“While You’re Down There”: The Unexplored Role of Estheticians in the Health of Their Clients

ABSTRACT

Young women (18–25 years) are more likely to engage in pubic hair removal and experience higher rates of negative sexual health outcomes (e.g., sexually transmitted infections [STIs]). Hair removal salons may serve as novel environments for health interventions. The Sexual Health and Esthetician (SHE) Study aimed to better understand the pubic hair removal profession, explore the esthetician–client relationship, and assess potential for esthetician offices/salons serving as health promotion/sexual health promotion intervention settings. Using an exploratory qualitative design, in-depth interviews (N = 28) were conducted with licensed estheticians who provided pubic waxing services. In a large urban area in Southern California, the catchment area of salons included five unique neighborhoods, each with high reported STI rates. Data were analyzed using a social constructivist perspective and emergent themes from interviews. Synthesis of data showed estheticians provide a variety of waxing services for young women; during appointments, sex-related discussions occur, creating “sexy spaces” where otherwise taboo conversations happen with ease; they notice clients’ possible health concerns, including STIs, but have no protocols/procedures for handling these occurrences; and interactions with clients often result in the development of an intimate bond. Results indicate estheticians may be effective conveyors of sexual health promotion and risk reduction interventions.

Sexual and reproductive health is a critical public health issue in the United States, especially pertaining to sexually transmitted infections (STIs) and unintended pregnancy. In particular, rates of chlamydia, gonorrhea, and syphilis have all increased nationally among the general population for the fifth consecutive year, with nearly 2.5 million combined cases (Centers for Disease Control and Prevention, 2019). Half of the STIs are among young people aged 15 to 24 years (Satterwhite et al., 2013). Additionally, women between the ages of 15 and 24 years experience some of the highest rates of unintended pregnancy (Finer & Zolna, 2016). Campaigns targeting STI prevention, promoting contraceptive use, and fostering other preventive health behaviors have demonstrated positive impacts on health behavior change, especially among young people, indicating a need to further these efforts in new and creative venues, to better reach important priority populations (McFarlane et al., 2015).

Research in barbershop settings is one illustration of such a new and creative venue for creating positive impacts on sexual health through health promotion campaigns (Baker et al., 2012; Brawner et al., 2013). For instance, HIV/STI risk-reduction interventions for African American men, facilitated by barbers, have proven to be successful when implemented in barbershop settings. Due to familiar cultural and social norms within the barbershop environment, as well as the established, trusting relationship between barbers and their clients, barbers can serve as advocates and facilitators for sexual health interventions with their clientele (Brawner et al., 2013).

Beauty shops and other, similar, settings represent potential, parallel venues for sexual health promotion efforts. For example, pubic hair removal practices are common around the world (Prabhune et al., 2019). In the U.S., more than 85% of women aged 18–24 years participate in some method of pubic hair removal (Herbenick et al., 2010) and, as noted above, many have increased rates of experiencing both STIs and unintended pregnancies. Like barbershops and beauty salons (Linnan et al., 2014), hair removal salons may also cultivate a safe, culturally relevant space for estheticians (i.e., skincare professionals) to deliver health promotion and, more specifically, sexual health promotion campaigns to young women. Similar to beauty shops and barbershops, clients may also visit hair removal salons on a routine basis, subsequently developing a consistent, familiar relationship with their esthetician; and given the regular exposure of client’s genitals during the service, the relationship between clients and their skincare professionals during a pubic hair removal session may prove even more intimate.

Herbenick et al. (2013) conducted a large study (N = 2,453) of pubic hair removal trends among women and revealed that pubic shaving and waxing behaviors were more strongly associated with young adult women (18–25 years of age), and that those who practiced pubic hair removal also possessed a greater interest in sex. College-aged women also report feelings of cleanliness, comfort, and greater sexual confidence as a result of waxing, though many frequently experience side effects such as ingrown hairs and skin irritation (Butler et al., 2015; DeMaria et al., 2016). Other research has revealed that routine body hair removal practices, specifically in the pubic area, are more common among sexually active individuals (Bercaw-Pratt et al., 2012). DeMaria and Berenson (2013) reported that women of varying backgrounds practice pubic hair grooming, but stronger associations were found with younger, white women, with normal or low bodyweight, an income greater than 30,000 USD, and experience with at least five sexual partners. Finally, while limited research (e.g., on a single college campus, with small convenience samples) has indicated that weekly pubic hair grooming is not an STI risk factor among college students (Luster et al., 2019) and that there is no association between recent pubic hair grooming and STIs among STI clinic patients (Gaither et al., 2020), a large-scale probability survey of 7,580 U.S. residents aged 18 to 65 years revealed positive correlations between pubic hair removal practices and a history of STIs in both men and women (Osterberg et al., 2016). There is also evidence that anal grooming is associated with rectal STIs among gay and bisexual men (Gaither et al., 2020).

