FACTORS ASSOCIATED WITH SEXUAL DYSFUNCTION AMONG FEMALE PATIENTS IN A NIGERIAN AMBULATORY PRIMARY CARE SETTING.

Sexual health is an important aspect of the overall health of women with Masters and Johnson describing the 4 phases of sexual experience and response in women as excitement, arousal with plateau, orgasm and satisfaction 1 . Sexual dysfunction is a disruption in this sexual response cycle which does not allow achievement of the expected outcome 2 . In females, sexual dysfunction is classified into five groups which comprise disorders of arousal, aversion, desire, orgasm, and pain 3 , 4 . Krakowsky and Grober in 2018, however, divided Female Sexual Dysfunction (FSD) into four groups consisting of sexual pain, low desire, low arousal and orgasmic dysfunction 4 . FSD could be caused by diabetes mellitus, hypertension, arthritis, dementia, dermatologic conditions including vulvar eczema; gynaecological problems such as pelvic inflammatory disease; and spinal cord problems, pituitary tumours, and urinary incontinence 5 . Sexual abuse, life stressors, interpersonal and relationship disorders are also implicated in FSD 6 , 7 . FSD could also be associated with antipsychotics 8 , antihistamines, metronidazole, antihypertensives, antiestrogens such as Tamoxifen, antiandrogens like cimetidine and spironolactone, antidepressants and alcohol 6 . Other drugs which lead to FSD include antilipids, narcotics, ketoconazole and hormonal contraceptives 5 . FSD is a very important aspect of health (WHO 2016) as women constitute half of the global population and even though men are more than women in the younger age group, from age 60 years and above, women are found to be a higher proportion (54%) 9 . There is a high prevalence of sexual dysfunction in both men and women6 with varying epidemiology. Globally, the prevalence of FSD falls between 35.4 – 62.1% 10 , 11 . In Northern Nigeria, the highest proportion of respondents (35.7%) defined FSD as having no desire for sex 12 , while authors based in South-western Nigeria in 2007, described the prevalence of FSD as 68.3% 13 . FSD could be assessed by several tools including the Female Sexual Function Inventory (FSFI) 14 , the Sexual Dysfunction Questionnaire (SDQ) 3 and the Sexual Function Questionnaire. The SFQ-34 was validated by Quirk and colleagues in 2002 15 . Since then, there have been several adaptations of the questionnaire such as the SFQ-28 and the SFQ–V2. There are also several versions of this questionnaire adapted to countries such as the Persian version 16 . A woman’s social, cultural, background, expectations, and relationships are also very important factors in sexual dysfunction 1 .In various cultures, sexuality is something difficult to discuss and there is usually more emphasis on male sexual dysfunction otherwise known as Erectile Dysfunction than FSD. In fact, it is already well established that there is more sexual dysfunction in men than women and as men grow older, there is increased sexual dysfunction 17 . However, in women, it is difficult to measure arousal and orgasm with women not as forthcoming with reporting problems in these domains and this is compounded by confounders in women such as depression 2 . Therefore, the need arose for this study to define the magnitude of FSD presently in South- western Nigeria. The aim of this study was to determine the prevalence of FSD among adult married women presenting in GOP clinic, UCH, Ibadan, Oyo State, Nigeria as well as to identify the pattern of presentation of females with FSD.

