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LIFE AFTER BARIATRIC SURGERY: PERCEPTIONS OF MALE PATIENTS

AND THEIR INTIMATE RELATIONSHIPS
Moore, Darren D; Cooper, Clinton E.Journal of Marital and Family Therapy; Hoboken Tomo 42, N.º 3, (Jul 2016): 495-508.
DOI:10.1111/jmft.12155

Resumen
This study explores the experiences of 20 men who have had bariatric surgery, focusing on their couple or marital relationships. The
researcher concentrates on men's perspectives regarding relationship satisfaction, sexual intimacy, and social support after surgical
intervention. Phenomenology and family systems theory were used to guide the study from which emerged three themes: (a)
Unintended consequences (unpredicted problems occurring within intimate relationships); (b) Intimacy as bittersweet (experiencing
increasing levels of intimacy, while still desiring more); and (c) Inconsistent social support (experiencing instances where social support
is provided, while simultaneously experiencing other areas where social support is not provided). The study includes a rich description of
the data, critical analysis, and discussion of clinical implications for therapists and other healthcare professionals.

Texto completo

Headnote
This study explores the experiences of 20 men who have had bariatric surgery, focusing on their couple or marital relationships. The
researcher concentrates on men's perspectives regarding relationship satisfaction, sexual intimacy, and social support after surgical
intervention. Phenomenology and family systems theory were used to guide the study from which emerged three themes: (a)
Unintended consequences (unpredicted problems occurring within intimate relationships); (b) Intimacy as bittersweet (experiencing
increasing levels of intimacy, while still desiring more); and (c) Inconsistent social support (experiencing instances where social support
is provided, while simultaneously experiencing other areas where social support is not provided). The study includes a rich description of
the data, critical analysis, and discussion of clinical implications for therapists and other healthcare professionals.

Obesity is an issue that negatively impacts an individual's health and overall quality of life. Although there are a number of treatment
modalities that address the obesity epidemic (such as diet/food changes, exercise, and other nonsurgical intervention), bariatric surgery
has been viewed as the most effective treatment, specifically as it relates to clients who are considered morbidly obese, those with a
body mass index (BMI) greater than 30 (Foster et al., 2003; Pories et al., 1995; Schauer et al., 2012). According to Wray and Deery
(2008), "BMI, a height to weight ratio, is often used to measure the medically defined condition of obesity" (p. 230). Persons are
considered obese if they have a BMI of 30 or higher. To date, the research regarding bariatric surgery has been focused on medical
outcomes (i.e., significant weight loss and associated co-morbidities) (Santry, Gillen, & Lauderdale, 2005).

Due to the medicalization of obesity, there has been less emphasis on exploring the role that family relationships have during the weight
loss surgery process. Few studies explore this surgery as it impacts the couple relationship (Van Hout, Verschure, & Van Heck, 2005).
Likewise, discussions have been focused exclusively on the experiences of the individual female patient or on the female patient/male
spouse dyad. To date, no investigators have focused solely on the experiences and perspectives of male bariatric patients. This study is
significant in that exploring the men's perspectives will provide marriage and family therapists, medical providers, and other
professionals with information that may be useful in helping male patients successfully navigate through the weight loss surgery process.
Exploring men's experiences, specifically within the contexts of couple relationships, may contribute not only information that could be
used for individual patients, but could provide a mechanism by which the needs of men and their spouses are accounted for and treated
during such a significant transition process.

While bariatric surgery is a medical procedure, it is also an individual and family process that can shape or influence intimate and
interpersonal relationships (Greenberg, Perna, Kaplan, & Sullivan, 2005). Some studies have found that bariatric surgery can negatively
affect and contribute to conflict within couple relationships postoperatively (Hafner, 1991; Hafner & Rogers, 1990). Additionally, some
others have suggested that individuals struggle postoperatively with adapting to a new lifestyle (Dymek, le Grange, Neven, & Alverdy,
2002). Furthermore, scholars have found that some individuals experience difficulties making the required behavior modifications
necessary to sustain weight loss success (i.e., adapting to a new diet, increasing their level of exercise, altering personal relationships
with food) (Hafner, Watts, & Rogers, 1991). Therefore, it is important to consider the effect that significant weight loss can have on
couples' relationships, as it could also impact weight loss outcomes. This study purposely explores the postoperative experiences and
perspectives of coupled men who have had bariatric surgery to develop an idea of the experiences, processes, and understanding they
had at the time of and after undergoing bariatric surgery.

