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Anorexia Nervosa: Changes in Sexuality During Weight Restoration

From the Eating Disorder Unit, St. George’s Hospital Medical School, London, United Kingdom.

Address reprint requests to: Dr. John Farnill Morgan, Department of General Psychiatry, St. George’s Hospital Medical School, Cranmer Terrace, London SW17 0RE, United Kingdom. Email: jmorgan{at}sghms.ac.uk

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
OBJECTIVE: We examined changes in sexual drive during weight restoration in patients with anorexia nervosa.

METHODS: Eleven women with anorexia nervosa prospectively completed the Sexual Daydreaming Questionnaire (SDQ) and the Hospital Anxiety and Depression Scale (HADS) at five time points during inpatient treatment involving weight restoration. SDQ and HADS scores were recorded every 4 weeks until 8 weeks after subjects had reached the mean matched population weight (MMPW), which was monitored against body mass index (BMI). Histories were taken for purging, self-cutting, childhood sexual abuse, and number of sexual partners. Repeated-measures analysis of variance, regression analyses, and t tests were performed.

RESULTS: BMI and sexual daydreaming were closely associated (p < .001). BMI and depression also achieved a statistically significant association (p = .046), with "caseness" for anxiety disorder throughout. Higher levels of sexual drive at MMPW seemed to be associated with purging, self-cutting, and childhood sexual abuse but not at low weight. Levels of sexual drive did not reflect previous sexual behavior.

CONCLUSIONS: An increase in sexual drive accompanies weight restoration in patients with anorexia nervosa, which is consistent with psychological and physiological explanations of altered sexuality. Transient depression is also associated with weight gain. Changes in sexuality should be considered in both recovery and treatment failure.

Key Words: anorexia nervosa • eating disorders • sexuality • affect

Abbreviations: BMI = body mass index; MMPW = mean matched populationweight; SDQ = Sexual Daydreaming Questionnaire; HADS =Hospital Anxiety and Depression Scale; ANOVA = analysis ofvariance; CI = confidence interval.

	INTRODUCTION

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Speculative theories of anorexia nervosa have linked it to sexual drive since the seminal descriptions of Lasègue in 1873 (1), but there have been few systematic studies of weight and sexuality. Most have been cross-sectional (2–4) or confined to weights below the peripubertal threshold (5). Beumont et al. (6) and Hsu et al. (7) have attempted to address the relationship between sexuality and BMI. Both studies suggested an association but were limited by their retrospective and cross-sectional designs, respectively. Beumont et al. found that the majority of patients reported a loss of sexual interest and enjoyment after weight loss, which was not reflected in changes in sexual activity. Thus, some increased and others decreased their sexual activity against a constant background of lowered libido. Hsu et al. applied a compound scale based on attitudes to sexuality, aim in sexual relationships, levels of sexual activity, and attitude to menstruation. Of patients with a "clearly abnormal psychosexual outcome (eg, aversion to sexual contact)," the majority had maintained a low body weight, suggesting that body mass correlated with sexual "health."

Validated rating scales of sexuality have rarely been applied to patients with anorexia nervosa. Rothschild et al. (8) reported use of the Derogatis Sexual Functioning Inventory on a heterogeneous group of patients with anorexia nervosa and bulimia nervosa. Surprisingly, restrictive anorectics were examined only after they had reached target weight. The eating disorder sample as a whole showed poor sexual functioning and satisfaction compared with normative data. Only sexual fantasy distinguished eating disorder subgroups, with a paucity of fantasy among restrictive anorectics at target weight, an intermediate state for bulimic (purging) anorectics, and normal levels of sexual fantasy among normal-weight bulimics. This cross-sectional study did not examine sexual functioning at low weight.

The present study aimed to examine prospectively changes in sexual drive in a small homogeneous group of women with anorexia nervosa during the process of weight restoration from low weight to a MMPW. Considering that anorexia nervosa is often accompanied by broader psychological disturbance affecting a variety of biological drives, including sexual desire, we also sought to observe changes in anxiety and depression during the weight restoration process. To our knowledge, this is the first published prospective study of its kind.

