Appearance dissatisfaction is a sensitive issue and has been tied to depression, dissatisfaction in romantic relationships, and reduced sexual satisfaction

Øverup CS, Strizzi JM, Cipric A, et al. Appearance Satisfaction as a Predictor of Specific Sexual Problems and Associated Distress. J Sex Med 2021;XX:XXX–XXX. Aug 2 2021. https://doi.org/10.1016/j.jsxm.2021.06.019

Abstract

Introduction: Appearance dissatisfaction is a sensitive issue and has been tied to depression, dissatisfaction in romantic relationships, and reduced sexual satisfaction.

Aim: This study sought to examine associations between appearance satisfaction and specific sexual problems and related distress, testing also the moderating role of relationship satisfaction.

Methods: A large web-sample of Norwegians in romantic relationships (N = 2,903) completed a one-time survey.

Outcomes: Participants reported on their experience of five different sexual problems and associated level of distress.

Results: We found that appearance satisfaction was associated with reporting fewer sexual problems, and specifically, with a smaller likelihood of experiencing problems with lack of enjoyment, lack of excitement, and lack of climax. Furthermore, appearance satisfaction was unrelated to overall sexual problem-related distress, but was associated with feeling less distress about lack of excitement and lack of climax. Relationship satisfaction did not serve as a moderator of the associations.

Clinical Translation: These findings suggest the importance of attending to appearance satisfaction when working with clients with multiple sexual problems, particularly those related to excitement and enjoyment.

Strengths and Limitations: Strengths of the study include a large sample of partnered adults and assessment of specific sexual problems and associated distress. A limitation is that outcomes were assessed using single items, rather than multi-item scales.

Conclusion: The study highlights the importance of examining the presence of sexual problems and associated distress separately, and to consider appearance satisfaction as a predictor of sexual functioning.

Key Words: Appearance satisfactionBody satisfactionBMISexual problemsSexual dysfunctionSexual distressRelationship satisfaction

Discussion

The current study is among the first to examine associations between appearance satisfaction and specific sexual problems and associated distress, as well as the cumulative number of sexual problems and overall distress related to any/multiple sexual problems, in a large sample of partnered Norwegian adults. A particular strength of the current study is the ability to look at the presence of specific sexual problems and the associated distress, as opposed to only general assessments of sexual functioning. Indeed, research highlights the distinction between sexual satisfaction and sexual difficulties,59,60 and that people who experience sexual problems may not necessarily experience distress related to those problems, especially at older age.28, 29, 30, 31, 32, 33, 34, 35, 36, 37 Moreover, much existing research has examined physiological predictors of sexual functioning, with a lesser focus on psychosocial factors. However, burgeoning research has begun to examine relational predictors of functioning and associated distress, putting sexual functioning squarely in the domain of relational functioning. The current research adds to this burgeoning field of study, by examining both psychological (appearance satisfaction) and social (relationship satisfaction) factors. In sum, it is important to examine the presence of sexual problems and the level of distress related to sexual problems separately, to understand the potentially disparate predictive ability of various factors, including psychosocial factors.

Number of Sexual Problems and the Presence of Specific Sexual Problems

Results demonstrated that appearance satisfaction was associated with reporting fewer sexual problems (H2), and specifically, with a smaller likelihood of reporting problems with sexual lack of enjoyment, excitement, and climax (H3). These findings are consistent with past research that has found that acceptance of one's body is associated with more sexual enjoyment,17 and that feeling negative about one's body is associated with decrements in orgasm,18,19 and overall sexual functioning61. Interestingly, and contrary to past research,17 we did not find an association between appearance satisfaction and lack of sexual interest (H3). It is unclear why we did not find this association; however, in the present sample, lack of interest was relatively common, with 30% of people endorsing this problem. Thus, it may be that other factors play a larger role than does appearance satisfaction in predicting whether people experience a lack of sexual interest. Factors may include age or sample population. Fooken used a sample of elderly women, while our study included both men and women of all ages.17