Impact of Obesity on the Patient

While the literature review is focused exclusively on the postoperative experiences of bariatric surgery, some information regarding

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obesity and experiences prior to surgical intervention is warranted to provide a context for understanding change after surgery. In
addition to the physical health consequences that obese individuals face, such as obstructive sleep apnea, hypertension, Diabetes Mellitus
II, heart disease, and various cancers, among others (Guh et al., 2009; Kim & Popkin, 2006; Mokdad et al., 2003), investigators have
found that obese patients suffer from negative consequences regarding their obesity status as it relates to social interaction and mental
health (Grilo, Masheb, Brody, Burke-Martindale, & Rothschild, 2005). Researchers have found that obese patients encounter weight-
based discrimination (Farrow & Tarrant, 2009), social stigmatization (Thomas, Hyde, Karunaratne, Herbert, & Komesaroff, 2008),
discrimination at the workplace (Swami, Chan, Wong, Furnham, & Tovee, 2008), discrimination when seeking treatment by a medical
professional (Teachman & Brownell, 2001), and discrimination as it relates to the perception of sexual desirability (Singh & Young, 1995).

Obesity Influences on Couple Relationship

Bariatric patients have been found to struggle with mental health concerns such as negative body image (Muennig, Jia, Lee, & Lubetkin,
2008), negative self-concept, (Blaine, 2009), eating disorders, (Grilo et al., 2005), and high levels of depression (Chen, Jiang, & Mao,
2009; Napolitano & Foster, 2008), among other mental health issues (Solow, 1977). Individuals who experience obesity not only
encounter negative consequences due to their weight status, but this status also negatively impacts couple and family relationships
(Barbarin & Tirado, 1985). Structural Family Therapy (Harkaway, 1986) and the Family FIRO Approach (Doherty & Harkaway, 1990)
(while not empirically based) are theoretical models that some mental health professionals, including marriage and family therapists,
have found helpful when working with obese populations. From a structural model perspective, obesity may serve as a stabilizing
function for the family system to divert attention from problems within the couple relationship. Harkaway (1986) stated that "attempts to
remove the symptom without attending to its place within the system would likely be met with resistance, sabotage, or failure" (p. 201).
Additionally, according to Doherty and Harkaway (1990), "sexual jealousy, based on feelings of betrayal, may emerge with weight loss in
one partner" (p. 292).

Relationship satisfaction has also been discussed regarding obese individuals prior to surgical intervention. Some researchers have
reported that obese populations exhibit a high prevalence of marital dissatisfaction prior to surgical intervention (Hafner & Rogers, 1990;
Sarwer, Wadden, & Fabricatore, 2005). For instance, Sobal, Rauschenbach, and Frongillo (1995) conducted a population study to assess
body weight and marital satisfaction among 1,980 married adults within the 48 contiguous states and found that "obese men were more
likely to have marital problems and that men who lost more weight were less likely to report marital problems" (p. 756). Likewise,
Ledyard and Morrison (2008) conducted a qualitative phenomenological study that explored the understanding of weight for 11 obese
couples and found that obesity becomes a third part of some couple relationships and serves as a form of triangulation for couples.
Ledyard and Morrison (2008) also found that in some situations, couples unite against obesity; in other situations, obesity divided the
couple, contributing to sexual and emotional distance, decreased frequency of sex, and reports of dissatisfaction during intercourse.

In addition to generating a discussion regarding intimacy, another outcome included addressing the impact of obesity status on physical
health related to sex. Investigators have suggested that obesity negatively affects men's reproductive system and increases risks of
sexual dysfunction and infertility (Pauli et al., 2008). According to Hammoud et al. (2008), obesity decreases the ability for men to
produce sperm and results in low sperm count.

Postbariatric Surgery Influences on Couple Relationships

Investigators who have examined the postoperative stage of bariatric surgery report that most individuals experience improvements in
psychological health and quality of life. Researchers have specifically found that rates of depression, negative body image, and anxiety
decrease postsurgery (Andersen et al., 2010; Frezza, Shebani, & Wachtel, 2007; Herpertz et al., 2003). However, there have been some
researchers who have found that psychosocial improvements only last for the first couple of years after surgery (Greenberg, Smith, &
Rockhart, 2004). Furthermore, other investigators have found that after surgery, some clients experience distress related to the
behavioral adjustments required after surgery (Tejirian, Jensen, Lewis, Dutson, & Mehran, 2008), develop eating disorders (Bonne,
Bashi, & Berry, 1994; Kalarchian et al., 2002), experience an increase in high risk-taking behaviors (Vazzana, 2008), or experience what
some have referred to as the "addictions transfer phenomenon" (Marcus, Kalarchian, & Courcoulas, 2009; Sarwer et al., 2008). Sarwer et
al. (2008) stated that addiction transfer "refers to the ideology that patients who go through the procedure of getting bariatric surgery
may develop addictions such as substance abuse, gambling, and sex to replace their preoperative 'addiction' to food" (p. 55). Other
issues that some clients have been found to experience are related to their social interaction with peers, co-workers, and family
members. Specifically, it has been found that some clients experience stigma from family members (Bray & Benfield, 1977; Earvolino-
Ramirez, 2008) as well as feeling uncomfortable when receiving compliments about their new change in body size (Sogg & Gorman,
2008).

