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ISSN: 2320–1959 Volume 10, Issue 6 (2021), PP 22-29

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The Association of Female Sexual Dysfunction and Type 2

Diabetes: A systematic Review Protocol
UGWU, A1 and OSSAI-CHIDI LN2.
1Department of Internal Medicine, University of Port Harcourt Teaching Hospital, Rivers state, Nigeria.
2School of Public Health, University of Port Harcourt, Rivers state, Nigeria

Abstract
The World Health Organization estimates that about 422 million people worldwide have diabetes,
the majority living in low-and middle-income countries, and 1.6 million deaths are directly
attributed to diabetes each year. Female sexual dysfunction (FSD) has been found to have
increased in prevalence in both persons with type 1 and type 2 diabetes mellitus when compared
to controls. A systematic review is expected to the prevalence and factors associated with sexual
dysfunction in women with type 2 diabetes. To identify appropriate and relevant studies for the
review, the following databases will be searched; MEDLINE, Embase, Cumulative Index of
Nursing and Allied Health Literature (CINAHL), Global Health, PsycINFO, African Journals
Online and African Index Medicus. We will also hand search reference lists of relevant studies to
identify further literature of interest.
1. Background
Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood
sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and
nerves. The most common is type 2 diabetes, usually in adults, which occurs when the body
becomes resistant to insulin or doesn't make enough insulin. The World Health Organization
estimates that about 422 million people worldwide have diabetes, the majority living in low-and
middle-income countries, and 1.6 million deaths are directly attributed to diabetes each year(1).
Diabetes mellitus (DM) can potentially lead to multiple difficulties in various areas of life, ranging
from quite well-known physical complications to psychological symptoms, which include
disturbances in sexual function. However, this impact on sexual function has long been
investigated mainly in men, and although there are some relevant papers in women dating back to
the 1970s and 1980s, this issue has not been specifically addressed until more recently(2–5).

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Sexual dysfunction in women is characterized by problems with sexual desire as well as

psychological and physiological problems that affect the normal sexual response cycle. Sexual
dysfunction in females has been less studied, despite the high prevalence (78.7%) of sexual
dysfunction amongst females living with diabetes mellitus(6). Female sexual dysfunction (FSD)
has been found to have increased in prevalence in both persons with type 1 and type 2 diabetes
mellitus when compared to controls(7). No global prevalence has been determined. The earliest
published study of sexual dysfunction amongst females living with diabetes was done in 1971 by
Kolodny(8), in which a greater prevalence was recorded amongst females living with diabetes
(35.2%) when compared with controls (6%). A direct association between sexual dysfunction and
the duration of diabetes was found; however, no association was established with age, insulin dose
or presence of complications.

Female sexual dysfunction is affected by varying factors such as psychological, endocrine,

neurological and vascular disorders(5). Cultural and religious misconceptions with regards to
sexual behaviour and sexual needs of women as well as partner/spouse interrelationship and
conflicts all adversely affect the presentation and expression of sexual dysfunction in women(2,3).
In culture restricted communities, lack of and expression of sexual desire by females is regarded
as normal and or a taboo respectively. These contribute to the low reportage on sexual/sexuality
problems among females(3).
Sexual health remains an important, but somewhat understudied component of healthcare in
people living with diabetes mellitus. Results of some studies done have shown a wide range (20-
80%) and as high as 94.4% in the prevalence of female sexual dysfunction in people living with
diabetes(2,4). However, sexual research has beamed its spotlight more on men living with
diabetes, considered to be at increased risk for impaired sexual function. Sexual research in
females living with diabetes has focused more on menstrual disorders, genital infections, oral
contraception and hormone replacement therapy. Understanding FSD is challenging as it is
complicated, multi-faceted and progressive. Thus, the aim of this systematic review and meta-
analysis is to answer the questions, what is the prevalence and factors associated with sexual
dysfunction in women with type 2 diabetes.

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2. Methods
The development and reporting of this protocol will be in accordance with the Preferred Reporting
Items for Systematic Review and Meta-Analyses Protocols (PRISMA-P) 2015 statement(9). This
protocol will be registered with the International Prospective Register for Systematic Reviews
(PROSPERO).

