allegations of child trafficking. although jolie's adoption facilitator was later convicted of visa fraud and money laundering, her adoption of maddox was deemed lawful. once the process was finalized, she took custody of maddox in namibia, where she was filming beyond borders (2003). jolie and thornton announced the adoption together, but she adopted maddox alone, becoming a single parent following her separation from thornton three months later. jolie adopted her second child, six-month-old zahara marley, from an orphanage in addis ababa, ethiopia, on july 6, 2005. zahara was born as yemsrach on january 8, 2005, in awasa. jolie initially believed zahara to be an aids orphan, based on official testimony from her grandmother, but zahara's birth mother later came forward in the media. she explained that she had abandoned her family when zahara became sick, and said she thought zahara was "very fortunate" to have been adopted by jolie. jolie was accompanied by her then-partner, brad pitt, when she traveled to ethiopia to take custody of zahara. she later indicated that they had together made the decision to adopt from ethiopia, having first visited the country earlier that year. after pitt announced his intention to adopt her children, she filed a petition to legally change their surname from jolie to jolie-pitt, which was granted on january 19, 2006. pitt adopted maddox and zahara soon after. a pregnant jolie attending the premiere of changeling with director clint eastwood at the 2008 cannes film festival in an attempt to avoid the unprecedented media frenzy surrounding their relationship, jolie and pitt traveled to namibia for the birth of their first biological child. on may 27, 2006, she gave birth to shiloh nouvel, in swakopmund. shiloh's middle name is homage to french architect jean nouvel. during labor, jolie had fits of hysteric laughter due to the administration of morphine. they sold the first pictures of shiloh through the distributor getty images with the aim of benefiting charity, rather than allowing paparazzi to take the photographs. people and hello! magazines purchased the north american and british rights to the images for $4.1 and $3.5 million, respectively, a record in celebrity photojournalism at that time, with all proceeds donated to unicef. on march 15, 2007, jolie adopted her fourth child, three-year-old pax thien, from an orphanage in ho chi minh city, vietnam. pax was born as pham quang sang on november 29, 2003, in hcmc, and was abandoned soon after birth. after visiting the orphanage with pitt in november 2006, jolie applied for adoption as a single parent, because vietnam's adoption regulations do not allow unmarried couples to co-adopt. after their return to the united states, she petitioned the court to change pax thien's surname from jolie to jolie-pitt, which was approved on may 31. pitt subsequently adopted pax on february 21, 2008. at the 2008 cannes film festival, jolie confirmed that she was expecting twins. for the two weeks she spent in a seaside hospital in nice, france, reporters and photographers camped outside on the promenade. she gave birth to twins knox léon and vivienne marcheline, on july 12, 2008. knox léon was named after two of the twins' ancestors and vivienne marcheline was named in honor of jolie's mother. the first pictures of knox and vivienne were jointly sold to people and hello! for a reported $14 million—the most expensive celebrity photographs ever taken. all proceeds were donated to the jolie-pitt foundation. cancer prevention treatment on february 16, 2013, jolie underwent a preventive double mastectomy at age 37 after learning she had an 87 percent risk of developing breast cancer due to a defective brca1 gene. her maternal family history warranted genetic testing for brca mutations: her mother, actress marcheline bertrand, had breast cancer and died of ovarian cancer, while her grandmother died of ovarian cancer. her aunt, who had the same brca1 defect, died of breast cancer three months after jolie's operation. following the mastectomy, which lowered her chances of developing breast cancer to under five percent, jolie had reconstructive surgery involving implants and allografts (transplantations from a donor). two years later, in march 2015, after annual test results indicated possible signs of early ovarian cancer, she underwent a preventive salpingo-oophorectomy (removal of an ovary and its fallopian tube), as she had a fifty percent risk of developing ovarian cancer due to the same genetic anomaly. despite hormone replacement therapy, the surgery brought on premature menopause. "i choose not to keep my story private because there are many women who do not know that they might be living under the shadow of cancer. it is my hope that they, too, will be able to get gene tested, and that if they have a high risk they, too, will know that they have strong options." —jolie on her reasons for speaking out about her mastectomy after completing each operation, jolie discussed her mastectomy and oophorectomy in op-eds published by the new york times, with the aim of helping other women make informed health choices. she detailed her diagnosis, surgeries, and personal experiences, and described her decision to undergo preventive surgery as a proactive measure for the sake of her six children. jolie further wrote: "on a personal note, i do not feel any less of a woman. i feel empowered that i made a strong choice that in no way diminishes my femininity." jolie's announcement of her mastectomy attracted widespread publicity and discussion on brca mutations and genetic testing. her decision was met with praise from various public figures, while health campaigners welcomed her raising awareness of the options available to at-risk women. dubbed "the angelina effect" by a time cover story, jolie's influence led to a "global and long-lasting" increase in brca gene testing: the number of referrals tripled in australia and doubled in the united kingdom, parts of canada, and india, as well as significantly increased in other european countries and the united states. researchers in canada and the united kingdom found that despite the large increase, the percentage of mutation carriers remained the same, meaning jolie's message had reached those most at risk. in her first op-ed, jolie had advocated for wider accessibility