{"paper_id":"d1eebd3f-7851-44f1-a996-c184f02dbddf","body_text":"BioMed Central\nPage 1 of 10\n(page number not for citation purposes)\nBMC Gastroenterology\nOpen AccessResearch article\nDeterminants of female sexual function in inflammatory bowel \ndisease: a survey based cross-sectional analysis\nAntje Timmer*1, Daniela Kemptner2, Alexandra Bauer3, Angela Takses3, \nClaudia Ott3 and Alois Fürst4\nAddress: 1Department of Medical Biometry and Statistics, University Hospital of Freiburg, Stefan-Meier Strasse 26, 79104, Freiburg, Germany, \n2Landratsamt, Regensburg, Altmühlstraße 3, 93059 Regensburg, Germany, 3Department of Medicine 1, University Hospital of Regensburg, Franz-\nJosef-Strauss-Allee 11, 93042 Regensburg, Germany and 4Department of Surgery, Caritas-Hospital St, Josef Landshuter Straße 65, 93053 \nRegensburg, Germany\nEmail: Antje Timmer* - timmer@cochrane.de; Daniela Kemptner - daniela.kemptner@landratsamt-regensburg.de; \nAlexandra Bauer - a5bauer@yahoo.de; Angela Takses - angela.takses@klinik.uni-regensburg.de; Claudia Ott - claudia.ott@klinik.uni-\nregensburg.de; Alois Fürst - chirurgie@caritasstjosef.de\n* Corresponding author    \nAbstract\nBackground: Sexual function is impaired in women with inflammatory bowel disease (IBD) as\ncompared to normal controls. We examined disease specific determinants of different aspects of\nlow sexual function.\nMethods: Women with IBD aged 18 to 65 presenting to the university departments of internal\nmedicine and surgery were includ ed. In addition, a random sample from the national patients\norganization was used (separate analyses). Sexual function was assessed by the Brief Index of Sexual\nFunction in Women, comprising  seven different domains of se xuality. Function was considered\nimpaired if subscores were < -1 on a z-normalized scale. Results are presented as age adjusted odds\nratios with 95% CI based on multiple logistic regression.\nResults: 336 questionnaires were includ ed (219 Crohn's di sease, 117 ulcerative colitis). Most\nwomen reported low sexual activity (63%; 17% none  at all, 20% moderate  or high activity).\nPartnership satisfaction was high in spite of low sexual interest in this group. Depressed mood was\nthe strongest predictor of low se xual function scores in all domains. Urban residency and higher\nsocioecomic status had a protecti ve effect. Disease activity was mo derately associated with low\ndesire (OR 1.8, 95% CI 1.0 to 3.2). Severity of the disease cour se impacted most on intercourse\nfrequency (OR 2.3, 95% CI 1.4 to 4.7). Lubrication problems were more common in smokers (OR\n2.5, 95% CI 1.3 to 5.1).\nConclusion: Mood disturbances and social environmen t impacted more on sexual function in\nwomen with IBD than disease specific factors. Smoking is associated with lubrication problems.\nBackground\nUlcerative colitis and Crohn's disease typically affect ado-\nlescents or young adults and are characterized by a chron-\nically remitting course. Many symptoms, complications\nand consequences of these diseases are likely to impact on\nbody image, intimacy and sexual function [1]. Fatigue,\nPublished: 3 October 2008\nBMC Gastroenterology 2008, 8:45 doi:10.1186/1471-230X-8-45\nReceived: 18 December 2007\nAccepted: 3 October 2008\nThis article is available from: http://www.biomedcentral.com/1471-230X/8/45\n© 2008 Timmer et al; licensee BioMed Central Ltd. \nThis is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), \nwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.\n\nBMC Gastroenterology 2008, 8:45 http://www.biomedcent ral.com/1471-230X/8/45\nPage 2 of 10\n(page number not for citation purposes)\npain and diarrhoe are typical features of relapse and may\nfurther be aggravated by the embarrassing features of\nincontinence and bad odours. Perianal disease affects\nabout one third of patients with Crohn's disease. Many\nwill require surgery, possibly including the installation of\na permanent or, more often, transient ostomy. Malnutri-\ntion or medical therapy with corticosteroids may also be\nassociated with changes in the bodily appearance. Fur-\nthermore, mood disorders, in particular depression, are\nreported to be common in IBD [2]. Mood disorders are, at\nthe same time, known to constitute a major risk factor for\ndecreased sexual function [3].