Sexual dysfunction in Assyrian/Syrian immigrants and Swedish-born persons with type 2 diabetes
BMC Research Notes
Sexual dysfunction in Assyrian/Syrian immigrants and Swedish-born persons with type 2 diabetes
Marina Taloyan 0 1 3
Alexandre Wajngot 2
Sven-Erik Johansson 1 2 3
Jonas Tovi 2
Kristina Sundquist 1 3
0 Stress Research Institute, Stockholm University , SE −106 91 Stockholm , Sweden
1 Center for Primary Health Care Research, Region Skåne/Lund University , CRC, hus 28, plan 11, Jan Waldenströms gata 35, SUS, 205 02 Malmö , Sweden
2 Karolinska Institutet, Center for Family and Community Medicine , Alfred Nobels allé 12, SE −141 83 Huddinge , Sweden
3 Center for Primary Health Care Research, Region Skåne/Lund University , CRC, hus 28, plan 11, Jan Waldenströms gata 35, SUS, 205 02 Malmö , Sweden
Background: Few studies have investigated sexual dysfunction in immigrant patients with type 2 diabetes in Sweden. The aim of this study was to examine the association between ethnicity and sexual dysfunction and to analyze if this association remains after adjusting for explanatory variables including age, marital status, HbA1c, triglycerides, and hypertension. This cross-sectional study was conducted at four primary health care centers in the Swedish town of Södertälje. A total of 354 persons with type 2 diabetes (173 Assyrians/Syrians and 181 Swedish-born patients) participated in the survey. The main outcome measure was the self-reported presence of sexual dysfunction based on two questions, one regarding loss of ability to have sexual intercourse and the other loss of sexual desire. Response rates were 78% and 86%, respectively. Findings: The total prevalence of loss of ability to have intercourse was 29.5%. In the multivariate models, the odds of loss of ability to have intercourse was significantly higher in the oldest age group (OR = 5.80; 95% CI, 2.33-14.40), in men (OR = 3.33; 95% CI, 1.33-8.30), and in unmarried individuals (OR = 2.40; 95% CI, 1.02-5.70). The odds of reporting loss of sexual desire was higher in Assyrians/Syrians than in Swedish-born patients and increased from 2.00 in the age- and gender-adjusted model to 2.70 in the fully adjusted model when all confounders were taken into account. Conclusions: Sexual dysfunction appears to be more common in Assyrians/Syrians than in Swedish-born patients. Health care workers should actively ask about sexual function in their patients with type 2 diabetes.
Sexual dysfunction; Diabetes type 2; Immigrants; Sweden
Individuals with type 2 diabetes have a higher prevalence
of sexual dysfunction than those without type 2 diabetes
[1,2]. Although type 2 diabetes is more common among
some immigrant groups, few studies have investigated
sexual dysfunction in immigrants with type 2 diabetes.
One of these few studies was a Swedish study exploring
beliefs about health and illness in men with diabetes .
This study showed that sexual function was one of the
most important health-promoting factors for Arab men
and men from the former Yugoslavia, whereas it was less
important among Swedish men . Most studies on the
topic have investigated men and women separately. For
instance, many studies have focused on erectile
dysfunction (ED) in men , which has been recognized as a
complication of diabetes. One study in 1312 Korean
men with type 2 diabetes concluded that they had a six
times higher prevalence of ED than the general male
population . Malavige et al. showed that ED in men
in Sri Lanka was strongly associated with reduced
The effects of diabetes on sexual function have been
less thoroughly studied in women than in men ,
although there is a growing number of studies of female
sexual dysfunction. In Malaysian women, older age,
longer marriage, having many children, and having a
level of higher education were risk factors for sexual
dysfunction . Young Turkish women with type 2
diabetes (mean age: 38.8 years) had a higher prevalence of
lack of libido than age-matched healthy women (77% vs.
20%, respectively) .
