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Revista do Colégio Brasileiro de Cirurgiões

Print version ISSN 0100-6991On-line version ISSN 1809-4546

Rev. Col. Bras. Cir. vol.41 no.6 Rio de Janeiro Nov./Dec. 2014

http://dx.doi.org/10.1590/0100-69912014006006 

Original Articles

Bariatric surgery: impact on sexuality of the obese person

Maria Luiza Lobato Mariano 1  

Maria Angela Boccara de Paula 1  

Deomir Germano Bassi 2  

Pedro Roberto de Paula 4  

1Department of Nursing, University of Taubaté, São Paulo / Brazil

2Department of Medicine, University of Taubaté, São Paulo / Brazil

ABSTRACT

Objective:

To assess the impact of surgical treatment in the sexuality of the obese.

Methods:

We conducted a qualitative / quantitative research with 30 patients who had undergone Fobi-Capella Roux-Y gastric bypass for at least one year. We collected data through individual interviews using a questionnaire with 10 mixed questions and one open, between May and June 2011. The objective data were quantified in absolute numbers and percentages, and the subjective ones were analyzed using the Discourse of the Collective Subject (DCS) and discussed in view of reference published on the subject.

Results:

30 patients were enrolled, with a mean age 44 ± 12 years, 24 (80%) were female and six (20%) were male, 23 (77%) were married, 23 (96%) were hypertensive and eight (33%) were diagnosed with Diabetes Mellitus. After the operation, 11 (37%) individuals reported no change in the number sexual intercourses, but 19 (63%) reported that this number was altered, 16 (53%) informed increased frequency, one (3%) reported a decrease in frequency, one (3%) did not practice sexual intercourse anymore and one (3%) did not report the frequency. The central ideas (CI) raised originated four DCSs: Experience of female sexuality; No experience of female sexuality; Experience of male sexuality; and improvements of comorbidities and psychological factor.

Conclusion:

there are positive repercussions of physical and emotional orders of the surgical treatment of obesity, favoring the quality of life, including sexuality.

Key words: Obesity, morbid; Comorbidity; Bariatric surgery; Sexuality

INTRODUCTION

Since the dawn of humanity, sexuality has always been and will be an essential part of people's lives, manifesting from childhood to old age, involving physical, biological and emotional aspects. It is an essential part in the relation of one with oneself and with others, and is closely linked to intimacy, affection, love and care of the human being 1; and the body serves as a tool to express feelings and emotions. This is the central element in love and erotic relationships 2.

Human sexuality is not just the the genitalia, but includes a set of behaviors in pursuit of pleasure, love and interpersonal relationships3. The practice of sexuality encompasses the sexual and emotional relationship throughout the whole life cycle. It can be influenced by internal and external factors, such as illness, drug use, psychological or emotional disorders, interference of others, historical, cultural, traditional, moral, ethical and environmental conditions, as well as physical changes of the body 2.

Among the diseases that can interfere with sexuality, obesity is considered a chronic, metabolic one, with various etiologies, whose incidence has been increasing in the last two decades, both in developed and developing countries 4 , 5. It reaches the most different social classes, being a major challenge to public health 6. The most likely cause for its emergence is related to genetic factors and the predisposition of the individual to have a positive energy balance, which happens when the amount of energy consumed is greater than the amount expended in carrying out vital functions and activities in general 7.

Obesity is considered grade I when the body mass index (BMI) is less than 30 kg/m2, grade II when the BMI is equal to or greater than 35 kg/m2, and grade III when the BMI is equal to or greater than 40kg/m2 8.

Obese people often have body image disorders and strong impact on the psychological aspect, favoring the development of anxiety, depression and low self-esteem, which contributes negatively to having sex 9 , 10. By experiencing feelings of frustration, sadness, guilt, failure, depression and isolation, the obese searches all kinds of weight loss treatments, which often brings adverse effects 11.

Surgical treatment is indicated in people with excess weight, which puts them at risk of complications and death because of associated medical problems, presenting BMI above 40 kg/m2, or greater than 35kg/m2 with comorbidities 12.

