Diabetes and Sexual Dysfunction

Sexual dysfunction can occur in both men and women living with diabetes. As health professionals, it’s important we create opportunities to talk to our patients living with diabetes about sexual dysfunction in our routine consultations. Not only will this increase the awareness of sexual dysfunction within the diabetes community. But it will also enable people experiencing sexual dysfunction to feel comfortable to talk to us and their wider health care team.

What is sexual dysfunction?

Sexual dysfunction (SD) is the inability to achieve or maintain an adequate sexual response to a sexual encounter or intercourse resulting in an orgasm or pleasure. Sexual dysfunction affects both males and females and their partners due to:

• diminished libido
• emotional issues leading to reduced desired to have sex such as achieving orgasms, erectile dysfunction in men, and pain and lubrication in women
• body image
• medications

Men, diabetes and sexual dysfunction

Erectile dysfunction

Erectile dysfunction (ED) is a persistent inability to achieve or maintain an adequate erection in order to have a satisfactory sexual encounter. For men with diabetes reduced blood flow and nerve damage can be the underlying cause of erectile dysfunction. Erectile dysfunction can sometimes affect ejaculation. Additionally, mental health, body image and high blood glucose levels can affect libido, which can reduce the desire to engage in sex.

Erectile dysfunction is often considered a condition of older males. It is the third most common complication of diabetes reported amongst men.¹ Demographics of erectile dysfunction in men in Australia have been reported as:

• 61% of men over 45 years presented some form of erectile dysfunction²
• 20% of men with diabetes^* experience significant ED in the late 40 years or older²

^*The type of diabetes was not reported.

Young men with type 1 diabetes may also experience ED. One overseas study focusing on 151 young men aged up to 35 years with type 1 diabetes found the overall prevalence of ED was 37% with over 58% of this group reporting mild ED.³

Other causes of erectile dysfunction

Other factors contributing to erectile dysfunction in men include:

• being tired, stressed, depressed and drinking alcohol
• high blood pressure, cholesterol, smoking, unhealthy weight, heart disease
• medications including blood pressure medications such as beta blockers, various groups of antidepressants (SSRIs and SNRIs), antipsychotics, antiepileptics and cancer medications
• spinal cord injury, pelvic surgery, multiple sclerosis

Treatment for erectile dysfunction

Treatment for erectile dysfunction in men with diabetes includes healthy lifestyle change, such as stopping smoking and reducing alcohol intake. Eating a healthy, balanced diet and doing regular exercise can also help with erectile dysfunction. Additionally, making positive lifestyle changes will help keep blood glucose levels in target range. Medications and devices can also be helpful in the treatment of erectile dysfunction.

Men who exercise regularly have a 70% risk reduction in erectile dysfunction compared to men that don’t exercise.⁴

Medications called phosphodiesterase 5 inhibitors (PDE5i)s are the usual treatment for erectile dysfunction and includes the drugs sildenafil and tadalafil. These medications are taken about one hour before desired effect. They are not suitable for people taking nitrate medications.

Other treatments include vacuum pumps, injections (alprostadil) or an inflatable prosthesis.

Women, diabetes and sexual dysfunction

Sexual dysfunction (SD) is not as well reported in women. This is because the diagnosis is harder to identify in women compared to men. Furthermore, there are more factors that affect women.

Women who have diabetes and sexual dysfunction may experience a range of symptoms. These include; vaginal dryness, a decrease in sexual desire, pain during sex and trouble having an orgasm. Women may also experience higher rates of sexual health and body image issues.

One study of women with type 1 diabetes and sexual dysfunction found 33% of women reported experiencing some form of SD.⁵ This study included younger women with the average age of participants being 42 years old. Women with sexual dysfunction reported⁵:

• decreased sexual desire (57%)
• problems with orgasm (51%)
• reduced vaginal lubrication (47%)
• reduced arousal (38%)
• pain (21%)

Women with type 2 diabetes report issues with SD also, with 68% of women experiencing symptoms⁶ such as decreased:

• sexual desire (64%)
• vaginal lubrication (70%)
• satisfaction (36%)
• orgasm (47%)

Other causes of sexual dysfunction in women

Other causes of SD in women include:

• damage to nerve & blood vessels
• low oestrogen levels
• mental health – antidepressant medication
• body Image

Body image and mental health

People living with type 1 and type 2 diabetes can experience body image and mental health issues that impact self-esteem and relationships, especially when trying to be intimate.

Body image can be impacted in the following ways:

• People living with type 1 diabetes may feel uncomfortable with partners seeing insulin pumps and CGMs, as well as bruising and scarring from injection sites. There may also be physical issues of trying to negotiate pump sites when being intimate.
• People living with type 2 diabetes may feel weight stigma surrounding type 2 diabetes, this is because they are often told it is a lifestyle condition. Issues with self-image regarding bruising and scarring can also occur if people are injecting insulin as part of their treatment.

Diabetes distress and the day-to-day decisions relating to diabetes can significantly impact on people’s mental health. This can result in depression and anxiety. Diabetes distress can affect both men and women, which can impact their confidence and self-esteem.

