Abstract
Men generally have a more positive body image than women. However, the extent to which scars negatively influence men’s body image is uncertain. The aim of the current study was to assess body image in men with and without scars while taking scar origin into account (nonsuicidal self-harming injuries [NSSI] vs. accidents or surgery). One hundred and nine men (n = 19 with NSSI) and 185 women (n = 96 with NSSI) filled in multidimensional body image questionnaires. Results indicate that on most clinical subscales women had a significantly more negative body image compared with men. However, within a subsample whose scars resulted from NSSI, gender differences vanished. Among men, scar origin was significantly associated with negative body image after partialling out scar characteristics, age, and borderline symptomatology. The visibility of scars was not associated with more severe body image disturbances. The results of our study indicate that self-inflicted scars adversely affect body image. Although women generally reported having a more negative body image, disturbances in body image should not be neglected among men, especially in those who have self-inflicted scars.
Body image is a multidimensional construct consisting of affective–cognitive, behavioral, and perceptive components (Cash, 2011). Until recently, researchers have tended to investigate women’s body image, most likely because women are known to generally have a more negative body image compared with men (e.g., Cash, Morrow, Hrabosky, & Perry, 2004; Smith, Thompson, Raczynski, & Hilner, 1999). There is, however, a lack of research on the prevalence of body image disturbances in men, which may, in turn, mean that the extent of the issue is underestimated.
There is indirect evidence that the number of men dissatisfied with their bodies has increased. For example, preoccupation with muscularity is common among some men (McCreary, 2011). Growth in demand for male body care and cosmetic products (i.e., Elsner, 2012) as well as for cosmetic surgery (American Society for Aesthetic Plastic Surgery, 2002) and body depilation (Boroughs, Cafri, & Thompson, 2005) also suggest that men are increasingly dissatisfied with their bodies. Furthermore, male prevalence of eating disorders (Hudson, Hiripi, Pope, & Kessler, 2007) and muscle dysmorphia (Murray, Rieger, Touyz, & Garcia, 2010) is higher than previously thought. These findings indicate that body dissatisfaction among men may have multiple consequences and that a closer examination of men’s body image is warranted.
Research on men’s body image has mainly focused on the figural characteristics of the body and its correlates (McCabe & Riciardelli, 2004). Only recently has attention been extended to the influence of scars on body image. A more negative body image is reported after facial trauma (Levine, Degutis, Pruzinsky, Shin, & Persing, 2005) and after burn injuries (Thombs et al., 2007). One important factor influencing the body image of patients with burn injuries is the subjectively rated importance of one’s appearance (Thombs et al., 2008). This finding complements the result that people consider visible scars as particularly distressing (Rumsey & Harcourt, 2004). Results from these studies indicate that scars affect body image. Although there was a focus on scars resulting from burn injuries in these studies, a much greater variety of scar origin is possible. For example, the context in which scars are sustained and the amount of control that one has over antecedent events may influence body image. Of particular note, self-inflicted wounds may result in scars, which bear particularly unpleasant associations. To assess the specific impact of scar origin on body image, scars resulting from surgery or accidents and nonsuicidal self-harming injuries (NSSI) were compared. In a previous study, the authors identified that women whose scars resulted from NSSI tend to have a more negative body image compared with women whose scars were caused by surgery or by an accident (Dyer, Hennrich, Borgmann, White, & Alpers, 2013). It is possible that a similar pattern of results would emerge among men with scars that resulted from NSSI or other external injuries. A first investigation of male responses is one of the motivations for the current study.
NSSI is particularly prevalent in patients with borderline personality disorder (BPD), a severe diagnosis that is otherwise characterized by affective dysregulation, problematic social interactions, as well as a negative self-concept (Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004). Up to 90% of BPD patients report repeated NSSI (Zanarini et al., 2008), which may result in scars. BPD patients also frequently engage in high-risk behavior and impulsive aggression (Lieb et al., 2004; Rüsch et al., 2007), which can also result in bodily harm and scars. In addition, patients with BPD symptomatology report a more negative body image compared with healthy individuals and other patients with mental disorders (Dyer, Borgmann, et al., 2013; Haaf, Pohl, Deusinger, & Bohus, 2001; Kazuko & Inoue, 2009; Sansone, Chu, & Wiederman, 2010; Sansone, Wiederman, & Monteith, 2001). In previous studies on BPD, there has been a focus on women with borderline symptomatology, despite the fact that BPD also occurs among men (Grant et al., 2008; Tadic et al., 2009).
