Psycho-Oncology

Psycho-Oncology (2013)
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.3271

Exploring the influence of gender-role socialization and

objectified body consciousness on body image disturbance in
breast cancer survivors
Virginia M. Boquiren1*, Mary Jane Esplen1,2,3, Jiahui Wong2,3, Brenda Toner2,5 and Ellen Warner4
1
Behavioural Sciences & Health Research Division, Toronto General Hospital, Toronto, ON, Canada
2
Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
3
de Souza Institute, Toronto, ON, Canada
4
Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
5
Centre for Addiction and Mental Health, Toronto, ON, Canada
*Correspondence to: Abstract
Behavioural Sciences & Health
Research Division, Toronto Objective: This study aimed to explore the relationships between gender-role socialization, objectified
General Hospital, 200 Elizabeth body consciousness and quality of life in breast cancer (BC) survivors with body image (BI) disturbance
St., 9EN-243, Toronto, ON, post-treatment.
Canada M5G 2C4. E-mail: Methods: A total of 150 BC survivors participating in an ongoing randomized clinical trial of a group
vboquire@uhnresearch.ca psychotherapy intervention for BI-related concerns completed a baseline battery of standardized mea-
sures including the following: Body Image Scale (BIS), Body Image after Breast Cancer Questionnaire
(BIBCQ), Objectified Body Consciousness Scale (OBCS) measuring Body Shame and Surveillance,
Gender-Role Socialization Scale (GRSS) measuring internalization of traditional gender roles and
attitudes and the Functional Assessment of Cancer Therapy-Breast Quality-of-Life Instrument
(FACT-B). Correlational analyses were conducted between the two BI questionnaires, the two primary
psychosocial variables GRSS and OBCS, and FACT-B. Path analysis was conducted on a proposed
theoretical model delineating pathways between the two primary psychosocial variables and BI
disturbance.
Results: Significant positive correlations were found between the two BI scales and (a) GRSS (average
r = 0.53, p < 0.000), (b) Body Shame (average r = 0.53, p < 0.000) and Surveillance (average r = 0.48,
p < 0.000). The BIS and BIBCQ were negatively associated with the FACT-B (r = 0.62, 0.73,
respectively; p < 0.000). Results from the path analysis demonstrated support for the proposed model.
Conclusion: Breast cancer survivors who endorsed greater internalization of traditional gender
roles and attitudes, who engaged in greater self-surveillance and experienced greater body shame,
reported greater BI disturbance and poorer quality of life post-treatment. Women with these predispo-
Received: 24 August 2012 sitions are likely to be more vulnerable for psychological distress and may experience poorer adjustment
Revised: 26 January 2013 after BC treatment.
Accepted: 4 February 2013 Copyright © 2013 John Wiley & Sons, Ltd.

Introduction her identity as a woman when coping with the physical

One of the most difficult and often persistent challenge
facing breast cancer (BC) survivors is coping with the
various changes to their physical appearance and function
resulting from treatment. Side effects from surgery, chemo-
therapy and radiotherapy can be significantly disfiguring,
including deformation and/or loss of breast(s), visible scar-
ring, hair loss and lymphedema. Side effects from hormonal
and maintenance regimens (e.g. premature menopause and
infertility) can prolong or exacerbate those arising from
previous treatment. A universal experience of BC survivors
is one of profound loss, of their body’s physical integrity
and functioning, perceived femininity, self-esteem and
confidence [1,2]. Not surprisingly, these considerable phys-
ical and physiological alterations can dramatically affect a
woman’s body image (BI). Moreover, the BC experience
can powerfully challenge core values and beliefs, including
those related to BI. These values and beliefs frequently need
to be redefined and integrated into a survivor’s new sense of
self [3]. It is not uncommon for a BC survivor to question
aftermath of treatment.
Body image is conceptualized as a multifaceted
construct, defined as the mental representation of one’s
body, thoughts and feelings about one’s physical appear-
ance, attractiveness and competence, as well as one’s
perceived state of overall health, wholeness, functioning
and sexuality [1,4–7]. A highly subjective experience, BI
is a dynamic interaction between this personal expression
of being and the social world [6]. For many BC survivors,
dissatisfaction with one’s ‘new’ body has detrimental
influences over many psychosocial domains. BI distur-
bance following treatment has been shown to be consis-
tently associated with mental distress, anxiety, reduced
physical health, sexual dysfunction and impaired quality
of life [4,8–12]. Although a majority of BC survivors do
eventually return to baseline or near-baseline levels of
physical, role and emotional functioning, a significant
subset continue to report BI-related difficulties years
post-treatment [1,13,14]. The diversity in treatment type
composing this subset reflects the disparity in findings

Copyright © 2013 John Wiley & Sons, Ltd.

