SLE might affect all aspects of life including sexual functioning; previous study found that body image disturbance (BID) was the most powerful predictors of impaired partner relationships and sexual function. The current study investigated the relationship among disease parameters, quality of life, the psychological status, BID, and sexual problems in Chinese patients with SLE. A self-report survey design was administered to 168 SLE patients and 210 healthy individuals. Our results showed that 86 (55.1%) SLE patients reported impaired relationships with a sexual partner or partners, and 100 (64.1%) patients reported impaired sexual function which were significantly higher than the control group (31.6%, 35.7%, rep.). Age, marital status, depression, and BIDQ were the most powerful predictors of impaired partner relationships, while BIDQ3 and education, disease activity, and depression were the most significant causes of impaired sexual function. The study for first time reported Chinese SLE patients had sexual problems and BID was associated with sexual problems. So, early detection and interventions might not only rehabilitate the patients and their loved ones, but also improve overall health outcomes and reduce the direct and indirect costs of their medical care.
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease that disproportionately affects young women; women are affected nine times more frequently than men. About two-thirds of patients develop cutaneous manifestations that may be visible, transient, or permanent rashes, scars, depigmentation, skin dimpling, photosensitivity, and hair loss. Arthritis, serositis, nephritis, and hematological and neuropsychiatric problems are common [
Body image disturbance (BID) is commonly defined as the distortion of perceptions or cognitions related to the weight or shape of the body [
Recently studies have reported that vaginal pain symptoms, poorer body image, and fatigue are independent predictors of sexual dysfunction in young breast cancer survivors [
The current study examines the independent association of BID occurrence with sexual function in a Chinese population in order to provide a preliminary analysis of the clinical parameters, disease activity, physical functions, and psychological parameters associated with sexual problems in SLE patients. As a result, the factors most closely linked to a patient’s sexual status can be documented and considered in the design of appropriate clinical treatment strategies.
SLE patients were recruited from The Second Affiliated Hospital of Nantong University from January 2010 to July 2011. A total of 170 SLE patients and 210 healthy individuals were consecutively invited to participate in a single-center cross-sectional study. Healthy individuals were used as the control group. All patients fulfilled the 1997 American College of Rheumatology (ACR) revised criteria for the classification of SLE. Patients were excluded based on the following conditions. (1) They did not complete the questionnaire; (2) they had comorbidities (e.g., serious infections or cardiac, respiratory, gastrointestinal, neurological, or endocrine diseases) that could influence SLE activity. This study was approved by the Ethics Committee of The Second Affiliated Hospital of Nantong University, and written informed consent was obtained from all participants.
SAS was used to evaluate the level of anxiety-related symptoms during the week prior to the survey. This self-administered test had 20 questions, with 15 items reflecting increasing anxiety levels and 5 questions reflecting decreasing anxiety levels. Each question was scored on a scale of 1 to 4 (rarely, sometimes, frequently, and always, resp.). The scores ranged from 20 to 80. Scores greater than 70 suggested severe anxious symptoms, scores between 60 and 69 indicated moderate to marked anxiety, scores between 50 and 59 suggested minimal to mild anxiety, and scores less than 50 indicated no anxious symptoms.
SDS was a 20-item questionnaire designed to assess mood symptoms over the past week (e.g., “I feel downhearted, blue and sad”). Each item was scored on a Likert scale ranging from 1 to 4; scores greater than 70 suggested severe depressive symptoms, scores between 60 and 69 indicated moderate to marked depression, scores between 53 and 59 suggested minimal to mild depression, and scores less than 53 indicated no depressive symptoms.
The patient’s general health status was measured using the Short Form- (SF-) 36 questionnaires, which measured eight multi-item dimensions: physical functioning (PF, 10 items); role limitations due to physical problems (RP, 4 items); role limitations due to emotional problems (RE, 3 items); social functioning (SF, 2 items); mental health (MH, 5 items); energy/vitality (VT, 4 items); body pain (BP, 2 items); and general health perception (GH, 5 items). For each dimension, item scores were coded, summed, and transformed on a scale from 0 (worst possible health state measured by the questionnaire) to 100 (best possible health state).
The Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was used to measure disease activity [
Body image was assessed using the Body Image Disturbance Questionnaire (BIDQ) containing seven scaled items scored from 0 (not affected) to 8 (extremely affected) pertaining to appearance-related concerns (BIDQ1); mental preoccupation (BIDQ2); emotional distress (BIDQ3); social, occupational, or functional impairment (BIDQ4); social life interference (BIDQ5) and educational, occupational, or other functional interferences (BIDQ6); and behavioural avoidance (BIDQ7), as previously described. Average Cronbach’s alpha value is 0.82 [
The questionnaire design was based on modified questions of numbers 13 and 14 of the Body Image Questionnaire provided in the digital form by the King’s College of London, UK (
Questionnaires and other assessments were administered to participants from January 2010 to July 2011. Written questionnaires were provided on papers, and all participants completed the questionnaire under physician’s supervision in a clinical setting. SLEDAI was evaluated by the same clinician for all patients. Nurses counted the results. The results were added to a computer database by 2 research assistants and double-checked against the original data prior to analysis.
