Presented by Esther M. Hooley, Ph.D.
During the 2023 Within Health Summit, Esther M. Hooley delivered a compelling talk about how eating disorders and sexuality are connected, the link between eating disorders and gender dysphoria, the assessment of sexuality concerns in eating disorders, and potential biases related to sexuality.
There are several ways eating disorders and sexuality overlap, including but not limited to the following:
A review of the research backs up the connection between eating disorders and sexuality. Some key findings include:
There is a wealth of research that supports the link between eating disorders and gender dysphoria. High rates of body dissatisfaction characterize both eating disorders and gender dysphoria. With eating disorders, body dissatisfaction is typically routed in a fear of weight gain or unhappiness with body size or composition. Body dissatisfaction in gender dysphoria is routed in having secondary sex characteristics that don’t align with gender identity.
This distress about self-image can lead to an increased risk of body image dissatisfaction, which in turn can lead to an increased risk of disordered eating behaviors. Furthermore, qualitative research suggests that transgender individuals may be at a high risk of body dissatisfaction, predisposing them to disordered eating.6
How may eating disorders mitigate or intensify gender identity distress? By investigating trans/non-binary understanding of the relationship between gender, eating, and body image concerns, research shows there are a few areas that are important in conceptualizing eating disorders concerning gender dysphoria.7
Gender-affirming care has consistently been shown to improve quality of life, improve health outcomes, and reduce rates of self-harm, suicide ideation, and suicide attempts.8 Aspects of gender-affirming care include:8
When carrying out any of these assessments, it’s important not to pathologize behaviors and instead be curious about your clients. Here are a few examples of how to assess sexual concerns and gather information on sexuality.
The Six Ps is a set of guidelines based on the CDC recommendations for sexual health assessment:
While using the Six P structure, it’s important to make no assumptions and to take gender-inclusive sexual health history with all clients, regardless of their gender identity.
The sexual ecosystem of a client can be used to understand and assess the unique systemic interactions that impact sexual development and sexual health, as well as what may be detrimental to sexual pleasure and well-being.
Specialized assessments for eating disorders and sexuality are important as there is evidence that the evaluation of sexuality is fundamental to obtaining a more accurate characterization of the severity and prognosis of eating disorders. A more severe compromise of sexual health in terms of dysfunction or risky behaviors can often represent a more severe eating disorder.9
“Many physicians still avoid speaking about sex with their patients because of shame or for the general belief that sexuality and sexual dysfunctions should be considered as secondary with respect to the other severe complications of eating disorders, including medical (e.g., hydroelectrolytic impairment or cardiocirculatory accidents) and psychological ones (e.g., risk of comorbid depression or suicide). However, empirical evidence suggests that assessing the sexual health of patients with eating disorders can be useful…”
- Castellini, Rossi, and Ricca, 2022
It’s not unusual for practitioners to have difficulties talking about sex and sexuality with their clients. This could be due to several reasons:
It’s important to engage in self-reflection on what contributed to the barriers in talking about sexuality with clients, your biases, and the impact this may have on treatment. Ask yourself the following questions: