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International Journal of Sexual Health logoLink to International Journal of Sexual Health
. 2025 Sep 1;37(4):771–784. doi: 10.1080/19317611.2025.2553850

Sexual Functioning and Eating Disorder Symptoms: Examining the Role of Gender and Internalizing Symptoms in an Undergraduate Population

Maegan B Nation a, Shane W Kraus a, Melanie Garcia a, Nicholas C Borgogna b,c, Kara A Christensen Pacella a,✉
PMCID: PMC12867417  PMID: 41641070

Abstract

Objective

Eating disorders (EDs) are frequently associated with sexual dysfunction; however, research has not tested this relationship while adjusting for the known effects of anxiety and depression on sexual functioning. Furthermore, there is a notable lack of research on sexual functioning problems and ED symptoms among men.

Method

Undergraduate cisgender women (n = 1488) and men (n = 646) completed measures of ED psychopathology and sexual functioning problems. Hierarchical linear regressions predicting sexual functioning problems were conducted separately by gender including BMI, age, sexual attraction, anxiety and depression symptoms in Step 1 and an ED psychopathology variable (e.g., global score, dietary restraint, preoccupation and eating concern, or shape/weight overvaluation) in Step 2.

Results

For women, changes in proportion of the variance in sexual functioning problems when adding global score, dietary restraint, and preoccupation and eating concern to the models were statistically significant, but effect sizes were very small. Change in variance when adding weight and shape overvaluation was not significant. For men, all ED psychopathology variables accounted for significant, but small, changes in the proportion of variance in sexual functioning problems.

Discussion

Sexual functioning problems observed in women may be better explained by depressive symptomology, as variance explained by ED variables, while statistically significant, was small and likely of lower clinical relevance. Sexual functioning problems in men may be minorly influenced by ED psychopathology, independent of depression and anxiety symptoms. Results suggest the importance of screening for sexual functioning problems and developing interventions that target potential mechanisms related to psychopathology.

Keywords: Eating disorders, sexual functioning, sexual dysfunction, depression

Introduction

Sexual functioning, including sexual desire, arousal and orgasm (Fielder, 2013), remains largely taboo in healthcare, with only 17.5% of psychiatrists reporting that they discuss sex-related concerns with their patients (Bungener et al., 2022). Furthermore, when patients mention sexual dysfunction with their provider, they often report feeling that their concerns are dismissed (Traumer et al., 2019). Yet, sexual functioning and satisfaction likely have a bidirectional relationship with quality of life across the lifespan (Cabo et al., 2024; Chang et al., 2019; Nappi et al 2016). For example, men reporting sexual functioning decline also reported significantly worse psychological and life satisfaction scores (Lu et al., 2020) and women reporting sexual dissatisfaction experienced lower psychological well-being, adjusting for menopausal status (Davison et al., 2009). In addition, women who endorsed arousal and orgasmic problems, and problems with enjoyment of sex also reported greater marital problems and symptoms of depression and anxiety (Dunn et al., 1999; Forbes et al., 2016).

Previous literature has found that sexual functioning problems are higher among people with eating disorders (EDs) when compared to non-ED controls (Pinheiro et al., 2010; Castellini et al., 2012; Price et al., 2020). Both physiological (e.g. hormone dysregulation and weight fluctuations; Castellini et al., 2019) and psychological symptoms (e.g. body-related cognitions; Dunkley, Svatko, et al., 2020) associated with EDs have been implicated in poorer sexual functioning. However, this research has primarily focused on cisgender women. There is a lack of research regarding sexual functioning among men with EDs (Dunkley, Svatko, et al., 2020), and even less contrasting gender groups. Although sexual functioning problems tend to improve with reduction of ED psychopathology and weight restoration among underweight patients (Castellini et al., 2017; Cyranowski et al., 2004; Fichter et al., 2006; Morgan et al., 1999), it is possible that clinicians could directly address these problems as part of ED treatment to promote better quality of life during recovery.

