prevalence and associated risk factors - Nature

International Journal of Impotence Research (2006) 18, 382–395 & 2006 Nature Publishing Group All rights reserved 0955-9930/06 $30.00

www.nature.com/ijir

ORIGINAL ARTICLE

Female sexual dysfunction in a population-based study in Iran: prevalence and associated risk factors MR Safarinejad Urology Nephrology Research Center, Shaheed Beheshti University of Medical Sciences, Tehran, Iran

To explore the prevalence and risk factors of female sexual dysfunction (FSD) in Iran. A total of 2626 women aged 20–60 years old were interviewed by 41 female general practitioners and answered a self-administered questionnaire on several aspects of FSD including desire, arousal, pain and orgasmic disorders (OD). Criteria of sexual dysfunction followed classification by DSM-IV. The sexual function was evaluated by the Female Sexual Function Index (FSFI). The subjects were randomly identified from 28 counties of Iran. Data on medical history, toxic habits and current use of medication were also obtained. Of the women interviewed, 31.5% (759) reported FSD. The prevalence increased with age, from 26% in women aged 20–39 years to 39% in those 450 years (tested for trend Po0.001). Thirty-seven percent reported OD, 35% desire disorders (DD) and 30% arousal disorders (AD), all of which increased significantly with age. Pain disorders were reported by 26.7%, occurring most frequently in women aged 20–29 years. The educational level (P ¼ 0.01) and marriage age (o18 years) (P ¼ 0.04) were inversely correlated with the risk of DD, OD and AD. No significant differences were detected in smoking history (P ¼ 0.18), the presence of previous pelvic surgery (P ¼ 0.08) and contraception methods used (P ¼ 0.42). A history of psychological problems (P ¼ 0.04), married status (P ¼ 0.03), low physical activity (P ¼ 0.012), chronic disease (Po0.01), multiparity (Po0.05) menopause status (Pp0.01) and spousal erectile dysfunction (P ¼ 0.01) were significantly associated with FSD. This study provides a quantitative estimate of the prevalence and the main risk factors for FSD in Iranian women. International Journal of Impotence Research (2006) 18, 382–395. doi:10.1038/sj.ijir.3901440; published online 5 January 2006 Keywords: sexual dysfunction; epidemiology; female; risk factors; women; prevalence

Introduction Female sexual dysfunction (FSD) is defined as persistent or recurring decrease in sexual desire, persistent or recurring decrease in sexual arousal, dyspareunia and a difficulty in or inability to achieve an orgasm.1 The report of the International Consensus Development Conference on Female Sexual Dysfunction classified FSD into four disorders: designated desire disorders (DD), arousal disorders (AD), orgasmic disorders (OD) and pain disorders (PD).1 Although FSD is a highly prevalent health problem affecting 25–63% of women,2–4

Correspondence: Dr MR Safarinejad, Urology Nephrology Research Center, PO Box 19395-1849, Tehran, Iran. E-mail: [email protected] Received 30 August 2005; revised 16 November 2005; accepted 18 November 2005; published online 5 January 2006

information with regard to their prevalence is still scarce in international literatures. Sexuality is an important and complex domain in quality-of-life studies. Sexual dysfunction is a taboo subject in many countries that negatively affects quality of life and may often be responsible for psychopathological disturbances. In many societies, such discussions are almost taboo; hence, these problems are often not volunteered. If female sexuality is disturbed, the consequences it might lead to include familial discord and divorce,5 and reproduction is also affected. FSD prevalence may vary according to cultural, racial and health variables among countries. In addition, epidemiological data represent an invaluable tool for the development of strategies and the allocation of adequate resources necessary for providing assistance for populations. Several studies have been conducted in various countries worldwide to determine the prevalence of FSD.5–8 Nevertheless, few series were population based and used probabilistic samples representative of the general population. We studied

Female sexual dysfunction in a population-based study MR Safarinejad

the prevalence of FSD in Iranian women aged 20–60 years old, addressing risk factors associated with FSD.

Materials and methods A total of 2626 women aged 20–60 years old enrolled in the cross-sectional cohort study. Sample sizes were determined for the 95% confidence interval (CI) with a design effect of 1.1. Using this assumption, a sample size of 2327 was required. With a projected subject dropout rate of 10%, the total number of subjects required for study was determined to be 2626. A two-stage cluster random sampling design was used, with stratification of the primary sampling units. It accounts for about 97% of the population in this age range – roughly 70 million Iranians. The primary sampling units were census sections, the secondary sampling units were dwellings, and the final sampling units were subjects. The subjects were divided into four age groups, including ages 20–29, 30–39, 40–49 and 50–60 years. For population density, three levels were considered, including fewer than 500 000, 500 001–1 000 000 and more than 1 000 000 inhabitants. The secondary sampling units or dwellings were selected using the random route procedure and a computerized generated random number list. Extensive discussion of the sampling design and evaluations of sample and data quality are found in the book by Laumann et al.9 They were identified by 41 female general practitioners from the national population in 28 counties, and invited to a confidential interview. Using a standard questionnaire, data were obtained about their age, education, marital status, toxic habits, medical history, disabilities and illnesses, help-seeking, economy, ethnicity, geographic location and age at which they first had intercourse. Female sexual function was evaluated with a detailed 19-item questionnaire (Female Sexual Function Index (FSFI)) described by Rosen et al.10 The entire questionnaire is presented in Appendix A. This standardized questionnaire evaluates six domains of female sexual functioning during the last 4 weeks: desire, arousal, lubrication, orgasm, satisfaction and pain during sexual intercourse. The domain of female sexual AD was assessed in terms of frequency, level, confidence and satisfaction with eight questions, which was further divided into two separate domains of lubrication (four items) and arousal (four items). This breakdown will assess both the peripheral (lubrication) as well as the central (subjective arousal and desire) components. Other domains assessed include pain (three items), orgasm (three items) and satisfaction (three items). A scoring algorithm was devised to assess each domain and

a composite score, thus, generated. Score ranges for items 3–14 and 17–19 are 0–5, and for items 1, 2, 15 and 16, 1–5. By adding the scores of the individual items that comprise the domain and multiplying the sum by the domain factor, individual domain scores were obtained. Factors were 0.6 for desire, 0.3 for arousal and lubrication, and 0.4 for orgasm, satisfaction and pain. Total score was obtained by adding the six domain scores. The full-scale score range is from 2.0 to 36.0, with higher scores associated with a lesser degree of sexual dysfunction (Appendix B). Scores o65% of maximum achievable score in each domain were considered as sexual dysfunction in that domain. Therefore, scores o3.9 in all six domains were considered as sexual dysfunction. We further categorized female sexual function as four groups: normal female sexual function (total score X23), mild FSD (total score 18–23), moderate FSD (total score 11–17), and severe FSD (total scorep10). Patients were asked to choose the response option that best suited their condition during the past 1 month. People living in-group quarters such as barracks and college dormitories were excluded from the study. Concerning medical history, whenever useful, information given by the patient was checked by his general practitioner with medical records. Interviewers matched respondents on various social attributes in an interview averaging 45 min. The average number of interviews for each general practitioner was 41 (range 11–79). Each subject gave his informed consent before the interview. The study protocol did not include any clinical or diagnostic procedures. Analyses performed in this study were made by the use of logistic and multinomial logistic regression. For assessing the prevalence of symptoms across demographic characteristics, we performed logistic regressions for each symptom. This approach produced adjusted odds ratios (ORs), which indicate the odds that member of a given social group (e.g., graduated) reported the symptom relative to a reference group (e.g., none educated). After the sample was weighted by the specified design, the percent or prevalence and population estimates of the degree of sexual dysfunction in the population and the corresponding standard errors were obtained to construct the 95% CI. To test a difference for the age categories, we used from w2 test to assess whether we have differences in the number of women who belong to each category group. A latent class analysis (LCA) was used to evaluate the syndromal clustering of individual sexual symptoms. The basic idea underlying LCA is that some of the parameters of a postulated statistical model differ across unobserved subgroups. These subgroups form the categories of a categorical latent variable. This basic idea has several seemingly unrelated applications, the most

383

International Journal of Impotence Research

Female sexual dysfunction in a population-based study MR Safarinejad 384

important of which are clustering, scaling, density estimation and random-effects modeling. Outside social sciences, LC models are often referred to as finite mixture models. Statistical analysis was performed using the computer statistical package SPSS/10.0 (SPSS, Chicago, IL, USA) and SAS/6.4 (SAS Institute Cary, NC, USA).

