Dissatisfaction with breast size affects 70.7 % of women sampled: linked to greater Neuroticism, lower Conscientiousness, lower Western media exposure, greater local media exposure, lower financial security, & younger age

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.