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ORIGINAL RESEARCH & REVIEWS
EPIDEMIOLOGY & RISK FACTORS
Appearance Satisfaction as a Predictor of Specific Sexual Problems
and Associated Distress
Camilla S. Øverup, PhD,
1
Jenna Marie Strizzi, PhD,
1
Ana Cipric, MA,
1
Bente Træen, PhD,
2
and Gert Martin Hald, PhD
1
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 work-
ing 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. Øverup CS,
Strizzi JM, Cipric A, et al. Appearance Satisfaction as a Predictor of Specific Sexual Problems and Associ-
ated Distress. J Sex Med 2021;XX:XXX−XXX.
Copyright © 2021 The Authors. Published by Elsevier Inc. on behalf of the International Society for Sexual
Medicine. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
Key Words: Appearance satisfaction; Body satisfaction; BMI; Sexual problems; Sexual dysfunction; Sexual dis-
tress; Relationship satisfaction
Body image is a sensitive issue for many individuals, as con-
temporary Western culture places a strong emphasis on physical
appearance.
1
As such, both men and women may feel pressure to
look the “right”way, but perceive that they do not.
2
Perceptions
that one’s appearance is discordant with some norm or ideal may
lead to feelings of body and appearance dissatisfaction.
2
Evalua-
tions of body image are multi-faceted, and often have a particular
focus on feelings about, or satisfaction with, one’s physical
appearance.
3
By some, such evaluations are termed body (dis)sat-
isfaction.
4
while others refer to appearance evaluations, or
appearance satisfaction,
3
Thus, below, we use body (dis)satisfac-
tion and appearance (dis)satisfaction interchangeably.
Such dissatisfaction is associated with various psychological,
social, and physical health outcomes. For instance, a negative
body image has been associated with poor self-esteem,
5,6
lower
Received February 25, 2021. Accepted June 24, 2021.
1
University of Copenhagen, Department of Public Health, København K,
Denmark;
2
University of Oslo, Department of Psychology, Harald Schjelderups hus,
Oslo, Norway
Copyright © 2021 The Authors. Published by Elsevier Inc. on behalf of the
International Society for Sexual Medicine. This is an open access article
under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
https://doi.org/10.1016/j.jsxm.2021.06.019
J Sex Med 2021;000:1−13 1
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subjective well-being,
7
depression,
8
social anxiety,
9
dissatisfac-
tion in romantic relationships,
10
disordered eating,
11,12
and gen-
erally diminished quality of life.
13
Importantly, appearance
dissatisfaction has also been associated with reduced sexual
satisfaction.
14
Beyond sexual satisfaction, research also suggests that appear-
ance dissatisfaction has implications for sexual problems. In the
current manuscript, we sought to examine associations between
appearance satisfaction and sexual functioning (interest/desire,
enjoyment, anxiety, excitement and arousal, and climax) in a
large web-sample of Norwegians in romantic relationships. In
addition, we examined whether appearance satisfaction was
related to the distress associated with experiencing sexual dys-
function. Lastly, we examined whether these associations differed
by level of relationship satisfaction.
APPEARANCE SATISFACTION AND SEXUAL
FUNCTIONING
Much research has examined whether body satisfaction is
associated with sexual functioning, particularly among women.
For instance, research suggests that women who are more dissat-
isfied with their appearance also experience decreased interest in
or desire for sexual activity, particularly post-partum
15
and post-
menopause.
16
Moreover, in a study of elderly women, those who
expressed less acceptance of their aging body, were more likely to
report less sexual interest, less sexual pleasure, and less sexual
enjoyment than the women who expressed acceptance of their
body.
17
Feeling negative about one’s own body and appearance,
as well as perceiving that others evaluate one’s body negatively,
has also been associated with decrements in arousal and
orgasm,
18,19
and these decrements in arousal and orgasm were
associated with decreased pleasure for both men and women.
19
Conversely, perceiving that one is attractive, as well as being sat-
isfied with one’s body image, has been found to be associated
with an increase in orgasms and orgasming more easily.
20,16
It is noteworthy that associations between body image varia-
bles and sexuality variables have been found after controlling
for the effects of actual body size.
21
This suggests that percep-
tions and cognitions about the body, rather than actual body
size, have a unique influence on people’s sexual experiences.
22
Moreover, the research into the associations between body mass
index (BMI) and sexual functioning and satisfaction have
yielded mixed results; some have found that increased BMI,
particularly obesity, is associated with poorer sexual functioning
and/or lower sexual satisfaction,
23-25
while others have found
no association.
