PERCEPTIONS OF OBESE WOMEN ON SEXUALITY

Obesity contributes to the development of both male and female sexual dysfunctions. Sexual function, regardless of the body mass, is an important aspect of the quality of life for women and men. The study aimed at grasping how the overweight woman perceives her body and how she relates to her sexuality. This was a descriptive and qualitative study, developed with seven overweight and/or obese women who are participants in an intervention group. The data were collected through semi-structured interviews and subsequently subjected to content analysis. The following categories emerged: “Obesity and sexuality: a conflictive relationship” and “Positive influences from the intervention group.” For these women, the relationship between obesity and sexuality was considered negative, encouraging the desire to change the body to match the desires imposed by society. After the start of the group’s activities, there was weight loss and, consequently, an improvement in selfesteem and sexual performance. We concluded that groups of interventions are important strategies to offer, in addition to guidance, emotional support, and help losing weight and improving the quality of life.


INTRODUCTION
The dissemination of obesity is currently a pandemic that affects developed and developing countries. 1In Latin America, obesity has been growing especially among adult women and in Brazil, 64.9% of women have some level of overweight. 3Increased weight has a multifactorial etiology resulting from the interaction between the individuals´ organic condition and lifestyle, which includes modifiable risk factors such as physical inactivity and diet rich in calories that elevate the risk of mortality. 1In addition, obesity predisposes to chronic diseases such as cancer, diabetes, high blood pressure, varicose veins, thrombosis in lower limbs, and psychic disorders. 1imilar to other cardiovascular risk factors, obesity also contributes to the development of both male and female sexual dysfunctions as a result of a deleterious action on the vascular and endothelial function. 4In women, these disorders involve alterations in menstrual cycles, sexual dysfunction, fertility reduction, 1 and reduction in sexual desire, arousal, orgasm, and dyspareunia. 4exual function is an important aspect of the quality of life of women and men, regardless of body mass.Thus, in addition to several limitations due to reduced mobility and social stigmatization, obesity decreases the quality of sexual life, making these people vulnerable to psychological and emotional disorders. 5It should be noted that the quality of sexual life is not restricted to the sexual act and to what is near to it, but also to eroticism, pleasure, emotional involvement, love, and reproduction. 6hus, the construction or experience of female sexuality is directly related to historical and social factors such as gender, values, beliefs, and cultural aspects. 7In the current society, thinness is the esthetic standard of absolute beauty and not fitting in this pattern can lead to discrimination and prejudice resulting in great personal suffering. 5Therefore, health professionals must consider not only the physiological aspects of obesity but also the psychological aspects when approaching this population. 5,7nderstanding obesity as an important public health thematic to be discussed; this study aimed to understand how overweight women perceive their bodies and how they relate to sexuality.

MATERIALS AND METHODS
This was a descriptive study of a qualitative nature, developed with overweight or obese women, participants in an intervention group called Group of Assistance and Health Promotion.
The intervention lasted four months, occurred three times a week, and involved health and nutritional guidance and practice of physical activities.The group was coordinated by a nurse and the practice of physical activities was guided and supervised by a professional in Physical Education.The topics for discussion were established together with the group's participants; conflict between obesity and sexuality frequently emerged in a tangential or direct way revealing the need for a more specific approach, which motivated the proposal of this study.
The data collection was in June of 2012, with seven women participants in the group and through semi-structured interviews.The interviews took approximately 20 minutes, were individually performed in a private place, and oriented by the following guiding questions: "How do you see your body?What is its meaning for you?How is your sexuality these days?Talk about your experience involving obesity and sexuality".
The interviews were transcribed in full and subsequently subjected to content analysis in a thematic mode, which works the words and their meanings describing the contents of messages allowing inferences. 8The analysis included the phases of pre-analysis and material exploration followed by a systematic organization. 8Subsequently, the results were grouped into thematic categories according to the similarity of testimonies; two thematic categories emerged: "obesity and sexuality: a conflictive relationship" and "positive influences from the intervention group".
The development of the study occurred in accordance with the ethical principles governed by Resolution 196/96 from the National Health Council and approved by the Permanent Ethic Committee in Research with Human Beings from the Maringá State University (Opinion 546/2011).All participants signed a volunteer informed consent term in duplicate.Fictitious names of Greek goddesses were used for identification of subjects and preservation of their identities, followed by age and body mass index (BMI).

RESULTS AND DISCUSSION
The seven women participating in the study were 28 to 56 years old with BMI ranging from 27.3 to 47.8 kg/m².Six of them were married and had children and only one was single and had no children.

