Keywords |
| Body Mass Index, Sexual life, Obesity |
Background |
| The relation between sexual fulfillment and
obesity, especially the morbid one, highlighted
a wide range of psychic effects like: low
energy, depression, diminished self esteem
and sexual problems. |
| A study of 40,086 African American and
White participants suggested an association
between BMI and major depression, suicide
ideation, and suicide attempts diagnosed
according to the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition. 1 |
| A study conducted on 82 female
patients preoperatively and at least 1 year postoperatively (gastric bypass surgery)
suggested that sexual problems of the obese
are related to lack of self-esteem,
unsatisfactory relationships, or collective
stigmatization of obese individuals. 2 |
| Diabetes, hypertension and elevated
cholesterol are clearly linked to erectile
dysfunction. The gastric bypass surgery
showed that the weight loss can help resolve
erectile dysfunction in some men with morbid
obesity. 3, 4 |
| The studies have found that the relation
between lower sperm count and infertility is
correlated with obesity and associated with an
unsatisfying sex life. The men who lost weight
through Roux-en-Y gastric bypass surgery
experienced a reduction in estradiol levels, an
increase in testosterone levels and an increase
in ratings of sexual quality of life. 5 |
| A Taiwanese study on 772 young men
subjects found a significant correlation
between waist circumference and the
International Index of Erectile Function–5. 6 |
| An American study, that investigated the
association between the quality of sexual life
and BMI class, sex, and obesity treatmentseeking
status, found that higher BMI was
associated with greater impairments in sexual
quality of life. Obesity was associated with
lack of enjoyment of sexual activity, lack of
sexual desire, difficulties with sexual
performance, and avoidance of sexual
encounters. Sexual quality of life is most
impaired for women, individuals with class III
obesity, and patients seeking gastric bypass
surgery. 7 |
| Another study in Sweden of 2,810 men and
women found no significant differences in
terms of satisfaction with sex life between the
overweight and obese people and normalweight
people. This is not a contradiction
with the other study, because the expectations
of what is that needed for satisfaction is lower
among overweight and obese persons
compared with subjects of normal weight.
Critical attitudes toward obese people are prevalent. Some obese people internalize the
negative social messages. This may be the
cause of self-imposed restrictions on
important aspects of life, such as enjoying a
sexual relationship. 8 |
| The limited number of studies on sexual
quality of life in obesity suggests that this is
an area in need of further study. We intend to
identify how the BMI (Body Mass Index) is
related and affects the subjects’ sexual
dynamics and sexual desire. |
Objectives |
| The gender, age and marital status are socio
demographic characteristics that may
influence BMI and sexual dynamic and
consequently we analyzed several interactions
and correlations, taking the variables two by
two. Further we investigated, using
correspondence analysis, latent class analysis
and logistic regression statistical models that
underlined the relation between BMI and
sexual life quality. 9, 10 |
Methods |
| The data have been collected using a
questionnaire in the period 2005-2007 from
1902 men and women, randomly selected,
aged between 18 and 90 years, 1493 of them
being sexually active. The studied sample of
sexually active subjects had a homogenous
structure by gender, age group, place of
residence (8 big cities zone covering the seven
representative geographical and historical
Romanian regions), instruction level and
socioeconomic status (low, medium, and
high). None of interviewed woman was
pregnant or in postpartum period. |
| The persons attended voluntarily to the study,
have been assured about confidentiality of
their answers and received from the interview assistances information regarding the research
objectives. During the process of research
arguments highlighted the accent targeted the
improvement of the relations within the
couple and between generations of the family
members, of the life quality, with the aim to
prevent prestige reaction or any potential
influence of the taboos related to sex. The
eight survey assistants, having expertise in the
field of sociology, psychology and medicine,
received training regarding the questionnaire
use and interview conducting in order to
obtain fair answers. The interview assistants
had the same gender as the respondents and
have been assigned in such manner to be
closer by age to the subjects to ensure the best
possibility that the respondents to feel
comfortable and safe to describe themselves
as much accurate. |
| The sexual life quality was measured based on
3 items regarding: sexual contacts frequency
in the last year, average duration of sexual
contact in the last year (not including sexual
prelude and postlude), and the pleasure to
receive sex when initiated by the partner. For
BMI determination the subjects were height
and weight measured. The diagnosed diseases
by doctor and other disordered in the last three
years that affected the sexual life were
identified based on respondents self response
and in cooperation with family doctor of the
subject. |
Results |
The sample characteristics regarding BMI
by gender, age group and marital status |
| The analyzed sample was characterized by an
average weight of 72.11 kilograms, an average
height of 1.71 m and a BMI average of 24.30.
