ultimately influences their quality of life and functional well-being in their daily environments. The changes to appearance or to body structures and functions that occur as a result of cancer and its treatment can cause individuals to become dissatisfied with their body image where maladaptive emotions, thought processes, and behaviors develop and may lead to deleterious consequences including social avoidance and isolation. Although reconstructive surgery is restorative in nature, it does not guarantee the mitigation of body image dissatisfaction when treating adults with cancer. The majority of adults who undergo reconstructive surgery for the treatment of cancer demonstrate some level of body image dissatisfaction during or after the reconstructive process. Therefore, a need exists for nurses and other oncological team members to recognize and address body image dissatisfaction and the detrimental emotional and behavioral consequences associated with it. This article provides guidance for nurses to address body image by understanding the effects of cancer and its treatment on body image, by recognizing the impact of reconstructive surgery on body image when treating cancer in adults, and by integrating body image assessment and interventions into practice., Competing Interests: The author reports no conflicts of interest., (Copyright © 2021 International Society of Plastic and Aesthetic Nurses. All rights reserved.)

Objective: Besides all visible somatic manifestations, distorted body representation is a key symptom for anorexia nervosa (AN). Body representation can be divided into a conscious component, body image, and an unconscious action-related one, body schema. As behavioral studies already explored the impact of a distorted body image in AN, we aimed to explore whether distortion also extends into unconscious body schema. This study is the first with an unbiased measurement of the body schema in a homogeneous sample of AN patients., Method: Twenty-three patients diagnosed with AN and 23 healthy controls (HC) walked through a door like aperture varying in width. Door width was based on participants shoulder width and ranged from an aperture-to-shoulder-ratio of (A/S) 0.9 to 1.45. Shoulder rotation was measured as indication of perceived body width. To measure the unconscious body schema, we used a cover story pretending to investigate the influence of change of position on retention memory., Results: We found a significantly higher critical A/S for AN than HC, which indicates that AN patients rotate their shoulders for relatively larger door widths than HC, thus unconsciously estimating their body size to be larger than in reality. Additionally, we found a correlation between negative body attribution and overestimation of bodily dimensions., Discussion: As stated by the "allocentric-lock"-hypothesis, AN patients might be locked to a stored representation of their body that cannot be updated and remains at pre-AN conditions. We suggest future AN-therapy to counter body schema alterations by combining cognitive behavioral therapy and virtual reality therapy., (© 2020 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Objective: This study provides a comprehensive assessment of own body representation and linguistic representation of bodies in general in women with typical and atypical anorexia nervosa (AN)., Methods: In a series of desktop experiments, participants rated a set of adjectives according to their match with a series of computer generated bodies varying in body mass index, and generated prototypic body shapes for the same set of adjectives. We analysed how body mass index of the bodies was associated with positive or negative valence of the adjectives in the different groups. Further, body image and own body perception were assessed., Results: In a German-Italian sample comprising 39 women with AN, 20 women with atypical AN and 40 age matched control participants, we observed effects indicative of weight stigmatization, but no significant differences between the groups. Generally, positive adjectives were associated with lean bodies, whereas negative adjectives were associated with obese bodies., Discussion: Our observations suggest that patients with both typical and atypical AN affectively and visually represent body descriptions not differently from healthy women. We conclude that overvaluation of low body weight and fear of weight gain cannot be explained by generally distorted perception or cognition, but require individual consideration., (© 2020 The Authors. European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd.)

Objective: The rate of contralateral prophylactic mastectomy (CPM) in women with early, unilateral cancer is relatively high and is increasing around the world a previous study. Women choose this option for many reasons other than reducing their risk of future cancer, including symmetry, reasons related to breast reconstruction and attempting to manage fear of recurrence. This systematic review evaluated patient-reported quality of life outcomes following CPM., Methods: A literature search of MEDLINE, PubMed and PsycINFO was performed to February 2019. Abstracts and full-text articles were assessed for eligibility according to pre-determined criteria. Data were extracted into evidence tables for analysis., Results: A total of 19 articles met eligibility criteria and were included in analysis. These included patient-reported data from 6088 women undergoing CPM. They reported high levels of satisfaction with the decision for surgery, low levels of decisional regret and high satisfaction with cosmesis and reconstruction. Breast-specific and general quality of life was high overall but was even better in women choosing breast reconstruction after surgery. Fear of cancer recurrence was high after CPM. Depression, distress and a negative impact on body image were evident; however, levels were high in both CPM and non-CPM groups., Conclusions: This study provides information that can be used by surgeons and psychologists when counselling women about the potential benefits and harms of CPM. This process must include discussion about the trade-offs such as body image issues and ongoing fear of recurrence in addition to the positive aspect of cancer risk reduction. Women are unlikely to regret their decision for CPM., (© 2020 John Wiley & Sons, Ltd.)