Critical Analysis

The research that has been conducted regarding bariatric surgery and couple relationships is inconclusive and preliminary at best, as
examiners have found various results over the years. Some investigators have found that clients benefit from improved couple and
marital relationships postbariatric surgery (Rand, Kuldau, & Robbins, 1982) and have found that clients specifically experience
improvements as it relates to sexual intimacy and frequency of sex (Camps, Zervos, Goode, & Rosemurgy, 1996; Kolotkin et al. (2008).
Two researchers found no significant change in marital satisfaction (Porter & Wampler, 2000; Rand, Macgregor, & Hawkins, 1986).
However, Neill, Marshall, and Yale (1978) conducted a qualitative retrospective study and found that clients reported stress and turmoil in
the relationship, extramarital affairs, separation, and divorce. Academics have also found that bariatric respondents experienced a
greater level of marital instability postsurgery (Macias, Leal, Lo^ pez-Ibor, Rubio, & Caballero, 2004) and that obese spouses are more
likely to experience weight gain while the patients lose weight (Madan, Turman, & Tichansky, 2005). Likewise, scholars Applegate and
Friedman (2008) suggest that "weight loss surgery issues for couples can stem from the patient's and their partner's expectations, the
patient's increase in energy, their enhanced confidence, and changes in appearance" (p. 135). In addition to bariatric surgery, other
medical procedures have been shown to have bearing on the couple relationship, which may provide some additional insight related to
viewing medical intervention from a relational perspective (Dankoski & Pais, 2007; Linville, Hertlein, & Lyness, 2007; McLean et al.,
2008; Phillips et al., 2000). Based on the literature and the gaps existing in regard to men's experience within couple relationships, the

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investigator developed research questions that will be examined in the next section.

RESEARCH QUESTIONS

The grand research question for this study was "How does the process of bariatric surgery influence men's experiences in their
intimate relationships postsurgery?" The research questions for this study also included the following: (a) How does bariatric surgery
influence men's experiences in their intimate relationships postsurgery? (b) How do men perceive relationship satisfaction after weight
loss surgery? (c) How do men perceive intimacy after bariatric surgery? and (d) How do men perceive social support within their
intimate relationships after bariatric surgery? These research questions were developed from the existing literature on couple
relationships and bariatric surgery. Specifically, the researcher was interested in gaining a better understanding of the interactional
patterns that may take place during the process of change after surgical intervention. With the gaps in the literature, regarding the
experiences of men in particular, the researcher also specifically wanted to explore the perceptions of weight loss surgery and its
impact on men's relationships.

With a focus on men's experiences within the context of their intimate relationships, the researcher made the decision to use family
systems theory to underline the study. Although one might posit that interviewing men individually is not systemic, it is important to
acknowledge three major tenets of family systems theory: a change in one part of the system has bearing on the entire system
(Hurley, 1982), parts of a system operate in a recursive relationship and are interdependent and involve circular causality or what
some refer to as mutuality or interdependence, and certain patterns occur within family relationships (i.e., complementary and
symmetrical relationships) (Becvar & Becvar, 1982).

While interviews in this study canvassed only men, the overall scope was relational in nature, using research questions developed from
a systems perspective to explore men's perceptions of the patterns they experienced during weight loss-as individuals and part of a
couple or family relational system. While the study focuses on male patients, the researcher has specifically concentrated on men's
perceptions of their interactions within the context of their intimate relationships, thus providing information that has implications for
men and their relational systems. Please see Appendix S1 for a list of sample research questions and Appendix S2 for the theoretical
model regarding the development of the research questions.

METHODS

Utilizing phenomenology research methods in this study, the researcher explored the experiences of individuals who had bariatric
surgery to learn more about the process of change and stability, regarding their individual self and aspects of their intimate
relationships. As a research method, phenomenology has been widely used in the nursing field and incorporated in several studies
regarding medical patients (Charalambous, Papodopoulos, & Beadsmoore, 2008) and in the field of marriage and family therapy
(Sprenkle & Piercy, 2005). Phenomenology is built on the epistemological premise that knowledge is socially constructed and based on
interpretation. A phenomenologist researcher explores the qualities of an individual's experience through interviews, stories, or
observations with people who are currently confronting the experience (Connelly, 2010; Dahl & Boss, 2005; McLeod, 2003). This
research study employed phenomenological methods to grasp the experience of men who have undergone bariatric surgery while in an
intimate relationship.

