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Sexual Dysfunction among Reproductive-Aged Chinese Married Women in Hong Kong: Prevalence, Risk Factors, and Associated Consequences Huiping Zhang, PhD,* Susan Fan, MBBS,† and Paul S.F. Yip, PhD‡§ *Department of Social Work, Renmin University of China, Beijing, China; †Family Planning Association of Hong Kong, Hong Kong; ‡Department of Social Work, The University of Hong Kong, Hong Kong; §Center for Suicide Research and Prevention, The University of Hong Kong, Hong Kong DOI: 10.1111/jsm.12791
ABSTRACT
Introduction. Although female sexual dysfunction (FSD) is a serious public health issue endangering women’s well-being, systematic research on FSD among reproductive-aged Chinese women in Hong Kong is quite scarce. Aim. This study aims to estimate the prevalence, risk factors, and associated consequences of FSD among reproductive-aged Chinese married women in Hong Kong. Methods. This study was based on a community-based survey across Hong Kong conducted by the Family Planning Association of Hong Kong in 2012 with 1,518 married women aged 21–49 years. Main Outcome Measure. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition classification was adopted to assess FSD. Results. It was found that 25.6% of the married women surveyed reported at least one form of sexual dysfunction and that the prevalence of six domains of sexual dysfunction was as follows: 10.6% for lack of interest in sex, 10.5% for not finding sex pleasurable, 9.3% for lubrication difficulties, 8.8% for inability to achieve orgasm, 8.8% for orgasm delay, and 8.4% for physical pain during sex. Multivariate analyses showed that low education and income, average or poor health, lower frequency of sex, abortion history, traditional attitudes toward sex, and marital dissatisfaction are all significant risk factors for different components of FSD. It was also been found that four domains of FSD (the exceptions being orgasm delay and physical pain during sex) have severe consequences for married women’s life satisfaction and sexual satisfaction. Conclusion. The prevalence of FSD is lower among reproductive-aged Chinese married women in Hong Kong than among women in the United States and some Asian countries. The risk factors associated with FSD include sociodemographic factors, physical health, sexual experience and attitudes, and relationship factors. FSD has significant consequences for married women’s life quality. These findings have great implications for FSD prevention and relevant service delivery. Zhang H, Fan S, and Yip PSF. Sexual dysfunction among reproductive-aged Chinese married women in Hong Kong: Prevalence, risk factors and associated consequences. J Sex Med 2015;12:738–745. Key Words. Female Sexual Dysfunction; Reproductive Age; Consequences
Introduction
F
emale sexual dysfunction (FSD) is a serious public health issue that is endangering women’s well-being. A review of the past 15 years of population-based studies on FSD has found that
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sexual dysfunction is quite prevalent among women in Western countries as well as in Asian countries. For instance, one epidemiological study conducted in the United States showed that 43% of females aged 18–59 years reported sexual dysfunction [1]. In a population-based survey in Iran, © 2014 International Society for Sexual Medicine
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Female Sexual Dysfunction in Hong Kong over 52% of females reported at least one type of sexual problem [2]. Another survey in South and East Asia using random sampling showed that more than 30% of females aged 40–80 years reported at least one sexual dysfunction [3]. A local territory-wide survey in 2007 found that 38% of Hong Kong married women aged 19–49 years had complained of at least one sexual dysfunction [4], which is relatively lower than that of their Western counterparts within a similar age range. However, the prevalence rate of FSD based on surveys conducted in hospitals or clinics is much higher than that found in the general population, ranging from 38% to 63% [5,6]. FSD is defined as sexual desire, arousal, orgasm, and painful sex disorders [7]. Regarding the prevalence of specific domains of FSD, one study in the United States has revealed that the prevalence rate of low sexual interest varies from 17% to 55% and that of lubrication difficulties from 8% to 15%, and that the prevalence rates of orgasmic dysfunction and vaginismus are, respectively, 25% and around 6% [8]. A systematic review of 22 epidemiological studies in Western countries showed that the prevalence of the inability to achieve orgasm varies from 5% to 30% and that of inhibited sexual desire from 1% to 35% [9]. Similarly, one study conducted in Japan has shown that a prevalence range of 27–57% for sexual desire disorder, 9.7–57.9% for arousal disorder and 15–32% for orgasmic disorder [10]. It has been found that FSD is associated with a wide range of factors, including biological, medical, psychological, and relationship factors [11–13]. To be specific, poor physical health, abortion history, and seeking medical help due to sex problems are the frequently studied variables among the biological factors, and these variables may increase the likelihood of FSD [1,14]. Regarding the psychological factors, feelings of distress and depression are reported to be positively associated with FSD. Relationship factors may include relationship status and relationship quality [1,4]. In addition, previous studies have found that sex-related variables, such as less sex experience and traditional attitudes are also important determinants of FSD [1,14]. These associated risk factors identified from previous studies may play a role in FSD depending on different life stages. On the basis of previous studies, we hypothesize that poor health, abortion history, seeking medical help, low relationship quality, lower frequency of sex, and traditional attitudes
are also positively associated with FSD among Chinese married women. Substantial studies have found that FSD adversely affects women’s quality of life and wellbeing [15,16]. For example, one study based on American females found that sexual dysfunction is associated with low physical satisfaction, low emotional satisfaction, and low general happiness [1]. Another study of Turkish women indicated that the importance of sexual health for quality of life and overall life satisfaction has been recognized [16]. A study of Japanese women aged 30–60 years showed that favorable sexual function is essential for sexual satisfaction in women [10]. According to the international standard, the reproductive age for females ranges from 19 to 49 years. Although studies on sexual dysfunction among reproductiveaged Chinese women have been emerging recently, population-based studies of FSD concerning the prevalence, risk factors, and consequences of this disorder are relatively scarce. On the basis of the above empirical evidence, we hypothesize that FSD is also negatively associated with Chinese married women’s life quality.
Aims
Using the most recent household survey on married women aged 21–49 years across Hong Kong, which was carried out in 2012, the present study attempts to: (i) estimate the prevalence of sexual dysfunction among reproductive-aged Chinese married women in Hong Kong; (ii) explore the risk factors that may predict FSD; and (iii) examine the associated consequences of sexual dysfunction on these reproductive-aged married women.
