Gout and sexual function: patient perspective of how gout affects personal relationships and intimacy

Abstract

Background
In absence of previous studies, we assessed how gout impacts relationship and intimacy with spouse/significant other.

Methods
We enrolled a convenience sample of consecutive patients with doctor-diagnosed gout from a community-based outpatient clinic. Nominal groups were conducted until saturation was achieved. Responses were collected verbatim, discussed and then rank-ordered by each participant with votes.

Results
Forty-four patients with gout participated in 14 nominal groups, seven male only groups, six female only groups and one group had people with both sexes. Overall, the mean age was 61.7 years (SD, 12.2), mean gout duration was 11.8 years (SD, 11.8), 50% were men, 68% African-American, 43% retired, 48% currently married, 94% were using either allopurinol and/or febuxostat, and 39% had had no gout flares in the last 6 months. The top five responses accounted for 75% of all votes and included physical (28%) or emotional impact (17.4%) on intimacy, disability (12.9%), issues with trust/understanding (10.6%) and social life interference (6.8%). When examining the top-rated concern for each nominal group, physical impact on intimacy was ranked top by eight nominal groups; and emotional impact on intimacy, physical function limitation, trust issues/understanding by two nominal groups each. There were no differences evident by patient gender in the concern that was top-ranked.

Conclusions
Gout significantly impacts relationship and intimacy with spouse/significant other. Our observation of the physical and emotional impact of gout on intimacy should lead to studies to understand this further and assess if more optimal gout control can improve sex lives of people with gout.

Electronic supplementary material
The online version of this article (10.1186/s41927-019-0056-9) contains supplementary material, which is available to authorized users.

Full text

R E S E A R C H A R T I C L E Open Access
Gout and sexual function: patient
perspective of how gout affects personal
relationships and intimacy
Jasvinder A. Singh
1,2
Abstract
Background: In absence of previous studies, we assessed how gout impacts relationship and intimacy with
spouse/significant other.
Methods: We enrolled a convenience sample of consecutive patients with doctor-diagnosed gout from a community-
based outpatient clinic. Nominal groups were conducted until saturation was achieved. Responses were collected
verbatim, discussed and then rank-ordered by each participant with votes.
Results: Forty-four patients with gout participated in 14 nominal groups, seven male only groups, six female only
groups and one group had people with both sexes. Overall, the mean age was 61.7 years (SD, 12.2), mean gout
duration was 11.8 years (SD, 11.8), 50% were men, 68% African-American, 43% retired, 48% currently married, 94% were
using either allopurinol and/or febuxostat, and 39% had had no gout flares in the last 6 months. The top five responses
accounted for 75%
of all votes and included physical (28%) or emotional impact (17.4%) on intimacy, disability (12.9%), issues with trust/
understanding (10.6%) and social life interference (6.8%). When examining the top-rated concern for each nominal
group, physical impact on intimacy was ranked top by eight nominal groups; and emotional impact on intimacy,
physical function limitation, trust issues/understanding by two nominal groups each. There were no differences evident
by patient gender in the concern that was top-ranked.
Conclusions: Gout significantly impacts relationship and intimacy with spouse/significant other. Our observation of the
physical and emotional impact of gout on intimacy should lead to studies to understand this further and assess if more
optimal gout control can improve sex lives of people with gout.
Keywords: Gout, Sexual function, Intimacy, Nominal groups, Qualitative, Personal relationships, Patient perspective
Background
Gout is the most common inflammatory arthritis in
adults with an increasing prevalence in the US and
worldwide [1,2]. Gout leads to a significant morbidity
burden and is associated with deficits in quality of life
(QOL) [3–6]. In a qualitative study assessing the QOL,
40% of the nominal groups reported that gout flares
negatively affected sexual function, leading to problems
in having sex as well as to low or no sexual desire [7].
Recent observational studies showed that gout was asso-
ciated with a higher risk of both organic and psycho-
genic erectile dysfunction in men [8–10]; data from
women are limited. This indicated that gout may be as-
sociated with sexual dysfunction.
Sex is an important contributor to QOL [11]. Under-
standing patient perspective related to sexual function is
important, since sexual dysfunction is often under-
detected and undertreated because of barriers to the dis-
cussion about sex in doctor-patient communication and
the lack of medical training in human sexuality [11].
Previous studies have reported that patients with chronic
diseases have a higher risk of sexual dysfunction, related
Correspondence: jsingh@uabmc.edu
1
Medicine Service, Birmingham VA Medical Center, 700 19th St S,
Birmingham, AL 35233, USA
2
Department of Medicine at School of Medicine, and Division of
Epidemiology at School of Public Health, University of Alabama at
Birmingham, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL
35294-0022, USA
BMC Rheumatolo
gy
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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to illness, treatment and concomitant depression [11–13].
