Sex and Diabetes: Some Hard Questions

Diabetes Health's column on love and diabetes is written by David Spero RN and Aisha Kassahoun (pictured).

| Jun 5, 2009

Dear Sex and Diabetes: I'm a disabled veteran. Type I diabetes ended my 14-year Army career in 1994.  I got married in 1999. About 3 years later, erectile dysfunction (ED) reared its ugly head. I tried various pills to help with erections, but nothing worked.  In the meantime, I lost my health insurance and had to fall back on Veterans Affairs (VA) health care.  Last week I had a urology appointment and, among other issues, discussed getting help for ED. 

I was advised that before a treatment strategy could be implemented, I'd be required to attend a regularly scheduled "impotence class" with other veterans.  I was told that it would cover symptoms and various treatment options.  I am not ecstatic to be required to attend such a thing! This is not a part of my life that I take pleasure in sharing with others.  In fact, the more I think of it, the more appalled, humiliated, and furious I become.

Before I really go off the handle about this, am I right in thinking that this type of forum is not really an appropriate clinical practice, or am I just being hypersensitive?  If I am right, to whom should I voice my concerns? If I do attend, can I wear a burkha to hide my face?

Upset Vet

Dear Vet,

"Impotence class," huh?  We thought we'd heard it all.  Support groups and classes can be good things, and the VA does provide some good care, but sexual function is not usually the time, place, or subject for group medicine. 

We did a Google search for "impotence class" and got exactly zero appropriate results.  There's no such thing. We know why they're doing this, of course. They're setting up barriers to care and hoping you give up.  If they wanted to help, they could just hand you a brochure. It would be cheaper and more effective.

You mentioned "pills not working."  The main ED pills, Viagra (sildenafil), Cialis (tadalafil), and Levitra (vardenafil) work by relaxing the blood vessels that bring blood to the penis.  The first one, sildenafil, was developed to treat high blood pressure and chest pain (angina). It didn't work so well for those, but had the side effect of strengthening men's erections. Lucky for Pfizer!

In the penis are two spaces called the corpus cavernosum, filled with spongy tissue. When a man is aroused, blood flows into the sponges, and the penis swells.  Diabetes, hypertension, and aging, however, can reduce the blood flow, blocking erections.  Reduced nerve function, depression, and the side effects of medications can also prevent erections.

The pills often work and are considered very safe. Viagra and Levitra are faster; Cialis is much longer lasting. But if they don't work because blood vessels are too blocked or nerves too damaged, there are other approaches.  Hormone-like substances called prostaglandins can be injected directly into the penis with a needle; or a tiny pill containing them can be inserted into the tip of the penis, causing erection.  Sometimes these cause irritation, and using them is too annoying for some people. Read about the pluses and minuses here.

Another option is the vacuum pump. It's a plastic tube with a pump attached. You put it over the penis and pump the air out. The resulting vacuum draws blood into the corpus cavernosum.  Once the penis is hard, there is an elastic band in the tube that you slide over the base of the penis to keep the blood from flowing back out. This seems to work for more than half the men who try it.

If you can get hard for a moment, but don't stay hard, you can use a "cock ring" like the one that comes with the vacuum pump. These rings are tight enough to keep blood from flowing out of the penis, but not so tight as to keep it from flowing in. They're safe to leave on for about 30 minutes.  It might be hot to let your partner put the ring on for you.

You can also go surgical with a penis prosthesis. It's two inflatable tubes that are surgically placed in the corpus cavernosum, connected to a reservoir of fluid. The reservoir is placed under the pelvic muscles. A squeeze pump is connected to the reservoir and sits under the loose skin of the scrotum, between the testicles. To inflate the prosthesis, the man presses on the pump. Most guys are very happy with this system. It's not noticeable to others or hard to use, although it will damage what is left of your natural erection response. 

