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)

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