Differentiation of self as a theoretical framework to understand comorbidity of sexual dysfunction and eating disorder symptoms: an exploratory study

Abstract

Although the empirical evidence supporting the comorbidity of sexual dysfunction and eating disorders is growing, the theoretical common ground of this comorbidity is not yet known. The aim of the current study was to examine the differentiation of self as a theoretical common ground of the comorbidity between sexual dysfunction and eating disorder symptoms (EDS). We used profiles of sexual dysfunction and eating disorders to examine how these profiles differed in terms of differentiation of self. The study was conducted as an online survey among a convenience sample of 985 Israeli women. Women in the comorbidity group (high levels of both sexual dysfunction and EDS) had significantly lower levels of differentiation of self than did women in the other groups: no disorder (low levels of sexual dysfunction and EDS), EDS (low levels of sexual dysfunction and high levels of EDS), and sexual dysfunction (high levels of sexual dysfunction and low levels of EDS). The current study suggests that differentiation of self may be a shared feature among both sexual dysfunction and EDS. Limitations of the study, directions for future research, and clinical implications are discussed.

LAY SUMMARY

The current study suggests that low levels of differentiation of self is a shared psychological feature in both eating disorders and sexual disorders. Both disorders can represent the need to establish a “no entry” system of defenses—by rejecting food and intimacy women try to maintain their sense of self.

Keywords:

• Sexual dysfunction
• eating disorders
• latent profile analysis
• differentiation of self

Introduction

Sexual dysfunction and eating disorder symptoms

The comorbidity of sexual dysfunction and eating disorder symptoms (EDS) has long been clinically observed. The empirical co-occurrence between these two conditions has also been investigated and empirically established (Castellini et al., 2016; Dunkley et al., 2020). The focus of the current study is on women in particular, as both sexual dysfunction (Laumann et al., 1999) and EDS (Galmiche et al., 2019) are more prevalent among women than men. Sexual dysfunction among women pertains to three main diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM): female sexual interest/arousal disorder, female orgasmic disorder, and genito-pelvic pain/penetration disorder (American Psychiatric Publishing, 2013). Eating disorder symptoms refer to preoccupations with weight, body, and food (Sharpe et al., 2018), and markedly differ from full-blown EDS according to DSM criteria (American Psychiatric Publishing, 2013).

Sexual dysfunction has also been found across samples of women struggling with EDS (Castellini et al., 2012, 2016; Dunkley et al., 2016, 2020). The literature in which the co-occurrence of sexual dysfunction and EDS has been examined suggests that women with EDS also experience sexual dysfunction across all areas of the sexual response cycle including low desire, problems with arousal and vaginal lubrication, difficulties achieving orgasm, and pain (Castellini et al., 2016; Dunkley et al., 2020). The comorbidity of sexual dysfunction and EDS is complex, in part because of the multiple possible causes for this comorbidity. Research on the mechanisms explaining the co-occurrence of sexual dysfunction and EDS is sparse and speculative. Possible mechanisms include psychological, physiological, etiological, and sociocultural factors, such as personality characteristics, history of childhood sexual abuse, unhealthy family dynamics, social interactions, and cultural factors (Dunkley et al., 2020; Ghizzani & Montomoli, 2000; Wiederman, 1996; Wiederman & Pryor, 1997). Physiology is discussed as a main factor that is likely to serve as a risk and maintenance factor regarding the co-occurrence of sexual dysfunction and EDS. Various physiological conditions related to EDS, such as hormonal and endocrine function, amenorrhea, malnutrition, changes in ovarian steroids and central nervous system neurotransmitters, and other physical conditions (Dunkley et al., 2020; Ghizzani & Montomoli, 2000; Pinheiro et al., 2010) could lead to decreased sexual desire, vaginal tightness, and lower levels of lubrication, which can in turn lead to painful intercourse and difficulties reaching orgasm (Castellini et al., 2012; Pinheiro et al., 2010). However, other possible mechanisms have only been studied in a limited fashion. Although empirical evidence supporting the co-occurrence of these two conditions is growing, there has not yet been an attempt to explain this comorbidity theoretically. To the best of our knowledge, differentiation of self has not been used as a potential theoretical framework to explain the association or comorbidity between sexual dysfunction and EDS. The aim of the current exploratory study was to examine the comorbidity of sexual dysfunction and EDS through the theoretical lens of the differentiation of self.

