There is increasing recognition of sexual dysfunction in eating disordered patients. It is theorized that such dysfunction is a consequence of poor object relations, blurred boundaries, and distorted body image. Many patients are so symptomatic that their sexual relationships are nonexistent. For the patient with AN, sex is experienced as a violation of boundary and space. Individuals with BN report more sexual experiences than do anorexics, but such experiences are described as superficial, and impulsive.

With the ED patient, timing is critical in approaching sexual dysfunction. Resistance to addressing sex in therapy must be understood as resistance to an overwhelming threat for the patient struggling with issues of survival and personal identity. Only after completing a course of treatment (nutritional rehabilitation, symptom interruption, etc.), do patients seek to begin or resume intimate relationships. Resolution of the sexual dysfunction is best achieved by a structured course of therapy that addresses problems unique to the eating disordered patient and their partner.

In couples sex therapy the work requires a very slow pace. Extreme body hatred and shame is common among patients. They do not want to be seen nude by their partner and often cannot pleasure themselves. It is not uncommon for patients to avoid looking in a mirror, let alone be looked at, or touched, by a loving partner. They are often critical of their sexual desires and bodily sensations. Struggles with feeling unclean and unworthy add to their tendency to avoid sexuality. Patients also describe how avoiding sex enables them to express a degree of control over their partners. Patients may also struggle with sexuality because of a lack of meaningful and authentic non-sexual connections in their lives.

Couples sex therapy is a natural extension of the empowerment model used in our individual and group work with the ED patient. This therapy offers a systemic perspective with a strong focus on self-soothing, self-differentiation, and enhancing selfdirection to improve relationships.

Sex therapy with couples is educational and relational. Questions are answered regarding the effects of eating disorders upon sex drive, the sexual side effects of medications, and how hormonal imbalances change the way a person even thinks about
sex. Time is spent discussing how clinical symptoms may be understood within the domain of the identified patient’s eating disorder, as well as within other contributing domains, including familial rules about sex, the couple’s past history, gender-based beliefs, popular sexual myths, or deeply ingrained cultural myths. When a more connected understanding of the symptoms is identified, the couple can establish an interpersonal view of the discrepancy in sexual desire rather than a linear view of something being “broken” within an individual. In traditional sex therapy, assignments are made with the intent that “practice makes perfect.” In the systemic approach, rituals are prescribed with the intent of providing information that will make a difference in the couple’s problem-solving abilities. This method enables the couple to avoid a blameful stance while also increasing a deeper connection with one’s self and partner. It is important that the therapist does not assume greater knowledge than the couple about their experiences, or how they should feel and act in the future. This approach characterizes the empowerment model and conveys respect for the autonomy of the couple.

The road to healthy sex may have very little to do with sex. In early stages of couples work, establishing safe boundaries, enhancing direct communication, exploring fears of intimacy, and sharing secrets that maintain shame and self-loathing, are themes that help to create the trust needed for intimacy in a healthy sexual relationship. We have witnessed each individual develop the ability to explore sex as an expression of selfcaring and intimate sharing.

One might never suspect the range of sexual concerns that trouble our patients. ED patients are often intensely isolated and focus their attention on their bodies instead of relationships. Clinical experience reveals that ED patients have a range of sexual problems that can easily be denied and avoided by both the patient and the therapist. It is critical that the therapist feel comfortable examining issues with respect to sexuality that affect ED patients. Not all patients want to make sexuality a major part of their lives. For those that do, couples sex therapy provides the venue to explore what impedes sexual expression, ultimately making sex fulfilling for the patient and their partner.

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