This is from the Summer 2013 edition of the OAC magazine.

Answer provided by Walter Medlin, MD, FACS

Dear Doctor, I am affected by

obesity and not interested in

intimacy. Why is this?

Dr. Walter Medlin

Putting the Frisky back in Our Business!

The dilemma for most of us: Wanting intimacy but

fearing vulnerability.

Sexuality is still probably the toughest issue to

discuss, or even to think clearly about in our

society. It’s very ironic that we are deluged with

sexual images and humor to sell stuff and to get

our attention, but Americans are fairly repressed

and conservative in terms of actual intimacy and

intercourse.

Media and society will show explicit violence over

sexuality for some reason, to the point of laughable

avoidance of male nudity. You can watch TV and see

murder, mayhem and meanness on network shows

even in the “family hour,” but there will be no actual

depiction of sexual pleasure on TV (unless it is

betrayal). We are far more comfortable as a country

with sexual tension than sexual activity.

Please let me remind you that you’re talking with

a surgeon about something that is usually more

in the realm of a counselor. As a member of your

healthcare team, I am very happy, though, to get

you started on this process and help if I am the

provider you’re most comfortable sharing these

issues with.

Getting Started

Let’s clarify some specifics. In what way (or ways) does

this loss of interest in intimacy bother you? Is it more of

an issue for you or your partner? Or maybe something

you have mutually decided is an area of desired change?

Misconception of Female Sexual Response

I highly recommend a book that I read for this article,

titled The Sex Starved Marriage, by Michele Weiner-

Davis, PhD. The book is very clearly written and reflects

an extensive clinical experience. One key concept is that

women often expect to be interested in sexual intimacy

prior to actually engaging in contact. This is often the

reverse of what actually occurs! Many women just don’t

get desire until actually involved in arousing activity. Dr.

Weiner-Davis also highlights many important areas in

her book that are listed on the following page.

One key concept is that women often expect

to be interested in sexual intimacy prior to

actually engaging in contact. This is often

the reverse of what actually occurs!

“ “

Medical

There are several factors that can lead

to loss of sexual desire or enjoyment.

Antidepressant medications in the

SSRI class can alter libido. These

include Celexa, Lexapro, Paxil,

Prozac, Zoloft and others.

Hormonal

Menopausal or premenopausal

changes can alter feelings of desire

and are often unrecognized in early

stages. The body can also have

adjustments after childbirth or

chemotherapy.

The term “chronic disease” covers a

lot of ground, but many conditions,

including diabetes, can contribute to

change in desire. Vascular disease is

more highlighted in males because of

the role in maintaining erection, but

likely has some role in female sexual

response as well. Smoking cessation

is always a good idea!

Polycystic ovary syndrome can give

women higher testosterone values,

which can lead to acne and hair

issues, as well as irregular periods.

Physical

Fatigue is probably most important,

medically, for desire. Low Vitamin D

is almost the rule in our patients, and

it takes weeks to months to correct.

Hypothyroidism is less common, but

treatable. Lack of regular exercise

directly affects sexual desire and

arousal and ability to orgasm. It also

indirectly affects fatigue, which is

part of the body’s counter-regulatory

efforts to dieting.

By the time many women reach our

clinic, they have been through dozens

of diet attempts throughout the years.

Their bodies have become welladapted

to this self-imposed “famine”

by going into a near hibernation

state, which is best characterized by

overwhelming chronic fatigue.

Medical, Hormonal and Physical issues

When you feel burnout in life, it is understandable to be

sexually disempowered. Clinical depression, medications

and body image problems can certainly have a role.

Understanding all of this is the first step to adjusting to it

all. Please note that I did not use the word “fixing” here!

An attitude of “fix” can block our ability to “treat.”

Behavioral and Relationship Issues

Another of Dr. Weiner-Davis’ ideas that I really appreciate

is that of “emotional nutrition,” which is an inborn need

to bond. How can we have a true sexual bond with our

partner if there is no friendship? Anger, cynicism and

even selfishness may all be reasonable responses to the

harsh reality of the world for many of us, but they also

isolate us. Balancing the need for self-care with the need

to be cared for requires a leap of faith!

Here are some questions for you and your partner that

may help you both identify intimacy issues:

• Are you in a relationship now? If so, how has

intimacy worked in this relationship in the past?

What previous relationships do you bring into the

current one?

• Are you a post-op metabolic/bariatric surgery

patient? Has your partner responded positively to

changes? Is your partner “oversexed” (exhibiting

an excessive sexual drive or interest)?

