Let’s talk about sex: Sexuality considerations in eating disorder care

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.  

The interconnectedness of eating disorders and sexuality

There are several ways eating disorders and sexuality overlap, including but not limited to the following:

• Both are a human drive, need, or function: For example, we need both food and sex to function, and the drive for both food and sex comes from the hypothalamus.‍
• Abstinence is the only model: Arguably a model that does not work. We cannot abstain from food or sex. Plus, research has shown that an abstinence model of sex education can be harmful, e.g., ineffective in preventing teenage pregnancy.¹‍
• Both are body-focused: For example, hunger cues and arousal.‍
• They both impact connection, relationships, and intimacy: Eating disorders are rarely about food, and sexual issues are rarely about sex.‍
• Pleasure and self-worth: Those with an eating disorder often feel they aren’t deserving of pleasure, while others may find self-worth in what their body can provide sexually.‍
• Both are impacted by multiple societal and cultural messages about the “right” kind of sexual expression, orientation, and identity, as well as the “right” body shape and weight.‍
• Social justice implications.

Review of the research

A review of the research backs up the connection between eating disorders and sexuality. Some key findings include:

• It’s hypothesized that sexual behaviors can align with some of the behaviors of eating disorders. For example, emotional constriction (as with anorexia) is connected to sexual constriction. Additionally, emotional dysregulation (as seen with purging and bingeing) is connected to sexual dysregulation, thanks to lower self-control and typically more chaotic and impulsive sexual profiles.²
• A healthy attitude towards body image is associated with positive sexual experiences, including engaging in a wider range of sexual activities and feeling more sexually desirable.³‍
• Body dissatisfaction correlates with the severity of sexual dysfunction.⁴‍
• The decrease in sex drive in those with anorexia nervosa is associated with hypogonadism and emaciation, while weight restoration is reported to favor an increase in sex drive.⁵

Gender dysphoria and eating disorders

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

Interactions of eating disorders and gender dysphoria

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

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

• Using a client’s correct pronouns
• Using a client’s preferred name
• Disclosing your own pronouns
• Using gender-neutral language, e.g., using “folks” instead of “guys” and “girls”
• Creating a safe space for all gender identities and sexualities
• Sensitive physical exams

General assessments of sexuality

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.

Six Ps

The Six Ps is a set of guidelines based on the CDC recommendations for sexual health assessment:

• Partners: Are you engaging in sexual activity of any kind? Can you tell me about the gender(s) of your partners?‍
• Practices: Specific questions about the nature of the recent sexual activity to understand the risk for STIs, e.g., Do you have vaginal (i.e., “penis in vagina”) sex? Do you have anal (“penis in anus”) sex? etc.‍
• Protection: What protection methods do you use? Do you discuss STI prevention and testing with your partner(s)? ‍
• Past history: Have you ever been tested for STIs and HIV? Have you or your partner ever been diagnosed with an STI in the past? Have you or your partner(s) ever injected drugs?‍
• Pregnancy: Would you like to become pregnant in the next year?‍
• Pleasure: Are you satisfied with your sex life right now? Are you and your partner(s) on the same page about desires and boundaries? Are you having any difficulties or problems when you have sex, such as pain or difficulty in maintaining an erection

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.

Four questions

• Satisfaction: Assessment of the quality of a client’s sex life and what could improve it.‍
• Difficulties/worries: What issues surrounding sex do you have concerns about? Do you want to discuss sexuality?‍
• Influence: Do you have a medical condition or are taking any medications, etc., that are impacting sexual function?‍
• Severity: How much impact is the sexual issues you’re experiencing affecting your life and relationships? 

Sexual ecosystem approach

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.

• Microsystems: For example, developmental experiences of early childhood, biological issues, etc.‍
• Mesosystems: Inquire about relationships in adolescence and adulthood, which have a high level of sexual influence.‍
• Ecosystems: Investigate the indirect influence of external systems on sexuality, such as religious or healthcare systems. ‍
• Macrosystems: Sociocultural influences on sexuality, e.g., what are your attitudes towards sexuality and gender, and how are they formed?

