"Feeling frumpy": the relationships between body image and sexual response changes in midlife women.

Many women notice changes in their sexual response as they move through the menopausal transition. These changes may involve sexual desire/interest, arousal, orgasm, enjoyment, or frequency of sexual activity. More often than not, the changes reflect decreased rather than increased sexual responsivity and activity, although some women do experience heightened sexual response during this time (Avis, Stellato, Crawford, Johannes, & Longcope, 2000; Bottiglioni & DeAloysio, 1982; Cole, 1988; Dennerstein, Alexander, & Katz, 2003; Dennerstein, Lehert, Burger, Garamszegi, & Dudley, 1999; Dennerstein, Smith, Morse, & Burger, 1994; Hallstrom, 1977; Hallstrom & Samuelsson, 1990; Mansfield, Koch, & Voda, 1998; Mansfield, Voda, & Koch, 1995; McCoy & Davidson, 1985; Pfeiffer, Verwoerdt, & Davis, 1972).

Menopause and sexuality researchers have used various theoretical paradigms to study these sexual changes, resulting in differing explanations (Rostosky & Travis, 2000; Voda & George, 1986). The biomedical/positivist perspective gives primary importance to hormonal changes that women experience during menopausal transition. This perspective purports that shifting hormone levels account directly, or indirectly through menopausal symptoms, for sexual response declines and that hormone therapy can improve sexual responsivity in midlife women (see Sherwin, 1991 for a review). However, the biomedical approach has been criticized as viewing menopause as a "deficiency disease" and sexual changes as problematic rather than adaptive (Bancroft, Loftus, & Long, 2003; Voda & George, 1986). A related perspective, evolutionary/sexual strategies theory, would argue that female sexual desire naturally diminishes with age and approaching loss of fertility since optimal reproduction (fueling natural selection and survival) is the basis for human sexuality (Buss, 1998). Yet many researchers purport that a purely biomedical or evolutionary model of women's midlife sexuality that poses a direct link between declining hormone levels and declining sexual response is insufficient or inconclusive (Bancroft et al., 2003; Burger, Dudley, & Hopper, 1995; Davis, 2000; Dennerstein, Dudley, Hopper, & Burger, 1997; Gannon, 1994; Mansfield, Koch, & Voda, 2000; Myers, 1995; Schreiner-Engel, Schiavi, White, & Ghizzani, 1989).

In contrast to the biomedical model, the social interpretive perspective emphasizes that context, including intrapersonal, interpersonal, and sociocultural factors, can account for midlife women's menopausal and sexual experiences more effectively than a strictly biomedical explanation (Ballinger, 1985; Bloch, 2002; Channon & Ballinger, 1986; Koch & Mansfield, 2001/2002). The feminist/critical perspective expands the meaning of context by seeking to clarify the interactive connections between women's experiences and the social, biological, and political forces that affect their lives (Irvine, 1990; Koch, 1997; Koeske, 1983; McCormick, 1994; Voda & George, 1986). This perspective, a "new view" of women's sexuality and sexual problems, advocates for sexuality research that is meaning-centered, consciously political, and humanistic (Kaschak & Tiefer, 2001; Tiefer, 2001). In light of this new view, the current research study explored the context and meaning of women's sexual response changes as they age.

One contextual factor that is important to women of all ages is body image (Pliner, Chaiken, & Flett, 1990). Body image refers to the attention to and evaluation of an individual's own physical attractiveness and overall appearance (Kelson, Kearney-Cooke, & Lansky, 1990; Silberstein, Striegel-Moore, Timko, & Rodin, 1988). Body esteem, another term used for body image, is thought to have three components: sexual attractiveness, weight concerns, and physical condition (Crose, 2002). The links between women's sexuality and physical attractiveness "make conceptual sense and are supported by everyday observation" (Wiederman & Hurst, 1997, p. 568). Yet few empirical studies have investigated this relationship in non-clinical groups of women.

