Sexual Body Image and Its Correlates: A Population-Based Study of Finnish Women and Men

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1 International Journal of Sexual Health ISSN: (Print) X (Online) Journal homepage: Sexual Body Image and Its Correlates: A Population-Based Study of Finnish Women and Men Monica Ålgars, Pekka Santtila, Patrick Jern, Ada Johansson, Minja Westerlund & N. Kenneth Sandnabba To cite this article: Monica Ålgars, Pekka Santtila, Patrick Jern, Ada Johansson, Minja Westerlund & N. Kenneth Sandnabba (2011) Sexual Body Image and Its Correlates: A Population- Based Study of Finnish Women and Men, International Journal of Sexual Health, 23:1, To link to this article: Published online: 18 Mar Submit your article to this journal Article views: 4291 View related articles Citing articles: 12 View citing articles Full Terms & Conditions of access and use can be found at Download by: [ ] Date: 10 January 2018, At: 08:25

2 International Journal of Sexual Health, 23:26 34, 2011 Copyright C Taylor & Francis Group, LLC ISSN: print / X online DOI: / SEXUAL BODY IMAGE AND ITS CORRELATES: A POPULATION-BASED STUDY OF FINNISH WOMEN AND MEN Monica Ålgars, Pekka Santtila, Patrick Jern, Ada Johansson, Minja Westerlund, N. Kenneth Sandnabba Department of Psychology, Åbo Akademi University, Turku, Finland ABSTRACT. Sexual body image was examined in a population-based sample of 9,532 Finnish men and women, age 18 to 49 years. More than one half of women and men were satisfied with their genitals, one half of the women were satisfied with their breasts. Higher levels of genital satisfaction were related to higher frequencies of sexual behavior and better sexual function for both genders. For men, penis size satisfaction was associated with lower levels of premature ejaculation and better erectile function. Sexual body image was related to overall perceived attractiveness, for women a higher body mass index was related to satisfaction with breast size. Having children was negatively related to women s sexual body image, abortions and miscarriages likewise. Limitations of the study and clinical implications of the findings are discussed. KEYWORDS. Body image, sexual function, BMI, children, abortion, miscarriage INTRODUCTION Despite the vast amount of research on body image, little is known about how people perceive the sexual areas of their bodies, that is, their genitals and breasts. Women s genital body image is a particularly overlooked area. Yet sexual body image has implications for psychological well-being, and men and women worry about the appearance of their genitals and breasts. Women s breasts are given much attention in our culture and are viewed as symbols of femininity and sexuality (Tantleff- Dunn & Thompson, 2000). Media images depict unrealistic breast sizes and the popularity of breast augmentation, reduction, and enhancement procedures suggests that women are dissatisfied with the sizes and shapes of their breasts (Tantleff-Dunn, 2001). Through popular media, boys and men receive the message that masculinity, virility, and potency are related to penis size (Lee, 1996), and exposure to pornographic material may cause men to overestimate the average penis size and underestimate the relative size of their own penis (Lever, Frederick, & Peplau, 2006). Men s worries about their penis size have also created a market for penis enlargement procedures and products (Lever et al., 2006), and this market possibly further enhances feelings of inadequacy. Likewise, advertisements for female hygiene products may cause women to feel insecure about the smell and cleanliness of their genitals (Reinholtz & Muehlenhard, 1995). The few existing studies of sexual body image indicate that men overall show more positive perceptions of their genitals than women do (Morrison, Bearden, Ellis, & Harriman, 2005; Reinholtz & Muehlenhard, 1995). In an Internet survey (N = 25,594) of heterosexual men age Received 30 November 2009; revised 10 June 2010; accepted 7 July Address correspondence to Monica Ålgars, Department of Psychology, Åbo Akademi University, Fabriksgatan 2, FIN Turku, Finland. monica.algars@abo.fi This research was supported by grants from the Academy of Finland, the Stiftelsen for Åbo Akademi Foundation,the Finnish National Graduate School of Psychology, and the Otto A. Malm Foundation. The data collection for this study was partly conducted by Markus Varjonen. 26