ED-related constructs have been associated with sexual functioning problems. Objectification theory has long posited that self-objectification, or an internalized view of self as an object, could lead to experiences with body shame or appearance anxiety, which are associated with sexual dysfunction (Fredrickson & Roberts, 1997). Greater body surveillance and body shame, both components of self-objectification, have been found to predict lower sexual satisfaction (Calogero & Thompson, 2009), supporting objectification theory. In addition, the relationship between greater self-objectification and poorer sexual functioning has been mediated by ED-related constructs, such as body shame and appearance anxiety (Calogero & Thompson, 2009; Steer & Tiggemann, 2008; Tiggemann & Williams, 2012). Furthermore, body shame and appearance anxiety may mediate the relationship between self-objectification and depressed mood (Chen & Russo, 2010; Hurt et al., 2007; Peat & Muehlenkamp, 2011; Szymanski & Henning 2007; Tiggemann & Kuring, 2004). However, although constructs like body shame or appearance anxiety may correlate with some aspects of ED pathology, such as shape or weight concern (Jin et al., 2022; Troop & Redshaw, 2012; Tylka, 2004), they are not synonymous and may not fully capture the range of ED pathology or behavioral manifestations of EDs. Thus, exploring these associations using more comprehensive ED-specific measures is needed.

ED symptoms may have unique associations with sexual functioning problems. Alternatively, these associations may be better accounted for by co-occurring internalizing symptoms. For example, sexual functioning scores have been correlated with depression among people with bulimia nervosa (Gonidakis et al., 2015). Furthermore, the relationship between sexual functioning and anxiety (r= −.53; Bradford & Meston) and depression (RR= 1.69; Atlantis & Sullivan, 2012) is established, but complex and likely bidirectional (Laurent & Simons, 2009). For example, women with recurrent major depression report less frequent physical pleasure and sexual arousal within their current relationships (Cyranowski et al., 2004; Forbes et al., 2016). State anxiety has been negatively associated with sexual arousal in and outside of lab settings (Bradford & Meston, 2006). Anxiety and depression symptoms are highly comorbid with ED symptoms and their outcomes (Blinder et al., 2006; Martín et al., 2019); however, literature on sexual functioning problems in people with EDs typically have not adjusted for the effect of co-occurring internalizing symptoms (e.g. Dunkley, Gorzalka, et al., 2020; Pinheiro et al., 2010, Castellini et al., 2012, Gonidakis et al., 2015). Thus, to better understand the unique contribution of ED pathology to sexual functioning problems, models must adjust for depression and anxiety symptoms.

Additionally, we included sexual attraction as a covariate for our analyses, based on research that sexual orientation has been associated with differing sexual functioning problems. Although sexual attraction is not identical to sexual orientation, they are often highly concordant (Fu et al., 2019). Overall, the literature on sexual orientation and sexual functioning is mixed and often differs between the domain of sexual functioning assessed and gender identity of respondents (Breyer et al., 2010; Flynn et al., 2017; Henderson et al., 2009; Muratore et al., 2025; Sobel et al., 2025). Furthermore, minoritized sexual orientation has also been linked to higher levels of disordered eating in both men and women (Dotan et al., 2021; Matthews-Ewald et al., 2014).

We hypothesized that among women, ED psychopathology would be positively associated with sexual functioning problems, and this relationship would continue to be significant when adjusting for anxiety and depression symptoms and sexual attraction. We had no a priori hypotheses on the association between ED psychopathology and sexual functioning problems in men, given the lack of literature on sexual functioning problems in clinical populations with EDs.

Method

Participants

Participants were undergraduate students from two public universities in the Southeast (n = 477) and Southwest (n = 1709) in the United States. A small proportion of participants (4.4%) were removed from the initial data set while cleaning for the following reasons: (a) missing data (30% or more), (b) completing the survey in less than 5 min, (c) not providing gender or race, or d) due to duplicate entries. The data were subset into participants who identified their gender as women (n = 1488) or men (n = 650). See Table 1 for additional demographic information and group difference statistics.

Table 1.

Characteristics of the sample.

  Men (n = 646)
 Women (n = 1488)
 Test statistic
  M(SD) Range M (SD) Range  
Age 20.34 (4.20) 18–55 19.73 (3.75) 18-57 t(1111.86) = 3.13 (p < .001) d = .15
BMI 25.05(5.87) 13.64–60.68 24.92(5.91) 14.72-53.24 t(1208.90) = 1.99 (p < .001) d = .10
EDE-Q Global Score 1.73 (1.73) 0–6 2.43 (1. 68) 0–6 t(1388.41) = −8.84 (p < .001) d= −.40
Dietary Restraint 1.65 0–6 1.88 0–6 t(1976) = −2.67 (p = .01) d= −.13
Preoccupation and Eating Concern 0.67 0–6 1.09 0–6 t(1456.23) = −6.32 ( p < .001 ) d= −.28
Shape/Weight Overvaluation 1.53 0–6 2.53 0–6 t(1403.65) = −12.98 ( p < .001 ) d= −.58
Sexual Functioning 34.59 (13.88) 25–100 43.73 (18.36) 25–100 t(1473.23) = −12.04 (p < .001) d= −.53
Anxiety symptoms 0.98 (0.92) 0–4 1.39 (1.09) 0–4 t(1438.35) = −8.88 (p < .001) d= −.39
Depression symptoms 1.14 (1.05) 0–4 1.37 (1.09) 0–4 t(2112) = −4.37 (p < .001) d= −.21
 
