|Year : 2021 | Volume
| Issue : 3 | Page : 357-362
Frequency of sexual dysfunction in women with diabetes mellitus: A cross-sectional multicenter study
Shabeen Naz Masood1, Saira Saeed1, Nusrat Lakho1, Yasir Masood2, Mahnoor Rehman3, Saleh Memon4
1 Department of Obstetrics & Gynaecology, ISRA University, Karachi, Pakistan
2 Race and Opportunity Lab, Brown School, Washington University in St. Louis, MO, USA
3 Researcher & Consultant Statistician, Isra University, Karachi, Pakistan
4 Department of Ophthalmology, Al-Ibrahim Eye Hospital, Isra University, Karachi Campus, Pakistan
|Date of Submission||16-Mar-2021|
|Date of Decision||30-Apr-2021|
|Date of Acceptance||04-May-2021|
|Date of Web Publication||30-Sep-2021|
Dr. Shabeen Naz Masood
Department of Obstetrics & Gynaecology, ISRA University, Karachi-Campus.
Source of Support: None, Conflict of Interest: None
Objectives: Female sexual dysfunction (FSD) with chronic diseases such as diabetes has received little attention globally. The aim of this study is to assess the frequency of sexual dysfunction (SD) in women with diabetes; an aspect of female health that has not been explored in our population. Materials and Methods: This cross-sectional observational study using non-probability convenient purposive sampling technique was carried out at three health facilities of Karachi, for a duration of 1 year. One hundred women with diabetes who consented to participate in the study were included. Pregnant, divorced, widowed, and unmarried females were excluded. Modified female sexual function index (FSFI) was used to gather information. Results: Out of 100 women, 88 women with diabetes completed the interviewer-based modified FSFI survey questionnaire. Among 88 women, 38 (43.2%) reported to have SD, whereas 50 (56.8%) were found to have no significant sexual issues. Partner’s age and occupation were significantly associated with FSD. All parameters of modified FSFI, i.e., sexual desire, arousal, lubrication, orgasm, and dyspareunia, were significantly associated (P < 0.001) with diabetes. Conclusion: Women with diabetes are at increased risk of SD and often do not volunteer information about their sexual issues. The most common cause of SD was dyspareunia, followed by lubrication, orgasm, lack of sexual arousal, and sexual desire. The healthcare providers should be aware to initiate and facilitate the discussion and need to develop their own comfort to talk about sexual issues.
Keywords: Diabetes mellitus, dyspareunia, female sexual dysfunction, modified female sexual function index
|How to cite this article:|
Naz Masood S, Saeed S, Lakho N, Masood Y, Rehman M, Memon S. Frequency of sexual dysfunction in women with diabetes mellitus: A cross-sectional multicenter study. J Diabetol 2021;12:357-62
| Introduction|| |
Female sexual dysfunction (FSD) is a multicausal and multidimensional issue. Chronic illnesses are major factors affecting the quality of relationship, further aggravated by disease-related pharmacological therapies.
Masters and Johnson developed the linear sexual cycle response model of desire, arousal, orgasm, and resolution. In previous studies, FSD apparently seem to be fitted into the model of physiological sexual cycle response.,, Recently, systemic reviews and studies have identified psycho-social aspects, particularly depression, as an important contributor to FSD.,,,,,
In clinical situation, focus on treatment in chronic diseases impedes the uncovering of sexual difficulties in women. In addition, healthcare providers’ (HCPs) limited experience, comfort, and time constrains leave the issue largely unaddressed. HCPs should approach this issue in a sensitive, culture-, and gender-specific manner.
| Materials and Methods|| |
The aim of the study was to assess the frequency of sexual dysfunction (SD) in women with diabetes mellitus.
This was a cross-sectional observational study using non-probability convenient purposive sampling technique, carried out at Isra University, Karachi Campus, Al-Ibrahim Hospital Karachi, and Al-Khidmat Hospital, Karachi, over a period of 1 year from February 2019 to January 2020. After ethical approval from the Institutional Review Board (IRB) of the hospital, 100 women with diabetes who consented were recruited for the study. The age limit of the participants was 18–60 years and for analysis purpose it was divided into two groups of less than 40 years and more than 40 years. Pregnant, divorced, widowed, and unmarried women were excluded from the study.
