Women with eating disorders often report a lack of sexual interest during the course of their eating disorder. Several solid studies, including one, which assessed 242 women, found that issues with physical intimacy, libido, sexual anxiety, and difficulty in romantic relationships are present among this population.
The results found that:
Intercourse (55.3%), having a partner (52.7%), decreased sexual desire (66.9%), and increased sexual anxiety (59.2%) were common. Women with restricting and purging anorexia nervosa had a higher prevalence of loss of libido than women with bulimia nervosa and eating disorder not otherwise specified (75%, 74.6%, 39%, and 45.4%, respectively). Absence of sexual relationships was associated with lower minimum lifetime body mass index (BMI) and earlier age of onset; loss of libido with lower lifetime BMI, higher interoceptive awareness and trait anxiety; and sexual anxiety with lower lifetime BMI, higher harm avoidance and ineffectiveness. Sexual dysfunction in eating disorders was higher than in the normative sample.(Poyastro Pinheiro, A., et al. Sexual function in women with eating disorders. International Journal of Eating Disorders. 2010)
Low body weight due to food restriction (resulting in low BMI) and poor nutrition (due to bingeing and/or purging) has a direct impact on the production of sex hormones. Eating fat is necessary for the production of estrogen, a vital sex hormone in women. The ovaries, which are the source of 50% of women’s testosterone level, become less active, decreasing the production of the sex hormone that is key to female libido. As estrogen decreases, so does testosterone. It’s this decline in testosterone that’s really responsible for a reduced sex drive. (Dr. Oz. Ultimate orgasm libido boosters. www.oprah.com)
My experience has shown me that even when weight is restored (resulting generally in restored cognitive functioning and normal hormone levels,) sexual issues and dysfunction often remain for people with eating disorders.
The Pinheiro, et al, findings confirm the connection between low weight and many of the reported physiological states and physical consequences that accompany sexual issues and eating disorders, however, the study does not detail the participants relational and subjective issues associated with sexual intimacy. Is extremely difficult, if not impossible, to assess subjective and relational issues in a broad quantitative study. Given the nature of the subject matter, it is also difficult to acquire authentic responses even if in-depth interviews of the participants were conducted.
Talking about sex is difficult for a lot of people with or without eating disorders. Trust takes time.
So what are some of the psychological and relational issues that people with eating disorders face regarding sex?
Let’s back up a moment.
Safety and trust and the ability to be an authentic self in all arenas of life are paramount goals in recovery. Often, without the reliability of these vital relational components it is difficult to allow for the openness that accompanies sexual abandon and ultimate sexual pleasure. If you don’t feel safe, trust yourself or others, sexual inhibition is a potential, if not likely, outcome. Being carefree about sex is generally the desired state of affairs. So, how can a person with an eating disorder who has major trust issues, body image distortion, demands perfection from herself, coupled with a desire to please and accommodate others at the expense of herself be in a situation which necessitates letting go - risking being out of control? Not easy.
Another significant risk factor for the absence of sexual feelings and desire for sex is whether or not the individual has suffered sexual abuse prior to the development of her eating disorder. Abuse has a devastating impact on relationships. Sexual freedom and joy are often riddled with guilt and shame, dissociative states are common, power issues are present and of course the ability to trust one’s partner is generally severely negatively affected.
Orgasm in French is referred to as “the little death,” (La petite mort) for a reason. It is used to describe the post-orgasmic state of unconsciousness that can accompany having some sexual experiences.
Only 25 percent of women are consistently orgasmic during vaginal intercourse. Orgasm for female patients with eating disorders is significantly reduced due to medical and psychological factors. Women with anorexia report having less sex than women with Bulimia. Restricting food often parallels restricting sex. Sex can also simulate, minus the arousal, the act of bingeing and purging. That, is both are generally engaged in vigorously and the net outcome is release. In my professional experience, I have never encountered an individual for whom sexual arousal was present during the binge and or purge phase of their bulimia. I suspect this exists, more frequently than a non-existent or rare event, however, there are no studies to validate this.
Sometimes, eating disorder behaviors occur following a sexual encounter i.e. as a punishment for pleasure, as a statement of self-loathing or criticism, as an undoing of needing someone or perhaps as self-reproach if the sexual encounter ended in rejection.
So, in recovery, the cart must come before the horse. Helping patients feel safe in the treatment process - that is with their therapist, is paramount. With safety comes trust. Trusting the therapist and being motivated to get well enable recovery, eventually including talking about sexual needs and desires. Weight restoration and symptom amelioration or reduction (no easy feat) generally must come first.
There are many concurrent and subsequent psychological and relational goals during the recovery process, which lead up to talking about sex.
• Help the individual begin to trust herself, her reactions, her thoughts and her internal cures. • Help the individual feel emotions, sometimes deeply painful or ambivalent ones.
• Help the individual abandon the relationship with food, rituals or body image obsession in exchange for relationships with people.
• Help the individual find and experience joy and pleasure in life…for some people this may mean finding joy and pleasure for the very first time.
• Help the individual see food as one pleasure in life.
Time once spent in rituals or hours spent over the toilet is now available. It is wonderful it is as a therapist to listen to patients report on new activities that are solely for the sake of pleasure without any compensatory eating disorder behavior (in order to undo or punish the person for indulging.)
Then, comes sex.
Food, like sex, is a pleasure. Helping patients work toward emotional and physical intimacy in relationships is an important and life sustaining goal. Usually, when a patient is well on her way toward recovery and trust is deeply established and maintained with the therapist opportunities for frank conversations about sex can occur.
What are her feelings about sex? How does she feel being naked? How does she feel about being pleasured? How does she experience the sexual situation? Is she aware of her body? Does she know or feel able to ask for what she needs sexually? Is she concerned about whether or not she is pleasured? How does being pleasured make her feel? Does she feel shame? Does she feel relationally safe? Does she trust her partner? Does she think that her partner’s aim is only for his/her own pleasure? Does that matter?
As patients recover they become increasingly observant of their behavior and reactions, notice how they feel and figure out what they want, including what they want from a sexual relationship. Having a full life including a full and normal sexual life is possible and is often desired by many patients. So much depends on physical stability and the ability to trust the therapist so that the psychological and relational issues surrounding sex can be discovered.
Judy Scheel, Ph.D., LCSW