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International Journal of Sexual Health logoLink to International Journal of Sexual Health
. 2021 Dec 15;34(2):209–220. doi: 10.1080/19317611.2021.2015038

Quality of Life, Sexual Functioning and Chronic Disease: A Comparative Study with Portuguese Women without Chronic Disease, and Women with Diabetes Type 1 and 2, and Arterial Hypertension

Maria Manuela Peixoto a,✉, Júlia Lopes b, Ana Luísa Rodrigues b
PMCID: PMC10903568  PMID: 38596520

Abstract

Aims: Previous research has focused on the impact of chronic diseases on men's sexual functioning and quality of life; however, little is known about the association between chronic disease and women’s sexual functioning and quality of life. Current study aimed at exploring the differences in quality of life and sexual functioning between women without chronic disease, and women with type 1 diabetes, with type 2 diabetes, and with arterial hypertension.

Methods: A web-survey was completed by 313 Portuguese women (167 without chronic disease, 48 with type 1 diabetes, 48 with type 2 diabetes, and 50 with arterial hypertension).

Results: Women without chronic disease scored significantly higher than women with chronic disease in quality of life and sexual functioning, adjusting for age.

Conclusions: Quality of life and sexual functioning in women with chronic diseases is impaired.

Keywords: Arterial hypertension, chronic disease, diabetes mellitus, quality of life, women sexual functioning

Introduction

Sexuality encompasses sexual behavior, sexual intimacy and sexual pleasure, and is considered a key dimension of global health and quality of life (World Association for Sexual Health, 2008), including for people with chronic diseases. Chronic diseases describe functional, structural and/or pathophysiological changes that occur over an extended period of time, without complete remission or cure, that can be managed or controlled to minimize symptoms or side effects (Wilmoth, 2007). Diabetes Mellitus (DM) and Arterial Hypertension (AH) are considered common chronic diseases affecting a large number of people in developed countries. Moreover, according to studies conducted in Portugal, DM and AH are major health problems, with higher rates of non-adherence treatment and several clinical implications on global health status (da Costa et al., 2015; Leão et al., 2016). Considering higher life expectancy, interventions for chronic diseases such as DM and AH, have focused not only on treating and managing symptoms, but also on promoting individual well-being and perceived quality of life (Verschuren et al., 2010).

Empirical research has mainly focused on DM, AH and male sexuality (Enzlin et al., 1998; Giraldi & Kristensen, 2010; Kizilay et al., 2017; Manolis & Doumas, 2009; Rainer, 2005; Rutherford & Collier, 2005; Schiavi et al., 1995; Schreiner-Engel et al., 1985), neglecting the relationship between chronic diseases and women’s sexuality. Studies within the Portuguese context also corroborate the negative implication of DM and AH for male sexual health (Morgado et al., 2019; Teles et al., 2008), but very limited empirical data was found for women (e.g., Santos et al., 2020). Given that sexual functioning and satisfaction are key dimensions of well-being and quality of life (Wilmoth, 2007), exploring the role of these variables in Portuguese women with DM and AH is of paramount importance.

Diabetes mellitus, women’s sexual functioning and quality of life

Developments in the medical treatment of DM have improved quality of life of people with this chronic condition (Enzlin et al., 2003), but sexual dimension is still overlooked. Furthermore, DM and men’s sexual health have been extensively studied, suggesting a negative influence of DM on men’s sexual response (Enzlin et al., 1998; Giraldi & Kristensen, 2010; Kizilay et al., 2017; Rutherford & Collier, 2005; Schiavi et al., 1995; Schreiner-Engel et al., 1985). However, little is known about this relationship in women (Schreiner-Engel et al., 1987).