We also did not find that appearance satisfaction was associated with feeling anxious during sex (H3). It is noteworthy that only 4% of the sample endorsed this problem, and thus, there may have been too little variability in this sample to examine the association. Conversely, it may be that people experience less anxiety during sex, when the sex is with a committed romantic partner. Future research may wish to examine within a sample of people who all report issues with sexual anxiety whether body and appearance satisfaction predicts the level of sexual anxiety. Indeed, past research suggests that one reason for feeling anxious during sex may be body self-consciousness and an anxious attentional focus on the body.19,20,21,62

Distress Related to Sexual Problems

Results also suggested that appearance satisfaction was unrelated to overall sexual problem-related distress (RQ1) and distress related to sexual lack of interest and enjoyment, and feeling anxious during sex (RQ2). Appearance satisfaction was related to feeling less distress about sexual lack of excitement and climax (RQ2). It may be that the link between appearance dissatisfaction, cognitive distractions, and sexual problems and related distress provides an explanation. Previous research has found that body dissatisfaction is associated with cognitive distractions63 and that body dissatisfaction is associated with distress related to sexual problems. In fact, Pascoal and colleagues64 found that the association between body dissatisfaction and sexual functioning was mediated by cognitive distractions. In contrast to this study64, Pascoal et al. measured overall distress for all/any sexual problems. It could be that lower levels of appearance satisfaction lead to higher levels of cognitive distraction and these are more influential during the arousal and orgasm phases of the sexual response cycle and consequently be associated with higher levels of distress associated with lack of excitement and climax. Future research should examine whether there is a differential effect of body satisfaction and cognitive distractions on the diverse sexual problems and their associated distress. Although these associations are small in magnitude, they represent a first examination of the associations between appearance satisfaction and distress over specific sexual problems. Past research has found that lower appearance dissatisfaction was associated with less sexual problem-related distress;39,64 this research, however, examined general distress and not problem-specific distress.

The Role of Relationship Satisfaction

It is noteworthy that as people reported higher relationship satisfaction, they were less likely to endorse having a sexual problem, but felt more distress over lack of excitement. This is consistent with past research, which has found that relationship satisfaction is associated with better sexual functioning.25,40, 41, 42, 43 However, in committed relationships, people may feel that sexual interactions are normative, and thus, they may feel more distressed about lack of excitement for a partner for whom they otherwise care and love. Future research should seek to examine the role of perceptions of sexual norms and expectations in romantic relationships, and their importance in predicting distress associated with sexual problems, particularly problems related to arousal.

Relationship satisfaction was unrelated to the presence of all five specific sexual problems, and unrelated to overall distress and distress related to all other problems (except for distress over lack of excitement). This is inconsistent with past research, which has found that lower relationship satisfaction was associated with greater distress48,65 and greater emotional closeness during sex was associated with less distress35,45, 46, 47. However, one reason for this lack of associations may be the relatively high levels of relationship satisfaction in the sample. Indeed, the average level of relationship satisfaction was 5.91 out of 7 (see Table 1); thus, there may be have been a ceiling effect that restricted the range in scores, leading to reduced variability. Consequently, we did not find indications of moderation by relationship satisfaction (RQ3a and RQ3b).

The Role of Gender

Much extant research in both sexuality and appearance satisfaction has focused on gender, often examining these construct separately for men and women. Indeed, sexual problems may vary by sex (i.e., men may have issues with erection and ejaculation, while women may have issues with vaginal lubrication and pain during intercourse). Similarly, appearance ideals may vary by gender, as women may strive for thinness and men may strive for muscularity.66 However, it is recognized that, while ideals may vary, both genders experience dissatisfaction with their appearance,2 though research suggests that women experience higher levels of dissatisfaction than do men. One might therefore expect that the association between appearance satisfaction and sexual problems, and associated distress, may be stronger for women, as they may internalize the importance that society places on ideal women's body shapes and appearances.67 However, in the current study, we found that the association did not vary by gender. That is, the associations between appearance satisfaction and the presence of sexual problems, and their associated distress, were not stronger for women than for men, as one might expect. However, we did find general gender differences, such that women were more likely to report sexual problems (though, not consistently higher distress than men). These findings suggest that when appearance satisfaction and sexual problems are assessed in general, men's and women's experiences are similar. Especially considering that recent theory and research suggests that men and women are more similar than they are different across most psychological variables,68,69 this may be relevant in the context to experiences with sexual problems and appearance satisfaction. However, it may be that this pattern of results would be different, if sexual problems and appearance evaluations were assessed in gender-specific ways.

