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This is ALL THINGS CONSIDERED from NPR News. I'm Melissa Block.

It is well known that obesity can lead to a wide range of health problems. But what's rarely talked about is the impact it can have on people's sexual health. As the obesity rate has soared in the U.S., more and more marriage and family therapists are getting questions from obese clients about problems in the bedroom. And that leads to this story as part of our series on how life is changing in a country where one in three people is obese.

Sarah Varney of member station KQED tells us about the intimate lives of three people brave enough to share their stories.

SARAH VARNEY: It's Dana Englehardt's 50th birthday, and she's flitting about in a tailored floral sundress.

UNIDENTIFIED WOMAN: We're going to eat cake soon.

VARNEY: Dana and her husband Larry Boynton chat with friends under the shade of the Monterey Cypress trees that line the backyard of their Belmont, California home, a small town south of San Francisco. This is, in a way, Dana's coming-out party and she's feeling a little flirty. At five foot three, she's lost 140 pounds. She has killer cheekbones, a slim waist and toned legs.

(SOUNDBITE OF SONG "HAPPY BIRTHDAY," CHEERING AND APPLAUSE)

VARNEY: A few hours into the party, Dana glowed from the warm afternoon sun and the highly trafficked margarita machine, the ultimate truth serum.

DANA ENGLEHARDT: Some of my single guy friends, they were saying, you know, if something ever happens to Larry, give them a call.

(SOUNDBITE OF LAUGHTER)

VARNEY: When Dana met Larry, more than a decade ago, she was quite heavy. She was a straight-talking nurse, widowed with three kids. He was a local contractor looking to end his swinging bachelor days and get serious. Larry says he didn't focus on Dana's size.

LARRY BOYNTON: Once I decided to put that out of my mind and allow the relationship to grow with the person I was falling in love with, her personality and how much fun we had together, it just really wasn't an issue.

VARNEY: After they married, Dana gained another 60 pounds. Her joints ached. She could barely stand during her nursing shifts. Grocery shopping and gardening left her winded. She had terrible sleep apnea and was exhausted all the time. And then there was the sex. The thought of making love to her husband felt like a chore.

ENGLEHARDT: I suffered a lot of guilt because I knew that, you know, I wasn't meeting my husband's needs. That was the worst part, was the guilt.

VARNEY: In all this, Dana came to see her body as something separate from herself. She wouldn't look at her reflection in storefront windows. She raised her make-up mirror so she could see only from her nose on up. And when she settled in for the night, she didn't want Larry to touch her.

ENGLEHARDT: I just felt kind of hideous. And I didn't like it when he would touch me 'cause it'd just remind me of all the bulk there. And then I just kind of avoided sex for a long time.

BOYNTON: At one point it was six months. And I was almost climbing the walls, okay? She would get intimate, you know, kissing and everything, but then there would be - it wouldn't go anywhere. And so - and that makes a guy very frustrated, okay. And so I didn't want to get frustrated, so therefore, I just shut it down.

VARNEY: All of this went unsaid. Larry and Dana didn't talk about it. They did what so many couples do - they retreated.

BLOCK: Obese people, especially those trying to lose weight, are more dissatisfied with their sexual lives, and obese women seem to suffer the most.

WOMAN: Instead of enjoying their sexual intimacy, they're worried about the size of their stomach, or oh, my gosh, he's going to touch me there. What's he going to think about my stomach?

VARNEY: Ronnie Kolotkin is a psychologist at Duke University Medical Center who designed a widely used survey that measures how obesity impacts quality of life.

KOLOTKIN: Women reported many more problems with sexual functioning than men. And, in fact, women's scores were even lower than a reference group of cancer survivors.

VARNEY: Kolotkin says the problems for men and women are different.

KOLOTKIN: Women often talk about difficulties with enjoyment, low sexual desire, avoidance of sexual intimacy, as well as some difficulty with sexual performance. Whereas men are more apt to tell me in private practice or in group therapy about performance difficulties and embarrassment related to that.

