Let’s Talk about Sexual Health

Diabetes can affect sexual health in several ways. Effective contraception and pregnancy planning   are vital. Genital yeast infections are common in men and women whose diabetes management is sub-optimal and the occurrence of sexual dysfunction is higher than the average, especially in older people with diabetes².

Diabetes educators are well placed to begin a conversation about sexual health issues. Providing this opportunity for the first step of a therapeutic journey that may involve several other health professionals is critical to providing comprehensive whole person care. This article aims to provide some guidance on how to approach discussing sexual health that may encourage you to do it more often.

Why is talking about sex challenging?

We might be quite comfortable discussing the need for contraception or pregnancy planning with a female client but feel challenged if she says, “I won’t need to worry about that, sex hurts too much” . Talking about the details of sexual function or how someone feels about their sexual experiences can be difficult for educators and clients. We can feel embarrassed talking about what is usually a private topic, not sure we have the right words or knowledge to tackle the issue or intimidated by not knowing where the discussion will go.

It’s my experience that health care clients can feel very similar. They may want to talk about sexual health issues but are reluctant to start the conversation, uncertain if it is appropriate to talk about sex, worried where the discussion will go and feeling inadequate from the loss of function.  There may also be feelings of shame or guilt and cultural, religious, or personal beliefs and values that can create barriers to discussing sexual matters.

Maintaining appropriate professional boundaries is vitally important. Enquiries about sexual activity should be framed within an appropriate clinical context and not appear voyeuristic. Starting a discussion about sexual health with an explanation of why the topic is important in relation to diabetes establishes this context and helps avoid any potential misunderstanding.

Things that help talking about sexual health

Ensuring privacy is important to allowing open discussions. Displaying a non-judgemental attitude is also vital, especially when we consider the huge variation in sexual expression and our own personal, limited experience. Human sexual behaviour is diverse -what we do, why we do it, who we do it with and how we identify sexually. All these factors can vary over time and how we describe gender is currently changing away from the binary male or female to encompass a much broader scope. Incorrect assumptions about a person’s sexual or gender characteristics can cause a loss of trust in the professional relationship, so ask, don’t assume.

Knowledge builds confidence in talking about any topic including sexual health. Finding reliable information can be difficult. SHINE SA, (Sexual Health Information, Networking & Education) have an online resource, SA Sexual Health Awareness or SASHA, that is broad and reliable³.

Sometimes people’s knowledge of the average parameters of sexual function is limited and the influences of media and increasing use of online pornography portray sexual attributes and activity that are more myth than reality. This can create frustration and disappointment when a person feels they are somehow inadequate in not meeting these unrealistic ideals.

 Sexual function and diabetes

Maiorino et al’s review article provides a detailed description of how diabetes can contribute to the development of sexual dysfunction ². It acknowledges the importance of psychological and emotional factors to satisfying sexual experiences including the influence of low mood and anxiety on libido and describes specific physiological factors that increase the risk of sexual function problems for people with diabetes.

Both men and women have erectile tissue in their genitals that engorges with sexual arousal. This makes the penis or clitoris erect and expands the tissue surrounding the vaginal opening. Good blood flow through the arteries suppling this erectile tissue is essential. Diabetes increases atherosclerosis which narrows arteries and compromises blood supply. The nitric oxide messenger pathway is critical for expansion of the tiny sinusoids in erectile tissue and lower levels of nitric oxide can occur in diabetes (endothelial dysfunction)². The Maiorino article also describes the important contribution of the autonomic nervous system to vascular smooth muscle relaxation in erectile tissue.

Diabetic autonomic neuropathy can also cause bladder dysfunction, retrograde ejaculation, erectile dysfunction, and vaginal pain with penetrative sexual activity due to decreased vaginal lubrication⁵. Symptoms may be present in up to 50 percent of individuals with diabetes⁴.

Desire for engaging in sexual activity is influenced by hormones, especially testosterone. It has been reported that up to one third of men with type 2 diabetes have low testosterone that can reduce libido and affect erectile function⁵.

Risk factors for erectile dysfunction include hypertension, hyperlipidaemia, and obesity, as well as diabetes⁶. The normal processes of aging and menopause can also contribute to sexual function as well as numerous common medications (antihypertensives, antidepressant, fibrates) and recreational drugs, especially alcohol and tobacco⁶. These factors may be relevant to people with diabetes and sexual dysfunction.

The most common sexual function problem for men with diabetes is erectile dysfunction². Low libido and rapid ejaculation can occur with erectile difficulty or independently. Women with diabetes describe pain with intercourse, reduced genital sensation and difficulty reaching orgasm⁷.

Tips for talking about sex

Using open ended questions can be useful as it allows people to tell their story. More specific questions will also be needed for clarification and details. Gentle prompting may help to overcome reluctance to talk about sex-related issues. For example:

• “Can you tell me more specifically what you mean by “Things aren’t working as well as they used to”?”
• Questions that may be perceived as judgmental are often associated with a higher level of inaccurate responses. As an example, asking “Are your erections normal?” is more likely to be answered with ‘yes’ than ‘no’. Whereas “Have you noticed any change in erections?” acknowledges that change may have occurred and then allows them to describe it.

