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Article

A Comprehensive Model of Embodiment in Late Pubertal Female-at-Birth Adolescents: The Role of Body Awareness and Mental Health

by
Greta Riboli
1,2,3,*,
Luca Daminato
1,2,
Mattia Nese
2,3,
Marina Cassola
4,
Gabriele Caselli
2,3,
Gianni Brighetti
2 and
Rosita Borlimi
2
1
Department of Psychology, Sigmund Freud Privatuniversität, 1020 Wien, Austria
2
Department of Psychology, Sigmund Freud University, 20143 Milan, Italy
3
Studi Cognitivi, Cognitive Psychotherapy School, 20121 Milan, Italy
4
Department of Social and Political Sciences, University of Milan, 20122 Milan, Italy
*
Author to whom correspondence should be addressed.
Adolescents 2025, 5(2), 14; https://doi.org/10.3390/adolescents5020014
Submission received: 6 December 2024 / Revised: 10 April 2025 / Accepted: 14 April 2025 / Published: 21 April 2025
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Abstract

Body awareness consists of aesthetic body image, functional body image, and interoception. Previous studies indicated a link between these components of body awareness and mental health. This study aims to clarify the relationship among these variables during the period of pubertal body changes. As puberty progresses, individuals’ perceptions of their bodies shift, which has been associated with a decline in mental health, according to the existing literature. To investigate this issue, a sample of 294 post-pubertal adolescents assigned female at birth completed assessments related to body awareness, mental health, psychosomatic symptoms, gender congruence, and eating disorders. A network analysis was conducted to illustrate the intricate interactions among the observed variables, and a mediation model was utilised to explore how body image influences overall health, with interoception and functional body image acting as mediators. The study identifies three key variables—body image, mental health, and interoception—as central within the network. Additionally, functional body image was significantly associated with other variables in the study. Ultimately, both direct and indirect effects of body image on mental health were found, mediated through interoception and functional body image. The clinical implications emphasise the importance of enhancing awareness of bodily sensations and functions to support psychological well-being, particularly during a developmental stage characterised by challenges related to body image due to rapid changes in puberty.

1. Introduction

Puberty is recognised as a critical phase for experiencing body image difficulties [1]. Puberty is defined as a developmental phase characterised by accelerated biochemical, physiological, and psychological transformations that emerge at the end of childhood [2,3]. While some changes are similar between the sexes, others are sex-specific, such as breast development, changes in body shape, and menstruation onset, and are dictated by gonadal estrogen. The pubertal developmental period could be different from one child to another due to genetic factors, environmental variables, and psychological factors [4].
In females, the onset of menstruation, identified with the term “menarche”, is a unique and specific experience which marks puberty, and the worldwide average for this bodily development is around 13 years of age. Menarche has an impact on the psychological and social functioning of females [5]. Providing adolescents with accurate information, emotional support, and positive narratives about menstruation can help mitigate anxiety and distress, fostering a more positive and integrated experience of this developmental transition [6,7].
Decades of research have highlighted the relatively low rates of psychiatric disorders in prepubertal children, compared with a sharp rise in rates of psychopathology among those who have commenced puberty. In a systematic review [6] of 15 years of research on mental disorders during childhood, adolescence, and early adulthood, the authors [8] found that approximately one in five adolescents was diagnosed with a psychiatric disorder. The study also highlighted a significant increase in the incidence of anxiety disorders, eating disorders, depression, and substance use disorders, particularly at the onset of puberty.
Further studies [7,8,9] revealed that early childhood disorders, such as autism, predominantly affect males, while disorders and symptoms that emerging during puberty, including anxiety, depression, and eating disorders, exhibit a marked preponderance in females [8,9,10]. In the literature, body awareness has been identified as a crucial factor in the development of psychological disorders and symptoms during puberty, especially in relation to eating disorders. Body awareness, or bodily self-consciousness, is divided into exteroception (body image) and interoception (internal bodily perception) [9]. Body image, encompassing both cognitive and emotional perceptions of one’s body, undergoes significant changes during puberty due to the physical transformations that occur. Body image has been defined by Cash [11] as a multidimensional construct which includes both self-perception and attitudes about one’s physical appearance. Furthermore, body image has two main characteristics: the aesthetic one and the functional one [12]. The aesthetic property of body image includes the evaluations people have of their bodies that determine their level of body (dis)satisfaction [12]. Functional body image refers to how individuals perceive their body’s