3 M. ÅLGARS ET AL to 65 years, 55% reported being satisfied with their penis size and 45% reported wanting to have a larger penis (Lever et al., 2006). Satisfaction with penis size was most common among men who viewed their penis as large and uncommon among men who viewed their penis as small. Age had no effect on penis size satisfaction. Men who reported having a large penis were more satisfied with their body and less concerned about exposing their body during sex. In a study of 112 single male college students (Lee, 1996), 68.8% estimated that they had average penis size, 25.9% estimated that their penises were smaller or much smaller than other males, and 5.3% indicated that they had larger-than-average penises. This shows a skew in estimated penis size toward smaller than average. In an Internet survey (N = 52,227) (Frederick, Peplau, & Lever, 2008) on 18- to 65- year-old women s and men s views about breast size and shape, 70% of women were dissatisfied with their breast size or shape. However, most men (56%) were satisfied with their partner s breasts. Women s breast dissatisfaction was associated with lower overall body satisfaction, more concern about wearing a bathing suit in public, and higher likelihood of concealing one s breasts. Another study (Tantleff-Dunn & Thompson, 2000) showed that 55% of women age 18 to 49 years wanted larger breasts, 16% were satisfied with their breast size, and 29% wanted smaller breasts. Breast size satisfaction was not associated with overall body image disturbance or low self-esteem. Men s ideal breast size in women has been found to be significantly larger than women s, but the breast size men prefer is smaller than the size women believe men prefer (Tantleff-Dunn, 2001). Sexual body image can also be expected to be associated with sexual behavior. In one study (Reinholtz & Muehlenhard, 1995), people with positive perceptions of their own and their partners genitals reported more frequent and diverse sexual behavior. More positive genital perceptions (of one s own as well as one s partner s genitals) were positively associated with participation in penile-vaginal intercourse, performing oral sex, receiving oral sex, and masturbation. Greater enjoyment of the sexual activities was also positively correlated with positive genital perceptions. Associations between general body image and sexual behavior have likewise been found. Women who have a positive body image report a higher frequency of sexual behavior and are more comfortable with sexual activities than women who are dissatisfied with their bodies (Ackard, Kearney-Cooke, & Peterson, 2000). Sanchez and Kiefer (2007) found that body shame predicted greater self-consciousness during physical intimacy in women and men, the association was stronger for women. The relationship between body shame and sexual pleasure and problems was mediated by sexual self-consciousness. Women and men who conceptualize their bodies in negative terms are also likely to report less sexual experience than those who had a positive body image (Faith & Schare, 1993). The purpose of the current study was to examine sexual body image in a large populationbased sample of adult Finnish men and women. Satisfaction with genitals and women s satisfaction with their breasts were studied. The associations between sexual body image and various other variables were analyzed. These included sexual functioning, frequencies of sexual activities, age, body mass index (BMI), having children, and overall body satisfaction. Because breasts and genitals are reproductive organs, the relation between sexual body image and having experienced abortions or miscarriages was also examined for women. Due to the relative lack of previous research in the area, no a priori hypotheses were made. METHOD Participants The participants in the study came from the second data collection of the Genetics of Sex and Aggression (GSA) sample, a populationbased sample of 9,532 (6,201 women and 3,331 men) Finnish twins and their siblings, age 18 to 49 years (M = 26.11, SD = 5.01). The data collection was carried out in 2006 and

