The Breast Size Satisfaction Survey (BSSS): Breast size dissatisfaction and its antecedents and outcomes in women from 40 nations. Viren Swami et al. Body Image, Volume 32, March 2020, Pages 199-217. https://doi.org/10.1016/j.bodyim.2020.01.006
Highlights
• Majority of women sampled (70.7 %) were dissatisfied with their breast size.
• A number of significant antecedents and outcomes of breast size dissatisfaction were identified.
• Relationships with antecedents and outcomes were stable across 40 nations.
Abstract: The Breast Size Satisfaction Survey (BSSS) was established to assess women’s breast size dissatisfaction and breasted experiences from a cross-national perspective. A total of 18,541 women were recruited from 61 research sites across 40 nations and completed measures of current-ideal breast size discrepancy, as well as measures of theorised antecedents (personality, Western and local media exposure, and proxies of socioeconomic status) and outcomes (weight and appearance dissatisfaction, breast awareness, and psychological well-being). In the total dataset, 47.5 % of women wanted larger breasts than they currently had, 23.2 % wanted smaller breasts, and 29.3 % were satisfied with their current breast size. There were significant cross-national differences in mean ideal breast size and absolute breast size dissatisfaction, but effect sizes were small (η2 = .02–.03). The results of multilevel modelling showed that greater Neuroticism, lower Conscientiousness, lower Western media exposure, greater local media exposure, lower financial security, and younger age were associated with greater breast size dissatisfaction across nations. In addition, greater absolute breast size dissatisfaction was associated with greater weight and appearance dissatisfaction, poorer breast awareness, and poorer psychological well-being across nations. These results indicate that breast size dissatisfaction is a global public health concern linked to women’s psychological and physical well-being.
4. Discussion
Women’s breasts – particularly breast size – play an important role in shaping body and appearance anxieties (e.g., Lee, 1997; Millsted & Frith, 2003; Swami, Cavelti et al., 2015),
yet comparatively little research has considered these issues from a
cross-national perspective. Even less research has examined antecedents
and outcomes of breast size dissatisfaction across nations, which is
important because it is unclear to what extent women’s breasted
experiences in WEIRD nations can be generalised to women in other
cultural and national contexts. The BSSS was set up to address these
gaps in the literature: through analyses of our data from 18,541 women
in 40 nations, we are able to draw a number of important conclusions
about cross-national differences and similarities in breast size ideals
and dissatisfaction, as well as antecedents and outcomes of breast size
dissatisfaction in diverse national contexts. Below, we provide a
summary of the main findings of the BSSS before considering implications
of our work.
4.1. Breast size ideals and dissatisfaction across nations
The
BSSS dataset suggests that breast size ideals were relatively
homogeneous across nations. Although there was a significant
cross-national difference in ideal breast size, the effect size of the
difference was small and suggestive of only minor cross-national
variation. In fact, ideal breast size ratings were relatively
homogeneous, with mean values falling between figures 6 through 8 in the
BSRS. This is consistent with the suggestion that, despite historical
differences across nations, breast size ideals have become largely
homogenous in nations sampled in the BSSS. Just as there now appears to
be a near-global idealisation of thinness in sites of high socioeconomic
status (Swami, 2015; Swami, Frederick et al., 2010),
the BSSS data indicate a similar homogenisation of breast size ideals
in women. This finding is important because it suggests that the
objectification of medium-to-large breasts is now a global phenomenon,
including in parts of the world that may have historically de-emphasised
breast aesthetics (Miller, 2003, 2006).
It should also be noted that, partially consistent with our hypothesis,
greater rurality (but not financial security) was associated with the
idealisation of larger breasts, although effect sizes were weak and
likely a reflection of sampling issues – a concern we return to below.
Importantly,
mean ideal breast size ratings were higher than mean current breast
size ratings in the vast majority that we sampled, although the
magnitude of the difference varied. In the total dataset, just under a
majority of women (i.e., 47.5 %) that were sampled indicated a
preference for larger breasts than they currently had, while just under a
quarter (i.e., 23.2 %) desired smaller breasts and under a third (i.e.,
29.3 %) reported no discrepancy between their ideal and current breast
sizes. This is consistent with existing research in WEIRD nations
suggesting that a majority (Swami, Cavelti et al., 2015) or close to a majority of women (Lombardo et al., 2019; Swami & Furnham, 2018)
wanted larger breasts than they currently had. Nevertheless, it should
be noted that there was some cross-national variation in (absolute)
breast size dissatisfaction ratings, with a small effect size. Of note,
larger breast size dissatisfaction in some nations (particularly the
United Kingdom, Egypt, China, Japan, and Brazil) appeared to be
primarily driven by smaller current breast size; that is, while ideal
breast size was largely homogeneous across nations, greater breast size
dissatisfaction was found in nations where women reported smaller mean
current breast sizes.
