Sexual activity in diabetic patients treated by continuous

Diabetes & Metabolism 36 (2010) 229–233
Original article
Sexual activity in diabetic patients treated by continuous subcutaneous
insulin infusion therapy
J.-P. Riveline a,b,∗ , S. Franc a,b , M. Biedzinski a,b , F.-X. Jollois c , N. Messaoudi d , F. Lagarde e ,
B. Lormeau f , S. Pichard g , M. Varroud-Vial a,b , A. Deburge h , E. Dresco i , G. Charpentier a,b ,
for the Groupe Pompe Sud-Francilien
a
Service de diabétologie, centre hospitalier Sud-Francilien, 59, boulevard Henri-Dunant, 91100 Corbeil-Essonnes, France
b Centre pour l’étude et l’intensification du traitement du diabète (CERIT)
c CRIP5, université Paris-Descartes, 12, rue de l’École de médecine, 75006 Paris, France
d Service de diabétologie, hôpital de Dreux, 44, avenue Président-J.-Kennedy, 28100 Dreux, France
e Service de diabétologie, hôpital de Montargis, 658, rue des Bourgoins, BP 725, 45207 Montargis cedex, France
f Service de diabétologie, CHU Jean-Verdier, avenue du 14 juillet, 93143 Bondy cedex, France
g Service de diabétologie, centre hospitalier d’Étampes, BP 107, 91150 Étampes, France
h Service de diabétologie, hôpital de Forcilles, 77150 Férolles-Attilly, France
i Service de diabétologie, hôpital de Dourdan, 2, rue Potelet, 91410 Dourdan, France
Received 26 October 2009; received in revised form 31 December 2009; accepted 6 January 2010
Available online 19 March 2010
Abstract
Background and aims. – As concerns over interference with sexual activity may be an obstacle to initiating pump therapy in diabetic patients,
the aim of the study was to assess the impact of continuous subcutaneous insulin infusion (CSII) therapy on sexual activity.
Patients and methods. – Patients filled out a questionnaire on their demographic data, diabetes history, pump-treatment history, metabolic control,
inconvenience/convenience of the pump and catheter, and information on sexual activity.
Results. – A total of 271 diabetic patients (aged 44 ± 17 years, 51% women, 22% single), treated with CSII for 4.2 ± 5.9 years and with a diabetes
duration of 19 ± 11 years, filled out the questionnaire. Their HbA1c was 7.7 ± 1.1%, with 2.4 ± 2.1 mild hypoglycaemic episodes over the past
week, and their frequency of sexual activity was: never 29.9%; < 1/month 12.3%; > 1/month and < 1/week 18.2%; and > 1/week 39.6%. Age and
cohabitation were independently correlated with frequency of sexual activity (P < 0.0001 and P < 0.0003, respectively), but not diabetes duration
or complications. To the question “Does the pump have an influence on your sexual activity?”, The answer was “no” in 90% and “yes” in 10%.
However, intercourse frequency was significantly decreased in the latter (P = 0.04). On multivariate analyses, this negative influence of CSII was
correlated with HbA1c (P < 0.05), discomfort with the pump (P < 0.05) and the number of mild hypoglycaemic episodes (P < 0.01).
Conclusion. – Frequency of sexual activity appears to be unaffected by pump therapy or diabetes, but is decreased by the expected
characteristics–namely, age and being single. Also, only 10% of patients believe that CSII is an obstacle during sexual activity and, in particular,
because of the catheter.
© 2010 Elsevier Masson SAS. All rights reserved.
Keywords: Type 1 diabetes; CSII; HbA1c ; Sexuality; Intercourse frequency
Résumé
Activité sexuelle chez les patients diabétiques traités par pompe à insuline.
Objectifs. – L’objectif de cette étude était d’évaluer l’impact du traitement par pompe à insuline sur l’activité sexuelle.
Patients et méthodes. – Les patients ont rempli un questionnaire concernant leurs données démographiques, le contrôle métabolique, la fréquence
des relations sexuelles et l’influence de la pompe. La gêne de la pompe et du cathéter était évaluée par une échelle visuelle analogique.
∗
Corresponding author. Tel.: +00 33 1 60 90 30 85 ; fax: +00 33 1 60 90 31 57.
E-mail address: [email protected] (J.-P. Riveline).
