The Breast Size Satisfaction Survey (BSSS): Breast size dissatisfaction and its antecedents and outcomes in women from 40 nations

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University of Groningen

The Breast Size Satisfaction Survey (BSSS)

Tran, Ulrich S; Barron, David; Afhami, Reza; Aimé, Annie; Almenara, Carlos A; Alp Dal,

Nursel; Amaral, Ana Carolina Soares; Andrianto, Sonny; Anjum, Gulnaz; Argyrides, Marios

Published in:

Body Image

DOI:

10.1016/j.bodyim.2020.01.006

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from

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Publication date:

2020

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Citation for published version (APA):

Tran, U. S., Barron, D., Afhami, R., Aimé, A., Almenara, C. A., Alp Dal, N., Amaral, A. C. S., Andrianto, S.,

Anjum, G., Argyrides, M., Atari, M., Aziz, M., Banai, B., Borowiec, J., Brewis, A., Cakir Kocak, Y., Campos,

J. A. D. B., Carmona, C., Chaleeraktrakoon, T., ... Vidal-Mollón, J. (2020). The Breast Size Satisfaction

Survey (BSSS): Breast size dissatisfaction and its antecedents and outcomes in women from 40 nations.

Body Image, 32, 199-217. https://doi.org/10.1016/j.bodyim.2020.01.006

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ContentslistsavailableatScienceDirect

Body

Image

j o u r n al ho me p ag e :w w w . e l s e v i e r . c o m / l o c a te / b o d y i m a g e

The

Breast

Size

Satisfaction

Survey

(BSSS):

Breast

size

dissatisfaction

and

its

antecedents

and

outcomes

in

women

from

40 nations

Viren

Swami

a,b,∗

_,

_Ulrich

_S.

_Tran

c

_,

_David

_Barron

b

_,

_Reza

_Afhami

d

_,

_Annie

_Aimé

e

_,

Carlos

A. Almenara

f

_,

_Nursel

_Alp

_Dal

g

_,

_Ana

_Carolina

_Soares

_Amaral

h

_,

_Sonny

_Andrianto

i

_,

Gulnaz

Anjum

j

_,

_Marios

_Argyrides

k

_,

_Mohammad

_Atari

l

_,

_Mudassar

_Aziz

m

_,

Benjamin

Banai

n

_,

_Joanna

_Borowiec

o

_,

_Alexandra

_Brewis

p

_,

_Yeliz

_Cakir

_Kocak

q

_,

Juliana

Alvares

Duarte

Bonini

Campos

r

_,

_Carmen

_Carmona

s

_,

_Trawin

_{Chaleeraktrakoon}

t

_,

Hong

Chen

u

_,

_Phatthanakit

_Chobthamkit

t,v

_,

_Bovornpot

_Choompunuch

w

_,

Togas

Constantinos

x

_,

_Aine

_Crumlish

y

_,

_Julio

_Eduardo

_Cruz

z

_,

_Simon

_E.

_Dalley

A

_,

Devi

Damayanti

B

_,

_Joanna

_Dare

C

_,

_Stacey

_M.

_Donofrio

A

_,

_Anja

_Draksler

D

_,

Michelle

Escasa-Dorne

E

_,

_Elaine

_Frances

_Fernandez

F

_,

_Maria

_Elisa

_Caputo

_Ferreira

G

_,

David

A. Frederick

C

_,

_Antonio

_Alías

_García

H

_,

_Shulamit

_Geller

I

_,

_Alexias

_George

x

_,

Louai

Ghazieh

J

_,

_Cosmin

_Goian

K

_,

_Colin

_Gorman

y

_,

_Caterina

_Grano

L

_,

Jonathan

Eliahu

Handelzalts

I

_,

_Heather

_Horsburgh

M,1

_,

_Todd

_Jackson

N

_,

Lady

Grey

Javela

Delgado

O

_,

_Marija

_{Jovi ´c}

P

_,

_Marko

_{Jovi ´c}

Q

_,

_Adam

_Kantanista

o

_,

Sevag

K. Kertechian

J

_,

_Loes

_Kessels

R

_,

_Magdalena

_{Król-Zieli ´nska}

o

_,

_Garry

_Kuan

S

_,

Yee

Cheng

Kueh

T

_,

_Sanjay

_Kumar

U

_,

_Ingela

_Lundin

_Kvalem

V

_,

_Caterina

_Lombardo

L

_,

Ernesto

Luis

López

Almada

W

_,

_Christophe

_Maïano

e

_,

_Mandar

_Manjary

U

_,

_Karlijn

_Massar

R

_,

Camilla

Matera

X

_,

_Juliana

_F.

_Figueiras

_Mereiles

G

_,

_Norbert

_Meskó

Y

_,

_Hikari

_Namatame

Z

_,

Amanda

Nerini

X

_,

_Felix

_Neto

aa

_,

_Joana

_Neto

ab

_,

_Angela

_Nogueira

_Neves

ac

_,

_Siu-Kuen

_Ng

ad

_,

Devi

R. Nithiya

ae

_,

_Salma

_Samir

_Omar

af

_,

_Mika

_Omori

ag

_,

_Maria

_Serena

_Panasiti

ah

_,

Irena

Pavela

Banai

n

_,

_Eva

_Pila

ai

_,

_Alessandra

_{Pokrajac-Bulian}

aj

_,

_Vita

_Postuvan

D

_,

Ivanka

Prichard

ak

_,

_Magdalena

_Razmus

al

_,

_Catherine

_M.

_Sabiston

am

_,

_Reza

_N.

_Sahlan

an

_,

Jacob

Owusu

Sarfo

ao

_,

_Yoko

_Sawamiya

Z

_,

_Stefan

_Stieger

ap,aq

_,

_Cindi

_{SturtzSreetharan}

p

_,

Eugene

Tee

F

_,

_Gill

_A.

_ten

_Hoor

R

_,

_Kulvadee

_Thongpibul

ar

_,

_Arun

_Tipandjan

as

_,

_Otilia

_Tudorel

at

,

Tracy

Tylka

au

_,

_Zahir

_Vally

av

_,

_Juan

_Camilo

_Vargas-Nieto

aw

_,

_Luis

_Diego

_Vega

ax

_,

Jose

Vidal-Mollón

s

_,

_Mona

_Vintila

at

_,

_Deborah

_Williams

ay

_,

_Amber

_Wutich

p

_,

Yuko

Yamamiya

az

_,

_Danilo

_Zambrano

aw

_,

_Marcelo

_Callegari

_Zanetti

Aa

_,

Ivanka ˇZivˇci ć-Be ćirevi ć

aj

_,

_Martin

_Voracek

c

a_School_of_Psychology_and_Sport_Science,_Anglia_Ruskin_University,_Cambridge,_United_Kingdom b_Centre_for_{Psychological}_Medicine,_Perdana_University,_Serdang,_Malaysia

c_Department_of_Basic_{Psychological}_Research_and_Research_Methods,_School_of_Psychology,_University_of_Vienna,_Vienna,_Austria d_Department_of_Art_Studies,_Tarbiat_Modares_University,_Tehran,_Iran

e_Department_of_{Psychoeducation}_and_Psychology,_Université_du_Québec_en_Outaouais,_{Saint-Jérôme,}_Canada

f_Institute_for_Research_on_Children,_Youth,_and_Family,_Faculty_of_Social_Studies,_Masaryk_University,_Brno,_Czech_Republic g_Midwifery_Department,_Munzur_University,_Tunceli,_Turkey

h_Federal_Institute_of_Education,_Science,_and_Technology_of_Southeast_Minas_Gerais,_São_Barbacena,_Brazil i_Department_of_Psychology,_Islamic_University_of_Indonesia,_Yogyakarta,_Indonesia

j_Department_of_Social_Sciences_and_Liberal_Arts,_Institute_of_Business_{Administration,}_Karachi,_Pakistan

∗ Correspondingauthorat:SchoolofPsychologyandSportScience,AngliaRuskinUniversity,Cambridge,CambridgeshireCB11PT,UnitedKingdom. E-mailaddress:viren.swami@anglia.ac.uk(V.Swami).