21,26,27
DISTRESS ABOUT SEXUAL PROBLEMS AND
APPEARANCE SATISFACTION
When studying sexual functioning, it is important to consider
distress; many of those who experience physiological symptoms
of sexual problems may not report experiencing associated dis-
tress.
28−37
This may particularly be true for older individuals.
30
Distress is an important element for determining the clinical rele-
vance of these symptoms. Since 1994, the distress associated with
sexual problems has been a key diagnostic criterion for sexual
dysfunctions in the Diagnostic and Statistical Manual of Mental
Disorders (DSM)
38
. However, surprisingly, the topic of distress
associated with sexual problems has received little scrutiny in the
literature, especially among men
29,30
.
Little research has been done regarding the associations
between body dissatisfaction, BMI, and distress about sexual
problems. In fact, to our knowledge, only one study has exam-
ined associations between appearance (dis)satisfaction and sexual
distress. This study found that lower appearance dissatisfaction
was associated with lower sexuality-related distress
39
. Thus, this
is a greatly understudied area.
THE ROLE OF RELATIONSHIP SATISFACTION
Sexuality and sexual functioning are important aspects of
human life, and may be particularly important in partnered rela-
tionships. Sexual satisfaction and sexual functioning have been
associated with relationship satisfaction, particularly among
women;
25,40−43
that is, when people feel greater relationship sat-
isfaction, they also tend to report greater sexual satisfaction and
better sexual functioning. Relatedly, greater relationship satisfac-
tion has been associated with larger gains in sexual satisfaction
and greater reductions in distress for women in treatment for sex-
ual dysfunction.
44
In general, increased emotional closeness dur-
ing sex, and longer duration relationships has been associated
with less distress,
35,45−47
while low relationship satisfaction and
low satisfaction with a sexual relationship have been associated
with greater sexual distress,
49,48
though not all studies have
found that association.
50
Further, studies have found the associ-
ated sexual distress, more than the experience of a sexual prob-
lem, to be a determinant of sexual satisfaction levels.
51
With respect to relationship satisfaction, it is associated with
greater body image satisfaction.
52,53
However, some research
suggests that relationship factors, such as intimacy and satisfac-
tion, are more important in predicting sexual satisfaction and
functioning than are body image variables.
53
Indeed, among
younger women, after controlling for relationship satisfaction,
body image variables no longer predicted sexual satisfaction or
sexual functioning.
53,54
This is echoed in an interview study of
20 Australian women aged 50−79, in which participants stated
that feeling loved and accepted by their long-term partners,
regardless of their appearance, was important for positive sexual
experiences.
55
Given that it appears that relationship satisfaction is associated
with both body satisfaction and sexual functioning and distress,
it may be that relationship satisfaction moderates the association
between body satisfaction and sexual functioning and distress.
That is, findings by Steer and Tiggemann,
54
and Træen and
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2Øverup et al
J Sex Med 2021;000:1−13
colleagues,
53
suggest that at high levels of relationship satisfac-
tion, the association between body dissatisfaction and sexual
functioning and distress is minimal. Conversely, it may be that
body dissatisfaction is related to poorer sexual functioning and
sexual distress for those with lower relationship satisfaction, as
the lower relationship satisfaction may exacerbate insecurities
about one’s body in sexual situations, though research is needed
to explore these possible associations.
CURRENT STUDY
The current research seeks to fill this gap in the literature,
using a large web-sample of Norwegian partnered adults. Specifi-
cally, we sought to address the following hypotheses and research
questions:
H1: Greater appearance satisfaction is associated with a
smaller likelihood of reporting any sexual problems.
H2: Greater appearance satisfaction is associated with report-
ing fewer sexual problems.
H3: Greater appearance satisfaction is associated with a
smaller likelihood of reporting specific sexual problems (lack of
interest, lack of enjoyment, feeling anxious during sex, not feel-
ing excitement, and not reaching orgasm).
RQ1: Is greater appearance satisfaction associated with less
overall sexual distress?
RQ2: Is greater appearance satisfaction associated with less
distress related to each sexual problem?
RQ3a: Is the association between appearance satisfaction and
sexual problems moderated by relationship satisfaction?
RQ3b: Is the association between appearance satisfaction and
distress related to sexual problems moderated by relationship sat-
isfaction?