	METHOD

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Subjects
Adult female patients admitted to the St. George’s Hospital Eating Disorder Unit for inpatient treatment of anorexia nervosa involving weight restoration were recruited sequentially by the female ward physician. Confidentiality was guaranteed, and ethical approval was obtained from the local ethical committee. An age restriction of 18 to 34 years was applied because of age-cohort differences in sexual drive (9). DSM-IV (10) diagnostic criteria were used to define anorexia nervosa. At entry, a structured history was taken for demographic information, length of illness, medication (including exogenous steroids), menstrual history, psychosexual history (including history of unwanted sexual experiences), childhood sexual abuse, number of sexual partners, and presence of purging or self-cutting behavior.

Questionnaires
Questionnaires were completed confidentially, with subjects identified by number. Sexual drive was estimated from sexual daydreaming rather than behavior, because the scientific literature indicates both the paucity of sexual behavior and the lack of an association between sexual behavior and sexual drive in patients with anorexia nervosa (6). Sexual daydreaming was measured by the SDQ, which correlates highly with sexual drive and sexual behavior in a normal population across a wide age range within given age cohorts. It explores frequency of self-reported sexually oriented daydreams by showing responses to 12 items on a five-point Likert scale, scored 0 to 4, giving a range of scores from 0 to 48. Higher scores indicate a greater likelihood of sexual daydreaming. For example, items include "My sexual daydreams are very vivid and clear in my mind" and "My daydreams tend to arouse me physically," with five response options from "definitely not true for me" to "Very true for me." The SDQ has been extensively validated, with good internal consistency and test-retest reliability (11, 12). Typical age cohort scores are exemplified by the following means: age 17–23, mean = 22.3; age 24–29, mean = 20.9; age 30–34, mean = 21.2; and age 40–44, mean = 17.0 (9, 13, 14).

We also sought to observe changes in anxiety and depression during the weight restoration process, because these might affect a variety of biological drives, including sexual desire. The HADS was used as a measure of mood, with established validity and reliability (15, 16), generating subscales of probable "caseness" for anxiety and depression and avoiding somatic confounders, such as fatigue and palpitations, which have rendered other screening instruments unreliable for physically ill subjects.

Procedure
As part of their treatment, all subjects received a prescribed diet designed to increase their weight at a rate of 1 to 1.5 kg/week until their MMPW was reached. Subjects were entered into the study at a time point estimated at approximately 8 weeks before reaching MMPW. Subjects were not entered into the study immediately on admission to hospital, because the standard treatment program involves an initial period of assessment during which it is policy not to conduct research that may impede the assessment process. Consequently, there was variation in time between admission to hospital and entry into the study, with a mean time lag of 18.5 days (SD = 3.89; range = 13–25). The SDQ and HADS were administered on entry to the study and at intervals of 4 weeks, continuing for 8 weeks after MMPW was reached and resulting in five study time points, which were recorded simultaneously with Quetelet’s BMI (kg/m2).

Statistical Analysis
Data were analyzed using SPSS for Windows. Repeated-measures ANOVA was used to compare the same variables at different time points. Student’s paired sample t test was also used to specifically compare variables at entry to the study and on reaching MMPW. Regression analyses were performed for individual patients, after data had been plotted to confirm linearity of the relationships. Student’s one-sample t test was then used to compare the mean of the regression line slopes against zero.

	RESULTS

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Sample Characteristics
Eleven patients agreed to participate in the study, representing all subjects approached over a 6-month period, of whom six fulfilled DSM-IV criteria for anorexia nervosa of the restrictive subtype and five of the purging subtype. Four subjects had regularly engaged in self-cutting before admission and entry into the study. Mean age was 26.1 years (SD = 3.52; range = 21–31), and mean length of illness was 8.9 years (SD = 3.11; range = 5–13). None of the patients were taking any form of exogenous steroids during the study.

