by Martin Binks, PhD and Ronette L. Kolotkin, PhD
Despite increasing awareness among practicing physicians of medical difficulties associated with obesity, the social and psychological consequences of increased weight?including depressed mood, low self-esteem, body image impairment and lowered overall quality of life?receive less attention despite having a significant negative impact on the lives of those who are affected. In this article we focus on one particular issue that receives little or no attention in clinical and research settings?sexual quality of life.
Sexual intimacy is among our most basic human needs, but obese individuals often face great sociocultural, psychological and physical barriers to having these needs met. Many obese individuals are able to experience rewarding intimate relationships despite societal pressures to be thin, stigmatization, discrimination and weight-related prejudice. Others, however, may have experienced a lifetime of negative feedback from society and the individuals close to them. Some individuals have adopted weight and negative body image as defining characteristics of who they are and how they value themselves. This is not an easy barrier to overcome. In addition, physical or sexual abuse in an individual?s past may negatively impact sexual quality of life and should be recognized and treated. These difficulties make the issues of sexual quality of life more complex to address, but they make it no less important in individuals? lives.
Quality of life refers to the overall impact of medical conditions on physical, mental and social well-being. Research relating to obesity and quality of life has increased in recent years and has provided valuable insights into the pervasive impact of obesity on individuals. Researchers have developed and refined assessment tools allowing for effective measurement of quality of life improvements in people undergoing weight loss. This allows us to see success not only in pounds lost, but also in improvements in daily functioning.
One such measure is a questionnaire called the Impact of Weight on Quality of Life-Lite (IWQOL-Lite). This tool measures issues of physical functioning, social relations, energy level, work productivity, self-esteem, mobility and sexual life. Studies have shown that quality of life worsens with increasing weight and is particularly impaired in people seeking bariatric surgery. However, as is the case with most weight-related medical conditions, overall quality of life can improve significantly with weight loss. This is especially true among those losing weight following bariatric surgery.
Our group has done several studies that have led to increased awareness of the relationship between weight and sexual life, including factors such as enjoyment of sexual activity, sexual desire, sexual performance and willingness to approach sexual encounters. In one study, we examined responses to sexual quality-of-life questions from over 500 individuals who were non-obese community volunteers or obese individuals who were either seeking obesity treatments of various types or were not seeking obesity treatment. Almost two-thirds (65.4 percent) of obese treatment seekers and 41.2 percent of obese non-treatment seekers reported experiencing sexual impairments in at least one area ?at least sometimes? or more frequently in the past week, compared to only five percent of normal weight individuals. Obese women in this study reported a greater degree of difficulty than did obese men, but difficulty with sexual quality of life was clearly an issue for both men and women.
In our next study we looked at the impact of significant weight loss over a two-year period on the sexual quality of life of individuals enrolled in a medication-based weight loss program. High rates of difficulty with sexual quality of life were reported at the start of the study. However, following a moderate (12 percent) weight loss, the number of individuals reporting difficulty ?at least sometimes? with sexual quality of life dropped by as much as 50 percent. The majority of improvement took place during the first three months of the study and was sustained throughout the remainder of the study.
Some additional studies of varying levels of scientific rigor have also considered the impact of weight loss on sexual quality of life. In general, the findings have been consistent with our work with weight loss resulting in improvement for both men and women.
What does all this mean to the person who is about to experience a rapid and significant weight loss following bariatric surgery? The answer varies across individuals. In both the existing literature and our clinical experience with obese patients, clearly not all obese individuals, even those with severe obesity, suffer from impaired sexual quality of life. For those who do, weight loss does not always lead to the improvements noted by the previous studies. Sexual quality of life is a complex issue.
For many people, lifestyle change alone (weight loss, improvements in nutrition, and increased exercise) will bring about substantial improvements in sexual quality of life. For others, more help is needed. Individual differences in self-esteem, body image, interpersonal relationships, personal histories and other important factors that may affect sexual quality of life.
Bariatric surgeons are becoming increasingly aware of the importance of psychosocial factors of weight and weight loss and often include a psychological evaluation prior to surgery as standard procedure. Mental health professionals working in conjunction with your surgeon can provide valuable insight into some of the issues you may face and direct you towards appropriate psychosocial treatment when needed.
