Obesity and poor sexual health outcomesBMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c2826 (Published 15 June 2010) Cite this as: BMJ 2010;340:c2826
- Sandy Goldbeck-Wood, associate specialist in psychosexual medicine1, specialty doctor in obstetrics and gynaecology2
- 1Sexual Problems Clinic, Camden and Islington Mental Health Trust, London WC1X 9DN
- 2Department of Obstetrics and Gynaecology, Ipswich Hospital, Ipswich IP4 5PD
Obesity and sex are subjects that doctors find especially difficult to discuss with patients, despite evidence that such discussions help. Although short conversations (three to five minutes) during routine visits can contribute to changes in behaviour, such as increasing physical activity, eating less fat, and losing weight, most primary care professionals do not talk to their patients about weight.1
Sex is an even greater taboo—even clinicians who are comfortable with discussing periods or bowel motions and treating conditions where sex is known to be affected routinely fail to ask about sexual function, with lack of skill and time and discomfort cited as reasons.2 3 Around 68% of respondents in a population based telephone survey from Washington said they would be reluctant to discuss a sexual problem for fear of embarrassing their doctor.4 The linked population based survey by Bajos and colleagues (doi:10.1136/bmj.c2573) relates to both of these taboo areas.5
Bajos and colleagues report the largest survey of obesity and sexuality to look at both men and women in a manner representative of the wider population. Previous studies of obesity and sexuality have tended to focus on small samples in particular subgroups, such as erectile dysfunction in morbidly obese men or sexual function in women awaiting bariatric surgery. Meanwhile, wider studies of sexual function often focus purely on biological aspects of sexual dysfunction in men, with few looking at wider indices of sexual experience or looking at women.
Bajos and colleagues’ study of 12 364 French men and women aged 18-69 found that obese men and women are at greater risk of negative sexual outcomes than their non-obese counterparts. This was particularly true for obese women, who were 30% less likely to report a sexual partner in the past 12 months, whereas obese men were 70% less likely to report more than one partner in the same period and 2.6 times as likely to report erectile dysfunction. Although no other differences were found in indices of sexual function in existing relationships, obese women were five times as likely to have met their partner on the internet, more likely to have an obese partner, and less likely to view sex as important for personal life balance.
The factors that underlie these observations of self reported sexual experience and the directions of causality cannot be determined from a cross sectional study, although we can expect that social issues such as perceived attractiveness; psychological factors such as self esteem; and confounding by comorbidity such as diabetes, genital prolapse, and musculoskeletal disease will all be relevant.
Most striking though are the findings that obese women in the 18-29 year old age group were less likely to report that they used oral contraception or sought contraceptive advice in the past year, and, most startling of all, they were 4.3 times more likely to report unintended pregnancy. Obesity in pregnancy is a major public health concern, as highlighted by the Confidential Enquiry into Maternal And Child Health (CEMACH) report.6 Obesity in pregnancy is associated with markedly increased maternal and neonatal morbidity and mortality, and increased healthcare costs. It is the principal maternal health project of the Centre for Maternal and Child Enquiries (CMACE) for 2008-2011, and it is the subject of a new joint guideline from CMACE and the Royal College of Obstetricians and Gynaecologists.7 So if the message of this paper—that obese women have nearly five times the risk of unwanted pregnancy—is reproducible in other populations, this should be a matter of concern for public health and practitioners in reproductive health.
The data on contraception need cautious interpretation, however, because they focus purely on oral contraception and condoms, ignoring long acting reversible contraceptives, which the UK’s National Institute for Health and Clinical Excellence (NICE) recommends as particularly suitable for obese women. This form of contraception carries lower risk of oestrogen related venous thromboembolism (compared with the combined pill) and of weight related dosage difficulties (compared with the progestagen only pill), and it requires fewer visits to the doctor. Although the authors argue that an overwhelming preponderance of oral contraceptive and condom use in French practice protects the study’s internal validity, its generalisability to settings where long acting reversible contraceptives are more widely used is necessarily limited. Another study of 5955 people aged 20-44 found that an initial association between poorer contraceptive use and body mass index greater than 35 disappeared after adjustment for confounders.8
So Bajos and colleagues leave us with several new questions, the most pressing of which is whether these findings on contraceptive use and unplanned pregnancy are reproducible in other populations. If so, we need to understand more about how obese people feel about their sex lives, and what drives the observed behaviours and attitudes. In particular, we need to know why obese women use less contraception and have more unwanted pregnancies despite having fewer sexual partners. The answers are likely to be complex, with biological, psychological, and social aspects that will require a qualitative research approach.
Why does this study, with its somewhat mixed messages about the association between obesity, sex, contraception, and pregnancy, matter? Clinically, it indicates that closer attention should be paid to the complex contraceptive needs of obese women. Epidemiologically, it sharpens an emerging picture of the multiple adverse effects on sexual function (and vice versa) of a wide variety of physical and mental illnesses, from obvious ones like depression, diabetes, urinary incontinence, and genital cancers to less obvious ones such as epilepsy, musculoskeletal disease, and psychosis. In doing so it reminds us of sexual dysfunction as a potential, hidden outcome or determinant of wider ill health and therefore potential confounder of a wide range of other associations. In public health terms, the study lends a new slant to a familiar message: that obesity can harm not only health and longevity, but your sex life. And culturally, it reminds us as clinicians and researchers to look at the subjects we find difficult.
.Cite this as: BMJ 2010;340:c2826
Competing interests: The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: (1) No financial support for the submitted work from anyone other than her employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouse, partner, or children with relationships with commercial entities that might have an interest in the submitted work; (4) She works as a specialist doctor in psychosexual medicine, within the NHS and with a small private practice, and as an NHS obstetrician/gynaecologist, dealing among other things with contraception, termination of pregnancy, and obstetrics. She is a member of the Institute of Psychosexual Medicine (IPM), a trainer for the IPM, and edits the IPM’s journal, IPMJ. She also has training in psychotherapy, and a longstanding interest in psychosomatic aspects of sexual and reproductive health.
Provenance and peer review: Commissioned; not externally peer reviewed.