All data were expressed as
A total of 170 patients met the eligibility criteria. 8.236% (
Demographic and psychological and disease characteristics in SLE patients and controls.
Variables | SLE patients |
Control subjects |
|
---|---|---|---|
Female gendera | 142 (91.2) | 176 (89.8) | 0.75 |
Age, yearsb | 32.9 ± 10.2 | 35.0 ± 11.4 | 0.19 |
SAS (≥50)a | 32 (20.51) | 14 (7.1) | <0.01 |
SDS (≥53)a | 52 (33.33) | 28 (14.3) | 0.003 |
SLEDAI | 11.8 ± 9.5 | ||
Marital statusb | |||
Single | 30 (19.23) | 56 (18.6) | 0.20 |
Married | 126 (80.76) | 140 (71.4) | |
Educationb | |||
<9 years | 86 (55.12) | 76 (49.0) | 0.46 |
≥9 years | 70 (44.87) | 100 (51.0) | |
Work statusb | |||
Working | 30 (19.23) | 44 (22.5) | 0.58 |
Unemployed | 126 (80.77) | 152 (77.5) | |
Income/personb | |||
≤2000 yuan | 100 (64.10) | 118 (60.2) | 0.68 |
>2000 yuan | 56 (35.90) | 78 (39.8) | |
Menstrual historyb | |||
Normal | 95 (66.90) | 102 (58.0) | 0.25 |
Abnormal | 47 (33.10) | 74 (42.0) |
aMean ± SD; bnumber (percentage). SLE: systemic lupus erythematosus; SAS: revised Self-Rating Anxiety Scale; SDS: revised Self-Rating Depression Scale; SLEDAI: Systemic Lupus Erythematosus Disease Activity Index.
There were significant differences in sexual relationship impairment as observed between SLE patients and healthy individuals. 86 (55.1%) SLE patients reported impaired relationships with a sexual partner or partners, with an overall mean score of
The sexual status in SLE patients in China.
SLE patients ( |
Control subjects ( |
|
---|---|---|
86 (55.1) | 62 (31.6) | <0.001*** |
1.8 ± 2.0 | 1.2 ± 1.3 | 0.0008*** |
100 (64.1) | 70 (35.7) | <0.001*** |
2.6 ± 2.7 | 1.7 ± 2.0 | 0.0004*** |
The effect of SLE on sexual partner relationships showed significant correlation with scores for age (
Relationships between psychological scores, disease parameters, and sexual problems in SLE patients.
Partner relationships | Sexual functions | |||
---|---|---|---|---|
|
|
|
| |
Age | 0.29 |
|
0.06 | 0.59 |
Sex | −0.19 | 0.09 | −0.03 | 0.80 |
BMI | 0.04 | 0.70 | −0.07 | 0.55 |
Marital status | −0.25 |
|
0.1 | 0.39 |
Education | −0.22 | 0.06 | −0.28 |
|
Work status | −0.06 | 0.59 | 0.07 | 0.53 |
Income/person | −0.12 | 0.29 | −0.07 | 0.57 |
Menstrual history | −0.24 |
|
−0.05 | 0.74 |
SLEDAI | 0.24 |
|
0.29 |
|
SAS | 0.09 | 0.42 | 0.1 | 0.36 |
SDS | 0.21 |
|
0.21 |
|
BIDQ1 | −0.27 |
|
−0.25 |
|
BIDQ2 | 0.33 |
|
0.18 | 0.12 |
BIDQ3 | 0.29 |
|
0.3 |
|
BIDQ4 | 0.33 |
|
0.33 |
|
BIDQ5 | 0.29 |
|
0.37 | <0.001 |
BIDQ6 | 0.19 | 0.09 | 0.38 | <0.001 |
BIDQ7 | −0.14 | 0.20 | −0.08 | 0.51 |
SLE: systemic lupus erythematosus; BMI: Body Mass Index; SLEDAI: Systemic Lupus Erythematosus Disease Activity Index; SAS: revised Self-Rating Anxiety Scale; SDS: revised Self-Rating Depression Scale.
Stepwise regression analyses were used to confirm the variables most significantly correlated with psychological problems. The results showed that age, marital status, depression, and BIDQ 3,5,2,1 were the most powerful predictors of impaired partner relationships (
Stepwise regression analyses of medical and psychological variables and their relationship to partner relationships in SLE patients.
