FACTORS IN THE SEXUAL SATISFACTION OF

OBESE WOMEN IN RELATIONSHIPS

Electronic Journal of Human Sexuality, Volume 5, Jan.
15, 2002

http://www.ejhs.org/volume5/Areton/TOC.htm

Lilka Woodward Areton

Chililka@msn.com

Abstract

A sample of 112 obese women who had been or were at present in long-term relationships
completed a questionnaire to determine the correlates of sexual relationship satisfaction.
Sixty-seven percent of the women reported being sexually satisfied. A linear regression
analysis showed sexual relationship satisfaction correlated significantly with sexual
communication, positive body image, and partner enjoyment of the sexual relationship.
Less important to the sexual satisfaction of these participants were their weight, their age
and their partner’s attitude regarding weight. There was a high correlation between the
weight negativity and body image (-.780).These findings suggest that appropriate sexual
therapy for the obese couple may lie more in greater couple communication and improved
body image than in weight loss.

Introduction
In our western society, women who consider themselves overweight are facing a personal
sexual crisis of enormous proportions. They have come to believe that as soon as they gain
even a small amount of weight, their bodies become undesirable, unattractive, lacking in
sexual appeal, even repulsive and ludicrous. An absence of images of large women in the
media implies that they are not attractive enough to sell products or even be seen. In fact,
the media's lack of portrayals of large women implies that large women do not really exist
or count in our society. Therapists and professionals working with obese persons have
revealed the following tragic consequences for those who consider themselves sexual
outcasts: they become exquisitely self-conscious about their appearance, immensely critical
of their bodies, especially their fat. They fail to flirt for fear of rebuff and ridicule. They
tend to avoid interpersonal erotic encounters, and come to expect the agony of frequent
rejection. Obese women are often full of shame about their bodies and consequently feel
deeply sexually disempowered. They fail to recognize sexual approaches because they can
not believe anyone could be attracted to them. During sexual intimacy, they may feel overly
exposed, critical of themselves, and hide their bodies from their partners (Abraham and
Llewellyn-Jones, 1997; Bess, 2000; Bovey, 1994; Faith, Myles, Schare, Mitchell, 1993;
Millman, 1980; Masters, Johnson, Kolodny, 1982).

Cash, Winstead, and Janda (1997) have interviewed women about their bodies every
decade since 1972. Some of the interviewees described the above dilemmas for large
women thus: "I try to lose weight for boyfriends. When I am fat, I know that no one wants
to be with me. I feel like unless I have a good body, no decent guy wants me!" "The less
attractive I feel, the less I desire sex. If at all possible, I avoid sex. However, if it should
happen, I am unwilling to let go. I have the feeling I may be vulgar to my partner." (p. 44)

Those who are affected by the societal attitudes about larger bodies can become fat phobic,
that is, develop a pathological fear of fatness in themselves and an aversion toward fat in
others. Fat phobia not only causes women to reject their bodies, it can also lead to eating
disorders of every kind: anorexia, bulimia, compulsive overeating, bingeing, crash dieting,
over-exercising, recipe scrounging and hoarding, fat and/or calorie counting, measuring
bites, obsessive taking of supplements, compulsive weighing in, and even the utilization of
dangerous, life threatening surgeries (Robinson, Bacon, and O'Reilly, 1993).

Adding to the problems of large women is the fact that many men are also convinced that
they need the "ideal woman," the "trophy wife," who is supposed to be trim, fit, and firm.
Sexual images for men are limited by the media to a narrow type that does not reflect the
society at large. Because there is only one perfect type (adolescent thin) presented in the
media, men attach high status to this type and can more easily be proud to be seen with
women who fit this image. On the other hand, fat, even a small amount, is seen as
unattractive or lower in status. The effect of this type of programming is that men become
ashamed to be seen with a fat woman, even if they prefer them sexually (Buss, 1994;
Farrell, 1986; Smith, 1995; NAAFA Newsletter, p. 79).

Large women are not only considered unattractive, they are also considered neurotic. Many
therapists suggest that women's overeating is due to suppressed sexuality which leads to
anger, frustration, compulsive eating, and a host of other psychological ailments and
personality disorders. Many large women have sought some form of therapy to assist them
in finding the solution to their eating problems and to help them lose weight. Therapy often
consists of recommended diets, exercises, nutritional awareness, changing one's lifestyle,
attending life-long meetings, and vigilant psychological reevaluations designed to assist the
woman in raising her awareness of her feelings and her eating behavior enough to alter it
(Fisher, 1996; Hollis, 1996; Hornyak and Baker, 1989; Katherine, 1991).

In spite of the problems associated with obesity, and in spite of the barrage of magazine
articles, TV programs, radio announcements, new diets, support groups, therapies, and
drugs that supposedly help people lose weight, women are getting heavier every year.
Currently, more than 50% of women in the U.S.A. are considered overweight, that is, have
a Body Mass Index (BMI) of more than 25 (see Definitions, or BMI Chart in Appendix A),
and 25% of U.S. women are considered obese, that is, have a BMI of 30 or more. Although
definitions and measuring strategies have changed over the years, studies that adjusted
older data to make it comparable to current data show that the percentage of overweight
people in each age group is rising (Flegal, Kuczmarski, and Johnson (1998) as cited in
NIDDK, 1998).

If being overweight carries so much self-condemnation for women, this growing increase in
weight points to a developing crisis in sexual self-esteem for women in the western world.
Feminists and other observers of the culture have been warning women about this emerging
predicament (Beller, 1977; Bordo, 1993; Bovey, 1989; Chernin, 1981; Epstein and
Thompson, 1994; Fraser, 1997; Hesse-Biber, 1996; Hirschmann and Munter, 1995).

In spite of the devaluing and shaming of obese women by our society, many have been able
to develop satisfactory sexual relationships. These women may have much to teach us.

Who are they?

How much do they weigh?
Have they always been large?
Is their weight interfering with their sexual satisfaction?
How do they feel about their bodies?
How do they feel about their sexuality?
Are they willing and able to talk with their partner about their sexuality?
Is their partner satisfied with their sexuality?
Is their partner focused negatively on weight?
Has their weight affected their sexual relationship?
Do they feel body shame?
Have they been abused?
Do they have sexual dysfunctions?
Has dieting assisted them in losing weight and feeling more desirable?

This study investigates the factors in the satisfactory sexual relationships of large women. It
is designed to discover which attitudes, circumstances, and essential conditions lead to the
enjoyment of their sexuality. Therapists, sexologists, sex educators, doctors, and
professionals working with adults and with young women and men need to have the
information that will be furnished by the subjects in this study. With this information, they
will be better able to teach, advise, support, and counsel women and their partners who are
struggling with issues of lower sexual self-esteem.

Definitions

Body Mass Index (BMI) - A measuring tool that is currently being used to determine
whether or not a person is overweight or obese. To calculate BMI, multiply the person's
weight in pounds by 705, then divide the result by the square of the person's height in
inches. Many organizations consider a BMI of 25 to 29.9 to be overweight, and a BMI of
30 or more to be obese (NIDDK, 1998). (See Appendix A for chart.)

Obese, fat, heavy, large, overweight - For the purpose of this study, anyone with a BMI of
30 or more.
Body image - The attitude one holds about oneself regarding one's appearance.

Body shame - A painful emotion that one's body is not desirable, needs to be hidden,
deserves to be rejected by others, and is not worthy of sexual pleasure.

Sexual satisfaction - A feeling that one is both desired and fulfilled sexually.

Fat phobia - A strong fear of being or becoming fat. A strong distaste for fat in others.

Fat acceptance - A political movement and an attitude that proclaims that one's body is
acceptable as it is, no matter how large.

Desexualization - A feeling that one is not desirable nor worthy of sexual pleasure or
expression.

Partner - For the purpose of this study, anyone, male or female, in a sexual relationship
with another.

Fat Admirer (FA) - Anyone who is sexually, sensually, and psychologically aroused by
and responsive to fat people of the same or opposite sex.

Obese couple- A couple in which one or both of the partners is obese.

Background of the Problem of Fat Phobia

Fat phobia, excessive fear and dislike of fat in oneself and in others, is a relatively new
phenomenon, born during the 20th century. Before that time, fat was accepted and admired
in women, and was considered a sign of affluence and therefore high status. One of the
greatly admired beauties of the end of the 19th century, Lillian Russell (1861-1922),
weighed over 200 pounds. Sarah Bernhardt (1844-1923) was an operatic star and actress of
large proportions. Elisabeth Cady Stanton (1815-1902), the feminist writer and lecturer and
the fiery labor organizer, Mary Harris "Mother Jones" (1830-1930) were both obese by
present day standards. Since then, a fear of fat has caused women to reject their bodies and
allow their obesity to take on negative meanings that profoundly affect them in many ways,
especially their sexuality. What happened to women during the 20th century? How did fat
take on so many negative connotations? It became such a affliction that Brown and
Rothblum (1989, pp. 1-2) editorialize in Overcoming Fear of Fat, "[Fat] became the
rationale for a thousand diets and an equal number of compulsive exercise programs. It is
the equation of fat with being out-of-control, with laziness, with deeply-rooted pathology,
with ugliness…a catalyst for energy-draining self-hatred. It leads us to starve ourselves, to
life-threatening surgeries…it places women at high risk for the development of chronic and
intransigent eating disorders such as anorexia and bulimia. It serves to give away our power
for self-affirmation to a culture that tells us that we can "never be too thin or too rich,"
equating value and class status with a starved body."
The existence of sexual self-rejection in women due to fat phobia has been extensively
documented (Brown, 1989; Chernin, 1981; Freedman 1989; and Hutchinson, 1985). In a
telephone poll of 350 readers of McCall's Magazine (1996), 40% reported they were less
interested in sex when they'd gained weight.

"When I'm honest with myself, I know Jack must find me attractive one way or another, but
when I go up a few pounds, I can't enjoy myself in bed. I'm afraid to let my belly out. I feel
embarrassed to make any noise, and I'm less relaxed about being touched." " I know my
husband would like me slimmer. It makes me cry because I feel too heavy to be attractive."
"I know in my heart I should be thinner and exercise more. Sometimes I get so wrapped up
thinking about it that I can't really enjoy Rob touching or even wanting me." (Klein, 1996,
pp. 95, 96)

Glenn Gaesser (1996), associate director of the adult fitness program of the University of
Virginia and a Fellow of the American College of Sports Medicine, blames the
development of fat phobia in this country during the 20th century on the following
influences: the insurance industry, that published what it deemed "healthy weights"; the
medical industry that promoted these ideas and complicated them even more by adding
psychological pathology to the etiology of obesity; the drug industry that gained by
assisting people to change their weight; the nutritionists who supported the insurance
companies, the medical community; the fitness industry making lean synonymous with
healthy; and the fashion industry that promoted beauty that was even thinner than the
insurance companies' recommendations (p. 31). Although researchers (Ernsberger and
Haskew, 1987; Fraser, 1997; Gaesser, 1996) have countered the reliability of the insurance
companies' claim to know the perfect healthy weight, further investigation into that
research is beyond the scope of this investigation.

In their research on culture, ideology, and anti-fat attitudes, Christian Crandall and Rebecca
Martinez (1996) found that our culture of individualism and self-responsibility might have
contributed to our attitudes about obesity. By comparing anti-fat attitudes in the United
States to those in Mexico, they found that the attitude that one is responsible for one's
weight is not prevalent in Mexico. More often, they found that people assumed it was part
of the genes or the physical makeup of the person. Additionally, there was little antipathy
toward fat people. The Americans believed that the fat people had no will-power, making
them culpable for the obesity, and they registered a much higher aversion toward fat and fat
people.

A review of Freud and Freudian psychologists reveals that another influence on the
development of fat phobia is the association of fat with psychological pathology. After
Freud, doctors, psychiatrists and finally the lay public began to believe that fat was a
symptom of psychological problems. This further intensified the anti-fat feelings in the
public and deepened the societal stigma against obesity.

Anthropological Perspective

According to anthropologist David Buss (1994) once a culture decides on the current image
of success (which can change) members of the society strive to achieve it. "The importance
that men assign to a woman's attractiveness has reasons other than her reproductive value.
The consequences for a man's social status are critical... status, reputation, and hierarchies
gain him additional resources and mating opportunities….Everyday folklore tells us that
our mate is a reflection of ourselves…Men seek attractive women as mates as signals of
status to same-sex competitors and to other potential mates." (p. 59)

Buss writes about his own study in which he found that "Dating someone who is physically
attractive greatly increases a man's status… In contrast, a man who dates an unattractive
woman experiences a moderate decrease in status and reputation" (p. 60). Buss tested the
status of physical attractiveness in other countries and found similar results.

Warren Farrell has also researched this point and describes a mating dance in which both
males and females participate. The male gains higher status from having a beautiful woman
as a partner; the woman gains status by having a partner who has wealth, peer respect,
success, and the potential to earn a beautiful woman (Farrell, 1986). Both males and
females participate in a fat-phobic dance in order to win the correct partner. This can be
seen particularly in adolescent boys who fear the ridicule of their peers should they be
interested in a plump girl who may lack status (Wachtel, 1976; Dachis, 1986).

In 1965, Goldblatt, Moore, and Stunkard, medical researchers, reported that the prevalence
of obesity in the United States is related to social class. The higher the social strata the
thinner the members. This may explain why women are so determined to be thin, in order
to attract a man with more status and wealth.

Psychiatrists, on the basis of their treatment of upper and middle-class women, for whom
obesity was a severe social handicap, formulated many of the present theories about human
obesity. In other segments of society, however, obesity appears to be by no means such a
handicap…. It seems quite possible that the lack of success in the control and treatment of
obesity stems from the fact that until now physicians have thought of obesity as always
being abnormal. This is certainly not true for persons in the lower socioeconomic
population. (pp. 101-102)

Although these anthropological studies suggest that the importance of women's appearance
in mating activity is inevitable, it is society that determines what type of appearance has
high status and is desirable. Contemporary American society is influenced by visual images
that convey the concept that almost unachievably thin bodies are what represent "beauty
status." However, researchers have established that standards for beauty have changed over
the century, with women expected to weigh less and less (Mazur, 1986). Even in the same
time frame, some other cultures that exist within the dominant culture have different
standards of beauty. Brown found that in the United States, Hispanic Americans, African
Americans, Native Americans, and Pacific Islanders are all larger than the average
Caucasian and consider the additional weight attractive (Brown, 1993, pp. 189-191).

Media's Influence on Ideals of Beauty and Fat Phobia

Research by Linda Smolak and Michael Levine (1996) confirm that most men and women
derive their idea of beauty from the socio-cultural influences of our media: TV, magazines,
movies, and other forms of entertainment. These influences account for much of our
society's high level of body image disturbance, body dissatisfaction, and the increasing rate
of eating disorders among women (p. 239).

In a study of young adolescents, Tiggemanna and Pickering (1996) found that watching
soaps, serials, movies and programs likely to show women in stereotyped roles was
positively correlated with body dissatisfaction. Questionnaires were given to 94 adolescent
women who reported how much and what television they had watched in the previous
week. Body dissatisfaction and drive for thinness were also assessed. The amount of TV
watched did not correlate with body dissatisfaction, but the type of program watched was
significant. Watching soaps, movies and sports correlated with body dissatisfaction but, in
particular, watching music videos was the primary indicator for a drive for thinness and
anorexia. The authors discuss the possibility that: "Perhaps music videos provide the
opportunity for explicit comparison with others, which has recently been postulated as a
major contributor to body image disturbance" (Striegel-Moore, McAvay, and Rodin, 1986;
Thompson and Heinberg, 1993). "The images of women portrayed in serials and movies are
implicit, in that the women also have other roles. The images portrayed in music videos,
however, may be quite deliberately presenting to young women what they should look
like..." (p. 202)

Sometimes the media's message is very explicit. The following advertisement was titled
"How I Lost 37 Pounds and had the Best Summer of My Life!"

"Yes! Being thin changes your life. Suddenly, everything's more fun…When you're with a
bunch of other girls, now you're the one the guys are looking at…. Your love life takes-off
and you have more friends than you ever imagined! Suddenly there are parties and dates
and kisses and fun!" (Young and Modern Magazine, 1999, May, p. 17)

Sometimes it is subtler: "Body Confidence! Featuring the sleekest thighs - guaranteed"

(Cardozo, 1994, cover), "Healthier bodies, sexier sex" (Glamour, 1993, cover), "Try our
basic training workout to blast fat and boost your confidence!" (Doheny, 1996, p. 18)
Visual images which convey the concept that almost unachievably thin bodies are what
makes a woman desirable, what gives her status and what gives status to her partner, may
account for the endless concerns so many women have about their bodies.

Current Situation

Kim Chernin is one of the great pioneers on the subject of obesity and fat phobia. In
Obsession (1981) she writes about the effects of fat phobia on women's relationships to
their own bodies. "We loathe the swelling of our breasts, an increase in our thighs, we are
terrified by the fullness in our flesh. We wear large towels or loose, concealing dresses; we
do not go near dressing rooms where other women could see the fullness of our breasts and
bellies. We hide from ourselves; we deny the seasons of our bodies, they become foreign to
us, strangers…None of us can identify with the hated flesh we are so determined to alter
and shape. Existing from the neck up, we live out our lives feeling alien with it,
disembodied." (p. 54)
In 1982, Masters, Johnson and Kolodny wrote about the four types of sexual problems
people encounter most frequently. The first one they listed as "inhibitions and guilt" (p.
441). They wrote, "Inhibitions and guilt about sex continue to be ubiquitous even as their
causes and directions may have shifted somewhat from earlier times… Today…we have a
whole set of sexual inhibitions that stem from our anxieties about our personal
attractiveness. …their intensity has been heightened by our everyday exposure to visual
media--television, most notably---and our current cultural obsession with physical fitness or
at least the appearance of physical fitness. Women…are apt to judge themselves harshly as
far as their erotic allure goes, often translating this personal sense of body-image deficiency
into tangible sexual behavior patterns….which often lead to a lack of sexual self-
confidence and behavioral hesitancy …holding back in sexual encounters because (they)
feel (they) are not really a sexual person." (pp. 441,442).

As a current critic of society's attitudes about obesity and obsessive fear of fat, Hesse-Biber
(1996) has called our anxiety about our bodies a Cult of Thinness, and a "ritualistic
performance and obsession with a goal or ideal. Weight becomes the primary definer of
women's worth and identity…. Thin is sacred. Thin is beautiful and healthy; thin will make
you happy. If you are female, thin will get you a husband…. Fat is profane. To be fat is to
be ugly, weak, and slovenly; to have lost control…. Achieving the proper weight is not just
a personal responsibility, it is a moral obligation." (pp. 5, 11)

Women are becoming even more obsessed with thinness (Abraham and Llewellyn-Jones,
1997; Mazur, 1986). The epidemic of fat phobia has affected women of all ages and is
getting worse. In 1997, Abraham and Llewellyn-Jones found that 65%-87% of women
between the ages of 20 and 60 were dissatisfied with their bodies due to a perception of too
much fat, compared to 48% in 1972. The Cash et al. (1997) survey on body image showed
that women's dissatisfaction with their bodies went up more than 100% from 1972 to 1997
and there was enough reason for concern in 1972.

The obsession with thinness can lead to unrealistic weight loss goals. Foster, Wadden,
Vogt, and Brewer (1997) conducted a study of 60 obese women to learn more about their
weight loss goals. Although the professionals assisting with the weight loss considered a
weight loss of 5-10% of body weight successful, the participants wanted to reduce their
weight by an average of 32%. Forty-seven percent of the participants who lost weight were
disappointed. They had set their goals too high and were dissatisfied with even a 30-pound
loss. Unrealistic and therefore unfulfilled weight loss goals can lead to continuous
disappointment and frustration, which can fuel women's dissatisfaction with their bodies.

A review of the literature examining fat-phobic attitudes in minority populations revealed

that the problem is not as prevalent yet but may be developing. Drago, Shisslak, Estes
(1995, p. 239) discovered that there was a less frequent occurrence of eating disorders
among African and Asian-American females than in Caucasian and Hispanic females.
"Risk-factors for eating disorders (ED's) are greater among minority females who are
younger, heavier, better educated, and more identified with White, middle-class values."
Furthermore, Fisher, Pastore, Schneider, Pegler and Napolitano (1994) surveyed 268
suburban females and 389 urban females in a city school with 92% black or Hispanic
students. They were surveyed for self-esteem, anxiety, and for eating disorders.
Significantly more suburban females (63%) than urban females (35%) considered
themselves overweight, although only 14 % of the suburban females were more than 10%
over the ideal weight, while 45% of the urban females were overweight. The urban females
also registered higher self-esteem and lower anxiety than the suburban females. This was
contrary to expectations. "Self-esteem and anxiety were each significantly correlated with
higher Eating Attitudes Test [EAT] scores in both populations, but believing oneself
overweight was correlated with higher EAT scores in only the suburban [females]" (p. 67).

The Lesbian community registers somewhat less fat phobia than the heterosexual
populations. Blank (2000) surveyed a number of fat gay women for her book, Big Big
Love. She writes, "While the fat gay women interviewed for this book all agreed that they
tended to fare better as fat women in the women's community than they did in the straight
world, they all also agreed that there is a certain amount of size discrimination in the
lesbian community….The truth is that looks do matter to lesbians just as they do to other
people and there are codes of beauty and attractiveness in dyke communities just as there
are in any other." (pp. 59,60)

Increasing Fat Phobia Among Young Girls and Young Women

Fat phobia is not just a problem for obese women; it has become a national obsession
among young girls and young women as well. A variety of statistics convey an alarming
trend in the U.S. Research is now pointing to the development of fat phobia in children as
young as seven and eight years old. In the Thompson study (1996) of fourth-grade children,
49% of the white girls believed they were too fat. Gustafson-Larson and Terry (1992)
found that 60.3% of a fourth-grade class in Iowa wanted to be thinner. In a study (Moreno
and Thelen, 1995) of girls at 12 years of age, 27% were on a diet at the time of the study.
When presented with figure drawings of children who were either in a wheelchair, on
crutches, facially disfigured, amputees or obese, the 12 year old girls disliked the drawing
of the obese child more than any other drawing, except the amputee (Goodman,
Richardson, Dornsbusch and Haastorf, 1963; Richardson, 1971). It has been documented
that 44% of high school young women are trying to lose weight at any given time (Frank,
1993). According to the 1996 Council on Size and Weight Discrimination, "90% of high
school junior and senior women diet regularly, even though only 10 to 15% are over the
weight recommended by the standard height-weight charts. Young girls are more afraid of
becoming fat than they are of nuclear war, cancer, or losing their parents." (p. 1)

Venes, Krupka, and Gerard (as cited in Stewart, 1995) asked college students who they
would be least inclined to marry and an obese person was rated fifth lowest in desirability
following 1) an embezzler, 2) a cocaine user, 3) an ex mental patient, and 4) a shoplifter.

Mellin, Irwin, and Scully (1992) tracked the prevalence of disordered eating in middle class
children. Their research indicates that obesity in children has increased 54% in the past 20
years. Moreover, their studies indicate that the development of eating disorders among
adolescents may be linked to early dieting. According to Mellin (1992), "Dieting, fear of
fatness, and binge eating were reported by 31% to 46% of 9-year-olds and 46% to 81% of
10 year olds…. The prevalence of these characteristics increased progressively with age.
Fifty-eight percent of the girls perceived themselves to be overweight, whereas only 15%
were overweight by objective standards. Fear of fatness and dieting were positively
associated with weight category (P<.005); body image distortion was negatively associated
with weight category (P<.005)….Does social pressure for thinness prompt dieting,
followed by binge eating and, particularly in the genetically predisposed, obesity?" (pp.
851, 853)

Mellin believes that dieting has been found to lower metabolism making weight gain easier,
which begins a never-ending battle to beat the metabolism. Mellin asks (p. 853), "Does
dieting create an endless cycle that looks very much like an addictive one, worsening every
time the person goes back on the diet?"