abilities and capacities rather than its external appearance. This perspective includes aspects such as physical endurance and movement (e.g., walking, dancing), sensory experiences (e.g., hearing, vision), internal bodily functions (e.g., digestion), as well as everyday activities related to self-care (e.g., showering) and non-verbal communication (e.g., body language). Unlike aesthetic body image, which focuses on how the body looks, functional body image emphasises the “body as process”, highlighting what the body is capable of doing and how it performs in daily life [12,13,14]. The scientific literature focuses more on the aesthetic value of body image, often leaving out the functional part and defining ‘body image’ as a construct that is more dependent on the aesthetic part [14]. Body concerns are a well-documented source of psychological distress, as body-related preoccupations are common in daily life [11]. A negative body image includes not only a poor evaluation of one’s body and shape but also behavioural, emotional, and cognitive aspects associated with body image, such as avoidance, checking behaviours, dysfunctional emotions, and ongoing concerns [15,16,17].
Body interoception is defined as the ability to perceive and process internal bodily signals (e.g., heartbeat, pain, hunger), which play a crucial role in regulating behaviours and emotions [18,19,20]. It has been identified as a significant risk factor, alongside body image, in the development of eating disorders and emotional disorders such as depression and anxiety [19,21,22]. The connection between body interoception and body image is deeply intertwined, with body interoception contributing to the reconstruction of the bodily self during adolescence [20,23]. Interoception can be considered a developmental factor [18,24] and, together with body image, plays a critical role in shaping personal identity [23]. Several studies have explored the complex interaction between body image and body interoception [18]. For example, a cross-sectional study [25] on a non-clinical sample of adolescents and young adults found a relationship between body interoception and negative body image, as well as body dissatisfaction. This relationship was observed not only in clinical populations with eating disorders [21,26,27] but also in non-clinical samples. Additionally, other authors [20] further found that lower accuracy in body interoception is associated with body image concerns and proposed a model integrating exteroceptive (body image) and interoceptive (interoception accuracy) bodily representations. The connection between body image concerns and interoception was also confirmed in another study [28], which identified interoception as a mediator between body image concerns and dysfunctional eating behaviours in a non-clinical sample of 200 young adult women. In the literature, numerous studies have examined the relationship between body image and mental distress or psychopathology, including psychosomatic symptoms [29] as well as the link between body interoception and various psychological conditions, including depression, anxiety, eating disorders, addictive behaviours, and psychosomatic symptoms [18,28,30]. For instance, another study [31] found a strong relationship between high accuracy in body interoception and positive body image in a sample of 265 adolescents aged 13–16, who completed several questionnaires on bodily dimensions. Many studies have confirmed the association between lower interoception and negative body image [20,24,26] and vice versa [28,31]. Additionally, some researchers hypothesise that interoception may play a predictive role in shaping body image [20]. The minor literature focuses on the relationship between specific functional body image and aesthetic body image and interoception: prior research suggesting that greater appreciation of body functionality is linked to reduced body dissatisfaction and improved well-being [12,14].
Based on these considerations, the present study aims to analyse the relationships among key psychological variables related to body awareness and mental health in female-at-birth adolescents in the late pubertal stage, a population particularly vulnerable to body-related concerns due to rapid physical changes. While existing research has primarily focused on aesthetic body image, this study addresses a significant gap by integrating functional body image and interoception. To achieve this, we employ a network analysis-based approach [32,33] to represent the complex interactions among multiple observed variables, providing a novel perspective on how aesthetic body image, interoception, and functional body image interact within the broader framework of psychological well-being. Additionally, a mediation model is used to test the hypothesis that interoception and functional body image mediate the relationship between aesthetic body image and mental health, offering new insights into potential protective mechanisms that could inform interventions aimed at fostering positive body awareness and mental well-being in adolescence. It is expected that body image dissatisfaction will be negatively associated with mental health, while higher interoception and greater appreciation of functional body image will show positive associations with mental health. Additionally, interoception and functional body image are hypothesised to mediate the relationship between aesthetic body image and mental health, potentially mitigating the negative effects of body dissatisfaction.

