Period Prevalence of and Biopsychosocial Factors Associated With Sexual Dysfunction in Self-Identified Females in Gauteng, South Africa, During 2013–2023

Female sexual dysfunction (FSD) is part of a broader sexual health state which is defined as “…a state of physical, emotional, mental, and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity” (World Health Organisation [WHO], 2023 ). Approximately 40–45% of women globally, and up to 80% of African women (Adebusoye et al., 2020 ), experience sexual dysfunction, suggesting a public health concern (McCool-Myers et al., 2018 ). FSD is complex and defined as a sexual complaint that results in personal stress or interpersonal difficulties (Campbell & Stein, 2014 ; Rogers et al., 2018 ; Wolpe et al., 2017 ), affect sexual satisfaction, may lead to psychological conflict, affect reproductive health and quality of life. FSD is categorized into female sexual interest/arousal disorder, female orgasmic disorder, genito-pelvic pain disorder or pleasure disorder (Campbell & Stein, 2014 ; Ishak & Tobia, 2013 ; Rogers et al., 2018 ). FSD has a biopsychosocial etiology, stemming from biological, social or psychological components (Butt et al., 2019 ). Factors that may be associated with FSD include genital mutilation, violence or other harmful practices; endometriosis, gynaecological cancer, urinary infections, reproductive tract infections, urinary incontinence, endocrine alterations, degenerative and vascular diseases (including HIV), psychological problems (e.g., depression) or consumption of psychoactive drugs (Wolpe et al., 2017 ; World Health Organisation, 2023 ). These factors, together with increasing survival rates and aging populations, raise a major concern regarding morbidity of women on the African continent. In many African countries and cultures female sexuality is something difficult to discuss and seek help for, while more emphasis is placed on male sexual dysfunction (Adebusoye et al., 2020 ). Approaches to sexuality have largely focused on the medical and biological factors, emphasizing adverse health outcomes and concomitant risks, rather than incorporating all aspects of the biopsychosocial model of care across the lifespan, sexual health and wellbeing (Mitchell et al., 2021 ). A systematic review by McCool-Myers et al. ( 2018 ), investigating the predictors of sexual dysfunction, focused on reproductive-age women in the general population. Studies were included if (i) all women surveyed were described as premenopausal, (ii) the age range of the participants was between menarche and 49 years, or (iii) data on women no older than 49 years could be extracted from the entire population. They found social and cultural factors such as unemployment of the partner, low partner education, female genital mutilation, sexual dysfunction of the partner, sexual abuse, relationship dissatisfaction, and religion to be associated with FSD. Older marital age, exercise, intimate communication, positive body image, affection, sex education, and recognizing sex as an important component of a relationship, are the factors that showed a protective effect across domains of sexual dysfunction (McCool-Myers et al., 2018 ). Biomedical factors (gynecological factors, chronic disease, obesity, amongst others) and psychological factors (poor mental health) are ther factors that most studies reported as a risk factor for FSD. McCool-Myers et al. ( 2018 ) indicated that risk and protective factors are not universal across countries and that the complexity of addressing factors depends on the country and their culture. Their review included only nine studies from Africa (out of a total of 135) and only three of the included studies were classified in the low human development quartile according to the Human Development Index. The review also highlighted that factors associated with women’s rights, gender identity, and reproductive health may lead to differences in population-based associated factors (McCool-Myers et al., 2018 ). Differences in associated factors are further highlighted by studies that have been conducted in African and the Eastern countries where education and age, amongst other factors, seem to have a more significant association with FSD. In addition, the findings from three cross-sectional studies in Africa on Nigerian women (Adebusoye et al., 2020 ) and Kenyan women (Butt et al., 2019 ; Oindi et al., 2019 ) respectively, also differed in findings and factors investigated. Table 1 is a summary of the biopsychosocial factors they investigated, with the associated outcomes. Interestingly, none of these studies focused on investigating psychological factors. The three studies did not agree on the association of biomedical factors such as age, fertility