It’s hard to feel sexy if you don’t feel good. And it can be hard to get the kind of caring and competent medical care you need when you’re fat. This section gives you tools to negotiate both sets of hurdles involving weight, health, and sex. It also walks you through the sexuality side of some common fat-related health conditions like polycystic ovary syndrome, lymphedema/lipedema, and gynecomastia. Additional tips help you slash your risk of a sexually transmitted infection, injuring yourself or a partner during sex, and becoming pregnant if you don’t want to be.
Ever heard the one about how fat girls can’t get pregnant? There’s no punch line, because it’s not a joke: fat women get pregnant all the time.
There is some research that indicates that fat women and men may be less easily fertile than thinner people for a variety of reasons that range from hormone levels to PCOS (polycystic ovary syndrome; see this page) to thyroid issues, but the relationship between fatness and fertility is neither particularly clear nor well understood. Research presented by groups including the American Society of Reproductive Medicine suggests that in some cases it may take longer for fat people to conceive. However, there is absolutely no reason to expect that any given fat person is, or will be, infertile.
In general, fat people who are sexually active but who are not trying to conceive have the same need for contraception as anyone else does. In general, fat people can use the same contraceptive methods as anyone else, too.
There are five basic types of contraception.
For more information on birth control methods and how each works, consult your doctor or clinic. For general online information, see PlannedParenthood.org or the Association of Reproductive Health Professionals website at arhp.org.
Contraceptive effectiveness may be a problem for some fat people. About 10 percent of the respondents to the Big Big Love survey—a fairly significant proportion—reported having experienced difficulties with contraception due to weight or size. There is evidence that suggests that fat women using hormonal contraception may experience higher failure rates than thinner women. It is not entirely clear why hormonal contraceptives fail for some fat women while others can use them without any problems. Increased failure rate of hormonal contraceptives in fat women may be due to inadequate dosage, meaning that some fat women might require higher doses of the hormones in question because their bodies are larger. It is also true that fat women are more likely to have underlying hormonal imbalances such as PCOS, which is highly correlated to fatness. Such endocrine disorders can change how effective contraceptives can be. There may be additional factors we don’t yet know about. Fat women who use hormonal contraceptives may wish to use a backup contraceptive like an IUD or condoms as well. The effectiveness of diaphragms and cervical caps can also be affected by changes in weight: your doctor can advise you on the fitting protocols for your particular device and let you know what you should look out for to know if it’s time to have a refitting.
Pregnancy and fatness are controversial, to say the least. Many medical sources claim that there are significantly higher risks of complications when fat people become pregnant. Risk is not the same thing as inevitability, however. Most fat people’s pregnancies proceed in a completely textbook fashion, while some thin people’s pregnancies involve complications. If you are pregnant or are planning to become pregnant, discussing it with a fat-friendly obstetrician or midwife is an excellent idea. Assembling a fat-friendly medical team that will be respectful of you, your pregnancy, and your baby-to-be may be challenging. Asking fat friends who are parents about their experiences is one good way to get recommendations for medical professionals with whom you will be able to work happily.
There are numerous things that those who are pregnant or who plan to become pregnant can do to improve their odds of a healthy pregnancy and a healthy baby. Chief among these is to make sure that you consume plenty of folic acid, a nutrient that is necessary for proper nervous system development in the fetus. Because there is evidence that babies born to fat parents have a higher incidence of the kinds of birth defects that can be prevented by adequate folic acid, fat parents-to-be should be especially careful to get enough of this critical nutrient.
If you can catch a cold, you can catch a sexually transmitted infection (STI). Fat does not protect anyone against STIs. The microorganisms that cause infections don’t know, and don’t care, how much you weigh. There is not a virus in the world that only infects people who wear smaller clothing sizes and leaves the fatter folks alone. Just like the flu or food poisoning, STIs are equal opportunity illnesses.
No doubt you already know that STIs are serious business: some of them can kill you. Even the nonfatal ones are a whole bunch of no fun and can cause pain, scarring, infertility, and cancer. Several of them are caused by viruses. HIV, which causes AIDS, is a virus, but human papilloma virus (HPV), hepatitis, and herpes are all viral as well. These cannot be cured. Some others can be cured, but unless they are nipped in the bud they can wreak all kinds of havoc on the body and particularly the reproductive organs, causing things like pelvic inflammatory disease (PID) and secondary infertility.
