The present study examines sexual behaviors in T1DM adolescents in comparison with their healthy peers and the factors affecting them. To the best of our knowledge, there are limited previous studies regarding sexual activity in T1DM adolescents in comparison with their healthy counterparts and the majority of them did not include control populations [5, 10], while this is the first relative study in Greece.
Chronic conditions affect transition of children to adolescence in multiple ways, including sexual exploration. In our study a significantly lower percentage of T1DM adolescents reported that they have had any sexual experience compared to their healthy peers. On the contrary no difference was reported in sexual intercourse. Similar results have also been reported by other authors, suggesting increased cautiousness and hesitance regarding sex from adolescents with T1DM [3, 11, 12]. This can be attributed to various reasons. Studies have shown that adolescents living with T1DM feel different from their peers, hence they prefer social withdrawal. They are constantly worried about being disdained or discriminated [13]. Additionally, they often develop negative emotions, such as shame, irritation and sadness and are at higher risk of depression [14, 15]. Hence, they will avoid emotional relationships with peers and eventually have fewer sexual experiences compared to healthy adolescents.
Another possible explanation for the reduced number of T1DM adolescents who have had any sexual experience is the fear of hypoglycemia during sexual activity. It has been reported in the literature, that in children and adolescents with T1DM, as well as in their parents, the fear of hypoglycemia is a significant clinical burden [16]. Additionally, in a previous study on young adult patients with T1DM, one-third of the study population has reported fear of hypoglycemia during sex, mostly singles and those who experienced hypoglycemia in the past [17]. Therefore, adolescents with T1DM, prefer to abstain from sexual activities or to modify their sexual lifestyle.
An important finding of this study is that female adolescents in both groups had lower sexual activity, compared to males. Previous studies have shown that adolescent girls with T1DM have lower percentage of sexual intercourse, compared to healthy counterparts, whereas no difference was noted in boys [17]. On the other hand, two other studies revealed no difference in terms of sexual activity between girls with T1DM and healthy counterparts, nevertheless these studies included adolescents with other chronic diseases, which differently affect everyday life [18, 19]. Gender differences in sexuality have been previously reported with men being more prone to sexual experiences [20]. These differences are more obvious during adolescence and are dictated by social norms which encourage girls to abstain from having sex. This is especially evident in Greece, whereas social environment and family greatly influence adolescents and traditional values dictate that girls should not engage in sexual relationships but seek love [21]. Another reason making female adolescents with T1DM more restrained is the fear of unplanned pregnancy or sexually transmitted diseases and their effect on diabetes [4]. Furthermore, the psychological impact of the disease is more pronounced in female patients, which also affects their quality of life and relationships with the other sex, due to low self-esteem [22].
In the present study the mean age of first sexual experience was 14.7 ± 1.5 years for the controls and 14.5 ± 2.3 years for the TIDM group and was similar in both groups. The mean age of first sexual intercourse was also similar in both study groups, at 15.2 ± 1.5 years for the controls and 15.9 ± 1.8 years for the TIDM group. Similarly in a study by Schwartz et al [5] on 89 T1DM adolescents from the USA the mean age of sexual debut was 15 years. The absence of difference between T1DM and healthy adolescents underlines the influence of other factors, rather than the presence of chronic disease, in the decision of when to commence sexual activity. Studies have revealed that the most influential factors in late adolescent sexuality are the social background, family, school, and peer contexts [23].
In our study we found that the age at first sexual experience and sexual intercourse of T1DM adolescents was inversely associated with maternal education level, thus higher maternal education was associated with earlier sexual debut. There is a controversy in the literature regarding parental educational status and early sexual debut. Studies from the USA and Sweden have shown that better socioeconomic level of the parents delay the age of first sexual experience [24, 25]. This can be attributed to the mechanism of “parental control”, which means that well educated parents are easier to monitor, advice and protect children from adverse events that could be associated with early sexual debut. On the contrary, in agreement with our study, Guetto et al have found that higher parental socioeconomic status and education was accelerating the sexual debut of Italian University students, effect which was influenced by low parental religiosity, higher level of sex communication and parental permissiveness [26]. The authors have stated that the higher education would allow the parents to be open with their children about sex and offer appropriate information to ensure that the offspring will have a higher chance of early, but safe intercourse. In a study by Valle et al on Norwegian 16-year-old adolescents it was found that for girls the association of age at sexual debut and social class was linear, with the highest proportions of early sexual debut found among working classes. Inversely for boys it was U-shaped, with upper managerial and working-class youths having higher proportions of early debutants [27].
Moreover, in the present study the age at first sexual experience and sexual intercourse were both negatively associated with HbA1c levels, indicating that early sexual debut was associated with poorer glycemic control. The early onset of sexual intercourse in adolescents has been associated with substance use, eating disorders, low self-esteem, antisocial personality, depression, suicidal ideation, and suicide attempts [28]. Additionally, for many adolescents, the constant effort to cope with the condition may often result in excessive level of stress, depression and a decrease in the level of quality of life. Consequently, it is highly likely that adolescents become disobedient, which may result in worsening of their self-management and in impaired metabolic control [29]. Hence, the association of poor metabolic control and early onset of sexual relations can be explained by the negative psychological impact that T1DM has on adolescents.
Our study has some limitations. First, due to the cross-sectional study design, the causal relationship between independent and dependent variables was partly restrained. Secondly, the study comes from one center and the size of the population was relatively small, which may have prevented the achievement of statistically significant results. Third, sexual behaviours were self-reported and could have been affected by poor recall, or motivational biases, since reporting sexual activities in Greece is difficult for teenagers and the responses may not accurately reflect reality. Nevertheless, these limitations were addressed by ensuring anonymity and privacy and by using a well validated and accurate questionnaire. Our study population is representative of the Greek adolescent population with T1DM, as our Diabetes Unit belongs to a University Department of a Tertiary Children’s Hospital, which is a referral center for central and southern Greece and the islands. This is the first study in Greece and one of the few in the literature that has investigated in depth sexual behaviors in adolescents with T1DM. Moreover, our study is among the very few in the literature including a healthy control group, collected from schools (matching 1:2).