and chronic disease or medication use with FSD. The studies on Kenyan women (Butt et al., 2019 ; Oindi et al., 2019 ) did however both find an association between the use of contraception and FSD. Education was the only socio-cultural factor that two of the studies found to be associated with FSD (Adebusoye et al., 2020 ; Butt et al., 2019 ). Investigation of and findings on other socio-cultural factors such as employment, parity, family dysfunction and alcohol consumption with FSD, seem to be inconsistent among the three studies (Adebusoye et al., 2020 ; Butt et al., 2019 ; Oindi et al., 2019 ). Due to the different settings and differences in populations, culture, religion, and measuring instruments used in these studies, the interpretation of the associations are limited. Comparison of biopsychosocial factors investigated in three African studies with the associated findigs (Biopsychosocial factors associated with sexual dysfunction in self-identified females, South Africa, 2023–2024). This trend toward disparate findings amongst African studies are also shown in prevalence rates (Campbell & Stein, 2014 ). The study by Adebusoye et al. ( 2020 ) reported FSD to have a point prevalence of 80% among 566 Nigerian women (Adebusoye et al., 2020 ), while the study by Butt et al. ( 2019 ) reported a prevalence of 38.7% among 480 Nairobian women (Butt et al., 2019 ). A systematic review and meta-analysis by Alidost et al. ( 2021 ) reported a pooled prevalence of FSD, as measured with the FSFI, of 50.75% (41.73–59.78). Their review included populations from Asia ( n  = 17), Africa ( n  = 3) and South America ( n  = 1), which might have more comparable socio-economic circumstances to South Africa, when compared to European countries (Alidost et al., 2021 ). No study on a South African population were included in their review. The high prevalence of FSD may indicate that the focus of investigating associated and risk factors, may still need to be elaborated on. As portrayed in Table 1 , there are trends in investigating reproductive factors and nonspecific or collective biomedical factors. Investigation of psychological factors and social factors such as gender identity, religion, and social justice are lacking. Only four studies have been published in South Africa and those focused on the association of FSD with biomedical factors such as comorbidities (Adebusoye et al., 2020 ). Campbell and Stein ( 2014 ) also highlighted in their systematic review that South-African based research on sexual health is limited and outdated (Campbell & Stein, 2014 ). The biomedical approach is still practiced in many settings, especially public health settings (Mitchell et al., 2021 ). Social factors seem under-investigated and interrelationships between factors are not established when conducting research and/or clinical screening globally (Wellings & Johnson, 2013 ). With limited studies available in Africa and in South Africa, and variability in the findings from studies, the question was raised which factors are associated with FSD in a South African population, and what is the prevalence? Without the information patient concerns remain unanswered, and compilation of effective, contextualized prevention programs remains neglected. Hypothesizing that we would find an association between a range of biopsychosocial factors and FSD, the aim of the study was formulated namely, to examine the period prevalence of and biopsychosocial factors associated with sexual dysfunction in self-identified females in Gauteng, South Africa, during 2013–2023.

A cross-sectional design was used to analyze patient information that was gathered at a once-off first clinic visit by the patient, during the period 2013–2023. No follow-up patient data were included for analysis. The electronic records of routinely collected data from two privately managed, medical sexual health clinics in the Gauteng Province, South Africa, were analyzed for the purpose of the study. The clinics were established in 2010 and serve a gender-diverse population in a wider geographical area due to limited availability of specialized sexual health services in the country. Patients visiting these clinics are from a variety of cultural backgrounds and socio-economic status. The size of the population was 4155, based on the available records for the period 2013–2023. The number of patients that completed the FSFI, used as outcome measure for this study, were 1598 during this period. Removing of duplicate entries and merging the FSFI dataset with the dataset on the intake questionnaires, yielded a final sample size of 1595. All available records were used and a post-hoc power calculation of the total sample size, after the merging of the medical intake questionnaire and