All subjects had an unambivalent heterosexual orientation and two (both of the purging subtype) had a history of serious childhood sexual abuse involving coitus. The median number of sexual partners per subject was two (zero for the restrictive subtype and three for the purging subtype) with a range zero to nine, and two subjects were in a relationship, although neither engaged in sexual activity with their partner during the study. One subject (restrictive) had never had sexual intercourse, and three subjects (one restrictive and two purging) had had five or more sexual partners.

Changes in Weight, Mood, and Sexual Daydreaming
Mean BMI on entry to the study was 16.1 kg/m2 (SD = 0.43; range = 15.5–16.7) and at MMPW was 20.4 kg/m2 (SD = 0.48; range = 19.6–21.0), which was a significant difference (p < .001, t = -21.80, Student’s paired t test). Means of BMI at all five time points were compared using repeated-measures ANOVA (-corrected), with significance set at p < .001 (F = 273, df = 2.00). Mean score on the HADS anxiety scale on entry to the study was 10.4 (SD = 3.32; range = 5–17) and at MMPW was 13.5 (SD = 3.30; range = 8–18), with significance set at p = .004 and t = -3.69. Again using repeated-measures ANOVA (-corrected) to compare means at all time points, the difference was significant at p = .003 (F = 9.94, df = 1.54). Mean score on the HADS depression scale on entry to the study was 6.3 (SD = 2.05; range = 4–10) and at MMPW was 8.7 (SD = 2.76; range = 5–13), with significance set at p = .002 and t = -4.25. Comparison of mean HADS depression scores at all time points was performed by repeated-measures ANOVA (Mauchly sphericity test, p > .05), and the difference was significant at p = .01 (F = 3.81, df = 4.00). Likely caseness on the depression and anxiety scales is indicated by a score of 8 or more. Ten subjects had scores indicating caseness on the anxiety scale at low weight, and 11 had sufficient scores at MMPW. Four subjects had scores indicating caseness on the depression scale at low weight, and seven had such scores at MMPW. SDQ scores at each time point are shown in Table 1.

View larger version (23K): [in this window] [in a new window]   Fig. 1. Means of BMI, SDQ score, and HADS anxiety and depression ratings at each time point (error bars represent 95% CIs for the means).

Descriptive Comparison of Sexual Daydreaming Between Subgroups
Given the small sample size, meaningful statistical comparison between subgroups was not possible. Certain trends were apparent at a descriptive level but should not be regarded as robust. At 8 weeks after reaching MMPW, purging anorectics and subjects with histories of sexual abuse or self-cutting seemed to have a higher SDQ score than their counterparts without these features (mean SDQ score = 17.4 vs. 13; 20 vs. 13.9; and 17.2 vs. 13.7, respectively), but this was not so for subjects with five or more lifetime sexual partners vs. those with fewer than five (mean SDQ score = 15.4 vs. 14.8). At low weight (8 weeks before MMPW), there did not seem to be any differences between restrictive and purging anorectics (mean SDQ score = 4.7 vs. 5.2), presence or absence of a history of sexual abuse (mean SDQ score = 4.5 vs. 5.0), presence or absence of a history of self-cutting (mean SDQ score = 4.8 vs. 5.0), or subjects with five or more or fewer than five lifetime sexual partners (mean SDQ score = 5.5 vs. 4.6).

	DISCUSSION

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Association Between Weight, Sexual Drive, and Mood
This study provides empirical evidence of a change in sexual drive during weight restoration in patients with anorexia nervosa. There is a highly significant positive association between those changes and the degree of weight gain. To our knowledge, this is the first empirical evidence of such an association despite the assumptions of the existing literature. Furthermore, there is a significant positive association between levels of depression and degree of weight gain, and the study sample demonstrated caseness for anxiety disorder throughout the study. The observation of high levels of anxiety in this study complements the observation of persistent phobic anxiety in long-term follow-up studies (17).