 V. M. Boquiren et al.

regarding adjustment, with some studies failing to find a object to be watched (i.e. self-objectification) underlies
difference between treatment groups [15–19], whereas others the construct of objectified body consciousness [34–37].
demonstrating poorer adjustment for women who have According to theories exploring self-objectification [38–40],
undergone mastectomy versus lumpectomy [1,11,20–23]. the sociocultural contexts that women inhabit instill
This discrepancy suggests that other factors impacting BI a tendency to internalize an ‘outsider’s gaze’ on the phys-
in BC survivors should be considered, in addition to surgery ical self, which in turn promotes habitual body monitor-
type and presence/absence of a breast. ing, self-surveillance and evaluation. Individuals with a
greater predisposition to self-objectify show a chronic
Gender-role socialization preoccupation with their physical appearance, with the
belief that their bodies will be observed and evaluated
One psychosocial factor believed to influence BI is the
by others [40]. Higher self-objectification has been shown
gender-role socialization of ‘standards’ regarding physical
to be associated with disordered eating [41–43], depres-
appearance and behaviour. Direct and indirect communica-
sion [44,45], sexual dysfunction [46,47] and greater
tions from various influential sources (media, family and
body shame in Western cultures [34,35,48]. Moreover,
friends/peers) indoctrinate, and more importantly, reinforce
it has been hypothesized that women who internalize
present-day cultural normative ideals of attractiveness
stereotypical gender roles are particularly vulnerable to
and the roles women are encouraged to adopt in order to
the negative consequences of self-objectification [40].
gain societal approval [24–26]. Research has shown that
Constant comparison and perceiving a discrepancy be-
an important influential factor is not the bombardment of
tween actual and ideal selves appear to play pivotal roles
media messages per se but the extent that an individual
in contributing to poorer BI [27,49,50]. Higgins’ Self-
internalizes the societal ideals, which become part of one’s
Discrepancy Theory describes how active comparison
self-concept [27].
with a cultural ideal and failing to meet those societal
Coming from a feminist theoretical tradition, Bepko and
prescriptions, or a perceived discrepancy between the
Krestan [24] proposed five ‘Codes of Goodness’, which
actual self and internalized standard, is associated with
they believe delineate the characteristics of an idealized
self-dissatisfaction that is often manifested in shame
‘good woman’, as valued by Western society; for exam-
[49]. Social comparison with cultural ideals of physical
ple, the ‘Be Attractive’ code places a woman’s external
appearance has been linked to body dissatisfaction
appearance as the basis of her worth, thus promoting
observed in the eating disorders [51–53] and general
behaviours that help her match a cultural physical ideal
female populations [54–56]. Reducing this perceived
[24]. The ‘Be Unselfish and of Service’ code subjugates
discrepancy has been hypothesized as a driving force
a woman’s needs below other’s needs and happiness.
for the beauty, exercise and dieting regimens followed
This code places the woman’s primary role as a nurturing
by many women, at least in Western societies. For
and selfless giver [24]. Research demonstrates that
the BC survivor, the comparison of one’s physical
women endorsing more traditional gender roles and atti-
appearance and role functioning with internalized
tudes have a greater tendency to internalize cultural
cultural expectations could contribute to BI disturbance
beauty standards and hold a greater investment in their
and negative self-view, potentially interfering with
physical appearance [25]. Women with BC who held
adjustment (especially with resumption of previous roles
greater investment in physical appearance exhibited
and routine), and impede the important task of rebuilding
greater difficulty adjusting post-treatment and reported
the self.
more body dissatisfaction and poorer mental health than
In previous work, Knauss and colleagues investigated a
those who held lower levels of investment [4,28,29].
model examining predictive links between perceived
The Gender-Role Socialization Scale (GRSS) [30]
media pressure to conform to the body ideal, internaliza-
was developed to measure the degree of internalization
tion of this ideal, body mass index, two elements of
of societal ideals. The GRSS widens the scope of clinical
objectified body consciousness (body shame and surveil-
focus from looking at individual pathology to the
lance) and body dissatisfaction in young adolescents
possible restrictive and oppressive social structures that
[34]. Given its marked similarity to the present study’s
women inhabit as contributors to poorer mental
theoretical bases and proposed linkages with core con-
health [31]. Social pressures to value gender character-
structs, this model was adapted to test a model (Figure 1)
istics (e.g. physical beauty, poise, passivity, femininity
predicting BI disturbance in BC survivors. Specifically, it
and nurturance) begin in early adolescence, with
was proposed that BC survivors who particularly endorse
depression and social rejection as consequences of non-
traditional gender roles would engage in greater self-
conformance [32]. The impact of gender-role socializa-
objectification and thus be at greater risk for poorer
tion on BI disturbance in BC survivors, particularly
BI post-treatment. For the present study’s model, the
with respect to adjusting and integrating a ‘new’ body,
degree of ‘internalization’ is measured by the degree of
changed self-identity and role functioning, has yet to
gender-role socialization of the cultural feminine ideal.
be deduced.