METHODS
Participants
Data comes from a larger study of sexuality in Norway
(N = 4,160 people). For this publication, we elected to focus on
men and women who had sexual experience (i.e., responded yes
to the question: “Have you ever had sexual intercourse (incl. vag-
inal, anal or oral sex)”) and were in partnered relationships
(whether married or dating).
The final sample consisted of 2,903 people (men = 54%;
women = 45%), who were on average 47 years old (SD = 16.42;
range = 18−87). The majority of participants reported being het-
erosexual (96%; 2% gay/lesbian and 2% bi/pansexual), and mar-
ried (86%). Participants reported having been with their romantic
partners for an average of 17 years (SD = 15.9; range = 0−63
years). The majority of the participants were overweight (39.1%)
and normal weight (38.2%); 18.5% of the sample were obese,
while 4.2% were underweight, according to their BMI.
Procedure
Approximately 46,000 Norwegians are members of Kantar’s
Gallup Panel.
64
These members are randomly recruited based on
questionnaire surveys conducted by phone using probability
samples. Self-recruitment is not possible. Members of the Gallup
Panel are representative of Norway’s Internet population, that is,
the 98% of the population with access to the Internet.
56
People
included in the Panel are not exposed to sale or marketing com-
munication, are guaranteed anonymity, and all participation in
surveys is voluntary.
Participants were initially recruited in March 2020 by e-mail;
the recruitment e-mail was sent to a randomly selected sample of
11,685 Norwegians registered in Kantar’s Gallup Panel. A total
of 4,160 individuals completed the survey, yielding a response-
rate of 35.6%. Nearly half of the participants (51%) completed
the survey on a mobile device.
The type of topics covered in the questionnaire were deter-
mined and constructed by researchers at the University of Oslo.
The questionnaire was designed to study several different topics;
in addition to the questions about sexuality, the questionnaire
contained several questions about social background (gender,
age, marital status, place of residence, level of education). It took
an average of 15 minutes to complete the survey. Prior to launch-
ing the survey, it was piloted to a self-selected sample recruited
on Facebook. The study was approved by Internal Ethical Com-
mittee at the Department of Psychology, University of Oslo.
Measures
Physical Appearance. To assess appearance satisfaction, par-
ticipants were asked “How dissatisfied or satisfied are you with
your physical appearance?”Responses were provided on a 7-
point scale (1 = “Very dissatisfied”;4=“Neutral/Neither nor”;
7=“Very satisfied”). Thus, higher scores indicate greater appear-
ance satisfaction.
Sexual Problems and Distress Related to Sexual Prob-
lems. To assess for the presence of sexual problems, participants
were asked whether, during the past 12 months, they had experi-
enced any of the following problems over a period of 3 months
or longer
46:
(1) Lacked interest in having sex, (2) Lacked enjoy-
ment in sex, (3) Felt anxious during sex, (4) Felt no excitement
or arousal during sex, and (5) Did not reach a climax (experience
an orgasm) or took a long time to reach a climax despite feeling
excited/aroused. Participants indicated their answer with a “yes”
(1) or a “no”(0).
For each endorsed sexual problem, participants were pre-
sented with a follow-up question that asked “How distressful was
this experience for you?”Participants responses on a 4-point scale
with the following response options: 1 = “No distress”,2=“Mild
distress”,3=“Moderate distress”, and 4 = “Severe distress”.
Thus, higher scores indicate greater distress.
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Covariates. Several relevant covariates were assessed. Sexual
dissatisfaction was assessed with the question: ”All things consid-
ered −how satisfied are you with your sexual life?”, to which par-
ticipants responded with the following options:
1=“Dissatisfied”,2=“A little dissatisfied”,3=“Neither satis-
fied nor dissatisfied”,4=“Quite satisfied”, and 5 = “Very satis-
fied”. Higher scores indicate greater satisfaction.
Relationship satisfaction was assessed with the question “All
things considered, how satisfied are you with your current rela-
tionship?”Participants responded on a 7-point scale (1 = “Not
satisfied at all”;7=“Completely satisfied”). Higher scores indi-
cate greater satisfaction with the romantic relationship.
Additionally, participants reported their gender (male/female),
age (in years), and length of relationship (in years). Participants
also reported on their height (in centimeters) and weight (in kilo-
grams); these measurements were converted into a BMI score
and subsequently categorized according to established guidelines
from the CDC and the WHO.
57,58
The categorical variable is
used for descriptive purposes, while the BMI score variable was
used in the analyses as a covariate.