Results Study population Of the 2626 women who were interviewed, 217 (8.3%) were excluded from analysis because of missing data (182) and response not completed personally (35). Baseline average age of the 2409 women in the analysis sample was 31.2 years (range 20–60). The women excluded from the study did not significantly differ from the study group with regard to age, education and marital status. The study subjects’ general characteristics are given in Table 1.

The mean age was 24.772.6 years in the ages of 20– 29 years, 34.872.9 years in the ages of 30–39 years, 45.272.2 years in the ages of 40–49 years and 54.472.1 years in the ages of 50–60 years, showing statistical significance among the age groups (P ¼ 0.001).

Prevalence of FSD and impact of age Of the 2409 women who provided information, 31.5% (759) reported at least one sexual dysfunction; 160 (21%) of them reported mild, 275 (36%) moderate and 324 (43%) severe FSD. Therefore, 24.9% of the population had moderate or severe FSD. The main FSD observed was OD (891, 37%), followed by DD (843, 35%), lubrication disorders (LD) (256, 33.7%), satisfaction disorders (239, 31.5%), AD (723, 30%) and PD (643, 26.7%). The prevalence of FSD increased with age (linear w2 216.014, 1 degree of freedom, Po0.001). Table 2 lists the distribution of FSD prevalence by age group. The prevalence increased from 26% in women aged 20–

Table 1 Demographic characteristics of study subjects Women with FSD

Women without FSD

No

%a

No

%b

P-value

Age at first intercourse (years) o18 18–20 X20

216 294 249

28.5 38.7 32.8

396 627 627

24 38 38

o0.05 NS o0.05

Education None Primary school High school Graduate

38 303 228 190

5 40 30 25

74 402 533 641

4.5 24.4 32.3 38.8

NS o0.01 o0.05 o0.05

Marital status Married Never married Divorced, separated or widowed

547 106 106

72 14 14

1122 297 231

68 18 14

NS o0.05 NS

Occupational status Unemployment (and/or housewife) Employment

600 159

79 21

1056 594

64 36

o0.05 o0.001

Menstruation status Menopause Menstrual cycle ( þ )

228 531

30 70

552 1098

33.5 66.5

NS NS

Contraception use – þ

592 167

78 22

1237 413

75 25

NS NS

Pregnancy and delivery Presence Absence

615 144

81 19

1139 511

69 31

o0.05 o0.01

FSD, female sexual dysfunction; NS, not significant. a P-value for comparison. b P-value for comparison.


Female sexual dysfunction in a population-based study MR Safarinejad Table 2 Age distribution and prevalence of FSD in 2409 women studied Age groups (years)

Some dysfunction n (%)

20–29 30–39 40–49 50–60

144 163 215 237

(25.1) (26.9) (34.7) (39)

Total n (%)

759 (31.5)

Without dysfunction n (%) 431 444 404 371

(74.9) (73.1) (65.3) (61)

1650 (68.5)

Table 3 Age adjusted relationship of FSD with physical and sociodemographic characteristics, and risk factors Odds ratios (95% CI)

Total n (%) Variables 575 607 619 608

(100) (100) (100) (100)

2409 (100)

FSD, female sexual dysfunction.

39 years to 39% in those 450 years (test for trend, Po0.001). The oldest cohort of women (age 50–60 years) is more than 4.4 times as likely to experience sexual dysfunctions (95% CI: 2.5–6.1) and to report low sexual desire (95% CI: 1.73–5.31) in comparison to women aged 20–39 years. The ORs for at least moderate FSD were 2.9 (95% CI: 2.1–3.3) in 50 and 6.3 (95% CI: 5.4–9.7) in 60-year-old women compared with that in 30-year-old women. The ORs of severe FSD increased even more with age. Owing to the strong relationship of age with FSD, the analysis of variables was age adjusted (Table 3). The age-adjusted prevalence was calculated by the direct method, assuming the total study population as standard. After adjusting for the strong effect of age on incident FSD, women with lower marriage age, financial dependency, lower educational level, lower physical activity and multiparity showed a significant increase in risk of FSD relative to those without these conditions at baseline. On the other hand, with regard to PD, age proved to be a protection factor for dysfunction.

385

Crude

Age adjusted

Education None Primary school High school Graduate

3.4 (1.17–7.8) 1.48 (0.69–2.05) 1.27 (0.57–2.23) 1

1.25 (1.07–1.86) 3.13 (2.21–4.41) 0.98 (0.47–1.52) 1

Race White Black Fair-haired Others

1 1.24 (1.11–2.09) 1.37 (1.31–2.26) 1.89 (1.40–2.05)

1 1.03 (0.65–1.57) 1.40 (0.50–1.83) 1.27 (0.62–1.73)

Body habits Height (cm) Weight (kg) BMI

0.83 (0.63–0.98) 1.00 (0.94–1.21) 1.11 (1.01–1.08)

0.82 (0.73–1.11) 1.00 (0.95–1.03) 1.03 (0.75–1.05)

Chronic disease

6.73 (4.45–9.36)

3.61 (2.72–5.32)

Medications Tranquilizer Antidepressants

3.45 (2.11–7.10) 3.31 (1.84–4.15)

2.61 (1.91–5.36) 2.62 (1.57–4.25)

Smoking history Current smoker Ex-smoker Never smoked

1.15 (0.64–2.07) 1.67 (0.93–2.98) 1.23 (0.76–2.82)

1.54 (0.95–2.32) 1.31 (0.93–2.06) 1.44 (0.79–2.04)

Physical activity Daily Several times/week Once/week Rarely/never

1 3.34 (2.53–4.52) 4.12 (2.35–5.41) 4.23 (2.2–6.1)

1 2.17 (1.41–2.67) 2.21 (1.47–3.81) 3.1 (1.2–6.2)

Psychological stress No Yes Severe

1 5.81 (4.37–8.13) 6.27 (4.51–8.67)

1 3.62 (2.31–5.23) 3.69 (2.31–5.40)

FSD, female sexual dysfunction; CI, confidence interval; BMI, body mass index.