Self-objectification Study objectives

Gender-role socialization can promote frequent self-scruti- The study aimed to examine two psychosocial constructs
nizing, as women constantly monitor and evaluate their – gender-role socialization and objectified body con-
overall physical appearance, conduct and performance in sciousness – believed to influence BI disturbance in a se-
fulfilling expected roles [33]. Viewing one’s body as an lect group of BC survivors who self-reported BI

Copyright © 2013 John Wiley & Sons, Ltd. Psycho-Oncology (2013)

DOI: 10.1002/pon
Gender-role socialization, objectified body consciousness, body image
Months since Diagnosis
Body Shame Surgery Type
Gender-Role
Socialization
Body Image Disturbance
Surveillance Work
Status
Income
Figure 1. Proposed model of factors contributing to body image
disturbance in breast cancer survivors
adjustment issues following treatment. The study hypoth-
esized that greater BI disturbance is associated with the
following: (a) greater endorsement of proscribed gender
role attitudes and socialization; (b) greater body shame
and self-surveillance, as measured by the Objectified
Body Consciousness Scale; and (c) poorer quality of life.
Using the theoretical framework proposed by Knauss
and colleagues [34], the present study delineated and
decomposed the hypothesized correlations into direct, indi-
rect or spurious effects between objectified body conscious-
ness, gender-role socialization and BI disturbance, thereby
testing the model’s applicability to a BC population. Given
the unique medical situation of the study participants, two
medical variables were added to the model as clinical factors
that might potentially influence BI: (a) Months since
Diagnosis and (b) Surgery Type (Figure 1).
Method
Participants
Women diagnosed with primary BC who had completed
treatment with curative intent were recruited from BC and
survivorship clinics at Princess Margaret Cancer Centre
and Odette Cancer Centre, Sunnybrook Health Sciences
Centre, Toronto. Baseline data of participants taking part
in an ongoing prospective, randomized controlled clinical
trial investigating the efficacy of a psychosocial group
therapy intervention for BC survivors self-reporting BI
issues were analyzed. Approval was obtained from the
University Health Network and Sunnybrook Health
Sciences Centre Ethics Review Boards, and informed
consent was obtained.
Participants were eligible if they had histologically
confirmed primary invasive carcinoma of the breast
(stages I, II and III) with no history of or current evidence
of metastatic disease, had undergone either lumpectomy
or mastectomy (including reconstruction and nonreco-
nstruction), had completed adjuvant chemotherapy and
radiotherapy, 18 years and older, and demonstrated suffi-
cient English speaking and writing proficiency. Participants
were deemed ineligible if they had a history of major
psychiatric disorder, resided more than 1 h away from the
treatment centre or were currently participating in a therapist-
led psychosocial support group.
Baseline questionnaire packages were completed at
home, prior to randomization into the intervention or
control arms of the study.
Copyright © 2013 John Wiley & Sons, Ltd.
Measures
Demographic and clinical characteristics
These included marital status, level of education, occupa-
tional status, self-identified ethnicity and household income.
Information was also collected through self-report on
menstrual and menopausal status, current smoking and alco-
hol use. Clinical characteristics included BC stage, surgery
type and reconstruction.
Body image
The Body Image Scale (BIS) [57] is a 10-item self-report
measure assessing BI in a heterogeneous cancer population.
Higher scores reflect greater BI disturbance. Examples of
items are as follows: ‘Have you been feeling self-conscious
about your appearance’ and ‘Have you felt less physically
attractive as a result of your disease or treatment?’ The
BIS demonstrated adequate internal consistency, consistent
with previously reported internal consistency estimates
(Cronbach alpha = 0.93) [57].
A second measure used to assess BI – the Body Image
after Breast Cancer Questionnaire (BIBCQ) [58] – was
included. The BIBCQ was developed to provide a more
comprehensive, multidimensional evaluation of the impact
of BC on BI. The BIBCQ is a self-report measure consisting
of 45 common items, regardless of BC surgery type. Partic-
ipants are asked to rate feelings on several BI domains;
higher scores reflect greater BI disturbance.
The BIBCQ yields a total score and six subscales:
(a) Vulnerability (feelings of susceptibility to illness and can-
cer; ‘I feel prone to cancer.’), (b) Body Stigma (feeling the
need to hide the body; ‘I avoid looking at my scars from
breast surgery’), (c) Limitations (feelings of competence
and ability in doing everyday tasks; ‘My body stops me from
doing things I want to do’), (d) Body Concerns (feelings of
satisfaction with one’s physical appearance; ‘I am satisfied
with the shape of my body’), (e) Transparency (feelings of
self-consciousness related to the obviousness of cancer-related
alterations to appearance; ‘I feel that people are looking at my
chest’) and (f) Arm Concerns (regarding arm symptoms and
appearance; ‘Arm pain is a problem for me’). The BIBCQ
demonstrated good construct validity, showing moderate to
strong correlations with measures of related constructs, such
as self-esteem and personal attitudes regarding BI [58].
Gender-role socialization
The Gender-Role Socialization Scale (GRSS) [30] is a
30-item self-report measure that assesses the degree to which
a woman internalizes the gender role norms proscribed by
modern day society. Higher scores reflect a greater degree
of internalization. Examples of items are as follows: ‘If I
don’t accomplish everything I should, then I must be a
failure’, ‘Whenever I see media images of women, I feel
dissatisfied with my body’ and ‘I can’t feel good about
myself unless I feel physically attractive’. In their preliminary
validation of the scale, Toner and colleagues [30] have shown
the GRSS to have good reliability (Cronbach alpha = 0.93)
Objectified body consciousness
The Objectified Body Consciousness Scale (OBCS) [37]
is a 24-item self-report questionnaire that was designed
Psycho-Oncology (2013)
DOI: 10.1002/pon
 V. M. Boquiren et al.