But you are missing a great bet if you don't take the time to learn about non-intercourse sex.  You can learn to get a woman off with your hands, mouth, and/or toys, and it might be better than intercourse for her. Most men can also have great pleasure, including orgasms, without erections. Explore. You can write us to get some info on using your hands to please women.

And don't give up on the pills. Perhaps if you get tighter glucose control or just better general health, they might start working. Also, consider whether psychological issues (like anxiety, depression, or relationship problems) could be contributing to your erection problems. They often do. 

Veteran's Affairs
This impotence class thing is ridiculous. You should take this up with your primary MD or the clinic administrator.  If you do decide to attend, your burkha idea might help them see the error of their ways.  (If you wear one, please take a picture and send it to us.)

Don't forget to include your partner, if you have one, in discussions and decisions.  It might be hard to talk about, but honest talk always helps.  Online support is available for couples and individuals dealing with ED here or here.

Dear Sex and Diabetes,

I am an 18-year-old man who has had type1 diabetes for 15 years. Recently my new girl friend indicated that she wanted to have sex for the first time. However, I am afraid that I will be unable to, due to erection problems. Is it true that men who suffer with type 1 will need drugs such as Viagra?

Newbie in Virginia

Hi Newbie,

At 18, you probably won't have erection problems from diabetes, unless your sugar is poorly controlled.  You might have problems from nerves. If you're both inexperienced, here's one bit of advice.  Try it with her on top. Go slow. You'll like it. 

We got a letter from Sam, who wrote, "There have been times when keeping an erection up was very difficult. When I checked my blood sugar level, it was pretty low.  I could not continue with the sex until I got my sugars back up." 

So it is probably a good idea to check your sugar beforehand. It may drop a little during sex or afterward, as it might with any exercise.  You'll feel safer and stronger if your sugar is where it should be.  Thanks for the tip, Sam.


David Spero, RN, is a nurse who has lived for 30 years with multiple sclerosis.  A leading expert on self-care, he has written two books, Diabetes: Sugar-coated Crisis, and The Art of Getting Well. He has learned to maintain and even improve sex and love despite disability and illness. 

Aisha Kassahoun is trained in marriage and family therapy.

Aisha and David present sex and intimacy programs for people with diabetes, people with multiple sclerosis, and  health professionals.  

Visit David and Aisha online at or check out their coaching and counseling services. You can also read David's blog.

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Categories: Blood Sugar, Columns, Community, Diabetes, Diabetes, Love and Diabetes, Sexual Issues, Type 1 Issues, Type 2 Issues

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Posted by Anonymous on 11 June 2009

My husband also suffers from ED with Type 2 Diabetes. Just two days ago his doctor sent him for lab work to check his Free Testosterone Level. He indicated that a low testosterone level may also be the cause of his ED and that with testosterone therepy he may regain his erection.

I'm curious to know what you all think about this.

Thank you.

Posted by Anonymous on 12 June 2009

"You will learn to get a woman off with your hands..." What a pathetic unprofessional statement for someone who looks as old as you. I would not expect my 19 year old son who has type one to speak like that. Shame on Diabetes Health for allowing such nonsense jargon hit this cover. Your article will also probably unnecessarily scare a wide audience of young males unnecessarily. Did you have good control? Maybe your problem with your penis is not related to diabetes at all. Whatever.

Posted by cde on 12 June 2009

As mentioned, hypoglycemia, in the period before and/or during sexual activity, is definitely a "downer" for pleasures in which an erection comes in handy.

However, chronic HYPERglycemia is definitely a more difficult (and more common) to reverse reason for erectile dysfunction in men with DM. In some persons, long-term return to chronically normal or very near-normal blood glucose levels (71-99 mg/dL) can be effective in partially reversing at least part of the problem. Nerves grow notoriously slowly...but they do grow given the right physiological conditions.

About 50% of erectile dysfunction is due to physiological causes, and about 50% of erectile dysfunction is due to psychological causes.

