International Journal of Impotence Research (2015) 27, 178–181 © 2015 Macmillan Publishers Limited All rights reserved 0955-9930/15 www.nature.com/ijir
ORIGINAL ARTICLE
Assessment of female sexual function in a group of uncircumcised obese Egyptian women ARM Elnashar1, NH Ibrahim2, H-EH Ahmed1, AM Hassanin1 and MA Elgawady1 The aim of the present study was to assess female sexual function in an obese group (250 women) and to compare it with a control group (100 women), among 25–35-year-old uncircumcised Egyptian women, using female sexual function index (FSFI) score. FSFI total score of ⩽ 26.55 was considered diagnostic of Female Sexual Dysfunction (FSD). The percentage of FSD in the obese group was 73.6% while it was 71% in the control group, which was statistically insignificant (P40.05). The difference between both groups regarding the total (FSFI) score was insignificant (P40.05), but arousal and satisfaction domains scores were significantly lower in the obese group. In the obese group, a strong negative correlation between body mass index and arousal, orgasm and the total FSFI score was found. Women with excessive obesity had the lowest total FSFI score. In the obese group, college graduates had the highest total scores and all domain scores of FSFI followed by high school graduates while the least educated women had the lowest scores and when these subgroups were compared, significant differences were found among them. We conclude that in uncircumcised 25–35-year-old Egyptian women, obesity is not a major detrimental factor for FSD, but it may affect some sexual domains such as arousal and satisfaction, although excessive obesity is associated with FSD. Also, educational and cultural factors may have an impact on perception of sex and pleasure. International Journal of Impotence Research (2015) 27, 178–181; doi:10.1038/ijir.2015.12; published online 9 July 2015
INTRODUCTION The female sexual response is multifaceted and involves neurovascular, endocrinal and psychosocial factors that can affect the female sexual function.1 Sexual dysfunction refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, arousal and/or orgasm that interfere with the individual or the couple satisfaction during the sexual activity.2
Prevalence of female sexual dysfunction (FSD) and female genital mutilation (FGM) in Egypt The exact prevalence of FSD in the Middle East is exceptionally difficult to determine in light of its sensitive nature and the conservative tinge of the population. In a study from Lower Egypt, it was found that 68.9% of 936 women (16–49 years) had one or more sexual problems; however, 23% of the women with sexual problems were not distressed by these issues.3 In another study from Upper Egypt, it was found that 76.9% from 601 women (18–60 years) reported one or more sexual dysfunction problems, and most of these women (87.7%) were distressed by these issues.4 The prevalence of female circumcision, FGM, is high among women at the reproductive age in Egypt, however, this prevalence is decreasing among the younger generations.5,6 FGM is followed by psychological and social complications as for many girls FGM is an experience marked by fear and suppression of feelings with a negative effect on sexual experiences.7–9
Obesity and its effects on general health Obesity is a disease in which excess body fat accumulates to such an extent that health may be negatively affected. Obesity is commonly defined as a body mass index (BMI) of 25 kg m − 2 or higher. BMI, or Quetelet index, is the individual's body weight divided by the square of his/her height.10 Obesity is associated with significant health issues as well as substantial psychosocial burden for many individuals. Numerous studies have documented the impairments in quality of life associated with extreme obesity. Sexual behavior and functioning is an important aspect of quality of life but is frequently overlooked in research studies as well as clinical care.11 Obesity can affect health in different ways. Many studies show an association between excessive body weight and various diseases, particularly cardiovascular diseases, type 2 diabetes mellitus, sleep apnea, certain types of cancer and osteoarthritis. Cardiovascular disease risk factors, hypertension, diabetes and dyslipidemia are present to a significantly greater degree in overweight/obese individuals.12 Obesity is also associated with numerous cardiac complications such as coronary heart disease, heart failure and sudden death, and with high risk of venous thromboembolism.13,14 Obesity has always been considered one of the criteria for diagnosing a metabolic syndrome that also includes elevated waist circumference, elevated triglycerides, reduceed HDL, elevated blood pressure and elevated fasting blood glucose.15 Obesity is associated with profound alterations in androgen secretion, transport, metabolism and action. Obese women tend to develop a condition of hyperandrogenism and
1 Department of Andrology and Sexology, Faculty of Medicine, Cairo University, Cairo, Egypt and 2Department of Gynecology and Obstetrics, Faculty of Medicine, Al-Azhar University (Females section), Cairo, Egypt. Correspondence: Dr AM Hassanin, Department of Andrology and Sexology, Faculty of Medicine, Cairo University, 1 Al-Saray Street, Al-Manial, 11559, Cairo, Egypt. E-mail: [email protected] or [email protected] Received 19 November 2014; revised 18 April 2015; accepted 9 June 2015; published online 9 July 2015
FSD in uncircumcised Egyptian women ARM Elnashar et al