The distributions of these three
anthropometrical characteristics were
relatively normal ones. |
| The distribution of the subjects by BMI class
11, 12 was as follows: 5.1%-Underweight, 53%-Normal, 34.6%, - Overweight and 7.3%-
Obese. |
| Most of them (70.3%) declared that they were
in perfect health. Still, 8.0% have been
diagnosed with coronary diseases, 4.2% with
endocrine problems, 3.4% with digestive
diseases and 3.3% with respiratory affections.
The structure of diagnosed diseases relatively
reflects the main mortality causes on national
level. In Romania, cardiovascular diseases
remaining for many years the main mortality
cause. |
| The incidence of cases diagnosed with arterial
hypertension is higher in overweight (51.3%)
or obese (19.7%) subjects. The χ2 Pearson test
χ2 (15, N = 1484) =148.54, p<0.001 indicated
that the correlation between the BMI and
some diseases’ incidence was significant.
There was also a significant relation between
age groups and the incidence of diagnosed
diseases χ2 (15, N = 1484) =384.976,
p<0.001). Thus, subjects in superior age
categories, aged over 50 years, reported more
frequently diagnosed diseases, especially
hypertension and diabetes. Respiratory and
digestive affections are less related to the
subject’s age. |
| Significant differences between BMI
classification were identified by sexes
(p<0.001). Normal weight and obese subjects
are relatively homogeneously distributed,
obvious differences by sex were noticed in the
underweight category – the women were 6
times more numerous than men in this
category. In the overweight category the
men’s proportion was twice higher (Table 1).
In each gender group significant differences
regarding BMI distributions by on age groups
(p<0.001) were founded. As the age increased
the proportion of the underweight and normal
persons decreased, while the proportion of the
overweight persons increased (Table 2). |
| According to the Kruskal-Wallis test H (3, N=
1484) = 421.646, p<0.001), BMI means
differences found in age groups were significant. The BMI mean was higher in the
higher age groups. |
| BMI class distributions by marital status were
also significant different (p<0.001). Within
married persons or living in consensual couple
the proportion of the overweight individuals
was by 1.59 greater and the proportion obese
ones was four times greater comparative with
the unmarried, divorced or widowers subjects
(Figure 1). |
Characteristics regarding the frequency,
duration and pleasure of sexual contacts in
the sample |
| In the entire sample the weekly sexual
contacts prevailed (49.1%), most of the
subjects reported an average duration of
sexual contacts in the last year (without
prelude and postlude) of 5-15 minutes (39.1%)
followed by those reporting a 15-30 minutes
duration. |
| A proportion of 79, 2% in the sample agreed
with pleasure, often or very often the sexual
contacts when they were initiated by the
partner. The Pearson χ2 test didn’t indicate a
direct statistically significant relationship
between subjects’ rating by BMI and the
frequency of sexual intercourse. However, as
shown in contingency Table 3, in the daily
sexual activity group the proportion of the
obese persons was lower (4.4%). |
| As the Pearson’s χ2 test didn’t indicate,
statistically speaking, a direct significant
correlation between subjects’ BMI
classification and the frequency of sexual
intercourses, we employed a qualitative
approach using the correspondence analysis
technique The correspondence analysis of
variables BMI Category and frequency of
sexual intercourse, allowed us to better
understand how the two variables were related
and interacted each other by exploring the data
in a bi dimensional space (Figure 2). |
| In the common space of sexual dynamics and
body weight rating related to normality we
could notice that obese individuals are situated in quadrant III, as opposed to normal rated
individuals situated in the first quadrant. Due
to the sharp angle created by the vectors
Normal and Daily and Weekly we concluded
that normoponderal persons usually have a
more intense sexual life. Likewise, reduced
sexual activity, that is Once in two months or
more rarely (2 Months +) and Monthly, was
related to subjects considered Obese.
Overweight subjects in quadrant IV were
characterized by monthly or weekly sexual
intercourses. From the sexual intercourse
point of view, Normal subjects were closer to
Overweigh. Obese were opposed to Normal
and Overweight were in contrast with
Underweight. |
Sexual life quality |
| The latent class model analysis was used to
classify cases into a set of latent classes,
representing the sexual life quality, based on
categorical indicator (or manifest) variables
such as survey items describing sexual life
activity: Frequency (frequency of sexual
contacts), Duration (average intercourse
duration) and Pleasure (frequency of sexual
attraction pleasure). Latent classes are the
dimensions which structure the cases in
respect with the observed (or manifest)
variables set. After cases were classified into
latent sexual life quality classes, then in
regression type manner, latent class analysis
with covariates was used with one additional
variable, Category (classification according
BMI), to predict or explain class membership.
