Is Sexual Dysfunction Associated with Diabetes Control and Related Factors in Women with Diabetes?
ABSTRACT This study was performed to evaluate the sexual dysfunction (SD) in women with diabetes and to correlate SD with the factors
related to diabetes and its control. The study was conducted in 310 non-pregnant women with diabetes, 19years and over. Socio-demographic
characteristics and other factors related to diabetes were evaluated using Participant Information Form. The Arizona Sexual
Experience Scale was used to evaluate sexual function. Rate of SD was found as 46.7%. SD was frequent in sexual desire(36.8%),
satisfaction from orgasm(25.5%) and orgasm(24.8%). Type of diabetes and treatment, blood pressure, cholesterol levels, BMI
were not associated with SD (P>0.05). SD increased with age, HbA1c, high number of diabetic complications and poor education (P<0.05). An one unit increase in HbA1c value caused 19.1% of dysfunction increase on sexual dysfunction, 23.2% on drive, 20.7% on satisfaction from orgasm and 17.5%
on orgasm(P<0.05). Increasing HbA1c, number of diabetic complications and low literacy should be considered as risk factors of SD and evaluated in routine clinical
care of women with diabetes.
- SourceAvailable from: Hatice Kaya[Show abstract] [Hide abstract]
ABSTRACT: This descriptive study investigated the relationship between depression and perceptions of sexuality in people with type II diabetes. The study population comprised all patients who came for check-ups at the polyclinic for diabetes at Istanbul Okmeydani Training and Research Hospital between November 2010 and February 2011. One hundred patients were willing to participate in the study and met the participant criteria. Socio-demographic characteristics, perceptions of sexuality, and other factors related to diabetes were evaluated from information provided by participants. The Beck Depression Inventory-II (BDI-II) was used to evaluate depression. Results revealed an average depression score of 16.34 ± 8.06. The average level of depression was higher in women, those whose level of education was low, and the unemployed. Of the participants, 53% reported that diabetes has affected their sex life adversely. There was no relationship between level of depression and aspects of the illness. However, level of depression was related to sexual satisfaction. Findings suggest that depression and sexually related problems should be addressed when providing care for people diagnosed with type II diabetes.Sexuality and Disability 31(1). · 0.72 Impact Factor
Is Sexual Dysfunction Associated with Diabetes Control
and Related Factors in Women with Diabetes?
Seyda Ozcan•Nevin Hotun Sahin•Dilek Bilgic•
Sema Dereli Yilmaz
Published online: 23 April 2011
? Springer Science+Business Media, LLC 2011
with diabetes and to correlate SD with the factors related to diabetes and its control. The
study was conducted in 310 non-pregnant women with diabetes, 19 years and over. Socio-
demographic characteristics and other factors related to diabetes were evaluated using
Participant Information Form. The Arizona Sexual Experience Scale was used to evaluate
sexual function. Rate of SD was found as 46.7%. SD was frequent in sexual desire(36.8%),
satisfaction from orgasm(25.5%) and orgasm(24.8%). Type of diabetes and treatment,
blood pressure, cholesterol levels, BMI were not associated with SD (P[0.05). SD
increased with age, HbA1c, high number of diabetic complications and poor education
(P\0.05). An one unit increase in HbA1cvalue caused 19.1% of dysfunction increase on
sexual dysfunction, 23.2% on drive, 20.7% on satisfaction from orgasm and 17.5% on
orgasm(P\0.05). Increasing HbA1c, number of diabetic complications and low literacy
should be considered as risk factors of SD and evaluated in routine clinical care of women
This study was performed to evaluate the sexual dysfunction (SD) in women
Diabetes ? Sexual ? Dysfunction ? Women ? ASEX ? Turkey
Diabetes has been reported to cause certain medical and psychological problems in
addition to problems related with sexual health. There is limited information on sexual
Department of Medical Nursing, Florence Nightingale Nursing Faculty, Istanbul University,
N. H. Sahin (&) ? D. Bilgic
Department of Obstetric and Gynecologic Nursing, Florence Nightingale Nursing Faculty,
Istanbul University, 80270 Sisli, Istanbul, Turkey
S. D. Yilmaz
Department of Midwifery, Faculty of Health Sciences, Selcuk University, Konya, Turkey
Sex Disabil (2011) 29:251–261
dysfunction (SD) in women; while sexual function is a generally neglected subject for
people with diabetes. Studies regarding sexual function in men with diabetes were started
after 1940s, however, it was investigated for women only after 1970s [1–4]. The study
carried out in postmenopausal women reported that sexual function was never examined in
72% of women with diabetes . Health care professionals have low awareness, insuffi-
cient approaches and attitudes for prevention and early diagnosis of sexual health problems
in women with diabetes .