The best defense against STIs is a good offense, and that means three things: getting tested regularly, practicing safer sex to reduce your risk of infection, and getting vaccinated where possible.
If you are sexually active, it is a good idea to get a full STI screening once a year. Your doctor can order these tests, or you can go to a clinic like Planned Parenthood that specializes in reproductive health. Sometimes, public health organizations make free testing available, especially for HIV. If you do not have health insurance, or your insurance does not cover STI testing, it may also be possible for you to get inexpensive or free STI testing through your local or regional government’s department of health.
Some people may decide to get tested more often than once a year. This can be a good idea if you are sexually active with multiple people, if you engage in sex play with strangers, or if you have a partner who does either of these things. People who are planning a pregnancy (or planning to father a child) should also be tested before they begin trying to conceive.
Other people may decide that based on their relative level of risk, they don’t need to get tested every single year. This may be perfectly appropriate. Or it may not: people in supposedly monogamous relationships can and do cheat, and they may lie about cheating. People also lie about STI status. According to Planned Parenthood, about one in three people who have a known STI will lie about their STI status in order to have sex. Adding injury to insult, people don’t always know when they are infected. Sometimes people can’t inform their partners that there’s an infection risk because they have no idea that they are infected with an STI, perhaps because they have had no symptoms.
“I went to the doctor with STD symptoms and he said it was probably just a UTI [urinary tract infection] because ‘girls like you’ don’t get STDs. He gave me antibiotics, and I guess that took care of it, but I still think he should have tested me and told me exactly what was going on. I had had UTIs before and I am pretty sure from the symptoms that I didn’t have a UTI.”
You can and should get tested as often as you think is right for you. If you should run into a health care provider who dismisses your request for STI testing, remind the provider that STIs are not weight related. If necessary, you can ask for a referral to another doctor, or you can simply go to a reproductive health clinic or specialized STI testing clinic.
Most STIs are transmitted through bodily fluids, which include semen, vaginal secretions, and blood. This means that the best way to prevent infection is to prevent contact with those fluids.
The highest risks of STI infection are found in the most common sexual activities: penis-in-vagina intercourse, anal intercourse, and oral sex. Not only do these involve body fluids, but they also involve the tender, fragile mucous membranes that line the vulva, vagina, anus, rectum, mouth, and throat, which means that it is easier to get an infection in these areas.
Fortunately it is very easy to reduce infection risks for these activities. Use a condom for any activity that involves a penis. Use a dental dam—a latex or polyurethane sheet that goes between your mouth and your partner’s body—for any activity that involves a mouth in contact with a vulva, vagina, or anus. Put the condom on the penis as soon as it is fully erect to ensure that pre-ejaculate and semen are completely contained. For a quick, easy dental dam, cut the tip off of an unlubricated condom, then cut from end to end along the tube so it can be unrolled into a stretchy sheet. Or try plastic wrap, which is inexpensive and is available in fun colors.
Other sexual activities are generally less risky in terms of STIs. However, there may still be some risk. You can reduce your risks further by using latex or nitrile gloves for penetration using the fingers or hand, avoiding getting anyone else’s body fluids on any part of your body where you have cuts or broken skin, and using condoms on dildos, vibrators, or other toys if they have more than one user.
Other STIs, like herpes, are transmitted by contact with a lesion or sore. The best way to prevent these infections is by preventing contact with lesions or sores, which means that taking a minute to turn the lights on and visually check out your partner’s genitals before you have sex is a great idea. The same visual check is a good way to make sure you’re not exposing yourself to parasites like lice or scabies. You can easily make this part of sex play. It’s a good argument for not leaving yourself in the dark.
Vaccinations do not exist for every STI, but the vaccines that we do have provide excellent protection against particular nasty bugs. Hepatitis A and hepatitis B vaccinations can benefit you regardless of your age. HPV (human papilloma virus) vaccination is recommended for women specifically, because of the connection between HPV infections in women and later cervical cancer. HPV vaccination is currently recommended for women under the age of twenty-six.
Love hurts. Sometimes it’s the unfortunate collision of someone’s knee with your groin, or an elbow with your head. In the heat of the moment, we can inadvertently pinch, whack, shove, and otherwise knock one another around without meaning to. Even kissing can result in unexpected, painful clanking of teeth on teeth or noses on foreheads. Being careful, and trying to pay close attention to what you’re doing, helps, but sometimes people move unexpectedly. It happens.