 %
 n
%
 n
 
Race/Ethnicity         X2 (8,2128) = 32.64, p < .001, Cramer’s V = .07
 Asian or Pacific Islander 26.9 174* 17.7 263*  
 Black/African American 8.0 52* 11.3 168*  
 Hispanic or Latino 13.9 90* 19.0 282*  
 Native American/American Indian 0.5 3 0.4 6  
 Middle Eastern 1.5 10 1.1 16  
 Multiracial 17 110 17.5 260  
 White 31.0 200 31.6 468  
 Other 0.8 5 0.5 8  
 Prefer not to say 0.3 2 0.7 11  
Sexual Attraction         X2 (2,2043) = 102.30, p < .001, Cramer’s V = .22
 Attraction to Opposite Gender 78.6% 508* 60.2% 892*  
 Some Attraction to Either Gender 13.3% 86* 33.1% 490*  
 Attraction to Same Gender 5.4% 35* 2.2% 32*  
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*Indicates significant difference between men and women at the p = .05 level.

Participants who reported more than one racial or ethnic identity were classified as multiracial.

Procedures and measures

Study procedures were approved by the Institutional Review Boards at the University of Nevada, Las Vegas and University of South Alabama. Participants were recruited between March 2020 and May 2021 from introductory psychology courses, completing the study online for course credit using Qualtrics. All participants provided informed consent for their participation and were informed of the study’s purpose: to explore sexual and mental health in college students. Participants completed questionnaires measuring demographics, sexual behaviors and functioning, symptoms of depression, anxiety, mania, somatic symptoms, substance use, eating disorders, and gambling. All questionnaires were randomly counter balanced to account for order effects. Other papers published from this data set included a network approach comparing structures of internalizing symptoms and sexual functioning among people with and without history of sexual trauma (Chen et al., 2024); correlations between sexting and mental health (Borgogna et al., 2023); correlations between sensation seeking, substance use, compulsive sexual behavior, and use of online dating platforms (Jennings et al., 2023); and combined with another dataset, a psychometric analysis of the Brief Pornography Screen across identity groups (Borgogna et al., 2024). However, only one study has examined ED symptoms. In this study, the authors completed a psychometric analysis of the EDE-Q with regards to race/ethnicity and gender, but did not examine associations between ED symptoms and other constructs (Habashy et al., 2023).

Demographics

Participants reported demographics including age, race/ethnicity, and gender. Participants reported sexual attraction in response to “Which best describes your feelings?” on a scale from one (only attracted to females) to five (only attracted to males). Sexual attraction was reclassified as exclusively attracted to opposite gender, attraction to men and women (some degree of attraction to both genders) and exclusively attracted to the same gender. Participants were selected for inclusion who identified as cisgender men or women in response to “What is your current gender identity?” 29 transgender or gender diverse participants were excluded from the analyses as the number of people in this group (n = 29; 1.33% of total sample) was underpowered to test hypotheses.

The Eating Disorder Examination Questionnaire (EDEQ)

The Eating Disorder Examination Questionnaire, sixth edition (EDE-Q 6.0; Fairburn & Beglin, 1994), contains 28 items which measure ED thoughts and behaviors over the last 28 days, as well as self-reported height and weight. The scale has strong test-retest reliability in college students (Spearman’s rho= >.89; Rose et al., 2013).

The four-factor structure of the EDE-Q is largely unsupported (Jenkins & Rienecke, 2022), therefore alternate scoring methods have been proposed. Using the ten-item version of the measure derived through factor analyses of this data by Habashy and colleagues (2023), three subscales (dietary restraint, preoccupation and eating concern, and shape/weight overvaluation) were calculated. Global score was calculated as an average of the three subscales. Self-reported height and weight were used to calculate body mass index (BMI). Behavioral characteristics are reported in Supplement Table 1. The global score had excellent internal consistency (α=.91) for women and good internal consistency for men (α=.89) in this sample.

