DOI 10.1007/s00737-002-0141-7
Original contribution
Sexual dysfunction in women: population based epidemiological study
N. Kadri
1, K. H. Mchichi Alami
1, and S. Mchakra Tahiri
21University Psychiatric Center, Casablanca, Morocco
2Department of Biostatistics, Faculty of Medicine, Casablanca, Morocco Accepted July 28, 2002; Published online October 1, 2002
© Springer-Verlag 2002
associated with sexual intercourse. It is classified as (American Psychiatric Association, 1994):
– Hypoactive sexual desire disorders: their essential feature is the deficiency or absence of sexual fantasies and desire for sexual activity.
– Sexual aversion disorders: their essential feature is the aversion to and active avoidance of genital sexual contact with a sexual partner.
– Sexual arousal disorders: their essential feature is a persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, adequate lubrication and swelling in response to sexual excitement.
– Orgasmic disorders: the essential feature of female orgasmic disorder is a persistent or recurrent delay in, or absence of, orgasm after a phase of normal sexual excitement.
– Sexual pain disorders: dyspareunia, vaginismus.
The essential feature of dyspareunia is genital pain that is associated with sexual intercourse. Although it is most commonly experienced during coitus, it may also occur before or after intercourse. In women the pain may be described as superficial during intromis- sion or as deep during thrusting. The intensity of the symptoms may range from mild discomfort to sharp pain.
The essential feature of vaginismus is a recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina Summary
Sexual dysfunction is defined as a disturbance of the processes that characterise the sexual response cycle or as pain associated with sexual intercourse. The objective of this epidemiological study, conducted in a representative sample of the population of women aged 20 and older in Casablanca, Morocco, is to determine the prevalence of sexual dysfunction in women. Criteria of sexual dysfunction followed classification by DSM-IV. The mean age of the sample (n ⫽ 728) was 36.76 ⫾ 12.67 years; 29% had no education, 78% pursued no professional activity; and 58% were married. The main results were that 26.6% had sexual dysfunction always or often during the 6 months before the study. The most common finding was hypoactive sexual desire disorder, and age, financial dependency, number of children, and sexual harassment were positively associated. The prevalence of remaining disorders resembled that found in the literature. Even though these women were aware about their disorder and its negative impact on their lives, only 17% of them asked for help.
Keywords: Prevalence sexual dysfunction; Moroccan women;
risk factors.
Introduction
Sexuality is a complex process coordinated by the
neurological, vascular, and endocrine systems
(Bachman and Philips, 1998). It also incorporates
familial, societal, and religious beliefs. It may suffer
disturbances due to ageing, health status, and per-
sonal experience. In addition, sexual activity incor-
porates interpersonal relationships, and each partner
brings unique attitudes, needs, and responses into
the coupling. A breakdown in any of these areas
may lead to sexual dysfunction. Sexual dysfunction
is defined as a disturbance of the processes that
characterise the sexual response cycle or as pain
when vaginal penetration with penis, finger, tampon, or speculum is attempted.
Research on female sexuality is an important field. Several studies found that if female sexuality is disturbed, the consequences were familial discord and divorce, and reproduction was affected. Sexual dys- function is a taboo subject that negatively affects quality of life and may often be responsible for psy- chopathological disturbances (such as anxiety and depressive disorders). The exact prevalence of sexual dysfunction is difficult to determine. Up to now, no study has explored sexual behaviour in Moroccan women. Objective of the study is to determine the prevalence of female sexual dysfunction and its risk factors.
Subjects and methods Sampling
This epidemiological study was conducted in a representative sam- ple of the population of women aged 20 and older in Casablanca, Morocco. Women aged 20 years or older were randomly selected by using systematic sampling from eight precincts of Casablanca, with stratification by age and precincts. The sample size was calcu- lated with 4% of precision, 5% as risk error, and with an assumed prevalence of sexual dysfunction of 50%. The minimum number required was 600 women. We contacted 800 and included 728 of these. Women interviewed had accepted and were available for a
“face to face” interview lasting one hour. In the field, stratification was done by quarters and houses. The study protocol and ques- tionnaires were reviewed and approved by the ethics committee at the University of Casablanca. To participate, participants had given oral informed consent.
