Mike’s doctor looked and sounded concerned. “Your sugars are up, your blood pressure is up, and you’ve gained 10 pounds since I last saw you,” she said. “You were doing so well. What happened? ”
“I don’t know,” said Mike. “I’m just down. Exercising and checking my blood glucose don’t seem worth the effort now. My neuropathy is burning holes in my feet. It’s been a hard year.”
“Sounds to me like you’re depressed,” said the doctor. She then wrote out a prescription for a selective serotonin reuptake inhibitor (SSRI) for Mike’s depression and another for a refill of Mike’s usual blood pressure medicine, but this time with a higher dose.
The doctor didn’t ask about Mike’s sex life, and Mike didn’t volunteer that what was really bothering him was that he and his wife Barbara had stopped having sex about 10 months before. He couldn’t count on getting erections or keeping them, and without them, he withdrew, both physically and emotionally. He and Barbara were miserable. Unfortunately, both of the medicines his doctor had just prescribed can have the side effects of decreasing sex drive and making it harder for men to have erections. So the new treatments were potentially going to make Mike’s problem worse.
Mike hadn’t mentioned his sexual problems to his doctor because he felt embarrassed about them, and his doctor apparently didn’t think to ask about sexual issues. Had she known about Mike’s erection difficulties, she might have prescribed a drug for erectile dysfunction rather than an antidepressant. But Mike had already bought some Viagra on the Internet. It had helped a little with the erections, but not much, and it did nothing for his desire level or low mood.
Barbara was at her wit’s end. She thought Mike’s withdrawal meant he didn’t love her anymore. True, there were problems in the relationship besides the cessation of their sex life. But Mike and Barbara did not talk about those or about sex, either, so they drifted farther apart.
Problems like Mike and Barbara’s happen all the time: Studies find that over 50% of men and 27% of women with diabetes have sexual difficulties. These conditions often don’t get talked about, either at home or in the doctor’s office, and pretty soon an individual’s or couple’s sex life is a distant memory. This can have major impact on a relationship and on a person’s mental and physical health. Sex with a caring partner can help people feel more connected and supported. It can be a form of relaxation, a pain reliever and a sleep aid. It can be a source of physical pleasure, even for people whose bodies more frequently give them pain and frustration.
Having a satisfying sex life can raise a person’s perceived quality of life, make him feel less stressed and serve as a motivator to care for himself and his diabetes. If sexual activity stops for any reason, it can reduce the motivation to carry out self-care tasks. Fortunately, there are always ways to restore and improve your sex and love life, whether or not you have a partner, no matter what physical or emotional challenges diabetes throws your way.
Diabetes’s effect on sex
Diabetes can interfere with sexual function in numerous ways. Chronic high blood glucose or blood pressure can contribute to both neuropathy (nerve damage) and impaired blood circulation, both of which can lead to decreased or delayed erections, lubrication, genital sensation and orgasm. In women, high blood glucose can lead to frequent vaginal yeast infections and urinary tract infections. Neuropathy can make bladder control more difficult.
Sex involves more than just genitals. Pain in any part of the body can make it hard to relax and enjoy sexual activity, and some diabetes complications can cause pain. Fatigue can make sex seem like more trouble than it’s worth, and diabetes can be related to fatigue in numerous ways, from interfering with a person’s sleep to causing a person to feel constantly drained from the effort of coping. Both high and low blood glucose can affect a person’s mood, energy level, and, hence, interest in sex.
Then there are the psychological effects of having diabetes. People with diabetes often become depressed, and depression negatively impacts sexuality. While many people with diabetes have a strong sense of self-worth, some feel that having diabetes or its complications makes them unattractive to others. These people may think of themselves as “damaged goods” and fear that nobody will want them as a partner. If people feel bad about themselves, they may lose sexual desire or withdraw socially.
A number of medicines that are commonly prescribed for people with diabetes are known to dampen sex drive and/or sexual function as a side effect. This is often true of antidepressants and blood pressure medicines. Pain medicines, especially narcotics but also some medicines commonly taken for neuropathy pain, can cause sexual problems. Alcohol and street drugs such as cocaine or marijuana can interfere with sexual functioning. And smoking tobacco impairs circulation and nerve function and lowers libido.
What can you do if you’re having sexual difficulties? You might start by talking with your doctor. Let him know what’s going on, and ask if your symptoms could be the result of a medical condition or a side effect of any drugs you are taking. Since high blood glucose can interfere with sexual functioning, ask how you can “tighten” your blood glucose control if it is not currently optimal. Ask about any signs of peripheral neuropathy in your feet, such as loss of sensation; this can easily be tested in a doctor’s office. Evidence of neuropathy in your feet may mean that nerves in other parts of your body are affected as well, possibly affecting your sexual functioning.