Prevalence of FSD and risk factors Desire disorders (35%, n ¼ 843/2409). Table 4 shows the results of the multiple logistic regression analysis obtained from the final model for each sexual dysfunction. A total of 35% of the sample specified having low sexual desire. A significant association was found between hypoactive sexual desire and age (OR: 2.97; 95% CI: 1.73–5.31; Po0.001). Sexual desire was highest between 20 and 39 years and declined gradually thereafter. Multiple logistic regression analysis showed that women aged 50–60 years had a 4.1-fold higher risk for a sexual DD as compared to those aged 20–29 years. DD were observed as significantly higher in the presence of financial dependency (OR: 1.63; 95% CI: 1.27–2.21; P ¼ 0.001), lower educational level (OR: 3.02; 95% CI: 2.15–4.23; P ¼ 0.01), married status (OR: 2.31; 95% CI: 1.34–4.1; P ¼ 0.013), chronic disease (OR: 1.95; 95% CI:

1.30–2.74; P ¼ 0.008), low physical activity (OR: 2.65; 95% CI: 1.41–5.10; P ¼ 0.042), a high number of children (OR: 1.81; 95% CI: 1.51–2.28; P ¼ 0.031), menopause status (OR: 1.65; 95% CI: 1.46–2.90; P ¼ 0.006), lower marriage age (OR: 1.93; 95% CI 1.30–2.64; P ¼ 0.04), psychological problems (OR: 1.61; 95% CI: 1.25–2.98; P ¼ 0.03) and occurrence of sexual harassment during childhood (OR: 2.52; 95% CI: 1.25–5.0; P ¼ 0.014). Illiterate women had more DD than women with primary and secondary levels of schooling (OR: 3.02; 95% CI: 2.15–4.23; P ¼ 0.026). Women with a higher educational level tended to have less DD. Married women had DD more often than single women and women who were living alone (OR: 1.32; 95% CI: 1.21–1.88; P ¼ 0.03). Women with three children and more had DD more often than women with two children. International Journal of Impotence Research


Arousal disorders (30%, n ¼ 723/2409). Out of 2409 responses, 30% had sexual AD. In the age group 20–39 years, approximately 24% of women reported on arousal problems, ‘never’ or only ‘occasionally’ experiencing arousal during sexual activity. This percentage increased substantially with age; in women aged 50–60 years, for instance, more than 35% fell in this category. A positive association was found between AD and low level of education (OR: 1.80; 95% CI: 1.22–2.61; P ¼ 0.002), low level of physical activity (OR: 5.02; 95% CI: 2.68–8.70; P ¼ 0.003), psychological problems (OR: 3.28; 95% CI: 1.96–5.18; P ¼ 0.01), chronic disease (OR: 1.94; 95% CI: 1.20–2.74; P ¼ 0.009), lower marriage age (OR: 1.49; 95% CI: 1.23–2.19; Po0.05), menopause status (OR: 1.79; 95% CI: 1.34–2.79; P ¼ 0.02) and how women were experiencing sexual intercourse (OR: 1.96; 95% CI: 1.32– 2.78; P ¼ 0.01).

1.57; 95% CI: 1.27–2.13; P ¼ 0.033), sexual harassment during childhood (OR: 1.53; 95% CI: 1.14– 2.01; P ¼ 0.003) and how the women were experiencing sexual intercourse (OR: 1.63; 95% CI: 1.23– 2.81; P ¼ 0.024). No positive association was found with financial dependency (OR: 0.99; 95% CI: 0.69– 1.31; P ¼ 0.08), physical activity (OR: 1.18; 95% CI: 0.68–1.95; P ¼ 0.072) or with number of children (OR: 1.69; 95% CI: 0.84–2.93; P ¼ 0.08). Lubrication disorders (33.7%, n ¼ 812/2409). Sexual dysfunction was detected as LD in 812 women (33.7%). LD was observed as significantly higher in the presence of older age (OR: 2.40; 95% CI: 1.4–4.14; Po0.001), lower educational level (OR: 3.08; 95% CI: 2.25–4.45; P ¼ 0.007), unemployment status (OR: 1.46; 95% CI: 1.24–2.21; P ¼ 0.017), chronic disease (OR: 2.38; 95% CI: 1.79–3.21; P ¼ 0.002), menopause status (OR: 1.83; 95% CI: 1.28–2.68; P ¼ 0.004), lower marriage age (OR: 2.02; 95% CI: 1.60–2.70; P ¼ 0.03) and psychological problems (OR: 2.69; 95% CI: 1.40–4.88; P ¼ 0.002). No positive association was found with physical activity (OR: 1.23; 95% CI: 0.90–1.72; P ¼ 0.072) or with number of children (OR: 1.34; 95% CI: 0.91– 1.67; P ¼ 0.08).

Orgasmic disorders (37%, n ¼ 891/2409). Out of 2409 responses, 891 (37%) of the sample had OD always or often during the sexual intercourse. Eighty-one percent (1951/2409) of the samples were aware of and had experienced orgasm, 30% had a problem achieving orgasm, whereas 26% had never achieved orgasm and 20% did so only with difficulty or manipulated to achieve it. Even in the youngest age groups (20–39 years), 31% of women reported on significant OD. With increasing age, this percentage increased substantially with an OR of 2.1 (50–60 years vs 20–29 years) and this increase did reach statistical significance (OR: 2.10; 95% CI: 1.51–4.31; P ¼ 0.001). OD was observed as significantly higher in the presence of chronic disease (OR: 2.20; 95% CI: 1.27–3.14; Po0.001), a high number of children (42) (OR: 1.78; 95% CI: 1.52–2.23; P ¼ 0.02), lower marriage age (p18 years) (OR: 2.38; 95% CI: 1.38–3.85; P ¼ 0.04), lower educational level (OR: 4.01; 95% CI: 2.75–5.77; Po0.01), financial dependency (OR: 1.94; 95% CI: 1.40– 2.70; P ¼ 0.03), menopause status (OR: 1.57; 95% CI: 1.42–2.81; P ¼ 0.01), psychological problems (depression, anxiety and irritability) (OR: 1.43; 95% CI: 1.17–2.06; P ¼ 0.02) and lower physical activity (OR: 2.11; 95% CI: 1.72–2.64; P ¼ 0.024).

Satisfaction disorders (31.5%, n ¼ 759/2409). In this sample, 31.5% (759) of the surveyed women reported satisfaction disorder. A positive association was found between satisfaction disorder and low level of education (OR: 2.55; 95% CI: 1.27–4.9; P ¼ 0.002), older age (OR: 3.80; 95% CI: 1.64–7.26; Po0.001), unemployment status (OR: 1.55; 95% CI: 1.22–2.8; P ¼ 0.02), menopause status (OR: 2.44; 95% CI: 1.31–3.6; P ¼ 0.002), chronic disease (OR: 2.24; 95% CI: 1.66–2.90; P ¼ 0.002), marriage age (OR: 2.51; 95% CI: 1.71–3.50; P ¼ 0.003), psychological problems (OR: 4.02; 95% CI: 2.47–5.7; P ¼ 0.001), physical activity (OR: 3.60; 95% CI: 1.73–6.78; P ¼ 0.009) and how the women were experiencing sexual intercourse (as a drudgery) (OR: 3.75; 95% CI: 1.75–7.89; P ¼ 0.001). This association was not significant for number of children (OR: 0.95; 95% CI: 0.45–1.46; P ¼ 0.341).