Differentiation of self as a possible theoretical framework

Differentiation of self is a complex construct that was originally proposed by Bowen (Bowen, 1985). It reflects the ability to be in an intimate relationship without losing one’s sense of a stable and integral self through extreme dependency and/or distancing from significant others, and includes two interrelated dimensions: the intra-psychic, which reflects one’s ability to regulate emotions and intellect (Bowen, 1985), and the interpersonal, which reflects the capacity to regulate closeness and autonomy (Bowen, 1985; Kerr & Bowen, 1988). Low differentiation of self is expressed by high fusion with others, emotional cutoff, and emotional reactivity, whereas a balanced differentiation of self occurs when an individual develops an I-position, a self-defined identity that is separate from close significant others. Individuals with balanced self-differentiation have flexible interpersonal boundaries and are able to engage in intimacy without fear of loss-of-self (Bowen, 1985; Kerr & Bowen, 1988). Imbalanced self-differentiation is manifested in pleasing others at the expense of one’s self (“fusion-with-others”), emotional withdrawing (“cutoff”), or emotional reactivity (being overwhelmed by emotions). Whereas individuals who are “fused” experience separation as overwhelming and actively avoid it, individuals who are “cut off” perceive closeness as threatening and seek to limit it.

In the context of differentiation of self, Blatt and colleagues’ theoretical formulations provide valuable insights into the early processes of boundary articulation and the establishment of mature levels of interpersonal relatedness. The Differentiation-Relatedness Scale operationalizes these theoretical concepts, allowing for a nuanced exploration of the dimensions of differentiation in individuals (Blatt & Auerbach, 2003). Blatt and colleagues emphasize the importance of the intra-psychic and interpersonal dimensions of differentiation (Blatt et al., 1996), aligning with Bowen’s conceptualization (Bowen, 1985; Kerr & Bowen, 1988). This includes the ability to regulate emotions and intellect intra-personally and the capacity to regulate closeness and autonomy interpersonally (Blatt et al., 1997). Furthermore, the Psychodynamic Diagnostic Manual (PDM-2) acknowledges the significance of differentiation and integration as a core domain of mental functioning. This inclusion in the PDM-2 underscores the broader recognition of differentiation as a fundamental aspect of psychological health (Lingiardi & McWilliams, 2015; Mirabella et al., 2023).

The connection between balanced differentiation of self and both sexual satisfaction/function and EDS is highlighted by several studies, contributing to a comprehensive understanding of these complex phenomena. In the realm of sexual satisfaction and function, balanced differentiation of self is an important component in sexual satisfaction and function (Burri et al., 2014; Ferreira et al., 2016; Timm & Keiley, 2011). Sex involves high levels of physical and/or emotional intimacy between two people. However, Perel (2006) noted that in order for one to experience sexual pleasure, a sense of freedom, autonomy, and separateness is needed. Without this sense of separateness, intimacy collapses into fusion, which impairs sexual function. When individuals have a balanced differentiation of self, they are more likely to be able to communicate their sexual and emotional needs, desires, and fantasies without feeling anxious about losing their sense of self during the close physical contact. However, individuals with low levels of differentiation of self may be more concerned about losing their sense of self during sexual activity and be emotionally overwhelmed by sex. As a result, they may use different strategies (cutoff, fusion) to maintain emotional stability in an intimate relationship.

As for EDS and differentiation of self, low levels of differentiation of self also play a role in EDS (Doba et al., 2018; Levy & Hadley, 1998; Rothschild-Yakar et al., 2016). From a psychological perspective, EDS can be conceptualized as entailing a struggle with identity in the context of the dependency-autonomy conflict, transferred to the realms of food and body (Fowler et al., 2002; Sands, 2003). Restricting food can be used as an emotional regulator or as a means to gain control and defend one’s self from diffusion or perceived invasion. Sands (Sands, 2003) suggested that all eating disorder subtypes are characterized by using and controlling the body to defend against any experience of dependency-related needs.