Would be nice to know if there were a study that clarified whether erectile dysfunction in males with DM can be due to physiological causes (not including physical trauma, of course) other than the neurological damages done by chronic hyperglycemia.

Posted by Anonymous on 12 June 2009

I am a 57 year-old female with type 2 diabetes. My non-diabetic husband has had erectile dysfunction most of our married life (34 years)and medication to lower his blood pressure has worsened the problem. Cialis does help but he is too impatient to see to my needs. After he broke his leg(not sex-related activity), he moved out of our bedroom 18 months ago. You can guess how long it is since we had sex. He is not an affectionate man, so kisses and cuddles irritate him. Considering both our problems- my body's responses have changed because of the diabetes, medication, peripheral neuropathy- perhaps solving this is beyond me. Upset Vet is clearly a guy who takes responsibilty for his own problems and he appears to want to keep his partner happy too. Way to go, Vet!!!

Posted by David Spero RN on 12 June 2009

It's hard having to call everyone who posts here "anonymous," but here are some replies to these valuable posts.

First, the testosterone check is just the right thing to do. As we wrote in our first column, people with T2D tend to have low testosterone, and for those who do, sex becomes much less likely. So if your man's level is low, he should definitely be treated. It could help a lot!

I'm sorry one reader had big problems with the phrase "get a woman off with your hands." What's pathetic to us is our society's narrow view of sex, the belief that anything other than penis/vagina intercourse doesn't count as sex. Our apologies to any narrow-minded readers who are offended.

CDE is right that good glucose control is most important and often restores sexual function. As CDE said, this can take a long time for nerves to grow back. The general understanding, as described in Janis Roszler and Donna Rice's book Sex and Diabetes, is that DM can cause ED in men by circulatory or neurologic damage. Of course, there may also be also psychological issues involved Either way, good glucose control should help.

Posted by Anonymous on 12 June 2009

What I'd like to know is, what are FEMALE diabetics able to do about intimacy issues? I'm only 34, and should be in the prime of my sexual peak. The main problem I have noticed is I'll get aroused for about 15 minutes, and then it will fall flat. This happens periodically throughout the day. Any suggestions?

Posted by T23liz on 14 June 2009

You always hear anout ED for men, in papers, on the new, and alway sports programs. I am a 50 year old woman with type1 diabetes since age 12, who suffers from sexual dissatisfaction. To complicate it even more I also have Multiple Scerosis. What can I do?

Posted by David Spero RN on 14 June 2009

Hi Liz,
Please look at our last month's column on some sex issues for women. You have MS; David does too, so we are familiar with that. You can write us at for a personal reply.

Posted by Anonymous on 15 June 2009

Hi David,
I am one of your anonymous readers who had a problem with the phrase "get a woman off with your hands". Actually, you are now being prematurely judgemental as I indicated I had a problem with the phrase, not the content of the statement. I am not narrow minded and of course I would hope that most woman know that it does not just take a penis and sex to satisfy. Enough said. Actually, I have a question: After re-reading your post, you called yourself a "disabled veteran". Are you calling yourself disabled d/t type one diabetes? If so, shame on you a second time. Many of us, especially those with young children with diabetes, REFUSE to call it a disability despite it is deemed as such. If we did that, we would unnecessarily put a psychological crutch in our childrens mind. Instead, the word disability is replaced with inconvenience and challenge. If you consider your type one diabetes a disability, I pity you. I work in a rehab facility and each day, I get so see what young patient has become a paraplegic, or quadraplegic or has had a traumatic brain injury - or is now on a vent. These are disabilities; diabetes is not. Your bar is as high as you set it. I think you are a downer and I will NEVER share your article with my son. I agree with the reader that stated EDS is 50% due to psychological reasons. Perhaps this is your case.

Posted by Anonymous on 15 June 2009

Not agreeing with your phrase "getting a woman off with your hands" does not mean a reader is narrow minded. It simply means they seemed to have disagreed with your choice of words. It's slang and offensive.