Theoretical models have been proposed for sexual dys-
function in chronic diseases to help understand the under-
lying constructs and mechanisms [14,15]. The
autoimmune counterpart of gout, rheumatoid arthritis is
associated with a high prevalence of sexual problems [16].
Despite the evidence of sexual dysfunction in other in-
flammatory arthritis [17–20] and these conceptual models
for chronic diseases, there is paucity of data related to sex-
ual function in gout. We know little or nothing about how
gout affects sexual life and relationships.
Our study aim was to address this important know-
ledge gap by performing formative work in people with
gout. The study objective was to assess the effect of gout
on the relationship with spouse or significant other, in-
cluding the effect on intimacy, using the Nominal Group
Technique (NGT). A secondary objective was to assess
whether these effects differed by patient gender.
Methods
Study sample
The study team invited a convenience sample of consecu-
tive patients with doctor-diagnosed gout identified with at
least one outpatient visit for gout between January 2016 to
August 2017 at a community-based outpatient clinic affili-
ated with University of Alabama at Birmingham (UAB),
Birmingham, Alabama, USA. Potential study participants
were identified by the presence of an International Classi-
fication of Diseases, ninth revision, common modification
(ICD-9-CM) code for gout (274.xx), a valid approach for
identifying patients with gout [21]. African-Americans are
usually under-represented in most qualitative research in
gout with few exceptions [22,23]; therefore a larger pro-
portion of African-Americans were invited to participate
in this study. The study participants received free parking,
refreshments during the session and a payment of $30 for
their participation. The Institutional Review Board (IRB,
i.e. ethics review board) at the University of Alabama at
Birmingham approved the study.
Nominal group technique (NGT) sessions and analyses
Question assessed and NGT overview
The study team conducted patient NGT sessions/meet-
ings lasting 1-h to understand whether and to what ex-
tent gout has an impact on relationships and sexual
function. The study PI (J.S) drafted the study question
with different formulations and shared separately with
colleagues, researchers and patients with gout at the
UAB gout clinic, who offered suggestions. After an itera-
tive process, the study question was finalized: “How has
gout affected your relationships? (think of relationship
with your spouse, boy-friend or girl-friend or significant
other including the effect of gout on intimacy)”. The
study PI (J.S), experienced in qualitative research
including NGTs [24,25], conducted these sessions. All
nominal group sessions included either women or men,
except the second NGT session that included both men
and women.
A nominal group technique is a variation of brainstorm-
ing where individuals come up with ideas on their own
and evaluate, rank, and agree on ideas as a group; in other
words it is a group process of problem identification, gen-
eration of solution/s and decision-making [26,27]. The
NGT is a variant on traditional focus group that taps the
participants’experiences, skills, views or feelings and pro-
motes that has been used successfully in various medical
settings [28–34]. One of the main differences from the
focus group is that NGT allows an even participation of
each participant, in contrast to possible domination by
only the most active participants, and less participation by
others participants. NGT also allows discussion of the
problems identified.
After brief introductions by all study participants, the
participants were asked if the question was clear; any/all
clarification were provided before the beginning of each
NGT session. A research assistant (C.G.) took notes dur-
ing NGT and audio-recorded each session; an administra-
tive assistant (D.F.) fully transcribed all the discussions
verbatim, which were reviewed to ensure that the essence
of discussion was captured.
NGT process
The NGT session consisted of the following discrete
steps. They were conducted with participants seated in a
large patient conference room with an oval table, and
the NGT moderator and the flip chart at the head of the
table. At first, each NGT participant independently
quietly generated as many word or short phrases as pos-
sible in response to the question on a sheet of paper,
without any discussions with other participants. This
step was allocated 5–7 min depending on whether par-
ticipants were still listing responses at the end of 5-min.
Each participant then nominated a single response
each in a round-robin fashion, which was recorded ver-
batim by the NGT moderator (J.A.S.) on a flip chart in
large letters visible to the group participants. Partici-
pants nominated responses until all responses were re-
corded. This approach prevents domination of this
phase by people with a higher number of listed re-
sponses. This step took 5–10 min, depending on the
number of nominated responses.
Participants then discussed and elaborated each re-
sponse as a group and combined responses that seemed
to be very similar, as appropriate. The NGT moderator
(J.A.S.) ensured that all NGT participants participated ac-
tively in the discussion of the responses. This step took
30–40 min.