The self-differentiation theory offers a common theoretical ground for both sexual function and EDS. Both conditions can develop from the fear of losing a sense of self and from an attempt to gain autonomy and a sense of differentiation. On the psychological level, sexual dysfunction can reflect the fear of merging with someone else, and restricting food intake or bingeing and compensatory behaviors can be viewed as strategies that reflect a struggle between dependence and independence (Fowler et al., 2002). Although differentiation of self has been used as a theoretical framework to study sexual function and EDS separately, to the best of our knowledge they have not to date been examined in relation to one another.

The current study

In light of the clinical and empirical evidence discussed in the introduction, our study posits several hypotheses to explore the relationship between sexual dysfunction, EDS, and differentiation of self among women. Our exploration extends to understanding differentiation of self across various profiles of EDS and sexual functioning. We expect nuanced patterns, anticipating that different comorbidity profiles may manifest distinct challenges in self-differentiation. We hypothesize that the impact of specific EDS and sexual dysfunction subtypes within the identified profiles will contribute to variations in levels of differentiation of self. More specifically, we hypothesize that individuals within the high comorbidity group, demonstrating elevated rates of both sexual dysfunction and EDS, will exhibit lower levels of differentiation of self. This expectation aligns with the notion that challenges in balancing closeness and autonomy may contribute to lower self-differentiation in this subgroup. Conversely, we hypothesize that groups with lower comorbidity, characterized by low levels of both sexual dysfunction and EDS, will display higher levels of differentiation of self. This hypothesis stems from the assumption that healthier psychological functioning is associated with a more balanced differentiation of self, as indicated by previous literature.

Methods

Participants and procedure

We conducted an online survey among a convenience sample of women in Israel. The sample was collected through ads posted on social media (Facebook and Instagram). To be included in the study, participants had to be older than the minimum consent age of 18 and be able to read and answer a survey in Hebrew. Participants were invited to participate in a study on eating tendencies and sexuality. A link to an online survey hosted by Qualtrics (a secure web-based survey data collection system) was provided in the advertisement. The survey took an average of 25 min to complete, and was open from December 2019 through February 2020. It was anonymous, and no data were collected that linked participants to recruitment sources. The Max Stern Yezreel Valley College institutional review board approved all procedures and instruments. Clicking on the link to the survey guided potential respondents to a page that provided information about the purpose of the study, the nature of the questions, and a consent form (explaining that the survey was voluntary, respondents could stop at any time, and responses would be anonymous). The first page also offered researcher contact information. Each participant was given the opportunity to take part in a lottery that included five $85 gift vouchers.

A total of 985 women participated. Their ages ranged from 18 to 56 years (M = 27.8, SD = 9.1). The majority of the sample defined themselves as heterosexual (82%) and secular (79.9%). About half (48.3%) reported having a high school diploma or under, another 13% had continued with their education to some extent (e.g., vocational studies), and 38.7% had acquired a bachelor degree or higher. More than half (66.2%) were working full- or part-time jobs and earned a below-average (48.4%) or average income (20.8%). Among the respondents, 61.9% reported being in a romantic relationship, 32% were single, and 6.1% were divorced, separated, or widowed. Those in a romantic relationship reported having been in their current relationship between 1-37 years (M = 5.4, SD = 6. 9). Finally, 23.2% reported having children.

Measures

Background variables

Participants completed a brief demographic questionnaire that assessed age, religiosity, education, income, and relationship status.