Pain disorders (26.7%, n ¼ 643/2409). Out of 2409 responses, 26.7% experienced pain within the vagina or the genital area during and after sexual activity. In women aged 20–29 years, 38.2% reported on sexual PD, in those aged 30–39 years 30.8%, and thereafter this percentage declined to 23.2% (40–49 years) and 15.8% (50–60 years). A positive association was found with chronic disease (OR: 1.87; 95% CI: 1.55–2.35; P ¼ 0.005), psychological problems (OR: 3.16; 95% CI: 2.15–4.35; P ¼ 0.032), low level of education (OR: 2.55; 95% CI: 1.76–3.70; P ¼ 0.01), lower marriage age (OR:

Frequency of sexual intercourse Overall 81% of the women had had intercourse during the last month and 67% had had it weekly. With increasing age, the proportion of women who did not have regular intercourse weekly increased (OR: 3.05; 95% CI: 2.14–4.51; P ¼ 0.001) (Table 5). In women aged 20–29 years, 68% reported of 1–2 sexual intercourses per week, 16% of 3–4/week and 8% of more than four intercourses per week. In women aged 50–60 years, 66% reported on regular sexual intercourses. The frequency of sexual intercourse has also been shown to be directly related to


Table 4 Prevalence of dysfunction items by demographic characteristics and risk factors surveyeda DD

AD OR (95% CI)

OR (95% CI)

No (%)

144 170 204 268

(25) (28) (33) (44)

1 1.43 (1.22–2.73)* 2.41 (1.22–2.94)** 2.97 (1.73–5.31)***

132 152 173 219

(23) (25) (28) (36)

1 1.11 (0.81–1.74) 2.14 (1.30–3.22)** 4.92 (2.69–8.37)***

184 182 241 298

(32) (30) (39) (49)

1 1.8 (1.52–2.35)* 1.94 (1.63–2.59)** 2.10 (1.51–4.31)***

219 188 142 97

(38) (31) (23) (16)

1 0.84 (0.69–0.94)* 0.61 (0.56–0.81)** 0.54 (0.42–0.84)***

161 176 211 268

(28) (29) (34) (44)

1 1.47 (0.91–2.12) 2.51 (1.23–4.88)** 2.4 (1.4–4.14)***

144 164 198 255

(25) (27) (32) (42)

1 1.71 (1.39–3.51)* 2.41 (1.29–4.87)** 3.8 (1.64–7.26)***

Education Graduate High school Primary school None

216 244 282 47

(26) (32) (40) (42)

1 1.33 (1.05–1.75)* 1.58 (1.14–2.12)* 3.02 (2.15–4.23)**

208 221 219 38

(25) (29) (31) (34)

1 1.37 (0.93–1.71) 1.54 (1.13–2.03)* 1.80 (1.22–2.61)**

249 274 268 49

(30) (36) (38) (44)

1 1.31 (0.98–1.90) 1.78 (1.36–2.36)* 4.01 (2.75–5.77)**

191 175 190 36

(23) (25) (27) (32)

1 1.13 (0.75–1.54) 1.44 (1.14–2.04)* 2.55 (1.76–3.70)**

249 244 247 41

(30) (32) (35) (37)

1 1.45 (1.15–2.19)* 2.53 (1.74–3.68)* 3.08 (2.25–4.45)**

244 221 233 41

(27) (29) (33) (37)

1 1.36 (0.74–2.1) 2.41 (1.85–3.2)* 2.55 (1.27–4.9)**

203 (27) 712 (43)

1 1.63 (1.27–2.21)***

218 (29) 513 (31)

1 1.03 (0.50–1.61)

264 (35) 646 (39)

1 1.94 (1.40–2.70)*

196 (26) 447 (27)

1 0.99 (0.69–1.31)

249 (33) 580 (35)

1 1.46 (1.24–2.21)*

233 (31) 547 (33)

489 (30)

1

407 (25)

375 (23)

1

456 (28)

505 (31)

1

505 (31)

OR (95% CI)

1

No (%)

SD

Age (years) 20–29 30–39 40–49 50–60

1

No (%)

LD

No (%)

Menstruation status Menstrual Cycle ( þ ) Menopause

No (%)

PD

Characteristics

Occupational status Employment Unemployment (and/or housewife)

OR (95% CI)

OD

OR (95%CI)

No (%)

OR (95%CI)

1 1.55 (1.22–2.8)*

1

234 (30)

1.79 (1.34–2.79)*

335 (43)

1.57 (1.42–2.81)**

172 (22)

1.55 (1.15–2.08)*

434 (44)

1.83 (1.28–2.68)**

273 (35)

2.44 (1.31–3.6)**

457 (36) 136 (34)

1 1.15 (0.50–1.96)

380 (30) 120 (30)

1 1.12 (0.49–1.76)

482 (38) 144 (36)

1 1.67 (0.84–2.68)

355 (28) 100 (25)

1 1.22 (0.54–1.98)

444 (35) 128 (32)

1 1.19 (0.69–1.95)

418 (33) 120 (30)

1 0.94 (0.45–1.59)

Number of children p2 42

225 (32) 496 (38)

1 1.81 (1.51–2.28)*

204 (29) 404 (31)

1 1.23 (0.54–1.96)

231 (33) 535 (41)

1 1.78 (1.52–2.23)*

197 (28) 326 (25)

1 1.69 (0.84–2.93)

232 (33) 443 (34)

1 1.34 (0.91–1.67)

225 (32) 404 (31)

1 0.95 (0.45–1.46)

Smoking history Absence Presence

767 (35) 76 (35)

1 0.91 (0.31–2.63)

680 (31) 63 (29)

1 1.26 (0.89–1.69)

855 (39) 76 (35)

1 1.15 (0.51–1.98)

592 (27) 56 (26)

1 1.32 (0.72–1.64)

745 (34) 72 (33)

1 1.14 (0.53–1.93)

701 (32) 67 (31)

1 0.95 (0.43–1.48)

Chronic medical disease Absence Presence

206 (30) 29 (40)

1 1.95 (1.30–2.74)**

179 (26) 25 (34)

1 1.94 (1.20–2.74)**

220 (32) 30 (42)

1 2.20 (1.27–3.14)***

186 (27) 19 (26)

1 1.87 (1.55–2.35)**

199 (29) 27 (38)

1 2.38 (1.79–3.21)**

192 (28) 25 (35)

1 2.24 (1.66–2.9)**

Previous pelvic surgery Absence Presence

643 (34) 95 (36)

1 0.94 (0.53–1.76)

542 (29) 187 (31)

1 0.89 (0.45–1.46)

651 (36) 229 (38)

1 0.9 (0.55–1.36)

452 (25) 169 (28)

1 0.95 (0.44–1.48)

614 (34) 199 (33)

1 1.04 (0.57–1.58)

596 (33) 181 (30)

1 1.14 (0.53–1.94)

Marriage age 418 years p18 years

655 (32) 144 (40)

1 1.93 (1.30–2.64)*

553 (27) 126 (35)

1 1.49 (1.23–2.19)*

635 (31) 163 (45)

1 2.38 (1.38–3.85)*

553 (27) 126 (35)

1 1.57 (1.27–2.13)*

614 (30) 137 (38)

1 2.02 (1.60–2.70)*

594 (29) 126 (35)

1 2.51 (1.71–3.5)**

Psychological problems Absence Presence

530 (31) 273 (39)

1 1.61 (1.25–2.98)*

428 (25) 245 (35)

1 3.28 (1.96–5.18)*

547 (32) 294 (42)

1 1.43 (1.17–2.06)*

410 (24) 203 (29)

1 3.16 (2.15–4.35)*

513 (30) 259 (37)

1 2.69 (1.40–4.88)**

445 (26) 259 (37)

1 4.02 (2.47–5.7)***

Physical activity Daily Several times per week Once/week Rarely/never

21 101 223 545

1 1.37 (0.86–2.3) 1.47 (1.16–2.0)* 2.65 (1.41–5.10)**

18 88 205 489

1 1.07 (0.87–1.72) 2.17 (1.19–3.95)* 5.02 (2.68–8.7)**

26 121 229 531

1 19 0.57 1.50 2.11

1 88 (26) 169 (28) 391 (28)