VARNEY: Some of this is biological. As men's weight increases, testosterone production can plummet, leading to erectile dysfunction. Weight-related diabetes, too, can result in sexual problems.

But sex is not simply desire and arousal. For many long-term couples, emotional closeness and physical intimacy hinge on trust. Eric Leckbee, a tall and friendly 42-year-old software engineer, knows all too well what happens when that trust is broken.

He lives in San Francisco with his wife, who didn't want to be interviewed. At times, he's reached 300 pounds. But it was when Eric's wife caught him hiding food that his sex life really took a nosedive.

ERIC LECKBEE: It causes the question of what else are you hiding? I'm not being honest with her. To be really, truly intimate with someone, you know, sexually and emotionally, you have to be able to trust them. So she puts barriers up and then I feel defensive and I put barriers up. And then it causes more of a chasm to occur between us.

When you start feeling more emotionally distanced from each other, then you're less likely to want to have sex or even to enjoy the sex that you have.

VARNEY: Eric has done a lot of therapy just to talk about all this. Still, he's often repulsed by his body and has had a hard time imagining that his wife finds him attractive.

LECKBEE: I felt nearly impossible - not impossible, but very, very hard to approach my wife for sex, to hit on my wife. And then I would think to myself, God, you're a loser, you don't know how to hit on your wife. The one woman in the world...

(SOUNDBITE OF LAUGHTER)

LECKBEE: ...who should be open to your sexual advances, and yet I would have a fear.

VARNEY: All of this would crawl around in Eric's head. It still does. When he feels confident, he's able to maintain his diet, even go on a bike ride. But those periods give way to darker ones when he becomes quiet and distant.

LECKBEE: When I'm feeling fat and depressed, I'm not communicating very well. And, you know, that breaks down the intimacy, which breaks down the, you know, the amount of sex - the frequency of, you know, sexual intimacy.

VARNEY: Eric's weight still fluctuates. He and his wife, though, are now trying a new approach: to separate his weight from their sex life.

LECKBEE: My wife, you know, saying to me that, you know, I love you and I'm attracted to you regardless of your weight, that was something I needed to hear and something I needed to believe, though I still struggle with it. I still struggle with it.

But now I'm more self-aware. Now I understand it. Now I'm able to look at it and go, I'm not feeling - my libido is really low right now because I have been eating too much and I'm feeling bad about myself. And, you know, I express it to my wife and let her know I'm feeling this way.

VARNEY: This process of recovery, both physical and psychological, is messy and seemingly unending. For Dana Englehardt, her health had become so bad she took the drastic step of getting bariatric surgery.

ENGLEHARDT: Put your knee over here.

BOYNTON: Yes, babe.

ENGLEHARDT: There you go. There you go.

VARNEY: Dana and Larry cuddled up together on their living room couch. We had decided to meet up one more time to talk about what happened after her surgery and weight loss. Dana says she fantasized about a renewed sex life with her husband.

ENGLEHARDT: I did have kind of unrealistic expectations that, yeah, I mean, after I got this new body that he was going to suddenly be all over me. And that didn't happen. And I think that he went so long with me being uninterested that when I was interested again, I don't know if you had trouble believing it, that I was interested again? But you kind of - it took a while for you come around.

BOYNTON: It took a while for me to realize what the signs were again.

VARNEY: Dana and Larry went to counseling and started figuring out how to communicate about a lot of things, including sex. Now, Larry says, I know the signs.

BOYNTON: I know it now and it's nice. It's very, very nice.

VARNEY: Dana sought her own counseling to exorcise her deeply held belief that she was an unlikeable fat girl.

ENGLEHARDT: It's kind of nice 'cause I can just kind of lose myself in the moment and not be thinking about, you know, oh God, he's touching my belly fat again, you know.

(SOUNDBITE OF LAUGHTER)

VARNEY: It's been several years now of hard discipline to keep the weight off, and painful therapy. But finally, Dana is able to fall into that fugue state, that dreamy abandon that lovers often inhabit.

For NPR News, I'm Sarah Varney.

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