1262-3636/$ – see front matter © 2010 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.diabet.2010.01.004
230
J.-P. Riveline et al. / Diabetes & Metabolism 36 (2010) 229–233
Résultats. – Deux cent soixante et onze patients diabétiques (51 % de femmes), âgés de 44 ± 17 ans, diabétiques depuis 19 ± 11 ans, traités par
pompe depuis 4,2 ± 5,9 ans, 22 % de célibataires ont répondu. L’HbA1c était de 7,7 ± 1,1 %, avec 2,4 ± 2,1 hypoglycémies légères au cours de la
semaine précédant la consultation. Les fréquences des rapports sexuels étaient : jamais 29,9 %, inférieur à un par mois 12,3 %, supérieure à un par
mois et inférieur à un par semaine : 18,2 %, supérieure à une fois par semaine : 39,6 %. La fréquence des activités sexuelles était corrélée avec l’âge
et le fait de vivre en couple (P < 0,0001 et 0,0003 respectivement), mais pas avec la durée du diabète ou les complications. À la question : « Est-ce
que la pompe a une influence sur votre activité sexuelle ? » La réponse était : non : 90 %, oui : 10 %. La fréquence des rapports était significativement
diminuée chez les 10 % de patients qui ont répondu « oui » (P = 0,04). En analyse multivariée, cette influence négative de la pompe était corrélée
avec l’HbA1c (P < 0,05), la gêne de la pompe (P < 0,05), le nombre d’épisodes d’hypoglycémie légère (P < 0,01).
Conclusion. – La fréquence des activités sexuelles ne semble pas être affectée par la pompe à insuline ou le diabète, mais est diminuée par des
variables « banales » telles l’âge et le célibat. Seulement 10 % des patients pensent que la pompe est un obstacle pendant l’activité sexuelle, en
particulier en raison du cathéter.
© 2010 Elsevier Masson SAS. Tous droits réservés.
Mots clés : Diabète de type 1 ; Pompe à insuline ; HbA1c ; Sexualité
The diabetes control and complications trial (DCCT) established that tight glucose control slowed the progression of the
long-term complications of type 1 diabetes mellitus [1]. Also,
continuous subcutaneous insulin infusion (CSII) therapy, using
fast-acting insulin analogues, appears to be the most efficient
means of achieving such glucose control [2–6]. However, only
a minority of type 1 diabetes patients is treated with CSII, especially in France [7], and the reason for this reluctance is not
economic, as full reimbursement has been in effect since November 2000. In fact, concerns over CSII interference with sexual
activity may be an obstacle to initiating pump therapy in type 1
diabetics, as patients have to carry the pump at all times. Patients
could be refusing CSII because of the fear that it might interfere
with their sex lives and, especially, intercourse frequency. For
this reason, the aim of the present study was to retrospectively
evaluate the influence of CSII on sexual activity, as reported by
diabetic patients who have accepted this form of treatment.
During the consultation visit, patients filled in a questionnaire
concerning the inconvenience/convenience of the CSII pump
and catheter, using three visual analogue scales (VAS) to measure the burden represented by the catheter (“I am very bothered
by my catheter”/“I am not bothered at all by my catheter”),
their acceptance of the pump (“I don’t tolerate my pump at
all”/“I tolerate my pump perfectly well”) and satisfaction with
the metabolic results achieved by CSII (“I’m not satisfied at all
with the result of my pump”/“I am perfectly satisfied with the
result of my pump”).
The relationship between CSII and sexual activity was evaluated both quantitatively (“How often do you have sexual
intercourse? Never/< 1 per month/> 1 per month and < 1 per
week/> 1 per week”) and qualitatively (“Does the pump have
a negative influence on your sexual activity? Yes/no”). The
connection/disconnection of the catheter was also evaluated
(“Do you disconnect the catheter during sexual intercourse?
Never/rarely/sometimes/always”). The data-filled forms were
then sent to the study centre and entered into a database.
2. Patients and methods
2.1. Statistical analysis
All of the patients included in the present study were on a
“pump” registry containing data on all diabetic patients treated
with CSII by the 40 diabetologists practising in 15 hospitals
or office practices in the Sud-Francilienne region of France
(immediately south of Paris). For 6 months, physicians filled
out questionnaires for every patient being treated by CSII. The
methodology and metabolic results of this registry have been
published elsewhere [8]. Briefly, the questionnaire was designed
to obtain the following data: age, gender, years of formal education and occupational status; type, duration and complications
of diabetes; type of pump, insulin doses, basal insulin rate and
infusion-set tolerance; and glucose control data–specifically,
HbA1c , mean number of moderate hypoglycaemic episodes
(defined as hypoglycaemia correctable by self-administration
of oral sugar) during the last week recorded by patients in their
“glycaemic diary” or directly reported by them, average number
of severe hypoglycaemic episodes (defined as a hypoglycaemic
episode that required the help of another person to correct), number of ketotic episodes reported by the patient and number of
ketoacidosis episodes.