4.2. Antecedents of breast size dissatisfaction
4.2.1. Socioeconomic status
In
the BSSS, we also examined a number of potential antecedents of breast
size dissatisfaction, but our results were inconsistent with our
hypotheses. That is, we hypothesised that greater financial security and
urbanicity (i.e., proxies for higher socioeconomic status),
respectively, would be associated with greater breast size
dissatisfaction. However, our results suggested that urbanicity was not
significantly associated with breast size dissatisfaction (except in
women who desired larger breasts than they currently had), whereas lower
rather than higher financial security was associated with greater
breast size dissatisfaction. One possibility here is that, unlike body
dissatisfaction (Swami, Frederick et al., 2010),
increasing financial security affords women greater opportunities to
negotiate breasted experiences by, for instance, de-emphasising the
importance of breast size, de-coupling the breasts from an aesthetic
gaze, or (re-)defining breast size ideals in a manner that is healthier
in terms of one’s body image. Conversely, the pressure to view the
breasts in purely aesthetic terms or to internalise a male gaze of
breasts as providers of gratification for men may be heightened for
women who are less financially secure, precisely because their financial
insecurity affords fewer opportunities to negotiate breasted
experiences. That is, among financially insecure women, there may be
greater pressure to treat the breasts as assets that play performative
roles, such as in terms of attracting potential partners or to attain
material benefits (see Edmonds, 2010).
Of
course, it should be noted that the weak relationships between proxies
of socioeconomic status and breast size dissatisfaction likely reflect
the fact that participants in the BSSS were all recruited from largely
urbanised sites. That is, we did not include samples from explicitly
rural research sites, which means there was limited within-nation
variation in actual socioeconomic status to warrant a fuller test of our
hypotheses. It may also reflect the fact that both urbanicity and
perceived financial security are imprecise indices of socioeconomic
status (Braveman et al., 2005).
The most direct way of examining this issue in further research would
be to sample participants from the same nation but from sites varying in
socioeconomic status (e.g., Swami & Tovée, 2005b, 2005b). Although such studies have previously examined breast size ideals within a single nation (Swami & Tovée, 2013a),
it is noteworthy that no previous study has extended this to include
examinations of breast size dissatisfaction. Doing so would provide a
fuller understanding of the relationships between socioeconomic status
and breast size dissatisfaction and also help clarify some of our
explanations above.
4.2.2. Personality
Consistent
with our hypothesis, we found that higher Neuroticism was significantly
associated with greater breast size dissatisfaction. This corroborates
previous work indicating that Neuroticism is associated with more
negative body image generally (for a review, see Allen & Walter, 2016)
and may reflect the fact that individuals who score highly on this
trait are more likely to experience negative emotional states and become
dissatisfied more easily. In addition, individuals who score highly on
Neuroticism may also be more sensitive to appearance evaluation and
rejection, which heightens breast size dissatisfaction. There is also
some evidence that women scoring higher on Neuroticism are more likely
to misperceive their body size as larger than they actually are (Hartmann & Siegrist, 2015; Sutin & Terracciano, 2016), and it might be suggested that these individuals are also more likely to misperceive their current breast size.
Beyond
Neuroticism, our results also indicated that lower Conscientiousness
was significantly associated with greater breast size dissatisfaction.
Although this result was unexpected, one recent review concluded that
there was a negative relationship between Conscientiousness and negative
body image, but only in studies classified as having low risk of bias (Allen & Walter, 2016; see also Allen, Vella, Swann, & Laborde, 2018).