Complications of diabetes show no distinctive difference between women and men [1,
3, 7]. The effect of diabetes on sexual function of women is rather complicated . Studies
indicate that the problem is caused by neuropathic and endocrinologic alterations and
vascular complications; in addition, neurogenic vascular and psychological causes should
be considered together [1, 4, 7, 9–12].
Current knowledge on sexual problems in women with diabetes is quite limited [1, 3,
13–15]. Limitations of the present studies are discussed in the systematic review which
analyzes the studies on sexual dysfunction in women with diabetes, and new studies are
needed to investigate sexual function and related factors . As a result of these limited
evidence, treatment of sexual dysfunction in women with diabetes is neglected in clinical
This study aimed to evaluate sexual dysfunction in women with diabetes and to cor-
relate sexual dysfunction with the factors related to diabetes and its control. The following
two questions are explored in the study.
What are the problems regarding sexual dysfunction in women with diabetes?
Is sexual dysfunction related to the characteristics of diabetes?
Materials and Methods
Study was carried out with 310 women with diabetes receiving outpatient treatment in
three different diabetes centers in Istanbul. Study sample was composed of women with
diabetes, 19 and over years of age, who came in polyclinics for routine controls during the
study period and agreed to participate in the study. Study was carried out in accordance
with the principles of Helsinki declaration in 2008 . Approval of the Ethical Com-
mittee of Medical Faculty of Istanbul University; institutional permissions from the
institutions where patients received treatment and the informed consent of patients were
granted in order to perform the study.
The study had a cross-sectional, descriptive and correlational design. The data was
collected using the Participant Information Form and the Arizona Sexual Experiences
Scale which were self or clinician-administered forms .
Participant Information Form prepared by researchers included the questions about
socio-demographic variables such as age, education, and marital status.
The Arizona Sexual Experience Scale (ASEX) developed by McGahuey et al. is a five-
item rating scale that quantifies drive (How strong is your sex drive?), arousal (How easily
are you sexually aroused?), vaginal lubrication (How easily does your vagina become
moist or wet during sex?), orgasm (How easily can you reach an orgasm?), and satisfaction
from orgasm (Are your orgasms satisfying?) . Participants were asked to rate the sexual
life in the last week for each question. While possible total scores range from 5 to 30, a
total ASEX score of[19, any one item with a score of[5, or any three items with a score
of [4 would mean sexual dysfunction. Validity and reliability of ASEX in Turkish
252Sex Disabil (2011) 29:251–261
adaptation was done by Soykan and then Turkish ASEX was used in several studies .
When the internal consistency of the questionnaire was re-tested in the study sample, the
correlation between the items of the questionnaire and total score was determined to
change between 0.82 and 0.86, and the Cronbach alpha value was 0.93, indicating the high
Diabetes control was evaluated with measurements of HbA1c, total, LDL and HDL
cholesterol, blood pressure, height and weight . Height and weight measurements were
used after being converted to Body Mass Index (BMI) by weight (kg)/height (m) formula
. Data for complications of diabetes (having any chronic complications and the number
of chronic complications) indicating diabetes control were collected from patient files
besides the data regarding the type of diabetes, duration of diabetes diagnosis, type of
diabetes treatment, and diabetic complications.