DM appears to put women at greater risk for sexual dysfunction (Bak et al., 2018; Bąk et al., 2021; Giraldi & Kristensen, 2010; Mezones-Holguin et al., 2008), as it can impair sexual arousal and, consequently, vaginal lubrication (Enzlin et al., 2003; Mezones-Holguin et al., 2008; Rutherford & Collier, 2005). Given the influence of DM on penile tumescence (Enzlin et al., 1998; Giraldi & Kristensen, 2010; Kizilay et al., 2017; Rutherford & Collier, 2005; Schiavi et al., 1995; Schreiner-Engel et al., 1985), it is possible that it also influences clitoral tumescence. However, the negative physiological influence is more significant in men (Rutherford & Collier, 2005), and less conclusive in women (Kizilay et al., 2017). Different pathophysiological mechanisms such as hyperglycemia (reduced hydration of mucous membranes in the vagina), microvascular damages and neuropathies may impair women’s sexual response (Enzlin, Mathieu, & Demytteanere, 2003; Giraldi & Kristensen, 2010; Rutherford & Collier, 2005; Schreiner-Engel et al., 1985).

There are several hypotheses that explain the lack of evidence that diabetic women’s sexuality is impaired, such as the lack of attention to female sexuality and chronic disease or the difficulty of properly addressing women’s sexual response (Enzlin et al., 1998). Although research has not empirically revealed the negative impact of DM on sexual functioning in women, sexual arousal appears to be the phase of sexual response that is significantly impaired in diabetic women (Enzlin et al., 1998). However, experimental studies showed no differences in physiological sexual arousal between women with and without DM (Slob et al., 1990).

A qualitative study of DM and women’s sexuality found that diabetic women were more likely to experience a decrease in sexual arousal and lubrication, followed by a decrease in sexual interest and desire, and increasing difficulties reaching orgasm (Lemone, 1996). Blood glucose status and general acceptance of chronic condition appear to affect women’s willingness to feel sexual (Lemone, 1996; Santos et al., 2020), underlining the role of psychosocial dimensions in the relationship between DM and women’s sexuality.

On the other hand, given the heterogeneity of findings on the relationship between DM and women’s sexual functioning, it is hypothesized that psychological factors may significantly interfere with sexual functioning in women with DM (Giraldi & Kristensen, 2010; Nowosielski et al., 2010; Rutherford & Collier, 2005; Verschuren et al., 2010), particularly in the association between depressed mood and lack of sexual desire in diabetic women (Kizilay et al., 2017). According to Hoorsan et al. (2021), chronical condition of DM has a psychological burden that affects sexual life and its quality, as well as overall quality of life. Women with DM type 2 were more likely to experience psychological maladjustment (Mezones-Holguin et al., 2008; Rutherford & Collier, 2005), and it is not clear in the literature whether sexual difficulties are caused by DM or psychological distress, or both (Rutherford & Collier, 2005). Furthermore, a study with type 2 diabetic women found that even after controlling for depression, these women were 6.2 more likely to report sexual difficulties than non-diabetic women (Mezones-Holguin et al., 2008).

Women with type 2 DM are at higher risk for sexual dysfunction than women with type 1 DM (Giraldi & Kristensen, 2010; Schreiner-Engel et al., 1987), primarily due to age differences, menopausal status, psychosocial aspects, and comorbid factors (Giraldi & Kristensen, 2010). In addition, women with type 2 DM reported more subclinical sexual difficulties compared to women with type 1 DM (Celik et al., 2015; Schreiner-Engel et al., 1987), and subclinical difficulties were strongly associated with lower sexual quality of life (Celik et al., 2015). Women with type 1 DM appear to be less satisfied with their sex lives, and reported more orgasmic difficulties and loss of sexual desire compared to women without chronic disease (Mellerio et al., 2015). Diabetic women appear to be less satisfied in their relationships, than women without DM, with little or no impairment of sexual response (Schreiner-Engel et al., 1985) or subjective and physiological sexual arousal (Slob et al., 1990). According to Lindau et al. (2010), although older women with DM reported no negative impact of chronic disease on sexual function, compared to nondiabetic older women, older women with diabetes had greater difficulty in discussing sexuality themes with their physicians.