A Swedish study assessing sexual function in patients
with chronic disorders found that general sexual
functioning decreased with age and was most common in
patients with diabetes, with loss of erection function a
dominant factor . This was explained by the presence
of microvascular complications, psychiatric disease, and
treatment with nitroglycerine. The same study found
that diabetes was a secondary risk factor for decreased
sexual function in patients with angina pectoris .
In Sweden there are approximately 70,000 to 80,000
Assyrians/Syrians , originating mainly from Turkey,
Syria, Iraq, and Lebanon. About 20,000 Assyrians/
Syrians live in the town of Södertälje. Assyrians/Syrians
are an ancient ethnic group from Mesopotamia whose
Christian religion is an important part of their identity
. Assyrians belong to one of four churches:
SyrianOrthodox, Nestorian, Chaldeian, and Syrian-Catholic.
Individuals from the Syrian-orthodox group and those
who do not want to be defined as Assyrians may identify
themselves as Syrians . Thus, both terms were used
in the present study.
Few studies have investigated sexual
function/dysfunction in immigrants with type 2 diabetes in general or in
Assyrians/Syrians with type 2 diabetes in particular. As
sexual health is an important issue and patients
themselves might be embarrassed to tell their doctor about
their sexual dysfunction, this study aimed to fill this gap
in the literature. To the best of our knowledge, this is
the second study on self-reported sexual health and the
first on self-reported sexual dysfunction in a population
consisting of Assyrians/Syrians and Swedes. Our first
study in the same Assyrian/Syrian sample investigated
dissatisfaction with one’s sexual life compared to
Swedish-born patients with type 2 diabetes . That
study showed no significant ethnic differences in the
dissatisfaction with one’s sexual life .
The first aim of the current study was to examine
whether there is an association between ethnicity and
self-reported sexual dysfunction in patients with type 2
diabetes. The second aim was to analyze whether this
association remained after adjusting for explanatory
variables including age, gender, marital status, raised
triglyceride levels, and hypertension.
Study setting and participants
This study is based on the same survey that was used to
investigate ethnic differences in dissatisfaction with one’s
sexual life and published in BMC Public Health (2010)
. The participants were consecutively selected from
the registers of patients with type 2 diabetes at four
primary health care centers in Södertälje. A total of 354
persons were included in the survey: 173 Assyrians/
Syrians and 181 Swedes. Ethnicity is discussed further in
the section on explanatory variables below. Medical
information and laboratory data were gathered from the
patient records of all participants.
Main outcome measure
The main outcome measure was the presence of sexual
dysfunction. Presence of sexual dysfunction was
ascertained on the basis of the participants’ answers to two
questions about sexual life that were asked as part of a
questionnaire on type 2 diabetes in Assyrians/Syrians
and Swedish-born individuals in Södertälje. Those
questions were not a part of a validated questionnaire and
the purpose of including them in the health survey was
to study subjective perceptions of type 2 diabetes
patients about their sexual life.
The first question was “Do you have the ability to have
sexual intercourse?” Responses were divided into two
groups: “yes” and “no”. The second question was “Do you
have any sexual desire?”, the answers to which were
categorized as “yes” or “no”. Prior to asking the two questions
on sexual life, we stated to the participants that these
particular questions may be perceived as being sensitive,
but we asked them to answer them as well as they could.
Age was divided into three groups: 32–59, 60–69,
and ≥ 70 years. There were similar numbers of patients
in the groups.
Self-reported ethnicity was defined as Assyrian/
Syrian or Swedish-born. The Swedish-born group was
ethnically homogeneous. The Assyrian/Syrian ethnic
group included both first- and second-generation
immigrants; that is, individuals born abroad and individuals
with at least one parent who was born abroad.
There is no registration of ethnicity in official Swedish
statistics; rather, immigrants are identified by country of
birth, parents’ country of birth, and/or citizenship. For
this reason, the identification of potential participants by
ethnicity took place as follows: First, we created a list of
the patients with diabetes type 2 at each of the four
participating primary health care centers. Second, we
identified Swedes and Assyrians/Syrians based on the patients’
surnames and the personnel’s personal knowledge of the
patients. Then, each health care center’s personnel
contacted prospective participants by phone and invited
them to fill out the questionnaire at the primary health
care center. The participants were interviewed
face-toface at the primary health care centers after verbal
agreement by phone. One of the questions in the
questionnaire was about ethnicity. Two persons who
identified themselves as neither Assyrian/Syrian nor
Swedishborn were excluded from the study.