The analysis of the study data was performed with the Statistical Package for Social
Science for Windows (SPSS for Windows, Client Version 11.9). Descriptive data were
presented as frequency data and mean ± standard deviation. In the comparison of mean
values, significance test of the difference between two mean values (t test) was used,
Mann–Whitney U test was used for nonparametric values; on the other hand, in the
comparison of the more than two groups, one-way ANOVA was used for parametric values
and Kruskal–Wallis was used for nonparametric values. Pearson correlation test was used
to analyze the significance level and direction of the difference between two variables.
Simple linear regression and multiple linear regression analyses were used to test the
relation between the determined dependent and independent variables. Results were ana-
lyzed at 95% reliability level, and the significance was set to P\0.05.
Socio-demographic and diabetes characteristics of the 310 women with diabetes and the
relation of these characteristics with sexual function are given in Table 1. The mean age of
the patients was 56.99 ± 13.69 years (min 19–max 80), 62.3% were married (n = 193),
31.2% were widowed (n = 97) and 6.5% (n = 20) were single. In addition, 14.5%
(n = 45) were illiterate, 47.1% (n = 146) were primary school graduates, 11.9% (n = 37)
secondary school graduates, 15.2% (n = 47) were high school graduates and 11.3%
(n = 35) were university graduates. No significant relation was determined between
marital status and sexual function (P[0.05). ASEX total score of the illiterate women
were found higher in favor of sexual dysfunction compared to other educated groups.
Domains detected with sexual dysfunction were drive and satisfaction from orgasm in
illiterate group (F = 2.66, P = 0.03; F = 5.29, P = 0.001).
Significant positive correlations were found between sexual function and age (r = 0.42,
P\0.001). Strong positive correlations were determined, indicating that sexual dys-
function was increased with age in all domains of sexual function including drive
(r = 0.39), vaginal lubrication (r = 0.22), arousal (r = 0.30), orgasm (r = 0.35) and
satisfaction from orgasm (r = 0.49) (P\0.001).
Of the women, 89.4% had type-2 diabetes, and 10.6% had type 1 diabetes. No sig-
nificant difference was detected between the types of diabetes (P[0.05). Diabetes
diagnosis duration was determined to change between 1 and 40 years, with a mean of
12.85 ± 8.26 years. Significant positive correlation was determined between ASEX total
score and diabetes diagnosis duration (r = 0.22, P = 0.008). Drive, satisfaction, orgasm
Sex Disabil (2011) 29:251–261253
scores were increased in favor of sexual dysfunction with the increasing diabetes diagnosis
duration (r = 0.24, P = 0.005; r = 0.32, P\0.001; r = 0.19, respectively, P\0.001).
As for the diabetes treatment methods, 42.9% of the patients received the combined
treatment with oral antidiabetic medicines (OAD) and insulin, 26.3% took OAD and 23.5%
used insulin. No significant relation was found between the treatment method and sexual
function (P[0.05). Of the study group, 80.7% had at least one or more chronic com-
plications of diabetes while the most frequent complications were neuropathy (34.8%),
Table 1 Relations between sexual function and socio-demographics, factors related to diabetes and its
control in women with diabetes
n/PercentTotal ASEX x ± sd
Married193/62.317.04 ± 6.13
Divorced/widowed 97/31.212.00 ± 9.89
Illiterate45/14.520.60 ± 5.45
Primary school146/47.116.59 ± 6.09
Secondary school 37/11.914.50 ± 6.51
High school 47/15.216.52 ± 5.68
University35/11.3 15.66 ± 6.47
Type of diabetes
Type 133/10.617.46 ± 8.39
Type 2277/89.4 16.94 ± 5.95
Type of treatment
Only diet 17/5.5 13.66 ± 7.050.16c
Insulin73/23.516.20 ± 6.04
OAD81/26.316.48 ± 6.43
OAD ? insulin133/42.9 18.04 ± 5.88
Min–maxMean ± SD of variables
Age, years310/10019–80 56.99 ± 13.69
Duration of diabetes diagnosis, years310/100 1–4012.85 ± 8.26
Blood pressure (mmHg)
310/1004.70–15.807.96 ± 2.03
Sistolic 310/10080–200 134.40 ± 21.870.35d
310/10040–120 77.80 ± 12.34
310/100 18.77–61.2230.62 ± 6.10