2. Materials and Methods

An online survey was developed to explore body perception in a sample of late pubertal females assigned female at birth. A total of 343 respondents were recruited through advertisements on blogs dedicated to psychology as well as social media pages (e.g., on Instagram and TikTok) focused on mental health. The advertisements targeted Italian-speaking adolescents assigned female at birth, aged 10–17 years, who had experienced at least 1 menstrual cycle. To encourage participation in the survey, a statement was used that highlighted the importance of the research for understanding the relationship between body awareness and mental health. The participants did not receive any financial compensation for their involvement. Prior to participation, informed consent was obtained from all participants at the beginning of the online survey. Participants were provided with a detailed study description, outlining the objectives, procedures, and confidentiality measures. They were informed that their participation involved completing a set of questionnaires assessing bodily changes, body image (aesthetic and functional), interoception, mental health, and gender congruence, with an estimated completion time of approximately 40 min. The study emphasised that their participation would contribute to a better understanding of the relationship between body awareness and mental health during female puberty. The inclusion criteria were as follows: (1) sex assigned female at birth, (2) aged over 14 and in Tanner Stage 4 (a developmental stage typically occurring between 10 and 17 years of age, 1–3 years after thelarche, and having experienced at least 1 menstrual cycle [34]), and (3) Italian speaker.
A self-administered online survey was completed by participants, which contained sociodemographic information, questions concerning menstruation, body image, interoception, and mental health.
Socio-demographics: Demographic characteristics were collected, including age, area of provenience, and gender identity.
Pubertal body changes: The female scale of the Pubertal Development Scale (PDS) [35] was administered as tool to include participants and possibly exclude participants who have not experienced menarche or were in the post pubertal stage, thus including participants in late-pubertal stage. The PDS is a self-report questionnaire based on continual pubertal growth indices, differentiated by the respondent’s sex, which investigates secondary sexual characteristics (e.g., Have you noticed that your breasts have begun to grow?) [36]. The scoring, based on the response options (I do not know, 0; not yet started, 1; barely started, 2; definitely started, 3; seems complete, 4; and binary options for menarche: no, 0; yes, 1) guarantees categorizations into pubertal stages based on and correlated with Tanner pubertal stages [37,38]: pre-pubertal, early pubertal, mid-pubertal, late-pubertal, and post-pubertal. The PDS has reported the following psychometric properties: internal consistency (Cronbach’s alpha 0.68–0.83) and test–retest reliability 0.70–0.80).
Body image attitudes: The Body Uneasiness Test (BUT) is a scale composed of 71 items in total used for the assessment of abnormal body image attitudes and eating disorders [15]. It is divided into two parts: BUT A (34 items) and BUT B (37 items), the latter evaluating concerns about specific body parts across 8 factors. BUT A comprises 5 factors: Weight Phobia (WP), the fear of being or becoming fat; Body Image Concerns (BIC), which describes worries related to physical appearance; Avoidance(A), referring to behaviours related to body image avoidance; Compulsive Self-Monitoring (CSM), which rates compulsive checking of one’s physical appearance; Depersonalization (D), which describes the feelings of detachment and estrangement from the body. BUT A scores are calculated through a 6-point Likert scale ranging from never (0) to always (5). In the present project, the Global Severity Index (GSI) is used to assess aesthetic body dissatisfaction and the relative emotional distress associated with it. The GSI is calculated by averaging all 34 items of BUT A (e.g., I like those clothes which hide my body; I spend a lot of time thinking about some defects of my physical appearance; I think my life would change significantly if I could correct some of my aesthetic defects). Higher scores correspond to greater levels of body dissatisfaction and related emotional distress. BUT A has reported good psychometric properties, with a satisfactory internal consistency (Cronbach’s alpha: 0.90–0.95), while BUT B also demonstrates good reliability (Cronbach’s alpha 0.85–0.91) and significant test–retest correlation coefficients (0.86–0.93).
Functional body image: The Embodied Image Scale (EIS) measures cognitive, behavioural, and affective components of body image, assessing both aesthetic and functional dimensions [12]. It includes 19 items across 6 subscales: Functional Values (4 items), Functional Behavioural Investment (3 items), Functional Satisfaction (3 items), Aesthetic Values (3 items), Aesthetic Behavioural Investment (3 items), and Aesthetic Satisfaction (3 items). The score is calculated through a 5-point Likert scale, ranging from 1 (not at all true for me) to 5 (very true for me). Higher scores on the Embodied Image Scale (EIS) indicate a stronger identification with either the functional or aesthetic dimensions of body image, depending on the specific subscale. Higher scores on the Functional Values, Functional Behavioural Investment, and Functional Satisfaction subscales reflect a greater appreciation of the body for its abilities, movement, and functionality. Conversely, higher scores on Aesthetic Values, Aesthetic Behavioural Investment, and Aesthetic Satisfaction subscales denote a stronger emphasis on appearance-based body image, including aesthetic appreciation and investment in one’s physical appearance. In the present project, functional subscales are used to assess functional body image. (e.g., How good I feel about my body depends a lot on what my body can do physically; I do physically active things often). The EIS has reported the following psychometric properties: internal consistency (Cronbach’s alpha 0.80–0.89) and test–retest reliability (0.82).