Partner relationships | Coef. | SE |
|
|
95% CI |
---|---|---|---|---|---|
Age | 0.07 | 0.03 | 2.73 | 0.009 | 0.02, 0.12 |
Marital status | −1.44 | 0.63 | −2.28 | 0.027 | −2.7, 0.2 |
SDS | 0.77 | 0.46 | 2.86 | <0.001 | 0.45, 0.89 |
BIDQ3 | 0.22 | 0.09 | 2.33 | 0.024 | 0.03, 0.40 |
BIDQ5 | 0.27 | 0.12 | 2.30 | 0.027 | 0.03, 0.52 |
BIDQ2 | 0.28 | 0.11 | 2.55 | 0.014 | 0.06, 0.50 |
BIDQ1 | −0.37 | 0.10 | −3.78 | <0.001 | −0.57, −0.17 |
_cons | 1.19 | 0.17 | 2.41 | 0.034 | 2.1, 2.5 |
Stepwise regression analyses of medical and psychological variables and their relationship with sexual functions in SLE patients.
Sexual functions | Coef. | SE |
|
|
95% CI |
---|---|---|---|---|---|
Q3 | 0.51 | 0.19 | 2.63 | 0.011 | 0.12, 0.90 |
Education | −1.40 | 0.69 | −2.04 | 0.047 | −2.79, −0.02 |
SLEDAI | 0.55 | 0.37 | 2.91 | 0.003 | 0.37, 0.68 |
SDS | 0.25 | 0.19 | 2.53 | 0.034 | 0.14, 0.51 |
_cons | 3.43 | 1.21 | 2.83 | 0.007 | 1.00, 5.9 |
SLE: systemic lupus erythematosus.
SLEDAI: Systemic Lupus Erythematosus Disease Activity Index; SDS: revised Self-Rating Depression Scale.
The associations among demographics, disease-related variables, psychological problems, BID, and sexual problem in Chinese SLE patients are examined, revealing that these SLE patients are much more likely to have impaired sexual health and partner relationships than their healthy counterparts. The current study is novel in that it assesses these parameters in a group representing the Chinese SLE population. These findings should be considered in clinical settings, where sexual health is often overlooked during the treatment of physical symptoms.
The underlying cause of disturbed sexual function in SLE patients is multifaceted, though the physical aspects are most easily assessed [
BID may adversely affect quality of life and result in psychosocial consequences, such as depression, social anxiety, impaired sexual functioning, and poor self-esteem. The effect has been previously demonstrated in body dysmorphic conditions and eating disorders, and it may also affect SLE patients with significant and chronic physical impairments [
This study has several limitations. First, the single-center study design may mean results are not necessarily generalizable to a broader population. Second, BID and sexual problem are not separately analysed in men and women. This is a necessary next step as men and women have a dichotomy of physical build and self-perception of fitness. Third, current treatments of SLE, such as prednisone and toxic immunosuppressive drugs, may adversely affect body image. The study did not focus on the relationship between drug side effects and BID. Finally, psychological factors and sexual problem were analyzed with self-report questionnaires. Thus, further exploration of SLE patients’ BID based on age, gender, and disease severity will be required to comprehensively supervise clinical prognostic guidelines, and further analyses should be conducted with assessment instruments weighted for use in SLE patients.
In summary, the study for first time has reported Chinese SLE patients have sexual problem and BID is associated with sexual problems. So, early detection and interventions may not only rehabilitate the patient and their loved ones, but also improve overall health outcomes and reduce the direct and indirect costs of their medical care. Discussions on changes in body image and the possible effects on patients with SLE need to be encouraged from both sides, by the patients and the physicians. This requires a major shift in the way we assess and provide medical care for these patients. Patients’ beliefs that “doctors care for your body but do not care how you feel about your body” should challenge our approach towards the care of these patients. This requires interdisciplinary health care research, clinical collaboration, and, above all, shifting from a biomedical model to a biopsychosocial model. Increased awareness of the physical and psychological factors will aid rheumatologists and nursing specialists in initiating proper management of this subgroup of SLE patients. Sexual health may be improved by treating BID along with the physical symptoms of SLE.
Systemic lupus erythematosus
Body image disturbance
Body Image Disturbance Questionnaire
Systemic Lupus Erythematosus Disease Activity Index
Self-Rating Anxiety Scale
Self-Rating Depression Scale.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Biyu Shen, Yan He, and Haoyang Chen contributed equally to this work.
This work was supported by the Natural Science Foundation of China (Grant no. 81401124); Science Foundation of Nantong City (Grant no. HS12966); Preventive Medicine Projects from Bureau of Jiangsu Province (Y2012083); and “Top Six Types of Talents” Financial Assistance of Jiangsu Province (Grant no. 10.WSN016).