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Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Sexual Function of Women Suffering From Anorexia Nervosa and Bulimia Nervosa a
a
a
Fragiskos Gonidakis , Vasilliki Kravvariti & Eleftheria Varsou a
Eating Disorders Unit, Athens University, Medical School, 1st Department of Psychiatry, Athens, Greece Accepted author version posted online: 29 Apr 2014.Published online: 11 Jun 2014.
To cite this article: Fragiskos Gonidakis, Vasilliki Kravvariti & Eleftheria Varsou (2014): Sexual Function of Women Suffering From Anorexia Nervosa and Bulimia Nervosa, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2014.915904 To link to this article: http://dx.doi.org/10.1080/0092623X.2014.915904
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JOURNAL OF SEX & MARITAL THERAPY, 0(0), 1–11, 2014 C Taylor & Francis Group, LLC Copyright ISSN: 0092-623X print / 1521-0715 online DOI: 10.1080/0092623X.2014.915904
Sexual Function of Women Suffering From Anorexia Nervosa and Bulimia Nervosa Fragiskos Gonidakis, Vasilliki Kravvariti, and Eleftheria Varsou
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Eating Disorders Unit, Athens University, Medical School, 1st Department of Psychiatry, Athens, Greece
The cross-sectional study aimed at examining the sexual function of young adult women suffering from eating disorders. The authors interviewed 53 women (26 with anorexia nervosa and 27 with bulimia nervosa) and 58 female students. Each participant was administered the Female Sexual Function Index, the Eating Attitudes Test, the Body Shape Questionnaire, and the Beck Depression Inventory. Comparisons among the 3 groups showed that patients with anorexia nervosa scored lower in each Female Sexual Function Index subscale than did healthy controls. There was no significant difference between bulimia nervosa and healthy controls. Sexual functionality of patients with anorexia nervosa was correlated only with body mass index (r = 0.5, p = .01). Sexual functionality of patients with bulimia nervosa was correlated only with the Beck Depression Inventory (r = –0.4, p = .03) Patients with anorexia nervosa had more disturbed sexual function than did controls. Sexual function can be related to the level of starvation and symptoms of depression.
Little empirical evidence exists concerning sexual function and sexuality in women suffering from eating disorders (Kravvariti & Gonidakis, 2014). The published literature has neither adequately addressed the prevalence of sexual dysfunction across the subtypes of eating disorders nor sufficiently explored the degree to which psychological and physiological features associated with eating disorders influence sexual functioning (Kravvariti & Gonidakis, 2014; Pinheiro et al., 2010). In addition, sexual functioning is rarely discussed as an important component of treatment except in the context of sexual abuse and trauma history (Pinheiro et al., 2010). The majority of the research findings indicate that eating disorders have a considerable effect on a patient’s sexual function (Kravvariti & Gonidakis, 2014). The factors, related to eating disorder symptoms that influence sexuality, are various and differ among each type of eating disorder. Considering anorexia nervosa, starvation and its consequences on human physiology—and especially on brain function—seems to be the main factor that leads to reduced sexual desire and scarce sexual activity (Pinheiro et al., 2010). Moreover, personality traits that are common in patients suffering from anorexia nervosa such as compulsivity and rigidity are also related to difficulties with romantic and sexual relationships (Leon, Lucas, Colligan, Ferdinande, & Kamp, 1985; Pinheiro et al., 2010).
Address correspondence to Fragiskos Gonidakis, Psychiatric Clinic, Eginition Hospital, Vas Sofias 74 str, 11528, Athens, Greece. E-mail: [email protected]
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Regarding bulimia nervosa, impulsivity and difficulties in emotion regulation that are common features of the disorder are also related to impulsive and sometimes self-harming sexual behaviors (Eddy, Novotny, & Westen, 2004). Research findings have indicated that although patients suffering from bulimia nervosa are more sexually active than patients suffering from anorexia nervosa, both groups report more often than do healthy individuals a lack of satisfaction from their sexual experiences (Wiederman, Pryor, & Morgan, 1996). A second common feature among anorexia nervosa and bulimia nervosa is that patients suffering from these disorders are not satisfied with their bodies because they perceive their bodies as fat and ugly (Wiederman & Pryor, 1997, 2000). The feelings of shame and disgust that arise from this distorted perception can lead to avoidance of intercourse with the sexual partner (Mazzei et al., 2011; Wiederman & Pryor, 1997, 2000). Other factors that are common to eating disorders and sexual dysfunction include adverse childhood experiences, negative family climate, and especially traumatic events such as childhood sexual abuse (Chou, 2012; Kravvariti & Gonidakis, 2014). Furthermore, the comorbidity of eating disorders and depression may have a negative effect on a patient’s sexual function (Pinheiro et al., 2010). The present study aimed to (a) examine sexual functioning in a group of young adult women suffering from eating disorders, (b) compare sexual functioning between anorexia nervosa and bulimia nervosa patients, and (c) research the relation between sexual dysfunction in patients with eating disorders and clinical variables such as depression and body dissatisfaction. We hypothesized that sexual dysfunction in patients with eating disorders would be higher than that in controls without eating disorders and that low body mass index, symptoms of depression, and more severe body dissatisfaction would be related to higher sexual dysfunction.
METHODS Sample For this study, we approached 60 women suffering from eating disorders and 60 female students at Athens University. In total, 53 (88.3%) of patients with eating disorders and 58 (96.7%) of the students agreed to participate. None of the participants met the exclusion criteria: suffering from psychosis, substance abuse, mental retardation, or chronic and severe physical illness. We recruited all patients with eating disorders at the Eating Disorders Outpatient Unit of Athens University, Medical School, 1st Psychiatric Department. Of the 53 patients, 26 (49.1%) were suffering from anorexia nervosa and 27 (50.9%) were suffering from bulimia nervosa. The diagnosis of eating disorders was confirmed with the eating disorder portion of Structured Clinical Interview for DSM Disorders (SCID) for the Diagnostic and Statistical Manual of Mental Disorders (4th edition). We included in the anorexia nervous group patients who were diagnosed as having eating disorders not otherwise specified (EDNOS) with anorectic-type symptoms but who did not meet all of the criteria for the diagnosis of anorexia nervosa (with the exception of the low weight criterion). Likewise, we included in the bulimia nervosa group patients who were diagnosed with ENDOS with bulimic-type symptoms but who did not meet all of the criteria
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for the diagnosis of bulimia nervosa (with the exception of the frequency of bulimic episodes criterion). All participants provided written informed consent according to the requirements of Athens University, Medical School, Eginition Hospital, Ethical Committee, which provided the necessary approval for the study. Measurements
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Each participant was administered the following questionnaires. Female Sexual Function Index (FSFI) The FSFI is a widely used 19-item self-reported questionnaire created by Rosen and colleagues (2000). Each item was reported on a 6-point Likert-type scale ranging from 0 (no sexual activity) to 5 (excellent sexual function), and a seventh choice states, “I do not have sexual activity.” The score of each item varies. The total score is produced by multiplying each item score with an impact factor and adding the adjusted scores of the 19 items. The FSFI total score varies from 1 to 36. Higher scores indicate higher sexual function. The questionnaire refers to the 4 weeks that preceded the survey. The questions have been phrased such that they apply to both heterosexual and homosexual respondents. The FSFI focuses on six areas of sexual function: desire, arousal, lubrication, orgasm, satisfaction and pain. The FSFI has been found to be reliable independently of age, nationality, education, or socioeconomic level (Meston, 2003), with a high internal consistency (Daker-White, 2002). For the present study and the group of all participating women, Cronbach’s alpha was calculated at .98 (desire, .9; arousal, .98; lubrication, .98; orgasm, .98; satisfaction, .66; pain, .98). To our knowledge, this is the first time the Greek version of the FSFI was used in a sample of participants with eating disorders. We decided not to use a cutoff point for the FSFI; instead, we treated the questionnaire’s score as a scale variable. Eating Attitudes Test (EAT-26) The EAT-26 is the one of the most often used questionnaires for measuring disordered eating attitudes (Garner, Olmsted, Bohr, & Garfinkel, 1982). The scale does not yield a specific diagnosis for an eating disorder by itself; however, it is consistently used as an effective screening instrument and has been found to be effective with clinical and subclinical populations (Koslowsky et al., 1992). The EAT-26 is called so because it consists of 26 items on which participants respond on a 6-point Likert-type scale ranging from always to never. Each answer score varies from 0 to 3, with a total score between 0 and 78. Higher scores indicate disordered eating attitudes. The EAT-26 has been translated in Greek and validated by Simos (1996). The EAT-26 consists of three subscales: diet, bulimia, and oral control. According to the Greek edition of the scale, participants who receive a score equal to or more than 20 are considered at risk for an eating disorder. For the present study and the group of all participating women, we calculated Cronbach’s alpha at .95 (diet, .93, bulimia, .91; and oral control, .81).