Interoception: The Interoceptive Accuracy Scale (IAS) [39] is a 21-item self-reported measure used to assess the dimension of accuracy, rather than attention, within interoceptive sensibility. The IAS asks respondents if they can “always accurately perceive” 21 specific bodily functions or sensations. Scores are calculated on a scale from 1 (strongly disagree) to 5 (strongly agree), with total scores ranging from 21 to 105. Higher scores indicate greater perceived interoceptive accuracy (e.g., Most of the time my attention is focused on whether my heart is beating fast; Most of the time my attention is focused on whether I am hungry). The IAS has reported the following psychometric properties: internal consistency (Cronbach’s alpha 0.85) and test–retest reliability (0.75–0.86).
Mental health: The General Health Questionnaire (GHQ-12) was originally developed by Goldberg [40], and it is used to measure short-term change in mental health and psychological functioning to study minor psychiatric disorders. It includes 12 items in total, divided into three factors: Social Dysfunction (6 items), which describes psychological health; Anxiety/Depression (4 items), which identifies mental disorders; and Loss of Confidence (2 items), which assesses the relationship with oneself. Scores are calculated on a 4-point Likert scale, from better than usual (1) to much less than usual (4). Higher scores indicate a greater mental health (e.g., being able to enjoy your normal day to day activities; Lost much sleep over worry). The GHQ-12 has reported the following psychometric properties: internal consistency (Cronbach’s alpha 0.82–0.91), and test–retest reliability (0.78–0.88).
Eating Disorder: The Eating Disorder Inventory-3 (EDI-3) [41] is a 91-item self-report questionnaire that assesses various dimensions of eating disorder pathology across 12 scales: Drive for Thinness, Bulimia, Body Dissatisfaction, Low Self-Esteem, Personal Alienation, Interoceptive Deficits, Interpersonal Insecurity, Interpersonal Alienation, Emotional Dysregulation, Perfectionism, Asceticism, and Maturity Fears. Of these, 3 scales specifically target eating disorder symptoms: Drive for Thinness, Bulimia, and Body Dissatisfaction, while the remaining scales address broader psychological characteristics. Each item is rated on a 6-point Likert-type scale ranging from “always” to “never”, but scoring is converted to a 0–4 scale, with higher scores indicating more severe symptoms. The Drive for Thinness scale (7 items) evaluates the desire to lose weight, including dieting and preoccupation with weight, and is considered a crucial criterion for diagnosis (score range: 0 to 28). The Bulimia scale (8 items) measures concerns related to overeating and eating in response to emotional distress (score range: 0 to 32). The Body Dissatisfaction scale (10 items) assesses dissatisfaction with overall body shape and specific body regions such as hips, stomach, and buttocks (score range: 0 to 40). In the EDI-3 version, these three scales are combined to form the Eating Disorder Risk Composite, with scores ranging from 0 to 100 (e.g., Have you been deliberately trying to limit the amount of food your eat to influence your shape or weight (whether or not you have succeeded?; Have you had a definite desire to have a totally flat stomach?). The EDI-3 has reported the following psychometric properties: internal consistency (Cronbach’s alpha 0.86–0.93) and test–retest reliability (0.87–0.94).
Gender congruence: The Gender Congruence and Life Satisfaction Scale (GCLS) [42] is a self-assessment tool comprising 38 items designed to evaluate gender congruence and life satisfaction. The items are formulated in a gender-neutral way, allowing the subscales to be applicable universally. Respondents rate the degree to which each statement reflects their experience on a five-point Likert scale (1 = strongly agree; 5 = strongly disagree). The GCLS is organised into seven subscales within two main clusters. The first, “Gender Congruence”, assesses comfort with genitalia, chest, other secondary sex characteristics, and social gender role affirmation. The second, “Gender-related Mental Wellbeing and Life Satisfaction”, evaluates aspects of physical and emotional intimacy, psychological health, and life satisfaction. Higher scores correspond to more favourable outcomes, reflecting greater gender congruence, body satisfaction, gender-related well-being, and overall life satisfaction. The present study utilised scores from the first cluster, “Gender Congruence” (e.g., I have felt my chest does not match my gender identity; I have felt extremely distressed when looking at my genitals). The GCLS has reported the following psychometric properties: internal consistency (Cronbach’s alpha 0.87) and test–retest reliability (0.84).
Psychosomatic symptoms: The Psychophysiological Questionnaire short-form (QPF/R) is a 30-item self-report questionnaire designed to assess the severity of psychophysiological symptoms, with responses rated on a scale from 1 (not at all) to 4 (very much), resulting in a total score range of 30 to 120 [43] (e.g., I have gastric or abdominal pain). The QPF/R has reported the following psychometric properties: internal consistency (Cronbach’s alpha 0.80–0.88) and test–retest reliability (0.76–0.85).
Statistical analyses: Statistical analyses were conducted using JASP software, version 0.19.3 (2024). Descriptive statistics, including means (M), standard deviations (SD), and frequencies, were computed to summarise the sample characteristics. Correlation analyses were performed to examine the relationships between the variables, with Pearson correlation coefficients used to understand the direction of each association. This initial correlation analysis provided insights into the fundamental relationships between variables, establishing the groundwork for subsequent, more complex analyses. Subsequently, a network analysis was conducted to investigate the interconnections among variables, allowing the visualisation of a system of variables as a network of nodes (variables) connected by edges (relationships), which helps identify clusters or groups of highly interconnected variables, making it easier to understand how variables interact as a whole rather than in isolated pairs. Network analysis utilised the Extended Bayesian Information Criterion graphical lasso (EBICglasso) estimator. Centrality measures, including betweenness, closeness, strength, and expected influence, were calculated to identify the most influential variables within the network. These centrality indices helped highlight variables that play pivotal roles in the overall structure of interrelationships. Finally, a structural equation modelling (SEM) was conducted to examine the direct and indirect effects of aesthetic body image on mental health, with interoception and functional body image serving as mediating variables of this relationship.