In the current study, the authors assessed body image in a sample of men and women with respect to scar origin, the influence of scars on men’s body image, as well as the visibility of scars. Since body image is influenced by several factors such as age (Öberg & Tornstam, 1999; Rø, Bang, Reas, & Rosenvinge, 2012; Tiggemann & Lynch, 2001) and borderline symptomatology (Dyer, Borgmann, et al., 2013; Haaf et al., 2001; Kazuko & Inoue, 2009; Sansone et al., 2001; Sansone et al., 2010), the authors decided to control for these in the analyses.
Specifically, the following hypotheses were addressed:
Method
Participants
To recruit a broad range of participants, an online survey was used. The questionnaire was available online for a period of 73 days. Invitations to participate were spread through social networks; mailings lists of the University of Mannheim, Germany; and specialized Internet forums (e.g., for burn victims). Informed consent was provided before potential participants filled in the online questionnaire. A total of 219 potential participants began filling in questionnaires, of whom 166 completed questionnaires. Five participants were excluded because they took an extremely short or long time to complete questionnaires. The sample of 63 women and 103 men was supplemented by the sample of Dyer, Hennrich, et al. (2013), which contained data from 122 women and 6 men. The final sample consisted of 109 men and 185 women. Altogether, 115 participants reported that the largest scar resulted from NSSI (19 male participants; 96 female participants). Participants received no payment. The ethics committee at the University of Mannheim approved the study.
Materials
The following instruments were used to characterize body image as well as psychopathology.
Multidimensional Body-Self Relations Questionnaires–Appearance Scales (MBSRQ-Appearance Scales)
The MBSRQ-Appearance Scales (Brown, Cash, & Mikulka, 1990; Cash, 2000) is a 34-item measure that assesses self-attitudinal aspects of body image, which include affective, cognitive, and behavioral components. Five subscales evaluate satisfaction with, and investment in one’s appearance and weight. In order to reduce the time needed to complete the questionnaire, scales that pertain to weight—Overweight Preoccupation and Self-Classified Weight—were excluded. Instead, the subscales Appearance Evaluation, Appearance Orientation, and Body Area Satisfaction Scale were assessed. Higher scores on the subscale Appearance Evaluation suggest greater satisfaction with one’s appearance (e.g., “I like my looks just the way they are.”). In the subscale Appearance Orientation, higher ratings indicate higher investment in one’s appearance and body care (e.g., “I check my appearance in a mirror whenever I can”). Higher values in the Body Area Satisfaction Scale represent a general satisfaction with most areas of one’s body (e.g., “How dissatisfied or satisfied are you with your face (facial features, complexion?”). Since the MBSRQ is not published in German, a translated and back-translated version was used. Internal consistency for the subscales of the MBSRQ ranged from .86 to .93 (Cronbach’s α) within this study.
Questionnaire for the Evaluation of Body Image After Burn Injuries (Fragebogen zur Erfassung des Körperbildes nach Brandverletzungen; FKBB)
The FKBB (Seehausen et al., 2010) is a German self-rating questionnaire used to capture body image of subjects with scars and/or disfigurement. The questionnaire itself does not specifically refer to the origin of scars and therefore it is not limited to participants with burn injuries. It was used in this study to evaluate body image in participants with scars in general. It consists of 23 items that probe the acceptance of physical changes, their impact on emotions and behavior, as well as happiness and engagement with one’s own appearance. Higher values reflect a more positive body image. The internal consistency was high in this study (Cronbach’s α = .83).