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Finally, all participants identified and rank-ordered the
three responses deemed important with votes from 1
(important) to 3 (most important) on index cards, 3
votes being the highest rank score. This was done by
placement of colored dots on a card where participants
listed their three top ranked responses (three dots for
the most important concern indicating 3 votes), which
were collected by the moderator or the research assist-
ant. Scores were added from each NGT participant and
the NGT moderator placed scores next to the listed
responses on the flip-chart. A rank-order of nominated
responses was created for each nominal group based on
total scores by NGT participants, with the highest score
corresponding to the top rank.
The number of nominal groups identifying responses
with high relative rank ordering was analyzed. Transcrip-
tions were examined to confirm that all main statements
made relative to each response (discussions directly con-
nected, etc.) were captured and led to the creation of a
comprehensive list of statements. Responses from each
NGT were compared to determine overlap, to ensure that
nominal groups were performed until saturation, which
was defined as the emergence of no new themes/
responses.
Analyses
For each nominal group, an aggregate total score was cal-
culated for listed responses on the flip chart and the rank-
ing was determined based on the total scores from all
participants, highest score being the top rank and next
highest score being the 2nd ranked response/concern. The
moderator calculated score for each concern. The scores
were double-checked by the study coordinator (C.G.) to
ensure accuracy. We examined the top ranked and top five
ranked responses from each nominal group in an overall
analysis across all nominal groups and presented the fre-
quency with which each concern appeared among the top
and top five responses. In addition, we also compared the
total scores for the responses across all nominal groups
and presented these data as a figure as a proportion of all
votes, i.e. a grand total score across all nominal groups
(equals 6-times the number of voting participants).
Results
Study participant characteristics
Fourteen nominal groups with 44 patients with gout were
conducted, and saturation of themes was achieved. The
mean age was 61.7 years (standard deviation [SD], 12.2;
range, 40 to 83 years), 50% were men, 68% were
African-American, 43% were retired and 48% were cur-
rently married (Table 1). Seven groups consisted of men
only and six consisted of women only; one group had men
and women. The mean duration of gout was 11.8 years
(SD, 11.8) (Table 1). Seventy-nine percent of participants
were using allopurinol (with/without colchicine, NSAIDs
or prednisone), 15% were using febuxostat, and 5% were
using only pain medications.
Themes from the NGT
Various responses from participants mapped to 7 key
concepts as described below. The top themes/responses
from each group are listed in Table 2with their ranking,
with themes and subthemes in Table 3with few repre-
sentative quotes. Additional details of participant votes/
ranking and concerns are provided in Fig. 1(Fig. 1
shows top responses across all nominal groups by the
total number score/vote for each concern, as a propor-
tion of all votes) and Additional file 1(Additional file
1provides study participant nominated responses, the
concept they map to along with patient quotes). The top
5 responses accounted for 75% of all votes and included
physical or emotional impact on intimacy, disability,
trust issues/understanding and social life interference
(Fig. 1).
Physical or emotional impact on intimacy
1. Physical impact on intimacy: 11 of the 14 nominal
groups ranked this among the top 5 responses, and
eight nominal groups ranked it as the top concern.
Patient-nominated responses, and the themes and
subthemes they mapped to, are shown in Table 3,
with illustrative quotes. Gout led to a reduction in
the frequency of sexual activity. Some people “lost
relationships over gout”and others were unable to
be in a relationship due to gout, since their partner
did not understand the pain/suffering from gout
and/or did not want to be in a relationship that
required them to take this kind of responsibility.
2. Emotional impact on intimacy: Nine of the 14
nominal groups ranked this among the top 5
responses; it was the top ranked concern in two
nominal groups. Patient-nominated responses, and
the themes they mapped to, are shown in Table 3.
Disability/dependence interfering with social life and intimacy
1. Disability: Six of the 14 nominal groups ranked this
among the top 5 responses; it was the top ranked
concern in two nominal groups.
2. Physical dependence: Four of the 14 nominal
groups ranked this among the top 5 responses.
3. Limitation of social life activities: Six of the 14 nominal
groups ranked this among the top 5 responses.
Patient-nominated responses, and the themes and
subthemes they mapped to, are shown in Table 3.
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Trust issues/understanding by spouse or significant other
Four of the 14 nominal groups ranked this among the
top 5 responses; it was the top ranked concern in two
nominal groups. Patient-nominated responses, and the
themes and subthemes they mapped to, are shown in
Table 3.One of the four nominal group that ranked this
concern high indicated that gout helped improve the un-
derstanding with their spouse, since it allowed them to
talk about their pain to someone. The other three
groups indicated that gout lead to less understanding
and significant trust issues with their spouse.
