Body image and female sexual functioning and behavior: a review.
At first sight, sexuality and body image are obviously connected. There is no doubt that physical appearance is a major component of the experiences of women's sexuality (McClintock, 2011). The concept of body image is comprised of cognitive and emotional meaning about the body (Cash, 2002). Having a positive body image is associated with a pleasurable sex life (Satinsky, Reece, Dennis, Sanders, & Bardzell, 2012). Satisfaction with one's body may result in greater confidence when a woman sexually interacts with a partner.
In Western cultures, a woman's appeal as a sexual partner seems to be heavily dependent on her visual stimulus value for her partner. Many women are aware of the gaze of men (Hall, 1984). Feminist theorists have argued that women often adopt an observer's perspective on their physical selves (e.g., Bartky, 1990). This implies that physical attractiveness and body image are relevant for women. According to evolutionary theorists (e.g., Buss & Schmitt, 2011), women's physical attractiveness is important because it gives male sexual partners reliable cues to gauge their health and potential reproductive success. This may have caused women to become--in the course of evolution--increasingly aware of how they appear to others, especially to sexual partners.
Media images of women's bodies often present an unusual, slim-hipped, long-legged, large-breasted ideal. Idealized women all tend to be several inches taller and many pounds lighter than most women (Byrd-Bredbenner & Murray, 2003). Media models are often more than 20% underweight (Dittmar, 2007). Mass media, such as fashion magazines and television, promote, if not establish, a beauty ideal that leads many women to feel badly about their weight and shape (Groesz, Levine, & Murnen, 2002). Women are labeled the aesthetic sex. It is women's bodies that are gazed at and judged (Bordo, 2003; Wolf, 1991). Men's gazes and unrealistic body ideals seem to work in concert to make it difficult for women to be satisfied with their own bodies.
The main question addressed in this review was, "How is body image related to female sexual functioning and behavior?" A growing literature highlights the importance of the body image construct for various aspects of sexual functioning (Wiederman, 2002). However, most of this research has examined the relationships between body image and sexual functioning among diseased, disabled, or eating-disordered women. In this review, we summarize the empirical findings regarding the relationship between body image and sexuality in healthy women.
Literature Search and Selection
We did not include research on women suffering from cancer or other diseases. Changes in vitality and physical and social functioning that often accompany major illness, such as cancer, impair sexual functioning and, thus, can obscure the direct relationship between body image and sexual functioning (Mock, 1993). For example, in one study, women with breast cancer were more likely than healthy women to experience reduced physical function, role function, vitality, and social function (Michael, Kawachi, Berkman, Holmes, & Colditz, 2000). Young breast cancer survivors were found to be less sexually active and had more body image and sexual problems than healthy women in the same age range (e.g., Fobair et al., 2006). Therefore, the interpretation of an expected relationship between body image and sexual functioning can be complicated by the occurrence of other, related factors, such as vitality and physical functioning. Because the focus of this review was on body image and female sexual functioning, we also excluded research on male samples. Although a recent meta-analytic review on gender differences in sexuality suggested that men and women are more similar than they are different in terms of sexuality, men reported slightly more sexual experience and more permissive attitudes than women (Petersen & Hyde, 2010). Men desire more sex partners, and there is evidence for sex differences in extramarital sexual behavior (Buss & Schmitt, 2011). Female sex drive is also more plastic and malleable than that of the male, in response to social, cultural, and situational stimuli (Baumeister, 2000).
Literature was found using Psychlnfo[R], MEDLINE[R], Google[TM] Scholar, and Social SciSearch[R]. The following search terms were used: female body image, body satisfaction, body dissatisfaction, body concerns, body evaluation, body image attitudes, appearance concerns, and self-objectification, combined with sexual behavior, sexual functioning, sexual attitudes, sexual satisfaction, sexual dissatisfaction, and sexual dysfunction. Titles and abstracts were examined to see if the articles contained any measure of sexuality linked to an aspect of body image. Specific author searches in Google Scholar were also conducted of authors who seemed to have an empirical or theoretical interest in this topic. The abstracts of all studies associated with these authors were examined. Furthermore, reference sections of all included articles were carefully reviewed, and relevant journals (e.g., Journal of Sex Research, Body Image, and Archives of Sexual Behavior) were searched.
Selection criteria did not include country of origin, ethnicity, or age. However, the 57 studies included in this review (see Table 1) exclusively represented Western nations, except for two studies, one conducted in China and one in South Africa. Thirty-seven studies were carried out in the United States, six in Canada, three in Australia, three in the United Kingdom, two in Portugal, one in Finland, one in Germany, one in Norway, one in New Zealand, and one in the Netherlands. In most studies, a large percentage of the participants were Caucasian young women. Only studies published in 1990 or thereafter were included because research on body image and sexuality has, for the most part, been performed in these two decades. Unpublished data were not included. Characteristics of the studies can be found in Table 1.
Conceptualizing Body Image and Sexuality
As noted earlier, the research fields of body image and sexuality have experienced considerable growth in the last two decades. This was paralleled by an increase in the number of assessment instruments that were developed to measure several aspects of both constructs. Therefore, the ways in which body image and sexuality were conceptualized in studies varies, and different terms have been used to refer to different aspects or dimensions of body image or sexuality.
Body image is often described as how one perceives one's own body. Despite the fact that this simple definition is often used, research has shown that there is much more complexity underlying the meaning of this term. Early researchers conceptualized body image as being one-dimensional. Now it is considered to be, and is mostly measured as, a multidimensional construct. Cash (2002) provided a useful multidimensional model. He referred to body image as the experience of embodiment and incorporation of the perceptions and attitudes about one's body, especially one's physical appearance. Three specified dimensions are evaluation, investment, and affect. Body image evaluation denotes feelings of satisfaction or dissatisfaction with different aspects of appearance. Body image investment refers to the importance one places on physical appearance and the effort one is willing to make to reach the desired physical appearance. Finally, body image affect refers to emotional experiences that result from body-related evaluations. These three global dimensions, or specific aspects of these dimensions, can be identified in the body image literature. However, the vast majority of studies have focused on the evaluative dimension--specifically, on body dissatisfaction. Another important distinction in the body image literature is between general, dispositional body image evaluations and contextual or state body image evaluations (e.g., during sexual activity; Cash, 2002).
Like body image, female sexuality is a complex phenomenon. Women's bodies are sexual objects of male desire (Blood, 2005). Sexuality is also multidimensional and contains different components, including biologic, psychological, sociocultural, and spiritual aspects. Sexuality is dynamic; it changes with time and place, as well as with different partners. It is individually and socially constructed; that is, sexuality is individually defined and experienced, often in relation to one or more partners, but it is also a part of culture (Bernhard, 2008). Female sexuality includes many different aspects; it encompasses women's sexual knowledge, beliefs, attitudes, values, and behaviors.
Studies in the field of female sexuality have measured and described a variety of variables of this construct. Researchers have suggested that, in comparison with men, women's sexuality may be more influenced by cultural factors. Baumeister (2000) coined the term erotic plasticity for this phenomenon. Three signs of plasticity were observed. The first is that a woman's sexual feelings tend to change more than a man's as she moves through her adult life. The second sign is that particular social and cultural factors (e.g., education and religion) have a larger impact on female sexuality than on male sexuality. A third sign of erotic plasticity is the greater gap between sexual attitudes and actual behaviors among women than among men (Miracle, Miracle, & Baumeister, 2003).
Research has linked body image to various important aspects of female sexuality--specifically, to sexual functioning, sexual schemas, sexual esteem, and sexual behavior.
Body Image and Sexual Functioning
Female sexual functioning can be described in biological, psychological, and social terms. Masters and Johnson's (1966) sexual response cycle characterized sexual response as a four-phase physiological process, including excitement, plateau, orgasm, and resolution. Sexual response begins with excitement or arousal. With continued and sufficient stimulation, excitement builds to a plateau followed by the orgasm phase. During resolution, the body returns to its normal state. In later refinements of this model, a preliminary appetitive phase was added to the sexual response cycle, which refers to sexual desire. A difficulty with this sexual response cycle model is that a successful sexual response seems to be synonymous with achieving an orgasm. However, experiencing physical pleasure and well-being during sexual activity might be independent of reaching an orgasm for many women. Therefore, we used a broader definition of female sexual functioning than a purely physical one, in which the domains were sexual desire, subjective arousal, lubrication, orgasm, satisfaction, and pain (Rosen et al., 2000). Research assessing these domains has successfully discriminated women with and without sexual complaints and dysfunctions (Meston, 2003; ter Kuile, Brauer, & Laan, 2006; Wiegel, Meston, & Rosen, 2005). Several studies have focused on direct relationships between body image and the different domains of sexual functioning. Other researchers have studied a mechanism that might underlie this relationship (e.g., using the objectification theory as a theoretical framework). Objectification theory places female bodies in a sociocultural context, with the aim of illuminating the lived experiences and mental health risks of girls and women who encounter sexual objectification. The common thread of sexual objectification is the experience of being treated as a body (or collection of body parts), predominantly valued for one's usefulness to others. Women can become preoccupied with their own physical appearance as a way of anticipating and controlling their treatment (i.e., "self-objectification"). Chronic attentiveness to one's own body may interfere with sexual activity and hinder women's sexual functioning (Fredrickson & Roberts, 1997). In one experimental study, a state of self-objectification led to a decrease in the appeal of the physical aspects of sex (Roberts & Gettman, 2004). The experience of self-objectification is also referred to as self-focus, spectatoring, or self-consciousness during sexual activity. Barlow's (1986) model of sexual functioning also suggests that inspecting, monitoring, and evaluating oneself during sexual activity interrupts sexual responses, with cognitions directed toward one's own sexual performance, rather than toward sensory aspects of the sexual experience. Although this model originally focused on the effects of concerns about erectile function in men, it has been suggested that self-focus during sexual activity may cause cognitive distraction and have a negative influence on sexual function in women as well. A study by Meana and Nunnink (2006) focused on gender differences in the content of cognitive distraction during sex. They found that women reported higher levels of overall and appearance-based distraction. In the following sections, we review the findings of studies in which the relationship of body image and the different domains of sexual functioning were investigated.
Problems with sexual desire are the most common sexual problems presented in therapy (Hock, 2007). We found few relevant studies on the topic of body image and female sexual desire. Seal, Bradford, and Meston (2009) examined the relationships between body image and self-reported sexual desire responses to erotica in a sample of college women. It was found that having positive feelings about one's body (i.e., high body esteem) was related to sexual desire in response to erotica. Similarly, having positive feelings about one's body was positively related to self-reported measures of sexual desire. Sexual attractiveness and weight concerns related to body characteristics that are most likely to be under public scrutiny, such as the face and appearance of weight, were particularly linked to sexual desire (Seal et al., 2009). Perceived attractiveness was also found to be related to sexual desire in midlife women. Although aging or menopausal status may change sexual feelings and responses, feelings of subjective attractiveness were still found to be important in the experience of sexual desire among older women. It was shown that the more a woman perceived herself as attractive, the more likely she was to experience an increase in sexual desire over the past decade. Decline in sexual desire was more likely to be reported when a woman perceived herself as less attractive than 10 years earlier (Koch, Mansfield, Thurau, & Carey, 2005). One Portuguese study found that sexual desire was predicted by various dysfunctional beliefs regarding sexual issues (i.e., failure disengagement, passivity and control, and lack of erotic thoughts), but not by body image beliefs (Carvalho & Nobre, 2010). Although there is still limited empirical data about the relationship between body image and sexual desire, the overall results indicate that positive body image experiences are associated with higher levels of sexual desire.