Causal Relations Between Weight, Sexuality, and Anorexia Nervosa
Association does not imply causation. The central mechanism of anorexia nervosa has been construed as an avoidance response to the "underlying sexual thrust and panic-inducing ramifications" of puberty (18). Our findings are consistent with such notions but are equally consistent with Tuiten et al.’s (19) antithetic hypothesis that changes in sexuality in patients with anorexia nervosa are solely due to the hypogonadism of emaciation. In our opinion, avoidance of sexual conflict by means of weight loss is relevant in some cases of anorexia nervosa but is neither necessary nor sufficient. Psychomaturational issues are more generally pertinent, but sexual drive forms only one component of the pubertal processes from which the anorectic seeks relief.

Differences Between Subgroups
The sample size is too small to permit reliable inferences, and we have been cautious in wringing meaning from between-group comparisons. Nonetheless, although speculative, the trends are worthy of further investigation. There seems to be greater sexual drive in purging than nonpurging anorectics at MMPW; this drive is obliterated at low weight, which can be explained in terms of the effects of hypogonadism. This is consistent with the findings of cross-sectional studies (8). Likewise, it seems that self-cutting is clustered with greater sexual drive. This may reflect an expression of self-disgust in the group with a naturally raised sexual drive or a cluster of subjects with impulsive personality traits (20), in which sexual impulsivity and self-damaging behavior are core behavioral components. Alternatively, Giambra (14) has shown that women who regularly felt "tense," "wound up," or "irritable" exhibit higher levels of sexual daydreaming than women who do not, suggesting the hypothesis that self-cutting in this study may represent a maladaptive means of discharging irritability and dysphoria in a vulnerable population.

There does not seem to be a link between sexual drive and sexual behavior, as indicated by number of sexual partners. This endorses Beumont’s (6) findings that sexual activity in patients with anorexia nervosa does not necessarily reflect levels of sexual interest or enjoyment. The disparity between the basic biological drive of sexual desire and its behavioral expression resonates with the equal disparity between hunger and feeding behavior in those with anorexia nervosa, the subversion of appetitive behavior being fundamental to anorexia nervosa.

The two subjects who experienced childhood sexual abuse seemed to have higher levels of sexual drive at MMPW than the others, consistent with the effects of premature sexualization. This raises the possibility that, for a minority of patients at least, anorexia nervosa may indeed represent an effective defense against issues of sexual conflict and confusion.

Clinical Relevance
Regardless of causal relations, it is clear that changes in sexuality are pertinent to intrapsychic processes during early treatment of anorexia nervosa and may therefore be of particular relevance when that treatment fails. The association between BMI and depression only just reaches statistical significance and may lack clinical significance. However, awareness of the possible relevance of sexuality and mood may allow patients’ motivational problems to be anticipated and addressed.

Confounding Effects
We did not compare subjects’ SDQ scores against normative data because the inpatient hospital conditions of the study were not comparable to those of the general population; instead, we chose to examine within-subject changes. However, we note that both mean and maximum daydreaming scores remained lower than means for similar age cohorts in the general population at all stages. Although this may indicate a paucity of sexual drive in the anorectic subjects in particular, it may also indicate the effects of hospital admission and communal living on sexual drive in general. The latter is consistent with the high levels of anxiety for all subjects at every stage of this study. We believe that some previous studies may have been too eager to attribute pathology to the illness that actually may represent a normal response to an unusual situation.

Conclusions
Sexual drive is closely associated with weight restoration in the treatment of anorexia nervosa, which is also associated with depression. Change in sexual drive may represent physiological or psychological maturation and, in our opinion, is likely to be multifactorial. Whether cause or effect, changes in sexuality during the treatment of anorexia nervosa should be considered both in the process of recovery and in cases of treatment failure, although the received wisdom that sexual conflict is at the core of anorexia nervosa requires more detailed empirical study before it is finally accepted.

	ACKNOWLEDGMENTS

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We gratefully acknowledge the contribution of Mrs. Sarah Reed, research secretary, in the preparation of this manuscript. We are indebted to the patients who participated in this study, from whom we continue to learn.

Received for publication November 3, 1998.

Revision received January 27, 1999.

	REFERENCES

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 

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