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Body Shape Questionnaire (BSQ-34)
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The BSQ-34 is a self-reported questionnaire measuring distress caused by body image and more specifically the subjective experience of feeling fat (Cooper, Taylor, Cooper, & Fairburn, 1987). The questionnaire focuses on the 4 weeks immediately preceding the survey. BSQ-34 consists of 34 items on which participants respond on a 6-point Likert-type scale ranging from always to never. Higher scores indicate more severe worry considering body image. BSQ-34 scores can be used mainly as a measurement of eating disorder symptoms considering body image disturbance rather than a screening instrument for eating disorder (Cooper et al., 1987). For the present study and the group of all the participating women, we calculated Cronbach’s alpha at .98. Beck Depression Inventory (BDI) The BDI is a widely used self-report questionnaire for the measurement of depression (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). It consists of 21 items reported on a 4-point Likerttype scale ranging from no symptom at all to the highest intensity of depressive symptom. Each item score varies from 0 to 3 with the exception of one answer whose score varies from 0 to 2. The total score varies from 0 to 62. Higher score indicates more severe symptoms of depression. The Greek version of the BDI was validated by Jemos (1987). According to the Greek version of the BDI, a score of more than 21 indicates a possible clinical case of depression, and a score more than 40 indicates severe depression. The BDI has been used successfully to measure symptoms of depression in studies that were conducted either in clinical or general population (Beck, Steer, & Garbin, 1988). For the present study and the group of all the participating women, we calculated Cronbach’s alpha at .91. We assessed participants also with a self-reported improvised questionnaire that included five items (sexual contact, dreams with sexual content, orgasm during sleep, daytime sexual fantasies, and masturbation) concerning the preceding 4 weeks. Participants responded to each question on a 5-point Likert-type scale ranging from 1 (none) to 5 (more than once per week). Last, each participant was asked to provide the researcher (V. K.) with the following data: age, family status, education, socioeconomic status, age at first romantic relationship, age at first sexual intercourse, current height, and current weight. Statistical Analysis We used SPSS 19 to conduct statistical analysis. Because of the small sample of the survey, we conducted a Kolmogorov-Smirnov Z test to detect the body mass index, FSFI, BDI, BSQ, and EAT-26 shape of distribution. The Z test showed that the hypothesis—that the aforementioned variables had a normal distribution—could be retained for body mass index (p = .5), FSFI (p = .06), BDI (p = .08), BSQ (p = .2), and EAT-26 (p = .06). On the basis of the aforementioned results, we used parametric tests to analyze the results of our study. We used a one-way analysis of variance with Bonferroni correction to compare scale variables, a chi-square test to compare nominal variables, and Pearson’s r test to explore possible correlations between FSFI and other scale measurements.
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TABLE 1 Demographic Characteristics and Body Mass Index Patients with anorexia nervosa
Patients with bulimia nervosa
Healthy controls
M
SD
M
SD
M
SD
Age Body mass index Age at first romantic relationship Age at first sexual intercourse
24.8 15.8 15.7 17.8
4.6 2.1 1.9 1.6
26.1 21.2 16.1 18.2
4.9 2.7 3.4 2.7
25.1 21.3 16.1 18.5
4.7 3.1 1.9 2.5
Qualitative data Living with the family Sexual relationship Financially dependent Steady job University education
n 14 14 12 16 21
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Quantitative data
% 53.8 53.8 46.2 61.5 80.8
n 15 13 14 11 24
% 55.6 48.1 51.9 48.5 88.9
n 22 44 19 37 47
% 37.9 75.9 32.8 63.8 81.0
RESULTS Differences Among the Three Groups The three groups presented similar demographic characteristics (Table 1). There were no significant statistical differences considering age (F = 0.6, p = .6), age at first romantic relationship (F = 2.5, p = .09), age at first sexual intercourse (F = 0.6, p = .5), education (χ 2[2] = 0.9, p = .6), employment (χ 2[2] = 4.4, p = .4), financial support (χ 2[2] = 3.2, p = .2), and living with parental family (χ 2[2] = 3.2, p = .2). The only two significant differences between the groups were body mass index (F = 35.2, p = .001) and the percentage of individuals who responded that they were at the moment in a sexual relationship. As expected, higher percentage of healthy controls responded that they were involved in a sexual relationship: χ 2(2) = 7.7, p = .02. Also, the body mass index of the patients with anorexia nervosa was significantly lower than that of both healthy controls (p = .001) and patients with bulimia nervosa (p = .001). No difference was found in the body mass index between healthy controls and patients with bulimia nervosa (p = .9). Sexual Function Comparisons among the three groups (one-way analysis of variance with Bonferroni correction for multiple comparisons) showed significant differences for each FSFI subscale: desire (F = 9.6, p = .001), arousal (F = 6.4, p = .02), lubrication (F = 4.8, p = .01), orgasm (F = 5.1, p = .008), satisfaction (F = 6.0, p = .003), pain (F = 4.9, p = .009) and total score (F = 6.9, p = .001). The between-groups analysis presented in Table 2 showed that the anorexia nervosa group had lower measurements than did healthy controls concerning each FSFI subscale. There was no significant statistical difference between the anorexia nervosa group and the bulimia nervosa group or between the bulimia nervosa group and the healthy controls group.