4 28 INTERNATIONAL JOURNAL OF SEXUAL HEALTH targeted 18- to 33-year-old twins and their older than 18-year-old siblings. The participants addresses were obtained from the Finnish population registry. The overall response rate was of 45%, which is comparable to prior studies on sexual behavior (Bailey, Dunne, & Martin, 2000). According to Statistics Finland (Statistics Finland, 2010) approximately 15% of Finns move each year. Considering that the data collection lasted more than a half-year, the real response rate was approximately 50%. The research plan was approved by the Ethics Committee of the Åbo Akademi University. Instruments Body Image. The participants responded to the body image subscale of the self-report Derogatis Sexual Functioning Inventory (DSFI; Derogatis, 1975). The DSFI is a multidimensional measure of human sexual functioning consisting of 10 subscales, among them the body image scale used in the current study. To measure sexual body image the items used for women were I have attractive breasts, and I am pleased with the way my vagina looks. For men, the item I am satisfied with the size of my penis was used. To assess general body image, a composite variable was computed from the items of the DSFI body image scale that are common for both genders. Cronbach s alpha for the composite variable was.66 for men and women. The rationale behind the body image subscale is that body image is related to sexual functioning and the ability to achieve relaxed sexual relationships. The body image subscale of the DSFI has been shown to correlate highly (.74) with global sexual satisfaction (Derogatis & Melisaratos, 1979). In addition to the DSFI items, items from a questionnaire about the body and sexual self-image (Hampson, 2000) were used. For women the items were I wish that I had bigger breasts, and I wish that I had smaller breasts. For men the item I wish that I had a larger penis was used. Each question was answered on a Likert-type scale, ranging from 1 (disagree) to5(agree). Sexual function. Female sexual function was assessed using the Female Sexual Function Index (FSFI; Rosen et al., 2000), applying a six-factor structure shown to be valid for the current sample by Witting et al. (2008). The six factors assessed desire, arousal, lubrication, orgasm, satisfaction, and pain. For men, similar items were selected from the International Index of Erectile Function (IIEF; Rosen et al., 1997). The five items measured how often, over the past 4 weeks, attempting sexual intercourse has been satisfactory, how much one has enjoyed sexual intercourse, how often one has reached orgasm or climax, the level of desire, and overall satisfaction with one s sex life. Male erectile function was assessed using a scale score of the five-item version of the International Index of Erectile Function (IIEF- 5; Rosen, Cappalleri, Smith, Lipsky, & Peña, 1999), measuring confidence about keeping an erection, erections being hard enough for penetration, ability to maintain an erection, and satisfaction with attempted intercourse. In the current sample, Cronbach s alpha for the five items was.93. Ejaculatory function was assessed using composite variables developed for the current sample by Jern et al. (2007), measuring premature and delayed ejaculation. The composite variables consisted of questions adapted from an unpublished questionnaire developed by Grenier and Byers (1997), including, for example, questions about ejaculation latency time, trying to speed up or delay intercourse, and feeling of control, higher values indicating more problems with ejaculatory function. Frequencies of sexual behaviors were assessed using a modified version of Section III from the DSFI (Derogatis & Melisaratos, 1979). Participants were asked how frequently they engage in sexual fantasies, kissing and petting, masturbation, oral sex, vaginal intercourse, and anal intercourse using a nine-point scale where 0 = not at all and 9 = 4 times a day. Statistical Analyses Descriptive phenotypic analyses were conducted using the statistical package SPSS 17.0 (2008). Because a large part of the

5 M. ÅLGARS ET AL. 29 participants were twins and variance thus possibly was reduced, inferential statistics were computed using the Generalized Estimating Equations module. RESULTS A little more than one half of the women (54.9%) agreed or somewhat agreed with the statement I am pleased with the way my vagina looks. A little less than one half (49.6%) agreed with the statement I have attractive breasts. More than one third (40.7%) of the women wished they had bigger breasts, and 13.0% wished their breasts were smaller. Of the men, 68.1% reported being satisfied with their penis size. However, 46.9% agreed or somewhat agreed that they wished they had a larger penis. Age had no effect on how satisfied men were with their penis. For women, age was likewise unrelated to satisfaction with genitals and breasts. Sexual Function and Sexual Behavior As shown in Table 1, for women higher levels of satisfaction with one s vagina, as well as satisfaction with one s breasts, were associated with better sexual function on