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Section 26
Sexuality in Women with Anorexia

Question 26 | Test | Table of Contents

Sexual Abuse: It has been repeatedly posited that a history of sexual abuse could be fundamentally involved in the development of eating problems. The experience of sexual abuse is unfortunately common to many (the reported rates are 10-15% of women) (Mullen, Martin & Anderson, 1993), but findings of sexual abuse in the eating-disordered population are not homogeneous and the idea of a direct link between abuse in childhood and eating disorders has not been supported. Also, clinical observation tells us that a sexual abuse history puts one at risk for a number of psychological problems such as anxiety, depression, and poor sexual functioning, not only eating disorders.  During the course of therapy, Tice, Hall, Beresford, Quinones, and Hall (1989) noticed that patterns of eating behavior occurred in patients as reaction to assault as a way to change the patient's body image or to deal with repressed anger toward males. The authors recommended that sexual issues be addressed early in treatment. Their opinion is shared by Leon, Lucas, Ferdinand, Mangelsdor, and Colligan (1987), who investigated a group of anorectics after hospitalization. They found that patients who had the most negative attitudes about sexuality, body image, and social relationships at the time of hospitalization had not improved significantly at follow-up and showed the greatest degree of general personality disturbance. Based on their findings, the authors suggest that sexuality and personality concerns be carefully dealt with as part of the treatment of AN.

Studies have proven that women with eating disorders see themselves as having limited control over external events and over their own lives. One event particularly worth investigation is sexual abuse, as it has been linked both to eating disorders and to poor perception of personal control. To test the hypothesis that eating-disordered women perceive less control over their own lives if they have suffered sexual abuse, Waller (1998) administered a battery of questionnaires and a psychosexual interview to women affected by anorexia or bulimia nervosa. In this study women who reported sexual abuse had a lower sense of control than women without such experience. Waller also found that patients with more severe eating psychopathology saw themselves as less in control of their lives. According to Waller, it remains to be determined whether the association of poor control and sexual abuse is specific to eating disorders or is common to other psychopathologies where issues of control are relevant. To explore the role of stressful life events in the onset of AN, Schmidt, Tiller, Blanchard, Andrews, and Treasure (1997) compared a group of eating-disordered patients with a control group. Subjects and controls were assessed to measure the occurrence of traumatic life events with a specific sexual meaning that could have triggered the disorder. They found that stressful experiences are common to all, but eating-disordered patients reported more traumas characterized by a sexual connotation or involving family and friends. Subjects and controls did not differ in the occurrence of at least one stressful event, but eating-disordered patients had experienced major coping difficulties. While most serious problems concerned family and close friends for all groups investigated, AN patients had experienced significantly more stressful events related to sexual matters. The authors concluded that problems with sexuality may be specific in triggering the onset of AN. Even if stressful events are reported to precede the onset of eating disorders, their incidence is not dramatically different from that seen in healthy women.

Psychosexual Attitudes: After examining the psychosexual attitudes of adolescents with AN, Beaumont, Abraham, and Simson (1981) reported that patients have little information on sexual matters included contraception. In addition, while some subjects said they wished they knew more, other clearly avoided sex-related material. Although most patients stated they wanted to marry, they were ambivalent toward menstruation, pregnancy, and common sexual behaviors such as masturbation or premarital intercourse. Most patients considered their actual sexual experiences in a negative, unfavorable way, or had guilt feelings. The group as a whole was much less sexually experienced than other girls of similar age.  When young bulimics were investigated on their attitude toward sexuality (Abraham et al., 1985), they were likely to have experienced a broader range of activities than anorectics. They had orgasm on masturbation, experimented with anal intercourse, and considered their libido as "above average." As a negative aspect, they felt unattractive when they reached a certain weight and tended to avoid social and sexual contact.

Eating-disordered patients are believed to have sexual difficulties, but it is not easy to determine if the assumption is correct and, if so, which psychological determinants are responsible. The Eating Disorders Inventory (EDI) (Gardner, Olmstead & Polivy, 1983) is a questionnaire that includes eight subscales and is specifically constructed to analyze cognitive and behavioral characteristics of anorectic patients. Its administration can be of help in understanding their attitudes toward sexuality. The scales related to sexual expressions are scale 6, "Interpersonal Distrust" (measures difficulty in forming intimate relationships), and scale 8, "Maturity Fear," related to resistance to assuming an adult role.  If the hypothesis of a relationship between AN and sexual inadequacy is correct, the scores obtained on scales 6 and 8 of the EDI should differ significantly from those of controls. In fact, when Santonastaso and Favaro (1995) validated the EDI in the Italian population, they observed that controls clearly differed from both anorectics and bulimics on scales 6 and 8 as well as on scale 5, "Perfectionism." It is worth noting that scales 6, 8, and 5 do not differentiate among subgroups of eating disorders, while the remaining subscales do. This can be explained by the fact that perfectionism, interpersonal distrust, and maturity fear are psychological attitudes common to all patients affected by an eating disorder, whereas the remaining scales measure characteristics that each subgroup presents in different percentages.