Problem with self-image and perception by partner
Two of the 14 nominal groups ranked this among the
top 5 responses. People with gout had issues with per-
ception of self, and they felt older than their age, due to
limitations related to gout, “Gout sometimes makes me
feel like an old man in the relationship”.
Restricted diet/food choices negatively impacting the relationship
Four of the 14 nominal groups ranked this among the top
5 responses. People watched what they ate and where they
went for dinner, in order to avoid foods that flared up
their gout. Spouses had to play an active role in helping
people avoid the foods that triggered gout attacks, and
also change their own diets, not by choice. Participants in-
dicated that restricted food choices for the couple nega-
tively influenced their relationship with spouse/significant
other.
Treatment-related financial burden stressing relationship
Two of the 14 nominal groups ranked this among the top
5 responses. People spent money on the care of gout, on
expensive medications and hospital stay costs, which
made it difficult to take vacation with spouse. Gout led to
difficulty with employment, which affected income, and
put a financial strain on personal relationships.
Table 1 Demographics of nominal group participants (n= 44)
N (%), unless
otherwise
specified
Age in years, mean (SD) 61.7 (12.2)
Sex, male (%) 22 (50%)
Race/ethnicity
White 14 (32%)
African-American 30 (68%)
Education level
High School graduate 13 (29%)
Some college or technical/vocational training 10 (23%)
College Degree: Bachelors and beyond 21 (48%)
Marital Status
Divorced 8 (18%)
Married 21 (48%)
Separated 3 (7%)
Single 6 (14%)
Widowed 6 (14%)
Employment status
Employed 4 (9%)
Homemaker 4 (9%)
Out of work 5 (11%)
Retired 19 (43%)
Self-employed 3 (7%)
Unable to work 9 (20%)
Disease duration in years
a
, mean (SD) 11.8 (11.8)
Current medications to treat gout
b
Allopurinol (with or without prednisone) 16 (36%)
Allopurinol + colchicine (with or without pain medication) 17 (41%)
Allopurinol + colchicine + prednisone
(with or without pain medication)
1 (2%)
Pain medications (NSAIDs or narcotics)
with or without prednisone
2 (5%)
Allopurinol + febuxostat 1 (2%)
Febuxostat (with or without prednisone) 3 (8%)
Febuxostat + colchicine + prednisone + narcotics 2 (5%)
None 1 (2%)
Current use of natural supplements for gout
b
None 23 (53%)
Cherry extract or concentrate 3 (7%)
Cherry juice 10 (23%)
Multivitamin or Vitamin B or Vitamin D 7 (17%)
Table 1 Demographics of nominal group participants (n= 44)
(Continued)
N (%), unless
otherwise
specified
Number of gout flares in the last 6 months
b
None 17 (39%)
One 3 (8%)
Two 10 (23%)
Three to five 5 (12%)
Six or more 8 (18%)
a
2 participants or
b
1 participant each did not respond to these questions;
Percentages are rounded off, so may not add up exactly to 100%; NSAIDs,
non-steroidal anti-inflammatory drugs; SD, standard deviation
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Emotional impact- communication, personality changes,
effect on self or spouse
Five of the 14 nominal groups ranked this among the top
5 responses. People perceived personality change due to
severe pain of gout and that they were short-tempered
and often snapped at their spouse. These often led to
miscommunication and misunderstanding. Several people
also reported that gout affected their spouse’s behavior in
a negative way, making them worried, aggravated and
sometimes blaming themselves. Gout led to a change in
social role in several relationships, where husband had to
learn to share household chores with the wife suffering
from gout.