For the statistical tests, SAS software version 9.1 (SAS Institute, Cary, NC, USA) was used. Descriptive statistics were
computed as mean ± SD, and percentages were determined
using the number of responses as the denominator. To test
the relationship between the three sexual-activity factors and
the other variables included in the questionnaire, analysis of
variance (ANOVA) was used for quantitative variables and the
chi-square test for qualitative variables. Logistic regression was
used for the overall assessment of the link between sexual factors and the variables correlated with these factors. For all tests,
P values less than 0.05 were considered significant.
1. Introduction
3. Results
Altogether, 271 diabetic patients treated with CSII agreed
to fill in the questionnaire, and their clinical characteristics are summarized in Table 1. Their demographic
characteristics were: mean age 44 ± 17 years; 51% women;
22% single; and diabetes duration 19 ± 11 years. Their diabetic
complications included retinopathy (45%), nephropathy (18%),
J.-P. Riveline et al. / Diabetes & Metabolism 36 (2010) 229–233
Table 1
Clinical characteristics of patients treated with continuous subcutaneous insulin
infusion therapy.
Centres participating in the study
Patients (male/female)
Age (years)
Single status
Diabetes duration (years)
Pump-therapy duration (years)
HbA1c (%)
Mild hypoglycaemic events during the past week
Severe hypoglycaemic events during the past year
Ketoacidosis during the past year
15
271 (134/137)
43 ± 16
21%
19 ± 11
4.2 ± 5.9
7.7 ± 1.1
2.4 ± 2.1
0.2 ± 0.6
0.03 ± 0.2
Data are expressed as means ± SD.
neuropathy (32%) and macroangiopathy (10%). Pump indications were: poor metabolic control (HbA1c > 8%) 42%;
glycaemic instability (recurrent hypoglycaemic episodes and/or
severe hypoglycaemia) 34%; pregnancy 13%; injection intolerance 6%; lifestyle 2%; and insulin resistance 3%. The studied
patients had been treated by CSII for 4.2 ± 5.9 years. HbA1c
was 7.7 ± 1.1%, with 2.4 ± 2.1 mild hypoglycaemic episodes
within the week prior to the visit, and 0.2 ± 0.6 severe hypoglycaemic episodes and 0.03 ± 0.2 ketoacidosis episodes during
the past year; the average number of blood glucose determinations was 4.2 ± 2.0/day. The mean duration of use per
infusion set was 3.1 ± 0.8 days, and the infusion set was disconnected by 241 (88.9%) patients for 37 ± 8 min/day. The reasons
for disconnection were: washing 84%; sports 15%; and sexual
intercourse 68%. Only 11.1% of patients reported never disconnecting their infusion set. The duration of disconnection did
not correlate with either HbA1c , ketosis or ketoacidosis. Over
the previous 6 months, infusion-set tolerance was considered
good in 80.2% of patients, and most of the infusion-set-related
adverse events were minor, comprising: irritation 9.0%; transient inflammation 6.0%; allergy to bandages 4.2%; and abscess
231
Table 2
Predictive factors for frequency of sexual intercourse by multivariate analysis.
Age ↑
Being single
Duration of CSII
Satisfaction with CSII outcome
Acceptance of CSII
Bothered/not bothered by catheter
↓ Intercourse frequency
↓ Intercourse frequency
P < 0.0001
P = 0.0003
NS
NS
NS
NS
CSII: continuous subcutaneous insulin infusion; NS: not significant.
requiring medical treatment 2.4%. No abscesses requiring surgical drainage occurred, and none of the local adverse events was
influenced by either the type of infusion set or the frequency of
infusion-set changes.
3.1. Visual analogue scale scores for discomfort,
acceptability and satisfaction
Relatively few patients felt embarrassed by their pump: the
VAS for “I don’t tolerate my pump at all” (= 0 cm)/“I tolerate my
pump perfectly well” (= 10 cm) was 8.5 ± 1.9 cm. The catheter
was also relatively well tolerated, with a VAS for “I am very
bothered with my catheter” (= 0)/“I am not bothered at all by my
catheter” (= 10) of 7.9 ± 2.2 cm. Patient satisfaction was high,
with a VAS score for “I’m not satisfied at all with the result of
my pump” (= 0)/“I am perfectly satisfied with the result of my
pump” (= 10) of 8.2 ± 2.0 cm.