Subjective Sexual Arousal and Lubrication
Sexual arousal refers to the physiological response to sexual stimuli, and can follow sexual desire. The relationship between sexual interest and sexual arousal, however, is complex. According to Basson (2000), a circular model of female sexual responding may more adequately represent women for whom desire is a response to arousal, instead of a precursor of arousal. Qualitative data analysis in a sample of adult women also showed that many women did not clearly differentiate between arousal and desire (Graham, Sanders, Milhausen, & McBride, 2004). Sexual desire was reported as sometimes preceding arousal, but at other times following it. Feeling comfortable and positive about one's body was frequently mentioned by women as a factor that would facilitate sexual arousal (Graham et al., 2004). Sanchez and Kiefer (2007) found, in a sample of mainly adult women, that body shame was related to greater sexual self-consciousness during sexual activity, which, in turn, predicted lower sexual arousability. The relationship between body shame and sexual arousal was mediated by sexual self-consciousness. These results support the notion that inspecting, monitoring, and evaluating oneself during sexual activity (Barlow, 1986) interrupts sexual responses. In their laboratory study, van Lankveld and Bergh (2008) found that genital response to induction of self-focus produced lower genital response in women with high levels of dispositional sexual self-consciousness, but not in women with low sexual self-consciousness. Subjective arousal was not affected. Another laboratory study found that genital response, but not subjective arousal, was impaired in women with different levels of dispositional self-consciousness (Meston, 2006; Seal & Meston, 2007). The fact that subjective arousal was not affected in these studies may be explained by the absence of a partner in laboratory settings. It might be that women do not experience a state of anxious apprehension that they typically experience in sexual situations, and that they are less likely to experience the characteristics of narrowed attentional focus to non-erotic thoughts, including high body awareness (Wiegel, Scepkowski, & Barlow, 2006) in laboratory settings.
Due to continued sexual arousal, physical changes, such as relaxation of the vaginal muscles and swelling of the labia and the clitoris, can occur and result in orgasm. When reaching an orgasm, the muscles of the vagina and uterus contract and create a strong feeling of pleasure for many women. As described earlier, body image issues may negatively influence sexual arousal in women. Sanchez and Kiefer (2007) found that body shame was indirectly related to orgasm difficulty through reduced arousal. Orgasm is more frequently reported by women who are satisfied with their bodies (Ackard, Kearney-Cooke, & Peterson, 2000) and perceive themselves as attractive (Koch et al., 2005). Moreover, cognitive distraction due to body concerns during sexual activity with a partner was associated with less consistent orgasms (Dove & Wiederman, 2000).
It is reasonable to expect that a woman who feels positively about her own body experiences more satisfaction during sexual activity. Indeed, several studies have found associations between body image variables and sexual satisfaction. Hoyt and Kogan (2001) found that women who were dissatisfied with their sex lives were more dissatisfied with their body appearance than those who were satisfied. Other studies have revealed that sexual satisfaction was positively related to appearance evaluation (Holt & Lyness, 2007), general body image (Meana & Nunnink, 2006; Tang, Lai, & Chung, 1997), general body esteem (Penhollow & Young, 2008), and self-perceived sexual attractiveness (Pujols, Meston, & Seal, 2010), and negatively related to body shame (Calogero & Thompson, 2009a). Self-perceived attractiveness has also been found to be positively related to sexual enjoyment (Koch et al., 2005). Although these results cannot confirm whether a causal relationship exists, there are findings suggesting that body image issues can harmfully affect sexual satisfaction. In a large online study (N = 1,736), heterosexual and lesbian women were asked if they believed that their feelings about their bodies affected their sex lives (Peplau et al., 2008). Nearly one-half of the women, including 48% of heterosexual women and 47% of lesbian women, reported that their body image had a positive effect on the enjoyment of their sex lives and feelings of acceptability as a sexual partner. Further, over one-fourth of both lesbian and heterosexual women reported that their feelings about their bodies had a negative effect on the enjoyment of their sex lives and feelings of acceptability as a sexual partner. Other studies have reported that women who were concerned about their bodily appearance during sexual activity with a partner reported relatively less sexual satisfaction (Dove & Wiederman, 2000; Meana & Nunnink, 2006; Purdon & Holdaway, 2006). How could this mechanism work?
A study exploring the role of sexual self-consciousness during physical intimacy in the relationship between body shame and sexual problems found that the relationship between body shame and sexual pleasure was mediated by sexual self-consciousness during physical intimacy (Sanchez & Kiefer, 2007). Women's body shame was related to greater sexual self-consciousness, which, in turn, predicted lower sexual pleasure. These patterns remained robust, even when controlling for relationship status and age. Another study that focused on a specific aspect of body evaluation--namely, genital satisfaction--showed that greater dissatisfaction with genital appearance was associated with greater genital image self-consciousness during physical intimacy, which, in turn, was associated with lower sexual satisfaction (Schick, Calabrese, Rima, & Zucker, 2010). Although most studies found a correlation between aspects of positive body image or a lack of self-consciousness of one's physical appearance and sexual satisfaction, some studies did not (Davison & McCabe, 2005).
Lack of a physical sexual response (i.e., incomplete or absent lubrication) can lead to discomfort and pain, and may contribute to the etiology of sexual pain in women (e.g., van Lunsen & Laan, 2004). To our knowledge, pain has mostly been included as part of general sexual functioning, and has not been separately studied and discussed in relation to body image in healthy women. Some studies have specifically focused on genital satisfaction. Among large samples of adult women, it has been found that higher levels of genital satisfaction were associated with less pain (Algars et al., 2011; Herbenick-et al., 2011). Another study, which included only 31 female health center patients, found that women's feelings about their genitals were unrelated to pain (Berman, Berman, Miles, Pollets, & Powell, 2003).
Sexual Functioning in General
As described earlier, most aspects of sexual functioning were separately studied in relation to body image. Sexual dysfunction in any of the domains may occur due to body image issues. Problems related to any of the stages of sexual response may interfere with sexual pleasure and satisfaction, or may lead to painful experiences. The sexual response cycle may not be linear for women (Basson, 2000). Several studies in this field have assessed overall sexual functioning instead of differentiating between dimensions or stages of sexual functioning. General sexual functioning has been found to be related to aspects of body image, such as body esteem (Wenniger & Heiman, 1998). In a large sample of 3,800 adult women, Herbenick et al. (2011) found that positive feelings and beliefs about their own genitals were related to better sexual functioning (higher arousal, desire, lubricant, orgasm, satisfaction, and less pain in women). With regard to general body image, qualitative research in adult women has indicated that experiencing a sense of bodily acceptance is critical to healthy sexual functioning (Daniluk, 1993). Recent quantitative research has confirmed a relationship between body image and sexual functioning. Weaver and Byers (2006) found that women who experienced negative feelings about their physical appearance and body dissatisfaction were more likely to have problems with regard to their sexual functioning. A study that investigated sexual beliefs in women with and without a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis of a sexual dysfunction showed that women with sexual dysfunction also presented more negative body image beliefs (Nobre & Pinto-Gouveia, 2009). On the other hand, positive body image was significantly associated with better sexual functioning, even after controlling for body mass index. Although related to body image, body mass index did not predict sexual functioning. This demonstrates, as many studies have done, that it is women's perceptions of their bodies, rather than any objective measures of their bodies, that predict their feelings and behaviors.
With regard to sexual functioning, associations with contextual body image (i.e., body image during sexual activity) are stronger than those with general body image. In a sample of female students, Cash, Maikkula, & Yamamiya (2004) found that higher sexual functioning was more strongly related to less anxious/avoidant body focus during sexual activity than to global body satisfaction, overweight preoccupation, and appearance investment. Other studies have confirmed that contextual body image is a better predictor of women's sexuality than general body image (Steer & Tiggemann, 2008; Yamamiya, Cash, & Thompson, 2006). Contextual body image during sex was also associated with reduced sexual assertiveness, lower sexual self-efficacy, and more emotional disengagement during partnered sex in young adult women (Yamamiya et al., 2006).
Specific situations, like weight changes during the lifespan of women (e.g., pregnancy), may impact the relationship between experiences of body image and sexual functioning. Pauls, Occhino, and Dryfhout (2008) assessed body image and sexual functioning during pregnancy and postpartum. They found that body image during sexual activity did not significantly change during pregnancy, although it worsened in the postpartum period. Especially in early pregnancy, poorer sexual functioning was associated with impaired body image. Research has also been carried out with obese women. One study assessed body image and sexual functioning in women enrolled in a weight management program. These women perceived significant improvements in their body image and sexual functioning after weight loss. Most of the women attributed the improvements to changes in body image that occurred along with weight loss (Werlinger, King, Clark, Pera, & Wincze, 1997).
The Role of Sexual Schemas, Self-Objectification, and Sexual Self-Esteem
Women's sexual responses depend heavily on what sex means to them: what it signifies about their relationship, what the context is, and which norms and expectations are applied. There are specific examples of erotic plasticity among women. Several studies have shown that body image is related to women's personal values and attitudes regarding sexuality. These may inhibit sexual functioning and interfere with the quality of sexual experiences. For example, positive general body image is associated with accurate knowledge regarding sexual matters, higher sex drives, liberal (instead of conservative) sexual attitudes, and more frequent sexual fantasies (Tang et al., 1997). Furthermore, body dissatisfaction is associated with women's sexual self-schemas. The concept of sexual self-schemas refers to the extent to which women see themselves as possessing a range of personal characteristics that are associated with participation in intimate sexual relationships and behavioral openness to sexual experiences and encounters. The three identified dimensions of women's sexual self-schemas are the "passionate/romantic" dimension (i.e., the propensity to experience positive emotions in the context of romantic and sexual relationships), the "open/direct" dimension (i.e., the extent to which one sees oneself as being broadminded and open to new experiences), and the "embarrassed/conservative" dimension (i.e., negative feelings about the self in relationships and a lack of confidence and experience; Andersen & Cyranowski, 1994). Women who were satisfied with their bodies were more likely to view themselves as romantic/passionate and open/direct persons (Donaghue, 2009). Women with more positive sexual self-schemas believed their bodies and faces to be more attractive, and were judged by others to be more attractive (Wiederman & Hurst, 1998). In turn, women who viewed themselves as romantic/passionate, open/direct, and not embarrassed/conservative experienced less anxious self-consciousness, and were less likely to avoid body exposure during sex. More positive sexual self-schemas were related to better sexual functioning (Cash et al., 2004), more arousal, longer-lasting sexual and affective relationships, and more positive attitudes regarding sex in general (Andersen & Cyranowski, 1994).
In addition to associations with women's sexual self-schemas, body image has also been found to be associated with sexual self-esteem. La Rocque and Cioe (2010) and Weaver and Byers (2006) found that young women with a more positive body image were more likely to be sexually confident. General self-objectification and body shame have also been found to be directly linked to sexual self-esteem (Calogero & Thompson, 2009b). Dove and Wiederman (2000) showed that concerns about sexual performance and body appearance cause cognitive distraction, which predicts low sexual self-esteem. Genital image self-consciousness during physical intimacy has also been associated with lower sexual esteem (Schick et al., 2010). Low levels of sexual self-esteem have been related to lower sexual functioning (Dove & Wiederman, 2000). In one study, an association between higher sexual self-esteem and higher sexual satisfaction was found (Calogero & Thompson, 2009a). The overall conclusion is that positive sexual self-schemas and sexual self-esteem are important for feeling comfortable during sex. Body evaluations and cognitions may interfere not only with responses and experiences during sexual activity, but also with sexual behavior.
Body Image and Sexual Behavior
Sexual behaviors include a variety of activities that include kissing and hugging, penile-vaginal intercourse, oral sex, anal sex, and masturbation. Women may engage in sexual behaviors alone or with one or more partners. Several studies have found associations between different dimensions of body image and sexual behaviors.