The researcher used a purposive sample of men, which as suggested by McCambridge, Mitcheson, Winstock, and Hunt (2005), is a
sample "constructed according to predefined needs for data collection" (p. 1142). Therefore, in order to participate in the Institutional
Review Board approved study, respondents had to meet certain criteria including (a) identify as a heterosexual man; (b) have had
weight loss surgery within the last 5 years; (c) be at least 26 years old at the time of surgical intervention; (d) be at least 6 months
postsurgery at the time the of study; (e) having been in at least one intimate or committed relationship after surgery; and (f) a U.S.
resident. The researcher based these criteria on an analysis of Erikson's stages of development (Erikson, 1963), data from the
Expanded Family Life Cycle (Carter & McGoldrick, 2009), and a minimum age of 26 to exclude adolescent populations and participants
who would be considered emerging adults, ages ending around the mid-20s (Arnett, 2000; Schwartz, Cote, & Arnett, 2005).
Additionally, an intimate relationship was defined as a close relationship in which an individual is afforded an opportunity to form a
strong emotional attachment, a sense of belonging, as well as being cared for within the bounds of a romantic or sexual relationship
(Miller & Perlman, 2008) and a committed relationship as "a monogamous and supportive relationship" (Jimenez & Tatem, 2007, p.
11). As participants must have been in at least one intimate or committed relationship to take part in the study, their responses
provided an understanding of the men's experience of weight loss inside the context of intimate relationships. As it relates to sexual
orientation, the authors decided to focus exclusively on heterosexual relationships in order to maintain a homogenous sample. After a
literature review regarding Gay men and men with varying sexual orientations, the author found major differences related to relational
dynamics, stress, body image, and masculinity that could confound the results of the study (Duncan, 2007; Kurdek, 1998; Manley,
Levitt, & Mosher, 2007; Meyer, 1995).

The researcher used two social networking sites (www.YouTube.com and www.facebook.com) for recruitment, along with a number of
other social websites focused on weight loss. To use YouTube as a recruitment method, a channel was created along with a video
containing information about the study that included a brief description with the purpose of the study, information for recruitment,
compensation as well as contact information, and a copy of the informed consent- all of which were accessible to the public when
searching for topics related to weight loss. Using Facebook as a recruitment method, the researcher created a professional page which
included the same information provided on the YouTube channel, listed alternative forms of contact, and also allowed messages to be
received and sent to targeted audiences. With both the YouTube and Facebook recruitment methods, the researcher had the ability to
transpose through each website's own advertisement programs. Additionally, the researcher recruited participants' offline from the
state of Georgia and specifically targeted hospitals and weight loss programs throughout the state.

As part of the research process, the current literature and theory served as the underpinning for the study. Specific interview
questions emerged directly from literature to demonstrate a rationale for the study, as referenced in Appendix S1.

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Before the interview, each respondent received a prompt to select a pseudonym in order to protect confidentiality. The primary
researcher conducted sixty- to ninety-minute interviews in participants' homes or other locations specified by the respondent, or via
Skype (an online video conferencing program). Once a secured transcriptionist transcribed the first interview, the research team,
consisting of the primary investigator and two additional research consultants, conducted a line-by-line text analysis and developed
codes and then reviewed all additional interviews and coded them independently (Parkman, 2009). After reading the interviews
multiple times, making notes, and re-working codes, ultimately, the research team developed final codes and incorporated member
checks to allow participants an opportunity to provide any feedback and further clarification regarding their interview (Guba &
Lincoln, 1989). Additionally, participants received a copy of the interview transcript and initial research findings for them to offer
their suggestions of any changes.

The author also incorporated transferability within the research study. This refers to the ability to "generate theories which will
provide descriptive data of a phenomenon which can be used to guide wider- and larger-scale studies from an informed starting
point" (Jasper, 1994, p. 313). To promote transferability, the researchers intentionally became integrated into the data to acquire a
rich description of the phenomenon by conducting a line-by-line analysis and coding the transcripts multiple times, individually and
with the research team. The rich description of the phenomenon included detailed accounts of the participants' answers via the
semi-structured interviews, as well as writing memos that documented the researchers' observations, including nonverbal
communication. The research team developed codes and themes to make inferences regarding possible transference and to find
ways to connect the study to theory. The primary investigator was the research instrument; therefore, he completed reflexivity
assignments consistently during the research process to promote and support credibility and dependability (Creswell & Miller, 2000;
Moore, 2015; Richardson & St. Pierre, 2005). Reflexivity assignments are "the process whereby researchers report on personal
beliefs, values, and biases that may shape their inquiry" (Creswell & Miller, 2000, p. 127) and is a criterion used for evaluating and
judging the practicality of a research study (Richardson & St. Pierre, 2005). Likewise, researchers used bracketing (Fischer, 2009)
during the in-home interviews in addition to keeping an audit trail (Golafshani, 2003; Lincoln & Guba, 1985) to increase credibility.
Tufford and Newman (2012) describe bracketing as "a method used in qualitative research to mitigate the potentially deleterious
effects of preconceptions that may taint the research process" (p. 80). The primary research investigator has experienced obesity as
well as contemplating several ways to produce weight loss, both surgically and nonsurgically. Thus, throughout the research study,
he documented his experiences, perspectives, and biases via bracketing before the interviews as well as during the research
process (Tufford & Newman, 2012). In an effort to remain objective, open-minded, and curious about the phenomena, and in an
effort to reduce bias (Richardson & St. Pierre, 2005), the author also completed a series of reflexivity assignments. Specifically, the
author discussed such topics as how his own context related to the research topic including, but not limited to age, race, ethnicity,
sex, and weight loss experience.

