A qualitative study of the experience of female diabetes mellitus type II with sexual diffusion

The sexuality of women with diabetes mellitus has not received much attention from the health team because patients rarely complain about it. This is related to cultural factors that are considered taboo. Research related to a sexual dysfunction that occurs in women with DM is relatively low. This study aims to explore the experiences of female patients with type II DM who experience sexual dysfunction. This study used a phenomenological qualitative design, 8 participants were women with type II DM. The results of this study showed the impact of sexual dysfunction greatly affected the quality of life of the participants, where participants experienced disturbances when having sexual intercourse namely decreased desire, and pain during intercourse, creating feelings of guilt then resulting in disharmony in the household which can trigger psychological problems namely feeling low self-esteem, disturbed body image, and depression. The role of the health team is necessary to carry out early screening and sexual assessment in patients with DM to find out whether there is a sexual dysfunction disorder. Sexologist is also needed in dealing with patients who experience sexual dysfunction due to type II DM so they can arrange appropriate interventions.

This open access article is under the CC-BY-SA license.

INTRODUCTION
Diabetes mellitus (DM) is one of the chronic diseases which is a major problem in the world of health (Diabetes Federation International, 2019). Data according to the World Health Organization (WHO) there are 422 million people in the world suffering from diabetes mellitus. As many as 8.5% are experienced by adults, as well as 2.2 million deaths as a result of diabetes mellitus from the American Diabetes Association (ADA, 2019). Indonesia is ranked 4th out of ten global countries, the problem of diabetes mellitus is 8.6% of the total population, an estimated increase of 8.4 million people. The International Diabetes Federation Organization (2019) estimates that there will be 436 million people aged 20-70 years in the world suffering from diabetes in 2019, or the equivalent using a prevalence rate of 9.3% of the total population at the same age. According to the International Diabetes Federation (IDF) classified by gender, the prevalence of diabetes in 2019 is around 9% in females and around 9.65% in males.
Data from the Indonesian Ministry of Health (2020) when classified according to gender the prevalence of DM in 2018 was 1.2% in males while females were around 1.8%. The prevalence rate of DM in Yogyakarta city is around 4.9%, Bantul district is around 3% (Basic Health Research, 2018). According to Basic Health Research data (2018), it was found that the prevalence of DM cases in females was higher than in males, with a comparison of cases of DM cases in females of 1.78% while cases of DM in males were 1.21 %. The data shows that there has been an increase in DM cases based on the results of Basic Health Research (2013) in females who experience new DM by around 1.7% and 1.4% in males.
Diabetes mellitus can cause complications such as macrovascular that causes blockage of large blood vessels in the heart and brain that can have adverse and even fatal effects. Large blood vessels in the lower extremities can experience blockages that can trigger foot gangrene. Amputation is an action that is performed mostly in patients with DM due to the appearance of gangrene. Complications in the form of microvascular, namely the presence of blockages in small blood vessels such as those in the kidneys have an impact on the appearance of kidney problems, disturbances in visual function, and result in blindness (Barakat et al., 2021). DM can also cause several problems such as medical problems, psychological problems to sexual dysfunction problems. In the case of males with diabetes, they will experience erectile dysfunction, which is a condition that often occurs and affects the quality of life, whereas, in the cases of females with diabetes, sexual dysfunction causes reproductive health problems, which is very important because it is directly related to sexual function.
The reproductive reality of a female (Lamuhammad, 2017). In line with research from Tahalele (2018) the effect that is experienced if a woman has DM is also a disturbance or decrease in the function of the female reproductive organs. According to Melza's research (2017), it states that the influence of women affected by DM is also directly related to the reproductive function of a woman's organs which causes sexual dysfunction.
The prevalence of sexual dysfunction in women in Asia reaches 40.2%, there is a change in arousal disorders as much as 32.7%, there are disturbances in orgasm as much as 27.5%, there is a feeling of pain 22.1% then there are only 7-13% of patients who come to health services to seek treatment (Lamuhammad, 2017).An international survey obtained 27,500 women with an age range between 40-80 years, found that 39% of women experienced problems related to sexual activity, while the data explained that on average these women were still sexually active (Rahayu et al., 2015). A survey, Asia Pacific Sexual Health and Overall Wellness (APSHOW) were conducted on 3,957 sexually active people consisting of 2,016 men and 1,941 women. The survey covering 13 countries, including Indonesia, gave the following results: (1) 57% of men and 64% of women felt sexually dissatisfied; (2) Sexual satisfaction is strongly related to overall life satisfaction (quality of life); (3) For men and women, satisfaction with erection quality is closely related to sexual satisfaction (Pangkahila, 2014). The results of a study conducted by Ziaei et al., (2010) showed that the incidence of sexual dysfunction in diabetes patients was also high in both women and men. A comparison between 200 patients consisting of 100 males and 100 females showed that 165 people (82.5%) experienced at least one sexual dysfunction.
Disorders of sexual activity can cause sexual dysfunction, sexual dysfunction in women is divided into four types, namely sexual desire, sexual arousal, lubrication, orgasm, satisfaction, and pain. during intercourse (pain) (DwiSahar & Santoso, 2020). According to Pangkahila (2014), sexual dysfunction in men is classified into four groups, namely sexual drive disorders, erectile dysfunction, ejaculatory disorders, and orgasmic disorders. In the case of men with erectile dysfunction, they will experience feelings of annoyance, anxiety, stress, anger, low self-esteem, and shame. This triggers a situation of blaming the wife as the cause, avoiding the wife so she doesn't have sex, and treating her in the wrong way. Likewise, this happens to women who experience sexual dysfunction, will experience the same feelings of feeling disappointed, dissatisfied, irritation, feel guilty for not being able to serve their husbands, and are afraid of their husbands having sexual relations with other women. Furthermore, psychosomatic symptoms can arise, such as difficulty sleeping, headaches, and irritability (Rahayu et al., 2015).
According to research conducted by Rezaei et al., (2020) in Iran, it has been proven that there are changes in sexual function that occur in DM patients caused by protective factors that can impact changes in decreased quality of life, for women with a good level of sexual function will have an impact on changes in improving living conditions for the better while on the contrary with women who experience sexual dysfunction it has the potential to have an impact on reducing the quality of life and the existence of disharmony in the household, one of the main keys for individuals to achieve a good and prosperous quality of life, namely by fulfilling sexual desires.
Sexuality in women with diabetes has not received much attention from the health team. This is because patients rarely complain about it. This is related to cultural factors, especially barriers resulting from telling what is experienced. Research related to a sexual dysfunction that occurs in women is still relatively low. Epidemiological data regarding this matter is still limited, but it is estimated that 43% of women experience complaints of at least one sexual problem (Lamuhammad, 2017). In line with research conducted by Laumann et al., (2015) in Indonesia, stating that the general public still thinks that sex is still a taboo subject that is inappropriate to talk about, the research that has been conducted it is stated that Indonesia is one of still thinks sexuality is not a priority and important thing, even though in reality sexuality has an important role in improving the quality of life. Even though sexual needs are part of basic human needs, based on Maslow's theory, it ranks third, however in reality, the lack of studies regarding sexuality and screening for sexual dysfunction in DM patients has not been touched by medical personnel so that appropriate interventions cannot be arranged (Rahayu et al., 2015). Based on the background described above, it is necessary to conduct an exploration regarding sexuality in women with diabetes mellitus at the Firdaus Primary Clinic, UMY Yogyakarta. This research was carried out at that place because the research location was still included in the UMY area, which provided primary services for educational research, and research had never been carried out at that place with the same title. Based on this, the researcher is therefore interested in researching sexuality in women, because it is still rarely done in Indonesia, and research related to sexuality is considered taboo, because of this reason, the researcher wants to conduct in-depth research with a qualitative design. To find out the experience of sexuality in female diabetes mellitus patients at the Firdaus Primary Clinic UMY, Yogyakarta.

