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Sexuality Matters
Obesity and Sexuality: Is There a Connection?
Bliss Kaneshiro, MD, MPH; Bruce Kessel, MD
The increasing weight demographic in
the United States has a direct impact on health care. Understanding
the effects of body weight on sexuality will help the clinician
promote physical and psychosocial well-being in the female patient.
Over the past century, popular culture’s portrayal of the physically
attractive woman has changed. The voluptuous figures of the 1920s gave
way to curvy pinups in the 1940s, then “twiggy” women of
the 1960s to the ultrathin “heroine sheik” look of the 1990s
and the fit and strong images of this decade. Within this context of
body size and beauty, the weight demographic in the United States has
steadily and markedly increased. Recent studies estimate that two-thirds
of all Americans are overweight or obese.1 While Hollywood’s image
of attractiveness continues to evolve, the widespread perception that
physical beauty is correlated with a slender figure has resulted in a
billion dollar weight-loss industry.
The etiology of obesity remains unclear and may be linked to an
interplay of social, behavioral, cultural, physiologic, and genetic
factors. It has also been hypothesized that increasing rates
of obesity are being compounded by the phenomenon of assortative
mating in which partnering is a nonrandom event spurred on by similarities
in phenotype.2 Regardless
of its cause, America’s weight problem has affected all aspects
of medical care in this country. Women’s health care providers
treat weight-related conditions like polycystic ovary syndrome
on a daily basis and diagnose obesity-related cancers like endometrial
cancer in younger and younger women. In addition to an increasing
prevalence of conditions such as hypertension, diabetes, and osteoarthritis,
clinicians must also consider the effect of weight on psychosocial
and emotional functioning.3
Sexual satisfaction and intimacy are integral components of psychosocial
functioning that contribute to an individual’s sense of well-being.
It is notable that oxytocin, a hormone that induces a feeling of
physical satisfaction and calmness, is released by orgasm and sexual
arousal, as well as the consumption of fat.4 A
handful of studies have examined the relationship between weight and
sexual behavior, and these hold interesting findings.
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Weight Loss and Antidepressants
As might be expected, an improvement in sexual functioning is
noted in formerly overweight and obese patients who undergo weight
loss.5 In addition
to promoting an improvement in personal body image and self-confidence,
it has been hypothesized that decreased weight results in alterations
in sex hormone–binding globulin,
which in turn changes estrogen and androgen activity.6 In
studies of women undergoing gastric bypass surgery, in which weight
loss is often dramatic, the women noted a significant increase
in sexual interest, enjoyment, and frequency; conversely, an increase
in these factors strongly correlates with overall satisfaction
with the surgery.7 Women
who use nonsurgical weight-loss methods also report improvements
in body image and an increase in sexual activity as weight decreases.5
In a study of the antidepressant sibutramine, a serotonin and norepinephrine
reuptake inhibitor that can result in weight loss, women experienced
a 6.03% decrease in weight, as well as an improvement in sexual
functioning.6 Subjects who took the sibutramine reported statistically
significant improvements in arousal and orgasm, as well as overall
sexual satisfaction, compared with those who did not take the study
medication. However, because this study was not placebo controlled,
it is unclear whether the improvement was due to placebo effect,
weight loss, the antidepressant, or a combination of these factors.
Additional research is needed before sibutramine can be recommended
as a treatment for sexual dysfunction and obesity.
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Demographic Comparisons
Because studies of sexual behavior in women undergoing weight
loss note positive findings, convention would suggest that at baseline,
obese women would be less sexually active than normal-weight women.
However, data on sexual behavior outcomes in women of different
body weights indicate the opposite. In the largest study to examine
this question, overweight and obese women were more likely to report
ever having sexual intercourse with a male (P<.001),
and this difference persisted when other demographic factors were
controlled for.8 However,
body mass index (BMI) was not significantly associated with sexual
orientation, age at first intercourse, or frequency of heterosexual
intercourse. It also did not result in differences in the number
of lifetime or current male partners.
Another large study also noted no significant differences in the
number of lifetime male partners of obese and normal-weight women
(7.96 vs 5.24, respectively), although obese and overweight women
had fewer male partners in the past year than did normal-weight
women.9 These results can be contrasted to studies in which normal-weight
men report significantly more lifetime partners than do obese men
(22.08 vs 11.94, respectively).9 It
is probable that weight has a differential effect on sexual activity
measures in males and females.
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Sexual Well-Being
More important than the frequency of intercourse or number of partners
is sexual satisfaction and sexual quality of life, and differences
in these measures have been noted in women of different BMIs.
In one study, women with sexual dysfunction were more likely to have higher
BMIs than women without this condition.10 The
sexual parameters that were most affected included arousal, lubrication,
orgasm, and overall sexual satisfaction, while sexual desire
and pain associated with intercourse did not differ between women
of different body weights. In this same study, BMI was more important
to sexual function than were fat distribution and proportion as measured
by waist-to-hip ratio. It is notable that other researchers, such as Adolfsson
et al, found no differences in sexual satisfaction among BMI
groups in either men or women.11
In certain populations, such as adolescents, dissatisfaction with
body image can have severe health consequences. In terms of sexual
attitudes and behavior, it can result in a greater fear of abandonment,
as a result of negotiating condom use, and a perception of limited
control in sexual relationships.12 Some
data show increased frequency of sexual intercourse in adolescent
girls with lower body fat indices.13 Since
adolescence can represent a vulnerable time, exploring how weight affects
sexual behavior in individual young patients is particularly important.
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Conclusion
As the weight demographic in this country continues to increase,
women’s health care providers must factor body weight into
the clinical decision-making process. While overweight and obese
women may be more at risk for certain medical conditions and
for sexual dysfunction, they form a heterogeneous group, and
it is important not to base health characteristics solely on
physical appearance.
Because sexuality is an integral part of
psychosocial functioning and a person’s sense of well-being,
addressing sexual quality of life and sexual dysfunction is essential,
even though questions about sexual satisfaction and behavior
may be difficult to ask. Importantly, all women should be counseled
about health outcomes related to sexual activity, such as sexually
transmitted infections and unintended pregnancy.
Dr Kaneshiro reports no actual or potential conflicts of interest
in relation to this article. Dr Kessel reports that he is a consultant
for Bayer HealthCare Pharmaceuticals, Boehringer Ingelheim, Eli
Lilly and Company, and Novartis and on the speakers bureau for Bayer HealthCare
Pharmaceuticals.
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Bliss Kaneshiro, MD, MPH, is Assistant Professor,
and Bruce Kessel, MD, is Associate Professor, both in the Department
of Obstetrics and Gynecology, University of Hawaii, Honolulu.
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