Women who were more satisfied with their body reported more frequent sexual activity, and were more likely to initiate sex and to try new sexual behaviors than those who were less satisfied (Ackard et al., 2000; Trapnell, Meston, & Gorzalka, 1997). Greater body comfort and low body image self-consciousness were associated with a higher level of sexual experience (Schooler, Ward, Merriwether, & Caruthers, 2005). In addition, self-rated attractiveness was found to be positively correlated with several sexual behaviors (i.e., the number of lifetime intercourse partners, age at first intercourse, and the number of non-intercourse sexual partners in the past three years; Weeden & Sabini, 2007). With respect to solo sex, there was a positive relationship between body satisfaction and masturbation frequency in European American women (Shulman & Horne, 2003). Other studies have reported that adolescent girls without coital experience were significantly more satisfied with their bodies, compared to girls who had coital experience. Body dissatisfaction increased the probability for coital onset (Kvalem, von Soest, Traeen, & Singsaas, 2011; Satinsky et al., 2012). A negative conceptualization of their body was associated with a lower frequency of sexual behavior in female students. However, frequency of sexual behavior was best predicted by sexual attitudes. Women with liberal and accepting attitudes toward their bodies reported greater frequencies of sexual behavior, whereas women ascribing to more conservative views of sexuality reported having fewer sexual experiences (Faith & Share, 1993).
Other studies have focused on body image in relation to fear and avoidance of sexual activities with a partner. Reissing, Laliberte, and Davis (2005) found that a more negative body attitude was related to higher levels of sexual aversion in a sample of young adult women. La Rocque and Cioe (2010) studied the relationship between body image and sexual avoidance. They found that female students with a more negative body image (i.e., negative body image evaluations, high body image investment, and high body self-consciousness during sexual activity) displayed a greater tendency to avoid sexual activity. Sexual esteem, sexual satisfaction, and sexual desire appeared to mediate this relationship (La Rocque & Cioe, 2010). Furthermore, women with a more positive body image were more likely to be sexually confident, desire sexual activity, and gain satisfaction from sexual experiences. Although support for a direct relationship between body image and sexual avoidance was found, lower levels of sexual esteem, sexual satisfaction, and sexual desire appeared to mediate this relationship. Wiederman (2000) also found that women who experienced higher levels of body image self-consciousness were more likely to avoid sexual activity because of fear and anxiety.
Besides avoidance of sex and lower frequency of sexual activities, body image issues could also impact risky sexual behaviors, such as less frequent or inconsistent condom use among women. Sexual risk behaviors have been examined more extensively in adolescent girls than in adult women. Pinquart (2009) found that German adolescents with body dissatisfaction showed higher levels of ambivalence during their sexual decisions. Ambivalence, in turn, was associated with a lower probability of using contraceptives during first intercourse. These findings are in line with other research in young women. Adolescent women who were more dissatisfied with their body image were more likely to fear abandonment as a result of negotiating condom use, more likely to perceive that they had fewer options for sexual partners, more likely to perceive themselves as having limited control in their sexual relationships, and more likely to worry about acquiring HIV. Having higher dissatisfaction with one's body image was associated with never using condoms during sexual intercourse and being more likely to engage in unprotected vaginal sex (Eisenberg, Neumark-Sztainer, & Lust, 2005; Gillen, Lefkowitz, & Shearer, 2006; Wingood, DiClemente, Harrington, & Davies, 2002). Lower body comfort and greater body image self-consciousness were also related to lower levels of sexual assertiveness and condom use self-efficacy in an ethically diverse, but mainly White, sample of American female students (Schooler et al., 2005). In addition, genital image self-consciousness during physical intimacy was associated with lower motivation to avoid unprotected sexual behavior (Schick et al., 2010). In a descriptive study by Akers et al. (2009), the relationship between (perceived) weight and sexual behavior among adolescents of various racial/ethnic groups was assessed. The results indicated that sexually active girls, who were or who perceived themselves to be at the weight extremes, as well as those with weight misperceptions, were more likely to report engagement in sexual risk behaviors, compared with normal weight peers or those who perceived their weight to be "about right." Sexual intercourse before the age of 13, having four or more partners, and not using condoms during the last sexual contact were the most consistently observed associations. In another study, satisfaction with weight was associated with regular contraception use and discussion of sexually transmitted infection prevention with partners in adolescent girls (Larson, Clark, Robinson, & Utter, 2011). Instead of the clear association between body and weight satisfaction and sexual risk behaviors, sexual self-esteem was found to be unrelated to risky sexual behavior in a sample of South African students (Wild, Flisher, Bhana, & Lombard, 2004). To our knowledge, only one study has assessed associations between aspects of body image and sexual behavior among both adolescents and adult women in a sample of women ranging in age from 12 to 56. In that study, high levels of appearance shame and appearance investment were significant predictors of inconsistent condom use, having multiple sex partners in the past year, and having sex after drinking alcohol or using drugs (Littleton, Radecki-Breitkof, & Berenson, 2005).
A large Internet survey performed in the United States (Albright, 2008) showed that women's perceptions of their own bodies can be negatively affected as a result of viewing pornography, with less frequent sexual activity as one outcome. Watching pornography was associated with negative feelings about their own bodies, increased pressure to perform acts seen in pornographic films, and the feeling that their partners were more critical of their bodies. It is noteworthy that men were more critical of their partners' bodies as a result of accessing erotic images and films online. In 12% of the women, the frequency of sexual activity decreased as the result of watching pornography.
Summary and Conclusion
The research fields of body image and sexuality have experienced considerable expansion in the last decade. The ways in which body image and sexuality have been conceptualized and measured, however, has varied greatly. The studies have shown great diversity in the ages of the participants, but are quite homogenous for other demographic variables (e.g., education). Also, most studies have relied on correlational analyses. Furthermore, most studies of associations between body image and female sexuality have focused on the evaluative dimension of body image, mostly referred to as body dissatisfaction. For these reasons, it is difficult to draw general conclusions across studies.
The commonsense notion of a simple relationship between body image and sexuality cannot be easily confirmed based on the scientific literature. However, in this review, we found support from both quantitative and qualitative research that negative body evaluations are likely to have a direct relationship with several aspects of female sexual functioning and behavior. There are indications that women low in body satisfaction report concerns about the appearance of their bodies during sexual interactions with their partners. Women who felt more negative about their bodies reported lower levels of desire and arousal (e.g., Ackard et al., 2000; Koch et al., 2005; Seal et al., 2009), increased avoidance (e.g., Reissing et al., 2005; La Rocque & Cioe, 2010), and decreased pleasure, orgasm, and sexual satisfaction (e.g., Sanchez & Kiefer, 2007; Yamamiya et al., 2006). Furthermore, in studies of young women, associations were found between negative body image and engagement in sexual risk behaviors, such as sexual activity with casual partners and inconsistent condom or contraceptive use (e.g., Akers et al., 2009; Eisenberg et al., 2005; Gillen et al., 2006; Kvalem et al., 2011). Cognitions and self-consciousness seem to be key factors in understanding the complex relationships between a woman's body image and her sexuality. Negative cognitions about one's physical appearance and monitoring oneself during sexual activity interact with sexual responses and experiences to a greater degree than general body image issues. In several studies, women reported higher levels of appearance distraction during sexual activity (e.g., Dove & Wiederman 2000; Meana & Nunnink, 2006; Seal et al., 2009). A self-conscious focus on one's appearance and avoidance of bodily exposure during sex undermines one's sexual functioning more than general feelings of body dissatisfaction (Cash et al., 2004). Body evaluations and cognitions not only interfere with responses and experiences during sexual activity, but also with general sexual behavior, sexual avoidance, and risky sexual behaviors.
There are also studies in which only modest or no relationships between body image and aspects of female sexuality were found (e.g., Davison & McCabe, 2005). In our opinion, one of the major explanations for inconsistent findings in the literature (see Table 1) is a great diversity of body image measures. There are body image measures assessing a trait dimension and measures that index a more immediate, state-like variable (Cash, 2002).
Female body image is extensively entwined with social ideals and norms of beauty that are always tied to a particular time and place. Women's bodies are socially constructed as objects to be watched and evaluated (Grogan, 2008). In fact, there is no objective, "ideal" body shape, size, or look; there is no "right" way a body should move or smell. Body image is inseparable from a particular society's understanding of race, gender, and class, to mention just a few social constructs that intersect with body image. The impact of body image is experienced by most of us in deeply personal ways; it is something that is socially constructed. None of us are born hating our bodies; it is something we seem to learn. As with body image, female sexuality is also heavily dependent on meanings, social norms, and expectations, rather than on physiological responses alone. As suggested by Baumeister (2000), women's sexuality may be more influenced by cultural factors than men's.
There are parallels between the self-surveillance practiced by many women in their daily lives and the self-surveillance reenacted in research situations. Both the researchers and the female participants see their bodies as objects (Blood, 2005). Also, experiences and responses during sexual activity have often been the focus of investigation. The stage of the sexual response cycle appears to be relatively unimportant for understanding the impact of body image. Although body image issues may affect all domains of sexual functioning separately, the result is likely to be quite consistent across domains. Body image issues may interfere with sexual pleasure and satisfaction, or may lead to painful experiences during sexual activity with partners. Research on body image suggests a connection between the ways a woman views her body and her sexuality (Seal et al., 2009). Relationships between body image variables and sexuality have been demonstrated beyond actual body size (Peplau et al., 2008; Seal et al., 2009; Weaver & Byers, 2006; Wiederman & Hurst, 1998), suggesting that a women's perceptions and cognitions about her body size, rather than her actual body, have an influence on her sexuality.
Researchers often study body image outside of a partner or romantic context. Women's prospects for relationships and intimacy are deemed largely dependent on their physical attractiveness to men (Bordo, 1993; Wolf, 1991). However, in the domain of body image and sexuality, we found some studies that incorporated the partner. Berman et al. (2003) reported more distress and depression among those women with more negative genital self-image. Peplau et al. (2008) questioned whether the negative impact of body attitudes is widespread or limited to a small group of women. They found that 48% of the heterosexual women and 47% of the lesbian women in their sample reported that a positive body image had a positive effect on their sex lives. However, 27% of the lesbians and 30% of the heterosexual women reported a negative effect of body image on their sex lives. Finally, they examined women's concern about exposing their bodies to partners during sex. More heterosexual women than lesbian women reported hiding at least one aspect of their bodies during sex (52% vs. 44%).
Many feminists have argued that women are often defined by their bodies, and their bodies are treated as objects that exist for the sexual pleasure of men (Murnen & Smolak, 2009). In the first explicit investigation of objectification theory as an explanatory framework for women's sexual functioning, Steer and Tiggemann (2008) found that self-objectification processes predicted higher self-consciousness during sex, which, in turn, predicted lower sexual functioning.
In a recent article, Bancroft and Graham (2011) suggested that a man's experience is dominated by the pursuit of sexual pleasure, whereas a woman's is dominated by a powerful sense of being desired and a sense of emotional intimacy. This notion could be tested in future research on female body image and sexual functioning and behavior. Furthermore, it is clear that there has been too little attention in research to positive aspects of body image and female sexuality. We expect that differences among women are much larger than the study results so far have suggested. For that reason, it would be interesting to focus more on positive body image with regard to sexual functioning in future research. An interesting example is the recent study by Satinsky et al. (2012), who explored positive body image and sexual functioning. Satinsky et al. found that body appreciation predicted arousal, satisfaction, and orgasm in women, but not sexual desire.