As the above-mentioned research indicates, the majority of individuals engaging in pubic hair removal is likely to be young women who are either interested, or currently engaging, in sexual activity. Surveillance data also indicate that this priority population is experiencing increased rates of negative sexual health outcomes. Coupled with the correlations between pubic hair removal and STI incidence, hair removal salons may serve as ideal, novel environments for sexual health promotion and risk reduction interventions. Currently, however, little is known about this specific setting or environment, and even less is known about the estheticians who perform pubic hair removal, and how these professionals may be potentially engaged in sexual health promotion efforts.

The purpose of this paper is to report on the Sexual Health and Esthetician (or SHE) Study. The SHE Study aimed to better understand the pubic hair removal profession, examine the esthetician–client relationship, and explore the potential of esthetician offices/salons as a community-based health promotion or sexual health promotion intervention setting. The exploratory study sought to identify the perceived and functional role of the esthetician in relation to the client, as well as the nature of the conversations and interactions between estheticians and their clients. It is anticipated that the knowledge gained from this exploratory study will provide key information that may result in the development of sexual health promotion interventions to be implemented in esthetician settings (community-based and community-placed research), as well as potential community-based participatory research (CBPR) (Rhodes et al., 2010) with estheticians.

Method

All study procedures and data collection instruments were reviewed and approved by the San Diego State University Institutional Review Board. Inclusion criteria for the study required participants to be licensed estheticians who provided pubic waxing services, spoke fluent English, and were at least 18 years of age. The catchment area for recruitment was determined based on spring 2016 Yelp ratings of the most popular/highly ranked salons in a large urban area in Southern California, and were focused in five key neighborhoods with the highest reported STI rates (County of San Diego Health & Human Services Agency, Public Health Services, HIV, STD & Hepatitis Branch, 2016). Yelp is a local-search app or website, which allows its members to rate and review local businesses, and the general public to search for and view these ratings and reviews. While each neighborhood had its own unique profile, the communities are similar in residential characteristics; residents are largely white, affluent, young, and unmarried (Space Informatics Lab/University of Cincinnati, 2017).

Recruitment was conducted by in-person visits to 10 salons in each identified neighborhood (N = 50), with follow-up communication via telephone and e-mail. The study was described as seeking information about the experiences of estheticians related to how they interact with their clients, specifically related to how they interact with those clients who seek pubic hair removal services. Ultimately, the final sample of participants included a total of 23 participating salons with 28 estheticians (27 females and 1 male); six estheticians were located in “The Gayborhood,” six were in “Hipster Haven West,” six were in “Hipster Haven East,” five were in “The City,” and five were in “The Beach Town.” Names of these neighborhoods have been changed to maintain participant confidentiality. The length of experience as an esthetician ranged from 4 months to 21 years. A 25 USD gift card was offered as remuneration for participation in interviews.

Prior to data collection, a semi-structured interview guide was developed and pilot-tested with three local estheticians for clarity, understandability, and readability. All interviews were conducted at the salons where the participants practiced. Interviews were conducted at a pre-arranged time, convenient for the participant, and interviews averaged approximately 30–50 minutes. The interviewer was female, in her mid-twenties, from Southern California, and who was part of the research team and had been trained in qualitative data collection and interviewing. Data saturation was reached by the 15^th interview.

Data Analysis

Data from the interviews were analyzed from a social constructivist perspective (Creswell, 2013; Saldaña, 2013). Based on formative research on estheticians and their relationships with clients (Linnan et al., 2014), use of a social constructivism lens, which maintains that people mentally create unique realities based on social experiences and interactions, was warranted (Guba & Lincoln, 1994). The researchers were interested in how the estheticians collectively constructed their experiences providing services to their clients. Interviews were digitally recorded and professionally transcribed into verbatim text documents for data analysis. Two researchers independently reviewed all transcripts with the audio recordings to check for errors.

A thematic process, with specific inquiry into recurring themes describing participants’ socially constructed perceptions of their relationships with clients and each of their unique realities, was applied to the development of the codebook (Creswell, 2013). Pre-determined codes were developed based on themes derived from literature reviews (see Appendix). Using QSR International’s NVivo 11 qualitative data analysis Software (2016) and the developed codebook, the data analyst and an additional researcher coded the same three interviews separately, and then compared coding together to establish absolute consensus through conversations between the coders. The primary data analyst then coded the remaining interviews. Using an iterative, rigorous process, prominent and recurring themes were determined, identified, and are described in the results section below. Illustrative quotes are reflected within these prominent and recurring themes. Findings were shared with participants as a member-checking process.

Results

The following four thematic areas were compiled from a synthesis of 10 main themes. In order to protect the confidentiality of participants, each salon has been anonymized by combining its neighborhood pseudonym with a corresponding number of the salon (i.e., The Beach Town 2). Participants are further identified by their gender and number of years of experience practicing as an esthetician.

