Journal of Youth and Adolescence, Vol. 19, No. 4, 1990
Sexual Attitudes and Behavior of Bulimic Women: A Preliminary Investigation Lori M. Irving, 1 Kathleen M c C l u s k e y - F a w c e t t , 2 and D a v i d Thissen ~
Received September 23, 1988; accepted November 20, 1989 One-hundred and seventeen college-aged women at varying risk for developing bulimia answered a number o f questions addressing their attitudes toward and comfort with sexuality as well as their sexual and contraceptive history. Risk fo r developing bulimia was unrelated to sexual attitudes and weakly related to greater comfort with sexuality. High-risk women reported first engaging in intercourse at earlier ages and were also more likely to engage in risky contraceptive behavior than their lower risk counterparts. Despite their tendency to report a greater number o f previous sexual partners, high-risk women currently engaged and expected to continue to engage in sex less frequently than lower risk women. Taken together with previous findings, results suggest that the relationship between risk for bulimia and certain patterns o f sexual behavior reflects a general cycle o f impulsive and controlling behavior exhibited by high-risk women. Limitations and implications o f the present study are discussed.
~Half-time Editorial Assistant, Journalof Socialand ClinicalPsychology, Quarter-time research assistant, University of Kansas. Obtained M.A. and currently working on Ph.D. in clinical psychology at the University of Kansas. Research interests include hope as it relates to personal health beliefs, eating disorders, and sexual attitudes. To whom reprint requests should be addressed at Department of Psychology, University of Kansas, Lawrence, KS 66045. 2Associate dean, College of Liberal Arts and Sciences, University of Kansas, Lawrence, Kansas. Obtained Ph.D. in human development from the University of Kansas. Presently studying adolescent pregnancy and parenting. 3Director, Program in Quantitative Psychology, University of North Carolina, Chapel Hill, North Carolina. Obtained Ph.D. in behavioral sciences from the University of Chicago. Presently researching item response theory. 395 0047-2891/90/0800-0395506.00/0 9 1990 Plenum Publishing Corporation
INTRODUCTION Anorexia nervosa and bulimia are most common in women approaching puberty and early adulthood. Consequently, the physical and emotional developments associated with this period of the life cycle are often implicated in the genesis of these disorders. One of these major facets, sexuality, has been a subject of much attention (Abraham et al., 1985; Beumont et al., 1981; Bruch, 1973; Buvat-Hervaut et ai., 1983; Herzog et al., 1984; Leon et al., 1985; Oppenheimer et al., 1985; Romeo, 1984; Scott, 1987). These researchers have explored dynamic, experiential, attitudinal, and behavioral factors in an effort to understand the relationship between eating disorders and sexuality.
Psychoanalytic theorists were the first to relate eating disorders and sexuality, viewing sexual anxiety as antecedent to anorexia nervosa. Early analytic thinkers viewed the weight loss accompanying anorexia nervosa as a manifestation of "oral impregnation" fears rooted in fixation at the oral stage of psychosexual development (cited in Scott, 1987). Contemporary analytic formulations no longer emphasize psychosexual stages, interpreting weight loss as the anorexic's attempt to delay impending sexuality and accompanying adult responsibility through curtailing the body's maturation (Bruch, 1973; Romeo, 1984). Bulimia has rarely been traced to psychosexual beginnings (Stein and Laakso, 1988). Lindner (1954) described his bulimic patient's voracious hunger as reflective of an insatiable desire for love, a lack of self-definition, and the desire to bear her father's child. Recent explanations reflecting dynamic thinking maintain that the behavior of the bulimic reflects a desire for intimacy, but an inability to feel nourished or satisfied by intimate relationships (Cauwels, 1982). Because analytic and dynamic formulations rely heavily on anecdotal accounts, the literature is void of empirical evidence addressing the role of psychosexual factors in the causation of eating disorders. The few existing empirical reports fail to offer support for the involvement of such factors in the development of anorexia nervosa and bulimia (Scott, 1987). Sexual Abuse or Trauma
Sexual abuse or trauma has also been viewed as playing a causal role in the development of eating disorders (Shepard-Devynyns, 1988; Goldfarb, 1987; Schechter et al., 1987).