to measure objectified body consciousness in women. Results

Higher scores reflect greater objectified body conscious-
ness. The OBCS contains three subscales: (a) Body
Shame (OBCSbs; feeling shame when the body fails to
meet societal norms; ‘I feel like I must be a bad person
when I don’t look as good as I could’), (b) Surveillance
(OBCSsur; surveying the body from an observer’s
perspective; ‘I rarely compare how I look with how other
people look’) and (c) Appearance Control Beliefs (beliefs
about personal responsibility and control over one’s
appearance; ‘I think a person can look pretty much how
they want to if they are willing to work at it’). The two
OBCS subscales of Body Shame and Surveillance were
used in all analyses.
Sample characteristics
The first 150 BC survivors who completed baseline
questionnaires in the randomized controlled clinical trial
were included in the analyses. Average participant age
was 49.5 years (SD = 8.8). Most participants identified
themselves as Caucasian (83.3%), and married/common-
in-law (64.0%). Fifty-three percent of the participants had
completed university/college, and 49.0% were working
full-time. A majority of women had been diagnosed with
Stage 1 (35.8%) or Stage 2 (41.9%) BC. Most of the women
had undergone mastectomy (64.0%) and have not had
reconstructive surgery (84.0%) (Table 1).

Descriptive analyses of main study variables

Quality of life
The Functional Assessment of Cancer Therapy-Breast
(FACT-B) [59] is a well-known multidimensional question-
naire, designed to assess quality of life in women who
have BC. The total score on the FACT-B (Version 4) is
composed of the FACT-General (27-items; FACT-G),
plus 10 additional BC-related items. The FACT-G has four
subscales: (a) Physical Well-being, (b) Social/Family Well-
being, (c) Emotional Well-being and (d) Functional Well-
being. Higher scores are reflective of higher levels of
reported quality of life.
Table 2 presents the means, standard deviations and
reliability measures of the primary study variables. On the
basis of the results of the descriptive statistical analyses,
the variable Months since Diagnoses appeared skewed;
thus, this variable was log-transformed before including in
the path analyses. Results from the Kruskal–Wallis analysis
of variance tests indicated significant group differences in
the demographic variable of Work Status (Not working vs
Working) in the GRSS. Additionally, there were significant

