First the bad news: Diabetes can interfere with sexual performance and satisfaction in both men and women. Now, some more bad news: Sometimes, the damage that sexual dysfunction inflicts on one's emotional well-being and interpersonal relationships is even worse that its physical effects.

The good news? Sexual dysfunction doesn't have to mean the end of sexual intimacy. By learning to communicate with your partner about bodily changes and other sexual issues and by learning to focus on your ability to give your partner pleasure, rather than on any impairment or limitations you may have, you can keep your love life alive.

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Who is affected?

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You may have already heard the frightening statistic that approximately 50% to 65% of men with diabetes experience impotence. (Impotence is the inability to achieve or maintain an erection sufficient for intercourse.) Like many statistics however, this one is somewhat misleading since it takes all men with diabetes-young, old, those with well-controlled blood sugar levels, those with uncontrolled blood sugar levels-into consideration. When only men with very well managed diabetes are considered, the rate of impotence is closer to 30%. In addition, it is estimated that approximately 35% of women with diabetes experience some sort of sexual impairment as a result of diabetes.

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Of those people who have begun to experience advanced diabetic complications, approximately 40% to 50% of women and 50% to 70% of men will have some form of sexual impairment as a direct result of nerve damage. But even these figures are complicated by the fact that sexual dysfunction is a common problem in the general population, affecting approximately 37.5 million people in the Unites States (15% of the population) at any given time. It is entirely possible for a person with diabetes to have a sexual dysfunction caused by something other than diabetes.

Some of the sexual complications brought about by diabetes affect only women, some affect only men, and some can affect either sex.

 

Women: Awareness of the effects of diabetes on women's sexual functioning is still very limited in the medical community. It is known, however, that for women, vaginal dryness is the most widespread sexual complication associated with diabetes. Normally, the vagina becomes lubricated in response to erotic stimulation. When it does not become lubricated, which can happen as a result of nerve damage, intercourse or attempts at stimulating the vagina may be uncomfortable and awkward. Nerve damage can also inhibit a woman's ability to experience orgasm. And the self-consciousness that may be brought on by any loss of sexual responsiveness can doubly interfere with a woman's enjoyment of sex.

 

Another common sexual complication among women with diabetes is a loss of sensation in the genital region. This loss of sensation can also inhibit or block the achievement of genital stimulation and gratification.

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Men: The most common sexual complication among men with diabetes is impotence, also known as erectile dysfunction. However, since impotence is one of the most common types of sexual dysfunction for men in the general population, one cannot assume that impotence in a man with diabetes is caused by his diabetes. Impotence can be caused by a number of medical conditions as well as psychological factors such as self-consciousness, difficulties with assertiveness, and fear of failure. A careful diagnosis of the problem and its origins can help determine the best means of treatment.

 

When diabetes is the cause of impotence, it generally impairs erectile functioning in two ways: by damaging the nerves that control vascular blood flow in the penis, and by accelerating hardening of the arteries, resulting in restriction of blood flow to the penis.

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Another sexual complication associated with diabetes in men is retrograde ejaculation, a phenomenon in which almost all of the ejaculate is discharged backward into the bladder. Retrograde ejaculation affects about 2% of men with diabetes. While the experience of orgasm is not affected, climactic discharge of semen is absent, which can cause infertility (the inability to conceive a child).

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Both sexes: Vaginal yeast infections are more common with women with diabetes, and it appears that yeast infections of the genitals are more common among men with diabetes, as well. Urinary tract infections may also be more common among people with diabetes. Urinary tract infections are associated with painful intercourse for women and discomfort during ejaculation and urination for men. Both yeast infections and urinary tract infections require an abstinence from sexual activity during treatment of the infection. Luckily, these complications are temporary, although they may recur frequently.

 

Diabetes places individuals, particularly women, at a higher risk for contracting sexually transmitted diseases (STD's). This is especially true in people with dry, cracked skin since any break in the skin raises one's chances of acquiring an infection. In addition, the course of treatment for STD's may be complicated by diabetes. Obviously, this suggests that safe sexual practices are critical among people with diabetes. If you have any questions about what constitutes "safe sex" and how to protect yourself from STD's, ask your health-care providers.