In an attempt to change the anti-fat attitudes of 974 females and 117 males who ranged in
age from 12-77 years, Robinson, Bacon, and O'Reilly (1993) devised a scale to measure
fat-phobic attitudes and examined fat phobia and its correlates in 1,135 subjects. They
divided their study into two phases. The first phase considered the degree of fat phobia in
the subjects. The findings indicated that the people most likely to be fat phobic were
average or underweight, under 55 years old, females, and those having more than a high
school education, or from non-medical professions. The second phase of the study used
educative therapy to change the attitudes of fat phobia encountered in the first phase. The
mean weight of this group was 205 lbs. The therapy was designed to increase positive
perceptions about fat people and to raise the participant's self-esteem if they were,
themselves, overweight. "This intervention strongly stressed removing blame from fat
people for their fatness by educating them about the complex etiology of obesity and the
difficulties of treatment" (p 477). There was an decrease in fat phobic attitudes. The authors
cannot, however, explain why this occurred as the only research up to that time found only
"a weak correlation between knowledge about fatness and more positive attitudes toward
fat people" (p. 477).

There is a virtual epidemic of fat phobia leading to self-rejection, and obsessive behaviors.
Statistics about the increase of fat phobia and dieting suggest that, in the years to come,
ever more people will be trying to reduce their body size. It is a well-known fact that 95%-
98% of people who lose weight by dieting, regain the lost weight within five years. A full
90% gain back more weight than they lost (National Institute of Health as cited in Atkins,
1991). Aside from the issue of health, it may also mean that ever more people will exhibit
some or all of the shame based sexual behaviors of obese women, as suggested in the
Introduction.

History and Development of Analytical Studies on

Obesity and Sexuality
In 1912, the insurance industry set guidelines for themselves on who was thin, normal, too
fat, and obese. Anyone, whether they exercised or not, who fell into the "too fat" or obese
category, was now labeled a health risk, subject to heart attacks, diabetes, arthritis, asthma,
and even homicide (Beller, p. 6). Now, it could be calculated and determined who were the
"overweight" and who were not.
Along with this occurrence, Sigmund Freud was developing his theories and determined
that subconscious psychological motivations could cause disturbances in normal
functioning. According to researchers and psychiatrists, Glucksman, Rand, and Stunkard
(1978), Freudian psychoanalysts "emphasized the notion that obese individuals have
encountered a serious disturbance during the oral stage of psychosexual development…
emotional deprivations or excesses in this stage of development somehow became
associated with nourishment in the potentially obese individual, presumably, because the
mother of the obese-prone child feeds it inappropriately in relationship to its emotional and
nutritional needs. As a result, many obese children and adults fail to distinguish between
hunger, satiation, and other sensations or emotions." (pp. 103,104)

Assigning this pathology to obesity served to cast aspersions, ascribe neurosis, and shift
responsibility for becoming fat onto the larger members of society. It gave permission to
many sectors of the culture to denigrate, reject and shame large people, especially women.
In turn, large women often denigrated, rejected and shamed themselves and their bodies,
which began to affect their sexual expression. It is valuable to review the development of
Freud's theories and studies on obesity because of the injurious influence they have had and
continue to have on women's lives through his heirs.

Long after Freud's death, many influential analysts continued to develop his theories,
identifying fatness with oral sexuality, and claiming that fat people did not experience the
fullness of adult genital gratification. Theorists suggested that because fat people were
unable to handle mature sex, they searched, through food, for what one Freudian
psychoanalyst, Sandor Rado (1926), termed the "alimentary orgasm" (p. 577). Although
Rado himself became disillusioned with traditional psychoanalytic theory (Rado and
Daniels, 1956, pp. 17-18), and the concept of the alimentary orgasm seems to have
disappeared from psychoanalytic writings, the idea that fat people were not able to
experience mature genital gratification did not disappear (Stunkard, 1976).

In the late 1950's, Harold Kaplan, a psychiatrist, and Helen Singer Kaplan, a clinical
psychologist, compiled analytical theories from the first half of the 20th century on the
psychosomatic concept of obesity. They wrote by way of introduction, "Almost all
conceivable psychological impulses and conflicts have been accused of causing overeating,
and meanings have been assigned to food" (Kaplan and Kaplan, 1957, p. 195). Some of the
90 analytic theories about overeating are:

Overeating may be:

a means of diminishing anxiety, insecurity, tension, worry, indecision.
a means of achieving pleasure, gratification, success….
a means of relieving frustration, deprivation and discouragement.
a means of expressing hostility, which hostility may be conscious, unconscious, denied, or
repressed…
a means of diminishing feelings of insecurity and inferiority
a means of rewarding oneself for some task accomplished…
a means of diminishing guilt, which guilt may itself be due to overeating.
a type of defiance, rebellion against authority and control, an attempt at independence.
a means of proving inferiority and justifying self-depreciation.
a means of avoiding maturity.
a means of handling anxiety from infantile oral frustration.

Overeating may serve:

as a substitute for love and affection
for showing love and affection
for pregnancy
for protection against men and marriage.

Overeating or food may be symbolically:

a representative of pre-Oedipal mother conflict.
a type of alimentary orgasm.
expression of unsatisfied sexual craving.
expression of destructive sadistic impulses.
expression of penis envy and a wish to deprive the male of his penis.
expression of a fantasy where overeating results in impregnation.
pathologically strong oral libido being gratified in an unsublimated way.
a means of possessing a "part-object" like a penis or breast.
a defense against threatening unconscious feminine or masculine wishes.
an indication of an early disturbed mother-child relationship. (pp. 195, 196)

The Kaplans concluded that: "It is difficult to describe all the many specific psychological
factors that have been proposed as being associated with obesity…it appears that the only
psychopathological generalization that can be made with confidence about obese patients is
that they are individuals whose life pattern is conflictual and anxiety ridden…the people
affected by obesity typically have some degree of personality disturbance and/or emotional
conflict which may be of any type or severity." (pp. 196- 199)

The findings of the studies compiled by the Kaplans appear today to be vague, ambiguous,
and contradictory. Furthermore, all the obese people who came to the psychoanalytic
authors felt a need for therapy. Obese people who did not feel a need for therapy were not
taken into account in the creation of the theories -- possibly skewing the theorists'
conclusions. Only one reference in the Kaplans' compilation suggests that it may be the
obesity that is creating the personality disturbance. Rather than indicating that an inferiority
complex, and feelings of inadequacy and shame, cause the obesity, we see the suggestion
that: "Obesity results [italics added] in feelings of inferiority, inadequacy and shame. These
feelings and the obesity associated with them then can be used to justify all the failures in
interpersonal relationships, which the obese patient has. They may be used as a
rationalization to avoid any further contact with people and threatening situations." (p. 196)

After the Kaplans' published their compilation, a number of studies emerged that countered
the idea that obesity was a symptom of pathology. Albert Stunkard, who was a leading
researcher and thinker contributed significantly to the changing attitudes about the
psychopathology of obesity. Originally from the psychoanalytic tradition, Stunkard, in
conjunction with other researchers, responded to the Kaplans' enumeration of pathology
theories by trying to determine whether, in fact, obese people were more neurotic than
thinner people. His first studies were of small numbers of people and showed virtually
equal psychological health. Rand and Stunkard (1977) combined the findings of four
different surveys, completed by 104 analysts on 147 patients. The results indicated that
there was either a very small or no difference in psychopathology between obese and non-
obese patients.

Then, in 1976, Goldblatt and Stunkard used a massive investigation done some years before
to collect information on the lives of 1,660 people from midtown Manhattan. The
investigation had collected but not correlated their weight and their psychological
condition. After re-analyzing the data, the researchers found that obese people scored
slightly higher on tests for "childhood anxiety, withdrawal, neurasthenia, depression,
anxiety, rigidity, suspiciousness, and immaturity than the rest of the Midtowners but that
the differences were not statistically significant [italics added]" (p. 145). This finding began
a revolution in thinking that is evidenced by Wadden and Stunkard's (1996) later statement,
"When psychopathology is observed in obese individuals, it is now seen as a consequence
rather than a cause--a consequence of the prejudice and discrimination to which the
overweight are subjected" (p. 163). Other studies (Crisp and McGuiness, 1976; Friedman,
1959; Weinberg and Stunkard, 1961, 1976; Wise, 1978; Wooley and Wooley, 1984) have
substantiated these results.

Another example of the changes slowly taking place in attitudes toward obesity can be seen
in the writings of Dr. Theodore Isaac Rubin (1967, 1970, 1978). Dr. Rubin is a well-known
psychiatrist who wrote three popular psychology self-help books on losing weight. His
books became best sellers and influenced many people in the late 1960's and 1970's. In
Forever Thin, Rubin (1970) wrote, "Obese people almost always have sexual problems.
The combination of grotesque fatness and repressed hostility are very destructive to
closeness and good sexual relating. As anger dissipates in obese people and with it, fat,
relations eventually improve" (p. 70). By 1978, however, Rubin was writing: "I do not
believe the fat half of the population is sicker than the thin half, either physically or
psychologically…. I feel that my earlier views in this regard were due largely to my own
unconscious prejudice against myself and other fat people" (p. 22).

The assumption that if one is obese, one must have an underlying pathology did not and has
not disappeared, however. Jungian, Marian Woodman (1980) wrote that the obese woman
and her body "takes on the projection of the shadow and is experienced as evil. Sexuality
therefore becomes evil. Femininity and sexuality are confused….[she] does not know
physically or psychically where she begins or where she ends….[her] frustrations,
aggressions, and inability to adjust to reality are expressed in craving for food. Tension in
the body for whatever reason is relieved through eating." (p. 41)

Judi Hollis's point of view and recommendations may also be influenced by Freudian ideas
that obesity is linked to repressed anger. In Fat and Furious, Hollis (1994) wrote, "I've
never met an eating-disordered person -- either bingeing or starving -- who wasn't raging
within" (p. xxvi).

Some theorists believe they have found an association between obesity and sexual trauma
suffered in childhood (Blume, 1991). Other theorists conclude that compulsive eating and
other addictions can result when women need to nurture themselves or suppress feelings
(Woititz, 1989).

Compulsive overeating can be one of the results of sexual abuse. The act of eating,
regardless of weight gain, is experienced as self-nurture. Since nurture by another cannot be
trusted, and since one is so needy, the need plays out in the eating. Obesity serves a
purpose. If you are obese, you usually feel sexually undesirable. If you are sexually
undesirable, you don't have to deal with sexual advances made toward you. Obesity enables
you to avoid the problem of having to deal with your sexuality. It is also true that if you
stay fat, you don't have to deal with the terrifying truth - as you see it - that if you were thin,
you'd still be undesirable because you are not worth much. (Woititz, 1989, pp. 64,65)

While many obese women did suffer sexual trauma in childhood, so did many other women
who are not obese. There are also women who are obese who were not molested as
children.

From the 1960s onward, overeating was often classified as an addictive behavior. For
many, the suggested solution to overeating was to follow the proposals of Alcoholics
Anonymous (an organization whose plan for stopping compulsive drinking was reportedly
successful for people who followed it rigorously). AA's recommendation was to eliminate
the addictive substance and find support through meetings, other people, and the help of a
"higher power." The problem with treating overeating as an addiction was that compulsive
overeaters had to taste their addictive substance every day. Eating was considered an
inappropriate self-nurturing coping mechanism for those who ate, not to satisfy hunger, but
to handle all the feelings and moods that caused a desire to eat (Overeaters Anonymous,
1939; Twelve Steps and Twelve Traditions, 1993).

Many addiction therapists (Klausner and Hasselbring, 1990; Lasater, 1988; McFarland and
Baker-Bauman, 1988; Siegel, Brisman, and Weinshel, 1989; and Wills-Brandon, 1993)
claimed and continue to claim that when large women suppress their feelings
inappropriately, they nurture themselves through their food. It is often suggested that the
problem begins in their family dynamics, for instance, a power struggle between the child
and the parent. Judi Hollis (1994) wrote that people with eating disorders use food to
become who others need them to be. "…daughters with eating disorders are carrying their
mother's disowned pain and anger…A mother's denied emotions are internalized by the
daughter….Too often the mother-daughter wound is based on unconscious enmeshment, a
blending of boundaries, a failure to see where you begin and your mother ends. This failure
creates self-destructive behavior that is played out on the plate." (pp. xiv-xv)

The addiction therapists (Austin, 1987; Bradshaw, 1988; Cavanaugh, 1989; Fossum and
Mason, 1986; Harper and Hoopes, 1990; Potter-Efron, 1989; McFarland, 1990) under the
leadership of John Bradshaw, discovered that shame is a key component of the struggle
with poor body image and sexuality. Those who deal with shame believe it may be the
connection that transfers poor self-esteem into a poor body image and then into one's sexual
behavior by causing women to hide their bodies, become self-conscious, retreat from
assertiveness, and become exquisitely vulnerable.
Searching further for the causes of obesity, the nutritional theorists claim that our sexual
lives will improve as soon as we eat a balanced diet or an appropriate diet (Katherine, 1991;
Walker, 1994). Fisher (1996) guarantees that a person will have increased sexual vitality as
soon as she begins Fisher's low cholesterol gourmet diet.

Heubner (1993) connects food intake and sexuality. "It has long been known that food
intake and sexuality are strongly influenced by the mechanism of reward-mediated by
'reward centers' of the brain. Together with other regulatory systems, such as hormones,
these reward centers primarily motivate the organism to engage in complex behavior to
secure maintenance of life and survival of the species. By linking these functions to
powerful brain reward mechanisms, nature insures that these essential tasks are repeated
over and over again. In other words, the organism does not grow tired of them, and thus the
likelihood of the survival of the species is increased." (p. 229)

Before 1985, most theorists believed that obesity was simply unattractive and therefore a
sexual derogator. From that assumption, they proceeded to interpret obesity as a deliberate
or unconscious attempt to avoid sexual contact. They also failed to consider, until very
recently, that their theories may have contributed to the very problems they attempted to
link with obesity, including sexual ones. Little notice was taken of the vast numbers of
women all over the world that by western standards would be considered obese,
unattractive and unconsciously attempting to avoid sexual contact, but by the standards of
their own country were considered highly prized and beautiful (Ford and Beach, 1951;
Brown, 1993). The theorists before 1985 also failed to account for the fact that, even in
western countries, there are many men who prefer large women (Dimensions). From the
literature, it appears that most theorists didn't consider the possibility that a woman could
be fat, have high self-esteem, feel good about her body, experience a sensual and fulfilling
sexual life, and not be a compulsive eater. It is important to keep this preconception in mind
when one reviews the literature on obesity and sexuality.

Many research teams have determined that isolating the etiology of obesity is not an easy
task. After a researcher or theorist would conclude that they had found the cause of obesity,
doctors would treat their patients from that perspective. Diets, calorie counting,
amphetamines, high protein, low fat, liquids only, whatever the remedy, one observation
became obvious. Although the patient might lose weight, she would gain it back and
usually gain more than she had lost. Even using the many forms of surgery that were
developed to suction off or diminish the intake of food, in the end, women regained much
of their weight (Berg, 1992, pp. 44-49).

Beginning circa 1980, a new group of investigators emerged, not necessarily scientific
researchers, but experiential theorists. Frances M. Berg (1992) writes, "From the turmoil of
widespread frustration with diets that don't work, pressures to be thin, and the crises in
eating disorders that grips America, a new movement is rising. It is a paradigm shift,
vigorously opposed to dieting" (p. 110).

In 1984, researchers finally, openly admitted that ascribing psychopathology to obesity and
treating it, appeared to intensify fat phobia and exacerbate not only the problem of
compulsive eating, but other forms of eating disorders as well (Wooley, 1984).
Starting with Susie Orbach's Fat is a Feminist Issue (1979), Marcia Millman's Such a Pretty
Face (1980), and Kim Chernin's The Obsession: Reflections on the Tyranny of Slenderness
(1981), the attitudes about obesity began to change. Slowly women began to get angry
about what had been "done" to their self-esteem, their bodies, and their spirits in the name
of thinness and beauty.

One assemblage that was very incensed was the feminists. This group found society at fault
for fat phobia, especially the males, the controlling half of the society. Some feminists
suggest that the reason responsible for fat phobia and body obsession is that the new power
and assertiveness that women were beginning to project threatened men in our culture. Men
want women to stay tiny, dainty, and manageable. By linking success to adolescent style
bodies, the patriarchal males create an impossible ideal that almost no one can attain. The
struggle to be adolescent thin, which mature women can rarely be, may cripple women's
energy, assertiveness, self-esteem, and self-confidence. When women accept and succumb
to this male dominated system, they disempower themselves sexually and in numerous
other ways, and keep themselves under paternalistic dominance.Should a woman break the
rules of our paternalistic society, she will be made to feel guilty about and displeased with
herself (Orbach, 1978; Woodman, 1980; Chernin, 1981; Bordo, 1993; Fallon et al., 1994).
In The Beauty Myth, Naomi Wolf (1996) describes this dynamic as an attempt to
undermine the new power of women that developed when women got the vote, birth
control and began working outside the home (p. 12).

Much has been written about the influence of capitalist pressure on women to buy goods
that improve their looks. Capitalism fuels and then profits from women's fears about failing
to attract a partner. Women spend $33 billion a year on diets, $20 billion on cosmetics, and
$300 million on cosmetic surgery (Wolf, 1991). Business interests that profit from women's
insecurities continue to offer warnings about women's health, fading beauty, deteriorating
bodies, and passing opportunities to attract a partner. The entire diet industry is supported
by women's fat phobia and the obsession with making one's appearance finally "good
enough" (Epstein, et al., 1994, and Wolf, 1991).

Capitalists' and men's interests intersect in patriarchal Capitalism. It is mostly men who
own and control capital; it is men who receive higher wages - and it is women who do most
of the work. The benefits of capital accumulation accrue mostly to men, and to women only
through men. This is what female supplication to catch the right man is based on…
(Szekely, 1988, p. 193)

Naomi Wolf (1991) combines feminist theory with economic theory: "The sexual
revolution promoted the discovery of female sexuality; "beauty pornography" - which for
the first time in women's history artificially links a commodified "beauty" directly and
explicitly to sexuality - invaded the mainstream to undermine women's new and vulnerable
sense of sexual self-worth….The weight of fashion models plummeted to 23 % below that
of ordinary women, eating disorders rose exponentially, and a mass neurosis was promoted
that used food and weight to strip women of that sense of control. Women insisted on
politicizing health; new technologies of invasive, potentially deadly "cosmetic" surgeries
developed apace to re-exert old forms of medical control over women." (p. 11)
Fraser (1998) conducted an exhaustive study of the diet industry and discovered that at
present the obesity researchers fall into two camps: medical researchers, who believe that
losing weight in any way, including surgery, is beneficial, even if people gain the weight
back, and anti-diet eating disorders researchers who point out that dieting and regaining
weight is doing more harm to the body and to the psyche than good (pp. 212-214).

Medical researchers study the etiology of obesity from a medical/physiological perspective

and there are researchers and medical personnel who believe that the source of obesity is in
the genes, or the endorphins, or the synapses, or the uptakers. These persons recommend
medical intervention such as drugs that curb appetites (Hudson, Pope, and Jonas, 1984),
doing intestinal or ileal bypass surgery (Mason and Doherty, 1993), readjusting metabolism
(Keesey and Corbett, 1984), and eliminating hunger sensors (Fischer, 1996; Walker, 1994).
There have been technical advances in the understanding of the neurotransmitters and
receptors that play crucial roles in feeding and weight regulation (Blundell and Lawton,
1993). It may be worth noting that there is significant financial support for many of these
investigations from drug companies that make profits from the fat-phobic public (Fraser,
1998).

The eating disorders researchers and activists found that dieting was having a disastrous
after-effect on the participants and asked, "Should Obesity Be Treated At All?" (Wooley,
1984) They stressed that physicians didn't take the psychological and physiological risks of
dieting seriously. By treating obesity as a disease, rather than acknowledging it as a natural
human variation, the medical establishment was contributing to the overwhelming cultural
prejudice against fatness.

By the middle 1980's a few women began to agree that all the anti-fat theories might have
actually hurt them, inducing them to disassociate from their hunger, their feelings, their
bodies, and from their sexuality. These Fat-Activists recommended giving up on the diets
and self-rejection. They suggested that women need to get back in touch with their true
hunger, their own bodies, their actual needs (Wooley and Wooley, 1980; Roth, 1983, 1984,
1991, 1996; Hirschman and Munter, 1988, 1995; Fraser, 1998; Normandi and Roark,
1998).

In 1984, Wooley and Wooley wrote: "Many treatment successes are in fact condemned to a
life of weight obsession, semi-starvation, and all the symptoms produced by chronic
hunger. We have encountered and have recently begun studying successful maintainers
from commercial weight loss programs and have been more impressed by their fortitude
than the quality of their life. …some consume as few as 800 calories per day… Perceptible
beneath the visible pride is often an unmistakable bitterness over the price they pay to have
a socially acceptable body." (p. 187)

Polivy and Herman (1983) found in their extensive research that dieting disrupted people's
physical sense of when and how much to eat and led to overeating. Dieting also taught
people to ignore other feelings as well. Dieters stopped being able to handle other emotions
-- anxiety, disappointment, fear, stress -- in a normal way, and used food instead to express
their feelings.
By 1993, the concept of eating disorders which had been applied only to anorexia and
bulimia now began to be applied to all those who had eating problems due to dieting,
including bingeing, and compulsive overeating (Stunkard and Wadden, 1993). All had one
factor in common: fear of fat. Smolak and Levine and Striegel-Moore (1996) stated that
programs for the primary prevention of eating disorders of adolescents fail, even when such
programs are implemented and evaluated by experts in prevention. The failures are seen as
"reflecting the monstrous impact of monolithic socio-cultural factors such as the media" (p.
252).