Quality of life is closely associated with chronic disease (Malik et al., 2021; Wilmoth, 2007), and sexual dysfunction in women (Nappi et al., 2016; Santosa et al., 2011). Given that women with chronic diseases are more likely to have reduced quality of life and impaired sexual functioning (Wilmoth, 2007), a deeper understanding of the relationship between DM, quality of life and sexual functioning in women is needed.

Arterial hypertension, women’s sexual functioning and quality of life

AH is considered a chronic disease with a negative impact on sexual health and quality of life (Alidu et al., 2018; Doumas et al., 2006; Grimm et al., 1997), as it is very common and frequently comorbid with obesity (Alidu et al., 2018). Most research has focused on the relationship between antihypertensive medications and male sexual function (Manolis & Doumas, 2009; Rainer, 2005), despite of higher rates of women with HA (Duncan et al., 2000), neglecting once again the relationship between chronic disease, sexual functioning and quality of life in women.

The prevalence of sexual dysfunction in women with HA ranges from 14.1 to 90.1% according to a recent meta-analysis, with aging, cultural and social factors, and assessment measures interfering with results discrepancy (Santana et al., 2019). AH, as DM, is a multifactorial medical condition which include vascular, neurogenic, hormonal, muscular, and endothelial impairments that may interfere with women’s sexual response (Santana et al., 2019). Overall, the sexual life of hypertensive women seems to be negatively affect by chronic disease. For example, hypertensive women reported lower vaginal lubrication, impaired orgasmic function, and sexual pain compared to women without hypertension. Nevertheless, there are no major differences in the quality of sexual life between hypertensive and non-hypertensive women (Duncan et al., 2000).

Compared to DM, AH is a chronic disease that receives less attention in terms of its impact on sexuality and quality of life. Nevertheless, as a chronic medical condition, it can be expected to negatively affect perceived quality of life and sexual response in women.

Study purpose

Chronic diseases such as type 1 and type 2 DM, and AH appear to have a negative impact on sexual functioning and quality of life. However, most empirical studies have been conducted largely with male subjects, and studies with women are sparse. In Portugal, medical professionals are aware of the association between chronic diseases and male sexuality (Morgado et al., 2019; Teles et al., 2008), but no corresponding empirical data for women were found. In addition, there is a higher prevalence of DM and AH in Portugal, which has increased in the last five years (da Costa et al., 2015; Leão et al., 2016), and general practitioners have reported that they need more information and knowledge on sexuality to improve their medical care in this specific area (Alarcão et al., 2012).

Furthermore, to our knowledge, no study has directly compared DM, AH and women without chronic disease in terms of sexual functioning and quality of life. In this sense, the current study aimed to investigate the differences in sexual functioning indexes (i.e., sexual desire, sexual arousal, lubrication, orgasmic function, and sexual pain) and quality of life domains (i.e., physical, psychological, social relationships, and environment) in women without chronic disease and in women with type 1 DM, with type 2 DM, and with AH. It is to be expected that women without chronic disease scored significantly higher on all variables than women with chronic diseases. As for the differences between women with different chronic diseases, the hypotheses are exploratory given the heterogeneity and the lack of empirical results. Overall, this study intends to contribute to the knowledge of chronic diseases, quality of life and sexuality in women.

Methods

Participants

A total of 353 Portuguese women completed the set of self-report measures. Of the original sample of 353 participants, 40 women were excluded because they had a clinical diagnosis of type 2 DM and AH simultaneously.