179 their sexual function is disturbed by the hyperandrogenic state.16–18 Effect of obesity on female sexual function Obesity can cause FSD in different ways. Physically, obesity may have a role in sexual avoidance or very rare sexual intercourse, despite having a partner, and difficulty in engaging in sexual intercourse because of physical problems.19 The association of metabolic syndrome, hyperlipidemia, hypertension and diabetes with FSD was investigated. It was confirmed that the metabolic syndrome and coronary heart disease are associated with more FSD and impaired desire and treatment of metabolic syndrome is associated with less FSD.20–22 These studies demonstrate that female patients with coronary heart disease have distinct sexual dysfunction and they should be evaluated, also, in terms of sexual function to provide better quality of life. A significant relationship of arousal and orgasmic problems, but not desire, was found with moderately raised hyperlipidemia in 400 studied women. This means that female sexual arousal is related to vascular risk factors in the same way as erectile dysfunction in men and endothelial dysfunction may affect pelvic and clitoral blood flow leading to reduced blood flow, engorgement, lubrication and orgasm.23 Similar links with diabetes and hypertension were found providing further evidence for a vascular link.24–26 Routine questioning about sexual dysfunction in women might detect early vascular changes and life style modification might improve sexual function in premenopausal women.25 Obesity may cause psychological difficulties as poor self-image, stress, anxiety and depression that can result in loss of desire and arousal problems.26 Obesity was found to increase the risk of depression,11 and it was reported that reduction of obesity was accompanied with significant reduction of depression and sexual pain and significant improvement of sexual functions.27 Moreover, excessive obesity in women is associated with lack of enjoyment of sexual activity, difficulties with sexual performance and avoidance of sexual encounters.28 After bariatric surgery, reduction of weight led to an improvement in body image and women felt more attractive with an improvement in paid employment, social life and sexual life indicating an improvement in interpersonal relationships and female sexual health and psychological difficulties.29,30 PATIENTS AND METHODS This cross-sectional controlled study was carried out after approval of the ethics committee of Andrology and Sexology Department, Faculty of Medicine, Cairo University. Participants were recruited from the outpatient clinics of hospitals of Faculties of Medicine, Cairo and Alazhar Universities, during the period from October 2012 to October 2013. In this study, we included uncircumcised, married, 25–35-year-old Egyptian women with regular sexual relationship. An informed consent was taken from each participant who was informed that the data would be used for research. All women were subjected to personal, medical and marital history taking, general and genital examinations and anthropometric studies including height and weight. BMI was calculated. Patient's data including name, age, address, education, marital status and duration, history of hypertension, peripheral neuropathy, coronary artery disease, past history of surgical operations, were all documented. Husband’s medical condition especially erectile dysfunction and premature ejaculation was recorded. Blood pressure was taken and genitalia were examined for the presence of clitoris and the vaginal orifice was inspected for the presence of discharge, bleeding or swelling. Patient was asked to cough and/or strain to comment on stress incontinence and genital prolapse. Women who have conditions requiring abstaining from sexual intercourse such as unexplained vaginal bleeding, discharge and erectile dysfunction of the partner, women suffering medical conditions such as hypertension, diabetes or thyroid disease, women suffering from psychiatric disease or on psychiatric treatment, and pregnant, divorced and widowed women were all excluded from the study. Ninety potentially eligible women were excluded from the study according to the exclusion criteria. Three hundred and fifty © 2015 Macmillan Publishers Limited
uncircumcised, married, 25–35-year-old Egyptian women with regular sexual relationship participated in the study. This study included two groups according to BMI. The first group, the obese group, included a total of 250 overweight and obese participants, while the second one, the control group, included 100 women of normal weight participants (BMI: 18.5–24.9). The obese group was further subdivided into four subgroups (BMI categories), the overweight (BMI:25.0–29.9), class 1 obesity (BMI:30.0– 34.9), class 2 obesity (BMI:35.0–39.9) and class 3 obesity (BMI ⩾ 40.0). Each participant was invited for a personal structured interview. Trained female interviewers (co-authors) conducted the interviews. The female sexual function index (FSFI) questionnaire was normally completed in privacy in paper and pencil format, the convenient method for participants. Interviewers explained items and assisted participants in completing the questionnaire, when necessary. Interviews were based on the 19-item FSFI questionnaire which was translated into Arabic.31,32 FSFI questionnaire assesses sexual functioning in women in six separate domains (desire, arousal, lubrication, orgasm, satisfaction and pain) and the total scale score was computed according to a scoring algorithm.31,32 FSFI total score of ⩽ 26.55 was considered diagnostic of FSD.33 Data were reviewed, entered and the analysis was carried out using Statistical Package for Social Sciences (SPSS) program version 15. Frequency tables were used to present data. Simple Frequencies, chi square (X2), T-test, Paired T-test, Independent T-test and regression analysis were used. Significant values were considered at Po0.05 and highly significant at Po0.01.