Sexual dysfunction

Sexual dysfunction was measured using the Arizona Sexual Experiences Scale (ASEX) (McGahuey et al., 2000). Information on both physiological and subjective sexual arousal is gathered through this 5-item self-report instrument. The ASEX asks patients to report on core elements of sexual function including sex drive, arousal, vaginal lubrication, ability to reach orgasm, and satisfaction with orgasm, for example: “How strong is your sex drive?” and “How easily are you sexually aroused (turned on)?” Based on previous studies (Brassard et al., 2015; Purcell-Lévesque et al., 2019), the authors added a question about sexual pain. Each ASEX item is rated from 1 to 6 and the score is summed, with higher scores representing less sexual dysfunction. The scale has excellent internal consistency (α = 0.91) and has been shown to be an accurate measure of sexual dysfunction, even in the absence of a current sexual partner (McGahuey et al., 2000). The ASEX was translated using the back translation method, following the guidelines for the process of cross-cultural adaptation of self-report measures (Beaton et al., 2000), and the Hebrew translation of the scale has been used in previous studies (Gewirtz-Meydan & Lahav, 2020a, 2020b). Cronbach’s alpha for the ASEX in the current study was good (α = .82).

Eating disorder symptoms

Eating disorder symptoms were measured using the Eating Disorders Inventory 2 (EDI-2) (Garner, 1991). The EDI-2 is a self-report measure of attitudes and behaviors associated with anorexia and bulimia. Each item is rated on a 6-point scale from 6 (always) to 1 (never). The current study included the following three subscales concerning eating and weight: drive for thinness (DT), bulimia (BUL), and body dissatisfaction (BD). DT and BUL are 7-item subscales including items such as “I am terrified of gaining weight” and “I stuff myself with food,” respectively. BD contains eight items including “I think my thighs are too large.” To decrease the burden on study participants, we excluded the five subscales measuring psychologically-oriented constructs, as modeled by other researchers (Stice et al., 2000). This decision was justified as investigations of the EDI-2 factorial structure have put into question the originally proposed 8-factor model with college samples (Klemchuk et al., 1990). Indeed, a higher-order factor structure has been supported in which the three eating-related (DT, BD, BUL) scales form an EDS factor (Espelage et al., 2003; Klemchuk et al., 1990). The EDI-2 subscales have been internally consistent in clinical samples, ranging from .83 for DT to .90 for BD (Garner, 1991). Within non-clinical samples, Cronbach’s alpha coefficients have ranged from .81 to .91 for DT, .82 to .83 for BUL, and .91 to .93 for BD (Raciti & Norcross, 1987; Vanderheyden et al., 1988). The EDI-2 has been previously validated in Hebrew (Niv et al., 1998), and the Hebrew translation of the scale has been used in many studies (Canetti et al., 2008; Latzer et al., 2015; Weinberger-Litman et al., 2018). In the current study, the Cronbach’s alpha coefficients for the BUL, DT, and BD subscales were .82 .89, and .89, respectively. Cronbach’s alpha coefficient for all three subscales was .93.

Differentiation of self

Differentiation of self was measured using the Differentiation of Self Inventory-Short Form (DSI-R; Sloan & van Dierendonck, 2016). The DSI-R is a 20-item version of the Differentiation of Self Inventory-Revised (DSI-R; Skowron & Schmitt, 2003) and was created using data from two adult samples (Sample 1: n = 541 and Sample 2: n = 203). The DSI-R assesses an individual’s ability to maintain equilibrium between their emotional and intellectual well-being and navigate relationships with others, emphasizing both closeness and independence. Similar to the original DSI, it is based on a 6-point Likert-type scale, ranging from not at all true of me (1) to very true of me (6). Skowron and Friedlander) Skowron & Friendlander, 1998) identified four aspects of differentiation of self as follows: (a) emotional reactivity (α = .80), (b) I-position (α = .60), (c) emotional cutoff (α = .62), and (d) fusion with others (α = .68). The Cronbach’s alpha in the present study for all subscales was 0.83.

Data analysis

Before main analyses were performed, Little’s Missing Completely at Random (MCAR) test was conducted to examine the pattern of missing data. Overall, 0.4% of the data were missing, with the MCAR test indicating that they were missing completely at random, χ²₍₅₀₎ = 46.51, p = .61. Missing data were then handled by multiple imputation (MI; Rubin, 2009) with 10 complete databases using SPSS v.25. All subsequent results were based on the pooled MI analyses.

The analysis included 985 participants with complete data. Based on a latent profile analysis (Gewirtz-Meydan & Spivak-Lavi, 2021), we examined differences in differentiation of self (emotional cutoff, emotional reactivity, fusion with others, and I-position), by conducting a multivariate analysis of variance (MANOVA) followed by Sidak post hoc analyses.

