Prevalence of female sexual dysfunction and associated factors among women in Ethiopia: a systematic review and meta- analysis.

The procedure for this systematic review and meta-analysis was developed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement [ 32 , 33 ]. The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD420251136497 [ 34 ]. A comprehensive literature search was conducted in PubMed, Embase, Scopus, Web of Science, CINAHL, the Cochrane Library (Cochrane Database of Systematic Reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL), African Journals Online (AJOL), and Google Scholar to identify relevant observational studies. To ensure completeness, grey literature sources, including Ethiopian institutional repositories, were also reviewed to capture unpublished studies. Furthermore, the reference lists of all included articles were manually screened to identify additional relevant publications. The search strategy combined Medical Subject Headings (MeSH) and free-text terms, applying Boolean operators (“AND,” “OR”), truncation (*), and phrase searching as appropriate (Table  1 ). Table 1 Search strategy for studies assessing women who screened positive for female sexual dysfunction in Ethiopia Component Inclusion Criteria Search Terms / Keywords (MeSH / Free Text) Limits / Exclusions Participants Women aged ≥ 15 years residing in Ethiopia “woman” OR “women” OR “female” English, full-text; published Jan 2015–Aug 2025 Exposure / Factors Demographic, reproductive, clinical, psychological, and socio-economic factors (e.g., chronic medical conditions, obstetric history, mental health, FGM) “risk factors” OR “associated factors” OR “determinants” – Comparator Not applicable – – Outcome Prevalence of FSD measured with standardized or validated tools “female sexual dysfunction” OR “sexual dysfunction in women” AND “prevalence” OR “epidemiology” OR “frequency” – Context Community- or facility-based studies conducted in Ethiopia (multi-country studies excluded) “Ethiopia” OR “Ethiopian” – Study Design Observational studies: cross-sectional, case–control, cohort – Excluded: case reports, qualitative-only studies, or studies lacking sufficient data Combined Search All PICO components combined using Boolean operators (“female sexual dysfunction” OR “sexual dysfunction in women”) AND (“Ethiopia” OR “Ethiopian women”) AND (“prevalence” OR “epidemiology” OR “risk factors” OR “associated factors” OR “determinants”) – Search strategy for studies assessing women who screened positive for female sexual dysfunction in Ethiopia The eligibility of studies for inclusion in this systematic review was rigorously determined based on predefined inclusion and exclusion criteria, as summarized in Table  1 . The selection process followed the PICO framework, specifying the key components of the research question: Population (women aged 15 years and above), Intervention/Exposure (factors associated with female sexual dysfunction), Comparison (not applicable), and Outcome (prevalence of female sexual dysfunction). Only observational studies (cross-sectional, case–control, and cohort) conducted in Ethiopia and published in English were eligible. Studies were excluded if they were case reports, qualitative-only studies, or lacked sufficient data to estimate prevalence or effect sizes. Study eligibility was independently assessed by three reviewers (AH, TK, AA), with discrepancies resolved through discussion with a fourth reviewer (AE) to achieve consensus. The primary outcome of this review was the prevalence of female sexual dysfunction among Ethiopian women. Female sexual dysfunction was assessed in the included studies using two validated instruments: the FSFI and CSFQ. Seven studies employed the FSFI, which assesses six domains of sexual function including desire, arousal, lubrication, orgasm, satisfaction, and pain, with a total score of 26.55 or below indicating sexual dysfunction. Four studies used the CSFQ tool, which evaluates changes in sexual desire, arousal, orgasm, pleasure, and satisfaction. In these studies, sexual dysfunction was defined based on reduced total CSFQ scores, with most studies applying the standard female cutoff of 41 or below, while others used study-specific thresholds consistent with established