RESULTS Participants in the obese group had a mean age of 29.5 ± 3.4 years while it was 28.9 ± 2.9 in the control group, with no significant difference (P40.05). In the obese group, the number and percentage of participants in different BMI categories was found as the following: the overweight subgroup included 154 participants (61.6%), class 1 obesity included 29 (11.6%), class 2 obesity included 37 (14.8%) and class 3 obesity included 30 participants (12%). In the obese group, the BMI was 31.6 ± 6.0 while it was 22.3 ± 1.8 in the control group with a highly significant difference (Po 0.01). When residence and educational level were compared, no statistical difference between both groups (P value40.05 in both) was found (Table 1). The percentage of FSD among the obese group was 73.6% while it was 71% among the control group but no statistical difference (P40.05) was found (Table 2). The difference between both groups regarding total FSFI score was statistically insignificant (P40.05) but considering individual domains, arousal and satisfaction domains were highly significantly lower (Po 0.01 for both) in the obese group (Table 2). In the obese group, a strong negative correlation between BMI and arousal, orgasm domains and total FSFI scores was found, and a medium strength negative correlation between BMI and both desire and lubrication domain scores was found (Table 3). Considering total FSFI score, class 3 obesity had the lowest score (16.5 ± 2.5 ) followed by class 2 obesity (20.4 ± 3.7) then class 1 obesity (24.6 ± 3.8) and the overweight group had the highest score ( 25.4 ± 3.5). Also, it was found that class 3 obesity had the
Table 1. Comparisons of both groups regarding residence and educational level. Obese group
Control group
P value
Residence Urban Rural
219 (87.6%) 81 (81.0%) 40.05 31 (12.4%) 19 (19.0%)
Educational level Least educated 43 (17.2%) 23 (23.0%) Up to high school 66 (26.4%) 24 (24.0%) 40.05 college graduates 141 (56.4%) 53 (53.0%)
International Journal of Impotence Research (2015), 178 – 181
FSD in uncircumcised Egyptian women ARM Elnashar et al
180 Table 2.
Comparisons of female sexual dysfunction and sexual
domains Female sexual dysfunction
Present Absent
Obese group
Control group
Na
%
Na
%
P value
184 66
73.6% 26.4%
71 29
71.0% 29.0%
40.05
Sexual domains
Arousal domain Satisfaction domain Total score
Obese group
Control group
Mean score
Mean score
P value
3.7 ± 1.3 4.0 ± 1.3 23.5 ± 4.7
4.4 ± 1.1 4.6 ± 1.0 23.3 ± 4.5
o0.01 o0.01 40.05
a
Number.
Table 3.
Correlation of BMI with sexual domains (obese group) BMI category
BMI
Desire Arousal Lubrication Orgasm Total Score
Ra
P value
Ra
P value
− 0.33 − 0.571 − 0.304 − 0.546 − 0.676
o 0.01 o 0.01 o 0.01 o 0.01 o 0.01
− 0.386 − 0.584 − 0.31 − 0.497 − 0.656
o0.01 o0.01 o0.01 o0.01 o0.01
Abbreviations: BMI, body mass index. A negative correlation between BMI and sexual domains and total score. aPearson correlation coefficient.
lowest score with regard to arousal, lubrication, orgasm, satisfaction and pain–(1.9 ± 1.0 ), (3.2 ± 1.2), (1.9 ± 0.8), (3.1 ± 1.6) and (3.3 ± 1.1), respectively. In the next place was class 2 obesity with regard to arousal, lubrication, orgasm and pain domains scores, (2.9 ± 0.4), (3.6 ± 1.6), (3.0 ± 0.7) and (3.9 ± 0.9), respectively, while it had the lowest score (2.7 ± 0.8) with regard to desire and the highest score (4.2 ± 1.2) with regard to satisfaction. Comparisons of different BMI categories, in the obese group, showed highly significant differences (P o0.01) regarding all sexual domains and total FSFI scores. It was found that college graduates had the highest scores on all sexual domains as well as the total score of FSFI, high school graduates had intermediate scores, while the least educated women had the lowest scores with highly significant differences (P o0.01) when they were compared. DISCUSSION This study included uncircumcised Egyptian women as FGM has psychological and social complications,7–9 and female genital cutting, FGM, was found to be associated with reduced scores of the Arab FSFI on all domain scores except the sexual pain domain.34 A limited participants’ age range, 25–35 years, avoided the effect of age as a confounder for FSD. It was convenient to define this age range as FGM is less practiced in younger generations5,6 and the uncircumcised women with regular sexual relationship, usually married women, are best met at this age range in this culture. In this study, the percentage of FSD among the obese group was 73.6% while it was 71% among the control group, which was statistically insignificant (P40.05). Considering the total FSFI score, the difference between both groups was statistically insignificant (P40.05) too. This agrees with Yaylali and colleagues35 who found that 86% of obese patients and 83% of controls suffered from FSD International Journal of Impotence Research (2015), 178 – 181
and the comparison of total FSFI score showed insignificant difference (P = 0.74). These findings also agree with Kadioglu and colleagues36 who reported insignificant difference, for both the percentage of FSD and the mean of the total FSFI score, between the obese and control groups. Findings of this study disagree with Veronelli and colleagues25 who reported a reduced total FSFI score in diabetic, obese and hypothyroid women compared with healthy ones (P o 0.01), but this can be explained easily as they included diabetic and hypothyroid patients with obese subjects in their study. This study indicates that obesity is not a major detrimental factor of FSD, a finding which agrees with the earlier research of Yaylali and collagues35 and Kadioglu and collagues.36 Considering individual domains, the results of this study indicated that arousal and satisfaction domains were significantly lower in the obese group compared with the control group indicating that although obesity is not a major detrimental factor of FSD, it may affect some sexual domains as arousal and satisfaction. Adolfsson and colleagues37 reported an insignificant difference, regarding sexual satisfaction, between obese and normal weight Swedish women aged 18–74 years old. However, in the younger age group, there was a tendency toward lower sexual satisfaction associated with higher weights and this agrees with the results of the present study that included young-aged women. In the obese group, in this research, a strong negative correlation between BMI and