Further support for these results was given by Wiederman and Pryor (1997), who observed that none of the EDI. subscales can differentiate the subgroups of alimentary disorders. The authors observed that married and single women have attitudinal differences that can be linked to their marital status. Their efforts were unsuccessful insofar as they could not establish correlations between any of the subscales and the fact that a patient was alone or in a committed relationship. In other words, marital experience was unrelated to any of the scores obtained in the group of women with AN. The data are in contrast with the prevailing wisdom; it would seem quite obvious that women in committed relationships have a better capability to maintain intimate relationships as part of an adult role. These apparently contradictory data can be explained by the observation that difficulties and uneasiness are inevitably part of the personalities of people who have eating disorders, and cannot be changed even by a positive and stable heterosexual relationship. Along those same lines, Sexton, Sunday, Hurt, and Halmi (1998) investigated the prevalence, stability, and clinical correlations of alexithymia in eating-disordered patients and controls. Alexithymia is defined as a very specific difficulty in distinguishing between different emotional states or between emotions and bodily sensations; it is usually associated with impoverished or constrained production of fantasies. Their results indicate that the subscale "Interpersonal Distrust" (related to alienation, difficulty in forming intimate relationships, and resistance to expressing thoughts and emotions) can separate patients from controls. It is also strong enough to differentiate between subgroups, being very high in anorectics. We must report that these data, although interesting, are not consistent with the results described above, which show a pattern of psychological distress in those with AN that explains the difficulties these women have in establishing sexual and interpersonal relationships.

Interpersonal Difficulties: Given the complex, multidimensional nature of both eating disorders and interpersonal difficulties, it is difficult to say which influences the other. Most likely they are connected to form a clinical pattern of generalized emotional disturbance. O'Mahony and Hollwey (1995) investigated three groups of women: the first included anorectics, the second included models and dancers (women obviously interested in their physical appearance), and the third group included "normal" women. The study sought to measure how attitudes toward food and interpersonal relations are connected. Their data show clear differences between the anorectics and the women in the other two groups, with the degree of AN being directly related to the difficulties in forming positive social contacts. The authors concluded that problems in social interaction are not a direct cause of AN; but when anorexia goes beyond a certain degree of severity, the two pathological behaviors become interrelated and their reciprocal dependence is as strong as the alimentary problem is severe.  Since anorectics have difficulties in establishing interpersonal relationships, it is difficult for them to stay in romantic relationships. According to Rothschild, Fagan, Woodall, and Anderson (1991), these patients show sexual functioning and gratification below the average scores of validated questionnaires, and feel uneasy in respect to their body image. According to Simson and Ramberg (1992), these patients show anxiety or even aversion to sexuality, are disturbed by nudity, deny sexual desire, are anorgasmic, and avoid sexual activity even when they live in a romantic, stable relationship.

The vast majority of anorectic women who became sick in adulthood recognize their sexual difficulties but state clearly that their sexuality was adequate before the disorder (Tuiten et al., 1993). The information was convincing enough for those authors to explore the hypothesis that the deterioration of sexuality is a response to the endocrine imbalance typical of AN. The reduction in the circulating levels of ovarian steroids is known to have a negative influence on sexual desire and fantasies, even if the expression of sexual interest in humans is inevitably linked to social and relational factors and cannot be reduced to the mere response to the plasma hormone concentrations. Still, the importance of normal and healthy endocrine functioning cannot be dismissed. Tuiten and colleagues further tested their theory by administering questionnaires for the retrospective evaluation of attitudes toward sexuality on the part of anorectics and matched controls. Their results show evidence that the premorbid sex life of the anorectics was absolutely similar to that of the controls in respect to sexual desire, eroticism, intimacy, and interest; salient differences only appeared later.