scoring guidelines. Using these classifications, each study reported the proportion of participants who screened positive for FSD, enabling calculation of a pooled prevalence estimate across studies. In addition to prevalence, the review also considered associated factors of FSD, which were measured in the primary studies using logistic regression analyses and reported as odds ratios [ 23 , 26 , 28 , 30 , 31 , 35 , 36 ]. Data were extracted independently by (AH and TK) using a structured Excel spreadsheet. Extracted variables included primary author, year of publication, study region/setting, study design, sample size, mean or median age of participants, response rate, prevalence of screen-positive FSD, and tools or screening instruments used to assess sexual dysfunction, and reported associated factors (sociodemographic, obstetric/gynecologic, psychological, relational, or sociocultural). Disagreements during the data extraction process were resolved through discussion, with third reviewers (AA and AE) consulted when necessary. Study quality was appraised using the Joanna Briggs Institute (JBI) checklist across nine criteria, and studies scoring ≥ 7 were considered low risk of bias (Table  2 ). Table 2 Critical appraisal results of eligible studies on women who screened positive for female sexual dysfunction in Ethiopia Author (Year) Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Total Zegeye et al. (2020) [ 31 ] Y Y Y Y Y Y Y Y Y 9 Tsehay et al. (2020) [ 35 ] Y Y N Y Y Y Y Y Y 8 Dheresa et al. (2019) [ 26 ] Y Y Y Y Y Y Y Y Y 9 Mihiret et al. (2024) [ 30 ] Y Y N Y Y Y Y Y Y 8 Ejigu et al. (2019) [ 28 ] Y Y N Y Y Y Y Y Y 8 Gebrezgabiher et al. (2019) [ 25 ] Y Y Y Y Y Y Y Y Y 9 Haile et al. (2025) [ 24 ] Y Y Y Y Y Y Y Y Y 9 Zeleke et al. (2023) [ 37 ] Y Y Y Y Y Y Y Y Y 9 Assefa et al. (2023) [ 27 ] Y Y N Y Y Y Y Y Y 8 Sisay et al. (2021) [ 36 ] Y Y N Y Y Y Y Y Y 8 Fanta et al. (2017) [ 29 ] Y Y N Y Y Y Y Y Y 8 Y Yes, N No, JBI critical appraisal checklist for studies reporting prevalence data: Q1 = was the sample frame appropriate to address the target population? Q2 = Were study participants sampled appropriately? Q3 = Was the sample size adequate? Q4 = Were the study subjects and the setting described in detail? Q5 = Was the data analysis conducted with sufficient coverage of the identified sample. Q6 = Were the valid methods used for the identification of the condition? Q7 = Was the condition measured in a standard, reliable way for all participants? Q8 = Was there appropriate statistical analysis? Q9 = Was the response rate adequate, and if not, was the low Critical appraisal results of eligible studies on women who screened positive for female sexual dysfunction in Ethiopia Y Yes, N No, JBI critical appraisal checklist for studies reporting prevalence data: Q1 = was the sample frame appropriate to address the target population? Q2 = Were study participants sampled appropriately? Q3 = Was the sample size adequate? Q4 = Were the study subjects and the setting described in detail? Q5 = Was the data analysis conducted with sufficient coverage of the identified sample. Q6 = Were the valid methods used for the identification of the condition? Q7 = Was the condition measured in a standard, reliable way for all participants? Q8 = Was there appropriate statistical analysis? Q9 = Was the response rate adequate, and if not, was the low Data analysis was conducted using STATA version 17. Heterogeneity among studies was assessed using Cochran’s Q and I² statistics, with I² values of 25%, 50%, and 75% interpreted as low, moderate, and high heterogeneity, respectively. When substantial heterogeneity was detected (I² > 70%, p  < 0.05), a random-effects model was applied to estimate the pooled prevalence of FSD with 95% confidence intervals. Subgroup analyses were performed based on study design, population characteristics, and study region to explore potential sources of variability. Publication bias and small-study effects were evaluated using funnel plots and Egger’s regression test. Pooled prevalence estimates and subgroup analyses are presented using forest plots, while study characteristics, meta-regression findings, and associated factors are summarized in tables to ensure comprehensive presentation of all results [ 38 , 39 ].