the FSFI, were done. It indicated a required sample size of 116–154, at α  = 0.05, to reach a power of 80–90%. Based on proportions of 0.50 and 0.75 in the unexposed and exposed respectively, a total sample size of 500 would be sufficient to achieve 100% power in the analysis. The study included the records of self-identified female patients (binary, cisgender, transgender, non-binary, agender, or gender-queer), older than 18 years of age, for whom the FSFI and medical intake questionnaire data were available. Patient files were shared in the format of Excel files (Microsoft 365). The Excel files were cleaned, checked and anonymized by the principal investigator, capturing only the variables to be analyzed in this study. Data were exported to Stata Version 18.0 for further analysis. The outcome variable of interest was the presence of FSD, defined and calculated as a total sexual dysfunction score of ≤ 26.55 on the FSFI (Oindi et al., 2019 ). The measured domains include sexual desire, arousal, lubrication, orgasm, satisfaction, and pain. The sum of each domain is multiplied by a factor and then summed to get the final sexual dysfunction score (Oindi et al., 2019 ). The following exposure variables were extracted from the patient records as single-item measures: Social factors—employment, relationship status, alcohol consumption, smoking, number of children, number of sexual partners, sexual orientation, and exercise; Psychological factors—concerned feelings about having a sexually transmitted infection (STI), about low sex drive, or about orgasm; Biomedical factors—age, number of pregnancies, regularity of menstruation period, hormone replacement therapy, contraception, fertility treatment, pain (subdivided into intercourse; abdominal; pelvic), hysterectomy, menopausal status, previous infections, bladder and bowel symptoms, comorbidities, and menopausal status. Social factors—employment, relationship status, alcohol consumption, smoking, number of children, number of sexual partners, sexual orientation, and exercise; Psychological factors—concerned feelings about having a sexually transmitted infection (STI), about low sex drive, or about orgasm; Biomedical factors—age, number of pregnancies, regularity of menstruation period, hormone replacement therapy, contraception, fertility treatment, pain (subdivided into intercourse; abdominal; pelvic), hysterectomy, menopausal status, previous infections, bladder and bowel symptoms, comorbidities, and menopausal status. Frequencies and percentages were used to describe categorical data. Means and SD (or medians and interquartile ranges in the case of non-linearity) was used to describe continuous and discrete data. Variables were tabulated by outcome and exposure and described in terms of prevalence odds ratios and prevalence ratios. Binomial logistic regression analysis was conducted including variables that suggested significant association with FSD based on the odds ratios, chi square values and p – value ( p  < 0.05). Two possible models were constructed using logistic regression methods. The first model (Model 1) excluded the variable “concerned feelings about sex drive” due to multiple missing values. In the case of confounding, possible interactions were explored. The second model (Model 2, n  = 622) included “concerned feelings about sex drive” as an exposure variable but excluded observations with the missing values as related to this variable. When the sample size was adjusted to drop missing values for concern about sex drive, the latter factor (concerned feelings about sex drive) was the only factor to be added to the fitted model, while other factors were dropped based on likelihood ratio testing. Variables that were included in model 1 (fitted without concerned feelings about sex drive), did not improve the fit of model 2. These factors included contraception use, urinary symptoms, concern about STI, and doing exercise. Considering the common associated factors among models 1 and 2, as well as literature (variables that have previously been shown to be associated with FSD namely menopausal status, employment, and age), a final third model (Model 3) was fitted. This model also did not include the missing values for the variable “concerned feelings about sex drive” ( n  = 622). Lastly, a Receiver Operating Characteristic (ROC) Curve and Analysis was used to determine the diagnostic performance of the final model. The study was performed in accordance with the ethical standards of the Human Research Ethics Committee of the University of the Witwatersrand (M240253), and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards (World Medical Association [WMA], 2024). Permission was also obtained from the gatekeeper of the electronic records.

