Today, we are going to take you on a journey exploring the intersection of eating disorders and sexuality. This episode will not only be helpful for clinicians but also for people who have struggled to experience pleasure in their body stemming from complicated relationships with food and body image. We sit down with Kelli Young, the only Certified Sex Therapist in Canada with a combined expertise in the field of eating disorders and sexuality. Kelli has worked in the field of Eating Disorders for more than 30 years, both in the public and private sectors. She has authored publications in professional journals and popular media, and she has presented internationally on topics related to eating disorders, couples, and sexuality. Kelli has a private practice in Toronto focused on relationship therapy and sex therapy. Are you ready to discover ways to support others or rediscover your own path to pleasure after navigating a complex relationship with food? Let's begin.
Today, we are going to take you on a journey exploring the intersection of eating disorders and sexuality. This episode will not only be helpful for clinicians but also for people who have struggled to experience pleasure in their body stemming from complicated relationships with food and body image. We sit down with Kelli Young, the only Certified Sex Therapist in Canada with a combined expertise in the field of eating disorders and sexuality. Kelli has worked in the field of Eating Disorders for more than 30 years, both in the public and private sectors. She has authored publications in professional journals and popular media, and she has presented internationally on topics related to eating disorders, couples, and sexuality. Kelli has a private practice in Toronto focused on relationship therapy and sex therapy. Are you ready to discover ways to support others or rediscover your own path to pleasure after navigating a complex relationship with food? Let's begin.
Show notes:
Eating Disorders versus Disordered Eating
Eating Disorders happen across genders
Common types of disorders
Survival vs Sex
Trauma history
Vaginismus
Pelvic pain
Eating disorders and their impact on relationships
Reclaiming your relationship with your body and pleasure
Where to find Kelli Young:
https://kelliyoungtherapy.com/
Support for Eating Disorders:
https://nedic.ca/
[THEME MUSIC]
[00:00:08] Michelle: today I'm joined by Kelli Young, a certified sex therapist who's worked in the field of eating disorders for more than 30 years. And whenever I struggle with clients that are avoiding connecting with their body and connecting with pleasure and also have a history of an eating disorder, I turn to her to see if there's maybe something I'm not doing that she'd be able to point out. This episode will be particularly helpful for clinicians who work in the sex therapy fields. I hope it can also provide validation to listeners who've had a history of eating disorders and wanna know where to begin if they are also experiencing sexual concerns. A hint, it starts with allowing yourself to get comfortable with pleasurable non-sexual activities first.
[00:00:54] Kelli: Allowing your body to be touched and to experience the pleasurable sensations of physical touch, starting with non-sexual touch. So for example, going for a massage with a registered massage therapist, and then building in the more sexual pieces. Even doing things like yoga is another way to just connect with your body, feel your body move, and notice the pleasurable sensations that come from that.
[00:01:25] Michelle: People with eating disorders often struggle with experiencing desire and arousal, and that's to be expected. The body can't prioritize sex when it's trying to survive.
[00:01:34] Kelli: Being at a low weight, for example, impairs the physiological functioning of the sex organs and the body when it's in a starved state, goes into sort of an emergency mode just in order to keep the person alive. So in this state, the sex hormones, they sort of go out the window.
[00:01:52] Michelle: Before you can tackle the sex piece, you have to be able to give yourself permission to nourish yourself with food before you can nourish yourself with sexual pleasure. And that means recovery comes first.
[00:02:05] Kelli: First step is. Treatment for the eating disorder, and then they come back when they're in recovery or they're in a more stable place, that's when you can start working on the sexual pieces. We just can't do that work when people are really, really sick. We absolutely cannot do that work.
[00:02:23] Michelle: As a sex therapist, my work often involves supporting people navigating complicated relationships with their body. I see women in their early thirties wanting to find a romantic partner and to start a family, but they don't know where to start because the majority of their life has been spent controlling their access to pleasurable experiences, including sex. If they've had sex, it's often been non-consensual or painful and left them feeling broken, afraid of sex and riddled with feelings of shame and guilt. Many of them have avoided dating in romantic interest from others to protect themselves.
