As a clinical psychologist, with expertise in health and illness, I am frequently asked to shed light on the concept of body image.  I often begin by pointing out that body image is a multidimensional concept that consists of self-perceptions, cognitions, emotions, and behaviors related to one’s physical characteristics. By and large, the research contains multiple definitions of body image, which include the degree to which a person is satisfied with his or her overall physical appearance, positive or negative feelings about one’s body, satisfaction with body weight, as well as feelings of sexual attractiveness. Indeed, the concept of body image is complex.

Although the majority of research on body image has been conducted with samples of female college students and individuals with eating disorders, some large national surveys have been done.  In one of these surveys, almost one half of healthy women were dissatisfied with their appearance. A separate and more recent study by Runfola and colleagues (2013) found that body satisfaction was endorsed by only about 11% of their sample of women aged 45–74 years. This is troubling, as high levels of body dissatisfaction have associated with high levels of health risk behaviors and low levels of self-esteem for both men and women.

The relationship between an individual’s feelings about his or her body and self-esteem is a powerful one. Studies have found that self-esteem and eating disorders predict body dissatisfaction. Research findings also suggest that women who express greater dissatisfaction with their bodies are more likely to have lower self-esteem than women who have a healthier body image. Of importance also is that self-esteem (defined as a person’s overall evaluation or appraisal of his or her own worth) includes a cognitive component (” I do not have much to be proud of”), along with an affective one (“I feel ashamed”).  Self-esteem can apply specifically to an attribute or part of the self (“I believe that my arms are too flabby”) or to the self in general (“On the whole I am satisfied with myself as a person”). Basically, body image can be viewed as a component of a larger concept of self that may include external appearance, intellectual abilities, strengths, and weaknesses.

In sharp contrast to the hefty amount of research on the expansive topics of body image and self-esteem, literature on body image and aspects of sexuality (e.g., sexual functioning, satisfaction, and feelings of sexual attractiveness) is relatively scarce.  The research that is available suggests a positive linear relationship between body image and sexual satisfaction in both males and females.  Of major interest, poor body image during sexual activity and body part dissatisfaction, may be linked to less confidence in performing certain sexual activities, less sexual assertiveness (self-confidence to refuse sex), and less confidence in experiencing sexuality in a satisfying and enjoyable way. What is more, a negative body image has been shown to lead to sexual avoidance, whereas positive body image was associated with greater frequency of sexual activity and better sexual response.

In one study, consisting of women between the ages of 18 to 86, Davison and McCabe (2005) discovered a negative relationship between body image satisfaction and sexual dissatisfaction that did not remain after adjusting for overall self-esteem.  The findings support the idea further that body image is an important component of the larger construct of self-esteem.  In my opinion, the study by Davison and McCabe (2005) has clinical utility, pointing to the role that interventions aimed at improving overall self-esteem can have on increasing body satisfaction, self-ratings of physical appearance, and, perhaps sexual satisfaction.

I believe that socio-cultural factors are key contributors to one’s feelings about his or her appearance, along with body image problems and disordered eating behavior. There are a multitude of studies that reveal self-esteem to be a determinant of internalization of societal standards of attractiveness, particularly among females. It is generally agreed upon that compared to men, women report lower self-esteem associated with body image dissatisfaction, and are more cognitively and behaviorally invested in their appearance, and are more likely to suffer from depression, and lower levels of satisfaction with their body.

At this point, it is important to emphasize that body image concerns are not solely a female problem. As a clinician, I have treated numerous male patients with body image and sexual attractiveness concerns. Moreover, I have seen an increase in body image disparagement, along with eating disorders (e.g., binge eating disorder) in my male patients. As an extension of this idea, I support the call by some to conduct studies that explore areas of body dissatisfaction that may have greater relevance for males (e.g., muscle-bound body building and performance-based concerns).

Along similar lines, more research attention needs to be placed on the impact of physical disability on body image since the literature, albeit limited, indicates that physical impairment is linked with negative feelings towards the body. Additionally, higher levels of body image dissatisfaction among patients with cancer and acquired disfigurement (e.g., serious burn injury) have been associated with general psychological distress, poor self-esteem, and symptoms of anxiety and depression, including more social anxiety, social isolation, and sexual problems.

Presumably, one may wonder what a body-satisfied individual looks like. While comprehensive studies are lacking, it is generally agreed upon that body satisfaction is related to key health behaviors (e.g. greater levels of physical activity) and less self-disparaging cognitions. To this last point, when treating patients with concerns relative to body image I encourage them to stray away from negative body talk. While moving away from a negative body image is a process, I teach patients early on how to “talk back” to negative body talk.  One way to talk back is through the use of affirmations and rational, rather than emotional language.  In addition, I also help patients to explore the deeper meanings of negative body talk, which may include feelings of worthlessness and a sense that his or her life lacks meaning. Specific coping strategies such as problem solving and positive reappraisal can also combat body image disturbances and mitigate body image related problems (e.g. disruptions in work, future plans, and sexual relationships), at least to some degree.

Additionally, one’s feelings about his or her appearance and sexual desirability, for example, can be closely connected to his or her current health state. As such, I encourage my patients to utilize their health services and engage in complementary pathways for enhancing body image. For example, I encourage some of my patients to engage in healthy weight-control behaviors (sustaining a well-balanced diet as opposed to using diet pills or skipping meals). Moreover, I advise many of my patients to reconnect their mind and body and engage in activities tailored to their level of functioning. Activities such as yoga, stretching, meditation, and acupuncture can promote body compassion when done in a safe and therapeutic way. Finally, I have seen how interventions aimed at fostering a sense of self that hinges on achievements and internal attributes (e.g. likeability), not just appearance, have helped my patients develop a more peaceful relationship with their body and thereby, significantly improved their overall quality of life. 

Dr. Julie Kolzet is a licensed psychologist whose therapeutic approach is cognitive-behavioral. With expertise in health, body image, and sexual functioning, Dr. Kolzet has helped countless women and men develop a more peaceful relationship with their body, themselves, and others. Her holistic approach has led to the adoption of key health behaviors in many people. Dr. Kolzet maintains a general psychology practice dedicated to the treatment of stress, depressed mood, and anxiety disorders.  To read more about Dr. Kolzet and to learn  about her practice on the Upper East Side of Manhattan, visit her website here.

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