1 _Heather_Horsbugh_is_now_at_the_School_of_Education_and_Social_Sciences,_University_of_the_West_of_Scotland,_Paisley,_United_Kingdom.

https://doi.org/10.1016/j.bodyim.2020.01.006

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SchoolofHealthSciences,NeapolisUniversityPaphos,Paphos,Cyprus

l_Department_of_Psychology,_University_of_Southern_California,_Los_Angeles,_United_States

m_Department_of_Social_Sciences,_Shaheed_Zulﬁkar_Ali_Bhutto_Institute_of_Science_and_Technology,_Karachi,_Pakistan n_Department_of_Psychology,_University_of_Zadar,_Zadar,_Croatia

o_Department_of_Physical_Education_and_Lifelong_Sports,_Pozna´_n_University_of_Physical_Education,_Pozna´_n,_Poland p_School_of_Human_Evolution_and_Social_Change,_Arizona_State_University,_Tempe,_United_States

q_Midwifery_Department,_Ege_{University, ˙Izmir,}_Turkey

r_Department_of_Food_and_Nutrition,_School_of_{Pharmaceutical}_Science_of_São_Paulo_State_University,_São_Paulo,_Brazil s_Department_of_Research_Methods_and_Diagnosis_in_Education,_University_of_Valencia,_Valencia,_Spain

t_Division_of_Psychology,_Faculty_of_Liberal_Arts,_Thammasat_University,_Pathumthani,_Thailand u_School_of_Psychology,_Southwest_University,_Chongqing,_China

v_School_of_Psychology,_University_of_Kent,_Canterbury,_United_Kingdom

w_Department_of_Educational_Psychology_and_Counseling,_Faculty_of_Education,_Khon_Kaen_University,_Khon_Kaen,_Thailand x_Department_of_Psychology,_Panteion_University_of_Athens,_Athens,_Greece

y_School_of_Psychology,_Ulster_University,_Coleraine,_Northern_Ireland,_United_Kingdom z_Department_of_Psychology,_University_de_los_Andes,_Bogotá,_Colombia

A_Faculty_of_Behavioural_and_Social_Sciences,_University_of_Groningen,_Groningen,_Netherlands B_Department_of_Psychology,_Ahmad_Dahlan_University,_Yogyakarta,_Indonesia

C_Department_of_Psychology,_Chapman_University,_Orange,_United_States

D_Slovene_Centre_for_Suicide_Research,_Andrej_Marusic_Institute_and_Department_of_Psychology_FAMNIT,_University_of_Primorska,_Koper,_Slovenia E_Department_of_{Anthropology,}_University_of_Colorado_Colorado_Springs,_United_States

F_Department_of_Psychology,_HELP_University,_Shah_Alam,_Malaysia G_Federal_University_of_Juiz_de_Fora,_Juiz_de_Fora,_Brazil

H_Department_of_Education,_University_of_Almeria,_Almeria,_Spain

I_School_of_Behavioral_Sciences,_Academic_College_of_Tel-Aviv_Yaffo,_Yaffo,_Israel J_Department_of_Human_Resources,_Saint_Joseph_University,_Beirut,_Lebanon K_Department_of_Social_Work,_West_University_of_Timis¸_oara,_Timis¸_oara,_Romania L_Department_of_Psychology,_Sapienza_University_of_Rome,_Rome,_Italy

M_School_of_Social_Sciences,_University_of_Southampton,_Southampton,_United_Kingdom N_Department_of_Psychology,_University_of_Macau,_Taipa,_China

O_Department_of_Psychology,_Universidad_del_Rosario,_Bogotá,_Colombia

P_Department_of_Marketing_Management_and_Public_Relations,_University_of_Belgrade,_Belgrade,_Serbia Q_Department_of_Plastic_and_{Reconstructive}_Surgery,_School_of_Medicine,_University_of_Belgrade,_Belgrade,_Serbia R_Department_of_Work_and_Social_Psychology,_Maastricht_University,_Maastricht,_Netherlands

S_School_of_Health_Sciences,_Universiti_Sains_Malaysia,_Kubang_Kerian,_Kelantan,_Malaysia

T_Unit_of_{Biostatistics}_and_Research_Methodology,_School_of_Medical_Sciences,_Universiti_Sains_Malaysia,_Kubang_Kerian,_Kelantan,_Malaysia U_Department_of_Psychology,_D.A.V._College,_{Muzaffarnagar,}_India

V_Department_of_Psychology,_University_of_Oslo,_Oslo,_Norway

W_Faculty_of_Humanities,_Universidad_Católica_Campus_Itapúa,_{Encarnación,}_Paraguay

X_Department_of_Education,_Languages,_{Intercultures,}_Literatures,_and_Psychology,_University_of_Florence,_Florence,_Italy Y_Department_of_General_and_Evolutionary_Psychology,_Institute_of_Psychology,_University_of_Pécs,_Pécs,_Hungary Z_Department_of_Psychology,_University_of_Tsukuba,_Tsukuba,_Japan

aa_Department_of_Psychology,_University_of_Porto,_Porto,_Portugal

ab_Department_of_Psychology,_Catholic_University_of_Brasília,_Taguatinga,_Brazil

ac_Division_of_Research,_Physical_Education_College_of_the_Brazilian_Army,_Rio_de_Janeiro,_Brazil ad_Physical_Education_Unit,_Chinese_University_of_Hong_Kong,_Hong_Kong,_China

ae_Department_of_Physiology,_Mahatma_Gandhi_Medical_College_and_Research_Institute,_Sri_Balaji_Vidyapeth,_India af_Department_of_Dermatology,_Venereology,_and_Andrology,_Alexandria_University,_Alexandria,_Egypt

ag_Department_of_Psychology,_Ochanomizu_University,_Tokyo,_Japan

ah_Santa_Lucia_Foundation,_Scientiﬁc_Institute_for_Research_and_Healthcare,_Rome,_Italy ai_School_of_Kinesiology,_University_of_Western_Ontario,_Ontario,_Canada

aj_Department_of_Psychology,_Faculty_of_Humanities_and_Social_Sciences,_University_of_Rijeka,_Rijeka,_Croatia ak_College_of_Nursing_and_Health_Sciences,_Flinders_University,_Adelaide,_Australia

al_Institute_of_Psychology,_Marie_{Curie-Skłodowska}_University,_Lublin,_Poland

am_Faculty_of_Kinesiology_and_Physical_Education,_University_of_Toronto,_Toronto,_Canada an_Department_of_Clinical_Psychology,_Iran_University_of_Medical_Sciences,_Tehran,_Iran ao_Department_of_Nursing,_All_Nations_University_College,_Koforidua,_Ghana

ap_Department_of_Psychology_and_{Psychodynamics,}_Karl_Landsteiner_University_of_Health_Sciences,_Krems_an_der_Donau,_Austria aq_Department_of_Psychology,_Research_Methods,_Assessment,_and_iScience,_University_of_Konstanz,_Konstanz,_Germany ar_Department_of_Psychology,_Faculty_of_Humanities,_Chiang_Mai_University,_Chiang_Mai,_Thailand

as_Indira_Gandhi_Government_General_Hospital_and_Postgraduate_Institute,_Puducherry,_India at_Department_of_Psychology,_West_University_of_Timis¸_oara,_Timis¸_oara,_Romania

au_Department_of_Psychology,_Ohio_State_University,_Columbus,_United_States

av_Department_of_Psychology_and_Counseling,_United_Arab_Emirates_University,_Al_Ain,_United_Arab_Emirates aw_Department_of_Psychology,_Fundación_{Universitaria}_Konrad_Lonrez,_Bogotá,_Colombia

ax_Department_of_Psychology,_Universidad_Latina_de_Costa_Rica,_San_José,_Costa_Rica ay_College_of_Health_Solutions,_Arizona_State_University,_Phoenix,_Arizona,_United_States az_Department_of_{Undergraduate}_Studies,_Temple_University_Japan,_Tokyo,_Japan Aa_Department_of_Physical_Education,_São_Judas_Tadeu_University,_São_Paulo,_Brazil

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Articlehistory:

Received13September2019

Receivedinrevisedform24January2020 Accepted25January2020

Availableonline4February2020

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TheBreastSizeSatisfactionSurvey(BSSS)wasestablishedtoassesswomen’sbreastsizedissatisfaction andbreastedexperiencesfromacross-nationalperspective.Atotalof18,541womenwererecruitedfrom 61researchsitesacross40nationsandcompletedmeasuresofcurrent-idealbreastsizediscrepancy,as wellasmeasuresoftheorisedantecedents(personality,Westernandlocalmediaexposure,andproxies ofsocioeconomicstatus)andoutcomes(weightandappearancedissatisfaction,breastawareness,and

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Keywords: Breastsize Breastideals Breastawareness Personality Psychologicalwell-being Cross-culturalpsychology

psychologicalwell-being).Inthetotaldataset,47.5%ofwomenwantedlargerbreaststhanthey cur-rentlyhad,23.2%wantedsmallerbreasts,and29.3%weresatisfiedwiththeircurrentbreastsize.There weresignificantcross-nationaldifferencesinmeanidealbreastsizeandabsolutebreastsize dissatisfac-tion,buteffectsizesweresmall(␩2₌_.02–.03)._The_results_of_multilevel_modelling_showed_that_greater Neuroticism,lowerConscientiousness,lowerWesternmediaexposure,greaterlocalmediaexposure, lowerfinancialsecurity,andyoungeragewereassociatedwithgreaterbreastsizedissatisfactionacross nations.Inaddition,greaterabsolutebreastsizedissatisfactionwasassociatedwithgreaterweightand appearancedissatisfaction,poorerbreastawareness,andpoorerpsychologicalwell-beingacrossnations. Theseresultsindicatethatbreastsizedissatisfactionisaglobalpublichealthconcernlinkedtowomen’s psychologicalandphysicalwell-being.