Bulimia and Sexuality
A history of "adverse sexual experience" was found in 2/3 of the anorexic and bulimic subjects studied by Oppenheimer et al. (1985). The utility of this finding was limited, however, by the absence of a noneating disordered comparison group. These authors remain unclear about the role such sexual experiences play in the development of eating disorders, but others have been more specific. Goldfarb (1987) and Schechter et al. (1987) documented cases of anorexia nervosa, bulimia, and compulsive overeating in patients with a history of sexual abuse or trauma. These cases of eating disorder were interpreted as defensive strategies employed to maintain a sense of control resulting from the powerlessness experienced during, and in response to, the abusive event. Shepard-Devenyns (1988) is the only author providing evidence of greater rates of sexual abuse in eating-disordered as compared to noneatingdisordered populations. Almost half of Devenyns' inpatient and outpatient bulimics reported a history of childhood sexual abuse, as compared to 4~ of nonbulimics. Inpatient and outpatient bulimics were also more likely to report a history of experiencing rape, physical abuse, and emotional abuse as children or adults. Sexual abuse has been implicated as an antecedent to a number of psychological symptoms such as depression, low self-esteem, and guilt (in Goldfarb, 1987). It is not surprising to find that eating disorders, related to both depression and low self-esteem (Fairburn and Cooper, 1984; Katzman and Wolchik, 1984), are also seen in individuals with a history of abuse. It is clear, however, that sexual trauma is not the only causal path in the formulation of eating disorders. One-third of Oppenheimer et al.'s (1985) and onehalf of Shepard-Devenyn's (1988) eating-disordered subjects had no history of childhood sexual abuse. Replication of Shepard-Devenyn's finding that relative rates of sexual abuse are greater in eating-disordered than noneatingdisordered populations will increase the confidence of researchers attempting to trace eating disorders to such beginnings. Sexual Attitudes and Behaviors
Studies of sexual attitudes and behavior have been more successful than dynamic and experiential work in providing empirical evidence relating eating disorders and sexuality (Abraham et al., 1985; Beumont et al., 1981; Buvat-Herbaut et al., 1983; Dykens and Gerrard, 1986; Leon et al., 1985; Leon et al., 1987). As with most research on eating disorders, anorexia nervosa has dominated this work. Anorexia Nervosa
Using clinical notes and interviews, Beumont et al. (1981) found anorexics to display wide variation in sexual knowledge, attitudes, and experience.
Irving et aL
Nearly half of this study's 31 subjects viewed anxiety and guilty feelings about sexual activity and pressure by boyfriends to engage in intercourse as precipitants of their illness. Subjects also indicated that sexual problems played a role in maintaining their anorexic behavior, and that interest in and pleasure derived from sex had decreased coincident to the onset of their illness. This study was the first to systematically record the sexual histories and attitudes of anorexics, but the absence of a control group limits its value. In a large-scale study comparing anorexics to normal school girls, BuvatHerbaut et al. (1983) found that anorexics were more likely than controls to experience fear or disgust in response to menstruation and sexuality. These authors stressed, however, that this disgust, or "rejection of a sexually attractive and menstruating body" was found only in a minority of the cases of anorexia nervosa. Leon et al. (1985) explored the sexual attitudes of inpatient anorexics and high school controls using a series of semantic differentials. Anorexics exhibited greater negative attitudes than controls regarding the sexual and feminine appearance of their bodies (sexual-nonsexual, masculine-feminine), the evaluation of sexual feelings (beautiful-ugly, pleasant-unpleasant), and sexual interest or arousal (powerful-weak, active-inactive). Anorexics did not differ from controls in response to items on a sexual morality scale (dirty-clean, immoral-moral). These authors also found that anorexics' attitudes toward sexuality were more positive after participating in treatment. Attitudes toward sexuality have also been examined as predictors of follow-up status in anorexics. Leon et al. (1987) found negative attitudes toward sexuality and one's body to be associated with greater personality disturbance at follow-up. This suggests the importance of obtaining sexual attitudinal data in the assessment and treatment of anorexic individuals. These studies provide evidence of differences in the sexual attitudes of anorexics and controls as well as revealing variation in the sexual attitudes of anorexics themselves. Anorexics are more likely than controls to exhibit negative feelings about their bodies, sexual feelings, and needs. Anorexics are also likely to perceive their disorder as related to sexuality. The relationship between anorexia nervosa and sexuality is further supported by parallel reductions in both anorexic symptomatology and negative attitudes toward sexuality at follow-up (Leon et al., 1985, 1987). Bulimia
There are few existing studies of the relationship between bulimia and sexual attitudes and behavior. In a counterpart to their earlier study, Abraham et al. (1985) found bulimics and controls to report similar age at first intercourse, number of sexual partners, attitudes toward sex-related be-
Bulimia and Sexuality