Theme 1: Notable Trends and Services among Pubic Hair Removal Clients

While the communities were similar in terms of residential characteristics, estheticians from all five of the neighborhoods reported having a diverse client base with a wide range of ages, races and ethnicities, sexual identities, and socioeconomic statuses.¹ Men as clients were reported to make up no more than 10–25% of estheticians’ client bases (n = 24), suggesting that the clients most served were women. Several participants reported that the majority of their clients requesting Brazilian waxes – the removal of all pubic hair including the anal region, except for possibly a small strip or triangle on the pubic bone (Hildebrandt, 2003) – were women in their 20s-30s:

“For Brazilians, it tends to be a little younger. I would say late 20s to early 30s. I think it’s also because of the area [of town] that I’m in though. When I worked in different areas, near college areas, it was early 20s but because I’m [in The City], it costs a lot of money to live [in The City]. People are usually young professionals. It usually falls into late 20s to early 30s.” – The City 4, Female, 9 years of experience

All participants stated that the Brazilian wax was the most popular service sought from their women clients, but waxing of the underarms, upper lip, eyebrows, and legs was also commonly requested. Sixteen estheticians noted that their men clients request the “Manzillian,” the male equivalent of a Brazilian wax, along with back, shoulders, chest, and eyebrows. Over half of estheticians reported not offering the Manzillian service due to feelings of awkwardness or discomfort:

“Some men can get a little awkward. Some cross that line where they get a little creepy. I’m like if we’re going to do this, that can’t happen. Guys tend to cross that line a little bit sometimes. You have to just nip it in the bud. I’m okay with turning people away. This is my job and I don’t want to be uncomfortable.” – The City 5, Female, 2 years

Theme 2: The Waxing Salon as a Sexy Space

Participants acknowledged that the pubic hair waxing experience, especially among those performing Brazilian waxes, tended to provoke clients to disclose intimate information about sex and sexual behavior. Accordingly, the waxing session may be deemed a sexy space (Caudwell & Browne, 2011, 2013), meaning that, in this context, the waxing salon (or rather, inside the esthetician’s salon room) is a place where sex talk is expected, comes naturally, and/or is a normal part of the client/esthetician encounter. All estheticians interviewed confirmed that clients discuss sex with them at some level, from basic questions about how long clients should wait after a wax before having sex to more detailed, personal anecdotes about sex. Such discussions ranged from anxieties about sex with long-term partners, aspirations to hookup with someone new, and, in five interviews, elaborate tales of sex-capades.

“It could be like they just met a guy online and they’re going to go mess around with him or they cheated on their boyfriend or they have sex with their best friend’s boyfriend… They’re having sex with their boss and he’s married.” – The Gayborhood 5, Female, 15 years

“The one I’m thinking of is a girl who’s single and she’s always talking about the dating life or the new jerk that she’s dating. So it comes up that way. And then she’ll be like, ‘Oh we had sex.’ It just always comes up the same exact way you talk about it with your girlfriend and it comes out. Like it flows so naturally. I think my single ladies are in that stage where they’re sleeping around a fair amount.” – Hipster Haven East 3, Female, 11 years

Seven estheticians specifically reported that, in addition to talking about sex with them, clients often get pubic waxes to prepare for sex, and are more likely to indicate their intent to be sexually active if they have had their pubic region waxed. When asked about client waxing preferences, or the conversational context when the topic of sex arises, these same estheticians commented on the influence of pubic waxing on their clients’ sexual behaviors. Five of these seven estheticians explained that single clients often come in and divulge that they need a Brazilian wax to prepare for a date, sometimes the first date with a new person.

“People will say “I need a wax. I have a date”. It’s not a detailed sex life but once in a while someone will give details or basically just say I need a wax because they’re planning on having sex or thinking about sex.” – The City 4, Female, 9 years

Many participants noted that clients who are in relationships frequently choose to get waxed because they say it pleases their partner.

“So this lady told me one time, ‘My husband’s addicted to porn and I decided to get a Brazilian to try to look more like those porn stars to please him.’ I was like, ‘Girl, you are going about this way the wrong way. His addiction to porn isn’t healthy. You shouldn’t be trying to feed that and you’re never going to be those girls in that movie.’” – The City 1, Female, 18 years

A few estheticians stated that their clients feel more confident about receiving oral sex after getting waxed. Half of estheticians reported that many clients have expressed that they prefer to get waxed before having sex, and six estheticians acknowledged that clients reveal getting waxed makes them more motivated to have sex.

“And he’s like, ‘Oh my god. I can’t believe she’s making me do this. I’m doing this just for her because she loves oral sex.’ And that’s what he said. He’s like ‘She grooms herself and she looks great so I figured I’ll groom myself and we’re both happy in the bedroom.’ And that’s what he said.” – Hipster Haven West 4, Female, 5 years

Theme 3: The Intimate Bond between Client and Esthetician

In addition to establishing the waxing salon as a sexy space, there appears to be a special level of intimacy that develops between an esthetician and their clients. A pubic hair waxing service not only involves the client being waist-down naked, but in the case of a Brazilian/manzillian (although estheticians also referred to these as “Brozilians”), the esthetician may be waxing intimate body parts like the labia, scrotum, and anal region. The esthetician is in close, physical proximity, touching their client throughout the service, which creates what estheticians described as a vulnerability allowing clients to open up to their esthetician about private, personal matters.

