Women who are more satisfied with their bodies & appearance are more comfortable undressing in front of a partner, having sex with the lights on, trying new sexual activities; initiate sex more often, report more orgasms

A review of research linking body image and sexual well-being. Meghan M. Gillen, Charlotte H. Markey. Body Image, Volume 31, December 2019, Pages 294-301. https://doi.org/10.1016/j.bodyim.2018.12.004

Highlights
•    We reviewed research on body image and sexual well-being.
•    The review focused on Dr. Thomas Cash’s contributions to this area.
•    Most research suggests a positive link between body image and sexual well-being.
•    We suggest research on new populations using new methods and on positive body image.

Abstract: The link between body image and sexual well-being is intuitive and increasingly supported by psychological research: individuals, particularly women, with greater body satisfaction and body appreciation tend to report more positive sexual experiences. Although both perceptions of one’s body and one’s sexual life are central to most adults’ experiences, this area of research has remained somewhat understudied. In this review, we discuss the findings that are available and suggest directions for future research and applied implications of this work. We highlight Thomas Cash’s contributions to this area of study, given his significant contributions to moving our understanding of body image and sexual well-being forward.



4.1. Body image and sexual experience

Sexual experience has been measured in a number of ways,such as relationship status (i.e., in a romantic relationship or not), ever engaging in sexual intercourse and oral sex, and frequency of sexual activities. Most of this research has been conducted among young adults, given that they are just beginning to navigate sexual experiences and romantic relationships. Studies suggest that individuals who are in romantic relationships have less body image self-consciousness during sexual intimacy (Sanchez & Kiefer, 2007; Steer & Tiggemann, 2008;Wiederman, 2000) and less difficulty achieving orgasm (Sanchez& Kiefer, 2007) as compared to those who are not in romantic relationships. Among college students, ever engaging in sexualintercourse is associated with higher body satisfaction, higher appearance evaluation, lower body dissatisfaction, lower bodyimage self-consciousness, and higher orientation toward appear-ance (Gillen, Lefkowitz, & Shearer, 2006; Merianos, King, &Vidourek, 2013; Wiederman, 2000). Interestingly, however, in one study (Wiederman & Hurst, 1998), college women who had ever had sexual intercourse reported similar body image as those who had never had sexual intercourse, yet experimenters rated women with no sexual intercourse experience as less attractive. Body image and oral sex experience have been found to be associated with each other. In one study, only receiving (rather than giving) oral sex was associated with higher self-perceptions of bodily attractiveness among college women (Wiederman & Hurst, 1998). Also among college women, ever engaging in oral sex is associated with lower body image self-consciousness (Wiederman, 2000). Body image is also associated with frequency of sexual experiences. Women who have higher body satisfaction report greater frequency of sex (Ackard,Kearney-Cooke, & Peterson, 2000), and women with higher body image self-consciousness during sexual intimacy have less variable and frequent heterosexual sexual experience (Wiederman, 2000).In sum, individuals who are in a romantic relationship, have ever had sexual intercourse and oral sex, and who have more frequent and variable sexual experiences tend to have more positive body attitudes and less self-consciousness during sexual intimacy.

Because the studies reviewed here are correlational, the directionality of these associations are not clear. For example, being in a romantic relationship with a supportive romantic partner who offers frequent compliments about one’s body can enhance body image (Markey & Markey, 2006). It is also feasible that individuals who have more positive body image have more confidence to seek out more romantic and sexual experiences. These relations maybe cyclical; the more confident individuals feel about their bod-ies, the more likely they are to seek out sexual experiences. Then,the more sexual experiences they have, the better they feel about their bodies. Although it is likely that the direction of effect runs both ways, longitudinal and experimental research is needed to help determine directionality.