For the current study, a total of 313 women with a mean age of 35.45 (SD = 16.52) and an age range of 18–78 years were included in the analysis. Of the 313 women, 167 women reported having no chronic disease and had a mean age of 27.01 (SD = 8.31), ranging from 18 to 60 years. Most of the women without chronic disease identified themselves as heterosexual (95.8%, n = 160), had 12 years of schooling (50.3%, n = 84), and were currently in an intimate relationship (71.9%, n = 120). A total of 48 women reported a diagnosis of DM type 1 and had a mean age of 34.24 (SD = 11.81), ranging from 19 to 62 years. Most of the women with type 1 DM identified themselves as heterosexual (95.8%, n = 46), having been in school for 13 years or more (68.8%, n = 33), and currently in an intimate relationship (81.3%, n = 39). The group of women diagnosed with DM type 2 consisted of 48 women with a mean age of 60.29 (SD = 15.31), ranging from 20 to 77 years. All women with type 2 DM identified themselves as heterosexual (100.0%, n = 48), had an education of 13 years or more (25.0%, n = 12), and were living in an intimate relationship (66.7%, n = 32). Of the 3133 women, 50 formed the group of women diagnosed with AH, with a mean age of 52.57 (SD = 12.81), ranging from 20 to 78 years. Most of the women in the group with AH identified themselves as heterosexual (98.0%, n = 49), had an education of 13 years or more (40.0% n = 20), and were living in an intimate relationship (76.0%, n = 38). Detailed sociodemographic characteristics are described in Table 1.

Table 1.

Sociodemographic Characterization (N = 313).

  Women without Chronic Disease
(n = 167)
 Women with DM type 1
(n = 48)
 Women with DM type 2
(n = 48)
 Women with AH
(n = 50)
  M(SD) Range M(SD) Range M(SD) Range M(SD) Range
Age 27.01 (8.31) 18–60 34.24 (11.81) 19–62 60.29 (15.31) 20–77 52.57 (12.81) 20–78
  n % n % n % n %
Sexual Orientation                
 Heterosexual 160 95.8 46 95.8 48 100.0 49 98.0
 Bisexual 4 2.4 – – – – – –
 Lesbian 3 1.8 2 4.2 – – – –
 Asexual – – – – – – 1 2.0
Current Intimate Relationship                
 Yes 120 71.9 39 81.3 32 57.9 38 76.0
 No 47 28.1 9 18.7 16 42.1 12 24.0
Educational Level                
 4 years – – – – 7 14.6 3 6.0
 6 years – – – – 9 18.7 6 12.0
 9 years 3 1.8 5 10.4 10 20.8 5 10.0
 12 years 84 50.3 10 20.8 10 20.8 20 40.0
 13 years or more 80 47.9 33 68.8 12 25.0 16 32.0
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Procedures

The present study was submitted to Ethical Committee by the academic institutions to which the authors belong. After ethical approval was granted and the Portuguese versions of the self-reports selected for the study were approved for participation, a web survey was developed on the platform Google Forms. A study on female sexuality and chronic diseases was advertised through social media (i.e., Facebook and LinkedIn) and mailing lists between May 2020 and June 2021. Participants were provided with a brief explanation of the purpose of the study and detailed information about study privacy and anonymity. After reading an informed consent form, women who agreed to participate in the study signed an informed consent form and were asked to complete a series of self-report questions, which took approximately 15 minutes. Participants received no monetary compensation nor were other incentives offered. Participation was voluntary and anonymous; no IP addresses or other personal identifying information was requested. All ethical standards and procedures established by Portuguese legislation and the Helsinki Declaration were followed.

Measures

Sociodemographic information

A sociodemographic information sheet assessing age, sexual orientation (i.e., heterosexual, lesbian, bisexual or asexual), years of schooling, having a current intimate relationship, and health status (i.e., not having a chronic disease, medical diagnosis of type 1 DM, type 2 DM, or AH) was developed for study purpose. Regarding health status, participants are asked to indicate the presence of a chronic disease based only on a clinical diagnosis made by a physician.

Quality of life

The World Health Organization Quality of Life – Bref Version (WHO, 1998) is a 26-item self-response measure, developed by the World Health Organization, assessing a global factor on Health and Quality of Life along with 4 sub-domains: physical, psychological, social relations, and environment. The original version of the instrument revealed good psychometric properties (WHO, 1998), as well as the Portuguese version of the WHOQOL-BREF (Vaz Serra et al., 2006), with Cronbach alpha values ranging from .64 to .87 for the domains, and .92 for the overall scale (Vaz Serra et al., 2006).