Marital status was divided into two groups: 1)
married or cohabiting and 2) living alone or with children
only. We combined those living alone with those living
with children because of the small number of
participants among Assyrians/Syrians who were living alone.
HbA1c was divided into two groups: normal (≤ 6.0%)
and high (> 6.0%) (Swedish mono-S method ).
Triglycerides were divided into normal (< 1.7 mmol/
L) and increased (≥ 1.7 mmol/L) levels.
Systolic blood pressure was dichotomized as normal (≤
130 mmHg) and high (> 130 mmHg). Diastolic blood
pressure was divided into normal (≤ 80 mmHg) and high
(> 80 mmHg). If systolic blood pressure was > 130 mmHg
and/or the diastolic blood pressure > 80 mmHg, the
patient was considered to be hypertensive; otherwise, the
patient was considered to be non-hypertensive.
Estimation of the prevalence of the outcome variable and
determination of the differences in socio-demographic
and medical characteristics between the two ethnic groups
were performed using several tests. The
KolmogorovSmirnov test was used to explore the parameter
distribution. Correlations were assessed by using Pearson’s and
Spearman’s methods for normally and non-normally
distributed data. In addition, the unpaired two-sided
Student’s t test was used to compare the means of
normally distributed parameters. For comparison of
nonnormally distributed parameters, Mann–Whitney U test
was performed. The statistical software used was Stata
version 9 . Unconditional logistic regression analysis was
applied to estimate the odds ratios (ORs) and 95%
confidence intervals (CIs) for the associations between sexual
dysfunction and the explanatory variables. We created two
models to assess differences in lack of sexual ability: one
model adjusted for age and sex and the other, fully
adjusted model included age, sex, marital status, HbA1c,
triglycerides, and hypertension. We lacked information on
menopausal status and therefore did not control for this
variable. Reference groups were the following: age 32–
59 years, male sex, being married/cohabiting, HbA1c < 6%,
raised triglycerides, and having hypertension. The fit of
the models was judged by the Hosmer-Lemeshow
goodness-of-fit test .
The study was approved by the regional ethical
committee at Karolinska Institutet (reference number 2006/4:8,
2006-09-27). The respondents provided verbal informed
consent for participation in the study and for the
gathering of data from patient records. They gave the same
verbal consent to participate on two occasions: once by
phone and once before starting the face-to-face
interviews at the primary health care centers.
In total, 354 participants filled out the questionnaire.
The Swedish population was somewhat older, with a
mean age of 64 years (range: 32–86 years), as shown in
Table 1. The Assyrian/Syrian population was younger
with a mean age of 61 years (range: 32–83 years). There
seemed to be ethnic differences in the duration of type 2
diabetes, which was self-reported and based on the age
of the participants when the diagnosis was made, but
these differences were not statistically significant. The
same pattern was observed for diabetes control with a
mean HbA1c of 6.1% (SD 1.2) in Swedish-born patients
and 6.3% (SD 1.6) in Assyrians/Syrians.
Table 2 presents the total prevalences of the outcome
variables; 78% of participants (n = 273) answered the first
question about their ability to have sexual intercourse.
Among Assyrians/Syrians the response rate was 65%
(n = 112), and among Swedish-born patients the
response rate was 89% (n = 161). The total prevalence of
lack of ability to have intercourse was 29.5%. No
significant differences were noted between the ethnic groups:
Table 1 Distribution (%, n) and anthropometric data
(means; standard deviations) of background variables in
Assyrian/Syrians and Swedes patients, n = 354
Smoking habits (yes)
Body mass index (MD)
Overweight (25.0 – 29.9)
Obese (≥ 30)
Duration (age of onset) (MD) 54
the prevalence was 28.3% among the Assyrians/Syrians
and 30.4% among the Swedish-born respondents. On
the other hand, there were differences according to sex:
76.5% of men and 23.5% of women reported loss of
ability to have sexual intercourse.