An extensive electronic search was conducted in PubMed, Scopus, Web of Science, CINAHL, Embase, the Cochrane Library, African Journals Online, and Google Scholar, supplemented by manual searches of additional sources. A total of 326 records were identified, and 45 duplicates were removed. The remaining 281 records underwent title and abstract screening, of which 268 were excluded. Of these, 257 records were excluded due to irrelevance to the topic at the title and abstract level, and 11 were excluded due to lack of full text availability. Thirteen full text articles were assessed for eligibility, and two studies were excluded because they were dissertations for which full texts could not be obtained. Finally, eleven studies met the inclusion criteria and were included in the systematic review on FSD among women in Ethiopia (Fig. 1 ). Fig. 1 PRISMA flow diagram of the study selection process for studies assessing women who screened positive for female sexual dysfunction in Ethiopia PRISMA flow diagram of the study selection process for studies assessing women who screened positive for female sexual dysfunction in Ethiopia A total of 11 studies involving 5,982 participants were included. Seven studies used the FSFI tool, while four studies used the CSFQ tool. Study populations comprised the general population, patients with medical conditions, and women with mental illness. The included studies were cross-sectional in design, and sample sizes ranged from 138 to 2,389 participants (Table  3 ). Table 3 Characteristics of studies included in the meta-analysis of women who screened positive for female sexual dysfunction in Ethiopia Author (Year) Region/Study area Study design Study population Sample size Instrument/tools used to assess FSD Prevalence (%) Zegeye et al. (2020) [ 31 ] Northern Ethiopia Cross- sectional Total population 397 FSFI 38.5 Tsehay et al. (2020) [ 35 ] Northern Ethiopia Cross-sectional Mental illness 189 CSFQ 50.8 Dheresa et al. (2019) [ 26 ] Kersa District, Eastern Ethiopia Cross-sectional Total population 2,389 FSFI 47.0 Mihiret et al. (2024) (30) Northern Ethiopia Cross-sectional Medical 138 FSFI 63.0 Ejigu et al. (2019) [ 28 ] Addis Ababa, Ethiopia Cross-sectional Mental illness 234 CSFQ 55.6 Gebrezgabiher et al. (2019) [ 25 ] Tigray Region, Northern Ethiopia Cross-sectional Total population 823 FSFI 57.1 Haile et al. (2025) [ 24 ] Bahir Dar, Northwest Ethiopia Cross-sectional Total population 583 FSFI 51.8 Zeleke et al. (2023) [ 37 ] Gurage Zone, Southern Ethiopia Cross-sectional Total population 402 FSFI 31.2 Assefa et al. (2023) [ 27 ] Southwest Ethiopia Cross-sectional Medical 142 CSFQ 56.6 Sisay et al. (2021) [ 36 ] North West Amhara, Ethiopia Cross-sectional Medical 156 FSFI 63.2 Fanta et al. (2017) [ 29 ] Addis Ababa, Ethiopia Cross-sectional Mental illness 132 CSFQ 78.6 FSFI Female Sexual Function Index, CSFQ  Changes in Sexual Functioning Questionnaire Characteristics of studies included in the meta-analysis of women who screened positive for female sexual dysfunction in Ethiopia FSFI Female Sexual Function Index, CSFQ  Changes in Sexual Functioning Questionnaire Initial fixed-effects analysis revealed significant heterogeneity across studies; therefore, a random-effects model was applied. The pooled prevalence of women who screened positive for FSD was 53.8% (95% CI: 46.38%–61.22%), with substantial heterogeneity across studies (I² = 96.39%, p  < 0.001) (Fig.  2 ). Given this high heterogeneity, the pooled estimate should be interpreted as a summary measure across heterogeneous populations rather than a precise national prevalence (Fig.  2 ). The 95% prediction interval ranged from 24.48% to 82.96%, suggesting that the prevalence of women who screened positive for FSD in individual Ethiopian populations may vary widely. Fig. 2 Forest plot showing the pooled prevalence of women who screened positive for female sexual dysfunction in Ethiopia using a random-effects model Forest plot showing the pooled prevalence of women who screened positive for female sexual dysfunction in Ethiopia using a random-effects model Subgroup analysis was conducted to identify potential sources of heterogeneity and to determine whether the prevalence of FSD varied across different population categories (Fig. 3 ). The highest pooled prevalence of women who screened positive for FSD was observed among women with medical conditions, with a prevalence of 61.06% (95% CI: 56.49–65.63) and no significant heterogeneity (I² = 0.0%, p  = 0.43). Similarly, studies conducted among women with mental illness showed a pooled prevalence of 61.65% (95% CI: 44.88–78.43), though with substantial heterogeneity (I² = 94.49%, p  < 0.001). In contrast, studies conducted among general/reproductive-age women demonstrated the lowest prevalence of FSD, estimated at 45.39% (95% CI: 38.63–54.16), with