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Educators can raise awareness of sexual complications in diabetes
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In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with diabetes educators Janis Roszler, MS, RD, LD/N, CDE, FAND, and Donna Rice, MBA, BSN, RN, CDE, FAADE, about recognizing and treating diabetes-related sexual issues.
How widespread are sexual complications among people living with diabetes?
Rice and Roszler: About 50% of men and 38% of women with diabetes develop some form of sexual complication. In men, the most common problems are erectile dysfunction, premature ejaculation, and reduced self-esteem and libido. Women with diabetes may have inadequate vaginal lubrication, reduced libido, difficulty climaxing, dyspareunia, low self-esteem and frequent vaginal infections, which can interfere with sexual activity.
As diabetes-focused health care providers, why should we care about the sexual well-being of our patients?
Rice and Roszler: First and foremost, sexual health issues are a red flag that can alert us to an array of serious issues that may have gone unnoticed, such as cardiovascular disease, poorly controlled diabetes and psychosocial changes. Erectile dysfunction may be a sign of coronary artery disease. Sexual issues can also affect our patients’ moods, motivation and self-esteem in such a profound way that, if unaddressed, they may limit our ability to successfully achieve our desired clinical goals as well as our patients’ personal health goals.
As health care providers, we are proficient in goal setting, evaluating patients’ progress and updating treatment plans. We also excel in the educational arena — we help our patients understand their target goals and treatment plans. Unfortunately, patients who struggle with sexual complications may arrive with hidden concerns that are often missed in a routine visit. They may feel discouraged, angry, sad, depressed, stressed, frustrated, hurt or more. They may have lost the support of their intimate partner if sexual difficulties cause them to avoid intimacy, which their loved ones may interpret as a lack of caring or sexual attraction, or worse yet, a sign that they are getting their sexual needs met elsewhere. With this on their minds, many patients can’t focus on new behaviors or lack support to help carry them out.
What can a diabetes educator do to address these issues?
Rice and Roszler: Three steps can help health care providers engage more effectively with patients who have diabetes-related sexual complications. Listen compassionately, be a source of basic medical information, and act as a liaison and refer.
First, listen compassionately. Demonstrate your concern for your patients’ challenges by employing the L.E.A.P strategy developed by Roszler and Rapaport:
- Listen — Listen to what your patient says. This may seem obvious, but people commonly complain that their health care providers don’t listen to them. So, put down the electronic tablet, face your patients, make eye contact and hear what they have to say. You don’t have to respond with sage words of wisdom. All you need to do is listen. According to Carl Rogers, father of client-centered therapy, having someone listen without trying to change you or pass judgment “feels damn good!”
- Empathize — Show that you hear your patients and appreciate their struggle. Do this by repeating what they say to you. For example, when John says, “I just can’t take this anymore!” Mirror what he says and respond with, “Wow, John. It looks like you can’t take this anymore.” John feels heard, so he answers, “Yes! You totally understand. Finally, someone gets what I’m going through!”
- Affirm — Tell your patients that many people with diabetes struggle with the same issues. Many patients find it comforting to know they are not alone.
- Positive reframe — Help your patients find a “silver lining” in the issues they bring up. “John, now that this is in the open, you can get help.
We know the time you spend with patients is limited. But this interaction doesn’t have to take more than a few minutes and can help you and your patient form a more trusting and supportive relationship.
What medical information is important for patients who experience sexual complications?
Rice and Roszler: The second step in helping to address sexual complications is to be a source of basic medical and treatment information. Men with diabetes may develop sexual complications because of physical, lifestyle or even pharmacologic issues. There is a strong correlation, for example, between a man’s HbA1c level and his risk for developing erectile dysfunction. If he smokes, his risk can also increase, as a healthy erection requires good blood circulation, and smoking compromises that. Mention that the presence of erectile dysfunction can be a sign of growing CAD. Discuss the relationship between CVD and diabetes, along with behavioral tips, to help alleviate the anxiety, blame and frustration that often accompany erectile dysfunction.
Photo by Jill Rollet.
Lifestyle changes, such as smoking cessation and limiting alcohol, can make a difference. Unfortunately, many men experience emotional issues that affect their ability to not only perform sexually, but to care for their diabetes-related needs. Counseling can help men deal with psychological concerns that accompany their complications. Encourage a man with erectile dysfunction to speak to his physician for evaluation and treatment options.
In women, except for the risk for vaginal infections, which increases with poor glucose control, the source of other female sexual complications is less than straightforward. To date, studies show no direct correlation between a woman’s HbA1c and her risk for developing many of these issues, but that doesn’t mean she is without options. While a man’s struggle to perform sexually can be greatly affected by performance anxiety, women tend to respond more significantly to emotional and relationship issues. Depression can also play a significant role. Therefore, individual or couples counseling may help your female patients deal with challenges that negatively affect their sexual performance. Other options include quality vaginal lubricants and time, as women with diabetes may take longer to become aroused. Some women also find masturbation to be a helpful way to encourage their bodies to experience sexual pleasure. Recently, the FDA approved flibanserin (Addyi, Sprout Pharmaceuticals), the “female Viagra,” but this drug is not approved for use in women with diabetes or other medical issues.
Where can health care providers refer their patients?
Rice and Roszler: Sexual topics aren’t easy to discuss. The fact that your patients talk about these issues says a lot about their trust in you. Some may opt not to tell their concerns to other members of their health care team who can help them. Offer to convey this information to fellow team members who need to know. Keep the names and contact information of qualified therapists to share with your patients. Hunt for reliable websites and products to suggest, if the need arises. If your patients want additional information about diabetes-related sexual complications, treatments and ways they can re-energize their love life, we encourage you to recommend our book, Sex & Diabetes – For Him and For Her. It’s a fun and informative book published by the American Diabetes Association.
- References:
- Phe V, et al. Diabetes Metab. 2012; doi: 10.1016/j.diabet.2011.09.003.
- Rice D, et al. Diabetes and Sexual Health. In: Weinger K et al, eds. Educating Your Patients with Diabetes. New York: Humana Press; 2009:213-234.
- Roszler J, et al. Approaches to Behavior: Changing the Dynamic Between Patients and Professionals in Diabetes Care and Education. Alexandria, VA: American Diabetes Association; 2015.
- For more information:
- Donna Rice, MBA, BSN, RN, CDE, FAADE, is Senior Medical Director for Sanofi US Diabetes She is also the past president of the American Association of Diabetes Educators (AADE) and the former president of the Diabetes Health and Wellness Institute, Baylor Healthcare System. She can be reached at donnaricecde@gmail.com.
- Janis Roszler, MS, RD, LD/N, CDE, FAND, is a past AADE Diabetes Educator of the Year. She is a registered dietitian, certified diabetes educator, marriage and family therapist, fellow of the Academy of Nutrition and Dietetics, and award-winning medical media producer. She can be reached at dearjanis123@gmail.com.
- Susan Weiner, MS, RDN, CDE, CDN, is the 2015 AADE Diabetes Educator of the Year and author of The Complete Diabetes Organizer and Diabetes 365 Tips For Living Well. She is the owner of Susan Weiner Nutrition, PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com.
Disclosures: Roszler and Weiner report no relevant financial disclosures. Rice is employed by Sanofi US, and the views expressed in this article do not represent the views of her employer.