Plan of Analysis
Three sets of analyses were conducted. One analysis examined
whether appearance satisfaction predicted the number of sexual
problems people endorsed (H1 and H2). To that end, a zero-
inflated negative binomial regression was conducted. The zero-
inflated negative binomial regression yields two sets of estimates:
(1) one set predicting the occurrence of zero sexual problems
(H1), using a logistic regression, and (2) one set of estimates for
predicting the number of sexual problems (H2), using a negative
binomial regression. This analysis was followed up by an exami-
nation of whether appearance satisfaction predicted overall sex-
ual-problem related distress (RQ1). Here, sexual-problem related
distress was calculated by multiplying the distress related to spe-
cific sexual problems with the presence of the problem, and then
summing these scores across all problems. A log-transformation
was then applied to this summed score
30
(please see Hald et al.,
2019 for more explanation).
Then, a set of analyses concerned the prediction of the pres-
ence of each of the sexual problems (H3), using logistic regres-
sion. Finally, a set of analyses focused on predicting the level of
distress with each of the sexual problems (RQ2), employing ordi-
nary least squares regressions. It should be noted that these analy-
ses focused on the subset of participants who endorsed
experiencing the corresponding sexual problem.
In all analyses, we examined the main effect of appear-
ance satisfaction in a first step and included BMI, sexual sat-
isfaction, gender, age, relationship satisfaction, and
relationship length as covariate. In a second step, we exam-
ined whether the effect of appearance satisfaction differed as
a function of relationship satisfaction (RQ3a and RQ3b).
All continuous predictors were grand-mean-centered prior to
inclusion in the analyses, and gender was dummy coded,
with men serving as the reference group. All analyses were
conducted in SAS, version 9.4.
RESULTS
Correlations and Descriptive Data
Over half of the participants (54.3%, N = 1577) reported no
sexual problems, while 45.7% of people (N = 1326) reported
experiencing one or more problems (one problem = 28.0%;
two problems = 9.3%; three problems = 5.1%; four
problems = 2.5%; five problems = 0.8%). Correlations and
descriptive data can be found in Table 1. Overall, less satisfac-
tion with one’s appearance was associated with expressing sexual
lack of interest, lack of enjoyment, feeling anxious, lack of
excitement, and lack of climax, and the distress associated with
sexual lack of interest, enjoyment, excitement, and climax.
Moreover, appearance satisfaction was associated with greater
feelings of satisfaction with the romantic relationship. BMI was
negatively associated with satisfaction with appearance, sexual
satisfaction, feelings of anxiety during sex, lack of excitement,
and relationship satisfaction, but positively associated with age
and relationship length.
Predicting the Number of Sexual Problems and
Overall Sexual-Problem Related Distress
First, we sought to examine whether appearance satisfac-
tion predicted the number of sexual problems people
reported (H1 and H2); to that end, a zero-inflated negative
binomial regression was specified (Table 2). Results suggested
that with regard to the logistic regression (predicting 0 prob-
lems; H1), neither appearance satisfaction nor BMI predicted
the absence/presence of a sexual problem. However, with
respect to the count portion of the regression (H2), both
appearance satisfaction and BMI significantly predicted the
number of problems, such that higher scores was associated
with fewer sexual problems.
Then, we sought to examine whether appearance satisfaction
predicted overall sexual problem related distress (RQ1), using a
general linear regression model and controlling for the number
of sexual problems. These results appear in Table 3. The analyses
showed that appearance satisfaction and BMI were unrelated to
overall sexual problem related distress.