\nIt was therefore not surprising, when, almost 15 years ago,\nMoody and Mayberry described significantly decreased\nsexual activity in women with Crohn's disease, based on\nstructured interviews in 50 women with friend controls\n[4]. Twenty-four percent of the cases abstained from sex-\nual activities altogether due to the disease (controls: 4%).\nMoody and Mayberry complemented this study by\nanother survey including 50 women with ulcerative colitis\n[5]. Since then, there has been very little research on this\nissue as recently reviewed [6,7]. The few studies available\nmostly focused on postoperative outcomes, as abdominal\nsurgery has the potential for structural changes or pelvic\nnerve damage [8-10]. Many other issues concerning sexual\nhealth in women with IBD remain unclear.\nWe have recently conducted a case control survey in mem-\nbers of the German IBD patients organization [11]. These\npersons form a relatively healthy group of IBD patients.\nEven so, all aspects of female sexuality covered by a sensi-\ntive validated instrument [12] were impaired in the IBD\ncases, as compared to controls. In contrast to the results in\nmen, impaired function in women did not depend on the\nactivity of the disease but was also manifest in remission.\nDue to the case-control design and the use of ambulatory\npatients only, this previous survey offered little informa-\ntion on disease specific risk factors.\nTo shed more light on the disease related determinants of\nsexual function in women with IBD, we have now con-\nducted a survey in a well described clinical sample of\npatients. Here, we present data from both surveys.\nMethods\nParticipants\nConsecutive patients with IBD, aged 18 to 65, were\nincluded on presentation to the university hospital\ndepartments of internal medicine and surgery. Patients\nwith major acute or chronic co-morbidity, unrelated to\nIBD, were excluded if interference with quality of life and\nsexuality in particular was considered likely. This was left\nto the discretion of the treating physician. The list of\nexamples for exclusion included the following: chronic –\nadvanced cancer, complicated diabetes, neurological dis-\nease compromising mobility (such as stroke or multiple\nsclerosis), remitting cardiac failure; acute – recent surgery\nfor any condition other than IBD, all patients currently in\nor recently transferred from intensive care. Outpatients\nwere also recruited. The response rate was calculated as\nthe proportion of contacted persons returning a com-\npleted questionnaire.\nThis clinical group was complemented by cases from the\nnational patient organization (German Crohn's and Coli-\ntis Association/Deutsche Crohn und Colitis Vereinigung,\nDCCV e.V.). These had been selected randomly from the\nmembers' list stratified by type of disease [11].\nQuestionnaire\nQuestionnaires were identical for the two groups (clinical\ngroup and national patient organization) with respect to\nthe assessment of exposures and sexual function. For clin-\nical patients additional modules on disease specific qual-\nity of life were included (Short Inflammatory Bowel\nDisease Questionnaire (S-IBDQ) [13], QLQ CR 38 mod-\nule of the European Organization for Research and Treat-\nment of Cancer (EORTC) [14].\nInformation on sociodemographic data, life style factors,\nco-morbidity, and co-medication was collected using a\nquestionnaire module developed by the German IBD\nCompetence Network for use in IBD patients. Life style\nfactors included sports, smoking and alcohol consump-\ntion. Socioeconomic status (SES) was calculated as a com-\nposite measure based on income, education and\nprofessional status, as suggested by the German Epidemi-\nological Association, DGEpi [15], and were summarized\nas low, middle, and high.\nSpecific questions related to the presence of diabetes and\nhypertension. Other co-morbidities and co-medications\nwere evaluated based on open questions. Diseases (such\nas cardiovascular, hepatobiliary) and medications (such\nas antihypertensive, antidepressant, other psychiatric)\nwere coded, grouped and used for a summary co-morbid-\nity measure: minor: one disease OR one medication;\nmajor: a) at least one disease AND at least one medication\nor b) more than one disease or medication.