• Does your body image or previous sexual trauma

create fear or reluctance toward intimacy?

• Are you sexually active but feeling a lack of

desire/pleasure or not having intercourse? Do

you have a sexual relationship with yourself?

(Yes, we are now talking about masturbating, an

even more taboo subject than sex!) Do you have

thoughts but not act on them?

• How is your underlying friendship with your

partner? What other conflicts may be unresolved?

Some relationships undergo radical “power”

changes after bariatric surgery, and the partner

who has been taking the other for granted often

reacts defensively.

• How do you handle stress now? Food can be a

crutch even for normal weight people – they don’t

call it comfort food for nothing! You may need to

replace old coping behaviors with new ones.

• Do you have “safe” space in your relationship to

talk about issues without causing hurt feelings?

Are you waiting for your partner to agree with

you before taking action? When we offload the

obligation for our happiness onto our partner, it

can lead to a compounding of problems.

• Remember, change can be stressful, even if it is

winning the lottery. A new life can be disruptive,

and adjustment disorder is common.

Recognizing Other Important Issues

Most relationships hit roadblocks at some point, and

counseling can give tremendous benefit even if it is

only for a few sessions or a few months. Even when

the underlying sexual problem is completely related

to medication or physical problems, our feelings and

communications are easily disrupted. As the saying goes,

“Sex is only 10 percent of the relationship – unless you’re

not having sex, then it’s 90 percent!”

Here is a list of other concepts to explore:

• Distracted society (Internet, TV, busy lives)

• Anxious society (continual messages of crisis

and tragedy)

• Neurotic society (continual messages of

inadequacy)

• Pornified society (inability to live up to fictional

standards)

• Hyper-society (inability to just chill out for a

day on the couch with partner or self)

• Habit of avoiding, delayed gratification

• Does only intercourse “count” anymore? Are we

keeping score too closely?

• Romantic fiction (Is it okay just to “hook up”

with your partner occasionally? Does all sex

need to have deep personal connection, or can

it just be fun?)

• Spontaneous ideal (Sometimes planning, even

scheduling, can be helpful.)

• Sensitive feelings (Innocent comments can

cause real harm. Your body language may

be misunderstood as rejecting, even if it has

nothing to do with your partner.)

• Discounting positive attention (Negative selftalk

blocks romance!)

• Honest and CLEAR communication of needs

and turnoffs

• Do you talk with friends, but your partner is in

the dark?

• Be VERY careful of the word “should.” It is the

root of a lot of toxic behavior and unrealistic

expectations.

• Is impatience for a complete solution keeping

you from making small steps?

• Would regular exercise help?

• Do we feel overly responsible for our partner’s

happiness?

As you can see, there are a wide variety of concepts that

may impact sexual behavior and desire. It is important to

discuss these issues with your partner to encourage clear

and honest communication.

The Takeaway

Communicate with your partner, take that leap of faith!

If you have major anger, or major vulnerability, it is a

good idea to have a counselor. Just get started! Don’t let

intercourse or orgasm problems block the enjoyment

you can have with other components of an intimate

relationship (even if it starts alone). Most important –

don’t ever count yourself out! This important part of life

has not passed you by, even if you are far out of practice.

Expect to have some dead ends in your search for

solutions. No single source or practitioner has every

answer, and many of us practitioners have only limited

experience with certain components of sexuality. Be

wary of the easy answers, this is complicated stuff!

As you progress through examining and making changes

in your sexual life, expect that the questions may change.

I am a strong advocate of Mindfulness-based Stress

Reduction techniques for keeping our problems in

perspective. Remember, your most important sex organ

is your brain! Self-care is fundamental to happiness.

Most of us have ongoing negative internal dialogue

about weight and self-worth. Don’t beat yourself up just

for having a challenge in desire. It is not a “fault,” but

another opportunity for learning about this amazing

journey of life.

Here’s hoping you all have the frisky, romantic summer

that you surely deserve!

Be positive, but be persistent!

Answer provided by:

Walter Medlin, MD, FACS, is director of the Metabolic

Surgery program at Billings Clinic in Montana and an

OAC Advisory Board Member. He struggled with his

weight since first grade. After performing hundreds of

bariatric surgeries, he underwent sleeve gastrectomy

in 2008, with outstanding results. Dr. Medlin is also a

participating practice in the OAC Sponsored Membership

Program where he gives each of his patients a one-year

membership in the OAC and he is honored to be a

longtime member of OAC. Dr. Medlin is also an avid user

of Twitter; his handle is “@bonuslife.”