haviors, and contraceptive knowledge. Bulimics were more likely than controls, however, to describe their libido as above average, to gain pleasure from intercourse when the female was in the superior position, to have experienced orgasm with masturbation, and to have engaged in anal intercourse. Despite reports of heightened sexual desire and propensity for engaging in a broader range of sexual activity, bulimics were less likely to have experienced orgasm with vaginal intercourse. They were also more likely to reduce their sexual activity at higher body weights that they perceived as making them unattractive. Interpreting these findings, Abraham et al. related bulimic women's preference for, and greater satisfaction with, sexual expression giving them control over the situation to a generalized struggle for control. While this struggle is most visible in bulimics' eating and weight-related behavior, Abraham et al. contended that desire for control extends to other areas of bulimics' lives as well. Contrary to Abraham et al.'s findings, Dykens and Gerrard's (1986) bulimic subjects reported engaging in first intercourse at earlier ages, and having a greater number of sexual partners than both repeat dieters and controls. Taken in conjunction with their finding that bulimics were more likely than the two other groups to report using marijuana and cocaine, Dykens and Gerrard interpreted this as supportive of studies relating bulimia to a generalized pattern of impulsive behavior characterized by substance abuse, impulsive shopping, stealing, and sexual behavior (Norton et al., 1985; Pyle et al., 1981; Rayes-Weiss and Ebert, 1983). Purpose of the Current Study
Empirical studies of the sexual attitudes and behavior of bulimic women provide some evidence supportive of previous anecdotally based hypotheses (Cauwels, 1983; Lindner, 1954) that bulimic women desire yet are uncomfortable with intimacy (reports of "heightened libido" yet inability to experience orgasm with vaginal intercourse), and that bulimics are sexually active despite conflicting feelings about intimacy (average or above average levels of sexual activity). Abraham et al.'s focus on control, and Dykens and Gerrard's focus on impulsivity, however, do not provide a unifying framework from which to view the sexual attitudes and behavior of bulimic women. The current study was undertaken to integrate previous empirical reports of the sexual attitudes and behavior of bulimic women by clarifying discrepancies in the findings and interpretations of this work. This was done by questioning women exhibiting high, moderate, and low scores on an index of bulimia about various aspects of their sexual attitudes and behaviors. Questions addressing levels of previous sexual activity replicate those used in the aforementioned studies, and were included to clarify prior discrepant find-
ings (e.g., Do bulimics exhibit average or above average levels of sexual activity?). Questions addressing level of commitment in current romantic relationships as well as questions regarding past and present contraceptive practices were included as important aspects of sexual intimacy that had not previously been explored. Sexual attitudes were assessed using both a wellvalidated index of emotional responses to sexuality (White et al., 1977) and a newer measure of intrapersonal comfort with sexuality (Irving and Thissen, 1987). These measures provide an assessment of individuals' perceptions o f their own sexual needs and desires as well as assessing attitudes toward sexual behavior, the sole focus of Abraham et al.'s (1985) earlier assessment o f sexual attitudes. An integration of previous work will help establish a general framework within which to conceptualize the relationship between bulimia and sexuality. This type of framework may be helpful in guiding future research, as well as emphasizing the potential importance of assessing sexual attitudes and behavior when working with bulimic women. METHOD Subjects Subjects were female students enrolled in introductory psychology courses at a large midwestern university during the 1988 school year. Students taking part in the study received research participation credits required to complete their psychology course. Of 499 initially screened female subjects, 150 were contacted to participate in the study. Thirty-three of these subjects canceled or did not attend their scheduled appointments; 117 subjects participated in the study. Subjects were selected on the basis o f their scores on the BULIT, a 36-item self-rating scale created to identify individuals with, or at risk for, developing bulimia (Smith and Thelen, 1984). High scores on the BULIT indicate the presence of bulimic symptomatology, and Smith and Thelen use a cutoff score of 102 to indicate the presence o f bulimia. Equal numbers o f high-, medium-, and low-risk subjcts were chosen using the initial distribution (n = 499) of BULIT scores. Subject attrition, however, led to unequal size groups. Forty subjects exhibiting the highest BULIT scores (M = 103.4, SD = 10.8), 38 subjects exhibiting scores closest to the median o f the BULIT distribution (M = 59.4, SD = 2.0), and 39 subjects exhibiting the lowest BULIT scores (M = 42.3, SD = 2.5) made up the high-, medium-, and low-risk groups, respectively. A lack of subjects with scores equal to or above 102 made it necessary to use subjects exhibiting scores be-
Bulimia and Sexuality
low Smith and Thelen's cutoff. Because of this, the BULIT was used as a crude index of "risk for bulimia," rather than as an indicator of the "presence" or "absence" of bulimia. Subject age, ethnicity, height, and weight were also obtained. The mean age of subjects participating in the study was 19. Sixteen subjects did not report their ethnicity. Of the remaining 101 subjects, 88 were white, 3 were black, 2 were Asian, 5 were Hispanic, and 3 reported belonging to "other" ethnic groups. There were no differences in the age or ethnicity of subjects in the different risk groups. A 3 (risk group membership) • 3 ("small," "medium," and "large frame" according to the Metropolitan height/weight tables) chi-square analysis, however, revealed that more high- than medium- or lowrisk subjects had a large frame as defined by 1983 Metropolitan height/weight standards (x214] = 13.92, p = .01).