In summary, women who had dieted for many years began to question the wisdom of so
much rejection of their large bodies. They saw the disastrous consequences of their
repeated dieting, obsessing and self-reproach on their sexual lives. Normandi and Roark
(1998) write: "The cultural pressures to be 'superwomen,' and to look beautiful while doing
it, creates women who are not only afraid of their own sexuality but many times they are
actually repulsed by sex. How can a woman relax and enjoy intimate relationships while
she is holding her stomach in? How can a woman enjoy sensual pleasure with her mate if
she is constantly worried about her cellulite? How many times does a woman go to bed and
have sex simply because it is expected of her? And if she said no, would she ever be asked
again, especially if she thinks she is overweight, old, ugly or somehow not 'sexy'? How
often do women simply stop eating because they don't want to have hips or thighs - the very
parts that make us women? How many women starve themselves in order to look
unwomanly and thus asexual? How often do women throw up their suppers because they do
not want their lovers to see their fat stomachs when they get into bed? How often do
women put weight on to insulate themselves from sexual attention, attraction, feelings?
How often do women keep weight on in order to make themselves unattractive to the
opposite sex, so that they will 'stay out of trouble,' or so that they won't be wounded again?
All are ways of disappearing, of hiding." (p. 7)

The extreme fat phobia of present U.S. society has resulted in a backlash, the creation of
the size/fat acceptance movement. This group says that they don't care what caused them to
be fat. They are. They are tired of trying to change themselves. They believe that many of
the problems in their lives and in their sexuality are related to accepting one or more of the
fat-phobic theories, dieting, obsessing, and rejecting themselves. They want to live, be
sexual, attract people who are attracted to them, assert their desires, say "no" if they don't
feel attracted, use their bodies for fun, fitness, and pleasure. They want to celebrate their
sexuality like other women. Among the many spokeswomen for this point-of-view are:
Wooley, Summer, Berg, Wann, Hirschmann, Munter, Gaesser, Glenn, Hall, Lindsey, Roth,
Blank and Freedman. This movement is growing and is beginning to influence both
professionals and the society at large. The organization that is leading this movement is the
National Association for the Advancement of Fat Acceptance. Susan Dubin, a member of
NAAFA, writes to her fellow members: "Let me explain a little about what fat activism
means to me. Previously, being fat for me meant being an invalid sexually, professionally
and personally. NAAFA is the greatest revolution in my life. I date interesting men and I
am beginning to be comfortable in a swim suit. I am taking Yoga and belly dancing classes.
Being an activist in NAAFA means a total, rewarding commitment to personal change and
fulfillment. Realization of your own potential and beauty awaits you. Are you ready?" (in
Smith, 1995, pp. 32,33)
 Chapter 5

Empirical Studies on Sexuality and Obesity

There is considerable research on obesity and on sexuality as separate issues. The lack of
research by sexologists or by obesity experts on the interrelation of the two subjects appear
to indicate that researchers do not imagine that sexuality and obesity can co-exist. The
prevailing attitude in the U.S. is that one must be thin to be sexual, that a fat individual does
not have many sexual opportunities, is not capable of expressing sexuality nor able to
perform sexually and therefore sexuality issues need not be considered. Researchers into
the subject of obesity and sexuality have remarked on this phenomenon before (Jordan and
Levitz, 1979; Shapiro, 1980; Spiegel, 1988; Blank, 2000). The lack of research leaves this
attitude virtually unchallenged. However, in spite of this scarcity, there are some empirical
studies that shed light on the subjects of obesity and sexuality.

Two well-researched and well-documented unpublished dissertations on obesity and

sexuality are Sharen Shapiro's (1980) Sexual Attitudes and Activities of Obese Women and
Joan Spiegel's (1988) Differences Between Obese Women in a Relationship and Obese
Women not in a Relationship. Shapiro administered a 137-item questionnaire about sexual
attitudes and behaviors to 100 Caucasian females, who were divided into two comparison
groups on the basis of weight. The weight of one-half of the women was in the "normal
range". The other half was obese. (For this Dissertation, obese was 25% above the
Metropolitan Life Insurance Company's Table of Desirable Weight, 1959.) The survey
results indicated that the obese women had a general, pervasively negative self-concept, felt
more inhibited in discussing sex with their partners, rated their primary relationships more
unhappy, and compared their physical attractiveness negatively to that of other women
around them. They frequently wished they could change some part of themselves, and felt
that their weight frequently interfered with their relationships - with sex in general and with
sexual positions in particular. The obese women stated that they would like to have sex
more frequently and that their sexual needs were often left unsatisfied. They wished they
did not have to be initiators of the sexual relationships as often as they felt called upon to
be. This study suggests that large women are interested in having more sex than they
actually are having.

One factor that may have influenced Shapiro's results is that many of the subjects were
found from people who were attending Overeaters Anonymous, a weight loss program.
These subjects may have had a higher instance of dissatisfaction with weight and of
negative body image (affecting self-esteem and self-concept) than a more randomly
selected group of obese women.This may account for so many of the women having an
extremely negative self-concept. It would be interesting to see the results of a similar study
that selected subjects more at random. However, the results of a current study would also
be affected by the development of the fat acceptance movement, which may have improved
the self-esteem of many large women.

Joan Spiegel's (1988) study of the differences between obese women in relationships and
obese women not in relationships surveyed 74 women between the ages of 23 and 52.
Forty-five of the women were in a relationship and 29 were not in a relationship. The mean
average weight of the women in a relationship was 236 pounds and the mean average
weight of women not in a relationship was 247 pounds. The women filling out her
questionnaire came from her article written for Radiance, a national size-acceptance
magazine and from a plus-size fashion show. The women in relationships scored higher in
self-satisfaction and self-esteem. The obese women not in relationships scored significantly
higher in the emphasis they put on their weight as a cause of not having a relationship.
They believed that their former partners cared a great deal about weight, and they felt that
their sexual relationship was affected by their weight. Significantly, they also said they
would more often have chosen a different partner if they had been thinner. They claimed
that sex was not important to them, that their sexual adjustment was below average, that
they would like to initiate sex more often, that their sexual needs were not satisfied, and
that they did not feel comfortable discussing sex with their partners. This study supports the
hypothesis that attitudes, not inherent psychological problems nor obesity, as such, are
responsible for women's relationship health.

In a 1976 unpublished study conducted at Michael Reise Hospital in Chicago, Shipman and
Schwartz found that fat women were more sexually appetitive than thinner women. This
study, described by Beller (1977), was particularly interesting because, as Freudians, the
researchers had hypothesized before the study that "fat was…a kind of somatic metaphor
for the psychic armor fat people are supposed to have elaborated as a defense against sex
and love" (p. 74). Furthermore, the factors that were supposed to have led the larger women
to become fat should also, according to the researchers' theories, have made the women
uninterested in sex. This hypothesis was not supported by the results of the study. Shipman
and Schwartz discovered that the fat women's desire for food and sex existed
simultaneously. "In terms of erotic readiness and general sexual excitability, fat women
outscored their thin sisters by a factor of almost two to one" (pp.74,75). Beller hypothesizes
that "the fat woman's sexual readiness may be part …of a generalized nervous-system
syndrome in which appetite, once triggered-- whether for food, sex, 'love,' housework,
poetry or anything else…may be much more difficult to turn off" (Beller, 1977, pp. 74,75).

Ileal and intestinal by-pass surgeons have contributed to our understanding of the meaning
of obesity and sexuality in marriages. Marshall and Neill (1978), studied the effect of
weight loss after surgery on the sexuality of married couples. The study involved 12
persons, 10 females and 2 males and their spouses before and a year after surgery. The
preoperative weight of the obese members averaged 338 pounds, with a range of 214
pounds to 485 pounds. After the operation had been performed and the subjects had lost an
average of 135 pounds, there were marked changes in the areas of sexuality and
dependence/ independence parameters. The authors concluded that there was a function to
the symptom of obesity within these marital systems. "Many of the men had dated only
obese females, and several had noted, 'I have always preferred heavy women (p. 278). Ten
of the 12 patients were obese when they married. This would indicate that these men were
sexually attracted to the obese women. An operation to eliminate the obesity would be
predictive of conflict. The interpretation of the data indicated that the obesity served as a
stabilizing force in the marriage as there were some sexual conflicts within the marriage
after the operation. Some female patients described themselves as "feeling sexually
attractive, playful, occasionally flirtatious, and more willing to initiate sexual encounters….
Several attributed the change to a diminished fear of rejection….Anxiety and jealousy were
prominent in the spouses (p. 276)." After surgery, the women shifted to greater
assertiveness, with more anger and hostility displayed. There were 2 divorces after the
surgery.

Wise (1978) studied twenty-three massively obese individuals, 13 men and 10 women, who
were screened for ileal bypass surgery. In addition to a test to determine the presence of any
psychiatric illness, the obese persons were given "...a detailed sexual history to ascertain the
frequency of sexual activity, their level of arousal…their global sexual attitudes…physical
ability to tolerate sexual activity, their libidinal drive, and self-concepts of body image were
also determined" (p.10,11). The conclusions of this study were that "There was no evidence
that core sexual identity or mechanical activity was aberrant in the massively obese….It is
apparent that hyper-obese individuals feel and display a sense of shame about themselves
as attractive individuals. This aspect of learned social behavior can modify sexual activity
(p.23)."

According to a retrospective study of 32 obese women, conducted by Werlinger, King,

Clark, Pera and Wincze (1997), participants were studied who lost weight by dieting under
a medically supervised weight management program using either OPTIFAST liquid diet or
a 1200 kcal per day diet. The participants were asked to complete two sets of
questionnaires. The first was to be filled out according to how they had felt before they
dieted and the second to how they were feeling in the present. Participants self reported
experiencing improvements in sexual function that they suggested was due to improved
body image occurring along with the weight loss (p. 77).

Wise (1978), Shapiro (1980), and Spiegel (1988) have established that obesity, in itself,
does not affect sexual functioning. These researchers found that the attitude of the obese
person toward her body and her sexuality was the determining factor in the prediction of
sexual functioning.

Stuart and Jacobson (1987) received 9,000 responses to a questionnaire about weight and
sex. The book, Weight, Sex and Marriage, published as a result of this survey discusses the
relationship of food and fat to many aspects of marriage and relationship, including
sexuality. The results of the survey were usually not statistically evaluated so that it is
difficult to establish the scientific evidence from the subjective evaluation of the data.
Women who said they did not enjoy or want sex were the exception in this study, and many
women reported a desire for more sex or for more satisfying sex. Most of the women
surveyed were having sex approximately 8 times per month. Women in unhappy marriages
had sex less than half as often and they would become particularly frustrated when the
number of times fell to less than once a week. If there were any problems with their sexual
lives, these women usually blamed the difficulty on their weight, even when the husband
was abusive, unfaithful, impotent or asexual. Stuart and Jacobson believe that women
overeat as a response to stress in their lives. Some of the stresses they list relate to
sexuality: not enough sex; bad sex; not enough foreplay; not enough time; not enough
intimacy, and a lack of comfort, support, and love. The authors write that those who said
they did not enjoy or want sex were extremely rare.
"A majority of women, however, believe that changes in their attitudes were as important
as the changes in their weight. Women reported greater sexual desire and less sexual
inhibition when they felt better about their bodies. This accounts for the fact that almost 60
percent of the women in our study have sex more often, and enjoy it more, after they lose
weight... Some (letters) were from the 40 percent of our sample who said their weight had
no effect on their husbands' sexual interest, but it made all the difference in their own
willingness to be sexual..." (p. 106).

Most of the book concentrates on how marriage is linked with sex and weight, and it
attempts to explain why losing weight is so difficult in marriages. Near the end of the book,
there is an interesting chapter that hints at the emerging attitude that maybe dieting is not
always the best path. Stuart and Jacobson address themselves to those who "don't naturally
[italics added] conform to current standards of thinness." (p. 116) The authors suggest that
for these people "the self-torture directed toward an impossible ideal is sheer foolishness….
The key here is a sense of self worth based on factors other than weight." (p.117)

"Once these women appreciate themselves, their bodies become a valuable part of a worthy
person. And once they accept their bodies, they are no longer self-conscious. In contrast to
the many women who let their inhibitions about their weight ruin their sex lives, these
women usually have very satisfying sexual experiences." (p. 118)

While Stuart and Jacobson's work is important because they established a clear link
between obesity and sexuality, some of their interpretations are subject to controversy since
most behaviors are multiply determined. The causes of weight gain have not been
irrefutably established. Blaming others and self-reported motivations and feelings provide
some information but will probably more than likely reflect the society's general ideas on
the subject. Furthermore, the questionnaire was sent to subscribers of a "national magazine
directed toward weight-conscious women" (p.19), a group which one can reasonably
assume to be significantly concerned about their weight. These individuals are not
necessarily representative of the obese population in general.

In 1997, Cash, Winstead, and Janda renewed the massive three decade long investigation
into the subject of body image. Approximately 2000 men and women that answered a query
from Psychology Today were surveyed in detail regarding their opinions and feelings about
their bodies. Thirty-eight percent said they were dissatisfied or very dissatisfied with their
body image (p. 32). Sixty-three percent of the women said they were afraid of becoming fat
(p. 34). One hypothesis is that body image dysphoria is highly correlated with sexual
dysfunction in women.

Faith and Schare (1993) explored this hypothesis by investigating whether negative body
image plays a role in sexually avoidant behavior. Using 108 males and 140 females and
using Masters and Johnson's concept of spectatoring ("cognitive self-absorption on one's
body parts and/or the adequacy of personal sexual functioning") (p. 345) the investigators
found that "body image scores significantly predicted frequency of sexual behaviors for
both genders" (p. 345). "Having a negative body conceptualization significantly predicts
sexual avoidance…" (p. 355). "Sexual avoidance is postulated to perpetuate a negative
view of the body, and so the cycle continues as the individual refrains from healthy sexual
relations" (p. 353). It is suggested in this study that "males and females who are more likely
to conceptualize their bodies and performance in negative terms are also more likely to
report less sexual experience (p. 352)." This study showed predictability of sexually
avoidant behavior in women with body image dysphoria. Sexually avoidant behavior
included self-consciousness, failure to flirt, avoidance of erotic encounters, anticipation of
rejection, feelings of shame, failure to initiate sexual encounters, and trying to hide one's
body.

Sexologist Marty Klein (1996) conducted an investigation in conjunction with McCalls

Magazine. An article titled "Is weight wrecking your sex life?" included the results of a
telephone survey of 350 McCalls readers who answered the question "Does your weight
affect how sexy you feel or how attractive your husband finds you?"

Fifty-four percent said they thought their husbands would find them less desirable if they
gained weight. Forty percent reported they were less interested in sex when they'd gained
weight. Thirty percent felt their husbands would find them more sexually desirable if they
were thinner. Nearly 20 % said their husbands were less interested in sex when they'd
gained weight. (p. 96)

Researchers Anderson and Legrand (1991) believe that: "Despite empirical efforts and
theoretical discussions…body image remains ill defined. We view women's body images as
attitudes--general and enduring positive or negative feelings about the body…. Current
assessment reviews note two general and independent contents--perceptions of the physical
self (or specifically body size estimations) and attitudes toward body parts. It is the latter
category, body part attitude measures, which the present research examines." (p. 458)

Anderson and Legrand studied the content and valence of women's body image attitudes,
general and enduring positive or negative feelings about the body. According to their
findings, weight, and its distribution, has the most significant effect on women's evaluation
of their bodies. "…measures of body image could be constructed which are little more than
measures of satisfaction with weight. Such findings could be interpreted as ''body image
dissatisfaction when the dissatisfaction is, more accurately, weight dissatisfaction (p.474)."
They also found that body attitudes remained stable following the diagnosis and treatment
of a physical disease. These results concur with the research of Kriss and Kraemer (1986),
and Ghizzani, Pirtoli, Bellezza, and Velicogna (1995).

Keeton, Cash, and Brown (1990) criticized the research on body image and the "dubious"
assumptions of the "unidimensionality of the construct and the equivalence of body image
measures (p. 214)." They found that there was a "distinction between attitudinal and
perceptual modalities of body image…only attitudinal body image and perceptual self-ideal
discrepancy measures were significantly linked to eating disturbance" (p. 214).

Haimovitz, Lansky and O'Reilly (1993) hypothesized that body satisfaction can be
influenced by situational factors. The subjects had significantly different body approval
scores for different situations, such as when they were on the beach, at home, or in a
dressing room. The subjects were especially self-critical when they were in more sexually
charged situations than in "everyday" places (p. 78). Keeton, et al. also suggested that "the
gender and attractiveness of the experimenter or of other subjects present during the
administration of a particular measure may significantly affect the results" (p. 83).

A study by Roth and Armstrong (1993) corroborated the last study when they found that a
participant's experience of bodily thinness-fatness was "influenced by the affective state,
performance evaluation, public scrutiny, self consciousness, and the nature of one's
interpersonal field" (p. 355).

In 1991, Burgard, co-author of Great Shape (p. 36), asked over 100 women, readers of
Radiance, "Is it possible to 'accept' your body size regardless of weight? " Of all the
respondents, whose average weight was 287 pounds, 50% were found to basically accept
their bodies no matter how much they weighed. Another interesting finding was that the
women who did not believe that they were responsible for their weight regain, that it might
be due to "normal physiological and psychological reactions to caloric deprivation (p. 38),"
these women registered higher self-esteem than those who constantly dieted and regained
the weight. The latter felt out of control and registered lower self-esteem.

Before we decide that all obese women are pathological, addicted, victims of dependent
marriages, under the power of Capitalism, or on the wrong diet, it might behoove us to
remember that other cultures do not experience any of this to be true and, instead, consider
large women to be the most beautiful (Ford and Beach, 1951; Brown, 1993). Beller, a
researcher on the history of obesity, also summarizes worldwide reports on men's
preferences regarding women's body size.

A strong presumptive case for the general desirability of fat women can be made from the
ethnographic evidence: Of a total of twenty-six tribes from all over the inhabited globe who
have ever been put on record as expressing any preference in the matter, only five preferred
their women slender. To this meager roster should now be added, presumably, the vote of
twentieth-century Americans and western Europeans; but even so, the naysayers are
resoundingly outnumbered by those who like their women fat.

Chapter 6

Partners, Sexuality, and Obesity

An extensive search for scientific studies and literature regarding the sexual partners of
obese women, for sexual information for obese couples, and for images of erotica that
include obese women yielded meager results.

Before the emergence of The National Association for the Advancement of Fat Acceptance,
the idea that a man could be attracted to a fat woman was almost inconceivable to most
obese women, and to most researchers. There were many myths about such men, most of
them uncomplimentary: they had to be fat themselves, weak, uneducated, lacking in
professional skills, and sexual misfits. In 1989, Blickenstorfer, himself a fat admirer,
surveyed the readers of his magazine, Dimensions, to gather information about men who
call themselves Fat Admirers (FA's). Fifty-four percent of the FA's were 30-39 years of
age. The average FA is between 5'9" and 5'11" tall and weighs between 175 and 199
pounds. Forty-one percent of all the respondents were single and 40% were married. Only
11% were divorced. Eighty-nine percent of the respondents had a least some college, 58%
were college graduates and 26% had advanced degrees. The average weight of the FA's
partner was 260 pounds (p. 75). In reviewing how FA's feel about their partners,
Blickendorfer writes, "Obviously they are attractive to us.… (Most of us) have spent hours
and hours trying to convince a fat girlfriend that she is indeed sexy and attractive. We know
how difficult it is to get through with this message" (p. 74). Seventy-nine percent of all
FA's agreed that fat women are reluctant to show their nude bodies to their lovers. Virtually
every FA wants his fat partner to feel happy with her size and 68% of all respondents
agreed with the statement "When it comes to size, the bigger, the better" (p. 75).

We receive a very different view of the men married to obese women who are trying to lose
weight from Stuart and Jacobson (1987). This study, reviewed in part in Chapter 3, was
based on 9,000 responses to a questionnaire about weight and sex. Stuart and Jacobson
include few percentages or other numerical measurements in their book. They summarized
and reported what they believed were the most prevalent comments from the questionnaire
responses. Regarding partners, they reported that many of the husbands were insecure and
became jealous as their wives became thinner. Some husbands used their wives' weight as
an excuse to have affairs. These husbands regarded their behavior as a perfectly legitimate
reaction to wives they considered too fat. If the husband neglected his wife, she often
believed that she deserved the neglect. Stuart and Jacobson found that weight issues
distracted attention from other marital and sexual problems. A husband could attribute his
lack of interest or inability to perform sexually to his wife's excess weight (pp. 75-77).

Although not directly a study of obese sexuality, in a holocultural study, Patrick Gray
(1984) tested how the dominance and assertiveness in relations between partners affected
sexual behaviors and attitudes. The results suggest that high levels of female power and
assertiveness within a marriage do not have an adverse affect on male sexual functioning
and that the more assertive women are in their marriages, the healthier the marriage
becomes. There is more discussion of sexual matters, more foreplay, more permission for
women to initiate sexual activity, less male fear of impotence and less sex anxiety. There
was a lower divorce rate. Studies on the sexuality of obese women have shown that these
women reduce assertiveness in their sexual relationships when their body-esteem is low
(Faith and Schare, 1993; Shapiro, 1980; Spiegel, 1988) and increase assertiveness when it
rises (Burcell, 1975).

The National Association for the Advancement of Fat Acceptance (NAAFA) has
contributed a great deal to our understanding of the sexual relationships of large people. In
1969, large people had little chance of meeting with Fat Admirers (FA's). Most large
women felt that they were too unattractive to appeal to anyone. There were no images of
obese couples in the media. There were no dances for fat women and men and for those
who enjoyed or preferred them. There was no defense of the feelings or even the rights of
people of size. The development of these phenomena was the result of the work of the
founder of NAAFA, Bill Fabrey, who was and is attracted to large women. He began
NAAFA with his wife in 1969. A few people joined. In 1970, the New York Times
published a half page article on NAAFA and after that the membership grew significantly.
Meetings and conventions sponsored by NAAFA provided many people with their very
first social opportunities and were widely imitated by profit-making social clubs and dating
services in the 1980's and 1990's. It became possible for many larger persons, especially
women, to have choices in their social lives (Fabrey, 1993, Summer)

Thirty years of NAAFA Newsletters reveal some interesting information about FA's, dating
practices between FA's and fat women, and developments over the years as the
organization matured. In 1970, when the organization was in its infancy, a small note
mentions that men and women of all ages are asking for a computer dating service tailored
to NAAFA members. In 1972, Bill Fabrey wrote a long column entitled "NAAFA men:
Who are they, and why aren't there more of them?"

"Some of our female members have come to accept the fact that there are men who find
them attractive--although many is the new member who is still incredulous at the idea! One
longtime member tells me that she has gone from one bad situation to another; before
hearing of NAAFA, the few men she knew liked her despite her figure, which they
disliked. After joining NAAFA, most of her dates like her only because of her figure. Many
(men) perhaps most, are painfully shy about their preference, and writing or joining
NAAFA is often their 'moment of truth'. It is very difficult, more difficult than the female
reader will ever believe, to find a permanent satisfying relationship, especially outside our
organization. The rule is that the majority of the plump public are so hung up about their
weight so as to make satisfying relationships hard to find. Some men are playboys, and
most are unlikely to change in this respect. If they join NAAFA, they are exposed to a large
number of available, beautiful and abundantly endowed femmes. Some, a few, are
"cheaters" to use a common phrase who seek variety from their marriage. The causes of
such marital "wanderings" are many. There is sometimes the sudden discovery by the
husband that cultural factors which led him to choose a thin wife have played a dirty trick
on him; he really digs the fat figure all along. There are other men who marry thin wives
for business and social reasons, knowing in the back of their minds that they really prefer,
and will later obtain, a mistress built along more generous lines. What is beautiful, in the
end, all depends on your point of view." (Fabrey, 1972, August, p. 3)

By 1976, more FA's were revealing themselves: "FA's are forced into a lonely pursuit of
their preference. The constant effort to hide their preference leads to frequently intense
feelings of shame, and the logical reluctance to share their true feelings with others.
Banding together, teenagers try to acquire confidence in dating skills. Moving in packs
from fear and ignorance, the youths judge the other boys and girls by their tenuous
standards. Those who do not fit are constantly ridiculed forcing the fat admirer to feel
different. As it is socially 'out' to seek a fat partner, most fat admirers are forced into covert
behavior, which scars them psychologically. Fat women too, are scarred by the ridicule and
are discouraged from perceiving themselves sexually and therefore do not learn to present
themselves sexually through their dress, movements and other forms of expression of their
sexuality. I prefer the soft feel of a fat woman. Psychologically, I enjoy the hedonistic
nature of many fat people, which is in the ideal expressed in sex, eating, and social
gregariousness." (Wachtel, 1976, March, p. 1)
In 1980, The Singles Scene column included a lecture to women: "Women: Please don't
lower your standards because you are fat…some of you wrote that you now enjoy being
regarded as sex objects for a change… All I am saying is -- it's a shame. Please try to avoid
being either a victim or an exploiter and be aware of the fact that NAAFA is no better or
worse in its social arena than the singles world out there, except that in NAAFA, being fat
is a social asset instead of a liability." (Fabrey, 1980, March, p. 5)

In 1982, in the column Sex at Conventions: "It has been said that NAAFA tries to promote
dignity and self-respect for fat people, yet much of the social environment provided at
conventions seems to be a "meat market" with much competitiveness between those
searching for sexual partners, and an occasional "wild party" becoming legendary in its
own time." (Fabrey, 1982, Jan-April, p. 13)

NAAFA had developed into a strong community of people who fought for their rights,
supported one another, found that there were others that could love them, and began to
suffer the same kinds of problems that couples from all walks of life suffer.