all measured items. As shown in Table 2, for men four of the five items selected from the IIEF (Rosen et al., 1997) to measure male sexual function covaried with penis size satisfaction. Satisfaction with penis size was also associated with lower levels of premature ejaculation (r =.20, B =.07, SE =.01, χ 2 = 78.90, p < 0.001) but higher levels of delayed ejaculation (r =.05, B =.02, SE =.01, χ 2 = 4.80, p < 0.05). Wishing one s penis was larger was positively associated with premature ejaculation (r =.12, B =.04, SE =.01, χ 2 = 28.19, p < 0.001). Penis size satisfaction was associated with better erectile function (r =.09, B =.02, SE =.01, χ 2 = 17.09, p < 0.001), wishing one s penis was larger was negatively related to erectile function (r =.09, B =.02, SE =.01, χ 2 = 18.13, p < 0.001). As shown in Tables 3 and 4, genital satisfaction was positively associated with the frequency with which participants reported engaging in several kinds of sexual behavior. For women, associations were found regarding frequencies of sexual fantasies, kissing and petting, oral sex, vaginal intercourse, and anal intercourse. For men, associations were found regarding frequencies of kissing and petting, oral sex, and vaginal intercourse. General Body Image For women, a more positive general body image was associated with satisfaction with one s vagina (r =.35, B =.06, SE =.01, χ 2 = , p < 0.001), as well as one s breasts (r =.42, B =.09, SE =.01, χ 2 = , p < 0.001). General body image was negatively associated with wishing one s breasts were smaller (r =.24, B =.05, SE =.01, χ 2 = , p < 0.001), as well as wishing one s breasts were bigger (r =.11, B =.03, SE =.01, χ 2 = 62.75, p < 0.001). For men, a more positive general body image was positively related to penis size satisfaction (r =.40, B =.08, SE =.01, χ 2 = , p < 0.001), TABLE 1. Women s Sexual Body Image and Sexual Function (Adjusted for Clustered Samples) I am pleased with the way my vagina looks I have attractive breasts r B SE χ 2 r B SE χ 2 Desire Arousal Lubrication Orgasm Satisfaction Pain Note. r = Pearson correlation, not adjusted for clustered samples. p < 0.05, p < 0.01, p <

6 30 INTERNATIONAL JOURNAL OF SEXUAL HEALTH TABLE 2. Men s Genital Satisfaction and Sexual Function (Adjusted for Clustered Samples) I am satisfied with the size of my penis r B SE χ 2 Attempting intercourse Enjoyment Orgasm Desire Satisfaction Note. r = Pearson correlation, not adjusted for clustered samples. p < 0.05, p < 0.01, p < TABLE 4. Men s Penis Size Satisfaction and Frequencies of Sexual Behavior (Adjusted for Clustered Samples) I am satisfied with the size of my penis r B SE χ 2 Sexual fantasies Kissing and petting Masturbation Oral sex Vaginal intercourse Anal intercourse Note. r = Pearson correlation, not adjusted for clustered samples. p < 0.05, p < 0.01, p < and negatively related to wishing one s penis was larger (r =.31, B =.07, SE =.01, χ 2 = , p < 0.001). BMI and Having Children The association between sexual body image and having biological children was analyzed using a multiple regression analysis, controlling for BMI. A total of 27.9% of the participants reported having biological children (30.6% of the women and 22.8% of the men). Women who had biological children (M = 3.49, SD = 1.11) were less satisfied with their genitals than women who had no biological children (M = 3.58, SD = 1.08), χ 2 = 7.19, p <.01. Women who had biological children (M = 2.78, SD = 1.24) were also less satisfied with their breasts than women who had no biological children TABLE 3. Women s Genital Satisfaction and Frequencies of Sexual Behavior (Adjusted for Clustered Samples) I am pleased with the way my vagina looks r B SE χ 2 Sexual fantasies Kissing and petting Masturbation Oral sex Vaginal intercourse Anal intercourse Note. r = Pearson correlation, not adjusted for clustered samples. p < 0.05, p < 0.01, p < (M = 3.27, SD = 1.25), χ 2 = , p < Women who had biological children (M = 1.75, SD = 1.26) were more likely to wish their breasts were smaller than women who did not (M = 1.60, SD = 1.11), χ 2 = 12.18, p < Men who had no biological children (M = 3.11, SD = 1.28) were more likely to wish they had a larger penis than men who had biological children (M = 2.91, SD = 1.34), χ 2 = 17.07, p < The mean BMI for the women was (SD = 4.17), and for the men it was (SD = 3.69). For women, a higher BMI was positively related to wishing one s breasts were smaller (r =.32, B =.10, SE =.01, χ 2 = , p < 0.001), and negatively related to wishing one s breasts were larger (r =.27, B =.09, SE =.01, χ 2 = , p < 0.001). For men, a higher BMI was negatively related to satisfaction with one s penis (r =.10, B =.09, SE =.01, χ 2 = , p < 0.001). Miscarriage and Abortion Of the women, 7.7% reported having experienced a miscarriage, and 9.1% reported having had an abortion. Women who reported having had an abortion (M = 2.94, SD = 1.33) were significantly less satisfied with their breasts than women who had not had an abortion (M = 3.21, SD = 1.26), t = 6.16, p < Women who had experienced an abortion (M = 3.44, SD = 1.15) were also less satisfied with their genitals than women who had not (M = 3.62, SD = 1.07), t = 3.01, p = Women who