People also injure themselves during sex in other, more preventable ways. Joint and muscle injuries are particularly common and are particularly relevant when you and/or your partner are fat.
When we get aroused, our ability to feel pain tends to diminish. The laws of physics, unfortunately, never take a vacation. Heavier bodies have a lot of momentum and that momentum can be hard to control. Some of us are not in great physical shape, which makes it that much more likely for things to get away from us. Even for very fit people, sometimes, if your alignment is off and/or your muscles, ligaments, and joints are not strong enough to take the stress, you can hurt yourself or a partner during sex, quite by accident.
Not only can you hurt yourself, but you may not even notice it immediately. Some injuries are sharp and unmistakable. But arousal has a tendency to raise people’s thresholds of pain considerably. Thanks to being aroused, you can sometimes hurt yourself and go on hurting yourself for as long as the arousal is present, only to come down and suddenly realize you’re in significant pain.
The best way to prevent a sex injury is the same as the best way to prevent a sports injury: training! Exercise strengthens muscles, ligaments, and joints throughout your body. You don’t have to turn into a gym rat. Even light exercise can increase your flexibility and your strength, improve your stamina, and reduce your chances of getting hurt. This is especially true if you have any known trouble spots, like bad knees, a bad back, or a repetitive stress injury like tendonitis. You can do specific exercises that strengthen and help to stabilize the parts of your body that are weak, possibly with the help of a physical therapist or personal trainer specializing in injury rehabilitation who can teach you techniques to help specific parts of the body and prevent specific types of damage.
Because sex is a form of exercise, you also want to warm up, if you can, before you launch into a full-blown “workout.” This might not seem sexy in the abstract, but when you consider that you can put your arms and legs through a significant range of motion in the process of making out, groping, caressing, and helping your partner disrobe, it soon becomes evident that you don’t necessarily have to run off for a quick ten minutes of calisthenics in order to warm up your muscles, joints, and connective tissues. Stretching—while bending over to untie your shoes or pull off a stocking—or shimmying out of your clothes also helps. If you feel particularly stiff, though, it’s really fine to take a moment to limber up the stiff bits. It sure beats having your sexy encounter interrupted by a yelp of pain.
It can be hard to concentrate on anything other than sensation and pleasure when you’re having sex, and in some ways that’s as it should be. If you know you are prone to joint or muscle injuries, though, it pays to be attentive to form as well. Try to check in with your body while you are having sex and see whether or not your body is positioned in ways that are well aligned, straight rather than twisted, and not unnecessarily restricted. See whether your knees and hips are moving easily and without a feeling of pain or resistance. Try to make sure, especially if you are thrusting with your hips and/or legs, that your trunk is aligned so that your knees, hips, and shoulders are all facing the same direction. If you are supporting a lot of weight on your hands, you might try putting the weight on your whole forearms rather than just on your hands, to relieve strain on the wrists. Avoid locking your elbows and knees, too, if possible. If something feels out of whack, or like it’s taking you a lot more effort to maintain a position or a posture than it should, take the few seconds to reevaluate and to shift position to something that feels better.
If you try to do something strenuous during sex and you hear that little voice in the back of your head protesting, try to pay attention. I know it’s not always easy, and things that sound cool and exciting sound even cooler and more exciting when you’re all aroused and feeling completely bulletproof. But the sad fact is that if you cannot do a hundred pushups without hurting yourself, having an erection is unlikely to make it possible. If you couldn’t do the splits yesterday morning, all that’s going to happen if you try it now is that you’ll be walking like a cowboy for the next two weeks. Sexual desire is not Magic Badass Juice. Being a little sore the next day is one thing. Ending up in your orthopedist’s office clutching a vial of pain pills and scheduling knee surgery is another. Enough said.
It’s all very well to have a book full of advice on how to have a better sex life. But what if the problem isn’t a lack of confidence or any problem finding a partner—it’s that things just aren’t physically working? There are many types of sexual dysfunctions to which the flesh can be heir.
Fat people are not necessarily more likely to suffer from sexual dysfunction than thinner people, but they are definitely more likely to have their sexual dysfunction be blamed on their fatness. This is unfair and unhelpful, and nothing but an easy out for the physician. After all, any idiot can look at you and say, “Ah, you’re fat! That must be why!” The visual diagnosis, in this case, is irresponsible: many sexual dysfunctions have distinctive, treatable causes, and they don’t generally have anything to do with weight or fatness. Knowing more about these dysfunctions and how they happen can help you troubleshoot, and it can also help you self-advocate for appropriate medical care if you choose to seek it.