Unfortunately some prescription medication for depression can cause sexual dysfunction as a side-effect.  The antidepressant group selective serotonin reuptake inhibitors (SSRIs) can cause sexual dysfunction between 20-70% of men and women.⁷

Treatment for women with sexual dysfunction

Treatment options for women living with diabetes include:

• lubricants to help with vaginal dryness during sex and reduce pain
• antidepressants to help with depression and improve mental health
• creams to help with vaginal dryness
• healthy lifestyle modifications

The first drug to treat low sexual desire in women was approved for use in premenopausal women with low sexual desire in the US. However, at time of publication, it is currently not available in Australia.

How to talk to patients with diabetes about sexual dysfunction

As a health professional you play an important role in raising awareness and encouraging discussions around sexual dysfunction with your patients.

Addressing barriers to discussing sexual dysfunction

It is not uncommon for barriers to exist between healthcare professionals and patients in initiating conversations around sexual dysfunction. This can be due to health professional – patient interaction difficulties including gender, age or culture differences.⁸ Additional barriers can include social stigma, media misrepresentations, discomfort and embarrassment and lack of awareness and knowledge. Consequently, some are not aware that sexual dysfunction is a medical issue associated with diabetes.⁹

Barriers health professionals may experience in discussing sexual dysfunction with patients include:

• time constraints
• lack of knowledge and training
• limited resources
• discomfort
• bias or lack of confidence to raise the topic⁹

Using the PLISSIT model framework

Overcoming barriers to discussing sexual dysfunction is highlighted in a framework called the PLISSIT model.¹⁰ This model outlines a four stage framework that includes permission to discuss, limited information, specific suggestion and intense sex therapy.⁸ Only permission to discuss and limited information are considered appropriate in a general practice setting.

Displaying information on sexual dysfunction in GP waiting rooms

Health professionals can help create opportunities to talk to patients about sexual dysfunction through displaying information or factsheets about sexual dysfunction in their waiting rooms. Health professionals can also introduce questions as part of the normal history taking routine questioning to prompt discussions around sexual dysfunction.⁹

Ask questions to prompt discussions about sexual dysfunction with patients

Examples of questions or statements to use in routine history taking to initiate discussions with patients about sexual dysfunction include¹¹:

“People living with diabetes can experience complications such as sexual dysfunction. This can be experienced as erectile dysfunction in men or vaginal dryness and pain in women. Is this something you feel you might experience and if so it’s ok to talk to me about it?”

“One of the lesser known complications of diabetes is sexual dysfunction which can affect intimacy in a relationship. Is this something that you feel you need to discuss?”

“I have noticed that you are taking an antidepressant, these medications can sometimes affect sexual dysfunction, have you noticed any changes with sexual intimacy while taking this medication that you would like to talk about?”

Referrals for patients with sexual dysfunction

Sexual dysfunction is a real issue among people living with diabetes. It affects personal relationships and quality of life. Diabetes management, mental health, medication, body image and lifestyle issues can all impact on sexual dysfunction.

Raising awareness and opportunities to talk to patients with diabetes about sexual dysfunction is an important first step. It not only allows patients an opportunity to discuss their experiences, similarly it also offers the opportunity for referral.

Appropriate pathways to address issues with patients experiencing sexual dysfunction include referrals to general practitioners, psychologists, sexual therapists, relationship counsellors or pharmacists for a home medication review.

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References

1. A comprehensive review of urologic complications in patients with diabetes, Springerplus, 2014 3:549.
2. Much more than prescribing a pill – Assessment and treatment of erectile dysfunction by the general practitioner Volume 46, No.9, September 2017 Pages 634-639 https://www.racgp.org.au/afp/2017/september/much-more-than-prescribing-a-pill/
3. Erectile dysfunction in young men with type 1 diabetes. Int J Impot Res 2017 Jan;29(1):17-22. https://pubmed.ncbi.nlm.nih.gov/27654032/
4. Understanding Erectile Dysfunction in Hypertensive Patients: The Need for Good Patient Management. Vascular health and risk management. 2020; 16: 231–239. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7297457/
5. Sexual Dysfunction in Women With Type 1 Diabetes, Diabetes Care. 2009 May; 32(5): 780–785. Long-term findings from the DCCT/ EDIC study cohort
6. Evaluation of sexual dysfunction and female sexual dysfunction indicators in women with type 2 diabetes: a systematic review and meta-analysis.2019. Diabetology & Metabolic Syndrome vol:11, no:73. https://dmsjournal.biomedcentral.com/articles/10.1186/s13098-019-0469-z
7. Pharmacogenetics of SSRIs and Sexual Dysfunction. Pharmaceutics. 2010 Dec; 3(12): 3614–3628 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4034069/
8. Sexual dysfunctions and sex therapy: The role of a general practitioner. The Australian Journal of General Practice. 2020. Volume 49, issue 7. https://www1.racgp.org.au/ajgp/2020/july/sexual-dysfunctions-and-sex-therapy
9. Female Sexual Health: Barriers to Optimal Outcomes and a Roadmap for Improved Patient–Clinician Communications. Journal of Women’s Health. 2019 Apr 1; 28(4): 432–443. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482896/
10. Annon, J. The PLISSIT Model: A Proposed Conceptual Scheme for the Behavioral Treatment of Sexual Problems. Journal of Sex Education and Therapy. Vol:2. No: 1. 1976
11. Let’s talk about sex. Australian Family Physician. 2017. Vol:46. No.1. p14-18. https://www.racgp.org.au/afp/2017/januaryfebruary/lets-talk-about-sex