19 1.18 1.05 1.18

1 88 (26) 169 (28) 391 (28)

19 1.18 1.50 1.23

1 94 (28) 217 (36) 503 (36)

1.4 (0.87–1.71) 1.95 (1.38–4.39)* 3.6 (1.73–6.78)**

(29) (30) (37) (39)

(25) (26) (34) (35)

(36) (36) (38) (38)

(26) (0.49–1.19) (1.16–2.75)* (1.72–2.64)*

(26) (0.50–1.87) (0.79–1.46) (0.68–1.95)

(26) (0.59–1.97) (0.69–2.88) (0.90–1.72)


1.65 (1.46–2.90)**

OR, odds ratio; CI, confidence interval; DD, desire disorders; AD, arousal disorders; OD, orgasmic disorders; PD, pain disorders; LD, lubrication disorders; SD, satisfaction disorders. *Pp0.05, **Pp0.01, ***Pp0.001. a Odds ratios for the presence of a given sexual symptom for members of a specific group in relation to a reference group. Percentages were derived from women who answered each of the categories, whereas the total number represents all women who answered the questions. 387


312 (40)

Contraception use þ


Table 5 Age and intercourse frequency

Table 6 Quality-of-life concomitants by latent classes of sexual dysfunction

Age groups (years) (%) 20–29 Intercourse frequency during An average week 0 8 1–2 68 3–4 16 Greater than 4 8 Total 100 Time since last intercourse 0–7 days 8–30 days 1–6 months Greater than 6 months Total

30–39

40–49

Satisfaction with partner and happinessa

50–60 Low general happiness

7 76 14 3 100

22 70 8 0 100

34 66 0 0 100

Low emotional satisfaction

1 1 1 2.26 (1.04–4.60) 0.62 (0.44–1.23) 2.40 (1.23–4.03) 2.24 (1.16–4.63) 4.02 (2.24–6.35) 2.21 (1.14–4.40) 2.36 (1.24–5.04) 3.13 (1.87–5.33) 1.44 (0.69–2.76)

a

Data are presented as adjusted odds ratio (95% confidence interval). 73 22 4 1 100

77 16 5 2 100

55 31 12 2 100

39 39 14 8 100

chronic disease (OR: 1.52; 95% CI: 1.27–2.17; P ¼ 0.01), physical limitations of a partner (OR: 1.44; 95% CI: 1.25–2.04; P ¼ 0.026), psychological problems (OR: 2.44; 95% CI: 1.30–4.30; P ¼ 0.002), multiparity (OR: 1.91; 95% CI: 1.33–4.31; P ¼ 0.01) and menopausal status (OR: 2.80; 95% CI: 1.42– 5.12; P ¼ 0.001). The association of moderate and severe FSD with nonregular weekly intercourse was strong (OR 3.7 and 2.64) but this was not so with mild FSD (OR 1.0) compared to women with no FSD. Search for help Our study showed that 22% of women with FSD sought help from their gynecologist and 17% consulted healthcare professionals. Of those who did not seek help for their problem, 63% stated they would like to. The reasons for helpseeking are as follows: under pressure from their husbands (69%), eagerness to have satisfying sexual intercourse (31%) and distress about normality (45%).

Reasons of sexual dysfunction reported by women When women were asked to explain the causes of sexual disorders they were suffering from, they linked them to the following: A conflict in the relationship with her partner (loss of intimacy, intimidating atmosphere, poor communication, etc.) (72.3%). Poor knowledge of their bodies and sexually sensitive areas (49.3%). Partner’s sexual dysfunction (82%). Poor partner performance and technique (87%). Personal psychopathological problems (66.4%). History of trauma (genital, obstetric, etc.) (42.6%). International Journal of Impotence Research

No problems Mild FSD Moderate FSD Severe FSD

Low physical satisfaction

Religion was not significantly associated with hypoactive sexual DD (OR: 0.64; 95% CI: 0.32–1.26; P ¼ 0.641). No differences between ethnicity and response to FSFI questions could be demonstrated (P ¼ 0.32). Owing to different racial residents in a specific geographic area, a simultaneous ethnicity, geographical location and FSD analysis was not possible. Therefore, two separate covariance analyses were performed. The first looked at race effects within one geographical location and the second analysis looked at geographical effects between all 28 counties. No effect of race was detected; neither the intercept (analysis of covariance P ¼ 0.32) nor the slope of the age relationship was influenced by race (analysis of covariance P ¼ 0.39). Drug intake, which respondents called medications for nerves and sleeping pill, correlated strongly (OR 2.42 and 3.3, respectively) with FSD. The results of LCA allow for analyzing risk factors and quality-of-life concomitants in relation to categories of sexual dysfunction. Four categories were identified by LCA. These include women without FSD, mild FSD, moderate FSD and severe FSD. Table 6 shows the associations of categories of sexual dysfunction with emotional and physical satisfaction with sexual partner and with feelings of general happiness. Women with moderate and severe FSD experience diminished quality of life. There was not a dose response in the three domains of quality of life examined with increasing severity of the latent class. Low level of satisfaction with partner relationship is closely associated with manifest distressing dysfunction of sexual interest, lubrication and orgasm. However, the logistic regression in this sample did not indicate causality. For example, a distressing sexual dysfunction may, to a great extent, be caused by a disharmonious partner relationship, or an unsatisfactory partner relationship may lead to distressing sexual dysfunctions. The mean scores of each dimension for each age group are shown in Table 7. Of all six measured domains, the mean scores in five tend to decline with increasing age, except that of pain.


Table 7 The domain scores (mean7s.d.) of each dimension for each age group Parameters

20–29 (n ¼ 575)

30–39 (n ¼ 607)

40–49 (n ¼ 619)

Desire Arousal Orgasm Pain Lubrication Satisfaction

5.1171.9a 5.1471.6a 5.1571.7a 3.1271.4a 5.1771.6a 5.1271.6a

5.1371.8b 5.1171.7b 5.0471.9b 3.5471.7b 5.1371.5b 4.9871.7b

3.7271.8c 3.1771.6c 3.1171.6c 5.0871.7c 3.6271.7c 3.2371.6c

Total score

26.377.61a

26.1710.8b

20.05712.27c

50–60 (n ¼ 608) 3.2671.7d 2.9871.9d 3.0971.7d 5.2371.9d 3.2171.8d 2.9471.5d 19.0711.04d

d

Pp0.001 vs cp0.01 vs bp0.05 vs a. Pp0.01 vs bp0.05 vs a. b Pp0.05 vs a. c

Discussion FSD has a major impact on quality of life and interpersonal relationships. For many women it has been physically disconcerting, emotionally distressing and socially disruptive. Sexual dysfunction can also severely impair a woman’s quality of life, selfesteem and interpersonal relationships. Although several investigators have looked upon covariates of women’s sexual functions/dysfunctions per se, we have, in the literature, not found any other regionally or nationally representative cross-sectional investigations that specifically address the likelihood of FSD. Results from a national survey of people aged 18–59 years indicated that sexual dysfunction was common among women in 43% of cases.11 In our study, the overall prevalence of FSD was 31.5%. In the entire study population, 37% reported on OD, 35% on DD, 30% on AD and 26.7% on PD, all of which (except pain) had a strong positive correlation with age. The literature estimates of sexual dysfunction in women range from 19 to 50% in ‘normal outpatient populations’.12,13 Although FSD is recognized as a widespread health problem, some controversy exists regarding the prevalence of FSD. Large differences are present in the prevalence of FSD between countries. They may reflect medical and psychological factors, particularly in the setting of possible socioeconomic, cultural and racial differences, the clinical definition used for each dysfunction, type of trial performed (self-applicable questionnaire, mailed questionnaire, interview by phone, personal interview) and the characteristic of samples (general population vs sexuality clinics) studied. Population prevalence data are scarcer. A study in Britain found 53.8% of women had a minimum of one sexual problem lasting at least 1 month over a 2-year period.14 The most widely cited study is based on the US National Health and Social Life Survey of 1992. This was published in 1999 and evaluated a National Probability Sample of 1749