All the models with up to 5 latent classes have
been analyzed with Latent Gold software and
in accordance with the minimum BIC
(BIC=9280.10) value criteria, the model with
two classes was selected “as the best fit”. Due
to the high bivariate residual values (values
grater than 2 indicated a local independence
assumption violation) the interaction effects of
the indicator variables have been added to the
model. In the final model all the parameters
are significant according to the Wald test. Using the software all the individuals (cases)
in the sample have been assigned to the latent
class with the highest latent classification
probability. This method of assignment is
sometimes referred to empirical Bayes modal
or modal a posteriori estimation. |
| The inspection of the resulted class profiles
indicated that the first class (cluster 1 -
Satisfactory sexual life) was characterized by
individuals reporting more frequent sexual
contacts, with longer duration and more
frequent accompanied by sexual attraction
pleasure while the second class (cluster 2 -
Not satisfactory sexual life) was characterized
by individuals that reported a lower sexual
dynamic and rare emotional pleasure. The
assignment to the classes was indicated by the
variable named Cluster with 2 values (1 or 2)
showing that individuals belong to the cluster
1 (78.9%) or to the cluster 2 (21.1%). |
| The independent samples t-test indicated
significant differences between the two
clusters by age t (1418) = - 11.50, p<0.001
and BMI value t (1409) = - 2.04, p =0.049.
The average age in the cluster 1 was 34.52
years while in the cluster 2 the average age
was 43,78 years. The difference between BMI
value was only 0.51 (24.20 in cluster 1 versus
24.71 in cluster 2). This gave us indications
that increase in age and BMI value was
associated with the sexual life quality
deterioration. |
| The cross tabulation of the classification
according BMI values and variable Cluster
indicated an increased proportion of obese and
overweight people in the cluster 2 but the
distributions by BMI categories in the clusters
did not significant differ, χ2(3, N=1484) =
4.95, p=0.175>0.05. The univariate binary
logistical regression of the variable Cluster
with the variable BMI indicated a significant
Wald = 4.16, p=0.041<0.05 but fragile (only
3.4%) increase in odds that a person belongs
to cluster 2 (not satisfactory sexual life
quality), when BMI value increase with one
unit. The percentage of the model correct prediction was 78.8%. No significant
differences regarding sexual life quality were
found by gender, both men and women having
similar distributions. |
| The marriage (or living in consensual union)
is a major life event that brings the
modification of the life style with a lot of
consequences to the sexual satisfaction. In the
Romanian space tradition, statistically the age
of 35 year is the maximum one for the
marriage and in this respect we can define two
important age groups: <35 years (50.1% of the
sample) and >=35 (49.9% of the sample). The
sexual insatisfaction was significant different
(p<0.001) between the two age groups. In the
unsatisfactory sexual life segment, the
proportion of the persons aged 35 years and
over was 3 times greater (74.0%). |
| The sexual rhythm was better for married
people. The lowest proportion of those who
reported sexual insatisfaction was found in
unmarried (18.9%) and living in cohabitation
person (34.5%) groups. For the Romanian
population the long term cohabitation is not
indicative, as living in consensual union, is
just a maximum 2 years stage of passage to
the legal marriage. The married persons,
separated, divorced were approximately
equally distributed in respect with the sexual
life satisfaction. The widows had the larger
proportion in the unsatisfactory sexual life
quality segment (72.2%), but in this case the
age has an important impact. |
| When we extend the previous univariate
binary logistical regression to multivariate by
adding more factors such as: age, gender and
marital status, the BMI effect was no more
significant. The all other three factor age,
gender and marital status were statistical
significant. The percentage of the model
correct prediction was 80.7%. Distributions of
the individuals by gender in the two clusters
were significant different χ2(1, N=1484) =
11.92, p=0.001. In the cluster 1 of the
individuals with satisfactory sexual life there
were 42.5 % females while in the cluster 2 the proportion of the females was 53.7%,
probably due to the more sensitive thresholds
regarding sexual life quality or due to the
more honesty in reporting. |
Discussion |
| As many other authors, we identified a
significant association between the
overweightness, obesity and the high blood
pressure. 13, 14 |
| The persons with coronary artery disease
should be considered a target population for
keeping the weight within the normal limits as
the disease medication treatment has as also a
side effect the libido decrease. |
| As other researcher we found that the obese
persons comparative with normal weight ones
reported the lack of desire and sexual
pleasure, abstention and difficulties in sexual
contact accomplishment. A study from Duke
University Medical Center highlights the fact
that in some circumstances the risk of such
problems is increased by a factor of 25 for the
obese persons. 15 |
| The article shows that the duration since the
persons are in a couple influences the BMI
value. In the married persons or in the persons
cohabitating for more than two years, we find
a behavior that may lead to obesity
comparative with the couple being in romantic
relation. To share the household environment
may increase the likelihood of becoming
obese and this people could be a target
population especially for obesity prevention.