It is not common to find images of obese couples, or personal ads for obese women in
mainstream newspapers and magazines, nor is it easy to find information for obese couples
on the issues that concern them. It is not common to hear about those who admire women
who are fat or to see an obese couple in a movie unless she or they play character roles.
Adult erotic movies usually show women that are under a BMI of 25. Some notable
exceptions follow.

In The Joy of Sex, Alex Comfort (1972) gave cursory suggestions for a few positions but
he advised, "Fatness in our culture is unlovely. If you are grossly overweight, set about
losing it, whether you value your sex life or only your life" (p. 245). Although 30 million
Americans were overweight by 1974, in More Joy, he chastised, "Meanwhile, do something
about the overweight, in the interests both of sex and of general health. It's ridiculous and
dangerous to carry a permanent 50 pound girdle" (Comfort, 1974, p. 218). Dr. Comfort's
attitudes were common for that time.

In 1974, Dr. Abraham Friedman wrote the first popular book that claimed, albeit
tentatively, that Fat Can Be Beautiful. This book was written at a time when the prevailing
societal belief was that dieting was the only answer to obesity. Dr. Friedman had
specialized in treating obesity and metabolic diseases for over 25 years. He theorized that
some people were "born to be fat" (p. 11) and should make the most of it. In Chapter 17,
"Sex for the Obese," Friedman described in detail sexual positions for couples in which one
or both are obese.

Images of large women in erotica can be found if one searches below the surface.
Dimensions, Plumpers and Big Women, Big Butt Magazine, Belly: Where Fat Chicks are
Cool, and Zaftig represent at present some images with erotic intent. Vendredi Enterprises
which is affiliated with Dimensions magazine has a large selection of Big Beautiful
Women (BBW) in erotica, videos, and other adult materials. Erotic images of large women
in heterosexual videos that are educational in nature are rare. Some are available in Lesbian
and Bondage/Discipline/Sadism/Masochism (BDSM) videos.
On the Internet, the Fat_Sex Website (Yohannon, 1996) is a creative list that receives
questions and gives advice to large persons interested in all forms of sexuality for large
people. Yohannon has a link that describes sexual positions for large lovers. Yohannon
writes, "The Mythology of Obesity tells us that sex with a fat partner is either fruitless or
impossible. It's a prejudice that crosses all boundaries of race, class, education, and
physique: you're as likely to encounter it in a gynecologist's office as in the pages of The
National Lampoon…. In the real world, sex is more likely to be impeded by anxiety than
adiposity. Fear of rejection, fear of not meeting the partner's expectations, and fear of not
being able to perform are among the most common emotional barriers to intercourse." (p.
1)

The most recent and most complete sourcebook for obese couples, published only this year,
is Big, Big Love by Hanna Blank (2000), who also published Zaftig, Sex for the Well
Rounded. Big, Big Love describes many ways of being sexual for large people, how to
meet others, information on social skills, health, sexual positions, ways of using fat to
eroticize sex, and includes a resource guide, all for large size people and specifically
designed for large lovers.

In discussing the lack of information on Fat Admirers, Mayer (1993) attempted to explain
the many forces in our society that keep men fearful of allowing themselves to be attracted
or to admit that they enjoy larger women: "In this highly technological and complicated
world, most men are feeling incompetent and scared. And women are paying the price.
Amidst their agony, men have made women, their one potential ally, their enemies. Men
are also going through a major crisis of sexual identity. The last thing they need is any
challenges to their masculinity. Trying to keep women physically small and feeble,
uncertain about their own sexual identity, and preoccupied with their body image is just
what the doctor ordered (literally). One way that women might reclaim their bodies from
the tyranny of male whim and social propriety is to free themselves of the chains of dieting.
Becoming bigger and stronger violates taboos, but these taboos are patrolled by men and
the financial interests of the fashion industry, not by the health and well-being of women.
How could we have traveled so far down the wrong road? This is not a health issue. It
never was. Our physically-endowed women are labeled obese, sick, while being told to
idolize shriveled creatures comprised of only skin, hair, bones and an attitude, who actually
are medically the sick ones." (p. 118)

Chapter 7

Sexual Therapy for Obese Women and their Partners

From studies of the sexual difficulties of obese women presented elsewhere in this
literature review, it is evident that therapeutic measures designed to resolve the sexual
concerns of obese couples need to address body image dysphoria as the primary element in
impaired sexual functioning.

The rejection of the body has ramifications for the obese couple that extend far beyond the
body. Research has indicated that for many women, when they feel "overweight," they feel
like sexual misfits, unattractive and undesirable. They withdraw from trying to attract
partners, and from communicating or asserting themselves in both potential relationships
and in actual sexual relationships. They often allow their body size to affect their self-
esteem in other areas as well. The shame they feel can affect their self-esteem, the way they
dress, move, eat, and respond to a sexual partner. Many large women have sought some
form of therapy to assist them in finding the solution to their eating problems, their
psychological concerns, and to help them enjoy a sexual relationship with a partner. The
appropriate and effective therapy for these concerns would probably be holistic in nature
and would most likely involve both partners. A search of the literature for obese couples
fails to disclose any approach of this nature. It does, however, propose therapies
individually, some of them unorthodox and outside the traditional methods.

There are two major pathways to treat body image dysphoria -- medical solutions and
psychological solutions. Medical solutions attempt to reduce body size and include drugs,
surgeries and dieting (some form of reduced eating, or restricted fat, calories, sugar or
carbohydrates). These methods have the advantage of working relatively quickly to reduce
body image dysphoria but are usually not permanent and cause physical and mental harm
when the weight returns and the dysfunctional sexual behaviors associated with body image
dysphoria re-manifest themselves. Psychological solutions attempt to reduce negative body
image, shame, and anxiety, no matter the size of the woman. These methods represent a
more permanent solution to body image dysphoria although they may take a longer time to
become effective due chiefly to the ever-present criticism and ridicule that people with
larger bodies are subjected to everywhere in the culture. This literature search will confine
itself to the therapies that direct themselves toward the more permanent solution.

There are three collateral issues upon which body image dissatisfaction rests and which it
affects -- lack of size-acceptance, shame, and impaired sexual functioning. Except for the
sexual therapies, the partner has not been included in these attempts to heal obese couples.
Many of these therapies do not appear to be of a sexual nature but due to the relationship
between body image dysphoria and the sexuality of those that suffer with it, all of them are
related and healing. Some of the therapies that address themselves to these issues are listed
below.

Size-Acceptance Therapies

Since the beginning of the Fat Acceptance Movement, the developing hypothesis has been
that fat-acceptance means self-acceptance or the converse, self-acceptance means fat-
acceptance. Women, having distanced themselves from their bodies by dieting, obsessing,
shaming, and rejecting themselves, need to reconnect (Freedman, 1989; Hutchinson, 1985;
Hirschman and Munter, 1995; Ross, 1984; Wooley, 1984). Rita Freedman's book,
Bodylove (1988) was written from the "deep concern" she had about the women she
worked with as a psychotherapist. She administered a survey to 200 women and the results
revealed a great anxiety in her clients about their body images.

Freedman's therapy consists of making over one's body image from within.. In a three-step
process, she guides women to pay attention to their physical needs, to appreciate the
pleasures their body provides, and to accept flaws and limitations. "Bodylove doesn't mean
creating a perfect body; rather, it means living happily in an imperfect one. After all, an
imperfect body is the only one you'll ever have" (p .4).

In Transforming Body Image: Learning to Love the Body You Have, Marcia Hutchinson
(1985) noticed that body image was more closely connected to self-esteem than to actual
physical appearance. "Image and reality are separate and distinct phenomena when there is
a distorted body image… Feeling lovely is more central than looking lovely. The inner shift
precedes the outer change…unless you love and accept your self, unless you feel beautiful
inside, you will not see your outer beauty, let alone believe it or enjoy it." (pp. 13-16)

With this understanding, Hutchinson developed a workshop with exercises that support
women to appreciate themselves whatever their size.

Bergner (1985) analyzed the results of the Transforming Body Image workshop. One
hundred and twenty-two women were initially tested to have a negative body image. "Very
little research has been done on women's body image and most counseling intervention
approaches have focused on changing the body itself (through exercise or dieting) rather
than helping women learn to appreciate the bodies they have" (p. 25).

"The cognitive intervention approach to negative body image used in this study was
determined to have a significant impact on self and total cathexis in a group format of
relatively short duration. Skills were learned which group members could generalize to
situations outside of the group…. Additionally, members came to realize that their thoughts
and feeling were products of their specific cultural learning histories rather than innate
characterological defects. This was a crucial shift in outlook for these women, many of
whom had spent years immersed in self-blame and self-hatred. Most members expressed
feelings of empowerment and excitement upon learning how to replace habitual, learned
patterns of thinking and behaving with new ones, and thus becoming active, informed
participants in their own growth. The approach used in this study was determined to have a
significant impact on self and total cathexis in a group format of relatively short duration
(eight weeks)." (p. 37)

Clinical psychologist and feminist Laura Brown (1985) recommends that therapists "seize
the concept of women's bodies from the definitions of sexist society in ways that celebrate
the diversity of our women's selves. When we begin to uncover our own participation in the
rules against women's eating and being large in body, we're more likely to deal in a healing
manner with our clients." (p. 71)

Susan Tenzer is the founder and director of the Eating Disorder Treatment Center of Lehigh
Valley. In Fat Acceptance Therapy (F.A.T.): A Non-Dieting Group Approach to Physical
Wellness, Insight and Self-Acceptance, she summarizes her therapeutic approach thus:
"Group support can address the fat woman's unique plight and help raise her self-esteem. It
can liberate her from a sense of powerlessness and worthlessness which is continually
reinforced…Her liberation begins with an understanding about why she cannot lose weight.
The therapist must be informed about the physiology of adiposity, and appreciate the reality
of fat existence in this society and the damage it wrecks on a client's sense of self." (1989,
p. 39)
Gage (1981) who researched body image and self-esteem in obese and non-obese women
concurs. "In the final analysis, the work that underlies issues of food and body size is the
work of teaching women to love themselves for being women…it is the theme that runs
through the struggle that women in American culture have with food. Most of the ways in
which women feel physically "wrong," e.g., having womanly hips, bellies, breasts, and
thighs, are manifestations of how their body is not that of a man." (p. 70)

Shame Therapies

Shame positively correlates with eating disorder symptoms (Sanfter, Barlow, Marschall and
Tangney, 1995). Freud did not address the concept of shame. Its importance emerged
through the editorial work of Nathanson and the late Silvan Tomkins (1987), an Affect
psychologist who contributed to The Many Faces of Shame. Popular understanding of the
significance of shame was facilitated by John Bradshaw, who wrote Healing the Shame that
Binds You in 1988 and who has televised his therapeutic approach. Shame has been
defined as an "unconscious feeling of unworthiness often crystallizing around some
hectoring, negative view of the self…. [In regard to the body, a feeling] that one is
unattractive" (Karen, 1992, p. 42).

Shame and Body Image, by McFarland and Baker-Baumann (1990), is an exhaustive study
of the phenomenon of shame and how it affects a woman's body image. This study found
that shame can affect the way a woman presents herself to others, her body movements, her
manner of eating, her self-image, and her self-esteem. The study suggests that although
shame is, by its very nature, hidden, it must be addressed if the large woman is to acquire
and retain feelings of self-acceptance. "When she deviates from her diet regimen… she
swings into a shame cycle in which she begins to hate herself - I am bad because I am out
of control - and feels fat - I look bad when I'm fat. Her body image and self-image can
dramatically change from acceptable to awful with just a few cookies. Consequently, shame
may become a dominant theme in her body image and her self-image." (p. 81)

McFarland and Baker-Baumann designed a therapeutic approach to healing the shame that
women carry for their bodies. "There are several steps to developing a more empathetic,
accepting relationship with your body" (p. 169). Among the exercises are deep breathing,
changing the way one talks to oneself, re-framing belief systems, examining the
relationship with one's mother, examining generational shame, strengthening activities that
bring joy and pride, letting go of areas that bring feelings of shame, visualizing, and
relaxing (pp. 165-180). In addition, they recommend yoga, massage, art therapy, and dance
therapy (p. 179).

Addiction therapists try to help people get back in touch with their feelings, in most cases
without reference to their body or to their sexuality (Beattie, 1987; Hollis, 1994; Katherine,
1991; Smith, 1990). Most food addiction therapists use the Overeaters Anonymous 12 Step
Program. In these therapists' writings, there is an attempt to assist the individual to look
within and to confront the family systems that may have contributed to difficulties, in
particular, to areas of shame.

Movement and Shame

Exercising the body brings up shame because it is difficult for obese women to move their
bodies after possibly many years of inactivity. For obese women, there is much shame
attached to exercising in public and appearing inadequate and ludicrous. As large women
begin to feel comfortable moving their bodies, their shame about their bodies decreases
(Lyons and Burgard, 1990). Books that encourage large women to move are now becoming
more popular and more support is being given to large women in the form of special swim,
aerobic and dance classes (Peterson, 1992; Price, 1989; Taylor, 1989; Hakala, 1997). Lyons
and Burgard write "Physically active large women have found that we can be fat and fit….
We've discovered that our bodies, like all human bodies, hunger to move; our muscles, too,
itch to be used; our spirits yearn to play…. We deserve the self-confidence and pleasure of
having responsive, capable bodies." (pp. 2,3)

Appearance and Shame

Shame about their fat has led most large women to hide their bodies. Clothes manufacturers
created loose garments made of polyester fabrics with little or no style for large women,
which only contributed to women feeling they should keep themselves covered. Designs
such as the tent dress and the flowery housedress were the only clothes available.
Complaints by Fat Admirers and fat women themselves that fat women did not and could
not dress in a sexually attractive manner began to be addressed by a number of designers
and fat activists (BBW, Radiance, Mode). In Breaking All the Rules: Feeling Good and
Looking Great, No Matter What Your Size, Nancy Roberts (1985) was one of the first
women to address herself to the issues of large women hiding, wearing loose clothing, and
assuming they were so unattractive that they were not worth dressing in fine clothing.
"When I see a big woman who has really put herself together with style and imagination,
my immediate reaction is that she must be very strong. I know the obstacles that she has
overcome…the ridicule of our society…and above all the overriding feeling that somehow
she is not entitled to look good or to feel good. All the rules of our contemporary culture
say she should be hidden away, dreaming of the day when she will be thin enough to care
about her looks and about her life. This kind of thinking has gone on too long…We want to
lead our lives to the full no matter what our size." (p. 7)

That was almost 15 years ago. Today there is Delta Burke (1998), of television fame, who
admits she was drugged most of her life in an effort to stay slim enough for television and
who finally gave up the struggle to stay slim. Now she designs clothes for large women and
models them herself in her new larger body. In a chapter called "Sexy Dressing," Burke
writes "A woman's neckline is one of the most beautiful of God's creations. So why do so
many designers feel the need to cover up real-size necks? …I like to play up my curves
with peplum jackets and fitted waistlines. I also like to wear what I call "glamour blouses"
…with plunging necklines, great prints, and sexy, silky fabrication, over a slim pair of
pants." (p. 126)

Large women who do not feel attractive can stop caring about their appearance because
they feel unworthy, shameful, and hopeless. A number of new writers are now addressing
this shame in its many manifestations. They speak about changing from the inside out,
doing the best with what you have, and learning to behave and present oneself in a sexy and
sensuous way. Some of them run Appearance Seminars that encourage women to wear
makeup, do their hair in a new fashion, dress for success, develop their own style, dare to
be different, and to introduce themselves in the best light possible (Johnson, 1995; Erdman,
1995; Hakala, 1997; Lippincott, 1997; Patterson, 1996).

Large women need to see themselves as desirable, curvy, soft, sensuous, and sexual. In
addition to specific therapeutic approaches, there is a general development of publications
designed to allow large women to see themselves as beautiful. These publications include
Women en Large (Notkin, 1994), Goddesses in Art (Graham, 1997), books with the
paintings of the Renaissance masters, Dimensions magazine, and videos of large people
being sexual together.

Eating and Shame

The shame that large women have developed over their eating patterns can hardly be over-
estimated. Obese women have broken and continue to break all the eating rules that have
ever been designed. Shame for breaking these rules can drum on in their heads all day.
Programs that assist women to reconnect with their hunger instead of with the "rules" of
eating have been developed over the last 15 years. The first was Alan Dolit's (1975) Fat
Liberation, The Awareness Technique. With 10 basic rules such as eat only when your
body and mind are relaxed and don't eat if you're not hungry, the anti-diet diet was born.
Dolit's was the first in a long line of therapies designed to help people get back in touch
with their hunger (Hirshmann and Munter, 1995; Roth, 1984). The Solution, written and
developed by Laurel Mellin (1997) combines the concepts of strong nurturing, effective
limits, body pride, good health, balanced eating and living fully. These books attempt to
release women from the diet programs and lead them back to a saner relationship with food.

Self-Esteem and Shame

Shame for one's body is a direct attack on self-esteem. There are a number of recent
publications that urge large women to start living full lives whether they lose weight or not.
In Self-Esteem Comes in All Sizes: How to Be Happy and Healthy at Your Natural Weight,
Carol Johnson (1995) encourages women to participate in society and in relationships. In
Full Lives: Women Who Have Freed Themselves from Food and Weight Obsession, edited
in 1993 by Lindsey Hall, women who had overcome their negative body images in different
ways agreed to talk about how this happened for them. Marcia Hutchinson, who wrote
Transforming Body Image was one of these women. She writes "It took me years to notice
a funny thing. Even when I did lose weight, changing my body never had any positive
effect on my feelings about myself or my body. …Because I had not changed my attitudes,
values, judgements, and self-talk, I was still locked in whatever negativity I had before
losing weight….I figured that I would have to transform the relationship that I had with
(my body)…I knew that I could not get on with my life until I changed the way I lived in
and related to the body I have. If it came closer to my ideal, that would be gravy. If not, I
would still be acceptable to myself." (pp. 99,100)

Touch and Shame

One problem for people experiencing shame regarding their bodies is that they often do not
feel comfortable allowing anyone, friend, healing body worker, potential or even current
sexual partner, too close to their bodies (Yohannon, 1996). Many obese women fail to find
partners with whom to share their sexuality. They become touch deprived and lack
knowledge about sexual issues that would assist them in relationships (Yohannon, 1996).

Therapies that teach couples how to touch have been designed by Masters and Johnson
(1970), who taught sensate focus exercises, and by Hartman and Fithian (1972), who
designed caress exercises.

At the world's only scientific center devoted to exploring the effects of touch on health,
Miami's Touch Research Institute, more than 50 studies have shown massage to have
positive effects on eating disorders (Colt, 1997, Aug).

Sexual Therapies

Well-established sex therapies (Annon, 1975; Hartman and Fithian, 1972; LoPiccolo, 1972;
Masters and Johnson, 1970) that assist couples with sexual dysfunctions are available for
obese couples as they are for other couples.

Sexual Communication and Assertiveness

Studies have shown that large women, due to diminished sexual self-esteem and lack of
experience, often have difficulty asserting their needs and communicating with their
partners about sexual issues (Shapiro, 1980; Spiegel, 1988; Yohannon, 1996). Tullman,
G.M., Gilner, Kolodny, Dornbush, and Tullman, G.D. (1981) measured the communication
skills of 43 couples undergoing sex therapy at the Masters and Johnson Institute, both
before and after therapy.

"Results showed that the females exhibited significant increases across the 2-week period
of therapy for the following skills: positive assertion in intimate heterosexual peer
relationships, assertiveness, verbal expression of feelings, tolerance for the less pleasant
aspects of the loved one, and nonmaterial support and evidence of love…. These results
lend empirical support to Masters and Johnson's theoretical model of communication and to
the view that much more than simple behavior therapy is involved in a successful sex
therapy program." (pp. 95,96)

Although the participants in this study were not specifically obese, the results can be
extrapolated to obese couples.

Other Sexual Therapies

There was nothing in the literature regarding therapies for the problem that obese couples
have if one of them is unable or unwilling to accept the fat of the other, although there is
literature that mentions this problem (Stuart and Jacobson, 1987). Tenzer (1989) was the
only reference that discussed it from a therapeutic perspective. Regarding her therapy
groups, Tenzer writes "What we really learn to handle is relationships, especially intimate
relationships. With the greatest of luck, these women have discovered friends who we call
FA's. If a woman can accept her size, but her loved one cannot, the group supports her in
accommodating that opinion for the sake of a relationship she likes or choosing to end the
relationship for the damage it does to her." (p. 46)

It is notable that Tenzer does not offer couples therapy to such a couple nor does she
suggest a therapy that might expand the partner's sexual stimulators to include larger
women. McIlvenna (1987) is the only reference that suggests that one can expand one's
sexual fantasies in order to improve one's sex life (p. 57).

Will the Real Women Please Stand Up! Uncommon Sense About Self-Esteem, Self-
Discovery, Sex, and Sensuality, by Ella Patterson (1996), is a publication mostly about
sexuality. Patterson, a large woman herself, did not write the book exclusively for obese
women. It is a guide for all women filled with exercises for the mind and body that
celebrate the sexuality of women of all sizes.

The newest source book for people of size and for those who love them, Big, Big Love
(Blank, 2000) has one of the most complete listings of resources specifically for obese
couples. In the chapter "Titillations and Tactics: Practical Sex for People of all Sizes,"
Blank lists positions for penetration, the use of bellies as erogenous zones, fat frottage,
breast frottage, bondage/discipline and sadism/masochism for fat lovers, as well as the
pleasures and pitfalls of crushing, trampling, face-sitting and smothering. The erotic
practice of feederism, encouraging a partner to gain weight, is described in Blank's book.
This practice is not well known, and many of the participants, "historically, have not been
open and honest about their interests, have not identified themselves as feeders to their
partners, or explained what feederism is and what it means to the very people they were
engaging in feeder relationships" (p. 243). This sexual information, most of which pertains
only to the obese, is an important aspect of sexual therapy for the obese couple.

The Fat_Sex Website is available as an information source to those who would like to learn
more about obesity and sexuality. It is not always clear if the information being offered is
accurate but the Webmaster is quite knowledgeable and offers his opinions quite often
when serious questions come up.

Although not a therapy as such, in the advice column, Aunt Agony, of the magazine, FAT!
SO?, a reader asked, "How can I learn to forget about my body during sex and just enjoy it?
Answer: "Forget about your body? My poor anxious dear, sex is about your body. Learn to
love it" (p. 32). In that same column, Aunt Agony gives instructions to a boyfriend who
wonders how to help his girlfriend accept herself as beautiful. "Tell her as often as possible
how beautiful you think she is, and how much you like her body, her appearance, and
everything else about her. If touching is part of your relationship, stroke her, pet her. That
will help her feel the love you express in words in her body. And if you get discouraged, or
if it seems like you're losing ground, try to remember that the little drops of love and
appreciation you give her add up, and may provide the nourishment she needs to bloom."
(p. 32)
 Chapter 8

Method
A questionnaire-based survey design was employed to develop data which would assess the
relationship between sexual satisfaction and other variable factors among obese women in
long-term relationships, which is the hypothesis of this dissertation. This chapter describes
the participant recruitment process, the instrumentation, and the procedures employed to
obtain the data.