For data collection, an interviewer-based modified female sexual function index (FSFI) questionnaire was used which was translated in the local language.,
For data analysis, SPSS version 20 was used. For qualitative data, frequency and percentages were reported and quantitative data were reported as mean and standard deviation. For comparison of scoring between the two groups, independent t-test and Fisher’s exact test were used. A P-value of less than 0.05 was considered significant.
| Results|| |
Out of 100 study participants who were recruited, 88 women consented for interview. Among the 88 women, 38 (43.2%) reported to have SD. Women without formal education had greater frequency of FSD with P-value of 0.048. Age of partner and occupation also had significant association with P-values of 0.001 and 0.002, respectively.
There was no significant association of women’s age, occupation, and partner’s educational status with FSD [Table 1]. Different parameters related to diabetes such as duration of diabetes (P = 0.364), awareness (P = 0.063), diagnosis and treatment modalities (P = 0.531) also had insignificant association [Table 2]. Duration of marriage (P = 0.464), number of children (P = 0.427), age of youngest child (P = 0.753), and history of contraception (P = 0.158) also had no significant association with FSD [Table 3].
Sexual problems were not discussed or inquired from 97% of the study participants attending clinics for their diabetes management. Similarly, women with diabetes never discussed their sexual issues with physicians in 89.8% of the cases.
FSD in the reproductive age of 18–40 years was 58% in this study, and various reasons were given by study participants for disinterest in sexual activity: lack of sexual desire in 56.8%, small house big family in 18%, dyspareunia 9.1%, and busy schedule of women in 2.3% [Table 4].
In terms of sexual desire, the mean and standard deviation was 1.73±1.032 in women with SD and 3.44±1.11 in women without SD, having a substantial P-value of <0.001. Likewise, P-value of less than 0.001 was observed in terms of sexual arousal, lubrication, level of orgasm, and dyspareunia [Figure 1] and [Figure 2].
|Figure 1: Graphical representation of dysfunctional sexual status of participants included in the study|
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|Figure 2: Graphical representation of risk factors for sexual dysfunction in participants|
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| Discussion|| |
According to DSM-V, SD is defined as “a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure.” SD among males is well-recognized and documented complication of DM. However, SD among women and their associated risk factors have been understudied and has received less attention when compared with males, although the risk of development of complications due to DM is the same among either gender., The difference in involvement of neurotransmitters of sexual response in males and females may be implicated. It is therefore easier to quantify the physiological sexual response of males, whereas it is difficult to identify and appraise genital arousal and congestion in females.
FSD is a relatively unaddressed issue. It is multifactorial in origin and includes vascular, neurological, endocrine, social, psychological, and biological factors. This may cause decreased libido, arousability issues, decreased vaginal lubrication, orgasmic dysfunction, and dyspareunia in women with chronic diseases such as diabetes.
Sexual health in women is equated to reproductive health. Therefore, sociocultural and psychological components responsible for FSD do not receive much attention.
The estimated prevalence of FSD is 20–80%. This wide variation in the prevalence of FSD may be due to non-uniform definition of FSD and may also be due to regional and cultural differences, associated endocrine disorders, and multiple drug therapies given for possible complications related to diabetes and chronic diseases.,, In Asian culture, 20–25% of the women revealed sexual problems; these low reported rates may be due to hesitancy in seeking help because of economic and sociocultural inhibitions and taboos. Even in developed countries where sex is less of a taboo, only 43% of the women are reported to suffer from SD., The wide variation in the frequency of FSD of 43.2% is also seen in our study compared with Nigerian study in which the prevalence is reported as 6.6%.