Social and cultural norms, as well as an individual's attitudinal biases, cognitive beliefs, and affective orientation, affect body image. Since a midlife woman in Western society faces the double jeopardy of ageism and sexism that could diminish her status and sense of attractiveness (Banister, 1999; MacDonald, 1991; Rostosky & Travis, 2000; Wolf, 1991), her own perception of her physical appearance could have a significant impact on her sexual response. For example, the stereotype of an older woman often includes ideas of being "unattractive" and "asexual" (Gerike, 1990). Perhaps in response to this stereotype, only about one third of a sample of 35- to 65-year-old Australian women evaluated their bodies as "sexually appealing" (Deeks & McCabe, 2001).

To address the gap in research, this study investigated the relationships between self-rated attractiveness and self-reported sexual response changes in midlife women. To examine these relationships, we asked four research questions:

1. Do midlife women's perceptions of their own attractiveness vary with age or menopausal status?

2. What changes do midlife women report in their sexual response and activity over a 10-year time frame?

3. Are there relationships between a midlife woman's body image and specific sexual response changes?

4. Is there a relationship between a midlife woman's changing body image and her sexual satisfaction?

LITERATURE REVIEW

Menopause is marked by 12 months without a menstrual period (Kaufert, Gilbert, & Tate, 1987; McCoy, 1992) and occurs, on average, at age 51 in the United States (Goodman, 1992). For the purpose of this discussion, we will adopt the commonly-used definition of the menopausal transition (or perimenopanse) as the period of time before menopause that is marked by noticeable changes in menstrual cycle length, duration, or amount of menstrual blood loss (Kaufert et al., 1987; Mansfield & Voda, 1997). The transition can last from 1 to 12 years, with a mode and median of 5.8 years (Treloar, Boynton, Behn, & Brown, 1967). Although individual women may experience the transition differently, the physiological changes accompanying the transition invariably include a decrease in ovarian estrogen production and an increase in the levels of follicle-stimulating hormone (FSH) and leutenizing hormone (LH) (Northrup, 1994). The reduction in gonadal hormone levels is the primary biomedical explanation for any decrease in sexual desire, arousal, orgasm, enjoyment, or frequency of sexual activity among menopausal women (Sherwin, 1991).

There is conflicting information about the sexual response changes that may accompany the menopausal transition. Increases in specific sexual responses and activities, or a lack of noticeable changes, have been reported by some researchers (Avis et al., 2000; Bachmann et al., 1985; Dennerstein et al., 1997; Dennerstein et al., 1994; Koster & Garde, 1993). For example, Adams and Turner (1985) found a relative maintenance of participation in many sexual activities over time from younger to older age, and almost three quarters (72.3%) of midlife women in Deeks and McCabe's study (2001) had not changed their intercourse frequency over the past year. However, others report that declines are more common, particularly declining sexual desire (Channon & Ballinger, 1986; Dennerstein et al., 1999; Dennerstein, Dudley, & Burger, 2001; Hallstrom & Samuelson, 1990; Hawton, Gath, & Day, 1994; McCoy & Davidson, 1985). For example, Mansfield et al. (1995) found that nearly half (46.2%) of their midlife respondents reported a change in their sexual response from the previous year. Of those women, more than half (54.5%) reported decreased sexual desire and almost one quarter reported less enjoyment with a partner (22.5%) or more difficulty achieving orgasm (24.6%). Bachmann and Leiblum (1991) also identified significant reductions in the ratings of sexual desire in their postmenopausal sample, as did Sarrel and Whitehead (1985) in their study of women attending menopause clinics for routine care. Whether such changes in midlife sexual response are related more to aging or to menopause is still debated, with some researchers finding that age has more impact than menopausal stage on sexual changes (Bancroft et al., 2003; Cawood & Bancroft, 1996; Hawton et al., 1994; Kingsberg, 2002; Mansfield, et al., 1995).

There is a growing body of research that demonstrates the important role that contextual factors play in midlife women's sexual responding. Relationship factors, physical and mental health of self and partner, partner availability, marital adjustment, intimacy, and life stressors (e.g., family and work) have all been shown to affect women's sexual response significantly (Avis et al., 1995; Bachmann et al., 1985; Bachmann & Leiblum, 1991; Bancroft et al., 2003; Cawood & Bancroft, 1996; Channon & Ballinger, 1986; Dennerstein, Lehert, Burger, & Dudley, 1999; Hallstrom & Samuelsson, 1990; Hawton et al., 1994; Koster & Garde, 1993; Mansfield et al., 2000). For example, Schnarch (1997) describes the scenario in which longer relationships with more mature partners might make midlife a time of heightened sexual potential.