The mean age of the 480 respondents was 35.4 ± 7.2 (19.0 – 56.0) years. Their partners were significantly older, mean age of [41.6 ± 7.9(25.0 – 70.0) years] t = 33.667, p <0.0001. The mean duration of relationship was 10.5± 7.4 (1.0 – 34.0) years. The modal age group was 31 – 40 years, 276 (57.5%) respondents had tertiary education and the highest proportion of respondents were traders 199 (41.5%). They earned a median monthly income of 20,000.00 (IQR 1,000.00 - 41,250.00) Naira with 214 (56.0%) respondents living above the Nigerian minimum wage. (Table 1 ). The point prevalence of sexual dysfunction was 80%. The commonest type of sexual dysfunction was problems with sexual desire (99.4%), while the least was problems with arousal cognition (5.8%). This is shown in Figure 1 . Table 2 describes the frequency of obstetric and gynaecological factors. The mean age at coitarche was 21.9 ± 3.7(13.0 – 32.0) years and median parity was 3 (IQR 2 – 4). The mean duration since last confinement was 6.1 ± 4.6 years (range 1 – 24 years), while the mean duration on contraception was 3.8 ± 3.3 years (range 2 months – 12 years). Table 3 shows the socio-demographic characteristics and the prevalence of sexual dysfunction. There was significant association between prevalence of sexual dysfunction and age (p < 0.0001), years of relationship (p = 0.002), number of children (p <0.0001), having ≥ 10 years of education (p <0.0001) and having family dysfunctionality (p = 0.001). The obstetric and gynaecological factors and the prevalence of sexual dysfunction are shown in Table 4 . There was a significant association between age at coitarche (p < 0.0001), parity (p = 0.001), duration since last confinement (p = 0.001) and sexual dysfunction. Figure 2 depicts the prevalence of sexual dysfunction and gynaecological problems in the respondents. The highest prevalence of sexual dysfunction was observed among the respondents with gynaecological -related malignancies (100.0%), while the least was found in those with vaginal discharge (50.0%). Logistic regression analysis carried out on variables which showed significant association with sexual dysfunction. The logistic model was statistically significant, χ 2 (8) = 66.726, p <0.001. The model explained 28.2% (Nagelkerke R 2 ) of the variance in sexual dysfunction and correctly classified 85.5% of cases. Age (OR = 0.893; 95% CI = 0.821 – 0.972, p = 0.008), parity (OR = 3.093; 95% CI = 1.174 – 8.151, p = 0.022), having family dysfunction (OR = 2.096; 95% CI = 1.129 – 3.891, p = 0.019) and having e- 10 years of formal education (OR = 4.808; 95% CI = 2.604 – 8.929, p < 0.0001) were found to be the predictors of sexual dysfunction. (Table 5 ).

This study has shown that the prevalence of FSD among female married women is high. Several socio-demographic factors such as age, education, years of relationship and the number of children were found to be associated with sexual dysfunction among women. Gynaecological factors like vaginal discharge and contraceptive use were also found to be associated with FSD. So, the diagnosis of FSD must be considered by physicians when managing other medical conditions. There is need for history related to sexual disorders to be taken along with clerking of patients and if suggestive symptoms are found, may be further confirmed using a validated tool. There is need prior to the commencement of sexual intercourse to put more effort into addressing the preventable causes of FSD. Sex education aimed at improving the knowledge of the sexual cycle, safer sex practices, relaxation techniques and elimination of female genital mutilation should be ensured.

This study employed the cross-sectional design for the 480 female respondents presenting to a primary care clinic while employing the use of the SFQ-28 to assess the sexual dysfunction. The highest proportion of women in this study were in the age group of 31-40 years 207 (43.1%) which was higher than that of another cross-sectional study in Ile-Ife, South-western Nigeria, in 2007 among 384 female respondents in which the highest proportion of women was in the age group 26-30 years (32.1%) 14 . The mean age of the respondents was similar to those in the survey by Khademi et al . who carried out a cross-sectional study on 547 women using the Persian version of the SFQ 14 . Nwagha et al . used the Female Sexual Function Inventory [FSFI] and carried out their study among students and staff of a university in Nigeria in which the greatest proportion was women between 21-30 years 13 . In our study, all the participants were married as compared to the study by Fajewonyomi et al . in which the majority were married (83.6%) and more of the participants (60.7%) were from monogamous family settings with the predominant tribe being the Yoruba tribe (84.9%) 14 . Aisuodionoe in 2012, conducted a study among 50 female health workers attending a seminar strictly for women at Abuja, Nigeria 12 . The age range of the respondents was 27 to 49 years with the mean age being 38.8+5.4, with married women constituted the majority (84%) 12 , which was comparable to our study in which the mean age of the women was 35.4 ± 7.2(19.0 – 56.0) years. Over half of the respondents, 