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TABLE 2 Between-Group Comparison Considering FSFI Measurements: Analysis of Variance With Bonferroni Correction Patients with anorexia nervosa
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FSFI subscale Desire Arousal Lubrication Orgasm Satisfaction Pain Total
Patients with bulimia nervosa
M
SD
2.6 2.3 2.5 2.2 3.4 2.4 15.4
1.5 1.3 1.5 1.5 1.2 1.7 9.7
Desire Arousal Lubrication Orgasm Satisfaction Pain Total
SD
3.4 1.5 2.9 1.4 3.3 1.7 1.7 1.4 3.7 1.4 3.4 1.8 19.2 9.8 (Between-groups comparison)
M
SD
3.9 4 4.2 3.8 4.4 4.2 24.7
1.1 2.1 2.3 2.2 1.3 2.3 10.1
Patients with anorexia nervosa vs. patients with bulimia nervosa
Patients with bulimia nervosa vs. healthy controls
Patients with anorexia nervosa vs. healthy controls FSFI subscale
M
Healthy controls
Mean difference
p
Mean difference
p
Mean difference
p
−1.3 −1.7 −1.7 −1.6 −0.9 −1.9 −9.2
.001 .003 .01 .01 .006 .007 .002
−0.5 −1.1 −0.9 −1.2 −0.7 −0.8 −5.4
.3 .5 .6 .09 .07 .5 .1
−0.7 −0.6 −0.8 −0.4 −0.3 −1.1 −3.8
.4 .6 .7 .6 .9 .4 .6
Furthermore, patients with anorexia nervosa reported lower frequency than did healthy controls on the questions concerning sexual contact (F = 4.9, p = .01) and daytime sexual fantasies (F = 3.7, p = .03), while no significant statistical difference was found concerning the questions on frequency of masturbation and sexual dreams. Twelve patients (46.2%) of the anorexia nervosa group, 10 patients (37%) of the bulimia nervosa group, and 12 participants (20.7%) of the healthy control group replied that they had no sexual contact during the 4 weeks before the investigation. The difference between the anorexia nervosa group and healthy control group reached statistical significance: χ 2(1) = 9.2, p = .02. Factors Related to Sexual Function Table 3 presents the comparison of the three groups regarding EAT-26, BSQ, and BDI measurements. Analysis of variance results showed significant differences among the three groups for all three measurements (EAT-26, F = 76.3, p = .001; BSQ, F = 27.7, p = .001; BDI, F = 41.4, p = .001). The between-groups analysis presented in Table 3 showed that the anorexia nervosa and bulimia nervosa groups had higher EAT-26 and BDI scores than did healthy controls, but there was no difference between the two groups. Considering the BSQ, the bulimia nervosa group scored higher than did the anorexia nervosa group and healthy controls, whereas patients
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TABLE 3 Between-Group Comparisons Considering EAT-26, BSQ, and BDI Measurements: Analysis of Variance With Bonferroni Correction Patients with anorexia nervosa
Patients with bulimia nervosa
Healthy controls
Measure
M
SD
M
SD
M
SD
EAT-26 BSQ BDI
38.6 93.3 22.1
18.8 41.9 11.7
35.1 126.9 25.1
13.7 39.3 10.3
6.3 69.5 8.5
3.2 24.9 3.2
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Between-groups comparison Patients with anorexia nervosa vs. patients with bulimia nervosa
Patients with bulimia nervosa vs. healthy controls
Patients with anorexia nervosa vs. healthy controls Measure
Mean difference
p
Mean difference
p
Mean difference
p
EAT-26 BSQ BDI
31.7 23.7 13.5
.001 .009 .001
28.1 57.4 16.6
.001 .001 .001
3.5 33.6 3.1
.9 .001 .6
Note. EAT-26 = Eating Attitudes Test; BSQ = Body Shape Questionnaire; BDI = Beck Depression Inventory.
with anorexia nervosa scored higher that did healthy controls, which indicates that patients with bulimia nervosa experienced more distress from their body image than did patients with anorexia nervosa. The sexual function of patients with anorexia nervosa as measured by the FSFI was correlated only with body mass index measurement. The same applied to the questions regarding sexual contact and daytime sexual fantasies (Table 4). Results indicated that patients with anorexia nervosa with lower body mass index have higher sexual dysfunction as well as scarcer sexual contact and daytime sexual fantasies. Considering FSFI subscales, desire (r = 0.5, p = .007), arousal (r = 0.5, p = .01), lubrication (r = 0.5, p = .02), orgasm (r = 0.4, p = .05), and pain (r = 0.5, p = .01) were correlated with body mass index, whereas satisfaction (r = 0.3, p = .1) was not. Sexual function of the patients with bulimia nervosa as measured with FSFI was correlated only with BDI measurements (Table 4). There was also a marginally nonsignificant correlation between the frequency of sexual intercourse 4 weeks preceding the survey and BDI measurements (r = –0.4, p = .06). Results indicate that patients with bulimia nervosa that report more depressive symptoms have worse sexual function. Considering FSFI subscales, desire (r = –0.4, p = .03), arousal (r = –0.4, p = .05), lubrication (r = –0.4, p = .05), orgasm (r = 0.4, p = .05), and pain (r = –0.4, p = .05) were correlated with the BDI, whereas orgasm (r = –0.4, p = .1) and satisfaction (r = –0.3, p = .1) were not. Last, among all the FSFI subscales, desire (r = –0.4, p = .05) was correlated with BSQ score. This result indicates that patients with bulimia nervosa that have higher worry about their body image have lower sexual desire. In healthy controls, sexual function was not correlated with any of the psychopathology measurements (Table 4).
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TABLE 4 Correlation Between Sexual Functionality and Measurements of Psychopathology
FSFI total Anorexia nervosa
Daytime fantasies
Masturbation
Sexual contact
r
p
r
p
r
p
r
p
r
p
.5 −.7 .4 −.3
.01 .7 .9 .2
.2 −.1 .05 −.1
.3 .6 .8 .6
.08 .8 .3 .07
.7 .7 .1 .8
.4 −.2 −.09 −.08
.03 .3 .9 −.7
.4 −.2 .1 −.1
.04 .5 .3 .6
Bulimia nervosa BMI EAT-26 BSQ BDI
−.3 −.2 −.3 −.4
.9 .4 .1 .03
−.1 −.2 .06 .2
.5 .3 .8 .2
−.1 .1 .1 −.08
.8 .5 .6 .7
−.1 −.2 −.2 −.2
.5 .9 .2 −.3
−.06 −.2 −.4 −.4
.8 .3 .08 .06
Healthy controls BMI EAT-26 BSQ BDI
−.1 −.7 −.03 −.07
.3 .6 .8 .6
−.04 −.07 .2 .04
.08 .6 .2 .8
−.05 −.04 −.09 .2
.7 .8 .4 .07
−.1 .1 .1 .1
.3 .4 .4 .3
.02 .09 .1 .07
BMI EAT-26 BSQ BDI
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Dreams
.9 .5 .9 .6
Note. FSFI = Female Sexual Function Index; BMI = body mass index; EAT-26 = Eating Attitudes Test; BSQ = Body Shape Questionnaire; BDI = Beck Depression Inventory.