When asked about the conversation topics that arise during waxing sessions, particularly during Brazilian waxes, all estheticians (N = 28) reported that clients, especially “the regulars” who return to the same esthetician for waxes on a routine basis, would often address very personal topics. Such topics included romantic relationships, family, health, and their sex lives. Half of the estheticians noted that the depth and breadth of these personal topics intensified with increased (i.e., more regular) visits. Estheticians attributed this openness to the intimate nature of the service itself:

“ … I mean the bonds that we forge with our clients are strong and I do absolutely think that the nature of the service, like I was saying, brings you closer with that client. It’s a very special relationship because when someone’s vulnerable, naked, laying there with no clothes on they have to trust you 100 percent. Then like I was saying, they tell you things that maybe they don’t tell other people and you just – you’re close. So after that’s over I can get to know the person a little bit better and you know. Yeah, then the conversation ranges from their sex life, who’s cheating on who, they’re pregnant with somebody else’s baby, what’s going on with their divorced parents, they found out their best friend had cancer. You name it, they tell me. I feel like it’s even stronger than a bartender or a hairdresser because I’m alone in the room with them. They’re naked basically, like I said, vulnerable. I don’t know if it’s just me being disengaging or what but they tell me everything. It’s not just me. It’s other estheticians that I talk to, also. So it’s very interesting the client relationship. It’s almost like the minute they walk out that door even after the first appointment they feel like we’re best friend. I am their friend, you know. It’s like they just went through this thing with me. It’s like we’ve both gone through this crazy experience and you’re instantly bonded. Yeah, they talk about anything and everything.” – The City 1, Female, 18 years

“I think you do because you’re touching them for 100 percent of the service. As you go on, you get to learn more about them. I definitely think it’s because you’re touching people that they feel more comfortable with you.” – The City 2, Female, 3 years

While participants reported that there is a unique bond or intimacy with women, they also commented that men are particularly vulnerable as waxing clients. In fact, six estheticians made reference to their men client experiences (e.g., feelings of vulnerability, being especially scared or nervous during their visits).

“Well males are very sweet. They are extremely nervous, more nervous than my females. Their pain tolerance is way lower. So you kind of have to coax it, coax them through it. But then we end up becoming like buddies with them because it’s kind of like we’ve gone through this traumatizing process with them. Honestly, most of my clients are my friends but I really do become buddies with the guy clients. It’s just completely professional and they’re just wanting somebody to help hold their hand and walk them through it. Men like to act like they’re all in charge and full of testosterone but once they get in that room they’re little puppy dogs” – The City 1, Female, 18 years

“No, I mean I’ve had guy clients, they’re probably the ones that bring it up the most because they’re just curious. This is all new to them and stuff so they’ll just – there’s not necessarily stories or things that they tell me about but they’ll just … Like my older clients they’ll confide that they’re on testosterone and they’re like I feel like I’m 18 again, I can’t get enough. And I’m like huh, well good for you. I’m like look at that testosterone go. So I’ll joke around and make light of it so it’s not like – because they’re opening up, they’re in a very vulnerable position and I don’t want to make them feel weird for asking a question.” – Hipster Haven East 4, Female, 19 years

It was common for estheticians to compare themselves to therapists (e.g., psychologists) when describing the intimacy they share with clients. In fact, some estheticians (n = 7) referred to themselves as therapists or “like therapists.” Eleven estheticians explained that clients feel the salon is a safe space to share, and that the esthetician is someone with whom they are comfortable sharing, perhaps because their interactions are isolated to the context of the waxing salon/space. Seven estheticians described their belief that their role as an esthetician allowed them to have an entrusted, insider relationship with clients. Based on the estheticians’ interpretations, clients seem to feel less judged in the room with the esthetician than they might feel with friends, family, and/or even medical providers.

“Oh yeah, all the time I get the comment that we’re the cheapest therapy in town. You know because it’s like, you know, we don’t know their history, their past, their people that they hang out with, and so it’s like kind of an unloading zone, so to speak.” – Hipster Haven West 4, Female, 19 years

“I don’t know. I mean sometimes just general things, just their gossip, their sex lives, you know? Sometimes they just wanna talk about the person they’re dating or, you know, or their recent sexcapades, you know, because I definitely think that, you know, it’s, like, a judgement-free zone here, you know what I mean? It’s like I’m already in their vagina so they feel like they can tell me anything. I’m not their doctor, you know what I mean? It’s kind of like their hairdresser.” – Hipster Haven East 1, Female, 2 years

“But yeah, the people that open up to me about their more intimate sexual relationships, it’s more like, “My kids have left and gone away from school. I’ve kind of just lost this relationship with my husband. I don’t know where to go from here type of thing.” So it’s very deep relationship stuff, too. Sometimes I’m like, “I’m a therapist. I need to get my degree.”” – The City 1, Female, 18 years

