Sex and Diabetes: Some Hard Questions

Dear Sex and Diabetes: I’m a disabled veteran. Type I diabetes ended my 14-year Army career in 1994.  I got married in 1999. About 3 years later, erectile dysfunction (ED) reared its ugly head. I tried various pills to help with erections, but nothing worked.  In the meantime, I lost my health insurance and had to fall back on Veterans Affairs (VA) health care.  Last week I had a urology appointment and, among other issues, discussed getting help for ED. 

I was advised that before a treatment strategy could be implemented, I’d be required to attend a regularly scheduled “impotence class” with other veterans.  I was told that it would cover symptoms and various treatment options.  I am not ecstatic to be required to attend such a thing! This is not a part of my life that I take pleasure in sharing with others.  In fact, the more I think of it, the more appalled, humiliated, and furious I become.

Before I really go off the handle about this, am I right in thinking that this type of forum is not really an appropriate clinical practice, or am I just being hypersensitive?  If I am right, to whom should I voice my concerns? If I do attend, can I wear a burkha to hide my face?

Upset Vet

Dear Vet,

“Impotence class,” huh?  We thought we’d heard it all.  Support groups and classes can be good things, and the VA does provide some good care, but sexual function is not usually the time, place, or subject for group medicine. 

We did a Google search for “impotence class” and got exactly zero appropriate results.  There’s no such thing. We know why they’re doing this, of course. They’re setting up barriers to care and hoping you give up.  If they wanted to help, they could just hand you a brochure. It would be cheaper and more effective.

You mentioned “pills not working.”  The main ED pills, Viagra (sildenafil), Cialis (), and Levitra () work by relaxing the blood vessels that bring blood to the penis.  The first one, sildenafil, was developed to treat high blood pressure and chest pain (angina). It didn’t work so well for those, but had the side effect of strengthening men’s erections. Lucky for Pfizer!

In the penis are two spaces called the corpus cavernosum, filled with spongy tissue. When a man is aroused, blood flows into the sponges, and the penis swells.  Diabetes, hypertension, and aging, however, can reduce the blood flow, blocking erections.  Reduced nerve function, depression, and the side effects of medications can also prevent erections.

The pills often work and are considered very safe. Viagra and Levitra are faster; Cialis is much longer lasting. But if they don’t work because blood vessels are too blocked or nerves too damaged, there are other approaches.  Hormone-like substances called prostaglandins can be injected directly into the penis with a needle; or a tiny pill containing them can be inserted into the tip of the penis, causing erection.  Sometimes these cause irritation, and using them is too annoying for some people. Read about the pluses and minuses here.

Another option is the vacuum pump. It’s a plastic tube with a pump attached. You put it over the penis and pump the air out. The resulting vacuum draws blood into the corpus cavernosum.  Once the penis is hard, there is an elastic band in the tube that you slide over the base of the penis to keep the blood from flowing back out. This seems to work for more than half the men who try it.

If you can get hard for a moment, but don’t stay hard, you can use a “cock ring” like the one that comes with the vacuum pump. These rings are tight enough to keep blood from flowing out of the penis, but not so tight as to keep it from flowing in. They’re safe to leave on for about 30 minutes.  It might be hot to let your partner put the ring on for you.

You can also go surgical with a penis prosthesis. It’s two inflatable tubes that are surgically placed in the corpus cavernosum, connected to a reservoir of fluid. The reservoir is placed under the pelvic muscles. A squeeze pump is connected to the reservoir and sits under the loose skin of the scrotum, between the testicles. To inflate the prosthesis, the man presses on the pump. Most guys are very happy with this system. It’s not noticeable to others or hard to use, although it will damage what is left of your natural erection response. 

But you are missing a great bet if you don’t take the time to learn about non-intercourse sex.  You can learn to get a woman off with your hands, mouth, and/or toys, and it might be better than intercourse for her. Most men can also have great pleasure, including orgasms, without erections. Explore. You can write us to get some info on using your hands to please women.

And don’t give up on the pills. Perhaps if you get tighter glucose control or just better general health, they might start working. Also, consider whether psychological issues (like anxiety, depression, or relationship problems) could be contributing to your erection problems. They often do. 

Veteran’s Affairs
This impotence class thing is ridiculous. You should take this up with your primary MD or the clinic administrator.  If you do decide to attend, your burkha idea might help them see the error of their ways.  (If you wear one, please take a picture and send it to us.)

Don’t forget to include your partner, if you have one, in discussions and decisions.  It might be hard to talk about, but honest talk always helps.  Online support is available for couples and individuals dealing with ED here or here.

Dear Sex and Diabetes,

I am an 18-year-old man who has had type1 diabetes for 15 years. Recently my new girl friend indicated that she wanted to have sex for the first time. However, I am afraid that I will be unable to, due to erection problems. Is it true that men who suffer with type 1 will need drugs such as Viagra?

Newbie in Virginia

Hi Newbie,

At 18, you probably won’t have erection problems from diabetes, unless your sugar is poorly controlled.  You might have problems from nerves. If you’re both inexperienced, here’s one bit of advice.  Try it with her on top. Go slow. You’ll like it. 

We got a letter from Sam, who wrote, “There have been times when keeping an erection up was very difficult. When I checked my blood sugar level, it was pretty low.  I could not continue with the sex until I got my sugars back up.” 

So it is probably a good idea to check your sugar beforehand. It may drop a little during sex or afterward, as it might with any exercise.  You’ll feel safer and stronger if your sugar is where it should be.  Thanks for the tip, Sam.


David Spero, RN, is a nurse who has lived for 30 years with multiple sclerosis.  A leading expert on self-care, he has written two books, Diabetes: Sugar-coated Crisis, and The Art of Getting Well. He has learned to maintain and even improve sex and love despite disability and illness. 

Aisha Kassahoun is trained in marriage and family therapy.

Aisha and David present sex and intimacy programs for people with diabetes, people with multiple sclerosis, and  health professionals.  

Visit David and Aisha online at or check out their coaching and counseling services. You can also read David’s blog.

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