Sexual functioning problems

Participants completed the Medical Outcomes Study (MOS) Sexual Functioning Scale (Sherbourne, 1992) by rating how much of a problem the following areas of sexual functioning caused them: “lack of sexual interest,” “difficulty in becoming sexually aroused,” “unable to relax and enjoy sex,” and “difficulty in having an orgasm.” Participants rated each area on a one (not a problem) to four (very much of a problem) scale. Items were averaged and transformed to a 0-100 scale to create an overall score of sexual functioning problems, with higher scores indicating more sexual functioning problems.The scale has been used to assess sexual functioning in a wide variety of populations (Zebrack et al., 2010) and demonstrated good internal consistency in the present study (αwomen=.80; αmen=.81).

Depression and anxiety symptoms

The DSM-5-TR Self-Rated Level 1 Cross-Cutting Symptom Measure (Narrow et al. 2013) was used to assess depression and anxiety symptomatology. Participants rated symptoms of depression and anxiety on a five-point scale (0 = none or not at all to 4 = nearly every day). The two depression items were averaged to create an overall depression score and the three anxiety items were averaged to create an overall anxiety score. The measure has been determined to be an appropriate screener for psychopathology in college students (Bravo et al., 2018). The measure has been shown to have intraclass correlation coefficients in the “good” range or better (Narrow et al., 2013) and showed good internal consistency in the present study for the depression subscale (αwomen=.81; αmen=.83) and the anxiety subscale for women (α=.83), and in the acceptable range for men (α=.78).

Data analytic plan

Shapiro-Wilk tests were performed to test normality of the distribution of total sexual functioning scores (W=.85, p<.001). The distribution departed significantly from normality and was corrected using a natural log transformation. Outliers for age (z-score > 3) were removed from the sample. Other questionnaire data were normally distributed and contained no outliers.

Four hierarchical linear regressions were conducted to test associations between sexual functioning scores and ED psychopathology separately in women and men while adjusting for BMI, age, sexual attraction, anxiety, and depression symptoms. Step 1 included BMI, age, sexual attraction, anxiety, and depression symptoms. Step 2 added an ED psychopathology variable (i.e., EDE-Q global score, dietary restraint, preoccupation and eating concern, or shape/weight overvaluation) as a predictor.

Results

Correlations between sexual functioning and internalizing symptoms by gender

Bivariate correlations were conducted to test for an association between internalizing symptoms and sexual functioning in this sample. Among women, anxiety (r=.20, p<.001) and depression symptoms (r=.25, p<.001) had a weak positive correlation with sexual functioning problems (Supplement Table 2). Among men, anxiety (r=.19, p<.001) and depression symptoms (r=.22, p<.001) had a weak positive correlation with sexual functioning problems (Supplement Table 3). All EDE-Q subscales and global score were positively correlated with each other among women and men (Supplement Tables 2 & 3).

Sexual functioning problems and ED psychopathology among women

Among women, 73.2% reported any sexual functioning problems, with the most common problems endorsed as difficulties in having an orgasm (61.6%), inability to relax and enjoy sex (43.7%), lack of sexual interest (41.5%), and difficulties in arousal (36.9%).

Four hierarchical linear regressions were conducted to examine associations between ED psychopathology and sexual functioning in women, while adjusting for BMI, age, sexual attraction, anxiety and depression (Tables 2–5).

Table 2.

Associations between ED psychopathology and sexual functioning problems among women - global score (n = 1488).

Global Score R 2 R2 Change F (df) Sig F Change B SE p VIF
Step 1 0.12   28.49       <.001  
 Constant         3.48 0.07 <.001  
 Depression         0.10 0.01 <.001 1.83
 Anxiety         0.02 0.01 .23 1.78
 Age         0.00 0.00 .53 1.03
 BMI         0.00 0.00 .90 1.04
 Some Attraction to Either Gender         0.07 0.02 <.001 1.10
 Attraction to Same Gender         −0.14 0.07 .05 1.02
Step 2 0.12 0.00 25.47 .01     <.001  
 Constant         3.49 0.07 <.001  
 Depression         0.10 0.01 <.001 1.85
 Anxiety         0.01 0.01 .56 1.88
 Age         0.00 0.00 .47 1.02
 BMI         0.00 0.00 .36 1.15
 Some Attraction to Either Gender         0.08 0.02 <.001 1.10
 Attraction to Same Gender         0.13 0.07 .06 1.02
 Global Score         0.02 0.01 <.01 1.32
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Table 3.