Examining associations between facets of Conscientiousness and breast
size dissatisfaction may help scholars to better understand this
relationship. For example, there is evidence that lower scores on some
Conscientiousness facets – primarily low self-control (i.e., greater
impulsivity, spontaneity, and carelessness) – are associated with
greater body preoccupation (Ellickson-Larew, Naragon-Larew, & Watson, 2013). Facet-level analyses may also be useful in terms of other personality dimensions (Roberts & Good, 2010), as it may help to more accurately determine personality traits that shape breast size dissatisfaction.
4.2.3. Media exposure
In
contrast to our hypothesis, we found that exposure to Western media was
negatively, rather than positively, associated with greater breast size
dissatisfaction. This finding stands in marked contrast to the extant
literature indicating that exposure to Western media is associated with
more negative body image (e.g., Swami, Frederick et al., 2010; Swami, Mada, & Tovée, 2012).
Interpreting the present finding is complicated by the fact that we
were working with the total BSSS dataset, which may obscure the meaning,
importance, and impact of Western media in specific national and
cultural contexts (Anderson-Fye, 2004; Becker, 2004; Swami, 2020). It should also be noted that these analyses are limited by the focus on media exposure per se,
rather than perceived pressure from, and the internalisation of, breast
size ideals that are communicated through Western media. In addition,
there were likely ceiling effects in mean Western media exposure across
nations (a reflection of the fact that all research sites were largely
urbanised), as well as limited variation in breast size dissatisfaction
scores that any predictor could account for.
In
contrast to the effects of exposure to Western media, our results
indicated that greater exposure to local media was significantly and
positively associated with breast size dissatisfaction. Indeed, the
strength of the relationship between local media exposure and breast
size dissatisfaction was stronger than that of Western media exposure.
Thus, it would seem that local media play an important role in
engendering breast size dissatisfaction, possibly through the
communication of breast size narratives that are “tailored” for local
populations (Swami, 2020).
A good example of such local transmission is Latin American
telenovelas, which idealise larger breast sizes though in ways that are
often specific to local socio-political and gendered narratives (Edmonds, 2010; Smith, 2017).
More generally, it has been reported that local (Asian) media play a
more important role than Western media in predicting appearance concerns
in Chinese women (Jackson, Jiang, & Chen, 2016).
The BSSS results fit this broader perspective and suggests that local
media may play a crucial role in communicating narratives about ideal
breast size, which in turn pressure women to attain
culturally-sanctioned ideals.
4.2.4. Age
The
results of our analyses also indicated that age was inversely related
to breast size dissatisfaction. Previous studies have neglected to
explore associations between breast size dissatisfaction and participant
age, whereas the broader literature examining associations between
negative body and age have returned equivocal results, with large-sample
studies indicating a positive relationship (Frederick et al., 2008; Swami, Frederick et al., 2010; Swami, Tran, Stieger, Voracek, & The YouBeauty.com Team, 2015), a negative relationship (Frederick et al., 2016), or no significant association (Runfola et al., 2013).
In terms of breast size dissatisfaction specifically, it is possible
that breast objectification pressures decline with age (see Tiggemann & Lynch, 2001),
such that older women experience less pressure to attain breast size
ideals or develop embodiment practices that challenge constraining
appearance ideals (Piran, 2016).
Older age may also be associated with lifespan experiences, such as the
transition to motherhood and breastfeeding, that help focus women’s
attention on breast functionality (e.g., a maternal view of breasts that
emphasises nurturing; Chang, Chao, & Kenney, 2006; Earle, 2003) and reduces preoccupation with the sexual uses of breasts (Bojorquez-Chapela, Unikel, Mendoza, & de Lachica, 2013; Harrison, Obeid, Haslett, McLean, & Clarkin, 2019; Lombardo et al., 2019), though it should also be noted that midlife breast changes may also impact sexual satisfaction (Thomas, Hamm, Borrero, Hess, & Thurston, 2019).
4.3. Outcomes of breast size dissatisfaction
4.3.1. Body image and psychological well-being
As
hypothesised, greater breast size dissatisfaction was significantly and
positively associated with both weight and appearance dissatisfaction.
This is consistent with previous work showing that greater breast size
dissatisfaction is significantly associated with higher scores on a
range of indices of negative body image (Forbes & Frederick, 2008; Frederick et al., 2008; Junqueira et al., 2019; Swami & Furnham, 2018).
The most straightforward interpretation of the present finding is that
breast size dissatisfaction is an important facet of global negative
body image (Swami, Tran et al., 2015).