Regardless of the sexual changes that midlife women may be experiencing, research indicates that they tend to be sexually satisfied (Avis et al., 2000; Cain et al., 2003; Trudel, 2002) and that sexual satisfaction tends to be related to age rather than to menopausal status (Deeks & McCabe, 2001; Hawton et al., 1994). In fact, factors associated with quality of life and aspects of the relationship (e.g., communication, emotional intimacy, respect, companionship, marital satisfaction) have been shown to be the best predictors of sexual satisfaction for women (Haavio-Mannila & Kontula, 1997; Hurlbert, Apt, & Rabehl, 1993; Johnson, 1998; Young, Denny, Luquis, & Young, 2000). Thus, in light of previous research demonstrating the importance of contextual factors, more attention should be paid to the role body image plays in midlife women's sexual responding and satisfaction.

It has been shown repeatedly that body dissatisfaction is a common concern among girls and women in the United States (Cash & Henry, 1995; Chrisler & Ghiz, 1993; Fallon & Rozin, 1985) and is more common among women than men of all ages (Pliner et al., 1990). Research on young women indicates that, regardless of their actual weight, significant numbers want to weigh less and look thinner and younger (Crose, 1999, 2002). Further, body image appears to be positively related to self-esteem and psychosocial adjustment (Cash & Pruzinsky, 1990; Franzoi & Herzog, 1986; Noles, Cash, & Winstead, 1985; Pearlman, 1993; Pliner et al., 1990).

Midlife women in Western society face both sexist and ageist pressures to hide any signs of aging in order to be considered attractive (Banister, 2000; Chrisler & Ghiz, 1993; Deeks & McCabe, 2001; Halliwell & Dittmar, 2003; MacDonald, 1991; Wolf, 1991). Interviews of women, ranging in age from 28 to 63, found that married women considered the peak years of women's attractiveness and sexual appeal as occurring from the early twenties to the mid-thirties, yet they judged men's peak years as occurring from their early forties to their late fifties (Giesen, 1989). In another study, middle-aged women considered themselves less attractive than they considered young or old women and young, middle-aged, or old men (Nowak, Karuza, & Namekas, 1976).

At the same time, midlife women may be more realistic about their bodies than their younger counterparts. While the few studies of older women's desired body image show that they, too, want to weigh less, the difference between their actual and desired weight is less than for younger women (Crose, 1999; Lamb, Jackson, Cassiday, & Priest, 1993; Rand & Wright, 2000). For example, a study of 20- to 84-year-old women found that, while body dissatisfaction remained stable across the age range, habitual body monitoring, appearance anxiety, and self-objectification decreased with age (Tiggerman & Lynch, 2002). In another study, more than a quarter of the naturally menopausal women felt more positive about their bodies and had become more comfortable with their bodies since menopause (Bellerose & Binik, 1993). This growing comfort or acceptance may be due to a developmental phenomenon known as perspective transformation, in which a person forms increasingly meaningful perspectives (Mezirow, 1991).

Little research has examined the relationships between body image and sexual activity and responsivity among non-diseased, non-disabled, or non-eating disordered women. Those studies that have been conducted offer inconsistent results (Weiderman & Hurst, 1997). For example, self-ratings of facial attractiveness, body image, and general body satisfaction have been found to relate to frequency of sexual behaviors and amount of lifetime sexual experience in some studies (Faith & Schare, 1993; MacCorquodale & DeLamater, 1979; Murstein & Holden, 1979). More specifically, a survey of 14- to 74-year-old women found that those who were more satisfied with their body image reported more sexual initiation, activity, experimentation, and orgasm than those who were dissatisfied (Ackard, Kearney-Cooke, & Peterson, 2000). Among 20- to 65-year-olds, Bancroft et al. (2003) found that sexually active women felt more sexually attractive than women who had been inactive over the last four weeks. Wiederman and Hurst (1997) found a significant relationship between sexual self-schema, or cognitive view of the self with regard to sexuality, and self-rated facial and body attractiveness among college women. In contrast, Walsh (1993, 1995) found a negative relationship between satisfaction with appearance among female college students and their lifetime number of sexual partners. Other researchers have found only a weak or no relationship between sexual experience or satisfaction and self-rated attractiveness (Curran & Lippold, 1975; Feingold, 1992; Walker-Hill, 2000).