1. Introduction

Whenawoman placesherhandover herheart,it liesonand betweenherbreasts.Ifherchestisthehouseofherbeing,from whichradiatesherenergytomeettheworld,herbreastsarealso entwinedwithhersenseofself.[...]Formanywomen,ifnotall, breastsareanimportantcomponentofbodyself-image;awoman maylovethemordislikethem,butsheisrarelyneutral(Young, 1992,p.215).

Thebodyisahighlysymbolicandimportantsiteforthe cre-ation,negotiation,andperpetuationofsocialandpowerrelations

(Backett-Milburn&McKie,2001;Jeffreys,2005;Scheper-Hughes&

Lock,1987;Thompson,Heinberg,Altabe,&Tantleff-Dunn,1999).

In this view,macro-level culturalfactors – such as patriarchal structures (Bartky, 1990; Jeffreys, 2005), masculine aesthetics

(Dworkin,1974),andbeautysystems(Bordo,1993;Turner,1984)

– tie women’s moral, economic, and socio-political worth to theirphysicalappearanceandwillingnesstoenactpersonalbody projects.Concomitantly,thosestructuresorsystemsalso propa-gateprescriptiveandunrealisticbeautyideals(Swami,2015,2020), rewardingwomenwhostriveandattainthoseidealsandpunishing ordenigratingthosewhodonot(Forbes,Collinsworth,Jobe,Braun,

&Wise,2007;Kimmel,2011;Ramati-Ziber,Shnabel,&Glick,2019;

Swami,Colesetal.,2010).Totheextentthatthosebeautyideals

areinternalisedbywomen,itoftenresultsinahostof detrimen-taloutcomes(e.g.,negativebodyimage,symptomsofdisordered eating,poorer psychologicalwell-being)when women perceive themselves as being unable to embody those ideals (Rodgers,

Campagna,&Attawala,2019;Thompsonetal.,1999;Tomiyama

etal.,2018).

Muchof the academic literature hasfocused on attainment ofathinideal,butsomeworksuggeststhistheorisingmayalso applytowomen’sbreasts(Gripsrud,Ramvi,Froggett,Hellstrand,

&Manley,2018;Lee, 1997)and “breastedexperiences”(Young,

1992,p.215).Thisisunsurprisingconsideringevidencethatthe breastsplayanimportantroleinjudgementsandobjectiﬁcationof women(e.g.,Bareket,Shnabel,Abeles,Gervais,&Yuval-Greenberg,

2019;Dixson,Grimshaw,Linklater,&Dixson,2011;Swami&Tovée,

2013b),andarereportedtobeafocusofwomen’sbodyanxieties

(e.g.,Beck,Ward-Hull,&McLear,1976;Lee,1997;Millsted&Frith,

2003;Young,1992).Yet,comparativelylittleiscurrentlyknown

aboutwomen’sbreastdissatisfaction,particularlyintermsof cross-nationalvariations,aswellasantecedentsandoutcomes.Torectify thisgapintheliterature,wereporthereontheresultsoftheBreast SizeSatisfactionSurvey,across-nationalsurveyofbreastsize ide-alsandbreastsizedissatisfactioninwomenacross40nations.Not onlydoesthissurveyrepresentthelargestmulti-sitestudyever conductedontheissueofbreastsizedissatisfaction,italsoprovides importantinsightsthatwillbeofusetohealthcarepractitioners, policy-makers,andactivists.

1.1. Breastsizeanddissatisfaction

Women’sbreastsvaryalongmanydimensions,suchasshape, symmetry,andﬁrmness(Atiye&Chahine,2018),butmany con-temporarybeautysystemsreportedlyobjectifywomeninterms of theirbreastsize (Calogero &Thompson,2010; Mazur,1986;

Seifert,2005;Tantleff-Dunn,2001).Inparticular,largebreastsare

commodiﬁedandfetishisedinmanyformsofmainstreamWestern media(Einon,2012;Gerald&Potvin,2009;Ward,Merriwether,&

Caruthers,2006),particularlymediathat(re)produce

stereotypi-calgenderrolediscourse(Graff,Murnen,&Krause,2013;Yockey,

King,Vidourek,Burbage,&Merianos,2019)andheteronormative

expectations(Murnen,Poinsatte,Huntsman,Goldfarb,&Glaser,

2015;Rodriguez&Hernandez,2019;Rogers&Liebler,2017;for

a counter-point,seeWebb, Vinoski,Warren-Findlow,Burrell, &

Putz, 2017).Thatis,in contemporary culturalimagery,“female

breasts arenot celebrated orscrutinized forwhat theydo, but for how theyaresupposed to look”(Naugler,2009, p.101). In addition to de-coupling breasts fromtheir functional purposes (e.g.,child-feeding),contemporarypopularculturealsotieslarge breaststoconceptionsofwomanhood,somuchsothatlargebreasts havebecomeadeﬁningcharacteristicoffemininity(Dozier,2005;

Gripsrud,2008;Young,1992).

Thiscommodiﬁcationandscrutinisationofbreastscaninﬂuence howwomenfeelabouttheirownbodies(Bonillas,2009;Goldsmith

&Byers, 2016; Millsted &Frith, 2003; Webb, Jacox,&

Temple-Oberle,2019).StudiesofNorthAmericanandWesternEuropean

womenhavedocumentedhighlevelsofbreastsizedissatisfaction –typicallyoperationalisedasadiscrepancybetweencurrentand idealbreastsizesand,lessfrequently,asattitudesaboutbreastsize –sinceatleastthe1950s(Forbes&Frederick,2008;Forbes,Jobe,&

Revak,2006;Jacobi&Cash,1994;Jourard&Secord,1955;

Tantleff-Dunn,2002;Tantleff-Dunn&Thompson,2000).Forexample,one

largesurveyofNorthAmericanheterosexualwomen(N=26,703) reportedthatthemajority(70%)weredissatisﬁedwithsomeaspect oftheirbreastsandthat,oftheseparticipants,28%wantedlarger breasts(Frederick,Peplau,&Lever,2008).InWesternEurope, stud-ieshavereportedthatamajorityofsampledwomenintheUnited Kingdom(Swami,Cavelti,Taylor,&Tovée,2015,Study3=54.3%, Study4=53.3%) or closeto amajority in theUnitedKingdom

(Swami,Caveltietal.,2015,Study2=49.7%;Swami&Furnham,

2018:44.2%)andItaly(Lombardo,Panasiti,Vacca,Grano,&Swami, 2019:44.4%)wantedlargerbreaststhantheycurrentlyhad.

Muchlessresearchhasexaminedratesofbreastsize dissatis-factionoutsideNorthAmericaandWesternEurope,aneglectthat isimportantbecausetheethnographicrecordsuggestssome vari-ationinidealbreastsize,atleasthistorically(Ford&Beach,1951). Inparticular,someculturesmayessentialisetheperformativityof womanhood andgender identitythroughsymbolicassociations with largebreasts. For example, somescholars have discussed theheightenedculturalpressureexperiencedbyLatinAmerican

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womentodemonstratefemininityand sexualitythroughbreast fullness(Correa&Shohamy,2018;Guimarãesetal.,2015). Con-sistentwiththisview,Junqueiraetal.(2019)reportedthat65.5% ofBrazilianwomenintheirstudydesiredlargerbreaststhanthey currentlyhad,althoughitshouldbenotedthesampleconsisted primarilyofyoungwomen.Incontrast,EastandSoutheastAsian womentypicallyhavesmallerbreaststhanwomeninotherparts oftheworld(Limetal.,2018),andsomeliteraturehasproposed thatbreastshavehistoricallyplayedasubsidiaryroleintermsof theculturalobjectiﬁcationofwomeninthisregion(Miller,2003;

seealsoMenon,2019)andareemphasisedlessoftenin

percep-tionsoffemininity(B ˛ak-Sosnowska,Pawlicka,&Warchał,2016;

seealsoChing&Xu,2019).Likewise,somenon-Western

commu-nitiesmayconstruelargebreastsasproblematic,eitherbecause largebreastsareperceivedasacauseofdisease(e.g.,breastcancer;

Naanyuetal.,2015)orbecausebeinglarge-breastedis

stereotypi-callyassociatedwithhypersexuality(Liebelt,2019)andnarcissism

(seeSmith,2017).

Nevertheless, it is also possible that breast size ideals are becomingincreasinglyhomogenisedacrosstheglobe.For exam-ple,in relation to thethin ideal, scholars have discussed how theinter-relatedforces ofglobalisation(particularlyinterms of theproliferationofWesternmassmediaandWesternisedbeauty ideals)andmodernisation(e.g.,changingnutritionalandlifestyle patterns, disruptions to gender inequality and traditional gen-derroles)haveservedtoenforceahomogenisedpreference for thinnessacrossmuchoftheglobe(Anderson-Fye,2018;Brewis,

Wutich,Falletta-Cowden,&Rodriguez-Soto,2011;Swami,2015).

