This study examined aspects of sexual functioning in a large sample of women with a lifetime history of eating disorders. Overall, the vast majority of women in this sample reported having experienced intimate relationships (98%), with 55% reporting relationships with intercourse, and 87% reporting significant relationships of varying degrees of stability. These figures concur with previous studies35, 36
that show a substantial proportion of individuals with eating disorders are in relationships.
Nearly two thirds of women with eating disorders reported loss of libido and sexual anxiety. Compared with women from a normative German sample, more women with eating disorders reported loss of libido, sexual anxiety, relationships without sex, and relationships with tension. Taken together, these findings indicate that women with eating disorders experience more difficulties in the sexual and relationship domain. One previous study found that women with eating disorders view their marital relationship as less satisfying than their spouses view it, but that satisfaction improved significantly in treatment as the eating disorder symptoms were addressed.37
Sexual intimacy is a fundamental aspect of healthy relationships that can be disrupted by an eating disorder, and should be assessed routinely along with other more commonly evaluated realms of functioning (e.g., social, occupational, exercise, nutritional).
Additionally, we found differences in sexual functioning across eating disorders subtypes: women with RAN or PAN reported a higher prevalence of loss of libido than women with BN or EDNOS. This finding is expected given that the results of the stepwise regression indicating that lower lifetime minimum BMI was associated with loss of libido.
One consistently observed finding across sexual functioning domains was the association between low lifetime minimum BMI and loss of libido, sexual anxiety and sexual relationships. These findings are consistent with the explanation that low body weight impairs the physiological functioning of sexual organs 7
and with evidence from other studies that fluctuations in BMI were directly related to changes in sexual interest.3–5
An alternative explanation is that independent of physical changes, individuals with lower BMI’s experience a more severe presentation of the eating disorder. This increased illness severity may be associated with more profound body dissatisfaction, distortion, depression and discomfort with physical contact, all of which may be associated with loss of libido and elevated sexual anxiety. Supporting that hypothesis, personality traits such as trait anxiety, ineffectiveness, harm avoidance and interoceptive awareness were also consistently associated with loss of libido and sexual anxiety in women with eating disorders. Most likely physiological and psychological factors converge to lead to disturbed sexual functioning in this group of patients.
Several limitations of this design should be considered. First, this is a cross sectional study and no conclusions concerning the direction of the observed associations can be drawn. Second, the associations identified in this study between self-reported symptoms and relationship variables are based on retrospective patient recall and are vulnerable to memory biases inherent in this type of data. Third, the SIAB was not designed specifically to measure sexual functioning and therefore, these results are considered to be preliminary and motivational for future studies to use instruments designed to assess relationship and sexual functioning. The SIAB questions do not have the sufficient specificity to determine when these variables occurred relative to the eating disorder symptoms. The SIAB questions encompass not only sexual functioning but interpersonal relationship functioning as well. Our data also only included patient ratings of sexual functioning. Inclusion of partner ratings would enrich the clinical picture beyond the patient perspective which may be negatively biased secondary to the specific pathology associated with the eating disorder (e.g. body dissatisfaction, body image distortion, perfectionism).1
Also, the sample of non-eating disorder women were not from the same study, thus prohibiting analytical comparisons between the groups.
One important feature that we were unable to address is the impact of comorbid depression on sexual functioning. Depression is known to affect libido40
and in most studies more than 80% of individuals with eating disorders report lifetime comorbid depression.41
Given that other studies have found that women with depression have high rates of sexual dysfunction 42
and have similar rates of sexual dysfunction as women with eating disorders,16
controlling for depression in this population will ultimately be necessary to clarify the unique contribution of an eating disorder to sexual functioning. This is underscored by the observed association in this study between ineffectiveness and sexual anxiety. Although not a perfect proxy measure for depression, ineffectiveness and depression ratings are highly correlated.43, 44
With these limitations in mind, women with eating disorders are engaging in relationships and report experiencing problems with sexual functioning. Very little is known regarding the impact of recovery from eating disorders on improvement in sexual functioning. Even less in known about sexual functioning from the perspective of partners of individuals with eating disorders. Women with eating disorders highlight the importance of relationships in their recovery,45
yet the extent to which improvement in sexual functioning is a goal in their recovery is unknown. Future studies of the impact of eating disorders on intimate relationships will assist with developing approaches to treatment that will address sexual concerns in a manner that is acceptable to individuals with eating disorders and provides them with the opportunity to improve intimacy and interpersonal connections that enhance their quality of life.