women and 1410 men, aged 18–59 years.4 The authors reported that sexual dysfunction occurs more often in female subjects (43% prevalence) than in male subjects (31%). In another survey in the USA conducted by the Kinsey Institute,15 440% of female respondents again reported sexual problems. In Brazil, Abdo et al.7 analyzed 1219 women (36712 years) by a 38-item questionnaire. FSD was present in 49% of women, lack of sexual desire reported by 26.7%, pain during sexual intercourse by 23% and orgasmic dysfunction by 21%. In a survey conducted on the Turkish women living in households, C ¸ ayan et al.6 studied 179 women aged 18–66 years using the FSFI. The prevalence of FSD increased from 22% in those aged 18–27 years to 66% in those aged 48–57 years. Castelo-Branco et al.16 assessed FSD in 534 healthy women (5276 years) living in Santiago de Chile by the Laumann’s test (DSM-IV). In this series, the prevalence of FSD increased from 22% in the 40–44 years age group to 66% in the 60–64 years age group. DD were reported by 38%, AD by 32%, OD by 25% and dyspareunia by 33%. In general, our data correlate well with the above-mentioned studies. Some studies reported low prevalence of FSD. In a study by Kadri et al.5 728 women (37713 years) living in Morocco were investigated. FSD was present in 27%, DD were reported by 18%, OD by 12%, AD by 8% and PD by 8%. This fact supports the role of social and cultural factors and the interrelation with the partner in the development of this dysfunction. However, a direct comparison between different studies is hampered by the lack of a uniform validated FSD questionnaire, characteristics of the study population, the method of assessment (self-applicable questionnaire, personal interview, phone interview, mailed surveys) and definitions of FSD. In this study, the most prevalent disorder was OD (37%). This disagrees with the findings of C ¸ ayan et al.6 in Turkish women, and Abdo et al.7 in Brazilian women and agrees with findings of Ponholzer et al.8 in Austrian women. A major limitation of C ¸ ayan’s study is International Journal of Impotence Research


the fact that standard epidemiological sampling did not generate study population and the women were chosen from the same city, Mersin, Turkey. On the other hand, in the Brazilian study, the studied group comprised women with an educational level (high school and college degree) higher than that of the average Brazilian woman and subjects were chosen from among weekend visitors to beaches, parks and shopping malls, and therefore the studied sample is not representative of general population. A major methodological problem when studying FSD is using the internationally accepted FSD questionnaires. The FSFI is currently the most frequently used FSD questionnaire, and the measure presents acceptable test–retest reliability, internal consistency and validity.10 The major advantage of our study is the fact that, in contrast to mailed surveys, co-morbidities were assessed and verified by interviewers. Furthermore, our study is not hampered by low response rates in mailed surveys. Also, in the current study, standard epidemiological sampling did generate our study population. Demographic characteristics and medical risk factors were assessed in all women, and the findings were compared between the women with and without sexual dysfunction. Of the sociodemographic data analyzed, age most strongly correlated with the likelihood of FSD. Low sexual desire, AD and orgasmic problems are age-dependent disorders, possibly resulting from physiological changes associated with the aging process. In our study, women aged 50–60 years had a 4.1 higher risk for DD, a 4.7 high risk for AD and a 3.4 higher risk for OD. In addition to hormonal alterations, psychosocial and interpersonal factors, medication use and associated illnesses are factors that mediate the effects of aging on sexual function in women. Although the prevalence of all aspects of FSD (except PD) increased substantially with age, sexuality remains an important aspect. In women aged 50–60 years, for instance, 65% reported on sexual desire, and almost 48% had at least three sexual intercourses per month. After adjusting for the strong effect of age on occurrence FSD, women with chronic disease, low education level, financial dependence, lower physical activity, multiparity, menopause status and lower marriage age (o18 years) showed a significant increase in risk of FSD relative to those without these conditions at baseline. In this study, 37% of the studied sample had OD. About 26% of women never attained orgasm. Possible explanations may include a restraining sexual education, poor partner performance and technique, and negative beliefs with regard to sexual activity. Insufficient clitoral stimulation may account for most cases of absent orgasm, and all women may be potentially orgasmic if adequately stimulated.


About 27% of samples specified having PD. Psychologic pressure and relationship issues often result from pain. There is a cascade of responses from initial pain experience to expectation of subsequent pain, sexual aversion, inconvenient relationship effects, and development of additional sexual dysfunction. The pain may prevent intromission, often resulting in unconsummated marriages. Its supposed causes are restraining education, negative beliefs with regard to the anatomy of the hymen, misunderstanding about the mechanism of intromission, and interrelationship conflicts. In the current study, women ascribed their own sexual disorders to a problem in the relationship with their husbands (72.3%) or husband’s sexual dysfunction (82%). A population-based study of the Iranian general population found a prevalence of 18.8% of sexual dysfunction in a representative sample of men.17 However, 66.4% of the women linked their disorder to a personal psychopathological problem. In our study, 35% reported having DD. Sexual aversion is the probable diagnosis in lifelong cases of sexual anhedonia. A significant association was found between DD and financial dependency, marital status, chronic disease, level of education, number of children and marriage age. Sexual arousal as a separate component of the sexual response cycle was first recognized by Kaplan,18 and arousal problems are often attributed to inhibited desire; they may occur independently.19 Of the samples, 30% had AD. In Ponholzer et al.’s8 study, 35% of the women had sexual AD. A lifelong diminished capacity for sexual arousal may be related to unawareness of genital anatomy and function. There was statistically significant relationship between AD and level of education, lower physical activity, marriage age, menopause status, psychological problems and chronic disease. Women reported in a significant manner that they considered sexual intercourse a drudgery. Sexual responsiveness is the result of an interaction of physical (e.g., depression, anxiety, medications for their treatment), psychosocial (e.g., chronic stress/ fatigue, gender or sexual identity issues) and relationship factors.20 Depression and associated drug therapy are the most common biological factors that inhibit sexual arousal.21,22 Psychological causes might be the same as that in female OD. Inadequate stimulation or psychological inhibition may result in inadequate vaginal lubrication and cause coital pain. This study indicated a statistically significant association between psychological problems and all six aspects of FSD. Female sexuality is more ‘contextual’ than male sexuality and, to specify dysfunctions without clearly acknowledging the strong interpersonal determinants of sexual response is problematical and probably confusing. Many women can experience adequate sexual arousal and even orgasm without experiencing any real satisfaction, pleasure