\nThe disease activity was classified as remission/low activ-\nity vs. moderate/high activity. The cut points were set at </\n> 220 for Crohn's disease on a modified Crohn's Disease\nActivity Index for use in surveys (S-CDAI), and </> 5 for\nulcerative colitis on the Clinical Activity Index survey ver-\nsion (S-CAI). This instrument was previously validated\n[16]. Disease course (severity) was graded as mild (less\nthan one relapse per year), medium (1 or 2 relapses per\nyear) and severe (frequent relapses or persistent prob-\n\nBMC Gastroenterology 2008, 8:45 http://www.biomedcent ral.com/1471-230X/8/45\nPage 3 of 10\n(page number not for citation purposes)\nlems). Psychological functioning was assessed with the\nHospital Anxiety and Depression Scale (HADS) [17,18].\nPersons were considered depressed or anxious if the\nrespective HADS-Subscore exceeded 10.\nAssessment of sexual function\nAs there was no validated questionnaire on female sexual\ndysfunction available for the use in German language, the\nBrief Index of Sexual Function in Women (BISF-W) was\ntransformed for use in German [12,19]. Formal cultural\nadaptation methods were used as described for other\nquality of life instruments [20]. This included independ-\nent translation of the questionnaire by two native speak-\ners of German and back-translation into English by a\nnative speaker of English. Further minor modifications of\nthe layout and wording were applied following a pilot\nstudy in 60 persons (patients with and without IBD,\nhealthy volunteers) to improve understandibility and ease\nof use. The questionnaire then underwent formal valida-\ntion assessments, including test-retest reliability, internal\nconcistency, construct validity and sensitivity for change\n[21]. Overall, the BISF-W showed excellent test properties\nfor all domains but the subscore of specific sexual problems,\nwhich lacked internal consistency. This domain combines\nseveral, mainly somatic problems occuring with sexual\nintercourse in women, such as vaginismus, bleeding or\nheadaches after intercourse.\nFor subscores and the total score, higher values denote\nbetter function with the exception of the specific sexual\nproblems (higher score = more problems). The scores were\ncalculated and transformed as suggested in the key-publi-\ncation by Mazer [12]. Due to a layout problem in the\nquestionnaire, one of two items pertaining to the arousal\ndomain was incorrectly or not at all answered by the\nmajority of patients. Arousal scores will therefore be omit-\nted from the subscore presentation in this paper due to\nlimited interpretability. Tests on correctly completed\nquestionnaires showed that total scores were reliably esti-\nmated without the missing item (correlation coefficient: r\n= 0.99).\nResults from a healthy German control group were used as\na standard population (friend controls from our matched\ncase control study). Due to a negative correlation with age\n(in particular, for the subscores of intercourse frequency\nand thoughts and desires), standardization was stratified\nby age. Z-transformation results in a score where 0 repre-\nsents the standard population mean, and 1 the standard\ndeviation. Low sexual function in any of the domains was\ndefined as a score < -1, representing a score lower than one\nstandard deviation from the mean score of the normative\nsample.\nThe EORTC module for colorectal cancer patients was\nchosen as it contains several direct questions on body\nimage, sexual function and satisfaction and ostomy func-\ntion [14]. It generally applies four answer categories,\nwhich were collapsed into two and presented as the pro-\nportion of those answering definitely or rather positive\n(vs. definitely or rather negative) for simplified graphical\ndisplay. Although previously used in IBD patients [22],\nthe instrument has not been developed and validated for\nthis purpose. Therefore, summary scores will not be pre-\nsented.\nStatistical analyses\nFor exploratory analyses graphical displays (means with\n95% confidence intervals (95% CI)) are used. In addition,\nthe frequency of low scores is reported separately for both\nstudy groups for descriptive purposes. As crude rates are\nnot comparable between women with and without part-\nners these figures are presented for women with partners\nonly. However, all women were included in the main\nanalyses.