More specifically, there has been a dearth of research examining the relationship between body image and women's sexual responses. A qualitative study of 60 West German women, ages 50 to 80, concluded that developing a positive body image, or accepting the outward signs of an aging body, helped to keep sexual feelings alive (Fooken, 1994). More specifically, older women with more positive body images had more liberal sexual attitudes and reported higher sexual interest, activity, and pleasure than those women with poorer body images. When midlife women in the U.S. were asked to provide their own explanations for their changed sexual responsivity, approximately 8-17% identified their changing appearance/appeal as the primary reason for a specific sexual response increase or decrease over the past year (Mansfield et al., 2000). Studying a sample of women 22 to 65 years of age, half with gynecologic disease and half disease-free, Anderson and LeGrand (1991) found that women with unfavorable evaluations of their bodies engaged in a more restricted range of sexual activities than those with more favorable evaluations. Further, women with poorer body images reported fewer satisfactory sexual responses and more problems with sexual desire, excitement, and resolution than women with more positive body images. These studies support a link between body image and sexual responding in women that needs further study.

METHOD

Sampling and Procedures

The TREMIN Research Program on Women's Health, the oldest ongoing longitudinal study of menstruation and women's health, was founded in 1934 and has recruited several thousand U.S. women over the last seven decades (Mansfield & Bracken, 2003a, b). Most of the women were recruited as undergraduates at the University of Minnesota in the 1930s (approximately 2,350 women, known as Cohort One) or in the 1960s (approximately 1,600 women, known as Cohort Two). The daughters of participants have also been invited to enroll, resulting in a rich intergenerational sample.

In 1990, women who were in midlife (ages 35 to 55) and still menstruating were invited into a specialized TREMIN study of midlife issues known as the Midlife Women's Health Survey (MWHS). Selection of a 35 to 55 age range ensured that information on the entire transitional period could be obtained. Most of these women were TREMIN participants, but an additional group of women, 1963 graduates of Douglass College, were also invited to take part in the study. These women later became part of the general TREMIN sample. Each year, from 1990 until 1999, MWHS participants completed an annual survey and a menstrual bleeding calendar.

This study focused on specific data from the 1993 survey, which included a section on body image. Of the 367 women who responded to the 1993 survey, 52 were eliminated because they had undergone a hysterectomy or were using hormone therapy, two conditions that might affect sexual response. Another eight self-identified lesbians were eliminated because studies suggest that sexuality issues of lesbians may differ from those of heterosexual women at midlife (Cole, 1988; Sang, Warshaw, & Smith, 1991). The remaining sample (n = 307) was predominantly Caucasian (99.2%), college-educated (99%), and employed outside the home (83%). Ages ranged from 39 to 56 (mean age = 50). The vast majority (80.1%) were married or had a live-in partner, 3.0% were in a relationship but were not living with their partner, and the remainder were either divorced (7.3%), single (7.6%), or widowed (2.0%). Nearly 21% self-reported as premenopausal, 63.5% as perimenopausal, and 15.5% as postmenopausal.

Measures

The MWHS contained questions about physical, emotional, sociocultural, psychological, and sexual aspects of midlife and menopause, as well as attitudinal questions regarding menstruation, menopause, and health care in general. Menopausal status was measured by self-reporting which category best described the participant's menstrual pattern: premenopausal (bleeding in regular pattern), perimenopausal (noticeable changes in one or more aspects of menstrual bleeding), or postmenopausal (no menstrual bleeding for one year). This practice of self-report is a standard method of assessing menopausal status in the absence of costly hormonal assays (Cutler, Garcia, & McCoy, 1987).

Of particular relevance to the current study were the questions regarding body image, sexual response, and sexual satisfaction. Three questions were posed concerning body image. The first asked, "In comparison to how you looked 10 years ago, do you feel you are: 1 (much more attractive) to 5 (much less attractive)?" The second and third questions asked, "What do you think are the most attractive parts of your body?" (open-ended); and "What do you think are the least attractive parts of your body?" (open-ended). Questions 2 and 3 were content analyzed separately into categories with consensus reached by the coders.