RESULTS

A total of 20 men provided interviews over the course of 6 months. The researchers stopped at twenty after receiving informational
redundancy or what is referred to as "saturation" (Sandelowski, 1995). According to Marshall (1996), "the size of the sample is
determined by the optimum number necessary to enable valid inferences to be made about the population" (p. 522). Of the
interviewees, 14 responded via social networking sites on the Internet, while an additional six responded to in-person recruiting
efforts. Among the participants, 17 individuals reported obtaining the gastric bypass surgical procedure (a procedure in which
staples are surgically inserted to divide the stomach and connect the new, smaller stomach to the small intestine, both limiting food
consumption and calorie absorption) (U.S. National Library of Medicine, 2015a); while the remaining three reported undergoing the
lap band procedure (a procedure in which an adjustable silicone band is surgically implanted around the stomach to help limit food
consumption) (U.S. National Library of Medicine, 2015b). All individuals identified as being in a significant relationship with 16
participants reporting being married and four participants reporting not being married. The research showed a substantial range (36
years) regarding the length of time married for participants. Likewise, there was a substantial range in terms of participant age. The
average age (range 29-64 years) of participants was 44.

The majority of participants in the study were Caucasian males (sixteen) while two participants self-reported as Hispanic and two
participants self-reported as biracial (Mexican and Caucasian; Caucasian and Native American). Respondents represented a number
of geographic locations including the Northeastern, Western, Midwestern, and Southern areas of the United States, and also
represented a number of occupations, religious affiliations, educational levels, and socioeconomic statuses. Three participants
reported having no religious affiliation; seven were Christian (nondenomination), two Catholic, two Baptist, two Methodist, one
Lutheran, one Protestant, and two Jewish (nonobservant). Participant education level varied with nine participants having reported
that their highest level of education was high school, six having some college education with no degree, and five having a Bachelor's
degree. The average salary among the participants was 115,000). In addition, the
average preoperative weight of participants was 363.03 pounds, while the range for total weight loss after surgical intervention was
67-190 pounds (M = 122.5). Likewise, the length of time postsurgery when the study took place ranged from 6 to 31 months (M =
13.3 months). Please see Appendix S3, for a list of sample demographics.

Emerging Themes of the Study

The primary research question was "How does the process of bariatric surgery influence the male patient's intimate relationships?"
In the study, three themes emerged, which included (a) Unintended consequences; (b) Intimacy as bittersweet; and (c)
Inconsistent social support. One of the interesting aspects of the themes found in the study is that they were not universally
positive, negative, or neutral. Rather, the themes that emerged demonstrate the complexity inherent in relational dynamics after
surgical intervention, in that a person can experience both positive and negative interactions simultaneously. Likewise, the themes
also demonstrate complexity in that participants can experience improvement in one aspect of their relation, while they may still not
be 100 percent satisfied. A description of each emerging theme follows.

Theme 1: Unintended Consequences

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While a majority of participants reported having an increased level of relationship satisfaction (n = 15), some individuals reported
problems that occurred after weight loss surgery (n = 7). A number of participants reported that their intimate partners felt
insecure within their relationships due to the surgery and the subsequent weight loss. Participants also discussed how negative
body image, the spouse's self-concept, feelings of intimidation, and jealousy compounded the level of insecurity within their
relationships. As described by James in his following statement:

In the beginning she thought I would have the surgery, lose the weight and possibly end our relationship, because I would end
up wanting or desiring to be with someone else. I think her sense of security was in the fact that we were both overweight and
thinking if I lost the weight, she would possibly lose me (James, Age 33).

Another phenomenon that occurred was the perceived insecurities of spouses, related to men becoming smaller than their wives.
Some participants mentioned that surpassing their partner's weight would be problematic for their partners. For example, Andrew
mentioned that he thought his wife was starting to become jealous because he was getting close to her weight. When asked to
reflect further about the idea of insecurity, Andrew stated the following:

I think her fear is someday I'll catch up to her and she will be the heavy one. Or that I'll get to a point where I look skinnier than
she does. I think all those things together, when it comes to my weight loss, scared her (Andrew, Age 29).

In addition, some men reported that their spouses became jealous and attempted to make them feel guilty when they would
leave home to exercise. For example, Nobley discussed how his wife struggled with feeling pressure to keep up with his new
lifestyle of running marathons. Researchers also reported the finding that as some intimate partners were already dealing with
their own weight and body image issues, their levels of insecurity within the relationships were exacerbated.

While men reported that divorce was not an option after surgical intervention due to an increased level of commitment to their
relationship (n = 18), they also reported on issues related to the romantic attention they received from others. Several
participants (n = 18) reported that although they may have received romantic "attention" from individuals outside of their
relationships, they often did not act upon advances made by others. However, while men reported that they would not leave their
spouses, at least four reported becoming curious regarding interactions with others. While no participants reported engaging in
sexual behavior with a partner outside of their committed relationship, participants did report that they were tempted at times.