What about your blood pressure? While high blood pressure can have negative effects on sexual functioning, so can some of the medicines used to treat it. Your doctor may be able to change your prescription to a blood pressure drug that is less likely to cause sexual side effects. In addition, lifestyle changes such as increased exercise, less sodium in your diet and increased consumption of fruits and vegetables can help to lower blood pressure and do not have negative sexual side effects. Your doctor can tell you whether your blood pressure is at the recommended level (below 140/90 mm Hg for most people with diabetes), point you toward safe and effective lifestyle changes and/or refer you to a dietitian or exercise specialist for help in these areas. For some people, losing weight if you are overweight can also improve sexual functioning, and a dietitian can help you work out a plan for weight loss.
If an antidepressant you are taking is a likely cause of your sexual dysfunction, it may be possible to take a brief “drug vacation” (usually 2–3 days) for sexual activity. However, you should be sure to clear this with the doctor who prescribed the antidepressant rather than doing it on your own. If you smoke, drink more than moderate amounts of alcohol or use recreational drugs, your doctor may be able to offer treatment or refer you to a treatment program for substance abuse.
Your doctor may also prescribe drugs or devices specifically for your sexual problems. For men with erection problems, there are four oral pills, an injectable drug, urethral suppositories or vacuum devices. Men who are found to have low testosterone levels may benefit from from testosterone supplementation.
For women, treatment of sexual dysfunction can include treatment of vaginal or urinary tract infections, treatment for urinary incontinence, oral or vaginal estrogen therapy for vaginal pain or low desire and over-the-counter lubricants for vaginal dryness. Testosterone supplementation may increase desire, lubrication and sensation. However, this use of testosterone is not approved by the Food and Drug Administration (FDA), and not all doctors may be willing to prescribe it. A device called Eros Therapy is approved by the FDA for sexual arousal and orgasmic disorders in women. The device applies a gentle vacuum to the clitoris, increasing blood flow to the clitoris and surrounding tissue, and is available by prescription.
Depending on the nature of your problem, its likely cause, and your doctor’s experience treating such problems, he may refer you to a specialist such as a urologist or gynecologist for diagnosis and/or treatment.
What if you feel your concerns are being brushed aside when you bring up sexual difficulties in the doctor’s office? It may be that your doctor feels uncomfortable talking about sexual issues. Neurologist Dr. Jack Burks suggests, “First ask the doctor if he feels comfortable talking about this. Or would he prefer to refer you to someone else? Include your partner in the discussion if you’re both willing. Ask for additional resources, such as a psychotherapist or sex therapist.”
There’s a lot you can do on your own, too, to improve your sex life, whether you are able to actually change your physical functioning or simply learn new ways to enjoy what you have. Here are some ideas:
- Make an effort to control your blood pressure with stress-reduction techniques, such as the relaxation response, as well as exercise and dietary changes. Even if you do not have high blood pressure, these lifestyle measures can improve your health.
- Make sensible dietary changes and increase physical activity. A Canadian study found that aging male rats recovered their erectile function with exercise and calorie restriction. If it works for rats, it might work for you!
- Commit to your diabetes care regimen. Psychologist Steven Phillipson says, “High blood sugar often decreases sexual interest. Libido may return as blood sugar is brought down to a normal level.”
- If vaginal dryness is a problem, make liberal use of personal lubricants, which are available over the counter at any drugstore.
- If decreased sensation is a problem, experiment with different ways of genital stimulation, possibly using more pressure than you usually do or using an electronic vibrator. Applying cold or heat to the genitals for a few minutes may increase sensitivity. A bag of frozen peas can be an effective cold pack.
- Gauge your energy level. If one or both partners are too tired, sex won’t be good. Some couples resolve this issue by scheduling sex for mornings or for whatever time they’re likely to have energy.
- Get in the mood. Most people can’t go directly from work, housework or taking care of others to sexual activity. You may need to take some time to relax or talk, dress up, go somewhere special, watch a sexy video or do something else to get in the mood.
- Relationship problems can interfere with the desire to have sex, so those may need to be addressed before mutually enjoyable sexual activity can take place.
- Reduce the likelihood of urinary incontinence by emptying your bladder before making love. For women, woman-on-top positions may reduce problems with incontinence or pain with intercourse. Such positions may also be more comfortable for some men, particularly those with back pain.
Try something new
One of the sad things about Mike and Barbara’s story is that when Mike couldn’t get a good erection, he thought he couldn’t have sex at all. Our society tends to think of heterosexual sex in a very limited way — as penis–vagina intercourse. There’s nothing wrong with that kind of sex, but there are many other ways to experience sexual pleasure that don’t require an erect penis.
For example, women do not require an erect penis to have an orgasm. In fact, most women can’t climax from intercourse alone because there are few nerve endings deep in the vagina. However, women do have a great number of nerves for pleasure around the outside of the vaginal opening and just inside. The organ best known for having a dense nerve supply is the clitoris. However, while many think of the clitoris as just the visible tip at the junction of the inner lips of the vulva, in fact, the clitoris is a horseshoe-shape structure that extends along the rim of the vaginal opening on either side. You can stimulate both the surface “button” and the deeper horseshoe shape with the fingers, the side of your hand or your mouth, using as much or as little pressure as is comfortable. Using some lubricant can also enhance a woman’s pleasure and comfort.