4.2. Body image and sexual functioning
Sexual functioning encompasses factors such as desire, arousal,orgasm, satisfaction, and pain (Rosen et al., 2000). Much of this liter-ature has focused on women, perhaps because they are more likelythan men to engage in appearance-based spectatoring, or being dis-tracted during sex with thoughts of how one’s body appears to apartner (Wiederman, 2012). Some research shows no significant associations between various measures of body image and sexualfunctioning among women, perhaps because women’s body image concerns have become so widespread that they do not meaningfully relate to women’s sexual experiences (Davison & McCabe, 2005; Milhausen, Buchholz, Opperman, & Benson, 2015). It may also be that context-specific measures of body image in sexual situations are better predictors of sexual functioning than more general mea-sures of body image (Wiederman, 2012; Yamamiya et al., 2006).Yet, most research shows that body image is related to various domains of sexual functioning (for a review, see Woertman & Brink,2012). In general, women with higher body and appearance satis-faction also appear to be more comfortable and satisfied in sexual contexts. Specifically, women who are more satisfied with their bodies and appearance are more comfortable undressing in front of a partner, having sex with the lights on, and trying new sexual activities; they also initiate sex more often, report more orgasms during sex, and have higher solitary and partnered sexual desire (Ackard et al., 2000; Dosch, Ghisletta, & Van der Linden, 2015).

Similar associations have been found for other body image con-structs. For example, among women, higher body esteem and fewer distracting appearance-based thoughts during sexual activity are associated with higher sexual satisfaction (Pujols et al., 2010), and higher situational body image dysphoria is associated with lower sexual assertiveness, lower sexual esteem, higher sexual anxiety,and more sexual problems (Weaver & Byers, 2006).Consistent with objectification theory, some work in this area has focused on objectification-related constructs and their linkswith sexual well-being. For instance, body surveillance is signif-icantly associated with lower sexual self-esteem, lower sexual self-competence, and lower sexual satisfaction among collegewomen (Calogero & Thompson, 2009a,2009b). Similarly, body shame is associated with lower sexual self-esteem, lower sex-ual satisfaction, and more self-consciousness during partnered sexual activity among college women (Calogero & Thompson, 2009a, 2009b; Steer & Tiggemann, 2008). Among adults, body shame is associated with lower sexual pleasure and more sexual problems (associations were also mediated by self-consciousness during sexual activity with a partner; Sanchez & Kiefer, 2007).
Although less often studied, appearance anxiety is also significantly associated with higher self-consciousness during sexual activity with a partner and decreased sexual functioning among college women (Steer & Tiggemann, 2008; Tiggemann & Williams, 2011).In one study, appearance anxiety in sexual situations also significantly mediated relations between body surveillance and sexual well-being (Vencill et al., 2015). That is, increased body surveillance related to increased appearance anxiety in sexual situations,which in turn related to decreased sexual well-being.Recent research has focused on associations between posi-tive body image and sexual functioning, in line with the call for more work on positive body image (Gillen et al., 2018; Smolak & Cash, 2011). This research has focused on body appreciation, a widely studied facet of positive body image. In samples of women,body appreciation was significantly associated with higher arousal (Brink, Smeets, Hessen, & Woertman, 2016; Satinsky et al., 2012), higher sexual desire (Brink et al., 2016), more frequent orgasms,and higher sexual satisfaction (Satinsky et al., 2012). Body appreciation also appears to be related to attitudes toward sexual practices.Among women and men, body appreciation is associated with higher sexual liberalism and more positive attitudes toward unconventional sexual practices (Swami, Weis, Barron, & Furnham, 2017).In sum, body image tends to be significantly associated with various dimensions of sexual functioning, although there are some exceptions. Most of this research focuses on women, with the limited research on men supporting similar conclusions (e.g., Sanchez& Kiefer, 2007). The reported associations are especially strong for contextual measures of body image (measures that capture body image in certain situations), and have been found for both negative and positive aspects of body image.