276 (57.5%) had tertiary education in this study and this was in tandem with the study by Fajewonyomi et al ., in which half of the women had tertiary education (43.3%) 14 . This finding was similar to that of a study in Enugu, Nigeria in which the majority of the women had either post-secondary education or tertiary education 13 . Occupation is also linked to FSD and Partin in 2014 in a review of the literature was able to adduce that those whose occupations involved cycling could have cycling injuries as well as neurovascular damage to the genitals and this could lead to FSD 20 . Cycling as an occupation is not common among Nigerian women and those who engage in it only do so for physical exercise or pleasure. The occupations of the respondents in this study were mostly traders, teachers, and civil servants. There were several factors associated with FSD. Years of relationship was related to sexual dysfunction and was highest in respondents married for less than 5 years. This was comparable to the study done in South-eastern Nigeria in 2014 in which the highest association was found among women who were married and co-habiting 13 . There was also less FSD noted in women with fewer than 2 children. This was supported by the report that those with FSD had a greater number of children 21 . Women with senior secondary school and tertiary education had a more significant association with sexual dysfunction. This was also similar to previously documented literature in which participants with post-secondary school education had the greatest association with sexual dysfunction 13 . People that are educated are more likely to be aware of the signs and symptoms of sexual dysfunction and more readily to admit to it when asked. It may also suggest that the uneducated or less educated women are more likely to be ignorant and does not see it as a problem. The prevalence of sexual dysfunction was found to be 80%. In this study, there was a statistically significant association between prevalence of sexual dysfunction and age as it was highest in the lowest age group, 18-30 years, though only slightly more than the age group 31-40 years. This was not in keeping with a study which revealed the greatest prevalence among women in the age group 41-50 years 13 . It may be due to fact that in our societal setting, sexual activity is linked to procreation rather than the pleasure derived from sex, so women are more likely to engage in sex more in the reproductive age group. They may be able to recall more of the symptoms of sexual dysfunction than in women with infrequent sex. More so many women would have completed their families by age 40 years and more likely to engage in less sex. The greatest type of sexual dysfunction was sexual desire (99.4%) while the least type was arousal cognition (5.8%). This differed from the findings in a Nigerian study in which the prevalence of FSD was 68.3% with the highest type of FSD being a disorder of orgasm (63.6%), followed by dyspareunia in 22.7%14. Reasons for sexual dysfunction included uncaring partner and inadequate foreplay 14 . In an additional Nigerian study, out of the 28 respondents who thought they knew what FSD was, the highest proportion (35.7%) defined FSD as a lack of or desire for sex, followed by inability to achieve orgasm in 17.9% 12 . Another Nigerian study also reported a prevalence of 53.5% in their study among female students 14 . A cross-sectional study among women reported a prevalence of 62.1% 11 while a study among married students documented the prevalence of orgasmic problems as 63% 21 . Infrasca 2011, using the (Sexual dysfunction questionnaire) SDQ found a prevalence of 52.5% 3 . Legocki also did a study among women with vulvar pain and were able to document using the SFQ-34 that participants with vulvodynia were more likely to have FSD than controls and this was shown in five out of seven domains (desire, arousal lubrication, pain, enjoyment, and partner domains, p<0.05) 22 . Coitarche was found to occur at a mean age of 21.9 ± 3.7 (13.0 – 32.0) years and those with sexual dysfunction had coitarche later than those without sexual dysfunction. In a study among married women between 15-49 years in an outpatient clinic, it was documented that Muslim women were younger (15.9+2.6 years) than Christian women at coitarche (18.4+3.3 years; p<0.001) 23 . The family plays a pivotal role in any community 21 . In this study, half of the respondents had family dysfunction and those with family dysfunction had less FSD. It has also been documented that those with FSD had a longer duration of marriage 11 . There were many obstetric and gynaecological conditions noted among the participants. These included previous episiotomy/tear, use of contraceptive, infertility and fibroids. Others included previous forced sexual intercourse and domestic conflicts, abdominal pain, vaginal candidiasis and previous gynaecological surgeries such as hysterectomy. This was also proven by Song et al . in 2014, who did a study among women in the post-natal clinics about 6 weeks after delivery using the same tool we used, the SFQ 28 and found that within the domains there were significant differences between the women who