Limitations and Future Directions

There are strengths to the current study, including a large sample of partnered adults and assessment of specific sexual problems along with associated distress. However, the current study should also be viewed in terms of its limitations.

For one, while it is a benefit that we were able to examine individual and specific sexual problems, they were assessed using single items, and not an established scale. This may be a limitation, as sexual problems were addressed generally and not with respect to gender-specific problems, such as problems with erection, ejaculation, vaginal lubrication, or pain during sex. Moreover, single-item measures of sexual satisfaction have the disadvantage of being unidimensional and may have low test-retest reliability.70 Relatedly, appearance satisfaction was assessed using a single item that asked about satisfaction with physical appearance (“fysisk utseende”), and did not use existing scales of body or appearance dissatisfaction71. However, single items (rather than scales) were employed in an effort to maximize response rates and reduce participant burden, and is generally accepted and widely used in the field, as they may capture the construct to a satisfactory degree.72 Moreover, the generality of the items allowed us to assess sexual problems and feelings about appearance that may be relevant to all, regardless of gender.

Moreover, due to the general population sample and concerns about participant burden in responding to survey questions, we did not collect any data regarding any general health concerns, medications (specifically those with possible sexual side effects or appearance-related side effects such as weight gain), sexual pathologies or related therapies. Future research should consider collecting such data, as these can interfere with sexual activity or with body image. Similarly, future research may wish to include extended (and validated) measurement of gender-specific sexual problems, as well as gender-specific appearance evaluations, as such measurements may provide useful information regarding the link between body appearance and sexuality. Some research suggests that evaluation regarding specific body parts may be uniquely associated with sexual functioning73. Future research may also wish to examine potential mediators of the association between appearance satisfaction and sexual functioning. One such mediator may be inhibition/excitation. It has been demonstrated that, in women, self-perceived sexual attractiveness influence sexual responses by acting on the excitation and inhibition response pathways.74

Norwegian Sexual Behavior surveys have been conducted in previous years, yielding responses of 23% in 2008, 34% in 2002, 38% in 1997, 48% in 1992, and 63% in 198775. Thus, a low response rate seems to be a common finding in Norwegian questionnaire surveys. However, the response rate in this survey was higher than that in the 2008 survey. It has been demonstrated that dropout from the survey was unrelated to sexual behaviour, and random rather than systematic.76 As this study had a similar response rate to previous iterations of the survey, there is reason to believe that dropout in this survey also was random rather than systematic.

The data is cross-sectional in nature and therefore, we are precluded from making conclusions about causality. Future research may wish to examine these associations using more naturalistic methods, such as event-contingent diary methods or ecological momentary assessments. Such methods are relatively rare in sex research, though much knowledge is to be gained. That is, such methods allow for an examination of associations between constructs as they occurred in daily life, reducing retrospective bias. Currently, much work focus on general reports of sexual functions and memory of feelings of distress, which may be skewed by recency effects.77 Moreover, as sexual interactions and sexual functioning may be impacted by mood, and many daily and relational events may influence mood, future daily diary research may wish to include a measure of mood, to examine its predictive association with daily sexual functioning and associated distress. Indeed, it may be that mood serves as a mediator of the association between daily relational events and daily sexual functioning and associated distress.

Lastly, consistent with past research,43,78 the current research examined relationship satisfaction as a predictor of sexual problems or sexual functioning. However, it may be that relationship satisfaction may serve as the outcome, such that sexual functioning predicts relationship satisfaction. Likely, there is a bidirectional association between the two, and future research should seek to disentangle the mechanisms underlying this association. Indeed, it may be that the association between appearance satisfaction and relationship satisfaction is moderated by sexual problems, rather than the reverse, as we examined here. Relatedly, situating sexual problems and associated distress in a relational context, it may be interesting to examine the appearance satisfaction and BMI of both partners in a couple. Much research in the relationship sciences has demonstrated the presence of contagion effects79, and such a dynamic may be at play with appearance satisfaction, relationship satisfaction, and sexual problems/distress as well. That is, it may be that individuals who are dissatisfied with their appearance foster appearance dissatisfaction in their partners, and that jointly, this dissatisfaction influence their sexual behavior in negative ways.