3. Results

A total of 343 individuals provided informed consent and completed the survey; however, 49 participants were excluded as they did not meet the inclusion criteria. The final sample consisted of 294 pubertal females assigned female at birth (mean age: 14.02, SD = 0.16, range: 14–15). Correlation analyses were conducted to explore the relationships between the key variables: emotions through menarche and pubertal body changes, aesthetic body image, functional body image, interoception, mental health, gender congruence, eating disorder risk, and psychosomatic symptoms (Table 1).
The analyses revealed that, in general, most of the variables correlated with each other except for psychosomatic symptoms. In particular, body image correlated negatively with multiple variables. Specifically, body image showed negative correlations with gender congruence (r = −0.62, p < 0.001), functional body image (r = −0.28, p < 0.001), interoception (r = −0.26, p < 0.001), and mental health (r = −0.27, p < 0.001). Interoception showed a positive correlation with functional body image (r = 0.52, p < 0.001), while demonstrating a negative correlation with body image (r = −0.26, p < 0.001). Functional body image was positively correlated with body image (r = −0.28, p < 0.001) and gender congruence (r = 0.18, p = 0.002). Mental health was positively associated with interoception (r = 0.35, p < 0.001) and functional body image (r = 0.39, p < 0.001) but negatively associated with body image (r = −0.27, p < 0.001). Finally, eating disorder risk was positively correlated with body image (r = 0.43, p < 0.001) and had a smaller positive correlation with gender congruence (r = −0.28, p < 0.001). In contrast, it correlated negatively with gender congruence (r = −0.28, p < 0.001), functional body image (r = −0.12, p = 0.042), interoception (r = −0.18, p = 0.002), and mental health (r = −0.19, p < 0.001).
A network analysis was conducted to examine the interconnections among key psychological variables, including gender congruence (GC), aesthetic body image (BI), functional body image (FBI), interoception (INT), mental health (MH), psychophysiological symptoms (PS), and eating disorder risk (ED-RISK). The network consisted of 7 nodes with 12 non-zero edges out of a possible 21, resulting in a sparsity value of 0.43 (Figure 1). Centrality measures indicated that body image (BI) had the highest betweenness (1.67) and closeness (0.50), followed by mental health (MH) (betweenness 0.98; closeness 0.55). As shown in Figure 2, nodes with high betweenness included body image (BI) (1.67), mental health (MH) (0.98), and interoception (INT) (0.29). Nodes with the highest closeness were interoception (INT) (0.62), body image (BI) (0.50), and mental health (MH) (0.55). Finally, the nodes with the strongest connections with as many other nodes as possible were body image (BI) (1.50), functional body image (FBI) (0.471), and interoception (INT) (0.37). Functional body image (FBI) (1.08), interoception (INT) (0.77), and mental health (MH) (0.703) have a positive expected connectivity score.
The mediation model examined the effects of body image on general health with interoception and functional body image as mediators (Figure 3). The model demonstrated an adequate fit with significant direct effects of body image and indirect effects mediated through interoception and functional body image. The R2 values illustrate the contribution of the mediators to the explanatory power of the model. Mental health (MH) demonstrated the highest R2 value (R2 = 0.26, 95% CI: 0.15–0.36), indicating that 25.8% of the variance in mental health was accounted for by the model. Interoception (INT) and functional body image (FBI) also showed significant explanatory power, with R2 = 0.15 for interoception and R2 = 0.18 for functional body image, reflecting the moderate contribution of these mediators in explaining the variance within the model. The analysis revealed notable direct and indirect effects of body image (BI) on mental health (MH), mediated through interoception (INT) and functional body image (FBI). The direct effect of body image on mental health was estimated at −0.15 (β = −0.15, p = 0.005), with 95% confidence intervals ranging from −0.25 to −0.04. Indirect effects through both interoception and functional body image were also statistically significant, with the strongest indirect effect observed through functional body image (−0.07; β = −0.18, p = 0.002). The pathway body image → interoception → mental health yielded an indirect effect estimate of −0.05 (p = 0.013), while the pathway body image → functional body image → mental health had an indirect effect estimate of −0.07 (p = 0.002)—both indicated the association of these mediators on mental health outcomes. Further parameter estimates indicated that body image positively predicted interoception (estimate = 0.29, p < 0.001) and functional body image (estimate = 0.37, p < 0.001), reinforcing the role of body image in enhancing both interoceptive awareness and the perception of functional body image. In terms of predicting mental health, both interoception and functional body image were significantly related to lower mental health scores: interoception had an estimate of −0.15 (p = 0.003), and functional body image showed an effect of −0.18 (p < 0.001). These findings highlight the association between body image dissatisfaction on mental health, particularly through these mediators. The total effect of body image on mental health was −0.26 (p < 0.001), with a combined total indirect effect of −0.11 (p < 0.001), indicating that the indirect pathways substantially contribute to the overall impact. For a detailed summary of all direct and indirect effects, including standardised values and confidence intervals, refer to Table 2.