METHODS
This study used a phenomenological design which to assess the experiences of women with type 2 diabetes mellitus related to the phenomenon of sexual dysfunction. Participants in this study were women who controlled DM at the Firdaus Clinic, Bantul Regency, Yogyakarta, aged 18 years and over, women, married, had a history of diabetes mellitus, were not yet menopausal, and were cooperative. The number of participants obtained by researchers was 8 people with visas 8 of these people experienced DM.
The data collection method that the researchers used was in-depth interviews with participants. Data collection was carried out first by participating in personal activities at the clinic, afterward, they approached the participants (BHSP), and then the researchers distributed 30 sheets of FSFI questionnaires to screen informants who experienced sexual dysfunction. After the screening was carried out, 10 people were obtained according to the inclusion criteria for interviews, but 2 participants refused to be interviewed therefore the researchers conducted interviews with 8 participants and fulfilled the data saturation. In this study, active researchers provided semi-structured questions then participants provided to answer the questions asked. The questions asked have been modified from Brief sexual symptoms for Women (BSSC-W, (Bijlsma-Rutte et al., 2017) and the Female Sexual Function Index questionnaire (FSFI) with a grid of questions covering disturbances of sexual interest or desire (desire disorders), lust or arousal disorders (arousal disorder), Orgasmic disorders (orgasmic disorder), sexual pain disorder (sexual pain disorder), Perception of sexual dysfunction, impaired self-esteem. This interview uses a recording device in the form of a voice recorder to record the results of the interview with an interview duration of about 15-60 minutes. The interview was conducted directly at the informant's house, where during the interview the informant was alone without any assistance, the interview was conducted at the informant's home in order to make the informant feel comfortable then the interview was conducted after the informant filled out an informed consent form first.
This inspection technique includes the test of credibility, transferability, dependability, and confirmability. The credibility test is carried out by member checks, preparation of reference materials, and triangulation. The transferability test uses external validity then the researcher describes the process descriptively and includes the coding, themes, and interview excerpts obtained to make it easier for the reader to understand the research being conducted. Dependability and conformability test by checking the processed results to the supervisor. The data analysis method used for this study uses a data analysis process based on Colaizzi's stages (Speziale et al., 2011) with the manual method.