Theme 2: Intimacy as Bittersweet

The second theme that emerged was intimacy as bittersweet. Participants in the study reported that they experienced an
increased level of intimacy within their significant relationship postsurgery and verbalized that they would not change anything
about their level of intimacy (n = 16). Participants reported on both their experiences of emotional intimacy and sexual intimacy.
Sixteen participants reported an increased level of emotional connection after surgery, with the remaining four participants
reporting that there was no improvement. Participants who discussed improvements in emotional intimacy reported that
emotional connection was expressed through an increase in verbal and nonverbal communication as well as physical touch.
Participants reported less arguing, feeling emotionally closer to their spouses, and engaging in better communication after
surgery, exemplified by participant Nobley:

Before surgery our sex life was very infrequent. Our sex life started increasing relatively soon after surgery...we actually talk
now. Before we didn't really talk. If something was bothering us we held it in until it blew up. Sometimes that would be days,
weeks, months, even years (Nobley, Age 42).

Respondents were also asked to describe how emotional intimacy was expressed in their relationships after surgery. Participants
reported that their spouses showed affection via compliments, intimate embraces, kissing, cuddling, spending more time
together, and engaging in more communication. For example, when Gratz was asked to describe emotional intimacy after
surgery, he stated the following:

She tells me she loves me all the time. She's a big toucher, hugger, kisser...We always ask how each other's day was. We take
time to communicate. That's our biggest thing, we communicate a lot. We don't keep secrets. We tell everything. (Gratz, Age
31).

With the exception of four participants, most individuals reported an increase in both emotional and sexual intimacy; however, it
was viewed as bittersweet as participants still often desired more. For example, among the study participants, an increase in
sexual interaction postsurgery was reported (n = 19). They also reported feeling more enjoyment from their sexual encounters.
When participants responded to the question of how their partners felt about sexual intimacy, most participants perceived that
their partners experienced improvements as well. Participants discussed having more stamina during intercourse, feeling less
weight conscious, feeling more comfortable initiating sex, and feeling less sexually inhibited. In addition, over half of the
participants (n = 13) reported having an increased desire for sexual intimacy after surgery.

However, while participants reported an increased desire for sexual interaction, their partners may not have experienced this
same desire. Within the study, some participants (n = 7) reported that they had a desire to change aspects of their sexual
intimacy after surgery. The men mainly voiced the desire for sexual interaction to occur more frequently, with some stating that
they desired to have sex daily.

Theme 3: Inconsistent Social Support

During the interviews, participants suggested that informal social support from their spouse was inconsistent, as there were both
instances where they received social support, while at the same time instances of not receiving social support. Participants

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reported that support and lack of support occurred simultaneously. All participants reported on instances where they received
support. Social support occurred through the use of encouragement, accountability, verbal praise, changing eating habits,
assisting with after care, financial support, and attendance at support groups. Spouses were viewed as key players in the
weight loss surgery process, from deciding to have surgery and preparing to have surgery to aftercare. Nobley reported that
his wife played a key role during his weight loss:

She was the pivotal role. She scheduled all my appointments. She was at every pre-op appointment with me. She goes to all
of my follow-up visits. She stayed in the hospital with me...I would not be here at the point I am in my post-op life if it wasn't
for her (Nobley, Age 42).

Participants also reported that their spouses assisted in providing "nursing"-like personal care (n = 5). The interviewees
discussed ways in which their spouses assisted with monitoring their compliance with postoperative medication, which included
attending medical appointments, communicating with medical professionals, and administering medication.

Although participants reported obtaining support from their spouses, many of them also reported instances where they felt
unsupported (n = 17). Failure of support consisted of negative feedback when discussing the desire for surgery, unwillingness
by partners to change eating habits, and negative feedback when participants attempted to exercise. Participants viewed this
failure of support as being counterproductive to their new lifestyle (n = 3). Gratz, one of the participants, described his
experience when faced with this situation:

She was very supportive. She was there for me, she made it a lot easier, but there was one point about 2 weeks after the
surgery where I could only eat pretty much just water and soup and she came home from work eating a Wendy's
cheeseburger and fries and I wanted to kill her (Gratz, Age 31).

In addition, other issues surfaced during the interviews regarding lack of support by spouses and family members. One issue
was related to intimate partners not attending support groups. Lack of empathy was also raised.

DISCUSSION

The phenomenology of men includes the perception of enhanced relationship satisfaction and intimacy. The term "enhanced" is
indicative of improvement or an increase in efficacy (Driskell, Copper, & Moran, 1994). Men reported that overall they had a
better relationship postsurgery than they had prior to surgery. One of the issues that emerged with participants was the
perception of their romantic partner's insecurity. This relates back to some of the major tenets of family systems theory; that a
change in one part of the system impacts the entire system, that relationships are recursive in nature and interdependent, and
that relationships can lead to specific patterns (Becvar & Becvar, 1982; Hurley, 1982). Men reported that their partners
became fearful that the men would want to leave the relationship and find another more compatible partner. This fear, as the
men viewed it, contributed to some conflict and issues with social support. Other reported issues and concerns which
contributed to insecurities included perceptions of the intimate partners' issues with their own weight, body image, and self-
esteem.