Female sexual functioning

The Female Sexual Functioning Index (FSFI; Rosen et al., 2000; Portuguese version from Pechorro et al., 2009) is a 19-item instrument, easily administered and scored, providing detailed information on the major dimensions of sexual function. A principal component analysis identified six factors: sexual interest/desire, sexual arousal, lubrication, orgasm, sexual satisfaction, and sexual pain. The measure presents acceptable test-retest reliability, good internal consistency and validity (Rosen et al., 2000). The measure allows the calculation of specific indexes for each dimension as well a sexual function index (calculated through the sum of the specific dimensional indexes), with higher scores indicating greater levels of sexual functioning (desire: 1.2–6, arousal: 0–6, lubrication: 0–6, orgasm: 0–6, global satisfaction: 0.8–6, pain: 0–6, total, 2–36). The Portuguese version also presented good psychometric properties, with good internal consistency, as well as convergent and discriminant validity (Pechorro et al., 2009).

Data analysis

For the present study, an a priori power analysis using G*power indicated that a sample size of 156 was recommended for a multivariate analysis of variance with four groups with equal sample size (n = 39) to detect a medium-size effect (f = 0.25) with a power of 95%.

Means and standard deviations were calculated for quality of life domains (i.e., physical, psychological, social relations, and environment) and for Female Sexual Functioning Indexes (i.e., sexual desire, sexual arousal, lubrication, orgasmic function, sexual satisfaction, and absence of sexual pain) separately for women without chronic disease, women with type 1 DM, with type 2 DM, and with AH. Multivariate analyses of covariance were performed with quality-of-life domains/Female Sexual Functioning indexes as the dependent variable, controlling for age and Bonferroni corrections, to examine differences between women with and without chronic disease. In addition, multivariate analyses of variance were performed with quality-of-life domains/Female Sexual Functioning indexes as dependent variable with Bonferroni corrections to examine differences between women without chronic disease, and women with type 1 DM, with type 2 DM, and with AH. Post-hoc comparisons using the HSD Tukey test were also performed to assess differences between groups.

Results

Quality of life, sexual functioning and chronic disease

Means and standard deviations for quality of life domains (i.e., physical, psychological, social relations, and environment) and for sexual functioning indexes (i.e., sexual desire, sexual arousal, lubrication, orgasmic function, sexual satisfaction, and absence of sexual pain) for women without chronic disease, and women with DM type 1, with DM type 2, and with AH were presented at Table 2.

Table 2.

Means and standard deviations for Quality of Life domains and Sexual Functioning indexes (N = 313).

  Women without Chronic disease
(n = 167)
 Women with DM type 1
(n = 48)
 Women with DM type 2
(n = 48)
 Women with AH
(n = 50)
  M SD M SD M SD M SD
Quality of life                
 Physical domain 80.45 11.59 56.30 12.02 44.27 14.42 47.02 10.45
 Psychological domain 72.53 12.80 62.72 12.29 49.67 15.32 53.33 8.50
 Social relations domain 77.30 15.97 61.84 19.82 51.75 18.60 55.56 15.21
 Environment domain 77.54 11.92 63.24 17.82 43.17abc 20.42 52.82abc 15.73
Female Sexual Functioning                
 Sexual desire 4.75 0.94 3.81 1.39 4.47 1.23 4.08 1.00
 Sexual arousal 5.04 1.14 2.43 1.56 1.96 1.99 2.70 1.78
 Lubrication 5.18 1.22 3.32 1.94 2.28 2.25 2.88 2.13
 Orgasmic function 4.64 1.46 2.59 1.54 1.95 1.93 2.36 1.80
 Sexual satisfaction 5.21 1.11 2.57 1.05 2.82 1.06 2.69 0.82
 (absence of) Sexual pain 4.85 1.30 3.55 2.02 2.29 2.27 3.15 2.39
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Note. Different letters in mean values indicated statistical significant differences between groups according to post hoc comparison with HSD Tukey test.

