In the Android mobile game Princess Plastic Surgery, a blonde, bug-eyed princess has been cursed by a witch. “The witch made them ugly!” the app description reads. “Only you can help them! Don’t miss the chance to become a professional plastic surgery doctor.” The app’s home screen icon depicts the princess staring at an approaching syringe, her eyes brimming with tears. Her lips have ballooned to take over the lower half of her face.

The app, created by Bravo Kids Media, is one of dozens of similar plastic surgery games and apps currently available for download. Nose Doctor Fun Kids Game, an Android app apparently designed for anyone who searches for those keywords, claims boys and girls will “learn a lot about medicine” by giving a cartoon character a nose job. Celebrity Plastic Surgery Hospital asks you to operate on different body parts of an animated woman. In Little Skin Doctor Treatment Game, you give a face-lift to a cringing cartoon patient.

Unsurprisingly, these brightly colored, cartoonish games, which are often explicitly designed for a younger, more vulnerable demographic, have been met with resistance. Endangered Bodies, a global organization that challenges cultural messages about negative body image, started a Change.org petition to raise awareness of the problem at Apple, Amazon and Google, with the help of The Butterfly Foundation, which works to prevent and treat eating disorders, and EMBodIED, a research team at La Trobe University in Australia. Their petition, titled “Stop cosmetic surgery apps aimed at kids: #surgeryisnotagame,” has since garnered more than 119,000 signatures.

Apple and Google have removed at least some of these apps from their app stores in the past. In 2013, an app called Plastic Surgery & Plastic Doctor & Plastic Hospital Office for Barbie was removed from the iTunes Store following backlash online. “This unfortunate girl has so much extra weight that no diet can help her,” the description read. “In our clinic she can go through a surgery called liposuction that will make her slim and beautiful. We’ll need to make small cuts on problem areas and suck out the extra fat. Will you operate her, doctor??” It was recommended for ages nine and up.

A liposuction app for ages 9 and up was pulled from iTunes

Still, this opposition doesn’t seem to have discouraged app developers. One of the apps that the petition singles out, Plastic Surgery Simulator (“turn into a Victoria’s Secret model at once”), has been downloaded anywhere from 10,000 and 50,000 times. Bravo Kids Media’s apps boast high ratings and huge download numbers, from Crazy Pregnant Mom Makeover (4.5 stars on the App Store) to Clumsy Santa ER Surgery (100,000+ Google Play downloads).

Like the reality shows Botched and I Want a Famous Face before them, these apps take advantage of our collective cultural obsession with cosmetic surgery. Unlike reality TV, however, there’s an explicit gamification at work: they’re listed in the Games categories of the App Store and Google Play Store, and they promote the idea that a perfect body or face is the goal, that “winning” comes only when you complete a surgery. In Princess Plastic Surgery, the patient is allowed to choose a ball gown as a prize.

While these apps aren’t new, they’ve become more absurd and widespread in recent years. Bravo Kids Media, launched in 2015, has created more than 30 Android apps. (In 2009, Reuters reported that there were just two plastic surgery apps available for the iPhone.) They’re also not a standalone oddity. They exist in a spectrum of apps — from filter-heavy Photoshopping apps to ones that connect users with real surgeons — that have become a significant part of the growing, lifelong culture surrounding cosmetic surgery. Together, it’s all part of an online ecosystem that has supercharged society’s age-old mission to make people feel bad about their bodies, and possibly spend money to feel better.

Last year, the UK’s Nuffield Council on Bioethics, an independent body that covers issues in medicine, released a report about the ethics of cosmetic procedures. It argued that cosmetic surgery apps were part of a troubling and growing trend of “self-monitoring apps,” like calorie-counters and sleep cycle apps, because they allow the user to “measure” one’s own face against an ideal.

“The ‘gaming’ aspect of some of the apps I found made me feel uneasy,” wrote Kate Harvey, a senior research officer who contributed to Nuffield Council report. “The invasiveness of cosmetic procedures, and the potential vulnerabilities of those who might access those procedures, means that ‘playing’ with beauty ideals is a road which should be travelled down very cautiously.”

According to a 2017 study published by the American Psychological Association, college students today suffer from higher levels of anxiety than previous generations, in part because of a need to achieve a “perfect” life like those that are carefully curated on social media:

Studies indicate that exposure to others’ perfect self-representations within social media can intensify one’s own body image concerns and sense of social alienation. Other data suggests that young people are struggling to cope with a visual culture which emphases unrealistic body ideals… Young people appear to have internalized irrational social ideals of the perfectible self that, while unrealistic, are to them eminently desirable and obtainable.

Whether these conditions are the cause or the effect of self-modification apps like Plastic Surgery Simulator, it nevertheless describes a climate ripe for their proliferation.

“One of our concerns was the apps made it easy to create images that would be pretty unattainable,” Harvey told The Verge. “The images that they create lead to unrealistic expectations about what cosmetic surgery can achieve.”

“One of our concerns was the apps made it easy to create images that would be pretty unattainable”

While most of these plastic surgery apps are rated 17+ or T for Teen, there’s no way to prevent someone younger than 17 from downloading them, unless there are parental controls on the phone. And though kids and teenagers might be the most vulnerable to the influence of plastic surgery apps, adults are hardly immune to the dream of physical perfection. If the weird, cartoonish games are for kids, then a group more realistic Photoshop apps could appeal to teenagers who are already used to filtering their selfies to perfection.