or even the tendency to repeat the experience. Sexual myths and misconceptions, negative emotions, anxiety, depression, body image concerns, relationship problems, communication-betweenpartner difficulties leading to poor sexual technique, previous or current sexual abuse or sexual harassment and substance abuse all contribute to FSD. Many women experience a lack of satisfaction with their sexual relationship, in spite of the ability to achieve arousal or orgasm. In our series, 31.5% of women had SD. Low physical activity, financial dependence, lower marriage age and lower educational level were correlated to SD. These data suggest that lifestyle changes may play a role in FSD. The introduction of a new diagnostic category of sexual satisfaction disorder is mandatory. This diagnosis must be applied when a woman is unable to achieve subjective sexual satisfaction, despite adequate desire, arousal and orgasm. In general, race played a very small role in women presenting sexual dysfunctions. Another study showed that black women had an increased DD; no other association with race was found.3 In spite of increasing chances of this disorder to occurring in black women, this study was not able to achieve statistical significance. Patients are becoming more contented with turning to their physician for help with sexual problems. A study showed that 42% of women with sexual complaints sought help from their gynecologist. Of those who did not seek help for their problem, 54% stated that they would like to.23 In this study, even if women were aware of the disorder, only 22% sought help from their gynecologist and 17% consulted healthcare professionals. Among those who did not seek help for their problem, 63% stated that they would like to. Risk factors, associated with health and lifestyle, including smoking, educational level, occupational status, drug use, chronic disease (e.g. hypertension, cardiovascular disease, neurological disease or diabetes), psychological problems (anxiety, depression, irritability) previous pelvic surgery (gynecologic, urologic or colorectal surgeries), menstrual cycle or menopause status, previous pregnancies, contraception methods, number of children and marriage age used were also assessed in all women. The ‘traditional’ risk factors for the development of erectile dysfunction such as hypertension, diabetes mellitus, hyperlipidemia and a history of cardiac diseases were generally not strongly correlated to the presence of FSD, underlining the multicausality of these disorders.7,24,25 There is limited literature on risk factors that may develop FSD. Laumann et al.3 assessed risk factors associated with health, lifestyle and sexual experience. However, they did not assess menopause status and clinical risk factors such as previous pelvic surgery and chronic disease. In this study, no significant differences were detected in smoking history, the presence of

previous pelvic surgery and contraception methods used between the women with and without FSD. However, our study showed significantly higher prevalence of sexual dysfunction in the presence of older age, lower marriage age, lower educational level, unemployment status, chronic disease, multiparity, low physical activity and menopause status. Lower educational levels are positively associated with the presence of sexual dysfunctions, as also shown by similar findings by several groups.3,5–7,26 Laumann et al.3 found that the risk of FSD was halved in graduate women compared with those who did not finish their studies. Our results confirmed these data, as more than 12 years of education reduced the FSD risk by 36%. The role of psychological factors is underlined by the ELIXIR study assessing sexual dysfunction in 4557 depressed patients.27 In our study, psychological problems were also the risk factor associated with FSD. The link between FSD and psychological problems seems undemanding and the association between mood disorders and FSD has already been described.28 Health status is a condition that reduces the FSD risk in women. In our study, the FSD risk diminished by 49% in healthy women. In a study, Avis et al.29 reported that health status also appeared as an important factor for a reduced risk of sexual dysfunction. Among the factors studied, the male partner’s erectile dysfunction increased the risk of FSD fourfold. It needs to be emphasized that many aspects of FSD, such as DD, however, also depend on the presence of an adequate partner. A Canadian study found that male impotence was the most common problem that affects the sexual life of older women.30 In addition, erectile dysfunction may eliminate sexual relationships completely.31 In this study, 82 and 87% of studied population linked their causes of sexual disorders to partner’s sexual dysfunction and poor partner performance and technique, respectively. Although our results suggest that the menopause increases the risk of sexual dysfunction, there are still conflicting data concerning the role of menopause on sexual dysfunction.32 Rosen et al.2 studied women between 18 and 73 years old, and found that almost 70% of them had an adequate sexual life; however, aging and spinsterhood were significant predictors of FSD. Additionally, Avis et al.29 evaluated sexually active women during the menopausal evolution and found that menopause was related to a loss of desire and sexual excitement. In our study, menopausal status showed a significant relationship with all aspects of FSD (except PD). Prevalence of FSD varies significantly across marital status; married women are at higher risk and single women at lowest risk. This agrees with the findings of Kadri et al.5 study and disagrees with the findings of the Laumann et al.3 study. This

391



phenomenon might be explained by the burden of high number of children, financial problems, illiteracy, and poor socioeconomic conditions of married women.

Conclusion FSD is frequent among different ethnic groups. Better understanding of the epidemiology of FSD is vital to plan effective treatment and prevention strategies. Still more epidemiologic research is essential to further understand the distribution as well as the prevalence of FSD in certain ethnic groups.

Acknowledgments We thank many physicians, coordinators, project managers and data reviewers who assisted in this study.

References 1 Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol 2000; 163: 888–893. 2 Rosen RC, Taylor JF, Leiblum SR, Bachmann GA. Prevalence of sexual dysfunction in women: Results of a survey study of 329 women in an outpatient gynecological clinic. J Sex Marital Ther 1993; 19: 171–178. 3 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA 1999; 281: 537–544. 4 Goldmeier D, Judd A, Shroeder K. Prevalence of sexual dysfunction in new heterosexual attenders at a central London genitourinary medicine clinic in 1998. Sex Transm Infect 2000; 76: 208–209. 5 Kadri N, Mchichi Alami KH, Mchakra Tahiri S. Women sexual dysfunction: a population-based epidemiological study. Arch Women Ment Health 2002; 5: 59–63. 6 C ¸ ayan S, Akbay E, Bozlu M, Canpolat B, Acar D, Ulusoy E. The prevalence of female sexual dysfunction and potential risk factors that may impair sexual function in Turkish women. Urol Int 2004; 72: 52–57. 7 Abdo CHN, Oliveira WM, Moreira Jr ED, Fittipaldi JAS. Prevalence of sexual dysfunctions and correlated conditions in a sample of Brazilian women – results of the Brazilian study on sexual behavior (BSSB). Int J Impot Res 2004; 16: 160–166. 8 Ponholzer A, Roehlich M, Racz U, Temml C, Madersbacher S. Female sexual dysfunction in a healthy Austrian cohort: prevalence and risk factors. Eur Urol 2005; 47: 366–374. 9 Laumann EO, Gagnon JH, Michael RT, Michaels S. The Social Organization of Sexuality: Sexual Practices in the United States. University of Chicago Press: Chicago, 1994.