Posted by Anonymous on 16 June 2009

The VA gives out lots of impotence pills. They even have a refill program where you call in your prescription and they dose it out. I think the allotment is in small doses as to stop people from reselling or using them all up and then running out. They will test your testosterone first.
Doctors or certain areas might have different criteria but the VA has no problem helping vets have an enjoyable life.
There might be other reasons why this vet was denied. could be health related. could be other reasons.
I do know they give out pills without having to go to a support group for ED. Maybe that was the doctors way of judging if the pill were really desired. I would have gladly volunteered to go the the meeting if I was truly interested in my partners well being.

Posted by Anonymous on 17 June 2009

To the (to me) very touchy, judgmental anonymous: I, too am a disabled vet with T2D and ED. 1) My disability is a very different matter than my diabetes. Your assumption that Vet's disability is not other than diabetes is (to me)very judgmental and offensive. 2) I have experienced many enjoyable, satisfying (for both) sexual encounters without an erection.
I find a mindset that advocates the denial of a free exchange of information that might be beneficial (or at least encouraging) for men with ED extremely offensive.

Posted by Anonymous on 17 June 2009

By definition, a "disabled veteran" is any veteran who has suffered an injury or illness resulting from their military service. It can range from PTSD to Traumatic Brain Injury. The criteria that the VA applies for each condition and the level of severity is codified in federal law.

I am sorry that you disagree with the terminology, however Diabetes Mellitus is a disabling condition, with ratings ranging from 0% to 100%. For many of us who do not enjoy the benefits of health insurance, this is an important matter as it allows us to see a physician for the treatment of our diabetes, in addition to little things like insulin, syringes, etc.

Posted by Anonymous on 21 June 2009

If the definition of a "dsiabled veteran" is any veteran who has suffered an injury or illness resulting from their military service, then this would mean that David the author of the article is not saying he is a disabled vet due to diabetes. Is this correct David?

There is a post that says IDDM "is" a disabling condition. I believe it is more accurate to state that IDDM "can be" a disabling condition.

No denying that IDDM absolutely sucks and no one deserves this. I watch my child deal with it everyday. But we should keep it real, call it what it is (my child knows its a "disease" and deemed a "disability") - but when we encourage, we do better. When we replace negative words with better jargon, it gives new light. It is what it is, but you can choose to live in the darkness of diabetes or challenge the heck out of it and beat it - or stay neck and neck with the darn condition. Give in to it be it with jargon or negativity and you let diabetes win. I wont let diabetes win.

Posted by Anonymous on 21 June 2009

To the vet who had ED and T2D - never meant to prevent free exchange of words. My father was a vet - a doctor in the army. Please remember that many young adults have T1D and I like to show my child the encouraging articles regardin althetes and their success stories. ED and slang jargon from an adult male who looks old enough to be my dad is just wrong. I agree with the reader who stated ED is partly psychological as is most things in life - but I find David leaving this part out and blaming diabetes for his ED. That is just sad and wrong information to pass onto young male adults. Plenty of men have ED and dont have diabetes. Lets keep it real.

Posted by mjensentulsa on 22 June 2009

Note to all the anonymouses -- you can log in and put in a pseudonym! It doesn't hurt.

I really enjoyed the reports from the woman who didn't want to send the article to her 19-year-old son. I wouldn't send a lot of good advice to my 21-year-old son, but I don't blame the author for my reluctance. Luckily, my son does a pretty good job reading on his own.

As for me, a 48-year-old Type 1, I find the candor of this column refreshing and well overdue. While it may be "unprofessional" (and tell me, how may professions have taken on the sexual dimension of living with a chronic disease that we might have a standard?), it should be remembered that in the area of intimacy, most of us remain amateurs. Speak to us in our own language! Publish, and conceal not!