Specialized assessment of sexuality

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

• Reactions during sexual experiences: Helps obtain information regarding the potential trajectory and development of eating disorders, e.g., an accurate evaluation of sexuality may reveal a client is experiencing dissociation during sexuality, which can also occur during disordered eating behaviors. ‍
• Risky sexual behaviors: Gather information on hypersexual behaviors as these may indicate the presence of previous sexual trauma, which is highly correlated with eating disorder development. Plus, risky sexual behaviors are often linked to attachment issues, which can help inform treatment planning. ‍
• Body image: A person with severe body image distortion may also show disordered eating behaviors, which are also associated with sexual dysfunction, e.g., inability to orgasm, low sex drive, etc. Poor sexual functioning at baseline is associated with a poor long-term prognosis of the eating disorder. ‍
• Pleasure/reward: Both sexual and eating behaviors are associated with dopamine circuits in the brains, particularly restriction, purging, and bingeing, which have all been conceptualized as reward-driven behaviors. When eating disorder behaviors are sustained, circuits in the brain are altered, resulting in these behaviors becoming the only salient (i.e., notable) stimuli. Therefore, sexual function can be affected due to a damaged reward system. ‍
• Severity of the compromise of sexuality: Provide information about how a person is able or unable to receive pleasure. Sexual dysfunction can cause distress, mental anguish, depression symptoms, and relationship isolation, all of which are known to play a role in the maintenance of eating disorders.

Advice for practitioners

“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:

• Shame and embarrassment talking about sex potentially stemming from upbringing
• Lack of training
• Fear of crossing boundaries
• Own bias or stereotypes surrounding sex and sexuality

Examples of common bias

• Do I consider clients with physical disabilities as sexual beings?
• Do I assume younger males are oversexed or sexually preoccupied?
• Have I assumed people who engage in BDSM have an underlying pathology that explains their behavior?
• Do I assume transgender clients will be unable to find and keep a romantic partner?

Provider assessment

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:

• What parts of you contribute to avoidance? Your story, fears, education, training, etc.?
• How does avoidance impact interactions in therapy, supervision, and/or case consultation?
• What are some of the assumptions or biases you hold regarding sexuality?
• Does your intake, BPS assessment, initial assessments, treatment goals, etc., reflect that you think sexuality is important?

Resources

1. Stanger-Hall, K. F., & Hall, D. W. (2011). Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S. PLOS ONE, 6(10), e24658. 
2. Westen, D., & Harnden-Fischer, J. (2001). Personality profiles in eating disorders: rethinking the distinction between axis I and axis II. American Journal of Psychiatry, 158(4), 547-562. 
3. Kinzl, J. F., Trefalt, E., Fiala, M., Hotter, A., Biebl, W., & Aigner, F. (2001). Partnership, sexuality, and sexual disorders in morbidly obese women: consequences of weight loss after gastric banding. Obesity Surgery, 11(4), 455-458. 
4. Pinheiro, A. P., Raney, T. J., Thornton, L. M., Fichter, M. M., Berrettini, W. H., Goldman, D., et. al. (2010). Sexual functioning in women with eating disorders. International Journal of Eating Disorders, 43(2), 123-129. 
5. Castellini, G., Lo Sauro, C., Lelli, L., Godini, L., Vignozzi, L., Rellini, A. H., et. al. (2013). Childhood sexual abuse moderates the relationship between sexual functioning and eating disorder psychopathology in anorexia nervosa and bulimia nervosa: a 1-year follow-up study. The Journal of Sexual Medicine, 10(9), 2190-2200. 
6. Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health, 57(2), 144-149. 
7. Cusack, C. E., Iampieri, A. O., & Galupo, M. P. (2022). “I’m still not sure if the eating disorder is a result of gender dysphoria”: Trans and nonbinary individuals’ descriptions of their eating and body concerns in relation to their gender. Psychology of Sexual Orientation and Gender Diversity, 9(4), 422–433. 
8. Bhatt, N., Cannella, J., & Gentile, J. P. (2022). Gender-affirming care for transgender patients. Innovations in Clinical Neuroscience, 19(4-6), 23.
9. Castellini, G., Rossi, E., & Ricca, V. (2022). Are there common pathways for eating disorders and female sexual dysfunction?The Journal of Sexual Medicine, 19(1), 8-11.