Not in a relationship currently/ no or positive effect on
relationship
Three of the 14 nominal groups ranked this among the
top 5 responses, of whom two nominal groups had
Table 2 Number of nominal groups with relative ranking of each major concern/theme
Among male
nominal groups
(n=7)
Among female
nominal groups
(n=6)
All nominal groups
(n= 14)
Among male
nominal groups
(n=7)
Among female
nominal groups
(n=6)
All nominal
groups
(n= 14)
Top concern Among top 5 concerns
A1. Physical impact on intimacy 4 4 8 6 4 11*
A2. Emotional impact on intimacy 1 1 2 5 4 9
B1. Physical function limitation 1 1 2 3 3 6
B2. Physical Dependence 0 0 0 2 1 4*
B3. Social life interference 0 0 0 3 2 6*
C. Trust issues/understanding 1 0 2 2 1 4*
D. Self-image/perception issues 0 0 0 1 1 2
E. Diet/food choices 1 0 1 3 1 4
F. Financial burden 0 1 1 1 1 2
G. Emotional impact: communication,
personality changes, effect on
self/spouse
00 0 415
H. Not in a relationship/no or
positive effect
00 0 213
There were 7 male only, 6 female only and 1 male and female combined nominal group
In two groups, two concerns each tied for the top rank score, therefore, there are 16 top ranked scores
*Includes one nominal group with males and females that ranked this concern in top five
Theme A consisted of Physical (A1) or emotional impact (A2) of gout on intimacy
Theme B consisted of Physical function limitation (B1), physical dependence (B2), or Social Life interference/limitation (B3)
In some nominal groups, all votes were given to < 5 concerns/themes, therefore the total rank sum for top 5 concerns adds up to less than 70
2.30%
2.30%
3.80%
4.90%
5.30%
5.70%
6.80%
10.60%
12.90%
17.40%
28%
0% 5% 10% 15% 20% 25% 30%
Financial burden
Self-image/ perception issues
Emotional impac t: Communication, personality, effe ct on spouse
Diet/Food choices
Physical dependence
Not in a relatioship/ no effect
Social life interference
Trust issues/ understanding
Physical function limitation
Emotional impact on intimacy
Physical impact on inti macy
PERCENT VOTES
Fig. 1 Top themes/responses of people with gout regarding its effect on the relationship with spouse or significant other.Thefigureshowsaggregated
top 11 themes/responses related to the effect of gout on relationships and intimacy. These responses accounted for 100% of the weighted votes
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people who had not been in a relationship since the
diagnosis of gout, and therefore were unable to assess
whether it would or would not have an effect on
relationships. Gout was not the reason to not be in a re-
lationship. In one nominal group, people noted that they
had had a good control of gout (with medications and
diet) with infrequent flare/s, and since their gout was in-
frequent, they had not had any impact of gout on their
relationship at all.
Figure 2shows the main themes/subthemes derived
from patient-nominated responses, and their mapping
to the generic conceptual framework proposed by
Verschuren et al. [14].
Effect of gender on intimacy/sexual function responses
The number of nominal groups ranking the following
overall top responses were similar between male and
Table 3 List of themes and subthemes from all nominal groups
combined, with representative quotes/responses which are
presented in bullets below each theme/subtheme
Theme/subtheme
A. Physical or emotional impact on intimacy
A1. Physical impact on intimacy: “I had
•Difficulty with sexual activity due to gout flare pain, gout attack
makes it impossible; Your whole body is to break in half if you try
to be intimate”;
•Lack of movement due to joint pain during gout flare;
•No feeling, can’t feel sex during a flare;
•Inability to maintain personal hygiene, making people feel less
attractive about self;
•All body pain, which made even touch to the body painful;
•To lie down in the quiet room in the bed;
•Inability to perform sexually when in pain;
•Less desire to have sex;
•Diarrhea and gas with colchicine, which was embarrassing during
intimacy with spouse;
•Felt sleepy with narcotic pain medication; and
•Sleeping separate (in different beds or different rooms) from the
spouse during a flare, for the fear of pain exacerbation with light
touch.”
A2. Emotional impact on intimacy: “I felt
•Emotional stress due to joint pain;
•Exposing I was vulnerabilities to spouse, which had a negative effect;
•Spouse wasn’t aggressive towards intimacy due to my gout;
•Emotional vulnerability due to “male ego”and inability to be
intimate during a gout flare;
•Embarrassed when my husband had to help me with personal hygiene;
•Depression, anger, frustration interfering with intimacy, gout
makes you mean;
•That I stayed in a bad mood;
•Inferior due to gout;
•Depressed due to no inability to be intimate due to gout;
•Emotional fragility, with my first attack, I cried like a baby; and
•Gout impacted sexual desire.”
B. Disability/dependence Interfering with Social Life and Intimacy
B1. Disability: “I had
•The inability to keep up physically with boy-friend in routine and
recreational activities;
•Physical disability, requiring the use of assistive devices;
•Difficulty in helping wife with household chores during flare; and
•The need to adjust life around the attack.”
B2. Physical dependence: “I had
•Total dependence on wife during a flare;
•To depend on my husband/significant other;
•Hospitalization for the severe pain, which was later diagnosed as
a gout flare;
•My spouse carry me around the house and up and down the stairs;
•Gout flares that kept me in bed two to three times a month;
•Inability to walk at all; and
•to use crutches to walk when the flare hit.”
B3. Limitation of Social Life activities: “I had difficulty
•With the ability to plan events;
•Going to football games or movies together with spouse;
•Doing usual social activities, such as going to the bar, or a concert;
•Going places due to gout pain;
•Interacting with peers;
•Missing church events such that spouse had to go alone;
•And had to quit going to the church due to gout;
•Maintaining the routine of going out for dinner due to gout pain,
“a lot of times, everything stops”; and
•Driving to important events due to flares, and my spouse had to drive.”