Methods
The data of this study came from the 11th Knowledge, Attitude, and Practice (KAP) survey, conducted by the Family Planning Association of Hong Kong from July 28 to December 31, 2012. The KAP survey is the longest running territorywide household survey of family planning in Hong Kong; it has been carried out every 5 years since 1967 and covers a wide range of family planning topics, such as sex-related issues and marital satisfaction. However, FSD was not included in this survey until 2007. This survey has been approved by the institutional ethical committees of the University of Hong Kong. J Sex Med 2015;12:738–745
740 A random stratified sampling method was used to collect data across Hong Kong; A total of 1,518 women aged 19–50 were successfully approached, with a response rate of 83%, and oral informed consent was obtained from all the participants. Participants were first asked to report their sociodemographic information. Then, they completed a self-administered questionnaire that included sensitive items such as sex frequency, sexual relationship and sexual dysfunction. It took them about one hour to finish all the procedures. Sexual dysfunction was assessed by six items, and each item measured, using a yes/no response format, whether there had been a critical symptom or problem for three consecutive months within the past 12 months. The detailed items were as follows: (i) lack of interest in sex; (ii) not finding sex pleasurable; (iii) lubrication difficulties; (iv) inability to achieve orgasm; (v) delayed orgasm during sexual intercourse; and (vi) physical pain during intercourse. These items captured the major problem domains in the classification of sexual dysfunction in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [17]. The reliability of FSD in this study was 0.75. Sociodemographic variables were obtained from the respondents directly. Age was selfreported as a continuous variable and recoded as three categories: 21–30, 31–40, and 41–50. Education and family income were self-reported and recoded as four categories, respectively. Married more than once and children were measured as a dichotomous variable using a yes/no response format. Employment status was measured by asking whether the respondent had a full-time/ part-time job or was unemployed. Abortion history and seeking medical help because of sex problems were classified as dichotomous variables using a yes/no response format. Sex frequency was measured by the number of times of the respondent had engaged in lovemaking in the past 1 month before the survey. Liberal attitudes toward sex were measured by asking whether the respondent would like to actively initiate sexual activity (response of “yes”, “neutral” or “no”). The perceived importance of sex was measured by asking the respondent whether she thought sexual satisfaction was important to her marital quality. Physical health was measured using a single item (“How would you evaluate your health status?”) and a five-point Likert scale (ranging from “1 = very good” to “5 = very poor”). Marital, life, and sexual satisfaction were assessed with a single item (“Are you satisfied with your life/sexual J Sex Med 2015;12:738–745
Zhang et al. relationship?”); the responses ranged from “1 = very satisfied” to “5 = very dissatisfied” and were coded as two groups by recoding (the “very satisfied” and “satisfied” respondents as the “satisfied group,” and the “fair” “dissatisfied” and “very dissatisfied” respondents as the “dissatisfied group”). To answer our research questions, statistical analyses were conducted using SPSS 17.0 (SPSS Inc., Chicago, IL, USA). First, descriptive statistics and χ2 tests were performed to provide the profiles of the sample and to compare the prevalence of FSD and each domain across age groups. Second, six separate multivariate logistic regressions were run to examine the relative importance of each risk factor to each domain of FSD after controlling for age. Adjusted odds ratios (ORs) and 95% confidence interval (CI) were provided to show the odds of members of a given group reporting a symptom relative to a reference group. Third, logistic regressions were run again to examine the association between each domain of FSD and life and sexual satisfaction. Results
Of the 1,518 sexually active female respondents, only those reporting at least one element of FSD were included in this study. A total of 17 respondents skipped all the sexual dysfunction items, and their profiles were not different from other respondents in terms of sociodemographic characteristics; these respondents were excluded from the final analysis. Table 1 presents the descriptive statistics for all the predictors in this study. A total of 1,501 female respondents were included in the analysis. Their average age was 39.0 years (standard deviation = 6.8), with their ages ranging from 21 to 49 years. Less than 10% of the respondents had only received primary or below education and 20% of them reported coming from a low-income family. A small proportion of the female respondents had married more than once and about one quarter (26.2%) did not have children. Around one-third (35.2%) were unemployed at the time of the survey, and 14.0% reported an abortion history. Over one-third (37.5%) reported being in average or poor health. Less than 2% had never sought any help because of sex problems. Over 40% held liberal attitudes toward sex and less than one quarter (24.7%) thought that sex was unimportant to a marital relationship. Over 20% of them were dissatisfied with their marital relationship.
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Female Sexual Dysfunction in Hong Kong Table 1 Descriptive characteristics of the respondents (N = 1,501) Variables
N (%)
Age groups 21–30 31–40 41–49 Education Primary school or lower Form 1–4 secondary school Form 5–6 secondary school University or above Family income Low income Between low and middle Between middle and high High income Not reported Married more than once No Yes Children No Yes Employment Full-time job Part-time job Unemployed Physical health Average or poor Good Sex frequency No more than once monthly More than once monthly Not reported Abortion history No Yes Not reported Seeking medical help because of sex problems No Yes Not reported Liberal attitudes to sex No Neutral Yes Sex perceived as important No Yes Marital relationship Satisfied Dissatisfied
Table 2
175 (11.7) 638 (42.5) 687 (45.8) 92 (6.1) 1,097 (73.1) 98 (6.5) 214 (14.3) 312 (20.8) 378 (25.2) 668 (44.5) 116 (7.7) 27 (1.8) 1,387 (92.4) 114 (7.6) 394 (26.2) 1,107 (73.8) 824 (54.9) 148 (9.9) 529 (35.2) 563 (37.5) 937 (62.4) 253 (16.9) 1,201 (80.0) 47 (3.1) 1,236 (82.3) 210 (14.0) 55 (3.7) 1,448 (96.5) 29 (1.9) 24 (1.6) 179 (11.9) 688 (45.8) 634 (42.2) 371 (24.7) 1,130 (75.3) 1,052 (77.2) 342 (22.8)