DISCUSSION Our research hypothesis, on the basis of the review of the literature on sexuality and eating disorders, was that sexual function of patients with eating disorders would be more disturbed than would controls and that low body mass index, symptoms of depression, and more severe body dissatisfaction would be related to higher sexual dysfunction of patients with eating disorder. Both parts of the hypothesis were partially confirmed. Results indicate that patients with anorexia nervosa reported significantly worse sexual function in general and in most of the specific areas that we measured. Moreover, it was less likely for their group to be involved in a sexual relationship. Among all of the clinical measurements that we used, only body mass index was correlated with sexual function of patients with anorexia nervosa. This result can lead to the hypothesis that starvation might be the factor that possibly has a strong effect on patients with anorexia nervosa sexual function. The correlation of low body mass index and reduced sexuality has been also reported by Pinheiro and colleagues (2010). Furthermore, there seems to be a probable neurobiological explanation of this correlation implicating the role of neuropeptide Y (S¨odersten, Nerg˚ardh, Bergh, Zandian, & Scheurink, 2008). It has been hypothesized that the normal behavioral role of neuropeptide Y is to facilitate the search for food and switch attention from sexual stimuli to food (S¨odersten et al., 2008). The activation of the neural neuropeptide Y receptor system may be involved in certain stages of anorexia nervosa as search for food and survival are prioritized over sexual desire and reproduction. The results of the study placed the sexual function of patients with bulimia nervosa in between that of patients with anorexia nervosa and that of healthy controls. This result suggests that
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sexual function of patients with bulimia nervosa is influenced but not so much as in the case of patients with anorexia nervosa. The small size of the sample probably prevented this difference to reach significant statistical levels. Symptoms of depression presented the strongest correlation with most areas of sexual functionality of patients with bulimia nervosa. It should be noted that depression has been found to share a strong relation to sexual dysfunction (Reynaert, Zdanowicz, Janne, & Jacques, 2010) and also depression is highly comorbid with bulimia nervosa (Godart et al., 2007; Mischoulon et al., 2011). Body dissatisfaction and especially the negative emotion of feeling fat was found to be correlated with low sexual desire in the bulimia nervosa group. A hypothesis concerning this result is that individuals with bulimia nervosa who feel that their bodies are ugly, fat, and unattractive would probably suppress their sexual desire. This kind of behavior can be seen as a protective measure against the distress caused from their perceived low probability of being wanted as sexual partners. Similar correlation between sexual function in patients with eating disorders and negative emotions concerning the body figure and weight have been reported by other studies in the literature (Mazzei et al., 2011; Wiederman & Pryor, 1997, 2000). Overall sexual function in patients with eating disorders was worse when compared with a group of healthy women with similar demographic characteristics. Patients with anorexia nervosa sexual function are more influenced probably because of the effects of starvation on the human brain. Results indicate that there might be differences between anorexia nervosa and patients with bulimia nervosa both in the sexual function measurements and in the psychopathology factors that were related to the sexual function measurements. This result can be placed in between a recent study by Castellini and colleagues (2012), which reported significantly lower FSFI scores in anorexia nervosa restrictive type as compared with bulimia nervosa and anorexia nervosa binge/purge type patients. Also, a similar recent study from Mazzei and colleagues (2011) did not observe any significant statistical differences among anorexia nervosa, bulimia nervosa, and Binge Eating Disorder (BED) in terms of FSFI scores, and thus, this topic of inquiry needs further investigation. The main limitation of the study was its small sample. Although the group of patients was small, the intergroup differences considering sexual function were so distinct that parametric tests showed significant statistical results. The second limitation was that the whole group of patients was recruited from the same eating disorder unit. It has been noted over the years of clinical practice that more severe and chronic cases of eating disorder are referred to this particular unit as a last resort of treatment. This has led to a clinical population of patients in treatment that presents more severe eating disorder symptoms than the clientele of other eating disorder units in the same city. The third limitation is the cultural differences between different nations and ethnic groups considering their sexual behavior. The study was conducted in a very specific cultural context of native Greek Christian orthodox young adult women living and studying in Athens, the capital of Greece. Various studies have indicated that factors such as social prejudice, common belief, and religion have a significant effect on human sexual behavior (Auslander, Rosenthal, & Blythe, 2007; Hunt & Jung, 2009; Wood, 2012). The conclusions drawn from the study should be viewed under the scope of participants’ cultural context. The fourth limitation of the study was that although the lack of sexual contact was recorded, there was no distinction among the reasons that lead to this absence of sexual activity the last month before the investigation. For some patients, it might be the result of separation from their previous relationship, whereas for other it might be the result of lack of sexual interest.
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It is evident that further research is needed on the issue of eating disorders and sexual function. The results of the study raise two major areas of interest. The first is the investigation of sexual function in recovered patients with anorexia nervosa. It would be interesting to find whether sexual function is restored and in what extent when starvation effects subside (Morgan, Wederman, & Pryor, 1995). The second area is the investigation of the biological and psychological factors, beyond symptoms of depression, that influence sexual function in patients suffering from bulimia nervosa.
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REFERENCES Auslander, B. A., Rosenthal, S. L., & Blythe, M. J. (2007). Understanding sexual behaviors of adolescents within a biopsychosocial framework. Adolescent Medicine: State of the Art Review, 18, 434–448. Beck, A. T., Steer, R. A., & Garbin, G. M. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8, 77–100. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. Castellini, G., Lelli, L., Lo Sauro, C., Fioravanti, G., Vignozzi, L., Maggi, M., . . . Ricca, V. (2012). Anorectic and bulimic patients suffer from relevant sexual dysfunctions. Journal of Sexual Medicine, 9, 2590–2599. Chou, K. L. (2012). Childhood sexual abuse and psychiatric disorders in middle-aged and older adults: Evidence from the 2007 Adult Psychiatric Morbidity Survey. Journal of Clinical Psychiatry, 73, 1365–1371. Cooper, P. J., Taylor, M. J., Cooper, J., & Fairburn, C. G. (1987). The development and validation of the Body Shape Questionnaire. International Journal of Eating Disorders, 6, 485–494. Daker-White, G. (2002). Reliable and valid self-report outcome measures in sexual (dys)function: A systematic review. Archives of Sexual Behavior, 31, 197–209. Eddy, K. T., Novotny, C. M., & Westen, D. (2004). Sexuality, personality, and eating disorders. Eating Disorders, 12, 191–208. Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The eating attitudes test: Psychometric features and clinical correlates. Psychological Medicine, 12, 871–878. Godart, N. T., Perdereau, F., Rein, Z., Berthoz, S., Wallier, J., Jeammet, P., & Flament, M. F. (2007). Comorbidity studies of eating disorders and mood disorders: Critical review of the literature. Journal of Affective Disorders, 97, 37–49. Hunt, M. E., & Jung, P. B. (2009). “Good sex” and religion: A feminist overview. Journal of Sex Research, 46, 156–167. Jemos, J. (1987). Standardization of Beck Depression Inventory for Greek population (Doctoral dissertation). Athens University, Medical School, Greece. Koslowsky, M., Scheinberg, Z., Bleich, A., Mark, M., Apter, A., Danon, Y., & Solomon, Z. (1992). The factor structure and criterion validity of the short form of the Eating Attitudes Test. Journal of Personality Assessment, 58, 27–35. Kravvariti, V., & Gonidakis, F. (2014). Eating disorders and sexual function. Psychiatriki. Leon, G. R., Lucas, A. R., Colligan, R. C., Ferdinande, R. J., & Kamp, J. (1985). Sexual, body-image, and personality attitudes in anorexia nervosa. Journal of Abnormal Child Psychology, 13, 245–257. Mazzei, C., Castellini, G., Benni, L., Godini, L., Lazzeretti, L., Pracucci, C., . . . Faravelli, C. (2011). Sexuality and eating disorders. Rivista di Psichiatria, 46, 122–128. Meston, C. M. (2003). Validation of the Female Sexual Function Index (FSFI) in women with female orgasmic disorder and in women with hypoactive sexual desire disorder. Journal of Sex & Marital Therapy, 29, 39–46. Mischoulon, D., Eddy, K. T., Keshaviah, A., Dinescu, D., Ross, S. L., Kass, A. E., . . . Herzog, D. B. (2011). Depression and eating disorders: Treatment and course. Journal of Affective Disorders, 130, 470–477. Morgan, C. D., Wiederman, M. W., & Pryor, T. L. (1995). Sexual functioning and attitudes of eating-disordered women: A follow-up study. Journal of Sex and Marital Therapy, 21, 67–77. Pinheiro, A. P., Raney, T. J., Thornton, L. M., Fichter, M. M., Berrettini, W. H., Goldman, D., . . . Bulik, C. M. (2010). Sexual functioning in women with eating disorders. International Journal of Eating Disorders, 43, 123–129. Reynaert, C., Zdanowicz, N., Janne, P., & Jacques, D. (2010). Depression and sexuality. Psychiatrica Danubina, 22(Suppl. 1), 111–113.