Table 1. Summary of participant demographic and clinical

Statistical analyses characteristics
Descriptive analyses were calculated for all variables. Mean (SD) Range N (%)
Nonparametric Kruskal–Wallis analysis of variance tests Demographic information
were conducted to compare BI disturbance, psychosocial Age (years) 49.47 (8.81) 26–75
and quality of life variables for each categorical demo- Ethnicity
Caucasian 125 (83.3)
graphic and clinical variable. Demographic and/or clinical
African-Canadian 8 (5.3)
variables showing significant group differences in the Asian 7 (4.7)
main study variables were included in the path analyses. Other 10 (6.7)
Relationships between the primary study variables were Marital status
analyzed through correlational analyses. Statistical analy- Single, never married 25 (16.7)
Married/common-law 96 (64.0)
ses were conducted using SPSS, version 20 (IBM Corpora-
Separated, divorced, widowed 29 (19.3)
tion, Armonk, NY, USA). Highest education level
The proposed theoretical model presented in Figure 1 Part of/completed high school 14 (9.3)
was examined via path analysis utilizing the structural Part of/completed university/college 104 (69.3)
equation modeling software AMOS, version 20 (IBM Graduate school 32 (21.3)
Corporation). Model fit was tested for the BIBCQ and Current occupational status
Employed full-time 73 (49.0)
BIS totals separately; these scores representing the Employed part-time 15 (10.0)
observed variable of ‘BI Disturbance’. The GRSS total Unemployed due to illness 33 (22.1)
score, OBCS Surveillance and Body Shame subscale Unemployed 3 (2.0)
scores, Surgery type and Months since Diagnoses repre- Retired/homemaker/student 25 (16.8)
Clinical information
sented their respective observed variable in the proposed
Months since diagnosis 44.41 (51.22) 3–264
model. Maximum likelihood estimation was used to Breast cancer stage
assess model fit. Four estimates of model fit were used, 1 53 (35.8)
on the basis of suggested recommendations in the litera- 2 62 (41.9)
ture [60,61]: (a) chi-square (w2), (b) root mean square error 3/4 33 (22.3)
of approximation (RMSEA), (c) normed fit index (NFI) Surgery type
Lumpectomy 54 (36.0)
and (d) comparative fit index (CFI). RMSEA index values Mastectomy 96 (64.0)
at or above 1.0 indicate a poor fitting model, values Reconstruction
between 0.05 and 0.90 indicate an average model fit, and No 126 (84.0)
values below 0.05 indicate a superior model fit. CFI and Yes 23 (15.3)
Lumpectomy 3
NFI index values greater than 0.90 indicate a good model
Mastectomy 20
fit [60,62].

Copyright © 2013 John Wiley & Sons, Ltd. Psycho-Oncology (2013)

DOI: 10.1002/pon
Gender-role socialization, objectified body consciousness, body image

Table 2. Means, standard deviations and Cronbach alpha of study variables (N = 150)
Mean (SD) Min Max Possible range Cronbach alpha

Body image measures

Body Image Scale 18.09 (7.88) 0 30 0–30 0.92
Body Image after Breast Cancer
Vulnerability 36.90 (8.46) 14 55 11–55 0.88
Body Stigma 36.89 (8.55) 14 53 11–55 0.83
Limitations 24.93 (6.23) 12 39 8–40 0.85
Body Concerns 21.02 (3.71) 10 27 6–30 0.54
Transparency 13.93 (4.94) 5 25 5–25 0.78
Arm Concerns 10.75 (3.0) 4 18 4–20 0.25
Total 144.43 (24.76) 73 214 45–225 0.90
Gender-Role Socialization Scale 119.79 (27.61) 55 193 30–210 0.88
Objectified Body Consciousness
Surveillance 4.54 (1.06) 2 7 1–7 0.77
Body Shame 3.78 (1.22) 1 7 1–7 0.81
Appearance Control 4.74 (0.99) 1 7 1–7 0.75
FACT-B
Physical Well-beinga 19.97 (5.87) 2 28 0–28 0.86
Social Well-beingb 18.13 (5.44) 2 28 0–28 0.81
Emotional Well-being 15.81 (4.92) 0 24 0–24 0.84
Functional Well-being 15.83 (6.04) 1 27 0–28 0.86
FACT-B Additional Items 21.20 (7.06) 4 37 0–40 0.70
FACT-Gb 70.06 (16.68) 20 105 0–108 0.91
Total Scoreb 91.44 (21.61) 29 138 0–148 0.91

FACT-B, Functional Assessment of Cancer Therapy-Breast Quality-of-Life Instrument; FACT-G, Functional Assessment of Cancer Therapy-General.
a
N = 149.
b
N = 148.

