The AWDISP Survey (Asking women with diabetes about sexual problems)

Information about diabetes and women’s sexual problems and why the study is needed

Women with diabetes are at high risk of untreated female sexual dysfunction (Winkley et al, 2021). Sexual health is considered an essential domain in good health (World Health Organization, 2010) and female sexual dysfunction involves experiencing distressing sexual symptoms, for over 6 months (American Psychiatric Association, 2013)

Research suggests many women experiencing symptoms of sexual problems and dysfunction, are not receiving professional help (Nusbaum et al, 2002) and barriers may include not being sure who to speak to, embarrassment and belief that sexual difficulties are to be expected as part of normal life and ageing (Bauer et al, 2016).

Women may prefer a physician to initiate discussions about sexual problems (Metz et al, 1988).

Healthcare professionals also experience their own difficulties and concerns asking about symptoms of female sexual dysfunction (Dyer et al, 2013)

Professionals have spoken of fears about the consequences of “opening a can of worms” by asking about sexual problems (Gott et al, 2004). Barriers mentioned by professionals included personal embarrassment, fear of causing offence, lack of training/ competence and lack of time, and professionals may “buy in” to the asexual discourse of aging (Gott et al, 2004)

Another barrier to professionals asking women about sexual problems is “insecurity that the answer will be affirmative” (Buster, 2013), and an assumption that a positive answer will reveal a problem which is in any case “difficult or even impossible to treat”. Studies state diagnosis and management of female sexual dysfunction is complex (Jackson et al, 2004).

We do not have clear data on the needs and attitudes of UK healthcare professional population, nor do we have nuanced data on practice and attitudes, by demographic category and job role.

Given that attitudes on sex are linked to social and cultural discourse, gaps are apparent in areas such as professionals’ beliefs about women’s sexuality and aging, professionals’ beliefs about expectations of patient offence and how women would like to be consulted, and professionals’ personal comfort/ embarrassment in asking about sexual problems

We will also ask professionals about their opinion of a short, self-administered screening tool for patients, the Female Sexual Function Index-6 (Isidori et al 2010), which may be helpful within consultations (Maiorino et al, 2020).

Resources for professionals

References to some research and publications relevant to our survey:

• American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition; Washington, DC.
• Bauer, M., Haesler, E. and Fetherstonhaugh, D., 2016. Let's talk about sex: older people's views on the recognition of sexuality and sexual health in the health‐care setting. Health Expectations, 19(6), pp.1237-1250.
• Buster, J.E., 2013. Managing female sexual dysfunction. Fertility and sterility, 100(4), pp.905-915.
• Dyer, K. and das Nair, R., 2013. Why don't healthcare professionals talk about sex? A systematic review of recent qualitative studies conducted in the United Kingdom. The journal of sexual medicine, 10(11), pp.2658-2670.
• Esposito, K., Ciotola, M., Marfella, R., Tommaso, D.D., Cobellis, L. and Giugliano, D., 2005. Sexual dysfunction in women with the metabolic syndrome. Diabetes care, 28(3), pp.756-756.
• Esposito, K., Ciotola, M., Giugliano, F., Bisogni, C., Schisano, B., Autorino, R., Cobellis, L., De Sio, M., Colacurci, N. and Giugliano, D., 2007. Association of body weight with sexual function in women. International journal of impotence research, 19(4), pp.353-357.
• Gott, M., Galena, E., Hinchliff, S. and Elford, H., 2004. “Opening a can of worms”: GP and practice nurse barriers to talking about sexual health in primary care. Family practice, 21(5), pp.528-536.
• Gott, M., Hinchliff, S. and Galena, E., 2004. General practitioner attitudes to discussing sexual health issues with older people. Social science & medicine, 58(11), pp.2093-2103.
• Isidori, A.M., Pozza, C., Esposito, K., Giugliano, D., Morano, S., Vignozzi, L., Corona, G., Lenzi, A. and Jannini, E.A., 2010. Outcomes assessment: Development and validation of a 6-item version of the Female Sexual Function Index (FSFI) as a diagnostic tool for female sexual dysfunction. The journal of sexual medicine, 7(3), pp.1139-1146.
• Jackson, G., 2004. Sexual dysfunction and diabetes. International journal of clinical practice, 58(4), pp.358-362.
• Maiorino, M.I., Bellastella, G. and Esposito, K., 2020. Diabetes and sexual disorders. Diabetes Complications, Comorbidities and Related Disorders, pp.473-494.
• Metz, M.E. and Seifert, M.H., 1988. Women's expectations of physicians in sexual health concerns. Family Practice Research Journal.
• Mitchell, K.R., Lewis, R., O'Sullivan, L.F. and Fortenberry, J.D., 2021. What is sexual wellbeing and why does it matter for public health?. The Lancet Public Health, 6(8), pp.e608-e613.
• Neijenhuijs, K.I., Hooghiemstra, N., Holtmaat, K., Aaronson, N.K., Groenvold, M., Holzner, B., Terwee, C.B., Cuijpers, P. and Verdonck-de Leeuw, I.M., 2019. The Female Sexual Function Index (FSFI)—a systematic review of measurement properties. The journal of sexual medicine, 16(5), pp.640-660.
• Nusbaum, M.R., Gamble, G.R. and Pathman, D.E., 2002. Seeking medical help for sexual concerns: frequency, barriers, and missed opportunities. Journal of Family Practice, 51(8), pp.706-708
• Sarkadi, A. and Rosenqvist, U., 2001. Contradictions in the medical encounter: female sexual dysfunction in primary care contacts. Family Practice, 18(2), pp.161-166.
• Winkley, K., Kristensen, C. and Fosbury, J., 2021. Sexual health and function in women with diabetes. Diabetic Medicine, 38(11), p.e14644.
• World Health Organization, 2010. Developing sexual health programmes: A framework for action (No. WHO/RHR/HRP/10.22). World Health Organization.
• Zeleke, B.M., Bell, R.J., Billah, B. and Davis, S.R., 2017. Hypoactive sexual desire dysfunction in community-dwelling older women. Menopause, 24(4), pp.391-399.

