The medical conditions associated with obesity (e.g. hypertension, type 2 diabetes, dyslipidemia, coronary artery disease, osteoarthritis, ischemic stroke and certain types of cancer) are well documented (1).Despite increasing awareness among practicing physicians of the increased morbidity and mortality associated with obesity, the psychosocial consequences of increased body mass (e.g. depressed mood, low self-esteem, body image impairment and lowered overall quality of life) receive less attention. In the present article we focus on one particular aspect of psychosocial functioning that receives little or no attention in either clinical or research settings–sexual quality of life.
Quality of life (QOL) refers to the patient’s report of the overall impact of medical conditions on physical, mental, and social wellbeing (2). Quality of life research as it specifically relates to obesity (3) has increased in recent years. The development and refinement of well-validated measures that are specific to the assessment of weight-related quality of life have allowed for quantification of patients’ perceptions with respect to these issues.One such measure is the Impact of Weight on Quality of Life-Lite (IWQOL-Lite) (4). Obese patients presenting for treatment have reported that weight has negatively impacted quality of life in the following areas: physical functioning, social interpersonal relations, energy level, work productivity, self-esteem, mobility and sexual life. These deficits appear to become more pronounced as the intensity of treatment sought increases, with patients seeking bariatric surgery showing the greatest level of distress (5).
Quality of life is an important focus of clinical attention in our work with overweight patients. By broadening their view from simply focusing on weight reduction and improvement of medical conditions, we facilitate a greater awareness of the additional benefits associated with healthier lifestyle. These benefits may include improvements in self-image, social functioning and quality of sexual life.
In a recent study presented in Las Vegas at the annual meeting of the North American Association for the Study of Obesity,we reported results from a study comparing items obtained from the IWQOL-Lite sexual functioning subscale in subjects categorized by weight and treatment-seeking status. We considered 506obese treatment-seekers (mean BMI = 41.3; mean age = 48.0;55.3 percent women), 422 obese non-treatment-seekers (mean BMI = 40.6; mean age = 45.0; 67.3 percent women) and 282normal weight non-treatment-seeking individuals (mean BMI= 22.1; mean age = 34.9; 71.6 percent women). Included were items pertaining to lack of enjoyment of sexual activity, lack of sexual desire, difficulty with sexual performance, and avoidance of sexual encounters. After controlling for age, both obese groups reported significantly greater impairments in sexual QOL than the normal weight group. Almost two-thirds (65.4 percent) of obese treatment seekers and 41.2 percent of obese non-treatment seek reported ers reported experiencing sexual impairments in at least one area “sometimes” or more frequently in the past week, compared to only 5 percent of normal weight individuals. Greater impairment was also seen among obese treatment seekers compared with obese non-treatment seekers on three of four sexual QOL items(sexual desire, difficulty with sexual performance, avoiding sexual encounters) and the Sexual Life scale score. Obese women in this study reported a greater degree of difficulty than did obese men;however, the gender differences were much less pronounced in the treatment-seeking group This study suggests that obesity is associated with impairments in sexual QOL and that obese individuals seeking treatment may experience reduced sexual QOL at higher rates than obese non-treatment seeking individuals.
It is important to note that this study represents a very preliminary look at an important issue in obesity and is presented in the context of a paucity of relevant literature. Therefore, the conclusions we can draw are somewhat limited. However, we will attempt to review some of the existing knowledge in this area,discuss possible contributors to impaired sexual quality of life, and provide guidance for your clinical work with patients.
In men, obesity has been associated with lower sexual satisfaction (7), increased erectile dysfunction (8,9) and penile vascular impairment (10). Less is known about the impact of obesity on sexual quality of life for women. Adolfson and colleagues found that when comparing obese and non-obese women, there were no differences reported in sexual satisfaction. They did, however,note that in their 18-49 year-old cohort, obese males and females seek reported a greater decrease in sexual desire over the preceding five years when compared with normal weight individuals from the same age group. A limited number of studies of varying levels of scientific rigor have considered the impact of weight loss on sexual quality of life, generally finding that weight loss results in improvement for both men and women (11,12). However, it is clear from the lack of well-controlled research in this area that further research is warranted in order to better understand this heterogeneous, multi-determined issue.
What directions should future research take? Where should we focus our work with patients on this issue? The answer to both of these questions is best informed by both the existing literature and our clinical experience in working with obese patients. Clearly,not all of our patients, even those with severe obesity, suffer from impaired sexual quality of life. However for those who do, it is important that their healthcare providers, regardless of specialty,recognize that a problem may exist and provide appropriate direction. Patients undergoing multidisciplinary behavioral weight loss treatment frequently describe substantial improvements in self-image and sexual quality of life. While limited in scope, existing research appears to support lifestyle change as contributory to improvements in sexual quality of life (11,12). This may be due in part to weight loss, improvements in nutrition and increased exercise. However, if we are to fully understand the needs of our patients in this regard, more comprehensive psychosocial assessment/intervention to address issues such as self-esteem, body image and sexual quality of life may be indicated.
Bariatric surgeons are becoming increasingly aware of the importance of psychological evaluation prior to surgery. The primary goal of preoperative evaluation is often to assess competency, the presence of significant psychopathology, and the patient’s ability to self-care post-operatively. However, it may also be valuable to evaluate psychosocial contributors to the patient’s overall quality of life. We make this assertion because behavioral learning principals suggest that the level of reinforcement or reward associated with certain behaviors influences the likelihood of that set of behaviors re-occurring. Improved quality of life may be seen as one such reinforcer that may influence patients to persist in self-care in the long term.
The need for sexual intimacy and sexual quality of life is among our most basic needs. Obese persons often face sociocultural, psychological and physical barriers to having these needs met. Despite stigmatization, discrimination and prejudice directed toward obese persons as well as societal pressures to be thin,many obese individuals are able to experience rewarding intimate relationships. Others, however, especially those for whom weight has been a long-standing issue, may have experienced a lifetime of negative feedback from both society and the individuals close to them (family, teachers, peers, coworkers, employers). Patients may have internalized weight and negative body image as defining characteristics of who they are and how they view themselves asa person. In addition, personal histories that include physical or sexual abuse may negatively impact sexual quality of life. Such is issues need to be a focus of clinical attention in the treatment of the obese individual.
Human sexuality is an essential element of overall quality of life; however, societal mores around sexuality coupled with the stigmatization faced by obese persons may lead obese individuals to avoid seeking help with this important issue. It is up to clinicians to create an environment in which issues such as these can be discussed without shame or embarrassment and to provide referrals for interventions as needed.
Information courtesy of Martin Binks, PhD & Ronette Kolotikin, PhD.
 Martin Binks, PhDDuke Diet & Fitness Center Durham, North Carolina |
 Ronette L. Kolotkin, PhDObesity & Quality of Life Consulting Durham, North Carolina |
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