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Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C. M., & Shabsigh, R. (2000). The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. Journal of Sex & Marital Therapy, 26, 191–208. Simos, G. (1996). Investigation of eating disorders and prevention interventions (Doctoral dissertation). Aristotelion University of Thessaloniki, Greece. S¨odersten, P., Nerg˚ardh, R., Bergh, C., Zandian, M., & Scheurink, A. (2008). Behavioral neuroendocrinology and treatment of anorexia nervosa. Frontiers in Neuroendocrinology, 29, 445–462. Wiederman, M. W., & Pryor, T. (1997). Body dissatisfaction and sexuality among women with bulimia nervosa. International Journal of Eating Disorders, 21, 361–365. Wiederman, M. W., & Pryor, T. (2000). Body dissatisfaction, bulimia, and depression among women: The mediating role of drive for thinness. International Journal of Eating Disorders, 27, 90–95. Wiederman, M. W., Pryor, T., & Morgan, C. D. (1996). The sexual experience of women diagnosed with anorexia nervosa or bulimia nervosa. International Journal of Eating Disorders, 19, 109–118. Wood, P. L. (2012). Teenage sexuality in different cultures. Journal of Paediatric and Adolescence Gynaecology, 25, 228–232.
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Sexual Function of Women Suffering From Anorexia Nervosa and Bulimia Nervosa a
a
a
Fragiskos Gonidakis , Vasilliki Kravvariti & Eleftheria Varsou a
Eating Disorders Unit, Athens University, Medical School, 1st Department of Psychiatry, Athens, Greece Accepted author version posted online: 29 Apr 2014.Published online: 11 Jun 2014.
To cite this article: Fragiskos Gonidakis, Vasilliki Kravvariti & Eleftheria Varsou (2014): Sexual Function of Women Suffering From Anorexia Nervosa and Bulimia Nervosa, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2014.915904 To link to this article: http://dx.doi.org/10.1080/0092623X.2014.915904
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JOURNAL OF SEX & MARITAL THERAPY, 0(0), 1–11, 2014 C Taylor & Francis Group, LLC Copyright ISSN: 0092-623X print / 1521-0715 online DOI: 10.1080/0092623X.2014.915904
Sexual Function of Women Suffering From Anorexia Nervosa and Bulimia Nervosa Fragiskos Gonidakis, Vasilliki Kravvariti, and Eleftheria Varsou
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Eating Disorders Unit, Athens University, Medical School, 1st Department of Psychiatry, Athens, Greece
The cross-sectional study aimed at examining the sexual function of young adult women suffering from eating disorders. The authors interviewed 53 women (26 with anorexia nervosa and 27 with bulimia nervosa) and 58 female students. Each participant was administered the Female Sexual Function Index, the Eating Attitudes Test, the Body Shape Questionnaire, and the Beck Depression Inventory. Comparisons among the 3 groups showed that patients with anorexia nervosa scored lower in each Female Sexual Function Index subscale than did healthy controls. There was no significant difference between bulimia nervosa and healthy controls. Sexual functionality of patients with anorexia nervosa was correlated only with body mass index (r = 0.5, p = .01). Sexual functionality of patients with bulimia nervosa was correlated only with the Beck Depression Inventory (r = –0.4, p = .03) Patients with anorexia nervosa had more disturbed sexual function than did controls. Sexual function can be related to the level of starvation and symptoms of depression.
Little empirical evidence exists concerning sexual function and sexuality in women suffering from eating disorders (Kravvariti & Gonidakis, 2014). The published literature has neither adequately addressed the prevalence of sexual dysfunction across the subtypes of eating disorders nor sufficiently explored the degree to which psychological and physiological features associated with eating disorders influence sexual functioning (Kravvariti & Gonidakis, 2014; Pinheiro et al., 2010). In addition, sexual functioning is rarely discussed as an important component of treatment except in the context of sexual abuse and trauma history (Pinheiro et al., 2010). The majority of the research findings indicate that eating disorders have a considerable effect on a patient’s sexual function (Kravvariti & Gonidakis, 2014). The factors, related to eating disorder symptoms that influence sexuality, are various and differ among each type of eating disorder. Considering anorexia nervosa, starvation and its consequences on human physiology—and especially on brain function—seems to be the main factor that leads to reduced sexual desire and scarce sexual activity (Pinheiro et al., 2010). Moreover, personality traits that are common in patients suffering from anorexia nervosa such as compulsivity and rigidity are also related to difficulties with romantic and sexual relationships (Leon, Lucas, Colligan, Ferdinande, & Kamp, 1985; Pinheiro et al., 2010).
Address correspondence to Fragiskos Gonidakis, Psychiatric Clinic, Eginition Hospital, Vas Sofias 74 str, 11528, Athens, Greece. E-mail: [email protected]
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Regarding bulimia nervosa, impulsivity and difficulties in emotion regulation that are common features of the disorder are also related to impulsive and sometimes self-harming sexual behaviors (Eddy, Novotny, & Westen, 2004). Research findings have indicated that although patients suffering from bulimia nervosa are more sexually active than patients suffering from anorexia nervosa, both groups report more often than do healthy individuals a lack of satisfaction from their sexual experiences (Wiederman, Pryor, & Morgan, 1996). A second common feature among anorexia nervosa and bulimia nervosa is that patients suffering from these disorders are not satisfied with their bodies because they perceive their bodies as fat and ugly (Wiederman & Pryor, 1997, 2000). The feelings of shame and disgust that arise from this distorted perception can lead to avoidance of intercourse with the sexual partner (Mazzei et al., 2011; Wiederman & Pryor, 1997, 2000). Other factors that are common to eating disorders and sexual dysfunction include adverse childhood experiences, negative family climate, and especially traumatic events such as childhood sexual abuse (Chou, 2012; Kravvariti & Gonidakis, 2014). Furthermore, the comorbidity of eating disorders and depression may have a negative effect on a patient’s sexual function (Pinheiro et al., 2010). The present study aimed to (a) examine sexual functioning in a group of young adult women suffering from eating disorders, (b) compare sexual functioning between anorexia nervosa and bulimia nervosa patients, and (c) research the relation between sexual dysfunction in patients with eating disorders and clinical variables such as depression and body dissatisfaction. We hypothesized that sexual dysfunction in patients with eating disorders would be higher than that in controls without eating disorders and that low body mass index, symptoms of depression, and more severe body dissatisfaction would be related to higher sexual dysfunction.