\nMultivariate logistic regression was applied to calculate\nadjusted odds ratios (OR) with 95% CI (SPSS\n©) [23].\nIncreased ratios (OR > 1.0) denote an increased risk for\nlow function in participants positive for the respective risk\nfactor. In the multivariate analyses, full models were ini-\ntially calculated, including all potential risk factors, fol-\nlowed by manual stepwise elimination based on model\nfit, and the robustness and the statistical significance of\nthe estimated coefficients. All models were adjusted for\nage and having a partner.\nEthical considerations\nThe study was approved by the ethics committee of the\ninstitution (02/163). The steering board of the patients'\norganization also approved of the protocol, question-\nnaires and information material. Clinical patients pro-\nvided written consent. Patient organization members\nconsented by returning a completed questionnaire based\non written information.\nResults\nParticipants\nClinical patient recruitment took place from September 1,\n2003 through October 31, 2005. 119 eligible women were\napproached, 107 agreed to participate (90%). Of these, 95\nreturned a completed questionnaire (clinical sample\nresponse rate 81%). No patient related characteristics\nwere found to be associated with response in this sample.\nIn addition, nineteen questionnaires from the outpatient\ndepartment were received. For this group, a response rate\ncould not be calculated as recruitment had to be paused\n\nBMC Gastroenterology 2008, 8:45 http://www.biomedcent ral.com/1471-230X/8/45\nPage 4 of 10\n(page number not for citation purposes)\nrepeatedly due to interference with competing clinical tri-\nals (unknown denominator).\nOf the patient organization member survey, 222 ques-\ntionnaires were available for analysis (500 women\nselected; response rate 44%). In this sample, the response\nrate was higher in younger women (< 30 years of age:\n58%). The combined sample comprised 336 women. 219\nof these (65%) had Crohn's disease, 117 ulcerative colitis.\nThe sociodemographic and other characteristics by dis-\nease type and patient group are shown in Table 1. Patients\nin the clinical group were younger. The regional East-\nBavarian catchment area of the university hospital is\nreflected by high proportions of rural residency and\ncatholicism. Clinical patients were also more often\ndepressed and more often smokers. As expected, smoking\nstatus was dependent on the type of disease (less smokers\nin ulcerative colitis).\nThe comparison of the disease specific characteristics\nrevealed the expected higher proportion of patients with\nsevere or active disease and those on steroids in the clini-\ncal group (Table 2). Long term immunosuppression, on\nthe other hand, was more common in the DCCV group,\nwhich was also characterized by a longer disease duration\nand higher percentage of past resecting surgery.\nSexual function – explorative analyses\nIn Figure 1, mean z-values for BISF-W subscores and the\ntotal score are shown by study group with 95% CI,\nrestricted to women with partners for better comparabil-\nity. Case scores were consistently lower (or higher for spe-\ncific problems ) than 0 (representing the standard\npopulation mean), but all deviations were minor (within\none standard deviation). For most subscores, patient\norganization members scored slightly better than clinical\ncases with the notable exception of partnership satisfac-\ntion. Differences between the groups were not statistically\nsignificant for any of the subscores.\nOn direct questioning (EORTC-items), issues relating to\nfeeling attractive or feminine as well as satisfaction with\nthe bodily appearance showed an association with disease\nactivity (p < 0.05 for all comparisons) (Figure 2, informa-\ntion available for clinical sample only). There was a strik-\ningly low general interest in sexual activities in both\npatients with active and quiescent disease. Only 20%\nreported a high or moderate level of sexual activity during\nthe preceding four weeks. The proportion not sexually\nactive at all was 17%.