Differences in quality of life domains in women with and without chronic disease

A multivariate analysis of covariance, with Bonferroni corrections, was performed to test the differences between women with and without chronic disease in quality of life domains, controlling for age. Significant main effects were found for group (with vs. without chronic disease), Wilks’ lambda = 0.57, F(4,267) = 51.23, p < .001, partial η2 = .434, but not for age, Wilks’ lambda = 0.96, F(4,267) = 2.67, p = .133, partial η2 = .008.

The univariate analysis revealed that significant main effects were found for Physical domain, F(1,272) = 200.03, p < .001, partial η2 = .426, with women without chronic disease reporting higher levels of physical quality of life (M = 80.45; SD = 11.60) compared with women with chronic disease (M = 49.36; SD = 13.51); for Psychological domain, F(1,272) = 55.75, p < .001, partial η2 = .171, with women without chronic disease scoring higher psychological quality of life (M = 72.53; SD = 12.80) compared with women with chronic disease (M = 55.39; SD = 13.73); for Social Relations domain, F(1,272) = 46.72, p < .001, partial η2 = .148, with women without chronic disease reporting higher levels of social relations quality of life (M = 77.30; SD = 15.97) compared with women with chronic disease (M = 56.45; SD = 18.52); and for Environment domain, F(1,272) = 64.56, p < .001, partial η2 = .193, with women without chronic disease reporting higher levels of environment quality of life (M = 77.54; SD = 11.92) compared with women with chronic disease (M = 53.10; SD = 20.00).

A multivariate analysis of variance with Bonferroni corrections was performed for assessing the differences between women without chronic disease and women with DM type 1, type 2, and AH in quality of life domains. Significant main effect were found for type of chronic disease, Wilks’ lambda = 0.33, F(12,266) = 30.13, p < .001, partial η2 = .306.

The univariate analysis revealed that significant main effects were found for Physical domain, F(3,269) = 152.87, p < .001, partial η2 = .630, for Psychological domain, F(3,269) = 46.24, p < .001, partial η2 = .340, for Social Relations domain, F(3,269) = 35.41, p < .001, partial η2 = .283, and for Environment domain, F(3,269) = 71.86, p < .001, partial η2 = .445.

According to post-hoc comparisons, with the HSD Tukey test, for the Physical quality of life domain, the group of women without chronic disease scored significantly higher compared with other groups of women (p < .001); women with type 1 DM scored significantly higher than women with type 2 DM (p < .001), and women with AH (p = .01). For the Psychological quality of life domain, the group of women without chronic disease scored significantly higher compared with other groups of women (p < .001); women with type 1 DM scored significantly higher than women with type 2 DM (p < .001), and women with AH (p = .017). For the Social Relations quality of life domain, the group of women without chronic disease scored significantly higher compared with other groups of women (p < .001). For the Environment quality of life domain, the group of women without chronic disease scored significantly higher compared with other groups of women (p < .001); women with type 1 DM scored significantly higher than women with type 2 DM (p < .001), and women with AH (p = .024); and women with type 2 DM scored significantly lower than women with AH (p = .046).

Differences in sexual functioning indexes in women with and without chronic disease

A multivariate analysis of covariance, with Bonferroni corrections, was performed to test the differences between women with and without chronic disease in sexual functioning indexes, controlling for age. Significant main effects were found for group (with vs. without chronic disease), Wilks’ lambda = 0.53, F(6,260) = 38.90, p < .001, partial η2 = .473, but not for age, Wilks’ lambda = 0.97, F(6,260) = 1.56, p = .159, partial η2 = .035.

