Dunkley : eating disorders and sexual function reviewed
● Women with eating disorders experience sexual problems across all areas of sexual
response
○ Difficulties with sexual interest/desire, arousal, lubrication, orgasm, satisfaction
and pain
● Sexual dysfunction associated with body dissatisfaction and physiological consequences
associated with the eating disorder
● Psychological + physiological factors serve as risk and maintenance factors regarding
the association between eating disorders and sexual dysfunction
● puberty/menarche onset and early sexual experiences → risk factors for developing ED
● AN, BN, and BED have many shared features, and people struggling with an eating
disorder often pass from meeting the symptom criteria from one diagnostic category to
another over time
● Shift towards a dimensional system more focused on the association between stable
psychological features, symptom presentation and body image disturbance
Anorexia nervosa
● reported pervasive sexual dysfunction, including decreased sexual desire, heightened
sexual anxiety, sexual infrequency, difficulties with arousal, lubrication, orgasm, sexual
satisfaction, and sexual pain
● Women with restricting AN report greater sexual difficulties
● Diminished levels of reproductive hormones contribute to sexual difficulties
● Endocrinological dysfunction → amenorrhea → difficulties with vaginal lubrication and
vulvar pain with penetrative sex
● Menstrual abnormalities → reduced orgasm frequency
● The decrease in sexual drive found in women with AN is thought to reflect
hypogonadism from emaciation as a result of extreme caloric restriction and malnutrition
● Loss of libido and sexual anxiety → lower lifetime BMI
● women diagnosed with both AN subtypes reporting a higher prevalence of low desire
than women with BN or eating disorder otherwise not specified
● More extreme weight loss = greater dysfunction and reduced sexual enjoyment
● Weight restoration → improved sexual satisfaction + increased libido
● Low BMI impairs the physiological function of sexual and reproductive organs (mixed
findings)
● Endocrinological dysfunction more in women with AN>BN
Bulimia nervosa
● Sexual problems (lack of desire and reduced orgasm) more severe in women with AN
● Women with BN are more likely to report being in a romantic relationship, higher levels
of sexual esteem and engage in partnered/solo sexual activity more frequently than
women with AN
● More interest in dating
● Less difference when comparing to binge-purge subtype of AN
, ● The extent to which women with binge-purge tendencies experience sexual problems
may depend on symptoms severity
● Poor body image + higher BMI + greater frequency of binge-eating behaviors = greater
sexual dysfunction + avoidance
● Bulimic symptoms : More likely to engage in risky sexual behaviors + earlier age of
sexual debut and sexual disinhibition
● Binge eating symptoms : disinhibited sexuality
● Women with BN more prone to self-harm behaviors, risky sexual behaviors is a form of
that
● Impulsivity and a tendency toward dissociative states have been suggested to be
potential mediators of the association between BN symptoms and sexual risk-taking
behaviors
● Impulsivity was found to mediate the association between compensatory behaviors and
sexual experiences
BED and obesity
● The sexual function of obese women with BED was more impaired compared with obese
subjects without BED and controls
● Greater frequency of objective binge-eating episodes was correlated with lower orgasmic
ability, sexual satisfaction, and overall sexual function
● Emotional eating was associated with sexual dysfunction
● Obese women with ED report greater sexual function difficulties → vaginismus and
sexual avoidance than obese women w/o ED
● Sexual function difficulties due to
○ Being significantly overweight
○ Obesity related gonadal dysfunction
○ Reduced vascular function in the genital tissues due to metabolic disruption
○ Psychological consequences of obesity
○ Metabolic abnormalities that arise from uncontrolled eating (only factor that
separates BED from non-BED obese individuals ⇒ possible that most of the
effects of BED on sexual function are due to being overweight)
Longitudinal and treatment research
● Women who recovered from AN, after 12 years, reported improvements in sexual
problems
● maturity fears and fears of becoming a sexual being in women with restrictive type AN
(but not of the binge/purge type or BN) to be highly correlated with poor outcome
● One year follow up study found that sexual function of women with BN and AN to
improve following CBT for ED
● reductions in eating disorder severity were associated with improvements in sexual
function without significant differences in diagnostic group
● Women with a history of CSA did not improve → history of CSA may moderate the