Participants and Sample Development

A sample of volunteers was developed by a variety of methods. Announcements of the

study were placed on the World Wide Web, in magazine articles, and on bulletin boards. A
modified "snowball" approach was initiated in which volunteers agreed to recruit additional
participants. (For breakdown of sources, see Appendix C.)

Inclusion criteria included: experience in a prior or current sexual relationship of at least 6

months, a Body Mass Index (BMI) of 30 or greater and female.

Exclusion criteria included: obvious psychopathology.

Instrumentation

The principal survey instrument was the Factors in the Satisfactory Sexual Relationship
Survey (FASSRS), a self-report instrument designed by the author for utilization in the
present research (contact the author for a copy). Items were selected from a variety of
previously developed questionnaires and augmented by items developed by the author.
Eight broad categories of sexuality in relationships were operationalized by items in a
variety of formats (e.g., Likert scales, true/false, fill-ins). The categories taken from the
various sections of the questionnaire included: demographics, body image, sexual
satisfaction, sexual self-confidence, communication and assertiveness, participant sexual
enjoyment, partner's sexual enjoyment, perceived partner's attitudes on weight, participants
weight negativity. (For the exact questions used in forming the tables and scales, see
Appendix F.) Only one member of the couple was questioned so that the study does not
reflect the actual opinions of the partner, only the perceived opinions by the FASSRS
participant.

The demographic section included items relating to age, weight, height, BMI, length of
relationship, marital status, occupation, income, religion of parents, present religion,
religious activity, diet history, abuse history, and therapy experience.

Procedure

Survey questionnaire packets were distributed by hand, were mailed to participants or were
sent via the Internet. Participants completed the form online and e-mailed the completed
document to the researcher or returned the completed instrument to the author using an
enclosed envelope. Each questionnaire contained a cover letter explaining the purpose of
the study and the participants' role in it, a consent form, and when appropriate, a stamped
self-addressed return envelope. A number of responses were obtained through an article
written by the author for oooO baby Baby fashion magazine for large women (Appendix
E). Respondents were invited to become participants in this research after reading the
article.

Measures

The dependent variable of interest in this study was the sexual satisfaction of the female
participant as measured by a number of questions, and the direct queries that asked her, on
a scale of 1-5 with 1 the lowest and 5 the highest, how satisfied she was with her sexual
relationship. The independent variables that were indicated in previous studies were used in
the analyses that followed. The mean in these cases is simply the percentage of the sample
for which the variable in question was present.

The independent variables are the demographics, the number of diets, the long term success
of the diets, body image, sexual attitudes, self-confidence, sexual communication,
enjoyment of sex from the point of view of the participant and the partner and the partner's
attitudes on weight. (For a complete list, see the scales in Appendix F.)

Limitations

The primary threat to the internal validity of the survey arises from the possible presence of
social desirability concerns influencing the respondents' answers. Without an independent
assessment of this threat its effects are unknown.

Another threat concerns instrumentation. The survey questionnaire is an original instrument

that was developed for the purpose of the study. No previously published instruments were
employed. The reliability of the overall instrument and its sub-scales is unknown. The
instrument may be presumed to have construct validity as each of the items was selected to
be relevant to sexual relationships and the collection of items was adjudged satisfactory by
three experts in sexology.

Another threat to external validity arises from the non-random, self-selected nature of the
sample. Since most of the respondents came from the Internet, we can assume a higher
level of education among them with knowledge of the resources and technology that are
associated with Internet use. The respondents were associated with the fat-acceptance
movement, through the Internet, the oooO baby Baby magazine, and through the lists
associated with Radiance magazine, to which I was referred. A related limitation stems
from the BMI inclusion criteria; females with BMI values which did not meet the criteria
were not included in the study, hence the results cannot be generalized to that portion of the
female population.

Chapter 9
 Results
A sample of 119 obese women was obtained for the purpose of determining those factors
that may lead to a sexually satisfying relationship. Each respondent completed a 17 page
survey that focused on her self image and history related to her relationships, weight and
diet, therapy and sexuality. This chapter presents the results of the data analyses performed
and begins with a summary of the sample results, followed by a presentation of the results
of the hypothesis testing. It concludes with a consideration of additional findings.

Scales were developed from sets of items so as to obtain satisfactory levels of reliability.
(Item composition for each scale may be found in Appendix F.)

Demographic Characteristics

The sample was comprised of 119 women who had a mean age of approximately 38 years,
16 years of education and earned an average of $35,000 per year (see Table 1). The
respondents were primarily Caucasian with a Protestant religious upbringing. Sixty- one
percent of the sample indicated that they are not active in their current religion.

The mean body weight of the sample is 298 pounds and the mean Body Mass Index (BMI)
is 49. The weight of the women ranged from 180-524 pounds. All of the respondents
reported a BMI in excess of 30, which is considered as "Obese" according to the National
Institute of Health.

Table 1

Sample Descriptive Statistics

Demographic Sample Statistics

N Mean SD
Age 38.17 9.31
Height 65.39 2.62
Weight 298.44 73.63
Body Mass Index 49.12 12.09
Years of Education 16.51 4.40
Income 110 35,429 28,175
Current Relationship Length
100 94.1 83.62
(months)
Length since Respondent was in
19 33.84 41.49
Relationship (mo)
Length of last Relationship (mo) 18 51.61 87.94
Family of Origin

Ethnic Background
Mother Father
N % N %
European 100 84.03 95 79.83
Other 11 9.25 17 5.88
Afro-American 10 6.72 7 14.29

Racial Background
Mother Father
N % N %
Caucasian 104 87.39 100 84.03
Afro_American 10 8.40 10 8.40
Other 5 4.21 9 7.56

Parents Religious
Upbringing
Mother Father
N % N %
Protestant 59 49.58 47 39.50
Catholic 35 29.41 33 27.73
Jewish 13 10.92 13 10.92
Other 12 10.09 26 21.85

Respondent's
Current Religion
N %
Protestant 43 36.13
None 20 16.81
Catholic 16 13.45
Other 16 13.45
Agnostic 9 7.56
Pagan 7 5.88
Jewish 5 4.20
Buddist 3 2.52

Active in
Current Religion
N %
No 73 61.34
Yes 46 38.66

Main Occupations N
Teacher/Social Worker 40
Professional/Business 38
Secretary/Trades 30
Laborer/Housewife 7
No Response 4

Relationship Characteristics

Of the 100 women in the sample who reported that they are currently in a relationship,
52.49% are not married to their current sex partner (see Table 2). The average length of the
long term relationship is approximately 7.5 years.

Overall, the respondents indicated that they have a sexually satisfying relation-ship with
65.6% of them indicating that they were "Quite Often to Almost Always" satisfied in their
relationship. This is also indicated in the mean response of 3.32 in the ranking of sexual
satisfaction. This item is considered critical as an indication of overall sexual satisfaction.
Eighty-four percent of the respondents indicated that "as far as they knew" their partners
were faithful to them. Sixty-six percent indicated that they have been faithful to their
partner.

Table 2

Relationship Characteristics

Current Marital Status N %

Married or Committed 61 51.26
Single 31 26.05
Divorced 26 21.85
Widowed 1 0.84

Married to current sex

N %
partner
No 63 52.49
Yes 55 46.22

Mean SD
Length of Relationship (in months) 85.38 86.29

Mean SD
Satisfaction with Sexual Relationship 3.32 1.37

Scale:
1 = not at all
2 = occasionally
3 = quite often
4 = very often
5 = almost always

Satisfaction with Sexual Relationship:

N %
Quite Often to Almost Always 83 65.55
Not At All to Occasionally 41 34.45

Partner Faithful to You

N %
Yes 100 84.03
No 19 15.97

You Faithful to Partner

N %
Yes 79 66.39
No 40 33.61

Weight History

Overall, the respondents indicated that in comparison with their peers, throughout their
lives, they had always been "somewhat bigger". This trend continued to the present (see
Table 3). There appears to be more variability during adolescence as noted by the standard
deviation of 3.5. The respondents also indicated that their peers' attitudes were more
negative and critical than their father or mother's attitudes.

The respondents reported "neutral" to "slight dissatisfaction" with their current weight.

Table 3

Weight and Diet History

Weight History Mean SD

Compared to your peers your
size was
Childhood 2.4 1.1
Adolescence 3.1 3.5
Young adulthood 3.4 1.5
During last 5 years 3.8 1.1

Scale:
1 = a little bigger
2 = somewhat bigger
3 = much bigger
4 = very much bigger

Attitudes toward your

Mean SD
appearance growing up
Peers 2.2 1.1
Mother 2.7 1.7
Father 3.0 1.9

Scale:
1 = very negative
2 = somewhat negative and critical
3 = neutral
4 = generally positive
5 = very positive

Mean SD
Satisfied with current weight: 2.4 1.2

Scale:
1 = very dissatisfied
2 = somewhat dissatisfied
3 = neutral
4 = somewhat satisfied
5 = very satisfied

Diet history
(The diet history of the respondents was reported per a multiple response mode. Some
respondents repeated diets many times. Twenty-seven percent never dieted.)

Success Rate Scale:

0 = no weight loss
1 = very little weight loss
2 = average weight loss
3 = good weight loss
4 = reached goal

Short Long
% of % of
Term Term
Count Responses Cases Mean SD Mean SD
Calorie
92 14.0 80.7 2.0 0.9 0.4 0.7
counting
Eating less with
66 10.0 57.9 1.9 1.1 0.9 1.1
exercise
Diet pille 61 9.3 53.5 2.0 1.2 0.4 0.9
Starving 60 9.1 52.6 2.0 1.1 0.2 0.7
Diet clubs 58 8.8 50.9 2.2 1.1 0.4 0.8
Counseling 54 8.2 47.4 0.9 1.0 0.3 0.9
Liquid diets 50 7.6 43.9 2.0 1.1 0.3 0.7
Overeaters
35 5.3 30.7 0.8 0.2 0.7 1.3
Anonymous
Support Groups 27 4.1 23.7 1.3 1.0 0.2 0.6
Over-exercising 20 3.0 17.5 1.9 1.2 0.5 0.8
Diuretics 20 3.0 17.5 1.2 1.1 0.3 0.5
Fen-Phen 18 2.7 15.8 1.7 1.3 0.7 1.1
Vomiting 17 2.6 14.9 0.9 1.2 0.2 0.4
Overcoming
Overeating 16 2.4 14.0 0.5 0.7 0.4 1.1
method
Body
acceptance 14 2.1 12.3 0.8 0.8 0.3 0.7
classes
Geneen Roth
12 1.8 10.5 0.7 0.8 0.0 0.0
method
Laxatives 11 1.7 9.6 1.4 1.3 0.3 0.5
Diet spas 10 1.5 8.8 1.3 1.1 0.1 0.3
Surgery 9 1.4 7.9 2.8 1.3 1.0 1.5
Thin Within 7 1.1 6.1 1.7 1.2 0.0 0.0
Total Responses 657 100

Counting calories was the most popular method of weight loss with women repeating this
method many times. The greatest short-term success rate was achieved through surgery,
however, there were only nine instances of this method of weight loss. Of more
significance, the mean short-term success rate for diet clubs of 2.2 (average weight loss)
was reported by fifty-one percent of the women. Overall, long-term diet success was not
reported.

Abuse History

The abuse history of the respondents indicated that approximately 50% were verbally
abused and 30% were sexually abused (see Table 4). They reported that the verbal abuse
affected them emotionally "very much" (Mean 4.19) and sexually affected them "some"
(Mean 2.4). The sexual abuse affected them emotionally "a medium amount" to "very
much" (Mean 3.63) and sexually affected them "a medium amount" (Mean 3.24). The
women reported that the abuse appears to have had a greater emotional rather than sexual
aftereffect. The variability in the subsequent sexual effects of sexual abuse is greater per the
higher Standard Deviations (SD).

Table 4

Abuse History

Affected emotionally by: Mean SD N

Verbal abuse 4.19 0.98 58
Physical abuse 3.83 1.20 29
Sexual abuse 3.63 1.42 38
Affected sexually by:
Sexual abuse 3.24 1.57 38
Verbal abuse 2.40 1.61 57
Physical abuse 1.90 1.75 30

Abuse Scale:
0 = not at all
1 = once or very little
2 = some
3 = a medium amount
4 = very often / much
5 = severely
Therapy History

Fifty-four women indicated they had used counseling or therapy to assist them in losing
weight (see Table 3). Those who were involved in individual therapy (see Table 5) reported
the highest level of weight loss (42%), body acceptance (28%) and other benefits (17%).
Overall, seventy-eight women indicated they had sought counseling for emotional issues.
Only thirteen had any specific sexual counseling, of these, seven provided effectiveness
information and it was said to be slightly effective (3.5 on a 5 point scale).

Table 5

Therapy History

% gained % other
% lost
body
weight
acceptance benefits
Individual therapy 42.1 28.3 16.7
Group therapy 19.0 15.8 12.5
Support group 10.7 5.0 3.3
Size acceptance
9.9 9.2 9.2
seminar
Body therapies 6.6 5.0 0.8
Specialized therapy 3.3 2.5 1.7

Sought Counseling for Emotional Issues:

N %
Yes 78 67.8
No 37 32.2

Sexual History, Activities and Relationship

Forty-five percent of the women in the survey indicated that they were sexually attracted to
"only men", whereas the remaining 55% of the women indicated that they had a orientation
other than "only men." Eight percent said they were attracted to mostly or only women.
Eighty-two percent of the women reported that their partners were only sexually attracted
to those of a different gender (see Table 6).

The mean age of the first sexual activity for the women was 15 years and they engaged in
sexual intercourse at the mean age of 17 years. The context of their first intercourse was
reported to be of free will by 76% of the respondents. The remaining 24% of the
respondents indicated that the context of their first intercourse involved either verbal,
physical or violent pressure. Since their first sexual intercourse, forty-seven women (39%)
reported that they had been forced into sexual intercourse. Thirteen of the women reported
violent force and thirty-one reported coercion or date rape.

Overall, the women reported satisfaction with their sexual relationships as reflected in a
mean satisfaction rating of 3.39 on a scale of one to five. Their non-sexual relationship
satisfaction was reported as 3.84. The women reported that the factors they believed to have
the most influence on feelings of satisfaction in their sexual relationship was their partner,
their own positive sexual outlook, and their own positive body image. Similarly, they
ranked their partner and their own negative body image as having the most influence on
their feelings of dissatisfaction in their sexual relationship. The women did not feel
counseling or diets had much influence on their reported satisfaction or dissatisfaction in
their sexual relationships.

The women reported that they enjoyed cuddling, stroking, kissing, sexual intercourse, oral
sex, and mutual masturbation. Correspondingly, they reported that their partners enjoyed
these same sexual activities. They reported favorable sexual positions of "partner on top",
"rear entry", and "you on top". "You on top" was reported as enjoyed by their partners by
90 of the respondents, whereas a lesser number of the respondents (64) reported enjoyment
in this position. The women reported sexual dysfunction related to orgasm difficulty (32%),
physical pain (10%), feeling anxious about ability to perform (13.4%), difficulty lubricating
(3.0%), decreased interest in sex due to medication(1.9%), arousal disorder, a decrease in
interest due to medication, or partner's erectile difficulty. They reported that 12% of their
partners had difficulty experiencing orgasm, 16% came to a climax too quickly, 18.% felt
anxious about the ability to perform, 24% have trouble achieving or maintaining an
erection. Some persons have more than one of these sexual dysfunctions.

Table 6

Sexuality

Self

Sexually attracted to:

N %
Only men 54 45.0
Mostly men 38 31.7
Both men and
18 15.0
women
Mostly women 4 3.3
Only women 5 4.2
Sex history:

Mean SD N
Age first petted (yrs) 15.01 3.78 114
Age first coitus (yrs) 17.24 3.26 96
Number of sex partners 21.64 30.84 111
Number of sex partners last year 1.64 1.35 118
Longest time with any partner
79.34 83.98 113
(mos)

Context of first sexual intercourse:

N %
Free will 90 75.6
Verbally pressured 14 11.8
Violently pressured 9 7.6
Physically pressured 6 5.0

Since first intercourse, have you ever been forced into sexual intercourse:

N %
No 71 60.2
Yes 47 38.8

How many times were you forced into sexual intercourse:

N %
1 28 58.3
2 4 14.1
3+ 16 27.6

How forced:

N %
Date rape 18 41.0
Violent 13 29.5
Coerced 13 29.5
Partner

Is your partner sexually attracted to those of a different gender from you:

N %
No 99 82.5
Sometimes 14 11.7
Yes 4 3.3
No answer 2 2.5

Relationship

Mean SD N
Sexual relationship
3.39 1.30 119
satisfaction
Non-sexual relationship
3.84 1.13 119
satisfaction

Relationship Scale:
1 = least
5 = most

Descriptive Statistics

Of those participants who considered themselves sexually satisfied, the following factors
were ranked as having the most influence on the feeling of satisfaction in the sexual
relationship (ranked in descending order).

Rank

1. Partner
2. Positive sexual outlook
3. Positive body image
4. Counseling
5. Diets

Of those participants who considered themselves sexually not satisfied, the following
factors were ranked as having the most influence on the feeling of dissatisfaction in the
sexual relationship (ranked in descending order).

Rank

1. Negative body image

2. Your partner
3. Negative sex attitudes
4. Lack of or poor counseling
5. Diets

Sexual Activities

You Partner
Mean SD N Mean SD N
Cuddling 3.65 0.77 117 3.26 1.04 117
Stroking 3.58 0.82 117 3.35 1.00 117
Enjoy kissing 3.46 0.93 115 3.15 1.22 115
Sexual intercourse 3.36 1.02 116 3.50 0.90 116
Receiving oral sex 3.32 1.13 117 3.47 1.13 117
Giving oral sex 2.85 1.32 117 2.75 1.48 117
Other 2.78 1.64 9 1.89 1.45 9
Mutual masturbation 2.68 1.41 115 2.69 1.46 115
Telephone sex 1.49 1.48 108 1.29 1.43 106
Anal sex 1.00 1.35 109 1.39 1.56 106
Light S & M 1.63 1.57 109 1.18 1.50 10
Heavy S & M 0.62 1.29 104 0.53 1.13 104

Scale:
0 = not at all
1 = enjoy somewhat
2 = enjoy quite a bit
3 = enjoy very much
4 = enjoy completely

Positions enjoyed

You % % Partner % %
Description Count Response Cases Count Response Cases
Partner on top 96 20.1 86.5 90 18.2 81.8
Rear entry 87 18.2 78.4 87 17.6 79.1
You on top 64 13.4 57.7 90 18.2 81.8
Sides, rear entry 52 10.9 46.8 55 11.1 50.0
Legs over side of bed 50 10.5 45.0 46 9.3 41.8
Scissors 44 9.2 39.6 39 7.9 35.5
Facing on sides 32 6.7 28.8 31 6.3 28.2
Sitting 24 5.0 21.6 26 5.3 23.6
In a swing 10 2.1 9.0 9 1.8 8.2
Standing 19 4.0 17.1 22 4.4 20.0
Total responses 478 100 495 100

Sexual Dysfunction

Partner
You % % % %
Description
Count Response Cases Response Cases
Count
Own orgasm difficulty 38 30.2 53.5 14 14.3 23.7
Arousal disorder 36 28.6 50.7
Decreased interest due to
23 18.3 32.4 14 14.3 23.7
medication
Performance anxiety 16 12.7 22.5 21 21.4 35.6
Physical pain during
12 9.5 16.9 2 2.0 3.4
coitus
Climax too quickly 1 0.8 1.4 19 19.4 32.2
Erectile difficulty 28 28.6 47.5

Weight and Relationship

The respondents indicated that they were "somewhat dissatisfied" with current weight (see
Table 7). They were "often" to "sometimes" self-conscious about their appearance and felt
similarly about themselves around potential sexual partners. They reported feeling
"somewhat negative and critical" to "neutral" about their nude body when alone. When
nude in sexual encounters, they reported feeling more "neutral."

In terms of sexual appeal, they rated themselves as "somewhat" to "quite sexually

appealing." They indicated that their body image is "about the same" to "somewhat better"
than 10 years ago.

Nearly half (44.8%) of the women reported that their weight had become a disability for
them in their daily life. They further indicated that they would enjoy their sexual life more
if they were thinner (52.4%) and that their weight affected their capacity to express
themselves sexually (47.1%).

Eighty one percent of the respondents reported "rarely" to "never" that weight has been an
issue in their relationships. 95.7% of the sample reported that "rarely" to "never" has their
partner pressured them to lose weight.

The percentage of women who reported that their partners are "very much" to "quite"
sexually attracted to them was 71%. Seventy-three percent of the women believed their
partners would not find them less desirable if they gained weight.

Table 7
Weight and Relationship

Mean Scale SD N
Frequency weigh self 5.53 1=2x day; 6=rarely 0.94 119
Is body sexually appealing 3.44 1=not at all; 5=extremely 1.08 117
Current body image vs. 10 1=much worse; 5=much
3.40 better
1.44 118
years ago
1=very negative; 5=very
Nude in sex encounters 3.19 positive 1.31 118
Comfortable sharing true
3.00 1=never; 4=always 1.31 119
weight
Self-conscious around sex
2.75 1=always; 5=never 1.28 119
partner
Physically active 2.74 1=very inactive; 5=very active 1.09 119
Self-conscious about
2.66 1=always; 5=never 0.98 119
appearance
1=very negative; 5=very
Nude self-perception 2.55 positive 1.21 117
Satisfied with current 1=verydissatisfied;5= very
2.38 satisfied
1.23 119
weight

If you were thinner, would you enjoy your sexual life more: Yes = 52.4%

Has your weight become a disability for you in your daily life: Yes = 44.8%

Are you physically disabled from any other cause: Yes = 28.8%

Does your weight affect your capacity to express yourself sexually: Yes = 47.1%

Weight influenced choice of sex partner: True = 46.7%

Weight interferes with sexual behavior: True = 33.6%

Weight interferes with sexual feelings: True = 24.4%

Your weight an issue in your relationship: Rarely to never = 80.9%

Does partner remind you gently to lose weight: Rarely to never = 90.4%

Has partner ever verbally abused you about your size: Rarely to never = 87.4%

Does partner pressure you to lose weight: Rarely to never = 95.7%

Does partner ask you to gain weight: Rarely to never = 98.3%

Does partner complain how much you are eating: Rarely to never = 93.2%

Do you believe your partner would find you less desirable if you gained weight: No =
73.0%

Would you be less interested in sex with your partner if you gained weight: No = 67.2%

Would you be more interested in sex with your partner if you lost weight: No = 55.9%

Would your partner find you more sexually desirable if you were thinner: No = 68.2%

In regards to your sexual desirability, who is more concerned about your weight:

f %

You 100 94.3

Your partner 6 5.7

Do you believe your partner is sexually attracted to you: Very much to quite attracted =
71.4%

How would you describe the size of your partner:

f %

Large 56 44.5
Average 44 40.2
Thin 18 15.3

Does your partner's body size affect your attraction to him/her: Not much to not at all =
67.5%

Would you be more interested in sex with your partner if your partner lost weight: No =
85.5%

Subgroup Analysis of Minority Participants

Ten African-American women participated in the study. Their average number of years in
school was 16. Of these 10 women, all but one were in a heterosexual relationship. One
was in a lesbian relationship. Six claimed to be satisfied in their sexual relationship, 4 were
not satisfied.

Five participants said they were only attracted to women, and 4 were attracted mostly to
women. Their average number of years in school was 17. Of these 9, 5 were in committed
relationships. One was in a heterosexual marriage. Three were not in committed
relationships. Of the 9, 4 said they were satisfied with their sexual relationship, 5 said they
were not.