4. Discussion

This study provides an in-depth analysis of key psychological dimensions related to body awareness and mental health in a sample of late-pubertal adolescents assigned female at birth, highlighting their reciprocal interconnections through a network approach. The study highlights three variables for their central role within the network: aesthetic body image, mental health, and interoception. These findings are consistent with the literature reporting the important role of body image during middle adolescence (ages 12–15), a period of life in which body dissatisfaction becomes more pronounced [44], posing a notable risk factor for mental health, particularly among adolescents assigned female at birth [45]. Also, the central role of interoception is consistent with the literature [21,32,46].
Functional body image holds a central position within the network, serving as a crucial connector between various dimensions of body image and mental health, offering a perspective on the potential spread of influence it can have within the network, influencing interconnected variables. Indeed, functional body image has a correlation with aesthetic body image and mental health outcomes. Previous research has indicated a correlation between positive functional body image and enhanced mental health outcomes, along with reduced body dissatisfaction [13].
Moreover, interoception and mental health are anticipated to play a moderately significant role, particularly influencing their neighbouring nodes: psychosomatic symptoms and the risk of eating disorders. Research indicates that interoception is a crucial factor in psychosomatic disorders [47,48,49]. Its position within the network suggests that it may play a key role in managing psychological symptoms and mitigating the risk of eating disorders [50,51]. Similarly, mental health, with its elevated significance, emerges as a central node, reinforcing the theory that interventions aimed at enhancing mental well-being could have beneficial effects on other dimensions of psychological and physical health [52,53,54].
Moreover, targeting functional body image might lead to substantial improvements across related areas due to its strong connection with them [55,56]. This suggests that interventions designed to enhance functional body image may have beneficial effects that extend across various dimensions of mental health and aesthetic body image.
Several observations can be drawn from the specific connections between some of the dimensions considered, as aesthetic body image is related to gender congruence, eating disorder risk, functional body image, interoception, and mental health. In the present study, consistent with the existing literature [57], a negative correlation was found between body dissatisfaction and gender congruence. Gender incongruence may exacerbate distress related to bodily characteristics, such as secondary sex traits, which are shaped by cultural norms surrounding ideals of masculinity and femininity [58]. This discomfort tends to intensify during puberty, a developmental stage in which bodily changes heighten the perceived discrepancy between gender identity and body image [59,60,61,62]. Puberty also constitutes a period of vulnerability for the development of eating disorders. The present findings confirm the positive relationship between eating disorders and body dissatisfaction widely reported in the literature [11,15,63,64,65,66,67,68,69]. Moreover, aesthetic body image was found to be associated with interoceptive awareness, with higher interoception correlating with a more positive perception of one’s body [32,70,71]. Interoceptive awareness also emerges as a protective factor for mental health, which is negatively correlated with body dissatisfaction and positively associated with interoception [30,72,73,74]. Furthermore, interoception is positively related to a functional body image, suggesting that individuals with greater awareness of internal bodily sensations tend to place higher value on the body’s functional abilities—such as movement and endurance—rather than solely on its aesthetic appearance [31,75,76]. Although still understudied through quantitative approaches [77], the relationship between aesthetic and functional body image has been emphasised in qualitative studies, which highlight its potential in fostering a more positive perception of the body [78,79]. The current findings also confirm a positive association between functional body image and mental health, consistent with previous studies on both adolescents and adult women [14,80,81,82]. Focusing on the body’s functionality rather than aesthetics appears to enhance psychological well-being and reduce feelings of inadequacy. Moreover, a positive body image is linked to better emotional regulation, which can mitigate the negative effects of body dissatisfaction on mental health [83]. Finally, while psychosomatic symptoms appear as a somewhat isolated construct, they nonetheless reveal a noteworthy association with body image: individuals who are predominantly focused on the aesthetic aspects of the body tend to accumulate psychological and physiological tension, manifesting in symptoms such as headaches, muscle tension, and fatigue—findings that are consistent with prior research [84,85,86].
Based on these results, it is hypothesised that interoception and functional body image mediate the relationship between aesthetic body image and mental health. Our findings support this hypothesis, confirming that interoception and functional body image play a mediating role. Specifically, the results reveal the direct effects of body perception on mental health. Individuals who perceive their body image as negative may experience a direct detrimental effect on their mental health status.
The reasons why body image and mental health have a close relationship can be attributed to several factors. This connection is largely due to the critical role that body perception plays in shaping self-image, which, when negative, becomes a source of insecurity, affecting self-evaluation and emotional stability [87].
In detail, our findings also support the hypothesis that interoception may mediate the relationship between aesthetic body image and mental health. The ability to perceive and interpret one’s bodily sensations is closely linked to how individuals feel about their bodies. High levels of interoception are associated with a more positive perception of one’s body [73], thereby mitigating the negative effect of body image on mental health. Conversely, low interoceptive awareness is associated with greater insecurities regarding aesthetic body image, thereby increasing the risk of psychological distress. As previously discussed, this suggests that in the absence of adequately functioning interoceptive awareness, individuals may increasingly focus on their bodily appearance. This heightened focus often co-occurs with greater body dissatisfaction [20,31,88], a phenomenon that is particularly pronounced during puberty, a period characterised by rapid bodily changes. The literature further indicates that interoception may mediate the effect of body image on mental health, as greater awareness of bodily sensations has been associated with a more positive body perception [49]. Individuals with heightened interoceptive sensitivity tend to perceive their body as a dynamic and capable entity, which reduces the emphasis on aesthetics and lowers the risk of aesthetic body image-related anxiety or depression [89]. Conversely, low interoceptive awareness is linked to difficulties in integrating bodily experiences and a more negative body perception, which may be associated with poorer psychological well-being and mental health [74].
Interoceptive awareness has been identified as a mediator in the relationship between aesthetic body image and mental health, as it enables individuals to recognise and interpret physiological sensations associated with emotions, thereby enhancing self-awareness and emotional regulation and potentially reducing vulnerability to mental distress and concerns related to aesthetic body image [89].
Conversely, low interoceptive awareness has been associated with various psychological disorders, including anxiety, depression, and eating disorders [74]. Individuals with diminished interoceptive skills tend to rely more on external cues such as societal beauty standards to assess their physical and psychological states, increasing their vulnerability to aesthetic body image insecurities. Enhancing interoceptive awareness helps individuals develop a more autonomous and positive perception of their body, fostering emotional stability and decreasing dependence on external validation, ultimately contributing to better mental health outcomes.

4.1. Implications

Our findings further support the hypothesis that functional body image serves as a mediator in the relationship between aesthetic body image and mental health. Unlike traditional body image, which is predominantly centred on aesthetics, functional body image focuses on how individuals perceive their body in terms of its abilities and physical capacities. Individuals who emphasise the functional aspects of their body tend to develop a more positive overall body image, which can mitigate or even counterbalance the negative effects of dissatisfaction with their aesthetic appearance on mental health. This mediating role suggests that an emphasis on functionality acts as a protective factor, fostering psychological well-being by encouraging individuals to reframe their perception of their body in a positive and empowering way.
This integration of functionality into body image not only enhances body satisfaction but also strengthens resilience by reshaping how individuals relate to their bodies, leading to improved mental health outcomes. Within the literature, functional body image is recognised as a key factor in mental health due to its capacity to mitigate psychological vulnerabilities associated with traditional body image perceptions. By reducing body objectification—where individuals primarily evaluate themselves based on appearance—functional body image lessens the persistent focus on physical aesthetic that contributes to anxiety and depression [90]. This shift towards valuing the body for its abilities fosters a self-perception that is less susceptible to aesthetic judgments, thereby promoting mental well-being. Moreover, emphasising bodily functionality enhances resilience to societal and media pressures, as individuals with a strong functional body image are less influenced by unrealistic beauty ideals, such as the ideals of thinness and perfection standards often reinforced by the media [90]. As a result, these individuals cultivate a more stable and positive self-assessment. Additionally, prioritising functionality over aesthetics has been shown to increase self-efficacy and self-satisfaction, as individuals experience a greater sense of autonomy, competence, and resilience, which further supports psychological well-being by reducing the impact of societal aesthetic standards and strengthening self-esteem [13]. Collectively, these factors illustrate why functional body image is a protective mechanism that mitigates the negative effects of traditional aesthetic body concerns on mental health.