7 M. ÅLGARS ET AL. 31 reported having had a miscarriage (M = 2.92, SD = 1.25) were significantly less satisfied with their breasts than women who had not (M = 3.20, SD = 1.27), t = 7.47, p < However, no differences were found regarding satisfaction with one s genitals. DISCUSSION Sexual body image was examined in a population-based sample (N = 9,532) of 18- to 49-year-old Finns of both sexes. Men s penis satisfaction was studied, as well as women s satisfaction with their breasts and genitals, and the relation between sexual body image and various aspects of life was analyzed. The current study is one of few to thoroughly study genital body image in a large sample of both genders. The results showed that more than one half of the participants expressed genital satisfaction. A larger proportion of men (68.1%) were satisfied with their penis size than the proportion of women being pleased with the looks of their vagina (54.9%). Although the two items were not directly comparable, the difference in frequencies agrees with previous research showing that men tend to be more satisfied with their genitals than women (Morrison et al., 2005; Reinholtz & Muehlenhard, 1995). There are several possible explanations for the gender difference in sexual body image. Cultural stereotypes about sexuality may enable men to be more comfortable than women enjoying their sexuality, a possible reason for women expressing more negative perceptions of their own (and their partner s) genitals (Reinholtz & Muehlenhard, 1995). There is also a greater emphasis on appearance for girls and women (Striegel-Moore & Franko, 2004), possibly resulting in women feeling more self-critical and self-conscious about their appearance than men. Almost one half of the women were satisfied with the appearance of their breasts, a higher degree of satisfaction than previous studies have found (Frederick et al., 2008; Tantleff-Dunn & Thompson, 2000). In line with past research (Lever et al., 2006) we found no age effects on sexual body satisfaction within the age range studied (18 49 years). For women higher levels of genital satisfaction were associated with better sexual function on all items measured, that is, desire, arousal, lubrication, orgasm, satisfaction, and pain. For men penis size satisfaction was most noticeably associated with higher levels of enjoying sexual intercourse, more overall satisfaction with one s sex life, lower levels of premature ejaculation, and better erectile function. Confirming a previous study (Reinholtz & Muehlenhard, 1995) we found that higher levels of genital satisfaction were related to more frequent sexual behavior for both genders. More genital satisfaction was mainly associated with more frequent sexual activity with a partner but unrelated to how often men and women reported masturbating, and how often men reported having sexual fantasies. This suggests that sexual body image is related to self-esteem in sexual situations including a partner. The direction of causality between sexual body image and sexual function is difficult to determine. It is conceivable that a more positive sexual body image can lead to a better sex life, but it is also possible that a better sex life can cause people to view their sexual body parts more positively. For women a higher BMI was related to wishing one s breasts were smaller and not wishing one s breasts were bigger. A plausible interpretation of this result is that women with a higher BMI are more likely to perceive their breasts as too big, as breast size is related to BMI. As Tantleff-Dunn and Thompson (2000) pointed out, however, it is remarkable that women consistently report feeling larger than their ideal figure, but at the same time many women want larger breasts, even though losing weight is likely to have the opposite effect. For the minority of women who want smaller breasts, however, losing weight may lead to the wished result. For men, a higher BMI was associated with lower levels of satisfaction with one s penis size. This possibly reflects general body dissatisfaction due to a higher BMI. Another conceivable explanation is that the penis may appear shorter in overweight men, because a

