When we talk about eating disorders, our main focus is often weight as we tend to prioritise conversations about dangerous food restrictions and other harmful eating behaviours. But the negative consequences of illnesses like anorexia, bulimia and binge-eating go well beyond body size and shape. The impact that an eating disorder can have on intimate relationships is enormous but often overlooked – even in therapy. “The professionals’ shame and embarrassment can make a huge difference here,” says Dr. Julia Coakes, a consultant clinical psychologist working in Leeds. “Very few professionals will say, ‘How is your sex life?’ We are embarrassed to ask and talk about it, which means it gets hidden under the carpet, not dealt with, left in denial and it can continue to be a problem long into recovery." As a physical experience, sex is obviously closely linked to body confidence. And battling an exhausting mental illness that typically unleashes self-loathing and body-image issues surely can’t help. Dr. Coakes explains, for instance, that many patients who develop anorexia as teenagers might have fewer romantic partners as their negative body perception amplifies the fear of intimacy. “My eating disorder completely robbed me of a typical teenage romantic experience,” says Holly Cassell, a 26-year-old freelance writer and blogger based in Cardiff, who began to develop anorexia around the age of 10. She recalls fantasising about having a boyfriend or falling in love but, at the time, the reality was that her body didn’t want it at all. “I didn’t have a sex drive until I was in my late teens, on my way to recovery.” Having recovered from her eating disorder about six years ago, Holly thinks that going through that experience has encouraged her, now, to live her sexuality and relationships more fully. “My sexual life now is one of the areas where I’m most happy, because I’m just so determined to make it wonderful, because I feel like I missed out on so much in my teens.” But eating disorders do not affect only young girls. It is not at all unusual for anorexia or bulimia, for instance, to appear later in life, affecting people who may be in a relationship and have already begun to avoid sexual contact. “I work with quite a lot of people where we talk about that for a significant amount of time, maybe a year or more, there has been no sexual intimacy, as they’re so unhappy with their body image”, Dr. Coakes says.
The more I felt like I didn’t want to, the more guilt I felt
Cathy Scott, a 25-year-old hairdresser from Yorkshire, has been struggling with anorexia and bulimia for 11 years. She’s been in recovery for a couple of years now, since becoming a mother. “When I was 14, I had a boyfriend at school. When I ended up in hospital, he broke up with me. Then, when I came out, I had another boyfriend, with whom I had a child. We were together seven years [and just recently split],” she tells us. Since improving her health and restoring part of her weight during pregnancy, Cathy has been feeling more comfortable with her body, which seems to have had a positive impact on intimacy, too. “I would say everything definitely improved, I've definitely got a sex drive now!” she says, laughing. But she remembers struggling in the past. Obsessing over food and weight loss didn’t leave much room for sexual desire, and her restrictive regimen drained her of energy. Despite having quite an understanding partner, as she puts it, she thinks her disorder probably put a strain on the couple, causing more arguments and tension: “The more I felt like I didn’t want to, the more guilt I felt. I think that had a bit of an impact on the relationship.” These kinds of feelings – guilt, anxiety, obligation – are fairly common among her patients, says Coakes: “More often I see that they stopped having sex and they are worried about that, and worried about how long the other person will stay around,” she says. Other times, they may continue to go through the motions of a regular sex life without wanting it, in a bid to please their partner and keep the relationship going. Physiologically, low weight can be to blame for a lack of sex drive, as it affects the production of the hormones thought to be responsible for women’s libido. “Particularly with anorexia, [patients] will stop producing oestrogen and testosterone and the sex drive will dramatically decrease,” says Coakes. However, as Coakes explains, while gaining weight is a necessary step towards becoming healthier, it is no magic fix: “If [patients] restore their weight, they might actually want to have sexual intimacy, but now they are getting bigger, they may have a battle between wanting more sexual intimacy but having perhaps even less confidence in their body.”
My sexual life now is one of the areas I’m determined to make wonderful, because I feel like I missed out on so much
If one of the main purposes of recovery is to discover and to own one’s identity outside of the disorder, then sparking a conversation around intimacy is pretty crucial. Yet the topic still causes embarrassment and often goes unspoken at all levels – among professionals, peer support groups, and in the media. As a teenager in therapy, Holly felt too scared to acknowledge and address the problem directly: “This isn’t an issue I worked on – I was 16 or 17, I wasn’t quite as mature about sexuality as I am now, and even though I recognised it as being a problem, I hadn’t had a boyfriend, I hadn’t kissed anybody. It wasn’t really a problem I wanted to raise in therapy and talk about already.” Even among recovering adults, just talking about the impact eating disorders have on relationships seems really rare. “It’s probably a forgotten-about topic, I never had a conversation about it with someone before,” Cathy says. “When you have an eating disorder your obsession is purely around your diet and obviously what you eat, so going through recovery, people talk more about their diet, their weight, but I do think that being in a relationship should be more spoken about, it is important.” Dr. Coakes argues that working on establishing healthy romantic relationships – as opposed to what she calls “companion relationships” – can aid recovery and even boost body confidence. But it is a complex and delicate process that involves not only self-esteem, trust and biology but also, on the partner’s side, an understanding of the eating disorder itself, its mechanisms and manifestations. Undeniably, the desire and need for intimacy is a fundamental part of the human condition; we thrive when we manage to connect with others in a positive and authentic way. As Dr. Coakes says: “If the therapist, or whoever, just doesn't ask about it, it gets assumed that it's not important, and it is an important part of everybody’s sense of self and identity.”