Eighteen participants said they were attracted to both men and women. Their average
number of years in school was 17.8. Of these 18 participants, one was in a committed
lesbian relationship, 7 were single, and the remaining 10 reported that they were married or
in committed heterosexual relationships. Of these 10, 2 were in a polygamous association.
One of these 2 was in an intergendered relationship and the other one was married to a
heterosexual with whom she was not satisfied, but had an additional transgendered
relationship which was highly satisfactory. Of the 18 women, 11 were sexually satisfied
and 7 were not.

Basic Research Question

The important question is "What are the significant factors in the satisfied sexual
relationships of large women?" Table 8 summarizes the scale variables used in answering
this question. Refer to Appendix F for a detailed listing of the questionnaire items included
in each of the scales. These scales represent items in the questionnaire that are consistent in
their content. For instance, the Sexual Attitudes - (SEXATT) scale was created from the
following selection of questions from the questionnaire.

Scale: 1 = mostly true, 2 = mostly NOT true

1. Expressing your sexuality is important to you.

3. You are comfortable discussing sexual attitudes and activities with close friends.
4. You are comfortable discussing sexual attitudes and activities with your sexual partner.
5. You enjoy sharing your body during lovemaking.
10. You are comfortable with your own sexuality.
11. You enjoy trying something new sexually.
12. You are aware of your sexual desires.
13. You feel that you are a sensual person.
14. You are comfortable pleasuring yourself sexually.
15. Dressing in a manner that makes you feel sexually attractive is comfortable for you.

Reliability analysis was performed for each of the scale variables and the overall alpha
calculated for these items indicating a significant relationship amongst themselves.

Two indexes have been created to provide further analysis of the sample data. These
indexes are referred to as the Weight Negativity index and the Sexual Satisfaction index.
These indexes contain questions with differing content that allow further examination of a
diverse set of items. The Weight Negativity index refers to a combination of question items
concerning the respondents' perceptions of their weight in the relationship. The Sexual
Satisfaction index refers to a combination of question items concerning the respondents'
perceptions of their sexual satisfaction.
The independent variable to be tested against the other variables is Sexual Satisfaction
(SEXSAT). The overall alpha of the seven questions included in this scale was .92
indicating a high level of reliability.

Table 8

Descriptive Statistics - Scale Variables

Range of
N Mean SD
Possible Values
Number of diets DIETNUM 91 23.27 25.74
Months of dieting DIETMOS 56 164.77 147.85
Short term success SHORTSUC 111 9.49 5.65
Long term success LONGSUC 110 2.13 3.08
Number of diet methods DMETHODS 114 5.76 3.20
Counseling and Therapy CTHELP 11 4.00 2.97
Body Image BODYIMAG 119 23.20 7.00 8 to 40
Sexual Satisfaction SEXSAT 119 22.51 7.77 7 to 35
Sexual Attitudes SEXATT 119 11.25 1.84 10 to 20
Sexual Self-Confidence SEXCONF 118 21.83 5.54 6 to 30
Sexual Communication SEXCOM 119 46.50 9.22 18 to 72
Own Sexual Enjoyment SEXJOY 117 27.37 6.78 10 to 50
Partner Sexual Enjoyment PRTSXJOY 117 26.20 6.85 9 to 45
Partner on Weight PRTONWT 119 29.04 4.36 7 to 28

The correlation coefficients, depicting the basic relationship across these scale variables,
were calculated for these items (see Table 9). Per review of the correlations of the
dependent scales, it was noted that Sexual Satisfaction had a mid-level (greater than .2 but
less than .5) negative correlation with Sexual Attitudes (-.494) and the Index of Weight
Negativity (-.236). This indicates that the lower the index of weight negativity, the better
the sexual satisfaction. These correlations may be attributed to the fact that the better one
feels about one's own weight, the better one's sexual attitudes, hence higher level of sexual
satisfaction. Sexual Satisfaction had mid-levels of positive correlation with Sexual Self-
Confidence (.476), Body Image (.356), Partner Sexual Enjoyment (.347), Partner on
Weight (.268) and Own Sexual Enjoyment (.258). These correlations indicate that the
higher the sexual self-confidence, body image, and partner's sexual enjoyment and, to a
lesser degree, partner's (perceived) positive attitude about participant's weight, coupled with
participant's own sexual enjoyment, the higher the sexual satisfaction of the study
participant. A high level of correlation (greater than .5) existed between Sexual Satisfaction
and Sexual Communication (.642), Counseling and Therapy (.585), Sexual Counseling
Effectiveness (.703) and the Sexual Satisfaction scale (.979). It is noted that there were only
eleven respondents who reported on the Sexual Counseling Effectiveness and Counseling
and Therapy. Consequently, less emphasis will be given to these items. Of greater
importance, is the high level of correlation between Sexual Satisfaction and Sexual
Communication. This indicates that the more communication with their partner, the better
the women felt about their sexual relationship.

Table 9

Intercorrelation of Dependent Scales

1 2 3 4 5 6 7 8 9
1 BMI 1.000
2 BODYIMAG .171 1.000
3 SEXSAT -.023 .356* 1.000
4 SEXATT .075 -.364* -.494* 1.000
5 SEXCONF .155 .771** .476* -.442* 1.000
6 SEXCOM -.052 .391* .642** -.516** .498* 1.000
7 SEXJOY .076 .313* .258* -.485* .447* .385* 1.000
8 PRTSXJOY -.186 .254* .347* -.437* .337* .552** .523** 1.000
9 PRTONWT .056 .439* .268* -.260* .311* .308* .133* .134 1.000
10 WTNEG -.152 -.780** -.236* .312* -.685** -.294* -.333* -.180 -.463*

Note: N = 119.
* A mid-level of correlation is noted: the absolute value of correlation coefficient is greater than 0.2 but less
than .5
** A high level of correlation is noted: the absolute value of the correlation coefficient is greater than 0.5 or
less than -0.5

Of interest is the high level of correlation existing between Sexual Self-Confidence and
Body Image (.771) and the Index of Weight Negativity (-.685). The Index of Weight
Negativity shows that the worse a participant feels about her weight the less confidence she
will feel in her sexuality and the less approval of her body image she will have.

Also of interest is the mid level of correlation existing between Sexual Attitudes and Sexual
Self-Confidence (-.442), Sexual Communication (-.516), Own Sexual Enjoyment (-.485),
Partner Sexual Enjoyment (-.437), Body Image (-.364) and Sexual Satisfaction (-.639).
This indicates that the more comfortable she is in her own sexuality, sexual self-confidence,
the more she asserts herself in sexual communication, the more enjoyment she feels in her
sexual relationship, the more she perceives that her partner is enjoying the relationship, and
the more positive her body image is, the more sexual satisfaction she will enjoy.

A mid-level of correlation exists between Partner on Weight and Body Image (.439). A
partner's perceived positive attitude on the participant's weight is correlated to her own
positive body image. In this questionnaire, it is the participants' belief about the partner's
attitude on her weight, as the partner was not asked for his/her opinion. Additionally, the
index of Weight Negativity has a high level of correlation between Body Image (-.780) and
Sexual Self-Confidence (-.685). If a woman does not perceive her weight as a drawback,
her body image will be positive and her sexual self-confidence will be high.

In order to determine what factors are most important in the satisfied sexual relationship of
large women, multiple regression analysis was performed. This analysis was necessary as it
has been determined that there are significant correlations as noted above. The question that
continues to arise is: What is the most important factor or factors? Given a comparison of
the beta weights in a multiple regression equation, one can determine what factors might
predict sexual satisfaction. Additionally, this analysis allows a look at the relative
importance of each of these factors.

In the linear regression analysis performed, the dependent variable was Sexual Satisfaction
(SEXSAT). Three levels of testing were performed using blocks of independent variables
that are otherwise known as predictors. The first level of independent variables included
demographic items such as relationship length, education and age. The second level of
independent variables included the demographic items and weight-related items such as
body image, total diet months, short-term success in dieting and the index of weight
negativity. The third level of independent variables included the demographic items,
weight-related items and partner-related items such as partner's sexual enjoyment, partner's
perceptions of weight and sexual communication (see Table 10).

Table 10

Model Summary

Adjusted R Std Error

Model R R squared
Squared of the Estimate
1 .213 .046 -.020 7.87
2 .480 .230 .073 7.51
3 .667 .445 .276 6.63

Model 1: Demographic Predictors:

Relationship Length, Education, and Age

Model 2: Weight Related Predictors:

Relationship Length, Education, and Age
Body Image, Number of Diet Months, Short Term Diet Success, Index of Weight
Negativity

Model 3: Partner Related Predictors:

Relationship Length, Education, and Age
Body Image, Number of Diet Months, Short Term Diet Success, Index of Weight
Negativity
Partner Sexual Enjoyment, Partner on Weight, Sexual Communication
The first model involving demographic predictors correlated .213 (R) with sexual
satisfaction and the R Square of .046 indicates that the demographic predictors account for
about 5% of the variability in the Sexual Satisfaction. In the next model, Correlation (R)
went up to .480 and the R Square indicated that the weight related predictors and
demographic predictors together, account for about 23% of the variability in the Sexual
Satisfaction. This is not a significant change from the first model. In the third model,
Correlation (R) rose to .667 and R Square accounts for 45% and this is a significant change.
The final model accounts for about 44% of sexual satisfaction. With a relative degree of
confidence, these predictors indicate whether one will report that they are sexually satisfied
or not.

To determine whether one predictor is more important than the other, the beta coefficients
have been calculated (see Table 11).

Table 11

Coefficients

Standardized
Model 1 Coefficients - Beta

Education .185
Relationship Length .117
Age -.174

Model 2

Body Image .557

Education .186
Index of Weight Negativity .157
Relationship Length .075
Short Term Success .039
Diet Months .023
BMI -.020
Age -.196

Model 3

Sexual Communication .363

Body Image .322
Partner Sexual Enjoyment .243
Education .135
Index of Weight Negativity .091
Age .047
Diet Months -.004
Relationship Length -.018
Short Term Success -.020
Partner on Weight -.069
BMI -.071

Per review of the coefficients in the first model, it should be noted that education is a more
important predictor of sexual satisfaction than any of the other items. That is, the more
education, the more sexual satisfaction. This may be attributed to the idea that more
education lends itself to more sex-positive attitudes.

The second model adds weight related predictors to the demographic predictors seen in
Model 1. It is apparent that body image with a co-efficient of .557 is by far the most
significant predictor of sexual satisfaction compared to all the other elements listed in
Model 2. The next predictor is education, with low predictor value of .186. The Index of
Weight Negativity scores only .157 as a predictor. All the other predictors of sexual
satisfaction in Model 2 are insignificant.

In Model 3, the beta for education is still high (.135), but is not as significant in comparison
with sexual communication (.363), body image (.322), and partner sexual enjoyment (.243).
On the entire list, sexual communication is the most important attribute.

Chapter 10

Discussion
The objective of the research was to discover which factors were predictive of sexual
satisfaction for obese women in long-term relationships. It was hypothesized that weight
(BMI), body image, sexual attitudes, sexual confidence, sexual communication, sexual
enjoyment, partner's sexual enjoyment, partner's attitude on weight, and the amount of
negativity the participant has on weight would correlate significantly with the sexual
satisfaction of the participant.

Linear regression was performed on the dependent variable, Sexual Satisfaction

(SEXSAT). Three blocks of independent variables, known as predictors, were tested
against it. By comparing the beta weights (in a multiple regression equation) we can
determine what factors might predict sexual satisfaction.

The first block (Model 1) contained three variables related to demographics only: Length of
the relationship, Education, and Age. The beta coefficient indicates that education (0.185)
is the most important predictor of sexual satisfaction when compared to length of
relationship (0.117) or age (-0.174). This means, that given the demographic information
only, it can be surmised that the higher the education the better the possibility of sexual
satisfaction in the participant.

The second block (Model 2), in addition to the block one demographics, contained added
weight-related variables, such as Body Image, Number of Diet Months, Short-term Diet
Success, and Index of Weight Negativity. While beta coefficient for education stayed
practically unchanged (0.186), it became the second most important predictor, quite below
the highest one, the body image. Body image then, with a beta of 0.557, is a major predictor
of sexual satisfaction, when demographic and weight-related variables are considered. If a
participant has a good body image the likelihood is substantial they will be sexually
satisfied. Education was next, followed by the Index of Weight Negativity (0.157).

By far the most useful block of variables is contained in Model 3. In addition to the
demographics and the weight-related items, the partner-related variables have been added,
such as Partner Sexual Enjoyment, Partner on Weight and Sexual Communication. The
analysis shows that education, as a predictor of sexual satisfaction falls to the 4th place, with
0.135 beta coefficient. Body image places second, with 0.322. The best predictor of sexual
satisfaction is sexual communication (0.363). Then comes body image and the third
predictor is partner sexual enjoyment (0.243).

Overall it can be summarized that sexual communication, body image, partner sexual
enjoyment, and education are the four best predictors of sexual satisfaction. These could be
considered the most useful areas a therapist would want to focus on when working with
sexually dissatisfied obese couples. Conversely, focusing on weight, relationship length,
and diet (all extremely small predictor betas) might mean a waste of expensive therapeutic
time and effort.

Next, we will review the relationship among the 10 survey-based variables in Table 9. By
ignoring the low (coefficient lesser than 0.2) and mid-level correlations (coefficients greater
than 0.2 and lesser than 0.5), and analyzing only the high correlations, this discussion will
bring into sharp focus the most significant findings of this study. (The high level of
correlation is indicated by the coefficient greater than 0.5 or lesser than -0.5.)

The most dramatic correlation in Table 9 is the one between the weight negativity
(WTNEG) and the body image (BODYIMAG), -0.780. The worse one feels about one's
weight, the greater impact on one's body image. Not surprisingly, the next highest
correlation is between the sexual confidence (SEXCONF) and body image, -0.771. Highly
negative body image profoundly influences sexual confidence. Impact of weight negativity
on sexual confidence has the third highest correlation among the participants of the survey,
-.685. This revelation of the weight negativity-body image-sexual confidence triangle is
most significant.

On the positive side and of tremendous importance is the finding of the fourth highest
correlation. It is between the sexual communication (SEXCOM) and sexual satisfaction
(SEXSAT), 0.642. Related to this finding is also the seventh highest correlation (0.516) -
between the sexual communication and sexual attitudes (SEXATT). To the degree sexual
communication takes place between the partners, the sexual satisfaction and positive sexual
attitudes prevail in their relationship.

The survey participants indicated there was another important correlation, the fifth and the
sixth highest, between the partner's sexual enjoyment (PRTSXJOY) and sexual
communication (0.552) and their own sexual enjoyment (SEXJOY) (0.523).
These correlations tie together the couples' sexual attitudes, enjoyment and satisfaction with
their ability to communicate. It is interesting to note that none of the 9 variables in Table 9
showed any significant, not even lower mid-level, correlation to the participants' weight
(BMI). Moreover, the relationship between the body image and the weight showed itself to
be of very low significance (0.171).

Our hypothesis, that the attitude of the partner on the weight of the participant would show
a significant correlation, did not relate in the expected direction. This was puzzling.
Although this was not a survey of the partner but of the participant's perceived attitude of
the partner, seventy-five percent of our participants believed that weight was rarely or never
an issue in their relationship. Ninety-four percent of the participants had never or rarely
been verbally abused about their size. Eighty-four percent did not believe their partner
would find them less desirable if they gained weight. Seventy-three percent believed that
their partners were quite attracted or very attracted to them. Obviously, sexually satisfied or
not, most of the participants felt their partners had few issues with them about their weight.
It would be an interesting subject for further research to ask the partners, themselves, about
their attitudes and to see if their answers would correlate with the way their partners
perceive them.

Comparisons with Past Research

Previous researchers have found that body image dysphoria is correlated highly with
sexually avoidant behavior (Faith and Schare, 1993; Stuart and Jacobson, 1987; Shapiro,
1980; Spiegel, 1988). The current research agrees with this finding if we assume that sexual
avoidance is the opposite of sexual satisfaction.

The current research indicates that sexual communication is the best predictor of sexual
satisfaction. Assertive communication has previously been indicated as lacking in the
sexual lives of obese women (Shapiro, 1980; Spiegel, 1988; and Stuart and Jacobson,
1987). Those researchers were not asking about sexual satisfaction factors but Stuart and
Jacobson certainly received thousands of letters from women who were most likely trying
to lose weight and who indicated that they were not satisfied sexually. These women were
not communicating about their sexuality with their partners. The current research seems to
corroborate these findings.

Weight has been predicted as a derogator to sexual satisfaction by many researchers

(Marshall and Neill, 1978; Wise, 1978; Werlinger, King, Clark, Pera and Wincze, 1997).
These researchers predicted that when their participants lost many pounds, their sexual
lives would change either for the better or for the worse. Marshall and Neill found that
there emerged conflict in the relationships of such couples. Marshall and Neill believed that
the conflict arose because the weight of the obese person stabilized the marriage and the
loss of it destabilized the marriage. The destabilization may have come from the fact that
the partners of the obese women liked them the way they were. The women did feel more
flirtatious and more willing to initiate sexual encounters due, they said, to a diminished fear
of rejection. In the Wise study, the conclusions were that "There was no evidence that core
sexual identity or mechanical activity was aberrant in the massively obese, however, they
did display a sense of shame about themselves as attractive individuals" (p. 23). In the
Werlinger et al. study, the participants suggested that their improved body image after
losing weight was responsible for their improved sexual functioning. Our study also shows
a correlation between sexual confidence and improved body image. If the weight loss leads
to an improved body image, sexual confidence can rise. Ultimately, as our study indicates,
body image does not depend on the weight of the woman but on her improved body image
which in turn correlates with greater sexual confidence. This may explain why the
conclusions of the medical approach were somewhat indecisive. If upon losing weight, the
wife felt improved body image, she felt her sexual life improved. If the husband's approval
of her new body was missing, there was conflict. The researchers did not test for improved
sexual functioning. The current research showed that the partner's attitude on weight had
almost no correlation to the sexual satisfaction of the participant.

The current research substantiated Masters and Johnson's claim that the therapist's "most
important role" is as a catalyst to sexual communication (p. 14). In the current study sexual
communication was most highly correlated to sexual satisfaction against all the other
factors presented.

Demographics

The population for this study was obtained primarily through announcements of the study
on the Internet, size-acceptance magazines, and an article written by the author for major
women's fashion magazine for large women. Of the approximately three hundred
communications sent to inquiring persons, and of the 200 questionnaires sent out, 119 were
returned. Of these 119 women, 100% had been or were presently in long-term relationships,
defined as at least six months. The mean period of time that all the women were in long
term relationships was 7.5 years. The mean age of the participants was 38 years. The mean
weight was 298 pounds or a mean Body Mass Indicator of 49. Their weights ranged from
180 pounds to 524 pounds. The respondents were well educated with the mean number of
years in school at 17 years. The mean income was $35,000. Eighty- four percent of the
participants were of European ancestry with 6.7 percent of Afro-American ancestry. The
rest were from various backgrounds. Seventy-eight percent of the women were
professionals, 30% were in the trades and 11 had no profession.

Weight History

Overall, the respondents indicated that in comparison with their peers, throughout their
lives, they had always been "somewhat bigger". This trend continued to the present time.
There appears to be more weight variability during adolescence. The respondents also
indicated that their peers' attitudes were more negative and critical than their fathers' or
mothers' attitudes. During their childhood, 80% of the respondents said they were bigger
than their peers, although 45% were only a small amount bigger than their peers. By
adolescence, 89% were bigger but 38% were only a medium amount bigger. As adults,
92% said they were bigger than their peers with 26% a little bigger to somewhat bigger.
Now, in the last 5 years, 100% said they were bigger than their peers with 13% saying they
were a little bigger to somewhat bigger than their peers and 85% saying they were much
bigger to super-size. Is the etiology of this obesity in their genes? Is it due to their
pathology? Is it due to their diets? Eighty-two of the 119 respondents had dieted over their
lifetimes. This is research that needs to be undertaken.

Additional Demographics of Interest

The women self-reported that the factors they believed to have the most influence on
feelings of satisfaction in their sexual relationship were their partner, their own positive
sexual outlook, and their own positive body image. Similarly, they ranked their partner and
their own negative body image as having the most influence on their feelings of
dissatisfaction in their sexual relationship. The women did not feel counseling or diets had
much influence on their reported satisfaction or dissatisfaction in the sexual relationship.

Forty-five percent of the women in the survey indicated that they were sexually attracted to
"only men", whereas the remaining 55% of the women indicated that they were attracted to
only women, mostly women, both men and women, and mostly men. Eight percent said
they were attracted to mostly or only women. Eighty-two percent of the women reported
that their partners were only sexually attracted to those of a different gender (see Table 6).

Self-Acceptance, Size-Acceptance, Self-Esteem

The respondents in the current research show an increased acceptance of their weight.
Sixty-nine percent of the respondents said they feel comfortable sharing the truth about
their weight always or sometimes. Eighty-one percent of the women said they did think
their bodies were somewhat to extremely sexually appealing. Forty-nine percent of the
women said that their current feelings about their bodies is somewhat better to much better.
Thirty-two percent felt somewhat worse or much worse. Another indicator of a growing
self-acceptance is that 87% of the respondents who do not believe that a person who prefers
large women must have something wrong with him/her. Although not a majority, 38% of
large women do not feel it is difficult to attract a partner. This may be due to the support
large women are receiving from the fat-acceptance movement and from their admirers.

Answers about the weight of the participants' partners are of interest. Fifty-one percent of
the partners are either about average (37%), somewhat thin (11.8%) or extremely thin
(2.5%). Forty-one percent are somewhat large. About 6% are very large.

Sexual Dysfunctions

Male

The women participating in this questionnaire (Table 6) answered these questions for their
partners so these are perceived difficulties, not necessarily actual ones. It is also important
to keep in mind that some women listed multiple answers for their partners. Sixteen percent
of the partners climax too quickly. Twenty-four percent have difficulty achieving or
maintaining an erection. Seventeen percent feel anxious about their ability to perform.
Finally, 11% have a decreased interest in sex due to medication.
Female

Our women respondents are most concerned with their difficulty in experiencing an orgasm
with 32% responding to this question. There were 19% of the women who had a decrease
in interest in sex due to medication. Thirty percent have difficulty lubricating which may be
a problem after menopause and may be associated with lack of desire. None of these
difficulties seem to be interfering with the sex lives of those that are sexually satisfied
which is represented by 67% of the respondents.

Abuse History

The abuse history of the respondents indicated that approximately 50% were verbally
abused, and 30% were sexually abused (see Table 4). They reported that the verbal abuse
affected them emotionally "very much" (Mean 4.19) and affected them sexually "some"
(Mean 2.4). The sexual abuse affected them emotionally "a medium amount" to "very
much" (Mean 3.63) and affected them sexually "a medium amount" (Mean 3.24). The
women reported that the abuse appears to have had a greater emotional rather than sexual
aftereffect.

Clinical Usage of the Data

Most of the information we receive on the sexuality of obese women is obscure and
inaccurate, based on assumptions, theories and unsubstantiated therapies that may have
done irreparable harm to women. Few empirical studies have been done on the obese
women, even though 52% of American women are now considered to be too heavy by the
Insurance Industry's calculations. With ever more women joining the ranks of those with
body-image dysphoria, it is important that we understand the truth about obese sexuality so
that we can use it wisely.

Appropriate sexual therapy for the obese couple has not yet been designed. Specific
recommendations could include those found in the literature reviewed, as they apply to
individuals and to non-obese persons. As far as obese couples are concerned, the
recommendations would need to be applied, where appropriate, to both persons.

Since it has been fairly well established, both in this study and in others, that a woman's
actual weight has almost nothing to do with her sexual satisfaction, it behooves the
therapist to desist from having any concern about this issue and address him/herself to
healing the body-image dysphoria. Advice to the woman to lose weight, with the evidence
that this may be a temporary adjustment of the woman's body image at best, would not be
recommended.