The total response rate for the question about sexual
desire was 86% (n = 301). Among Assyrians/Syrians the
response rate was 76% (n = 132), and among
Swedishborn patients the response rate was 93% (n = 169).
Significant differences were noted in loss of sexual desire
only between Assyrian/Syrian and Swedish women.
In Table 3, ORs for loss of ability to have sexual
intercourse are shown in a model adjusted for age and sex
and in a final model. After adjusting for age and sex, the
odds of loss of ability to have intercourse were 5.00
times higher in those ≥ 70 years of age (95% CI, 2.10–
11.40) than in those 32–59 years old. Furthermore, men
had higher odds of reporting loss of ability to have
sexual intercourse than women (OR = 3.01; 95% CI, 1.30–
7.23). In the fully adjusted model, the odds of reporting
loss of ability to have sexual intercourse was higher in
those aged ≥ 70 years (OR = 5.80; 95% CI, 2.33–14.40), in
men (OR = 3.33; 95% CI, 1.33–8.30). Moreover, the
results for the full model showed that those living alone
or with children had higher odds of reporting loss of
ability to have sexual intercourse (OR = 2.40; 95% CI,
1.02–5.70) than those who were married or cohabiting.
As shown in Table 4, the odds of reporting loss of
sexual desire were two times higher in the Assyrian/Syrian
group than in the Swedish-born participants in the
ageand sex-adjusted model (OR = 2.00; 95% CI, 1.02–4.00).
Both the older age groups (60–69 years and ≥ 70 years)
had higher odds of reporting loss of sexual desire (OR =
2.20 and OR = 4.50, respectively) than the youngest age
group. Women had more than seven times higher odds
of loss of sexual desire than men (OR = 7.10, 95% CI,
In the fully adjusted model, the ORs for reporting loss
of sexual desire remained higher for the oldest age group
(OR = 4.60; 95% CI, 2.00–11.00) and for women (OR =
6.54; 95% CI, 3.40–13.00), regardless of ethnicity.
Furthermore, those who lived without a partner had higher
odds of loss of sexual desire than married individuals
(OR = 2.42; 95% CI, 1.20–5.01). The odds of loss of
sexual desire were significantly higher in Assyrians/Syrians
than in Swedish-born subjects (OR = 2.70, 95% CI, 1.30–
5.50). The models were considered acceptable if p was <
0.05 in a likelihood ratio test. All models met this
In this study, the self-reported loss of ability to have
intercourse was not associated with ethnicity. On the
other hand, self-reported loss of sexual desire was
independently associated with ethnicity (Assyrian/Syrian
vs. Swedish-born) in the fully adjusted model. In
addition, loss of ability to have intercourse was
independently related to older age, male sex, and living
without a partner.
Advanced age is a risk factor for poor general health
[17,18] and diabetes . The sexual lives of individuals
are influenced by several health and socio-demographic
factors. According to studies investigating this subject,
the following are risk factors for the absence of a normal
sexual life in diabetic individuals: sexual dissatisfaction,
lack of orgasm/erection, low sexual arousal, lack of
lubrication, and sexual pain. A study of 230 married
Malaysian women showed that factors such as older age,
being married more than 14 years, and having less
sexual intercourse were associated with a lack of lubrication
. A large study of 7,243 healthy middle-aged women
aged 40–59 found that the prevalence of sexual
dysfunction was high but differed between different populations.
The most important associated risk factor was a
decrease in vaginal lubrication. Additionally, and in
contrast to the study of Malaysian women, higher
educational level protected against sexual dysfunction
. The female participants of Assyrian/Syrian origin
in the present study have a low educational level and
20% of the Assyrian/Syrian participants are illiterate
[25% of women and 14.6% of men], which may highlight
the need for prospective studies exploring the
association between educational level and sexual life.