both arousal, orgasm and total FSFI scores and a medium strength negative correlation between BMI and both desire and lubrication domains scores were found (Table 3). This agrees with Esposito and colleagues,23 Yaylali and colleagues35 and Pace and colleagues38 who reported negative correlations between BMI and FSFI domain scores. Now, it is apparent that increasing the BMI increases the possibility of occurrence of FSD. This finding was confirmed, in this study, when the sexual functions of different BMI categories were compared in the obese group. In the obese group, considering the total FSFI score, class 3 obesity has the lowest score followed by class 2 obesity and the overweight subgroup has the best score in this work. Also, it was noticed that class 3 obesity has the lowest score of all sexual domains but desire. When different BMI categories were compared, all the FSFI domains and the total scores were significantly different indicating that excessive obesity is associated with FSD. This is supported by Bond and colleagues39 who found that severely obese women had significantly lower FSFI domains scores, compared with controls. In this study urban, college and high school graduates represented the majority of participants of both groups as FGM is less commonly practiced in these classes and this research was carried out at Cairo, where most of inhabitants are of the same classes. When the obese group was studied, it was found that college graduates had the highest scores of the total and all domains scores of FSFI, high schools graduates had intermediate scores, while the least educated women had the lowest ones, and when these were compared, significant differences were found among them indicating that cultural and educational factors can affect the perception of sex and pleasure. This was confirmed by Lucena and Abdo40 who studied the factors affecting the orgasmic feeling in women. They found that educated women, high school graduates, had a significantly higher experience of orgasmic feeling compared with less educated women. Also, Pascual and colleagues41 reported that emotional intimacy was found to be the main predictor of sexual satisfaction. These studies confirm the assumption that cultural and educational factors can affect the perception of sex and pleasure. This study clarifies that increasing BMI increases the occurrence of FSD and excessive obesity is associated with FSD; it is necessary to fight obesity to avoid its effects on FSF and on general health, and it emphasizes the value of education and its important effect on perception of sex and pleasure. © 2015 Macmillan Publishers Limited
FSD in uncircumcised Egyptian women ARM Elnashar et al
181 We conclude that in the group of uncircumcised 25–35-year-old Egyptian women, obesity is not a major detrimental factor for FSD, but it may affect some sexual domains as arousal and satisfaction, although excessive obesity is associated with FSD. Also, educational and cultural factors may have an impact on perception of sex and pleasure. We recommend that medical professionals should pay more attention to the impact of obesity on health and the government should apply public awareness programs to fight obesity in Egypt. Also, cultural and educational factors can change the perception of sex and pleasure, hence, more attention should be paid towards educating women in our society. A randomized study representative of all classes of the population of obese uncircumcised Egyptian women, all over the country, is encouraged to generalize the results of this study, when possible, to the whole uncircumcised Egyptian population. CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGMENTS This research was not funded.
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18 Sasaki Y, Arai T. Obesity and disturbance of sexual function. Nihon Rinsho 1997; 55: 3007–3011. 19 Luppino FS, de Wit LM, Bouvy PF, Stijnen T, Cuijpers P, Penninx BW et al. Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry 2010; 67: 220–229. 20 Esposito K, Ciotola M, Marfella R, Di Tommaso D, Cobellis L, Giugliano D. The metabolic syndrome: a cause of sexual dysfunction in women. Int J Impot Res 2005; 17: 224–226. 21 Ponholzer A, Temml C, Rauchenwald M, Marszalek M, Madersbacher S. Is the metabolic syndrome a risk factor for female sexual dysfunction in sexually active women? Int J Impot Res 2008; 20: 100–104. 22 Miner M, Esposito K, Guay A, Montorsi P, Goldstein I. Cardiometabolic risk and female sexual health: the Princeton III summary. J Sex Med 2012; 9: 641–651. 23 Esposito K, Ciotola M, Giugliano F, Bisogni C, Schisano B, Autorino R et al. Association of body weight with sexual function in women. Int J Impot Res 2007; 19: 353–357. 24 Jha S, Thakar R. Female sexual dysfunction. Eur J Obstet Gynecol 2010; 153: 117–123. 25 Veronelli A, Mauri C, Zecchini B, Peca MG, Turri O, Valitutti MT et al. Sexual dysfunction is frequent in premenopausal women with diabetes, obesity, and hypothyroidism, and correlates with markers of increased cardiovascular risk. A preliminary report. J Sex Med 2009; 6: 1561–1568. 26 Giraldi A, Kristensen E. Sexual dysfunction in women with diabetes mellitus. J Sex Res 2010; 47: 199–211. 27 Assimakopoulos K, Karaivazoglou K, Panayiotopoulos S, Hyphantis T, Iconomou G, Kalfarentzos F. Bariatric surgery is associated with reduced depressive symptoms and better sexual function in obese female patients: a one-year follow-up study. Obes Surg 2011; 21: 362–366. 28 Kolotkin RL, Binks M, Crosby RD, Ostbye T, Gress RE, Adams TD. Obesity and sexual quality of life. Obesity 2006; 14: 472–479. 29 Camps MA, Zervos E, Goode S, Rosemurgy AS. Impact of bariatric surgery on body image perception and sexuality in morbidly obese patients and their partners. Obes Surg 1996; 6: 356–360. 30 Dziurowicz-Kozłowska A, Lisik W, Wierzbicki Z, Kosieradzki M. Health-related quality of life after the surgical treatment of obesity. J Physiol Pharmacol 2005; 56: 127–134. 31 Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsign R et al. The female sexual function index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marit Ther 2000; 26: 191–208. 32 Anis TH, Gheit SA, Saied HS, Al kherbash SA. Arabic translation of Female Sexual Function Index and validation in an Egyptian population. J Sex Med 2011; 8: 3370–3378. 33 Wiegel M, Meston C, Rosen R. The female sexual function index (FSFI): crossvalidation and development of clinical cutoff scores. J Sex Marital Ther 2005; 31: 1–20. 