Sexual dysfunction can arise as a complication for men and women living with diabetes. As health professionals, it is important that we address these sensitive topics regularly in routine history questioning so that the topic of sexual dysfunction awareness is raised within the diabetes community and so that people experiencing sexual dysfunction, raise it with their health care team.
What is sexual dysfunction?
Sexual dysfunction (SD) is defined as the inability to achieve or maintain an adequate sexual response to a sexual encounter or intercourse resulting in a satisfactory orgasm or pleasure. Sexual dysfunction affects both males and females and their partners due to:
Emotional issues leading to reduced desired to have sex such as achieving orgasms, erectile dysfunction in men, and pain and lubrication in women.
Men and 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 issue of erectile dysfunction. Erectile dysfunction may or may not affect ejaculation. Mental health, body image and high blood glucose levels can affect libido reducing 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 quoted the overall prevalence of ED in this group was 37% with over 58% of this group reporting mild ED.3
Other causes of ED
Other factors that may contribute to or cause erectile dysfunction in men include:
Being tired, stressed, depressed and drinking alcohol.
High blood pressure, cholesterol, smoking, unhealthy weight, heart disease
Medications include blood pressure medications s such as beta blockers, various groups of antidepressants (SSRIs and SNRIs), antipsychotics, antiepileptics and cancer medications.
Treatment for erectile dysfunction in men with diabetes include healthy lifestyle modifications such as stop smoking, decrease alcohol intake, increase healthy eating and exercising, increase maintaining blood glucose levels in target range, medications and devices.
It is reported that 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 most commonly available treatment for erectile dysfunction and includes the drugs sildenafil and tadalafil. These medications are taken about one hour before desired effect. These medications are not suitable for people taking nitrate medications.
Other treatments include vacuum pumps, injections (alprostadil) or inflatable prosthesis.
Women and sexual dysfunction
Sexual dysfunction (SD) is not as well reported in women, as the diagnosis is harder to identify than in men and there are multiple factors that affect women more.
Women living with diabetes experiencing sexual dysfunction may experience vaginal dryness, a decrease in sexual desire, pain during sex and trouble having an orgasm. Women may experience higher rates of issues with sexual health and body image.
In one study women with type 1 diabetes and sexual dysfunction, 33% of women reported to 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%
Vaginal lubrication 47%
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%
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
Treatment options for women living with diabetes is considered to be:
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
A drug approved in the US, the first ever drug to treat low sexual desire in women has been approved for use in premenopausal women with low sexual desire. It is currently not available in Australia.
Body Image and Mental Health
People living with type 1 and type 2 diabetes can experience body image and mental health issues that can impact on self-esteem and relationships when trying to be intimate.
Body image can be impacted:
In people with type 1 diabetes, issues may present such as feeling uncomfortable with partners seeing insulin pumps and CGMs, bruising and scarring from injection sites, or it may be the issue of trying to negotiate pump sites when being intimate.
In people living with type 2 diabetes, they may feel weight stigma surrounding type 2 diabetes, as they are 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 ongoing issues dealing with daily diabetes decisions impacts significantly on people’s mental health, causing depression and anxiety. These issues that both men and women face can impact their confidence and the image that they hold of themselves.
Medication that may be prescribed for depression can affect sexual dysfunction as a side effect. The antidepressant group selective serotonin reuptake inhibitors (SSRIs) is reported to cause sexual dysfunction between 20-70% of men and women.7
Sexual dysfunction discussions with patients
Raising awareness and encouraging discussions around sexual dysfunction with patients who live with diabetes is an important discussion that health professionals should encourage with their patients.
Barriers can exist between healthcare professional and patients to initiate such conversations due to health professional – patient interaction difficulties such as different genders, ages or culture.8
Barriers for patients include social stigma, media misrepresentations, discomfort and embarrassment discussing such issues and lack of awareness and knowledge regarding sexual dysfunction being a medical issue associated with diabetes.9
Barriers that health professionals may experience in discussing these topics with patients include:
lack of knowledge, training and resources,
discomfort, bias or lack of confidence to raise the topic.9
Ways to address and overcome barriers to begin a conversation about sexual dysfunction is highlighted in a framework called the PLISSIT model.10 This model outlines four stages for the 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 for a general practice setting.
Ways in which health professionals can help patients raise the topic of sexual dysfunction is by displaying general information leaflets or factsheets in waiting rooms regarding sexual dysfunction, display posters encouraging patients to raise the topic with their health team and introducing questions as part of the normal history taking routine questioning.9
Examples of questions or statements that may be used in routine history taking to initiate discussions around sexual dysfunction may 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?”
Ultimately, sexual dysfunction is a real issue amongst people living with diabetes and can affect their personal relationships and quality of life. Sexual dysfunction can be affected by diabetes management, mental health, medication, body image and lifestyle issues.
Raising awareness amongst people living with diabetes of this issue is an important first step so patients can recognise that this may be an issue that they experience and wish to discuss.
Appropriate pathways to begin to address issues with patients experiencing sexual dysfunction are referral to general practitioners, psychologists, sexual therapists, relationship counsellors or pharmacists for a home medication review.
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
Pharmacogenetics of SSRIs and Sexual Dysfunction. Pharmaceutics. 2010 Dec; 3(12): 3614–3628 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4034069/
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