\nDeterminants of impaired sexual function\nAdjusted odds ratios from multivariate analyses are pre-\nsented in Table 3 for selected variables. There was no evi-\ndence for differences between patients with Crohn's\ndisease and patients with ulcerative colitis. Depressive\nTable 1: Participants' characteristics – demographics and other general information\nGroup A – clinical Group B – DCCV\nCrohn's disease Ulcerative colitis Crohn's disease Ulcerative colitis\nAge (median) 38.5 yrs 38.0 yrs 38.0 yrs 38.0 yrs\nWorking fulltime 32 (36%) 5 (21%) 40 (31%) 31 (33%)\nIn training/at school 5 (6%) 1 (4%) 10 (8%) 5 (5%)\nSES high 8 (10%) 4 (20%) 48 (39%) 35 (40%)\nSES low 31 (38%) 5 (25%) 13 (11%) 3 (3%)\nUrban residency 13 (15%) 5 (21%) 51 (40%) 36 (39%)\nSmokers 46 (52%) 6 (25%) 38 (30%) 6 (7%)\nRoman catholic 74 (82%) 15 (63%) 35 (27%) 27 (29%)\nProtestant/Lutheran 9 (10%) 5 (21%) 55 (43%) 33 (36%)\nComorbidity, minor 19 (21%) 4 (3%) 20 (16%) 14 (15%)\nComorbidity, major 22 (24%) 5 (21%) 31 (24%) 24 (26%)\nDiabetes 5 (6%) 6 (3%) 1 (1%) 2 (2%)\nAntihypertensive Therapy 7 (8%) 4 (17%) 7 (5%) 5 (5%)\nOn hormonal contraception 25 (28%) 6 (25%) 29 (22%) 24 (26%)\nOn hormone replacement 3 (3%) 1 (4%) 5 (4%) 4 (3%)\nAnxiety 33 (37%) 7 (30%) 38 (30%) 20 (22%)\nDepression 19 (21%) 8 (35%) 12 (10%) 9 (10%)\nHas a partner 61 (69%) 18 (78%) 93 (74%) 74 (80%)\nMarried 41 (46%) 16 (67%) 65 (51%) 53 (57%)\nN9 0 2 4 1 2 9 9 3\nNot all categories shown for most variables.\n\nBMC Gastroenterology 2008, 8:45 http://www.biomedcent ral.com/1471-230X/8/45\nPage 5 of 10\n(page number not for citation purposes)\nmood was the only consistent risk factor, with strong asso-\nciations for all subscores. Anxiety seemed to be of impor-\ntance for the domain of intercourse frequency only. For\nother characteristics, associations were sparse.\nThe multivariate analysis confirmed the difference in part-\nnership satisfaction between clinical and DCCV cases:\nwomen in the clinical group were less often dissatisfied,\neven after adjustment for SES, disease activity, depression,\nage and partnership status (OR 0.6; 95% CI 0.3 to 1.0).\nOtherwise, there was no evidence for systematic differ-\nences between the two groups. Also, there was not differ-\nence between women with Crohn's disease and women\nwith ulcerative colitis.\nDisease activity contributed to the prediction of a low\nthoughts & desire score (OR 1.8; 95% CI 1.0 to 3.2). The\ndisease course (severity) was more consistently predictive\nwith OR > 1.0 for all subscores and a strong positive asso-\nciation with intercourse frequency (OR 2.3). Current use of\nsteroids was associated with low pleasure & orgasm scores.\nFor the presence of an ostomy or current perianal disease,\nassociations were not detected for any of the subscores.\nThe direction of the results for these factors was inconsist-\nent, rendering a relevant effect unlikely. Confidence inter-\nvals for effects of these infrequent situations were too\nwide to provide conclusive evidence.\nIn contrast, a marked differential effect was found for high\nSES, which was protective of low thoughts & desire , but a\nrisk factor for low partnership satisfaction. Urban residency\nshowed consistently low odds ratios with strong negative\nassociations for initiative & receptivity and pleasure &\norgasm. Specific lifestyle factors (smoking, sports, alcohol)\ndid not show conclusive associations with any of the sub-\nscores.\nSpecific sexual problems\nAs the subscore of specific sexual problems performed\npoorly as an aggregate measure in the validation assess-\nment (see methods), analyses for this domain were based\non answers to single items. Insufficient lubrication was\nreported to occur at least occasionally in 30% of the par-\nticipants who had a sexual relationship. Current smoking\nwas identified as a strong (and only) predictor of this\nproblem (OR 2.5, 95% CI 1.3 to 5.1). Pain during inter-\ncourse was also quite common (25%), followed in preva-\nlence by vaginal infections (9%) and vaginismusus (8%).\nPredictors for any of these complaints were not identified.