34 Anis TH, Aboul Gheit S, Awad HH, Saied HS. Effects of female genital cutting on the sexual function of Egyptian women. A cross-sectional study. J Sex Med 2012; 9: 2682–2692. 35 Yaylali GF, Tekekoglu S, Akin F. Sexual dysfunction in obese and overweight women. Int J Impot Res 2010; 22: 220–226. 36 Kadioglu P, Yetkin DO, Sanli O, Yalin AS, Onem K, Kadioglu A. Obesity might not be a risk factor for female sexual dysfunction. BJU Int 2010; 106: 1357–1361. 37 Adolfsson B, Elofsson S, Rossner S, Unden AL. Are sexual dissatisfaction and sexual abuse associated with obesity? A population-based study. Obes Res 2004; 12: 1702–1709. 38 Pace G, Silvestri V, Gualá L, Vicentini C. Body mass index, urinary incontinence, and female sexual dysfunction: how they affect female postmenopausal health. Menopause 2009; 16: 1188–1192. 39 Bond DS, Wing RR, Vithiananthan S, Sax HC, Roye GD, Ryder BA. Significant resolution of female sexual dysfunction after bariatric surgery. Surg Obes Relat Dis 2011; 7: 1–7. 40 de Lucena BB, Abdo CHN. Personal factors that contribute to or impair women’s ability to achieve orgasm. Int J Impot Res 2014; 26: 177–181. 41 Pascoal PM, Narciso I, Pereira NM. Emotional intimacy is the best predictor of sexual satisfaction of men and women with sexual arousal problems. Int J Impot Res 2013; 25: 51–55.
International Journal of Impotence Research (2015), 178 – 181
ORIGINAL ARTICLE
Assessment of female sexual function in a group of uncircumcised obese Egyptian women ARM Elnashar1, NH Ibrahim2, H-EH Ahmed1, AM Hassanin1 and MA Elgawady1 The aim of the present study was to assess female sexual function in an obese group (250 women) and to compare it with a control group (100 women), among 25–35-year-old uncircumcised Egyptian women, using female sexual function index (FSFI) score. FSFI total score of ⩽ 26.55 was considered diagnostic of Female Sexual Dysfunction (FSD). The percentage of FSD in the obese group was 73.6% while it was 71% in the control group, which was statistically insignificant (P40.05). The difference between both groups regarding the total (FSFI) score was insignificant (P40.05), but arousal and satisfaction domains scores were significantly lower in the obese group. In the obese group, a strong negative correlation between body mass index and arousal, orgasm and the total FSFI score was found. Women with excessive obesity had the lowest total FSFI score. In the obese group, college graduates had the highest total scores and all domain scores of FSFI followed by high school graduates while the least educated women had the lowest scores and when these subgroups were compared, significant differences were found among them. We conclude that in uncircumcised 25–35-year-old Egyptian women, obesity is not a major detrimental factor for FSD, but it may affect some sexual domains such as arousal and satisfaction, although excessive obesity is associated with FSD. Also, educational and cultural factors may have an impact on perception of sex and pleasure. International Journal of Impotence Research (2015) 27, 178–181; doi:10.1038/ijir.2015.12; published online 9 July 2015
INTRODUCTION The female sexual response is multifaceted and involves neurovascular, endocrinal and psychosocial factors that can affect the female sexual function.1 Sexual dysfunction refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, arousal and/or orgasm that interfere with the individual or the couple satisfaction during the sexual activity.2
Prevalence of female sexual dysfunction (FSD) and female genital mutilation (FGM) in Egypt The exact prevalence of FSD in the Middle East is exceptionally difficult to determine in light of its sensitive nature and the conservative tinge of the population. In a study from Lower Egypt, it was found that 68.9% of 936 women (16–49 years) had one or more sexual problems; however, 23% of the women with sexual problems were not distressed by these issues.3 In another study from Upper Egypt, it was found that 76.9% from 601 women (18–60 years) reported one or more sexual dysfunction problems, and most of these women (87.7%) were distressed by these issues.4 The prevalence of female circumcision, FGM, is high among women at the reproductive age in Egypt, however, this prevalence is decreasing among the younger generations.5,6 FGM is followed by psychological and social complications as for many girls FGM is an experience marked by fear and suppression of feelings with a negative effect on sexual experiences.7–9
Obesity and its effects on general health Obesity is a disease in which excess body fat accumulates to such an extent that health may be negatively affected. Obesity is commonly defined as a body mass index (BMI) of 25 kg m − 2 or higher. BMI, or Quetelet index, is the individual's body weight divided by the square of his/her height.10 Obesity is associated with significant health issues as well as substantial psychosocial burden for many individuals. Numerous studies have documented the impairments in quality of life associated with extreme obesity. Sexual behavior and functioning is an important aspect of quality of life but is frequently overlooked in research studies as well as clinical care.11 Obesity can affect health in different ways. Many studies show an association between excessive body weight and various diseases, particularly cardiovascular diseases, type 2 diabetes mellitus, sleep apnea, certain types of cancer and osteoarthritis. Cardiovascular disease risk factors, hypertension, diabetes and dyslipidemia are present to a significantly greater degree in overweight/obese individuals.12 Obesity is also associated with numerous cardiac complications such as coronary heart disease, heart failure and sudden death, and with high risk of venous thromboembolism.13,14 Obesity has always been considered one of the criteria for diagnosing a metabolic syndrome that also includes elevated waist circumference, elevated triglycerides, reduceed HDL, elevated blood pressure and elevated fasting blood glucose.15 Obesity is associated with profound alterations in androgen secretion, transport, metabolism and action. Obese women tend to develop a condition of hyperandrogenism and