The researchers who have examined sexual intimacy in individuals after bariatric surgery have concluded that sexual
frequency increases and sexual intimacy improves (Camps et al., 1996; Kolotkin et al., 2008). A new finding is that while men
experienced increased sexual intimacy after surgery, many also still desired additional sexual interaction. The new sexual
desire may contribute to concerns and/or conflict within couple relationships. One notable aspect of the phenomenon regarding
sexual intimacy is that while men may have the desire for more sexual interaction and intimacy, their spouses who have not
undergone weight loss surgery may not experience the same desire. The other new finding that emerged in this study was
that of stronger emotional intimacy through better communication. Better communication included feeling more comfortable
with engaging in communication, increased frequency of communication, and less tension regarding discussing thoughts,
feelings, and areas of conflict.

From a family systems perspective, individuals experience the most stress during periods of transition. Weight loss surgery
ignites a transition phase for individuals, couples, and families. How a system broaches bariatric surgery may in fact influence
how a couple experiences life after weight loss surgery. From this theoretical perspective, an open system may produce a more
positive experience for individuals, couples, and families. Additionally, one hypothesis could be that a more positive experience
may contribute to a better outcome in terms of long-term weight loss. Also, preparing individuals and couples for such a
significant change may produce a better outcome for the entire family system.

Social support provided by spouses is an important part of the adjustment that individuals make after bariatric surgery. During
research, the men reported on the inconsistency of social support received from their partners. Men obtained support from
their spouses, peers, and families, while experiencing some aspects of the process (such as diet and exercise) where they felt
a lack of support from the same individuals. Family systems theory also is applicable to the topic of social support, specifically
as it relates to meaning making. How a family makes sense of weight loss and how open a family is to weight loss will
determine the extent to which it is accepted into the system. Likewise, how individuals within a man's social network construct
meaning around weight loss surgery will also determine to what extent a man receives social support. In some ways, social
support could be a threat to the relationship as it could be viewed as contributing to the demise of the relationship if the
couple centered their relationship on their obesity status.

Clinical Implications

In addition to marriage and family therapists possibly assisting with identifying reasons why men overeat, addressing issues
related to body image, attitudes toward food, and sexual intimacy, they could also work with men and their intimate partners

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prior to surgical intervention. Marriage and family therapists could help couples prepare for having surgery by discussing
motivations for surgery, goals and expectations postsurgery, intimacy, social support, self-esteem, and couple dynamics.
Another thought that was disclosed was that marriage and family therapists could assist with facilitating communication
regarding fear, insecurity, relationship dynamics, and intimacy, among others. More research is needed to explore what
happens when one partner desires sexual intimacy while the other does not. Conflict and issues around sexual intimacy
could possibly lead to a breakup, separation, divorce, infidelity, porn addiction, and an increase in masturbation (Metz &
Epstein, 2002). Additional research related to emotional closeness, communication, and sexual interaction could be
conducted to explore emotional intimacy further.

Family systems theory also could be applied to the notion of men receiving romantic attention from others outside of their
intimate relationships. When thinking about change and the concept of wholeness, experiencing romantic attention could
impact both men and their partner's level of security in the relationship. When one person shifts and the spouse does not
(in the case that one has surgery while the other stays the same), it can contribute to the spouse feeling as if the man has
one foot in the relationship and one foot out (Neill et al., 1978). Likewise, spouses could also become upset with the new
change, especially if now the person who loses weight becomes the center of attention, while the spouse becomes viewed
as lazy and nonsupportive for not keeping up and losing weight. This could contribute to the man feeling guilty about having
surgery and could contribute to the spouse feeling guilty for not losing weight (assuming they both needed to lose weight)
(Ravitch & Brolin, 1979).

One of the topics discussed during the interviews was related to social support. Marriage and family therapists could assist
men who have had weight loss surgery by facilitating support groups for them and their intimate partners. In addition,
marriage and family therapists could also provide support groups for intimate partners to address any issues and/or
concerns with other group members' spouses in a group therapy setting. Mental health "check-ups" by marriage and family
therapists after surgery could be implemented for surgical patients and their partners. In addition, current medical
practitioners could incorporate systemic, biopsychosocial, structural, and Family FIRO models of health into their treatment
modalities (Boyd, Watters, Canfield, & Nativ, 2011; Doherty & Harkaway, 1990; Doherty, McDaniel, & Hepworth, 1994;
Harkaway, 1986).

Implications for Training and Education

Currently, most AAMFT-accredited educational programs do not include training in handling matters related to obesity in
their standard curricula. The lack of training programs prevents therapists from being accredited to qualify them to work
with bariatric clients. Therefore, incorporating the findings into formal graduate school education would be one way to
maximize their impact. Marriage and family therapists could greatly benefit from a better understanding of how weight and
weight loss surgery are important contextual factors when working with bariatric clients as individuals or part of a couple or
family system. As educators, family therapists could not only expand the awareness for the need for more research with
bariatric clients but-equally as important-could inform students about working with this ever-growing population. Other
recommendations would be the incorporation of training via distance learning, workshops, and clinical internships. Also, the
findings could be used to train medical professionals in how to work with patients, as well as to train bariatric patients and
their spouses about the potential changes that may occur through the weight loss surgery process.