4.2. Limitations and Future Directions

This study serves as an initial and modest contribution toward better understanding the connections between interoceptive awareness, functional body image, and mental health. However, several limitations must be acknowledged. The study focuses on a sample of 294 late-pubertal adolescents assigned female at birth, within a narrow age range (14–15 years). This limits the generalizability of the findings to other age groups and pubertal stages, particularly those outside the late pubertal stage. Furthermore, the study relies exclusively on self-administered questionnaires, which introduces the possibility of response biases. This methodology may affect the accuracy of assessing subjective constructs such as interoceptive awareness and body image, as self-reported measures are inherently influenced by individual perception and potential social desirability biases.
Future research could adopt a longitudinal design to better understand the causal relationships between body image, interoception, and mental health. Tracking participants over time would help clarify the developmental dynamics of these variables, particularly during the critical period of puberty. Additionally, rather than relying solely on self-reported measures, future studies could incorporate experimental tasks to assess interoceptive accuracy and sensibility. For instance, heartbeat detection tasks or breath-holding exercises could provide more objective insights into interoceptive processes. Expanding the sample to include individuals across different pubertal stages would also enhance the generalizability of findings and provide a broader understanding of body awareness and mental health across diverse populations. Lastly, intervention studies could explore the effectiveness of targeted approaches, such as mindfulness-based programmes or activities emphasising body functionality, to improve interoceptive awareness, promote positive body image, and mitigate the adverse mental health impacts associated with body dissatisfaction.

5. Conclusions

The complexity of the direct and indirect effects of body image on mental health highlights the importance of adopting a multidimensional perspective on body image. Approaches that integrate internal body awareness with a focus on functional capabilities may prove more effective in promoting psychological well-being than interventions that focus solely on the aesthetic aspects of body image. These findings suggest potentially valuable pathways for the development of therapeutic strategies aimed at reducing the negative effect of body image on mental health by emphasising functionality and interoception. Approaches that combine mindfulness practices with a focus on bodily functionality have been particularly effective in mitigating the risk of psychological disorders. For instance, physical activity programmes that emphasise body strengthening and functional abilities rather than weight loss or aesthetics have been shown to promote a more positive body image and reduce vulnerability to aesthetic ideals [91]. Mindfulness practice is closely linked to interoceptive awareness, as it fosters conscious attention to bodily sensations. Studies such as those by [49] demonstrate that mindfulness-based practices can enhance interoceptive sensitivity, fostering a perception of the body as integrated and in harmony with the mind. This integrated approach has been shown to reduce self-criticism and promote a positive body image, resulting in tangible benefits for mental well-being and stress management.

