More than just diabetes...

Recently, I was kindly asked to speak at Hull and East Riding diabetes network meeting on the effects of diabetes on sexual functioning and relationships.

On arrival in the foyer, I got myself a coffee and had a look at some of the pharmaceutical stands. A friendly guy started talking about the drugs he was promoting, he looked at my name badge and said “hmmm... psychosexual therapist... why are you here then?” I explained what my talk was on and he looked puzzled. So I asked him "If I told you that your diabetes diagnosis would probably affect your erections and maybe your orgasms too, would you look after your health a little more?” He laughed and said yes, he hadn’t put much thought into what else it affected, he automatically thought about eyes and feet!

My aim was to broaden the professional's views about the impact of diabetes on sex and relationships and encourage the full holistic care of the patients. This would hopefully help them to talk more openly with their patients thus enabling the patient to make a more informed choice about their future self-care.

Diabetes type 2 accounts for 90% of all diabetes. In 2010 there was approx. 285 million with diabetes and it looks set to rise to 438 million in 2030! Plus 472 million people that will be pre-diabetes. That’s an awful lot of people who may suffer with their sex lives and relationships. The sad part is, although diabetes is equal between male and female; half of men will seek help but only 19% of women. I can presume that this is maybe because in men you can tell when something isn’t working. Whereas with women, you can’t see if the desire isn’t there. It’s not a physical thing to see.

I know that sex isn’t for everyone and that some really aren’t that bothered about having penetrative intercourse, and that’s ok, it’s their choice. But when you have a choice taken away from you by long term illness (losing erections, arousal, orgasm) then some people want it back, and much better to be informed of future options as close to diagnoses as possible than later down the line. Also, there is sometimes a resistance to being told what you ‘have to’ or ‘should do’ to help make your life healthier following a diagnosis. Not everyone can put these changes into place, but maybe relating the different parts of their body and how diabetes could impact them will help patients be more inclined to take a more pro-active approach. Not all diabetics will have sexual disorders but Diabetes UK estimate that 50% will.

So, what bits of your sexual health will be affected by diabetes?

All of it, I’m afraid. Lets look at arousal for starters. I’m not talking about desire, I will do that later; but about what the body needs to be physically aroused. It needs a good blood supply, it needs a good cardio-vascular system working to send all the blood around the body and to get to the smaller arteries and veins and capillaries. Amongst other places these are found in the pelvic region - penis, vagina and clitoris. If your arteries are clogged, and your blood flow is slow, it will not get to the penis enough to make it erect, it will not allow blood flow into the vaginal area or the clitoris either to allow arousal to take place. Cardiovascular disease (CVD) causes huge problems for blood flow and if you are diabetic then you have a 50% increase in developing CVD.

Orgasms are affected too. This is due to not being able to be aroused enough to be able to orgasm. Around 70% of women orgasm clitorally as this is where all the nerve endings are, opposed to women who orgasm through penetration. Women may suffer from vaginal dryness too with diabetes. This can make sex very uncomfortable and can result in atrophy (tears in the vaginal wall) and increase the chances of developing GPPPD (Genito-Pelvic Pain Penetration Disorder). Basically, your body will respond to the fear of painful sex and will tighten at the entrance and penetration can become impossible. For men, the type of ejaculation problem is retrograde ejaculation. This is because diabetes affects the nerves in the body, and the part that affects the pelvic region and bladder is called ‘autonomic neuropathy’. The nerves that shut the bladder off when ejaculating may not work properly with diabetes and the ejaculate will go round the urethra and back into the bladder. (Oh and sorry, but this neuropathy also affects the erections! As if erections haven’t got enough to contend with already!)