[00:03:00] Kelli: Quite often we see people who have been ill for a really long time, so it might have started in their teens and they might have missed those developmental milestones, right, that first kiss. The experimentation, playfulness around sexuality. And so then even if they were to years later recover from their eating disorder and be ready to engage in sexual relationships, they have missed all that, they're at the level of 13 year. Right? So that can be incredibly anxiety provoking. For sure.
[00:03:35] Michelle: It bears mentioning that the majority of clients that I see with eating disorders are white, heterosexual, affluent, cisgender women, and that is due to having to pay for private psychotherapy out of pocket.
[00:03:48] Kelli: I don't want it to sound like eating disorders only happen in women. Approximately 25% of men and males, and also a significant number of trans people...
[00:04:00] Michelle: Transgender men and women have been shown to be over four times more likely to receive an eating disorder diagnosis, and two to three times more likely to engage in behaviors such as diet, pill, use, vomiting, or laxative use compared to their cisgender counterparts. There is a scarcity of research that looks at intersectionality and how race, gender, sexual orientation, and weight can play a part in eating disorder recovery. As a clinician, it's very important to not forget to ask about a history of trauma.
[00:04:35] Kelli: Upwards of 50% of people with eating disorders have a previous trauma history, so we're dealing with all the aftermath of trauma and the effects of the trauma on people's bodies and on their sex lives.
[00:04:48] Michelle: Here's my conversation with Kelli Young, registered psychotherapist, marriage and family therapist and occupational therapist.
[00:05:06] Kelli: So the two most common types of eating disorders are called anorexia nervosa and bulimia nervosa. And then even those eating disorders are split up into smaller categories. So let me just start with anorexia nervosa. So anorexia nervosa involves severe restriction of food, which leads to a significantly low body weight. In addition to that, there is an intense fear of gaining weight or becoming fat, despite the fact that the person is very much emaciated. Another feature is an overvaluation of weight and shape, so that the person's appearance becomes the most significant portion of their self-worth or their self-esteem. And then the final major criteria for anorexia would be body image disturbance. That's a cardinal feature of anorexia. So the person is unable to recognize their body as too thin, or there's a lack of recognition of the seriousness of their currently low weight. So usually on a rational level, they know like if you weigh 60 pounds at five seven, that that is underweight, that most people weigh more than that, but when they look in the mirror and they see their body, their body image is distorted. It's like those fun house mirrors that you see at circuses, right, where you can look in the mirror and if you don't have an eating disorder or any kind of body image distortion, you see what the mirror shows you, but they would see somebody that they would view as too fat, too big, too ugly, what have you, despite what the scale says. There are two different types of anorexia and one of them looks a lot like bulimia. So there's the binge eating and purging type of anorexia and the restricting type of anorexia. So in the binge eating purging type, the person engages in recurrent episodes of binge eating, which is eating an excessive amount of food in a very short period of time with a feeling of being totally out of control during that experience. Or the person also has purging behaviors and purging behaviors can be things like vomiting, laxative abuse, excessive exercise, or diuretics. Then there's restricting type, which is essentially just restricting your food without those binge eating and purging qualities. So similarly, bulimia nervosa, which is the other main type of eating disorder, is very similar to the binge eating, purging type of anorexia only that the person is not necessarily underweight. In fact, they're not underweight, and in many cases they're actually average weight or even a little bit overweight. Bulimia includes recurrent episodes of binge eating and also recurrent inappropriate compensatory behaviors like the vomiting, periods of fasting, extreme exercise or laxative abuse, what have you.
[00:08:09] Michelle: Right. So you would compensate from a binge with doing these other behaviors like using a laxative?
[00:08:18] Kelli: Exactly. People feel very shameful over having binge eaten this large amount of food and to compensate, they would then do something like fast for a couple of days, or vomit, or use laxatives or what have you in order to prevent weight gain. So people who don't, who binge and then don't do those compensatory behaviors would often fall into the category of binge eating disorder. They binge, they eat an excessive amount of food, same kind of out of control feeling. They don't compensate in any way for the binge, and then they end up gaining a lot of weight. So people with binge eating disorder tend to be quite overweight or obese.
[00:08:59] Michelle: Right. And it sounds like depending on the disorder that you are dealing with, that a person's relationship to sex and the struggles that they may have can be different.