Another potential source of sexual pleasure for women is the G-spot, a spongy mass of tissue believed by some to exist on the front wall of the vagina. Its existence is doubted by others, but it certainly can’t hurt to try stimulating it: If it feels good, it feels good; if it doesn’t, it doesn’t. You can stimulate the G-spot by inserting one or more fingers into the vagina, curving them toward the belly button and stroking with a “come-hither” finger flexing. Not all women enjoy this, but many report the best orgasms of their lives from G-spot stimulation.
Men also may not require an erect penis to have an orgasm. Many men can have intensely pleasurable orgasms from stimulation of the prostate gland, even if they can’t have erections or ejaculations. The prostate can be stimulated by stroking or pressing on the perineum, the area between the scrotum and the anus, or by inserting a finger into the anus. Men can also enjoy having other sensitive areas stimulated with hands, mouth or toys whether or not it leads to orgasm. Again, use lubricants, try different ways of touching and pay attention to your partner’s response.
Most women and men have pleasures zones they have never explored or are unaware of. For example, many women and men find anal stimulation very pleasurable. And then there’s the whole rest of your body to explore. It helps to explore yourself to see what gives you pleasure. You might even draw a map of your body with the pleasurable spots marked with an X.
Massage is a terrific way to give and receive pleasure. You don’t have to be an expert. Just have some nice massage oil, start with long, gentle strokes to warm up the muscles before going deeper and ask your partner what feels good as you proceed. Massage between partners can include genitals, too, if that’s what both people want.
Sex toys are another way to improve a sexual experience. Some vibrate, some oscillate and some just sit there. You can use any of them in partner sex as well as masturbation.
Communicating about sex is important, too. You have to tell your partner what you like and what you don’t like. One idea is to take clothes off, lie down facing each other and just talk about sex, perhaps while looking into each other’s eyes.
Building the relationship
Toys, erections, lubrication and orgasms don’t take the place of a strong, intimate loving relationship. And having a good relationship is the best way to have good sex.
Dr. Burks says, “Intimacy involves sexual feelings and actions, but also loving feelings, cuddling, holding hands, honesty, commitment and acceptance.”
Psychologist and certified sex therapist Joe Nelson writes, “A doctor can prescribe medicine like Viagra or Cialis, but a couple may still need to work on the relationship before the medicine will help. The causes of sexual problems for people with diabetes are not just physical.” Disagreements or hard feelings about money, housework or values may need work before sexual issues can be addressed.
Building intimacy in a relationship takes being open, honest and brave. Each person needs to learn to express his feelings and desires without attacking the other person. It’s also important to learn to listen attentively to what the other person has to say. It gets easier with practice. Many couples find that talking about sexual issues is a good place to start and opens the door to better communication in all areas of their relationship. However, if you and your partner are having trouble, you might consider getting help from a therapist.
Finding a partner
The same things that can help to build intimacy in an established relationship — communication, courage to be open about yourself, willingness to explore new approaches — are needed to find a partner in the first place. It can be scary to start conversations and get to know people, because when you do, you risk rejection. For this reason, people with diabetes often wonder how or when to bring up their diabetes in dating situations.
“It’s usually best to let a person get to know you and see how wonderful you are before bringing up health issues,” says Dr. Burks. “Usually the second or third date or meeting is all right, but it varies among individuals.”
Of course, to get to a second or third date, you need a first date, and for that, it helps to put yourself where people can find you. Many people find attending church, participating in organized social activities, volunteering or exercising with others to be better ways to meet potential partners than going to nightclubs or bars. But clubs and bars can work, too.
If you don’t believe people will find you attractive, try looking in the mirror and telling yourself, “I’m attractive; I’m deserving,” or something like that. Not everyone will find you attractive, but you don’t need everyone; you just need one other person who does. Steven Phillipson says that once a mutual interest between two people has developed, hiding your diabetes and any related sexual issues is a mistake. “If you are considering becoming physically intimate with someone,” he says, “it would seem that you have developed enough intimacy and trust to share information about [sexual] impairments related to diabetes.”
If you don’t have a partner, you can also have sex by yourself. In fact, taking some solo pleasure time can help you explore your body and make you a sexier partner for when you do find someone compatible.
Barbara and Mike worked things out. They talked honestly about their situation and their feelings. They started having cuddling and caressing time that didn’t include intercourse. They learned how Mike could bring Barbara to orgasm with his hands, and they both felt good about that. Mike felt better and more supported, and he started exercising again. He asked his doctor for a different blood pressure medication. He got his blood glucose levels back in target range, and with the help of Viagra (which hadn’t worked before), his erections came back. Now Mike and Barbara have a more varied sex life and are more in love than ever.
Their outcome is realistic for anyone, with or without diabetes. All it takes is a little courage, creativity and communication.