Bariatric surgery is mainly based on three technical details, which improve and become every day less invasive, making patient recovery more rapid. The techniques are classified as: restrictive, aimed at restricting the volumetric capacity of the stomach; disabsorptive, which aim to achieve weight loss through the intestine's inability to absorb nutrients; and mixed, associating the previous two modalities 13.

Based on this information and observations of everyday life for obese people assisted in professional practice, some questions emerged about the experience of sexuality by the obese and about how the surgical treatment reflected in this dimension of his life. Therefore, the aim of this study was to investigate the effects of surgical treatment in the sexuality of the obese person.

METHODS

We conducted a qualitative / quantitative and exploratory study, held in the Paraíba Valley Hospital, São Paulo, Brazil. Of the 65 patients enrolled in the hospital's bariatric surgery program, a non-random sample of 30 patients who had complete data in the chart and agreed to participate were included, in the period from May to June 2011.

To sample selection, we included patients aged greater than or equal to 18 years, of both genders, with at least 12 months of postoperative period of the Fobi/Capella Roux-en-Y gastric bypass, followed at the outpatient clinic of the university hospital.

We collected the survey data through individual interviews after medical and/or nursing examination in the health service or in the person's home, when he/she was invited to participate. On that occasion, a questionnaire was applied, In the first part, it containing data on the socio-demographic characteristics such as gender, age, marital status, occupation, religion, date of the operative procedure, and weight information related to comorbidities. In the second part, it had ten mixed questions related to data specific to the topic of study, one of them being an open guiding question: "How do you feel about the experience of sexuality today?".

The objective data were tabulated and presented in absolute numbers and percentages, means and standard deviations in the form of tables.

Subjective data relative to the open question were recorded in digital media, transcribed and subjected to analysis by means of the Collective Subject Discourse (CSD), which consists of a research technique that analyzes the collective discourse as a single speech, made from fragments or key phrases taken from the common speech of the participants 13. The following DSC were developed: 1. Experience of female sexuality; 2- No experience of female sexuality; 3- Experience of male sexuality; and 4- Improvement of comorbidities and psychological factor. Then the data were discussed in light of the reference published on the subject.

The project was approved by the Ethics in Research Committee of the University of Taubaté (CEP / UNITAU # 209/09), and authorized by the hospital where the study was conducted.

RESULTS

The study included 30 patients, with a mean age of 44 ± 12 years, predominantly female and married. Other data related to baseline characteristics of the sample are described in Table 1.

Table 1 -  Baseline characteristics of the sample. Taubaté, SP, 2011. 

Characteristics n=30
Age* 44 ± 12
Female Gender 24 (80%)
Married or with a Partner 23 (77%)
Women 17 (57%)
Men 6 (20%)
Working Activity
Paid
19 (63%)
Non-paid 11 (37%)
Religion Catholic 16 (53%)
Evangelical 8 (27%)
Spiritual 4 (13%)
Jehovah’s Witness 2 (7%)
Pre-surgical weight (total, men and women) * 130.3 ± 22.8
Average time after surgery (years) * 5.7 ± 1.3
Comorbidities before surgery 24 (80%)
SAH 23 (96%)
DM 8 (33%)
DYSLIPIDEMIA 4 (17%)
Other ** 5 (21%)

* Variable expressed as mean ± standard deviation, other variables expressed as n (%).

** Other: Elevation of uric acid, liver cirrhosis, arrhythmias, sleep apnea, hypothyroidism.

Among the paid professionals, six (20%) worked in health, five (17%) in the administrative area, two (7%) were teachers, one (3%) quality inspector, one (3%) state civil servant, one (3%) kitchen assistant, one (3%) production manager, one (3%) trader and one (3%) advertising. Among the unpaid, there were one student (3%), one (3%) retired and nine people (30%) who did housework.

After the operation, 26 (86.67%) patients had no comorbidities associated with obesity, four (13.33%) had hypertension (SAH), one of these also reporting changes of the menstrual cycle and labyrinthitis. The average weight loss was 44 ± 13,8Kg for women and 47 ± 16,3Kg for men, and the weight loss percentage was 36% for both genders. Table 2 presents the main difficulties of physical and emotional order related to the experience of sexuality reported by participants, referring to periods before and after surgical treatment.

Table 2 -  Distribution of the main physical and emotional difficulties related to the experience of sexuality. Taubaté-SP, 2011. 