Predicting the Presence of Specific Sexual Problems
Table 4 presents the results of the logistic regressions focused
on predicting the presence of each sexual problem (lack of inter-
est, lack of enjoyment, feeling anxious during sex, lack of excite-
ment, or lack of climax; H3). Appearance satisfaction was
negatively associated with three of the sexual problems. That is,
reporting lower levels of appearance satisfaction were associated
with a greater likelihood of endorsing sexual lack of enjoyment,
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Table 1. Correlations, means and standard deviations for all study variables
12345678910111213141516171819
1Appearance
Satisfaction
−
2BMI -0.29*** −
3Sexual dis-
satisfaction
0.23*** -0.15*** −
4Number of sex
problems
-0.14*** -0.06** -0.20*** −
5Overall Distress -0.16*** -0.03 -0.30*** 0.56*** −
6Lack of Interest -0.11*** -0.02 -0.26*** 0.68*** 0.24*** −
7Distress: interest -0.09** -0.02 -0.21*** 0.27*** 0.86*** NA −
8Lack of enjoyment -0.11*** -0.02 -0.15*** 0.69*** 0.37*** 0.29*** 0.22*** −
9Distress: enjoyment -0.15** 0.01 -0.26*** 0.30*** 0.86*** 0.28*** 0.66*** NA −
10 Anxious -0.06*** -0.05*-0.11*** 0.44*** 0.33*** 0.15*** 0.16*** 0.23*** 0.20*** −
11 Distress: anxious -0.09 -0.10 -0.34*** 0.15 0.76*** 0.16 0.50*** 0.10 0.61*** NA −
12 Lack of excitement -0.08*** -0.09*** -0.13*** 0.68*** 0.39*** 0.31*** 0.24*** 0.46*** 0.17** 0.21*** 0.16 −
13 Distress: excitement -0.17** 0.00 -0.32*** 0.34*** 0.89*** 0.23*** 0.70*** 0.19*** 0.80*** 0.25*** 0.62*** NA −
14 Lack of climax -0.07*** -0.03 0.02 0.60*** 0.04 0.12*** 0.12*** 0.27*** 0.10 0.17*** -0.01 0.21*** 0.16** −
15 Distress: climax -0.17*** 0.02 -0.31*** 0.23*** 0.71*** 0.14*** 0.38*** 0.15*** 0.45*** 0.21*** 0.15 0.17*** 0.45*** NA −
16 Relationship
satisfaction
0.15*** -0.07*** 0.48*** -0.15*** -0.13*** -0.15*** -0.09** -0.13*** -0.18** -0.04*-0.04 -0.11*** -0.03 -0.03 -0.12** −
17 Gender -0.06** -0.15*** 0.09*** 0.19*** 0.11*** 0.19*** 0.10** 0.12*** 0.07 0.05** 0.14 0.11*** 0.04 0.08*** -0.05 0.05** −
18 Age 0.02 0.15*** -0.13*** -0.21*** -0.13*** -0.07*** -0.07*-0.16*** -0.10 -0.16*** 0.09 -0.19*** -0.03 -0.13*** 0.02 0.03 -0.18*** −
19 Relationship length -0.02 0.11*** -0.15*** -0.17*** -0.12*** -0.02 -0.10** -0.13*** -0.12*-0.12 0.11 -0.16*** 0.01 -0.14*** 0.01 0.05** -0.11*** 0.78*** −
Mean 4.73 26.33 3.51 0.76 1.84 0.30 2.43 0.11 2.65 0.04 2.94 0.11 2.69 0.20 2.04 5.91 0.46 47.43 17.14
SD 1.12 4.62 1.15 1.06 1.62 0.46 0.89 0.31 0.87 0.20 0.75 0.32 0.91 0.40 0.90 1.21 0.50 16.42 15.90
Range 1 to 7 16 to 61 1 to 5 0 to 5 0 to 6.22 0 or 1 0 to 4 0 or 1 0 to 4 0 or 1 0 to 4 0 or 1 0 to 4 0 or 1 0 to 4 1 to 7 0 or 1 18 to 87 0 to 63
Note. Gender (men = 0; women = 1), Relationship length is in years. The N for the correlations vary as a function of missing data.
*
P<.05
**
P<.01
***
P<.001
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lack of excitement, and lack of climax. BMI was negatively asso-
ciated with two outcomes, such that reporting lower BMIs were
associated with a greater likelihood of endorsing feeling anxious
during sex and sexual lack of excitement.
Moreover, results revealed that greater sexual satisfaction was
associated with a smaller likelihood of feeling anxious during sex
and experiencing sexual lack of interest, lack of enjoyment, and
lack of excitement. Greater relationship length was associated
with a smaller likelihood of reporting sexual lack of excitement
and lack of climax.
Predicting Severity of Distress Related to Specific
Sexual Problems
Table 5 provides the results of the regression predicting the
severity of distress related to sexual problems (RQ2). Less appear-
ance satisfaction was associated with greater distress related to
lack of excitement and greater distress related to lack of climax,
while BMI was unrelated to distress. Only greater sexual satisfac-
tion was consistently associated with less distress related to all
sexual problems.
The Role of Relationship Satisfaction
A key component of the analyses was the examination of rela-
tionship satisfaction as a predictor of endorsement of sexual
problems and associated distress. We found that relationship sat-
isfaction was associated with a smaller likelihood of reporting the
presence of sexual problems (Table 2, top), but was unrelated to
any specific problem (Table 4). Interestingly, though, relation-
ship satisfaction was unrelated to the number of sexual problems
(Table 2, bottom). With respect to sexual distress, relationship
satisfaction was only related to more distress related to sexual
lack of excitement (Table 5), but unrelated to overall distress
(Table 3). Moreover, there were no significant interactions
between appearance satisfaction and relationship satisfaction in
any of the analyses (RQ3a and RQ3b).