The B U L I T This 36-item self-rating scale was developed to assess the symptoms of bulimia. Items on the BULIT reflect behavioral and emotional dimensions of bulimia, and parallel the diagnostic criteria for bulimia outlined in the Diagnostic and Statistical Manual o f Mental Disorders (American Psychiatric Association, 1980). BULIT items are scored on a 5-point Likert scale, with 1 indicating the least symptomatic, and 5 indicating the most symptomatic response. Order of response is varied so that the first response is not always the one that is the least or most symptomatic. Scores are derived by summing subjects' responses to the 36 items, and can range from 36 to 180 points. Authors of the BULIT recommend a cutoff score of 102 to distinguish bulimic from nonbulimic individuals. The BULIT's test-retest reliability was found to be .87 (p < .0001) in a nonclinical sample (Smith and Thelen, 1984). The BULIT was found to be convergently valid with the Binge Scale (r = .93, p < .0001), another index of bulimia, and less convergently valid with the Eating Attitudes Test (EAT), an index of anorexia nervosa (r = .68, p < .0001; Smith, and Thelen, 1984).
The Sexual Opinion Survey (SOS) This 21-item scale was initially developed by White et al. (1977) to measure individuals' emotional orientation toward sexuality. Subjects indicate their extent of agreement with each statement (e.g., "The thought of engag-
Irving et al.
ing in unusual sex practices is highly arousing") on a 7-point Likert type scale from 1 (I Strongly Disagree) to 7 (I Strongly Agree). SOS scores can range from 0 to 126, with low scores indicating negative or "erotophobic," and high scores indicating positive or "erotophilic," emotional responses to sexuality. The split-half reliability of the SOS has been reported to be .84 and above (Fisher et al., 1979). Construct validity has been demonstrated in the SOS's ability to consistently predict emotional responses to erotica across different samples of subjects (cited in Fisher et al., 1983). These same authors found SOS scores to be unrelated to responses on a measure of social desirability.
The Sexuafity Scale This 21-item scale was designed to measure intrapersonal comfort with sexuality (Irving and Thissen, 1987). Items are scored on a 7-point Likert type scale ranging from 1 (extreme discomfort) to 7 (extreme comfort). Responses to these 21 items can be summed to create a total Sexuality Scale score, with higher scores reflecting greater comfort with sexuality. Sexuality Scale items are also broken down into 4 related but distinct factors: thoughts about sex and being a sexual person; frequency of sexual thoughts, fantasies, and arousal; importance of sexuality in one's life; and pleasure derived from engaging in sexual activity and being a sexual person. Scores on these factors are derived by summing items making up each respective factor, with higher scores reflecting greater comfort with the aspect of sexuality represented by each factor. This set of four scales was derived from an item factor analysis of data from a large sample of subjects who completed a previous version of the scale (Irving and Thissen, 1987). Data from this pool of 314 female undergraduates were factor analyzed using an item analysis model especially formulated for Likert-type scales (Muthen, 1987), following procedures illustrated by Thissen et al. (1983). The results suggested the four-factor structure described above. The X 2 goodness-of-fit test for the factor model was n o n s i g n i f i c a n t (X2138] = 42.1, p -- .3), indicating that the model fits these data well and that items on the Sexuality Scale represent four related underlying dimensions (Irving and Thissen, 1987). Coefficient alpha reliabilities for the four scales were .86 (thoughts), .82 (frequency), .86 (importance), and .87 (pleasure). One motivation for the development of the Sexuality Scale was the need for a viable alternative to the widely used SOS. While the SOS has proven to be a valid index of attitudes toward sexuality-related topics such as pornography and homosexuality, its validity as a measure of acceptance of or intrapersonal comfort with sexuality has been questioned (Seikel, 1988). The Sexuality Scale was used in the present study to provide a more comprehen-
Bulimia and Sexuality
sive evaluation of comfort with sexuality than could be provided by the SOS alone.
Sexual and Contraceptive History This 20-item questionnaire was developed for use in a previous study (Frost and McCluskey-Fawcett, 1988), and is used to obtain information about sexually active subjects' sexual and contraceptive history. The 20 multiple-choice items include age at first intercourse, number of previous sex partners, commonly used and preferred methods of contraception, patterns of communication regarding use of contraception, and duration and level of commitment of current love relationship(s). Procedure
Questionnaires were administered by a female experimenter to the subjects in groups ranging from 5 to 10 individuals. Standardized instructions were given by the experimenter, after which subjects read and signed consent statements. Subjects were administered a packet of 10 randomly ordered questionnaires. Three of these questionnaires (The Sexuality Scale, SOS, and Sex and Contraceptive History questionnaire) were administered for use in the present study, while the other 7 were part of a separate ongoing project. Subjects were given two hours to complete the questionnaires, although the average completion time was one hour. After finishing the packet of materials, subjects were given a brief written explanation of the study's purpose. Before leaving, subjects signed statements requesting that they not reveal the nature or purpose of the study to classmates who might later be asked to participate. RESULTS Sexual A t t i t u d e s
Pearson correlation coefficients were computed for the BULIT, SOS, and the Sexuality Scale and its respective factors (see Table I). The SOS and the Sexuality Scale were significantly correlated (r = .55, p < .001). The SOS was also significantly correlated with each factor of the Sexuality Scale, although these correlations differed in magnitude. The SOS was most strongly correlated with thoughts about sexuality (r = .61, p < .001), followed by frequency of sexual thoughts/fantasies/arousal (r = .47, p < .001), importance of sexuality (r = .45, p < .001), and finally, pleasure in response to
Irving et aL Table I. Correlations Between Risk and Sexuality Scales*
1. Risk (BULIT score) 2. Sexuality Scale 3. Thought factor 4. Importance factor 5. Frequency factor 6. Pleasure factor 7. SOS
1.00 .10 (. 15)c .09 (. 18) .11 (. 12) .16 (.04) -.06 (.27) .05
aAll correlations between the SOS, and the Sexuality Scale, and its respective subscales are significant at the .001 level. Only the remaining significance levels are shown. bNumbers appearing in parentheses represent the number of subjects completing all items on each individual scale. CNumbers appearing in parentheses are significance levels.