of brca gene testing and acknowledged the high costs, which were later greatly reduced after the u.s. supreme court, in a june 2013 ruling, invalidated brca gene patents held by myriad genetics. reception public image jolie at the 2007 cannes film festival as the daughter of actor jon voight, jolie appeared in the media from an early age. after embarking on her own career, she earned a reputation as a "wild child", which contributed to her early success in the late 1990s and early 2000s. celebrity profiles routinely covered her fascination with blood and knives, experiences with drugs, and her sex life, particularly her bisexuality and interest in sadomasochism. in 2000, when asked about her outspokenness, she stated: "i say things that other people might go through. that's what artists should do—throw things out there and not be perfect and not have answers for anything and see if people understand." another contributing factor to her controversial image were tabloid rumors of incest that began when jolie, upon winning her oscar for girl, interrupted, kissed her brother on the lips and said, "i'm so in love with my brother right now." she dismissed the rumors, saying, "it was disappointing that something so beautiful and pure could be turned into a circus," and explained that, as children of divorced parents, she and james relied on one another for emotional support. jolie's reputation began to change positively after she, at age 26, became a goodwill ambassador for the united nations high commissioner for refugees, later commenting, "in my early 20s i was fighting with myself. now i take that punk in me to washington, and i fight for something important." owing to her extensive activism, her q score—a marketing industry measure of celebrities' likability—nearly doubled to 25 between 2000 and 2006. her recognizability grew accordingly; by 2006, she was familiar to 81% of americans, compared to 31% in 2000. she became noted for her ability to positively influence her public image through the media, without employing a publicist or an agent. her q score remained above average even when, in 2005, she was accused of ending brad pitt's marriage to jennifer aniston, at which point her public persona became an unlikely combination of alleged homewrecker, mother, sex symbol, and humanitarian. a decade later, jolie was found to be the most admired woman in the world in global surveys conducted by yougov in 2015 and 2016. jolie's general influence and wealth are extensively documented. in a 2006 global industry survey by acnielsen in 42 international markets, jolie, together with pitt, was found to be the favorite celebrity endorser for brands and products worldwide. jolie was the face of st. john and shiseido from 2006 to 2008, and a decade later became a spokesmodel for guerlain. her 2011 endorsement deal with louis vuitton, reportedly worth $10 million, was a record for a single advertising campaign. jolie was among the time 100, a list of the most influential people in the world as published by time, in 2006 and 2008. she was named the world's most powerful celebrity in forbes's celebrity 100 issue in 2009, and, though ranked lower overall, was listed as the most powerful actress from 2006 to 2008 and 2011 to 2013. forbes additionally cited her as hollywood's highest-paid actress in 2009, 2011, and 2013, with estimated annual earnings of $27 million, $30 million, and $33 million respectively. appearance jolie at the premiere of a mighty heart in 2007; several of her tattoos are visible jolie's public image is strongly tied to her perceived beauty and sex appeal. many media outlets, including vogue, people, and vanity fair, have cited her as the world's most beautiful woman, while others such as esquire, fhm, and empire have named her the sexiest woman alive; both titles have often been based on public polls in which jolie places far ahead of other celebrity women. her most recognizable physical features are her many tattoos, eyes, and in particular her full lips, which the new york times considered as defining a feature as kirk douglas' chin or bette davis' eyes. among her estimated 20 tattoos are the latin proverb quod me nutrit me destruit ("what nourishes me destroys me"), the tennessee williams quote "a prayer for the wild at heart, kept in cages", four buddhist sanskrit prayers of protection, a 12-inch tiger, and geographical coordinates of where she first met her adopted children. over time, she has covered or lasered several of her tattoos, including "billy bob", the name of her second husband. professionally, jolie's status as a sex symbol has been considered both an asset and a hindrance. some of her most commercially successful films, including lara croft: tomb raider (2001) and beowulf (2007), overtly relied at least in part on her sex appeal, with empire stating that her "pneumatic figure", "feline eyes", and "bee-stung lips" have greatly contributed to her appeal to cinema audiences. conversely, salon writer allen barra agreed with critics who suggested that jolie's "dark and intense sexuality" has limited her in the types of roles she can be cast in, thus rendering her unconvincing in many conventional women's roles, while clint eastwood, who directed her oscar-nominated performance in changeling (2008), opined that having "the most beautiful face on the planet" sometimes harmed her dramatic credibility with audiences. beyond her career, jolie's appearance has been credited with influencing popular culture at large. in 2002, afterellen founder sarah warn observed that many women of all sexual orientations had publicly expressed their attraction to jolie, which she considered a new development in american culture, adding that "there are many beautiful women in hollywood, and few generate the same kind of overwhelming interest across genders and sexual orientations that she does". jolie's physical attributes became highly sought-after among western women seeking cosmetic surgery; by 2007, she was considered "the gold standard of beauty", with her full lips remaining the most imitated celebrity feature well into the 2010s. after a 2011 repeat survey by allure found that jolie most represented the american beauty ideal, compared to model christie brinkley in 1991, writer elizabeth angell credited society with having "branched out beyond the barbie-doll ideal and