Author Contributions

Conceptualization, G.R.; methodology, G.R.; M.N.; L.D.; formal analysis, G.R.; G.B.; data curation, G.R.; L.D.; M.C.; writing—original draft preparation, G.R.; writing—review and editing, M.C.; G.R.; L.D.; G.C.; supervision, G.C.; R.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and it was approved by the Ethics Committee of the Sigmund Freud University (protocol code ACAFMPM@B@ELOL89182; 30 January 2021).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors on request.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Network analysis. Note: Nodes represent the primary study variables, with edges indicating significant connections between them; thicker lines show stronger connections. Blue lines indicate positive relationships between variables, while red lines denote negative relationships. BI = aesthetic body image, FBI = functional body image, INT = interoception, MH = mental health, PS = psychosomatic symptoms, ED-RISK = eating disorders risk, GC = gender congruence.
Figure 1. Network analysis. Note: Nodes represent the primary study variables, with edges indicating significant connections between them; thicker lines show stronger connections. Blue lines indicate positive relationships between variables, while red lines denote negative relationships. BI = aesthetic body image, FBI = functional body image, INT = interoception, MH = mental health, PS = psychosomatic symptoms, ED-RISK = eating disorders risk, GC = gender congruence.
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Figure 2. Centrality measure plot for the network analysis. Note: The network includes BI = aesthetic body image, FBI = functional body image, INT = interoception, MH = mental health, PS = psychosomatic symptoms, ED-RISK = eating disorders risk, and GC = gender congruence. Betweenness measures the extent to which a variable appears a significant number of times in the shortest path between two other nodes. Closeness represents how proximal a variable is to all other variables in the network. Strength indicates the total weight of the connections associated with a variable. Expected influence reflects the impact a variable has on its neighbouring variables, accounting for both direct and indirect connections.
Figure 2. Centrality measure plot for the network analysis. Note: The network includes BI = aesthetic body image, FBI = functional body image, INT = interoception, MH = mental health, PS = psychosomatic symptoms, ED-RISK = eating disorders risk, and GC = gender congruence. Betweenness measures the extent to which a variable appears a significant number of times in the shortest path between two other nodes. Closeness represents how proximal a variable is to all other variables in the network. Strength indicates the total weight of the connections associated with a variable. Expected influence reflects the impact a variable has on its neighbouring variables, accounting for both direct and indirect connections.
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Figure 3. Mediation model path plot: Effects of Aesthetic Body Image (BI) on Mental Health (MH) with mediators (interoception, INT; and functional body image, FBI). Note: Figure 2 illustrates the mediation model, where aesthetic body image (BI) is the independent variable, and interoception (INT) and functional body image (FBI) act as mediators. The dependent variable in this model is general mental health (MH). Path coefficients (β), showed in the figure, are rounded to two decimal places.
Figure 3. Mediation model path plot: Effects of Aesthetic Body Image (BI) on Mental Health (MH) with mediators (interoception, INT; and functional body image, FBI). Note: Figure 2 illustrates the mediation model, where aesthetic body image (BI) is the independent variable, and interoception (INT) and functional body image (FBI) act as mediators. The dependent variable in this model is general mental health (MH). Path coefficients (β), showed in the figure, are rounded to two decimal places.
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Table 1. Pearson correlation coefficients between key variables and descriptive statistics (mean and standard deviation) for each key variable. Specifically: gender congruence, aesthetic body image, functional body image, interoception, mental health, psychosomatic symptoms and eating disorder risk.
Table 1. Pearson correlation coefficients between key variables and descriptive statistics (mean and standard deviation) for each key variable. Specifically: gender congruence, aesthetic body image, functional body image, interoception, mental health, psychosomatic symptoms and eating disorder risk.
VariableM
(SD)		123456
1. GC3.17
(1.19)		—
2. BI2.81
(0.95)		−0.62
***		—
3. FBI3.11
(1.25)		0.18
**		−0.28
***		—
4. INT2.49
(1.09)		0.16−0.26
***		0.52
***		—
5. MH2.28
(0.90)		0.24
***		−0.27
***		0.39
***		0.35
***		—
6. PS60.49
(20.21)		0.09−0.05−0.010.0320.07—
7. ED-RISK38.06
(20.75)		−0.28
***		0.43
***		−0.12 *−0.18 *−0.19
***		−0.03
Note: * p < 0.05, ** p < 0.01, *** p < 0.001; GC = gender congruence, BI = aesthetic body image, FBI = functional body image, INT = interoception, MH = mental health, PS = psychosomatic symptoms, ED-RISK = eating disorder risk.
Table 2. Mediation analysis results: direct and indirect effects on general health.
Table 2. Mediation analysis results: direct and indirect effects on general health.
TypeEffectEstimate ± SE95% CIβzp
IndirectBI ⇒ FBI ⇒ MH−0.07 ± 0.02−0.11; −0.07−0.18−3.160.002
BI ⇒ INT ⇒ MH−0.05 ± 0.02−0.08; −0.01−0.15−2.480.013
ComponentBI ⇒ FBI0.37 ± 0.070.23; 0.520.375.08<0.001
BI ⇒ INT0.29 ± 0.060.17; 0.430.294.68<0.001
FBI ⇒ MH−0.18 ± 0.05−0.27, −0.09−0.18−4.04< 0.001
INT ⇒ MH−0.15 ± 0.05−0.25, −0.05−0.15−2.930.003
DirectBI ⇒ MH−0.15 ± 0.05−0.25; −00.44−0.15−2.810.005
Note: CI = confidence intervals; β = betas (completely standardised effect sizes); BI = aesthetic body image; INT = interoceptive awareness; FBI = functional body image; MH = mental health.
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Riboli, G.; Daminato, L.; Nese, M.; Cassola, M.; Caselli, G.; Brighetti, G.; Borlimi, R. A Comprehensive Model of Embodiment in Late Pubertal Female-at-Birth Adolescents: The Role of Body Awareness and Mental Health. Adolescents 2025, 5, 14. https://doi.org/10.3390/adolescents5020014

AMA Style

Riboli G, Daminato L, Nese M, Cassola M, Caselli G, Brighetti G, Borlimi R. A Comprehensive Model of Embodiment in Late Pubertal Female-at-Birth Adolescents: The Role of Body Awareness and Mental Health. Adolescents. 2025; 5(2):14. https://doi.org/10.3390/adolescents5020014

Chicago/Turabian Style

Riboli, Greta, Luca Daminato, Mattia Nese, Marina Cassola, Gabriele Caselli, Gianni Brighetti, and Rosita Borlimi. 2025. "A Comprehensive Model of Embodiment in Late Pubertal Female-at-Birth Adolescents: The Role of Body Awareness and Mental Health" Adolescents 5, no. 2: 14. https://doi.org/10.3390/adolescents5020014

APA Style

Riboli, G., Daminato, L., Nese, M., Cassola, M., Caselli, G., Brighetti, G., & Borlimi, R. (2025). A Comprehensive Model of Embodiment in Late Pubertal Female-at-Birth Adolescents: The Role of Body Awareness and Mental Health. Adolescents, 5(2), 14. https://doi.org/10.3390/adolescents5020014

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