METHODS Sample For this study, we approached 60 women suffering from eating disorders and 60 female students at Athens University. In total, 53 (88.3%) of patients with eating disorders and 58 (96.7%) of the students agreed to participate. None of the participants met the exclusion criteria: suffering from psychosis, substance abuse, mental retardation, or chronic and severe physical illness. We recruited all patients with eating disorders at the Eating Disorders Outpatient Unit of Athens University, Medical School, 1st Psychiatric Department. Of the 53 patients, 26 (49.1%) were suffering from anorexia nervosa and 27 (50.9%) were suffering from bulimia nervosa. The diagnosis of eating disorders was confirmed with the eating disorder portion of Structured Clinical Interview for DSM Disorders (SCID) for the Diagnostic and Statistical Manual of Mental Disorders (4th edition). We included in the anorexia nervous group patients who were diagnosed as having eating disorders not otherwise specified (EDNOS) with anorectic-type symptoms but who did not meet all of the criteria for the diagnosis of anorexia nervosa (with the exception of the low weight criterion). Likewise, we included in the bulimia nervosa group patients who were diagnosed with ENDOS with bulimic-type symptoms but who did not meet all of the criteria
ANOREXIA NERVOSA AND BULIMIA NERVOSA
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for the diagnosis of bulimia nervosa (with the exception of the frequency of bulimic episodes criterion). All participants provided written informed consent according to the requirements of Athens University, Medical School, Eginition Hospital, Ethical Committee, which provided the necessary approval for the study. Measurements
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Each participant was administered the following questionnaires. Female Sexual Function Index (FSFI) The FSFI is a widely used 19-item self-reported questionnaire created by Rosen and colleagues (2000). Each item was reported on a 6-point Likert-type scale ranging from 0 (no sexual activity) to 5 (excellent sexual function), and a seventh choice states, “I do not have sexual activity.” The score of each item varies. The total score is produced by multiplying each item score with an impact factor and adding the adjusted scores of the 19 items. The FSFI total score varies from 1 to 36. Higher scores indicate higher sexual function. The questionnaire refers to the 4 weeks that preceded the survey. The questions have been phrased such that they apply to both heterosexual and homosexual respondents. The FSFI focuses on six areas of sexual function: desire, arousal, lubrication, orgasm, satisfaction and pain. The FSFI has been found to be reliable independently of age, nationality, education, or socioeconomic level (Meston, 2003), with a high internal consistency (Daker-White, 2002). For the present study and the group of all participating women, Cronbach’s alpha was calculated at .98 (desire, .9; arousal, .98; lubrication, .98; orgasm, .98; satisfaction, .66; pain, .98). To our knowledge, this is the first time the Greek version of the FSFI was used in a sample of participants with eating disorders. We decided not to use a cutoff point for the FSFI; instead, we treated the questionnaire’s score as a scale variable. Eating Attitudes Test (EAT-26) The EAT-26 is the one of the most often used questionnaires for measuring disordered eating attitudes (Garner, Olmsted, Bohr, & Garfinkel, 1982). The scale does not yield a specific diagnosis for an eating disorder by itself; however, it is consistently used as an effective screening instrument and has been found to be effective with clinical and subclinical populations (Koslowsky et al., 1992). The EAT-26 is called so because it consists of 26 items on which participants respond on a 6-point Likert-type scale ranging from always to never. Each answer score varies from 0 to 3, with a total score between 0 and 78. Higher scores indicate disordered eating attitudes. The EAT-26 has been translated in Greek and validated by Simos (1996). The EAT-26 consists of three subscales: diet, bulimia, and oral control. According to the Greek edition of the scale, participants who receive a score equal to or more than 20 are considered at risk for an eating disorder. For the present study and the group of all participating women, we calculated Cronbach’s alpha at .95 (diet, .93, bulimia, .91; and oral control, .81).
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Body Shape Questionnaire (BSQ-34)
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The BSQ-34 is a self-reported questionnaire measuring distress caused by body image and more specifically the subjective experience of feeling fat (Cooper, Taylor, Cooper, & Fairburn, 1987). The questionnaire focuses on the 4 weeks immediately preceding the survey. BSQ-34 consists of 34 items on which participants respond on a 6-point Likert-type scale ranging from always to never. Higher scores indicate more severe worry considering body image. BSQ-34 scores can be used mainly as a measurement of eating disorder symptoms considering body image disturbance rather than a screening instrument for eating disorder (Cooper et al., 1987). For the present study and the group of all the participating women, we calculated Cronbach’s alpha at .98. Beck Depression Inventory (BDI) The BDI is a widely used self-report questionnaire for the measurement of depression (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). It consists of 21 items reported on a 4-point Likerttype scale ranging from no symptom at all to the highest intensity of depressive symptom. Each item score varies from 0 to 3 with the exception of one answer whose score varies from 0 to 2. The total score varies from 0 to 62. Higher score indicates more severe symptoms of depression. The Greek version of the BDI was validated by Jemos (1987). According to the Greek version of the BDI, a score of more than 21 indicates a possible clinical case of depression, and a score more than 40 indicates severe depression. The BDI has been used successfully to measure symptoms of depression in studies that were conducted either in clinical or general population (Beck, Steer, & Garbin, 1988). For the present study and the group of all the participating women, we calculated Cronbach’s alpha at .91. We assessed participants also with a self-reported improvised questionnaire that included five items (sexual contact, dreams with sexual content, orgasm during sleep, daytime sexual fantasies, and masturbation) concerning the preceding 4 weeks. Participants responded to each question on a 5-point Likert-type scale ranging from 1 (none) to 5 (more than once per week). Last, each participant was asked to provide the researcher (V. K.) with the following data: age, family status, education, socioeconomic status, age at first romantic relationship, age at first sexual intercourse, current height, and current weight. Statistical Analysis We used SPSS 19 to conduct statistical analysis. Because of the small sample of the survey, we conducted a Kolmogorov-Smirnov Z test to detect the body mass index, FSFI, BDI, BSQ, and EAT-26 shape of distribution. The Z test showed that the hypothesis—that the aforementioned variables had a normal distribution—could be retained for body mass index (p = .5), FSFI (p = .06), BDI (p = .08), BSQ (p = .2), and EAT-26 (p = .06). On the basis of the aforementioned results, we used parametric tests to analyze the results of our study. We used a one-way analysis of variance with Bonferroni correction to compare scale variables, a chi-square test to compare nominal variables, and Pearson’s r test to explore possible correlations between FSFI and other scale measurements.