Results

Profiles of eating disorder symptoms and sexual functioning

Fit indices for latent profile analyses are presented in Table 1. The 4-class solution was chosen because it had the lowest AIC, BIC, and adjBIC values, the highest entropy, and a significant BLRT test. As can be seen in Figure 1, the four profiles were no disorder (54.6%, n = 538), EDS (29.7%, n = 293), sexual dysfunction (4.3%, n = 42), and comorbidity (11.4%, n = 112). The MANOVA results showed significant differences in EDS (F(9, 2943) = 100.45, p < .001, ɳ2p = .24) and sexual functioning (F(18, 2934) = 34.38, p < .001, ɳ2p = .17). Individuals with EDS and comorbidities had higher tendencies for thinness and bulimia compared to those with sexual dysfunction and no disorder, but no significant differences were found within these pairs. In sexual functioning, the sexual dysfunction and comorbidity groups showed lower desire, stimulation, arousal, orgasm, satisfaction, and higher pain compared to the EDS and no disorder groups, with no notable differences within these pairs.

Figure 1. The four profiles regarding EDS and sexual functioning.

Table 1. Fit indices for latent profile analysis.

	1 Class	2 Classes	3 Classes	4 Classes	5 Classes
AIC	5584.83	5507.89	5502.56	5479.76	6203.03
BIC	5609.30	5547.05	5546.40	5545.28	6288.45
adj BIC	5593.42	5521.64	5521.47	5503.82	6234.46
Entropy		0.68	0.66	0.78	0.64
LMR-LRT		79.11***	10.87	27.47	12.91
BLRT		82.93***	11.33*	28.80***	9.52
Class I	n = 985	n = 575 (no disorder)	n = 326 (ED symptoms)	n = 538 (no disorder)	n = 361 (average levels)
Class II		n = 410 (ED symptoms)	n = 585 (no disorder)	n = 293 (ED symptoms)	n = 349 (no disorder)
Class III			n = 74 (comorbidity)	n = 42 (sexual dysfunction)	n = 48 (sexual dysfunction)
Class IV				n = 112 (comorbidity)	n = 244 (ED symptoms)
Class V					n = 120 (comorbidity)

Note. *p < .05, ***p < .001. LMR-LRT, Lo-Mendell-Rubin likelihood ratio test; BLRT, bootstrap likelihood ratio test.

Do women with varying profiles of eating disorder symptoms and sexual functioning have different degrees of differentiation of self?

Means, standard deviations, univariate statistics and effect sizes are presented in Table 2. Differentiation of self was examined among four profiles: no disorder (54.6%, n = 538), EDS (29.7%, n = 293), sexual dysfunction (4.3%, n = 42), and comorbidity (11.4%, n = 112). The analyses indicated significant differences in differentiation of self, F_{(12, 2940)} = 13.43, p < .001, ɳ²_p = .05 (see Figure 2). Specifically, we found that the comorbidity group was significantly higher on emotional reactivity and fusion with others and lower on I-position than all the other groups (ps < .05). The comorbidity group was also significantly higher on emotional cutoff than the no disorder (p < .001) and EDS (p < .001) groups but not the sexual dysfunction group (p = .12).

Figure 2. The four profiles regarding differentiation of self.

Table 2. Means, standard deviation, univariate statistics, and effect sizes for examining the differences in EDS, sexual functioning, and the factors of differentiation of self by profiles.