Changes in sexual response were measured by first using a screening question: "Have you noticed changes in your sexual response from 10 years ago?" If a respondent replied in the affirmative, she then was asked to specify which changes she noticed in the respective time period: more or less sexual enjoyment, more or less desire, more or less ease of arousal, more or less ease of orgasm, and more or less frequency of sexual activity.

Sexual satisfaction was determined by three questions. In the first two, participants rated their physical and emotional satisfaction from their sexual relationship with their primary partner on a Likert scale from 1 (very unsatisfying) to 5 (very satisfying). Then they rated their overall satisfaction with this sexual relationship using the same scale.

At the end of the MWHS, a space was provided where the respondents could "discuss any issues regarding your sexuality." We content analyzed these responses for positive or negative body image comments as well as comments related to sexual response.

RESULTS

Body Image, Age, and Menopausal Status

The first research question concerned women's perceptions of their attractiveness and whether these were age- or menopause-related. In the respondents' open-ended responses about their most and least attractive features, the women regarded their most attractive features as their hair (31.6%), eyes (28.5%), legs (25.5%), and face (24.8%). It is interesting to note that, in response to this question, nearly 21% could not think of one attractive feature and reported an overall sense of dissatisfaction with their bodies. The features that the women considered least attractive were stomach/abdomen (36.2%), hips (26.5%), thighs (22.4%), and legs (20.4%). Comparing themselves at the present time to 10 years previously, half of the participants (51.5%) felt less attractive, whereas one third (32.8%) felt as attractive and far fewer felt more attractive (15.7%).

To answer the question of whether age affects one's body image, we conducted a correlation analysis. No significant relationship was found between current age at midlife and perceived attractiveness when compared to 10 years earlier (r = .10, p > .05). Thus, regardless of the woman's age, she was more likely to consider herself more attractive when she was 10 years younger. To test the relationship between a woman's menopausal status and her perception of her own attractiveness, we conducted a one-way analysis of variance. No significant relationship was found between menopausal status (pre-, peri-, or postmenopausal) and women's perceptions of their own current attractiveness in comparison to themselves 10 years earlier (F = .52, p = .42). In other words, perceived attractiveness did not differ across menopausal status groups.

Sexual Response Changes and Sexual Satisfaction

The second research question addressed changes in sexual responsivity and activity. Of the total midlife sample, two thirds (67.8%) reported one or more changes in their sexual response over the past 10 years; see Table 1.

Most noticeable is that the two items to which a majority of the women reported sexual changes were both sexual response decrements: desiring sex less (experienced by 57.2% of women with changing sexual response) and engaging is sex less often (57.7%). Enjoying sex less and finding orgasms more difficult to achieve also were noted by 39.4% and 31.7%, respectively, of the women who reported that their sexuality had changed. However, about one quarter (26.9%) of the women reporting changes indicated that orgasms were easier to achieve, and one third (33.2%) indicated that they enjoyed sex more over the past 10 years.

Despite reported changes in sexuality, sexual satisfaction in this sample was reported as high: 72% of participants with sexual partners reported being physically and emotionally satisfied in their sexual relationships, and 71% reported general sexual satisfaction.

Body Image, Sexual Response Changes, and Sexual Satisfaction

To determine the relationships between the midlife women's body image and specific sexual response changes over the past l0 years, we performed t-tests. These t-tests compared perceived attractiveness scores (how attractive women rated themselves as compared to 10 years previously) of participants who reported a specific sexual response change ("Yes") to those who did not report the specific change ("No"). See Table 2.

Uniformly, the more a woman perceived herself as less attractive, the more likely she was to report a decline in sexual response or activity over the past 10 years. Most of these associations were statistically significant (p < .05) or approaching significance: enjoying sex less, desiring sex ess, and having sex less often. Conversely, the more a woman perceived herself as attractive, the more likely she was to report an increase in sexual response or activity. Once again, most of these associations were statistically significant (p < .05) or approaching significance: enjoying sex more, desiring sex more, experiencing orgasm more easily, and having sex more often.

A correlational analysis revealed no significant relationship between women's perceptions of their own attractiveness as they aged and their current physical (r = -.11, p = .079), emotional (r = -.06, p = .371), or overall (r = -.07, p = .271) sexual satisfaction.

