Breaking the silence: sexual dysfunction in diabetes

The world over, sexual health in diabetes is a topic that is often overlooked and not given the attention it deserves. Conversations about sexual function and dysfunction are extremely rare because they are considered “taboo” or “too private” for public platforms or even clinical and social settings. This is particularly true for conservative cultures like many found in Zimbabwe. 

The topic is the elephant in the room that nobody wants to talk about or even acknowledge. This article summarises some of the insights from a discussion that I had on this topic with members of my diabetes community in Zimbabwe, including recommendations to improve dialogue on this issue which affects the well-being of people with diabetes and their relationships.

Diabetes and sexual health: physical, psychological and medical factors

Diabetes affects sexual health in both men and women and in all its types. This is mainly because persistent high blood sugar levels contribute both to the development of atherosclerosis (build-up of plaque in the arterial walls), which restricts blood flow, and diabetic neuropathy which reduces nerve stimulation, both of which compromise genital sensitivity. 

After attending sessions examining the connection between sexual health and diabetes at the 60th European Association for the Study of Diabetes (EASD) annual meeting in Madrid in September 2024, I decided to bring the issues to the context of my diabetes community in Zimbabwe. Participants found the discussion interesting and informative, and a refreshing departure from the normal silence on it. 

The session at EASD entitled “When sex is ex: for her or him” identified the causes of sexual problems in people with diabetes as falling under three dimensions: physical, psychological and medical. Results from studies carried out on the topic revealed that the severity of this condition and resistance to treatment is more pronounced in people with diabetes compared to the general population. Recommendations for improved sexual performance included physical activity (particularly exercises), improved metabolic control (weight management, lower HbA1C, improved blood sugar, blood pressure and cholesterol levels), adequate sleep, sticking to the recommended healthy diet and bariatric surgery. 

Research on sexual dysfunction in diabetes was presented at EASD 2024. Source: Heather Koga

The presentations confirmed that it is important for doctors to talk to their patients about this sensitive topic. It was noted that in most cases, patients are often willing to have this conversation but only when the doctor initiates it, and usually with a health practitioner with whom they are already familiar. 

Impact of diabetes and sexual health on relationships 

The discussion with community group members revealed that for some of them, sexual performance is indeed affected by the physical, psychological, and medical states of people with diabetes. One participant stated: “During my first encounter with my girlfriend I could not do anything at all, and I had to explain my condition of which she understood and encouraged me to adhere to a healthy lifestyle.”

There was also consensus that sexual problems contribute to the destruction of many intimate relationships including marriages, despite the unwillingness to talk about them and to seek help. As one of the participants observed: “Marriages are being shaken…some destroyed because of this.”

For some of the participants in the discussion, being overweight has contributed to sexual problems in their relationships. Some noted that the use of insulin for diabetes management has resulted in weight gain which has negatively affected their sexual function. It is, however, important to note that this is not true for everyone who takes insulin for their diabetes management. Weight loss can be achieved by sticking to the recommended diet and employing effective exercise strategies. One participant observed that her sexual problems were resolved when she successfully lost some body weight. In addition to improved sexual performance, she observed that losing weight made her feel “lighter” and more confident of herself and secure in her relationship. 

Participants also felt that diabetes management comes with some psychological aspects that can contribute to a decline in sexual performance. One participant reported that insulin injection marks on her body make her feel very unattractive and less desirable, which affects the mood for intimacy. Other community group members responded to this by saying that they make use of creams to lighten the marks on their bodies to boost their confidence in themselves. 

Diabetes distress also leads to fatigue that dampens sexual performance, as people with diabetes often have too many thoughts on their minds which leaves them exhausted at the end of the day. A participant pointed out that for most people with diabetes, their minds are preoccupied with thoughts about “the pain that is brought about by injections, the stigma and discrimination we face, preparing for the next meal, doctors’ reviews, working to get money to purchase drugs and so on”. All this contributes to exhaustion which leaves little or no energy for intimacy with their partners.

Side-effects of diabetes medications are also blamed for a reduction in sexual performance and participants bemoaned that health practitioners never open up about this and people with diabetes have to learn about it as they go on with their diabetes management.

Culture of silence: the impact of taboo on PWD 

Societal and cultural dynamics were also blamed for discouraging people to speak up on the subject which ultimately prevents the seeking of solutions to the problem. The belief that sexual performance can be a result of being bewitched — “kusungwa” (being tied) — still persists in many countries and this prevents a lot of people from seeking medical help and advice. Societal norms discourage conversation on this topic, as couples are counselled during premarital and relationship counselling that they must not ‘wash their dirty linen in public’ by discussing sensitive subjects outside the home and especially with third parties. This has, however, resulted in many relationships and marriages suffering because of lack of resolution to sexual issues that they face.

The discussion also revealed that silence on diabetes and sex has culminated in the mushrooming of sex enhancer vending, especially on the social media. As people with diabetes, their support groups and healthcare practitioners maintain the silence, vendors of ‘sex enhancing’ products capitalise on this problem to make business. This highlights a gap in healthcare communication that needs to be addressed urgently. These drugs and treatments that claim a boost in sex drive and performance usually come without any medical prescription or supervision. This lack of regulation potentially exposes consumers of these products to hidden substances and ingredients that may pose a significant danger to their health. Health professionals must also engage with the community more directly on platforms where these products are being sold, in order to counter the misinformation of the marketers. 

Participants complained about healthcare practitioners who are not willing to engage with them on the subject of sexual health during consultations.  One of them remarked: “My experience is that not all doctors we visit are well versed with such… They don’t listen fully to their patients…which is not helpful, and it becomes very discouraging to continue seeking medical assistance.” 

Participants recommended that healthcare practitioners change their attitudes and perceptions on the issue. Interventions on this should include healthcare training programmes on sexual health for people with diabetes. People with diabetes must also be willing to bring up this topic during consultations to reduce the taboo from the patient side as well.

Going forward: a clear need to improve communication around diabetes and sexual health

The discussions with community group members concluded that there is need to improve communication and open up on the subject between couples, in families, diabetes communities and with healthcare practitioners. Medical specialists on reproductive issues like urologists and gynaecologists, as well as endocrinologists and mental health experts, are best placed to identify and treat issues and conditions contributing to sexual dysfunction. Religious leaders, counsellors and other social influencers also have a part to play on this subject. Relaxation and meditation sessions were also recommended to improve well-being.

The need for adherence to a recommended diet and a regime of physical exercises was emphasised by discussion participants. Eating a healthy diet will enable better management of blood glucose, leading to the body functioning at its best, including in sexual matters. Regular physical exercise, including simple activities like walks to the market, are also recommended for optimal health benefits for people with diabetes.  

It is very important that conversations on sexual and reproductive health and rights be normalised within our communities, in both clinical and social settings. Only then will we be able to seek help and manage to resolve the issues. Open communication, psychological safety and person-centred care are all crucial for effective diabetes management and in dealing with all complications including those related to sexual health. By tackling sexual and reproductive health matters in diabetes openly, people living with this condition can improve both their physical and emotional well-being. It is important for people with diabetes not to suffer in silence, but to always seek help when needed.

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