4.3. Body image and risky sexual behavior and attitudes
Researchers have also investigated associations between body image and risky sexual behavior and attitudes. Risky sexual behav-ior includes behaviors such as having casual sex, sex without protection, and having multiple partners. Risky sexual attitudes includes low condom use self-efficacy (i.e., low confidence in using condoms), perceiving more barriers to condom use, and endorsing the sexual double standard (i.e., that it is acceptable for men to have more sexual freedom than women). In terms of risky sexual behaviors, one study of college students reported no significant differences between students with low and high body satisfaction on a range of sexual risk behaviors (Merianoset al., 2013). However, several other studies indicate significant associations between body image and risky sexual behavior, particularly among young women. For young women, poor body image appears to be related to increased risk for engaging in risky sexual behavior. For example, among sexually active women, those who have higher body shame, higher body dissatisfaction, and perceive themselves as overweight report more unprotected sex (Hollander,2010; Littleton, Breitkopf, & Berenson, 2005; Wingood, DiClemente, Harrington, & Davies, 2002). Women with higher body shame also report multiple sex partners in the past year, and women with higher body surveillance report being more likely to mix substance use and sex (Littleton et al., 2005). So, it can be surmised that women who are less satisfied with their physical selves are less confident in approaching sexual encounters and less willing to demand condom use or other contraceptive use. Just as negative body image appears to make women vulnerable to engaging in risky sexual behavior, positive body image seems to be a protective factor. Among sexually active women, more positive body image(i.e., body appreciation) is associated with greater use of barrier and non-barrier contraceptive methods (Gillen et al., 2006; Ramseyer Winter, Ruhr, Pevehouse, & Pilgrim, 2018) and more engagement in a variety of preventive sexual health behaviors (Ramseyer Winter,2017). Body satisfaction may even predict protective sex behavior at a later time point. For instance, among adolescent girls, Schooler (2013) found that body satisfaction in 8th grade predicted consistent condom use in 12th grade (with the exception of girls who had sex before 10th grade). For men, there are less data, yet findings point to a pattern of associations among body image and risky sexual behavior.Two studies to our knowledge have been conducted on this topicamong college men. Schooler and Ward (2006) found no significant association between body comfort and risky sexual behavior.Yet, in another study (Gillen et al., 2006), men who evaluated their appearance in a more positive way had more lifetime sex partners, more unprotected sex, and believed that condoms were less efficacious than their peers who evaluated their appearance more negatively. Also, men who were more oriented toward their appearance had more lifetime sex partners. This may be indicative of a constellation of personality qualities consistent with superficiality. It could also be that positive body image gives men a boost of confidence in sexual situations where they may already feel power through embodiment of the male sexual role (Gillen et al.,2006). Data on sexual attitudes generally suggest that poorer body image is related to risky sexual attitudes. Regarding attitudes toward condoms, a meta-analysis of studies on men and women demonstrated that individuals with higher body dissatisfaction have less condom use self-efficacy (Blashill & Safren, 2015); further, male and female college students with less positive views of their appearance perceive more barriers to condom use. It maybe that individuals who do not feel particularly positive about their bodies also feel a low sense of efficacy in their intimate lives. Demanding condom use of partners may be inconsistent with what they believe they deserve from a sexual partner. Body image is also related to attitudes toward men’s and women’s rolesin sexual situations. College men and women who are more oriented toward their appearance more strongly endorse the sexual double standard, the idea that men should have more sexual free-dom than women (Crawford & Popp, 2003; Gillen et al., 2006). Individuals who are more concerned with their appearance may invest more in achieving cultural standards of beauty. Because they endorse these gendered appearance standards, they may also believe more in the sexual double standard, which argues for gender-specific attitudes and behavior with regard to sex (Gillenet al., 2006).In sum, for sexually active women, there is a clear association between poor body image and risky sexual behavior. Recent research also suggests that measures of positive body image are linked to less sexual risk for women. For men, there are less data on these associations and therefore a strong conclusion cannot be drawn. One study suggests that these associations may work in the opposite direction, in that favorable appearance evaluations might actually increase sexual risk for men (Gillen et al., 2006). More studies are needed, however, to support this idea. There is less research on body image and sexual attitudes, but studies generally suggest that poor body image is associated with more risky sexual attitudes.