The mean age of the analytical sample ( N  = 1595) was 37.18 years ( SD  = 11.00). Most of the patients in the reviewed sample identified as straight ( n  = 1506, 95.08%), while those who identified as gay/lesbian had the second highest frequency ( n  = 39, 2.46%). The biopsychosocial characteristics and socio-demographic variables of the sample are summarized in Table 2 . Socio-demographic characteristics per biopsychosocial factor in a sample of self-identified females visiting sexual health clinics ( N  = 1595) (Biopsychosocial factors associated with sexual dysfunction in self-identified females, South Africa, 2023–2024). Of the total sample, 1345 (84.17%) presented with FSD, which was defined as a total sexual dysfunction score of ≤ 26.55 on the FSFI. The mean FSFI total score for sexual dysfunction was 17.66 ( SD  = 8.76), which is below the cutoff value of 26.55. The mean transformed arousal score for the sample was 2.74 ( SD  = 1.79), for the lubrication domain it was 3.08 ( SD  = 2.07), for the orgasm domain 2.93 ( SD  = 2.09), for the satisfaction domain 2.98 ( SD  = 1.61), for the desire domain 0.96 ( SD  = 0.19), and for the pain domain 2.84 ( SD  = 2.29). According to the established cutoff value for the desire domain, 1538 (96.42%) participants from our sample presented with a score ≤ 5, and therefore with possible hypo-active sexual disorder (HSDD). When looking at the prevalence of FSD per biopsychosocial factor ( Supplemental Table S1 ), the prevalence ratios ranged from 0.87 to 1.34, with most ratios equaling an approximate ratio of one. The highest prevalence of FSD were in the higher age groups (51–65 years and > 80 years). Regardless of the number of pregnancies, the prevalence of FSD remained above 80%. The same trend was observed in the rest of the biomedical factors, whether exposed or not exposed to the factor. For those who experienced pain during sex and complained of urinary frequency, the prevalence of FSD was > 90%. Participants that presented with psychological factors, had a high prevalence of FSD of > 90%. These included the patients’ concern about having an STI, concern about sexual drive, and concern about orgasm respectively. With majority socio-cultural factors the prevalence of FSD remained above 80% irrespective of the level of the factor ( Supplemental Table S1 ). Initial analysis of the data indicated evidence of association between FSD and use of contraception (OR = 1.33, Ӽ 2 = 3.91, p  = 0.048); recurrent yeast infections (OR = 1.71, Ӽ 2 = 9.25, p  = 0.002); pain during sex (OR = 4.88, Ӽ 2 = 135.31 , p  = 0.000); bothersome pain in the pelvic or genital region (OR = 1.64, Ӽ 2 = 9.33, p  = 0.002); urinary frequency (OR = 2.22, Ӽ 2 = 25.24, p  = 0.000); constipation (OR = 1.54, Ӽ 2 = 9.98, p  = 0.002); and irritable bowel syndrome (OR = 1.49, Ӽ 2 = 6.44, p  = 0.011). Evidence was strong for the association of FSD with psychological factors such as concerned feelings about having a low sex drive (OR = 9.42, Ӽ 2 = 100.76, p  = 0.000), about orgasm (OR = 4.47, Ӽ 2 = 113.06, p = 0.000), and about having an STI (OR = 0.37, Ӽ 2 = 19.50, p  = 0.000). Strong evidence of association of sociocultural factors with FSD were also found such as exercise (OR = 0.56, Ӽ 2 = 17.43, p  = 0.000), relationship status (Ӽ 2 = 30.52 , p  = 0.000), alcohol consumption (Ӽ 2 = 9.75, p  = 0.045), and number of sexual partners (Ӽ 2 = 36.90, p  = 0.000). The first regression model (Model 1) was statistically significant with Ӽ 2 (11)= 195.77, p  = 0.000 and included the following variables in the fitted model: contraception, recurrent yeast infections, urinary symptoms, concerned feelings about having an STI or orgasm, relationship status, number of partners, and exercise. Model 2 was also significant (Ӽ 2 (11) = 137.75, p  = 0.000) and included the following variables in the fitted model: concerned feelings about sex drive and about orgasm, recurrent yeast infections, relationship status, number of partners and employment. Model 3, based on 622 observations, indicated no lack of fit (Ӽ 2 (8) = 7.75, p  = 0.458) and is shown in Table 3 . No effect modifications were found in any of the models. A final logistic regression model determining factors associated female sexual dysfunction. (Biopsychosocial factors associated with sexual dysfunction in self-identified females, South Africa, 2023–2024). *Significant at p  < 0.05. STI: sexually transmitted infections. The area under the ROC curve (AUC) for the final model (Model 3) equaled 0.861 (where 0.8 ≤ AUC < 0.9 is considerable, and AUC ≥ 0.9 is considered excellent) (Çorbacıoğlu & Aksel, 2023 ).