Physical and emotional repercussions Before After
n (%) n (%)
Physical* (fatigue, impaired mobility, decreased stamina, dyspareunia, unwillingness and discomfort) 16 (56) 2 (7)
Emotional * (low self-esteem, body shame, sagging, fear of not being accepted, of relating, of failing, and of not satisfying the partner, shyness and sadness) 15 (50) 4 (13)

* Variable expressed as n (%).

With regard to sexual practice before the operation, 15 (50%) participants reported that they maintained regular sexual activity, two to five times a week, nine (30%) irregular, one to four times a month, and six (20%) did not maintain sexual practice. After the operation, 11 (36.67%) reported no change in the number of sex intercourses, but 19 (63.33%) reported that the number was altered, and 16 (53.33%) reported increased frequency, one (3.33%) reported a decrease, one (3.33%) no longer practiced sexual intercourse and one (3.33%) did not report the frequency.

Four CSDs were elaborated on the theme: "How do you feel about the experience of sexuality today?" (Annex 1).

DISCUSSION

Obesity has affected much of the world's population and in Brazil its prevalence has been higher in the lower income strata and the female adult population, being twice higher than in men in the group older than 40 years7. Women more often experience a major concern with the external appearance. Body image present in all human dimensions, when altered, favors the demand for cosmetic operations and bariatric surgery, in the hope of having a body closer to the one being repeatedly disseminated and thus feeling desired by the partner and socially acceptable14. The surgical treatment of obesity has been carried out mainly in the female population, if patients meet the criteria for such treatment12 , 15. These data corroborate those found in this study, showing that the prevalence of obese females patients.

In the obese, the chronic imbalance between food intake and energy expenditure favors the development of cardiovascular and cerebrovascular disease, and some types of cancers, increasing morbidity and mortality. It is also a risk factor for onset of hypertension, resulting from insulin resistance and hyperinsulinemia, mainly associated to the distribution of body fat in the abdomen, stimulation of the renin-angiotensin-aldosterone system, increased salt and caloric intake, increased activity of the sympathetic nervous system and renal reabsorption7. SAH was the main associated disease in the studied population. Another obesity-associated disease that also stood out in this study was diabetes mellitus (DM), which is 2.9 times more frequent in obese subjects than in those with normal weight 7. In Brazil, changes in eating habits, in particular the increase in consumption of high-calorie foods, meat, milk and derivatives, rich in saturated fats, and sugars, and reducing consumption of foods rich in fiber, such as cereals, fruits and vegetables, associated with sedentary lifestyle, favor the increase in body mass, which in turn is a risk factor for the development of DM 16.

Obesity, especially the one constituted by the accumulation of visceral fat, leads to lower liver insulin extraction, promotes increased hepatic glucose production and the reduction in its uptake by the muscle tissue, resulting in varying degrees of glucose intolerance that will influence glycemic control, translated by increased blood glucose levels in diabetic individuals. The reduction of weight favors the stabilization of type-II DM after surgical treatment of obesity due to the improvement in glucose tolerance. Many surgical techniques can be employed for the treatment of obesity 17.

The coexistence of diabetes and hypertension is about three times more frequent in the population with BMI e" 35kg/m² than in the population with a BMI < 25kg/m² 18. This fact may explain the presence of hypertension and diabetes mellitus in most of the study participants, which resulted in poor quality of previous life. Dissatisfaction with the presence of comorbidities and feelings of discrimination and exclusion, low self-esteem, body shame, physical and emotional difficulties in affective relationships and failure in clinical treatments and conventional diet motivated individuals to seek surgical treatment, hoping to recover quality of life, both in physical and emotional aspects.

Most conventional obesity treatments involve reducing the intake of high-calorie foods and increasing physical activity, helping reduce the risk of metabolic diseases, but in practice, obese patients have difficulty adhering to treatment. Greater weight loss can be achieved with appropriate medications and surgical treatment, if the risk/benefit is valid to justify such treatment. Surgical treatment should only be performed when all conventional treatments have failed, and it aims at weight loss followed by the reduction of associated comorbidities.

