Obesity is a global epidemic that negatively affects individuals’ physical, emotional, and psychosocial well-being. The number of people affected by this epidemic is steadily increasing. Obesity has been linked to diabetes, heart disease, hypertension, urinary incontinence, and various cancers. In addition to these diseases, it can also lead to sexual problems. Studies exist that indicate weight loss improves sexual function. It remains unclear whether obesity itself causes sexual dysfunction or if sexual dysfunction develops due to diseases caused by obesity.

The Connection Between Obesity and Sexual Function

Sexual response is multidimensional and influenced by an individual’s psychological well-being, physical, and physiological factors, leading to many sexual problems. Disorders of sexual function typically affect at least one of the three stages of the sexual response cycle: desire, arousal, and orgasm. In men, the most common problem related to the arousal phase is the inability to achieve an erection and/or difficulty maintaining an erection; common issues related to the orgasm phase include premature ejaculation and delayed or inhibited ejaculation. In women, common problems during the desire-arousal phase include low desire, lack of lubrication, and insufficient psychological arousal; the most common issue in the orgasm phase is the inability to reach orgasm or difficulty achieving it. Obesity has the potential to affect each of these areas. For example, obesity is associated with depression, anxiety, poor body image, and low self-esteem, all of which can interfere with sexual function. Dyslipidemia, insulin resistance, hypertension, hyperglycemia, increased cardiovascular disease, and chronic inflammation caused by obesity negatively impact sexual function. Obesity can adversely affect sexual relationships by reducing partner attractiveness and/or sexual intercourse.

Evidence Linking Obesity to Sexual Dysfunction

Sexual problems in women occur more frequently or more severely in the obese population. In a study involving over 200 sexually active obese women, it was found that 48.3% had issues related to desire, 35.9% with arousal, 45.0% with lubrication, and 42.9% with pain. Another study investigating the connection between obesity and sexual behavior through responses from 553 women regarding weight, current sexual partner status, and sexual partner frequency found that obese women were 30% less likely to report sexual activity in the past 12 months compared to women of average weight. Similar studies have shown that overweight women experience more significant problems with arousal, lubrication, orgasm, and sexual satisfaction.

Studies investigating sexual dysfunction in men have shown that body weight is an independent risk factor for erectile dysfunction. A comparison of body dissatisfaction, sexual feelings, erotic imagery, and sexual dysfunction in 30 obese and 30 normal-weight men revealed that obese men had higher levels of sexual dysfunction and dissatisfaction regarding dimensions such as sexual desire, erotic fantasy, and motivation for sexual advances. Additionally, obese men reported less sexual pleasure due to fear of hurting their partners.

Obesity and Sexual Function

Obesity represents an accumulation of fat in the body. Adipose tissue can influence various biochemical processes that can directly affect sexual function in both men and women. The biochemical consequences of excessive adipose tissue may lead to endocrine changes that produce different effects between genders.

In women, fat is stored subcutaneously, particularly in the hips and thighs. Men, on the other hand, tend to store visceral (intra-abdominal) fat. Visceral fat is associated with higher rates of insulin resistance, type 2 diabetes, dyslipidemia, and cardiovascular disease. As women enter menopause, their fat storage patterns become more similar to those of men. The differences in fat storage patterns between men and women suggest that obesity may affect sexual function differently between genders.

Endocrine Function of Adipose Tissue

Historically, adipose tissue was seen primarily as a fat reservoir. However, we now understand that adipose tissue behaves like an endocrine organ. It appears to be responsible for nearly all circulating estrogen in postmenopausal women and about 50% of testosterone in men. Adipose tissue houses enzymes necessary for the activation of steroid hormones and allows for the conversion of androgens to estrogens. It is an important area for the production and secretion of steroid sex hormones. This suggests a direct connection between adipose tissue and sexual response. However, since various sex steroids affect men and women differently, their effects will vary between genders.

Male Sexual Function

In men, erectile function is the aspect of sexual response most affected by obesity. The roles of known neuromodulators such as testosterone, estrogen, and nitric oxide (NO), as well as the circulating androgens and estrogens, may play a role in the connection between obesity and erectile function. Specifically, obese men tend to have lower concentrations of sex hormone-binding globulin. Serum concentrations of testosterone are lower along with hypogonadism. Male hypogonadism reduces sexual desire and erectile response, decreasing sexual sensitivity. Due to the common increase in estrogen in obese men, some researchers suggest that increased estrogen activity may harm male sexual sensitivity. NO is a neurotransmitter that contributes to penile erection by relaxing smooth muscles and facilitating vasodilation. As a result of obesity, the amount of enzymes responsible for NO synthesis decreases in nerve and vascular tissues.

Female Sexual Function

The hormonal responses affecting sexuality in men and associated with obesity are less clear in women. It remains uncertain whether obesity has significant effects on sex steroids in women. Elevated levels of estrogen and androgens in obese women may contribute to sexual desire and sensitivity in some cases, but the effects may be ambiguous. The effects of sex steroids and nitric oxide levels on female sexuality are much less clear. Direct endocrine effects stemming from adipose tissue may have very little or no effect on women’s sexual function.

Obesity itself can cause sexual dysfunction, but the diseases accompanying obesity can also lead to sexual dysfunction, making it difficult to distinguish between the two. Although the precise role of obesity in sexual response remains unclear, the highest degree of erectile dysfunction is observed in men with waist circumferences exceeding 120 cm. Increased visceral fat and severity of metabolic syndrome in men increase the risk of erectile dysfunction. Additionally, high glucose and triglyceride levels negatively affect erectile function. In premenopausal women with diabetes, structural abnormalities of the clitoral cavernous tissue have been observed. These data suggest that the underlying mechanisms of genital tissue vasocongestion and thus sexual function may be compromised in men and women with diabetes and/or metabolic syndrome.

Obesity has various psychological consequences known to affect sexual function. Given the sociocultural pressures related to physical appearance on women, these factors may affect them more than men. In the current “thin” culture, obese individuals often experience stigma resulting from comments, discrimination, and ridicule related to weight, leading to a poor body image and low self-esteem. Sexual dysfunctions are often associated with increased anxiety and depression due to significant personal distress and low quality of life.

Weight loss has been shown to have positive effects on sexual function. Weight loss can improve sexual response in multiple ways:

• Positive biochemical (e.g., endocrine) effects resulting from reduced adipose tissue
• Improving overall health, thereby reducing the harmful effects of accompanying diseases such as cardiovascular diseases, diabetes, and metabolic syndrome
• Affecting psychological parameters such as self-esteem, confidence, body image, depression, and anxiety, leading to greater sexual interest, more positive feelings regarding sexuality, and increased desire for relationships and sexual intercourse.

Rowland DL, McNabney SM, Mann AR. Sexual Function, Obesity, and Weight Loss in Men and Women. Sex Med Rev. 2017 Jul;5(3):323-338. doi: 10.1016/j.sxmr.2017.03.006. Epub 2017 Apr 26. PMID: 28456610

M. Temel, N. E. Boyacıoğlu, S. Çaynak, M Çaynak. Psychosocial and Sexual Life in Morbidly Obese Individuals Following Bariatric Surgery: A Qualitative Study. 7 Jul 2022 https://doi.org/10.1089/bari.2022.0016