According to Morgan, Wiederman, and Pryor (1995) and Wiederman, Pryor, and Morgan (1996), anorectics and bulimics have different attitudes toward sexuality and specific characteristics can be attributed to each of the two subgroups. In their studies, anorectic women seem to have a narrower capability for sexual expression, are (or have been) in romantic relationships less often, have a poorer self-image, do not consider themselves as possible object of desire, do not engage in self-pleasuring, refuse oral sex, and are quite ignorant about contraception. Conversely, bulimic women are happier about themselves, engage in sexual activity more frequently, and are generally more satisfied with their relationships.  In a later study, Wiederman and Pryor (1997) found that body dissatisfaction in bulimics was related to low incidence of masturbation and to dissatisfaction with one's sexual life. It is difficult to draw conclusions from these data. In fact, the authors did not explain their findings, nor did they hypothesize a causal relation for the differences they described.  It is generally accepted that people with sexual inadequacy or avoidant behavior are likely to present a negative cognitive attitude wherein they fixate on their bodies or body parts. Faith and Schare (1993) investigated a large group of university students (males and females) by means of self-administered questionnaires to examine this phenomenon. Items such as body image, sexual knowledge, sexual attitude, and psychological adjustment to sexual experience were investigated. The authors found that only two variables significantly predicted sexual frequency for both genders: positive or negative self-appreciation of body image, and liberal or conservative sexual attitude. Although the authors did not study eating-disordered patients, in our opinion their findings help explain the mechanism of sexual inadequacy in both anorectics and bulimics.

The fact that anorectic, patients show an aversion toward sex is not surprising, given how they relate to their own bodies. Many of the studies mentioned above describe how deeply AN patients are concerned and displeased with their physical appearance. A sex therapist would recognize that such concern and displeasure is enough to generate anticipatory negative feelings (also called spectatoring by Kaplan, 1974), which in turn interfere with desire. The picture becomes ever clearer if we consider that sexual aversion and phobia are believed to strike emotionally vulnerable individuals who are unable to sustain psychodynamic and relational stressors in the way that "biologically normal" people would (Kaplan, 1987). However, Stuart, Hammond, and Pratt (1986) failed to shed light on the psychobiological characteristics of women who did not experience sexual drive. In our opinion, their pool of patients was not homogeneous enough to allow clear-cut results.

As mentioned before, the onset of AN can occur (but is less common) in adulthood and consequently may strike married women and create problems in the couple's functioning. Van der Broucke, Vandereycken, and Vertommen (1993) hypothesized that marital communication in these couples would be blocked by the patient's inability to express her feelings. The authors conceptualized a distinction between couples wherein a spouse was sick before the marriage or became ill at a later time: an eating-disordered patient may enter and maintain a marital relationship in a certain way, whereas the characteristics of couples struck by a later onset are presumed to be completely different. Contrary to expectations, their findings did not distinguish between early or late onset. When compared with the non eating-disordered couples, subjects with AN showed a flat way of communicating (meaning that they used less criticism or disagreement) and their interaction was less destructive in case of conflicts. On the other hand, those couples made fewer positive comments and thereby contributed to the impression that couples with an eating-disordered spouse had distant and less rewarding interactions.
- Ghizzani, Anna; Montomoli, Marcello; Anorexia Nervosa and Sexuality in Women: A Review; Journal of Sex Education & Therapy, 2000, Vol. 25 Issue 1, p80

Personal Reflection Exercise #12
The preceding section contained information about sexuality in women with anorexia nervosa.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Exploring the link between eating disorders and
persistent genital arousal disorder/genito-pelvic
dysesthesia: first description and
a systematic review of the literature

Imgart, H., Zanko, A., Lorek, S., Schlichterle, P. S., & Zeiler, M. (2022). Exploring the link between eating disorders and persistent genital arousal disorder/genito-pelvic dysesthesia: first description and a systematic review of the literature. Journal of eating disorders, 10(1), 159. https://doi.org/10.1186/s40337-022-00687-7

Peer-Reviewed Journal Article References:
Duffy, M. E., Calzo, J. P., Lopez, E., Silverstein, S., Joiner, T. E., & Gordon, A. R. (2021). Measurement and construct validity of the Eating Disorder Examination Questionnaire Short Form in a transgender and gender diverse community sample. Psychological Assessment, 33(5), 459–463.

Romano, K. A., & Lipson, S. K. (2021). Weight misperception and thin-ideal overvaluation relative to the positive functioning and eating disorder pathology of transgender and nonbinary young adults. Psychology of Sexual Orientation and Gender Diversity. Advance online publication.

Tanofsky-Kraff, M., Schvey, N. A., & Grilo, C. M. (2020). A developmental framework of binge-eating disorder based on pediatric loss of control eating. American Psychologist, 75(2), 189–203.

QUESTION 26
According to Ghizzani, why do many anorexic female clients show an aversion toward sex? To select and enter your answer go to Test.

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