\nIn particular there was no difference by disease type or\nactivity, use of steroids, co-morbidity or presence of peri-\nanal disease. Incontinence of urine during intercourse (n\n= 5, 2%), headaches following sexual activity (n = 5; 2%)\nand postcoital bleeding (n = 12; 5%) were considered too\nTable 2: Participants' characteristics – disease related information (self reported)\nGroup A – clinical Group B – DCCV\nCrohn's disease Ulcerative colitis Cr ohn's disease Ulcerative colitis\nDisease duration (median) 9.0 yrs 6.0 yrs 13.0 yrs 9.0 yrs\nDisease onset > 40 yrs 14 (16%) 3 (13%) 7 (6%) 6 (7%)\nDisease onset < 18 yrs 16 (18%) 3 (13%) 28 (22%) 15 (17%)\nActive disease 38 (42%) 19 (80%) 28 (22%) 31 (35%)\nMild disease course 22 (26%) 5 (23%) 44 (36%) 32 (37%)\nSevere disease course 35 (42%) 7 (32%) 45 (37%) 21 (24%)\nPast resecting surgery 38 (42%) 1 (4%) 73 (57%) 10 (11%)\nOstomy 10 (11%) 1 (4%) 13 (10%) 4 (5%)\nIleocecal resection 27 (30%) 48 (37%)\nPerianal disease, current 19 (22%) 26 (21%)\nPerianal disease, ever 23 (27%) 36 (28%)\nCurrently on steroids 39 (44%) 11 (48%) 35 (28%) 25 (28%)\nOther immunosuppression 18 (20%) 6 (25%) 43 (34%) 19 (21%)\nTotal/substantial Colitis 14 (64%) 44 (49%)\nLeft sided colitis 5 (23%) 29 (33%)\nProctitis only 3 (14%) 16 (18%)\nSmall bowel only 14 (19%) 25 (20%)\nLarge bowel only 14 (19%) 37 (29%)\nCombined disease 41 (56%) 61 (48%)\nUpper Gi Involvement 4 (5%) 5 (4%)\nN9 0 2 4 1 2 9 9 3\nNot all categories shown for most variables, missing values not reported\n\nBMC Gastroenterology 2008, 8:45 http://www.biomedcent ral.com/1471-230X/8/45\nPage 6 of 10\n(page number not for citation purposes)\ninfrequent for meaningful further exploration or multi-\nvariate analysis.\nThe extent to which the disease was perceived to have had\na negative influence on sexual activities over the last four\nweeks is displayed relative to other common distractors in\nFigure 3.\nDiscussion\nThis study was designed to examine disease specific deter-\nminants of impaired sexual function in women. The com-\nbination of two different case groups enabled us to\nexamine both patients in their normal living environment\nas well as those patients typically encountered by the uni-\nversity specialist, representing a wide array of clinical\nproblems.\nNo particular feature of IBD was identified that would\nexplain the predescribed high prevalence of sexual imped-\niments in women suffering from this chronic disease.\nRather, the significance of psychosocial factors for female\nsexuality, well known from studies in normal popula-\ntions, was further underlined [24,25]. Foremost,\ndepressed mood was confirmed as the strongest and most\nconsistent risk factor. With the exception of specific sexual\nproblems, depression impacted on all aspects of sexuality\nas assessed by the BISF-W. Anxiety seemed less important\nbut may play a role in certain aspects of sexuality ( inter-\ncourse frequency). Urban residency was protective for sev-\neral problems while the impact of socioeconomic status\nvaried by subscore: Women with a higher socioeconomic\nstatus had higher scores for pleasure & orgasm, but scored\nworse on partnership satisfaction.\nThis subscore was also unique in that it was the only score \nthat differed between the two study groups\nThe clinical patients were characterized by a higher than\naverage level of partnership satisfaction. This phenomenon\nwas underlined by several free-text comments such as \"the\ndisease has brought us closer together\". Several women\nexpressed gratefulness for their understanding partners\nwho did not let them down in the difficult times of the\ndisease. The importance of an understanding social envi-\nronment, including the partner, for coping with IBD has\nbeen repeatedly observed in studies using analytic inter-\nviews, foremost in the context of adjustment to an ostomy\n[26].\nIt is unclear why this effect was different in the two groups\nin spite of control for potential confounders of relation-\nship appreciation. As the DCCV sample suffered from a\nrather low response rate, responder bias may have caused\nthis observation. Possibly, for some reason, women in\nunsatisfactory relationships were more likely to respond.\nBISF-W scores (z-values) by case group, women with partners onlyFigure 1\nBISF-W scores (z-values) by case group, women with partners only. 0: standard population mean, +/- 1 = +/- 1 stand-\nard deviation from standard population mean. *specific problems: higher value = more problems, other scores: higher value = \nbetter function.\n\n\nBMC Gastroenterology 2008, 8:45 http://www.biomedcent ral.com/1471-230X/8/45\nPage 7 of 10\n(page number not for citation purposes)\nAlternatively, it is conceivable that partnership apprecia-\ntion in stressful situations is regionally different due to\ncultural factors beyond those assessed (rural residency,\nconfession of faith, SES), or is different in persons joining\nself help organizations.