Human sexuality is arguably one of the main pillars of health, like nutrition and sleep. Improvements in diagnostic and therapeutic biotechnologies have enabled focus on not only deadly diseases, but also on the quality of life and sexual functions of men and women. Digital media also play a considerable role in the social presence and psychological well-being of humans.
The World Health Organization constitution states: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”1 In this context, sexual function plays a valuable role in human health. In healthy women, the sexual response cycle consists of sexual desire, arousal, orgasm and sexual satisfaction. Any biological, mental or social condition that interferes with this cycle may cause sexual dysfunction and personal distress. Compared with its male counterpart, female sexual dysfunction (FSD) is less studied. The prevalence of FSD, which is estimated to be at 29–40% among women, spans across different age groups.2,3 Evidence suggests that some medications; culture; and biological (e.g. ageing, hormones, neurological diseases, genitourinary disorders, etc.), cognitive (distraction, negative body image, etc.), behavioral (avoidance), emotional (anxiety, insecurity, etc.), and environmental (obligations, decreased attraction, etc.) states and factors play an aetiological role for FSD.4,5
Plenty of studies have been conducted to investigate the interrelation between body mass index (BMI) and FSD, and revealed conflicting results.6 One study observed that later research have revealed another aspect of the interrelation—that obese women who have eating disorders, lower self-esteem or depressive mood were more likely to suffer from FSD.6 Therefore, sexuality investigation have focused more on the psychological aspects of body morphology such as self-esteem, subjective body image, appearance anxiety, and depressive mood, rather than actual body size of women in the last decade. A review of studies revealed that distorted body image and appearance anxiety interferes with all domains of sexual function among women.7 Self-objectification and cognitive distraction during sexual activity are 2 main theories posited to explain the background psychological pathways in the latter context.8-10 However, the concept of the ‘‘ideal beauty’’ propagated all over the world through digital media, alongside genetic and sociocultural factors are on the whole, notable aspects for consideration, in implementing measures to address the interrelation between body image and sexual functioning.
In this issue of the Annals, the online survey of young women conducted by Husain et al. investigated the association of BMI, body image and self-esteem with sexual function in young women.11 Body Image States Scale (BISS), Rosenberg Self-Esteem Scale (RSES), and Female Sexual Function Index (FSFI) were used in the study with the aim to examine this association. A significant correlation was found between the FSFI scores of the 514 respondents with BISS and RSES scores. Lower self-esteem, poorer body image, being married, having 1 child, and perceived mental conditions were found to correlate with FSD. On the opposite end, being overweight (BMI=23.0–27.4 kg/m2) and being of Malay compared with Chinese ethnicity was found to lower odds for FSD. The study concluded that women with a poorer body image and lower self-esteem were more likely to have sexual dysfunction and the abovementioned factors may be better predictors—rather than BMI—to identify the population at risk.
Acknowledging some limitations to the study, such as selection and expression bias, quality of evidence, and lack of advanced body composition measurement methods (e.g. lean body mass, skinfold thickness, etc.), Husain et al.’s study provides added support to how ethnicity and sociocultural environment may shape an individual’s psychology in relation to body image and indeed, female sexual function. Notably, the prevalence of FSD in this study was higher than in reports from Western countries.1,3,7 The study’s findings on the comparatively weaker association between BMI and female sexual function index scores are concordant with previous findings indicating the absence of direct correlation.5,6 The findings shine the spotlight on self-esteem and body image as shaped by sociocultural factors; postpartum sexual health in noting the importance of transition, development and support for a new normal routine of sexual function; and the need to improve public knowledge and active observation of body image issues in the clinical setting to trigger conversation about sexual function. The study complements and advances research that have focused solely on the individual’s cognitive and emotional disturbances as causes for negative body image and/or sexual dysfunction in women.
Further research is necessary to clarify the exact psychobiological pathways beyond the thoughts, beliefs or perceived shame related to body image, in relation to their possible association between negative body image and female sexual functions. This can enable targeted measures to help individuals overcome sexual dysfunction and improve quality of life.
- World Health Organization. Constitution of the World Health Organization. https://www.who.int/about/governance/constitution. Accessed 18 April 2023.
- Zhang C, Tong J, Zhu L, et al. A population-based epidemiologic study of female sexual dysfunction risk in Mainland China: Prevalence and predictors. J Sex Med 2017;14:1348-56.
- McCool ME, Zuelke A, Theurich MA, et al. Prevalence of female sexual dysfunction among premenopausal women: A systematic review and meta-analysis of observational studies. Sex Med Rev 2016;4:197-212.
- Hubin A, De Sutter P, Reynaert C. Etiological factors in female hypoactive sexual desire disorder. Sexologies 2011;20:149-57.
- Jha S, Thakar R. Female sexual dysfunction. Eur J Obstet Gynecol Reprod Biol 2010;153:117-23.
- Kadioglu P, YetkinDO, Sanli O, et al. Obesity might not be a risk factor for female sexual dysfunction. BJU Int 2010;106:1357-61.
- Cihan A, Cihan E. Interrelation Between Appearance Anxiety and Sexual Functions in Women: The Role of Surgical Scars, Morphologic Features, and Accompanying Depression. J Sex Med 2019;16:1769-78.
- Fredrickson BL, Roberts T-A. Objectification theory: Toward understanding women’s lived experiences and mental health risks. Psychol Women Q 1997;21:173-206.
- Fredrickson BL, Roberts TA, Noll SM, et al. That swimsuit becomes you: Sex differences in self-objectification, restrained eating, and math performance. J Pers Soc Psychol 1998;75:269-84.
- Dove NL, Wiederman MW. Cognitive distraction and women’s sexual functioning. J Sex Marital Ther 2000;26:67-78.
- Husain FS, Lulla D, Tay TKC, et al. Association between body mass index, body image and self-esteem with sexual function: A survey of young women in Singapore. Ann Acad Med Singap 2023;52:191-199.