Objective: Breast cancer is the most common cancer among women world-wide. In North America survival rates are >80%, resulting in a large population of survivors. The goal of this review was to systematically explore the literature to identify the status of body image and factors that can impact the body image of older breast cancer survivors., Methods: A systematic review of the literature was conducted and registered with PROSPERO (CRD42019133617). EMBASE and PubMed were searched for articles including terms related to "body image" and "breast cancer." Duplicates were removed and the remaining 322 abstracts were screened. Articles published before 2000, were off-topic, or those that were non-primary research articles were excluded. Sixty-nine remaining full-length articles were screened for language, gender and location. Seven articles underwent quality assessment of which five passed and were reviewed in depth. The remaining two articles were briefly discussed., Results: The literature review suggests that body image is considered important in older BCS and that body image may impact or be impacted by several factors including age, menopausal status, mental health, treatment modality and exercise. Additionally, themes of dealing with physical changes and the length of time women are impacted following treatment were explored., Conclusion: Our findings highlight that older women may be at an advantage in terms of being post-menopausal, however concerns surrounding physical and emotional changes affecting body image are indeed present. Future studies on breast cancer survivorship should consider the inclusion of body image as an outcome measure in addition to including individuals representing a wide range of ages., (© 2020 John Wiley & Sons, Ltd.)

Objective: Most advertisements contain thin-ideal imagery enhanced by digital modification. The deleterious effects on body image and eating disorder risk of exposure to such images have been well documented. One of the proposed macro-level solutions to mitigate these effects has been the use of labels on images, primarily disclaimer labels. A growing number of studies have explored the usefulness of such labels in protecting body image against the detrimental effects of media exposure; however, findings have been divergent., Methods: The current study aimed to conduct a systematic review and meta-analysis of the existing literature investigating the effects of including labels on media images on body image., Results: The systematic review identified n = 22 studies that were included in a narrative review, n = 18 were included in the meta-analysis. Overall, findings provided little support for the use of disclaimer or warning labels as a means of protecting against the detrimental effects of media exposure on body image. Furthermore, findings suggested that such labels might increase state appearance comparison when exposed to media images., Discussion: These findings are especially concerning in light of recent legislative efforts to mitigate media effects through the use of labels on imagery, as well as industry initiatives based on image labeling. Additional research examining alternative strategies for universal prevention of body image and eating concerns is warranted., (© 2020 Wiley Periodicals, Inc.)

Study Design: Cross-sectional., Objective: The aim of this study was to describe the self-experienced trunk appearance in individuals with and without idiopathic scoliosis., Summary of Background Data: Idiopathic scoliosis is the most common spinal deformity. A large scoliotic deformity increases the risk of back pain and pulmonary dysfunction. The deformity has also a psychological impact., Methods: The pictorial part of the spinal appearance questionnaire (pSAQ) was administered to 1416 individuals with idiopathic scoliosis (386 untreated, 529 brace treated, 501 surgically treated) and 272 individuals without scoliosis from the general population. Comparisons were made between individuals with and without scoliosis, between treatment groups and sex in the scoliosis group., Results: Mean (95% confidence interval) age of the individuals with scoliosis was 36.2 (35.5-36.9) years and for the individuals without scoliosis 40.2 (37.9-42.4). pSAQ total was 12.3 (12.1-12.5) for individuals with scoliosis and 7.4 (7.3-7.6) for individuals without scoliosis (P < 0.001, adjusted for age and sex). pSAQ total was 11.5 (11.1-11.9) for untreated, 13.0 (12.6-13.3) for brace treated, and 12.3 (11.9-12.6) for surgically treated individuals (P < 0.001, adjusted for sex and curve size). The pSAQ total between males and females with idiopathic scoliosis did not differ (P = 0.22 adjusted for age and curve size)., Conclusion: This study shows that individuals with idiopathic scoliosis have more concern about their body appearance than individuals without scoliosis. Untreated individuals are not as bothered of their spinal appearance as treated individuals. Males and females with scoliosis do not differ significantly in the perception of their spinal appearance., Level of Evidence: 3.

Purpose: The views of butch- and femme-identified lesbians toward their own breasts, breast cancer, breast cancer screenings, and their behavior and intentions toward breast health care were examined and compared in this study., Methods: A total of 208 Taiwanese lesbians (134 butch-identified lesbians and 78 femme-identified lesbians) completed an online survey., Results: Butch-identified lesbians were more likely to hold negative views regarding their own breasts, which were found to be significantly and negatively associated with their actions in performing breast self-examinations when compared with femme-identified lesbians., Conclusions: Healthcare providers should be aware of and provide culturally competent care to lesbians with different identities., Clinical Relevance: The results can be employed as evidence for promoting lesbians' breast health, particularly butch-identified lesbians. Healthcare providers should provide a supportive environment in order to promote a positive body image and improve breast health among lesbians., (© 2020 Sigma Theta Tau International.)