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High blood sugar levels can have a significant effect on sexuality. A person experiencing high blood glucose (hyperglycemia) generally also experiences a decrease in sexual interest. Such a decrease may be temporary, with sexual drive, or libido, returning as blood sugar is brought down to a normal level. (A more chronic drop in libido may be related to depression.) It is also fairly common for those experiencing high blood glucose to be supersensitive to touch, which can make physical intimacy uncomfortable. Knowing about this connection between high blood glucose and sensitivity to touch is beneficial to not only the person with diabetes, but also to that person's partner, who risks feeling rejected when his or her touch is refused.

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Just as other forms of exercise lower blood sugar levels, so can having sex, although how commonly this leads to hypoglycemia (low blood sugar) is not known. If you do experience symptoms of hypoglycemia-such as light-headedness, crankiness, anxiety, or excessive sweating-after sex, diabetes experts advise testing your blood sugar to check it out. It can also be a good idea to inform your sexual partner of your typical symptoms of low blood sugar so that he or she is not surprised or hurt by what may appear to be peculiar behavior after intercourse. And it can't hurt to teach your partner how to treat hypoglycemia, should it be necessary.

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Diagnosing the problem

 

While some of these sexual complications-such as those caused by high or low blood sugar-can be diagnosed and treated quite readily at home, others may require a doctor's attention. For many of us, however, talking about sexual problems with a doctor is not easy. Many men feel too humiliated by sexual complications to bring them to a doctor's attention. Many women, too, feel uncomfortable discussing sexual functioning with their doctors and, unfortunately, their doctors may feel the same way. Sexual bias and lack of understanding on the part of some physicians can lead to ignoring the existence or the importance of sexual impairment in women. Dealing with a doctor who seems uninterested or unwilling to discuss sexual difficulties can be upsetting. Remember that you deserve to be listened to and to have your problems treated seriously and with sensitivity. If your doctor cannot offer at least that, you may need to find a new doctor.

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Probably the best type of doctor to diagnose the origins of a sexual dysfunction is a urologist. One of the things that a urologist tries to determine is the extent to which a person's sexual dysfunction has physical or psychological roots. (Of course, since sexual dysfunction tends to evoke strong emotional reactions, a problem with physical origins can easily be complicated and compounded by psychological issues.) There are several ways to answer this question, and some of the most effective "tests" can be dome at home.

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A person's sexual response during masturbation goes a long way toward determining whether sexual dysfunction is of physical or psychological origin. This is because any performance anxiety one might feel in the presence of a partner is absent, and performance anxiety can greatly contribute to impaired sexual functioning. This diagnostic test works best if masturbation is a natural part of one's sexual repertoire. As a result, it is generally easier to follow for men. The running joke in the sexual counseling community is that "99% of men masturbate and 1% lie about it." Actual statistics regarding the percentages of men who masturbate are not far afield. In contrast, it is estimated that 60% of women masturbate. In any case, if a person were able to achieve and maintain an erection or become lubricated without complication through masturbation but then experienced difficulty in the presence of a partner, it would be reasonable to conclude that the difficulty was of psychological origin.

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Another way to determine the origin of sexual dysfunction is to observe whether a person experiences early-morning erections or vaginal lubrication. Such sexual responses occur naturally during sleep; their presence suggests that a person does not have a physical complication. This observation can be made at home, upon awakening.

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It is also important to consider how and when a sexual impairment took place. The onset of a sexual dysfunction that constitutes a diabetic complication would tend to be slow and progressive. Dramatic changes in sexual functioning or different responses in different situations (for example, with different partners) suggest a psychological origin.

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If these "home tests" are inconclusive, a urologist can use a number of devices to measure the natural ebb and flow of nocturnal erections or existence of vaginal lubrication. A device that uses technology similar to ultrasound can be used to observe blood flow into the penis and to detect any obstructions or complications. (For more on diagnosing and treating impotence, see "Treating Impotence" on page 37.)

Once the origin of a sexual dysfunction is determined, effective treatment can be started. But a treatment is not necessarily a cure. Some changes in physical functioning, including some caused by diabetes, cannot be reversed. Your sexual life may indeed be different. But with an open mind and open communication with your partner, it doesn't have to end.

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Keeping Intimacy Alive

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Talking with your partner about changes in your sexual functioning is at least as important (if not more so) as talking with your doctor. Keeping sexual dysfunction a secret from your partner can be isolating and can lead a person to approach each sexual encounter with trepidation, fearing yet another disappointing failure. Such intense anxiety can eventually cause a person to avoid sex altogether. Unless couples engage in open and ongoing discussion about their feelings associated with sexual complications, the result is usually misunderstanding, frustration, and discord.