2.1 Study selection criteria

A summary of the participants, interventions, comparators and outcomes considered, as well as
the type of studies included according to PICOS strategy, is provided in Table 1.
Table 1: Criteria for study selection
Population Females with type II diabetes
Intervention Type II Diabetes
Comparison Females with no diabetes
Outcome Female Sexual Dysfunction

2.2 Search Strategy

To identify appropriate and relevant studies for the review, the following databases will be
searched; MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature
(CINAHL), Global Health, PsycINFO, African Journals Online and African Index Medicus. We
will also hand search reference lists of relevant studies to identify further literature of interest.
Additionally, we will use ProQuest Dissertation & Theses, Web of Science, Google Scholar and
Google search engine to identify grey literature such as government and institutional reports,
theses and dissertations, as well as to track citations. Key authors for studies that meet eligibility
criteria will be contacted if there is some missing information or full texts of their studies cannot
be accessed. A comprehensive search strategy and terms was developed by the team in
collaboration with a medical librarian. We will conduct a broad search, adopting some search terms
from previous systematic reviews on the topic(10–12). Search terms will include “sexual
dysfunction”, “diabetes”, “prevalence”, and their synonyms. Medical subject headings (MeSH)
and key texts words will be developed and combined with Boolean operators “AND” and/ “OR”

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across and within categories. A full search strategy for MEDLINE database is provided in Table
2, and will be tested and adapted to other databases.

Table 2: Full search strategy for MEDLINE

1 sexual dysfunction*mp
2 female sexual dysfunction*mp
3 prevalence$diabetes$female*mp
4 1 OR 2 AND 3
5 type ii diabetes$female*mp]
6 risk$diabetes*mp
7 risk$sexual dysfunction*mp
8 5 AND 6 AND 7
9 4 AND 8
10 4 OR 8
11 4 AND 8 AND 9 AND 10

2.3 Data Collection and Analysis

2.3.1 Selection Process

For the first stage of the review, titles and abstracts of potentially eligible studies identified through
electronic database searches, will be extracted to Endnote Library (EndnoteX9). Duplicates will
be removed (both via Endnote function, and manual checking). Two reviewers will then
independently review the titles and abstracts of the remaining studies to identify studies that
potentially meet the inclusion criteria. If any discrepancies arise the two reviewers will discuss
them and reach an agreement, with a third reviewer providing input. Selection of full text studies
against the eligibility criteria will be carried out independently by the two reviewers. The third
reviewer will also randomly check 10% of selected studies to check for consistency. Reasons for
excluding studies will be documented throughout the process. A PRISMA flow diagram will be
used to outline the literature search and selection process as shown in Figure 1.

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Identification

# of records identified through # of additional records

database searching identified through other sources

# of records after duplicates removed

Screening

# of records screened # of records excluded

Eligibility

# of full-text articles # of full-text articles

assessed for eligibility excluded, with reasons

# of studies included in
qualitative synthesis
Included

# of studies included in
quantitative synthesis
(meta-analysis)

Figure 1: PRISMA-P Flowchart(13)

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2.3.2 Data Extraction

Data extraction from selected studies will be carried out independently by two reviewers. In the
event that there are disagreements, there will be discussions between the two reviewers and if a
consensus is not reached the third reviewer will adjudicate. The team will develop a data extraction
form which will be pre-tested. Key study characteristics are shown in Table 3 below

Table 3: Key study characteristics

Study Characteristics

1.Authors, publication year and source of funding

2.Title and journal

3.Year of study

4.Country of study and location

5.Study design

6.Sample size

7.Study population characteristics (age, any other measures such as rural/urban setting, education level)

8.Definition of sexual dysfunction

9.Measure of prevalence of diabetes (simple diseases counts or weighted indices)

10.Source of prevalence data (self-reported, clinical records)

2.3.3 Quality Assessment

We will evaluate the overall quality of individual studies using the Joanna Briggs Institute
Prevalence Critical Appraisal Tool(14). This tool appraises external and internal validity of each
individual study by addressing issues of representativeness of sample, recruitment of participants,
identification of the condition, its measurement and statistical analysis among others. Two
reviewers will independently assess the quality of included studies and disagreements will be
resolved through discussions with a third reviewer.

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2.3.4 Data Analysis

We will conduct a narrative synthesis of data from all included studies using “Guidance On The
Conduct of Narrative Synthesis In Systematic Reviews”(14). We will generate evidence tables to
summarise, descriptively, study and participants’ characteristics. Characteristics of comorbidity
studies versus multimorbidity will also be captured in table format. We anticipate that potential
studies that will meet the inclusion criteria, are likely to be heterogeneous in different features such
as study population, settings and data sources hence we expect that meta-analysis might not be
suitable(14). However, if there are sufficient data that we are able to synthesise through meta-
analysis, we will estimate a pooled prevalence of female sexual dysfunction among diabetics using
random effects model together with their 95% confidence intervals (CI). Heterogeneity of studies
will be assessed using the I2 statistic. An I2 value of 25%, 50% and 75% indicating low, medium
and high heterogeneity, respectively.

3. Conclusion

This review will identify and summarise evidence on the burden of female sexual dysfunction
among type II diabetics. Results of this review will be published in peer reviewed journals and
shared through relevant academic conferences.

References
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