Importantly, the BSSS data also indicated that greater breast size
dissatisfaction was significantly associated with lower self-esteem and
subjective happiness. The former finding corroborates previous research
showing that breast size dissatisfaction is associated with lower
self-esteem (Koff & Benavage, 1998; Swami, Tran et al., 2015).
Taken together, the present results suggest that breast size
dissatisfaction may have substantive and detrimental links to both
global body image and psychological well-being.
4.3.2. Breast awareness
Partially consistent with our hypothesis and previous research with British women (Swami & Furnham, 2018),
analysis of the BSSS dataset indicated that greater breast size
dissatisfaction was associated with poorer breast awareness, as indexed
through lower breast self-examination frequency and lower confidence in
detecting breast change, though not greater estimated delay in seeking
professional help upon discovering breast change. These effects appeared
to be primarily driven by participants who desired larger breasts than
they currently had, whereas associations in participants who desired
smaller breasts were not significant. These findings nevertheless remain
important: breast cancer is the leading cause of cancer-related
mortality in women worldwide (Torre, Siegel, Ward, & Jemal, 2016) and poor survival rates are reliably associated with poorer breast awareness (for a review, see Richards, Westcombe, Love, Littlejohns, & Ramirez, 1999). Conversely, more positive breast awareness is associated with improved efficacy in breast cancer detection (Harmer, 2011; Mant, 1991; World Health Organization, 2017) and early diagnosis (Gadgil et al., 2017), but our results suggest that breast size dissatisfaction may act as a barrier to optimal breast awareness. As discussed by Swami and Furnham (2018),
breast size dissatisfaction may result in avoidance behaviours and
cognitions (i.e., avoiding or distrusting one’s breasts) that reduce
breast awareness, particularly if one’s breasts trigger feelings of
anxiety, shame, and embarrassment. Importantly, our results indicated
that the negative association between breast size dissatisfaction and
self-examination frequency and confidence in detecting breast change,
respectively, was stable across nations sampled in the BSSS, which
requires urgent public health intervention.
4.4. Implications
The
results of the BSSS suggest a relatively homogenised idealisation of
medium-to-large breasts, in tandem with similar levels of breast size
dissatisfaction across all sites that were sampled. Indeed, over
two-thirds of women sampled in the BSSS reported some form of breast
size dissatisfaction, with most of these women indicating that they
wanted larger breasts than they currently had. Just as a thin ideal for
women’s bodily attractiveness is now dominant across many nations (Swami, 2015; Swami, Frederick et al., 2010),
our results point to the homogenisation of breast size ideals, which in
turn may shape women’s breasted experiences. Perhaps most importantly,
greater breast size dissatisfaction was robustly associated with poorer
psychological well-being and lower breast awareness. Based on these
results, one conclusion we might draw is that breast size
dissatisfaction represents a global public health, with important
consequences for the psychological and physical well-being of women in
many places.
Most immediately, we urge greater
scholarly attention to issues related to breast size dissatisfaction
and, concomitantly, the development of targeted interventions aimed at
reducing breast size dissatisfaction. Various techniques – such as
cognitive restructuring, changing negative body language, and
size-estimate exercises – have been shown to successfully promote
healthier body image (for a meta-analysis, see Alleva, Sheeran, Webb, Martijn, & Miles, 2015),
but it will be important to determine the extent to which such methods
are efficacious at reducing breast size dissatisfaction specifically. Of
course, it is possible that reducing breast size dissatisfaction will
require more tailored interventions. Such a tailored approach might
involve interventionist and therapeutic techniques designed to reduce
self-objectification of one’s breasts and effective negotiations of
sociocultural contexts that value idealised feminine embodiment (see Roberts & Waters, 2004; Tylka & Augustus-Horvath, 2011).
In addition, interventions that promote greater appreciation of the
functional value of women’s breasts (e.g., their role in nurturing and
sustenance) may be vital to shift attention away from unrealistic and
unattainable beauty ideals, though this should not come at the expense
of women’s own needs (Piran, 2016; Schmied & Lupton, 2001).
Such interventions may be particularly valuable if they also promote
better breast awareness, which could empower women to take a more active
role in breast cancer practices (Anastasi & Lusher, 2019).
Importantly, whatever intervention methods are developed will need to
be sensitive to national contexts and meet the informational,
healthcare, and corporeal needs of women.