16 |
| In our sample, taking into consideration only
the analyzed variables, we can affirm the
following issues. The marital status, duration
of the relation appears as and intervening
variable between the BMI and sexual
satisfaction. Usually a nonsexual and sexual
relation debut is “in force”, then has an inertial
trend sometimes becoming the expression of sexual interest lack without a sexual
dysfunction existence. Also, at the beginning
of relation the interest for physical aspect is
more active and so, the desire not to be obese
or overweight, makes the couple partners to be
more carefully with maintaining of a normal
weight. Later the partner sharing the same
household environment acquires a specific
attitude and behavior pattern. She cooks,
prepares the meals to show him her abilities
and how devoted is to him. He eats everything
to express his full gratitude and recognition of
her qualities. All this issues have a sense if we
think that in prevention is very important to
identify the target, to which we address to be
heard. |
| After several years of marriage the risk of
overweight, obesity and sexual insatisfaction
increases and from this moment, in this
circumstances the relation between them may
become a strong and biunivoque one disregard
the age. We think how many couples visit the
therapist for sexual problems such as
infidelity, lack of sexual attraction due to a
partner who became overweight or obese, that
can presented in the Diagram 1. |
| The fact that the overweight men are twice
numerous as the women, showed that the
husbands should be considered as another
special target public. In this respect the wife
have an important role because the domestic
duties entitle her to have some authority
regarding cooking, meals schedule. |
| At least at a first glance the myth of “gaining
weight after marriage” is a real one. A critical
moment is the one when over the daily
comfort, the change of the life style imposed
by the a marriage, the age increase is added
with hormonal modifications that involve
gaining the weight, change of the body shape
and on the other hand the sexual dysfunctions.
Especially to the couples established since
many years, with women at menopause onset
and men experiencing the pre-andropause
symptoms should be advised to change their
life style to prevent the weight excess. |
| An American study, demonstrated an
improvement of sexual dynamic following the
weight loss by 18.8%, comparing with the
previous sexual life status. Specially, the
females that avoided the sexual relations,
because they felt themselves physical
unattractive, but also the males, reported an
improvement of sexual life quality by 3 times
and a real participation to the sexual act.17 |
| A study of obese persons, having erectile
dysfunction, without diabetes, hypertension,
or hyperlipidemia, showed that the lifestyle
changes are associated with improvement in
sexual function in about one third of obese
men with erectile dysfunction at baseline.18 |
| It is clear how much important is the erection
for the man; it is the basis of his identity,
meaning the masculinity, power. Therefore
beginning with the intrinsic male desire to
achieve sexual potency we can easier
convince the obese or overweight ones to
obtain a weight loss, which could have other
benefits also such as improvement of heart
functionality, cholesterol level decrease, selfesteem
increase. |
| The society has it own stereotypes regarding
the obesity relating it to pejorative terms like
lack of will and control, overindulgence etc.
The marginalization feeling and social
exclusion due to the stereotypes linked to fat
as well as the disease fear affect the couple
relation. |
| In the street the obese feels real or not that the
people turn their heads after him and partners
is embraced in his company. The sexual
activity of the obese is low, seems to be
tiresome and the sex interest decrease seems
to increase the food intake desire. The
communication between the obese partners is
bad because the feeling of non sexual
attractive person is expressed with fear of not
offending. Part of the males considers more
attractive and sensual the women with
rounded shapes. The obesity means another
dimension. A partner with normal weight or
overweight should support with honesty the obese partner to ask for medical qualified
help. 19 |
| Our body, with all its organs and of course our
brain, is programmed by the genetic code
transmitted from generation to generation.