	No disorder		ED symptoms		Sexual dysfunction		Comorbidity
	M	SD	M	SD	M	SD	M	SD	F(3, 981)	ɳ^2p
Drive for thinness	19.15^a	7.65	34.34^b	5.65	18.05^a	7.29	34.74^b	5.69	397.29***	.55
Bulimia	23.39^a	8.87	41.92^b	7.30	24.26^a	6.99	43.11^b	8.11	411.56***	.56
Body dissatisfaction	15.01^a	5.43	27.78^b	7.07	14.21^a	6.05	28.43^b	7.14	351.32***	.52
Desire	4.30^a	1.01	4.43^a	1.00	2.95^b	0.96	3.04^b	1.10	74.44***	.19
Sexual stimulation	4.46^a	0.92	4.55^a	0.86	2.62^b	0.91	2.84^b	0.95	156.34***	.32
Sexual arousal	4.52^a	0.94	4.67^a	0.92	2.71^b	0.97	3.09^b	0.95	127.33***	.28
Orgasm	3.80^a	1.16	3.94^a	1.09	1.48^b	0.59	1.95^b	0.89	151.97***	.32
Sexual satisfaction	4.48^a	1.24	4.45^a	1.14	1.60^b	0.96	2.04^b	1.03	204.37***	.39
Pain	1.85^a	1.18	1.84^a	1.14	2.93^b	1.49	3.03^b	1.57	38.00***	.10
Emotional cutoff	2.61	0.96	2.97	0.96	2.98	1.07	3.38	0.94	23.90***	.07
Emotional reactivity	3.66	1.12	4.25	1.03	3.96	1.05	4.56	0.90	33.82***	.09
Fusion with others	3.18	0.89	3.71	0.90	3.38	0.99	3.99	0.82	39.19***	.11
I-position	4.19	0.84	3.79	0.87	3.97	0.92	3.48	0.85	28.45***	.08

Note. ***p < .001. Means with different superscript letters are significantly different at p < .01 (i.e. ^a ≠ ^b). ɳ²_p = partial eta-square (an effect size).

Discussion

The goals of this study were to identify distinct profiles of sexual dysfunction and EDS among women, and to examine how these profiles differed in terms of differentiation of self. Four distinct profiles were identified. Most women in the group were categorized in the profile termed “no disorder.” The no disorder group was characterized by low levels of sexual dysfunction and EDS. The second profile, “eating disorder symptoms,” pertained to 30% of the sample. They had high levels of EDS but low levels of sexual dysfunction. The third profile, which we termed “sexual dysfunction,” was characterized by high levels of sexual dysfunction and low levels of EDS. This profile was the least frequently found among the women in the study. The fourth profile, “comorbidity,” reflected high levels of both sexual dysfunction and EDS. The comorbidity profile pertained to 11% of the participants.

These empirically-derived profiles do not support a full comorbidity hypothesis—that is, that sexual dysfunction always co-occurs with EDS. The observed patterns suggest that although women displaying EDS may not consistently experience sexual dysfunction, there appears to be a stronger trend wherein women with sexual dysfunction often exhibit EDS. About one in ten women in the sample were identified as being comorbid, experiencing both sexual dysfunction and EDS. Although the comorbidity group was not the largest, it differed from the rest of the profiles in terms of differentiation of self. Women who indicated having both sexual dysfunction and EDS had lower levels of differentiation of self than did the others.

Analyzing the profiles in the current study revealed that the comorbidity group had significantly lower levels of differentiation of self than did the other groups. Previous literature has indicated that both EDS (Doba et al., 2018) and sexual dysfunction (Ferreira et al., 2014, 2016) are associated with low self-differentiation; in the current study this construct was also found in the comorbidity group. It is possible that the interpersonal domain of differentiation—the balance between connection and autonomy in relationships (Bowen, 1978; Kerr & Bowen, 1988)–makes it harder for women with EDS to engage in emotional and physical intimacy. However, the intrapersonal domain of differentiation—the difficulty in identifying, accessing, and expressing emotions—is also relevant for sexual functioning. If a woman cannot identify and assert her sexual needs, she may feel sexually frustrated. Also, if a woman tends to lose her sense of self during intimacy, she may concede to her partner’s needs and desires, which can lead to frustration and dissatisfaction. Finally, high levels of self-differentiation among women with EDS may buffer against poor body image (Buser & Gibson, 2018). When a woman experiences EDS and has low levels of self-differentiation, she is more likely to experience a disturbed body image, which can also inhibit sexual function.