The univariate analysis revealed that significant main effects were found for Sexual desire, F(1,268) = 23.11, p < .001, partial η2 = .080, with women without chronic disease reporting greater sexual desire (M = 4.75; SD = 0.94) compared with women with chronic disease (M = 4.12; SD = 1.25); for Sexual arousal, F(1,268) = 124.29, p < .001, partial η2 = .319, with women without chronic disease scoring higher on sexual arousal index (M = 5.04; SD = 1.14) compared with women with chronic disease (M = 2.34; SD = 1.79); for Lubrication, F(1,268) = 64.66, p < .001, partial η2 = .196, with women without chronic disease reporting higher levels of lubrication (M = 5.18; SD = 1.22) compared with women with chronic disease (M = 2.82; SD = 2.14); for Orgasmic function, F(1,268) = 87.79, p < .001, partial η2 = .249, with women without chronic disease reporting higher levels of orgasmic function (M = 4.64; SD = 1.46) compared with women with chronic disease (M = 2.29; SD = 1.77); for Sexual satisfaction, F(1,268) = 211.82, p < .001, partial η2 = .249, with women without chronic disease reporting higher levels of sexual satisfaction (M = 5.21; SD = 1.11) compared with women with chronic disease (M = 2.69; SD = 0.99); and for (absence of) Sexual pain, F(1,268) = 36.87, p < .001, partial η2 = .122, with women without chronic disease reporting lower levels of sexual pain (M = 4.85; SD = 1.30) compared with women with chronic disease (M = 2.98; SD = 2.26).

A multivariate analysis of variance, with Bonferroni, corrections was performed for assessing the differences between women without chronic disease and women with type 1 DM, type 2 DM, and AH in sexual functioning indexes. Significant main effect were found for type of chronic disease, Wilks’ lambda = 0.36, F(18,259) = 17.61, p < .001, partial η2 = .287.

The univariate analysis revealed that significant main effects were found for Sexual desire, F(3,268) = 9.99, p < .001, partial η2 = .102, for Sexual arousal, F(3,268) = 77.82, p < .001, partial η2 = .469, for Lubrication, F(3,268) = 47.42, p < .001, partial η2 = .350, for Orgasmic function, F(3,268) = 47.77, p < .001, partial η2 = .352, for Sexual satisfaction, F(3,268) = 119.85, p < .001, partial η2 = .577, and for absence of Sexual pain, F(3,268) = 28.51, p < .001, partial η2 = .245.

According to post-hoc comparisons, with the HSD Tukey test, for Sexual desire, the group of women without chronic disease scored significantly higher compared with women with type 1 DM (p < .001), and women with AH (p = .01); and women with type 1 DM scored significantly lower than women with type 2 DM (p = .042). For Sexual arousal, the group of women without chronic disease scored significantly higher compared with other groups of women (p < .001). For Lubrication, the group of women without chronic disease scored significantly higher compared with other groups of women (p < .001), and women with type 1 DM scored significantly higher than women with type 2 DM (p = .036). For Orgasmic function, the group of women without chronic disease scored significantly higher compared with other groups of women (p < .001). For Sexual satisfaction, the group of women without chronic disease scored significantly higher compared with other groups of women (p < .001). For absence of Sexual pain, the group of women without chronic disease scored significantly higher compared with other groups of women (p < .001), and women with type 1 DM scored significantly higher than women with type 2 DM (p = .01).

Discussion

The current study examined differences in quality of life (i.e., physical, psychological, social relations, and environment) and sexual functioning indexes (i.e., sexual desire, sexual arousal, lubrication, orgasmic function, sexual satisfaction, and sexual pain) between women without and with chronic diseases (i.e., type 1 DM, type 2 DM, and AH). The main findings showed that women without chronic disease perceived better physical, psychological, social relationships, and environment quality of life, and experienced greater sexual desire, arousal, lubrication, orgasmic function, sexual satisfaction, and lack of sexual pain than women with chronic diseases.

Regarding quality of life and chronic disease, women with type 1 DM perceived higher physical and psychological quality of life than women with type 2 DM and with AH. Both type 2 DM and AH are considered chronic diseases with late onset (Laakso & Pyörälä, 1985; Piko et al., 2020), which could explain additional difficulties in physical and psychological condition that affect well-being and perceived quality of life. In addition, women with type 2 DM and AH may experience other changes in general health status due to their disease, such as weight gain, limited mobility, or a sedentary lifestyle (Abboud & Karam, 2021; Alidu et al., 2018; Ley et al., 2018; Martins et al., 2021), which may also affect physical and psychological quality of life.