Thisissupportedbyempiricaldatashowingarelatively standard-isedpreferenceforfemalethinnessandsimilarratesofactual-ideal weightdiscrepancyacrossnations (e.g.,Swami,Fredericketal., 2010).Similarprocesseshavenotbeenexaminedvis-à-visbreast size,althoughsomescholarshavesuggestedtheincreasing com-modiﬁcationandobjectiﬁcationoflargebreastsinsomepartsof theworld(e.g.,inEastandSoutheastAsia;Rongmuangetal.,2011;

Wong,2019),aswellasamarkedshiftawayfromafocusonthe

functionsofthebreaststowardtheirtreatmentinpurelyaesthetic terms(Miller,2006).Intheabsenceofempiricaldata,however,it isdifﬁculttoknowtowhatextentahomogenisingpatterncould beobservedglobally,andsoaﬁrstaimofthepresentstudywasto examinebreastsizeidealsandbreastdissatisfactionacrossdiverse nationalsites.

1.2. Antecedentsofbreastsizedissatisfaction

Here,wealsoconsideredantecedentsofbreastsizeidealsand breastsizedissatisfaction,whichhavenotbeeninvestigatedinany depthinpreviousresearch(Lombardoetal.,2019).Onesuch poten-tialantecedentissocioeconomicstatus:intermsofthethinideal, forexample,cross-sectional (e.g.,Mintem, Horta,Domingues,&

Gigante,2015;Swami,Fredericketal.,2010;Swami,Jones,Einon,

&Furnham,2009;Swami&Tovée,2005b,2005b),experimental

(Swami&Tovée,2006),andethnographic(Anderson-Fye&Brewis,

2017)researchhasdocumentedaninverserelationshipbetween socioeconomicstatusandidealisationofathinideal.Inexplanation, ithasbeensuggestedthatindividualsfromsitesofrelativelylow socioeconomicstatusmayidealiselargerbodysizesbecausebody fatissymbolicofresourcesecurity(e.g.,accesstofoodorwealth), whereasthinnesscomestobeassociatedwithwealthandstatusin sitesofrelativelyhighersocioeconomicstatus(forreviews,seeFox,

Feng,&Asal,2019;Swami,2015,2020).Asimilarpatternhasbeen

proposedforbreast sizeideals, withcross-sectionaland experi-mentalresearchsuggestingapreferenceforlargerbreastsizeswith decreasingsocioeconomicstatus(Dixson,Vaseyetal.,2011;Swami

&Tovée,2013a;butseeGray&Frederick,2012).Assuch,itmight

beexpectedthattherewouldbevariationinwhatisperceivedto

betheidealbreastsizeasafunctionofinter-individualdifferences insocioeconomicstatus.

Ontheotherhand,ratesofbreastsizedissatisfaction(i.e.,a dis-crepancybetweencurrentandidealbreastsizes)mightbeexpected tobelower among participantsof lower socioeconomicstatus. For example,based ondata fromresearchsites in two nations (MalaysiaandSouthAfrica)thatdifferedinsocioeconomicstatus,

Swami,Fredericketal.(2010)reportedsigniﬁcantlylower

actual-idealweightdiscrepancy inparticipantsfromsites ofrelatively lowcomparedtohighsocioeconomicstatus.Similarﬁndingshave alsobeenreportedinBrazil(Laus,Miranda,Almedia,BragaCosta,

&Ferreira,2012),MalaysianBorneo(Swami,Kannan,&Furnham,

2012),andMexico(Penelo,Negrete,Portell,&Raich,2013),with participantsfromsitesofhighersocioeconomicstatusreporting morenegativebodyimagecomparedtothosefromsitesoflower socioeconomicstatus.Thissuggeststhatparticipantsofrelatively lowsocioeconomicstatuswouldreportlowerratesofbreastsize dissatisfaction.Thereareanumberofreasonsforexpectingthis patternofresults(forreviews,seeAnderson-Fye&Brewis,2017;

Swami,2015), includinglowerpressurefrombeautysystemsto

attainbeautyidealsinsitesofrelativelylowsocioeconomicstatus andlowerexposuretoWesternmassmediathatconstructlarge breastsasideal.

In terms of the latter, previous cross-national research has shown that exposureto Western mediais signiﬁcantly associ-atedwithboththeidealisationofthinfemalebodiesandwomen’s bodydissatisfaction(Swami,Fredericketal.,2010).Someresearch hasexaminedtheimpactof exposuretomassmediaonbreast sizeideals and breastsize dissatisfaction.For example, qualita-tiveresearchwithwomenfromtheUnitedStateshasimplicated exposuretolargebreastsdepictedinmassmediaasanimportant inﬂuenceonbreastsizedissatisfaction,despiteparticipants’stated dislikeof those mediated images (Goodman & Walsh-Childers, 2004).Similarly,exposuretoidealisedbodiesinmassmediahas beenassociatedwithapreferenceforlargerbreastsincollege-aged NorthAmericanwomen(Harrison,2003)andhasalsobeen associ-atedwithnegativefeelingsaboutwomen’sownbreasts(Frederick,

Daniels,Bates,&Tylka,2017).OnestudywithruralNicaraguans

foundthatexposuretoWesterntelevisionwasassociatedwitha preferenceforlargerbreasts(Thornborrow,Jucker,Boothroyd,&

Tovée,2018),althoughthestudyonlyconsideredmen’sratingsof

women.

Alternatively,somescholarshavesuggestedthatmediaeffects havebeenexaggerated(e.g.,Ferguson,2018;Swami,2020).For example,Ferguson’s(2013)meta-analysis,which included stud-iesthatweremainlyconductedinadvancedeconomies,concluded therewasnooveralleffectofmediaexposureonwomen’sbody dissatisfaction.Instead,theyconcludedthatmediaeffectsonbody dissatisfactionwerelimitedtothosewithpre-existingbody dissat-isfactionorpossiblythosewithvulnerablepersonalitytraits,such ashighNeuroticism.Infact,asidefromthispotentialmoderating role,Neuroticismhasalsobeenfoundtobedirectlyassociatedwith morenegativebodyimage(Frederick, Sandhu,Morse,&Swami,

2016;Sutin&Terracciano,2016;Swami,Taylor,&Carvalho,2011,

2013).Indeed,onerecentsystematic reviewreportedthat Neu-roticismwaspositivelyassociated withnegativebody imagein women(Allen&Walter,2016),possiblybecauseindividualshighin Neuroticismaremoreself-consciousandvulnerabletobodyimage threats.Relationshipsbetweenotherpersonalitytraitsandbody imagearemoreequivocal(Allen&Celestino,2018;Allen&Walter,

2016;Swami&Furnham,2016),thoughitshouldbenotedthatno

studyhasexaminedassociationswithbreastsizedissatisfaction speciﬁcally.

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1.3. Outcomesofbreastsizedissatisfaction

Intermsofthebodyimageliterature,breastsizedissatisfaction istypicallyconceptualisedasafacetofnegativebodyimagemore generally(Ålgarsetal.,2011;Swami,Caveltietal.,2015).Thus, wewouldexpectsigniﬁcantassociationsbetweenbreastsize dis-satisfactionandotherindicesofnegativebodyimage.Indeed,the availableevidencesupportssuchassociations:greaterbreastsize dissatisfactionhasbeenfoundtobesigniﬁcantlyassociatedwith greaterbodydissatisfaction(Forbes&Frederick,2008;Frederick

etal.,2008;Swami,Caveltietal.,2015;Swami&Furnham,2018),

greater actual-idealweight discrepancy (Junqueira et al., 2019;

Swami,Caveltietal.,2015), lowerbodyappreciation(Junqueira

etal.,2019;Swami,Caveltietal.,2015),greaterappearance

pre-occupation(Koff&Benavage,1998),andgreaterdriveforthinness

(Swami,Caveltietal.,2015).Thestrengthofassociationshas

gen-erally been weak-to-moderate (e.g., Swami & Furnham, 2018), althoughitshouldbenotedthatatleastonestudyfoundno sig-niﬁcantassociationwithbodyimagedisturbance(Tantleff-Dunn

&Thompson,2000).Beyondindicesof bodyimage,twostudies

have reported that greater breast size dissatisfaction is signiﬁ-cantly,albeitweakly, associatedwithlowerself-esteem(Koff &

Benavage,1998;Swami,Caveltietal.,2015;butforanulleffect,

seeTantleff-Dunn&Thompson,2000).