There are several broad types of sexual dysfunction, of which the most common are loss of desire, erectile dysfunction, dyspareunia, and vaginismus.
If you used to feel sexual desire on at least a somewhat regular basis, but your sexual desire wanes or suddenly stops, it is called loss of desire. (This is distinct from the experience of those whose lack of desire is consistent, which is not necessarily a sign of dysfunction. People for whom this is true may simply be asexual.) Loss of desire can be psychological: new parents often report losing sexual desire for a while, due to stress, lack of sleep, and new responsibilities. It is a common symptom of depression, sometimes going along with what is called anhedonia, the reduced ability to feel pleasure. Traumatic experiences (especially if they are sexual in nature) can cause people to lose desire for significant periods of time. Loss of desire can also be biological—the result of changes in hormone levels or an underlying illness. Endocrine disorders, like thyroid malfunction, can often affect sexual desire. Women may experience loss of desire more frequently than men do, but whether this is due to biological factors or social ones—including the fact that in our society, masculinity is expected to include constant sexual desire—is not clear.
If you believe that your loss of desire is psychological or stress related, just giving yourself some time and space, and not worrying about it overmuch, can help. Talking to a therapist or counselor might also be a good idea. If you suspect that the cause might be biological, or the “relax and wait a while” approach isn’t helping, talk to your doctor.
This is the modern Viagra-ad-friendly euphemism for impotence, the inability for men to get or keep an erection. Impotence happens for many reasons. Sometimes it happens just once or twice and then resolves itself. Other times it is chronic and consistent. Almost all men experience it at one point or another in their lives.
Doctors tend to talk about impotence as being either “organic” (biological), or “psychogenic” (meaning psychological, emotional, or stress related). Some types of biological impotence that have to do with poor blood flow to the penis can be helped with drugs, including Viagra and its relatives. Other types of biological impotence might be caused by smoking (another reason to quit!), neurological problems, or the side effects of drugs, whether prescription or recreational. Alcohol, which is a central nervous system depressant, is notorious for causing impotence.
Psychogenic impotence can come from stress, guilt, fear, worry, or, paradoxically enough, too much excitement. Depression and anxiety disorders often have impotence as a symptom, and traumatic experiences may also include impotence in their fallout.
Psychotherapy or counseling, and possibly working with a sex therapist, can help when being patient and trying to cut yourself some slack doesn’t. Viagra and similar drugs will not help psychogenic impotence except via the placebo effect. Save the money you were going to spend on little blue pills and spend it on a therapist who specializes in helping people with sexual dysfunction instead: it’s a much more appropriate treatment.
Dyspareunia is a catch-all diagnosis that really means “in women, chronically painful penetration.” Typically, if a woman has been experiencing painful vaginal penetration (or painful attempted penetration) for six months or more, it is diagnosed as dyspareunia. Dyspareunia, like other sexual dysfunctions, can be psychological or biological in nature, or some combination of the two. There are many biological conditions that can make vaginal penetration painful for women (the Johns Hopkins Dyspareunia and Vulvar Pain Center lists more than forty). Because some of the conditions that can create dyspareunia are quite serious indeed, and also because many dyspareunia-causing conditions can be treated successfully, this is something that should definitely be checked out by a doctor.
If you and a doctor have ruled out a biological origin for dyspareunia, psychotherapy with a sex-positive therapist may help. Some women also have good luck self-educating about sex and arousal by reading, masturbating, and having frank talks with their partner(s) about what works for them and what does not. Since one possible cause of dyspareunia is simple lack of arousal and lubrication, learning more about what arouses you (and paying attention to that when you have sex) and using a good sexual lubricant can help.
Vaginismus means that the muscles surrounding the vagina clamp down whenever one attempts to insert something into the vagina. Women with vaginismus may find it impossible to use tampons or have gynecological exams performed, let alone be penetrated sexually. The causes of vaginismus are often psychological, but not always. Vaginismus could be originally triggered due to some biological problem, illness, or infection that made penetration extremely painful at one time, causing the body to develop the protective reflex to try to close the vagina and prohibit any further penetrations. It may develop due to a traumatic, violent, or abusive sexual history. Many women who experience vaginismus may never actually know why it began or be able to trace it to any particular incident. Fortunately, it is not always necessary for women with psychogenic vaginismus to know why they have it in order to make progress in reducing or curing it.