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TABLE 1 Demographic Characteristics and Body Mass Index Patients with anorexia nervosa
Patients with bulimia nervosa
Healthy controls
M
SD
M
SD
M
SD
Age Body mass index Age at first romantic relationship Age at first sexual intercourse
24.8 15.8 15.7 17.8
4.6 2.1 1.9 1.6
26.1 21.2 16.1 18.2
4.9 2.7 3.4 2.7
25.1 21.3 16.1 18.5
4.7 3.1 1.9 2.5
Qualitative data Living with the family Sexual relationship Financially dependent Steady job University education
n 14 14 12 16 21
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Quantitative data
% 53.8 53.8 46.2 61.5 80.8
n 15 13 14 11 24
% 55.6 48.1 51.9 48.5 88.9
n 22 44 19 37 47
% 37.9 75.9 32.8 63.8 81.0
RESULTS Differences Among the Three Groups The three groups presented similar demographic characteristics (Table 1). There were no significant statistical differences considering age (F = 0.6, p = .6), age at first romantic relationship (F = 2.5, p = .09), age at first sexual intercourse (F = 0.6, p = .5), education (χ 2[2] = 0.9, p = .6), employment (χ 2[2] = 4.4, p = .4), financial support (χ 2[2] = 3.2, p = .2), and living with parental family (χ 2[2] = 3.2, p = .2). The only two significant differences between the groups were body mass index (F = 35.2, p = .001) and the percentage of individuals who responded that they were at the moment in a sexual relationship. As expected, higher percentage of healthy controls responded that they were involved in a sexual relationship: χ 2(2) = 7.7, p = .02. Also, the body mass index of the patients with anorexia nervosa was significantly lower than that of both healthy controls (p = .001) and patients with bulimia nervosa (p = .001). No difference was found in the body mass index between healthy controls and patients with bulimia nervosa (p = .9). Sexual Function Comparisons among the three groups (one-way analysis of variance with Bonferroni correction for multiple comparisons) showed significant differences for each FSFI subscale: desire (F = 9.6, p = .001), arousal (F = 6.4, p = .02), lubrication (F = 4.8, p = .01), orgasm (F = 5.1, p = .008), satisfaction (F = 6.0, p = .003), pain (F = 4.9, p = .009) and total score (F = 6.9, p = .001). The between-groups analysis presented in Table 2 showed that the anorexia nervosa group had lower measurements than did healthy controls concerning each FSFI subscale. There was no significant statistical difference between the anorexia nervosa group and the bulimia nervosa group or between the bulimia nervosa group and the healthy controls group.
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TABLE 2 Between-Group Comparison Considering FSFI Measurements: Analysis of Variance With Bonferroni Correction Patients with anorexia nervosa
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FSFI subscale Desire Arousal Lubrication Orgasm Satisfaction Pain Total
Patients with bulimia nervosa
M
SD
2.6 2.3 2.5 2.2 3.4 2.4 15.4
1.5 1.3 1.5 1.5 1.2 1.7 9.7
Desire Arousal Lubrication Orgasm Satisfaction Pain Total
SD
3.4 1.5 2.9 1.4 3.3 1.7 1.7 1.4 3.7 1.4 3.4 1.8 19.2 9.8 (Between-groups comparison)
M
SD
3.9 4 4.2 3.8 4.4 4.2 24.7
1.1 2.1 2.3 2.2 1.3 2.3 10.1
Patients with anorexia nervosa vs. patients with bulimia nervosa
Patients with bulimia nervosa vs. healthy controls
Patients with anorexia nervosa vs. healthy controls FSFI subscale
M
Healthy controls
Mean difference
p
Mean difference
p
Mean difference
p
−1.3 −1.7 −1.7 −1.6 −0.9 −1.9 −9.2
.001 .003 .01 .01 .006 .007 .002
−0.5 −1.1 −0.9 −1.2 −0.7 −0.8 −5.4
.3 .5 .6 .09 .07 .5 .1
−0.7 −0.6 −0.8 −0.4 −0.3 −1.1 −3.8
.4 .6 .7 .6 .9 .4 .6
Furthermore, patients with anorexia nervosa reported lower frequency than did healthy controls on the questions concerning sexual contact (F = 4.9, p = .01) and daytime sexual fantasies (F = 3.7, p = .03), while no significant statistical difference was found concerning the questions on frequency of masturbation and sexual dreams. Twelve patients (46.2%) of the anorexia nervosa group, 10 patients (37%) of the bulimia nervosa group, and 12 participants (20.7%) of the healthy control group replied that they had no sexual contact during the 4 weeks before the investigation. The difference between the anorexia nervosa group and healthy control group reached statistical significance: χ 2(1) = 9.2, p = .02. Factors Related to Sexual Function Table 3 presents the comparison of the three groups regarding EAT-26, BSQ, and BDI measurements. Analysis of variance results showed significant differences among the three groups for all three measurements (EAT-26, F = 76.3, p = .001; BSQ, F = 27.7, p = .001; BDI, F = 41.4, p = .001). The between-groups analysis presented in Table 3 showed that the anorexia nervosa and bulimia nervosa groups had higher EAT-26 and BDI scores than did healthy controls, but there was no difference between the two groups. Considering the BSQ, the bulimia nervosa group scored higher than did the anorexia nervosa group and healthy controls, whereas patients
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ANOREXIA NERVOSA AND BULIMIA NERVOSA
TABLE 3 Between-Group Comparisons Considering EAT-26, BSQ, and BDI Measurements: Analysis of Variance With Bonferroni Correction Patients with anorexia nervosa
Patients with bulimia nervosa
Healthy controls
Measure
M
SD
M
SD
M
SD
EAT-26 BSQ BDI
38.6 93.3 22.1
18.8 41.9 11.7
35.1 126.9 25.1
13.7 39.3 10.3
6.3 69.5 8.5
3.2 24.9 3.2
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Between-groups comparison Patients with anorexia nervosa vs. patients with bulimia nervosa
Patients with bulimia nervosa vs. healthy controls
Patients with anorexia nervosa vs. healthy controls Measure
Mean difference
p
Mean difference
p
Mean difference
p
EAT-26 BSQ BDI
31.7 23.7 13.5
.001 .009 .001
28.1 57.4 16.6
.001 .001 .001
3.5 33.6 3.1
.9 .001 .6
Note. EAT-26 = Eating Attitudes Test; BSQ = Body Shape Questionnaire; BDI = Beck Depression Inventory.
with anorexia nervosa scored higher that did healthy controls, which indicates that patients with bulimia nervosa experienced more distress from their body image than did patients with anorexia nervosa. The sexual function of patients with anorexia nervosa as measured by the FSFI was correlated only with body mass index measurement. The same applied to the questions regarding sexual contact and daytime sexual fantasies (Table 4). Results indicated that patients with anorexia nervosa with lower body mass index have higher sexual dysfunction as well as scarcer sexual contact and daytime sexual fantasies. Considering FSFI subscales, desire (r = 0.5, p = .007), arousal (r = 0.5, p = .01), lubrication (r = 0.5, p = .02), orgasm (r = 0.4, p = .05), and pain (r = 0.5, p = .01) were correlated with body mass index, whereas satisfaction (r = 0.3, p = .1) was not. Sexual function of the patients with bulimia nervosa as measured with FSFI was correlated only with BDI measurements (Table 4). There was also a marginally nonsignificant correlation between the frequency of sexual intercourse 4 weeks preceding the survey and BDI measurements (r = –0.4, p = .06). Results indicate that patients with bulimia nervosa that report more depressive symptoms have worse sexual function. Considering FSFI subscales, desire (r = –0.4, p = .03), arousal (r = –0.4, p = .05), lubrication (r = –0.4, p = .05), orgasm (r = 0.4, p = .05), and pain (r = –0.4, p = .05) were correlated with the BDI, whereas orgasm (r = –0.4, p = .1) and satisfaction (r = –0.3, p = .1) were not. Last, among all the FSFI subscales, desire (r = –0.4, p = .05) was correlated with BSQ score. This result indicates that patients with bulimia nervosa that have higher worry about their body image have lower sexual desire. In healthy controls, sexual function was not correlated with any of the psychopathology measurements (Table 4).