Total cholesterol (mg/dl)310/10084–408 197.85 ± 50.58
HDL cholesterol (mg/dl) 310/10025–123 50.35 ± 13.33
LDL cholesterol (mg/dl0 310/100 24–240116.24 ± 39.57
OAD Oral antidiabetic drug
aMann Whitney-U test
bStudent t test
cOne-way anova test
254Sex Disabil (2011) 29:251–261
Table 2 Effects of age, diabetes diagnosis duration and number of diabetic complications on total ASEX scores
Diabetes diagnosis duration
Number of diabetic complications
Model F value
Satisfaction from orgasm
Diabetes diagnosis duration
Number of diabetic complications
Model F value
* Standardized beta coefficient
Sex Disabil (2011) 29:251–261 255
retinopathy (33.5%), and ischemic heart disease (21.6%), respectively. ASEX total scores of
patients with one or more diabetes complications (17.72 ± 5.73) were significantly higher
than those with no complication (14.50 ± 6.65) (t = 2.61; P = 0.01). Drive (t = 2.63,
P = 0.01),orgasm(t = 2.64,P = 0.001)andsatisfactionfromorgasm(t = 2.65,P = 0.01)
scores of patients were higher in patients with diabetic complications. The effects of age,
diabetes diagnosis duration and number of diabetic complications on sexual function were
investigated within the same model (Table 2). Age was found effective on all domains of
sexual function except for arousal. Only age was effective on ASEX total, drive and vaginal
(b = 0.266, P\0.05 and b = 0.209, P\0.05) and satisfaction from orgasm (b = 0.388,
P\0.05 and b = 0.160, P\0.05). Regression models in Table 2 demonstrated that dia-
betes duration had no effect on sexual function (P[0.05).
Considering the variables of diabetes control for participants, blood pressure was found
systolic 134.40 ± 21.87 and diastolic 77.80 ± 12.34 mmHg, BMI 30.62 ± 6.10 kg/m2,
and HbA1c was 7.96% ± 2.03. No significant relation was observed between sexual
function and blood pressure, BMI and cholesterol values, while there was a significant
positive correlation with HbA1cvalue (r = 0.21, P = 0.02) (Table 1). Regression models
developed to determine the effect of HbA1con sexual function supported the determined
relations (Table 2). The increase in HbA1ccaused significant increases in both drive
(b = 0.232, P\0.05) and satisfaction from orgasm (b = 0.207, P\0.05) scores in favor
of sexual dysfunction, while there was an increase in orgasm score near significance level
(b = 0.175, P = 0.07). On the other hand, no significant relation was observed in the
models analyzing the effect of HbA1con arousal and vaginal lubrication (P[0.05).
In general, it was determined that 46.7% of the women with diabetes had sexual
dysfunction. Drive (36.8%), satisfaction from orgasm (25.5%) and orgasm (24.8%)
domains of sexual function were found to have more dysfunctions. A decrease was
observed in vaginal lubrication, while arousal dysfunction was at similar rates (19%).
Different components of sexual dysfunction in women with diabetes including drive,
arousal, vaginal lubrication, orgasm and satisfaction from orgasm were investigated in the
present study. The findings showed the significant relation between diabetes control and
sexual dysfunction and its effecting factors in women with diabetes.
Sexual dysfunction rate was reported to change between 42 and 60% for women by
studies implemented in a healthy society [3, 20]. Rates of sexual dysfunction in women
with diabetes showed differences among studies and sexual dysfunctions were determined
higher compared to healthy women [9, 21, 22]. Newman et al. reported sexual dysfunction
rate in women with diabetes as 47% . In the study of Mezones-Holguin et al. sexual
dysfunction was determined as 30% in control group, while it was 75% in women with
diabetes . In a study carried out on Turkish women, sexual dysfunction was observed in
42% of type-2 diabetes patients and 71% of type-2 diabetes patients, while this rate was
37% for control . The present study signified a sexual dysfunction rate close to the
reports in literature, and it should be disregarded that this problem is seen in nearly half of
women (46.7%). In the sample group including all women with diabetes, the rates of type-1
and type-2 diabetes are compatible with the distributions in general diabetes population.