sexuality (r = .30, p < .001). The direction of these correlations indicates that a positive emotional response to sexuality (erotophilia) is related to increased comfort with sexuality. The BULIT was positively correlated with the Frequency factor of the Sexuality Scale (r = . 16, p = .04). The BULIT was not significantly correlated with the SOS, the total Sexuality Scale, or any remaining Sexuality Scale factors. Although most of these correlations were nonsignificant, it is interesting that the direction of correlations between the BULIT and all but the Pleasure factor of the Sexuality Scale were positive.
Sexual and Contraceptive History Sexual and contraceptive history were examined in a series of contingency tables analyzing subject response by risk group membership (high, medium, and low). Chi-square analyses were used to test differences in risk group responses. Thirty-three subjects who had not yet engaged in sexual intercourse were omitted from these analyses. Similar numbers of high-, medium-, and low-risk subjects reported previously engaging in sexual intercourse (73 070, 71~ and 71 ~ respectively). Age at first intercourse was analyzed by placing the categorical responses "less than 14" and "15-16" years of age into a general "earlier age at first intercourse" category, and the categorical responses "17-18," "19-21," and "greater
Bulimia and Sexuality
405 Table II. Risk by Age at First Intercourse a
High risk Medium/low risk
Less than 17 years N (~ 18 (62) 20 (37)
Greater than 17 years N (~ 11 (38) 34 (63)
Total 38 (46) 45 (54) *Thirty-three subjects had not yet engaged in intercourse. X2(1) = 3.81, p = .05.
than 21" years o f age in a "later age at first intercourse" category. Using this classification, high-risk subjects reported initially engaging in sex at an earlier age than m e d i u m - or low-risk subjects (X212] = 3.81, p = .05; see Table II). While there was a tendency for high-risk subjects to report a greater number o f previous sexual partners, this difference was not large e n o u g h to warrant significance (see Table III). There were no risk g r o u p differences in the self-reported m e t h o d o f contraception used by subjects (1) at first intercourse, (2) at most recent intercourse, (3) most frequently, or (4) currently. There were differences, however, in preferred m e t h o d o f birth control. High-risk subjects reported a preference for not using birth control, or for using withdrawal as a means o f contraception (see Table IV). M e d i u m - and low-risk subjects preferred to use the pill or c o n d o m s rather than using withdrawal or engaging in unprotected sex (X212] = 6.78, p -- .03). Consistent with this, high-risk subjects reported engaging in unprotected intercourse m o r e frequently than did lower risk subjects (X218] = 19.88, p = .01; see Table V). There appears to be a linear relationship between risk and frequency o f unprotected intercourse, with medium-risk subjects engaging in unprotected intercourse less frequently than high-risk subjects and more frequently than low-risk subjects. Despite higher rates o f unprotected intercourse, there were no differences in the n u m b e r o f unplanned pregnancies occurring in sexually active high-, medium-, and low-risk subjects (10070, 1 1 070, and 15070, respectively). There were also no differences in the action subjects would take if they were
Table III. Risk by Self-Reported Number of Previous Sexual Partners a
One/two Three/four Five to ten More than ten N (~ N (~ N (~ N (~ High risk 10 (33) 11 (37) 5 (17) 4 (13) Medium risk 15 (56) 6 (22) 5 (19) 1 (4) Low risk 15 (56) 6 (22) 5 (19) 1 (4) *Thirty-three subjects had not yet engaged in intercourse. X 2 ( 6 ) = 6.01, p = .4.