One common contributor to difficulties in sexual relationships involves unrealistically negative perceptions about one?s body (negative body image). The term body image refers to both the way that we perceive our bodies and the level of comfort we have with our bodies. Weight is only one part of our overall appearance, but all too often societal norms have led people to adopt an unrealistic and often unattainable ideal of physical attractiveness. This can lead individuals to develop poor relationships with their bodies, which can make enjoyment of a healthy sexual life particularly challenging regardless of actual body shape.
While some people may require professional support, there are also high-quality professional self-help resources that address this issue. One particularly good resource for people struggling with body image issues is The Body Image Workbook by Thomas Cash. Dr. Cash is a leader in the field of body image treatment and research and has provided this excellent guide to body- and self-acceptance. The guide can be used in conjunction with an individual therapist or as a self-guided treatment. The workbook includes an array of self-assessment tools and self-directed exercises that have proven helpful to many who struggle with body image.
Another area of importance is self-confidence and communication. Obese people often express that excess weight provides a protective barrier against sexually-motivated interactions with other people. A history of sexual trauma is often, though not always, seen in people who experience this difficulty. Seeking appropriate professional help is essential if you are a victim of past or current abuse.
There are, however, other reasons why a person may come to use weight as a protective shield. Some people experience a general lack of confidence in being able to deal with intimate relationships in all their complexity. It is not uncommon for people who are interpersonally strong and successful in many other areas of their lives to feel completely vulnerable and ?disarmed? when it comes to intimate relationships. Improving confidence in setting boundaries and in effectively communicating those boundaries to a prospective sexual partner is often helpful. Realizing that you have the inner strength and skill to be in control during intimate encounters also leads to significant improvement in intimate relationships. This improved confidence often allows for exploration of relationships without the fear of losing control or being enveloped by the relationship.
Some common helpful techniques include:
- Self-affirmation, where you practice telling yourself you are capable in various situations.
- Assertive communication, involving the practice of clearly stating your needs in a way that can be heard by others.
- Role-playing, by acting out difficult situations and practicing a range of responses.
A final area of importance when considering issues with sexual quality of life involves issues of physical performance. Research indicates that several common physical performance issues, erectile dysfunction in particular, in men are likely to decrease as a direct result of the functional improvements brought about through weight loss. For women, however, little is known about the impact of weight loss on physical performance issues such as painful intercourse. There may be psychological causes underlying performance difficulties for both men and women. We strongly recommend seeking appropriate professional guidance should physical difficulties persist following weight loss.
Human sexuality is an essential element of overall quality of life; however, societal norms around sexuality, coupled with the stigmatization faced by obese persons, may lead obese individuals to avoid seeking help with this important issue. While our empirical understanding of this complex issue is in its earliest stages, our work with patients has shown us that with proper treatment, difficulty in intimate and sexual relationships can be overcome. The best thing you can do is to create open dialogue, without shame or embarrassment, with healthcare providers who can direct you toward appropriate assistance.
Dr. Martin Binks is Director of Behavioral Health and Research Director at the Duke Diet and Fitness Center. He is also Clinical Assistant Professor in the Division of Medical Psychology, Department of Psychiatry and Behavioral Sciences at Duke University Medical Center. Dr. Binks received his PhD in clinical psychology from Fairleigh Dickenson University in New Jersey and went on to complete additional training and post-doctoral work in behavioral medicine at the Medical University of South Carolina in Charleston.
Dr. Ronette ?Ronnie? Kolotkin is a clinical psychologist, researcher, and consultant who specializes in the treatment of obesity and the study of quality of life in obesity. She is the former director of the Behavioral Program at the Duke University Diet and Fitness Center, developer of a widely used questionnaire that assesses the impact of weight on quality of life (IWQOL-Lite), co-author of scientific publications on obesity and a book on obesity treatment, developer of an audio CD for weight loss, and consultant to companies whose products affect the lives of obese persons. Her Web site is www.qualityoflifeconsulting.com.