\nThe most striking finding in our survey might be the very\nlow levels of sexual interest and activity. A high prevalence\nof low sexual desire is known from surveys in healthy\npopulations [24,27]. Although low desire is acknowl-\nedged as a disease entity in the Diagnostic and Statistical\nTable 3: Determinants of low sexual function\nThoughts & Desire Intercourse \nfrequency\nInitiative & \nreceptivity\nPleasure & orgasm Partnership \nSatisfaction\nBISF-W – Total \nScore\nClinical vs. DCCV \ncase\n1.4 (0.8 to 2.4) 1.3 (0.6 to 2.8) 1.3 (0.7 to 2.2) 1.5 (0.9 to 2.6) 0.6 (0.3 to 1.0) 0.9 (0.5 to 1.5)\nUlcerative colitis \nvs. Crohn's disease\n1.3 (0.7 to 2.1) 1.4 (0.8 to 2.7) 1.3 (0.8 to 2.3) 1.3 (0.8 to 2.2) 1.1 (0.7 to 1.9) 1.3 (0.8 to 2.2)\nOstomy 0.8 (0.3 to 2.1) 1.2 (0.5 to 3.0) 1.5 (0.6 to 3.7) 0.5 (0.2 to 1.3) 0.9 (0.4 to 2.0) 0.7 (0.3 to 1.8)\nCurrent perianal \ndisease\n0.8 (0.4 to 1.7) 1.6 (0.8 to 3.1) 0.7 (0.3 to 1.6) 0.8 (0.4 to 1.7) 1.7 (0.8 to 3.5) 1.0 (0.5 to 2.0)\nActive disease 1.8 (1.0 to 3.2) 1.7 (0.9  to 3.1) 1.5 (0.8 to 2.7) 1.2 (0.7 to 2.1) 0.9 (0.5 to 1.6) 0.9 (0.5 to 1.6)\nFrequent relapses 1.2 (0.6 to 2.3) 2.3 (1.4 to 4.7) 1.6 (0.8 to 3.1) 1.8 (0.9 to 3.5) 1.2 (0.7 to 2.3) 1.3 (0.7 to 2.4)\nDisease duration > \n10 yrs\n0.7 (0.3 to 1.7) 0.6 (0.3 to 1.5) 0.9 (0.4 to 2.1) 0.6 (0.3 to 1.2) 1.2 (0.5 to 2.6) 0.8 (0.4 to 1.7)\nCurrent steroids 1.0 (0.6 to 1.7) 1.9 (1.1 to 3.3) 1.2 (0.7 to 2.0) 2.5 (1.5 to 4.4) 1.2 (0.7 to 1.9) 1.0 (0.6 to 1.7)\nUrban residency 0.8 (0.4 to 1.5) 0.8 (0.4 to 1.4) 0.4 (0.2 to 0.8) 0.5 (0.3 to 0.9) 0.9 (0.5 to 1.6) 0.6 (0.3 to 1.0)\nHigh SES 0.4 (0.2 to 0.8) 0.6 (0.2 to 1.3) 0.8 (0.3 to 2.0) 1.5 (0.8 to 2.8) 2.4 (1.0 to 5.5) 0.8 (0.3 to 1.7)\nCo-morbidity \n(major)\n1.4 (0.7 to 2.6) 1.9 (1.0 to 3.5) 1.1 (0.5 to 2.0) 1.5 (0.8 to 2.8) 1.8 (1.0 to 3.2) 1.3 (0.7 to 2.4)\nDepression 2.9 (1.5 to 5.7) 3.5 (1.6 to 7.9) 4.4 (2.1 to 9.1) 4. 8 (2.2 to 10.1) 2.7 (1.4 to 5.4) 3.4 (1.4 to 6.9)\nAnxiety 1.6 (0.9 to 2.7) 2.0 (1.1 to 3.6) 1.4 (0.8 to 3.9) 1.7 (1.0 to 3.0) 1.5 (0.8 to 2.6) 1.4 (0.8 to 2.3)\nAll odds ratios (95% CI) controlled for age, partnership status and determinants significantly contributing to the respective model; n = 336 or less. \nStrong associations in bold font (OR > 2.0; OR < 0.5)\nResults from EORTC-QLQ CR30 items, clinical sample only (n = 114)Figure 2\nResults from EORTC-QLQ CR30 items, clinical sample only (n = 114). Proportions of those answering \"very\"/\"mod-\nerate\" (vs. \"little\"/\"not at all\").\n\n\nBMC Gastroenterology 2008, 8:45 http://www.biomedcent ral.com/1471-230X/8/45\nPage 8 of 10\n(page number not for citation purposes)\nManual of Mental Disorders (DSM IV – R), it remains con-\ntroversial whether it constitutes a sexual disorder [28,29].\nFor example, in women with chronic disease, loss of\ndesire might be considered a physiological response to\npain, fatigue or psychological distress. We do not wish to\nimply that all women with low scores consider themselves\ndeficient or should receive treatment.\nIt was unfortunate that we were not able to calculate\narousal subscores for the majority of participants, as some\nmight suspect arousal to be particularly sensitive to struc-\ntural changes or inflammatory processes in the perivagi-\nnal and pelvic region. The BISF-W arousal domain focuses\non the subjective perception of sexual arousal which has\nbeen shown to poorly correlate with the physiological\nresponses characterized by genital vasocongestion and\nlubrication [30]. We were able to assess predictors of\nlubrication as a somatic aspect of arousal and found a\nstrong association with smoking. Confounding by this\nknown risk factor of Crohn's disease should therefore be\nconsidered when vaginal dryness in Crohn's disease is\nreported. We are not aware of any data explaining this\neffect of smoking on the vaginal mucosa and would wel-\ncome any discussion on this issue. There were no disease\nspecific determinants. In particular, there was no epidemi-\nological evidence for a causative effect of immunosup-\npression, disease activity, or perianal disease in the\npathogenesis of this or any of the other more common\nspecific sexual problems.