May 20, 2009

Bad Science: Study of Diabetic Women's Sexual Response Gets it Backwards

The latest contribution to the growing genre, "More Bad News for People with Diabetes" is a study which is being reported with headlines like this one from Diabetes in Control: Diabetes Affects Women's Sex Life.

But as is always the case we see a different picture emerge when we look more closely at what was actually reported.

The study cited is this one:

Sexual Dysfunction in Women with Type 1 Diabetes. Paul Enzlin, et al. doi: 10.2337/dc08-1164 Diabetes Care, May 2009 vol. 32 no. 5 780-785

The full text is (temporarily?) available HERE.

Here is the conclusion presented in the abstract:
Depression is the major predictor of sexual dysfunction in women with type 1 diabetes. These findings suggest that women with type 1 diabetes should be routinely queried about the presence of sexual dysfunction and possible co-association with depression.
Sounds pretty clear cut doesn't it, and the final sentence suggests strongly that doctors should be cross examining women with Type 1 to see if they have any of the long laundry list of "depressive symptoms" that suggests 99.3% of all human beings need expensive SSRI anti-depressive drugs.

These questionnaires, helpfully supplied by the drug manufacturers, consider things like "always hungry" and "not hungry", "sleep easily" and "can't sleep" all as indicators of depression. So are positives answers to "sometimes I feel sad" or "Sometimes I feel anxious". Unless you are manic, you probably get diagnosed as depressed, if you're manic you get diagnosed as bi-polar and put on the drugs anyway.

But that said, let's look at what the study actually did and what it really found.

For starters, the study took a subset of 550 female participants in DCCT and had them answer a seven question questionnaire about their sexual response. The researchers then discarded the responses from women who weren't sexually active during the past year and ended up with 434 women whose average age was 42.8 ± 7.1 years old. They'd had diabetes for an average of 22.8 ± 5.0 years.

Now given that the conclusion of this study was that depression was the only factor they found that predicted sexual dysfunction more strongly than expected in this group, it's worth asking "how did they determine if these women were depressed?"

And here's the answer:
the prevalence of depression was assessed by means of a composite depression variable, which was based on study coordinator ratings of clinical depression, based on DSM-IV criteria, in addition to patient self-reports of use of antidepressant medications and/or psychological counseling for depressive symptoms
Am I the only person who sees a huge methodological problem here?

I hope not. Because what they are saying is that the use of antidepressant medication was the main way they determined if someone was depressed.

But hold on folks, did everyone forget that loss of libido is one major very common side effect of the use of antidepressant medication is in women?

So what we have here is the finding that people who are taking drugs that destroy libido have higher than normal loss of libido. NOT that women with diabetes who are depressed need antidepressants.

And if we read the extended conclusion section of this study, what we discover is NOT that women with diabetes have lousy sex lives. Instead, we find the exact opposite!

Here's some of the detailed finding:
the overall prevalence of FSD among sexually active women in this study was found to be 35.4%. Univariate analyses revealed that women meeting criteria for FSD were on average older than women without FSD (P = 0.0041), were more likely to be married (P = 0.0016), be (post)menopausal (P = 0.0019), have evidence of microvasculopathy (composite diabetes complications variable, P = 0.0092), and be depressed (P = 0.0022) than women without FSD (Table 2).

Among those women who met the criteria for FSD, 57% reported a problem with decreased desire, 51% had problems with orgasm, 47% had inadequate lubrication, 38% had problems with sexual arousal, and 21% reported pain during intercourse. Additionally, 25% of sexually active women reported low overall sexual satisfaction. For all sexual domains, study participants without FSD scored higher (i.e., had better function) than women with FSD (P < 0.001).
What this says is that slightly over 1/3 of the women had some form of sexual dysfunction. This it turns out is BETTER than what is found in normal patients seen in gynecological practice who responded to a similar questionnaire:

Prevalence of female sexual dysfunction in gynecologic and urogynecologic patients according to the international consensus classification..

In that study the prevalence of female sexual dysfunction was 50%!

Their analysis of statistics yielded this finding:
When controlling for the effects of other variables, depression status (depressed vs. nondepressed) and marital status (married vs. not married) were the only variables in the multivariate model that were significant predictors of FSD.
Other statistics cited reveal that the diabetic women most likely to report dysfunction were older post-menopausal ladies who were having sex with husbands. If this strikes you as an amazing finding, you aren't an older menopausal lady having sex with a long-term husband.

In the extended conclusion section we read this:
Although rates of sexual dysfunction in women are not dissimilar to those in men, the pattern of specific effects of diabetes on men and women is markedly different.... while ED is strongly correlated with A1C and the cardiovascular and neuropathic complications of diabetes (3,4,10).... The lack of association between any measurement of A1C and FSD in this study suggests that compared with men, the sexual response in women with diabetes is more likely to be affected by the psychosocial aspects (e.g., depression) than by the metabolic control or complications of the disease.
So what they really found was that diabetes and complications made no difference in women's reporting of sexual functioning.

What did correlate was depression--which was in many of these women's cases (stats not given) a synonym for "taking antidepressants known to depress libido." The other significant factor associated with sexual dysfunction was being married to the same old boring husband.

So one wonders why the abstract does not conclude this way:
Measures of blood sugar and indications of complications did not correlate to self-reported sexual dysfunction in women. Use of antidepressants and marriage to boring spouses did. Doctors should wean diabetic patients complaining of sexual dysfunction off these deleterious drugs and suggest they find new and more stimulating sex partners.
Instead, doctors will be told by the ever helpful drug companies that DCCT results prove that diabetic women need more antidepressants.

Who the heck peer reviewed this pathetic excuse for a study?



Brenda Bell said...

I distrust most of what I read in Diabetes in Control and Endocrine Today; most of it is either straight Reuters Health newsfeeds (already condensed with all the nutrients removed) or a further condensed (and thereby sensationalized) version of the same, rather than an examination of the source material.

It really scares me that those two publications are aimed at our medical practitioners and may be all they have time to read...

Anonymous said...

Oh Jenny! That is funny! Gosh I know I should not laugh, but the misinformation is getting so absurd, and your alternate summary takes the cake!

Unknown said...

LOL! So much easier to get rid of the boring husband! :-) I, too, am so tired of the bad rap diabetics are getting, especially women. If I show some emotion or spunk, it's because of my diabetes...if I'm depressed about the state of the world, it's because of my diabetes...if I don't want to have sex with my boring spouse, it's because of my diabetes! I only wish the doctors would read this blog...

Lili said...

Wow, that just kept getting better and better. *eyeroll*

Pubsgal said...

This cracked me up, Jenny. I love your critiques of these studies. :-) Keep the common sense coming!

Trinkwasser said...

So women aren't affected by neuropathy like us men then?

Just because you can't see the genitalia at half mast (BTDT both with neuropathy and the infamous Paxil Droop) doesn't mean it isn't happening . . .