Ancillary Analyses: The Role of Gender
We also elected to examine the role of gender in these analy-
ses. Specifically, in all analyses, we examined whether the effect
of appearance satisfaction differed as a function of gender. All
interactions were non-significant, suggesting that associations
between appearance satisfaction and the outcome (number of
problems, endorsement of specific problems, or distress over
Table 2. Zero-inflated negative binomial regression predicting the number of sexual problems
Parameter Estimate St. Error Wald x2 P-value OR/IRR
No problem vs. any problem
Intercept -8.004 2.096 14.57 <.001
Appearance Satisfaction 0.025 0.119 0.04 0.834 1.025
BMI -0.001 0.032 0.00 0.969 0.999
Sexual satisfaction 0.979 0.224 19.05 <.001 2.662
Relationship Satisfaction 0.456 0.174 6.92 0.009 1.578
Gender 0.156 0.372 0.18 0.676 1.169
Age -0.000 0.015 0.00 0.981 1.000
Relationship length -0.016 0.016 0.94 0.333 0.984
Appearance satisfaction*
relationship satisfaction
-0.157 0.141 1.23 0.267 0.855
Appearance satisfaction* Gender 0.208 0.241 0.74 0.389 1.231
Number of problems
Intercept 1.783 0.295 36.54 <0.001
Appearance Satisfaction -0.080 0.028 8.08 0.005 0.923
BMI -0.019 0.007 7.65 0.006 0.981
Sexual satisfaction -0.137 0.030 21.39 <0.001 0.872
Relationship Satisfaction -0.010 0.023 0.17 0.679 0.990
Gender 0.501 0.070 50.50 <0.001 1.650
Age -0.014 0.003 16.58 <0.001 0.986
Relationship length -0.007 0.004 4.27 0.039 0.993
Appearance satisfaction*
relationship satisfaction
-0.029 0.017 2.86 0.091 0.971
Appearance satisfaction* Gender 0.046 0.053 0.76 0.384 1.047
Dispersion 0.087 0.054
Note. For the logistic regression, the outcome being modeled is no problems. The dispersion factor is from the main effects model. OR = Odds ratio.
IRR = Incidence rate ratio, or, relative risk. The OR is presented for the logistic regression (top half of table), while the IRR is presented for the count regres-
sion (lower half of table). Gender (men = 0; women = 1), Relationship length is in years.
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Table 3. Regression predicting overall sexual-problem related distress
Parameter Estimate St. Error t-value P-value
Intercept 1.732 0.410 4.23 <0.001
Appearance Satisfaction -0.067 0.037 -1.78 0.075
BMI -0.009 0.009 -1.05 0.295
Sexual satisfaction -0.348 0.038 -9.06 <0.001
Number of sexual problems 0.846 0.041 20.44 <0.001
Relationship Satisfaction 0.028 0.033 0.85 0.396
Gender 0.095 0.081 1.18 0.239
Age 0.005 0.004 1.23 0.219
Relationship length -0.004 0.004 -0.96 0.337
Appearance satisfaction* relationship satisfaction -0.017 0.026 -0.64 0.520
Appearance satisfaction* Gender -0.015 0.070 -0.21 0.831
Note. Gender (men = 0; women = 1), Relationship length is in years.
Table 4. Logistic regressions predicting presence of sexual problems
Lack of interest Lack of enjoyment Feeling anxious during sex Lack of excitement Lack of climax
(71.9 %) (73.3 %) (78.4 %) (74.7 %) (63.2 %)
b OR b OR b OR b OR b OR
Intercept 2.799 2.360 2.934 3.697 0.498
Appearance Satisfaction -0.065 0.937 -0.150*0.861 -0.161 0.851 -0.162** 0.851 -0.171*** 0.843
BMI -0.020 0.980 -0.013 0.987 -0.051*0.950 -0.066*** 0.936 -0.012 0.988
Sexual satisfaction -0.556*** 0.573 -0.431*** 0.650 -0.614*** 0.541 -0.449*** 0.638 0.054 1.055
Relationship Satisfaction -0.053 0.948 -0.102 0.903 0.087 1.091 -0.078 0.925 -0.066 0.936
Gender 0.484*** 2.631 0.363*** 2.067 0.144 1.335 0.305*** 1.839 0.161** 1.381
Age -0.016*** 0.984 -0.031*** 0.970 -0.061*** 0.941 -0.023*** 0.978 -0.007 0.993
Relationship length 0.008 1.008 -0.009 0.991 -0.009 0.991 -0.027** 0.973 -0.016** 0.984
Appearance satisfaction*
relationship satisfaction
-0.051 0.950 -0.039 0.962 -0.075 0.928 -0.023 0.977 -0.048 0.953
Appearance satisfaction* Gender -0.04 0.96 -0.01 0.99 -0.04 0.97 0.04 1.04 -0.02 0.98
Note. Gender (men = 0; women = 1), Relationship length is in years. Concordance is provided in parentheses below the outcome and is based on main
effects.