The commonly observed SD among females is arousal, reduction in sexual desire, lubrication, and dyspareunia., In women with diabetes, dyspareunia may be caused by hyperglycemia through reduction of mucus membrane’s hydration, poor lubrication of vagina, genitourinary infections, and psychological distress related to disease and its treatment., In this study also, the most common cause of FSD (84.1%) was dyspareunia, similar to other studies.,
Women with diabetes have a negative effect on most sexual parameters including sexual satisfaction, sexual desire, pleasure, lubrication, and orgasmic abilities.,,
In this study, lubrication and anorgasmia were also most commonly reported in 81.8% of females followed by sexual arousal (75%) and sexual desire (75%) with a P-value of 0.001%.
When it comes to chronic diseases such as diabetes, women and HCP are more diseased-focussed, omit, and are oblivious toward addressing their sexual concerns. In this study, 75% of the women had lack of sex desire. The studies show that women are considered to be a passive partner, and their lack of sexual desire may be considered as a norm.
Chronic diseases are known to impact FSD, and aging is said to be associated with decreased sexual activity and libido due to hormonal changes.,, In this study, no association was seen between SD and age of the women; similar findings were observed in other studies., Whereas study conducted by Esposito et al. showed significant association of age with FSD.
Duration of diabetes is related to erectile dysfunction in men, but the duration of diabetes in women has been reported to be less proportional with SD including our study (P = 0.364), although it can lead to multiple difficulties from physical complications to psychological duress as reported in other studies.,,
In spite of longer duration of diabetes and frequent visits to HCP, 97% of them said that their sexual matters were never brought up in discussion by HCPs. Neither doctor nor patient seemed to be comfortable to talk about this issue. Sociocultural taboos or the belief that SD does not exist in females may be the reason for the silence on this topic.
In this study, SD was common in the younger age group (58%), the possible reasons for the FSD in the younger age group were lack of privacy due to small house and big families, busy schedule, and weakness after long day work.
Biological factors such as pregnancy, lactation, contraceptives, and menopause superimposed by chronic diseases such as diabetes may impact women’s sexual functions due to hormonal changes and vasculopathy as in this study 42% of women with FSD were postmenopausal.,
Formal education in our country does not incorporate sexual education. The primary source of sex education in relatively educated class is media messages or religious beliefs which may affect both genders. Less-educated population cannot get these information in local languages which may force them to dwell on religious beliefs and societal pressures which often influence intimate relationship which may add to feeling of anxiety and guilt.,
Limitations and strength of the study
Sexual behavior and functioning may be influenced by cultural, religious, and social norms.
Use of FSFI which is prepared on western standards for the measurement of SD needs to be modified according to our cultural and social parameters.
FSFI domain scores and full scale scores were not applied as the FSFI questionnaire was modified and customized for this study.
Psychiatric faculty was not included in interview of the women; psycho-sexual issues may have been missed.
Results are not generalizable because of small sample size and specified clinical settings. All the women in the study were interviewed by senior female faculty members.
All the women in the study were very comfortable and pleased to talk SD issues.
| Conclusion|| |
Sexual health is a basic human right and needs diligent and sensitive assessment by HCP to address anxiety, guilt, and stigma associated with SD.
According to the results of this study, SD was commonly observed in women with diabetes. The most common cause of SD was dyspareunia followed by lubrication and orgasm issues and lastly lack of sexual arousal and sexual desire.
Screening of SD should be routinely undertaken in clinical settings in people with diabetes and in those suffering from chronic diseases.
Healthcare professionals should be trained to communicate and bring up the sexual issues during their clinical consultation.
Mr. Javed Jabbar, Department of Obstetrics and Gynecology, ISRA University, Karachi Campus for technical help. Seema Memon, Diabetes Educator, Al-Ibrahim Eye Hospital, Isra University, Karachi Campus for technical support.
Professor Shabeen Naz Masood: Concept and design of study, definition of intellectual content, literature search, manuscript editing and review, final approval of version. Dr. Saira Saeed: Literature search, clinical studies, drafting of article. Dr. Nusrat Lakho: Data collection, literature search, manuscript preparation. Dr. Yasir Masood: Literature search, data analysis, manuscript preparation. Mahnoor Rehman: Statistical analysis and data interpretation. Professor M. Saleh Memon: Concept design, revision of intellectual content and final approval of version.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]