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Liesbeth Woertman and Femke van den Brink
Department of Psychology, Division of Clinical and Health Psychology, Utrec ht University
Correspondence should be addressed to Liesbeth Woertman, Department of Psychology, Division of Clinical and Health Psychology, Utrecht University, P.O. Box 80140, 3508 TC Utrecht, Netherlands. E-mail: firstname.lastname@example.org
Table 1. Overview of the Literature Body Image Author Study Design Measure(s) Ackard, Survey; Degree of Kearney-Cooke, & cross-sectional, satisfaction with Peterson (2000) correlational the body when design looking in the mirror, self-consciousness about appearance, importance of physical attractiveness Akers et al. (2009) Survey; Perceived weight, cross-sectional, weight perception correlational accuracy (comparing design BMI with perceived weight) Albright (2008) Survey; Impact of sexual cross-sectional, activities online correlational on sexual design self-image (e.g., partner more critical of me) Algars et al. Survey; Sexual body image (2011) cross-sectional, (items: "I have correlational attractive design breasts," "I am pleased with the way my vagina looks), BI-DSFI, wish to have larger or smaller breasts Berman, Berman, Survey; GSIS Miles, Pollets, & cross-sectional, Powell (2003) correlational design Calogero & Survey; IG-SATAQ-3, Thompson (2009a) cross-sectional, BSh-OBCS, BSu-OBCS correlational design Calogero & Survey: Study 1: BD-EDI-2, Thompson (2009b) cross-sectional, DT-EDI-2, BS-OBCS correlational Study 2: BD-EDI-2, design DT-EDI-2, BS-OBCS Carvalho & Nobre Survey; BIB-SDBQ, LSBIT-SMQ (2010) cross-sectional, correlational design Cash, Maikkula, & Survey; BASS-MBSRQ, OP-MBSRQ, Yamamiya (2004) cross-sectional, ASI, BESAQ, PSCSQ correlational design Daniluk (1993) Qualitative focus Subjective group study experiences of body image Davison & McCabe Survey; BIS-BIBCQ, (2005) cross-sectional, BII--BIBCQ, PAS, correlational BCS-BIBS, BIS-BIBS, design SPAS, PACS Donaghue (2009) Survey; Overall cross-sectional, satisfaction with correlational body and weight design Dove & Wiederman Survey; GBDS, ABDs (2000) cross-sectional, correlational design Eisenberg, Survey; Satisfaction with Neumark-Sztainer, cross-sectional, body image/size & Lust (2005) correlational during the past 30 design days Faith & Share Survey; BI-DSFI (1993) cross-sectional, correlational design Gillen, Lefkowitz, Survey; CDRS, AE-MBSRQ, & Shearer (2006) cross-sectional, AO-MBSRQ correlational design Graham, Sanders, Qualitative focus Subjective feelings Milhausen, & group study about one's body McBride (2004) Herbenick et al. Survey; FGSIS (2011) cross-sectional, correlational design Holt & Lyness Survey; AE MBSRQ, AO MBSRQ, (2007) cross-sectional, FE-MBSRQ, correlational FO-MBSRQ, HE MBSRQ, design HO MBSRQ, 10-MBSRQ, BASS MBSRQ, SW-MBSRQ Hoyt & Kogan Survey; Satisfaction with (2001) cross-sectional, body parts and correlational global appearance design items of the BRSS Koch, Mansfield, Survey; Self-attractiveness Thurau, & Carey cross-sectional, in comparison to 10 (2005) correlational years ago design Kvalem, von Soest, Survey; BASS Trwen, & Singsaas prospective, (2011) correlational design van Lankveld & Laboratory study; SSF-SSCS, SE-SSCS, Bergh (2008) cross-sectional, self-focus on experimental design physical appearance (experimental condition) Larson, Clark, Survey; Weight Robinson, & Utter cross-sectional, satisfaction, (2011) correlational trying to lose design weight Littleton, Survey; BC-OBCS, BSh-OBCS, Radecki-Breitkof, cross-sectional, BSu-OBCS & Berenson (2005) correlational design Meana & Nunnink Survey; BI-DSFI, ABDs (2006) cross-sectional, correlational design Meston (2006) Laboratory study; BI-DSFI cross-sectional, experimental design Nobre & Survey; BIB-SDBQ Pinto-Gouveia cross-sectional, (2006) correlational design Pauls, Occhino, & Survey; prospective, BESAQ Drythout (2008) correlational design Peplau et al. (2008) Survey; AE-MBSRQ, OP-MBSRQ, cross-sectional, BIQLI correlational design Penhollow & Young Survey; BISC, BES (2008) cross-sectional, correlational design Pinquart (2009) Survey; AS-BIQ cross-sectional, correlational design Pujols, Meston, & Survey; Weight concern, Seal (2010) cross-sectional, physical condition correlational and sexual design attractiveness subscales of the BES, ABDs Purdon & Holdaway Survey; NETCQ (2006) cross-sectional, correlational design Reissing, Survey; BAQ Laliberte, & Davis cross-sectional, (2005) correlational design Roberts & Gettman Laboratory study; AAS, self- (2004) cross-sectional, objectification or experimental design body competence condition (priming condition) La Rocque & Cioe Survey; AE-MBSRQ, AO-MBSRQ, (2010) cross-sectional, BASS-MBSRQ, BESAQ correlational design Sanchez & Kiefer Survey; BSh-OBCS, BISC (2007) cross-sectional, correlational design Satinsky, Reece, Survey; BAS Dennis, Sanders, cross-sectional, & Bardzell (2012) correlational design Schick, Calabrese, Survey; VAS, GISC Rima, & Zucker cross-sectional, (2010) correlational design Schooler, Ward, Survey; BCBM, BISC Merriwether, & cross-sectional, Caruthers (2005) correlational design Seal, Bradford, & Laboratory study; BES Meston (2009) cross-sectional, correlational design Seal & Meston Laboratory study; Body awareness (2007) cross-sectional, (experimental experimental design condition), BES Shulman & Horne Survey; BIA, BASS-MBSRQ (2003) cross-sectional, correlational design Steer & Tiggemann Survey; SOQ, BSu-OBCS, (2008) cross-sectional, BSh-OBCS, AAS, BISQ correlational design Tang, Lai, & Chung Survey; BI-DSFI (1997) cross-sectional, correlational design Trapnell, Meston, & Survey; BI-DSFI Gorzalka (1997) cross-sectional, correlational design Vasilenko, Ram, & Survey; AE-MBSRQ Lefkowitz (2011) cross-sectional, correlational design Weaver & Byers Survey; BD-EDI-2, BIAQ, (2006) cross-sectional, SIBID correlational design Weeden & Sabini Survey; Self-ratings of (2007) cross-sectional, overall physical correlational attractiveness design Wenniger & Heiman Survey; AE-MBSRQ, AO-MBSRQ, (1998) cross-sectional, FE-MBSRQ, FO-MBSRQ, correlational HE-MBSRQ, HO-MBSRQ, design 10-MBSRQ Werlinger, King, Survey; AE-MBSRQ, BASS Clark, Pera, & cross-sectional, MBSRQ Wineze (1997) correlational design Wiederman (2000) Survey; Study 1: BD-EDI-2, cross-sectional, self-rated bodily correlational attractiveness, design BISQ Study 2: BD-EDI-2, self-rate bodily attractiveness, BISQ Wiederman & Hurst Survey; BD-EDI-2, (1998) cross-sectional, self-rated bodily correlational attractiveness, design AO-MBSRQ Wild, Flisher, Survey; BI-SEQ Bhana, & cross-sectional, Lombard (2004) correlational design Wingood, Survey; A modified version DiClemente, cross-sectional, of the BAQ Harrington, & correlational Davies (2002) design Yamamiya, Cash, & Survey; BIQ, BESAQ Thompson (2006) cross-sectional, correlational design Sexuality Sample: N, Age, M Author Measure(s) (SD) Ackard, Frequency of sex, 3,627 Northern Kearney-Cooke, & frequency of American women Peterson (2000) initiating sex, (81%, Caucasian), comfort undressing, 14-74, 28.50 (7.37) sex with lights on, new things in bed, partner pleasure, orgasm frequency Akers et al. (2009) Having ever had 7,173 Northern vaginal sex; age at American female coitarche; number high school girls of lifetime sexual (62%, White, 15%, partners; alcohol, Black, 10%, Latina, condom, and oral 13%, "other"), contraceptive use [+ or -] 12-18, -- at last sex Albright (2008) Sexual activities 15,246 Northern online (e.g., American adults intentionally (3,859 women), --, viewing or 35.15 (10.78) downloading erotic pictures or films) Algars et al. FSFI, modified 9,532 (n-6,201 (2011) version of Section women) Finnish 3 of the DSFI twins and their siblings, --, 26.11 (5.01) Berman, Berman, FSFI, FSDS 31 Northern Miles, Pollets, & American female Powell (2003) health center patients (ethnic composition unknown), --, 38 (--) Calogero & SSE, SSS 101 English female Thompson (2009a) students (65% self-identified as British), --, 22.13 (3.94) Calogero & Study 1: SSE Study Study 1: 104 Thompson (2009b) 2: SSE, SSE-SS Northern American female students (87% European American, 10%, African American, 3% Asian American), --, 18.63 -1.14 Study 2: 111 English female students (64.9% White, 4.5%, Black, 14.4% Asian, 12.6% Southern European, 3.6%, American), --, 22.00 -3.81 Carvalho & Nobre Sexual desire 237 Portuguese (2010) dimension of the women, --, 35.30 FSFI (10.80) Cash, Maikkula, & CSFQ, SSSS 263 Northern Yamamiya (2004) American students (59%, White, 26% African American; n=145 women), 18-50 (Mdn=21), -- Daniluk (1993) Subjective 10 Canadian women experience and (primarily White), expression of --, 42.20 (--) sexuality Davison & McCabe SOS-MSSCQ, 437 Australian (2005) SSES-MSSCQ, participants (80% SSS-MSSCQ originally from Australia; n=226 women); --, 42.26 (17.11) Donaghue (2009) SSSS 91 Australian female students, --, 30.16 (11.11) Dove & Wiederman SOS, DSD-SDI, short 120 Northern (2000) form of the SES, American women OC, PO, percentage (93%) Caucasian), of orgasms --, 18.85 (0.85) pretended, SSE-SS Eisenberg, Casual partners, 1,168 Northern Neumark-Sztainer, condom use, American students & Lust (2005) contraceptive use, (n=593 women; 86%) number of sex White), 18-22 (for partners, 7%), -- intoxication Faith & Share SI-DSFI, AS-DSFI, 248 undergraduate (1993) SES-DSFI and graduate Northern American psychology students (n = 140 women), --, -- Gillen, Lefkowitz, Risky sexual 434 Northern & Shearer (2006) behavior (e.g., American students lifetime frequency (52%. female, 39%, of condom use), European American, SDSS, use and 32%, African buying and barrier American, 29%,, subscales of the Latino American), SRBBS, CCS --, 18.50 (0.40) Graham, Sanders, Cues for sexual 80 Northern Milhausen, & arousal, American women McBride (2004) relationship (mixed ethnic between arousal and composition), --, sexual interest, 34.30 -16.1 enhancers/ inhibitors of arousal Herbenick et al. FSFI 2,056 Northern (2011) American women (66.2% White, 13.1%, Black, 13.7%, Hispanic), 18-60, -- Holt & Lyness GSS-PSS1, SP-PSS1 44 English college (2007) students (n= 130 women), 21.50 (ages 18-21) Hoyt & Kogan Sex life item of 288 Northern (2001) the BRSS American college students (95.1% Caucasian; n = 187 women), --, 20.71 (3.30) Koch, Mansfield, Changes in sexual 307 Northern Thurau, & Carey response in the American women (2005) past 10 years (99.2%) Caucasian), (e.g., higher/ --, 50, (ages 39- lower frequency of 56) sexual activity) Kvalem, von Soest, Coital onset Time 1: 5,055 Trwen, & Singsaas Norwegian (2011) adolescents (n = 2,535 girls), --, 14.00 (0.85) Time 4: 1,449, --, 26.80 -0.75 van Lankveld & FSFI, genital 40 Dutch women, Bergh (2008) measure of sexual --, 28.70 -10.5 responding (vaginal photoplethysmo- graph), subjective sexual responding (potentiometer) Larson, Clark, Sexual activity, 9,107 New Zealand Robinson, & Utter STI prevention students (n=4,187 (2011) communication, females; 55.3% condom use, European, 24.7% New contraception use Zealand Maori, 8.2% Pacific, 7.2% Asian), 12-18, -- Littleton, Condom use, sex 1,547 Northern Radecki-Breitkof, after alcohol or American women (37% & Berenson (2005) drug use, binge, Caucasian, 34% number of sexual Hispanic, 29%, partners African American), --, 25.00 (7.50) Meana & Nunnink Global Sexual 457 Northern (2006) Functioning Score American college of the SHF, students (56.5%, SI-DSFI, SES-DSFI, Caucasian, 14%, AS-DSFI, PD-DSFI, Asian American, AfS-DSFI, FS-DSFI, 11%, African SSS-DSFI American, 9% Hispanic American), 18-20 (for 78%); n = 237 women), -- Meston (2006) FSFI, SSSW, 32 