Scott Kober

Business closures, remote schooling, and social distancing have all been regularly in the news and discussed widely both in public and private. Then there are some of less well-publicized downstream effects of the pandemic – things like unemployment, mental health issues, and social isolation.

A recent article by Bhambhvani et al took a look at another downstream consequence of the COVID-19 pandemic – female sexual function and frequency. This study utilized the Female Sexual Function Index (FSFI), a validated questionnaire consisting of 19 questions focused on 6 unique domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. A total of 91 women who had visited a partner cannabis dispensary completed 2 surveys: 1 pre-pandemic (between October 20, 2019 and March 1, 2020) and an intra-pandemic survey (between August 1 and October 10, 2020). Along with the FSFI, intra-pandemic surveys included the addition of questions related to sexual frequency, mask-wearing habits, job loss, whether participants knew anyone who tested positive for COVID-19, recent relationship changes, and recent anxiety/depression symptoms.

Results showed that overall FSFI scores significantly decreased during the COVID-19 pandemic (27.2 vs. 28.8, 

=.002), although the absolute difference in scores was modest. Several domains, including arousal, lubrication, and satisfaction, were specifically impacted. There was no impact on sexual frequency among the 58 women in the survey cohort with known sexual frequency during the course of the full survey period.

Subset analyses showed that nearly half of all participants knew someone who had tested positive for COVID-19 (45/91, 49.5%); a similar percentage had suffered job loss or reduction in employment hours (46/91, 50.5%). Due to these and other factors, it was not surprising that 42 women (46.5%) screened positive for anxiety and 22 (24.2%) for depression. These women were specifically found to be at greater risk for female sexual dysfunction (RFSD) during the COVID-19 pandemic (defined at FSFI score <26.55). RFSD was not found to be impacted by other domains such as age, mask-wearing habits, relationship changes, or job loss/reduction.

Previous research has consistently demonstrated an association between sexual dysfunction and mental health issues such as depression, anxiety, and stress. Early estimates and observational studies suggest that these mental health issues have been exacerbated during the pandemic, making it no surprise that RFSD also would be impacted among sexually active patients.

 The impact of COVID-19 on sexual function is thought to be regionally specific based on the variability of the disease and policy interventions that have been introduced in each country. Some studies have shown both an increase in RFSD as well as frequency of intercourse in specific regions (eg, Italy, Turkey) while others have shown no impact on sexual lifestyle.

“The direct relationship between female sexual dysfunction and depression, anxiety, and stress has been studied extensively,” the study authors wrote. “Many pharmacologic therapies for depression and anxiety have (female sexual dysfunction) as a potential adverse effect, but depression and anxiety are themselves, even in the absence of treatment, risk factors for (female sexual dysfunction)…In light of recent evidence that demonstrates that sexual activity can have a protective effect on the development of quarantine-related anxiety and mood disorders, optimization of patients’ sexual health and optimization of patients’ mental health are reciprocal and synergistic goals.”

Based on the results of this study by Bhambhvani et al, it is suggested that ob-gyns and other providers who encounter patients with sexual function be especially vigilant in screening for pandemic-related mental health issues such as depression and anxiety.

Bhambhvani HP, Chen T, Kasman AM, Wilson-King G, Enemchukwu E, Eisenberg ML. Female sexual function during the COVID-19 pandemic in the United States. 

. 2021;9(4):100355. doi: 10.1016/j.esxm.2021.100355

Benke C, Autenrieth LK, Asselmann E, et al. Lockdown, quarantine measures, and social distancing: Associations with depression, anxiety and distress at the beginning of the COVID-19 pandemic among adults from Germany. 

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Ettman CK, Abdalla SM, Cohen GH, et al. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. 

. 2020;3:e2019686. doi: 10.1001/jamanetworkopen.2020.19686

Omar SS, Dawood W, Eid N, et al. Psychological and sexual health during the COVID-19 pandemic in Egypt: Are women suffering more? 

. 2021;9(1):100295. doi: 10.1016/j.esxm.2020.100295

Cito G, Micelli E, Cocci A, et al. The impact of the COVID-19 quarantine on sexual life in Italy. 

. 2021;147:37-42. doi: 10.1016/j.urology.2020.06.101

Arafat SMY, Alradie-Mohamed A, Kar SK, et al. Does COVID-19 pandemic affect sexual behaviour? A cross-sectional, cross-national online survey. 

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Articles

The COVID-19 pandemic has affected the global community in countless ways, some of which are more obvious than others.

The impact of the COVID-19 pandemic on female sexual function

Female sexual health education, while identified as a priority by many ob-gyn residency directors, remains a work in progress at many academic institutions throughout the United States.

 Previous surveys have shown that recent medical school graduates and residents feel ill-equipped to manage patients with specific sexual health issues such as sexual dysfunction and arousal issues.