As shown in Table 2, among the women who participated in this survey, 25.6% (382) reported at least one form of sexual dysfunction. The most common problems were lack of interest in sex (159, 10.6%) and not finding sex pleasurable (157, 10.5%), followed by lubrication difficulties (139, 9.3%), inability to achieve orgasm (131, 8.8%), orgasm delay (131, 8.8%) and, lastly, the pain during sexual intercourse (126, 8.4%). The prevalence of FSD and three domains (not finding sex pleasurable, lubrication difficulties, and inability to achieve orgasm) increased with age. The other three domains (lack of interest in sex, orgasm delay, and pain during sex) also increased with age; however, it was not statistically significant. In order to know the relative importance of each factor in predicting FSD, multivariate logistic regressions were performed for each domain of FSD, as shown in Table 3. Women with a university or above education were about 50% less likely to report a lack of interest in sex compared with those with secondary or blow education (95% CI, 0.23–0.94). Women with children were 40% less likely to report physical pain during sexual intercourse (95% CI, 0.36–0.99) than those without children. Women from middleincome families were about 50% less likely to report orgasm delay than those from low-income families (95% CI, 0.35–0.98 between low and middle income; 95% CI, 0.26–0.72 between middle and high income). Compared with those in good health, women in average or poor health were 50% more likely to report not finding sex pleasurable (95% CI, 1.03– 2.18) and 67% more likely to report physical pain during sexual intercourse (95% CI, 1.10–2.54). In terms of frequency of having sex, women had sex no more than once during the previous 1-month period were 95% more likely to report inability to achieve orgasm (95% CI, 1.25–2.05) than those who had sex more than once during the same
Prevalence of FSD and each domain by age distribution
Age groups
Total
n (%) 21–30
n (%) 31–40
n (%) 41–49
Prevalence
Test statistics
Domains Lack interest in sex Sex not pleasurable Trouble lubricating Unable to achieve orgasm Orgasm delay Physical pain during sex At least one FSD
1,499 1,497 1,495 1,493 1,496 1,497 1,493
11 (6.3) 6 (3.4) 7 (4.0) 7 (4.0) 12 (6.9) 13 (7.4) 29 (16.7)
64 (10.0) 56 (8.8) 49 (7.7) 46 (7.3) 57 (9.0) 51 (8.0) 149 (23.5)
84 (12.2) 95 (13.8) 83 (12.1) 78 (11.4) 62 (9.0) 62 (9.0) 204 (29.7)
159 (10.6) 157 (10.5) 139 (9.3) 131 (8.8) 131 (8.8) 126 (8.4) 382 (25.6)
χ2 = 5.44 χ2 = 19.34** χ2 = 13.80* χ2 = 12.48* χ2 = 0.89 χ2 = 0.67 χ2 = 14.87**
*P < 0.01, **P < 0.001
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J Sex Med 2015;12:738–745 0.61 (0.25–1.47) 0.47 (0.23–0.94)* 0.49 (0.21–1.15) 1.00 (0.60–1.67) 0.70 (0.37–1.34) 0.85 (0.57–1.27) 1.30 (0.76–2.22) 1.49 (0.91–2.46) 1.34 (0.53–3.35) 1.40 (0.95–2.05) 1.13 (0.72–1.62) 1.25 (0.77–2.03) 2.02 (1.18–3.48)* 1.43 (0.96–2.15) 1.09 (0.73–1.62) 2.05 (1.38–3.05)***
18 (12) 54 (10)
40 (10) 76 (11) 8 (7)
84 (15)
39 (15)
26 (12)
80 (11) 46 (7) 108 (9)
63 (18)
OR (95% CI)
7 (7) 12 (5) 11 (9) 123 (11)
No. (%)
64 (18)
41 (22) 79 (11) 56 (15)
32 (15)
46 (18)
91 (16)
39 (10) 67 (10) 8 (7)
22 (15) 56 (10)
5 (5) 13 (14) 15 (13) 131 (11)
No. (%)
1.63 (1.10–2.42)*
3.0 (1.75–5.17)*** 1.97 (1.28–3.02)** 1.16 (0.78–1.72)
1.30 (0.82–2.05)
1.42 (0.92–2.17)
1.50 (1.03–2.18)*
0.85 (0.51–1.40) 0.86 (0.54–1.37) 0.85 (0.34–2.13)
0.97 (0.54–1.74) 0.86 (0.57–1.28)
0.51 (0.18–1.46) 0.68 (0.34–1.36) 1.30 (0.82–2.05) 1.27 (0.73–2.21)
OR (95% CI)
Sex not pleasurable
41 (12)
23 (12) 75 (11) 49 (13)
30 (14)
39 (15)
71 (12)
40 (10) 55 (8) 11 (9)
16 (11) 44 (8)
6 (6) 24 (11) 9 (8) 109 (10)
No. (%)
1.06 (0.68–1.65)
1.43 (0.78–2.62) 1.72 (1.12–2.62)* 1.45 (0.97–2.18)
1.62 (1.01–2.60)*
1.43 (0.91–2.25)
1.38 (0.92–2.04)
1.24 (0.72–2.14) 0.92 (0.54–1.57) 0.93 (0.39–2.22)
0.89 (0.46–1.70) 0.80 (0.52–1.24)
0.76 (0.29–1.98) 1.54 (0.85–2.77) 0.84 (0.37–1.87) 0.95 (0.56–1.62)
OR (95% CI)
Trouble in lubricating
40 (11)
29 (16) 64 (9) 41 (11)
23 (11)
41 (16)
71 (12)
33 (8) 56 (8) 10 (8)
19 (13) 43 (8)
5 (5) 18 (8) 14 (12) 106 (9)
No. (%)
0.90 (0.57–1.42)
2.09 (1.16–3.77)* 1.66 (1.06–2.59)* 1.02 (0.66–1.57)
1.05 (0.62–1.76)
1.95 (1.25–2.05)**
1.48 (0.98–2.22)
1.05 (0.60–1.84) 1.05 (0.62–1.78) 1.12 (0.46–2.75)
1.33 (0.72–2.47) 0.95 (0.61–1.48)
0.63 (0.22–1.81) 1.20 (0.63–2.29) 1.99 (0.98–4.04) 1.37 (0.76–2.46)
OR (95% CI)
Inability to achieve orgasm
40 (11)
29 (16) 64 (9) 41 (11)
23 (11)
41 (16)
71 (12)
33 (8) 56 (8) 10 (8)
19 (13) 43 (8)
10 (10) 13 (8) 7 (6) 106 (9)
No. (%)
0.59 (0.34–1.01)
0.91 (0.46–1.78) 1.14 (0.76–1.71) 0.89 (0.56–1.41)
0.99 (0.57–1.70)
0.94 (0.55–1.61)
0.98 (0.64–1.48)
0.59 (0.35–0.98)* 0.44 (0.26–0.72)* 0.44 (0.18–1.10)
1.14 (0.59–2.19) 0.97 (0.63–1.49)
1.50 (0.73–3.09) 0.84 (0.42–1.68) 0.71 (0.29–1.72) 1.28 (0.74–2.20)
OR (95% CI)
Orgasm delay
40 (11)
29 (16) 64 (9) 41 (11)
23 (11)
41 (16)
71 (12)
33 (8) 56 (8) 10 (8)
19 (13) 43 (8)
10 (10) 13 (6) 7 (6) 106 (9)
No. (%)
0.92 (0.57–1.50)
1.90 (1.01–3.56)* 1.84 (1.18–2.87)** 1.81 (1.19–2.74)
1.84 (1.11–3.05)*
1.07 (0.65–1.75)
1.67 (1.10–2.54)*
1.34 (0.72–2.50) 1.16 (0.64–2.10) 1.27 (0.52–3.07)
0.54 (0.24–1.19) 0.64 (0.39–1.02)
0.93 (0.40–2.16) 1.31 (0.73–2.34) 0.42 (0.16–1.12) 0.60 (0.36–0.99)*
OR (95% CI)
Physical pain during sex
Note: The reference group was primary school or below, first marriage, no children, full-time job, low income, good health, sex frequency more than once, no abortion history, liberal attitudes to sex, perceived sex as important, and satisfying relationship, respectively *P < 0.05, **P < 0.01, ***P < 0.001
Sociodemographic factors Education High school or equal University or above Married more than once Have children Employment Part-time job Unemployed Family income Between low and middle Between middle and high High income Health Average or poor health Sexual experience Sex frequency no more than once monthly Had an abortion ever Sexual attitudes Neutral attitudes to sex Traditional attitudes to sex Sex not important Relationship quality Dissatisfying relationship
Lack of interest in sex
Prevalence of FSD domain by sociodemographic characteristics and risk factors after adjusting for age (N = 1,501)
Characteristics
Table 3
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Female Sexual Dysfunction in Hong Kong Table 4
The associations between FSD and life and sex satisfaction (N = 1,501) Life dissatisfaction
Lack interest in sex Sex not pleasurable Trouble lubricating Unable to achieve orgasm Orgasm delay Pain during sex
Sex dissatisfaction
OR (95% CI)
Significance
OR (95% CI)
Significance
1.97 (1.41–2.77) 2.57 (1.83–3.60) 1.83 (1.28–2.63) 1.78 (1.22–2.58) 0.88 (0.58–1.33) 1.02 (0.68–1.53)
0.000 0.000 0.001 0.002 0.54 0.92
2.31 (1.66–3.23) 3.20 (2.29–4.48) 1.86 (1.30–2.66) 2.48 (1.73–3.57) 0.66 (0.43–1.01) 1.12 (0.76–1.66)
0.000 0.000 0.001 0.000 0.05 0.55
period. Women with an abortion history were 84% more likely to report physical pain during sexual intercourse (95% CI, 1.11–3.05) than those without an abortion history. Compared with those holding liberal attitudes toward sex, women holding neutral attitudes toward sex were more than twice as likely to report a lack of interest in sex (95% CI, 1.18– 3.48) and an inability to achieve orgasm (95% CI, 1.16–3.77), over three times more likely to report not finding sex pleasurable (95% CI, 1.75–5.17) and 90% more likely to report physical pain during sexual intercourse (95% CI, 1.01–3.56). Similarly, women holding traditional attitudes toward sex were 97% more likely to report not finding sex pleasurable (95% CI, 1.28–3.02), 72% more likely to report lubrication difficulties (95% CI, 1.12–2.62), 66% more likely to report inability to achieve orgasm (95% CI, 1.06–2.59), and 84% more likely to report physical pain during sex (95% CI, 1.18–2.87). Compared with those in a satisfying marital relationship, women in a dissatisfying marital relationship were over twice as likely to report a lack of interest in sex (95% CI, 1.38–3.05) and 63% more likely to report not finding sex pleasurable (95% CI, 1.10–2.42). In addition, it was found that compared with those without sexual dysfunction, the women who reported a lack of interest in sex, not finding sex pleasurable, lubrication difficulties, and an inability to achieve orgasm were more likely to be unsatisfied with their life (OR = 1.78–2.57) and sexual relationship (OR = 1.86–3.20). However, orgasm delay and physical pain during sex were not associated with life and sexual satisfaction (See Table 4). Discussion
Using a representative sample of 1,501 reproductive-aged Chinese married women in Hong Kong, this study has estimated the prevalence, risk factors, and associated consequences of FSD.