Associations between ED psychopathology and sexual functioning problems among women - dietary restraint (n = 1488).

Dietary Restraint R 2 R2 Change F (df) Sig F Change B SE p VIF
Step 1 0.12   28.49       <.001  
 Constant         3.48 0.07 <.001  
 Depression         0.10 0.01 <.001 1.83
 Anxiety         0.02 0.01 .23 1.78
 Age         0.00 0.00 .53 1.03
 BMI         0.00 0.00 .90 1.04
 Some Attraction to Either Gender         0.07 0.02 <.001 1.10
 Attraction to Same Gender         −0.14 0.07 .05 1.02
Step 2 0.12 0.00 25.11 0.04     <.001  
 Constant         3.48 0.07 <.001  
 Depression         0.10 0.01 <.001 1.83
 Anxiety         0.01 0.01 .39 1.83
 Age         0.00 0.00 .57 1.03
 BMI         0.00 0.00 .56 1.10
 Some Attraction to Either Gender         0.08 0.02 <.001 1.10
 Attraction to Same Gender         −0.13 0.07 .06 1.02
 Dietary Restraint         0.01 0.01 .04 1.12
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Table 4.

Associations between ED psychopathology and sexual functioning problems among women - preoccupation and eating concern (n = 1488).

Preoccupation and Eating Concern R 2 R2 Change F (df) Sig F Change B SE p VIF
Step 1 0.12   28.71       <.001  
 Constant         3.48 0.07 <.001  
 Depression         0.10 0.01 <.001 1.83
 Anxiety         0.02 0.01 .24 1.78
 Age         0.00 0.00 .51 1.03
 BMI         0.00 0.00 .79 1.04
 Some Attraction to Either Gender         0.08 0.02 <.001 1.10
 Attraction to Same Gender         −0.14 0.07 .05 1.02
Step 2 0.12 0.00 26.06 <.01     <.001  
 Constant         3.49 0.07 <.001  
 Depression         0.10 0.01 <.001 1.85
 Anxiety         0.01 0.01 .57 1.86
 Age         0.00 0.00 .43 1.03
 BMI         0.00 0.00 .41 1.08
 Some Attraction to Either Gender         0.08 0.02 <.001 1.10
 Attraction to Same Gender         −0.14 0.07 .05 1.02
 Preoccupation and Eating Concern         0.01 0.01 <.01 1.21
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Table 5.

Associations between ED psychopathology and sexual functioning problems among women - shape/weight overvaluation (n = 1488).

Shape/Weight Overvaluation R 2 R2 Change F (df) Sig F Change B SE p VIF
Step 1 0.12   28.49       <.001  
 Constant         3.48 0.07 <.001  
 Depression         0.10 0.01 <.001 1.83
 Anxiety         0.02 0.01 .23 1.78
 Age         0.00 0.00 .53 1.03
 BMI         0.00 0.00 .90 1.04
 Some Attraction to Either Gender         0.07 0.02 <.001 1.10
 Attraction to Same Gender         −0.14 0.07 .05 1.02
Step 2 0.12 0.00 24.61 0.25     <.001  
 Constant         3.48 0.07 <.001  
 Depression         0.10 0.01 <.001 1.89
 Anxiety         0.01 0.01 .35 1.87
 Age         0.00 0.00 .48 1.03
 BMI         0.00 0.00 .61 1.18
 Some Attraction to Either Gender         0.07 0.02 <.001 1.10
 Attraction to Same Gender         −0.14 0.07 .05 1.02
 Shape/Weight Overvaluation         0.01 0.01 .25 1.35
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Both steps of the regressions with global score (Step 1: R2=.12, F(6, 1,316)=28.49, p<.001; Step 2: R2=.12, F(1, 1,315)=6.63, p<.001), dietary restraint (Step 1: R2=.12, F(6, 1,316)=28.49, p<.001; Step 2: R2=.12, F(1, 1,315)=4.42 p<.001), preoccupation and eating concern (Step 1: R2=.12, F(6, 1,316)=28.71, p<.001; Step 2: R2=.12, F(1, 1,315)=26.06, p<.001), and weight and shape overvaluation (R2=.12, F(6, 1,316)=28.49, p<.001) were significant. However, the change in the proportion of variance accounted for by Step 2 with EDE-Q global score (ΔR2=.004), dietary restraint (ΔR2=.003), or preoccupation and eating concern (ΔR2=.01) was very small. The change in the proportion of variance explained by Step 2 for weight and shape overvaluation was not significant (ΔR2=.001, p=.25).