The content analysis of the open-ended responses in which the women could discuss any issue regarding their sexuality shed further light on the women's experiences of body image and its impact on their sexuality. Of the 87 comments, 35 (40%) mentioned body image. The other comments focused primarily on relationship issues. In 26 (74%) of the 35 body image comments, women made negative remarks about their bodies, with half of these specifically mentioning feeling overweight. Some typical examples follow:

   Body weight (the rounded areas that came in the past few years)
   makes me feel frumpy.

   Not being able to achieve significant weight loss has some effect
   on my self image. 'Matronly' is not a sexy term (unless you're
   Mae West).

Three quarters of these women with body image concerns also described specific sexual concerns, such as the following:

   Sometimes my fat literally gets in the way. I wish I was more
   flexible and lithe, for sexual reasons.

   During the last three months, I feel out of control ... have gained
   almost 20 pounds. This is beginning to affect my sexuality (desire
   for sex) in a negative way.

On the other hand, almost one quarter of the women described feeling sexually satisfied despite having body mage concerns. Some examples of these comments follow:

   I keep gaining weight ... the weight doesn't seem to affect my
   husband's desire and I don't feel less sexy. Hurray!

   I'm heavier than I'd like to be but some of it 'goes with the
   territory' of being older and somewhat less active than I used to
   be. Sex appeal with my husband has as much to do with having a
   strong commitment to one another as it does to how we look to
   one another.

   I don't like getting older and seeing my body age, but I do enjoy
   the passion and feeling of intimacy I enjoy in sexual relations. I
   feel lucky to have a satisfying relationship and I get a great deal
   of enjoyment from my creative partner. I think sex won't get old.

In only nine comments did women express a positive body image, and these were all accompanied by positive comments about their sexuality as well.

   Since I turned 40, I feel more at ease with myself. I feel more
   attractive, can accept things better about myself that I cannot
   change, and feel more passion.

   I feel that I am still attractive. My husband and I have a very
   close, warm relationship. We are each other's best friend. Sex is
   only part of it.

DISCUSSION

By 2020, there will be as many women facing menopause in the United States as there will be women in their child-bearing years (United States Department of Commerce, 1998). With so many aging women, understanding sexuality during midlife and beyond has gained more importance both for professionals (e.g., health-care professionals, policymakers) and for women themselves. This study attempted to shed some light on the relationships between body image and sexual response changes in midlife women. However, the limitations of this study must be kept in mind. The sample was very homogeneous, consisting primarily of well-educated White women. Thus, results can not be generalized to other women of diverse racial, ethnic, or socioeconomic backgrounds. Further, the research is cross-sectional in design so that causation in the relationships can not be determined. In addition, data were self-reported, so perception bias and recall may have influenced some of the responses. Yet even with these limitations, this study fills a gap in the research on women's sexuality.

Midlife Women and Body Image

The analyses revealed several interesting findings regarding body image perceptions among midlife women. The results are congruent with previous research on women's body image, indicating that it is the norm for women to be dissatisfied with their bodies. Previous research reveals that U.S. women are particularly dissatisfied with their middle (waist, abdomen) and lower (hips, thighs, buttocks, and legs) torso and that younger women (in their teens and twenties) receive the most favorable appearance evaluations (Cash & Henry, 1995). In Banister's (1999) qualitative study, most of the midlife participants revealed a sense of grief over the loss of their youth. In the current study, about half of the midlife women, regardless of their specific age, perceived themselves as less attractive than they were 10 years before. In their own eyes, the effects of aging diminished their attractiveness. Similarly, in her sample of 28- to 63-year-old women, Giesen (1989) also found no age difference in the number of women who considered themselves more or less attractive currently than 10 years ago.

Throughout women's lives, their weight tends to be a recurring issue, and this concern is quite evident among midlife women. Physiologically, the body's basal metabolic rate slows down with age and is accompanied by a decrease in lean body tissue and an increase in fat (Beser, Aydenir, & Bozkaya, 1994; Rodin, Silberstein, & Striegel-Moore, 1984; Voda, Christy, & Morgan, 1991). The percentage of body fat generally doubles by the time women reach 50 years of age, which corresponds to the time they are reaching menopause as well (Rodin et al., 1984). Their weight also tends to be redistributed so that their breasts become larger, their waists thicken, and fat increases on their upper back. Thus, it is a natural developmental phenomenon for midlife women to change shape, just as they did when they went through puberty.

