Special Issues in Diabetes 205ED. In women, the incidence, prevalence, etiology, and treat-
ment options are much less clear. Studies of sexual dysfunc-
tion in diabetic women, although still lagging behind studies
in men, have improved methodologically over the past
20 years and have provided strong evidence for the presence
of sexual problems in women. Psychosocial factors may be
more strongly related to sexual dysfunction in women than in
men, but this conclusion remains tentative and may be,
in part, linked to the lack of a consistent etiologic factor in
women. Future studies should include longitudinal designs,
larger sample sizes, and control groups; studies in women
should incorporate factors such as diabetes type, menopausal
status, and obesity/body image concerns. Given that sexual
functioning is an important part of life, sexual dysfunction is
integral to the challenge of improving quality of life in indi-
viduals with diabetes.
Hypoglycemia
With the recognition that tight glycemic control can reduce
the risk of complications associated with diabetes (DCCT,
1993; UKPDS, 1998), intensi“ed treatment regimens (e.g.,
multiple daily insulin injections, subcutaneous insulin pumps)
have been increasingly important in diabetes management.
One well-documented side effect of such tight glycemic con-
trol is hypoglycemia (Cryer, 1994). Hypoglycemia (BG levels
70 mg/dl) has been estimated to occur three times more
often in patients on intensive insulin regimens (DCCT, 1993)
and is more common in patients with a history of hypo-
glycemia and lower BG levels (Gonder-Frederick, Clarke, &
Cox, 1997). Hypoglycemia is designated as either mild or
severe depending on whether the person is able to treat his or
her BG, loses consciousness, and/or experiences seizures.
However, mild hypoglycemia is associated with serious phys-
ical, emotional, and social consequences (Gonder-Frederick,
Clarke, et al., 1997).
Consequences of Hypoglycemia
Hypoglycemia, if undetected and thus untreated, can pro-
gress to loss of consciousness, coma, and death. Severe hy-
poglycemia is the fourth leading cause of mortality in type 1
diabetes (Gonder-Frederick, Cox, & Clarke, 1996). Hypo-
glycemia is also associated with a variety of physical
symptoms as well as behavioral, emotional, and social conse-
quences that may affect patients• quality of life. The symp-
toms of hypoglycemia stem from the autonomic nervous
system•s release of counter-regulatory hormones (such as
epinephrine) to raise BG levels and from neuroglycopenia
(when the brain is not receiving suf“cient glucose for normal
functioning). As reviewed by Gonder-Frederick et al. (1996),
there are many autonomic (e.g., tachycardia, sweating, shak-
ing) and neuroglycopenic (e.g., dif“culty concentrating,
lightheadedness, lack of coordination) symptoms stem-
ming from these physiological changes. Task performance
may therefore decline with hypoglycemia, with obvious im-
plications for occupational and educational functioning (Cox,
Gonder-Frederick, & Clarke, 1996). The emotional sequelae
of hypoglycemia may include transient mood changes (e.g.,
irritability, tension) due to neuroglycopenia (Gonder-
Frederick, Clarke, et al., 1997), as well as speci“c anxiety sur-
rounding the occurrence of hypoglycemia (Cox et al., 1987).
The Hypoglycemia Fear Survey (Cox et al., 1987) can be
effectively used with patients or family members to ascer-
tain the degree of worry regarding hypoglycemia and the
behavioral consequences of their fear. In addition, Gonder-
Frederick et al. (1996) have provided useful clinical
guidelines regarding such assessment. The social conse-
quences of hypoglycemia may include embarrassment when
hypoglycemia occurs in public, work-related problems, and
interpersonal problems (e.g., con”ict both during hypo-
glycemia and afterwards; Gonder-Frederick, Clarke, et al.,
1997). The long-term effects of repeated hypoglycemia on re-
lationship dynamics and satisfaction is a fruitful area for
future research.Detection of HypoglycemiaImportantly, the symptoms of hypoglycemia and the thresh-
old for their occurrence differ both between persons and
within individuals over time and situations. In fact, patients
may fail to detect hypoglycemia half of the time that it occurs
(Clarke et al., 1995), possibly due to inattentiveness (e.g.,
being distracted by competing demands); inaccurate symp-
tom beliefs (e.g., using unreliable or inaccurate symptoms to
detect hypoglycemia); and/or misattribution of symptoms
(e.g., misattributing symptoms of actual hypoglycemia to an-
other cause). All of these factors may be readily assessed and
used as a focus of treatment in diabetes patients.
To enhance patients• awareness and use of appropriate
corrective actions to treat the hypoglycemia, Cox and col-
leagues have developed a manualized behavioral group
treatment program, Blood Glucose Awareness Training
(BGAT; Cox, Carter, Gonder-Frederick, Clarke, & Pohl,
1988). The intervention program is designed to teach persons
with diabetes to anticipate when hypoglycemia may occur,
to prevent its occurrence when possible, to be aware of their
symptoms of hypoglycemia, and to engage in appropriate
corrective actions to treat hypoglycemia when it occurs. To
do this, the program involves an individualized educational