First, it is estimated that 25.6% of married young and middle-aged women in Hong Kong report at least one form of FSD; this figure is lower than the 37.9% of women of a similar age range reported in one local study [4] and much lower than the figure of 43% reported for American women aged below 59 years [1]. Furthermore, this study has also found that the prevalence of six domains of FSD ranges from 8.4% to 10.6%; this prevalence range is lower than that previously found among Hong Kong women (11.7–16.3%) [4] and much lower than the reported prevalence rates for Iranian women (26.7– 37.0%) and Japanese women (12.5–29.7%) [10,18]. The lower prevalence rate of FSD in our sample may be due to the fact that our study was based on a population-based survey rather than a hospitalbased survey [6] and also the relatively younger age of our respondents compared with those in previous studies [1,10]. Second, multiple logistic regressions were performed to analyze the risk factors for six domains of FSD, and it was found that education was negatively associated with lack of interest in sex, which is consistent with previous findings that indicated that a lower level of education is a risk factor for sexual dysfunction [19,20]. Having children was found to be a protective factor for physical pain during sex. Compared with the women from lowincome families, the women coming from a middle-income reported less orgasm delay, which is similar to the finding that unemployment is a risk factor for orgasm delay [4]. Similar with previous findings [14,21], our study found that poor physical health, lower frequency of sex, and abortion history are risk factors for different domains of FSD. Regarding sexual attitudes, either neutral or traditional attitudes to sex were found to be associated with nearly all domains of FSD (the exception being orgasm delay), which confirms the previous finding of one local study [4] and suggests the necessity for professionals to promote liberal attitudes in women’s sexual health service delivery. Consistent with one previous study [22], marital J Sex Med 2015;12:738–745
744 dissatisfaction was found to be a risk factor for lack of interest in sex and not finding sex pleasurable, which further confirms the significance of mutual passion and intimacy during lovemaking [23]. Third, this study has shown that four domains (lack interest in sex, not finding sex pleasurable, lubrication difficulties, and inability to achieve orgasm) of FSD are positively associated with life dissatisfaction as well as sex dissatisfaction, which is consistent with previous finding that sexual dysfunction adversely affects women’s quality of life [10,15]. However, orgasm delay and physical pain during sex were not found to be associated with either life dissatisfaction or sex dissatisfaction. Sex was once a taboo in Chinese culture [24], and women were expected to be passive in sexual behavior and were inhibited from sexual agency [25]. It is highly possible that women experiencing orgasm delay or physical pain during sex may regard these as normal parts of the sexual process. However, the associations between orgasm delay and physical pain and women’s quality of life should be investigated further. There are several limitations to this study that should be noted. First, considering this study’s large-scale community survey, the measurement of FSD was simply based on self-report of six dimensions of FSD instead of formal clinical diagnosis by trained professionals. To capture the rich dimensions of FSD, it is necessary to adopt a wellvalidated international scale, such as the Female Sexual Function Index. Furthermore, the diagnostic parameter of sex-related personal distress should be included in the next community survey on reproductive-aged Chinese women in Hong Kong. Second, all the participants were married at the time of the survey; single or divorced women were excluded from our survey. Meanwhile, all of these married women were young and middleaged, and thus our results may lead to an underestimation of the prevalence rate of FSD in the whole population. Therefore, the results from this study cannot be generalized to all women in Hong Kong. Third, although most of the risk factors were identified from previous studies, due to the cross-sectional design of this study, cause and effect were not separated from each other in time, and so may only produce the correlates of FSD. In other words, it is also possible that some risk factors might be the consequences of FSD: for example, physical health and marital dissatisfaction may be the results of FSD. Providing evidence for the valid risk factors of FSD requires a longitudinal design in future studies. J Sex Med 2015;12:738–745
Zhang et al. Conclusion
Using a population-based sample, this study contributes to our understanding of FSD in a nonWestern context in several ways: First, it shows that FSD is also a prevalent phenomenon among reproductive-aged Chinese married women in Hong Kong, although the prevalence rate is relatively lower compared with previous studies, and this deserves more academic and clinical attention. Second, the results of this study show that multiple factors including low education and income, average or poor health, lower frequency of sex, abortion history, traditional attitudes toward sex, and marital dissatisfaction are risk factors for sexual dysfunction. Therefore, the prevention of FSD can start from these risk factors to design relevant programs. Third, the study shows that most domains of FSD (except for orgasm delay and physical pain during sex) have severe consequences on married women’s life satisfaction and sexual satisfaction; thus, the professionals in women’s sexual health should keep in mind that not all symptoms of sexual dysfunction play similar negative roles in Chinese married women’s life quality. Corresponding Author: Huiping Zhang, PhD, Department of Social Work, Renmin University of China, No.59, Zhongguancun Street, Haidian District, Beijing 100872, China. Tel: 86-18611727250; Fax: 86-10-82502546; E-mail: [email protected] Conflict of Interest: The author(s) report no conflicts of interest.