The Roux-en-Y gastric bypass has been proven effective19. This operation was performed in all patients participating in the study, with weight reduction, together with the adequacy of dietary patterns and improvement of comorbidities. The follow-up time ranged from two to nine years, enough time to review the restructuring and adaptation to new conditions of life of individuals submitted to gastric bypass. In this study, the majority of participants (86.67%) reported that, after the operation, they did not have hypertension nor DM.

Surgical treatment of obesity is an effective and efficient solution to control excess weight, but does not guarantee a favorable long-term prognosis. It is just part of the treatment, as the guarantee of quality of life depends on the patient's awareness regarding changes in eating habits and lifestyle.

The Fobi-Capella operation is one of the most widely used techniques for promoting weight loss of around 40% of the initial weight, which may be maintained in the long term, besides reducing important nutritional and metabolic disorders20. The values of weight loss found in our study are very close to other reported results.

Bariatric surgery provides positive changes in sexual function in obese men, with increased sexual desire, erectile function and orgasm domains, reflecting in improved quality of sexual life within six months after the surgical procedure 5.

It has been observed that morbid obesity affected the frequency or the realization of sexual practice, by either fatigue, lack of physical stamina, mobility difficulty or the feeling of low self-esteem, body shame, and other feelings. Sexuality is an integral part of life and body, and its image in particular occupies a central place in the life of the modern man in his relation with the world and peers. Changes in self-image and self-esteem occur frequently, affecting the quality of life, including the sexual one 2 , 4 , 5.

Obese individuals are more likely to prejudice and discrimination than other groups, including within their own group, since "the other" becomes a reflection of the self-image, which can generate low self-esteem, helplessness and prejudice. In addition, the imposition by the media of a lean and healthy body increases the stigma and the feeling of social exclusion in the morbidly obese, negatively influencing sexual experience of these individuals 21. These facts may explain the irregularity of the frequency of sex of the participants of this study before the operation, because the physical difficulties and emotional changes were present in most patients. After surgical treatment, there was decrease in physical and emotional difficulties and improvement in sexual function, causing an increase in the frequency of sexual practice. One patient reported decrease in frequency, as he required a prosthesis use in the legs, making the intercourse difficult, even after weight reduction. Another patient reported no to practice sex anymore, keeping the marriage for convenience only.

Obesity is not only the risk of developing diseases, but also cause daily difficulties, such as buying clothes, getting a job, in addition to interfering with the affective relationship of the individual. Surgical treatment of obesity provides improved quality of life, with the recovery of self-esteem and social, emotional, psychological and family reintegration of the individual 9, data that corroborate those found in this study. In DSC1, we observed the aspects of the experience of sexuality of female participants.

The process of formation of sexuality begins in the conception of the human being and develops over the life cycle, receiving direct influence of biological, physiological, emotional, social and cultural factors. The myths and taboos about sexuality are still very common nowadays, this being considered a theme repressed by society. The repression in sexual education and social training, started since the first stages of human development, directly influences the sexual behavior of the adult individuals and the way they experience their sexuality, and may interfere with social and psychological aspects, depressing feelings, low self-esteem and frustrations in interpersonal relationships 2.

Obesity is one of the oldest diseases of humankind, and its complications go beyond organic diseases. The biological, physiological, and especially the physical alterations cause in obese women feelings of rejection, low self-esteem, inferiority and negative body image perception. In addition, obese women suffer difficulties in carrying out everyday activities of professional life and social and interpersonal relationships. Nowadays, there is a strong sociocultural tendency to consider thinness as the ideal situation of acceptance, self-control and competence. On the other hand, there are increasing numbers of obese individuals worldwide.

Thus, as seen in DSC, the changes caused in the body due to obesity and the fact that patients feel out of social aesthetic standards generated feelings of body shame. Due to excess weight, these women preferred to isolate themselves, making it difficult to face the partner, either by fear, insecurity or even because with an oversized body it was complicated to end the sexual act, since the physical fatigue and the difficulty of mobility were always present. These changes commonly experienced by the obese indicate that the prejudice of obesity begins with the very obese individual, as she has a negative perception of her own body image and low self-esteem.