In addition, women with type 1 DM experienced a higher environmental quality of life than women with type 2 DM and with AH, as women with AH perceived a higher environmental quality of life than women with type 2 DM. Regarding the evaluation of environmental conditions, women with type 2 DM perceived a greater impairment in their lives and mentioned more obstacles. It is possible that women with type 2 DM need more medical consultations and had more difficulty enjoying their leisure time. Because the current study is cross-sectional, it is not possible to say whether chronic disease affects environmental conditions or vice versa. A deeper understanding of the phenomena should be explored, but assessment and intervention in women with type 2 DM and their immediate environment is crucial. In the area of social relations domain, no differences were found in relation to the type of chronic disease. The domain of social relationships focuses on interpersonal and intimate relationships, and the current findings suggest that chronic disease negatively affects social interactions without specific clinical conditions having particular impact.

In terms of sexual functioning, no differences were found by type of chronic disease for sexual arousal, orgasmic function, and sexual satisfaction, suggesting that chronic disease negatively affects women’s sexual functioning without any specific impact of medical conditions on arousal, orgasm, and satisfaction. In addition, women with type 2 DM had identical levels of sexual desire as women without chronic disease and greater sexual desire than women with type 1 DM, which is consistent with previous recent findings (van Cauwenberghe et al., 2021). In contrast, women with type 1 DM had higher levels of lubrication and less pain during sexual intercourse compared with women with type 2 DM, which is partially consistent with previous research that suggested that women with type 2 DM are at higher risk for sexual dysfunction than women with type 1 DM (Giraldi & Kristensen, 2010; Schreiner-Engel et al., 1987), and are more likely to experience subclinical sexual difficulties compared to women with type 1 DM (Celik et al., 2015; Schreiner-Engel et al., 1987). However, considering the age gap between the two groups of women, it is possible that decreased levels of lubrication in type 2 DM group may be due to aging process and menopause status. These results suggest that although women with type 2 DM experience greater sexual desire and motivation for sexual activity compared with women with type 1 DM, no significant differences in subjective sexual arousal were observed and lubrication was impaired, which may help explain the perception of pain during intercourse.

Limitations

Despite the relevance of the current findings, the present study has limitations that should be considered when interpreting the results. First, the sample size for the chronic disease groups is relatively small between the groups are substantial, so and future studies should consider larger samples. The age gap between groups, particularly between women with type 1DM and without chronic disease and women with type 2 DM and AH, constituted a significant limitation. The age gap between women with type 1 and 2 diabetes is a global issue (Giraldi & Kristensen, 2010), considering the onset of these clinical conditions. In addition, information was only collected on the presence (or absence) of diagnoses, not on diagnostic history (i.e., history of diagnosis and associated medications). Moreover, current findings rely on the assumption that participants accurately indicate the presence of a chronic disease based only on a clinical diagnosis made by a physician. Little information was also collected on sexual history. The sample was collected online, favoring access by women who have easy Internet access and are familiar with Web surveys. However, during the COVID-19 pandemic, in-person sample collection was discouraged. Future studies should acknowledge and take into account the current limitations in order to plan further research to overcome them.

Conclusions

Chronic disease is a major health concern affecting a large percentage of women worldwide. The current study examined the differences in perceived quality of life and sexual functioning in women with and without chronic diseases, and reinforced the negative association between chronic diseases and quality of life and sexual functioning. In addition, type 2 DM was the chronic disease with the strongest association with poorest quality of life and sexual functioning. Considering that type 2 DM was strongly associated with an unhealthy lifestyle, it is of utmost importance to promote a healthy lifestyle and prevent type 2 DM, reflecting the negative association with quality of life and sexual functioning.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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