Northern self-report sexual American women: n = responses to the 16 sexually erotic film, functional women, physiological --, 28.90 (8.40); sexual responses to n= 16 sexually erotic film dysfunctional (vaginal women, --, 32.30 photoplethysmograh) (10.20) Nobre & FSFI, other SDBQ 488 Portuguese Pinto-Gouveia domains women: n= 160 (2006) without sexual problems, --, 30.40 (11.40); n=47 with diagnosis of sexual dysfunction, --, 28.70 -6.7 Pauls, Occhino, & Frequency of 107 pregnant, Drythout (2008) various sexual Northern American practices (e.g., women (51%, African vaginal American, 48%) intercourse), FSFI Caucasian, 1% Hispanic), --, 24.00 (5.00) Peplau et al. (2008) Sex life items of Study 1: 2,512 the BIQLI Northern American adults: n= 1,619 heterosexual women, --, 27.05 (8.85); n=117 lesbian women, -29.59 (9.62) Penhollow & Young Modified DSFI 408 Northern (2008) American students (84% White, 11% Black; n=290 women), --, -- Pinquart (2009) AS, love attitude, 687 German initiative to have adolescents (n=405 intercourse, women), --, 15.80 postponing the (1.19) decision Pujols, Meston, & FSFI, SSSW 154 Northern Seal (2010) American women (79% Caucasian, 4% African Americans, 7% Asians, 6%, Hispanics- Latinas), --, 26.03 (6.60) Purdon & Holdaway SFQ, GMSEX, SOS 97 Canadian (2006) psychology students (almost exclusively Caucasian; n = 50 females), --, 20.00 -1.5 Reissing, SAS, SSSS, SSES-F, 107 Canadian women Laliberte, & Davis FSFI (94% identified (2005) themselves as Canadian), 18-29, -- Roberts & Gettman Appeal of Sex Scale 160 Northern (2004) American undergraduate students (82% European American, 15% Hispanic, 3%, African American; n = 90 women), 17-30, 19.00(--) La Rocque & Cioe Sexual avoidance 362 Canadian (2010) dimension of the students (n=264 SAS, SSE-SS, women; 86.5% SS-ESLS, DSD-SDI White), --, 19.41 (1.42) Sanchez & Kiefer OG-SAI, SI-SAI, 320 Northern (2007) difficulty with American reaching orgasm, participants (85%, sexual pleasure Caucasian, 4% Asian, 4% Hispanic, 1%, African American; n = 198 women), --, 31.01 (12.96) Satinsky, Reece, FSFI 247 Northern Dennis, Sanders, American women & Bardzell (2012) (66.8%, White), --, 29.90 (7.77) Schick, Calabrese, MRS-MSSCQ, 188 Northern Rima, & Zucker SE-MSSCQ, SSS-MSSCQ American female (2010) undergraduate students (80% White), --, 19.39 (1.41) Schooler, Ward, HISA, SE, PS-SSE, 199 Northern Merriwether, & actual condom and American female Caruthers (2005) contraceptive use undergraduate during vaginal psychology students intercourse (67%, White, 19%, Asian, 7%, multiracial, 5%, Black, 3%, Latina), 17-23, 19.70 (-) Seal, Bradford, & Desire, arousal, 85 Northern Meston (2009) and lubrication American female dimensions of the students (54% FSFI, SSAS White, 21%, Hispanic-Latina, 12% African American, 11% Asian), --, 18.90 (0.90) Seal & Meston Self-reported 21 Northern (2007) mental arousal, American sexually perceptions of dysfunctional women physical arousal, (71.4X, White, 9.5% autonomic arousal, Asian, 4.8% Black, physiological 14.3% Hispanic), sexual arousal (VPA --, 24.40 (7.10) responses), cognitive distraction, FSFI Shulman & Horne Presence and 96 Northern (2003) frequency of American women masturbation (n=51 African American, n=45 European American), 18-49, -- Steer & Tiggemann Desire, arousal, 116 Australian (2008) orgasm, and female students satisfaction (>90% Caucasian), dimensions of the --, 22.74 -8.44 FSFI Tang, Lai, & Chung SES-DSFI, SI-DSFI, 305 Chinese college (1997) AS-DSFI, FS-DSFI, students (n= 145 SSS-DSFI, DS-DSFI females), --, 20.50 (1.40) Trapnell, Meston, & SES-DSFI, SI-DSFI, 722 Canadian Gorzalka (1997) AS-DSFI psychology students (51% East or Southeast Asian ancestry; n=437 women), 17-55 (Mdn =19), -- Vasilenko, Ram, & Age of first Time 4: 100 Lefkowitz (2011) intercourse Northern American college students (49% European American, 26% Latino American, 25% African American; 45% female), --, 23.00 (5.40) Weaver & Byers HISA, SAISAI, SSE-SS, 241 Canadian female (2006) SFQ, GMSEX university students, --, 20.64 (5.37) Weeden & Sabini Sexual behaviors 456 Northern (2007) (e.g., number of American students lifetime (71% non-Hispanic intercourse European descent, partners) and 15%, Asian descent, attitudes (e.g., 3%, African number of descent; n=238 intercourse women), --, 19.02 partners expected (1.14) over the next 5 years) Wenniger & Heiman BSFQ 104 Northern (1998) American women (n=57 CSA survivors: 79%, White, 5%, African American, 2%, Asian American, 4%, Hispanic, 5%, American Indian; n=47 women without a history of CSA; 75% White, 15%, Asian American), --, 31.00 -9.8 Werlinger, King, DS-DSFI, SSS-DSFI, 32 Northern Clark, Pera, & GSSI-DSFI, American obese Wineze (1997) importance of the women (91%, White), various factors in --, 47.00 (--) perceived changes in sexual functioning (e.g., being more attractive to others) Wiederman (2000) Study 1: SSE-SS, Study 1: 232 heterosexual Northern American experiences Study heterosexual female 2: SSE-SS, SAI, psychology students HISA, SAS, extent (89.9%) White, 7,6% and frequency of Black, 2.5% heterosexual Latina), --, 18.89 experiences (0.09) Study 2: 227 Northern American heterosexual female psychology students (90.9% White, 7,7% Black, 1.5% "other"), --, 18.36 (0.65) Wiederman & Hurst Sexual experience 192 Northern (1998) (e.g., experience American female of sexual psychology students intercourse with a (89.6 White, 7.8% male), short form Black, 2.6% of the SSE-SS, Latina), --, 18.91 brief form of the (0.90) SOS, three items from the SOI Wild, Flisher, SR-RB 939 South African Bhana, & students (56% Lombard (2004) female)-Grade 8: n=480 (51%), --, 14.10 (1.22); Grade 11: n=457, --, 17.40 (1.70) Wingood, Personal interview 522 Northern DiClemente, assessed sexual American females Harrington, & behaviors (e.g., (100% African Davies (2002) age of adolescent's American), 14-18, initial sexual 16.00 (--) intercourse), HIV-A, POS, CRUS Yamamiya, Cash, & Self-efficacy in 384 Northern Thompson (2006) refusing sex American female subscale from the students (58.1%, SRBBS; SSES-F, European American, SA-SAQ, FTSEQ 18.2%, African American, 10.9%, Hispanic Latina, 5.5% Asian), --, 20.00 -1.96 Results (for Female Author Participants) Ackard, Women more satisfied with body image Kearney-Cooke, & reported more sexual activity, orgasm, and Peterson (2000) initiating sex; greater comfort undressing in front of their partners, having sex with the lights on; trying new sexual behaviors; and pleasing their partners sexually than those dissatisfied with body image. Body image was predictive of one's comfort undressing in front of partner ([beta]=.50), having sex with lights on ([beta]=.44), frequency of initiating sex (([beta]=-.11), frequency of achieving orgasm during sex [beta]=.15), comfort trying new sexual activities ([beta]=.21), and partner pleasure ([beta]=.13). Akers et al. (2009) Among White girls, there were no significant associations between perceived weight and sexual risk behaviors. Compared with girls with accurate weight perceptions, those with underweight misperceptions had 1.3 times the odds of reporting ever having sex; for sexually active girls, those with underweight misperceptions had 1.9 times the odds of reporting [greater than or equal to] 4 lifetime partners, whereas those with overweight misperceptions were one-half as likely to report condom use at last sex. Among Black girls, there were significant associations between perceived weight and sexual risk behaviors. Compared with girls who perceived their weight as "about right," those who perceived themselves as overweight had 1.5 times the odds of reporting [greater than or equal to] 4 lifetime partners. Sexually active Latina girls who perceived themselves as overweight had more than twice the odds of reporting alcohol use at last sex compared with those who perceived their weight as "about right." Girls with underweight misperceptions had >3 times the odds of reporting coitarche before age 13, but were only one-third as likely to report [greater than or equal to] 4 lifetime partners compared with those who accurately estimated their weight. Albright (2008) 9% of the women reported that watching pornography was likely to make their partners more critical of them. Algars et al. Better sexual function was significantly (2011) associated with higher levels of satisfaction with one's vagina (desire, r = .09; arousal, r=.10; lubrication, r=.12; orgasm, r=.12; satisfaction, r=.12; pain, r=-.09), as well as satisfaction with one's breasts (desire, r=.11; arousal, r=.08; lubrication, r=.10; orgasm, r=.09; satisfaction, r=.10; pain, r=-.06). Genital satisfaction was significantly associated with the frequency of sexual fantasies (r=.05), kissing and petting (r=.09), oral sex (r= 10), vaginal intercourse (r=.09), and anal intercourse (r=.04). Berman, Berman, Positive genital self-image negatively Miles, Pollets, & correlated with amount of sexual distress Powell (2003) (r=-.50), but not with overall sexual function. However, within the FSFI categories of sexual function, a positive genital self-image was associated with higher desire (r=.39), but not with arousal, lubrication, orgasm, satisfaction, or absence of pain. Calogero & Internalization of appearance ideals from Thompson (2009a) media sources negatively correlated with sexual self-esteem (r=-.41) and sexual satisfaction (r=-.33). Body surveillance and body shame negatively correlated with sexual self-esteem (r=-.48 and r=-.50, respectively) and sexual satisfaction (r=-.46 and r=-.42, respectively). Path analysis indicated that greater internalization led to more body surveillance ([beta]=.42), which led to higher body shame ([beta]=.34) and lower sexual self-esteem ([beta]=-.38), which, in turn, predicted less sexual satisfaction (body shame [beta]=-.29). In addition, more body shame led to lower sexual self-esteem directly (fl=-.21), and body surveillance led to less sexual satisfaction directly ([beta]=-.28). Calogero & Study l: Sexual self-esteem was negatively Thompson (2009b) correlated with self-objectification (r=- .56). Self-objectification predicted sexual self-esteem ([beta] = -.56). Study 2: Self-objectification was negatively correlated with sexual self-esteem and sexual self-competence (r =-.38 and r = - .36, respectively), and body shame was negatively correlated with sexual self- esteem (r=-.35). Self-objectification and body shame were directly linked to sexual self-esteem ([beta]=-.36 and [beta]=-.21, respectively). Self-objectification directly predicted sexual self-competence ([beta]=-.35), and body shame did not. Carvalho & Nobre Body image beliefs and self body image (2010) thoughts did not predict sexual desire. Cash, Maikkula, & All three SSSS schema subscales were Yamamiya (2004) significantly (p < .01) related to women's anxious-avoidant body focus scores (i.e., romantic-passionate, r=-.24; open-direct, r=-.23; embarrassed -conservative, r=.26). Women experiencing more anxious-avoidant body focus during sex had significantly poorer sexual functioning in their current relationship (sexual pleasure, r=-.39; frequency of sexual desire, r=-.33; arousal, r=-.27; orgasmic experiences, r=.26). An anxious-avoidant body focus during sex was more strongly correlated with sexual functioning (r=-.26) than were the trait body image measures (body satisfaction, r=.18; appearance investment, r=.17; overweight preoccupation, r=ns). More positive functioning was related to less anxious-avoidant body focus ([beta]=-.25). Daniluk (1993) The participants struggled with the perception that they were somehow to blame for the excessive "femaleness" of their bodies or for their bodies' lack