FSD is clinically a complex dysfunction to address, as multiple biopsychosocial factors have been identified to be related to it. Pain during sex, recurrent yeast infections, concern about sex drive and orgasm, number of sexual partners and relationship status were found to be associated factors of FSD. In addition, factors supported by literature, such as contraception use, urinary symptoms, concern about STI, and doing exercise were also associated with FSD and included in a final regression model. The association of biopsychosocial factors with FSD seems to vary among different populations and literature, and perhaps emphasize the complexity and specificity of FSD.

This cross-sectional study of the biopsychosocial factors and FSD in self-identified females visiting a sexual health clinic in South Africa, yielded important findings. The period prevalence of FSD in our sample was estimated at 84.17% (N = 1595). FSD had a prevalence of > 90% in participants presenting with concerned feelings about sex drive, orgasm, and sexually transmitted infections (STI). Factors associated with FSD (p ≤ 0.05), based on the bivariate analysis and regression modeling, included concerned feelings about sex drive (AOR = 5.99) and orgasm (AOR = 5.30), contraception use (AOR = 2.02) and urinary symptoms (OR = 2.22). Number of sexual partners (AOR = 0.68), relationship status (AOR = 0.18), concerned feelings about STI (OR = 0.37), and doing exercise (OR = 0.56) were protective factors. There is a public health concern regarding the increased prevalence of FSD (Alidost et al., 2021 ). The period prevalence of clinically relevant FSD found in our sample, is higher than many reported prevalence rates for FSD in mid- and low-income countries. For example, point prevalence of 80% amongst Nigerian women, 38.7% among Nairobian women and a pooled prevalence of 50.75% have been reported by authors (Adebusoye et al., 2020 ; Alidost et al., 2021 ; Butt et al., 2019 ). The differences in reported prevalence rates may support the hypothesis that prevalence of FSD may vary based on the population investigated, different tools used to measure FSD, the country, differences in ethnicity and related biopsychosocial factors (Salari et al., 2023 ). Although our prevalence estimate seems similar to the prevalence established by Adebusoye et al. ( 2020 ) in a Nigerian population, our study differed in methodology by establishing the period prevalence over ten years, compared to determining the point prevalence in the case of the above studies. Sampling over a period may depict a more representative or comprehensive picture of the prevalence, as it may rule out transient factors that could affect point prevalence. However, Zingg et al. ( 2013 ) indicated that period prevalence may again overestimate conditions of short duration, and in sub-acute and long-term care settings (Zingg et al., 2013 ). Most studies investigating FSD, sample their participants from outpatient clinics, family medicine, and sexual and reproductive health clinics. This phenomenon helps with comparing results across studies, as one would expect that patients presenting at these types of clinics demonstrate sexual health seeking behavior. They would likely have sexual complaints or concerns, and it might contribute to a higher observed prevalence than one would find amongst the broader public. Other than the observed FSD, the self-identified females included our study was relatively young and generally of good health ( Table 2 ). They also seemed to have an acceptable lifestyle based on the 88.65% (n = 1414) that were nonsmokers, and majority (92.72%, n  = 1479) using between 0 and 7 units of alcohol. This is contradicting the increased trend in number of female smokers in South Africa that has been seen the past 13 years (Statista, South Africa: number of female smokers 2001–2029 | Statista). The 51.35% ( n  = 819) that did not engage in regular exercise, did however not support the assumption of a healthy lifestyle. Stratified by biomedical factors, some of the highest prevalences of FSD was noted in those who who experienced urinary frequency. The effect of urinary incontinence on female sexual function can either be direct, or indirect. Urinary incontinence can directly affect sexual function due to leaking during intercourse, or indirectly due to consequent avoiding of intercourse due to fear of leaking (Koparal et al., 2024 ). The concern is that approximately 25-45% of women will experience some form of urinary incontinence symptoms in their lifetime and perhaps FSD based on this assumption (18). The prevalence of FSD amongst those complaining of urinary frequency in our study were higher than the 82.5% and the 87.5% (as related to incontinence and double incontinence respectively) prevalence that Koparal et al. ( 2024 ) found among a sample of Turkish women with and without urinary symptoms. Their sample size was however quite small consisting of 40 age-matched participants (Koparal et al., 2024 ). Whilst urinary tract infections, yeast infections or sexually transmitted diseases may be a cause of dyspareunia (Alidost et al., 2021 ), majority of the participants in our sample did not complain of concerned feelings regarding STIs nor reported to have yeast infections. This did not exclude the possibility of these factors being associated with FSD in our sample as was seen in the regression analysis. In order to move away from a biomedical approach, our study included analysis of several psycho-social variables. The systematic review by McCool-Myers et al. ( 2018 ) stated that there is still a lack of research on several socio-cultural factors to determine whether they play a role in FSD. Some of these factors include employment, relationship, age, parity, alcohol use and smoking. Our study’s findings on prevalence by biopsychosocial factors are shown in Supplementary file 1 . Highlighting some previously under-investigated factors, we found the prevalence of FSD in the unemployed category to be the highest (88.89%, n  = 128, prevalence ratio = 0.97), compared to other forms of employment. It is known that unemployment is strongly associated with other risk factors of sexual dysfunction such as anxiety, depression, low-self esteem and strained relationships (Jabat et al., 2018 ). It might therefore be a proxy for stressors or a mediator in the development of FSD. It is also important to view this contextually as a public health concern, as the female unemployment rate in South Africa was predicted to be 33% in 2023, compared to a 29.5% male unemployment rate (Statista, Southern Africa: unemployment rate by gender 2010–2023 | Statista). Similar to the findings of Butt et al. ( 2019 ), who investigated factors associated with FSD among Nairobian women, prevalence of FSD did not differ regarding other employment categories (Butt et al., 2019 ). The prevalence in our study was however almost double the prevalence they reported per employment category (Butt et al., 2019 ). Interestingly, majority of participants in our study were nonsmokers. The prevalence of FSD was high (84,79%, n  = 1199, prevalence rate = 0.94) in the nonsmoking group of females and perhaps due to chance however, no significant association was found with FSD. Comparing the total sexual dysfunction scores between the smoking and nonsmoking group yielded a SE of 0.69 and a 95% CI of [−1.92,0.80], p  = 0.418.,. Our findings are therefore in contrast with literature and with the systematic review by Salari et al. ( 2023 ) which indicated significantly higher prevalence and odds of having FSD in female smokers (Salari et al., 2023 ). Factors related to family planning and relationships had similar prevalences of FSD, such as by number of pregnancies and children. It was supported by the prevalence ratios of one respectively ( Supplementary file 1 ). We therefore did not anticipate finding an association of these variables with FSD in the regression analysis. The prevalence of FSD did however decrease with an increased number of reported sexual partners in our study. This trend could be expected as self-identified females with FSD would most likely be less willing to engage in sexual activities or relationships, due to the physical, psychological or emotional factors related to it. This observation aligns with the noted prevalence of FSD that was the highest among married participants (86.65%, n = 974). It has also been reported that FSD is more common in marriages with a longer duration (Alidost et al., 2021 ). In the broader public health context, we should consider that, according to Park et al. ( 2023 ), decreased sexual frequency and communication barriers that might develop parallel with it may adversely affect marital satisfaction and healthy relationships (Park et al., 2023 ). Ninety three percent ( n  = 458) and 92.08% ( n  = 884) of participants who had concerned feelings about low sex drive and orgasm respectively, had clinically relevant FSD, which in turn could affect sexual frequency and marital satisfaction as introduced in the above section. Inclusion of these factors are unique to our study, and comparison to empirical literature therefore limited. Due to the complex interactions among several biopsychosocial variables, the variables were fitted in a regression model, highlighting factors common to all three models. These factors included recurrent yeast infections, concerned feelings about orgasm, relationship status, and number of partners. Looking at the literature, some of the interactions explored could be explained as follows. There is for example, a close relationship among the terms libido, sex drive, sexual desire, and hypoactive sexual disorder (HSDD), as they are often incorrectly and interchangeably used in sexual health literature. HSDD is defined as the absence of sexual fantasies/thoughts and/or desire for sexual activity and is one type of FSD (Sharma & Kalra, 2016 ). To make a diagnostic classification of any form of FSD, a form of