Statement of Authorship
Category 1 (a) Conception and Design Huiping Zhang; Paul S.F. Yip (b) Acquisition of Data Susan Fan; Paul S.F. Yip (c) Analysis and Interpretation of Data Huiping Zhang; Paul S.F. Yip
Category 2 (a) Drafting the Article Huiping Zhang (b) Revising It for Intellectual Content Huiping Zhang; Susan Fan; Paul S.F. Yip
Category 3 (a) Final Approval of the Completed Article Susan Fan; Paul S.F. Yip
Female Sexual Dysfunction in Hong Kong References 1 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA 1999;281: 537–44. 2 Goshtasebi A, Vahdaninia M, Rahimi Foroshani A. Prevalence and potential risk factors of female sexual difficulties: An urban Iranian population-based study. J Sex Med 2009;6:2988– 96. 3 Nicolosi A, Glasser DB, Kim SC, Marumo K, Laumann EO, GSSAB Investigators’ Group. Sexual behavior and dysfunction and help-seeking patterns in adults aged 40–80 years in the urban population of Asian countries. BJU Int 2004;95:609–14. 4 Zhang H, Yip P. Female sexual dysfunction among young and middle-aged women in Hong Kong: Prevalence and risk factors. J Sex Med 2011;9:2911–8. 5 Schokrollahi P, Mirnohamadi M, Mehrabi F, Babaei G. Prevalence of sexual dysfunction in women seeking services at family planning centers in Tehran. J Sex Marital Ther 1999;25:211–5. 6 Lo S, Kok WM. Sexual behavior and symptoms among reproductive age Chinese women in Hong Kong. J Sex Med 2014;11:1749–56. 7 Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J, Goldstein I, Graziottin A, Heiman J, Laan E, Leiblum S, Padma-Nathan H, Rosen R, Segraves K, Segraves RT, Shabsigh R, Sipski M, Wagner G, Whipple B. Report of the international consensus development conference on female sexual dysfunction: Definitions and classifications. J Urol 2000;163:888–93. 8 Lewis RW, Fugl-Meyer KS, Bosch R, Fugl-Meyer AR, Laumann EO, Lizza E, Martin-Morales A. Epidemiology/risk factors of sexual dysfunction. J Sex Med 2004;1:35–9. 9 Nathan SG. The epidemiology of the DSM-III psychosexual dysfunctions. J Sex Marital Ther 1986;12:267–81. 10 Hisasue S, Kumamoto Y, Sato Y, Masumori N, Horita H, Kato R, Kobayashi K. Prevalence of female sexual dysfunction symptoms and its relationship to quality of life: A Japanese female cohort study. Urology 2005;65:143–8. 11 Berman JR, Goldstein I. Female sexual dysfunction. Urol Clin North Am 2001;28:405–16.
745 12 Graziottin A, Serafini A, Palacios S. Aetiology, diagnostic algorithms and prognosis of female sexual dysfunction. Maturitas 2009;63:128–34. 13 Leiblum SR. Sexual problems and dysfunction: Epidemiology, classification and risk factors. J Gend Specif Med 1999;2:41–5. 14 Pan L, Zhang X, Wang Z, Pan F, Bao L, Yan X. Risk factors for low sexual function among urban Chinese women: A hospitalbased investigation. J Sex Med 2011;8:2299–304. 15 Hatzimouratidis K, Hatzichhristou D. Sexual dysfunctions: Classifications and definitions. J Sex Med 2007;4:241–50. 16 Oksuz E, Malkan S. Prevalence and risk factors for female sexual dysfunction in Turkish women. J Urol 2006;175:654–8. 17 Laumann EO, Gagnon JH, Michael RT, Michaels S. The social organization of sexuality: Sexual practices in the United States. Chicago, IL: University of Chicago Press; 1994. 18 Safarinejad MR. Female sexual dysfunction in a populationbased study in Iran: Prevalence and associated risk factors. Int J Impot Res 2006;18:382–95. 19 Abdo CHN, Oliveira WM, Moreira ED Jr, Fittipaldi JAS. Prevalence of sexual dysfunctions and correlated conditions in a sample of Brazilian women—Results of the Brazilian study on sexual behavior. Int J Impot Res 2004;16:160–6. 20 Gramegna G, Blumel JE, Eoncagliolo ME, Aracena B, Tacla X. Patterns of sexual behavior in Chilean women. Rev Med Chil 1998;126:162–8. 21 Song SH, Jeon H, Kim SW, Paick JS, Son H. The prevalence and risk factors of female sexual dysfunction in young Korean women: An internet-based survey. J Sex Med 2008;5:1694– 701. 22 Jiann BP, Su CC, Yu CC, Wu TT, Huang JK. Risk factors for individual domains of female sexual function. J Sex Med 2009;6:3364–75. 23 MacNeil S, Byers S. The relationships between sexual problems, communications, and sexual satisfaction. Can J Hum Sex 1997;6:277–83. 24 So HW, Cheung FM. Review of Chinese sex attitudes and applicability of sex therapy for Chinese couples with sexual dysfunction. J Sex Res 2005;42:93–101. 25 Pan S. A sex revolution in current China. J Psychol Hum Sex 1993;6:1–14.
J Sex Med 2015;12:738–745
Sexual Dysfunction among Reproductive-Aged Chinese Married Women in Hong Kong: Prevalence, Risk Factors, and Associated Consequences Huiping Zhang, PhD,* Susan Fan, MBBS,† and Paul S.F. Yip, PhD‡§ *Department of Social Work, Renmin University of China, Beijing, China; †Family Planning Association of Hong Kong, Hong Kong; ‡Department of Social Work, The University of Hong Kong, Hong Kong; §Center for Suicide Research and Prevention, The University of Hong Kong, Hong Kong DOI: 10.1111/jsm.12791
ABSTRACT
Introduction. Although female sexual dysfunction (FSD) is a serious public health issue endangering women’s well-being, systematic research on FSD among reproductive-aged Chinese women in Hong Kong is quite scarce. Aim. This study aims to estimate the prevalence, risk factors, and associated consequences of FSD among reproductive-aged Chinese married women in Hong Kong. Methods. This study was based on a community-based survey across Hong Kong conducted by the Family Planning Association of Hong Kong in 2012 with 1,518 married women aged 21–49 years. Main Outcome Measure. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition classification was adopted to assess FSD. Results. It was found that 25.6% of the married women surveyed reported at least one form of sexual dysfunction and that the prevalence of six domains of sexual dysfunction was as follows: 10.6% for lack of interest in sex, 10.5% for not finding sex pleasurable, 9.3% for lubrication difficulties, 8.8% for inability to achieve orgasm, 8.8% for orgasm delay, and 8.4% for physical pain during sex. Multivariate analyses showed that low education and income, average or poor health, lower frequency of sex, abortion history, traditional attitudes toward sex, and marital dissatisfaction are all significant risk factors for different components of FSD. It was also been found that four domains of FSD (the exceptions being orgasm delay and physical pain during sex) have severe consequences for married women’s life satisfaction and sexual satisfaction. Conclusion. The prevalence of FSD is lower among reproductive-aged Chinese married women in Hong Kong than among women in the United States and some Asian countries. The risk factors associated with FSD include sociodemographic factors, physical health, sexual experience and attitudes, and relationship factors. FSD has significant consequences for married women’s life quality. These findings have great implications for FSD prevention and relevant service delivery. Zhang H, Fan S, and Yip PSF. Sexual dysfunction among reproductive-aged Chinese married women in Hong Kong: Prevalence, risk factors and associated consequences. J Sex Med 2015;12:738–745. Key Words. Female Sexual Dysfunction; Reproductive Age; Consequences
Introduction
F
emale sexual dysfunction (FSD) is a serious public health issue that is endangering women’s well-being. A review of the past 15 years of population-based studies on FSD has found that
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sexual dysfunction is quite prevalent among women in Western countries as well as in Asian countries. For instance, one epidemiological study conducted in the United States showed that 43% of females aged 18–59 years reported sexual dysfunction [1]. In a population-based survey in Iran, © 2014 International Society for Sexual Medicine