Due to this the feelings and actions related to
sex are the result of some millenary evolutions
which are manifested in us through attraction,
desire, jealousy and competitiveness. This
makes, in spite of the fact that great cultural
differences are in men, the sexual behavior to
be similar, the basic elements being: looking,
conversation, contact (coupling) and the
“clink” (the spark, agreement, concordance,
harmony). |
| The eyes are looking 2-3 seconds, the most
primitive part of the brain is activated and
results the interest or rejection. For the most
people of the western population, the body of
an obese person or of excessive slim one, at a
first glance may be unattractive. Because the
body, the appearance has an important place
in the modern society, for the obese this may
be a drawback. The next sequence, the
communication is in risk not to take place.
May be after the first glance the attractiveness
is in decrease, not necessary being a rejection,
that stuck the question which could bring the
revelation of a special qualities person. 20 |
| Sometimes a huge psychological pressure is
created related to the silhouette, physical
appearance, that does not solve the problem,
rather brings the stigmatization. The obese
person is discriminated in employment, in
medical care, in school, and this a fact we
must fight against, if necessary by legislative
measures. 21 |
| It is not sufficient to look at obesity as a social
problem or a cosmetically one. Obesity
became a serious disease, responsible for the
premature death and morbidity. Awareness of
the socioeconomic and psychological costs of
the obesity could be another way to reduce it.
22 |
| A study over persons aged 45-74 years finds
that the frequency of intercourse and desire do not correlate with the BMI, the duration of the
present relationship and other social and
sexual factors (education, income, frequency
of exercise, stress symptoms etc.). 23 Also,
even in our sample, when in the regressive
model of the dependent variable that describe
the sexual life quality (contact frequency,
pleasure, sexual fit) all the interest
independent variables have been added
(gender, marital status, health status, age and
BMI) then the BMI is no more a statistical
significant factor influencing the sexual life. |
| Thus latent class analysis we shows how the
sexual life quality decreases by age and BMI
value. Yet, the univariate binary logistical
regression shows only a fragile association
between high BMI values and the sexual
insatisfaction. Checking the amount of
unindependence, using Pearson χ2 test and by
addition of another variables into the analysis
the perspective changes. |
| In these circumstances, in spite of the fact that
the proportion of the obese and overweight
persons is higher in the unsatisfactory sexual
life segment than in the satisfactory sexual life
segment, the difference is not significant. And
more, in the case into the regression analysis
we add more factors the BMI effects on sexual
satisfaction vanish. |
| The fight against obesity must start from all
the possible intrinsic motivations with honesty
and care. Our study highlights the fact that for
an obese or overweight male the motivation
for the weight loss is the improvement of his
sexual activity, and then this may be one of
importance. Also, if the obese or overweight
female is not too much aware that her health
status is not good but feels herself unattractive
because of this, then it could be a good reason
to lose weight. |
| To become a normal weight person for the
benefits brought to the sexual activity up to
elder age may be a good enough reason. The
tenderness, the erotism and sexuality are
eustres factors. Sexual relations 2-3 times per
week with a constant partner constantly up to elder ages increase the immunity. Also, the
males with constant regular sexual activity
have important chances to be a person
enjoying the longevity. 24 |
Conclusion |
| Obvious, the BMI influences sexual dynamics
but the length, frequency and the quality of
sexual intercourse requires multifactor
evaluations and determinations, and variables
like age, marital status, health status, the time
since the couple was established, the partners
fit, the quality of non sexual relation, life
style, temperament etc, should be considered
in this equation. |
| Despite the fact no significant correlation
between BMI high values and the frequency
of sexual contacts, nevertheless we found a
tendency, a specific pattern by weight groups
of sexual contacts frequency decrease in the
case of overweight and obese people. Subjects
with a normal weight are closer to a more
intense sexual activity. From the normal
sexual activity point of view, normal subjects
are closer to overweighed ones. |
| With no doubt the most influencing variable
over BMI and sexual satisfaction is the age
followed by marital status. Although the BMI
increases by age yet at adult age (40-50 years)
the overweightness and obesity are less
frequent to the persons who do not share the
household environment. The same occurs with
the sexual satisfaction that despite its decrease
with the age increase, those who are in a
romantic relation or are at the beginning of the
marriage, although are aged 40-50 years
declare a satisfactory sexual life similar to the
younger respondents. |
| For the obese people the benefits of weight
loss to improve sexual life may be a way to
motivate them to start and continue a special
nutritional and physical activity program. |
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|
 |
| Table 1: BMI variability by sexes |
 |
| Table 2: BMI variability by age groups and gender |
 |
| Figure 1: BMI Class Variability by marital status |
 |
| Table 3: The frequency of sexual intercourse and BMI category |
 |
| Figure 2: Correspondence analysis of BMI category and frequency of sexual intercourse
(symmetric normalization) |
 |
| Diagram 1 |