Obesity and sexuality: a conflictive relationship
The women in the study considered the relationship between obesity and sexuality as negative, showing that being overweight, not only disturbs the performance of daily tasks but also influences on their disposition (or lack of it) and sexual desire (or lack of it).
The heavier I am, the more harm, isn't it, when you're fat, everything weighs, everything hurts.So obesity makes everything more difficult, actually, at that time, isn't it?!And you realize that it harms because you are heavy and everything is more difficult.My husband, he's with a hun-ies, becoming thin, and thus corresponding to the demands imposed by society and confirmed by themselves.
I was very fond of my body, then I started getting fat, getting fat, then I started getting upset (Diceia, 43 years old, BMI 34.3).
But when I was thinner, I was using even makeup, I felt more feminine and happy with my body (Aphrodite, 36 years old, BMI 38).

A little strange [in relation to the body] because that's not what I want, I wanted it a little bit thinner (Artemis, 46 years old, BMI 30.6).
It is clear that because thinness has been established by society as a fundamental factor for the identification of femininity and attractiveness to the opposite gender, the overweight women feel inadequate to the imposed weight standards and measures, making them vulnerable to psychological and emotional disorders. 15he image of the beautiful and skinny woman overlaps to what is seen as healthy and leads many women to diets and surgical procedures that do not have health as the real reason.Study with obese women undergoing bariatric surgery showed that the main reason for the surgery was not related to health but to the desire to improve their appearances and, consequently, their sexual relationships. 1 Another study found that the bariatric surgery is seen as the possibility of solving problems since the beginning of a new life is related to esthetics, that is, the social acceptance of a body that is no longer obese, which have an impact on health. 16he desire to be thin and the search for a different appearance were emphasized by the participants who demonstrated that this can be even more damaging when the partner shows not being happy with the woman's body.

I know that my husband would be much happier if I were thinner, just like when we met… Then how are you going to do things, there's no way, so he blames me and tells me that I'm fat and ugly (Aphrodite, 36 years old, BMI 38).
When the woman feels dissatisfied with her body and is undervalued by her sexual partner, the sexual and emotional installed commitment are intensified considering that the obese subject often already have repressed sexuality due to dissatisfaction and body image distortion. 4,5,17uch difficulties with sexuality, imposed both by the women who are off the standards and their partners who do not feel attracted to them, may be more apparent when considering the frequency of sexual relations.dred and a few kilos and he doesn´t have a desire anymore, he even has fatigue (Artemis, 46 years old, BMI 30.6).

I feel the tiredness [during intercourse]
, I find it difficult even to walk.I feel that the body does not go together with the head (Hecate, 52 years old, BMI 31.6).
Sexual difficulties seem to be more diffused in women than in men because generally women are more easily influenced by psychological and relational factors. 9However, other factors, such as, for example, psychic, neurovascular, and hormonal affect sexual quality in both women and men, and therefore, affect their quality of life and interpersonal relationships. 9][11] Moreover, epidemiological studies demonstrate a correlation between obesity and sexual dysfunction 4,9 defined as a disorder of sexual desire, arousal, orgasm, or pain during sexual intercourse, leading to personal suffering. 9uch suffering gets worse when the woman does not feel attractive or is not satisfied with her own body.

It's kind of weird because it's not what I want, I wanted to be a little bit thinner because I´m fat in the waist, so I don't like that part (Artemis, 46 years old, BMI 30.6). I feel embarrassed because I'm chubby (Nike, 28 years old, BMI 39.7).
The reports show that women have damaged body images, built from the physiological, psychic, and social dimensions. 12The construction of body image based on the physiological dimension is permeated by the self-image commitment, which is distorted, and the individual has difficulties in dealing with his own body and recognizing his dimensions. 13,14Regarding the psychic dimension, the inadequacy of the body to fit beauty standards reduces self-steem 13 and brings feelings of rejection and social exclusion, 1 making the individual more vulnerable to pain caused by the body image. 13n the social sense, the body is one of the founding elements of the individual presence in society; the construction of identity is directly linked to it, which is designed and perceived according to the representations available in society, that is, the body is socially constructed. 14In this regard, it is noted in general that the great desire of obese women is to change their bod-

If I tell you that is two to three times a month, because he has no desire […]. But for me is bad, right, because I want to (Artemis, 46 years old, BMI 30.6).
It's not because I'm overweight, I'm not within the parameters, that I don't feel the desire.It's been over a year since I have no relationship with him [husband] (Aphrodite, 36 years old, BMI 38).

The body is important for the woman, but I don't use mine for nearly four years. I don't feel these desires, I don't feel attractive (Hebe, 56 years old, BMI 27.3).
The big interval between sexual relationships may be linked to the lack of desire and arousal considering that these alterations are frequent in obese people, especially in men. 4 It should be also considered that the lack of sexual desire can be associated with marital problems, related or not to obesity in these women.Sometimes the food becomes the element of comfort that softens a context of adversity.More than satisfying hunger, food fulfils affective deprivation and relieve anguish. 5owever, one of the women showed self-confidence and self-esteem about her sexuality in addition to validating the importance of her partner´s support.