From a psychodynamic perspective, restricting the intake of food and developing sexual dysfunction can be seen as strategies used to gain a sense of self-differentiation: The woman adopts rigid boundaries and does not tolerate entrance of a “foreign body.” This perspective was suggested by Williams (Williams, 1997) who described how patients with EDS establish a “no entry” system of defenses. In other words, they reject any input into their body, a rejection that is not confined to food intake only. They may also reject sexual or emotional “entry.” In the case of sexual dysfunction, intercourse can be perceived as penetration into one’s self, and different dysfunctions may develop (e.g., low sexual desire, problems with arousal, pain during penetration), reflecting a rejection of unwanted entry.

Limitations and future research directions

In interpreting the findings of our study, it is essential to consider certain limitations. Firstly, our research was specifically tailored to individuals identifying as women, and therefore, the generalizability of our conclusions to other gender populations, such as assigned males, trans individuals, or those with different gender identities, may be limited. By inclusively exploring the experiences of individuals across the gender spectrum, research can provide more nuanced insights into the intersectionality of sexual dysfunctions, eating disorders, and differentiation of self. Secondly, the cross-sectional design employed in our investigation restricts our ability to establish causal relationships, emphasizing the need for future studies incorporating longitudinal approaches. Additionally, the reliance on self-report measures to assess variables introduces potential biases, including social desirability, impacting the objectivity of our results, especially in such sensitive topics such as sexuality and EDS. Furthermore, the study’s scope may not encompass individuals with a full-blown eating disorder or other specific subgroups, limiting the overall generalizability of our findings. Finally, our study primarily focused on individual experiences, overlooking the dyadic nature inherent in differentiation of self. Differentiation of self involves interpersonal dynamics, and our findings may not fully capture the nuanced interactions within relationships. Future research should adopt a dyadic approach, exploring how differentiation of self-manifests interpersonally and understanding the reciprocal effects between partners.

Clinical implications

Findings from the current study suggest that women exhibiting EDS and sexual dysfunction frequently experience challenges in self-differentiation, it is highly probable that this circumstance has an impact on the woman’s partner as well. Yet, sexual dysfunctions are often treated in coupled-based interventions, the standard treatment for EDS remains individual therapy (Kirby et al., 2015). Despite the conventional utilization of individual therapy in the treatment of EDS, interventions oriented toward couples—which harness the supportive capacity of partners and the therapeutic dynamics of the relationship—hold the potential to augment the outcomes and recovery rates for adults contending with EDS (Dimitropoulos et al., 2018; Kirby et al., 2015). Thus, we suggest that therapists treating women with the comorbidity of EDS and sexual dysfunction consider couple-based therapy. Couple-based therapy would support the women that are struggling with EDS, would address the relationship distress around difficulties in sexual functioning and intimacy, and promote differentiation of self within the couple relationship. A couple-based intervention would also allow the struggles of the women’s partners to be addressed, such as being frustrated by the women’s withdrawal from intimacy and feeling rejected by them; the need to repeatedly prove their love and commitment; balancing their own emotional, relational, and physical needs with those of their partners; feeling guilty about expressing their needs; and fearing they might lose or hurt their partners if they do so. Finally, involving the partners reflects the understanding that they may also be contributing to the development or persistence of their partners’ condition (and not only affected by it). A couple-based therapy would reframe the women’s challenges as a dyadic issue, thereby reducing their self-blame.

Conclusions

The present study drew upon previously established profiles of sexual dysfunction and EDS profiles: no disorder (low levels of sexual dysfunction and EDS), EDS (low levels of sexual dysfunction and high levels of EDS), sexual dysfunction (high levels of sexual dysfunction and low levels of EDS), and comorbidity (high levels of both sexual dysfunction and EDS) (Gewirtz-Meydan & Spivak-Lavi, 2021). The comorbidity profile, which reflected high levels of sexual dysfunction and EDS, involved lower levels of differentiation of self, suggesting that differentiation of self can be used as a theoretical framework to understand the associations and comorbidity between sexual dysfunction and EDS.

Disclosure statement

The authors have no conflicts of interest to disclose.

Data availability statement

Due to confidentiality obligations, we are unable to share any data or information related to this project

Additional information

Funding

This project was supported by the Max Stern Yezreel Valley College at Emek Yezreel.