406 Table IV. Risk by Preferred Method of Contraception~
High risk Medium risk Low risk
None/withdrawal N(%) 5 (18) 1 (4) 0 (0)
Pill/condom N(%) 23 (82) 25 (96) 25 (100)
Total 6 (8) 73 (92) ~Thirty-three subjects had not yet engaged in intercourse, 2 subjects failed to respond, and 3 subjects reported using other methods of contraception. X 2 ( 1 ) = 6.78, p = .03.
to b e c o m e p r e g n a n t within the next six m o n t h s ( a b o r t , keep the b a b y , o r p u t the b a b y up for a d o p t i o n ) . There were risk g r o u p differences in the s e l f - r e p o r t e d frequency o f sexual intercourse in the past six m o n t h s , a n d in the estimated frequency o f sexual i n t e r c o u r s e in the next six m o n t h s . H i g h - r i s k subjects r e p o r t e d engaging in sexual i n t e r c o u r s e less f r e q u e n t l y in the p a s t six m o n t h s (X214] = 11.04, p = .03), a n d e s t i m a t e d engaging in i n t e r c o u r s e less f r e q u e n t l y in the next six m o n t h s (X214] = 10.09, p = .04) t h a n d i d m e d i u m - a n d low-risk subjects (see T a b l e s VI a n d VII). O n c e again, t h e r e a p p e a r s to b e a linear relationship b e t w e e n f r e q u e n c y o f p a s t a n d e s t i m a t e d f u t u r e sexual activity, with m e d i u m - r i s k subjects falling in b e t w e e n high- a n d l o w - r i s k g r o u p s . T h e r e were no reliable differences in the level o f c o m m i t m e n t or d u r a tion o f the c u r r e n t relationship(s) o f high-, m e d i u m - , a n d low-risk subjects. T h e r e were risk g r o u p differences, however, in the m a n n e r in which cont r a c e p t i o n h a d been discussed in p r e v i o u s r e l a t i o n s h i p s . H i g h - r i s k subjects were m o r e likely to have m e n t i o n e d b i r t h c o n t r o l a f t e r first engaging in intercourse, or n o t at all, while m e d i u m - a n d low-risk subjects were m o r e likely to have discussed b i r t h c o n t r o l b e f o r e engaging in intercourse. L o w - r i s k
Table V. Risk by Preferred Method of Contraceptiona On
High risk Medium risk Low risk
Never N (~ 0 (0) 7 (26) 13 (48)
Infrequently N (~ 13 (45) 11 (41) 7 (26)
occasion N (%) 8 (28) 3 (11) 4 (15)
Often N (%) 5 (17) 4 (15) 1 (4)
Always N (~ 3 (10) 2 (7) 2 (7)
Total 20 (24) 31 (37) 15 (18) 10 (12) 7 (8) aThirty-three subjects had not yet engaged in intercourse, and 1 subject failed to respond. X2(8) = 19.88, p = .01.
Bulimia and Sexuality
Table VI. Risk by Self-Reported Frequency of Intercourse in the Last Six Monthsa
High risk Medium risk Low risk Total
Once a week or more N (a/o)
Once or twice a month N (~
Less than once a month/never N (%)
10 (33) 7 (26) 17 (63)
7 (28) 11 (41) 6 (22)
13 (43) 9 (33) 4 (15)
aThirty-three subjects had not yet engaged in intercourse, x2(4) = 11.04, p = .03.
subjects were m o r e likely to report discussing c o n t r a c e p t i o n " o n l y if a n ongoing relationship were established" (x214] = 10.09, p = .04; see Table VIII). This final response choice could reflect responsible or irresponsible contraceptive behavior, m a k i n g i n t e r p r e t a t i o n difficult.
DISCUSSION Risk for b u l i m i a was n o t associated with greater negative attitudes t o w a r d or d i s c o m f o r t with sexuality in the c u r r e n t study. I n fact, the m e a n SOS a n d Sexuality Scale scores of high-risk w o m e n were higher (albeit insign i f i c a n t l y except for the frequency factor o f the Sexuality Scale) t h a n those of lower risk subjects. It is possible that the measures used in the c u r r e n t study did n o t accurately assess c o m f o r t with or attitudes t o w a r d sexuality. It is also possible that w o m e n at risk for b u l i m i a do n o t evidence the degree o f sexual d i s c o m f o r t suggested b y earlier authors. R e p l i c a t i o n of the present study with clinically diagnosed b u l i m i c w o m e n would help address this issue.
Table VII. Risk by Estimate of Frequency of Intercourse in the Next Six Monthsa Once a week Once or twice Less than once or more a month a month/never N (~ N (~ N (07o) High risk Medium risk Low risk
10 (45) 5 (29) 15 (63)
3 (14) 8 (47) 3 (12)
9 (41) 4 (24) 6 (25)
Total 30 (48) 14 (22) 19 (30) aThirty-three subjects had not yet engaged in intercourse, and 21 subjects responded "I don't know." x2(4) = 10.09, p = .04.
Irving et ai.
Table VIII. Risk by Communication Regarding Contraception: When Has Birth Control Been Mentioned in Past Relationships? a
High risk Medium risk Low risk Total
Sometimes before/immediately before intercourse N (%)
After intercourse/ not at all N (~
13 (45) 18 (67) 15 (58)
11 (38) 4 (15) 2 (8)
Mentioned only if committed N (~ 5 5 9
(17) (19) (35)
aThirty-three subjects had not yet engaged in intercourse, and 2 subjects failed to respond. X2(4) = 10.09, p = .04.