RESULTS
Based on Table 4.1, it shows that all participants were female patients with type II DM who experienced sexual dysfunction at the Firdaus clinic, Yogyakarta. Participants have an age range of 41-48 years. There were 5 participants who worked as households, while there were 3 people who worked as entrepreneurs and 1 person who worked as private employees. The highest distribution of participant education was high school with 3 people, followed by junior high school with 2 people, and participants with elementary education only 1 person, only 1 person with D3, and only 1 person with S1. Based on the length of time they had diabetes mellitus, the most was around 2 years, and the earliest they had DM was around 3 months and had experienced sexual dysfunction.
Based on the result of Based on the result of research conducted by interviewing informants, a plot is described Based on the result of research conducted by interviewing informants, a plot is described regarding the experiences of type II diabetes mellitus female patients who experience sexual dysfunction at the Primary Firdaus Clinic UMY, Yogyakarta. The result of the analysis of the data that has been collected found 3 main themes that describe the experiences of type II diabetes mellitus female patients who experience sexual dysfunction, namely 1) description of sexual dysfunction, 2) Trying to function as a wife, 3) the impact of sexual dysfunction. The following is a visualization of the experiences of female diabetes mellitus type II patients who experience sexual dysfunction at the UMY Primary Clinic, Yogyakarta: research conducted by interviewing informants, a plot is described regarding the experience.

Theme 1: Features of Sexual Dysfunction
This theme describes the picture of sexual dysfunction felt by participants who have type II diabetes mellitus. This theme consists of 2 categories, namely 1) Decreased desire for sexuality, and 2) Pain during sexual intercourse. Based on the results of the interview, it is described as follows: CATEGORY THEME

1) Decreased sexual desire
The results of interviews with participants who had type II diabetes mellitus stated that participants felt a decrease in their desire to have sex. The following is a quote from the participant's statement: "In the beginning, it was still often related, and it was still normal. Now it is easy to get tired, and not as often as before." (P6) "Yes, in the past, I often asked first. Now I feel lazy if I ask first."(P7)

2) Pain during intercourse
The result of interviews with participants who had type II diabetes mellitus stated that participants now experience pain during sexual intercourse. The following is a quote from the participant's statement: "There is pain, now when intercourse." (P1) "Since getting DM, now I feel pain during intercourse.

"(P3)
Theme 2: Trying to carry out the role of a wife This theme describes how the participants are still trying to carry out their functions as wives in having sexual relations even though the participants have type II diabetes mellitus experiencing sexual dysfunction. This theme is divided into 2 categories, namely 1) Keeping in touch even though you are sick, 2) Trying to satisfy your husband. Based on the description of the interview results are described as follows: This category describes how participants try to carry out their functions as wives even though they have type II diabetes mellitus with sexual dysfunction and continue to have sexual intercourse even though they feel pain. Following are the participant statements: "Even though it hurts, I can bear it, I don't say it directly, I just say it slowly sir, the important thing is that my husband will come out" (P7) "Continue slowly. Yes, it's continued, just play slowly, that's it. Until it's finished." (P1) 2) Trying to satisfy husband This category describes how participants with type II diabetes mellitus who experience sexual dysfunction still try to carry out their functions as wives by trying to satisfy their husbands by balancing the husband's desires during sexual intercourse. Following are the participant statements: "Yes, I try to follow the wishes of my partner even though it hurts. The problem is that we are already married, we have to serve well." (P8)