Anotherimportantoutcomeofbreastsizedissatisfactionmaybe decreasedbreastawareness,whichinvolvesfamiliaritywithone’s breasts(i.e.,howtheynormallylookandfeel,andhowtheychange throughouta woman’slife),as wellas theconﬁdence tonotice anddetectanychange(e.g.,throughbreastself-examinationfor breastcancersymptoms)andtoseekimmediatemedicalhelpwhen achangeis detected(McCready,Littlewood,&Jenkinson,2005;

Thornton&Pillarisetti,2008).Althoughhealthcarepoliciesinmany

countriescontinuetoadvocate breast self-examinationalone, a growingbody ofevidencesuggeststhat,whendoneonitsown andwithoutpropertraining,breastself-examinationmaynot nec-essarilyimprovebreastcancerdetectionandmortalityreduction (forareview,seeKösters&Gøtzsche,2003).Instead,amore holis-ticapproachbasedonbreastawarenessappearstoofferimproved efficacyintermsofbreastcancerdetection(Harmer,2011;Mant, 1991).Importantly,inacohortofBritishwomen,greaterbreastsize dissatisfaction–butnotbodydissatisfaction–wassignificantly associatedwithlowerbreastawareness(i.e.,lessfrequentbreast self-examination, lower confidence in detecting breast change, andgreaterdelayinseekingprofessionalhelpfollowingabreast change) (Swami &Furnham,2018).In explanation,theauthors suggestedthat theseassociationsmaystem fromwomen seek-ingtoavoidfocusingonthesiteoftheirdissatisfactionornegative emotions(e.g.,shameandembarrassment)thatresultfromvisual inspectionofone’sbreasts.

Whilethesestudiesareimportantintheirownright,itis impor-tanttonotethat theyaregenerallylimited topopulationsin a smallhandfulofworldregions(i.e.,NorthAmericaandWestern Europe)anditisuncleartowhatextentsimilarassociations(i.e., withnegativebodyimage, psychologicalwell-being, and breast awareness)mightbeexpectedinsamplesfromagreaterdiversity of populations.The associationbetweenbreast size dissatisfac-tionandbreastawarenessinparticulardeservesgreaterattention acrossnations. For example, ifscholars areto design interven-tionstopromoteimprovedbreastawarenessbasedonreducing breastsizedissatisfaction,itwillﬁrstbeimportanttoshowthat theassociationsbetweenthesevariablesarerobustacrossnational groups.However,cross-nationaldifferencesinculturalbeliefsand attitudes(e.g.,bodyorbreast embarrassment,lackof a preven-tivehealthorientation,andfatalism;forareview,seeLee,2015) mayattenuateanyassociationbetweenbreastsizedissatisfaction andbreastawarenessinsomenationalgroups.Forthesereasons,

weexaminedassociationsbetweenbreastsizedissatisfactionand keyoutcomevariables inthepresentstudy,namelyweightand appearancedissatisfaction, psychologicalwell-being, and breast awareness.

1.4. TheBreastSizeSatisfactionSurvey

Whilethenumberofstudiesfocusedonbreastsize dissatisfac-tionhasgrown,animportantlimitationofthisresearchisthatithas primarilyconsideredtheexperiencesofwomeninNorthAmerica andWesternEurope,totheexclusionofwomeninotherpartsof theworld.Thisisnotablebecauseitshouldnotbeassumedthatall populationswillsharesimilarexperiencesoftheirbreastsorthat ﬁndingsfromWestern,educated,industrialised,rich,and demo-cratic(WEIRD)societieswillgeneralisetoothersettings(Henrich,

Heine,&Norenzayan,2010).Moreover,as discussedby Swami,

Cavelti et al.(2015), there areadditional limitations that

ham-per our understanding of women’s breasted experiences, even in WEIRD populations, including wide variation in the manner inwhichbreastsizedissatisfactionisoperationalised,theuseof measuresofbreastsizedissatisfactionwithunknownoruntested psychometricproperties,andarelianceonsamplesofcollege-aged women.Inshort,thereisasyetnosystematicinvestigationofbreast sizeidealsandbreastsizedissatisfactionacrossalargeanddiverse setofnations,andscholarshavecalledforfurtherworkthatfocuses onwomen’sbreastedexperiences(Gillen&Markey,2019;Prieler

&Choi,2014).

Toaddresstheseissues,wereportontheﬁndingsoftheBreast SizeSatisfactionSurvey(BSSS),whichinvolved18,541womenin 61researchsitesacross40nations completingavalidated mea-sure of perceptual breast size dissatisfaction (i.e.,current-ideal breastsizediscrepancy;Swami,Caveltietal.,2015).Thisallowed us to examine the extent to which there exist cross-national differencesinratingsofidealbreastsizeand breastsize dissat-isfaction.Basedonpreviouscross-nationalresearchonbodyimage (e.g.,Swami,Fredericketal.,2010),weexpectedtheretobe sig-niﬁcant cross-national differences across both scores, but also expectedthose differencestobenegligible-to-small instrength (Hypothesis1).Thisalsomirrorstheargumentspresentedabove, which suggestthatbreast sizeidealsare becomingincreasingly homogenisedoruniformacrosstheglobeasaresultofthe pro-cessesofglobalisationandmodernisation.Inadditiontotestingfor thesecross-nationaldifferences,theBSSSdatasetalsoallowedusto examineantecedentsandoutcomesofbreastsizedissatisfaction.

In terms of antecedents, we includedvalidated measuresof theBigFivepersonalityfacetsandnovelmeasuresofexposureto Westernandlocalmedia,whichweexaminedforcross-national measurement invariance here. In addition, we also included measures of financial security and urbanicity as proxies for socioeconomicstatus and, for exploratorypurposes,participant age. In terms of outcomes,we includedvalidated measures of appearanceandweightdissatisfaction,breastawareness(breast self-examinationfrequency,confidenceindetectingbreastchange, anddelayinseekingprofessionalhelpfollowingbreastchange), and psychological well-being (subjective happiness and self-esteem).Multilevelmodellingwasusedtoexaminetherobustness of these antecedents and outcomes of breast size dissatisfac-tion across nations. In terms of antecedents, we hypothesised thatpersonality(specifically,higherNeuroticism),greater expo-suretoWesternand localmedia,greaterfinancialsecurity,and higherurbanicitywouldbesignificantlyassociatedwithgreater breast sizedissatisfaction (Hypothesis2).Interms ofoutcomes, wehypothesisedthatgreaterbreastsizedissatisfactionwouldbe significantly associated with greater appearancedissatisfaction, greaterweightdissatisfaction,lowerbreastawareness(i.e.,lower breastself-examinationfrequency,lowerconfidenceindetecting

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Fig.1. SchematicRepresentationoftheHypothesisedAssociationsbetweenAntecedentsandOutcomesofBreastSizeDissatisfaction.Note:Personality=Opennessto Experience,Conscientiousness,Agreeableness,Extraversion,andNeuroticism;BSE=BreastSelf-Examination;Conﬁdence=ConﬁdenceinNoticingBreastChange.

breastchange,andgreaterdelayinseekingprofessionalhelp fol-lowing breast change), lowerhappiness, and lower self-esteem (Hypothesis3).Fig.1presentsaschematicrepresentationofthese hypothesisedassociations,whichweexpectedtobestableacross allnationssurveyedintheBSSS.

2. Method

2.1. Breastsizesatisfactionsurveyoverview

ThedatareportedherewerecollectedaspartoftheBSSS,a col-laborativeresearchprojectinvolving104scientistsworkingacross 61researchsitesin40nations.Acallforcollaboratorswasplaced onasocialnetworkingsiteforscientistsinSeptember2017,sent outtopotentialcollaboratorsinternationallybythefirstauthor, anddisseminatedopportunisticallyanddirectlytointerested par-tiesuntilDecember2018.TheBSSSdataset,therefore,represents sitesthatwereselectedonaconveniencebasis.Thisisreflected inthefactthat,ofthe61researchsites,mostwereinAsia(23) andEurope(22).Incontrast,therewerefewerresearchsitesin SouthAmerica(8),NorthAmerica(5),Africa(2),andAustralia(1). OnceacollaboratoragreedtobeinvolvedintheBSSS,theywere expectedtoapplyforlocalethicsapprovalwhererequired, trans-late(wherenecessary)andadapt theBSSSsurveyfor localuse, recruitaminimumof200women(relaxedinfourcases:Koforidua, Osaka,Rijeka,andTelAviv)fromthecommunity(relaxedinfour cases–Germany,Hungary,theNetherlands,andPeru–where par-ticipantswererecruitedonline)tocompletetheBSSSsurvey,and returnthedatatothefirstauthorbyApril2019.

2.2. Participants

The BSSS dataset included a total of 18,541 women from 40 nations, ranging in age from 19 to 94 years (M=34.19, SD=13.71)andinself-reportedbodymassindex(BMI)from12.04 to49.78kg/m2_(M₌_23.57,_SD₌_4.54)._In_terms_of_{ethnic/racial}

affil-iation,78.9%self-reportedasbeingmembersoftheethnic/racial majorityoftheirrespectivenationsand9.6%asmembersofan ethnic/racialminority,whereas 11.5%wereunsure.Interms of educationalattainment,0.7%hadnoformaleducational qualifi-cation,4.0%hadcompletedprimaryeducation,21.8%secondary education,21.6%werestillinfull-timeeducation,30.8%hadan undergraduatedegree,16.6%apostgraduatedegree,and4.5%had someotherqualification.Interms oftheircurrentplaceof resi-dence,31.0%ofparticipantslivedinacapitalcity,14.3%incapital citysuburbs,26.1%inaprovincialcity(morethan100,000

resi-dents),16.7%inaprovincialtown(morethan10,000residents), and11.8%inruralareas.Withregardstotheirﬁnancialsecurity, 22.5%ofparticipantsreportedthattheyfeltlesssecurerelativeto othersoftheirownageintheircountryofresidence,57.8%equally secure,and19.8%moresecure.