group differences in the categorical variable of Income
in OBCS Surveillance (results not shown). Thus, these
variables were included in the path analyses.
Correlational analyses
Body image disturbance, regardless if measured by
the BIS or BIBCQ, was significantly associated with a
greater degree of gender-role socialization and greater
experience of body shame and self-surveillance. Correla-
tion sizes among these constructs were moderate (range =
0.35–0.56) [62,63]. All correlations were significant at the
p < 0.01 level (Table 3).
Similarly, positive associations were found between
five of the six BIBCQ subscales, the GRSS and the two
OBCS subscales; that is, greater feelings of Vulnerability,
Body Stigma, Limitations, Transparency and Body Con-
cerns were significantly associated with greater gender-role
socialization, body shame and surveillance. Correlation
sizes were modest, ranging from 0.24 to 0.51 (p < 0.01)
[63,64]. The Vulnerability subscale showed the largest cor-
relation with the Surveillance and Body Shame subscales
(r = 0.45 and 0.51, respectively), whereas the Body Stigma
subscale demonstrated the largest correlation with the
GRSS (r = 0.48). The Arm Concerns subscale did not show
significant associations with other measurements (Table 4).
As predicted, negative associations were found between
the FACT-B, all its subscales and both measures of BI
disturbance, suggesting that greater BI disturbance was
associated with lower levels of quality of life, across several
domains. Correlation sizes were moderate to large, ranging
from 0.24 to 0.73 (p < 0.01) [62,63]. The smallest
correlations were observed between the FACT-B Social
Well-being subscale and the BIS and BIBCQ (r = 0.24
and 0.28, respectively), whereas the largest correlations
were observed between the FACT-B total score and the
BIS and BIBCQ (r = 0.62 and 0.73, respectively)
(Table 5).
Path analyses
In the first path analyses using BIS Total as the indicator
of the observed variable of ‘BI Disturbance’, the proposed
model suggested a good fit to the data. Estimates of model

Table 4. Correlations among the Body Image After Breast Cancer

Table 3. Correlations among body image total scores, degree of Questionnaire subscales, degree of gender-role socialization and
gender-role socialization and two elements of objectified body two elements of objectified body consciousness (N = 150)
consciousness (N = 150)
Vulner BodyStig Limit Concern Transp Arm Conc
1 2 3 4 5
1 GRSS 0.45 0.48 0.38 0.26 0.39 0.002*
1 BIS Total – 0.78 0.52 0.54 0.56 2 OBCSsur 0.45 0.32 0.24 0.40 0.24 0.001*
2 BIBCQ Total – 0.53 0.43 0.49 3 OBCSbs 0.51 0.37 0.26 0.43 0.29 0.004*
3 GRSS – 0.35 0.56
4 OBCSsur – 0.55 Vulner, BIBCQ Vulnerability subscale; BodyStig, BIBCQ Body Stigma subscale; Limit,
5 OBCSbs – BIBCQ Limitations subscale; Concern, BIBCQ Body Concerns subscale; Transp,
BIBCQ Transparency subscale; Arm Conc, BIBCQ Arm Concerns subscale; GRSS,
BIS, Body Image Scale; BIBCQ, Body Image after Breast Cancer Questionnaire; GRSS, Gender-Role Socialization Scale; OBCSsur, Objectified Body Consciousness Scale
Gender-Role Socialization Scale; OBCSsur, Objectified Body Consciousness Scale Surveillance; OBCSbs, Objectified Body Consciousness Scale Body Shame.
Surveillance; OBCSbs, Objectified Body Consciousness Body Shame. All correlations significant at p < 0.01 with the * exceptions; * correlations were
All correlations significant at p < 0.01. not significant.

Copyright © 2013 John Wiley & Sons, Ltd. Psycho-Oncology (2013)

DOI: 10.1002/pon
 V. M. Boquiren et al.

Table 5. Correlations among the Body Image after Breast Cancer Questionnaire subscales and the FACT-B quality of life measure (N = 150)
Physical Social Emotional Functional FACT-G FACT-B Total

1 BIS Total 0.37 0.24 0.61 0.44 0.53 0.62

2 BIBCQ Total 0.50 0.28 0.66 0.57 0.64 0.73

FACT-G, Functional Assessment of Cancer Therapy-General; FACT-B, Functional Assessment of Cancer Therapy-Breast Quality-of-Life Instrument; BIS, Body Image Scale; BIBCQ,
Body Image after Breast Cancer Questionnaire.
All correlations significant at p < 0.01.