considerable heterogeneity (I² = 98.83%, p  < 0.001). The test for subgroup differences was statistically significant (Q = 9.85, p  = 0.01) (Fig. 3 ). Fig. 3 Subgroup analysis by population type of women who screened positive for female sexual dysfunction in Ethiopia Subgroup analysis by population type of women who screened positive for female sexual dysfunction in Ethiopia Publication bias was examined through visual inspection of the funnel plot and Egger’s test. The funnel plot showed a relatively symmetrical distribution of studies, and Egger’s test was not statistically significant ( P  = 0.075), suggesting no evidence of publication bias (Fig. 4 ). Fig. 4 Funnel plot assessing publication bias among studies assessing women who screened positive for female sexual dysfunction in Ethiopia Funnel plot assessing publication bias among studies assessing women who screened positive for female sexual dysfunction in Ethiopia To explore potential sources of heterogeneity, a meta-regression analysis was conducted using sample size category and instrument type as covariates. The analysis showed that sample size category did not significantly explain variations in the pooled prevalence of female sexual dysfunction (β = − 10.83, p  = 0.144). Similarly, the effect of instrument type was minimal and not statistically significant (β = 12.79, p  = 0.060), indicating that differences in the tools used to assess FSD (FSFI vs. CSFQ) contributed little to the overall heterogeneity (Table  4 ). Table 4 Meta-regression analysis of factors affecting heterogeneity among studies assessing women who screened positive for female sexual dysfunction in Ethiopia Source of heterogeneity Coefficient (β) Standard Error P -value Sample size category –10.83 7.42 0.144 Instrument type 12.79 6.80 0.060 Meta-regression analysis of factors affecting heterogeneity among studies assessing women who screened positive for female sexual dysfunction in Ethiopia A leave-one-out sensitivity analysis was performed to evaluate the influence of each individual study on the overall pooled prevalence. Exclusion of any single study did not cause substantial changes in the pooled prevalence, with recalculated estimates ranging between 51.27% and 55.35%, confirming the robustness of the findings (Fig.  5 ). Fig. 5 Sensitivity analysis of the pooled prevalence of women who screened positive for female sexual dysfunction in Ethiopia Sensitivity analysis of the pooled prevalence of women who screened positive for female sexual dysfunction in Ethiopia In this review, three major factors were eligible for meta-analysis, as each was reported in at least two primary studies. Substance use was associated with higher odds of screen-positive FSD; however, the pooled effect was not statistically significant (AOR = 2.04, 95% CI: 0.72–5.77; I² = 77.8%) (Fig. 6 ), indicating insufficient evidence to support a clear association. Depression was significantly associated with increased odds of FSD, with women experiencing depressive symptoms having approximately threefold higher odds of FSD compared with those without depression (AOR = 3.06, 95% CI: 1.82–5.15; I² = 0.0%) (Fig. 7 ). Similarly, older age was significantly associated with increased odds of FSD (AOR = 3.61, 95% CI: 1.71–7.61; I² = 0.0%) (Fig. 8 ). Fig. 6 Forest plot showing the association between substance use and screening positive for female sexual dysfunction in Ethiopia Forest plot showing the association between substance use and screening positive for female sexual dysfunction in Ethiopia Fig. 7 Forest plot showing the association between depression and screening positive for female sexual dysfunction in Ethiopia Forest plot showing the association between depression and screening positive for female sexual dysfunction in Ethiopia Fig. 8 Forest plot showing the association between older age and screening positive for female sexual dysfunction in Ethiopia Forest plot showing the association between older age and screening positive for female sexual dysfunction in Ethiopia

This meta-analysis found that the pooled prevalence of women who screened positive for FSD using validated instruments was 53.8% (95% CI: 46.38–61.22; I² = 96.39%). The wide 95% prediction interval (24.48% – 82.96%) suggests substantial variation in the prevalence of women who screened positive for FSD across Ethiopian populations. Depression (AOR = 3.06; 95% CI: 1.82–5.15) and older age (AOR = 3.61; 95% CI: 1.71–7.61) were significantly associated with increased odds of FSD, while substance use was associated in some primary studies but did not reach statistical significance in the pooled analysis. The pooled prevalence estimate in this review is comparable with a prior meta-analysis conducted in Africa (52.1%) [ 40 ], but higher than estimates reported in Brazil (42.9%) and Colombia (30%) [ 41 , 42 ]. It is