“Clients who I’ve seen for a long time, you know, you get to talking about personal lives as we said. And I’ve had women crying on my table, telling me that they fight with their boyfriend, that they’ve called the police already, they have restraining orders, they don’t know what to do. I’ve had girls bring up that they’ve been sexually abused before. Just you hear everything. It’s seriously like almost we’re therapists as well.” – Hipster Haven West 4, Female, 4 years

Theme 4: Estheticians’ Awareness of Client Health

Part of the interview with estheticians involved asking if clients ever disclosed information about STIs or other sexual health-related matters, or if the estheticians ever noticed a client with symptoms of an STI or other health issue. Most participants (n = 19) affirmed that concerns about STIs, as well as visible signs of STIs, skin lesions, rashes, suspicious-looking moles, and warts were brought up by clients during a waxing session. Due to the large number of clients that estheticians see for pubic hair waxing, many estheticians (n = 18) spoke confidently about knowing what is normal and what is not with their clients’ bodies and that they notice potential health concerns during their daily practice. During routine waxing sessions, for example, estheticians described periodically discovering possible health concerns (n = 22), including potential STIs such as herpes and genital warts (n = 8), abnormal moles (n = 4), and one even reported finding a breast lump during an underarm wax. Only two estheticians noted that genital waxes in particular had a greater likelihood for these discoveries and indicated this was likely due to clients not routinely examining these regions of their bodies themselves.

“Well a couple of weeks ago I had a girl and she’s a regular. She was like, “I have a bump. I’m really worried about it. I can’t see it. I don’t know if I need to go to the doctor. Can you look at it?” And I was like “Yeah. I’ll look at it for you. I’m right there anyway.” And so I looked at it, and it was fine. I was like, “That’s probably just an ingrown hair.” I asked her a ton of questions about it, and then was like if it doesn’t go away by this period of time, you probably need to go to a doctor. But to me it looks like nothing.” – The Gayborhood, 5, Female, 15 years

“I’ve had one client where I had to turn her away where I used to work. Obviously, we don’t know anything until we get into a room. She had a full on outbreak. She had herpes. If you don’t have an outbreak then I can do it. I’m not going to turn you away. But one, that’s not sanitary and, two, you have these sores and all that. Me putting wax on it, I’m going to hurt you. Something is going to go wrong. I’m not going to put myself on the line. I did have to tell her I can’t until this is gone. Whatever you need to do, until then I can’t.” – The City 5, Female, 2 years

“We saw a lot of younger girls, and there were conversations sometimes that we had to have with these young college girls: “We can’t continue and you need to go to Planned Parenthood immediately””

Interviewer: And what prompted that?

Really bad smells. Unhealthy looking discharge. I know one of our colleagues – there was like even like a worm or weevil or something not right.” – Hipster Haven East 3, Female, 16 years

“Yeah, I mean I’ve had people – I’ve had a lot of people who have hemorrhoids and so people are like is there something back there? And so I’ll look and I’ll go, oh it looks like a hemorrhoid you should probably should go see your doctor or how long have you had it? You know, you should probably go get that checked. So it’s more like just advising them to seek some medical advice or like, one of my clients she was pregnant and I’m like you look super bruised down here what the heck is going on? It turns out she had a varicose vein right in her crease, hip crease and it was just due to the pregnancy and the weight of everything. But yeah, it’s just more like, hey since you’re down there can you just look, I felt something. I’m like, oh it’s a pimple or oh it looks like you had a mole crop up out of nowhere. Because if I see them every month I get to know – I get to know their anatomy pretty quickly so I know when stuff pulls up. And if – and sometimes if I see something that I’m like maybe skin cancer, I’m like how long has this been here? This wasn’t here last time or you should probably get this looked at.” – Hipster Haven East 4, Female, 19 years

Even though the estheticians interviewed appeared to be very aware of the bodies and health of their clients, it was clear that they did not consider themselves to be authorities on matters of sexual health. Furthermore, estheticians reported that they did not always have a protocol for how to deal with such matters. Estheticians explained in six interviews that they are “not doctors” and that there were limited, or a complete lack of, protocols in place for dealing with sexual health issues during waxing sessions (n = 7). A couple of estheticians felt that it was not their business to tell clients what they found.

“You don’t say anything. Just continue your service and that’s it. It’s really if they ask you or if they’re concerned and bring it up. But if we see anything it’s not our job. We’re not doctors.” – Hipster Haven West 4, Female, 5 years

“So we obviously can’t diagnose them with anything if we see any type of maybe sexual STD. But I have had girls come in and they’re like “I was looking and I saw this down here. Do you know what it is? Do you know what it could be?” And then she’s like “I’ve been with this guy. I thought it was a yeast infection. It could be this. That’s why I haven’t been in.” And then they come and talk about that. And then you just kind of steer the conversation like “Oh I’m not a doctor but” and then you kind of give examples of maybe something you’ve been through or what you think.” – Hipster Haven West 2, Female, 8 year

While there was some hesitancy to bring up sensitive sexual health issues, such as a possible STI, it was more common that the estheticians would suggest a client see a doctor if they saw something unusual (n = 18). Estheticians practiced varying approaches on deciding if and how to communicate these discoveries to clients, but none of them felt comfortable attempting to diagnose the issues.