fit were as follows: (a) w 2 = 27.348 (df = 18; p = 0.073), (model 1: r = 0.09, p = 0.14; model 2: r = 0.09,
(b) RMSEA = 0.059, (c) NFI = 0.882 and (d) CFI = 0.954. p = 0.146). A chi-square difference test was conducted to
The model explained 48% of the variance in BI distur- compare the originally proposed model and a more parsimoni-
bance, 12% of the variance in Surveillance and 46% of ous model that eliminated these pathways. Results demon-
the variance in Body Shame (Figure 2). strated no significant difference: w 2-difference = 21.52, df
The results of the second path analyses using BIBCQ as difference = 15, at p <0.05. These pathways were removed
the indicator of the observed variable of ‘BI Disturbance’ in each model in favour of the simpler model, as shown in
were similar to those found in the first path analyses. The Figures 2 and 3.
proposed model also suggested a good fit to the data.
Estimates of model fit were as follows: (a) w 2 = 27.348
(df = 18; p = 0.073), (b) RMSEA = 0.059, (c) NFI = 0.871 Discussion
and (d) CFI = 0.951. The model explained 42% of the vari-
ance in BI Disturbance, 12% of the variance in Surveillance The goal of the current study was to examine the relation-
and 46% of variance in Body Shame (Figure 3). ships between gender-role socialization, objectified body
Results indicated that all pathways in both models were consciousness and BI disturbance in BC survivors. The
significant, with several exceptions: (a) Months since study also explored the relationship between BI disturbance
Diagnosis to BI Disturbance (model 1: r = 0.04, p = 0.50; and quality of life post-treatment. Our findings lend empiri-
model 2: r = 0.08, p = 0.195), (b) Work Status to BI cal support to the hypothesized relationships between these
Disturbance (model 1: r = 0.02, p = 0.76; model 2: constructs; that is, BC survivors who demonstrated greater
r = 0.08, p = 0.201) and (c) Income to BI Disturbance internalization of gender role beliefs, engaged in greater
self-surveillance and reported greater levels of body shame
46% showed poorer BI adjustment post-treatment. Consistent
Body Shame Surgery Type with previous studies [9,11,12], empirical support was also
0.42
a
0.25
b provided for the third study hypothesis: Greater BI
0.40
a
0.12 c 48% disturbance was significantly associated with lower levels
Gender-Role Body Image Disturbance of quality of life across many domains.
Socialization
0.27
a (BIS Total)
Overall findings suggest that the influence of gender-role
0.35a 0.31
a socialization and objectified body consciousness on BI
12%
disturbance is extensive, touching upon many BC-related
Surveillance BI domains, particularly those related to appearance satis-
faction (Body Concerns) and self-consciousness (Body
Stigma). This is consistent with findings from studies
looking at BI in the general female and eating disorders
populations, which demonstrated that objectified body con-
Figure 2. Results of path analysis: standardized regression
weights and percentage of variance explained in model; body image sciousness and internalization of cultural ideals regarding
disturbance, represented by the Body Image Scale (BIS) Total score. physical appearance was related to poorer BI, body dissatis-
a
p ≤ 0.001, bp ≤ 0.01, cp ≤ 0.05 faction and self-esteem [27,41–43,65,66]. Gender-role
socialization and objectified body consciousness were
46% interestingly related to increased feelings of vulnerability
Body Shame Surgery Type to illness and cancer (Vulnerability). One could speculate
0.42 a 0.22
b that for these BC survivors, internalization of gender roles
0.40
a
0.15b 42%
may engender an overall sense of physical weakness.
Gender-Role Body Image Disturbance Clinically, we often observe this sense of powerlessness,
Socialization (BIBCQ Total)
0.32
a frailty and greater susceptibility to cancer, such as when
a
BC survivors state that they can ‘no longer trust their body
0.35 0.22 b
(functioning)’ or that their bodies ‘betrayed’ them. Future
12%
Surveillance
research is needed exploring gender-role socialization,
behaviours related to objectified body consciousness and
this sense of vulnerability, perhaps in relation to specific
cancer-related quality of life impacts, such as the fear of
recurrence or sense of illness intrusiveness.
Figure 3. Results of path analysis: standardized regression weights
and percentage of variance explained in model; body image distur- The present study tested a predictive model, hypothesiz-
bance, represented by the Body Image after Breast Cancer Question- ing that endorsement of traditional gender roles contributed
naire (BIBCQ) Scale Total score. ap ≤ 0.001, bp ≤ 0.05 to increased body shame and self-surveillance, which in turn

Copyright © 2013 John Wiley & Sons, Ltd. Psycho-Oncology (2013)