Questionnaire design and completion
A questionnaire available from the authors inquiring about socio- demographic status was used. The criteria of sexual dysfunction were those of DSM-IV (American Psychiatric Association, 1994).
Hence, we inquired about low sexual desire (hypoactive sexual disorder, aversion), sexual arousal disorder, orgasmic disorder, and sexual pain disorder (dyspareunia, vaginismus).
The questionnaire inquired about sexual dysfunction during the 6 months prior to the study. Each entity was considered as abnormal when it happened always or often for women who were sexually active or were in a regular sexual relationship. The questionnaire was written in Moroccan Arabic. Five qualified and trained psychologists women assisted in filling in the completed questionnaires. All the interviews were done face to face, in the homes of the interviewed women.
A pilot study was conducted among 20 subjects in order to adapt the questionnaire, to identify the difficulties in the field, and to train the interviewers in administering the questionnaire.
Statistical analysis
Data analysis was performed on a personal computer using Epi- Info version 6.0. In bivariate analysis, we used the chi2 test to compare discrete variables (95% confidence interval). When the
conditions of the application were not satisfied we used the chi2 test corrected (Yates) or the exact Fisher test.
Sample sociodemographic characteristics
The mean age of the sample (n ⫽ 728) was 36.76 ⫾ 12.67 years (range 20–80 years). The sample consisted of young women; 53%
of them were aged between 20 and 34 years.
Twenty nine per cent of the sample had no education, 14% a university qualification, and 78% were not pursuing a professional activity. Fifty eight per cent were married, and 24% were single.
For women who were married the mean age at first marriage was 19.51 ⫾ 4.45 years (range 10–40 years); 88% were married once.
Nine per cent (9%) had no children, 59% had between one to four children, and 32% had more than four children. Just over two thirds (71.2%) were financially dependent.
With regard to the medical condition of the sample, 10%
reported that they had diabetes, 23% hypertension, 35% had had pelvic surgery, 31% depressive symptoms, 31% anxiety symptoms, and 30.5% sleep disorders.
Results
Altogether 491 women from the sample satisfied the criteria “sexually active or having a regular sexual relationship.”
Sexual dysfunction (26.6%, n ⫽ 131/491)
Twenty six per cent of the sample had sexual dys- function. This subgroup had the following charac- teristics: mean age 36.3 ⫾ 10.28 years; 29% were illiterate; 14% had more than 12 years and 12% had less than 12 years of education.
With regard to their marital status, 85.4% were married, 0.4% were single, 3.7% divorced, 1,1%
widowed, and 0.4% were living in unmarried rela- tionships. Fifty three per cent had one to four children and 23.7% had more than four.
Hypoactive sexual desire disorder: (18.3, n ⫽ 90/491) A total of 18.3% of the sample specified having low sexual desire always or often during the preceding 6 months. A significant association was found between hypoactive sexual desire and:
– Age (P ⬍ 0.0001); the prevalence tends to decrease with increasing age.
– Financial dependency (P ⫽ 0.00052); women financially dependent on their husbands tend to have hypoactive sexual desire disorder more often.
– A high number of children (P ⬍ 0.0001); women with four children and more had hypoactive sexual desire disorder more often than women with two children.
– Occurrence of sexual harassment during childhood
(P ⬍ 0.05).
– Marital status (chi
2⫽ 15.67, ddl ⫽ 2, P ⬍ 0.0001);
married women had hypoactive sexual desire dis- order more often than single women and women who were living alone. Women who were living alone had less desire than single women.
– Level of education (chi
2⫽ 28.88, ddl ⫽ 3, P ⬍ 0.0001). Illiterate women had more hypoactive sexual desire disorder than women with primary and secondary level of schooling. However, women with secondary level schooling tended to have less desire.
Religion was not significantly associated with hypoactive sexual desire disorder (P ⫽ 0.69).
Sexual aversion disorder: (15%, n ⫽ 70/466)
Out of 466 responses, 15% of women reported having sexual aversion always or often, during the preceding 6 months. A significant association was found between sexual aversion and:
– Marital status (P ⬍ 0.0001); married women had aversion more often than single ones and women who were living alone.
– Diabetes (P ⫽ 0.003) and hypertension (P ⫽ 0.03) The association with financial dependency was not significant (P ⫽ 0.064); independent women had the same rate of aversion as dependent ones.