also lower than findings from Turkey (61.5%), China (63.3%) and Egypt (67.8%) [ 43 – 45 ]. Such variations may reflect differences in study populations, methodological approaches, cultural norms, and the measurement instruments used. Cultural sensitivities surrounding sexual health may limit open reporting in some settings, while increasing disclosure in others where sexual discussions are more acceptable. Additionally, inconsistencies in the tools used to assess FSD, each varying in sensitivity and specificity, may contribute to disparities in prevalence estimates across studies [ 40 ]. Subgroup analyses suggested variation in FSD prevalence across population groups. Higher pooled prevalence was observed among women with chronic medical conditions (61.06%) and those with mental illness (61.65%), whereas general/reproductive-age women had a lower prevalence (45.39%). These findings should be considered exploratory, as differences in population characteristics, study settings, and assessment tools may influence subgroup estimates. Similar trends have been reported in other settings, including Iran (47.8% among healthy reproductive-age women) and African studies (58.42% among individuals with mental disorders), supporting the potential influence of health status on FSD [ 46 , 47 ]. The observed differences may reflect multifactorial influences, hormonal alterations, medication side effects, and psychological distress, which may contribute to decreased sexual function and satisfaction [ 48 ]. Older age was significantly associated with increased odds of FSD, with older women having more than threefold higher odds compared to younger women (AOR = 3.61, 95% CI: 1.71–7.61). This finding aligns with a systematic review on sexual health in older women, which reported a marked reduction in sexual function after the age of 60 [ 49 ]. Age-related physiological changes, including reduced estrogen levels, vaginal atrophy, and decreased genital blood flow, as well as psychosocial factors such as widowhood and chronic illness, may contribute to reduced sexual function with advancing age [ 50 ]. Depression was also significantly associated with increased odds of FSD, with women experiencing depressive symptoms having approximately threefold higher odds of FSD compared with those without depression (AOR = 3.06, 95% CI: 1.82–5.15). This result is consistent with a study among postmenopausal women found that 70.5% of those with FSD had moderate-to-severe depression [ 51 ]. Likewise, a cross-sectional study among women with major depressive disorder reported a significantly higher prevalence of sexual dysfunction compared to non-depressed women. Depression can impair sexual function by reducing libido and arousal, disrupting hormonal balance, and causing interpersonal and self-esteem difficulties [ 52 ]. In summary, older age and depression were significantly associated with higher odds of FSD, whereas substance use showed no statistically significant association in the pooled analysis. Given the substantial heterogeneity and the cross-sectional design of the included studies, these findings should be interpreted cautiously and regarded as correlational rather than causal. Prospective, methodologically robust studies are needed to clarify determinants of FSD among Ethiopian women [ 46 , 53 ]. This study used a comprehensive systematic review and meta-analysis, conducted in accordance with the PRISMA guidelines, to generate a pooled prevalence estimate of women who screened positive for FSD across diverse Ethiopian populations. Subgroup analyses further highlighted variations across population groups. However, the number of eligible studies was limited, with underrepresentation of some regions, which may affect generalizability. Substantial heterogeneity was observed, likely reflecting differences in study populations and measurement tools. Moreover, all included studies were cross-sectional, limiting causal inference. This systematic review and meta-analysis found a high pooled prevalence of women who screened positive for FSD in Ethiopia, with older age and depression significantly associated with increased odds of FSD. The burden was particularly pronounced among women with chronic medical and mental health conditions, highlighting the importance of recognizing sexual health as a key component of overall and reproductive well-being. To address this burden, routine FSD screening should be incorporated into reproductive, chronic disease, and mental health services, with special focus on older women and those with chronic illnesses. Enhancing healthcare providers’ skills in sexual health assessment, counseling, and evidence-based management is critical. Public awareness campaigns aimed at reducing stigma and promoting open discussions on sexual health can improve early identification and care-seeking.