Sexual functioning problems and ED psychopathology among men

Among men, 49.8% reported any sexual functioning problems, with the most common problems endorsed as lack of sexual interest (32.1%), inability to relax and enjoy sex (28.1%), difficulties in having an orgasm (26.3%), and difficulties in arousal (23.8%).

Four hierarchical linear regressions were conducted to examine associations between ED psychopathology and sexual functioning in men, while adjusting for BMI, age, sexual attraction, anxiety and depression (Table 6, 7, 8 and 9).

Table 6.

Associations between ED psychopathology and sexual functioning problems among men - global score (n = 646).

Global Score R 2 R2 Change F (df) Sig F Change B SE p VIF
Step 1 0.15   16.34       <.001  
 Constant         3.25 0.08 <.001  
 Depression         0.07 0.02 <.001 1.53
 Anxiety         0.03 0.02 .05 1.54
 Age         0.00 0.00 .51 1.10
 BMI         0.00 0.00 .46 1.09
 Some Attraction to Either Gender         0.17 0.04 <.001 1.03
 Attraction to Same Gender         0.19 0.06 <.001 1.03
Step 2 0.17 0.03 17.35 <.001     <.001  
 Constant         3.27 0.07 <.001  
 Depression         0.06 0.02 <.001 1.55
 Anxiety         0.03 0.02 .15 1.57
 Age         0.00 0.00 .25 1.11
 BMI         0.00 0.00 .37 1.25
 Some Attraction to Either Gender         0.16 0.04 <.001 1.04
 Attraction to Same Gender         0.17 0.05 <.01 1.04
 Global         0.05 0.01 <.001 1.22
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Table 7.

Associations between ED psychopathology and sexual functioning problems among men - dietary restraint (n = 646).

Dietary Restraint R 2 R2 Change F (df) Sig F Change B SE p VIF
Step 1 0.15   16.34       <.001  
 Constant         3.25 0.08 <.001  
 Depression         0.07 0.02 <.001 1.53
 Anxiety         0.03 0.02 .05 1.54
 Age         0.00 0.00 .51 1.10
 BMI         0.00 0.00 .46 1.09
 Some Attraction to Either Gender         0.17 0.04 <.001 1.03
 Attraction to Same Gender         0.19 0.06 <.001 1.03
Step 2 0.16 0.01 15.31 <.001     <.001  
 Constant         3.25 0.07 <.001  
 Depression         0.07 0.02 <.001 1.54
 Anxiety         0.03 0.02 .06 1.54
 Age         0.00 0.00 .34 1.11
 BMI         −6.11 0.00 .98 1.17
 Some Attraction to Either Gender         0.16 0.04 <.001 1.03
 Attraction to Same Gender         0.19 0.06 <.001 1.03
 Dietary Restraint         0.02 0.01 <.01 1.09
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Table 8.

Associations between ED psychopathology and sexual functioning problems among men - preoccupation and eating concern (n = 646).

Preoccupation and Eating Concern R 2 R2 Change F (df) Sig F Change B SE p VIF
Step 1 0.15   16.34       <.001  
 Constant         3.25 0.08 <.001  
 Depression         0.07 0.02 <.001 1.53
 Anxiety         0.03 0.02 .05 1.54
 Age         0.00 0.00 .51 1.10
 BMI         0.00 0.00 .46 1.09
 Some Attraction to Either Gender         0.17 0.04 <.001 1.03
 Attraction to Same Gender         0.19 0.06 <.001 1.03
Step 2 0.16 0.02 15.79 <.001     <.001  
 Constant         3.26 0.07 <.001  
 Depression         0.07 0.01 <.001 1.54
 Anxiety         0.03 0.02 .15 1.58
 Age         0.00 0.00 .42 1.10
 BMI         0.00 0.00 .908 1.13
 Some Attraction to Either Gender         0.17 0.04 <.001 1.03
 Attraction to Same Gender         0.19 0.05 <.001 1.03
 Preoccupation and Eating Concern         0.04 0.01 <.001 1.10
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Table 9.

Associations between ED psychopathology and sexual functioning problems among men - shape/weight overvaluation (n = 646).