*
P<.05.
**
P<.01.
***
P<.001.
Table 5. OLS Regressions, with distress related to sexual problems as outcomes
Lack of interest Lack of enjoyment Feeling anxious during sex Lack of excitement Lack of climax
N = 747 N = 269 N = 103 N = 292 N = 510
bBbB b B b Bb B
Intercept 3.237 0 3.806 0 3.499 0 3.883 0 3.461 0
Appearance Satisfaction -0.029 -0.037 -0.079 -0.104 -0.014 -0.021 -0.100*-0.133 -0.087*-0.106
BMI -0.005 -0.029 -0.000 -0.001 -0.022 -0.136 -0.014 -0.065 -0.011 -0.057
Sexual satisfaction -0.200*** -0.254 -0.185*** -0.245 -0.227*** -0.391 -0.268*** -0.342 -0.233*** -0.293
Relationship Satisfaction 0.006 0.008 -0.041 -0.059 0.085 0.143 0.092*0.131 0.021 0.027
Gender 0.212** 0.118 0.116 0.065 0.137 0.090 0.017 0.009 -0.122 -0.068
Age 0.001 0.023 -0.001 -0.015 0.005 0.085 -0.003 -0.037 0.001 0.022
Relationship length -0.007*-0.128 -0.008 -0.103 0.001 0.012 0.003 0.035 -0.002 -0.032
Appearance satisfaction*
relationship satisfaction
-0.021 -0.228 -0.020 -0.204 -0.107 -1.251 -0.014 -0.143 -0.005 -0.046
Appearance satisfaction*
Gender
-0.10 -0.26 0.08 0.20 0.09 0.26 0.08 0.22 0.02 0.06
Note. Gender (men = 0; women = 1), Relationship length is in years. The N for each analysis is provided below the outcome.
*
P<.05.
**
P<.01.
***
P<.001.
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Appearance Satisfaction And Sexual Problems 7
J Sex Med 2021;000:1−13
problems) did not differ for men and women. Moreover, in the
context of the remaining variables, there were no gender differen-
ces (i.e., main effect of gender) in terms of absence /presence of
any problem (Table 2), overall sexual-problem related distress
(Table 3), lack of climax (Table 4), or in terms of distress related
to lack of enjoyment, feeling anxious during sex, lack of excite-
ment or lack of climax (Table 5). However, women reported
more problems (Table 2), and they were more likely to report
problems with lack of interest, lack of enjoyment, feeling anxious
during sex, and lack of excitement (Table 4). Lastly, women
reported greater distress over lack of interest than did men
(Table 5).
1
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 prob-
lems, in a large sample of partnered Norwegian adults. A particu-
lar 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 satis-
faction and sexual difficulties,
59,60
and that people who experi-
ence sexual problems may not necessarily experience distress
related to those problems, especially at older age.
28−37
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 poten-
tially disparate predictive ability of various factors, including psy-
chosocial 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 enjoy-
ment, excitement, and climax (H3). These findings are consistent
with past research that has found that acceptance of one’sbodyis
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 functioning
61
. Interestingly, and contrary to past
research,
17
we did not find an association between appearance sat-
isfaction 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 experi-
ence 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 associ-
ated 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 atten-
tional focus on the body.
19,20,21,62
Distress Related to Sexual Problems
Results also suggested that appearance satisfaction was unre-
lated to overall sexual problem-related distress (RQ1) and dis-
tress 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 dis-
tractions
63
and that body dissatisfaction is associated with dis-
tress related to sexual problems. In fact, Pascoal and
colleagues
64
found that the association between body dissatisfac-
tion and sexual functioning was mediated by cognitive distrac-
tions. In contrast to this study
64
, 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 dis-
traction 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 prob-
lems. Past research has found that lower appearance dissatisfac-
tion was associated with less sexual problem-related distress;
39,64
this research, however, examined general distress and not prob-
lem-specific distress.