Female sexual dysfunction (FSD) refers to persistent problems with sexual desire, arousal, orgasm, or sexual pain, resulting in distress and reduced quality of life. It is increasingly recognized as a public health concern, with consequences extending to intimate relationships, mental health, and reproductive outcomes. Globally, an estimated 43–51% of women are affected, underscoring the substantial magnitude of FSD across diverse settings [ 1 , 2 ]. Despite recognition by the World Health Organization (WHO) of sexual health as a core component of women’s reproductive health and human rights [ 3 , 4 ], FSD remains under-recognized and undertreated, particularly in low-income settings where reproductive health services largely prioritize HIV, sexually transmitted infections, and family planning [ 5 , 6 ]. Clinically, FSD includes three major diagnostic categories that frequently overlap rather than occur in isolation. Sexual interest/arousal disorder is characterized by reduced sexual desire, diminished arousal, and decreased sexual activity or pleasure, while orgasmic disorder involves persistent difficulty, delay, or absence of orgasm despite adequate stimulation. Genito-pelvic pain/penetration disorder is marked by pain, fear, or difficulty during vaginal penetration and is often associated with anxiety and involuntary pelvic floor muscle contraction [ 7 – 10 ]. However, in epidemiological and public health research, including studies conducted in Ethiopia, FSD is typically identified using standardized screening instruments rather than formal clinical diagnostic criteria [ 11 ]. FSD has a multifactorial etiology. Obstetric-related contributors include perineal trauma, episiotomy, pelvic floor injuries, and childbirth-related complications that directly affect genital anatomy and function. Gynecological conditions, such as endometriosis, infertility, and pelvic organ prolapse, further compromise sexual health. Chronic medical and psychiatric conditions, including diabetes, cardiovascular disease, cancer, depression, and anxiety, are also associated with FSD. In addition, sociocultural determinants, particularly female genital mutilation and intimate partner sexual violence, exacerbate FSD and limit access to appropriate care [ 7 , 12 – 16 ]. The consequences of FSD extend beyond sexual dissatisfaction, causing emotional distress, reduced self-esteem, compromised intimate relationships, and psychological distress among affected women. In severe cases, particularly when associated with childbirth-related injuries such as obstetric fistula, FSD contributes to physical morbidity, marital disruption, and profound social isolation, further reinforcing cycles of stigma and vulnerability [ 17 – 20 ]. In sub-Saharan Africa, prevalence estimates of FSD range from 46% to 73% [ 1 , 7 ]. In Ethiopia, studies report prevalence between 32% and 52% among reproductive-age women. Rates exceed 60% among women with chronic medical or psychiatric conditions, including diabetes, epilepsy, heart failure, and schizophrenia [ 21 – 30 ]. Psychosocial factors like depression, low self-esteem, marital dissatisfaction, harmful cultural practices, limited sexual communication, and stigma further aggravate FSD. Structural barriers, including inadequate screening, poor integration of sexual health into reproductive services, and limited provider training, impede prevention, early detection, and management [ 23 , 24 , 31 ]. Although several primary studies on FSD have been conducted in Ethiopia, the existing evidence base is fragmented, largely small-scale, and methodologically heterogeneous, limiting its generalizability and policy relevance. Moreover, the only national-level review to date included both sexes and did not adequately capture women’s experiences across different reproductive stages, leaving a critical gap in sex-specific and contextually relevant evidence. Addressing this gap is essential for informing reproductive health policy, strengthening the integration of sexual health into routine care, and improving provider capacity to address women’s sexual concerns. Therefore, this systematic review and meta-analysis aims to estimate the pooled prevalence of women who screened positive for FSD and to identify associated factors among Ethiopian women.