Thelistofresearchsitesandnations,includingnation-speciﬁc sample characteristics are reported in Table 1 (for individual research sites and associated sample sizes, seeSupplementary Materials). Nations differed with a large effect size in mean age, F(39, 17441)=73.92, p< .001, ␩2₌_.14 _(lowest: _Malaysia,

highest: Norway), with a medium effect size in mean BMI, F(38, 18088)=46.49, p< .001, ␩2₌_.09 _(lowest: _China, _highest:

Egypt), and with a small-to-medium effect size in mean self-rated ﬁnancial security, F(39, 18422)=21.28, p< .001, ␩2₌_.04

(lowest:Brazil,highest:UnitedArabEmirates).Therewerealso signiﬁcantbetween-nationdifferencesinthedistributionof par-ticipants by ethnicity status, ␹2_(78, ₁₈₃₆₇₎₌_2875.01, _p_< _.001,

W=.40(lowestafﬁliationtomajority:CostaRicaandIndia, high-est:ThailandandCroatia),education(secondary/tertiaryvs.other), ␹2_(39,₁₈₄₃₂₎₌_1891.20,_p_<_.001,_W₌_.32_(lowest:_China,_highest:

Austria),andurbanicity(urbanvs.rural),␹2_(39,₁₈₄₆₈₎₌_1871.53,

p<.001,W=.32(lowest:Ireland,highest:Colombia,Pakistan,and Peru).

2.3. Measures

2.3.1. Breastsizedissatisfaction

AllparticipantswereaskedtocompletetheBreastSizeRating Scale(BSRS;Swami,Caveltietal.,2015),afiguralratingscale con-sistingof14computer-generatedimagesofwomenwithincreasing breastsize.Imageswerepresentedingreyscaleandwithoutthe appearanceoffacialfeaturessoastominimisetheimpactofthese featuresonratings.Participantswereaskedtoratetheimagethat mostcloselymatchedtheircurrentbreastsizeandtheimagethey wouldmostliketopossess,withresponsesmadeona14-point scale(1representingthefigurewiththesmallestbreastsize,14 rep-resentingthefigurewiththelargestbreastsize).Anindexofbreast sizedissatisfactioncanbecomputedasboththeabsolutedifference betweenidealandcurrentbreastsizeratings(sothathigherscores reflectgreaterbreastsizedissatisfactionregardlessofthedirection ofthisdissatisfaction)orassignedscores(sothatnegativevalues representadesireforsmallerbreastsandpositivevaluesrepresent adesireforlargerbreasts).Bothscoreswereusedinour analy-ses,assignpostedbelow.ScoresderivedfromtheBSRShavebeen showntohavegoodconstructvalidity,acceptabletest-retest

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relia-Table1

SampleDescriptionsofDatafromtheBreastSizeSatisfactionSurvey.

Nation n Meanage Meanbodymass

index %Ethnic/racial majority %Secondary/ tertiary education %Urban residence Meanﬁnancial security

%Preferenceforlarger breasts/smaller breasts/satisﬁedwith currentbreastsize

Australia 201 36.30(13.95) 24.54(4.87) 86 90 97 2.17(0.57) 43/28/28 Austria 229 27.20(11.28) 22.56(3.57) 83 91 87 2.13(0.69) 45/24/31 Brazil 822 31.74(10.85) 24.36(4.12) 53 70 95 1.68(0.64) 51/21/28 Canada 463 38.19(15.46) 25.19(5.30) 79 75 90 2.21(0.64) 41/30/29 China 897 24.16(9.19) 20.45(2.73) 91 27 98 1.92(0.56) 73/14/13 Colombia 483 37.72(13.83) 24.62(3.68) 77 64 100 1.91(0.68) 33/11/57 CostaRica 225 34.05(13.16) 24.95(4.65) 44 81 96 2.09(0.65) 41/23/36 Croatia 414 33.62(13.77) 22.81(3.28) 94 69 89 2.16(0.59) 55/17/28 Cyprus 284 34.26(12.21) 23.31(4.67) 90 78 83 1.89(0.64) 41/22/37 Egypt 200 34.27(9.43) 29.07(6.17) 87 77 99 2.13(0.70) 52/36/13 Germany 387 27.21(13.40) 21.97(3.06) 87 83 74 2.19(0.65) 54/20/26 Ghana 174 28.18(9.37) 24.68(6.87) 43 79 94 2.11(0.73) 33/16/52 Greece 1888 34.74(13.15) 23.41(4.05) 81 64 92 1.93(0.62) 47/23/30 Hungary 831 28.50(11.60) 23.52(4.84) 88 54 82 2.02(0.64) 51/19/30 India 441 38.54(9.19) 24.63(4.26) 43 72 75 1.98(0.73) 42/40/18 Indonesia 266 28.77(8.86) 22.66(3.94) 89 72 85 2.04(0.59) 51/19/30 Iran 946 33.92(8.86) 24.71(4.55) 94 89 98 2.02(0.63) 34/33/33 Ireland 219 34.11(16.51) 24.19(4.59) 71 66 36 1.90(0.62) 41/34/26 Israel 187 36.65(13.85) 23.03(3.43) 82 80 83 2.19(0.63) 37/27/36 Italy 747 39.34(13.76) 22.88(4.24) 87 75 89 1.94(0.58) 49/23/29 Japan 423 39.86(17.88) 20.98(2.77) 82 53 94 2.07(0.53) 70/20/10 Lebanon 406 34.87(10.84) 24.45(4.01) 48 90 98 1.79(0.62) 56/20/24 Malaysia 720 22.50(4.81) 22.25(4.67) 71 79 82 1.75(0.66) 55/23/22 Netherlands 512 43.34(15.21) 25.68(5.12) 83 65 69 2.00(0.64) 34/26/40 Norway 254 49.94(15.05) 25.26(4.28) 88 82 71 2.27(0.61) 28/28/44 Pakistan 419 37.68(14.18) 23.55(4.60) 79 85 100 2.20(0.76) 30/49/21 Paraguay 202 37.45(14.32) 26.15(4.91) 80 44 83 2.10(0.70) 31/19/51 Peru 232 31.89(11.65) 24.00(3.56) 47 54 100 2.03(0.69) 51/16/32 Philippines 200 42.29(21.04) N/A 77 85 94 1.93(0.80) 45/22/34 Poland 999 33.33(13.61) 23.21(4.00) 90 71 76 1.92(0.53) 50/22/28 Portugal 203 41.99(15.23) 24.26(3.99) 78 63 96 1.93(0.62) 33/21/45 Romania 428 30.49(13.64) 22.56(5.07) 62 39 79 1.95(0.66) 54/17/29 Serbia 211 34.28(12.90) 22.55(3.86) 83 73 95 2.07(0.70) 50/15/36 Slovenia 343 35.93(13.23) 23.36(3.83) 82 85 72 1.94(0.47) 50/20/31 Spain 712 37.94(14.12) 23.49(4.44) 83 70 72 1.98(0.64) 36/19/45 Thailand 644 29.59(9.24) 22.56(4.89) 95 70 90 1.87(0.59) 60/17/23 Turkey 211 34.13(11.38) 23.65(4.54) 71 64 99 1.69(0.62) 46/26/28 UAE 205 26.71(9.78) 24.23(4.84) 75 64 89 2.30(0.68) 52/28/20 UK 204 36.70(14.62) 24.01(2.75) 90 77 94 1.86(0.73) 56/32/25 USA 699 38.51(14.85) 24.88(5.39) 69 82 91 1.96(0.77) 43/32/25 Total 18541 34.11(13.39) 23.58(13.69) 79 69 88 1.97(0.65) 48/23/30

Note.Numbersaremeansandstandarddeviations(inparentheses),andpercentages(roundedtothenearestinteger)whereindicatedotherwise.Numberswerebasedon allavailabledata.UAE=UnitedArabEmirates,UK=UnitedKingdom,USA=UnitedStatesofAmerica;%Preferenceforlargerbreasts/smallerbreasts/satisﬁedwithbreast size=percentagesofparticipantswithsignedbreastsizedissatisfactionscores>0/<0/=0.

bilityupto3months,andadequatepatternsofconvergentvalidity

inwomen(Junqueiraetal.,2019;Swami,Caveltietal.,2015).

2.3.2. Appearanceandweightdissatisfaction

FollowingFredericket al.(2016),participantswereaskedto respondtotwoitemsaskingabouttheirsatisfactionwith physi-calappearanceandweight,respectively(1=Extremelydissatisfied, 7 =Extremelysatisfied). Althoughsingle-item measuresof body imageareunlikelytocapturethecomplexityofbodyimage con-structs, theirscores neverthelesspresent adequate evidence of convergentvalidity(Sandhu&Frederick,2015).Foranalytic pur-poses,scores onboth itemswere reverse-codedsothat higher scoresreflectedgreaterdissatisfactionwithone’sappearanceand weight.