Research Implications

This research study revealed that bariatric surgery not only affects men as individuals, but also has a significant influence
on intimate relationships. One possible limitation to the current research is the exclusion of the participants' romantic
partners; perhaps future research could include both partners' perceptions of identity through the weight loss surgery
process. Other possible limitations to the current study include the sample size and population and the inclusion of only
male participants. Acknowledging that men are only one part of a system, a future study could include women. Another
avenue of research to investigate would be whether preparing individuals and couples for surgical intervention would
produce a better surgical and relational outcome. Furthermore, one could conduct a study and interview couples as dyads
and compare their responses to other couples regarding their experiences after surgery. In addition, one limitation could
include the phrasing of the research questions. While most of the questions were open-ended, some may have been
interpreted as closed-ended, which could ultimately impact how respondents answered a specific question.

Life after bariatric surgery was the focus of the study, but there appears to be significant information that might be relevant
that occurs within intimate relationships prior to surgical intervention. A future study could be conducted to explore more
information regarding family dynamics prior to surgical intervention. As men feel more comfortable about their bodies and
their experiences, presumably their spouses could in fact start to feel alone, abandoned, left out, depressed, and isolated.
Exploring the topic of social support from more of a relational perspective could help promote the inclusion of spouses,
partners, and children with the consideration that weight loss surgery is a family process and not simply an individual
process. Finally, the current research topic could be expanded in a number of ways, specifically by including a more diverse
sample to include African American men, members of other races and ethnicities, as well as gay, bisexual, and
transgendered males. Likewise, a future study to explore the impact of weight loss surgery on the larger family system,
which could include children might have merit. From a family systems theoretical perspective, one could hypothesize that a
change in one part of the system could impact children and other members of a family (Alexander, 1973; Boulding, 1956).

Sidebar
SUPPORTING INFORMATION

Additional Supporting Information may be found in the online version of this article:

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Appendix S1. List of sample research questions.

Appendix S2. Theoretical model of research questions.

Appendix S3. Sample demographics.

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AuthorAffiliation
Darren D. Moore and Clinton E. Cooper

Mercer University School of Medicine

Darren D. Moore, PhD, in Human Development: Marriage and Family Therapy from Virginia Tech, and is an
Assistant Professor of Psychiatry and Behavioral Sciences at Mercer University School of Medicine; Clinton E.
Cooper, BA, in Psychology from High Point University and is a graduate student in the Master's degree program
in Marriage and Family Therapy at Mercer University School of Medicine.

Thank you to my dissertation chair Dr. April Few-Demo, and committee members, Dr. Damion Waymer, Dr.
Fred Piercy, and Dr. Kathryn Allen.

Address correspondence to Darren D. Moore, Department of Psychiatry and Behavioral Sciences, Mercer
University School of Medicine, 655 First Street Rm: 311, Macon, Georgia 31201; E-mail:
moore_dd@mercer.edu

Copyright Blackwell Publishing Ltd. Jul 2016

Detalles

Materia Studies;
Intimate relationships;
Phenomenology;
Gastric restriction surgery;
Intimacy;
Marital relationships;
Health professionals;
Surgery;
Men;
Systems theory;
Therapists;
Social support;
Obesity;
Gastrointestinal surgery;
Patients;
Couples;
Perceptions;
Males

Lugar United States--US

Empresa/organización Nombre: National Library of Medicine

NAICS: 519120;

Nombre: Mercer University

NAICS: 611310

Título LIFE AFTER BARIATRIC SURGERY: PERCEPTIONS OF MALE

PATIENTS AND THEIR INTIMATE RELATIONSHIPS

Autor Moore, Darren D; Cooper, Clinton E

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Tomo 42

Número 3

Páginas 495-508

Número de páginas 14

Año de publicación 2016

Fecha de publicación Jul 2016

Editorial Blackwell Publishing Ltd.

Lugar de publicación Hoboken

País de publicación United Kingdom, Hoboken

Materia de publicación Social Services And Welfare, Matrimony, Psychology,

Sociology

ISSN 0194472X

CODEN JMFTDW

Tipo de fuente Scholarly Journals

Idioma de la publicación English

Tipo de documento Journal Article

Características del References

documento

DOI http://dx.doi.org.ezproxy.uned.es/10.1111/jmft.12155

ID del documento de 1807487572

ProQuest

URL del documento https://search-proquest-com.ezproxy.uned.es/docview

/1807487572?accountid=14609

Copyright Copyright Blackwell Publishing Ltd. Jul 2016

Última actualización 2018-10-05

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Research Library
Sociology Collection

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condiciones

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