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Female Sexual Dysfunction in Hong Kong over 52% of females reported at least one type of sexual problem [2]. Another survey in South and East Asia using random sampling showed that more than 30% of females aged 40–80 years reported at least one sexual dysfunction [3]. A local territory-wide survey in 2007 found that 38% of Hong Kong married women aged 19–49 years had complained of at least one sexual dysfunction [4], which is relatively lower than that of their Western counterparts within a similar age range. However, the prevalence rate of FSD based on surveys conducted in hospitals or clinics is much higher than that found in the general population, ranging from 38% to 63% [5,6]. FSD is defined as sexual desire, arousal, orgasm, and painful sex disorders [7]. Regarding the prevalence of specific domains of FSD, one study in the United States has revealed that the prevalence rate of low sexual interest varies from 17% to 55% and that of lubrication difficulties from 8% to 15%, and that the prevalence rates of orgasmic dysfunction and vaginismus are, respectively, 25% and around 6% [8]. A systematic review of 22 epidemiological studies in Western countries showed that the prevalence of the inability to achieve orgasm varies from 5% to 30% and that of inhibited sexual desire from 1% to 35% [9]. Similarly, one study conducted in Japan has shown that a prevalence range of 27–57% for sexual desire disorder, 9.7–57.9% for arousal disorder and 15–32% for orgasmic disorder [10]. It has been found that FSD is associated with a wide range of factors, including biological, medical, psychological, and relationship factors [11–13]. To be specific, poor physical health, abortion history, and seeking medical help due to sex problems are the frequently studied variables among the biological factors, and these variables may increase the likelihood of FSD [1,14]. Regarding the psychological factors, feelings of distress and depression are reported to be positively associated with FSD. Relationship factors may include relationship status and relationship quality [1,4]. In addition, previous studies have found that sex-related variables, such as less sex experience and traditional attitudes are also important determinants of FSD [1,14]. These associated risk factors identified from previous studies may play a role in FSD depending on different life stages. On the basis of previous studies, we hypothesize that poor health, abortion history, seeking medical help, low relationship quality, lower frequency of sex, and traditional attitudes
are also positively associated with FSD among Chinese married women. Substantial studies have found that FSD adversely affects women’s quality of life and wellbeing [15,16]. For example, one study based on American females found that sexual dysfunction is associated with low physical satisfaction, low emotional satisfaction, and low general happiness [1]. Another study of Turkish women indicated that the importance of sexual health for quality of life and overall life satisfaction has been recognized [16]. A study of Japanese women aged 30–60 years showed that favorable sexual function is essential for sexual satisfaction in women [10]. According to the international standard, the reproductive age for females ranges from 19 to 49 years. Although studies on sexual dysfunction among reproductiveaged Chinese women have been emerging recently, population-based studies of FSD concerning the prevalence, risk factors, and consequences of this disorder are relatively scarce. On the basis of the above empirical evidence, we hypothesize that FSD is also negatively associated with Chinese married women’s life quality.
Aims
Using the most recent household survey on married women aged 21–49 years across Hong Kong, which was carried out in 2012, the present study attempts to: (i) estimate the prevalence of sexual dysfunction among reproductive-aged Chinese married women in Hong Kong; (ii) explore the risk factors that may predict FSD; and (iii) examine the associated consequences of sexual dysfunction on these reproductive-aged married women.
Methods
The data of this study came from the 11th Knowledge, Attitude, and Practice (KAP) survey, conducted by the Family Planning Association of Hong Kong from July 28 to December 31, 2012. The KAP survey is the longest running territorywide household survey of family planning in Hong Kong; it has been carried out every 5 years since 1967 and covers a wide range of family planning topics, such as sex-related issues and marital satisfaction. However, FSD was not included in this survey until 2007. This survey has been approved by the institutional ethical committees of the University of Hong Kong. J Sex Med 2015;12:738–745
740 A random stratified sampling method was used to collect data across Hong Kong; A total of 1,518 women aged 19–50 were successfully approached, with a response rate of 83%, and oral informed consent was obtained from all the participants. Participants were first asked to report their sociodemographic information. Then, they completed a self-administered questionnaire that included sensitive items such as sex frequency, sexual relationship and sexual dysfunction. It took them about one hour to finish all the procedures. Sexual dysfunction was assessed by six items, and each item measured, using a yes/no response format, whether there had been a critical symptom or problem for three consecutive months within the past 12 months. The detailed items were as follows: (i) lack of interest in sex; (ii) not finding sex pleasurable; (iii) lubrication difficulties; (iv) inability to achieve orgasm; (v) delayed orgasm during sexual intercourse; and (vi) physical pain during intercourse. These items captured the major problem domains in the classification of sexual dysfunction in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [17]. The reliability of FSD in this study was 0.75. Sociodemographic variables were obtained from the respondents directly. Age was selfreported as a continuous variable and recoded as three categories: 21–30, 31–40, and 41–50. Education and family income were self-reported and recoded as four categories, respectively. Married more than once and children were measured as a dichotomous variable using a yes/no response format. Employment status was measured by asking whether the respondent had a full-time/ part-time job or was unemployed. Abortion history and seeking medical help because of sex problems were classified as dichotomous variables using a yes/no response format. Sex frequency was measured by the number of times of the respondent had engaged in lovemaking in the past 1 month before the survey. Liberal attitudes toward sex were measured by asking whether the respondent would like to actively initiate sexual activity (response of “yes”, “neutral” or “no”). The perceived importance of sex was measured by asking the respondent whether she thought sexual satisfaction was important to her marital quality. Physical health was measured using a single item (“How would you evaluate your health status?”) and a five-point Likert scale (ranging from “1 = very good” to “5 = very poor”). Marital, life, and sexual satisfaction were assessed with a single item (“Are you satisfied with your life/sexual J Sex Med 2015;12:738–745
Zhang et al. relationship?”); the responses ranged from “1 = very satisfied” to “5 = very dissatisfied” and were coded as two groups by recoding (the “very satisfied” and “satisfied” respondents as the “satisfied group,” and the “fair” “dissatisfied” and “very dissatisfied” respondents as the “dissatisfied group”). To answer our research questions, statistical analyses were conducted using SPSS 17.0 (SPSS Inc., Chicago, IL, USA). First, descriptive statistics and χ2 tests were performed to provide the profiles of the sample and to compare the prevalence of FSD and each domain across age groups. Second, six separate multivariate logistic regressions were run to examine the relative importance of each risk factor to each domain of FSD after controlling for age. Adjusted odds ratios (ORs) and 95% confidence interval (CI) were provided to show the odds of members of a given group reporting a symptom relative to a reference group. Third, logistic regressions were run again to examine the association between each domain of FSD and life and sexual satisfaction. Results
Of the 1,518 sexually active female respondents, only those reporting at least one element of FSD were included in this study. A total of 17 respondents skipped all the sexual dysfunction items, and their profiles were not different from other respondents in terms of sociodemographic characteristics; these respondents were excluded from the final analysis. Table 1 presents the descriptive statistics for all the predictors in this study. A total of 1,501 female respondents were included in the analysis. Their average age was 39.0 years (standard deviation = 6.8), with their ages ranging from 21 to 49 years. Less than 10% of the respondents had only received primary or below education and 20% of them reported coming from a low-income family. A small proportion of the female respondents had married more than once and about one quarter (26.2%) did not have children. Around one-third (35.2%) were unemployed at the time of the survey, and 14.0% reported an abortion history. Over one-third (37.5%) reported being in average or poor health. Less than 2% had never sought any help because of sex problems. Over 40% held liberal attitudes toward sex and less than one quarter (24.7%) thought that sex was unimportant to a marital relationship. Over 20% of them were dissatisfied with their marital relationship.