2.3.3. Personality

ParticipantswereaskedtocompletetheFive-ItemPersonality Inventory(FIPI;Gosling,Rentfrow,&Swann,2003),which mea-surestheBigFivepersonalityfacetsofOpennesstoExperience(“I seemyselfasopentonewexperiences”),Conscientiousness(“_._._.as dependableandself-disciplined”),Extraversion(“...asextroverted andenthusiastic”),Agreeableness(“...aswarmandsympathetic

toothers”),andNeuroticism(“...anxiousandeasilyupset”)with oneitemforeach facet.Allitemswereratedona 5-pointscale rangingfrom1(stronglydisagree)to5(stronglyagree).Although therearelimitationstomeasuringtheBigFive facetsusing sin-gleitems,Gosling etal.(2003)reportedthat scoresontheFIPI haveadequatelevelsofconvergentvalidity(e.g.,signiﬁcant correla-tionswithothermeasuresoftheBigFive)andadequatetest-retest reliabilityuptotwoweeks.

2.3.4. Mediaexposure

To measureexposureto Westernand localmass media,we adaptedthemediaexposurescaledevelopedandusedbySwami,

Fredericketal.(2010).Initsoriginalversion,thescaleincluded8

itemsthataskedaboutfrequencyofexposuretoWestern(4items) andlocal(4items)televisionshows,movies,magazines,andmusic, butwereplacedthetwomusicitemswithtwoitemsabout expo-suretoInternetsitesin thepresentstudy.Allitemswererated ona5-pointscale(1=Lessthanonceamonth,2=Onceortwicea month,3=Onceaweek,4=Severaltimesaweek,5=Everyday).The dimensionality,internalconsistency,andmeasurementinvariance ofscoresonthismeasurearereportedintheResults.

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2.3.5. Breastawareness

Toprovideanindexofbreastawareness,wefollowedSwami

andFurnham(2018)inusingthreeitemsfromtheBreast

Mod-uleoftheCancerAwarenessMeasure(BCAM;Linselletal.,2010). TheBCAMisaself-reportedmeasureofmultipledomainsofbreast cancerawarenesswithadequateconstructvalidityandtest-retest reliabilityupto2weeks.Thefirstitem askedaboutbreast self-examinationfrequency(“Howoftendoyoucheckyourbreast?”) withresponsesmadeona4-pointscale(1=Rarelyornever,2=At leastonceeverysixmonths,3=Atleastonceamonth,4=Atleast onceaweek).Linselletal.(2010)suggestedthatwomenweremore likelytobebreastawareiftheyengagedinbreastself-examination atleastonceaweekoronceamonth.Theseconditemaskedabout participants’confidenceinnoticingachangeintheirbreasts(“Are youconfidentyouwouldnoticeachangeinyourbreasts?),with responsesmadeona 4-pointscale (1=Notatall confident,2= Slightlyconfident,3=Fairlyconfident,4=Veryconfident).Thefinal itemaskedparticipants,usinganopen-endedformat,howsoon theywouldcontactahealthprofessionaliftheynoticedachange intheirbreasts(“Ifyoufoundachangeinyourbreasts,howsoon wouldyoucontactyourdoctor?).Responsestothequestionwere scoredbasedona7-pointscaledevelopedbySwamiandFurnham

(2018):1=Immediatelyorassoonaspossible,2=Withinafewdays,

3=Withinaweek,4=Withinamonth,5=Withinthreemonths,6 =Delayaslongaspossible,7=Wouldnotseedoctor.Researchers ineachsitescoredparticipants’responsesascloselyaspossible totheseresponseoptionsandinsomecasesdiscussed categori-sationswithotherscientistsunafﬁliatedwiththeprojectand/or withtheﬁrstauthor. For comparativepurposes, womenin the UnitedKingdomareencouragedtocontacttheirdoctorora health-careprofessionalassoonaspossibleupondiscoveringachangein theirbreasts,asearlydetectionincreasesthelikelihoodofpositive outcomes(NationalHealthService,2015).

2.3.6. Psychologicalwell-being

Twosingle-itemmeasureswereusedtoassessdistinctaspects ofpsychologicalwell-being.First,weaskedparticipantsto com-pletetheGlobalHappinessItem(Bradburn,1969),whichprovides an index of subjectively-assessed happiness(“Taking all things together,howwouldyousaythingsarethesedays?”).Theitem wasratedona3-pointscale(1=Nottoohappy,2=Prettyhappy,3= Veryhappy)andscoreshavebeenshowntohaveadequate conver-gentvalidity(e.g.,Lyubomirsky&Lepper,1999;Swami,2008).The seconditemwastheSingle-ItemSelf-EsteemScale(SISE;Robins,

Hendin,&Trzesniewski,2001),inwhichparticipantsareaskedto

ratethestatement“Ihavehighself-esteem”ona7-pointscale(1 =Notverytrueofme,7=Verytrueofme).SISEscoreshavebeen showntohaveadequateconstructvalidity(Robinsetal.,2001).

2.3.7. Socioeconomicstatus

Becauseunderstandingsofsocioeconomicstatusarelikelyto varybothwithinandacrossnations,andduetodifﬁcultiescreating acommonmetricofsocioeconomicstatusacrossnations,weused twoproxiesforsocioeconomicstatus inthepresentwork.First, followingSwami,Kannanetal.(2012),weaskedparticipantsto self-reporthowﬁnanciallysecuretheyfeltrelativetoothersoftheir ownageintheircountryofresidence(1=Lesssecure,2=Same,3 =Moresecure).Second,weaskedparticipantsabouttheircurrent placeofresidence(i.e.,urbanicity),withresponseoptionsadapted

fromPedersenandMortensen(2001)asfollows:Capitalcity,Capital

citysuburbs,Provincialcity(morethan100,000residents),Provincial town(morethan10,000residents),andRuralareas.Responseoptions werecollapsedintourbanversusruralfordescriptivepurposesat thenationallevelandwereassignedvalues1–5(intheaboveorder) forfurtherstatisticalanalysis.

2.3.8. Demographics

Participantswereaskedtoprovidetheirdemographicdata con-sisting of age, height,and weight using open-ended questions. Heightandweightwererecodedintokilogramsandmetres,and wereusedtocomputeself-reportedBMIaskg/m2_._{Self-reported}

height and weight data are strongly correlated with measured

data(Spencer,Appleby,Davey,&Key,2002)andwereincludedin

thepresentstudyfordescriptivepurposes.2_Improbable_BMI

val-ues(<12or>50kg/m2_;_Swami,_Weis,_Barron,_&_Furnham,₂₀₁₈₎

werediscarded(0.1%ofthetotaldataset).Participantsalso indi-catedtheirhighesteducationalqualiﬁcationbyselectingoneof several options presented (No formal education, Primary educa-tion,Secondaryeducation,Stillinfull-timeeducation,Undergraduate degree, Postgraduate degree, Other). Response options were col-lapsedintosecondary/tertiary(Secondaryeducation,Undergraduate degree,Postgraduatedegree)versusother(remainingcategories)for descriptivepurposesatthenationallevel.Finally,toensure com-parability of ethnicor racial backgrounds acrossresearchsites, participantswereaskedtoself-describetheirethnic/racial afﬁlia-tionbyselectingoneofthreepresentedoptionsrelativetotheir nationofresidence(Ethnic/racialmajority,Ethnic/racial minority, Notsure).

2.4. Testadaptation

WhereEnglishwasnottheprimarylanguageorlinguafrancain anation,themeasuresincludedintheBSSSsurveyweretranslated intotheappropriatelocallanguage(seeSupplementary Materi-alsforthelistoflanguages).ThiswasdoneusingBrislin’s(1970)

back-translationtechnique,whichusesaniterativeprocessof inde-pendentforward-andback-translationbyindependentbilingual translators.Specifically,abilingual translatorfirstblindly trans-latedthe measuresincludedin theBSSS questionnaire – along withinstructions,responsecategories,aninformationsheet,and aninformedconsentform–fromEnglishtothelocallanguage.A secondbilingualtranslatorthenback-translatedthematerialfrom thelocallanguagetoEnglish.Thetwoversionsofthematerials werecompared for equivalence and, where issues were raised, thesewerediscussedwiththefirstauthorandresolvedthrough consensus.In practice,therewere veryfew translationalissues encountered.Alltranslationsareavailablefromthefirstauthor. 2.5. Procedures

Ethicsapprovalfortheoverallprojectanddatamanagement wasobtainedfromthedepartmentalethicscommitteeatAnglia Ruskin University (approval number: ESH17-006). In addition, mostBSSScollaboratorsobtainedethicsapprovalfromlocalethics committeesorInstitutionalReviewBoards.Threeexceptionsto thisoccurredinAustria,CostaRica,andGermany,wherenational lawsdidnotrequireethicsapproval.Intheseand allcases,the projectwasconducted inaccordance withtheprinciplesofthe Declaration of Helsinki (6th _revision, ₂₀₀₈₎ _and _following _local

institutionalguidelines.OncetheBSSSinstrumentshadbeen trans-latedand/oradaptedforlocaluse,collaboratorsrecruitedsamples ofwomenfromthecommunityusingdirectapproachesinareas ofcongregateactivityineachresearchsite.Attemptsweremade toreduceselectionbiasbysamplingatdifferenttimesoftheday andfromdifferentsitesofcongregateactivity,andinsomecases this method wassupplemented withadvertisements to poten-tial participantsplaced in local media. Four exceptions to this generalrecruitmentmethodoccurredinGermany,Hungary,the

2_There_were_{difﬁculties}_in_{understanding}_and_completing_height_and_weight_data

(10)

Netherlands,andPeru,wheredatawerecollectedonline follow-ingbest-practiceguidelines(e.g.,Meade&Craig,2012).Inclusion criteriaforallresearchsitesincludedbeingﬂuentinthelocal lan-guageandbeing18yearsofageorolder.Potentialparticipantswere givenaninformationsheet,whichprovidedbriefdetailsaboutthe studyandanestimatedsurveycompletiontime(10min). Partici-pantswhoagreedtotakepartprovidedwritteninformedconsent or digital informed consent for online studies. Thesurvey was anonymous and participantstook partvoluntarily and without remuneration.Allparticipantsreceivedwrittendebrieﬁng infor-mationupon returnof completedquestionnaires.Alldatawere collectedin2018-2019.