Theme 3: Impact of Sexual Dysfunction
This theme describes the impact felt by participants from sexual dysfunction. This theme consists of 2 categories, namely 1) Feeling guilty, and 2) The household becomes disharmonious. Based on the description of the interview results are described as follows: CATEGORY THEME

1) Feel guilty
In this category, the participants expressed that they felt guilty because they experienced sexual dysfunction since suffering from type II diabetes mellitus. Following are the quotations from the participants' statements: "Yes, does not satisfy the husband for sure. So, I feel a bit bad for my husband." (P6) "Hmm, if I experience that, I feel guilty because I can't serve my husband with satisfaction, perfectly, like that. If we are sick, yes, but if we are healthy, we can serve well, with mutual satisfaction." (P8) 2) The household becomes not harmonious In this category, the participants stated that there was an impact of the sexual dysfunction they experienced. This affects the harmony of the household because the participants are worried that they will not be able to serve their husbands well. Following are the quotations from the participants' statements: "Yes, it affects Ms. I'm afraid that maybe this is what makes a partner interested in other women, right? That must have had an effect there as well, right?" (P7) "You have to continue to serve your husband, right? For example, if you don't serve your husband well, you don't have harmony, that is also a need." (P1)

1) Overview of Sexual Dysfunction
Based on the result of the research, the description of sexual dysfunction felt by the participants made various kinds of disturbances felt by the participants. This picture is like a decrease in sexual desire and pain during sexual intercourse. This certainly can make participants uncomfortable. Reduced desire for sexuality and pain during sexual intercourse due to diabetes mellitus that occurs in women are major reproductive health problems because they are directly related to the physiological function of reproduction. The causes of this disorder include medical Trying to carry out the role of a wife Keeping in touch even though you are sick Trying to satisfy your husband

Impact of Sexual Dysfunction
Feel guilty The household becomes not harmonious and psychological aspects. Of course, this has an unfavorable impact on harmony in a household (Lamuhammad, 2017). According to Bargiota et al., (2011) that the influence of DM on sexuality can affect all aspects of the sexual domain. Pathogenic factors for sexual dysfunction in diabetic women include hyperglycemia, infection, and neurovascular and psychological disorders. The effect of hyperglycemia can reduce hydration in the mucous membranes of the vagina and in vaginal tissue which causes reduced lubrication in the vagina which causes dyspareunia which increases the occurrence of genitourinary infections. Symptoms of genitourinary infection include burning, itching, urgency, vaginal dryness, pain, and feeling of pelvic floor discomfort. Vascular damage due to diabetes can cause local blood flow and inhibition in tightening the clitoris and reducing vaginal lubrication which can cause the weakening of the vaginal muscles so that women who experience sexual dysfunction due to diabetes experience pain disorders (Bargiota et al., 2011).
In line with the research of Rahmanian et al., (2019) sexual dysfunction is a combination of disturbances in a person's ability to respond to sexual response or sexual pleasure. These disorders include abnormalities in female orgasm and decreased sexual arousal (Rahmanian et al., 2019). This occurs due to decreased function of blood vessels and clitoral nerves and degeneration of the autonomic nervous system that occurs in the genital organs of patients with diabetes (Rahmanian et al., 2019).
According to Winkley et al., (2021) the cause of sexual dysfunction in women with DM is due to the high level of depression experienced in diabetics that can cause decreased sex drive. In addition to being bored with all the routine diabetes care starting from glucose monitoring which is done every day which results in lipo hypertrophy around the insulin injection site which can affect body image and selfesteem as well as discomfort in self-managing diabetes that can affect spontaneity in sexual intercourse (Winkley et al., 2021).
Based on the results of the research and discussion above, it can be concluded that the impact of diabetes mellitus greatly affects sexual activity in women to prevent further sexual dysfunction, it is necessary to identify and support patients in self-care. Effective self-management in diabetes treatment is an important step in achieving a healthy and fulfilling life.
2) Trying to carry out the role of a wife Based on the results of this study, it showed that the participants continued to try to carry out their functions as wives, even though the participants experienced pain during sexual intercourse, they still tried to continue having sexual intercourse and tried to satisfy their husbands. This was still carried out by the participants even though they experienced sexual dysfunction.
The results of the above research are in line with research conducted by Supatmi et al., (2020) that a woman who experiences sexual dysfunction will continue to have intimate relations with her partner because wives want to show loyalty to their husbands because of their obligation to meet their husband's sexual needs. Women think that having sex with a partner is something that must be done because this is something that can balance the harmony in their household even though they feel uncomfortable during intercourse due to sexual dysfunction (Supatmi et al., 2020). According to Research from Masood et al., (2021) states that women with diabetes never discuss their sexual problems because they perceive the changes that occur in sexual relations with partners as something that does not need to be uncovered. They still carry out their role as wives to meet the inner needs of their partners (Barbagallo et al., 2020).
Sexual dysfunction often goes undiagnosed and almost always goes untreated. Data on the true prevalence of sexual dysfunction are difficult to obtain and are generally underestimated (Barbagallo et al., 2020). Nowadays, sexual dysfunction in patients with DM is associated with psychogenic factors due to cultural and ethnic causes, sexual dysfunction caused by DM can be ignored in women. In contrast to cases of sexual dysfunction experienced by men, they receive more special attention than cases of sexual dysfunction among women who receive less attention when compared to men, although the risk of developing complications due to DM is the same between the sexes (Yenice et al., 2020).The problem of sexual needs is often ignored from a diagnostic perspective, even though it can affect the lives of DM patients both physically and psychologically. Even though it is a less common occurrence among patients, it is difficult to assess diagnostically. This is also related to cultural factors, especially barriers due to the embarrassment to declare it because it is considered taboo to talk about it. Patients who experience sexual problems found that the average number of patients who consult this problem is still very low (Malik & Purnamasari, 2021).
Based on the result of the research and discussion above, it can be concluded that the wife is still trying to carry out her role to fulfill the needs of her partner's sexual relations even when intercourse feels pain. This can be prevented if there is mutual understanding between the partners and support for treatment so that the wife does not feel guilty and fearful about her household.