\nOur findings in women were quite different from our pre-\nvious observations in men [31]. Erectile function was\nmainly effected by somatic problems, while mood had\nmore impact on issues of satisfaction. A similarly clear cut\ndifferentiation between the somatic and psychosocial\naspects of sexuality was not possible in women. This may\nbe innate to the more complex sequence of sexual behav-\nior in women [28]. In addition, our results confirm previ-\nously reported observations that women perceive the\nimpact of the disease on sexuality and partnership differ-\nently [32].\nConclusion\nIn summary, while low sexual function is common in\nwomen with IBD, no specific disease related characteris-\ntics were identified. Rather, as in women without chronic\ndisease, psychosocial factors play a predominant role.\nWhile our data provide some basis for patient counsel-\nling, the existence and relevance of sexual problems and\nany need for therapy should be determined individually\nin sympathetic patient-doctor interviews, if the patient\nwishes to do so. Often, treatment of mood disorders\nmight be more important than specific sexual therapy.\nWith respect to the most common specific sexual prob-\nlem, insufficient lubrication, our study provides yet\nFrequency with which different problems were felt to have impacted negatively on sexual activities (women with partners onlyFigure 3\nFrequency with which different problems were felt to have impacted negatively on sexual activities (women \nwith partners only).\n\n\nBMC Gastroenterology 2008, 8:45 http://www.biomedcent ral.com/1471-230X/8/45\nPage 9 of 10\n(page number not for citation purposes)\nanother reason to advice patients with Crohn's disease\nagainst smoking.\nAbbreviations\nBISF-W: Brief Index of Sexual Function in Women, CAI:\nColitis Activity Index; CDAI: Crohn's Disease Activity\nIndex; EORTC: European Organization for Research and\nTreatment of Cancer; HADS: Hospital Anxiety and\nDepression Scale; IBD: Inflammatory bowel disease; QLQ\n– CR: Quality of Life, Colorectal Cancer; S-CAI: Survey\nbased Colitis Activity Index; S-CDAI: Survey based\nCrohn's Disease Activity Index; S-IBDQ: Short Inflamma-\ntory Bowel Disease Questionnaire.\nCompeting interests\nThe authors declare that they have no competing interests.\nAuthors' contributions\nAT conceived and planned the study, developed the ques-\ntionnaire, recruited patients, did the analysis and wrote\nthe manuscript. DK participated in the planning of the\nstudy, piloted instruments and recruited patients. AB\norganized the survey, recruited patients and did some\nanalyses. AT organized clinical recruitment and was\nresponsible for data management. CO participated in\npatient recruitment. AF participated in the planning of the\nstudy, the development of the questionnaire and data\nretrieval. All authors read and the final version of this\nmanuscript.\nAcknowledgements\nU. Steder-Neukamm and A. Dignass for relevant input during the concep-\ntion phase; L. Bjerre for back-translation of the questionnaire; F. Klebl for \nhelp with patient recruitment in outpatient clinics; B. Bokhof for help with \npatient recruitment and data entry; B. Effenberger and M. Bauer for data \nentry; G. Rogler, K.-H. Jöckel, J. Schölmerich and M. Singer for support and \nhelpful comments on the project. C Mavergames for language editing.\nFinancial support:The German competence network inflammatory bowel \ndisease (KNCED)/Federal Ministry of Education and Research (BMBF) \nfunded personnel for epidemiological research in IBD. The positions of A. \nBauer, D. Kemptner and A. Takses (authors) and B. Bokhof and B. Effen-\nberger (acknowledgements). were funded by this programme. The funding \nagency was not involved in the planning, conduct and publication of this \nproject.\nPart of the patient organization cases (n = 181) were included in the publi-\ncation on a matched case control analysis [11].\nReferences\n1. Giese LA, Terrell L: Sexual health issues in inflammatory bowel\ndisease.  Gastroenterol Nurs 1996, 19:12-17.\n2. Farrokhyar F, Marshall JK, Easterbrook B, Irvine EJ: Functional gas-\ntrointestinal disorders and mood  disorders in patients with\ninactive inflammatory bowel disease: prevalence and impact\non health.  Inflamm Bowel Dis 2006, 12:38-46.\n3. 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