On the other hand, sexual function was not examined considering the type of diabetes in
the present study.
256Sex Disabil (2011) 29:251–261
Sexual dysfunction could demonstrate itself in women as sexual drive problems,
decreasing sexual arousal, decreasing orgasm capacity and dyspareunia [2–4, 7, 20, 25].
Important domains of sexual dysfunction was determined in the study as drive (36.8%),
satisfaction from orgasm (25.5%) and orgasm (24.8%), respectively. Similarly, Enzlin
et al. reported that sexual drive (57%) and orgasm (51%) problems were more common in
women with diabetes, which were followed by vaginal lubrication (47%) and arousal
(38%) problems . Various studies conducted on women with diabetes, decrease in
sexual drive was reported to change between 14 and 15% . Sexual drive rate was
determined as 20–78% in the systematic review prepared by Giraldi and Kristiensen .
Mezones-Holguin et al. determined sexual drive as the most frequent sexual dysfunction
problem for a Peruvian female group . Erol et al. reported that the leading problem of
Turkish women with diabetes was sexual drive (77%) . In certain studies performed in
comparison with control group, no significant difference was detected between healthy
women and women with diabetes regarding sexual drive [2, 22, 25]. Certain studies
reported that women with diabetes had more orgasm problems compared to healthy women
[22, 23]. However, other studies reported no difference [2, 26]. In the present study, nearly
a quarter of the patients was determined to experience orgasm and satisfaction from
orgasm problems. Orgasm problems were reported in different rates changing between 1
and 35% in women with diabetes [2, 26]. Erol et al. determined orgasm dysfunction as 49%
in a group of Turkish women group with diabetes . It was determined as 80% in a study
implemented in Northern European Countries .
Sexuality is a complex matter for humans, and it is not affected only by biological factors
to do objective evaluations on sexual drive, satisfaction and orgasm, and this limitation
data, as well [1, 2]. In this Turkish sample, findings of sexual dysfunction on these domains
could be related to social and cultural values inhibiting the sexual life and expressions of
care professionals in the care of women with diabetes.
The study found sexual dysfunction was less frequent in arousal and vaginal lubrication
domains. Some of the studies reported arousal and vaginal lubrication problems as the most
frequent sexual dysfunction problems in women with diabetes [1, 25]. Decreasing vaginal
lubrication (70%) was determined as the most frequent problem for a group of women with
diabetes . These rates were significantly higher compared to healthy women. Kolodny
found decreased vaginal lubrication in 14% of women with diabetes . In another study,
decreased vaginal lubrication was 40% in women with type-1 diabetes, and 47% in women
with type-2 diabetes . However, these results were not different for healthy women in
control group [10, 26].
Strong correlation findings determined in the present study indicating the increased
sexual dysfunction with age and duration of diabetes diagnosis were supported by
regression model and age was found effective on sexual dysfunction while diabetes
duration was not found effective in the same model (Table 2). Genital sensitivity was
reported to decrease with age [1, 27]. Decrease in sexual drive increasingly continued in
women with age, it was 10% for women less than 49 years of age, 22% for women
between 50 and 65 years of age, while it was increased to 47% for women between 66 and
74 years of age . Chedraui et al. determined age as the most important risk factor for
sexual dysfunction in women (OR = 3.3, 95% CI = 1.6–6.8, P = 0.001) . However,
Sex Disabil (2011) 29:251–261 257
there are limited data explaining the relation between the diagnosis duration of diabetes
and sexual dysfunction in women . Although a few studies reported the increase of
sexual dysfunction with age and diabetes duration, they do not investigate the effect of
diabetes duration independently from age [8, 22, 29, 30]. This study showed that age had
an independent effect on sexual dysfunction while the effect of diabetes duration was
dependent to age.