To help address this deficiency, the Council on Resident Education in Obstetrics and Gynecology (CREOG) was formed in 2005 to create a set of specific learning objectives for residents focused on sexual health education. Specific areas of focus included education of the normal/abnormal sexual response, issues related to sexual dysfunction, key steps when taking a sexual history, and potential interventions in cases of identified sexual dysfunction. Ten years later, in 2015, CREOG established the Sexual Health Task Force to help create specific educational interventions tied to these learning objectives.

To gauge progress that had been made in the decade since the establishment of CREOG, more than 4,000 U.S.-based ob-gyn residents were sent a 32-item survey in June 2016 to gauge their comfort level in asking patients about their sexual history and providing counseling to patients of varying ages and ethnic/racial backgrounds. Brief case vignettes were used to pinpoint specific potential scenarios that would raise or lower respondents’ comfort levels.

For each of the 9 case vignettes, participants were asked to respond to 2 questions via a 5-point Likert scale (Very comfortable, somewhat comfortable, not very comfortable, not at all comfortable, I don’t know):

How comfortable would you be in obtaining a sexual history from (this) patient?

How comfortable would you be counseling (this) patient?

The case vignettes included the following patient descriptions:

35-year-old presenting with vaginal discomfort that worsens with intercourse;

28-year-old who has never had an orgasm and is incredibly nervous during the pelvic exam;

26-year-old Somali refugee (interpreter is available as needed);

57-year-old who complains of pain during intercourse and decreased libido;

31-year-old who desires pregnancy and presents with her female partner;

58-year-old transgender patient planning hormone therapy and surgery;

17-year-old who discloses that she is a victim of sex trafficking;

25-year-old who presents with vaginal discharge and discloses that she is a sex worker.

Results showed that at least 75% of respondents were comfortable taking a history and providing counseling for the majority of these patients, with the lone exceptions being patients 7 (transgender patient planning hormone therapy and surgery) and 8 (adolescent victim of sex trafficking). The highest level of comfort – topping 95% – came for patient 3 (teenager seeking contraception).

“I was pleasantly surprised by the wide-reaching interest in sexual health residents have,” Brett Worly, MD, MBA, an associate professor in the Department of Obstetrics and Gynecology at The Ohio State University Wexner Medical Center in Columbus, Ohio, and lead author of the study, told 

“They realize that sexual health education is an important component of their training in being prepared to take care of their patients,” he said. “I had hoped that the opportunities for more education would have been less pronounced, but areas like sex trafficking survivorship, cultural competency, and transgender care are real areas of opportunity for change.”

Overall, of the 968 respondents to the survey, 63.2% said that sexual health training was either “a priority” (53.5%) or a “top priority” (9.7%) during residency. However, the majority of respondents added that they didn’t have the ability to either describe disorders of sexual function (56.1%) or prepare a list of medications that affect sexual function (53.5%) following their residency program. Additionally, more than half of respondents said they were unaware that a comprehensive sexual history includes questions about masturbation and masturbation devices.

A final section of the survey asked about specific topics highlighted in the CREOG educational objectives that were or were not included in residents’ academic training. Correlating with the case vignette responses, only 16.8% of respondents said that they had received education focused on screening for human sex trafficking. Other areas of deficiency included sexual health for women with disabilities, cultural competence in sexual health, and therapies for sexual dysfunction.

Worly said that the COVID-19 pandemic has changed the way that education is broadly delivered, which may provide easier access to sexual health education resources for ob-gyn residents. This, he said, gives him hope that some of the deficiencies identified in this survey will be addressed in the future.

“COVID-19 has been horrible in every single way, but over the past 1.5 years, we have learned to be more accepting of virtual learning,” Worly said. “We no longer have to take several days out of our lives to travel across the country to give a 60-minute lecture on a subspecialized area of expertise. We can now use taped lectures, virtual platforms, and centralized access points to reach ob-gyn residents across the country and around the world. An important next step would be to create online learning experiences with subspecialized curriculum experts so that we can disseminate this information easily to residency programs who may not have an expert in a particular area. This will allow us to provide top notch education to our next generation of ob-gyn physicians.”

Worly B, Manriquez M, Stagg A, et al. Sexual health education in Ob/Gyn residencies – the program directors’ perspective. 

Pancholy AB, Goldenhar L, Fellner AN, et al. Resident education and training in female sexuality: Results of a nationwide survey. 

Worly B, Manriquez M, Stagg A, et al. Sexual health education in obstetrics and gynecology residencies – a resident physician survey. 

To gauge progress that had been made in the decade since the establishment of CREOG, more than 4,000 U.S.-based ob-gyn residents were sent a 32-item survey in June 2016 to gauge their comfort level in asking patients about their sexual history and providing counseling to patients of varying ages and ethnic/racial backgrounds. 

Sexual health education of ob-gyn resident physicians: How are we doing?

Ob-gyns are well positioned to assist in opening a dialogue with female patients about their sexual health. In a recent review article by Winkley et al, it was determined that even though sexual dysfunction causes substantial distress and negatively impacts quality of life, there is significant under-reporting of its incidence in woman with diabetes, with a disparity seen between spontaneous reports of sexual dysfunction compared with screen-detected sexual dysfunction in research trials.