[00:09:15] Kelli: Absolutely. Even the personality types tend to be different. So for example, people with anorexia tend to be sort of over controlled. Food becomes the main way that they can control their environment. Whereas people with bulimia tend to go to the opposite extreme. They tend to be more impulsive in their behavior, and they tend to engage in more high risk sexual behaviors, which puts them at higher risk of sexually transmitted infections, unplanned pregnancies, regret and shame after sexual experiences. Lack of respect for one's body can lead somebody to engage in these behaviors, even though they know that it's risky and that you know, they're putting themselves at risk of getting pregnant or getting a sexually transmitted infection, they often feel like their body is not meant to be respected. It's meant to be abused or mistreated, particularly for people who have a sexual abuse history. And we know from the literature that upwards of 50% of people with eating disorders have a previous trauma history. So we're dealing with all the aftermath of trauma and the effects of the trauma from people's bodies and on their sex lives. Let's just look at the physiological piece cuz that's like a massive impact unto itself. So, for example, starvation, emaciation, malnutrition, electrolyte imbalance, purging, excessive exercise. All of these behaviors that go along with most of these eating disorders, they all can have significant and detrimental effect on one's sexuality on our sexual response and sexual functioning more globally. So being at a low weight, for example, impairs the physiological functioning of the sex organs and the hormones that are responsible for sexual response. And the body, when it's in a starved state, goes into sort of an emergency mode just in order to keep the person alive. So the body's much more concerned in that state with its most vital functions such as keeping the heart beating, making sure the lungs are filling with oxygen or, and what have you. So in this state, the sex hormones, they sort of go out the window. They're considered somewhat of a luxury in this emergency state, and they shut down. So as a result, people experience incredibly low sex drive or decreased sexual desire. It's almost universal. Women who are underweight so in the anorexia category will lose their menstrual periods, which can impair fertility and have a whole bunch of other consequences. And psychological emotional consequences. There's a major lack of vaginal lubrication, which can lead to quite a lot of pain and irritation with any kind of sexual activity, particularly penetrative sexual activities can lead to small tears, which can make the person much more prone to vaginal infections or urinary tract infections. Arousal mechanisms are impaired, so the person has difficulty getting turned on and difficulty getting up to that heightened state of arousal and orgasm, and which is the muscles in the pelvic floor surrounding the vaginal opening become so tense that they effectively close up the vaginal opening. So penetrative activities become exceptionally difficult or painful, and vaginismus is very, very common in people with anorexia. I don't want it to sound like eating disorders only happen in women. Cause we're talking primarily about vaginas and vulvas and what have you. Approximately 25% of men and males and also a significant number of trans people with eating disorders...
[00:13:28] Michelle: I would say that that's what I've seen in my practice with people who are struggling with anorexia, is that there's been either current or previous pain associated with insertion, and then that sort of turns into a real fear around having sex, so a lot of the work that we're doing is really trying to help understand some of the fear that's coming up for them. But you're right, like lots, lots of vaginismus in the clients that I see and it kind of makes sense cuz the body is trying to protect itself from pain, right? So yeah, it would tighten up because it doesn't want you to get hurt.
[00:14:24] Kelli: And then if we look more to the bulimia side of things, the repetitive vomiting leads to very swollen glands in the face and the neck. Lots of cavities, teeth breaking, crumbling, falling out, bad breath. And all of this just exacerbates the poor body image and self-image that people have.
[00:14:44] Michelle: And so like for you when you are working with people. When you start asking them about sex and their relationship to sex, what is that like?
[00:14:56] Kelli: I think for many people it's actually a relief. I mean, what we know to be true in healthcare in general is that patients and clients often have sexual concerns and healthcare professionals often don't ask, particularly in the medical realm, right? In hospitals and primary healthcare, generally eating disorder or not, quite often people's sexual healthcare concerns go unaddressed. So even in an eating disorder program where the major focus is the treatment of the eating disorder, when you ask about the sexual effects or sexual concerns, most often people feel very relieved and it provides a forum for them to be able to talk about the many ways in which their sexual lives or sexual self-esteem is affected by and affect their eating disorder behavior.
[00:15:49] Michelle: What is it that you've seen that has come up in terms of the emotional impact and effects of eating disorders on people's sex lives?