Shape/Weight Overvaluation R 2 R2 Change F (df) Sig F Change B SE p VIF
Step 1 0.15   16.34       <.001  
 Constant         3.25 0.08 <.001  
 Depression         0.07 0.02 <.001 1.53
 Anxiety         0.03 0.02 .05 1.54
 Age         0.00 0.00 .51 1.10
 BMI         0.00 0.00 .46 1.09
 Some Attraction to Either Gender         0.17 0.04 <.001 1.03
 Attraction to Same Gender         0.19 0.06 <.001 1.03
Step 2 0.17 0.03 17.20 <.001     <.001  
 Constant         3.29 0.07 <.001  
 Depression         0.06 0.01 <.001 1.56
 Anxiety         0.02 0.02 .16 1.57
 Age         0.00 0.00 .28 1.11
 BMI         0.00 0.00 .33 1.27
 Some Attraction to Either Gender         0.15 0.04 <.001 1.05
 Attraction to Same Gender         0.16 0.05 <.01 1.05
 Shape/Weight Overvaluation         0.04 0.00 <.001 1.27
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Both steps of the regressions with global score (Step 1: R2=.14, F(6, 580)=16.34, p<.001; Step 2: R2=.17, F(1, 579)=17.35, p<.001), dietary restraint (Step 1: R2=.15, F(6, 580)=16.34, p<.001; Step 2: R2=.16, F(1, 579)=15.31, p<.001), preoccupation and eating concern (Step 1: R2=.15, F(6, 580)=16.34, p<.001; Step 2: R2=.16, F(1, 579)=15.97, p=.001) and weight and shape overvaluation (Step 1: R2=.15, F(6, 580)=16.34, p<.001; Step 2: R2=.17, F(1, 579)=15.97, p<.001) were significant. The change in the proportion of variance accounted for by Step 2 with EDE-Q global score (ΔR2=.03, dietary restraint (ΔR2=.01); preoccupation and eating concern (ΔR2=.02) and weight and shape overvaluation (ΔR2=.03) was small; however, it suggests that ED psychopathology predicted variance in sexual functioning above and beyond internalizing symptoms in men.

Discussion

Sexual functioning is an important factor in determining quality of life (Cabo et al., 2024; Nappi et al., 2016). The current study fills an important gap in the literature and is the first to explore the relationship between sexual dysfunction and ED psychopathology while accounting for internalizing symptoms, as well as the first to study the relationship between sexual functioning and ED psychopathology in men. The positive association observed between ED symptoms and sexual functioning problems was consistent with our hypothesis and previous research (Castellini et al., 2012; Pinheiro et al., 2010; Price et al., 2020); however, caution should be made when interpreting findings for men and women in terms of clinical significance due to small effect sizes.

Among women, when adjusting models for anxiety and depression symptoms, the relationship between ED pathology and sexual functioning was statistically significant although effect sizes were largely negligible, suggesting potentially low clinical significance. Depression symptoms, not anxiety symptoms, were significant predictors of sexual functioning problems. This finding suggests that the elevated sexual functioning problems among women with EDs observed in the literature may be best explained as a function of co-occurring depressive symptoms, with potentially minor influence from ED pathology specifically. This is consistent with previous findings that depression has been associated with increased sexual functioning problems (Bradford & Meston, 2006; Cyranowski et al., 2004; Fabre & Smith, 2012; Stevens et al., 2024). Previous literature has found that sexual dysfunction is higher among people with ED pathology, however, these studies have not controlled for co-morbid depressive symptoms (e.g. Dunkley, Gorzalka, et al., 2020; Pinheiro et al., 2010, Castellini et al., 2012, Gonidakis et al., 2015). Our findings suggest the possibility that some of the findings in the current literature on sexual dysfunction and ED symptoms among women may be confounded because depression was not controlled for in models or examined as a mediator. Future research should seek to replicate this finding in non-clinical and clinical samples to better understand the potential explanatory role of depressive pathology compared to ED symptomatology.

Among men, when adjusting models for anxiety and depression symptoms, the relationship between ED pathology and sexual functioning was statistically significant; however, effect sizes were small. This suggests that ED pathology uniquely accounts for a small amount of variance (1-3%) in sexual functioning problems beyond co-occurring internalizing pathology. A possible pathway could be through the drive for muscularity or the pursuit of a “masculine” muscular body-type, which is often elevated in men with EDs (Lavender et al., 2017). Furthermore, some young men report feeling inspired by the hyper-masculine ideals often portrayed in pornography (Mattebo et al., 2012), which could impact sexual functioning, as well as influence the drive for muscularity, and thus, disordered eating. Future studies should seek to replicate this finding, including effect sizes, and explore the processes that could contribute to sexual functioning problems in a clinical sample of men with EDs, including using ED assessments tailored to men, such as the Eating Disorder Assessment (Stanford & Lemberg, 2012) and the Eating Pathology Symptoms Inventory (Forbush et al., 2013), which measure both standard and muscularity-oriented ED symptoms and have been noted by Lavender and colleagues (2017) as appropriate for assessing EDs in men. Providers offering interventions for sexual dysfunction among men may wish to assess and address problematic eating behaviors or cognitions that may worsen or maintain sexual functioning difficulties.

