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Developing intimacy involves trusting and learning to understand the other person. Unfortunately, sexual issues, especially for women with diabetes, are often kept in the dark.
If you have felt emotional burdens related to sexual health and diabetes such as a lack of self-esteem, negative body image or fear of rejection, you are not alone. Luckily, doctors and therapists can offer encouraging and helpful advice on how to overcome the physical and mental barriers to intimacy that diabetes can create.
Wendy Ullman, a licensed marriage and family therapist in San Francisco, Calif. points out that entering and maintaining a relationship while taking care of a chronic illness can trigger many conflicting feelings. "A woman with diabetes might be confused about how much to share about her physical problems and fears. People with diabetes often end up reassuring the other person that they are okay when oftentimes they need to tell someone how they are feeling, " she says.
Sharing the facts about your diabetes may be difficult, but it is crucial in forging a lasting relationship. According to Ullman, open communication is the best way for couples to handle diabetes.
Sarah Smith (name changed on request), a type 1 for 24 years, always makes a point of being up front about her diabetes. "A lot of people are afraid to tell someone that they have diabetes. However, I usually tell someone on the first date. Since it'll usually be a dinner date anyway, and I'll have to inject at the table. It's never been a problem for me," she adds.
Help! I Need Somebody
Ullman encourages therapy as a tool for achieving greater self-understanding. She maintains that being able to talk to an objective, non-judgmental person who is a good listener is "part of staying healthy."
A therapist can also be helpful at lessening the emotional intensity of opening up to a partner. "Without a doubt it's more complicated to have a relationship when diabetes is involved," says Ullman. "The issue of maintenance and mortality in the middle of a relationship changes things."
According to Ullman, many women with diabetes have a hard time relaxing and letting the body take over in intimate situations. Because diabetes requires constant self-monitoring, it becomes difficult to "just let go," she says. "Because you constantly have to monitor your health, you may feel like being more careful than average and not taking risks in physical situations."
In some cases, women with diabetes confront this fear by becoming more athletic. Doing physical activities like dancing or running can help a person look at her body in a different light and help her foster better self esteem.
Massage is another way to increase comfort with your body. "Professional, safe, non-sexual massage can let a woman experience touch as non-threatening," says Ullman.
Nerve damage, or autonomic neuropathy, is a common complication of diabetes, which can lead to poor bladder control and inadequate vaginal lubrication. However, since the majority of studies conducted have been limited in size or inconclusive in their findings, it is still unknown just how much these complications affect a diabetic woman's sexuality.
"There have been very few studies documenting the effects of neuropathy on women and sexual function. However, from what has been done, there is very little to show that neuropathy affects libido or the ability to climax," says neuropathy expert, Aaron Vinik, MD, PhD.
However, others disagree. As Lois Jovanovic-Peterson, MD, et al., report in The Diabetic Woman, a study by Dr. Judith Lorber of Columbia University found that diabetic neuropathy in women can affect nerves to the genital area and "can prevent adequate lubrication as well as orgasmic climax."
In addition, neuropathy has been associated with depression and apathy, both of which affect libido.
Poor Bladder Control
Another problem women with neuropathy may face is that damaged nerves to the bladder can lead to poor bladder control and an inability to empty the bladder completely. This may lead to leaking during sex as well as bladder and urinary tract infections. The ADA suggests people suffering from inconsistent urine release follow a planned bladder-emptying program.
The ADA suggests trying to urinate every hour or two, instead of waiting until the bladder feels full.
Women suffering from the problems associated with a neurogenic bladder are advised to urinate before intercourse and within 30 minutes after to prevent infections.
An Issue of Dryness
Vaginal dryness is an uncomfortable complication arising from neuropathy which can affect both women with type 1 and type 2 diabetes. Ordinarily, sexual arousal releases lubrication fluids in the vaginal area which prepare the body for intercourse. If the nerve fibers that stimulate the genitalia are damaged, this arousal may not occur, and intercourse can be painful because of inadequate lubrication.
There are a number of water-soluble lubricants which can help to alleviate this problem. Vaseline or other oil-based products are not advisable lubricants because they can damage condoms and foster bacterial growth, leading to infection.
Vaginal dryness may also be the result of low hormone levels. To counter this, a doctor might recommend estrogen, also called hormone replacement therapy (HRT). HRT is also beneficial for women entering menopause.
Estrogen can be delivered to the body by taking an oral medication, wearing a patch or applying a vaginal cream. The estrogen doses in HRT are so tiny that they rarely affect sugar metabolism according to Lila Nachtigall, MD, of New York University Medical Center, author of Estrogen: The Facts Can Change Your Life..
Recurring Yeast Infections
Women with diabetes are also more likely to have recurring yeast infections. Yeast infections often occur when a woman is in poor control of her diabetes. When BGs are not under control, the resulting sugary environment allows yeast to proliferate in vaginal secretions.
Susceptibility to yeast infections and vaginitis can also increase when women with type 2 diabetes enter menopause. Menopause slows down estrogen production, decreasing the amount of nourishment supporting the vaginal lining. This makes it easier for yeast and bacteria to grow.
The ADA's Complete Guide to Diabetes. provides the following precautions for menopausal women to help prevent vaginal infections: keep blood glucose levels under control, bathe regularly to keep fecal bacteria from entering the vagina and consider hormone replacement therapy. Some doctors also recommend eating low-fat yogurt with active cultures on a daily basis to help battle yeast in the digestive tract.
