Sexuality in Eating Disorders Patients: Etiological Factors, Sexual Dysfunction and Identity Issues

Horm Mol Biol Clin Invest 2015; x(x): xxx–xxx Giovanni Castellini, Lorenzo Lelli, Valdo Ricca and Mario Maggi* Sexuality in eating disorders patients: etiological factors, sexual dysfunction and identity issues. A systematic review DOI 10.1515/hmbci-2015-0055 an association between sexual orientation and gender dys- Received October 20, 2015; accepted November 24, 2015 phoria with EDs psychopathology and pathological eating behaviors, confirming the validity of research developing Q1: Abstract: The scientific community appears to be less new models of maintaining factors of EDs related to the Some edito- interested in sexuality of eating disorders (EDs) as com- rial assis- topic of self-identity. pared to other psychiatric or medical comorbidities. tance has been given However, a clear association between sexual problems Keywords: eating disorders; gender identity; puberty; to improve and ED psychopathology was reported from different per- sexuality; sexual abuse; sexual dysfunction; sexual the clarity of spectives. The overarching goal of this systematic review orientation. this article - was to evaluate the general approach of the scientific please check and confirm literature toward the topic of sexuality and EDs. In par- that none of ticular, four different categories of research have been your original individuated, encompassing the role of puberty, and Introduction meaning has sexual abuse in the pathogenesis of the disorders, sexual been lost or Eating disorders (EDs) are severe psychiatric syndromes dysfunctions, and the association between sexual orienta- misconstrued affecting especially young women. In most cases, EDs have tion and EDs psychopathology. Timing of puberty with its a long lasting duration (longer than 2 years) and a chronic hormonal consequences and the changes in the way per- course [1, 2]. The two well-known diagnoses of anorexia sons perceive their own body represent a crucial period nervosa (AN) and bulimia nervosa (BN) share a similar of life for the onset of the disorder. Sexual abuse, and psychopathological core of extreme concerns about shape especially childhood sexual abuse are well- recognized and weight that significantly impact the individual’s risk factors for the development of ED, determining a self-esteem, and they are essentially differentiated by the worse long-term outcome. Recent research overcome the condition of underweight (i.e. their weight must be > 85% approach that considers sexual activity of EDs patients, of ideal), associated with the diagnosis of AN [3]. Typical in terms of hypersexuality and dangerous sexual behav- psychopathological features of EDs are represented by an iors, considering the sexuality of EDs persons in terms of intense fear of becoming fat or of gaining weight, distor- sexual desire, satisfaction, orgasm and pain. Results from tion in the way in which body weight and shape are per- this line of research are promising, and describe a clear ceived, undue influence of body weight and/or shape on relationship between sexual dysfunction and the core self-esteem. Abnormal eating behaviors include binge psychopathological features of EDs, such as body image eating, use of inappropriate compensatory behaviors (i.e. disturbances. Finally, the analysis of the literature showed self-induced vomiting, or abuse of laxatives, diuretics, or enemas, excessive exercise, fasting), body checking, and body avoidant behaviors. Q2: *Corresponding author: Mario Maggi, MD, Sexual Medicine and From an epidemiological point of view, AN and BN full Please Andology Unit, Department of Experimental, Clinical and Biomedical syndromes represent only the tip of an iceberg, with AN confirm Sciences, Florence University School of Medicine, Viale Pieraccini 6 correspond- 50139, Florence, Italy, Phone: +39 55 4271415, Fax: +39 55 4271413, occurring in 0.4% of the population and BN in 1%–1.5% ing author E-mail: [email protected]; and Department of Neuroscience, [3]. Indeed, the last version of the Diagnostic and Statisti- address and Psychology, Drug Research and Child Health, University of Florence, cal Manual of Mental Disorders (DSM 5) [3] considers also co-authors Italy the so-called other specified FED or unspecified FED, and affiliation Giovanni Castellini, Lorenzo Lelli and Valdo Ricca: Sexual Medicine the binge eating disorder (BED), that showed a lifetime and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Italy; and Department prevalence of 0.8% and 1.6% in men and women, respec- of Neuroscience, Psychology, Drug Research and Child Health, tively [3]. BED is characterized by frequent and persistent University of Florence, Italy overeating episodes that are accompanied by feelings Q3: 2 Castellini et al.: Sexuality in eating disorders patients Please confirm short running title of loss of control and marked distress, in the absence of and qualitative aspects of EDs presentation, as well as on regular compensatory behaviors. the association between specific expressions of EDs psy- As far as the psychopathological assessment of these chopathology and sexual orientation, and gender identity syndromes, dimensional rather than categorical models variance. seem to be more appropriate [4, 5], as suggested by two Indeed, it is noteworthy that, despite the clear asso- main issues: 1) the higher prevalence of subthreshold ciation between sexuality and EDs from different per- conditions, which are the most frequently encountered spectives (sexual abuse, puberty as risk factors, sexual in clinical [6] and community [7, 8]; 2) the “instability” of orientation), few studies attempted to clarify the nature of the DSM diagnoses, with a substantial crossover between this relationship, and sexual dysfunction comorbidity is the different EDs categories [9, 10]. Indeed, EDs patients rarely considered a potential target of treatment or indica- often move in and out of illness states over time, display tor of long-term outcomes of the disorders. The scientific a high frequency of relapse [10], and the majority of them community appeared to be less interested in sexuality of migrate between different ED diagnoses, without a sub- EDs as compared to other psychiatric or medical comor- stantial psychopathological change [9–14]. bidities, and the DSM 5 Workgroup considered redundant The pathogenesis of EDs is multi-factorial, and it most the criteria for AN of primary amenorrhea or (in post- likely results from sociocultural, psychological and bio- menarche females) loss of menses for ≥ 3 consecutive logical factors [15, 16]. Considering environmental condi- months. tions, adverse early life events showed a relevant role as a According to this background, the overarching goal predisposing factor for EDs [16]. In particular, longitudi- of this systematic review was to evaluate the general nal and cross-sectional studies reported that sexual abuse approach of the scientific literature toward the topic of had a significant association with the disorder’s onset [16, “sexuality and eating disorders”, and synthesize the Q4: 17]. These conditions are supposed to affect child devel- available data from different points of view. Should this opment in behavioral, emotional, social, physical, and be “... are cognitive areas [18], increasing the risk for EDs adult psy- thought to affect”? chopathology. For example, they can be associated with low self-esteem and depression, severe body image distor- Methods tion [19], and deficit in emotion regulation [19]. Moreover, chronic stressful conditions occurring during childhood Time-frame may damage neurobiological and neuroendocrine aspects for long time [18], leading to greater vulnerability in the A systematic review of the literature was performed using development of general psychopathology and psychiatric PubMed (U.S. National Library of Medicine, 1995–October disorders throughout life [17]. 2015) electronic database. EDs patients show a high rate of comorbidity, especially with mood (including unipolar and bipolar disorder), and anxiety disorders [3]. A large number of studies has been published on this topic, suggesting a common Inclusion criteria psychopathological trait related to emotion dysregula- tion between these syndromes. However, considering the According to the DSM 5 categorization for EDs [3], we used psychiatric comorbidities of EDs, very few studies evalu- the key words “eating disorder” in combination with “sex- ated the co-occurring sexual dysfunction, and sexuality in uality”. Articles were selected according to the following terms of desire, sexual satisfaction, and relationship with inclusion criteria: original studies, articles in English, own body. human studies effectively related with the mentioned From a biological point of view, puberty has been one areas of interest. Subsequently, a further research was of the most frequently discussed risk periods for the devel- performed combining “eating disorder” with “puberty”, opment of EDs. Indeed, puberty is characterized by physi- “hormonal levels”, “sexual dysfunction”, “sexual abuse”, cal changes such as menarche and increased adiposity, and “sexual orientation”, “gender identity”. We focused which may lead to body dissatisfaction [20]. At the same on studies reported in the past 20 years but also included time, girls or boys perceive sexual drives for the first time, commonly referenced and highly regarded older pub- and their bodies become sexual targets for other persons. lications. Review articles and book chapters were

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