2.6. Analyticstrategy

Allwithin-nationdatawerepooledsothatanalysesproceeded atthelevel ofthe nation,ratherthan individualresearchsites. AnalysisoftheBSSSdatathenproceededinfourstages.First,we investigatedcross-nationaldifferencesincurrentandidealbreast size,andinabsolutemeanbreastsizedissatisfaction,using analy-sesofvariance,andreportonthepercentagesofparticipantswith apreferenceforlargerbreasts,smallerbreasts,andnodiscrepancy betweenidealandcurrent breastsizes(Hypothesis1).Wethen checkedwhetheridealbreastsizeratingsweresigniﬁcantly asso-ciatedwithsocioeconomicstatus(urbanicityandﬁnancialsecurity) acrossnationsusingamultilevelmodel(Davidovetal.,2018;van

derVijveretal.,2008)withthetwovariablesaslevel-1predictors

andnationasalevel-2predictor.Interceptswereallowedtovary betweennations.Alllevel-1predictorsweregrandmean-centred andMplus8.2wasutilisedforanalyses,usingMonteCarlo integra-tiontoevaluatethelikelihoodfunction(Heck&Thomas,2015).We reportontheoutcomevarianceexplainedbythemodelonlevels-1 and-2(R12andR22)usingapproximateformulaeprovidedbyBryk

andRaudenbush(1992),whichcomparesthemodelofinterestto

abaselinemodelandincludesonlyrandomintercepts.

Second,todeterminewhetherthemediaexposureitemsformed one-dimensionalscales(separatelyforWesternandlocalmedia), multi-groupmodelswerefittedontheitemsassessingmedia expo-sure,testing for measurement invarianceof theseitems (Chen, 2008).Forthisanalysis,datafromAustriaandGermany,Croatia andSlovenia,theUnitedKingdomandIreland,andJapanandChina, respectively,hadtobemergedinordertomakecomputations fea-sible(thatis,wemergeddataacrossnationswithsimilarcultural backgroundsandthatweregeographicneighbours).Wefirst exam-inedconfiguralinvariance(i.e.,whetherscoresonthe4itemsof eachmeasureformedone-dimensionalscoresineverynation)and thenfullmeasurementinvariance(i.e.,whetheritemparameters –seebelow–wereidenticalacrossnations).Iffullmeasurement invariancewasnotobserved,itemparameterswererelaxedin indi-vidualnationstotestforpartialmeasurementinvariance(which meansthattheparametersofsome,butnotall,itemswereequal acrossnations).Items weretreated asordered-categorical vari-ables,usingthematrixofpolychoriccorrelationsandtheWLSMV estimator(weightedleastsquareestimatorusingadiagonalweight matrixwithstandarderrorsandmean-andvariance-adjusted chi-squareteststatisticthatuseafullweightmatrix)inMplus8.2. Missingdata(0.4%)weretreatedusingfullinformationmaximum likelihood(FIML)estimation,whichissuperiortoothermethods fordealingwithmissingdata(Enders&Bandalos,2001).Eachitem wasmodelledwithtwo sets of parameters:one discrimination parameter(itemloading)andm–1(m=numberofitemresponse categories)thresholdparameters,whichdescribetheprobability foreachresponseoption.Setsofitemparameterswerefreedin tandemforpartialmeasurementanalyses(Sass,2011).Wereport ␻totalasmeasureofreliability(Dunn,Baguley,&Brunsden,2014) forthemanifestscoresofthetwomediaexposurescales.However,

standardisedfactorscoresofWesternandlocalmediaexposure wereusedforfurtheranalyses.

Fortheevaluationofmodelﬁt,thecomparativeﬁtindex(CFI), the Tucker-Lewis index (TLI), and the standardised root mean squareresidual(SRMR)wereused,utilisingguidelinesprovidedby

HuandBentler(1999)andSchermelleh-Engel,Moosbrugger,and

Müller(2003))(CFI,TLI:>.90acceptableﬁt,>.95goodﬁt;SRMR:

<.10acceptablefit,<.05goodfit).WLSMVestimatesthemodel degreesoffreedom(df)fromthedata(Muthén,duToit,&Spisic, 1997);thedfarenotderivedbycomparingthenumberofavailable andestimatedparameters,asinmaximumlikelihood(ML) estima-tion.CFIandTLIusethedftopenaliseformodelcomplexity(the TLImorestronglythantheCFI).UnderMLestimation,thisentails TLI<CFI.However,inthemulti-groupcontextofthepresentstudy, estimationofdfbyWLSMVcouldeitherexcessivelydisadvantage TLItoCFIvalues (especiallyinmodelswitha largernumberof estimatedparameters;i.e.,configuralinvariancemodels)or exces-sivelydisadvantageCFItoTLIvalues (especiallyinmodelswith fewestimatedparameters,suchasfullandpartialmeasurements models,leadingtoCFI<TLI,whichisnotpossibleunderML estima-tion).Thus,modelfitwasconsideredacceptableiftheSRMRand eitherCFIorTLIvaluesindicatedanacceptablefit.Forthe vari-ousmeasurementinvarianceanalyses,modelfitwasinterpreted independently,astheWLSMVestimatordoesnotallowfordirect comparisonsbetweenmodels basedonindices likeCFI (Sass, 2011);becauseofthelargesamplesizesinvolved,wealsodidnot relyon␹2_tests,_as_these_tend_to_become_too_liberal_(rejecting_the

nullhypothesistoooften)withincreasingN(Cheung&Rensvold,

1999).

In the third stage of analysis, using multilevel modelling, we examinedassociations of potential antecedents withbreast sizedissatisfaction,namelypersonality(OpennesstoExperience, Conscientiousness, Extraversion, Agreeableness, Neuroticism), Westernandlocalmediaexposure(factorscoresfromthe afore-mentionedanalyses),socioeconomicstatus(urbanicity,financial security), andage(level-1predictors), usingnationasa level-2 predictorandallowingforrandomnessin theinterceptand the slopes of Western and local media exposure (i.e.,allowing for differencesbetweennationsintheseparameters;slopesand inter-ceptswereallowedtocorrelate)(Hypothesis2).Fig.1 presents a schematic representation of this model. Multilevel modelling wasutilisedbecauseofthenestednatureofthedata(participants withinnations)(Davidovetal.,2018;Hox,1998).Furthermore,it allowedtestingofwhetherassociationsofmediaexposurewith breastsizedissatisfactionvariedacrosscountries.Guidedbythe resultsofthisinitialmodel,level-1predictorswerethenremoved iftheywerenotsignificantlyassociatedwithbreastsize dissat-isfaction,andslopesofWesternandlocalmediaexposurewere estimatedasfixedeffectsiftheseparametersdidnotexhibit sig-nificantamountsofrandomnessaccordingtolikelihoodratio(LR) tests(Hox,1998).Theremainingsetoflevel-1predictorsservedin theanalysesofthefourthstage.

Inthefourthstageofanalysis,theﬁnalmodelofthethirdstage incorporatedappearanceandweightdissatisfaction,breast aware-ness,andpsychologicalwell-beingpotentialoutcomesofbreast sizedissatisfaction(Hypothesis3)(seeFig.1).Conceptually,we testedinthismultilevelmodelwhetherbreastsizedissatisfaction mediatedtheeffectsoftheantecedentsontheseoutcomes. Differ-encesbetweennationsintheinterceptsofoutcomeswereallowed forinthismodel.Fortheanalysesinthethirdandfourthstages, alllevel-1predictorsweregrandmean-centred(Hofmann&Gavin, 1998)3 _._Mplus_8.2_was_utilised,_using_Monte_Carlo_integration_to

3_Grand_{mean-centering}_subtracts_the_grand_mean_of_a_predictor_using_the_mean