Desire is slightly more elusive. There is so much which can affect desire levels and also male desire is driven differently to female. Plus each persons desire is individual to them. There is no rule to say what level desire has to be at to be OK. Male desire is mainly in the head driven by the limbic system, and cerebral cortex. The cerebral cortex is the part that when you think about sex it tells the rest of your body you are becoming aroused and sends signals to increase your heart and blood flow to your penis, and tells you that you are getting an erection. The limbic system is all about emotion, motivation and sex drive. Testosterone is the hormone closely associated with male sex drive. This slowly decreases with age anyway but it not so noticeable if there are no other problematic factors.

For women, it’s not as easy to describe as with men. It’s more complex and there isn’t a pill or a quick fix to help with this either I’m afraid. As with male desire, it comes from the head but more psychological than physical. Stress, relationship friction, change of roles (becoming a mum or a career), having any kind of loss, can have a huge impact. As well as all the problems listed in the paragraphs below too. In women desire can be spontaneous - you may feel sexual, think about having sex, have daydreams and fantasies and then start to become aroused. Or desire can be acquired. This means that even if you don’t feel like sex at all, you may start to be sexual with a partner, and at some point hopefully your mind will start to feel in the mood. However; this can take up to 40 minutes of foreplay and teasing from a ground zero feeling of no desire (and that’s a researched fact!).

The majority of clients I see will describe at some point a loss in desire which has then in turn impacted on their sex lives and then further into their relationship too. So when a long-term illness such as diabetes comes into a relationship, this and the other factors that go with it can really impact on desire.

Medication is a big problem for desire. Especially medications used for high blood pressure, statins (used for cholesterol control, and SSRI’s used for the treatment of depression) which can also be a factor for those with diabetes.

Body image can impact on how you feel about sex, if diabetes has affected your weight then this can sometimes give you a negative view and stop you wanting to be naked and get down to it. Also, think about urinary tract infections and re-occurring thrush – they are no fun whatsoever.

So it all sounds like doom and gloom for sex and diabetes? Not quite, there is some help.

For men and erectile problems, there are PDE5 inhibitors such as Cialis, Muse pellets (inserted down the penis), Muse gel (which gets put into the meatus - the hole at the end of the penis), vacuum pumps, and cock rings.

For women and vaginal dryness try Yes lube (www.yesyesyes.org). Totally organic and the water based one is available on prescription. To help ease friction you can use the oil-based one, in and around the vagina first then use the water based one on the penis or dildo - if you prefer. This will give a ‘double glide’ motion and you should feel less friction. There is also Licx lube- cream or gel, which is very good too (http://www.licx.co.uk). The lubes need to be sugar-free if possible.

Try to increase blood flow to the vaginal area especially the clitoris. Massage the whole area with either a hand or fingers or a vibrator. There is a small suction pump available in America called Eros to ‘pull’ the blood flow into the clitoris. But this could also be achieved by using the mouth. Needs two of you though to accomplish this part!

For GPPPD you may need some specialist help from either a sex therapist or from your local GUM clinic and they can give you some gradual exposure exercises using dilators to help overcome the anxiety and pain.

Above all, look after your body and its blood sugar levels. It may feel like you are being forced into ‘behaving’ yourself and you have to be ‘good’ but if you consider the whole approach to looking after your body and think about the full effects it can have on all aspects of your life then you may be more inclined to be a bit more gentle on yourself. No-one likes to be told what’s best for them to do, but take a look at where you are now in your diabetic or pre-diabetic health and take some choices that are ‘good enough’ for you.

And lastly, for now, I can’t emphasise enough to keep good communication between partners and friends and family. When changes happen in relationships, the space to talk can become a vast place where intimacy can become lost. Lots of feelings become unsaid for fear of hurting the other. Needs are not met and as the talking stops so do other parts of the relationship too. A big part of any long term illness is loss. It can mean the loss of a certain lifestyle, of who the person was, their independence, loss of a friend, partner, lover, the list can go on. And with loss comes loads of different emotions. Not all easy to talk about or understand. But it is this part (talking) which can help the couple stay connected and intimate together. If you find it hard to talk about impacts of life or changes happening in your relationship contact a relationship therapist and talk it through together.

Good luck, Karen.