Appropriate therapy would need to acknowledge that, indeed, large women are just as
psychologically healthy as their thinner sisters, except they may be harboring a great deal
of dissatisfaction with their bodies. Large women are not asexual. They are sensual and can
enjoy their sexuality. Therapy should focus on the improvement of self-esteem, and it
should encourage women's assertiveness and willingness to talk about their sexual needs,
feelings, and concerns. It should help them to love and appreciate their bodies. Very
importantly, it needs to identify and lower their shame, not only for their bodies, but for all
those other areas related to shame: movement, appearance, eating, self-esteem, touching
and being touched, and their sexuality. Furthermore, and most important, it needs to bring
in the partner with whom the woman wants to be sexual. What good would body-image-
improvement make to a relationship if the partner can not accept the body of his/her lover.
Lovers are hurt by the fat-phobia of the society also. Expanding the lover's erotic taste to
include large women may be difficult but it needs to be addressed by the therapist, if
effective change is to occur.

Treatment in the prevention of sexual dissatisfaction would include information from this
study and from the literature review. Education would suggests that weight gain is normal,
excessive caloric restriction is not effective in the long-term, and caloric restriction may
actually potentiate weight gain. The more girls are concerned about gaining weight, the
higher the risk for eating disorders later on. Young people would be forewarned about the
way our society attaches status to thinner bodies and ridicules the larger bodies, making it
almost impossible for young people, boys in particular, to show an appreciation for bigger
girls. The consequences of rejecting our bodies should be taught. When we look for
symptoms of sexual avoidance we see that there is little sexual communication, agonizing
self-consciousness, a tendency to avoid interpersonal erotic encounters, neglect of one's
appearance, a possible failure to be seen athletically or in sexy clothing. These are the
surface symptoms that we can pinpoint early. Finally, we should make available to young
people Body Acceptance classes. Our society has wounded our young people and there are
so many forces that pressure them to reject themselves.

Therapists who work with obese couples must learn the specific problems that accompany
people with large bodies other than body image concerns, such as difficulty in finding
comfortable positions for sexual intercourse, difficulties accepting the lower status that
being with a large woman implies, the problems of handling ridicule and ostracism from
peers, difficulties for the obese woman who feels she is not desirable.

Therapists, educators, sexologists, sex educators, doctors, and professionals working with
young people and adults need to use the information learned here, the better to teach,
advise, support and counsel.

Limitations of Study

The limitations of the study are two-fold.. The vast majority of the respondents were from
the Internet. This limited the population to the highly educated (a mean of 17 years of
education) and may have skewed the results. The other problem stems from the fact that
most of the respondents were connected in some way with the size-acceptance movement
through Radiance magazine, size acceptance newsgroups referred from Radiance
participants, and from other size-acceptance magazines. Only 20 of the respondents
participated anonymously or came from other resources and it could not be ascertained
where they heard about the survey. It would be helpful to reach large women at all levels of
the social strata for a more representative group. Nevertheless, it became apparent that
many of the women who volunteered did report being sexually satisfied and did volunteer
information that led to new knowledge. Any other group of large women might not have
been as satisfied as this group. We were also limited to using large women only. This
prevented from including all the thinner females that may have had the same experience.

Suggestions for Future Research

Many women, who are not obese, feel unattractive due to even a small amount of weight
gain. It would be appropriate to survey all sizes of women for body image dysphoria, their
sexual communication with their partner, discovering how much negativity they have about
their weight, and their BMI. This might lead to firm predictors of sexual satisfaction of all
women, not just the obese ones. In 1997, Abraham and Llewellyn-Jones found that 65%-
87% of women between the ages of 20 and 60 were dissatisfied with their bodies due to a
perception of too much fat, compared to 48% in 1972. This statistic implies that there are
great many women who are or will be struggling with issues of sexual satisfaction.

It would also be of interest to question large men about their sexual lives to discover what
brings them sexual satisfaction. We would then have a composite, which could be
compared to women. Is the lack of sexual communication, body image dysphoria and a
partner who does not enjoy sex, interfering with obese male sexual satisfaction? Should
these questions be answered, therapists would then know more about appropriate treatment
for both members of the obese couple rather than just one half of it.

In addition, there needs to be more research done on how the therapy that heals body image
dissatisfaction affects that person's sexual life. There are a number of healing therapies for
the body (Hutchinson, 1985; Bergner, 1985; Tenzer, 1989; Freedman,1988), but an
integration of these therapies with the sexual lives of the participants has not been
surveyed. More research in this area would be very helpful.

Finally, there needs to be developed an integrative therapy that addresses obese couples and
their particular concerns. It should addresses itself to any issues they have that may affect
their sexual life together. Obviously, our predictors would most likely be involved; not
enough sexual communication, dissatisfaction with the body of one or both persons, and a
lack of shared sexual joy. Those therapeutic and educational therapies deemed appropriate
from the literature review might be included.

Bibliography
Abraham, S., & Llewellyn-Jones, D. (1997). Eating disorders: the facts (4th ed.). Oxford,
England: Oxford University Press.

Adler, J. with Lewis, S. D. (1993, May 17). The joys of living large. Newsweek, 55.

Alcoholics Anonymous, (1976) Big Book, World Service Inc., Hazelton, New York,USA.

Andersen, B. L., & Broffitt, B. (1988). Is there a reliable and valid self-report measure of
sexual behavior?. Archives of Sexual Behavior, 17(6), 509-525.
Andersen, B. L., & LeGrand, J. (1991, August). Body image for women:
Conceptualization, assessment, and a test of its importance to sexual dysfunction and
medical illness. The Journal of Sex Research, 28(3), 457-477.

Aron, A., & Henkemeyer, L. (1995). Marital satisfaction & passionate love. Journal of
Social & Personal Relationships, 12(1), 139-146.

Atkins, D. (1991). Weight Loss and Your Health. BITF [On line]. Available:
http://home.earthlink.net/~dawn_atkins/diets.htm (Also available from: Body Image Task
Force, P.O. Box 360196, Melbourne, FL 32936-0196)

Atwood, J. D., & Dershowitz, S. (1992, Fall). Constructing a sex & marital therapy frame:
Ways to help couples deconstruct sexual problems. Journal of Sex & Marital Therapy,
18(3), 196-218.

Aunt Agony. (1996). Aunt Agony (Advice Column). FAT!SO?, 6, 32.

Barnett, L., & Chambers, M. with Davidson, S. (1996). Reiki energy medicine. Rochester,
Vt: Healing Arts Press.

Barr, S. L. (1996, October). The Obesity epidemic. Shape, 114-120, 146.

Barron, N., & Lear, B. H. (1989). Ample opportunity for fat women. In Brown, L.S., &
Rothblum, E. D. (Eds.), Overcoming fear of fat (pp. 79-92). Binghamton, New York:
Harrington Park Press.

Beattie, M. (1987). Codependent no more. San Francisco, California: Harper/Hazelden.

Beck, J. G., & Bozman, A. W. (1995). Gender differences in sexual desire: The effects of
anger and anxiety. Archives of Sexual Behavior, 24(6), 595-612.

Beller, A. S. (1978). Fat & thin. New York: McGraw-Hill.

Bemporad, J. R. (1996). Self-starvation through the ages: Reflections on the pre-history of

anorexia nervosa. International Journal of Eating Disorders, 19(3), 217-237.

Bennett, W. (1983, Fall). Reprint: Letter to Senator Michael Schwarzwalder, Columbus,

Ohio (Originally written July 16, 1983). NAAFA Newsletter, 10(2), 9-12.

Bennett, W., & Gurin, J. The dieters' dilemma. (1982) New York: BasicBooks.

Berg, F. M. (1995). Health risks of weight loss [Special issue]. Healthy Weight Journal.

Bergner, M., Remer, P., & Whetsell, C. (1985, Fall). Transforming women's body image: A
feminist counseling approach. Women & Therapy, 4(3), 25-38.
Blank, H. (2000). Big big love. San Francisco: Greenery Press.

Blickenstorfer, C. H. (Ed.). (1996, February). Dimensions: Where big is beautiful.

Dimensions, 12

Blume, E. S. (1993). Secret survivors (10th ed.). New York: Ballantine Books. (Original
work published 1991)

Bogaert, A., Turkovich, D., & Hafer, C. (1993, May). A content analysis of playboy
centrefolds from 1953 through 1990: Changes in explicitness, objectification, & model's
age. The Journal of Sex Research, 30(2), 135-139.

Bordo, S. (1993). Unbearable weight. Berkeley, California: University of California Press.

Bovey, S. (1994). The forbidden body (Rev. ed.). London: Pandora. (Original work
published 1989)

Bradshaw, J. (1988). Healing the shame that binds you. Deerfield Beach, Fl: Health
Communications, Inc..

Bradshaw, J. (1991, April). To eat or not to eat. Lear's, 59.

Bray, R. L. (1992, January). Heavy burden. Essence, 52-54,90.

Brecher,E. M., & the Editors of Consumer Reports Books. (1984). Love, sex, & aging.
Boston, Ma: Little, Brown & Co..

Brightwell, D. R. (1979, January). Commentary on: "Obesity & human sexuality" by

Colleen Rand. Medical Aspects of Human Sexuality, 151-152.

Brill, A. A. (Ed.). (1938). The basic writings of Sigmund Freud. New York: The Modern
Library.

Broderick, C. (1979). Couples. New York: Simon & Schuster.

Brown, L. S. (1985, Spring). Women, weight, & power: Feminist theoretical & therapeutic
issues. Women & Therapy, 4(1), 61-71.

Brown, L. S., & Rothblum, Esther D. (Eds.). (1989). Overcoming fear of fat. Binghamton,
New York: Harrington Park Press.

Brown, P. (1993). Cultural perspectives on the etiology and treatment of obesity. In

Stunkard, Albert & Wadden, Thomas (Eds.), Obesity: Theory and therapy (2nd ed., pp.
179-191). New York, New York: Raven Press (Original work published 1993).

Bruch, H. (1957). The importance of overweight. New York: W. W. Norton.

Bruch, H. (1973). Eating disorders. New York: BasicBooks Inc..

Bruch, H., (1969, February). Obesity & sex. Medical Aspects of Human Sexuality, 42-52.

Burchell, R. C. (1975, January). Self-esteem and sexuality. Medical Aspects of Human

Sexuality, 74-90.

Burgard, D. (1991, Fall). Is giving up on dieting giving up on yourself?. Radiance, 28, 36-
39.

Burke, D. with Lipsitz, A. (1998). Delta style. New York: St. Martin's Press.

Buss, D. M. (1994). The evolution of desire. New York: BasicBooks.

Butler, N. (1988). An overview of anorexia nervosa. In Derek Scott (Ed.), Anorexia &
bulimia nervosa-practical approaches (pp. 3-24). New York: N.Y. University Press.

Bychowski, G. (1950). On neurotic obesity. Psychoanalytic Review, 37(4), 301-309.

Cakes,F. (1993). Ho' Lotta Love [Film]. (Available from Midnight Video, Wilbur Ave,
Northridge, CA 91324)

Cardozo, C. (1994, June). The tightest thighs ever-guaranteed!. Self, 162-165,176.

Cash, T. F. (1991). Binge-eating & body images among the obese: A further evaluation.
Journal of Social Behavior & Personality, 6(2), 367-376.

Cash, T. F. (Author/Speaker). (1991). Body-image therapy: A program for self-directed

change (Cassette Recording No. 0-89862-965-9 [cat #2965]). New York: The Guilford
Press.

Cash, T. F., & Pruzinsky, T. (Eds.). (1990). Body images. New York: The Guilford Press.

Cash, T. F., Winstead, B. A., & Janda, L. H. (1986, April). The great American shape-up.
Psychology Today, 30-37.

Cash, T. F., Winstead, B. A., & Janda, L. H. (1997, Jan/Feb). Body image. Psychology
Today, 32-84.

Cauwels, J. M. (1983). Bulimia. Garden City, New York: Doubleday & Company, Inc..

Cavanaugh, E. (1989). Understanding shame. Minneapolis, Mn: Johnson Institute.

Chernin, K. (1981). The obsession. New York: Harper & Row.

Clement, U., & Pfafflin, F. (1980). Changes in personality scores among couples
subsequent to sex therapy. Archives of Sexual Behavior, 9(3), 235-244.

Clements, M. (1995, January). The death of sex (And don't blame AIDS). New Woman,
86,136.

Cohn, L., M.A.T., & Staff. (Eds.). (1998, Summer). Eating disorders. The Journal of
Treatment and Prevention, 6(2).

Colt, G. H., & Hollister, A. (Schatz, Howard-Photography) . (1997, August). The magic of
touch. Life, 52-57,60,62.

Comfort, A., (1974) More joy. New York; Mitchell Beazley Publisherzs

Comfort, A., (Ed.). (1972). The joy of sex. New York: Crown Publishers, Inc..

Cook, K.V., Reiley, K.L., Stallsmith, R., & Garretson, H.B. (1991, Summer). Eating
concerns on two christian & two nonsectarian college campuses: A measure of sex &
campus differences in attitudes toward eating. Adolescence, 26(102), 273-286.

Costin, C. (1996). The eating disorder sourcebook. Los Angeles, California: Lowell House.

Council on Size & Weight Discrimination, Inc. (1996). Kid's Curriculum and Outreach
Project (Available from Council on Size & Weight Discrimination, Inc., P.O. Box 305,
Mount Marion, NY 12456).

Crago, M., Shisslak, C. M., & Estes, L. S. (1996). Eating disturbances among American
minority groups: A review. International Journal of Eating Disorders, 19(3), 239-248.

Crandall, C. S., & Martinez, R. (1996, November). Culture, ideology, & anti-fat attitudes.
Personality and Social Psychology Bulletin, 22(11), 1165-1176.

Crisp, A. H., & McGuiness, B. J. (1976). Jolly fat: A relation between obesity and
psychoneurosis in general population. Journal of British Medicine, 1, 7-9.

Dachis, N. (1983, Summer). The fat admirer. NAAFA Newsletter, 10(1), 12,13.

Davis, D. (1986, Summer/Fall). Fat admirers: Problem or solution?. Radiance, 19-21.

Dixon, M., (1996). Love the body you were born with. New York: Perigee Books.

Dobson, E. (1975, February). Ballad of the sad young men[A poem]. NAAFA Newsletter,
4(2), 4.

Doheny, K. (Ed.). (1996, October). In shape. Shape, 18-24.

Dolit, A. (1975). Fat liberation. Millbrae, California: Celestial Arts.

Donnelly, D. A. (1993, May). Sexually inactive marriages. The Journal of Sex Research,
30(2), 171-179.

Dwyer, J. T. (1973, March). Psychosexual aspects of weight control and dieting behavior in
adolescents. Medical Aspects of Human Sexuality, 82-114.

Edison, L. T., & Notkin, D. (1994). Women en large. San Francisco, California: Books In
Focus.

Eiser, J. R., & Ford, N. (1995). Sexual relationships on holiday: A case of situational
disinhibition?. Journal of Social & Personal Relationships, 12(3), 323-339.

Engel, B. (1992). The emotionally abused woman. New York: Fawcett Columbine.

Engley, H. L. (1994, October 3). We're fat; we're proud. Marin Independent Journal, pp.
D1,D3.

Epstein, D., & Thompson, K. (1994). Feeding on dreams. New York: Macmillan
Publishing Company.

Erdman, C. K. (1996). Nothing to lose. San Francisco, California: Harper, San Francisco.

Ernsberger, P., & Haskew, P. (1987). Health benefits of obesity. Journal of Obesity and
Weight Regulation, 6(2)

Fabrey, W. (1980, March-April). The singles scene--NAAFA style. NAAFA Newsletter,

8(2), 5.

Fabrey, W. (1972, August-September). NAAFA men: Who are they, & why aren't there
more of them?. NAAFA Newsletter, 2(4), 2,3.

Fabrey, W. (1982, January-April). C.O.B.'s corner: Sex at conventions. NAAFA

Newsletter, 9(2), 13.

Fairburn, C. G. (1995). Overcoming binge eating. New York: The Guilford Press.

Faith, M. S., & Schare, M. L. (1993). The role of body image in sexually avoidant
behavior. Archives of Sexual Behavior, 22(4), 345-356.

Fallon, P., Katzman, M. A., & Wooley, S. C. (Eds.). (1994). Feminist perspectives on
eating disorders. New York: The Guilford Press.

Farrell, W. (1986). Why men are the way they are. New York: McGraw-Hill.
Fichter, M. M., Quadflieg, N., & Brandl, B. (1993). Recurrent overeating: an empirical
camparison of binge eating disorder, bulimia nervosa, and obesity. International Journal of
Eating Disorders, 14(1), 1-16.

Fischer, L. (1996). The better sex diet. Washington, D.C.: Living Planet Press.

Fisher, H. E. (1982). The sex contract. New York: William Morrow & Company, Inc..

Fisher, M., Pastore, D., Schneider, M., Pegler, C., & Napolitano, B. (1994). Eating attitudes
in urban & suburban adolescents. International Journal of Eating Disorders, 16(1), 67-74.

Fisher, S. (1980). Personal correlates of sexual behavior in black women. Archives of

Sexual Behavior, 9(1), 27-35.

Ford, C. S., & Beach, F. A. (1980). Patterns of sexual behavior. Westport, Ct: Greenwood
Press.

Fossum, M. A., & Mason, M. J. (1989). Facing shame. New York: W.W. Norton &
Company.

Foster, G. D., Wadden, T. A., Vogt, R. A., & Brewer, G. (1997). What is a reasonable
weight loss? Patients' expectations and evaluations of obesity treatment outcomes. Journal
of Consulting and Clinical Psychology, 65(1), 79-85.

Frank, A. (1993). No article title. Journal of the American Medical Association, 269, 2132-
2133.

Fraser, L. (1997, May/June). The diet trap. Networker, 45-52,67.

Fraser, L. (1998). Losing It. New York: Plume.

Frauman, D. C. (1982, February). The relationship between physical exercise, sexual

activity, and desire for sexual activity. The Journal of Sex Research, 18(1), 41-46.

Freedman, R. (1989). Bodylove. New York: Harper & Row.

French, M. (1993). The war against women. New York: Ballantine Books.

Friday, N. (1978). My mother/my self. New York: Dell Publishing Co..

Friday, N. (1996). The power of beauty. New York: HarperCollins.

Friedman, A. I. (1974). Fat can be beautiful. New York: Berkley Publishing.

Friedman, J. (1959). Weight problems and psychological factors. Journal of Consulting

Psychology, 23, 524-527.
Gage, A. ( 1981). Women's body image; an inquiry into the relationship between body
imge and self-esteem in obese and non obese women. Unpublished Women's Studies
Senior Thesis, University of Washington.

Garner, D. M., & Garfinkel, P. E. (Eds.). (1985). Handbook of psychotherapy for anorexia
nervosa & bulimia. New York: The Guilford Press.

Ghizzani, A., Pirtoli, L., Bellezza, A., & Velicogna, F. (1995, Spring). The evaluation of
some factors influencing the sexual life of women affected by breast cancer. Journal of Sex
& Marital Therapy, 21(1), 57-63.

Gil, E. (1990). Treatment of adult survivors of childhod abuse (2nd ed.). Walnut Creek,
California: Launch Press. (Original work published 1988)

Gilbert, S. (1989). The psychology of dieting. London: Routledge.

Gilles, J. (1994, September 12). Buxom beauties' secret. Marin Independent Journal, p. B6.

Glucksman, M. L., Rand, C. S., & Stunkard, A. J. (1978). Psychodynamics of obesity.

Journal of the American Academy of Psychoanalysis, 6(1), 103-115.

Gold, M. S. (1992). Are eating disorders addictions?. In E. Ferari, F. Brambilla, & S. B.

Solerte (Eds.), Primary & secondary eating disorders (pp. 455-463). Oxford, England:
Pergamon Press.

Goldblatt, P. B., Moore, M. E., & Stunkard, A. J. (1965, June 21). Social factors in obesity.
Journal of the American Medical Association, 192(12), 97-102.

Goldfarb, L. A., Dykens, E. M., & Gerrard, M. (1985). The goldfarb fear of fat scale.
Journal of Personality Assessment, 49(3), 329-332.

Goodman, N., Richardson, S.A., Dornbusch, S.M., & Hastorf, A.H. (1963). Variant
reactions to physical disabilities. American Sociological Review, 28, 429-235.

Goodman, W. C. (1995). The invisible woman. Carlsbad, California: Gurze Books.

Gossett, H. (1986). Fat chance. Alexandria, Virginia: Independent Hill Press.

Graham, L. (1997). Goddesses In art. New York: Artabras.

Grannick, C. C., Hirschmann, J., Matz, J., & Munter, C. (Eds.). The overcoming overeating
newsletter. The Overcoming Overeating Newsletter, 1(1).

Gray, J. P . (1984). The influence of female power in marriage on sexual behaviors &
attitudes: A holocultural study. Archives of Sexual Behavior, 13(3), 223-231.
Greenberg, D. R., & LaPorte, D. J. (1996). Racial differences on body type preferences of
men for women. International Journal of Eating Disorders, 19(3), 275-278.

Grenier, G., & Byers, E. S. (1997). The relationships among ejaculatory control, ejaculatory
latency, & attempts to prolong heterosexual intercourse. Archives of Sexual Behavior,
26(1), 27-47.

Grosswirth, M. (1971). Fat pride: A survival handbook. New York: Jarrow Press.

Gustafson-Larson, A. M., & Terry, R. D. (1992, July). Weight-related behaviors &

concerns of fourth-grade children. Journal of the American Dietetic Association, 92(7),
818-822.

Haimovitz, D., Lansky, L. M., & O'Reilly, P. (1993). Fluctuations in body satisfaction
across situations. International Journal of Eating Disorders, 13(1), 77-84.

Hakala, D. with D'Orso, M. (1997). Thin Is not a four-letter word. Boston, Ma: Little,
Brown & Company.

Hall, L. (1993). Full lives. Carlsbad, California: Gurze Books.

Hartman,W. & Fithian, M. (1972). Treatment of sexual dysfunction. Long Beach,

California: Center for Marital and Sexual Studies.

Harper, J. M., & Hoopes, M. H. (1990). Uncovering shame. New York: W.W. Norton &
Company.

Harris, R., Yulis, S., & Lacoste, D. (1980, February). Relationships among sexual
arousability, imagery ability, & introversion-extraversion. The Journal of Sex Research,
16(1), 72-86.

Hartman, W. E., & Fithian, M. A. (1974). Treatment of sexual dysfunction. New York:
Jason Aronson.

Healthier bodies, sexier sex. (1994, February). Glamour, 180-183.

Hesse-Biber, S. (1996). Am I thin enough yet? New York: Oxford University Press.

Hirschmann, J. R., & Munter, C. H. (1988). Overcoming overeating. Reading,

Massachusetts: Addison-Wesley Publishing Co., Inc..

Hirschmann, J. R., & Munter, C. H. (1995). When women stop hating their bodies. New
York: Fawcette Columbine.

Hollis, J. (1985). Fat is a family affair. Center City, Mn: Hazelden.

Hollis, J. (1994). Fat and furious. New York: Ballantine Books.

Hornyak, L. M., & Baker, E. K. (Eds.). (1989). Experiential therapies for eating disorders.
New York: The Guilford Press.

Huebner, H. F. (1993). Endorphins, eating disorders and other addictive behaviors. New
York: W.W. Norton & Company.

Hurlbert, D. F. (1991, Fall). The role of assertiveness in female sexuality: A comparative

study between sexually assertive & sexually nonassertive women. Journal of Sex & Marital
Therapy, 17(3), 183-190.