That’s why filters on apps like Instagram and Snapchat are a part of this ecosystem, too. Snapchat users, for instance, have criticized the company for its “beauty filters,” which, instead of highlighting a user’s particular beauty, often actually just bring them closer to a white European ideal by lightening skin tones, shading eyes blue, and slimming noses and jawlines.

“Selfies have a higher amount of engagement, in terms of likes and comments, than other photos [on Instagram], and the filters increase it even more,” Yuheng Hu, an assistant professor at the University of Illinois, who studies Instagram filters and their effects on users, told The Verge. “And then once that happens, it encourages users to keep posting selfies.”

The relationship among filters, Photoshop apps, and plastic surgery apps is certainly correlative, if not causative. Slim & Skinny, a photo-editing app, invites users to upload photos of themselves and digitally alter them. Against a bright pink interface, you’re presented with several options, in which “thin” becomes a verb: you can “thin” your face, “thin” your chin, and “thin” your head. The plastic surgery app eBody provides a virtual tour of a surgeon’s office where you can “perform a Lipo to your boyfriend and give him the six-pack you always wanted.” (This would involve uploading a photo of your boyfriend and slimming down his torso.) “For the girls, you can have a virtual breast augmentation, buttocks, or just a Liposuction.” (This would involve uploading a photo of yourself, a woman, and manipulating it.) As with many of these self-modification apps, the instructions are explicitly addressed to women.

As plastic surgery itself becomes safer and more accessible, it’s also becoming more pervasive. In 2016, Americans spent more than $16 billion on plastic surgery procedures. The trend is also global. In a 2013 report for The Atlantic, Zara Stone details how K-pop stars influence aesthetics in South Korea, where one in five women has had cosmetic surgery. One recently popular procedure among K-pop stars, V-line surgery, involves shaving the jawline to create a V-shaped face. Technically called “corrective jaw surgery,” it’s a procedure that requires the jaw to be wired shut for six weeks and could result in permanent numbness or death.

But thanks to technological advances, the stakes have dropped for many procedures, making cosmetic surgery more appealing to a wider potential clientele. According to a 2017 report by the American Society of Plastic Surgeons, “minimally invasive cosmetic fat injections” increased 13 percent from 2016 to 2017; while face-lifts increased 4 percent from 2015. As Annie Lowrey pointed out in The Cut in 2016, the prevalence of injectables and lasers in Hollywood has made it difficult to tell what “natural” even looks like anymore. “Patients are captivated by instant improvements to the face,” ASPS president Debra Johnson said in the 2017 report. “It’s evident in the popularity of apps and filters that change how we can shape and shade our faces.”

That popularity of those apps isn’t limited to simple games. In the digital era, medical professionals have begun designing and using legitimate plastic surgery apps that allow potential patients to envision or even plan for body-altering operations. Often tied to a specific surgeon’s office, these apps give users price quotes for procedures and the option to request consultations.

“[These apps] are for enhanced communication with the patient: your idea of a subtle change and my idea might be very different,” Dr. Richard Rival, a cosmetic surgeon in Toronto, told The Verge. Rival has had a custom app for about two years that allows his patients to see what they might look like after a particular surgery. “Our ideas [of a feminine-looking” nose] might be very different. With the apps, you’re [more] likely to be on the same page.”

For patients, it’s about visualizing their options before going under the knife. For doctors, it’s about making sure patients get what they’re looking for. Dozens of surgeons offer apps like this, which are similar to the software already in use at their offices.

“At the end of the day, elective surgery is a business,” says Hisham Al-Shurafa, the founder of Pixineers, the medical software company that created Rival’s app. Al-Shurafa, whose company has created more than 20 apps for surgeon clients, explains that these apps are meant to encourage more hesitant potential patients. “Some clinics approach it from a heavy sales type. So this app provides people the opportunity to explore the option without the pressure or having to go through any hurdles.”

But even as the apps relieve pressure for some, they can increase it for others. “It’s always a concern, particularly with younger people,” Rival says. “I don’t market [the app]; people really only get to it through my website, so they’re already interested in rhinoplasty. It’s not like the app creates that insecurity — the insecurity is already there.”

“It’s important to distinguish between some apps run by cosmetic surgeons that are more of a marketing tool and apps that are pitched as more of a game,” Harvey says. “There’s been very little empirical research on the effects these [games] have on people, including whether they then actually are motivated to have a cosmetic procedure. But what we can say is, playing with appearance in this way, and encouraging people to manipulate their appearance in accordance with social norms, is detrimental to [confidence in] appearance.”

“It’s not like the app creates that insecurity — the insecurity is already there”

While the medical apps can help solve a problem for communication and avoiding aggressive sales tactics, games and filter apps might simply exacerbate a problem that already exists. Cosmetic surgery apps are just one aspect of a culture that prioritizes youth and beauty, especially women’s, over almost everything else. And as long as there’s a financial incentive to continue to prioritize it, the products will probably continue to exist.

Or, as Benjamin Melki, creator of the Face and Body Photo Editor app puts it: “I knew there was a market for this, because the concept relied on the fact that people want to be beautiful.”

Correction 4/12/18 4:00 pm ET: The article previously identified Endangered Bodies as an initiative of The Butterfly Foundation. They are separate organizations that were both involved in the Change.org petition and the #surgeryisnotagame hashtag.