of socially valued attributes. It was only later in life when they perceived society as disqualifying the bodies of women as being of worth, or, at times, they were involved in mutually enabling relationships that some of the women in the study began to experience a sense of bodily acceptance. This "experience of integration and wholeness" was viewed by the women as being critical to their healthy sexual functioning. Self-acceptance and self-love were viewed as the road to such integration. Davison & McCabe The body image variables were unrelated to (2005) aspects of sexual functioning. Body satisfaction was positively correlated with the passionate/romantic (r=.33) and open/ direct dimensions (r=.36) of sexual self-schemas, but not significantly related to the embarrassed-conservative dimension (r=-.18, ns). Donaghue (2009) Dove & Wiederman For sexual esteem, sexual satisfaction, orgasm (2000) consistency, and frequency of pretending orgasm, cognitive distraction explained additional, statistically significant variance above and beyond general affect, sexual desire, general self-focus, sexual attitudes, and body dissatisfaction (change in [R.sup.2]=.05, .10, .07, and .08, respectively). Eisenberg, Satisfaction with body image had an inverse Neumark-Sztainer, association with having a casual partner and & Lust (2005) a marginal inverse relationship to using no or unreliable contraception during last intercourse. No associations between body image satisfaction and any of the high-risk sexual behaviors were found in multivariate analysis. Faith & Share Worse body image conceptualizations (1993) significantly predicted lower frequency of sexual behaviors ([beta]=-.22), whereas general sexual knowledge and psychological adjustment did not predict sexual behaviors. Sexual attitude scores were the best predictors of sexual approach /avoidance behaviors ([beta] = .36). Gillen, Lefkowitz, Sexually active individuals had more & Shearer (2006) positive views of their appearance and were less dissatisfied with their bodies, but were also more oriented toward their appearance than were sexually abstinent individuals. More positive evaluation of appearance was associated with less risky sexual behavior (lifetime unprotected sex, r=-.20; using and buying condoms, r=.16; barriers to condom use, r=-.21; less self- confidence in communicating with a partner about condom use, r=-.29). Body dissatisfaction (i.e., discrepancy between current and ideal body figure) was also related to less risky sexual behavior (lifetime alcohol use before-during sex, r = .20; less self-confidence in communicating with a partner about condom use, r=.22). Females who evaluated their appearance in a more positive way had less unprotected sex in their lifetime and perceived fewer barriers to condom use. Those who were more oriented toward their appearance endorsed the sexual double standard to a greater extent. Graham, Sanders, Feeling comfortable and positive about one's Milhausen, & body was frequently mentioned as a factor McBride (2004) that would facilitate sexual arousal. Herbenick et al. Positive genital perceptions were associated (2011) with more sexual desire (r=.20), arousal (r=.12), lubrication (r-.16), orgasm (r=.14), satisfaction (r=.15), and pain (indicating less pain, r=.15). Holt & Lyness There was a significant, positive, linear (2007) relationship between both body image (whole MBSRQ, r=.35) and reflected appraisal (BASS/ MBSRQ, r=.34) and sexual satisfaction. Regression analysis showed that appearance evaluation (AE/MBSRQ) and overweight preoccupation (OP/MBSRQ) were significant in predicting sexual satisfaction ([beta]=.29 and [beta]=.26, respectively). Appearance evaluation was the only significant predictor of sexual satisfaction, in general ([beta]=.31), and overweight preoccupation was the only significant predictor of sexual satisfaction with a partner ([beta]=.25). Hoyt & Kogan Women who were dissatisfied with their sex (2001) lives were more dissatisfied with their body appearance than those who were satisfied with their body appearance. Koch, Mansfield, The more a woman perceived herself as less Thurau, & Carey attractive than before, the more likely she (2005) was to report a decline in sexual desire or frequency of sexual activity. The more she perceived herself as attractive, the more likely she was to experience an increase in sexual desire, orgasm, enjoyment, or frequency of sexual activity. There were no significant statistical relationships between a woman's perception of her own attractiveness as she aged and her current sexual satisfaction. Kvalem, von Soest, Girls between 14 and 17 years of age (Time Trwen, & Singsaas 2) without coital experience were (2011) significantly more satisfied with their bodies, compared with girls who lacked coital experience. There were no cross- sectional differences in body evaluation in relation to coital experience among girls at the other time periods. For early adolescent girls body evaluation did not influence the probability of coital onset during the first 2-year period. In the subsequent 5-year period, body dissatisfaction increased the probability for coital onset (OR = 0.64). van Lankveld & Induction of state self-focus per se did not Bergh (2008) affect genital responses, but an interaction effect of self-focus and participants' level of trait sexual self-focus was revealed. Compared with women with low scores on this trait, women with high scores exhibited smaller genital responses when state self-focus was induced. Both groups did not differ when no self-focus was induced. Increase of state self-focus did not affect subjective sexual arousal, but participants with a high level of trait sexual self-focus reported stronger subjective arousal compared with those with a low trait level. Larson, Clark, Weight satisfaction was found to be Robinson, & Utter associated with regular contraception use (2011) (OR=2.06) and discussion of STI prevention with partners (OR= 1.41). Weight-loss attempts were found to be positively associated with female sexual activity (OR= 1.58). Littleton, Appearance shame was a predictor both of Radecki-Breitkof, more inconsistent condom use (AOR =1.28) and & Berenson (2005) having more sexual partners in the past year (AOR =1.22). Appearance investment was a predictor of more frequent drinking (AOR = 1.21) and substance use (AOR = 1.12) before sex. In addition, the interaction term was associated with more inconsistent condom use (AOR=0.94). Finally, binge drinking was predicted by surveillance (AOR =1.47), shame (AOR = 1.68), and the interaction term (AOR = 0.90). Meana & Nunnink Appearance distraction was negatively (2006) related to sexual satisfaction (r=-.32), but not related to global sexual functioning, sexual knowledge, sexual attitudes, sexual information, experiences, psychological distress, affect, and fantasy. Negative body image was related to psychological distress (r = .31) and positive affect (r = -.42). Appearance-based distraction was predicted by psychological distress ([beta]=.21) and negative body image ([beta]=.50). Meston (2006) Sexually dysfunctional women showed a trend toward lower body image than did sexually functional women (p=.07). Nobre & The discriminant function showed that body Pinto-Gouveia image beliefs distinguished sexually (2006) dysfunctional from functional women (r=.58). Pauls, Occhino, & In early pregnancy, low sexual function was Drythout (2008) associated with impaired body image (r=-.38). Peplau et al. (2008) Nearly one-half of the women, including 48% of heterosexual women and 47% of lesbian women, reported that their body image had positive effects on their sex lives. Over one-fourth of both lesbian women (27%) and heterosexual women (30%) reported that their feelings about their bodies had negative effects on the quality of their sex lives. No significant mean difference was found between lesbian and heterosexual women. Penhollow & Young Sexual satisfaction was significantly (2008) correlated with concerns about being nude (r=-.50), concerns about partners making negative judgments about their body (r=- .38), fitness (r=.19), problem areas (r=.19), strength and build (r=.14), appearance of eyes and face (r=.14), and weight (r=.16). Body image and fitness variables were significant predictors of sexual satisfaction. The overall regression explained 46% of the variance in sexual satisfaction. Three predictor variables were identified in the best-fit model for women: concerns about being nude, fitness, and exercise frequency. Pinquart (2009) Lower body satisfaction was associated with higher decisional ambivalence ([beta] = -.13), and not associated with delayed first sexual intercourse. Pujols, Meston, & Body esteem and appearance-based thoughts Seal (2010) during sexual activity were significantly correlated with sexual satisfaction (r=.44 and r=39, respectively). Sexual satisfaction was predicted by high body esteem ([beta]=.20) and low frequency of appearance-based distracting thoughts during sexual activity (#=.15), after controlling for sexual functioning status. Post hoc testing revealed that the sexual attractiveness subscale of the BES was the only significant predictor of sexual satisfaction. Purdon & Holdaway Greater frequency of and anxiety evoked by (2006) thoughts (e.g., body image thoughts) were associated with lower sexual satisfaction; 13 of 41 women reported body image concerns as the first or second most frequent type of non-erotic thought experienced during typical sexual activities with a partner. Reissing, Body attitudes were significantly associated Laliberte, & Davis with sexual aversion (r=-.33), but not (2005) associated with low sexual self-efficacy, negative sexual adjustment, and negative sexual self-schema. Negative body attitudes were not predictive of lower sexual self-efficacy ([beta]=.15). A more negative body attitude was associated with an increase in sexual aversion ([beta]=-.33), which, in turn, was associated with negative sexual adjustment ([beta]=.38). Roberts & Gettman Women's ratings of the appeal of physical (2004) sex were significantly higher in the body competence condition than in the self-objectification condition. La Rocque & Cioe A relationship between negative body image (2010) and a greater tendency to avoid sexual activity was found ([beta]=-.35). Sexual esteem, sexual satisfaction, and sexual desire appeared to mediate this relationship (body image significantly predicted these mediators, 13=.62, [beta]=.48, and [beta]=.17, respectively). In turn, these variables were associated with greater sexual avoidance ([beta]=-.42, [beta]=-.12, and [beta] =-.18, respectively). The direct relationship between body image and sexual avoidance was not significant in the mediation model. Sanchez & Kiefer Body shame was related to arousability (r = (2007) -.14) and sexual pleasure (r=-.31), but not related to orgasm difficulty. Sexual self-consciousness was associated with arousability (r=-.34), sexual pleasure (r= -.46), and orgasm difficulty (r = .27). The relationship between body shame and sexual pleasure and problems was mediated by sexual self-consciousness during physical intimacy. Body shame was related to greater sexual self-consciousness ([beta]=.53), which, in turn, predicted lower sexual pleasure ([beta]=.28) and sexual arousability ([beta]=-.29). Results persisted, controlling for relationship status and age. Being in a relationship was associated with less sexual self-consciousness (l=.27) and less orgasm difficulty (l=.29). Satinsky, Reece, Body appreciation was associated with sexual Dennis, Sanders, arousal (r=.19), sexual satisfaction & Bardzell (2012) (r=.35), and general sexual functioning (full FSFI; r=.28). Body appreciation was not associated with desire, lubrication, orgasm, and pain. After controlling for sexual orientation, partner status, and age, body appreciation predicted the arousal ([beta]=.27), orgasm ([beta]=.24), and satisfaction aspects (fl=.37) of sexual function. Schick, Calabrese, Vulva appearance dissatisfaction and genital Rima, & Zucker image self-consciousness were associated with (2010) sexual esteem (r=-.21 and r=-.28, respectively) and sexual satisfaction (r=-.22 and r=-.34, respectively), but not associated with motivation to avoid risky sex. Path analyses indicated that dissatisfaction with genital appearance was associated with higher genital image self-consciousness during physical intimacy, which, in turn, was associated with lower sexual esteem, sexual satisfaction, and motivation to avoid risky sexual behavior. Schooler, Ward, Greater body comfort was associated with Merriwether, & higher levels of sexual assertiveness Caruthers (2005) (r=.55), higher levels of sexual experience (r=.20), lower levels of risky sexual behavior (r=-.19), and greater condom use self-efficacy (r=.51). Greater body image self-consciousness was associated with lower levels of sexual assertiveness, (r=-.55), lower levels of sexual experience, (r= -.18), and lower condom use self-efficacy (r=-.48). Sexual assertiveness and sexual risk were each directly predicted by body shame (BCBM and BISQ; [beta]=-.67 and r=.42, respectively). There was a significant mediating role of sexual assertiveness in the relation between body shame and sexual experience, and the relation between body shame and sexual risk. Seal, Bradford, & There was a significant correlation between Meston (2009) body esteem and sexual desire post erotica (r=.35). Mental sexual arousal and physical sexual arousal did not correlate with body esteem. The FSFI desire domain score was correlated with the weight concern (r=.27) and sexual attractiveness (r=-.25) subscales of the BES, but not with the physical condition subscale. Similarly, the composite score of items assessing sexual desire responses to the erotic story was significantly correlated with the BES weight concern (r=.31) and sexual attractiveness (r=.33) subscales, but not with the BES physical condition subscale. Seal & Meston Women's self-reported mental sexual arousal (2007) to the erotic audiotapes significantly increased in both the No Body Awareness condition and the Body Awareness condition, as did perception of physical sexual arousal and autonomic arousal. Self-reported mental sexual arousal, perceptions of physical sexual arousal, and autonomic arousal were all significantly higher in the Body Awareness condition than in the No Body Awareness condition. There was no difference in VPA difference scores between the conditions. Women with low and average body esteem (BES) scores responded equally in both the Body Awareness and the No Body Awareness conditions. There were positive relationships between the sexual attractiveness subscale of the BES and FSFI total score (r=.62), sexual arousal, (r=.67), orgasm (r=.44), and satisfaction (r=.51). There was also a trend for the BES sexual attractiveness subscale to be positively related to FSFI lubrication (r=.31, p=.07). The weight concern subscale of the BES was positively related to the FSFI total score (r=.50) and lubrication (r=.47), and marginally related to arousal (r=.44, p=.06). The BES total score was significantly and positively correlated with the FSFI total score (r=.53), arousal (r=.56), and orgasm (r = .48). Shulman & Horne No differences in body image, as measured (2003) either by the BIA or the BASS, were found across four different levels of masturbation frequency. For African American women, no relationship was found between both the BIA and the BASS and masturbation frequency. Among the European American women, no relationship was found between the BIA and masturbation frequency. However, there was a significant, positive relationship between the BASS and masturbation frequency, with women who reported masturbating 7-10 times per month having significantly higher rates of body satisfaction on the BASS than those women who reported masturbating 1-3 times and 4-6 times per month. Steer & Tiggemann Self-objectification and self-surveillance (2008) were not related to sexual functioning, both general and current. For sexual functioning, body shame and appearance anxiety (AAS) were negatively correlated with the general measure (r = -.26 and r=-.32, respectively), but were not related to current sexual functioning among the sexually active participants. Self-consciousness (BISQ) during sexual activity was negatively correlated with sexual functioning, both among the broader group of participants (r= -.44) and among the smaller group of currently sexually active participants (r= -.32). Self-consciousness during sexual activity fully mediated the relationships between body shame and appearance anxiety, on the one hand, and general sexual functioning, on the other hand. Path analysis showed that self-objectification led to self-surveillance ([beta]=.69), which led to body shame (f=.41) and appearance anxiety ([beta]=.42), which, in turn, led to self-consciousness during sex (P=.21 and [beta]=.47, respectively) and, finally, to sexual dysfunction (l=-.41). There was just one additional, direct pathway from self-surveillance to self-consciousness during sex ([beta]=.21). There were no direct pathways from self-objectification, self-surveillance, body shame, or appearance anxiety to sexual functioning. Relationship satisfaction was a unique predictor of general sexual functioning (f = .41) and current sexual activity ([beta]= .44). Tang, Lai, & Chung Positive body image was associated with a (1997) higher score on the sex-related variables experience (r=-.24), drive (r=-.25), liberal attitudes (r=-.22), affects (r=-.29), satisfaction (r=.30), and a feminine gender role definition (r=.37). Sexually active students had a more positive, better body image compared to students who had no sexual intercourse experiences. Trapnell, Meston, & Poor body image was associated with less Gorzalka (1997) sexual experience (r=-.31), more conservative sexual attitudes (r=-.31), and less sexual knowledge (r=-.17). Body image was a unique predictor of sexual experience. Vasilenko, Ram, & Transitioning to first intercourse was Lefkowitz (2011) associated with an average 0.57-point decrease in satisfaction with appearance. On average, female students became more satisfied with their appearance over time, but were somewhat less satisfied after first intercourse. Weaver & Byers Situational body image dysphoria was (2006) associated with all four sexuality variables (sexual anxiety, r=.28; sexual assertiveness, r=-.22; sexual esteem, r= -.32; and sexual problems, r=.28). Body dissatisfaction was associated with sexual assertiveness (r=-.16) and sexual esteem (r=-.18). Only situational body image dysphoria was uniquely associated with sexual assertiveness (sr=-.15), sexual problems, and sexual esteem (sr=-.27). Both body dissatisfaction and situational body image dysphoria were uniquely associated with sexual anxiety (sr=-.17 and sr=.32, respectively). Women with higher situational body image dysphoria reported lower sexual assertiveness, more sexual problems, lower sexual esteem, and higher sexual anxiety than those with lower situational body image dysphoria. Weeden & Sabini Higher self-rated attractiveness was (2007) associated with sex prior to age 18 (r=.23), a higher number of intercourse partners (r=.31), a higher number of non-intercourse sexual partners (r=.45), and sociosexuality (r=.21). Wenniger & Heiman CSA survivors evaluated their health more (1998) negatively than comparison individuals, indicating that they were feeling less healthy or experienced more bodily symptoms of illness or vulnerability to illness. Childhood physical abuse did not significantly predict sexual functioning. A more positive evaluation of physical fitness or being "in shape" ([beta] =-.37), less investment in being physically fit ([beta]=.31), and lower body esteem regarding sexual attractiveness were associated with a lower level of sexual functioning ([beta]=.43). Werlinger, King, 53%, of the women felt that their sexual Clark, Pera, & behaviors had changed since they had lost Wineze (1997) weight. The most frequently endorsed explanations for sexual changes were "because I feel better about my body" (72%) and "because I feel less depressed/down about my weight" (74%). Wiederman (2000) Study 1: Higher body image self- consciousness during sexual activity was associated with less sexual esteem (r=-.45). Body image self-consciousness during sexual activity significantly added to the prediction of the experience of vaginal intercourse, fellatio, and cunnilingus. Study 2: Higher body image self-consciousness during sexual activity is associated with less sexual esteem (r=-.52), frequency of heterosexual experience (r =-.56), higher sexual anxiety (r=.48), lower sexual assertiveness (r=-.56), and higher sexual avoidance (r=.46), and significantly added to the prediction of the experience of vaginal intercourse, fellatio, and cunnilingus. Wiederman & Hurst There were no differences in self-rated (1998) facial attractiveness, self-rated bodily attractiveness, body dissatisfaction, and appearance orientation between women who had experienced sexual intercourse and those who had not and between women who had performed oral sex and those who had not. Women who had ever received oral sex perceived their bodies as more attractive compared to women without such experience. Sexual attitudes were unrelated to any of the attractiveness or body image variables. For lifetime number of sexual partners among non-virgins, only the relationship with self-rated facial attractiveness was significant (r=.27). Sexual esteem scores were positively related to self-rated facial (r=.47) and bodily attractiveness (r=.35). Affective orientation toward erotic stimuli and attitudinal acceptance of casual sex were unrelated to self-rated facial and bodily attractiveness. Wild, Flisher, Low self-esteem with respect to body image Bhana, & was significantly associated with risky Lombard (2004) sexual behavior, after controlling for the clustering according to school, grade, and race (OR= 1.82). After controlling for the other self-esteem scales, the association between sexual self-esteem and risky sexual behavior was no longer significant. Wingood, Women who were more dissatisfied with their DiClemente, body image were more likely to fear Harrington, & abandonment as a result of negotiating Davies (2002) condom use (AOR=3.30), perceive that they had fewer options for sexual partners (AOR=2.40), perceive themselves as having limited control in their sexual relationships (AOR = 2.00), and to worry about acquiring HIV (AOR=1.50). There was an association between body dissatisfaction and never using condoms during sexual intercourse in the past 30 days (AOR =1.60) and engaging in unprotected vaginal sex in the prior 6 months (AOR =1.60). Yamamiya, Cash, & Higher physical self-ideal discrepancies Thompson (2006) (BIQ) were significantly and negatively correlated with self-efficacy to refuse sex (r =-.20), confidence in sexual functioning (r = -.28), sexual assertiveness (r =-.20), ambivalence in sexual decision-making (r=.11), and higher emotional engagement during sex (r=.13). Higher body consciousness and exposure avoidance in sexual contexts (i.e., BESAQ) was significantly correlated with confidence in sexual functioning (r = -.54), sexual assertiveness (r=-.37), ambivalence in sexual decision-making (r=.34), and higher emotional engagement during sex (r=.41), but not with sexual self-efficacy to refuse sex. Only BIQ scores significantly accounted for general self-efficacy to refuse sex ([beta]=-.19). BESAQ scores accounted for initial ambivalence about having sex with a partner ([beta]=.26) and degree of emotional disengagement during sex ([beta]=.29). Associations between dispositional body image and sexual assertiveness, as well as dispositional body image and confidence level in sexual functioning, were fully mediated by body consciousness during sexual activity. Note. For both the modified version of Section 3 of the Derogatis Sexual Functioning Inventory (DSFI) and the modified version of the DSFI (Column 4), see Derogatis and Melisaratos (1979). AOR=Adjusted Odds Ratio; BISQ=Body Image Self-consciousness Questionnaire; BMI=body mass index; CSA=childhood sexual abuse; OR =odds ratio; STI=sexually transmitted infection; VPA= vaginal pulse amplitude. Body image measures: AAS=Appearance Anxiety Scale (Dion, Dion, & Keelan, 1990); ABDs=Appearance-Based Distraction subscale of the Cognitive Distraction During Sexual Activity Scale (Dove & Wiederman, 2000); AE-MBSRQ=Appearance Evaluation subscale of the Multidimensional Body-Self Relations Questionnaire (Cash, 1994x, 2000); AO-MBSRQ=Appearance Orientation subscale of the Multidimensional Body-Self Relations Questionnaire (Cash, 1994x, 2000); AS] -Appearance Schemas Inventory (Cash & Labarge, 1996); AS-BIQ=Attractiveness Scale of the Body Image Questionnaire (Strauss & Richter-Appelt, 1996); BWBAQ=Ben-Tovim Walker Body Attitudes Questionnaire (Ben-Tovim & Walker, 1991); BAQ=Body Attitude Questionnaire (Story, 1998); BAS=Body Appreciation Scale (Avalos, Tylka, & Wood-Barcalow, 2005); BASS =Body Areas Satisfaction Scale (Brown, Cash, & Lewis, 1989); BASS-MBSRQ=Body Areas Satisfaction Scale of the Multidimensional Body-Self Relations Questionnaire (Cash, 1994x, 2000); BAQ=Body Attitude Questionnaire (Story, 1998); BCBM=Body Comfort-Body Modesty Measure (Merriwether & Ward, 2002); BCS-BIBS=Body Concealment Scale of the Body Image Behavior Scales (Davison & McCabe, 2005); BC-0BCS=Body Control subscale of the Objectified Body Consciousness Scale (McKinley & Hyde, 1996); BD-EDI-2=Body Dissatisfaction subscale of the Eating Disorder Inventory-Second Edition (Garner, 1991); BES=Body Esteem Scale (weight concern, physical condition, and sexual attractiveness dimensions; Franzoi & Shields, 1984); BESAQ=Body Exposure during Sexual Activities Questionnaire (Cash, 2004); BIA=Body Image Assessment (Williamson, Davis, Bennett, Goreczny, & Gleaves, 1989); BIAQ=Body Image Avoidance Questionnaire (Rosen, Srebnik, Saltzberg, & Wendt, 1991); BIB-SDBQ=Body Image Beliefs Dimension of the Sexual Dysfunctional Beliefs Questionnaire (Nobre, Pinto-Gouveia, & Gomes, 2003); BI-DSFI=Body Image subscale of the Derogatis Sexual Functioning Inventory (Derogatis, 1975); BIQ=Body Image Ideals Questionnaire (Szymanski & Cash, 1995); BII-BIBCQ=Body Image Importance subscale of the Body Image and Body Change Questionnaire (Ricciardelli & McCabe, 2001); BIQLI=Body Image Quality of Life Inventory (Cash & Fleming, 2002); BIS--BIBCQ=Body Image Satisfaction subscale of the Body Image and Body Change Questionnaire (Ricciardelli & McCabe, 2001); BISC=Body Image Self-Consciousness scale (Wiederman, 2000); BI-SEQ=Body Image subscale of the Self-Esteem Questionnaire (DuBois, Feiner, Brand, Phillips, & Lease, 1996); BIS-BIBS=Body Improvement Scale of the Body Image Behavior Scales (Davison & McCabe, 2005); BRSS = Body and Relationship Satisfaction Survey (Hoyt & Kogan, 2001; based on the Body Satisfaction Scale: Berscheid, Walster, & Bohrnstedt, 1973); BSh-0BCS=Body Shame subscale of the Objectified Body Consciousness Scale (McKinley & Hyde, 1996); BSu-0BCS=Body Surveillance subscale of the Objectified Body Consciousness Scale (McKinley & Hyde, 1996); CDRS=Contour Drawing Rating Scale (Thompson & Gray, 1995); DT-EDI-2=Drive for Thinness subscale of the Eating Disorder Inventory--Second Edition (Garner, 1991); FGSIS-Female Genital Self-Image Scale (Herbenick et al., 2011); FE-MBSRQ=Fitness Evaluation subscale of the Multidimensional Body-Self Relations Questionnaire (Cash, 1994x, 2000); FO-MBSRQ=Fitness Orientation subscale of the Mul tidimensional Body-Self Relations Questionnaire (Cash, 1994x, 2000); GBDS =General Body Dissatisfaction subscale of the Body Attitude Test (Probst, Vandereycken, Van Coppenolle, & Vanderlinden, 1995); GSS-PSSI-General Sexual Satisfaction and Satisfaction with Partner subscales of the Pinney Sexual Satisfaction Inventory (Pinney, Gerrard, & Denney, 1987); GISC=Genital Image Self-Consciousness scale (Schick et al., 2010; modified version of the BISC scale: Wiederman, 2000); GSIS=Genital Self-Image Scale (Berman et al., 2003); HE-MBSRQ=Health Evaluation subscale of the Multidimensional Body-Self Relations Questionnaire (Cash, 1994a, 2000); HO-MBSRQ= Health Orientation Subscale of the Multidimensional Body-Self Relations Questionnaire (Cash, 1994a, 2000); 10-MBSRQ = Illness Orientation Subscale of the Multidimensional Body-Self Relations Questionnaire (Cash, 1994a, 2000); IG-SATAQ-3 = Internalization-General Subscale of the Social Attitudes Toward Appearance Questionnaire-Third Edition (Thompson, van den Berg, Roehrig, Guarda, & Heinberg, 2004); LSBIT-SMQ=Low Self Body Image Thoughts Dimension of the Sexual Modes Questionnaire (Nobre & Pinto-Gouveia, 2003); NETCQ= Non-Erotic Thought Content Questionnaire (Purdon & Holdaway, 2006); OP-MBSRQ=Overweight Preoccupation Subscale of the Multidimensional Body-Self Relations Questionnaire (Cash, 1994a, 2000); PACS=Physical Appearance Comparison Scale (Thompson, Heinberg, & Tantleff, 1991); PAS -Physical Attractiveness Scale (Davison & McCabe, 2005); PSCSQ=Physical Self-Consciousness during Sex Questionnaire (Cash et al., 2004); SP-PSSI= Satisfaction with Partner Subscale of the Pinney Sexual Satisfaction Inventory (Pinney et al., 1987); SW MBSRQ= Self-classified Weight Subscale of the Multidimensional Body-Self Relations Questionnaire (Cash, 1994a, 2000); SE-SSCS=Sexual Embarrassment Dimension of the Sexual Self-Consciousness Scale (van Lankveld, Geijen, & Sykora, 2007); SR-RB=sexual risk behavior items of a self-report risk questionnaire (Wild et al., 2004); SSF-SSCS=sexual self-focus dimension of the Sexual Self-Consciousness Scale (van Lankveld et al., 2007); SIBID=Situational Inventory of Body Image Dysphoria (Cash, 1994b); SPAS =Social Physique Anxiety Scale (Hart, Leary, & Rejeski, 1989); VAS = Vulva Appearance Satisfaction Scale (Schick et al., 2010; modified version of the Body Satisfaction Scale: Rapport, Clark, & Wardle, 2000). Sexuality measures: AfS-DSFI =Affect Scale of the Derogatis Sexual Functioning Inventory (Derogates, 1975); AS=Ambivalence Scale (Pinquart, 2009); AS-DSFI=Attitude Scale of the Derogatis Sexual Functioning Inventory (Derogates, 1975); BIQLI; BRSS; BSFQ=Brief Sexual Functioning Questionnaire (Wenniger & Heiman, 1998); CSFQ=Changes in Sexual Functioning Questionnaire (Clayton, McGarvey, & Clavet, 1997); CCS=Communication about Condoms Scale (Barkley & Burns, 2000); CRUS =Confidence in Refusing an Unsafe Sexual Encounter (Wingood et al., 2002); DS-DSFI = Drive Scale of the Derogatis Sexual Functioning Inventory (Dero gatis, 1975); DSD-SDI=Dyadic Sexual Desire Factor of the Sexual Desire Inventory-Second Edition (Spector, Carey, & Steinberg, 1996); FS-DSFI=Fantasy Scale of the Derogatis Sexual Functioning Inventory (Derogates, 1975); FSDS = Female Sexual Distress Scale (Derogates, 2001); FSFI = Female Sexual Functioning Index (desire, arousal, lubrication, orgasm, satisfaction, and pain dimensions; Rosen et al., 2000); FTSEQ=First-Time Sexual Experience Questionnaire (Yamamiya et al., 2006); GMSEX=Global Measure of Sexual Satisfaction-Revised (Lawrance & Byers, 1995); GSSI-DSFI=Global Sexual Satisfaction Index of the Derogatis Sexual Functioning Inventory (Derogates, 1975); HISA=Hurlbert Index of Sexual Assertiveness (Hurlbert, 1991); HIV-A=HIV Anxiety (Wingood et al., 2002); MRS-MSSCQ= Motivation to Avoid Risky Sex Subscale of the Multi Dimensional Sexual Self-Concept Questionnaire (Snell, 1995); OC=Orgasm Consistency (Dove & Wiederman, 2000); OG-SAI = Oral-Genital subscale of the Sexual Arousability Index (Andersen, Broffitt, Karlsson, & Tumquist, 1989); PD-DSFI =Psychological Distress Scale of the Derogatis Sexual Functioning Inventory (Derogates, 1975); POS=Perceived control Over Sexuality (Wingood et al., 2002); SSE=Precautions subscale of the Sexual Self-Efficacy scale (Rosenthal, Moore, & Flynn, 1991); SAI=Sex Anxiety Inventory (Janda & O'Grady, 1980); SAISAI=Sexual Arousability Inventory and Sexual Anxiety Inventory (Hoon, Hoon, & Wincze, 1976); SA-SAQ=Sexual Assertiveness subscale of the Sexual Awareness Questionnaire (Snell, Fisher, & Miller, 1991); SAS=Sexual Aversion Scale (sexual avoidance, sexual anxiety, self-consciousness, sexual inadequacy, fear of sexually transmitted infections, and childhood sexual trauma dimensions; Katz, Gipson, Kearl, & Kriskovich, 1989); SDBQ=Sexual Dysfunctional Beliefs Questionnaire (sexual conservatism, sexual desire and pleasure as a sin, age-related beliefs, body image beliefs, motherhood primacy, and denying affection primacy domains; Nobre et al., 2003); SDSS=Sexual Double Standard Scale (Muehlenhard & Quackenbush, 1996); SE =Sexual Experience (Kissing and Petting experience, Oral Sex experience, and Vaginal Intercourse Experience subscales; Schooler et al., 2005); SE-MSSCQ=Sexual Esteem Scale of the Multidimensional Sexual Self-Concept Questionnaire (Snell, 1995); SES-DSFI =Sexual Experience Scale of the Derogatis Sexual Functioning Inventory (Derogates, 1975); SFQ=Sexual Functioning Questionnaire (Lawrance & Byers, 1992); SI DSFI = Sexual Information subscale of the Derogatis Sexual Functioning Inventory (Derogates, 1975); SI-SAI = Sexual Intercourse subscale of the Sexual Arousability Index (Andersen et al., 1989); SHF=Sexual History Form (Crete et al., 1998); SOS =Sexual Opinion Survey (Fisher, Byrne, White, & Kelley, 1988); SOS-MSSCQ=Sexual Optimism Scale of the Multidimensional Sexual Self-Concept Questionnaire (Snell, 1995); SOQ=Self- Objectification Questionnaire (Noll & Fredrickson, 1998); SRBBS=Sexual Risk Behavior Beliefs and Self-efficacy scales (Basen-Engquist et al., 1996); SSES F=Sexual Self-Efficacy Scale for Female functioning (Bailes et al., 1998); SSS=Sexual Satisfaction Scale (Dove & Wiederman, 2000); SS-ESLS=Sexual Satisfaction subscale of the Extended Satisfaction with Life Scale (Alfonso, Allison, Rader, & Gorman, 1996); SSSW =Sexual Satisfaction Scale for Women (contentment, communication, compatibility, interpersonal concern, and personal concern dimensions; Meston & Trapnell, 2005); SSS-DSFI=Sexual Satisfaction Scale of the Derogatis Sexual Functioning Inventory (Derogates, 1975); SSS-MSSCQ=Sexual Satisfaction Scale of the Multidimensional Sexual Self-Concept Questionnaire (Snell, 1995); SSSS=Sexual Self-Schema Scale (Andersen & Cyranowski, 1994); SSES-MSSCQ=Sexual Self-Efficacy Scale of the Multidimensional Sexual Self-Concept Questionnaire (Snell, 1995); SSe=sexual self-esteem (measured by a modified version of Rosenberg's Global Self-Esteem Scale; Calogero & Thompson, 2009a); SSE-SS=sexual Self-Esteem subscale of the Sexuality Scale (Snell & Papini, 1989); SOI=Sociosexual Orientation Inventory (Simpson & Gangestad, 1991); SSAS=Subjective Sexual Arousal Scale (mental sexual arousal, physical sexual arousal, and sexual desire dimensions; Heiman & Rowland, 1983).