“But if I’m down there and I notice something that I know looks weird especially after all my years of doing this I’m like, “You know, I’m not a doctor but you might want to go get that checked out.” So I don’t come right out and say, “You have genital warts.” I’m just like – they’re like, “Really?” They’re kind of clueless especially that – Then once they get it done, once they go to the doctor and get medicine or whatever I really don’t hear anything else about it.” – The City 1, Female, 18 years

“If it’s like an open sore or something I’ll tell them, “I can’t do your appointment today. We can reschedule. Go get this checked out first because I’m worried about it spreading or whatever.” So that definitely happens. We’re extremely clean and sanitary here, as you can see. I’m like OCD about everything. So yeah, I want to make sure also that they get the proper health. I have a girl that comes to me that works for Planned Parenthood and I always send them to her office because she knows me.” – The City 1, Female, 18 years

Also notable, but less common, was the esthetician discovering evidence of self-harming, sexual abuse, or physical abuse (n = 3). Like with seeing something unusual, such as a possible STI, estheticians provided varying responses to how they typically handle these discoveries like self-harming, sexual abuse, or physical abuse. For example, they noted either deciding that it is not their business, or they noted taking a more active approach.

“For me to be able to sit with them and explain that no matter what happens, no matter how big a jerk you could have ever been you do not deserve this ever and to have that dialogue. To know that there are guys out there who are jerks and we start there. Then we’ll have dialogue about what’s going on, who is the abuser, how long has this been going on, what is your family dynamic, what safety nets do you have, is there a safe place you can be. From there, we start trying to troubleshoot, to try to find solutions because my first instinct is I want to call the police. I want someone to come and arrest the jerk and make sure that she is safe here and now. That’s not always practical.” – The Gayborhood 2, Male, 14 years

Discussion

The purpose of this study was to better understand the pubic waxing profession and its clients, and to explore the relationship between estheticians and their clients through exploratory interviews with estheticians in five neighborhoods in a large urban area in Southern California. Ultimately, the results revealed that estheticians provide a variety of waxing services, especially among young adult women. During their brief 15-to-20-minute appointments, estheticians noted that their interactions with clients often turn toward sex-related discussions, creating “sexy spaces” where otherwise taboo conversations happen with ease. Estheticians reported noticing clients’ possible health concerns, such as skin cancer, herpes, genital warts, and even evidence of physical abuse, but have no protocols or procedures for handling these occurrences. Regarding the esthetician–client relationship, estheticians reported that interactions with clients often result in physically and emotionally intimate bonds where the esthetician gets to know their client’s body well and may act as a quasi-therapist during a session.

Social Penetration Theory (SPT) may help to explain the relational phenomenon, as its fundamental construct posits that people develop close relationships over time by openly sharing on personal matters (Bylund et al., 2012). Perhaps the fact that estheticians utilize conversation as a distraction tactic from the very first appointment eventually helps to establish rapport, ultimately leading to the formation of deep, trusting relationships. SPT also likens people to onions, with the outer layers being the more superficial aspects, and the inner layers containing more private, closely guarded information. People are likely to reveal their “inner layers” if they feel rewarded and comfortable after initially sharing the outer layers (Bylund et al., 2012). Our interview data illustrate that estheticians strive to create a comfortable, safe, and judgment-free discourse with clients, which may explain their clients’ desire to openly share about deeply personal topics after two or three appointments.

Prior research has revealed beauty shops and barbershops to be effective platforms for public health interventions due to the safety and familiarity of the environment, and the recurring, trusting relationship that develops between barbers and their clients (Baker et al., 2012; Linnan et al., 2014). We believe that estheticians similarly create an environment within their salons and salon rooms that exude safety and comfort, and that the esthetician–client relationship is also founded upon consistency and trust, which may be further amplified by the physical intimacy of a pubic wax. To our knowledge, the SHE Study is the first qualitative exploration of the waxing profession and esthetician–client relationship, and the results lead us to believe that estheticians may be effective conveyors of, and partners in, health (and possibly sexual health) promotion interventions. In fact, we have found only one intervention study in which researchers worked with estheticians for such purposes (Leinberger-Jabari et al., 2016).

