Female sexual dysfunction in Lower Egypt
Dr AM Elnashar, Department of Obstetrics and Gynaecology, Benha University Hospital, Benha, Egypt.
Objective The aim of this study was to assess the prevalence and associated factors of female sexual dysfunction (FSD) in Lower Egypt.
Design A cross-sectional clinic-/hospital-based survey.
Setting Five district medical centres in Dakahlia Governorate: Shirbin, Bilquas, Samblawen, Dekrinis and Mansoura City.
Population One thousand married women aged between 16 and 49 years.
Methods Data were collected by personal interview in a questionnaire format in addition to physical examination (when allowed).
Main outcome measures FSD and associated risk factors.
Results The response rate was 93.6%. 68.9% of women had one or more sexual problems; however, 23% of the women with sexual problems were not distressed by these issues. 31.5% of women suffered from dyspareunia. 49.6% of the women had decreased sexual desire, 36% had difficult arousal and 16.9% had anorgasmia (primary and secondary). Marital disharmony, ‘hate’ and unfavourable socio-economic circumstances were the most common aggravating factors (28.1%) for sexual dysfunction among the participants, followed by pregnancy-related events (15.7%). Most women (84.5%) received no help for their sexual problems. 90.3% of the women were circumcised. Only 7.1% (46 of 645) of women with sexual problems had received treatment, with no real improvement reported in 58.7% (27 of the 46 women).
Conclusions FSD is a highly prevalent problem within the scope of this study. Low reporting rates and very low treatment rates were identified in the sample from Lower Egypt.
Sexuality is an important part of health, quality of life and general wellbeing.1 Sexual dysfunction is characterised by disturbance in sexual desire and psychophysiological changes associated with the sexual response cycle in men and women.2 Epidemiological data on sexual dysfunction are relatively scanty and vary widely. Sexual dysfunction is more prevalent in women than in men and is associated with various demographic characteristics, including age and educational attainment.3 Women of different racial groups show different patterns of sexual dysfunction. Experience of sexual dysfunction is more likely among women with poor physical and emotional health. Moreover, sexual dysfunction is highly associated with negative experiences in sexual relationships and overall wellbeing. Female circumcision is one of the traditional practices that is still performed in Egypt and is a possible cause of female sexual dysfunction (FSD). To the best of our knowledge, there is no Egyptian epidemiological study on FSD. This fact stimulated the present study.
Epidemiological data would be of obvious value in developing appropriate service delivery and resource allocation models. Our objective was to study the prevalence and the associated factors of FSD in Lower Egypt.
Materials and methods
A cross-sectional clinic-/hospital-based survey was designed for implementation in married women aged between 16 and 49 years. The study was performed from June 2002 through April 2003.
To determine the size of the sample in terms of a statistical approach, the following formula was used to estimate the minimum sample size for health surveys, using Epi-Info version 5.01, 1990. If we are working on proportions, then N is the minimum sample size required; P, the proportion affected; Q, the proportion not affected and D, the sampling error. To obtain the required power with an alpha of 0.05 and a beta of 0.8, a constant Z needs to be introduced with a value of 1.96. If the approximate prevalence of the problem is 34% (0.34) and the magnitude of the absolute sampling error that can be tolerated ‘d’ is 0.04, for example, then N=Z2PQ/D2; N= (1.96)2× 0.34 × 0.66/(0.04)2 and N= 538.78. Thus, at least 539 individuals should be surveyed to achieve the study objective. A total of 1000 women were chosen to increase the statistical reliability of the study.
The study sample was selected from women in the Dakahlia Governorate. This we consider to be a representative sample of the wider area of Lower Egypt (there are similar demographic and cultural characteristics in most governorates of Lower Egypt [Egyptian Demographic Health Survey, 2000]). Dakahlia Governorate is composed of 11 districts. Five districts were chosen for our sample. These five districts represent the north, south, east, west and middle of Dakahlia Governorate. These districts were Shirbin, Samblawen, Dekrinis, Bilquas and Mansoura City. In each district, all sites providing services for women were included, i.e. general hospitals, maternal and child healthcare centres and family planning centres. From these sites in each district, 200 women were chosen by systematically selecting every third woman (patient or woman accompanying the patient). A total of 1000 married women were selected for the interview. Their ages ranged from 16 to 49 years, with a mean age of 29.9 ± 7.7 years. Nine hundred and thirty-six women complied with the study, while 64 refused to participate, giving a response rate of 93.6%.