3.2. Impact of continuous subcutaneous insulin infusion on
sexual activity
3.2.1. Quantitative aspects
To the question “How often do you have sexual intercourse?”,
The answer was: never 29.9%; < 1/month 12.3%; > 1/month and
< 1/week 18.2%; and > 1/week 39.6%. On univariate analyses,
Table 3
Clinical characteristics of those who answered either “yes” or “no” to the question “Does the pump has an influence on your sexual activity?”.
Patients (n = 271)
Patients’ gender (male/female)
Age (years)
Single status
Diabetes duration (years)
Pump-therapy duration (years)
HbA1c (%)
Mild hypoglycaemic episodes
during the past week
Severe hypoglycaemic episodes
during the past year
Intercourse frequencya (n)
Never
< 1/month
> 1/month and < 1/week
> 1/week
Yes
No
No answer
P (yes vs no)
P (yes vs no
answer)
27 (10 %)
11/16 (40 %/60 %)
48 ± 16
8 (30 %)
21 ± 12
4±5
7.77 ± 1.20
3.2 ± 2.9
195 (72 %)
97/98 (50 %/50 %)
43 ± 15
37 (19 %)
19 ± 11
3±3
7.62 ± 1.08
2.4 ± 2.1
49 (18 %)
26/23 (53 %/47 %)
43 ± 21
16 (34 %)
23 ± 13
4±5
8.02 ± 1.16
2.0 ± 1.8
NS
NS
NS
NS
NS
NS
0.058
NS
NS
NS
NS
NS
NS
0.04
0.5 ± 1.0
0.2 ± 0.6
0
NS
0.002
6
8
6
7
29
28
45
93
49
0
0
0
Of 84 patients who reported no sexual activity, 35 answered, 6 (17%) by “yes”; of 100 patients who reported greater than one sexual intercourse/week, only seven
patients (7%) answered “yes”; data are expressed as means ± SD; NS: not significant.
a Lower intercourse frequency if answer was “yes” (P = 0.04).
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J.-P. Riveline et al. / Diabetes & Metabolism 36 (2010) 229–233
Table 4
Predictive factors by multivariate analysis of the answers to the question “Does
the pump has an influence on your sexual activity?”.
Bothered with catheter
Mild hypoglycaemic episodes
Diabetes duration
HbA1c
↑ with “yes”
↑ with “yes”
↑ with “yes”
↑ with “yes”
P = 0.01
P = 0.01
P = 0.02
P = 0.04
intercourse frequency decreased with age (P < 0.0001), living
alone (P < 0.01), higher HbA1c (P < 0.05), and the presence
of complications such as nephropathy (P < 0.05), neuropathy
(P < 0.05) and macroangiopathy (P < 0.01). Intercourse frequency did not correlate with the VAS for “dislike/like” of the
pump or catheter. Multivariate analyses demonstrated that only
age and cohabitation were independently correlated with sexualactivity frequency (P < 0.0001 and P < 0.0003, respectively), and
not diabetes duration or complications (Table 2).
3.2.2. Qualitative aspects
To the question “Does the pump have an influence on
your sexual activity?”, The answer was: no 72%; yes 10%; no
answer 18% (n = 49). Those patients who answered “yes” had
a significant decrease in their self-declared frequency of sexual intercourse (P < 0.05; Table 3;). Yet, there were no clinical
differences between these patients and the others in terms of
complications, except for mild hypoglycaemic-event frequency,
which was slightly greater (3.2 ± 2.9 vs 2.4 ± 2.1, respectively;
P = 0.058; Table 3). All of the patients who did not answer
this question had no sexual activity (Table 3). On multivariate analyses, the negative impact of the pump on the patient’s
sex life, indicated by the answer “yes”, was independently
associated with discomfort with the catheter (P < 0.05), higher
HbA1c (P < 0.05) and more frequent mild hypoglycaemic events
(P < 0.01; Table 4).
3.2.3. Disconnection
To the question “Do you disconnect the catheter during
sexual activity?”, The answer was: never 22%; rarely 12%;
sometimes 18%; and always 48%. On multivariate analyses,
catheter disconnection during sexual intercourse was independently associated with male gender (P < 0.05), younger age
(P < 0.05), higher HbA1c (P < 0.05) and catheter discomfort
(P < 0.05; Table 5). Disconnection was less frequent in patients
with longer pump-therapy durations (P < 0.01).
Table 5
Predictive factors by multivariate analysis of the answers to the question “Do
you disconnect the catheter during sexual activity?”.