1 Department of Andrology and Sexology, Faculty of Medicine, Cairo University, Cairo, Egypt and 2Department of Gynecology and Obstetrics, Faculty of Medicine, Al-Azhar University (Females section), Cairo, Egypt. Correspondence: Dr AM Hassanin, Department of Andrology and Sexology, Faculty of Medicine, Cairo University, 1 Al-Saray Street, Al-Manial, 11559, Cairo, Egypt. E-mail: [email protected] or [email protected] Received 19 November 2014; revised 18 April 2015; accepted 9 June 2015; published online 9 July 2015
FSD in uncircumcised Egyptian women ARM Elnashar et al
179 their sexual function is disturbed by the hyperandrogenic state.16–18 Effect of obesity on female sexual function Obesity can cause FSD in different ways. Physically, obesity may have a role in sexual avoidance or very rare sexual intercourse, despite having a partner, and difficulty in engaging in sexual intercourse because of physical problems.19 The association of metabolic syndrome, hyperlipidemia, hypertension and diabetes with FSD was investigated. It was confirmed that the metabolic syndrome and coronary heart disease are associated with more FSD and impaired desire and treatment of metabolic syndrome is associated with less FSD.20–22 These studies demonstrate that female patients with coronary heart disease have distinct sexual dysfunction and they should be evaluated, also, in terms of sexual function to provide better quality of life. A significant relationship of arousal and orgasmic problems, but not desire, was found with moderately raised hyperlipidemia in 400 studied women. This means that female sexual arousal is related to vascular risk factors in the same way as erectile dysfunction in men and endothelial dysfunction may affect pelvic and clitoral blood flow leading to reduced blood flow, engorgement, lubrication and orgasm.23 Similar links with diabetes and hypertension were found providing further evidence for a vascular link.24–26 Routine questioning about sexual dysfunction in women might detect early vascular changes and life style modification might improve sexual function in premenopausal women.25 Obesity may cause psychological difficulties as poor self-image, stress, anxiety and depression that can result in loss of desire and arousal problems.26 Obesity was found to increase the risk of depression,11 and it was reported that reduction of obesity was accompanied with significant reduction of depression and sexual pain and significant improvement of sexual functions.27 Moreover, excessive obesity in women is associated with lack of enjoyment of sexual activity, difficulties with sexual performance and avoidance of sexual encounters.28 After bariatric surgery, reduction of weight led to an improvement in body image and women felt more attractive with an improvement in paid employment, social life and sexual life indicating an improvement in interpersonal relationships and female sexual health and psychological difficulties.29,30 PATIENTS AND METHODS This cross-sectional controlled study was carried out after approval of the ethics committee of Andrology and Sexology Department, Faculty of Medicine, Cairo University. Participants were recruited from the outpatient clinics of hospitals of Faculties of Medicine, Cairo and Alazhar Universities, during the period from October 2012 to October 2013. In this study, we included uncircumcised, married, 25–35-year-old Egyptian women with regular sexual relationship. An informed consent was taken from each participant who was informed that the data would be used for research. All women were subjected to personal, medical and marital history taking, general and genital examinations and anthropometric studies including height and weight. BMI was calculated. Patient's data including name, age, address, education, marital status and duration, history of hypertension, peripheral neuropathy, coronary artery disease, past history of surgical operations, were all documented. Husband’s medical condition especially erectile dysfunction and premature ejaculation was recorded. Blood pressure was taken and genitalia were examined for the presence of clitoris and the vaginal orifice was inspected for the presence of discharge, bleeding or swelling. Patient was asked to cough and/or strain to comment on stress incontinence and genital prolapse. Women who have conditions requiring abstaining from sexual intercourse such as unexplained vaginal bleeding, discharge and erectile dysfunction of the partner, women suffering medical conditions such as hypertension, diabetes or thyroid disease, women suffering from psychiatric disease or on psychiatric treatment, and pregnant, divorced and widowed women were all excluded from the study. Ninety potentially eligible women were excluded from the study according to the exclusion criteria. Three hundred and fifty © 2015 Macmillan Publishers Limited
uncircumcised, married, 25–35-year-old Egyptian women with regular sexual relationship participated in the study. This study included two groups according to BMI. The first group, the obese group, included a total of 250 overweight and obese participants, while the second one, the control group, included 100 women of normal weight participants (BMI: 18.5–24.9). The obese group was further subdivided into four subgroups (BMI categories), the overweight (BMI:25.0–29.9), class 1 obesity (BMI:30.0– 34.9), class 2 obesity (BMI:35.0–39.9) and class 3 obesity (BMI ⩾ 40.0). Each participant was invited for a personal structured interview. Trained female interviewers (co-authors) conducted the interviews. The female sexual function index (FSFI) questionnaire was normally completed in privacy in paper and pencil format, the convenient method for participants. Interviewers explained items and assisted participants in completing the questionnaire, when necessary. Interviews were based on the 19-item FSFI questionnaire which was translated into Arabic.31,32 FSFI questionnaire assesses sexual functioning in women in six separate domains (desire, arousal, lubrication, orgasm, satisfaction and pain) and the total scale score was computed according to a scoring algorithm.31,32 FSFI total score of ⩽ 26.55 was considered diagnostic of FSD.33 Data were reviewed, entered and the analysis was carried out using Statistical Package for Social Sciences (SPSS) program version 15. Frequency tables were used to present data. Simple Frequencies, chi square (X2), T-test, Paired T-test, Independent T-test and regression analysis were used. Significant values were considered at Po0.05 and highly significant at Po0.01.