The body, though silent, all the time expresses feelings, emotions and messages about its pleasures and dislikes, fear, insecurity and expectations with respect to each other through non-verbal language. It is through this approach that the body explains its acceptance or denial of the inter-relationship process, based on the beliefs and values learned during the psychosocial and cultural formation of the individual22. The overvaluation of aesthetic body imposed by society, the discrimination and the social prejudice experienced by obese women favor the development of depression, behavioral disorders and altered perception of self-image, interfering with their sexual experience 23. The altered body image causes the opposite of the cult of the body, of the aesthetic value, of the sensuality, flexibility and agility. Thus, they are more prone to extreme suffering resulting from low self-esteem, discrimination, social hostility, functional and physical, family and / or marital problems, feelings of shame and self-punishment, anger, dissatisfaction with life and social isolation. Consequently, there remain no other ways to protest but getting sick and closing for oneself and for the world, generating changes in various spheres of life, including those related to female sexuality 24, which was also observed in this study.

For women, sexuality is experienced and expressed through thoughts, fantasies, desires, beliefs, attitudes and values, and involves, beyond the body, the history, customs, culture and experiences of affective relationships. Thus, having a slim, beautiful, sensual body and that is closer to what the media imposes is the greatest desire of obese women 25. In ancient times, sex was seen only as something linked to reproduction. For women, the pleasure was repressed and considered sinful or objectionable. Today, sexuality is part of daily life and in a relationship between two people, the pursuit of pleasure being mutual. Relationships are based on affection, desire, pleasure and acceptance of others. In women, sexuality is closely linked to the subjective aspects related to mental, cultural and social conditions and her body perception 26.

For most obese women, discrimination and prejudice in relation to their bodies makes the relationship with their own bodies unpleasant. They seize knowing their boding or touching them, their sexuality is repressed. The feeling is of individual disability 24. They have higher chances of disorders of sexual desire that can be organic, such as hormonal, neurological, arterial alterations, neurotransmitter or stress-related; or psychological, such as feelings of rejection, low self-esteem, anxiety, shyness, perfectionism, lack of money; or they may have mixed origin 27. These facts corroborate our data. In DSC1 it is evident that some women could not even look in the mirror. The low self-esteem and difficulty in physical mobility due to excess fat interfered in not only interpersonal relationships and experience of sexuality, but also in contact with other people. This entire process propitiated a reduced perspective of affective and sexual life for these people, proving that female sexual dissatisfaction is linked to social and cultural factors, and especially the negative perception of their body image.

For a healthy and satisfying sexual life, it is important that there is increased self-esteem through self-acceptance, facilitating being accepted by the other. The reconstruction of body image, the physical and psychological well-being brought to these women more physical and emotional disposition, beyond redemption from society, increased vanity, desire, sensuality and security towards the partner in the experience of their sexuality.

Operated individuals, when presenting with reduction in body weight, are more satisfied with their body image, with improved quality of life 28 , 29. This fact does not allow the interruption of a multidisciplinary team postoperative follow-up of these patients, especially women. We observed that there was a progressive decrease in weight loss, which gave women a new body identity, favoring improved self-esteem and social life, reflecting positively on the experience of sexuality.

The psychological unpreparedness to adapt to new eating habits and adhere to treatment can lead to frustration and negative expectations regarding the operation 28. The postoperative period, as observed in the DSC2, showed complications such as depression and weight gain, as this individual failed to adhere to the new conditions imposed by the operation, by either dietary modification or the need to adopt a new lifestyle. Thus, some patients failed to recover self-esteem and their weight regain favored the isolation and repression towards the experience of sexuality.

The treatment of obesity is not just limited to gastric bypass. Often, after the procedure, there may be the need of performing plastic surgery, which contributes to raising self-esteem and positive body image perception and the improvement of the individual's quality of life. It is very important that the patient receive guidance from the healthcare team about the changes in eating habits and lifestyle, because the aim of the operation is the pursuit of health with disease reduction.

For women there is a strong cultural tendency to believe that the thin body is the passport to social acceptance, while for men the trend is to demonstrate a strong and bulky body that is associated with strength and power 30.