Although not the focus of inquiry in this study, it may be noted that sexual attraction predicted sexual functioning in this sample. Among men, compared to exclusively being attracted to women, Some attraction to either gender or exclusively attracted to the same gender was significantly associated with higher sexual functioning problems, consistent with previous research (Flynn et al., 2017). Among women, compared to exclusively being attracted to men, identifying as exclusively attracted to women was associated with lower sexual functioning problems, consistent with previous research (Muratore et al., 2025). Furthermore, an analysis of variance showed that EDE-Q global scores differed by sexual attraction for women (F(2,1403)=7.86, p<.001; Supplement Table 4), but not for men (F(2,626)=2.01, p=.14; Supplement Table 5). The current study contributes to the larger body of literature regarding sexual attraction and sexual functioning (see reviews in Bondarchuk-Mclaughlin & Anderson, 2025; Cheng, 2022; Croteau & Morrison, 2025; Flynn et al., 2017). Furthermore, consistent with previous research, women who identified as bisexual, or some degree of attraction to both men and women, reported higher eating disorder psychopathology when compared to women who identify as heterosexual or same gender attraction (Dotan et al., 2021). Future studies should seek to replicate these findings, include factors such as stigma, identity conflict, and sociocultural pressures, and explore unique variables related to sexual orientation, sexual functioning, and ED pathology (for further information on sexual orientation and ED pathology, see reviews in Dotan et al., 2021; Cao et al., 2023; Morrison et al., 2020).

The current study benefited from a large (n = 2,182) and racially/ethnically diverse sample collected from two different regions in the United States. However, the analytic sample was limited to cisgender men and women, limiting generalizability to other gender identities. Future studies should explore the relationship between ED symptoms and sexual functioning problems in a more gender diverse sample, particularly given literature suggesting that this population is at risk for greater ED pathology (e.g., Rasmussen et al., 2023). Furthermore, future studies should also use an updated measure of sexual functioning, such as the Arizona Sexual Experience Scale (McGahuey et al., 2000; recent validation: Ballester-Arnal et al., 2024). In addition, the use of cross-sectional data prevented making causal inferences about the relationship between ED symptoms and sexual functioning problems. Additional longitudinal studies should be conducted to further explore potential mechanisms for these relationships. It is important to note that ED psychopathology accounted for a small proportion of the variance in sexual functioning problems among men and, although statistically significant, likely had negligible contributions to the variance among women, possibly due to the large sample size. Replication is necessary in order to explore the potential clinical implications of these findings, as the effects observed in this study were small. It is possible that this may translate to lower practical significance; however, it is also possible that if associations between ED pathology and sexual functioning are bidirectional, intervening on symptoms improving either pathology could have beneficial effects on the other that amplify over time. Additionally, the pervasiveness of sexual functioning problems within this population underscores the importance of screening for these behaviors in clinical settings. Furthermore, the authors would like to highlight the potential influence of gendered sexual socialization and sex education on sexual functioning as additional considerations for study (Grose et al., 2014; Hall et al., 2016; further review of gender roles and physiology see Arbanas et al., 2018). Future research should include a measure of comprehensive sexual education to better understand the findings in the context of sex education. Finally, it is important to note that it is unclear if these results generalize to a clinical sample of people with EDs.

This study provided novel evidence that sexual functioning problems in women were better accounted for by co-occurring depressive symptoms; whereas in men, ED pathology significantly accounted for small differences in sexual functioning scores. Future studies should pursue replication of these findings and further exploration of the relationship between sexual functioning problems, especially among men with EDs.

Supplementary Material

SHS Supplement RR2.docx
WIJS_A_2553850_SM2799.docx (18.9KB, docx)

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Authors contributions

MN conceptualized research question, performed data analyses, and contributed to writing and editing the manuscript. SWK conducted data collection and contributed to writing and editing. MG contributed to writing and editing. NCB conducted data collection and contributed to writing and editing. KCP contributed to conceptualization of research question, data analysis, writing, and editing.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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