Table 3 List of themes and subthemes from all nominal groups
combined, with representative quotes/responses which are
presented in bullets below each theme/subtheme (Continued)
Theme/subtheme
C. Trust issues/ understanding by spouse or significant other: “I noted
•Less understanding with my spouse;
•Partner not taking time to understand how gout affected me;
•That if the relationship was new, spouse wouldn’t understand how
gout was affecting me; and
•That gout made me ill-tempered with my spouse.”
D. Problem with Self-image and perception by partner
•“When I first had gout 15 years ago, I was in late 30s and I could not
walk, holding on to walls; I could not drive –there was nothing
going on; and
•I was in a relationship and could not carry on the relationship;
I couldn’t stand a sheet on my foot.”
E. Restricted Diet/Food choices negatively impacting the relationship
•“It affects a lot;
•Food choices change –no shellfish, seafood; and
•Places we could not eat and go out due to gout.”
F. Treatment-related Financial Burden stressing relationship
•“Gout affected income and us;
•It’s stressful for the relationship; and
•Medications are expensive even with insurance.”
G. Emotional Impact- communication, personality changes, effect on self or
spouse
•“Women are nurturers and she could not resolve how to help me
with my pain;
•She wanted to find a solution for me, just couldn’t; and
•She goes with me to the doctor –She is my snitch to the doctor;
we had quite a different view-point about treatments, now we have
a shared viewpoint: For years, I declined any medication treatment,
I doctored myself- you know you go on the Internet, self-diagnose
and treat yourself; it was a difficult obstacle for me to overcome.”
H. Not in a relationship currently/ No or positive effect on relationship
•"I don’t have a personal relationship;
•If you are in a spiritual relationship, you can still cope; and
•I knew its limitations before getting mine; It drew us closer
together."
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female nominal groups: (1) physical impact on intimacy,
4/7 male vs. 4/6 female; (2) emotional impact on intim-
acy, 1/7 male vs. 1/6 female; and (3) disability, 1/7 male
vs. 1/6 female; and (4) trust issues/understanding, 1/7
male vs. 0/6 female.
Potentially more male than female nominal groups
ranked the following among the top five responses, (1)
emotional impact on communication and personality
change, 4/7 male vs. 1/5 female and (2) restricted diet/
food choices negatively impacting the relationship, 3/7
male and 1/6 female nominal groups.
Discussion
This formative research showed that gout had a signifi-
cant impact on relationships and sexual activity of
people with gout. The physical impact of gout on intim-
acy was the top-ranked concern across all nominal
groups by the number of votes (28%), as well as the
number of nominal groups ranking it the highest, eight
of the 14 nominal groups. Gout impacted relationship
and intimacy in both men and women with gout. With
minor exceptions, we did not note any significant differ-
ences in the top concern related to gout by patient gender.
These data provide the patient perspective of the impact
of gout on intimacy. Inclusion of African-Americans and
women in our study sample makes these findings more
generalizable.
Studies in other inflammatory arthritides reported that
pain, physical disability, joint deformity and concomitant
depression were associated with sexual dysfunction [17–
20]. Studies in men with gout showed that gout was as-
sociated with more erectile dysfunction [8–10]. No data
on sexual impact are available for women with gout.
Our formative study advances the field by providing
quantitative and qualitative data on sexuality in people
with gout, and including women in our study, both first
to our knowledge.
Data from our nominal groups mapped to the generic
conceptual framework proposed by Verschuren et al. [14].
This framework considers sexuality to be a multifaceted
phenomenon, affected by organic, hormonal, and psycho-
social factors, and that chronic illness involves physical
symptoms and psychosocial stressors. Several themes and
subthemes mapped to the key constructs of physical con-
dition, psychological well-being (two top-ranked themes
in our nominal groups were similar –physical/emotional
impact on intimacy), and relationship, in the conceptual
framework [14](Fig.1). The current study found that dis-
ease and/or treatments impact sexual function in patients
with gout. Gout is associated with a higher risk of meta-
bolic syndrome [35], which might also contribute to sex-
ual desire and performance in gout. Mapping our data to
this framework not only provides insight into possible
mechanisms of sexual dysfunction in gout, but may also
form the basis of the development of interventions to ad-
dress sexual dysfunction in gout.