The questionnaire used to measure sexual dysfunction comprised six response items, each assessing the presence of a critical symptom or a sexual problem. Response items included lacking or having reduced desire for sex; frequency of sexual activity; arousal difficulty, i.e. erection problem, ejaculating too rapidly in men and lubrication difficulties in women; inability in achieving orgasm; physical pain during intercourse or finding sex unpleasurable.
The assessment questionnaire also included demographic characteristics such as respondent age, duration of marriage, other wives, residence status, level of education, work and other source of income, if any. Other aspects of reproductive function were included such as the number of children, mode of delivery and method of birth control, if any. Assessment also involved risk factors associated with health and lifestyle such as experience of emotional and psychological causes or stress-related problems, e.g. potentially traumatic events such as sexual harassment or termination of pregnancy, circumcision, health status and husband travelling abroad. Finally, general physical and pelvic examination was performed when allowed.
All the data were entered into a computerised database. Descriptive statistics were computed for each questionnaire item. Categorical data were expressed in percentages and comparisons made using chi-square tests. The level of statistical significance used was P < 0.05. Continuous variables were expressed as mean and SD, if normally distributed and compared by Student’s t test or analysis of variance.
Table 1 shows that most participants were in the age groups 20 to 29 years and 30 to 39 years (48.9 and 30.9%, respectively). Many of the participants (28.6%) were illiterate and most of them (70.4%) were housewives. Six hundred and forty-five (68.9%) women had one or more sexual problems. It must be noted that many (215 - 23%) women with sexual problems were not distressed by these issues. One hundred and eight (11.5%) women suffered from sexual abuse in addition to other sexual problems. Table 2 shows that the most common frequency of sexual intercourse reported among participants was two to four times per week. More than one-third of the women (36.2%) thought this was too frequent, saying that once per week is more ‘convenient’. Table 3 shows that decrease or loss of desire was the most common sexual problem among participants (49.6%), followed by orgasmic problems (43%), while arousal problems and dyspareunia occurred in 36 and 31.5%, respectively. From the women’s point of view, 17.1% of husbands were reported to have impotence, while 5% were reported to have premature ejaculation (Table 4). Table 5 shows the significant association between women’s age and sexual problems. Sexual problems were reported to be less common in women aged 20–29 years and more common in women aged 40–49 years. The level of education was also significantly correlated with the extent of sexual problems, as was circumcision status. Table 6 shows that parity was a highly significant variable, in particular for those who had delivered more than five times, although nulliparity also showed a significant association. Abnormal menstrual patterns were significantly associated with female sexual problems. Mode of delivery and type of contraception used were not statistically significantly associated with sexual dysfunction. Table 7 shows that unsuitable social circumstances and economic stress (28.1%) were the most common aggravating factors for sexual dysfunction. Table 8 shows that most women respondents reported receiving no assistance for their sexual problems. The study also indicates that sexual problems tended to have a gradual onset in most women (63%), and worsen with time (44%). Only 7.1% (46 of the 645) women with sexual problems had received treatment, and of these, there was no demonstrable improvement in over half (27 of the 46 women, 58.7%).