Some women have success with a DIY treatment for vaginismus that involves a lot of self-education, reading, discussion, and perhaps psychotherapy to find out what helps them feel relaxed and aroused. They follow this up with gentle attempts at inserting something into the vagina—at first something quite small like a pinkie finger, but gradually, with time and patience and lubrication, perhaps something larger like a small dildo. Other women prefer to work with doctors, sex therapists, or psychotherapists in their efforts to overcome vaginismus.
Some women, however, simply decide that they are happier and better off not having to deal with vaginal penetration of any kind and don’t worry about it. The only medically relevant argument against doing this is that penetrating the vagina is necessary for standard gynecological health care. If a woman is unable to bear having her vagina penetrated in any way for any reason, pelvic exams will be difficult or impossible, leaving her at risk of being unable to take advantage of early detection methods for cervical and other cancers.
I have yet to meet anyone, regardless of body size or weight, who looks forward to the annual gynecological exam, for the very good reason that there is really nothing about it that is in the slightest bit pleasant. For some of us, the only thing that gets us in the door at all is the knowledge that getting that annual exam might make a huge difference in our health: the earlier cervical and uterine cancers are detected, the better your odds of survival in the long term. So we grit our teeth, perch our naked butts uncomfortably on the end of those narrow exam tables, endure the duck lips of doom, and wait impatiently for the cavity search to be over. All the while, we try our best to retain a mature, even-tempered, reasonable tone of voice while talking with this person who is twiddling a bottle brush in a place where Nature never intended a bottle brush to go.
Being fat can make it even harder to stay calm, cool, and collected at the gyno’s, not least because recent research has revealed that doctors’ anti-fat prejudice makes them less than likely to be comfortable performing routine gynecological exams on fat women. In an article called “Stigma and Discrimination in Weight Management and Obesity” in the Permanente Journal, researchers Kelly Brownell and Rebecca Pugh reported that 17 percent of physicians were reluctance to perform them on fat women, and as many as 83 percent said they were reluctant to perform the exams on women who themselves seemed reluctant about the examination, as many fat women understandably are. In the Big Big Love Survey, although 93 percent of respondents said they had access to adequate routine reproductive and sexual health care, 31 percent of respondents said they had experienced complaints from health care practitioners that it was difficult to examine them properly because of their weight, and 40 percent had been treated disrespectfully or dismissively by medical personnel because of the patients’ size.
There’s not much to love about the gynecological experience at the best of times, and feeling like your practitioner does not want to deal with a fat patient, or that you are imposing an enormous burden on your practitioner because of your size (you aren’t!), makes it all the worse. Here are some tips that will let you help yourself, and help your doctor, be less reluctant, more comfortable, and more likely to accomplish this vital health care screening with the recommended frequency.
You can learn a lot—and help them learn, too—by asking your doctor and your doctor’s staff whether they are prepared to deal with someone of your size. Ask them if they have dealt with fat patients in the past, and, if you think it is likely to be relevant, whether their chairs, exam tables, and other facilities are large and sturdy enough for someone of your size. You may also want to ask whether there are armless chairs in the waiting area, if armchairs and your hips don’t get along very well. Sometimes these things just haven’t occurred to them, remarkable as that may seem. Take advantage of the teachable moment.
Being weighed, for some people, is worse by far than any gynecological exam. (I personally experience what I call PTSD—post-traumatic scale disorder—so you’re in good company if you say no.) Fortunately, there is no law that says you must submit to being weighed if you don’t want to be. It is not a medically necessary part of a gynecological exam. Besides, your health care practitioner can see that you’re fat. She doesn’t need a scale to figure it out. Deciding in advance whether you want to be weighed lets you prepare what you want to say about it to your health care practitioners. Usually, a firm, calm “I prefer not to be weighed” is sufficient. If they balk, as they may, you can tell them that if there is a compelling medical reason that they need to know your weight, such as calculating the dosage of a medication, you will be happy to discuss it with them, but otherwise you prefer not to be weighed. Note that if you do choose to be weighed, and you think or know that you weigh more than 300 pounds, you might want to ask in advance to make sure your doctor’s office scales will accommodate you. Scales come in a range of weight limits and if you’re going to be weighed, it might as well be on a scale that can actually weigh you accurately.