RESULTS Participants in the obese group had a mean age of 29.5 ± 3.4 years while it was 28.9 ± 2.9 in the control group, with no significant difference (P40.05). In the obese group, the number and percentage of participants in different BMI categories was found as the following: the overweight subgroup included 154 participants (61.6%), class 1 obesity included 29 (11.6%), class 2 obesity included 37 (14.8%) and class 3 obesity included 30 participants (12%). In the obese group, the BMI was 31.6 ± 6.0 while it was 22.3 ± 1.8 in the control group with a highly significant difference (Po 0.01). When residence and educational level were compared, no statistical difference between both groups (P value40.05 in both) was found (Table 1). The percentage of FSD among the obese group was 73.6% while it was 71% among the control group but no statistical difference (P40.05) was found (Table 2). The difference between both groups regarding total FSFI score was statistically insignificant (P40.05) but considering individual domains, arousal and satisfaction domains were highly significantly lower (Po 0.01 for both) in the obese group (Table 2). In the obese group, a strong negative correlation between BMI and arousal, orgasm domains and total FSFI scores was found, and a medium strength negative correlation between BMI and both desire and lubrication domain scores was found (Table 3). Considering total FSFI score, class 3 obesity had the lowest score (16.5 ± 2.5 ) followed by class 2 obesity (20.4 ± 3.7) then class 1 obesity (24.6 ± 3.8) and the overweight group had the highest score ( 25.4 ± 3.5). Also, it was found that class 3 obesity had the
Table 1. Comparisons of both groups regarding residence and educational level. Obese group
Control group
P value
Residence Urban Rural
219 (87.6%) 81 (81.0%) 40.05 31 (12.4%) 19 (19.0%)
Educational level Least educated 43 (17.2%) 23 (23.0%) Up to high school 66 (26.4%) 24 (24.0%) 40.05 college graduates 141 (56.4%) 53 (53.0%)
International Journal of Impotence Research (2015), 178 – 181
FSD in uncircumcised Egyptian women ARM Elnashar et al
180 Table 2.
Comparisons of female sexual dysfunction and sexual
domains Female sexual dysfunction
Present Absent
Obese group
Control group
Na
%
Na
%
P value
184 66
73.6% 26.4%
71 29
71.0% 29.0%
40.05
Sexual domains
Arousal domain Satisfaction domain Total score
Obese group
Control group
Mean score
Mean score
P value
3.7 ± 1.3 4.0 ± 1.3 23.5 ± 4.7
4.4 ± 1.1 4.6 ± 1.0 23.3 ± 4.5
o0.01 o0.01 40.05
a
Number.
Table 3.
Correlation of BMI with sexual domains (obese group) BMI category
BMI
Desire Arousal Lubrication Orgasm Total Score
Ra
P value
Ra
P value
− 0.33 − 0.571 − 0.304 − 0.546 − 0.676
o 0.01 o 0.01 o 0.01 o 0.01 o 0.01
− 0.386 − 0.584 − 0.31 − 0.497 − 0.656
o0.01 o0.01 o0.01 o0.01 o0.01
Abbreviations: BMI, body mass index. A negative correlation between BMI and sexual domains and total score. aPearson correlation coefficient.