Body Distortions - Eating Disorders and Diabetes
Many women with diabetes, especially those on insulin, develop eating disorders. Cindy Onufer, RN, MA, CDE, believes that eating disorders are related to women, sex and diabetes because these problems stem from the desire to be attractive. This desire, combined with the weight inducing properties of insulin, has led many women to go without insulin in order to lose weight.
Taking less insulin than required in order to stay thin is a dangerous practice to say the least.
Among other things, the kidneys can take a beating because the sugar in the bloodstream goes out through the kidneys rather than being metabolized. Also, cheating yourself of insulin can lead to ketoacidosis, a potentially deadly complication.
"You can keep from getting sick in the short term, but you will get devastating complications later on," says Onufer. "I am seeing more and more of this (skimping on insulin to stay thin) and it really worries me. The people doing it are getting younger and younger."
A recent study published in the November Diabetes Care, shows that this trend of young girls trying to lose weight is disturbingly common. "Forty percent of 9-to 10- year-old girls are already trying to lose weight," the study reads.
Body image problems and fears of rejection are even more complicated if a woman is concerned about her ability to have children.
"The effects of diabetes on intimacy are layered. First, there are concerns over being able to bear a healthy child, and second, will the child get diabetes? Women are often afraid to discuss these things with their partner for fear that it might make them less desirable," explains Onufer.
Additionally, problems can be magnified when women hear stories about miscarriages or babies having birth defects in diabetic pregnancies. Often, consultations with educators and doctors can answer questions and ease fears.
The more informed a woman is before pregnancy, the better the odds of a healthy childbirth. The key is to gain extremely tight control over BGs a few months before trying to conceive. "Basically, stay in control and your chances of a healthy pregnancy increase enormously," says Onufer. " Type 1s and 2s are having healthy kids, but extensive counseling from an endocrinologist prior to getting pregnant is vital," she stresses.
A pregnancy consultation with an endocrinologist can provide a woman with information on the possibility of complications and how to prevent them. Onufer also adds that if a woman has mild or the beginning stages of retinopathy before pregnancy, it often worsens during pregnancy but almost always clears up after the pregnancy.
Women with diabetes should be extra cautious about unplanned pregnancies because of the importance of preconception BG control. There are a number of contraceptive options available.
In the past, women with diabetes were told to avoid the pill, but no longer, say Laurinda Porier, RN, MPH, CDE, and Katharine Coburn, MPH, co-authors of Women and Diabetes, Life Planning for Health and Wellness.
Women with diabetes were told to stay away from the pill because it complicated BGs and added to the risk of developing circulation and clotting problems. Now, both complications can be prevented with a doctor's help.
Routine blood fat and blood pressure checks are also important, says Porier, because high blood pressure on the pill can worsen eye and kidney disease. Jovanovic-Peterson also notes that the best oral contraceptives for women with diabetes have low doses of estrogen and progesterone.
However, "Oral contraceptives may not be for you if you have a medical history of heart disease, stroke, high blood pressure or blood vessel problems such as phlebitis," says Jovanovic-Peterson. Smoking and being over 30 also are additional health risks to oral contraception.
Contraceptives also come in injection form, such as Depro-Provera, or in an implantable form like Norplant. Depro-Provera is an injection that lasts for up to three months and Norplant, a device implanted under the skin, lasts for five years.
If these contraception options aren't for you, others like the diaphragm, condoms, or intra-uterine device (IUD) are also available. The rhythm method is not advisable, however, as its reliability is unpredictable and unplanned pregnancies for women with diabetes can be dangerous for the mother and the child.
You're Not Alone
Research on women with diabetes and sexuality is hard to come by. There are two schools of thought as to why. Either professionals believe that women with diabetes don't suffer from sexual complications, or the topic simply isn't discussed with health care professionals. "There is deterioration to nerves that enervate that part of the body, but it is often discounted in health care because you can't measure it," says Porier.
Thankfully there are doctors such as Pat Schreiner-Engel, PhD, at Mt. Sinai Hospital in New York, who are currently exploring this uncharted territory.
According to her work, women with type 1 diabetes do not have higher rates of sexual problems. However, women with type 2 diabetes are more likely to have sexual difficulties than others in their age group.
If you are a woman with diabetes who is experiencing sexual difficulties there is help.
Doctors and psychotherapists can offer resources for both type 1 and 2 women, help them to avoid complications and keep them current with helpful products. Whatever your personal or physical issues are, sexual health involves self-awareness and a level of comfort with one's own body. Hopefully, getting advice from caring health care professionals and taking advantage of current therapies and products can lead to this increased self-understanding.
Finding the most comfortable mode to communicate your emotional and physical needs will only lead to healthier, happier intimate situations.
Sarah Smith, by the way, is happy with her current boyfriend. "I'm dating a doctor now. And thankfully he understands my diabetes."
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Gyne-Lotramin (800) 899-3116
Yeast-Gard Homeopathic Vaginal Suppositories, Lake Consumer Products, Inc. (800) 537-8658
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Aqua Lube (800) 426-6366
Astroglide from Biofilm, Inc. (800) 849-5900
WonderGel Personal Liquid Gel in Aloe Vera and Ginseng formulas, Lake Consumer Products, Inc. (800) 537-8658
Replens Vaginal Moisturizer, Warner Lambert (800) 524-2624
Comfort and Wet Light Products, Wet International (800) 248-4811
Estrex for Hot Flashes, Lake Consumer Products, Inc.
Advantage 24 Bioadhesive Contraceptive Gel, Lake Consumer Products, Inc. (800) 537-8658
Vagi-Gard, maximum strength or advanced sensitive formula, Lake Consumer Products, Inc. (800) 537-8658