8 32 INTERNATIONAL JOURNAL OF SEXUAL HEALTH larger proportion of it is hidden in the fat around its base. Confirming a previous study (Lever et al., 2006) but partly contradicting another (Tantleff-Dunn & Thompson, 2000), we found that sexual body image was associated with general body image for women and men. However, the direction of causality is not known, it remains unclear if global body satisfaction has an effect on sexual body image, or if the direction is the opposite. It is also possible that a third factor affects general and sexual body satisfaction. Having biological children was related to lower levels of satisfaction with breasts and genitals for women. This is understandable because pregnancy and nursing may cause changes in breast size and shape, as well as genital appearance and function. However, it is interesting to note that having children apparently did not cause women to attain a more positive or accepting of their reproductive body parts. Interestingly, having biological children was associated with lower levels of wishing one s penis was larger for men. One possibility is that having conceived a child confirms masculinity and may cause a man to feel more confident about his genitals, another possible interpretation is that men who do not wish they had a larger penis are more likely to have children. The associations between having children and sexual body image were not explained by age or BMI. The present results indicate an association between having experienced an abortion and lower levels of sexual body satisfaction for women. Previous studies have shown an association between abortion and risk of mental health problems (Fergusson, Horwood, & Bode, 2008), although the magnitude of the increased risk is small (Charles, Polis, Sridhara, & Blum, 2008). A plausible interpretation of the current results is that abortions cause women to view the parts of their bodies that are linked to reproduction more negatively. However, it is also possible that women with a negative sexual body image are more likely to have an abortion. Our results also showed that having had a miscarriage was associated with lower levels of satisfaction with one s breasts for women. Previous research has found a relation between miscarriages and psychological distress, such as anxiety and depressive symptoms. These psychological symptoms could persist for one year after a miscarriage (Lok & Neugebauer, 2007; Lok, Yip, Lee, Sahota, & Chung, 2010). A miscarriage can be described as something being lost from the body, and grief and mourning as feelings taking place inside the body (Dubos, 1997). A miscarriage may thus cause women to view themselves and their bodies more negatively, explaining the detected association. Limitations The study had some limitations that should be mentioned. First, neither the actual nor the self-reported sizes of the breasts or penises were known, so we do not know how realistic the participants perceptions of their genitals and breasts were. Second, sexual body image was assessed using only a few items, and it is thus possible that some aspects of participants perceptions of their genitals and breasts were not included. It should also be noted that most detected correlations were relatively low. Clinical Implications The current findings have several clinical implications. Almost one half of the participants were not satisfied with their breasts and genitals, indicating that sexual body dissatisfaction is common among adults. In addition, sexual body image was associated with general perceived attractiveness for both genders and should thus not be overlooked when overall body image is assessed and addressed. Higher levels of genital satisfaction were partly associated with better sexual functioning and more frequent sexual behavior, and as Reinholtz and Muehlenhard (1995) pointed out, genital perceptions could be an important focus for sex therapy or couples therapy. The current results suggest that a negative sexual body image may be associated with a higher risk for unplanned pregnancies. Also, attending physicians should be aware that abortions and miscarriages may increase the risk for a negative sexual body image. Miscarrying women and women who

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