Table 1. Socio-demographic characteristics of women (n = 936)
|Age (in years)|
|Type of family|
Table 2. Frequency, satisfaction of current frequency and satisfying frequency of sexual intercourse among women (n= 936)
|Once per day||118 (12.6)|
|More than once per day||25 (2.7)|
|Once per week||114 (12.2)|
|Two to four per week||547 (58.5)|
|Less than one to two per month||132 (14)|
|Not satisfied||339 (36.2)|
|Satisfying frequency of intercourse|
|Total no. of unsatisfied women||339 (100)|
| One per week||116 (34.2)|
| Two per week||87 (25.7)|
| Three per week||58 (17.1)|
| Others*||78 (23.0)|
Table 3. Distribution of sexual problems by type among women (n= 936)
|Decrease or loss of desire||464 (49.6)|
|Increased desire||34 (3.6)|
|Occasional difficulty||232 (24.8)|
|Always difficult||105 (11.2)|
|Primary anorgasmia||98 (10.5)|
|Secondary total anorgasmia||60 (6.4)|
|Occasional anorgasmia||244 (26.1)|
|All through||135 (14.4)|
Table 4. Prevalence of male sexual problems from the women’s point of view (n= 936)
|No problem||729 (87.9)|
|Premature ejaculation||47 (5.0)|
Table 5. Proportions of female sexual problems relative to socio-demographic characteristics of the women
|Age (in years)|
|<20||29 (10.0)||57 (8.8)||0.57|
|20–29||156 (53.6)||302 (46.8)||0.031|
|30–39||86 (29.6)||203 (31.5)||0.99|
|40–49||20 (6.9)||83 (12.9)||0.017|
|Rural||178 (61.1)||378 (58.6)|| |
|Urban||113 (38.8)||267 (41.4)|| |
|Type of family|
|Extended||52 (17.9)||114 (17.8)||0.94|
|Nuclear||239 (82.1)||531 (82.3)||0.83|
|Illiterate||89 (30.6)||179 (27.8)||0.28|
|Primary||37 (12.7)||98 (15.2)||0.31|
|Secondary||140 (48.1)||409 (63.4)||0.001|
|University||25 (8.6)||59 (9.1)||0.80|
|Professional||56 (19.2)||119 (18.4)||0.77|
|Farmer||12 (4.2)||36 (5.6)||0.55|
|Labourer||14 (4.8)||40 (6.2)||0.31|
|Housewife||209 (71.8)||450 (69.8)||0.25|
|No||33 (11.3)||58 (9)|| |
|Yes||258 (88.7)||587 (91)|| |
Table 6. Proportion distribution of female sexual problems according to reproductive features of the women
|Marriage duration (in years)|
|<5||130 (44.7)||255 (39.5)||0.089|
|5–9||66 (22.7)||145 (22.5)||0.52|
|10–14||42 (14.4)||91 (14.1)||0.78|
|>15||53 (18.2)||154 (23.9)||0.064|
|Yes||29 (10.0)||79 (12.2)|| |
|No||262 (90.0)||566 (87.8)|| |
|Normal||214 (73.5)||413 (64)|| |
|Abnormal||87 (26.5)||232 (36)|| |
|Nullipara||30 (10.3)||96 (14.9)||0.032|
|One to two deliveries||136 (46.7)||298 (46.2)||0.89|
|Three to five deliveries||80 (27.5)||221 (34.3)||0.013|
|More than five deliveries||45 (15.5)||30 (4.7)||0.002|
|Mode of delivery|
|Normal||194 (76.4)||411 (75.3)||0.82|
|Assisted||15 (5.9)||27 (4.9)||0.52|
|Caesarean section||45 (17.7)||118 (21.6)||0.32|
|Nonuser||133 (45.7)||284 (44)||0.61|
|Intrauterine device||104 (35.7)||226 (35.0)||0.77|
|Hormonal||49 (16.8)||123 (19.1)||0.25|
|Others||5 (1.7)||11 (1.7)||0.87|
Table 7. Frequency and percentage of aggravating factors in relation to female sexual problems (n= 645)
|No aggravating factors||181 (28.1)|
|Unfavourable conditions*||181 (28.1)|
|Marital disharmony and hate||103 (16.0)|
|Pregnancy-related factors||101 (15.7)|
|Delivery-related factors||20 (3.1)|
|Contraception-related factors||20 (3.1)|
|Infertility-related factors||15 (2.3)|
Table 8. Frequency and percentage of ameliorating factors in relation to female sexual problems (n= 645)
|No ameliorating factors||545 (84.5)|
|Marital adjustment||68 (10.3)|
The possibility of underreporting biases in face-to-face interviews should be considered because of occasional lack of adequate privacy during interviews and women’s reluctance to talk about such sensitive issues. Some participants required repeated questioning before they understood the questions. Moreover, one particular group failed to understand clearly at the initial interview and had to be re-interviewed. Many participants refused genital examination, which may have resulted in missing an organic aetiology for their problems. All information with regards to the health and sexual problems of the male partners was provided by their wives, as the men were not personally interviewed. This may result in under- or overreporting bias.