That’s bring your own bathrobe (although I’ll be honest—there’ve been a few gynecological experiences in my life where a healthy snort of bourbon would’ve been welcome). The paper gowns that are commonly used in many clinics these days are not only flimsy and way too tiny to accommodate many fat women’s assets but also fugly as sin, fragile, drafty as only glorified pieces of tissue paper can be, and environmentally wasteful to boot. Do the fashion-forward, ecofriendly thing and bring your own (scrupulously clean, please!) bathrobe with you from home. You’ll be much more comfortable and you won’t be worrying about how to keep the damn paper gown on when it rips like the Incredible Hulk’s T-shirt.
Before you go in to the office, make a list of the things you want to have your practitioner address. If you like, you can make two copies and ask that one of them be placed in your chart. Depending on how long your practitioner is able to spend with you and how many items are on your list, you may require a return visit or visits to address them all, but at least you will have them all written down so you won’t forget when you get distracted.
For a variety of reasons, doctors sometimes have difficulty performing pelvic exams on fat women. The exam does not have to be a problem; it’s really just a matter of having the right skills and knowing the right tricks.
If you have a prominent mons (the mound of flesh just above your vulva) or carry a lot of fat in your inner thighs, you may need to tell the health practitioner(s) that your flesh can be moved gently to make it easier to see the whole vulva. You can volunteer to be an extra set of hands and do this yourself, if reach is not a problem for you. If this seems a little embarrassing, don’t worry: the doctor is likely to be even more embarrassed than you are. You are the one with the insider knowledge here—it’s your body, and you know it much better than your doctor does. Your doctor may not realize it’s even an option to move fleshy bits around. Being willing and able to help move things around can also help during ultrasounds and other types of examinations.
Practitioners may also be shy about reaching into skin folds. In women with hanging bellies, bimanual exams can be facilitated more easily by having the practitioner simply reach into the under-apron crease with the external hand, in order to put the necessary pressure on the uterus or ovaries so that they can easily be felt and examined by the internal fingers. It may be necessary for you to tell your practitioner that it’s okay to do this.
If your doctor is having a hard time seeing your cervix, find out if she is using a metal or a plastic speculum, and what size. Different people’s anatomies may work better with specula of different sizes and materials. If you can remember what worked from one exam to the next, it can be useful for you to tell your practitioner and have it added to your chart—the practitioner won’t necessarily remember, and it might save you both the trouble of having to go through the whole process of elimination all over again. Also, because fatness does not actually change the size or length of the vagina, there is no truth to the notion that all fat women need to be examined with the largest speculum size.
If your practitioner is using an appropriately sized speculum and is still having trouble seeing things properly, it may be because the walls of your vagina are pressing in between the speculum blades, cutting off the view. Your doctor can take an exam glove, cut off the thumb, cut the tip off the thumb, and place the tube around the speculum blades. Once the practitioner reinserts the speculum, there will be a convenient tube of springy material that will form side walls between the speculum blades, holding the vagina open for better viewing of the cervix. Some practitioners also use a condom with the tip cut off for this, but glove material is somewhat thicker and less stretchy and may provide better results.
In the unlikely but possible event that your doctor claims to be unable to perform a particular exam on you because of your size, ask clearly and directly what the problem is. You know your body better than your doctor does. You may already know exactly what to do to shift position, tilt your pelvis, or what-have-you to make things easier on everyone. If a doctor claims to be unable to perform an exam on a fat person, it may simply be because the doctor lacks the experience and specific technique to negotiate that particular body. The more both you and your doctor can think of an exam as a collaborative event, where you are an active, helping participant, the more likely both of you are to end up with a successful exam.
Polycystic ovary syndrome (PCOS) is one of the most common reproductive health disorders in women. It is a complex condition that is not completely understood. It is considered to be primarily an endocrine (gland-related) disorder. One of the chief features of PCOS is that it causes higher than normal levels of androgens (sometimes called “masculine hormones,” although all sexes have them) such as testosterone. This in turn causes some of the symptoms, like excess facial and body hair. Other symptoms include not only the ovarian cysts that give the syndrome its name but also other things that are more likely to be noticed by the individual: irregular and/or prolonged menstrual periods, thinning hair on the head, skin discolorations, skin tags, infertility, and acne.
