Body Image and Female Sexual Functioning and Behavior: A Review

Knowledge in the research fields of body image and sexuality has significantly increased in the last decade. In this review, data from 57 studies were compiled for a review of empirical evidence regarding the association between sexuality and body image among healthy women. The overall conclusion is that body image issues can affect all domains of sexual functioning. Cognitions and self-consciousness seem to be key factors in understanding the complex relationships between women's body image and sexuality. Body evaluations and cognitions not only interfere with sexual responses and experiences during sexual activity, but also with sexual behavior, sexual avoidance, and risky sexual behavior.

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 PsychInfo 1 , MED-LINE 1 , Google TM Scholar, and Social SciSearch 1 . 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 .20 (-) 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. (ages 39-56) The more a woman perceived herself as less attractive than before, the more likely she 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 and among the smaller group of currently sexually active participants (r ¼ À.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
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.

Sexual Desire
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.

Orgasm
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).

Satisfaction
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 ¼ 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 selfconsciousness 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).

Pain
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 (Å lgars 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 selfschemas 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 selfschemas were related to better sexual functioning , 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 selfschemas, 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, Laliberté, 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 selfconsciousness 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 . 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 selfsurveillance 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.