[00:15:58] Kelli: Like if we talk specifically about people with anorexia, they have a very negative body image and distorted body image as we've talked about. So they feel fat, they feel ugly, disgusting, and they tend to have significant feelings of shames about their body and often feel like they need to cover up with big and baggy clothing. So being naked or in various states of undress as we often are when we are being sexual, is especially difficult for people that can feel really, really quite vulnerable, especially for people who have a trauma history. Sexual anxiety and self-consciousness makes it very difficult to relax and to focus on sexual sensations, and then thats the physiological dampening effects on arousal and orgasm that we've already talked about. I think in order to even get anywhere with affecting any kind of change in people's body image, the initial focus needs to be on treatment for the eating disorder because you can't just tell somebody, you know, you gotta just change the way that you think about your body. It doesn't work. When it's a very serious eating disorder, people really need treatment focused on that, focused on normalization of eating patterns, medical stability, cuz people are very often, very medically unstable. Their electrolytes are all out of whack. They can be at high risk of heart attack. So medical stability is really critical and really we can't work on that unless they're involved in intensive, often hospital-based type of treatment, weight restoration for people with anorexia. We're not gonna get anywhere in helping them to normalize or improve their satisfaction with sexuality if they're extremely emaciated. So that needs to be approached.
[00:17:51] Michelle: And I imagine that can take years for some people, right? And I don't know this for sure and I'll ask you, but I imagine in, let's say hospitals that have programs that many of the people that are inpatients are at that age where people are like starting to date or I don't know, like I imagine people to be like in their teens and mid twenties to thirties or something around that age, is that correct?
[00:18:25] Kelli: We actually see people with eating disorders across the entire age spectrum. Ah, so no, not necessarily. Average age is kind of mid twenties, but we see people of all ages quite often. We see people who have been ill for a really long time, so it might have started in their teens and they might have missed those developmental milestones, right, that first kiss. The experimentation, playfulness around sexuality. And so then even if they were to years later recover from their eating disorder and be ready to engage in sexual relationships, they have missed all that and it's like starting at the level of 13 year. Right? So that can be incredibly anxiety provoking.
[00:19:11] Michelle: For sure. Do you come up against that where people are saying, but I wanna learn about this other stuff. Like I wanna go date, I wanna do these things. And then, you know, you're like, yeah, well you can't do any of those things until you start focusing on the medical piece. Cuz it's quite dangerous.
[00:19:29] Kelli: I don't see that a lot in anorexia because people that I see in intensive therapy are so medically ill that they're not usually saying things like, I wanna go out and date. In fact, more than not, they're quite fearful about that. And, you know, motivation to recover. We see a lot of ambivalence around recovery, particularly for people with anorexia cause it means giving up the sickness. More often than not, people with bulimia are very motivated to give up the eating disorder because it's egosyntonic.
[00:20:04] Michelle: What is egosyntonic? What does that mean?
[00:20:06] Kelli: It feels good. Egodystonic means it feels bad, it doesn't fit with who they want to be. So most people don't enjoy the experience of binging. Most people don't enjoy the experience of vomiting or taking a whole bunch of laxatives. They do it because they feel out of control and, and it's to compensate for the binging behavior. It also serves to manage unwanted feelings, impulse control, that kinda thing. So, no, I don't usually see people. When they're really, really underweight saying, I just wanna get back into a relationship. But they do wanna get back into their lives. People want to live normal, healthy lives and to have relationships, but sometimes it's difficult for them to connect the dots in knowing that they need to do this intensive eating disorder of therapy piece of work before they're gonna be able to really engage meaningfully in relationships and in their lives more generally. When they've done that piece of work and they're in recovery and we can start to shift our attention to other aspects of enjoyment, pleasure being in their lives. So we wanna look at other ways of feeling pleasure, for example. Practicing mindfulness, right? Mindfulness is about being in the moment, being in one's body, just noticing without judgment what is happening in their body. That's a really, really important skill for somebody who has been so disconnected from the their bodies, right? And then practicing feeling more safe and more comfortable in relationships that don't have necessarily a sexual context can be another helpful strategy. So for example, eating with friends at a restaurant, being in tighter or more form fitting clothing in various states of undress in a nonsexual way. So for example, on a beach, in a pool at a spa, experimenting with and allowing non-sexual types of touch, like going for a massage with a registered massage therapist,
[00:22:23] Michelle: or like maybe getting your nails done,
[00:22:25] Kelli: getting facials, allowing your body to be touched and to experience the pleasurable sensations of physical touch without that really vulnerable piece and that worry about being hurt. In some ways that can be, it's like sort of like a hierarchy, like starting with non-sexual touch and then building in the more sexual pieces. Even doing things like yoga, right? Restorative yoga is another way to just connect with your body, feel your body move and notice the pleasurable sensations that come from that.