Borderline Symptom List (BSL-23)
The BSL-23 (Bohus et al., 2009) is a self-rating instrument for specific assessment of borderline-typical symptomatology. In its short version, it contains 23 items rated on a Likert-type scale ranging from 1 (not at all) to 4 (very strong). Participants rate symptoms that they had experienced within the past week. Higher scores indicate a higher borderline-typical symptomatology. The questionnaire used in this study has been psychometrically validated in German and had high internal consistency in this study (Cronbach’s α = .97).
Scar Characteristics
To the author’s knowledge, no standardized measure of scar size is available that allows individuals to rate the appearance and size of their own scars. The authors have previously described a method of rating scar characteristics (Dyer, Hennrich, et al., 2013). For a detailed description of the largest scar with respect to conglomeration of scars, participants were asked to categorize the origin (intentional self-harm, accident, surgery, other) and rate the size (Scar Size: length and width), as well as the appearance (Scar Appearance: visibility, redness, elevation on a 5-point Likert-type scale) of the scar. The authors did not provide a definition of the word “scar” and participants therefore relied on their own concept of this term. A rating of the largest scar as a representation of all existing scars was chosen. The authors assumed that individuals who were concerned with scars were also probably concerned with the largest scar. It is therefore possible that participants whose largest scar resulted from an accident might have exhibited self-harming behavior that resulted in smaller scars. The size of the scar was calculated by multiplying its length by width (Dyer, Hennrich, et al., 2013). A mean value for the Scar Appearance was calculated.
Survey of Body Areas
The location of scars was assessed by the Survey of Body Areas (http://www.sci-mate.org/wiki/index.php/Survey_of_Body_Areas_-_female). Participants were asked to mark scar position on the outline of a male/female silhouette. Participants who reported at least one scar in a visible area (e.g., face and hands) were coded with “1,” at least one scar in a partly visible area (such as lower legs, lower arms) with “2,” and at least one scar in a normally not visible area (such as torso) with “3.”
Data Analysis
ANOVA was used to assess group differences (men vs. women, participants with NSSI vs. participants with scars of other origin). When group variances were significantly different, Brown-Forsythe F values were reported. In addition, regression analyses were performed to control for age, the size and the appearance of scars, as well as borderline-typical behavior.
Valid information about the size of the largest scar was provided by 89% of the sample. Complete answers to the other outcome measures (body image subscales, appearance of scars) were provided by 93% to 99% of the sample. Within the smallest subgroup (men with NSSI; N = 19), no missing data were detected except on the subscale Scar Size (N = 17).
Results
Participant Characteristics
Men were aged between 18 and 72 years (M = 29.95; SD = 13.19) and had average body mass index (BMI) of 23.92 (SD = 3.62). Women were between 18 and 60 years old (n = 180; M = 26.23; SD = 8.95) and had an average BMI of 24.05 (SD = 6.49). Participant groups did not differ significantly with regard to BMI. However, age differences were present (Table 1). Age was weakly, inversely correlated with Appearance Orientation, r = −.22, p < .001, but not with any other variables related to body image.
Means, Standard Deviations, and Group Differences on Clinical Scales Among Men and Women Whose Scars Resulted From Self-Harming Behavior or Accident, Respectively, Surgery.
Note. A/S = largest scar after accident or surgery; NSSI = nonsuicidal self-harming injuries; BSL = Borderline Symptom List (Bohus et al., 2009); FKBB = Questionnaire for the Evaluation of Body Image after Burn Injuries (Seehausen et al., 2010). Since population variances were heterogeneous (as tested using Levene’s test), we used the more robust Brown–Forsythe test.
Comparison of Body Image in Gender Specific Subgroups
Men reported a more positive body image than women on the following subscales: Appearance Evaluation, FBrown–Forsythe(1, 237.71) = 31.56, p < .001, Body Area Satisfaction Scale, F(1, 279) = 30.33, p < .001, and FKBB total score, F(1, 271) = 20.74, p < .001. These results indicate that men were more satisfied with their appearance and were generally content with more areas of their body. However, the authors were unable to detect a statistically significant effect of gender on Appearance Orientation, F(1, 273) = 0.66, p = .418, which suggests that men and women invested equally in their appearance. Concerning scar variables, Scar Appearance ratings indicated that women regarded their scars as considerably more noticeable than men, F(1, 290) = 25.65, p < .001; however, no difference was detected for Scar Size, F(1, 259) = 0.11, p = .746. The same pattern of results regarding body image and scar variables was reported for participants whose largest scar was the result of an accident or surgery. Among participants whose largest scar was the result of NSSI, no statistically significant differences between men and women were detected (Table 1).