Sexual dysfunction is an amalgamation of physical and psychological issues, including inadequate communication between sexual partners, poor body image, job loss, and medical considerations. Updates to the Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) reduced the number of diagnostic categories of sexual dysfunction from 4 to 3, along with introducing a 6-month minimum duration of symptoms for a formal diagnosis since some sexual disorders may be temporary or stress-induced. In order to determine if a sexual disorder is temporary, a deeper exploration of what is happening needs to take place. The challenge is that this assessment can be a sensitive topic for women and clinicians to raise and discuss during clinical consultation.

The American Diabetes Association notes that the lack of conversations surrounding this issue is 2-fold. Only 19% of women with diabetes have spoken with their doctor about sexual problems, and doctors aren’t comfortable delving into their patient’s sexual performance and health.

 According to 1 study, only 40% of ob-gyns routinely ask their patients about sexual problems.

With limited physician-patient dialogue, all members of the diabetes interprofessional team need to increase their awareness that sexual health, albeit an uncomfortable subject, needs to be discussed more frequently with patients.

“Diabetes specialists are not used to asking women about sexual functioning as they normally are focused on pregnancy and contraception,” said Kirsty Winkley, Ph.D., a diabetes specialist nurse and health psychologist at King's College London & Florence Nightingale Faculty of Nursing & Midwifery and co-author of the recent review article. “They may be worried they could offend a woman, especially if women with diabetes are unaware that some of their problems with sex are related to diabetes.”

The recent review article notes that there are several screening questionnaires that can be leveraged as tools to open the lines of communication when determining if sexual dysfunction is present among women with diabetes. These include the Female Sexual Function Index (FSFI), the Brief Sexual Symptom Checklist for Women (BSSC-W), and the Changes in Sexual Functioning Questionnaire 14 (CSFQ-14). However, the use of these tools is not widespread in the clinical setting.

“In the U.K. at least, these are not routinely used,” Winkley said. “They have been used in a research context. However, it might be easier for diabetes specialists to raise the issue if women complete the scales or perhaps are provided with some information on the association between sexual dysfunction and diabetes.”

There are several indicators that demonstrate that women with diabetes are at greater risk for sexual dysfunction. Glucose levels can impact sexual intercourse by altering vaginal lubrication, causing pain during sex, and affecting the ability to orgasm. Depression, which is noted with increased prevalence in all patients with diabetes, can be linked to diminished sexual drive. General fatigue or having sex without concerns of hypoglycemia, as well as a negative body image due to the use of medical devices to manage the disease (insulin pumps, injection site scarring), can be additional troubling matters for patients.

Several treatment options have demonstrated the ability to reduce levels of sexual dysfunction in women with diabetes, including pharmacological interventions (phosphodiesterase 5 [PDE 5] inhibitors, hormone replacement or anti-depressant therapy), non-pharmacologic interventions (weight loss, psychological interventions) and sexual health information guides utilized as part of clinical consultations. Once sexual dysfunction is identified in a patient with diabetes, shared decision-making efforts can be put into place to reduce or ease the negative aspects of sexual dysfunction that are impacting these women and their quality of life.

Part of that mindset needs to include the consideration of the patient as a whole entity. The Diabetes Care for You (DCFY) service, which was developed in accordance with National Health Service care guidelines in the United Kingdom, combines diabetes and psychotherapy services. The DCFY service incorporates the use of patient health questionnaires with improvements in diabetes self-management to address overall well-being as part of disease management. Validating the value of this model, the recognition of sexual dysfunction in women with diabetes within this service was particularly commended when DCFY won the 2019 UK Quality in Care (QiC Diabetes) award under the Mind and Body Healthy Together category.

Continued improvements in the care of women with diabetes enduring sexual dysfunction warrants emphasis. Winkley offered that continuing the educational efforts is an ongoing necessity. “By raising awareness of the issue, I hope that this may lead to more research and better treatment and support for women with diabetes,” Winkley said. “Women's health issues in general need to be given more attention.”

Winkley K, Kristensen C, Fosbury J. Sexual health and function in women with diabetes. 

Lindau ST, Tang H, Gomero A, et al. Sexuality among middle-aged and older adults with diagnosed and undiagnosed diabetes: a national, population-based study. 

. 2010;33(10):2202-10. doi: 10.2337/dc10-0524

Sobecki JN, Curlin FA, Rasinski KA, Lindau ST. What we don't talk about when we don't talk about sex: results of a national survey of U.S. obstetrician/gynecologists. 

. 2012;9(5):1285-94. doi: 10.1111/j.1743-6109.2012.02702.x

The management of diabetes is multifaceted, often requiring the collaboration of a multidisciplinary team of providers. While sexual side effects of diabetes are not commonly discussed during patient visits, there is a correlation between the presence of diabetes and frequent sexual dysfunction in women. 

Scott Kober

Articles

The impact of the COVID-19 pandemic on female sexual function

Sexual health education of ob-gyn resident physicians: How are we doing?

Bringing sexual dysfunction to the conversation for women with diabetes