Table 3 List of themes and subthemes from all nominal groups combined, with representative quotes/responses which are presented in bullets below each theme/subtheme

A. Physical or emotional impact on intimacy

 A1. Physical impact on intimacy: “I had

  • Difficulty with sexual activity due to gout flare pain, gout attack makes it impossible; Your whole body is to break in half if you try to be intimate”;

  • Lack of movement due to joint pain during gout flare;

  • No feeling, can’t feel sex during a flare;

  • Inability to maintain personal hygiene, making people feel less attractive about self;

  • All body pain, which made even touch to the body painful;

  • To lie down in the quiet room in the bed;

  • Inability to perform sexually when in pain;

  • Less desire to have sex;

  • Diarrhea and gas with colchicine, which was embarrassing during intimacy with spouse;

  • Felt sleepy with narcotic pain medication; and

  • Sleeping separate (in different beds or different rooms) from the spouse during a flare, for the fear of pain exacerbation with light touch.”

 A2. Emotional impact on intimacy: “I felt

  • Emotional stress due to joint pain;

  • Exposing I was vulnerabilities to spouse, which had a negative effect;

  • Spouse wasn’t aggressive towards intimacy due to my gout;

  • Emotional vulnerability due to “male ego” and inability to be intimate during a gout flare;

  • Embarrassed when my husband had to help me with personal hygiene;

  • Depression, anger, frustration interfering with intimacy, gout makes you mean;

  • That I stayed in a bad mood;

  • Inferior due to gout;

  • Depressed due to no inability to be intimate due to gout;

  • Emotional fragility, with my first attack, I cried like a baby; and

  • Gout impacted sexual desire.”

B. Disability/dependence Interfering with Social Life and Intimacy

 B1. Disability: “I had

  • The inability to keep up physically with boy-friend in routine and recreational activities;

  • Physical disability, requiring the use of assistive devices;

  • Difficulty in helping wife with household chores during flare; and

  • The need to adjust life around the attack.”

 B2. Physical dependence: “I had

  • Total dependence on wife during a flare;

  • To depend on my husband/significant other;

  • Hospitalization for the severe pain, which was later diagnosed as a gout flare;

  • My spouse carry me around the house and up and down the stairs;

  • Gout flares that kept me in bed two to three times a month;

  • Inability to walk at all; and

  • to use crutches to walk when the flare hit.”

 B3. Limitation of Social Life activities: “I had difficulty

  • With the ability to plan events;

  • Going to football games or movies together with spouse;

  • Doing usual social activities, such as going to the bar, or a concert;

  • Going places due to gout pain;

  • Interacting with peers;

  • Missing church events such that spouse had to go alone;

  • And had to quit going to the church due to gout;

  • Maintaining the routine of going out for dinner due to gout pain, “a lot of times, everything stops”; and

  • Driving to important events due to flares, and my spouse had to drive.”

C. Trust issues/ understanding by spouse or significant other: “I noted

 • Less understanding with my spouse;

 • Partner not taking time to understand how gout affected me;

 • That if the relationship was new, spouse wouldn’t understand how gout was affecting me; and

 • That gout made me ill-tempered with my spouse.”

D. Problem with Self-image and perception by partner

 • “When I first had gout 15 years ago, I was in late 30s and I could not walk, holding on to walls; I could not drive – there was nothing going on; and

 • I was in a relationship and could not carry on the relationship; I couldn’t stand a sheet on my foot.”

E. Restricted Diet/Food choices negatively impacting the relationship

 • “It affects a lot;

 • Food choices change – no shellfish, seafood; and

 • Places we could not eat and go out due to gout.”

F. Treatment-related Financial Burden stressing relationship

 • “Gout affected income and us;

 • It’s stressful for the relationship; and

 • Medications are expensive even with insurance.”

G. Emotional Impact- communication, personality changes, effect on self or spouse

 • “Women are nurturers and she could not resolve how to help me with my pain;

 • She wanted to find a solution for me, just couldn’t; and

 • She goes with me to the doctor – She is my snitch to the doctor; we had quite a different view-point about treatments, now we have a shared viewpoint: For years, I declined any medication treatment, I doctored myself- you know you go on the Internet, self-diagnose and treat yourself; it was a difficult obstacle for me to overcome.”

H. Not in a relationship currently/ No or positive effect on relationship

 • "I don’t have a personal relationship;

 • If you are in a spiritual relationship, you can still cope; and

 • I knew its limitations before getting mine; It drew us closer together."