Comparison of Body Image With Respect to Scar Origin
When participants whose scars resulted from NSSI were compared with participants with scars of other origin, highly significant differences were reported on three of the four body image scales, Appearance Evaluation, FBrown–Forsythe(1, 277) = 145.21, p < .001; Body Area Satisfaction Scale, F(1, 279) = 129.27, p < .001; FKBB total score, F(1, 205) = 171.23, p < .001; Appearance Orientation, FBrown–Forsythe (1, 181.76) = 0.36, p = .541. These differences are consistent with the complete sample as well as with the male and female subsamples (Table 1). Participants whose scars resulted from NSSI reported significantly smaller scars, FBrown–Forsythe(1, 173.16) = 4.48, p = .036. No differences were reported in the gender-specific subgroups. Participants whose scars resulted from NSSI reported that the appearance of their largest scar was more pronounced, FBrown–Forsythe(1, 269.26) = 68.26, p < .001; Table 1). This result is replicated in the male and female subgroups.
Influence of Scar Origin on Men’s Body Image
Among men, scar origin proved to influence Appearance Evaluation, β = −.338, p = .001, Regression Model: F(5, 89) = 24.85, p < .001; Body Area Satisfaction Scale, β = −.317, p = .003, Regression Model: F(5, 92) = 20.57, p < .001; and FKBB total score, β = −.315, p < .001, Regression Model: F(5, 89) = 48.46, p < .001. This indicates that men whose scars resulted from NSSI have a more negative body image than men whose scars had other origins.
Comparison of Body Image With Respect to Visibility of Scars
Male and female participants whose scars were more visible (e.g., scars on face and hands) were not identified to be statistically different from those with less visible scars (e.g., torso) in terms of body image subscales and Scar Size, Appearance Evaluation: F(2, 276) = 0.28, p = .758; Body Area Satisfaction Scale: F(2, 278) = 0.65, p = .524; FKBB Total Score: F(2, 270) = 0.91, p = .524; Appearance Orientation: F(2, 272) = 0.16, p = .159; Scar Size: F(2, 256) = 0.22, p = .800; Scar Appearance: F(2, 287) = 1.62, p = .097. Regarding Scar Appearance, there was an overall trend for more visible scars to be rated as more noticeable. That is, participants rated theirs scars to be more visible, more elevated or redder, when they were located, for example, on the face and hands. When the analysis was restricted to male participants, it was identified that those with visible scars reported that their scars were more noticeable compared with males whose scars were less conspicuous, F(2, 105) = 3.77, p = .026 (Table 2).
Means, Standard Deviations, and Group Differences of the Employed Scales in Participants With Not Visible, Not Fully Visible, and Visible Scars.
Note. NVS = not visible scars; NFVS = not fully visible scars; VS = visible scars; FKBB = Questionnaire for the Evaluation of Body Image after Burn Injuries (Seehausen et al., 2010).
Discussion
To our knowledge, this is the first study in which the correlation between scar origin and body image has been examined in men. In line with previous studies, men had fewer body image disturbances than women (Cash et al., 2004; Smith et al., 1999). However, regarding the extent to which participants invested in their appearance, the authors were unable to detect gender differences. This result is contrary to evidence from current body image literature. In other studies, females typically reported greater investments in their appearances than men; women rated their looks as more important and reported to engage more extensively in grooming behaviors (Muth & Cash, 1997; Smith et al., 1999).