lowest score with regard to arousal, lubrication, orgasm, satisfaction and pain–(1.9 ± 1.0 ), (3.2 ± 1.2), (1.9 ± 0.8), (3.1 ± 1.6) and (3.3 ± 1.1), respectively. In the next place was class 2 obesity with regard to arousal, lubrication, orgasm and pain domains scores, (2.9 ± 0.4), (3.6 ± 1.6), (3.0 ± 0.7) and (3.9 ± 0.9), respectively, while it had the lowest score (2.7 ± 0.8) with regard to desire and the highest score (4.2 ± 1.2) with regard to satisfaction. Comparisons of different BMI categories, in the obese group, showed highly significant differences (P o0.01) regarding all sexual domains and total FSFI scores. It was found that college graduates had the highest scores on all sexual domains as well as the total score of FSFI, high school graduates had intermediate scores, while the least educated women had the lowest scores with highly significant differences (P o0.01) when they were compared. DISCUSSION This study included uncircumcised Egyptian women as FGM has psychological and social complications,7–9 and female genital cutting, FGM, was found to be associated with reduced scores of the Arab FSFI on all domain scores except the sexual pain domain.34 A limited participants’ age range, 25–35 years, avoided the effect of age as a confounder for FSD. It was convenient to define this age range as FGM is less practiced in younger generations5,6 and the uncircumcised women with regular sexual relationship, usually married women, are best met at this age range in this culture. In this study, the percentage of FSD among the obese group was 73.6% while it was 71% among the control group, which was statistically insignificant (P40.05). Considering the total FSFI score, the difference between both groups was statistically insignificant (P40.05) too. This agrees with Yaylali and colleagues35 who found that 86% of obese patients and 83% of controls suffered from FSD International Journal of Impotence Research (2015), 178 – 181
and the comparison of total FSFI score showed insignificant difference (P = 0.74). These findings also agree with Kadioglu and colleagues36 who reported insignificant difference, for both the percentage of FSD and the mean of the total FSFI score, between the obese and control groups. Findings of this study disagree with Veronelli and colleagues25 who reported a reduced total FSFI score in diabetic, obese and hypothyroid women compared with healthy ones (P o 0.01), but this can be explained easily as they included diabetic and hypothyroid patients with obese subjects in their study. This study indicates that obesity is not a major detrimental factor of FSD, a finding which agrees with the earlier research of Yaylali and collagues35 and Kadioglu and collagues.36 Considering individual domains, the results of this study indicated that arousal and satisfaction domains were significantly lower in the obese group compared with the control group indicating that although obesity is not a major detrimental factor of FSD, it may affect some sexual domains as arousal and satisfaction. Adolfsson and colleagues37 reported an insignificant difference, regarding sexual satisfaction, between obese and normal weight Swedish women aged 18–74 years old. However, in the younger age group, there was a tendency toward lower sexual satisfaction associated with higher weights and this agrees with the results of the present study that included young-aged women. In the obese group, in this research, a strong negative correlation between BMI and both arousal, orgasm and total FSFI scores and a medium strength negative correlation between BMI and both desire and lubrication domains scores were found (Table 3). This agrees with Esposito and colleagues,23 Yaylali and colleagues35 and Pace and colleagues38 who reported negative correlations between BMI and FSFI domain scores. Now, it is apparent that increasing the BMI increases the possibility of occurrence of FSD. This finding was confirmed, in this study, when the sexual functions of different BMI categories were compared in the obese group. In the obese group, considering the total FSFI score, class 3 obesity has the lowest score followed by class 2 obesity and the overweight subgroup has the best score in this work. Also, it was noticed that class 3 obesity has the lowest score of all sexual domains but desire. When different BMI categories were compared, all the FSFI domains and the total scores were significantly different indicating that excessive obesity is associated with FSD. This is supported by Bond and colleagues39 who found that severely obese women had significantly lower FSFI domains scores, compared with controls. In this study urban, college and high school graduates represented the majority of participants of both groups as FGM is less commonly practiced in these classes and this research was carried out at Cairo, where most of inhabitants are of the same classes. When the obese group was studied, it was found that college graduates had the highest scores of the total and all domains scores of FSFI, high schools graduates had intermediate scores, while the least educated women had the lowest ones, and when these were compared, significant differences were found among them indicating that cultural and educational factors can affect the perception of sex and pleasure. This was confirmed by Lucena and Abdo40 who studied the factors affecting the orgasmic feeling in women. They found that educated women, high school graduates, had a significantly higher experience of orgasmic feeling compared with less educated women. Also, Pascual and colleagues41 reported that emotional intimacy was found to be the main predictor of sexual satisfaction. These studies confirm the assumption that cultural and educational factors can affect the perception of sex and pleasure. This study clarifies that increasing BMI increases the occurrence of FSD and excessive obesity is associated with FSD; it is necessary to fight obesity to avoid its effects on FSF and on general health, and it emphasizes the value of education and its important effect on perception of sex and pleasure. © 2015 Macmillan Publishers Limited
FSD in uncircumcised Egyptian women ARM Elnashar et al
181 We conclude that in the group of uncircumcised 25–35-year-old Egyptian women, obesity is not a major detrimental factor for FSD, but it may affect some sexual domains as arousal and satisfaction, although excessive obesity is associated with FSD. Also, educational and cultural factors may have an impact on perception of sex and pleasure. We recommend that medical professionals should pay more attention to the impact of obesity on health and the government should apply public awareness programs to fight obesity in Egypt. Also, cultural and educational factors can change the perception of sex and pleasure, hence, more attention should be paid towards educating women in our society. A randomized study representative of all classes of the population of obese uncircumcised Egyptian women, all over the country, is encouraged to generalize the results of this study, when possible, to the whole uncircumcised Egyptian population. CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGMENTS This research was not funded.
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