Age
Gender ratio
Bothered by catheter
HbA1c
Pump-therapy duration
Disconnection ↑ in young vs older
Disconnection ↑ in men vs women
Disconnection ↑
Disconnection ↑ when HbA1c
increases
Disconnection ↓ when pump-therapy
duration increases
P = 0.01
P = 0.0029
P = 0.01
P = 0.03
P < 0.05
4. Discussion
The aim of the present study was to evaluate the influence of
CSII on self-declared sexual activity. To answer this question,
we used a “pump” registry that had data for 271 adult diabetic
patients treated with CSII in the Sud-Francilienne region of
France. For 6 months during these patients’ visits, physicians
filled in a questionnaire on their clinical data. The patients were
also asked to answer questions on the impact of CSII on their
sex lives. Most patients (90%) felt that CSII had no impact on
their sexual activity. Data on CSII (duration of CSII, burden represented by the catheter and difficulty in accepting the device)
did not correlate with intercourse frequency. On multivariate
analyses, only the usual demographic data–single status and
age–influenced intercourse frequency, as is observed in France
in general [9]. Indeed, a survey of sexual activity in the general
French population showed that, while 10% of those living with
a partner reported having no sexual intercourse (vs 26% in our
registry), the rate was 34% for people living alone (vs 45% in the
present study population). Furthermore, in the general population as in our diabetic population treated with CSII, the frequency
of sexual intercourse decreased with age [9]. A small percentage
of our diabetic patients–10%–believed that CSII had a negative
impact on their sexual activity. Interestingly, these patients had
no clinical differences in comparison to the others except for
metabolic control, which was impaired (higher HbA1c and a
greater frequency of mild hypoglycaemic episodes; Table 3),
and, as expected, a lower frequency of sexual intercourse. As
to why these patients had greater CSII discomfort during their
sexual activity, the answer was often because of the catheter.
However, 18% of patients did not answer the question; the reason for this was that all of these patients reported no sexual
activity at all (Table 3). The majority of patients who admitted
to disconnecting the catheter during intercourse were particularly men, young people and those who felt embarrassed by the
catheter. However, the longer their duration of CSII therapy,
the more the patients kept their catheter connected during intercourse. This finding suggests that, over time, patients tolerate the
device better and/or prefer to avoid the potential disadvantages
of transient pump/catheter removal, despite the easy and temporary comfort of disconnection. Nevertheless, disconnection
did not either worsen metabolic control or increase ketoacidosis
frequency (data not shown).
The quality of life (QOL) in type 1 diabetes patients treated
with CSII has been evaluated in the literature, but the results
are mixed [10]. There is no strong evidence to support QOL
benefits associated with CSII or otherwise, although the issue
is clouded by poor methodology and inconsistent assessment of
QOL in many trials. Most of the studies reported a problem of
“inconvenience” with CSII, but gave no precise details [11–13].
A more recent case-control study demonstrated better QOL in
CSII patients, compared with either a glargine- or NPH-based
injected regimen, because of greater lifestyle flexibility, less fear
of hypoglycaemia and greater treatment satisfaction [14]. However, we could find no data on patients’ sex lives, which could be
an important factor for refusing CSII. The factors related to discontinuing CSII have been studied elsewhere [15,16]. For 27%
J.-P. Riveline et al. / Diabetes & Metabolism 36 (2010) 229–233
of patients, the reason given was “inconvenience” and “discomfort”. Being single was also a predictor of prematurely stopping
CSII, suggesting that sexual activity could, indeed, be a cause.
Nevertheless, the results of the present study suggest that CSII
does not interfere with sexual activity except in 10% of patients.
This subgroup of patients feels particularly embarrassed by the
catheter and, in some cases, it will lead to a decrease in their
frequency of sexual intercourse. Yet, this disadvantage appears
to diminish over time.
In conclusion, the present study demonstrates that CSII has
no impact on sexual activity in the vast majority of patients, with
only 10% of patients having their sexual activity disrupted by
the pump and that mainly because of the catheter. Indeed, this
indicates that new devices such as the “patch-pump”, which uses
no catheter [17], needs to become available as soon as possible
to improve the QOL of diabetic patients in general and that of the
adversely affected minority of patients in particular. Indeed, all
diabetic patients are likely to prefer such pumps. Nevertheless,
even now, it is at least possible to prove to candidates for CSII
that, for the vast majority of patients, the device is not an obstacle
to sexual activity.
Conflict of interest
I have received fees from Medtronic and Roche.
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
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