[00:23:04] Michelle: Yeah, it's been such a challenge in my practice. Really trying to encourage people to just, like you said, start small, right? Where it's go get a pedicure or do like a hobby that you like to do things that actually maybe in the past they used to feel pleasure with. There's a lot of work that goes into people giving themselves permission to go and do this thing for themself that feels good.
[00:23:44] Kelli: And then doing things for themselves that feel good sexually, I think starts with self pleasuring. Learning about what feels good sexually on their own before they introduce a partner or partners. And so I always encourage my clients to experiment with self-pleasure and start to notice what feels good on their own so that when they're ready to introduce a partner or partners, they know themselves what feels good and they can help direct their partner in that kinda a way. And then there's a hierarchy within the partner relationships as well. So we don't wanna go right necessarily to genital pleasuring, especially for people who have a trauma history. We wanna start at a point that they feel comfortable. So it could be quite simply an arm around the shoulder, an arm around the waist, right? Even that for somebody who has body image concerns, an arm around the waist can feel particularly frightening, vulnerable, and then all focus goes to their body image. So we really wanna work with them to set up a hierarchy of intimate behaviors, intimate touch. Both alone and with a partner so that they're feeling all along like, this isn't gonna hurt physically or otherwise. This is gonna feel okay. And going on a date for somebody who struggled with an eating disorder is so complicated on so many levels, right? Often on a date it involves food. So we're working on that level, like how you gonna manage the food piece? And then you're layering on top of that, the relationship piece, the self-image piece, the sexual piece. It's all so complicated. So we move really slowly and. In a hierarchical fashion.
[00:25:47] Michelle: And that nothing has to happen unless you want it to happen. Right? And really encouraging patience, because sometimes I will have people who just kind of jump right in. They go from zero to a hundred because they're like, okay, I need to get this done. Like I need to finally have my sexual debut, which aka for some people is like losing their virginity and it's like, okay, you know, you've tried that before. Didn't go very well. There was a lot of fear. There was a lot of pain. Let's try this in a different way. But people get so, stuck on the beginning part and you can't skip it. The part where you introduce self-pleasure or become friends with your body, with your vulva.
[00:26:34] Kelli: Partners. We haven't talked at all about partners, but partners. There's a whole other realm of issues that goes on for partners so they can feel really quite rejected. Especially for partners who have had a sexual relationship with their partner before the development of the eating disorder. They can sort of feel like in competition with the eating disorder because it takes up so much space in their lives. Partners worry about hurting them physically. Working in relationship therapy and couples therapy can be a really important piece so that we're working not only with the person who has or who has had the eating disorder, but with their partners who have you know, a whole host of other issues, it becomes almost like an unhappy threesome. The eating disorder is like a third identity in this relationship.
[00:27:29] Michelle: Yeah. And I imagine the work would have to be trying to take that third party, the eating disorder out of the relationship. And then I guess if the relationship, let's say there was always an eating disorder within it, and sex wasn't pleasurable. It also like you would have to start from the bottom and work your way up to create a new sex life.
[00:27:59] Kelli: Yeah. Which we're doing with many couples with or without eating disorders, right. When they have had relationships that aren't working, a history of trauma, we're often doing that, starting from the bottom, or you know, trying to work at developing a different kind of relationship than the one that they've had before. So I often use a lot of sensate focus. I think you've done a podcast actually on sensate focus, but it's non-demand pleasuring, working on that hierarchy together as a couple, starting from a place of what feels safe and then looking at what feels pleasurable together. You wanna start over to help that person and their partners to become safe, comfortable, and experience pleasure in a sexual realm.
[00:28:51] Michelle: Yeah, and I imagine that patience is a really big part of that, and also that it's a lifelong journey that isn't just going to change, you know, in a week or in a month, or even a year or more. Right? I think just even for anybody, sex is a journey through the lifespan, right? There's a lot of work and I imagine it also requires two people in a relationship to be working together.