Orgasmic disorder: (12%, n ⫽ 53/459)
Out of 459 responses, 12% of the sample had orgas- mic disorder always or often during the preceding 6 months. The association was positive with diabetes (P ⫽ 0.02), and negative with financial dependency (P ⫽ 0.34).
Sexual arousal disorder: (8.3%, n ⫽ 38/460)
Out of 460 responses, 8.3% had sexual arousal disorder always or often during the 6 months prior to the study. A positive association was found between arousal disorder and low level of education (P ⫽ 0.001), sleep disorder (P ⫽ 0.004), and how women were experiencing sexual intercourse (as a drudgery) (P ⫽ 0.01). This association was negative for financial dependency (P ⫽ 0.239).
Sexual pain disorders
Dyspareunia: (7.5%, n ⫽ 35/464)
Out of 464 responses, 7.5% had dyspareunia always or often during the 6 months prior to the study. A positive association was found with hypertension (P ⫽ 0.04), depressive symptoms (P ⫽ 0.01), sleep disorders (P ⫽ 0.001), and how the women were
experiencing sexual intercourse (as a drudgery) (P ⫽ 0.025). No positive association was found with financial dependency (P ⫽ 0.8) or with sexual harass- ment during childhood (P ⫽ 0.62).
Vaginismus: (6.2%, 29/465)
Out of 465 responses, 6.2% of the sample specified having vaginismus always or often during the 6 months prior to the study. A positive association was found with diabetes (P ⫽ 0.027) but not with financial dependency (P ⫽ 0.62).
For the whole subgroup with sexual dysfunction (26.6%), a positive association was found with sexual dysfunction and the fact that women were not able to express their sexual pleasure (P ⫽ 0.00007).
Reasons of sexual dysfunction reported by women Asked to explain the causes of disorders they were suffering, women linked them to:
– A conflict with the partner (92.9%) – Sexual dysfunction of their partner (90%)
– Poor knowledge of their bodies and erogenous zones (89.1%)
– Consequences of sorcery (82.3%)
– Personal psychopathological problems (86.4%), or history of obstetric trauma (72.7%).
Search for help
Among the 131 women with sexual dysfunction 17%
consulted healthcare professionals; 33% consulted in primary health care, 57% talked to their gynaecolo- gist about their problem, and 10% consulted tradi- tional healers or talked about their problem when consulting other providers of medical services.
These women asked for help for the following reasons:
– Willingness to have a satisfying sexual life (22%).
– Concern about normality (80%).
– Under pressure from their partner (78%).
Discussion
In our study the overall prevalence of sexual
dysfunction was 26.6%. The literature estimates of
sexual dysfunction in women range from 19% to
50% in “normal outpatient populations”(Bachman
et al., 1989; Michael, 1994). Results from a national
survey of people aged 18–59 years indicated that sexual dysfunction was common among women in 43% of cases (Hwang, 1999). On the other hand, the national health and social life survey, a study of adult sexual behaviour in the United States, found that 43% of women had sexual dysfunction (Laumann et al., 1994). Finally, most of the studies found a higher prevalence of sexual dysfunction in women than in men (Hwang, 1999, Laumann et al., 1999).
In this sample, the most prevalent disorder was low desire (18.3%). This agrees with the findings of the Hwang study (Hwang, 1999), which found 22%.
This prevalence tends to decrease with increasing age, similarly to the study by Laumann et al.
(Laumann et al., 1999). It also varies significantly across marital status; married women are at higher risk and single women at lowest risk, contrary to the findings of the Laumann study (Laumann et al., 1999). This phenomenon might be explained by the burden of high number of children, illiteracy, and unfavourable social conditions of married Moroccan women. This fact is supporting the role of social, cultural factors and the interrelation with the partner in the development of this dysfunction.
In this sample 15% reported having sexual aver- sion always or often, during the 6 months prior to the study. Sexual aversion is the probable diagnosis in lifelong cases of sexual anhedonia. A significant association was found between sexual aversion and financial dependency, marital status, and medical conditions such as diabetes and hypertension.
In this sample, 12% had orgasmic disorder always or often during the 6 months prior to the study. About 10% of women never attained orgasm regardless of the stimulation of situation. Possible explanations may include a restrictive sexual education, negative beliefs with regard to the anatomy of the sexual organs, and the taboo of pleasure even if Islam is among the monotheist religions that encourages women to have pleasure during sexual intercourse.