Reports of earlier age at first intercourse and tendency toward a greater number of sexual partners among high-risk women are consistent with Dykens and Gerrard's (1986) finding that bulimic women exhibit greater precocious sexual activity than nonbulimic women. High-risk women in the current study were also more likely to use unreliable contraceptive methods and to discuss contraception with their partners after rather than before engaging in sexual intercourse. These risky contraceptive practices appeared in the absence of a relationship between risk for bulimia and level of commitment to current love relationship(s), length of current love relationship(s), and negative attitudes toward sexuality, all factors previously found to be related to ineffective contraceptive practices (Fisher et al., 1980, 1983). Rather than being related to these factors, high-risk women's risky contraceptive behavior could be related to a general impulsive pattern of behavior as suggested by Dykens and Gerrard (1986). Effective contraception requires foresight and planfulness. Impulsive sexual behavior leaves little time for such initiative. Despite engaging in sex at earlier ages, high-risk subjects currently engaged in sex less frequently, and expected to continue to engage in sex less frequently than lower risk subjects. Given their earlier initiation into sexual activity (offering the opportunity for a greater number of sexual partners), this finding could represent a reduction in the recent sexual activity of high-risk women. Abraham et aL (1985) found that bulimics reduced their social and sexual activity at higher body weights that subjects related to feeling unattractive. In the current study, high-risk subjects reported weighing more than lower risk subjects. Reductions in sexual activity could be a result of dissatisfaction with current body weight. Lower levels of recent and projected sexual activity could also be related to the bulimic syndrome itself, a cycle involving great amounts of time and energy. Bulimics have been known to binge for hours on end, sacrificing relationships with friends and family in order to maintain their behavior (Cauwels, 1983). Finally, reductions in sexual behavior could be related to depression coincident to the bulimic syndrome.
Bulimia and Sexuality
Unfortunately, the present study did not include data addressing these questions. Both generalized impulsivity (Dykens and Gerrard, 1986) and a need for control (Abraham et al., 1985) have been used to conceptualize the relationship between bulimia and sexuality. Rather than providing evidence staunchly supportive of either of these views, the current study points to the utility of incorporating them. Both impulsivity and a lack of control are evident in bulimics' eating behavior, which is characterized by a pattern of repeated rigid dieting followed by uncontrollable eating "binges." High-risk women's earlier initition into, and lower current as well as projected levels of sexual activity, may reflect alternations between impulsive and controlling extremes of this bipolar cycle. If this is the case, factors that lead to a generalized impulsive behavior pattern rather than specific attitudes toward sexuality may be operating in the mediation of the sexual behavior of these women. Future research addressing the relationship between bulimia and sexuality may benefit from identifying and examining such factors. Researchers linking bulimia to childhood sexual abuse may want to explore the relationship between abusive experiences and later issues of control and impulsivity. The current study is limited by both the population and method used. High-risk subjects identified by the BULIT distribution represent female college students evidencing high levels of food and weight preoccupation rather than clinically diagnosed bulimics. Results must be interpreted with caution, for they cannot be generalized to an actual bulimic population. Those interested in replication are advised to utilize a subject pool screened through the use of diagnostic interviews as well as paper and pencil measures. As with all correlational research, the current study's observed relationships do not answer questions of cause and effect. A cross-sectional, or ideally, longitudinal design, could better address such issues. Finally, the limited amount of information collected in the current study leaves gaps in understanding the research question under investigation. Future research in this area should include a broader data set to supplement and expand upon present results. Results of the current study suggest that the sexual activity of women at risk for developing bulimia may reflect a generalized pattern of behavior rather than specific attitudes toward or comfort with sexuality. Future research in this area should address issues underlying this general behavior pattern, acknowledging its potential impact on various dimensions of the lives of women at risk for bulimia.
ACKNOWLEDGMENTS The authors would like to thank research assistants Alison Janes and Taryn Van Gilder for collecting and entering all data.