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Female Sexual Dysfunction in Hong Kong Table 1 Descriptive characteristics of the respondents (N = 1,501) Variables
N (%)
Age groups 21–30 31–40 41–49 Education Primary school or lower Form 1–4 secondary school Form 5–6 secondary school University or above Family income Low income Between low and middle Between middle and high High income Not reported Married more than once No Yes Children No Yes Employment Full-time job Part-time job Unemployed Physical health Average or poor Good Sex frequency No more than once monthly More than once monthly Not reported Abortion history No Yes Not reported Seeking medical help because of sex problems No Yes Not reported Liberal attitudes to sex No Neutral Yes Sex perceived as important No Yes Marital relationship Satisfied Dissatisfied
Table 2
175 (11.7) 638 (42.5) 687 (45.8) 92 (6.1) 1,097 (73.1) 98 (6.5) 214 (14.3) 312 (20.8) 378 (25.2) 668 (44.5) 116 (7.7) 27 (1.8) 1,387 (92.4) 114 (7.6) 394 (26.2) 1,107 (73.8) 824 (54.9) 148 (9.9) 529 (35.2) 563 (37.5) 937 (62.4) 253 (16.9) 1,201 (80.0) 47 (3.1) 1,236 (82.3) 210 (14.0) 55 (3.7) 1,448 (96.5) 29 (1.9) 24 (1.6) 179 (11.9) 688 (45.8) 634 (42.2) 371 (24.7) 1,130 (75.3) 1,052 (77.2) 342 (22.8)
As shown in Table 2, among the women who participated in this survey, 25.6% (382) reported at least one form of sexual dysfunction. The most common problems were lack of interest in sex (159, 10.6%) and not finding sex pleasurable (157, 10.5%), followed by lubrication difficulties (139, 9.3%), inability to achieve orgasm (131, 8.8%), orgasm delay (131, 8.8%) and, lastly, the pain during sexual intercourse (126, 8.4%). The prevalence of FSD and three domains (not finding sex pleasurable, lubrication difficulties, and inability to achieve orgasm) increased with age. The other three domains (lack of interest in sex, orgasm delay, and pain during sex) also increased with age; however, it was not statistically significant. In order to know the relative importance of each factor in predicting FSD, multivariate logistic regressions were performed for each domain of FSD, as shown in Table 3. Women with a university or above education were about 50% less likely to report a lack of interest in sex compared with those with secondary or blow education (95% CI, 0.23–0.94). Women with children were 40% less likely to report physical pain during sexual intercourse (95% CI, 0.36–0.99) than those without children. Women from middleincome families were about 50% less likely to report orgasm delay than those from low-income families (95% CI, 0.35–0.98 between low and middle income; 95% CI, 0.26–0.72 between middle and high income). Compared with those in good health, women in average or poor health were 50% more likely to report not finding sex pleasurable (95% CI, 1.03– 2.18) and 67% more likely to report physical pain during sexual intercourse (95% CI, 1.10–2.54). In terms of frequency of having sex, women had sex no more than once during the previous 1-month period were 95% more likely to report inability to achieve orgasm (95% CI, 1.25–2.05) than those who had sex more than once during the same
Prevalence of FSD and each domain by age distribution
Age groups
Total
n (%) 21–30
n (%) 31–40
n (%) 41–49
Prevalence
Test statistics
Domains Lack interest in sex Sex not pleasurable Trouble lubricating Unable to achieve orgasm Orgasm delay Physical pain during sex At least one FSD
1,499 1,497 1,495 1,493 1,496 1,497 1,493
11 (6.3) 6 (3.4) 7 (4.0) 7 (4.0) 12 (6.9) 13 (7.4) 29 (16.7)
64 (10.0) 56 (8.8) 49 (7.7) 46 (7.3) 57 (9.0) 51 (8.0) 149 (23.5)
84 (12.2) 95 (13.8) 83 (12.1) 78 (11.4) 62 (9.0) 62 (9.0) 204 (29.7)
159 (10.6) 157 (10.5) 139 (9.3) 131 (8.8) 131 (8.8) 126 (8.4) 382 (25.6)
χ2 = 5.44 χ2 = 19.34** χ2 = 13.80* χ2 = 12.48* χ2 = 0.89 χ2 = 0.67 χ2 = 14.87**
*P < 0.01, **P < 0.001
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J Sex Med 2015;12:738–745 0.61 (0.25–1.47) 0.47 (0.23–0.94)* 0.49 (0.21–1.15) 1.00 (0.60–1.67) 0.70 (0.37–1.34) 0.85 (0.57–1.27) 1.30 (0.76–2.22) 1.49 (0.91–2.46) 1.34 (0.53–3.35) 1.40 (0.95–2.05) 1.13 (0.72–1.62) 1.25 (0.77–2.03) 2.02 (1.18–3.48)* 1.43 (0.96–2.15) 1.09 (0.73–1.62) 2.05 (1.38–3.05)***
18 (12) 54 (10)
40 (10) 76 (11) 8 (7)
84 (15)
39 (15)
26 (12)
80 (11) 46 (7) 108 (9)
63 (18)
OR (95% CI)
7 (7) 12 (5) 11 (9) 123 (11)
No. (%)
64 (18)
41 (22) 79 (11) 56 (15)
32 (15)
46 (18)
91 (16)
39 (10) 67 (10) 8 (7)
22 (15) 56 (10)
5 (5) 13 (14) 15 (13) 131 (11)
No. (%)
1.63 (1.10–2.42)*
3.0 (1.75–5.17)*** 1.97 (1.28–3.02)** 1.16 (0.78–1.72)
1.30 (0.82–2.05)
1.42 (0.92–2.17)
1.50 (1.03–2.18)*
0.85 (0.51–1.40) 0.86 (0.54–1.37) 0.85 (0.34–2.13)
0.97 (0.54–1.74) 0.86 (0.57–1.28)
0.51 (0.18–1.46) 0.68 (0.34–1.36) 1.30 (0.82–2.05) 1.27 (0.73–2.21)
OR (95% CI)
Sex not pleasurable
41 (12)
23 (12) 75 (11) 49 (13)
30 (14)
39 (15)
71 (12)
40 (10) 55 (8) 11 (9)
16 (11) 44 (8)
6 (6) 24 (11) 9 (8) 109 (10)
No. (%)
1.06 (0.68–1.65)
1.43 (0.78–2.62) 1.72 (1.12–2.62)* 1.45 (0.97–2.18)
1.62 (1.01–2.60)*
1.43 (0.91–2.25)
1.38 (0.92–2.04)
1.24 (0.72–2.14) 0.92 (0.54–1.57) 0.93 (0.39–2.22)