A distinctive feature of this study is the analysis of subsamples with respect to scar origin and gender. Among participants whose largest scar resulted from accidents or surgery, women reported a more negative body image than men. This result is not unexpected, since it is in line with previous research (i.e., Cash et al., 2004; Smith et al., 1999). Although the general findings of our study replicated those of previous studies, one result stands out—men with NSSI report a negative view on their body that is comparable with women with NSSI. A psychological disorder often associated with NSSI is borderline personality disorder (Zanarini et al., 2008). BPD is also associated with body image (e.g., Dyer, Borgmann, et al., 2013). Negative body image among men whose largest scar is the result of NSSI appears to be independent of the tested covariates, including BPD. In line with the results of Rumsey and Harcourt (2004), who reported that scar visibility is an important factor influencing body image, the authors identified that men rated their scars as more prominent when the scars were visible to others.
There were several limitations within the current study. First, it is possible that the Internet recruitment procedure may not have yielded a representative sample. An advantage of the recruitment via the Internet is that it enabled us to recruit a large sample of participants, especially men with NSSI, who are rarely present in clinical settings. The feeling of anonymity may also have been an advantage of the Internet (Muehlberger, Alpers, & Pauli, 2009). In fact, disclosing information about self-inflicted harm via the Internet may have been preferable for participants who are reluctant to openly discuss such issues. Individuals with NSSI are often ashamed of their behavior and that assessment was not face-to-face might have allowed them to answer questions more openly. Nonetheless, it is possible that our recruitment procedure resulted in sample with a higher prevalence of NSSIs than is reported in the general population. Epidemiological studies have suggested that within the general population the period prevalence rates is between 4% (Kerr, Muehlenkamp, & Turner, 2010) and 46% (Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007) depending on the age group studied and behaviors defined as NSSI. In our sample, among those whose largest scar resulted from something other than NSSI, 19.3% reported to have cut themselves at least once in their life.
Our results also need to be interpreted bearing in mind that the authors relied on participants to rate the appearance and size of their largest scar. Therefore, these ratings might be influenced by the participant’s evaluation of the scars. In addition, the subgroups were divided by the origin of the largest scar. It is possible that an accident, and not an NSSI, caused the largest scar. In such cases, participants should have been allocated to the accident (e.g., surgery) subgroup. Nevertheless, groups differed significantly regarding the Self-Harm Inventory (Sansone, Wiederman, & Sansone, 1998), NSSI: M = 18.56, SD = 3.59; A/S: M = 9.42, SD = 4.04; F(1,220.64) = 387.03, p < .001. The authors decided against using a Self-Harm Inventory cutoff since self-harming behavior does not necessarily result in scars. Nevertheless, the assumption that the largest scar is a representative for other scars is a limitation of the current study.
Since our participants were not clinically evaluated, it is difficult to rule out the possibility that our sample included individuals with body dysmorphic disorder. According to Thombs et al. (2008), the subjectively rated importance of one’s appearance can significantly influence body image. The authors take the view that subjective accounts of one’s own body play a central role in body image perception. In future studies, however, an objective assessment of scar size and appearance should be conducted. In addition, measures of bias toward one’s scars could be undertaken using eye-tracking methodology (Meyer-Marcotty, Gerdes, Stellzig-Eisenhauer, & Alpers, 2011; Meyer-Marcotty, Gerdes, Stellzig-Eisenhauer, Reuther, & Alpers, 2010).
The groups differed significantly regarding age. It was identified that age was inversely correlated with Appearance Orientation but not with any other body image dimension. The influence of age on body image has not yet been clearly established in the literature. Although one study did not report that age influences body image significantly (Tiggemann & Lynch, 2001), other findings suggest that a more positive body image is reported among older individuals (Öberg & Tornstam, 1999). Therefore, the authors decided to statistically control for age in the regression analysis.
In summary, the authors believe that the findings may help to close an important gap in the literature—namely, that scars resulting from NSSI affect not only female but also men’s body image. If body image is studied in relation to scars, the origin of these scars needs to be taken into account. In clinical settings, this means that assessment for possible body image disturbances among patients with NSSI is important. Given the negative effects of scars resulting from NSSI on body image, clinicians should prioritize helping at-risk populations to stop self-harming behavior.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.