1
Please see the supplemental materials for t-test comparing men and
women on all variables, as well as correlations and results of analyses strat-
ified by gender.
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The Role of Relationship Satisfaction
It is noteworthy that as people reported higher relationship
satisfaction, they were less likely to endorse having a sexual prob-
lem, but felt more distress over lack of excitement. This is consis-
tent with past research, which has found that relationship
satisfaction is associated with better sexual functioning.
25,40−43
However, in committed relationships, people may feel that sexual
interactions are normative, and thus, they may feel more dis-
tressed about lack of excitement for a partner for whom they oth-
erwise 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 associ-
ated 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 distress
48,65
and greater emotional closeness during sex
was associated with less distress
35,45−47
. However, one reason for
this lack of associations may be the relatively high levels of rela-
tionship 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 satis-
faction 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 ejacula-
tion, 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 experi-
ence higher levels of dissatisfaction than do men. One might
therefore expect that the association between appearance satis-
faction 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 appearan-
ces.
67
However, in the current study, we found that the associa-
tion 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 prob-
lems along with associated distress. However, the current study
should also be viewed in terms of its limitations.
For one, while it is a benefitthatwewereabletoexamine
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 prob-
lems with erection, ejaculation, vaginal lubrication, or pain
during sex. Moreover, single-item measures of sexual satisfac-
tion have the disadvantage of being unidimensional and may
have low test-retest reliability.
70
Relatedly, appearance satis-
faction was assessed using a single item that asked about sat-
isfaction with physical appearance (“fysisk utseende”), and
did not use existing scales of body or appearance dissatisfac-
tion
71
. 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 satisfac-
tory 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 con-
cerns about participant burden in responding to survey ques-
tions, 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 use-
ful information regarding the link between body appearance
and sexuality. Some research suggests that evaluation regarding
specific body parts may be uniquely associated with sexual func-
tioning
73
. Future research may also wish to examine potential
mediators of the association between appearance satisfaction
and sexual functioning. One such mediator may be inhibition/
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excitation. It has been demonstrated that, in women, self-per-
ceived 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 1987
75
. 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 demon-
strated 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 ran-
dom rather than systematic.
The data is cross-sectional in nature and therefore, we are pre-
cluded 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 con-
structs as they occurred in daily life, reducing retrospective bias.
Currently, much work focus on general reports of sexual func-
tions 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 rela-
tional 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 associa-
tion 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 prob-
lems or sexual functioning. However, it may be that relationship
satisfaction may serve as the outcome, such that sexual function-
ing predicts relationship satisfaction. Likely, there is a bidirec-
tional 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 satis-
faction and relationship satisfaction is moderated by sexual prob-
lems, 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 satisfac-
tion and BMI of both partners in a couple. Much research in the
relationship sciences has demonstrated the presence of contagion
effects
79
, and such a dynamic may be at play with appearance sat-
isfaction, 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 part-
ners, and that jointly, this dissatisfaction influence their sexual
behavior in negative ways.
CONCLUSIONS
Previous research suggests that appearance satisfaction is
associated with better sexual functioning and greater relation-
ship satisfaction. The current study examined whether appear-
ance satisfaction was associated with the presence of specific
sexual problems and associated distress. Results indicated that
appearance satisfaction was associated with reporting fewer sex-
ual problems, and specifically, with a smaller likelihood of
experiencing problems with lack of enjoyment, lack of excite-
ment, 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. These findings suggest the importance of attend-
ing to appearance satisfaction when working with clients with
multiple sexual problems, particularly those related to excite-
ment and enjoyment.
Corresponding Author: Camilla S. Øverup, PhD, Department
of Public Health, University of Copenhagen, Øster Farimagsgade
5, 1014 København K, Denmark; E-mail: Camilla.
oeverup@sund.ku.dk
Conflict of Interest: The authors report no conflicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Conceptualization: C. S. Ø; Methodology: B.T; Investiga-
tion: B.T; Formal Analysis: C. S. Ø.; Writing: C. S. Ø & J.M.S.;
Review & Editing: A.C., G.M.H, & B. T; Funding Acquisition:
B.T.
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SUPPLEMENTARY MATERIALS
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.
jsxm.2021.06.019.
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