The current study presents epidemiological data on the prevalence and predictors of FSD in Lower Egypt, represented by a sample taken from the Dakahlia Governorate. It emphasises the high prevalence (68.9%) of sexual difficulties among the women studied. Interestingly, the data are consistent with those of Daker-White and Crowley4 who performed a cross-sectional questionnaire survey on 216 men and 191 women attending Department of Genitourinary Medicine, University of Bristol, UK and found that 69% of women had sexual dysfunction.
Demographic characteristics were found to be strongly predictive of sexual difficulties. Sexual problems increased with increasing age. The results suggest that this increase was associated with the increasing demands of growing children and running an expanding family. The educational level of the couple, and particularly whether they had received secondary education, was correlated with the incidence of sexual problems. This higher incidence of sexual dysfunction in better educated individuals is surprising given that they are healthier and have lifestyles that are less physically stressful and emotionally demanding. However, a higher educational level may also be associated with an increase in the women’s ability freely to express their dissatisfaction. This finding agrees with those of van Gleen et al.5 who showed a positive correlation between level of education and sexual dysfunction.
In the present study, work status and source of income did not impact upon sexual function greatly, although in 28.1% of respondents, unfavourable economic circumstances were among the aggravating factors for their sexual problems. This finding contradicts that of Laumann et al.3 who found a positive correlation between deterioration in economic position and sexual dysfunction. In Egypt, the lack of correlation may be because of a lack of a large difference in the economic situation of the studied groups.
The majority of respondents were housewives (70.4%), with only 1.3% owning property, and among their spouses, 55.6% had private work, 21.2% had a government job and only 4.8% had their own property.
The low rate of overt complaint relative to sexual problems among Egyptian women does not indicate lack of sexual interest but rather reflects cultural factors, i.e. shyness, embarrassment and reluctances. In addition, lack of physicians’ awareness and training leads to inadequate identification and management of such problems.
Our results emphasise the high prevalence of sexual problems among apparently healthy individuals, and the importance of direct questioning about sexual function in gynaecology and family planning clinics. This finding is consistent with that by Berman et al.6 who reported that 40% of women did not seek help from a physician for their sexual complaints, while 54% reported that they would like to do so.
The number of pregnancy losses and parity both correlated positively with sexual dysfunction, but the mode of delivery did not. This was most marked in women who delivered more than two children and is probably due to anatomical changes associated with repeated pregnancy and delivery, e.g. piles, weakening of the pelvic floor and various degrees of genital tract descent.
Circumcision status (now called female genital mutilation according to the World Health Organisation’s latest recommendations)7 was associated with an elevated risk of experiencing sexual problems. Approximately 90% of women in this study were circumcised; therefore, this was a significant cause of sexual problems. Among the examined group, either first- and second-degree circumcision were present in 62% of women. This corroborates the report of EL-Hady and EL-Nashar8 who found, in their sample of 264 women in Benha City, that circumcised women (75.8%) were more likely to have marital problems such as loss of sexual desire, dyspareunia and lower satisfaction rate, in addition to psychological problems, mainly anxiety, depression and hostility.