DOI: 10.1002/pon
Gender-role socialization, objectified body consciousness, body image
would lead to BI disturbance. Path analyses provided empir-
ical support for the proposed model. In our model, gender-
role socialization had both direct and indirect pathways to
BI disturbance. The significant direct pathway between
these constructs is in line with previous research, particu-
larly in the eating disorders field, demonstrating an associa-
tion between BI dissatisfaction and perceived gender-role
adherence, especially in adolescent girls and young women
[34,65]. Our model also demonstrated that gender-role
socialization indirectly predicted BI through the compo-
nents of objectified body consciousness: body shame and
self-surveillance. One possible mechanism is that greater
gender-role socialization exerts a pressure on BC survivors
to continue to meet personal standards held prior to the
illness. This necessitates frequent monitoring and compari-
son of one’s current state to a prior, perhaps idealized self,
which then increases the chance of experiencing shame
at perceived discrepancy between the two [34,67]. With
such visible physical reminders of treatment and marked
changes in functioning, it is understandable for many BC
survivors to be keenly aware of such discrepancy. For
women who are unable to resume a level of functioning or
attain an earlier sense of control or self (e.g. inability to
return to previous body weight), or for those focused on
body disfigurement, feelings of shame and loss may endure.
The profound impact on BI seen in BC may be due to the
specific nature of the side effects of its treatment, affecting
those parts of a woman’s body and psyche that society
connotes with ‘what it means to be a woman’. The breast
symbolizes many aspects of womanhood, for example,
ability to nurture others and sexual desirability [68]. The
same could be said about hair, which for many women,
reflects beauty, gender and maturity [69]. In a literature
review of chemotherapy-induced alopecia and its impact on
quality of life [70], BC survivors frequently rank hair loss
as one of the most distressing and traumatizing treatment side
effects. Moreover, for women whose self-worth is fulfilled by
adherence to socialized gender roles, adjustment in the
survivorship period might be extremely challenging as they
(and often family and friends/peers) expect to ‘return to
normal’ and resume routine home and work duties. For the
BC survivor with strong self-identities as the selfless,
emotional caretaker, nurturing child-bearer and/or sexual
lover, perceived failure to fully meet such socialized roles
will negatively impact her self-esteem and confidence,
contributing to ongoing negative BI disturbance.
Clinical implications
This study provides some new insights into some of the
psychosocial and cultural factors contributing to BI distur-
bance for a subgroup of women continuing to report
adjustment difficulties post-treatment. Our findings suggest
that traditional psychosocial-oriented interventions, such
as cognitive behavioural, mindfulness-based or expressive
supportive group therapeutic approaches [e.g. 71–73] that
support coping in the survivorship stage, may benefit from
incorporation of a discussion of gender-role socialization
and its behavioural impacts (e.g. frequent body scrutiny and
evaluation). Psychoeducation that help increase women’s
insight into the forces shaping their beliefs and goals (e.g.
pressures to adhere to ‘Codes of Goodness’) might encourage
Copyright © 2013 John Wiley & Sons, Ltd.
building ‘personal codes of conduct’ that are less driven by
societal expectations. This in turn may foster more realistic
and self-nurturing appraisals that build esteem, conscious
engagement in activities that contribute to self-worth
(e.g. other aspects of self), an increased willingness to let
go of aspects that cannot be changed and movement towards
a kind of grieving of the former self to make room for a new
emerging sense of self following the BC experience. Such
approaches are typically used in women’s health to build
self-esteem, empowered models of self, resulting in improved
psychological functioning and quality of life [e.g. 31].
A few notable limitations of the present study must be
addressed. The study sample consists of BC survivors who
have self-reported BI difficulties and actively sought treat-
ment as part of their study participation. Therefore, general-
izability of results to the general population of BC survivors
is limited. Future studies examining the impact of these
psychosocial and cultural factors on BI adjustment in other
cancer types are needed. The study was cross-sectional in
design, limiting conclusions to be drawn on causality. Lastly,
it is unclear as to the generalizability of these findings to
cultural societies outside Western nations. The GRSS, for
example, was based on Western cultural norms and may
not be reflective of ideals held by other societies.
Conclusion
The present study represents a novel exploration of two
psychosocial–cultural constructs’ impact on BI in BC survi-
vors. Findings indicate that survivors who demonstrated
greater internalization of gender role beliefs, engaged in
greater self-surveillance and reported greater levels of body
shame showed greater BI disturbance post-treatment.
Greater BI disturbance was also significantly associated
with poorer quality of life. From a clinical standpoint,
results suggest that it is important for healthcare providers
to acknowledge that women come into the BC experience
with strong beliefs regarding their bodies, roles and charac-
teristics that define themselves as women and as unique
individuals. Increasing awareness of cultural forces shaping
gender-role expectations and behaviours may be an impor-
tant element in psychosocial interventions implemented in
the BC survivorship stage. Psychosocial interventions that
help women redefine personal standards of beauty, feminin-
ity and role functioning that are realistic, achievable and less
focused on societal expectations might facilitate flexibility
in perceptions and dim potential negative self-evaluation
post-treatment, thus promoting adjustment and survivor
well-being. Further work is needed using prospective,
longitudinal studies to explore these psychosocial–cultural
factors’ impact on BI and adjustment in the survivorship
stage, with additional groups of BC survivors.
Acknowledgements
We would like to acknowledge grant #017731 from the Canadian
Breast Cancer Research Alliance and a grant from the Canadian
Breast Cancer Foundation as well as all the women who participated
in the study.
We would also like to acknowledge Project Coordinator Ms.
Nicole Taylor and Research Assistants Ms. Noor Malik and Ms.
Rodica Mandel.
Psycho-Oncology (2013)
DOI: 10.1002/pon

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