A clinical implication of this study is that a patient-phys-
ician dialogue is necessary to assess whether or not gout is
Fig. 2 Responses from NGT participants regarding the impact of gout on their relationships with spouse or significant other. The figure shows
the associations of key themes (black shaded boxes) and contributing categories (clear boxes) to various constructs from a generic conceptual
framework (colored ovals)
Singh BMC Rheumatology (2019) 3:8 Page 7 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

currently impacting their sexual life, and if so, better
understand the effect. Considering the important
contribution of sexuality to QOL [11], optimal gout man-
agement with treat-to-target strategy [36,37]toreduce
gout symptoms and flare rates can potentially reduce the
impact of gout in sexual health and improve patient’s
QOL. For people with refractory sexual dysfunction des-
pite optimal gout management, referral to an expert in
psychiatry or sexual health may benefit a sizeable propor-
tion of gout patients and improve their QOL.
Considering that we invited a convenience sample of
consecutive patients with gout (not people with diag-
nosed sexual health problems), the proportion of people
reporting and discussing the impact of gout on relation-
ships with spouse/significant other and sexual dysfunc-
tion was much higher than expected; with the exception
of a few, almost everyone reported some impact. While
sexual problems were a hallmark of gout flare associated
severe pain, a majority of the nominal groups reported
frequent sexual dysfunction due to chronic joint pain
due to gout, most notably difficulty performing sexually
due to gout-associated pain. The study findings demon-
strate the physical impact of acute and chronic pain of
gout and associated disability on intimacy and sexual
function. Future studies that aim for a reduction of gout
flares and chronic joint pain in gout should examine
whether acute and chronic pain reduction can potentially
have a positive impact on sexual activity and relationship
with spouse as important patient-centered domain/out-
come. Inclusion of sexual function as a secondary or ex-
ploratory outcome in clinical trials of gout will improve
our understanding of the relationship of active gout
symptoms and sexual dysfunction. They will also help us
understand whether therapies with varying effects on in-
flammation and hyperuricemia differ in their ability to re-
duce gout’s impact on sexual function. Could a more
optimal gout control (fewer gout flares, reduced joint
pain) improve relationship and intimacy? Might manage-
ment and optimization of associated depression have a
positive impact? These hypotheses need to be tested in fu-
ture studies.
Another important, novel study finding was the emo-
tional impact of gout on intimacy. This was the 2nd
top-ranked concern across all nominal groups based on
the number of votes (17.4%) and two of the 14 nominal
groups had this as their top concern. We are unaware of
any other published studies of the emotional impact of
gout on sexuality, intimacy and relationships, except our
previous study where the focus was quality of life [7].
Associated depression, emotional stress, anger and frus-
tration impact intimacy. Gout-related pain exposed pa-
tient’s vulnerabilities to their spouse that negatively
affected their relationship. Patients identified several
other causes of emotional impact of gout on intimacy,
including the need to get help from spouse in maintain-
ing personal hygiene. A feeling of inferiority due to the
inability to be intimate also affected people with gout.
Feeling of emotional fragility by both women and men
with gout and of vulnerability due to “male ego”by men
with gout were also reported. Patients also reported a re-
duced sexual desire due to gout, which might be related to
associated depression and/or to concomitant metabolic
syndrome associated conditions. Trust issues, disability
and social life interference due to gout were of concern to
the patients and ranked among the top five responses
across all groups, as shown in the figure.
Some people lost relationship due to active, symptom-
atic gout (usually under-treated and sometimes undiag-
nosed/misdiagnosed) and some had difficulty getting
into a relationship due to gout, demonstrating a signifi-
cant effect of gout on people’s lives. To our knowledge,
this has not been previously described. This finding indi-
cates the severe, disruptive effect of inadequately con-
trolled gout. Interestingly, one nominal group with gout
under good control with few/no flares indicated that
gout had not affected their relationship. Additionally, a
few people in two nominal groups had not had a rela-
tionship since the diagnosis of gout, and therefore could
not assess its effect on relationships; the choice of not
being in a relationship was not related to gout (different
from people described at the beginning of the para-
graph). We also found that in rare instances, gout had
no effect or a positive impact participant’s relationship.
Participants attributed this positive experience to an un-
derstanding spouse, a strong relationship with spouse
prior to the disease appearance, and infrequent gout
flares.
Study findings must be interpreted with caution con-
sidering study limitations. Findings may not be
generalizable to all Americans with gout, since this was
a single center study of people previously evaluated for
gout at a community-based clinic, and the nominal
groups were conducted in English only. Due to the sen-
sitive nature of the question, it is possible that people
did not share the most intimate aspects of their relation-
ships; some responses may have been missed. Assess-
ment of possible solutions to the prioritized problems by
the patients would have required another 1–1.5 h of
nominal group discussions and were not assessed due to
limited time. This is an important research agenda that
needs to be addressed with future studies. Interpretation
of findings by a single researcher is another study limita-
tion. However, phrasing and nomination of responses,
addition of details to the participant-nominated re-
sponses, the decision to group or ungroup responses,
voting and ranking are all done by the nominal group
participants, not the moderator. Therefore, it is unlikely
that the number of researchers involved had any impact
Singh BMC Rheumatology (2019) 3:8 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

on the quantitative aspect of the NGT, which were the
main study findings.