People use euphemisms or colloquial terms when discussing awkward or embarrassing topics and the language of sex is full of them. Try to use simple, standard words and seek clarification if necessary. This is particularly important in discussions with people from a different linguistic background or if using interpreters.

Before starting to discuss sexual health it’s good to give a context and rationale for exploring this area of care.  This gives the person a bit of time to prepare mentally and emphasises the clinical value rather than it being an inappropriate enquiry (some examples follow).

Introducing sexual health review into routine care

Given the high frequency of sexual dysfunction in those with long-term type 1 diabetes (T1D) or older people with type 2 diabetes (T2D)^{2, 6, 7} , it is probably important to raise this topic at some point soon after diagnosis, if it’s appropriate to their stage of development and care needs.  This pre-emptive discussion to optimise their sexual health may include contraception, pregnancy planning and maintaining sexual function. Using fear of loss of sexual function to encourage optimal glycaemic management may appeal but framing it positively rather than as a threat may be more encouraging.

• “We’ve talked a lot about how to manage diabetes, but this condition is only one part of your life. What things are important to you now and in the future – sport, study, work, travel, having a family, sexual relationships?”
• This helps individualise the discussion and identify sexual matters as important to consider.

Normalising an issue is another way of saying to a person that it’s ok to talk about this and it’s normal to be concerned about it.

“We’ve talked a lot about diet and measuring your blood glucose levels and there’s something else I’d like to discuss with you.  It’s quite common for people with diabetes to have some difficulty with sexual activity at some point.”

1. How have things been going for you?
2. Would you like to know more about this?
3. Is this something that concerns you?

If you sense reluctance, pause and give them a chance to gather their thoughts or courage, and if they don’t have current concerns it’s good to provide for future opportunities. “It’s a topic we can talk about another time.”

In the annual cycle of care there are opportunities to ask about sexual function⁸. Firstly, in the “Physical Activity Review”, the current recommendation is for “30 mins moderate exercise, 5+ times a week”.  The list of exercise options is endless and could include “sexercise”. This could give positive reinforcement for physical activity they didn’t realise they were doing and encourage them to keep on engaging in sex with long-term benefits – if you don’t use it, you lose it.

• Secondly, sexual activity could be discussed as part of “Emotional Health”. For those with a partner, asking how the relationship is going could then lead to discussion about intimacy and sexual activity. People without a partner may still be having sex, or wanting to, and difficulty with sexual function may be a barrier to them embarking on an intimate relationship.
• Exercise, including sexual activity, effects energy utilisation and glycaemic management⁹. This is of course very variable between individuals, and for one person over time and related to the type of activity. Generally, lower intensity or aerobic activity will lower blood glucose levels (BGLs) and can increase the risk of hypoglycaemia. This hypoglycaemia can be delayed, so sexercise in the evening may cause hypos during sleep.  High intensity physical activity, which can include vigorous sexercise, may increase BGLs and require adjustment of insulin dosing.

Managing erectile dysfunction

The development of erectile dysfunction can be an indicator that there is vascular disease generally².  The penile blood vessels are very narrow, and reduction of flow here may precede that of coronary or other arteries. Identification of a decline in erectile function should therefore prompt referral to GP or other medical review for comprehensive cardiovascular assessment as this change in erectile function may be a warning for undiagnosed ischaemic heart disease.

Specific management of erectile dysfunction includes the use of oral medication with the phosphodiesterase 5 inhibitors². These drugs increase and maintain blood flow into the erectile tissue.  These tablets are often effective for men with diabetes but can be expensive and can’t be used in those with severe or unstable cardiac ischemia due to potential drug interactions.

If oral therapy is not effective there are directly acting blood vessel dilators that can be injected into the penile erectile tissue. GPs can prescribe these products but not all will be familiar with them and referral to a specific prescriber may be needed. Vacuum pumps draw blood mechanically into the erectile tissue which is then trapped by using a tight band around the base of the penis. The band should be removed after 20-30 minutes to ensure return of oxygenated blood flow. Pumps can be bought from some pharmacies or online. The insertion of a penile prosthesis to enable erections can be done but the process destroys the erectile tissue and is very expensive. A useful resource is the Healthy Male site¹⁰.

Pain with vaginal intercourse

Pain with intercourse is described as contributing to sexual dysfunction for women with diabetes⁷.  This pain may be felt at the vaginal opening and may be associated with other symptoms such as vulval itch, burning or irritation. Whilst vulvo-vaginal candidiasis (a yeast infection commonly called “thrush”) is very common in all women and more common in women with diabetes, it’s important not to assume that it is the cause of these symptoms in every situation.  A woman may have been incorrectly self-diagnosing “thrush” for years, using repeated treatments from the chemist and been experiencing frustrating recurrence or persistence of symptoms because she has another condition that causes similar symptoms.

Using soap, body wash or ‘feminine hygiene products’ are common causes of contact dermatitis.  Incontinence or the use of pads or liners can also cause allergic or irritant dermatitis of the yulva. Low oestrogen levels occur after menopause and this can also lead to discomfort with intercourse. Aging is also often associated with women needing more stimulation to gain adequate arousal and vaginal lubrication. A referral to a GP with expertise in Woman’s Health or the local Family Planning service could be worthwhile to address this situation. The Jean Hailes organisation is a useful online resource on female sexual issues¹¹.