Unlike many other common types of “female trouble,” PCOS has a distinctive fat-related component: about 60 to 70 percent of women who have PCOS are fat. Those PCOS sufferers who are fat tend to carry their weight primarily in their bellies and torsos, in the male-typical pattern better known as “apple shape.” This appears to be related both to the high androgens associated with PCOS and to the fact that PCOS causes significant metabolic disturbances. Many PCOS sufferers are insulin resistant, which can lead to type 2 diabetes. High blood pressure is another common symptom of PCOS, as are high cholesterol levels and high blood lipids (hyperlipidemia). These things can, if not managed properly, raise the risk of things like heart attack and stroke.
We do not yet know what causes PCOS, but it does have a strong genetic component. If you have a sister or mother with PCOS, chances are good that you may also have it. If you have PCOS and have a daughter, there is a good chance that she may also have it.
Interestingly, PCOS is also one of the most commonly misdiagnosed or undiagnosed reproductive health conditions, despite the fact that as much as 10 percent of the adult female population may have it. This may be partly because so many PCOS sufferers are fat. It is easy, and common, for doctors to blame PCOS symptoms like irregular periods, infertility, excess hair growth, insulin resistance, and high blood pressure on fatness. However, thin women with PCOS have the same symptoms. So do fat women with PCOS who do manage to successfully lose weight, something that is made more difficult than it might otherwise be by the effects of insulin resistance on the metabolism.
Insisting that a patient lose weight is not an appropriate response to a PCOS diagnosis. Fatness does not cause PCOS and weight loss does not cure it. Some women find that weight loss (even small amounts) can help alleviate some PCOS symptoms; others do not experience this at all.
“My PCOS has changed, but it has not actually gotten any better despite medication and losing over one hundred pounds. I still have the full list of classic PCOS symptoms. Some of it is better than it was. My bloodwork looks much better now, but I think that has more to do with the fact that I exercise every day now than anything else. I still have no idea when or whether I will get a period. I’m still insulin resistant. I’m still fat. I’m still hairy. Don’t believe it if your doctor tells you that it’ll all get better if you just lose weight. It might change things, and some aspects of it could improve, but it won’t necessarily go away.”
PCOS cannot be cured, but some of the symptoms can be treated. Hormonal birth control pills can regulate menstruation so that periods are more predictable and easier to manage. Insulin-sensitizing drugs like metformin can help to reduce insulin insensitivity. Regular exercise also helps reduce insulin insensitivity and high cholesterol/triglycerides. Some women benefit from androgen blockers like spironalactone, which can help reduce excess facial and body hair as well as some of the other side effects of elevated androgen levels.
Because ovulation is often unpredictable in PCOS women and may not occur at all for some, fertility can present a problem. PCOS women who are trying to get pregnant can often increase their chances of ovulating with drugs like clomiphene (Clomid). Pregnant women with PCOS are more prone to gestational diabetes than women without, and they should talk to their doctors about this so that proper steps can be taken to normalize blood sugar if it gets out of whack during pregnancy. PCOS women who do manage to get pregnant do not necessarily have problematic pregnancies; it is often only conception that presents a problem.
Lipedema is a medical condition in which fat deposits in a distinctive pattern, from waist to ankles, in the lower half of the body, often creating an exaggerated pear-shaped body. It can be intensely painful and can create major problems for lymphatic drainage (lymphedema), leading to increased potential for infections and other issues. It is found primarily in women and is often misdiagnosed. Doctors, trained to see fat as the enemy, often fail to see lipedema for what it is; they often assume that the woman is merely fat and that if she loses weight, it will all get better.
This attitude can cause active harm to women with lipedema. Perhaps the most distinctive feature of lipedema is that the fat in the lower half of the body behaves differently from other body fat and is virtually impossible to lose. Sufferers who undergo weight loss surgery find that they lose weight from the waist up only; anorexic women can lose virtually all other body fat yet still retain lipedemic fat in the lower body. Attempts to remove this lower-body fat surgically with liposuction have, in general, not helped solve the problem (and in some cases it seems to have created additional ones). “Just lose weight” is therefore not a medically appropriate response to the possibility of lipedema. Weight loss won’t make lipedema go away.
Lipedema can be treated, but so far it cannot be cured. Successful treatments include lymphatic drainage massage, the use of elastic bandages and compression garments to help with lymphatic drainage and blood flow, and physical activities like swimming that encourage better circulation. Weight maintenance can help keep lipedema from worsening, in some cases.
Women who have a distinct persistent pattern of fat deposition in the lower half of the body, especially if they tend to lose weight only in the upper half of the body, should discuss lipedema with a doctor.