Sexual dysfunction in women might be related to the
menopausal status and the negative impact of
menopause on sexuality [21,22]. A study in American women
aged 30 to 70 years who had been in stable relationships
for more than 3 months concluded that the prevalence
of low sexual desire is higher in menopausal women
than in premenopausal women . Another study
assessing the prevalence of sexual dysfunction in
premenopausal women showed that, compared to the control
group, those with the metabolic syndrome had reduced
sexual function . The associations between sexuality,
hyperglycemia, elevated body weight, and the metabolic
syndrome are also strong in menopausal women .
Relationships between hyperglycemia and higher BMI
and lipid abnormalities were observed in several studies
[26-28]. Despite the fact that 48% of the participants in
the current study had BMI values higher than 30 kg/m2,
the BMI variable was not a statistically significant
confounder. Our results are based on self-reporting, and
physical health and culture may have influenced the
responses to sensitive questions on sexuality. It is
important to note that, due to cultural and religious values,
individuals with an Assyrian/Syrian ethnic background
were presumed to only have a sexual life within the
context of marriage .
Assyrians/Syrians are an ancient ethnic group from
Mesopotamia. The Christian religion is one of the
important parts of their identity . The majority of the
participants in the present study accepted their diabetes
as being sent by God and the separation from or loss of
a life partner was not followed by another partner. “We
do not do that”, said the separated woman when we
asked whether she had a sexual partner or not. Perhaps
this was one of the reasons for the proportion of
Assyrians/Syrians who responded to this question being
smaller compared to the proportion of Swedish-born
participants. On the other hand, patients’ perceptions of
sex and sexual practices may be individual. This might
be investigated more deeply using valid and standardized
scales on sexual life and sexual function.
Strengths and limitations
This study has several strengths. Registration by
ethnicity does not occur in the official Swedish statistics,
where immigrants are identified according to country of
birth, parents’ country of birth, and/or citizenship. A
unique feature of this study is the use of data on
selfreported ethnicity and its main strength is that it is the
first study of sexual life in Assyrians/Syrians with type 2
diabetes. Another strength of this study is the inclusion
of patients from several health care centers; the sample
can therefore be considered highly representative of
Assyrians/Syrians in Södertälje.
One limitation of the study is that the instrument used
to explore sexual dysfunction has not been validated.
Another limitation is that it assessed Assyrian/Syrian
patients with type 2 diabetes living in one town and the
results cannot therefore be generalized to the entire
Assyrian/Syrian population with diabetes in Sweden. A
third limitation is that the cross-sectional nature of the
study and the relatively small sample size precluded the
possibility of drawing extensive causal conclusions.
Loss of sexual desire was independently associated with
ethnicity (Assyrian/Syrian vs. Swedish-born) in the fully
adjusted model. Sexual function is an important part of
general health status and quality of life and should be
included in the clinical evaluation of patients with type 2
diabetes. The results of this study suggest that physicians
and other health care workers should feel encouraged to
ask about sexual function in their patients, regardless of
the patients’ ethnic background, age, or sex.
MT conceived the idea for the survey. MT, AW, JT, SEJ and KS designed the
study. MT and SEJ performed the statistical analysis. MT drafted the
manuscript. KS, AW, JT and SEJ revised the manuscript. All authors read and
approved the final manuscript.
This work was supported by grants from the Research Unit in Södertälje, the
Swedish Research Council (2008–3110), the Swedish Council for Working Life
and Social Research (2007–1754 and 2007–1962) and the Swedish Research
Council Formas (2007–1352).
The authors had no conflicts of interest. The funding bodies played no role
in the study design or the collection, analysis, and interpretation of data, the
writing of the manuscript, or the decision to submit the manuscript for
publication. We thank all the GPs and personnel at the primary health care
centers who contributed to the study by gathering data. Furthermore, we
thank Scientific Editor Kimberly Kane and Stephen Gilliver for linguistic
revision of the manuscript and useful comments on the text.
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