Important variables showing the diabetes control level are HbA1cand development of
chronic complications . It is known that increased number of diabetic complications
occur as the result of poor diabetes control . In the study, sexual dysfunction increased
with increasing HbA1cand increasing number of chronic complications (Tables 2, 3). The
present diabetes complication load was effective on dysfunction of orgasm and satisfaction
from orgasm domains (Table 2). Previous studies analyzed the effects of vascular prob-
lems and neuropathy on sexual dysfunction by exploring their pathophysiological mech-
anisms but those effects were not fully explained in those studies yet [1, 3, 8, 9, 22, 28–31].
This study do not analyze the effects of types of complications on sexual dysfunction
because of their different pathophysiological mechanisms requiring to be investigated with
different methods . Present study highlighted the chronic complications which are the
result of poor diabetes control as a risk factor of sexual dysfunction in women with
diabetes. Women with diabetes having chronic complications should be evaluated for
sexual dysfunction in routine diabetes care.
In the study, an one-unit increase in HbA1cvalue caused 19.1%, of dysfunction increase
on sexual dysfunction, 23.2% on drive, 20.7% on satisfaction from orgasm and 17.5% on
orgasm (Table 3). Bultrini et al. claimed that sexual dysfunction could be decreased in
women with diabetes by improving the metabolic control . Veronelli et al. demon-
strated the relation between high HbA1cand sexual dysfunction in postmenopausal women
with diabetes . Findings of the present study supported the studies reporting that high
HbA1cincreased sexual dysfunction [4, 5, 8, 29, 30]. This study stated that two variables as
Table 3 Effect of HbA1clevel on total ASEX scores
Independent variable Dependent variables
Model F value3.80 5.758 .356
Independent variableDependent variables
Satisfaction from orgasm
Model F value1.4143.1504.483
* Standardized beta coefficient
258Sex Disabil (2011) 29:251–261
HbA1cand present diabetic complications indicating diabetes control level had strong
effect on sexual dysfunction.
In the study, no significant relation was determined between marital status, types of
diabetes, treatment method, blood pressure, cholesterol levels, BMI and sexual dysfunc-
tion, which is similar to the findings of many studies [3, 21, 22, 30, 33, 34]. However,
illiterate women had higher sexual dysfunction compared to other educated groups. Sexual
dysfunction was found in domains of drive and satisfaction from orgasm in this poor
education group. Dennerstein et al. was reported that higher education level ameliorates
sexual dysfunction . Similarly, the study by Chedraui showed that education level
significantly increased the risk of sexual dysfunction in healthy women . In the study
with healthy control group of Turkish women, poor education predicted sexual dysfunction
. Education level could affect the sexual attitudes and expressions of sexuality in
women. Findings of the study highlighted the need for rigorous evaluation in women with
diabetes having poor education.
The high rate of sexual dysfunction determined nearly half of the women with diabetes.
Poor glucose control with increased HbA1cand presence of diabetic complications, and
poor education were determined as risk factors to increase sexual dysfunction. Age had
strong effect on sexual dysfunction. Contrary to the previous studies, the study indicated
clearly that effect of diabetes duration on sexual dysfunction depended on was dependent
to age .
Clinicians should evaluate HbA1c, diabetic complications, age and education level to
expose the risk factors of sexual dysfunction in women with diabetes as an indispensable
component of clinical approach. Patient files should include the data related to these
variables. Women with diabetes having the risk factors of sexual dysfunction should be
early diagnosed and multidisciplinary approach should be considered for those women to
prevent severe sexual problems.
Limitations of the Study
Comparisons with healthy women were carried out using only the data in literature as there
was no control group in the study. As indicated in similar studies, data was limited to
patient statements since sexual function was evaluated by subjective methods based on
ation’’ Meeting and supported by Scientific Research Projects Coordination Unit of Istanbul University.
Project number: 809.
This study was presented in ‘‘68th Scientific Session of American Diabetes Associ-
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