4.4. Body image and communication about sex
The literature on body image and communication about sex suggests that individuals with a more favorable body image are more comfortable communicating with a partner about sexual issues.These associations have been found for both men and women. For example, among women, those with higher body esteem and body appreciation communicate more easily with a partner about sex(Pujols et al., 2010; Ramseyer Winter, Gillen et al., 2018). Similarly,research examining adolescent girls demonstrates that those with higher body dissatisfaction were more likely to fear their partners leaving them if they brought up condom use and perceive less control in their relationships (Wingood et al., 2002). Research on boys and young men is consistent with this work on girls and women.College men who reported greater comfort with their bodies (e.g.,facial hair) were more sexually assertive and had higher safer sex self-efficacy (Schooler & Ward, 2006). Similar associations were found among adolescent boys. Across findings from both qualitative and quantitative work, boys with higher body satisfaction had greater clarity about their personal sexual needs and values,and felt more comfortable communicating these ideas to a partner (Schooler, Impett, Hirschman, & Bonem, 2008). Body image mayeven be protective for communication about the sensitive topic of HIV. College students with more positive views of their appearance were more likely to have ever asked a partner’s HIV status and to have asked a partner to get tested for HIV (Gillen & Markey, 2014).In sum, both boys/men and girls/women who have more positive and less negative body image tend to be more comfortable discussing sexual topics with a partner. This comfort includes discussing HIV status, a sensitive topic that may be difficult to approach with a partner.

4.5. Perceptions of breasts and genitals and sexual well-being
Given that breasts and genitals are likely to be visible in sex-ual situations, it is important to consider how perceptions of theseparts of the body relate to sexual well-being. Few studies, however,have considered this, especially individuals’ perceptions of theirbreasts. Increased breast size is associated with increased percep-tions of sexual attractiveness, although medium and large breastsizes (versus small and very small breasts) do not differ significantlyin perceptions of sexual attractiveness (Dixson, Duncan, & Dixson, 2015). Little is known, however, about how women’s breast satis-faction is related to their sexual well-being. In one study (Didie & Sarwer, 2003), women who were pursuing breast augmentation were compared to similar women who were not candidates for this procedure. Women who were candidates for breast augmentation reported higher dissatisfaction with their breasts, but also higher sexual functioning, including greater sexual drive and arousal, as compared to women who were not candidates. This may indicate that women who are interested in increasing their breast size are more interested in sex and more interested in being sexually appealing to partners or potential partners.There is more research on genital self-image, which suggests that these perceptions are important for sexual well-being (Wiederman, 2012), including feelings of sexual attractiveness(Amos & McCabe, 2016). Women’s genital dissatisfaction (e.g.,with the appearance of the vulva) is associated with lower sexual esteem, lower sexual satisfaction, lower sexual functioning, more pain during sexual intercourse, and higher sexual distress (Amos & McCabe, 2016; Pazmany, Bergeron, Van Oudenhove, Verhaeghe, & Enzlin, 2013; Schick, Calabrese, Rima, & Zucker, 2010). Further,women with higher genital self-consciousness, a related construct, have lower sexual esteem and lower sexual satisfaction (Amos &McCabe, 2016; Schick et al., 2010). Among men, results are similar. Men with higher genital satisfaction (e.g., length of penis) and lower genital self-consciousness have higher sexual esteem (Amos & McCabe, 2016). In another study of young men, higher genital satisfaction was related to less sexual anxiety, which was inturn related to less erectile dysfunction (Wilcox, Redmond, & Davis,2015). Some research has also focused on men’s attitudes toward their circumcision status. Men who are happier with their circumcision status (i.e., circumcised or not) reported better global body image, better sexual context-specific body image, greater satisfaction with their genitals, and higher sexual functioning (Bossio &Pukall, 2018).

In sum, there is still more work to be done on the associations between breast and genital perceptions and sexual well-being.There is too little research on breast perceptions and sexual-well-being to draw conclusions. Research on genital self-image suggests that it is significantly related to sexual well-being for both men and women. Individuals who have more positive perceptions of their genitals tend to have higher sexual well-being.