Regarding the waxing clientele of the estheticians in our sample, the majority were young adult women. In concordance with recent national and local STI data, this is the age group that experiences the highest rates of chlamydia, making this a relevant priority population (Centers for Disease Control and Prevention, 2019; County of San Diego Health & Human Services Agency, Public Health Services, HIV, STD & Hepatitis Branch, 2016). The emergent theme also revealed that women who request Brazilian waxes often do so to prepare for sex, and sometimes to please their partners during sexual activities. In fact, a recent study of women living in Italy found that sexual partners often influenced pubic hair removal (DeMaria et al., 2020). Further, another recent study of adult men and women in Belgium found that, among men, sexual satisfaction, and relationship satisfaction were correlated with their partner’s pubic hair removal practices (Enzlin et al., 2019). Prior studies have also illustrated this link between pubic hair removal and sexual activity (Bercaw-Pratt et al., 2012; Ramsey et al., 2009), and even found an association between public hair removal and a history of STIs (Osterberg et al., 2016). Because estheticians described their tendency to discover potential STIs on occasion, and not being formally trained to handle these delicate situations, there is an opportunity to guide estheticians to prepare for these circumstances so that they can effectively assist their clients in seeking a diagnosis, information, or treatment options.

Furthermore, estheticians revealed the nature of their unique relationships with clients, making them privy to personal details pertaining to family, health, and sexual activities during pubic waxing appointments. Estheticians only know their clients within the context of the waxing salon and have no ties to their clients’ pasts or social circles, so they often learn more private information about their clients than the clients’ own friends, family, or even doctors. Clients will often seek advice from their estheticians and come into their appointments prepared to unload their latest trials and tribulations. Estheticians described their appreciation of these special and intimate relationships, but also struggled with maintaining their professionalism with such personal issues such as sex and relationships.

The SHE Study has major implications on the future of health promotion and sexual health promotion efforts in communities. With STI rates growing among young women, and unintended pregnancy more common in the U.S. than in other developed, Western nations, there is a clear need for innovative and effective approaches to interventions (Centers for Disease Control and Prevention, 2019; Turok et al., 2016). Data from this interview study of estheticians reveal a distinct opportunity for a novel sexual health partnership. Among the estheticians interviewed for this study are professionals who are passionate about their clients’ health and wellbeing. They are more than simply a hair removal specialist to their clients, valuing their additional roles of listener, purveyor of advice, and friend. These professionals often discover health concerns during their practice, and face challenges of deciding how to advise clients on serious and sensitive personal issues. They are not trained as physicians or psychologists, leaving them to rely on their best judgment. With appropriate training, support, and resources, estheticians may be able to confidently help their clients more than ever. Perhaps future work is needed, across U.S. states, regarding individual esthetician training and continuing education around health and, specifically, sexual health. However, as to what specific intervention partnerships look like and what sexual health promotion content they facilitate is dependent on additional formative research.

This study had a number of limitations that need to be acknowledged. First, as an exploratory study, 28 participants were interviewed, meaning that the findings may not be transferable to the general population of estheticians in this large urban area in Southern California or elsewhere. Second, all interviews were conducted with estheticians who practice within five neighborhoods in the urban area, meaning that the findings reflect the unique culture and demographics of these particular neighborhoods, which as described above, are largely white, affluent, young, and single, again leading to uncertainty regarding the transferability of the findings.

Furthermore, we may have missed a priority population also worthy of study: men. Only one of the estheticians we interviewed was a man, and many of the women estheticians interviewed in our study noted that they do not, or are reticent to serve men. Accordingly, we were not able to include issues such as men’s health, including but not limited to HIV and AIDS among young sexual minority men. Given that gay-identified men more often remove their body hair compared with heterosexual men (Fahs, 2015), and given that there is evidence that anal grooming is associated with rectal STIs among gay and bisexual men (Gaither et al., 2020), this is an important priority population on which to focus future exploratory research.

While our study has limitations, this research also contains notable strengths. The SHE Study explored the previously unassessed areas of the waxing profession, its clientele, and the esthetician–client relationship from the perspective of the estheticians. When exploring the esthetician–client relationship through the scope of the beauty shop-barbershop model, there are clearly parallels that lead us to believe that the pubic waxing profession may be ideal for a sexual health intervention or initiative targeting some groups of young women receiving Brazilian waxes. The SHE Study research also points out future directions for research with estheticians. One key area is more in-depth study of estheticians and their willingness to serve as health promotion and/or sexual health promotion lay interventionists. Due to their busy schedules and the relatively short appointment times (approximately 15 minutes each), it will be vital to work closely with them as implementing any intervention may be challenging. Another area for future research is with clients of estheticians. While estheticians commented frequently that they often serve in therapist or therapist-like roles, would clients even be open to an esthetician-delivered intervention?

Conclusion

Until the SHE study, there was very little information on the relationship between estheticians and their clients, with no rich, descriptive data regarding the waxing profession. Past research has shown that 85% of young adult women practice pubic hair removal, which coincides with the population experiencing high rates of STIs and unintended pregnancy (Herbenick et al., 2010). Other studies have also illustrated a link between pubic hair removal and sexual activity, or at least an interest in becoming sexually active (Bercaw-Pratt et al., 2012; Herbenick et al., 2013). Based on the parallels between the beauty shop/barbershop model and the esthetician-client dynamics that we found, along with the ties to the Social Penetration Theory, there is an ample opportunity to utilize the unique relationship between estheticians and clients, ideally for a community-based, public health intervention. Estheticians who practice pubic waxing may be a fruitful, untapped resource for sexual health promotion, especially to their young women clients, as well as other vulnerable populations such as gay men and men who have sex with men.