My real question is, since the drugs that are doled out as $10 nightly cocktails (so to speak) were originally developed as (failed) heart pills, is there a possibility that we can get the dang things for their original intent without paying for the branding and commercial messaging? I mean, isn't there a generic form of Cialis, that our physician can prescribe with a normal Bic pen instead of one of those phancy pharma giveaway quills?

And can anyone explain to me the significance of the twin bathtubs in those Cialis commercials?

Posted by Anonymous on 24 June 2009

You have not answered the readers question if you consider yourself a disabled vet due to diabetes or due to some other condition. I think you have an obligation to respond to any questions that are generated by your original article. Please respond. I too am curious.

Posted by Anonymous on 24 June 2009

To mjensentulusa,

You consider telling your 21 year old son about ED "good advice"? Wow. My son is 14 and I agree with the mother of the 19 year old.

Also, not sure the anonymous writer who also has young son was blaming the author for her reluctance. What basis does she give you to form that judgemental opinion? Her reluctance seemed totally self owned and b/c she probably felt the information about ED does not need to be prematurely passed onto a young adult.

Remember - psychological thoughts can interfer whereas physical barriers may not have even been an issue until you decide to put that psychological thought/idea/information in a young person's mind.

Hopefully this will not be the case with your son.

Posted by tonyp3101 on 25 June 2009

As a diabetes educator at the VA, I've never heard of an "impotence class" so it surprises me that one exists. It's more offensive to me to assume that the VA is putting up barriers to care (as per David's comment). We spend 40+ hours a week doing nothing but caring for those who have sacrificed for our country, and the evidence shows our care is often better than the private sector for veterans/persons with diabetes! I find it refreshing that people have been so candid in their posts, but my question for the original subject would be "Can you talk freely with your Primary Care Provider?" If not, time for a Change of Provider form to be completed... If you can, TELL YOUR DOCTOR that the classroom setting is too embarrassing for you.

Posted by David Spero RN on 1 July 2009

The reason I haven't answered these questions about my disability and diabetes is that the questions don't make sense. The article wasn't about me; it's an answer to a reader, a veteran, who wrote in. I don't have diabetes; I have multiple sclerosis, but I'm a diabetes educator who has written a book and many articles about diabetes self-care and who, with Aisha, leads workshops on sex and intimacy in chronic illness.

For people who wrote in defending the VA; I'm a fan of the VA's care. But this particular practice was clearly putting up barriers to care. The writer received ED drugs easily, but when he asked about more complex approaches, he was told to take this "class."

As for getting ED drugs cheaply, it's easy on the Internet. You can get generic cialis for about $3.00 a dose.

Posted by Anonymous on 25 July 2009

I was the veteran who sent the original question to David. I'm old-fashioned, hence the anonymous post to protect the privacy of my family.

My objection to the class was the lack of sensitivity involved. It was bad enough to sit in a classroom with other veterans for such a discussion, but wives and even a couple of children attended. I had a couple of questions, but did I ask them? NOT ON YOUR LIFE.

I've been able to avoid the psychological issues that go with ED, until that point. I never went back to that Urology Clinic, and never will. I'll save my nickels and dimes until I can afford to buy a device on the internet. But even more troubling was when I told my primary care provider about it, SHE laughed.

National health care, anyone?

Posted by Anonymous on 4 August 2009

Hi I'm 18 and don't have any diabetes
but Ive had erectile problems twice lately. I'll get hard but not stay and I don't know why, I've never had this problem before.
Idk if it's me doing to much thinking or me being nervous
but I wanna know what you think
Plz help

Posted by David Spero RN on 11 August 2009

To the 18 y.o. without diabetes who has occasional problems staying hard: that happens. Yes, you are probably thinking too much, and perhaps you didn't really want to be there. If there is any reason to suspect a circulatory or neurological problem, do consult a urologist. But that sounds unlikely if everything else is OK.

Posted by Anonymous on 14 October 2014

my boyfriend has ed how can we get it to work? he has had a heart attic so pills are out can any one tell me is there any thing else we can do?

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