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It is important, therefore, to have open and detailed discussions with your partner about how diabetes affects the whole body as well as how diabetes can effect sexual functioning. Communicating effectively about a sensitive topic such as this is often awkward and, consequently, neglected. However, if you are involved in a physically intimate relationship or are considering becoming physically intimate with someone, it would seem reasonable that you have developed enough intimacy and trust for your partner to be willing to share detailed information about any sexual impairments related to diabetes.

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Telling a partner about a possible complication beforehand can often lower the level of anxiety. When someone is considering participating in a greater level of physical intimacy with a new partner, I often recommend that the person tell the new partner something like this: "I feel I owe it to you to tell you of a possible complication connected with my diabetes that may affect my ability to perform sexually. I find you very attractive and I feel we can enjoy each other's bodies without the state of my genitals being a distraction. I'm telling you this because I don't want you to think that the possible absence of the physical reaction on my part that you might expect indicates a lack of excitement about being with you." This might not be exactly the way you would phrase this message, but you get the idea. Making such a statement-briefly, directly, and honestly-can clear the air and lower the level of anxiety.

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I often recommend to clients and friends that the way to be attractive to others is not to focus on being seen as worthwhile but to discover the aspect's of one's partner that are appealing. In other words, take the focus off yourself and place it on the person you're with. Being preoccupied with the impression you're giving creates a great deal of discomfort and an unattractive air of self-consciousness. Focusing on the delivery of sexual intimacy rather than the receiving of it generally facilitates successful sexual encounter.

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Often in relationships, people use sexual frequency as a measure of intimacy. For people with diabetes and their significant others, an absence of sexual response need not be a reflection of emotional distance. If the success of a sexual encounter is measure by the degree of one's expression of genuine love and not the magnitude of an orgasm, then the likelihood of failure is minimized.

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The partner of a person with any degree of sexual dysfunction can do a lot to encourage a sense of sexual comfort and security. Partners can help by expressing their acceptance of the person as whole and by refocusing the delivery of physical intimacy toward the whole body, not just the genitals. Partners can also help by openly communicating what sort of touch gives them pleasure and by encouraging their partner to do likewise. Since the genitalia are no longer a reliable indicator of arousal, verbal feedback must play a greater role in communicating sexual preferences.

During a sexual encounter in which one's partner is not having the desired sexual response, I suggest a statement along these lines: "Darling, what matters now is that we just enjoy each other and focus on our mutual desire to give pleasure. There are many different ways in which I enjoy being touched by you. My pleasure now is not limited to how any one part of your body is responding." Of course, there are many ways to say the same thing.

 

Some couples find it beneficial to seek professional guidance in learning how to communicate openly and without embarrassment about a topic often associated with shame and guilt. For persons wishing to work with a qualified sex therapist, the Association for the Advancement of Behavior Therapy offers a free referral service. You can get a referral by calling (212) 647-1890.

Feeling Whole Again

 

No matter what the cause of a sexual dysfunction, the psychological consequences associated with sexual problems are far-reaching. With the focus that is placed on being a "good lover" in today's society, it is not difficult to understand why some people mistakenly equate their adequacy as a person with their sexual functioning. Many people feel that they are less than whole if their genitals do not function properly, but nothing could be further from the truth. In fact, as one of my college professors once said, "Even a war veteran who has had his genitals blown off by a land mine can still be the greatest lover in the world." In other words, functioning genitals are not necessary for the giving of sexual pleasure because, ultimately, intimacy is not located in one's genitals: it is located between the ears. Unless an individual comes to terms with sexual dysfunction, however, feelings of hopelessness and, eventually, depression, are likely.

I strongly believe that all humans carry a certain amount of "baggage," by which I mean either physical or emotional problems that complicate our lives. In my mind, the complications associated with any physical disabilities are just part of that aspect of being human. Illness doesn't have to separate us from the full range of experiences of life; instead, it can be seen as a pat of our existence in fulfilling our destiny as humans.

 

By accepting that life is difficult, complicated, and full of imperfection, we can more easily regard ourselves as human-not more, not less. Having handicaps imposed on us physically and psychologically is an almost universal fate that we all face in our own way. How we handle out handicaps is the measure of our success.