Diabetes

Diabetes Mellitus is a serious, common medical condition that causes higher than normal blood sugar levels because the body cannot make or effectively metabolize insulin, a hormone made in the pancreas (Diabetes Research Institute Foundation: https://www.diabetesresearch.org/what-is-diabetes). Type I and type II diabetes are the most common forms of the disease, but there are also other kinds, such as gestational diabetes. Approximately 5-10% of people with diabetes have type I and approximately 90-95% of Diabetics have type II according to the Centers for Disease Control and Prevention. In type I diabetes, insulin is not produced. In type II, the body does not respond to insulin and later in the disease often does not make enough insulin. Both types of diabetes can lead to chronically high blood sugar levels that increase the risk of other medical complications such as damage to the nerves and small blood vessels of the eyes, kidneys, and heart and lead to atherosclerosis, or hardening of the arteries that can cause heart attack and stroke.

Diabetes will commonly have an impact on sexual functioning in men and women, affecting desire, arousal, and orgasm. Erectile Disorder is sometimes the first symptom of diabetes in men. Between 35 and 75% of men with type I diabetes will experience sexual dysfunction (Tams 2014). Female sexual dysfunction has been observed in approximately 40% of women with type I diabetes (Both et al., 2015; Hotaling et al., 2016). The most common form of diabetes, however, type II, can also have an impact on sexual health. This disease is also associated with clinical depression which can be a risk factor causing and resulting from sexual problems and other debilitating body changes (Onalan, Gokalp, Mehmet, Burkay & Dbnder 2019). The therapist will want to monitor depression as well as providing sex therapy for the treatment of sexual symptoms.

The importance of conducting a thorough Intersystem assessment for all sexual problems is underscored by the fact that many men who present for ED treatment may not have had the requisite medical screening/testing. Without a screening, the therapist cannot rule out diabetes as a factor in the etiology of a client’s sexual problems. Additionally, diabetes is a couple/family problem. A wealth of information for clients with diabetes can be found on the American Diabetes Association website (https://www.diabetes.org/diabetes) and the Centers for Disease Control and Prevention website (https://www. cdc.gov/diabetes/basics/diabetes.html).

Sexuality and Disability

Disability can be conceptualized as an “interaction between physical, sensory, or cognitive differences and environmental and sociocultural contexts that facilitate or impede adaptive functioning” (Mona et al. 2017, p. 1000). This broad definition subsumes areas of intersectionality such as gender, race, ethnicity, age, and sexual orientation. Persons with disabilities (PWD) comprise over 26% of American adults (see https://www.cdc.gov/ ncbddd/disabilityandhealth/documents/disabilities_impacts_all_of_us.pdf.)

Comprehensive Assessment and Treatment

Disabled persons often present for psychotherapy with biological and psychological issues, relational concerns, and introjected societal messages that have influenced their life schemas. Disabled individuals also interact with complex cultural, religious, and environmental factors and have minority cultural status and consequent marginalized and stigmatized identities (Mona et al. 2017). Cognitive, behavioral, and physical issues can directly or indirectly affect sexual functioning (Thom, Grudzinskas, 8c Saleh, 2017) and can interfere with the ability to develop and maintain relationships and to give and receive affection. The therapist can help to explore the client’s self-image and understanding of their sexual problem. If an individual with a disability does not feel attractive or desirable, such feelings can reduce the initiation of sex or responses to a partner’s invitations. Consequently, a negative selfimage diminishes opportunities for intimate relationships and sexual activity, which in turn reinforces the client’s belief that they are undesirable. The Intersystem Approach addresses the client’s right to being valued and desired in a relationship, the right to sexual pleasure; and, regardless of physical limitations the right to giving pleasure to another. In short, a person with a disability is not necessarily sexually disabled.

Attending to Sexual Mythology

Therapists will want to be familiar with societal misconceptions as well as the extent to which disabled persons internalize mythology about their particular situation. The most overarching myth is the assumption that PWD are disinterested in or not capable of sexual enjoyment (Rohleder, Watermeyer, Braathen, Hunt, 8c Swartz, 2019). Another myth equates disability with asexuality, fostering societal practices that fail to educate and protect the civil rights of disabled persons (Joy 8c Weiss, 2018). Negative internalized beliefs about physical appearance often discourage disabled persons from dating, diminishing opportunities for intimate relationships and sexual activity, which in turn reinforces beliefs about undesirability.

Brown and McCann (2018) conducted a systematic literature review of 23 studies of sexuality issues of adults with intellectual disabilities. The most salient themes that emerged were the need to be sexually autonomous without experiencing harm from others; the need for knowledge about sexuality, relationships, and intimacy; and the need for sexuality education and support. Related areas in the literature review involved the rights of disabled persons to sexual expression and satisfaction.

Traumatic brain injury (TBI), another form of physical/emotional disability, can inhibit all phases of the sexual response, particularly affecting erectile functioning in men and changes in genital sensation and lubrication for women (Julia & Othman, 2011). Strizzi et al., (2017) found that men with TBI had significantly lower overall and dyadic sexual desire, sexual satisfaction, and sexual quality of life when compared to a control group without TBI.

Disabled persons, their partners, and caregivers can and do seek help, support, and education in sex/relationship therapy. It is beyond the scope of this text to offer a detailed discussion of this topic, yet we have found some helpful resources on sexual expression, sexual intimacy, and sexual behaviors for caregivers, partners, and disabled straight, aging, and LGBT persons such as (https://www.biami.org/wp-content/uploads/ 2019/09/Disability-and-Sexuality.pdf).