Nevertheless, it is widely acknowledged that the standard of attractiveness for women in American society is based on youthfulness and a slender body, creating anxiety about aging and pressure for older women to disguise the physical signs of aging to appear younger (Chrisler & Ghiz, 1993; Rostosky & Travis, 2000). For example, Wolf (1991) interviewed editors of women's magazines who admitted that it is routine practice to "airbrush" photographs through computer imaging to make an older woman appear younger. Such cultural messages may create an expectation in older women to appear 10 or more years younger than they are and cause distress when their bodies naturally age despite all of their efforts to the contrary (Kingsberg, 2002).

This distress was apparent in the themes that emerged in Banister's (1999) ethnographic research exploring midlife women's perceptions of their changing bodies. Sensing incongruence was one of the themes that was also apparent in the optional open-ended comments made by the midlife women in the current study. While many of the women judged their appearance negatively, some expressed incongruence between what they considered society's evaluation of female attractiveness and their own evaluation. Banister described this as being caught between cultural norms and one's own reactions. The theme of personal transformation was also apparent in some comments in which women displayed self-acceptance of their changing bodies.

As in this study, Giesen (1989) found that some women felt more attractive as they aged while others did not. She found that more single women perceived themselves as having grown more attractive and sexually appealing as they grew older than did married women. She suggested that these differences were the result of qualitatively differing experiences between these groups of women. Future research should continue to explore the characteristics and circumstances that influence some aging women to be dissatisfied, whereas others are accepting and even positive about their changing bodies.

While aging appeared to have had a negative effect on body image, menopausal status did not. Given the stigma associated with menopause (Youngs, 1990), it might be expected that peri- and postmenopausal women would have poorer body images than premenopausal women would. The absence of such a relationship suggests that sociocultural factors (ageism and sexism) play a more potent role in determining body image at midlife than do the physiological changes of menopause (Pacquette & Raine, 2004).

Sexual Response Changes of Midlife Women

Reflecting over the past 10 years, two thirds of the TREMIN midlife women reported a change in their sexual responsivity or activity. Declines in sexual response were experienced most frequently, with more than half of those who reported changes reporting feeling less sexual desire and having sex less often than before. One quarter to one third also reported more difficulty in achieving orgasm and less enjoyment of sex, respectively. Numerous other studies have reported similar patterns, with the greatest declines appearing to occur in the later stages of menopausal transition (Cole, 1988; Cutler, Garcia, & McCoy, 1987; Hallstrom & Samuelsson, 1990; Kinsey, Pomeroy, Martin, & Gebhard, 1953; McCoy & Davidson, 1985; Sarrel & Whitehead, 1985).

However, it is also noteworthy that nearly one third of the TREMIN women did not report any changes in their sexual responsivity or activity over a 10-year time period. Further, considerable numbers of midlife women who did report change indicated that their responsivity or activity had increased: enjoy sex more (33.2%), orgasm easier to achieve (26.9%), desire sex more (17.8%), and sex more often (16.3%). While other researchers have also noted increased sexual responsivity or activity or no change among aging women (Adams & Turner, 1985; Avis et al., 2000; Bachmann et al., 1985; Deeks & McCabe, 2001; Dennerstein et al., 1997; Dennerstein et al., 2001), these findings do not tend to garner much attention. The reasons why some women experience increases in their sexual responsivity and activity while others experience decreases should be explored more fully through future research.

Further, the majority (nearly three quarters) of the TREMIN midlife women reported that they were sexually (both physically and emotionally) satisfied in their relationships, even though many reported sexual responsivity and activity declines. This finding is consistent with previous research into sexual satisfaction which shows that, regardless of the specifics of their sexual responsivity, most older women tend to indicate that they are sexually satisfied (Avis et al., 2000; Trudel, 2002).

Body Image, Sexual Response Changes, and Sexual Satisfaction

A consistent pattern emerged in which reporting a decrease in sexual responsivity or activity was associated with lower perceived attractiveness. This pattern confirms other research that has found significant relationships between body image and sexual activity and response (Ackard et al., 2000; Anderson & LeGrand, 1991; Bancroft et al., 2003; Fooken, 1994).