[00:29:24] Kelli: Yeah, for sure.
[00:29:25] Michelle: Say you're struggling, either you are struggling with your relationship to food, or maybe you're a therapist out there that has some clients who. Have some disordered eating or an eating disorder where do you begin?
[00:29:40] Kelli: Well, the short answer is that depends. It depends on the person who's walking in your door, right? So if the person who comes into your door is, let's say, has bulimia, they're average weight, their symptoms, their binging and purging happen relatively infrequently. Most areas of their life are intact. They have a job or they're in school, or they are otherwise in their lives happily. Then I think it's reasonable to expect that you can start on this sexual level. But if you have somebody who comes into your office who is severely underweight, not managing in most areas of their lives, is medically unstable, first step is treatment for the eating disorder, and then they come back when they're in recovery or they're in a more stable place, that's when you can start working on the sexual pieces. We just can't do work when people are really really sick. We absolutely cannot do that work.
[00:30:39] Michelle: So when they're not really, really sick and they come into your office and they haven't had sex with somebody, but like they really want to experience that, step two might be?
[00:30:54] Kelli: That's when we were talking about some of the other things like learning to be undressed or minimally dressed in other types of environments, like on the beach or in a pool or what have you. So getting comfortable with your body in various states of undress before you enter in with a partner. Self-help books on body image, like doing some real focused body image work. There's a book called The Body Image Workbook by Thomas F Cash. That's like the sort of bible of body image work, so that can be really helpful. And we also talked about self pleasuring, so learning about what feels good on your own before introducing a partner. So I think there's a lot of work that people have to do on their own to feel less vulnerable, more comfortable, know what pleasure in their body feels like through yoga and mindfulness, some of those other things that we were just talking about. Then we start to look at introducing partners or potential partners when they feel ready to do that piece.
[00:32:07] Michelle: Yeah. And working on that mind body connection. And a really great way of doing that is incorporating a daily mindfulness routine. Really understanding what mindfulness is and not getting caught up with maybe you've tried it before and you don't want to meditate because it's not actually what you think it is. It's more just about awareness, so you can be more aware of like even if you're feeling arousal or desire.
[00:32:41] Kelli: Quite often people that we work with because they have been so disconnected from their body, haven't been able to really experience what sexual arousal feels like. So that's where the self pleasuring comes in. That's where learning what arousal feels like an orgasm feels like for people who haven't yet had an orgasm. So there's a really excellent website called OMGyes, which actually has real people demonstrating real methods of self pleasuring that have worked for them. So that can be a really nice tool as well.
[00:33:17] Michelle: Did you become a certified sex therapist cause of your work with clients that have eating disorders because you saw some of the struggles they were having? What came first for you?
[00:33:34] Kelli: Well, so my first profession was as an occupational therapist and as an occupational therapist, I started working in a hospital setting with people with eating disorders, and then in my work with clients with eating disorders, I started to become very much aware of the impact that it had on their sexuality, their sexual relationships, and I didn't really have any training in those areas. So I went back to school and I got a master's in counseling psychology, and then I started doing marriage and family therapy training, and then I started doing sex therapy training and just kind of all folded into itself and evolved in that way.
[00:34:16] Michelle: Yeah, I love hearing about how people become a sex therapist because people can come into it from so many different angles and some people just fall into it, but then other people, the interest was peaked in the work they were doing, and then they found themselves going down this other avenue.
[00:34:36] Kelli: Yeah, that was definitely the case for me. I didn't know when I was in OT school that I was eventually gonna be a sex therapist as well.
[00:34:43] Michelle: For sure. Kelli, thank you so much for being here and for doing the work that you do and for supporting people that are struggling with eating disorders to develop a healthier relationship with themselves and with their sexuality. We're so lucky to have you.
[00:35:11] Kelli: Oh, thank you. Thank you for saying that, and thank you for having me here today. It's been great.
[00:35:19] Michelle: That was my conversation with Kelli Young. This show is produced by Katie Jensen at Vocal Fry Studios. If you have show ideas or even a confession that you want me to answer in an episode, Email me at michelle@getsome.ca. And don't forget to follow me on Instagram @getsome_podcast.You'll get great ideas around sex and sexuality as well as to see what's happening between episodes. Thank you for listening.