Acknowledgments

This research was supported by university start-up funding to the corresponding author. Thank you to the 28 estheticians who agreed to participate in this research. This study would not have been possible without their invaluable contributions.

Additional information

Funding

This work was supported by San Diego State University.

Notes

¹ Estheticians indicated that their client base was diverse; however, the demographics of the neighborhoods where the salons reside do not reflect the same diversity. This may be indicative that clients travel outside of their home neighborhoods to seek waxing services.

Appendix:

Main predetermined parent codebook (N = 27 interviews).

Table

Parent Code	N = % of interviews that were coded	Definition	Examples
Phone and e-communication	56	Different ways of interacting with clients outside of salon to maintain regular visits, provide general info, and sustain mass communications	Phone calls, texts, e-mails, web-based (Yelp, Groupon, etc.)
Depth of esthetician-client relationship	96	Process of growing closer, evidence of building trust, length of time to develop closeness	Sharing secrets, opening up about personal experiences
Esthetician-client relatability	88	How well esthetician and client can relate on a topic or shared life experience	Divorce, pregnancy, marriage, illness, etc.
Client waxing preferences	88	Type of waxing services that clients tend to prefer	Men often request back waxing, women prefer Brazilian wax
Perceived role	84	How estheticians view themselves in their role	Friend, therapist, compassionate listener, improver of client’s quality of life
Functional role	96	What functional/job specific actions estheticians perform for clients	Professional hair remover, conversation partner, distractor from pain
Professional background	100	What drove them toward this career, years of experience, geographic locations of experience	Inspired to seek out the career after being a client, passionate about skincare, etc.
Client characteristics	100	How does esthetician categorize their client gender, race/ethnicity, SES, age
Esthetician-client relationship/rapport building	100	Esthetician vs. client driven process (ask questions & share about self), openness of each party, gaining familiarity, developing a personal relationship	Ex. esthetician recalls that client is going through a divorce; asks how she’s doing and shares her own recent relationship experiences
Judgment vs. non-judgment	68	Esthetician judgment of client behavior/lifestyle choice (or non-judgment)	Esthetician ensures client she is in a “judgment free zone”, or holding their tongue when client shares something they disagree with
Comfort/discomfort when navigating touchy topics	100	Esthetician’s comfort level with discussing, listening, advising, and following-up on touchy topics. Perceived client’s comfort with sharing, receiving feedback, and following up on advice.	Touchy topic examples: cheating, casual sexual encounters, staying in an unhealthy relationship
Mechanics of the waxing profession	100	Necessary client preparation, duration of waxing process, hygiene, pain and trauma of waxing, getting naked, routine and uniform processes	Laying down fresh paper or towels on the waxing bed, cleaning client’s skin before and after, wearing gloves, using new tools with each client, stepping out of the room while client disrobes, etc.
Sexuality	100	Sex-related behaviors, sexual preferences, sexual identity	Foreplay, oral sex, intercourse, pornography, dressing in drag, prostitution, erotic dancing, LGBTQI
Sexual health	100	Contraception, STDs/STIs, pregnancy and fertility, menstruation, perceived vulvar esthetics, body image, sexual abuse/violence	Experiences on the pill or Depo shot, being diagnosed with HPV, difficulty conceiving, discomfort with vulvar appearance, rape
General health	56	Health issues that are NOT sexual or mental	Skin cancer, lupus, Lyme disease, etc.
Messaging bad news: How, what, when	92	Telling clients when something does not look right (physically) or sound right (in conversation), helping vs. not helping, referring to a doctor, advising vs. diagnosing, telling vs. not telling	Offering advice to a client who is explaining an abusive relationship (or not), seeing a suspicious bump in pubic region and pointing it out to client (or not), suggesting client see a doctor about a mole that has changed
Waxing males	100	Any descriptive experience waxing males (positive, negative, or neutral), feelings/experiences unique to waxing males, perceptions of male clients, esthetician comfort level with male client	Awkwardness or discomfort of female providing pubic waxing to a male, erections, perverts, men don’t tolerate pain as well as women
Waxing culture	100	Trends among those who get waxed	Frequency of regular customer visits, busier times of the week/month/year, reasons people get waxed, popular services
Romantic relationship status	100	The existence, degree, and/or type of romantic relationship	Single, dating, monogamous, polyamorous, engaged, married, divorced, widowed, gay/lesbian/bi couple, etc.
Mental heath	72	A person’s condition with regard to their psychological and emotional well-being	Depression, alcohol or substance abuse, suicide, anxiety, etc.