Wiederman and Hurst (1997) have summarized the various explanations for the relationship between body image and sexual response. First, the relationship could be due to subjective dissatisfaction with one's appearance that leads to avoidance of sexual interaction or decreased sexual response, as expressed in the above comments. Alternatively, the relationship could be due to sexual experiences that subsequently influence a woman's view of her own attractiveness. Also, the relationship could be due to real or perceived imperfections in physical appearance that discourage sexual partners. It is likely that for different women, differing explanations apply, and that the relationship between body image and sexual responsivity is an interactive process. Prospective longitudinal research exploring specific aspects of body image and sexual response is needed to disentangle these relationships.

This study demonstrated that body image has a significant impact on sexual desire, orgasm, enjoyment, and frequency of sexual activity, but no such relationship was found with sexual satisfaction. Other studies have also found that older women's sexual satisfaction seems to be influenced more by contextual factors than by bodily responses. For example, in Bancroft et al.'s (2003) national probability sample of 987 women, ages 20 to 65 years, it was found that impaired sexual interest or response were more common in older women, but younger women were more troubled by the experience. Lessened sexual responsivity generally did not concern most of the older women. Other researchers have found that sexual satisfaction for women is best predicted not by specific sexual responses, but by qualities of their relationships and lives (Haavio-Mannila & Kontula, 1997; Hurlbert, Apt, & Rabehl, 1993, Young, et al., 2000).

Bancroft and others have advocated for the "normalizing" of aging and the encouragement of adaptation without classifying common sexual changes as "dysfunctional" (Bancroft et al., 2003). Many have called for a "new view" in which women's lived experiences guide the understanding of their sexuality (Kashak & Tiefer, 2001; Tiefer, 2001). The findings from this study seem to support these approaches to the study of aging women's sexuality. Thus, to understand aging women's sexuality, we should place more emphasis on the sociocultural effects of aging (e.g., impacting body image) and the contextual features of women's lives (e.g., relationships). On the other hand, a primary focus on improving aging women's sexuality through the "treatment" of menopausal symptoms seems unwarranted in light of the findings that menopausal status did not have a significant impact on the sexual responding of the women in this study.

Manuscript accepted November 9, 2004

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Patricia Barthalow Koch, Phyllis Kernoff Mansfield, Debra Thurau, and Molly Carey

Penn State University

Address correspondence to Patricia Barthalow Koch, Ph.D., Penn State University, E-304 Health & Human Development Building, University Park, PA, 16802; e-mail: [e-mail].

Table 1. Sexual Response Changes Over the Past 10 Years

                               % of Total       % of Women
Sexual Response                  Sample     Reporting a Change
   Change                 N    (n = 307)        (n = 208)

Enjoy sex less            82      26.7             39.4
Enjoy sex more            69      22.5             33.2
Desire sex less          119      38.8             57.2
Desire sex more           37      12.1             17.8
Orgasm more difficult     66      21.5             31.7
Orgasm easier             56      18.2             26.9
Sex less often           120      39.1             57.7
Sex more often            34      11.1             16.3

Table 2. Relationships Between Perceived Attractiveness
and Reported Sexual Response Changes in the
Past 10 Years

                                   Perceived Attractiveness
                                   Scale Means (a)

                                   Those Reporting

Sexual Response Changes            "Yes"   "No"      t      P

Decreased Responding
  Enjoy sex less                    3.61   3.38     1.76   .079
  Desire sex less                   3.64   3.25     3.08   .002
  Experience orgasm less easily     3.61   3.41     1.45   .150
  Have sex less often               3.58   3.31     2.03   .043
Increased Responding
  Enjoy sex more                    3.22   3.60     2.70   .008
  Desire sex more                   3.19   3.53    -1.98   .054
  Experience orgasm more easily     3.25   3.55    -2.02   .046
  Have sex more often               3.15   3.53    -1.97   .055

(a) Mean attractiveness scores in comparison to themselves 10 years
earlier on a five-point Likert scale: 1 (much more attractive), 2
(a little more attractive), 3 (of equal attractiveness), 4 (a little
less attractive), and 5 (much less attractive).