Some obese patients have no psychological preparation for postoperative coping and express expectations beyond reduced weight, adding to the treatment the resolution of marital and interpersonal conflicts and changes in the characteristics of their personalities. After surgery, it is common for the patient to experience surgical stress, presenting with emotional destabilization due to pain, or the need to adapt to the new liquid diet and subsequent dietary restrictions. At follow-up, we have observed that in some individuals the sudden weight reduction favors the onset of depression, anxiety, alcohol and drugs abuse, especially in younger patients, and of conjugal problems. This study showed that, in addition to aesthetics, some women already had problems of domestic order and were no longer interested in continuing the relationship. Thus, obesity should be seen as a complex situation that involves physical and mental status, and its resolution through the surgical treatment must take into account other dimensions of living, including the difficulties and psychological limitations of each patient.

Sexual function for most men is an important aspect of quality of life, regardless of their body mass. However, the man with morbid obesity has alterations in his sex life due to sexual dysfunction, which can compromise erection, ejaculation, orgasm, sexual desire and cause infertility. These dysfunctions, added to the difficulty of mobility due to increased body mass and social stigmatization, lead him to isolation and feelings of failure 5 , 9.

In the obese, there is a relationship between exaggerated eating and sexual frustration. This is understood as the absence of a satisfactory sexual liberation to achieve orgasm. The habit of overeating arises as a way to extrapolate the frustration that results from the individual's inability to relate sexually with another person, becoming a vicious cycle 25 that can generate embarrassment and insecurity for the obese, even interfering with reproduction.

In contemporary society, the search for gender equality is present in many respects. However, with regard to sexuality, the man still lives the myth that he will always be seen as responsible for the implementation of the sexual act, a manly being. The fact that he can not complete the sexual act or breed generates in the obese feelings of helplessness and frustration, who then starts to evade physical and emotional contact with his partner to avoid possible embarrassment 31. Male sexuality can be demonstrated in the DSC 3. In this study, after surgical treatment there was an improvement in the quality of sexual life in all participating men, including achievement of fatherhood and increased security towards the partner, promoting feelings of happiness, rescue of self-esteem, increased vanity, affection and contact with the partner, which resulted in increased frequency of intercourse. Obese individuals undergoing gastric bypass by the Fobi/Capella technique achieve greater domain of erectile function, increased desire and are able to complete the sexual act, recovering the quality of sexual life, in addition to greater sociability and willingness to work 5.

DSC4 emphasized aspects related to diseases and emotional changes associated with obesity after the surgery. The construction of body image comes from the intercom experiences and social relations between individuals. The focus are the subjects themselves itself, who use near and meaningful images as reference for the formation of their body identities. Obese women experience body shame and the blame for being fat. Excess weight is often associated with lack of control over the mouth and the body due to the lack of adherence to a balanced diet or physical activity. In addition, the obese may also experience feelings of exclusion that can lead to serious psychological disorders 25. The increase in the level of emotional and psychopathological change leads to a greater tendency to food compulsiveness and increases in BMI 23.

In obese men, the personality changes are related to the greater tendency to alcohol abuse and dependence, and to difficulties in social relations. Women are more prone to compulsive, anxiety, and personality disorders. These factors affect not only the quality of social life, but also reflect negatively on the experience of sexuality, since they can generate physical / organic and emotional disorders in the obese. This may explain the presence of low self-esteem, shame, rejection of the body and social isolation reported by participants prior to operation. The recovery of self-esteem, social reintegration, and the exclusion or reduction of prejudice and discrimination after operative treatment provided better quality of life in organic and psychosocial aspects. Thus, in DSC4 we observed improvement of quality of life, since a new relationship with the body was established, the recovery of health, of their role in the social context and security towards personal relationship, with recovery of pleasure, increased frequency of intercourse, closeness, complicity, intimacy, affection, happiness, security, and freedom between the couple.

In conclusion, the analysis of the results allows us to conclude that there are positive physical and emotional repercussions of the surgical treatment of obesity, favoring the quality of life, including sexuality.

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Source of funding: none.

ANNEX 1

Speeches / Reports on the theme: “How do you feel about the experience of sexuality today?” presented to research participants.

Received: December 20, 2013; Accepted: April 15, 2014

Mailing address: Maria Luiza Lobato Mariano E-mail: malu_lobato@hotmail.com Maria Paula AngelaBoccara E-mail: boccaradepaula@hotmail.com

Conflict of interest: none.

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