Hurlbert, D. F., Apt, C., & Rabehl, S. M. (1993). Key variables to understanding female
sexual satisfaction: An examination of women in non-distressed marriages. Journal of Sex
& Marital Therapy, 19(2), 154-165.

Hutchinson, M. G. (1985). Transforming body image. Freedom, California: The Crossing

Press.

Ingram, D. H. (1979, January). Commentary on: "Obesity & human sexuality" by Colleen
Rand. Medical Aspects of Human Sexuality, 151.

Johnson, C. A. (1995). Self-esteem comes in all sizes. New York: Doubleday.

Johnson, J. (1994, May). Caring for the woman who's had a mastectomy. American Journal
of Nursing, 25-31.

Jones, K. W. (1974, Sept.-Oct.). Fat and female--one woman's view. NAAFA Newsletter,
3(6), 3.

Jones, L. (1995, February 10). Your changing body. Science World, 11-13.

Jordan, H. A., & Levitz, L. S. (1979, October). Sex & obesity. Medical Aspects of Human
Sexuality, 105-117.

Kagan, D. M., & Squires, R. L. (1983, Autumn). Dieting, compulsive eating, and feelings
of failure among adolescents. International Journal of Eating Disorders, 3(1), 15-26.

Kaplan, H. I., & Kaplan, H. S. (April-June, 1957). The psychosomatic concept of obesity.
The Journal of Nervous and Mental Disease, 125(1), 181-201.

Kaplan, H. S. (1974). The new sex therapy. New York: Brunner/Mazel.

Kaplan, H., Kaplan, H. S. (1957). The psychosomatic concept of obesity. Journal of

Nervous and Mental Disease, 125, 181-201.
Karen, R. (1992, February). Shame. The Atlantic Monthly, 40-70.

Katherine, A. (1996). Anatomy of a food addiction (3rd ed.). Carlsbad, California: Gurze
Books. (Original work published 1991)

Keeton, W. P., Cash, T. F., & Brown, T. A. (1990). Body image or body images?:
Comparative, multidimensional assessment among college students. Journal of Personality
Assessment, 54(1 & 2), 213-230.

Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1953). Sexual behavior in the human male
(11th ed.). Philadelphia, Pa: W. B. Saunders Company (Original work published 1948).

Kinsey, A. C., Pomeroy, W. B., Martin, C. E., & Gebhard, P. H. (1953). Sexual behavior in
the human female. Philadelphia, Pa: W.B. Saunders Company.

Klausner, M. A., & Hasselbring, B. (1990). Aching for love. San Francisco: Harper & Row.

Klein, M. (1996, January). Is weight wrecking your sex life? McCall's, 95,96.

Kriss, R. T., & Kraemer, H. C. (1986, November). Efficacy of group therapy for problems
with postmastectomy self-perception, body image, & sexuality. The Journal of Sex
Research, 22(4), 438-451.

Lamm, S., & Couzens, G. S. (1995). Thinner at last. New York: Simon & Schuster.

Lasater, L. (1988). Recovery from compulsive behavior. Deerfield Beach, Fl: Health
Communications, Inc..

Leonard, L. S. (1985). The wounded woman. Boston, Ma: Shambhala Publications.

Lobitz, W. C., & Lobitz, G. K. (1996, Summer). Resolving the sexual intimacy paradox: A
developmental model for the treatment of sexual desire disorders. Journal of Sex & Marital
Therapy, 22(2), 71-84.

Louderback, L. (1970). Fat power. New York: Hawthorne Books.

Lowen, A. (1969). The betrayal of the body. New York: Collier Books.

Lyons, P. (1989). Fitness, feminism and the health of fat women. In Brown, L. S., &
Rothblum, E. D. (Eds.), Overcoming fear of fat (pp. 65-77). Binghamton, New York:
Harrington Park Press.

Lyons, P., & Burgard, D. (1990). Great shape. Palo Alto, California: Bull Publishing
Company.
MacKenzie, M. (1986, Summer/Fall). A cultural study of weight: America vs. Western
Samoa. Radiance, 23-25.

Madigan, M. F. (1976, March-April). The fat teenager. NAAFA Newsletter, 5(2), 1,2.

Manheim, C. (1999). Wake up, I'm fat. New York: Broadway Books.

Marano, H. E. (Ed.), Garner, D., Cooke, A. K., & Psychology Today staff. (1997, Jan/Feb).
1997 Body image survey. Psychology Today, 32-44,75,78,80,84.

Markle, R.J. (1971, February). Whatever you weigh is right [Review of the book Fat
Power]. NAAFA Newsletter, 1(4), 3.

Marshall, D. S., & Suggs, R. C. (Eds.). (1971). Human sexual behavior. New York: Basic
Books, Inc..

Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. Boston, Ma: Little,
Brown & Co.

Matsakis, A. (1990). Compulsive eaters and relationships. New York: Ballantine Books
(Original work published 1988).

Mayer, K. (1993). Real women don't diet! Silver Spring, Md: Bartleby Press.

Mazur, A. (1986, August). U. S. trends in feminine beauty and overadaptation. The Journal
of Sex Research, 22(3), 281-303.

McCarthy, B. W. (1995, Spring). Learning from unsuccessful sex therapy patients. Journal
of Sex & Marital Therapy, 21(1), 31-38.

McFarland, B., & Baker-Baumann, T. (1987). Sexuality & compulsive eating. Center City,
Mn: Hazelden.

McFarland, B., & Baker-Baumann, T. (1988). Feeding the empty heart. San Francisco,
California: Harper/Hazelden.

McFarland, B., & Baker-Baumann, T. L. (1990). Shame and body image. Deerfield Beach,
Fl: Health Communications, Inc..

McIlvenna, T. (Ed.). (1987). The complete guide to safe sex. San Francisco, California:
Specific Press.

Meadow, R. M., & Weiss, L. (1992). Women's conflicts about eating and sexuality.
Binghamton, NY: Harrington Park Press.

Mellin, L. (1997). The solution. New York: ReganBooks.

Mellin, L. M. (1987). Shapedown (4th ed.). Larkspur, California: Balboa Publishing
(Original work published 1979).

Mellin, L. M., Irwin , C. E., Jr., & Scully, S. (1992,July). Prevalence of disordered eating in
girls: A survey of middle-class children. Journal of the American Dietetic Association,
92(7), 851-853.

Mendelson, M., Weinbert, N., & Stunkard, A. (1961). Obesity in men, a clinical study of 25
cases. Annals of Internal Medicine, 54, 660-671.

Mendelson, Weinbert and Stunkard, 1961(Crisp H. and McGuiness J., 1976)(Friedman.,

1959). Psychoanalysis and obesity. Journal of the American Academy of Psychoanalysis,
5(4 ), 459-497.

Millman, M. (1981). Such a pretty face. New York: Berkley Books (Original work
published 1980).

Money, J. (1986). Lovemaps. New York: Irvington Publishers, Inc..

Montag, K. R., & Wilson, G. L. (1992, Winter). An empirical evaluation of behavioral &
cognitive-behavioral group marital treatments with discordant couples. Journal of Sex &
Marital Therapy, 18(4), 255-269.

Moreno, A. B., & Thelen, M. H. (1995, Spring). Eating behavior in junior high school
females. Adolescence, 30(117), 171-174.

Morgan, C. D., Wiederman, M. W., & Pryor, T. L. (1995, Summer). Sexual functioning &
attitudes of eating-disordered women: A follow-up study. Journal of Sex & Marital
Therapy, 21(2), 67-77.

Mornell, P. (1984). Passive men, wild women (7th ed.). New York: Ballantine Books
(Original work published 1980).

Mosher, D. L., Barton-Henry, M., & Green, S. (1988, August). Subjective sexual arousal &
involvement: Development of multiple indicators. The Journal of Sex Research, 25(3), 412-
425.

National Institute of Diabetes and Digestive and Kidney Diseases. (20 February 1998).
Gastric surgery for severe obesity. Weight-control Information Network [On line].
Available: http://www.niddk.nih.gov/health/nutrit/pubs/gastsurg.htm

NIH Publication No. 96-4006. April 1996.

(Also available from: 1 Win Way, Bethesda, MD 20892)

National Institute of Diabetes and Digestive and Kidney Diseases. (12 February 1998).
Statistics related to overweight and obesity. Weight-control Information Network [On line].
Available: http://www.niddk.nih.gov/ health/nutrit/pubs/statobes.htm

NIH Publication No. 96-4158. July 1996.

(Also available from: 1 Win Way, Bethesda, MD 20892)

Neimark, J. (1994, November/December). The beefcaking of america. Psychology Today,

27, 32-39,70,72.

Neuman, P. A., & Halvorson, P. A. (1983). Anorexia nervosa and bulimia. New York: Van
Nostrand Reinhold Company.New York: Raven Press.

Normandi, C. E., & Roark, L. (1998). It's not about food. New York: Grosset/Putnam.

Norton, G. R., & Jehu, D. (1984). The role of anxiety in sexual dysfunctions: A review.
Archives of Sexual Behavior, 13(2), 165-183.

Ogden, G. (1994). Women who love sex. New York: Pocket Books.

Orbach, S. (1979). Fat is a feminist issue. New York: Berkley Books.

Orbach, S. (1982). Fat is a feminist issue II. New York: Berkley Books.

Overeaters Anonymous (1990) Twelve steps and twelve traditions, Overeaters Anonymous,
Inc. United States of America

Packer, J. (1989). The role of stigmatization in fat people's avoidance of physical exercise.
In Brown, L. S., & Rothblum, E. D. (Eds.), Overcoming fear of fat (pp. 49-63).
Binghamton, New York: Harrington Park Press.

Palmer, R. L. (1993). Weight concern should not be a necessary criterion for the eating
disorders: A polemic. International Journal of Eating Disorders, 14(4), 459-465.

Patterson, E. (1996). Will the real women...please stand up! New York: Simon & Schuster.

Peterson, S.L. (1992, Spring). Getting a kick from Karate: where size is a plus. (Price,
1989)Radiance, 30, 38-40.

Phelps, S., & Austin, N. (1992). The assertive woman (8th ed.). San Luis Obispo,
California: Impact Publishers. (Original work published 1987)

Pinney, E. M., Gerrard, M., & Denney, N. W. (1987, May). The Pinney sexual satisfaction
inventory. The Journal of Sex Research, 23(2), 233-251.
Pipher, M. (1995). Reviving ophelia. New York: Ballantine Books.

Polivy, J & Herman, P. (1983). Breaking the diet habit. New York: Basic Books.

Pomeroy, W. B., Flax, C. C., & Wheeler, C. C. (1983). Taking a sex history. New York:
The Free Press.

Potter-Efron, R., & Potter-Efron, P. (1989). Letting go of shame. San Francisco:

Harper/Hazelden.

Price, J. (1989, Summer). Are you stuck in the waiting line of life?. Radiance, 43-45.

Qualls-Corbett, N. (1988). The sacred prostitute. Toronto, Canada: Inner City Books.

Rabuzzi, K. A. (1991, October). Healing by women's-light: From "Womanization" to

women's healing. Second Opinion, 17, 28-45.

Rado, S. (1926). Ueber die Psychische Wirkung der Rauschgifte. Internationale Zeitschrift
fur Psychoanalyse, 12, 577.

Rado, S., & Daniels, G. (Eds.). (1956). Changing concepts of psychoanalytic medicine.
New York and London: Grune and Stratton.

Rand, C. S.W. (1977). Psychoanalytic treatment of obesity. In E. B. Wolman (Ed.),

Psychological aspects of obesity: A handbook (pp. 177-191). New York: Van Nostrand
Reinhold Corp.

Rand, C. S., & Stunkard, A. J. (1977). Psychoanalysis and obesity. Journal of the American
Academy of Psychoanalysis, 5(4), 459-497.

Rand, Colleen S. W. (1979, January). Obesity & Human Sexuality. Medical Aspects of
Human Sexuality, 140-152.

Reading, A. E., & Wiest, W. M. (1984). An analysis of self-reported sexual behavior in a

sample of normal males. Archives of Sexual Behavior, 13(1), 69-83.

Register, L. M., & Henley, T. B. (1992). The phenomenology of intimacy. Journal of Social
and Personal Relationships, 9, 467-481.

Remington, J. (Ed.). (1996, Fall). Great bodies: Big women and fitness. Melpomene: A
Journal for Women's Health Research, 15(3).

Richardson, S.A. (1971). Research report: handicap, appearance and stigmata. Social
Science and Medicine, 5, 621-628.

Roberts, N. (1987). Breaking all the rules. New York: Penguin Books.
Robinson, B. E., Bacon, J. G., & O'Reilly, J. (1993). Fat phobia: Measuring, understanding,
and changing anti-fat attitudes. International Journal of Eating Disorders, 14(4), 467-480.

Rosen, J. C., Reiter, J., & Orosan, J. (1995). Assessment of body image in eating disorders
with the body dysmorphic disorder examination. Behaviour Research and Therapy, 33(1),
77-84.

Rosenbluth, S. C., & Steil, J. M. (1995). Predictors of intimacy for women in heterosexual
& homosexual couples. Journal of Social and Personal Relationships, 12(2), 163-175.

Roth, D., & Armstrong, J. (1993). Feelings of fatness questionnaire: A measure of the
cross-situational variability of body experience. International Journal of Eating Disorders,
14(3), 349-358.

Roth, G. (1983). Feeding the hungry heart. New York: New American Library/Signet.

Roth, G. (1984). Breaking free from compulsive eating. Indianapolis, In.: Bobbs-Merrill
Co..

Roth, G. (1991). When food Is love. New York: Dutton/Penguin.

Roth, G. (1996). Appetites. New York: Dutton/Penguin.

Rubin, T. I. (1967). The thin book by a formerly fat psychiatrist. New York: Essandess
Special Editions.

Rubin, T. I. (1970). Forever thin. New York: Gramercy Publishing Co..

Rubin, T. I. (1978). Alive and fat and thinning in America. New York: Coward, McCann &
Geoghegan, Inc..

Schaef, A. W. (1992). Beyond therapy, beyond science. San Francisco, California: Harper
SanFrancisco.

Schwartz, B. (1986). Diets don't work! (10th ed.). Las Vegas, Nv: Breakthru Publishing.
(Original work published 1982)

Shapiro, S.L. (1980). Sexual attitudes and activities of obese women. Unpublished doctoral
dissertation, The Institute for the Advanced Study of Human Sexuality.

Shoemaker, M. M. (1977, November-December). Letters: Tribute to NAAFA_Date Match.

NAAFA Newsletter, 6(4), 6.

Sholty. M.J., Ephross, P.H., Plaut, S.M., Fischman, S.H., Charnas, J.F., & Cody, C.A.
(1984). Female orgasmic experience: A subjective study. Archives of Sexual Behavior,
13(2), 155-164.
Siegel, M., Brisman, J., & Weinshel, M. (1989). Surviving an eating disorder. New York:
Perennial Library. (Original work published 1988)

Smith, A. W. (1990). Overcoming perfectionism. Deerfield Beach, Fl: Health

Communications, Inc..

Smith, S. E. (Ed.). (1995). Size acceptance & self-acceptance/ The NAAFA workbook: A
complete study guide (2nd ed.). Sacramento, Ca.: NAAFA.

Smolak, L., Levine, M. P., & Striegel-Moore, R. (Eds.). (1996). The developmental
psychopathology of eating disorders: Implications for research, prevention & treatment.
Mahwah, NJ: Lawrence Erlbaum Associates.

Social Issues Research Center. (June 20, 2000). Vital statistics show 'overweight' women
are healthy. SIRC [On line]. Available: http://www.sirc.org/news/vital_statistics.html

Spiegel, J. (1988). Differences between obese women in a relationship and obese women
not in a relationship. Unpublished doctoral dissertation, California Graduate School of
Marital and Family Therapy.

Srebnik, D. S., & Saltzberg, E. A. (1994). Feminist cognitive-behavioral therapy for

negative body image. Women & Therapy, 15(2), 117-133.

Staley, Deloris. (1977, May). Letters: Grateful for NAAFA. NAAFA Newsletter, 6(1), 3.

Steinberg, D. (Ed.). (1988). Erotic by nature. No. San Juan, California: Shakti Press/Red
Alder Books.

Stewart, J. (1995). Obesity: Etiology and treatment. San Luis Obispo, California: California
Polytechnic State University, Psychology & Human Development Dept.

Stop dieting and start living. (1980, May-August). NAAFA Newsletter, 8(3), 1,2.

Stuart, R. B., & Jacobson, B. (1987). Weight, sex & marriage. New York: W.W. Norton &
Company.

Stunkard, A. J. (1976). The pain of obesity. Palo Alto, California: Bull Publishing
Company.

Stunkard, A. J., & Wadden, T. A. (1993). Obesity: Theory and therapy (2nd ed.). New York:
Raven Press

Summer, N. (1996, Winter). The making of young activists: Bringing size awareness to the
classroom. Radiance, 10-13.
Sundermeyer, C. A. (1990). Emotional weight (5th ed.). Sacramento, California: New
Outlook. (Original work published 1989)

Swartz, L. H. (1994, Fall). Absorbed states play different roles in female & male sexual
response: Hypotheses for testing. Journal of Sex & Marital Therapy, 20(3), 244-251.

Szekely, E. (1988). Never too thin. Toronto, Canada: The Women's Press.

Taylor, A. (1999, May). Advertisement: How i lost 37 pounds & had the best summer of
my life!. Young & Modern Magazine.

Taylor, C. (1989, Summer). It's your move. Radiance, 40-42.

Tenzer, S. (1989). Fat acceptance therapy (F. A. T.): A non-dieting group approach to
physical wellness, insight, and self-acceptance. In Brown, L. S., & Rothblum, E. D. (Eds.),
Overcoming fear of fat (pp. 39-47). Binghamton, New York: Harrington Park Press.

Thomas, C. D., & Freeman, R. J. (1990). The body esteem scale: Construct validity of the
female subscales. Journal of Personality Assessment, 54(1 & 2), 204-212.

Thompson, J. K. (1986, April). Larger than life. Psychology Today, 38,39,42,44.

Thompson, S. H., Corwin, S. J., & Sargent, R. G. (1997). Ideal body size & weight
concerns of fourth-grade children. International Journal of Eating Disorders, 21(3), 279-
284.

Tiggemann, M., & Pickering, A. S. (1996). Role of television in adolescent women's body
dissatisfaction and drive for thinness. International Journal of Eating Disorders, 20(2), 199-
203.

Tobin, D. L., & Griffing, A. S. (1996). Coping, sexual abuse, and compensatory behavior.
International Journal of Eating Disorders, 20(2), 143-148.

Trapnell, P. D., Meston, C. M., & Gorzalka, B. B. (1997). Spectatoring & the relationship
between body image & sexual experience: Self-focus or self-valence?. The Journal of Sex
Research, 34(3), 267-278.

Tuiten, A., Panhuysen, G., Everaerd, W., Koppeschaar, H., Krabbe, P., & Zelissen, P.
(1993). The paradoxical nature of sexuality in anorexia nervosa. Journal of Sex & Marital
Therapy, 19(4), 259-273.

Tullman, G.M., Gilner, F. H., Kolodny, R.C., Dornbush, R.L., & Tullman, G.D. (1981).
The pre- & post-therapy measurement of communication skills of couples undergoing sex
therapy at the Masters & Johnson Inst. Archives of Sexual Behavior, 10(2), 95-109.
Vansteenwegen, A. (1996, Spring). Who benefits from couple therapy? A comparison of
successful & failed couples. Journal of Sex & Marital Therapy, 22(1), 63-67.

Wachtel, K. (1976, March-April). Some social implications of ridicule. NAAFA

Newsletter, 5(2), 1,4.

Wadden, T. A., & Stunkard, A. J. (1993). Psychosocial consequences of obesity and

dieting-Research and clinical findings. In Stunkard, A. J., & Wadden, T. A. (Eds.), Obesity:
Theory and therapy (2nd ed., pp. 163-177). New York: Raven Press.

Waldberg, P. (1969). Eros in la belle epoque (2nd ed.) (H. R. Lane, Trans.). New York:
Grove Press Inc. (Original work published 1964).

Walker, M. (1994). Sexual nutrition. Garden City Park, NY: Avery Publishing .

Waterhouse, D. (1997). Like mother, like daughter. New York: Hyperion.

Waterman, C. K., Chiauzzi, E., & Gruenbaum, M. (1979, November). The relationship
between enjoyment & actualization of self & sexual partner [Abstract]. The Journal of Sex
Research, 15(4), 253-263.

Weis, D. L., Slosnerick, M., Cate, R., & Sollie, D. L. (1986, May). A survey instrument for
assessing the cognitive association of sex, love, & marriage. The Journal of Sex Research,
22(2), 206-220.

Werlinger, K., King, T. K., Clark, M. M., Pera, V., & Wincze, J.P. (1997). Perceived
changes in sexual functioning & body image following weight loss in an obese female
population: A pilot study. Journal of Sex & Marital Therapy, 23(1), 74-78.

Westheimer, R. (1984). Dr. Ruth's guide to good sex. New York: Warner Books.

Whiteis, D. (1983, Summer). How to meet guys!. NAAFA Newsletter, 10(1), 7.

Wiederman, M. W. (1996). Women, sex, & food: A review of research on eating disorders
& sexuality. The Journal of Sex Research, 33(4), 301-311.

Wiederman, M. W., & Pryor, T. (1997). Body dissatisfaction & sexuality among women
with bulimia nervosa. International Journal of Eating Disorders, 21(4), 361-365.

Wilchins, R. A. (1996). Some thoughts on body image & sexuality.

Williamson, D. A., Barker, S. E., Bertman, L. J., & Gleaves, D. H. (1995). Body image,
body dysphoria, and dietary restraint: Factor structure in nonclinical subjects. Behaviour
Research and Therapy, 33(1), 85-93.
Wills-Brandon, C. (1993). Am I hungry...or am I hurting? San Diego, California: Recovery
Publications, Inc..

Wilson, C. P., Hogan, C. C., & Mintz, I. L. (Eds.). (1987). Fear of being fat (Rev. ed.).
Northvale, NJ: Jason Aronson Inc. (Original work published 1983).

Wise, T. N. (1978, January). Massive obesity & sexual activity. Medical Aspects of Human
Sexuality, 7-23.

Woititz, J. G. (1989). Healing your sexual self. Deerfield Beach, Fl.: Health
Communications, Inc..

Wolf, N. (1991). The beauty myth. New York: William Morrow & Company, Inc..

Women's Therapy Centre Institute; Bloom [et al.]. (1994). Eating Problems. New York:
BasicBooks.

Woodman, M. (1980). The owl was a baker's daughter. Toronto, Canada: Inner City Books.

Woodman, M. (1982). Addiction to perfection. Toronto, Canada: Inner City Books. p.41

Woodside, D. B., Shekter-Wolfson, L. F., Brandes, J. S., & Lackstrom, J. B. (1993). Eating
disorders & marriage: The couple in focus. Eating Disorders Monograph Series (#8).

Wooley, S. C. & Wooley, O. W. (1984). Should obesity be treated at all?. In A. J. Stunkard,

& E. Stellar (Eds.), Eating & it's disorders (pp. 185-192). New York: Raven Press.

Wooley, S. C., et al. (1979). Theoretical, practical & social issues in behavioral treatments
of obesity. Journal of Applied Behavior Analysis, 12, (3).

Yohannon. (1996). Fat sex: About positions and attitudes. Dimensions [On line]. Available:
http://www.pencomputing.com/dim/dimtext/positions/fat_sex.html

Young, W. (1964). Eros denied. New York: Grove Press, Inc..

Zilbergeld, B. (1978). Male sexuality. New York: Bantam Books.