10 Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsig R et al. The female sexual function index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26: 191–208. 11 Hwang MY. Sexual dysfunction. Silence about sexual problems can hurt relationships. JAMA 1999; 281: 584. 12 Bachmann GA, Leiblum S, Grill J. Brief sexual inquiry in gynecologic practice. Obstet Gynecol 1989; 73: 424–427. 13 Michael RT. Sex in America: A Definitive Survey. Little, Brown: Boston, 1994, pp 111–131. 14 Mercer CH, Fenton KA, Johnson AM, Wellings K, Macdowall W, McManus S et al. Sexual function problems and help seeking behavior in Britain: national probability sample survey. BMJ 2003; 327: 426–427. 15 Bancroft J, Loftus J, Long JS. Distress about sex. A national survey of women in heterosexual relationships. Arch Sexual Behavior 2003; 32: 193–208. 16 Castelo-Branco C, Blumel JE, Araya H, Riquelme R, Castro G, Haya J et al. Prevalence of sexual dysfunction in a cohort of middle-aged women: influences of menopause and hormone replacement therapy. J Obstet Gynaecol 2003; 23: 426–430. 17 Safarinejad MR. Prevalence and risk factors for erectile dysfunction in a population-based study in Iran. Int J Impot Res 2003; 15: 246–252. 18 Kaplan HS. The New Sex Therapy: Active Treatment of Sexual Dysfunctions. Brunner/Mazel: New York, 1974, 86pp. 19 Reader F. Disorders of female sexuality. In: Studd J (ed). Progress in Obstetrics and Gynaecology, vol. 9. Churchill Livingstone: London, 1991, pp 303–317. 20 Heiman JR, Meston CM. Evaluating sexual dysfunction in women. Clin Obstet Gynecol 1997; 40: 616–629. 21 Clayton AH. Female sexual dysfunction related to depression and antidepressant medications. Curr Womens Health Rep 2002; 2: 182–187. 22 Rosen RC, Lane RM, Menza M. Effects of SSRIs on sexual function: a critical review. J Clin Psychopharmacol 1999; 19: 67–85. 23 Berman L, Berman J, Felder S, Pollets D, Chhabra S, Miles M et al. Seeking help for sexual function complaints: what gynecologists need to know about the female patient’s experience. Fertil Steril 2003; 79: 572–576. 24 Salonia A, Munarriz RM, Naspro R, Nappi RE, Briganti A, Chionna R et al. Women’s sexual dysfunction: a pathophysiological review. BJU Int 2004; 93: 1156–1164. 25 Davis SR. Androgens and female sexuality. J Gend Specif Med 2000; 3: 36–40. 26 Gramegna G, Blu¨mel JE, Roncagliolo ME, Aracena B, Tacla X. Patterns of sexual behaviour in Chilean women. Rev Med Chile 1998; 126: 162–168. 27 Bonierbale M, Lancon C, Tignol J. The ELIXIR study: evaluation of sexual dysfunction in 4557 depressed patients in France. Curr Med Res Opin 2003; 19: 114–124. 28 Baldwin DS. Depression and sexual dysfunction. Br Med Bull 2001; 57: 81–99. 29 Avis NE, Stellato R, Crawford S, Johannes C, Longcope C. Is there an association between menopause status and sexual functioning? Menopause 2000; 7: 297–309. 30 Loehr J, Verma S, Seguin R. Issues of sexuality in older women. J Women’s Health 1997; 6: 451–457. 31 Riley TO, Riley E. Behavioural and clinical findings in couples where the man presents with erectile disorder: to retrospective study. Int J Clin Pract 2000; 54: 220–224. 32 Bachmann GA. Influence of menopause on sexuality. Int J Fertil Menopausal Stud 1995; 40: 16–22.


Appendix A Female Sexual Function Index Scoring 1. Over the past 4 weeks, how often did you feel sexual desire or interest?

5 ¼ Almost always or always 4 ¼ Most times (more than half the time) 3 ¼ Sometimes (about half the time) 2 ¼ A few times (less than half the time) 1 ¼ Almost never or never

2. Over the past 4 weeks, how would you rate your level (degree) of sexual desire or interest?

5 ¼ Very high 4 ¼ High 3 ¼ Moderate 2 ¼ Low 1 ¼ Very low or none at all

3. Over the past 4 weeks, how often did you feel sexually aroused (‘turned on’) during sexual activity or intercourse?

0 ¼ No sexual activity 5 ¼ Almost always or always 4 ¼ Most times (more than half the time) 3 ¼ Sometimes (about half the time) 2 ¼ A few times (less than half the time) 1 ¼ Almost never or never

4. Over the past 4 weeks, how would you rate your level of sexual arousal (‘turn on’) during sexual activity or intercourse?

0 ¼ No sexual activity 5 ¼ Very high 4 ¼ High 3 ¼ Moderate 2 ¼ Low 1 ¼ Very low or none at all

5. Over the past 4 weeks, how confident were you about becoming sexually aroused during sexual activity or intercourse?

0 ¼ No sexual activity 5 ¼ Very high confidence 4 ¼ High confidence 3 ¼ Moderate confidence 2 ¼ Low confidence 1 ¼ Very low or no confidence

6. Over the past 4 weeks, how often have you been satisfied with your arousal (excitement) during sexual activity or intercourse?


7. Over the past 4 weeks, how often did you become lubricated (‘wet’) during sexual activity or intercourse?


8. Over the past 4 weeks, how difficult was it to become lubricated (‘wet’) during sexual activity or intercourse?

0 ¼ No sexual activity 1 ¼ Extremely difficult or impossible 2 ¼ Very difficult 3 ¼ Difficult 4 ¼ Slightly difficult 5 ¼ Not difficult

9. Over the past 4 weeks, how often did you maintain your lubrication (‘wetness’) until completion of sexual activity or intercourse?


10. Over the past 4 weeks, how difficult was it to maintain your lubrication (‘wetness’) until completion of sexual activity or intercourse?




Appendix A (Continued) 11. Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)?


12. Over the past 4 weeks, when you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)?


13. Over the past 4 weeks, how satisfied were you with your ability to reach orgasm (climax) during sexual activity or intercourse?

0 ¼ No sexual activity 5 ¼ Very satisfied 4 ¼ Moderately satisfied 3 ¼ About equally satisfied and dissatisfied 2 ¼ Moderately dissatisfied 1 ¼ Very dissatisfied

14. Over the past 4 weeks, how satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner?

0 ¼ No sexual activity 5 ¼ Very satisfied 4 ¼ Moderately satisfied 3 ¼ About equally satisfied and dissatisfied 2 ¼ Moderately dissatisfied 1 ¼ Very dissatisfied

15. Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner?

5 ¼ Very satisfied 4 ¼ Moderately satisfied 3 ¼ About equally satisfied and dissatisfied 2 ¼ Moderately dissatisfied 1 ¼ Very dissatisfied

16. Over the past 4 weeks, how satisfied have you been with your overall sexual life?

5 ¼ Very satisfied 4 ¼ Moderately satisfied 3 ¼ About equally satisfied and dissatisfied 2 ¼ Moderately dissatisfied 1 ¼ Very dissatisfied

17. Over the past 4 weeks, how often did you experience discomfort or pain during vaginal penetration?

0 ¼ Did not attempt intercourse 1 ¼ Almost always or always 2 ¼ Most times (more than half the time) 3 ¼ Sometimes (about half the time) 4 ¼ A few times (less than half the time) 5 ¼ Almost never or never

18. Over the past 4 weeks, how often did you experience discomfort or pain following vaginal penetration?

0 ¼ Did not attempt intercourse 1 ¼ Almost always or always 2 ¼ Most times (more than half the time) 3 ¼ Sometimes (about half the time) 4 ¼ A few times (less than half the time) 5 ¼ Almost never or never

19. Over the past 4 weeks, how would you rate your level (degree) of discomfort or pain during or following vaginal penetration?

0 ¼ Did not attempt intercourse 1 ¼ Very high 2 ¼ High 3 ¼ Moderate 4 ¼ Low 5 ¼ Very low or none at all



Appendix B FSFI domain scores and total scale score

Domain

Questions

Score range

Factor

Minimum score

Maximum score

Desire Arousal Lubrication Orgasm Satisfaction Pain

1, 2 3, 4, 5, 6 7, 8, 9, 10 11, 12, 13 14, 15, 16 17, 18, 19

1–5 0–5 0–5 0–5 0 (or 1)–5 0–5

0.6 0.3 0.3 0.4 0.4 0.4

1.2 0 0 0 0.8 0

6.0 6.0 6.0 6.0 6.0 6.0

2.0

36.0

Total scale score range FSFI, female sexual function index.