Information for professionals on some different screening tools for female sexual dysfunction and links to the tools

Female Sexual Function Index 

This is a brief, self-reported questionnaire for female sexual dysfunction, available in different languages. It involves answering 19 questions. It has been validated in a number of different locations and with different patient populations.

Here is some research about it:

• Meyer-Bahlburg, H.F. and Dolezal, C., 2007. The Female Sexual Function Index: A methodological critique and suggestions for improvement. Journal of sex & marital therapy, 33(3), pp.217-224.
• Neijenhuijs, K.I., Hooghiemstra, N., Holtmaat, K., Aaronson, N.K., Groenvold, M., Holzner, B., Terwee, C.B., Cuijpers, P. and Verdonck-de Leeuw, I.M., 2019. The Female Sexual Function Index (FSFI)—a systematic review of measurement properties. The journal of sexual medicine, 16(5), pp.640-660.
• Rosen, C. Brown, J. Heiman, S. Leiblum, C. Meston, R. Shabsigh, D. Ferguson, R. D'Agostino, R., 2000. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. Journal of sex & marital therapy, 26(2), pp.191-208.
• Wiegel, M., Meston, C. and Rosen, R., 2005. The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores. Journal of sex & marital therapy, 31(1), pp.1-20.

Briefer versions of FSFI involving asking fewer questions have also been validated and used in different settings.

The FSFI-6 ask 6 questions from FSFI- 19 (questions 2,4,7,11,16 and 17)

Here is some research about it in different settings (non-exhaustive list):

• Isidori, A.M., Pozza, C., Esposito, K., Giugliano, D., Morano, S., Vignozzi, L., Corona, G., Lenzi, A. and Jannini, E.A., 2010. Outcomes assessment: Development and validation of a 6-item version of the Female Sexual Function Index (FSFI) as a diagnostic tool for female sexual dysfunction. The journal of sexual medicine, 7(3), pp.1139-1146.
• Chedraui, P., Pérez-López, F.R., Sánchez, H., Aguirre, W., Martínez, N., Miranda, O., Plaza, M.S., Schwager, G., Narváez, J., Quintero, J.C. and Zambrano, B., 2012. Assessment of sexual function of mid-aged Ecuadorian women with the 6-item Female Sexual Function Index. Maturitas, 71(4), pp.407-412.

FSFI questionnaire 2000 (PDF) FSFI 6 questionnaire (PDF)

Arizona Sexual Experiences Scale (ASEX)

This is a five-question self-completed patient survey. Questions include sex drive, arousal, vaginal lubrication, ability to reach orgasm, and satisfaction from orgasm.

Here is some additional research about it (non-exhaustive list):

• McGahuey, Alan J. Gelenberg, Cindi A. Laukes, Francisco A. Moreno, Pedro L. Delgado, Kathy M. McKnight, Rachel Manber, C., 2000. The Arizona sexual experience scale (ASEX): reliability and validity. Journal of Sex &Marital Therapy, 26(1), pp.25-40.
• Sánchez Fuentes, M., Moyano, N., Granados, R. and Sierra Freire, J.C., 2019. Validation of the Spanish version of the Arizona Sexual Experience Scale (ASEX) using self-reported and psychophysiological measures.

Sexual Satisfaction Questionnaire

This is a 10-question self-completed patient survey, with a focus on quality of sexual life.

There is a link to it in the article below

Nomejko, A. and Dolińska-Zygmunt, G., 2014. The sexual satisfaction questionnaire–psychometric properties. Polish Journal of Applied Psychology, 12(3), pp.105-112.

Here are some other research articles about its use in different settings (non-exhaustive list)

Sánchez-Fuentes, M.D.M., Santos-Iglesias, P., Byers, E.S. and Sierra, J.C., 2015. Validation of the interpersonal exchange model of sexual satisfaction questionnaire in a Spanish sample. The Journal of Sex Research, 52(9), pp.1028-1041.

Bahrami, N., Yaghoob Zadeh, A., Sharif Nia, H., Soliemani, M.A. and Haghdoost, A.A., 2016. Validity and reliability of the persian version of Larson sexual satisfaction questionnaire in couples. Journal of Kerman University of Medical Sciences, 23(3), pp.344-356.

Links for professionals to patient information about Female Sexual Dysfunction, Sexual Problems for women, and sexual problems for women with diabetes (non-exhaustive list, accessed 18/7/22))

• Diabetes UK: Diabetes and sexual problems - in women
• Healthline: Type 2 diabetes and sexual health
• NHS: Guide to sexual health services
• Institute of Psychosexual Medicine: Common problems
• Patient: Female sexual dysfunction.