Lymphedema usually goes along with lipedema, but it can also exist on its own, without lipedema. Unlike lipedema, lymphedema can affect just one limb, or it may affect more than one. Lymphedema is caused by blockages of the lymphatic system and can affect men or women of any size or weight. Lymphedema does not feature fat deposits as part of its normal symptoms in the way lipedema does. However, medical sources agree, although they do not necessarily agree on why this is so or how it happens, that fatness itself can contribute to lymphedema.
Sexually speaking, lipedema and lymphedema can be challenging, to say the least. One of the nicknames of lipedema is “painful fat syndrome.” The affected areas can become highly sensitive, and it can be painful to be touched. Given that lipedema affects the body below the waist, this has obvious repercussions for many sex activities.
For both lipedema and lymphedema patients, flexibility and the ability to flex and bend the legs may be compromised by the swelling of the legs and/or hips. This varies from person to person, and some people are naturally more flexible than others. The legs may also feel uncomfortably heavy, and it may be hard for people to hold their legs up in the air for long periods or even at all. Some lymphedema/lipedema patients also experience edema swelling in the abdomen or genitals. How and whether this complicates sex will likely be highly individual and variable.
That being said, there is no reason for lipedema and lymphedema patients to avoid sex. One lipedema patient in her forties, interviewed for this section of the book, said that she thinks sex is good for lymphedema/lipedema in some ways, “because it’s exercise for the bottom half, provides some massage that gets lymph moving, and keeps things more supple. It can, depending on position, open up the inguinal lymph nodes a bit.” She also spoke in favor of eroticizing the elastic bandages and compression garments that edema patients often wear in order to support lymphatic flow. “I have had sex both while bandaged and wearing compression stockings: bandages make good sex handles!”
Lipedema, specifically, is responsible for a very particular form of the “pear” body shape. The pear shape is often eroticized by fat admirers who like the big butt, hips, and thighs that are its hallmark. People dealing with lipedema may have strong feelings about having others get an erotic charge out of something that is a medical problem and a health concern. On the flip side, some women with lipedema capitalize on its extreme effects on body shape; not a few adult BBW website models clearly show the characteristics of lipedema in the bodies they show off to admiring paying audiences.
Lipedema and lymphedema patients must take special care to avoid injuring swollen tissues, including during sexual activities. Because lymph circulation is poor, the risk of infections and tissue damage is high and recovery from injury or infection takes longer. Pressure, impact, or friction on affected areas can cause damage more easily than it would on a person without edema, so be careful when grabbing, kneading, spanking, slapping, and so on. People who engage in BDSM play need to be especially careful: bondage, flogging, whipping, pinching, restraint positions, and even some types of sensation play involving affected areas may cause significant problems for someone with lipedema or lymphedema.
Gynecomastia is enlargement of the breasts in people whose breasts are not supposed to be enlarged—that is, biological males. It has two primary causes: enlargement of the mammary glands, and deposits of fat in the breasts. In some men, both causes can be present simultaneously. Because the breasts are one of the places where bodies deposit fat, fat men in particular often do have noticeable breasts instead of the flat chest that is considered male typical.
Gynecomastia caused by fat is not a disease and does not present health risks. It is really a cosmetic issue. Some men do choose to have their gynecomastia “fixed” with cosmetic surgery, either through the removal of enlarged mammary glands or through liposuction. Like all liposuction, this lasts only as long as the fat stores are not replenished, so it may well end up being a temporary measure.
Gynecomastia does not appear to have any link to the risk of breast cancer. Both biological males and biological females can get breast cancer; the risk is far higher for biological females. Some men who begin to develop gynecomastia, however, are not sure what is going on and worry that they might have cancer. If you experience swelling in your breasts and it worries you, or you aren’t sure what’s causing it, you should talk to your doctor.
Regardless of whether you ever encounter gynecomastia, lymphedema, lipedema, PCOS, or any of the other health conditions in this chapter, taking care of your body and your health is an important part of your sex life. Few people are capable of feeling sexy and saucy when they feel unwell or are in pain. No body is always healthy—that goes for thin bodies as well as fat bodies. We all get sick sometimes; we all suffer injuries and accidents. But there’s no reason to think that because you’re fat you have no recourse if you feel unwell. You have every right to do whatever feels appropriate to help yourself have the healthiest body you possibly can, regardless of your size. Looking after yourself with appropriate medical care, good nutrition, pleasurable movement, and restful sleep are all part of taking care of yourself and your health—and, of course, good lovin’ never hurt either!