Study strengths were the inclusion of women and
African-Americans, the achievement of data saturation,
and the study cohort demographics being similar to
other studies of gout populations.
Conclusions
In conclusion, this formative study assessed the effect of
gout on relationships with spouse/significant other and
sexual function. In a community-based outpatient clinic
sample of people with gout, we found that gout affected
relationships with spouse and sexual function quite
commonly, and in several ways. A major impact was
related to the acute and chronic joint pain and the asso-
ciated disability, with physical and emotional impact on
intimacy being the highest ranked responses. Study par-
ticipants also noted loss of trust with spouse, loss of
relationship, and significant social life impact due of
gout. This study advances our knowledge of the true im-
pact of gout on people’s sex lives. This study also brings
to light an aspect of patient suffering, previously not rec-
ognized or well-described. The healthcare providers
should discuss the impact of gout on relationships with
patients with gout during clinic visits and address it ap-
propriately. A reversal of a negative impact of gout on
intimacy with appropriate disease control can serve as a
positive reinforcement for some patients and might help
to increase treatment and medication adherence.
Additional file
Additional file 1: Study participant nominated responses (numbered),
the concept they map to (in parenthesis) along with patient quotes
(individually bulleted items) and the score/votes each received from the
nominal group participants in the final voting phase. (DOCX 79 kb)
Abbreviations
ER: Emergency room; NGT: Nominal Group Technique; UAB: University of
Alabama at Birmingham; ULT: Urate-lowering therapy
Acknowledgements
I am thankful to UAB student Sara Chirambo (S.C.) for her help in scheduling
the patients and data entry; research assistant, Candace Green (C.G.), BS for
scheduling the patients and providing support for conducting the nominal
groups by taking notes during nominal groups and checking the total votes
and ranking of responses; and administrative assistant, Diana Florence (D.F.)
for the administrative oversight and transcribing the nominal group discussion.
I thank several colleagues and patients who provided informal input into
drafting the question for the nominal groups.
Ethics/IRB approval and consent to participate
The University of Alabama at Birmingham’s Institutional Review Board approved
this study (X120404005) and all investigations were conducted in conformity
with ethical principles of research. All patients involved in the study provided
written informed consent to participate in the study.
Funding
This material is the result of work supported by research funds from the
Division of Rheumatology at the University of Alabama at Birmingham and
the resources and use of facilities at the Birmingham VA Medical Center,
Birmingham, Alabama, USA. The funding body did not play any role in design,
in the collection, analysis, and interpretation of data; in the writing of the
manuscript; and in the decision to submit the manuscript for publication.
Availability of data and materials
We are ready to share the data with colleagues, after obtaining appropriate
permissions from the University of Alabama at Birmingham (UAB) Ethics
Committee, related to HIPAA and Privacy policies.
Authors’contributions
JAS designed the study, developed the protocol, conducted the nominal
sessions, analyzed the data, wrote the first draft of the manuscript and
revised it and made the decision to submit it.
Consent for publication
Not applicable since there are no individually identifiable data.
Competing interests
JAS has received research grants from Takeda and Savient pharmaceuticals
and consultant fees from Savient, Takeda, Regeneron, Merz, Iroko, Bioiberica,
Crealta/Horizon and Allergan pharmaceuticals, WebMD, UBM LLC, Medscape,
Fidia pharmaceuticals and the American College of Rheumatology. JAS owns
stock options in Amarin pharmaceuticals and Viking therapeutics. JAS serves as
the principal investigator for an investigator-initiated study funded by Hori-
zon pharmaceuticals through a grant to DINORA, Inc., a 501 (c)(3)
entity. JAS is a member of the executive of OMERACT, an organization that
develops outcome measures in rheumatology and receives arms-length funding
from 36 companies. Jas has previously served on the following commit-
tees: member, the American College of Rheumatology’s (ACR) Annual Meeting
Planning Committee (AMPC) and the ACR Quality of Care Committee; Chair of
the ACR Meet-the-Professor, Workshop and Study Group Subcommittee; and a
member of the Veterans Affairs Rheumatology Field Advisory Committee. JAS is
the editor and Director of the UAB Cochrane Musculoskeletal Group Satellite
Center on
Network Meta-analysis.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Received: 27 September 2018 Accepted: 25 January 2019
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