Despite being chubby, I feel good, I feel like a woman. I would like to lose weight, but I'm happy […]. I have sex four times a week. I'm not ashamed because I think if you are married to whom you like and trust. I've been married
23 years and never think that my husband cheats on me because we go everywhere together and he never showed that he is ashamed of me, so I'm not ashamed of having sex with my husband at all (Metis, 50 years old, BMI 47.8).
Normally, the obese person feels sexually undesirable; however, when she feels attractive and desired by the sexual partner, obesity is not an obstacle to exercising sexuality in a positive way.Study with 197 overweight and obese women in Florianópolis-SC found a positive correlation between body mass and desire, sexual arousal, and frequency and intensity of orgasm, 10 that is, when there is no sexual dysfunction with physiological basis, the woman, has perfect conditions for exercising her sexuality when desired and encouraged by someone who loves her. 5

Positive influences from the intervention group
The women stated that they lost weight after the start of the group's activities.As a result, they were feeling better and reported a change in the way they see themselves as a woman, as well as improving desire and sexual performance.
First, before I work out, I felt pain [laughs] and after working out I was good!There are even different positions, before it was only the normal position every day, and now everything is fine (Metis, 50 years old, BMI 47.8).
Since the opportunity to come here and work out, I've lost 7 kilos and I started to accept my body again, all my life I have been very vain, and now I've started again to feel difference in my body and be more cheerful (Diceia, 43 years old, BMI 34.3).

I lost weight with the group and feel great (Aphrodite, 36 years old, BMI 38).
The group served as a channel for the development of corporal expression and creativity for these women because the experience of their movements in dance and exercise classes, health guidelines, and moments of conversations in which they could express their feelings and share their questions allowed the change in lifestyle and raised their self-esteem.
Modifications in lifestyle are important to reduce the prevalence of sexual disorders in obese women. 10Thus, the adoption of a healthy lifestyle, such as exercising and adopting a balanced diet, promotes the improvement in the endothelial function, which is directly related to sexuality aspects. 4n addition, the practice of physical exercises has been highlighted as a factor in primary prevention to promote health and quality of life. 9herefore, primary health care professionals, especially nurses by being in greater contact with the population, can adopt this model of intervention to prevent the complications that result from obesity and promote health.For these women, the group provided not only gains on sexuality but in all dimensions in addition to encouraging the continuation of activities.

I'm feeling better now […] my physical and mental
performance has vastly improved, because everything you do is much better.I don't feel so much pain, I don´t feel back and bursitis pain any more, I had so much pain to work, to take care of the house, everything, I'm feeling a lot better performance (Hecate, 52 years old, BMI 31.6).
Even when the group is over I want to keep doing the diet and physical activity.I was too fat and wasn't happy, my jeans didn´t fit anymore, that made me feel very bad (Aphrodite, 36 years old, BMI 38).
The results showed that the intervention can positively influence the change in behavior, which corroborates the experimental research of serial cases type performed in Santos-SP, mainly related to changes in the practice of physical activities and proper nutrition. 18However, for the action of an intervention group to contribute effectively to health promotion or even in the control of diseases associated with the practice of unhealthy lifestyles, it is fundamental to have permanent methodologies developed in various contexts providing better control of risk factors for health and quality of life. 18he multidisciplinary approach confirmed its importance and effectiveness in the group because it facilitated the understanding about the need for a change in the women´s behavior, which is complex, especially when considering food issues expressed in a network of social, cultural, and emotional meanings. 18Moreover, the need for continuation of activities, aimed primarily at awareness for changes in lifestyle is indicated.Group activities enable deepening discussions related to health issues once the group's participants can better address their limitations through the rescue of autonomy and ability to live with their condition in a more harmonious way. 19

FINAL CONSIDER ATIONS
The results of this study show that sexuality has been experienced by overweight and obese women in a negative way.It is possible to see the complex set of physiological, social, and psychic aspects involving the dynamics of female obesity.Therefore, professional nurses, by being directly in contact with the population, can act together with these women through group activities seeking to providing guidance related to health and emotional support, and helping with weight loss.
It is believed that the results of this study can contribute to the advancement of nursing knowledge considering the lack of studies, discussions, and reflections about this subject.Based on the results, it is suggested that further studies are conducted to identify not only how obese women experience their sexuality but also their suggestions about the best approach for nurses, aiming at the promotion of health and quality of life for these subjects.