Irving et aL REFERENCES
Abraham, S. F., Bendit, N., Mason, C., Mitchell, H., O'Connor, N., Ward, J., Young, S., and Llewellyn-Jones, D. (1985). The psychosexual histories of young women with bulimia. Austral. N. Zeal J. Psychiatr. 19: 72-76. American Psychiatric Association. (1980). Diagnostic and Statistical Manual o f Mental Disorders (3rd ed.). American Psychiatric Association, Washington, DC. Beumont, P. J. V., Abraham, S. F., and Simson, K. (1981). The psychosexual histories of adolescent girls and young women with anorexia nervosa. Psychol. Med. 11: 131-140. Bruch, H. (1973). Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. Basic Books, New York. Buvat-Herbaut, M., Hebbinckyus, P., Lemaire, A., and Buvat, J. (1983). Attitudes toward weight, body image, eating, menstruation, pregnancy, and sexuality in 81 cases of anorexia compared with 288 normal control school girls, lnternat. J. Eat. Disord. 2: 45-59. Cauwels, J. (1983). Bulimia. Doubleday, New York. Dykens, E. M., and Gerrard, M. (1986). Psychological profiles of purging bulimics, repeat dieters, and controls. J. Consult. Clin. PsychoL 54: 283-288. Fairburn, C. G., and Cooper, P. J. (1984). The clinical features of bulimia nervosa. Br. J. Psychiatr. 144: 238-246. Fisher, W. A., Byrne, D., Edmunds, M., Miller, C. T., Kelley, K., and White, L. A. (1979). Psychological and situation-specific correlates of contraceptive behavior among university women. J. Sex Res. 15: 38-55. Fisher, W. A., Miller, C. T., Byrne, D., and White, L. A. (1980). Talking dirty: Responses to communicating a sexual message as a function of situational and personality factors. Basic AppL Social PsychoL 1: 115-126. Fisher, W. A., Byrne, D, and White, L. A. (1983). Emotional barriers to contraception. In Byrne, D., Fisher, W. A. (eds.), Adolescents, Sex, and Contraception. Erlbaum, Hillsdale, NJ. Frost, H. L., and McCluskey-Fawcett (1988). Responsible Sexual Behavior: Communication, Contraception, and "Safer Sex"Practices. American Psychological Association, Atlanta, GA. Goldfarb, L. A. (1987). Sexual abuse antecedent to anorexia nervosa, bulimia, and compulsive overeating: Three case reports. Internat. J. Eat. Disord. 6: 675-680. Herzog, D. B., Norman, D. K., Gordon, C., and Pepose, M. (1984). Sexual conflict and eating disorders in 27 males. Am. J. Psychiatr. 141: 989-990. Irving, L. M., and Thissen, D. (1987). The Sexuality Scale: A measure of intrapersonal comfort with sexuality. Unpublished raw data. Katzman, M. A., and Wolchik, S. A. (1984). Bulimia and binge eating in college women: A comparison of personality and behavioral characteristics. J. Consult. Clin. PsychoL 52: 423-428. Leon, G. R., Lucas, A. R., Colligan, R. C., Ferdinande, R. J., and Kamp, J. (1985). Sexual, body-image, and personality attitudes in anorexia nervosa. J. Abnorm. Child Psychol. 13: 245-258. Leon, G. R., Lucas, A. R., Ferdinand, R. F., Mangelsdorf, C., and Colligan, R. C. (1987). Attitudes about sexuality and other psychological characteristics as predictors of follow-up status in anorexia nervosa. Internat. J. Eat. Disord. 6: 477-484. Lindner, R. H. (1954). The Fifty-Minute Hour. Bantam Books, New York. Muthen, B. O. (1987). LISCOMP: Analysis o f Linear Structural Equations Using a Comprehensive Measurement Model. Scientific Software, Mooresville, IN. Norton, K. R., Crisp, A. H., and Bhat, A. V. (1985). Why do some anorexics steal? Personal, social and illness factors. J. Psychiat. Res. 19: 385-390. Oppenheimer, R., Howells, K., Palmer, R. L., and Chaloner, D. A. (1985). Adverse sexual experience in childhood and clinical eating disorders: A preliminary description. J. Psychiat. Res. 19: 357-361. Pyle, R. L., Michell, J. E., and Eckert, E. D. (1981). Bulimia: A report of 34 cases. J. Clin. Psychiat. Res. 42: 60-64.
Bulimia and Sexuality
Rayes-Weiss, S., and Ebert, M. H. (1983). Psychological and behavioral characteristics of normalweight bulimics and normal-weight controls. Psychosom. Med. 45: 293-302. Romeo, F. F. (1984). Adolescence, sexual conflict, and anorexia nervosa. Adolescence 19: 551-555. Schechter, J. O., Schwartz, H. P., and Greenfeld, D. G. (1987). Sexual assault and anorexia nervosa. Internat. J. Eat. Disord. 6: 313-316. Scott, D. W. (1987). The involvement of psychosexual factors in the causation of eating disorders: Time for a reappraisal. Internat. J. Eat. Disord. 366: 199-213. Seikel, P. (1988). Contraceptive use in college women. Unpublished doctoral dissertation. University of Kansas, Lawrence. Shepard-Devenyns, L. (1988). The incidence of alcoholism and victimization in the bulimic population. Paper presented at the 96th annual meeting of the American Psychological Association, Atlanta, GA. Smith, M. C., and Thelen, M. H. (1984). Development and validation of a test for bulimia. J. Consult. Clin. Psychol. 52: 863-872. Stein, D. M., and Laakso, W. (1988). Bulimia: A historical perspective. Internat. J. Eat. Disord. 7: 201-210. Thissen, D., Steinberg, L., Pyszczynski, T., and Greenberg, J. ( 1983). An item response theory for personality and attitude scales: Item analysis using restricted factor analysis. Appl. Psychol. Measure. 7: 211-226. White, L. A., Fisher, W. A., Byrne, D., and Kingma, R. (1977). Development and validation of a measure of affective orientation to erotica: The Sexual Opinion Survey. Midwestern Psychological Association, Chicago.