3) Impact of Sexual Dysfunction
Based on the results of the study, the impact felt by participants from sexual dysfunction was a feeling of guilt and the household became disharmonious. This greatly affects sexual activity with partners. In line with research conducted by Alikamali et al., (2019) that sexual dysfunction in women will increase the risk of marital dissatisfaction, and physical and mental stress. Certainly, this can reduce the health status and sexual and physical abilities of a person which results in divorce and leads to the destruction of married life.
Even though sexual activity is a normal human activity, and lack of sexual activity can reduce the quality of life and can also affect the dynamic quality of relationships with partners. Patients with diabetes are generally less satisfied with their lives and they are less satisfied with sexuality and passion, compared to individuals who do not suffer from the disease (Malik & Purnamasari, 2021).
Diabetic patients have an increased risk of developing depressive symptoms compared to a healthy population. Depression can significantly impair the quality of life of these patients, including sexual function. Therefore, depression is recognized as the most significant risk factor for sexual dysfunction in women with diabetes and can impair sexual health to varying degrees. Other psychological problems such as changes in self-image, feelings of loneliness, isolation, and loss of attractiveness are common in diabetic women (Barbagallo et al., 2020). This makes a large number of women have lower self-esteem, feel less attractive, accept their low sexuality, and perceive that they are less in the eyes of their partners (Kalra et al., 2018). Based on the results of the research and discussion above, it can be concluded that support from partners is needed to understand the condition of wives who experience sexual dysfunction to prevent divisions in the household.

LIMITATIONS OF THE STUDY
Based on the research process that has been passed, some of the limitations in this study include: Found several participants who answered questions not optimally, because the things asked were related to sensitive matters, Difficulty getting patients because the topics raised were still considered taboo, In the research process required confirmation from the partner, but in this process, the partner did not want to be involved, to participate in the interview, because the partner felt that this was taboo.

CONCLUSIONS AND SUGGESTIONS
Based on the results of the research on the three themes above, it can be concluded that the impact of sexual dysfunction greatly affects the quality of life of participants, where participants experience disturbances when they have to have sexual intercourse, starting from decreased desire, pain during intercourse, causing feelings of guilt and resulting in disharmony in the household that can trigger psychological problems such as feeling low self-esteem, body image disturbance, depression, and anxiety. This can be prevented if there is support from the partner who will understand his wife's condition by encouraging his wife to routinely take medication and express her illness. It is also important for the role of health workers to conduct early sexual screening and assessment in patients with diabetes mellitus to determine whether there is sexual dysfunction or not so that appropriate interventions can be arranged.
Recommendations for this study: Clinics must have SOPs regarding special studies regarding sexual dysfunction in female diabetes mellitus type II patients so that they can carry out earlier screening and hoped that the clinic would have a specific service system for handling sexual dysfunction that occurs in cases of female diabetes mellitus in collaboration with sexologist doctors. For health workers it is necessary to carry out health promotion, both through research, seminars, and social media, it is expected that health workers will do more education and promotion about sexual dysfunction in women so that the community.