relationship btw ED psychopathology and sexual function
, ● sexual function tends to improve alongside reductions in eating pathology, but that
psychosexual and etiological factors may influence this association
Men and sexual/gender minorities
● Very little research
● non-heterosexual men are at a greater risk of developing an eating disorder
○ minority stress as well as cultural pressures concerning physical appearance
among men of same-sex attraction
● Also for transgender or non-binary individuals
● Role of body image should be investigated more
Non-clinical samples
● the association between sexual function and disordered eating behaviors has also been
observed in non-clinical samples of women without an eating disorder diagnosis
● Binge-purge symptoms, body dissatisfaction and a drive for thinness → more body and
performance based cognitive disruptions during sexual activity + lower sexual self
efficacy
● Dysfunctional body image and binge-eating tendencies were similarly associated with
greater sexual distress among a community sample of women
● Link between poor body esteem and negative sexual outcomes in non-clinical samples
→ associations exist even when difficulties didn’t cross a diagnostic threshold
Eating disorders and sexual dysfunction as internalizing psychopathology
● Psychopathological features common to EDs and sexual function conditions represent
risk factors for the development + maintenance of both eating pathology and sexual
dysfunctions
● area of study consistent with the Hierarchical Taxonomy of Psychopathology (HiTOP)—a
new research based classification system of mental disorders derived from the structural
analysis of empirical research
● HiTOP constructs psychopathology based on covariation of symptoms, grouping related
symptoms together while combining co-occurring syndromes on a dimensional “spectra,”
thereby addressing problems relating to diagnostic boundaries and instability, as well as
issues of comorbidity and heterogeneity
● HiTOP internalizing disorders
○ Eating pathology
○ Sexual problems
○ Fear-based disorders
○ Distress based disorders
● Internalizing disorders → symptom components and maladaptive traits → manifestation
of symptoms and signs of psychopathology
● a model for conditions of sexual function, mood, and anxiety as internalizing disorders
that arise as a result of psychodynamic, cognitive behavioral, sociocultural, and
physical/biological factors
● Women with eating disorders experience sexual problems across all areas of sexual
response
○ Difficulties with sexual interest/desire, arousal, lubrication, orgasm, satisfaction
and pain
● Sexual dysfunction associated with body dissatisfaction and physiological consequences
associated with the eating disorder
● Psychological + physiological factors serve as risk and maintenance factors regarding
the association between eating disorders and sexual dysfunction
● puberty/menarche onset and early sexual experiences → risk factors for developing ED
● AN, BN, and BED have many shared features, and people struggling with an eating
disorder often pass from meeting the symptom criteria from one diagnostic category to
another over time
● Shift towards a dimensional system more focused on the association between stable
psychological features, symptom presentation and body image disturbance
Anorexia nervosa
● reported pervasive sexual dysfunction, including decreased sexual desire, heightened
sexual anxiety, sexual infrequency, difficulties with arousal, lubrication, orgasm, sexual
satisfaction, and sexual pain
● Women with restricting AN report greater sexual difficulties
● Diminished levels of reproductive hormones contribute to sexual difficulties
● Endocrinological dysfunction → amenorrhea → difficulties with vaginal lubrication and
vulvar pain with penetrative sex
● Menstrual abnormalities → reduced orgasm frequency
● The decrease in sexual drive found in women with AN is thought to reflect
hypogonadism from emaciation as a result of extreme caloric restriction and malnutrition
● Loss of libido and sexual anxiety → lower lifetime BMI
● women diagnosed with both AN subtypes reporting a higher prevalence of low desire
than women with BN or eating disorder otherwise not specified
● More extreme weight loss = greater dysfunction and reduced sexual enjoyment
● Weight restoration → improved sexual satisfaction + increased libido
● Low BMI impairs the physiological function of sexual and reproductive organs (mixed
findings)
● Endocrinological dysfunction more in women with AN>BN
Bulimia nervosa
● Sexual problems (lack of desire and reduced orgasm) more severe in women with AN
● Women with BN are more likely to report being in a romantic relationship, higher levels
of sexual esteem and engage in partnered/solo sexual activity more frequently than
women with AN