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TABLE 4 Correlation Between Sexual Functionality and Measurements of Psychopathology
FSFI total Anorexia nervosa
Daytime fantasies
Masturbation
Sexual contact
r
p
r
p
r
p
r
p
r
p
.5 −.7 .4 −.3
.01 .7 .9 .2
.2 −.1 .05 −.1
.3 .6 .8 .6
.08 .8 .3 .07
.7 .7 .1 .8
.4 −.2 −.09 −.08
.03 .3 .9 −.7
.4 −.2 .1 −.1
.04 .5 .3 .6
Bulimia nervosa BMI EAT-26 BSQ BDI
−.3 −.2 −.3 −.4
.9 .4 .1 .03
−.1 −.2 .06 .2
.5 .3 .8 .2
−.1 .1 .1 −.08
.8 .5 .6 .7
−.1 −.2 −.2 −.2
.5 .9 .2 −.3
−.06 −.2 −.4 −.4
.8 .3 .08 .06
Healthy controls BMI EAT-26 BSQ BDI
−.1 −.7 −.03 −.07
.3 .6 .8 .6
−.04 −.07 .2 .04
.08 .6 .2 .8
−.05 −.04 −.09 .2
.7 .8 .4 .07
−.1 .1 .1 .1
.3 .4 .4 .3
.02 .09 .1 .07
BMI EAT-26 BSQ BDI
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Dreams
.9 .5 .9 .6
Note. FSFI = Female Sexual Function Index; BMI = body mass index; EAT-26 = Eating Attitudes Test; BSQ = Body Shape Questionnaire; BDI = Beck Depression Inventory.
DISCUSSION Our research hypothesis, on the basis of the review of the literature on sexuality and eating disorders, was that sexual function of patients with eating disorders would be more disturbed than would controls and that low body mass index, symptoms of depression, and more severe body dissatisfaction would be related to higher sexual dysfunction of patients with eating disorder. Both parts of the hypothesis were partially confirmed. Results indicate that patients with anorexia nervosa reported significantly worse sexual function in general and in most of the specific areas that we measured. Moreover, it was less likely for their group to be involved in a sexual relationship. Among all of the clinical measurements that we used, only body mass index was correlated with sexual function of patients with anorexia nervosa. This result can lead to the hypothesis that starvation might be the factor that possibly has a strong effect on patients with anorexia nervosa sexual function. The correlation of low body mass index and reduced sexuality has been also reported by Pinheiro and colleagues (2010). Furthermore, there seems to be a probable neurobiological explanation of this correlation implicating the role of neuropeptide Y (S¨odersten, Nerg˚ardh, Bergh, Zandian, & Scheurink, 2008). It has been hypothesized that the normal behavioral role of neuropeptide Y is to facilitate the search for food and switch attention from sexual stimuli to food (S¨odersten et al., 2008). The activation of the neural neuropeptide Y receptor system may be involved in certain stages of anorexia nervosa as search for food and survival are prioritized over sexual desire and reproduction. The results of the study placed the sexual function of patients with bulimia nervosa in between that of patients with anorexia nervosa and that of healthy controls. This result suggests that
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sexual function of patients with bulimia nervosa is influenced but not so much as in the case of patients with anorexia nervosa. The small size of the sample probably prevented this difference to reach significant statistical levels. Symptoms of depression presented the strongest correlation with most areas of sexual functionality of patients with bulimia nervosa. It should be noted that depression has been found to share a strong relation to sexual dysfunction (Reynaert, Zdanowicz, Janne, & Jacques, 2010) and also depression is highly comorbid with bulimia nervosa (Godart et al., 2007; Mischoulon et al., 2011). Body dissatisfaction and especially the negative emotion of feeling fat was found to be correlated with low sexual desire in the bulimia nervosa group. A hypothesis concerning this result is that individuals with bulimia nervosa who feel that their bodies are ugly, fat, and unattractive would probably suppress their sexual desire. This kind of behavior can be seen as a protective measure against the distress caused from their perceived low probability of being wanted as sexual partners. Similar correlation between sexual function in patients with eating disorders and negative emotions concerning the body figure and weight have been reported by other studies in the literature (Mazzei et al., 2011; Wiederman & Pryor, 1997, 2000). Overall sexual function in patients with eating disorders was worse when compared with a group of healthy women with similar demographic characteristics. Patients with anorexia nervosa sexual function are more influenced probably because of the effects of starvation on the human brain. Results indicate that there might be differences between anorexia nervosa and patients with bulimia nervosa both in the sexual function measurements and in the psychopathology factors that were related to the sexual function measurements. This result can be placed in between a recent study by Castellini and colleagues (2012), which reported significantly lower FSFI scores in anorexia nervosa restrictive type as compared with bulimia nervosa and anorexia nervosa binge/purge type patients. Also, a similar recent study from Mazzei and colleagues (2011) did not observe any significant statistical differences among anorexia nervosa, bulimia nervosa, and Binge Eating Disorder (BED) in terms of FSFI scores, and thus, this topic of inquiry needs further investigation. The main limitation of the study was its small sample. Although the group of patients was small, the intergroup differences considering sexual function were so distinct that parametric tests showed significant statistical results. The second limitation was that the whole group of patients was recruited from the same eating disorder unit. It has been noted over the years of clinical practice that more severe and chronic cases of eating disorder are referred to this particular unit as a last resort of treatment. This has led to a clinical population of patients in treatment that presents more severe eating disorder symptoms than the clientele of other eating disorder units in the same city. The third limitation is the cultural differences between different nations and ethnic groups considering their sexual behavior. The study was conducted in a very specific cultural context of native Greek Christian orthodox young adult women living and studying in Athens, the capital of Greece. Various studies have indicated that factors such as social prejudice, common belief, and religion have a significant effect on human sexual behavior (Auslander, Rosenthal, & Blythe, 2007; Hunt & Jung, 2009; Wood, 2012). The conclusions drawn from the study should be viewed under the scope of participants’ cultural context. The fourth limitation of the study was that although the lack of sexual contact was recorded, there was no distinction among the reasons that lead to this absence of sexual activity the last month before the investigation. For some patients, it might be the result of separation from their previous relationship, whereas for other it might be the result of lack of sexual interest.
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It is evident that further research is needed on the issue of eating disorders and sexual function. The results of the study raise two major areas of interest. The first is the investigation of sexual function in recovered patients with anorexia nervosa. It would be interesting to find whether sexual function is restored and in what extent when starvation effects subside (Morgan, Wederman, & Pryor, 1995). The second area is the investigation of the biological and psychological factors, beyond symptoms of depression, that influence sexual function in patients suffering from bulimia nervosa.
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