Hypoactive sexual desire disorder was reported in 49.6% of women, with only 3.6% reporting increased desire. These findings largely correspond with other studies such as that by Johnson9 who showed that more than 40% of women in the USA reported infrequent desire or enjoyment of sex and the study by Oberg et al.10 who reported that 45% of Swedish women had decreased desire. Other studies reported higher rates of diminished libido, ranging from 52 to 87%,11,12 while Shokrollahi et al.12 reported a lower rate of inhibited desire (15%). This difference in prevalence rate may be explained by the differences in definition, methodology and population studied. In the current study, many participants explained their lower sexual desire to be because of circumcision and socio-economic circumstances such as economic stressors and increased household duties. This was also noted by Shokrollahi et al.12 who found too little foreplay before sexual intercourse to be the most common sexual difficulty among their sample of women.
In the current study, most women related their anorgasmia to inadequate sexual stimulation, interruptive thoughts or failure to maintain an adequate level of excitation if their husbands reach orgasm first.
31.5% of women suffered from dyspareunia. Deep dyspareunia was three times more common than superficial dyspareunia (12.5 versus 4.6%). This difference in prevalence rate may be explained by the difference in age groups of the women studied and also their cultural background. Laumann et al.3 showed differing patterns of dyspareunia across age and demographic groups. However, Gurel and Atar-Gurel13 found no correlation between severe dyspareunia and various socio-demographic factors (i.e. age, parity, income, marital status and education). Furthermore, pregnancy and lactation may affect the prevalence rate. In this study, approximately 19% of women were pregnant or in the early postpartum period, and approximately 15% of women reported pregnancy as an aggravating factor for their sexual problems. Oruc et al.14 found that the prevalence of dyspareunia was 26% throughout pregnancy.
Many of the women in this study reported that they engage in sexual activity because of marital commitment, financial reasons, to avoid sense of guilt, for religious reasons and also to reduce the risk of their husbands engaging in extramarital sexual relationships. Husbands’ choice of unsuitable time for sexual intercourse, unfavourable socio-economic circumstances such as lack of adequate privacy at home and low income were the most common aggravating factors. This was also shown by Shokrollahi et al.12 who noted that one of the most common sexual difficulties reported was partners choosing inconvenient times. This was noted in 8% of the women in this study. Similarly, Leiblum and Rosen15 reported that relationship conflict (specifically, lack of trust and intimacy), conflicts over power and control and loss of physical attraction to the partner are important causal factors for hypoactive sexual desire. Also, McCabe and Cobain16 mentioned that women experiencing sexual dysfunction almost invariably reported dissatisfaction with the nonsexual aspects of their relationship. This emphasises the concept of multifactorial aetiology of any FSD and frequent overlap of the disorders.17
In 84.5% of cases, there were no ameliorating factors, and only 7% had received any form of treatment. This finding was also noted by Aristotelis et al.17 who confirmed the high prevalence of sexual dysfunction, which is often untreated and receives little medical attention.
With regards to genital examination, in this study, only 31.2% (201) of affected participants agreed to be examined. The remainder refused because they either did not wish an examination or were pregnant or menstruating at the time. The results of examination showed no abnormality in 80% of the women studied. This finding is not surprising as in the literature, dyspareunia was the only sexual dysfunction in which organic factors have been shown to play a major role.18
The generally low rate of overt complaints regarding sexual problems among Egyptian women does not indicate lack of sexual interest but rather reflects cultural factors such as shyness, embarrassment and reluctances of the women and lack of physicians’ awareness and training, which lead to inadequate identification and management of such problems. This result emphasises the high prevalence of sexual problems even among apparently healthy individuals and also emphasises the importance of direct questioning about sexual function as part of the routine checklist in gynaecology and family planning clinics. This is consistent with the findings of Berman et al.6 who reported, in their study, that 40% of the women did not seek help from a physician for their sexual complaints, while 54% reported that they would like to do so.
Female sexual dysfunction is under-researched in Egypt and therefore warrants recognition as a significant public health concern, with a need for further epidemiological research. Finally, studies of physicians’ awareness and competency in FSD are urgently needed. Most physicians and other healthcare providers receive little or no formal training in this critical area.