had vaginal delivery and those who had operative delivery. This was particularly noted in the orgasm and pain domains 18 . Our findings on gynaecological issues among respondents were also comparable to the study by Ojomu et al . in which abnormal vaginal discharge was the most common gynaecological issue with candidiasis as the greatest cause of vaginal discharge and this was closely followed by a history of pelvic surgery and lower abdominal pain 23 . In this Nigerian study, some had fibroids, others had been circumcised in the past (38%) and a few had dyspareunia 23 . A great proportion of the women had forced sexual intercourse either by their husband or significant other and marital conflicts was high on the list while some were on treatment for hypertension 23 . Respondents who were on contraceptives, had more sexual dysfunction in this study. This differed from a report in which those on contraceptives had lower risk of a sex pain problem (0.53; 0.29–0.95) as well as less orgasmic problems (0.63;0.38–1.0) 23 . Faubion et al . in 2015 also documented the relationship between FSD and gynaecological conditions such as Sexually Transmitted Infections (STI), endometriosis, chronic pelvic pain and gynaecological malignancies. Beta-blockers and thiazide diuretics used to treat hypertension were risk factors for sexual dysfunction 24 . In our study, using multivariate analysis, the woman's age (p = 0.008), parity (p = 0.022), family dysfunction (p = 0.019) and being literate with over 10 years of formal education (p < 0.0001) were the predictors of sexual dysfunction. On the other hand, the study by Song 2014, in which multiple regression analysis was done showed that the predictors of sexual health were also maternal age and cesarean section which were significant predictors of the domains of desire (P = 0.005 and P = 0.015, respectively), arousal (lubrication) (P = 0.003 and P = 0.032, respectively), and arousal (cognitive) (P = 0.007) and P = 0.036, respectively). Maternal age was a significant predictor of the enjoyment domain (P = 0.001) Our study has shown a high prevalence of FSD and physicians should be aware of the treatment approach. The management of FSD is multi-specialty and may involve one or more of the following specialties, gynaecologist, family physician, psychiatrist, nurses, psychologist and sex therapist. The treatment must be comprehensive and focused on the sexual dysfunction diagnosis and any other underlying physical, psychological, and relationship factors. It is a team effort, aimed at providing education, counselling, reassurances enhancing stimulation, encouraging non-coital behaviours, minimizing pain through the changing sexual positions, and the use of non-oestrogen lubricants and medications 23 , 24 . Surgical procedures may be indicated some types of sexual dysfunction. The treatment may also be modified according to the specific type of dysfunction experienced. Following treatment, arrangement should be provided for longtime follow up.

This cross-sectional study was carried out at the General Outpatient Clinic (GOPC) of the University College Hospital (UCH) Ibadan, South-western Nigeria. GOPC is the outpatient clinic of the Department of Family Medicine and it serves as the gateway for most of the patients presenting at the UCH. Four hundred and eighty female respondents were selected consecutively during the study period of October 2012 to January 2013. The sample size was calculated using the Leslie and Kish formula for single proportion and the prevalence of sexual dysfunction in Nigeria of 63%11 after an attrition rate of 25% was added. The inclusion criteria were married females of reproductive (18 – 49 years) age while the exclusion criteria were non-consent and currently not living with the spouse. Informed consent was obtained, and the respondents were interviewed using a semi-structured questionnaire which was pre-tested before use. The respondents’ socio-demographic characteristics, lifestyle habits, obstetric and gynaecologic histories were obtained. The Sexual Function Questionnaire (SFQ-28) is a multi-dimensional and patient-centered tool and is used to check for all areas of the sexual response cycle 16 . The SFQ-28 was used to determine sexual dysfunction and is made up of 28 questions with 7 domains of dysfunction 18 , 19 . FSD was described as a minimum of a score in one of the domains showing high probability on the SFQ-28. The questionnaire was administered both in English and Yoruba languages (after back-translation) by trained female research assistants and the interview took an average of 25 minutes each. Data entering, cleaning and analysis were carried out using Statistical Package for Social Sciences (SPSS) version 20. Descriptive statistics were used to describe socio-demographic characteristics and appropriate charts were used to illustrate categorical variables. Student t-test and Chi-square test were used to test the association between continuous and categorical variables respectively. Logistic regression analysis was used to explore the relationship between significant variables at the bivariate level and sexual dysfunction. The level of significance (p-value) was set at 5%.