● More interest in dating
● Less difference when comparing to binge-purge subtype of AN
, ● The extent to which women with binge-purge tendencies experience sexual problems
may depend on symptoms severity
● Poor body image + higher BMI + greater frequency of binge-eating behaviors = greater
sexual dysfunction + avoidance
● Bulimic symptoms : More likely to engage in risky sexual behaviors + earlier age of
sexual debut and sexual disinhibition
● Binge eating symptoms : disinhibited sexuality
● Women with BN more prone to self-harm behaviors, risky sexual behaviors is a form of
that
● Impulsivity and a tendency toward dissociative states have been suggested to be
potential mediators of the association between BN symptoms and sexual risk-taking
behaviors
● Impulsivity was found to mediate the association between compensatory behaviors and
sexual experiences
BED and obesity
● The sexual function of obese women with BED was more impaired compared with obese
subjects without BED and controls
● Greater frequency of objective binge-eating episodes was correlated with lower orgasmic
ability, sexual satisfaction, and overall sexual function
● Emotional eating was associated with sexual dysfunction
● Obese women with ED report greater sexual function difficulties → vaginismus and
sexual avoidance than obese women w/o ED
● Sexual function difficulties due to
○ Being significantly overweight
○ Obesity related gonadal dysfunction
○ Reduced vascular function in the genital tissues due to metabolic disruption
○ Psychological consequences of obesity
○ Metabolic abnormalities that arise from uncontrolled eating (only factor that
separates BED from non-BED obese individuals ⇒ possible that most of the
effects of BED on sexual function are due to being overweight)
Longitudinal and treatment research
● Women who recovered from AN, after 12 years, reported improvements in sexual
problems
● maturity fears and fears of becoming a sexual being in women with restrictive type AN
(but not of the binge/purge type or BN) to be highly correlated with poor outcome
● One year follow up study found that sexual function of women with BN and AN to
improve following CBT for ED
● reductions in eating disorder severity were associated with improvements in sexual
function without significant differences in diagnostic group
● Women with a history of CSA did not improve → history of CSA may moderate the
relationship btw ED psychopathology and sexual function
, ● sexual function tends to improve alongside reductions in eating pathology, but that
psychosexual and etiological factors may influence this association
Men and sexual/gender minorities
● Very little research
● non-heterosexual men are at a greater risk of developing an eating disorder
○ minority stress as well as cultural pressures concerning physical appearance
among men of same-sex attraction
● Also for transgender or non-binary individuals
● Role of body image should be investigated more
Non-clinical samples
● the association between sexual function and disordered eating behaviors has also been
observed in non-clinical samples of women without an eating disorder diagnosis
● Binge-purge symptoms, body dissatisfaction and a drive for thinness → more body and
performance based cognitive disruptions during sexual activity + lower sexual self
efficacy
● Dysfunctional body image and binge-eating tendencies were similarly associated with
greater sexual distress among a community sample of women
● Link between poor body esteem and negative sexual outcomes in non-clinical samples
→ associations exist even when difficulties didn’t cross a diagnostic threshold
Eating disorders and sexual dysfunction as internalizing psychopathology
● Psychopathological features common to EDs and sexual function conditions represent
risk factors for the development + maintenance of both eating pathology and sexual
dysfunctions
● area of study consistent with the Hierarchical Taxonomy of Psychopathology (HiTOP)—a
new research based classification system of mental disorders derived from the structural
analysis of empirical research
● HiTOP constructs psychopathology based on covariation of symptoms, grouping related
symptoms together while combining co-occurring syndromes on a dimensional “spectra,”
thereby addressing problems relating to diagnostic boundaries and instability, as well as
issues of comorbidity and heterogeneity
● HiTOP internalizing disorders
○ Eating pathology
○ Sexual problems
○ Fear-based disorders
○ Distress based disorders
● Internalizing disorders → symptom components and maladaptive traits → manifestation
of symptoms and signs of psychopathology
● a model for conditions of sexual function, mood, and anxiety as internalizing disorders
that arise as a result of psychodynamic, cognitive behavioral, sociocultural, and
physical/biological factors