distress related to sexual function must actually be present. This distress might be in the form of concern such as concerned feelings about sex drive, orgasm or STI (Sharma & Kalra, 2016 ). Approximately 92% of the patients who complained of concerned feelings regarding low sex drive in our study, were classified with clinically relevant FSD ( Supplementary file 1 ). It is also worth noting that 96.25% ( n  = 1538) of the patients whose records were analyzed in this study, were classified as having clinically relevant HSDD according to the FSFI. It might therefore be worth exploring concerned feelings about sex drive and orgasm, as established in our study, as possible predictors or characteristics of FSD using longitudinal designs. Considering further associations that was found in our study between contraception, urinary frequency, concerned feelings about STI and exercise with FSD respectively, as well as the fact that these variables improved the fit of model 1, it was decided to include these factors in a final model. Inclusion of these variables are also supported by previous studies that found significant associations between these factors and FSD. As indicated above, the systematic review by McCool-Myers et al. ( 2018 ) found exercise to be a protective factor to FSD (McCool-Myers et al., 2018 ). A cross-sectional study conducted by Butt et al. ( 2019 ) on a sample of 566 Nairobian women, indicated a strong association of FSD with hormonal contraception with an AOR of 2.695 ( p  < 0.0001) (Butt et al., 2019 ). In 2020 a systematic review was published, authored by Bezerra et al. (2020), that indicated urinary incontinence can affect sexual function in different ways, depending on the type of incontinence (Pinheiro Sobreira Bezerra et al., 2020 ). Based on our findings, empirical literature, and statistical rigor, a final regression model with good precision was established. Comparing our findings with pooled results from two systematic reviews (Alidost et al., 2021 ; Ishak & Tobia, 2013 ), yielded clear differences in associated biopsychosocial factors amongst the different study populations. This could be attributed to an inconsistency amongst studies on how factors are described or classified, which makes comparison of results difficult. Secondly, differences in the findings may speak to the complexity, overlap and biopsychosocial specificity of factors related to FSD, depending on the population investigated. For example, in lower socio-economic populations, such as in African countries, there will be a tendency toward lower levels of education, which may contribute to women being more ignorant or less aware of the symptoms and signs of sexual dysfunction. Sexual activity in these populations are also many times linked to procreation rather than pleasure while untreated gynaecological or obstetric conditions may contribute to higher prevalences and unique associated factors (Adebusoye et al., 2020 ). To our knowledge, this study was the first of its kind to be done on a South African population. It went beyond the investigation of biomedical factors (that have a dominating prevalence in African countries) by including psychological and socio-cultural factors unique to the investigated population; shifting the focus from a biomedical focused approach to sexual health and wellbeing. Analysis included factors that have not been researched extensively (such as exercise and gender identification) and could contribute to the understanding of the complexity of FSD on a global scale. There were a variety of biopsychosocial factors to analyze and fit into a regression model and it posed the opportunity to investigate for interactions between biomedical, psychological, and sociocultural factors that has not previously been determined. The factors that were investigated in this study, were however limited to the availability, measurement and quality of data captured in the original patient records. The fact that the clinics are privately managed and located in city centers, could have introduced a patient population that are reflective of a higher socio-economic status when compared to more rural populations. Medical clinics also do not focus on the psychosocial factors, when compared to psycho-sexual providers. Future research should therefore focus on in-depth interviews, longitudinal or cohort designs to determine risk and directionality, as well as investigate selected factors, such as exploring psychological factors. Attempts to infer causality are quite tentative in a cross-sectional study design, especially when considering factors such as concerned feelings about sexual function, versus actual sexual dysfunction. Ather medical factors that should be explored include differentiation between the types of incontinence during routine patient assessment, inclusion of data about ethnicity and culture, and including a standardized questionnaire such as the Female Sexual Distress Scale (FSDS) (DeRogatis et al., 2008 ), to assess distress.