Sexual arousal disorder
In this sample 8% had sexual arousal disorder always or often during the 6 months prior to the study. In the Hwang study (1999) 14% of the women had sexual arousal disorder.
A lifelong diminished capacity for sexual arousal may be related to ignorance of genital anatomy and function. Anxiety has an impact, and ignorance and anxiety are mutually reinforcing.
In our sample we investigated only the 6 months prior to the study, not the lifelong experiences of the subjects. We found that a low level of education is linked to this disorder, which might lead to ignorance of genital anatomy and function. Women reported in a significant manner that they considered sexual intercourse a drudgery.
In this sample about 14% of the surveyed women reported sexual pain disorder. In Hwang study (1999) 7% reported pain during intercourse.
However, 7.5% of the sample had dyspareunia always or often during the 6 months prior to the study. In the literature, causes include psychological factors or local trauma. The condition can also be a result of the menopause, with symptoms of dryness and thinning of the mucosa. Psychological causes might be the same as in female orgasmic disorder.
Inadequate stimulation or psychological inhibition may result in inadequate vaginal lubrication and cause coital pain. In our sample we found a positive association with hypertension, depressive symptoms, sleep disorders, and when intercourse is not desired and felt to be a drudgery.
In this sample, 6% specified having vaginismus always or often during the 6 months prior to the study. The pain of vaginismus may prevent intromis- sion, often resulting in unconsummated marriages. In Morocco, its is the most frequent motive of sexology consultation (Kadri et al., 2001). Its supposed causes are restrictive religious education, negative beliefs with regard to the anatomy of the hymen, miscon- ception about the mechanism of intromission, and learnt beliefs that is very painful, and trauma after sexual assault.
Every disturbance of the quality of the relation- ship between the partners may disturb the quality and frequency of sexual intercourse – 92.9% of the women in the current sample attributed their sexual disorders to a problem in the relationship with their partner. However, 90% of them linked their own sexual dysfunction to their husband’s sexual dysfunc- tion, which had a negative impact on the sexual intercourse of the two partners. A population based study of Morocco’s general population found a pre- valence of 54% of sexual dysfunction in a repre- sentative sample of men (Berrada et al., 2001).
However, 86.4% of the sample related their disorder to a personal psychopathological problem.
Sexual dysfunction is a complex phenomenon
resulting from various factors, including mainly
psychological ones such as anxiety, distress. It is well
known that depression is commonly associated with a disturbance of sexual response, and this disturbed response might be the pre-eminent symptom of depression. About one third of our sample reported depressive and anxious symptoms as well as sleep disorders.
In the popular context in Morocco, people com- monly link sexual dysfunction, especially erectile dysfunction and vaginismus, to the effects of sorcery or «ettkaf». This cultural explanation of sexual dysfunction may happen in very different circum- stances. It may happen in acute circumstances, for example during the night of wedding festivities.
Culturally, during this night the newly married couple have to give to the guest the proof of the virginity of the woman. Hence they have to have their first sexual intercourse, during which the guests are waiting to see the “Seroual,” which is a dress stained with the blood. Often the new spouses are very tired, and the man is completely sexually impotent due to anxiety and fatigue. Chronic sexual dysfunction, however, is seen as an evil action of somebody who wants to hurt the person. This happened in the opinion of 82.3% of our sample.
Finally, 72.7% of the sample related their disorder to a history of obstetric trauma. In their medical history, third of them specified having had pelvic surgery.
Even if women were aware of the disorder, only 17% consulted a doctor, most of them a gynaecolo- gist or general practitioner.
In conclusion, sexual dysfunction is a taboo, frequent, and treatable illness. In our context, even if the women’s sexual behaviour is concealed by
cultural factors, we found the same prevalence of sexual dysfunction as in other cultures.
We stress the necessity of information for and training of Moroccan healthcare professionals in diagnosing and treating these illnesses to allow these women to have a satisfying sexual life and improve their quality of life in general.
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Correspondence: Prof. Nadia Kadri M.D., University Psychiatric Center Ibn Rushd, Rue Tarik Ibn Ziad, Casablanca, Morocco. E-mail: [email protected]