0.89 (0.46–1.70) 0.80 (0.52–1.24)
0.76 (0.29–1.98) 1.54 (0.85–2.77) 0.84 (0.37–1.87) 0.95 (0.56–1.62)
OR (95% CI)
Trouble in lubricating
40 (11)
29 (16) 64 (9) 41 (11)
23 (11)
41 (16)
71 (12)
33 (8) 56 (8) 10 (8)
19 (13) 43 (8)
5 (5) 18 (8) 14 (12) 106 (9)
No. (%)
0.90 (0.57–1.42)
2.09 (1.16–3.77)* 1.66 (1.06–2.59)* 1.02 (0.66–1.57)
1.05 (0.62–1.76)
1.95 (1.25–2.05)**
1.48 (0.98–2.22)
1.05 (0.60–1.84) 1.05 (0.62–1.78) 1.12 (0.46–2.75)
1.33 (0.72–2.47) 0.95 (0.61–1.48)
0.63 (0.22–1.81) 1.20 (0.63–2.29) 1.99 (0.98–4.04) 1.37 (0.76–2.46)
OR (95% CI)
Inability to achieve orgasm
40 (11)
29 (16) 64 (9) 41 (11)
23 (11)
41 (16)
71 (12)
33 (8) 56 (8) 10 (8)
19 (13) 43 (8)
10 (10) 13 (8) 7 (6) 106 (9)
No. (%)
0.59 (0.34–1.01)
0.91 (0.46–1.78) 1.14 (0.76–1.71) 0.89 (0.56–1.41)
0.99 (0.57–1.70)
0.94 (0.55–1.61)
0.98 (0.64–1.48)
0.59 (0.35–0.98)* 0.44 (0.26–0.72)* 0.44 (0.18–1.10)
1.14 (0.59–2.19) 0.97 (0.63–1.49)
1.50 (0.73–3.09) 0.84 (0.42–1.68) 0.71 (0.29–1.72) 1.28 (0.74–2.20)
OR (95% CI)
Orgasm delay
40 (11)
29 (16) 64 (9) 41 (11)
23 (11)
41 (16)
71 (12)
33 (8) 56 (8) 10 (8)
19 (13) 43 (8)
10 (10) 13 (6) 7 (6) 106 (9)
No. (%)
0.92 (0.57–1.50)
1.90 (1.01–3.56)* 1.84 (1.18–2.87)** 1.81 (1.19–2.74)
1.84 (1.11–3.05)*
1.07 (0.65–1.75)
1.67 (1.10–2.54)*
1.34 (0.72–2.50) 1.16 (0.64–2.10) 1.27 (0.52–3.07)
0.54 (0.24–1.19) 0.64 (0.39–1.02)
0.93 (0.40–2.16) 1.31 (0.73–2.34) 0.42 (0.16–1.12) 0.60 (0.36–0.99)*
OR (95% CI)
Physical pain during sex
Note: The reference group was primary school or below, first marriage, no children, full-time job, low income, good health, sex frequency more than once, no abortion history, liberal attitudes to sex, perceived sex as important, and satisfying relationship, respectively *P < 0.05, **P < 0.01, ***P < 0.001
Sociodemographic factors Education High school or equal University or above Married more than once Have children Employment Part-time job Unemployed Family income Between low and middle Between middle and high High income Health Average or poor health Sexual experience Sex frequency no more than once monthly Had an abortion ever Sexual attitudes Neutral attitudes to sex Traditional attitudes to sex Sex not important Relationship quality Dissatisfying relationship
Lack of interest in sex
Prevalence of FSD domain by sociodemographic characteristics and risk factors after adjusting for age (N = 1,501)
Characteristics
Table 3
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Female Sexual Dysfunction in Hong Kong Table 4
The associations between FSD and life and sex satisfaction (N = 1,501) Life dissatisfaction
Lack interest in sex Sex not pleasurable Trouble lubricating Unable to achieve orgasm Orgasm delay Pain during sex
Sex dissatisfaction
OR (95% CI)
Significance
OR (95% CI)
Significance
1.97 (1.41–2.77) 2.57 (1.83–3.60) 1.83 (1.28–2.63) 1.78 (1.22–2.58) 0.88 (0.58–1.33) 1.02 (0.68–1.53)
0.000 0.000 0.001 0.002 0.54 0.92
2.31 (1.66–3.23) 3.20 (2.29–4.48) 1.86 (1.30–2.66) 2.48 (1.73–3.57) 0.66 (0.43–1.01) 1.12 (0.76–1.66)
0.000 0.000 0.001 0.000 0.05 0.55
period. Women with an abortion history were 84% more likely to report physical pain during sexual intercourse (95% CI, 1.11–3.05) than those without an abortion history. Compared with those holding liberal attitudes toward sex, women holding neutral attitudes toward sex were more than twice as likely to report a lack of interest in sex (95% CI, 1.18– 3.48) and an inability to achieve orgasm (95% CI, 1.16–3.77), over three times more likely to report not finding sex pleasurable (95% CI, 1.75–5.17) and 90% more likely to report physical pain during sexual intercourse (95% CI, 1.01–3.56). Similarly, women holding traditional attitudes toward sex were 97% more likely to report not finding sex pleasurable (95% CI, 1.28–3.02), 72% more likely to report lubrication difficulties (95% CI, 1.12–2.62), 66% more likely to report inability to achieve orgasm (95% CI, 1.06–2.59), and 84% more likely to report physical pain during sex (95% CI, 1.18–2.87). Compared with those in a satisfying marital relationship, women in a dissatisfying marital relationship were over twice as likely to report a lack of interest in sex (95% CI, 1.38–3.05) and 63% more likely to report not finding sex pleasurable (95% CI, 1.10–2.42). In addition, it was found that compared with those without sexual dysfunction, the women who reported a lack of interest in sex, not finding sex pleasurable, lubrication difficulties, and an inability to achieve orgasm were more likely to be unsatisfied with their life (OR = 1.78–2.57) and sexual relationship (OR = 1.86–3.20). However, orgasm delay and physical pain during sex were not associated with life and sexual satisfaction (See Table 4). Discussion
Using a representative sample of 1,501 reproductive-aged Chinese married women in Hong Kong, this study has estimated the prevalence, risk factors, and associated consequences of FSD.
First, it is estimated that 25.6% of married young and middle-aged women in Hong Kong report at least one form of FSD; this figure is lower than the 37.9% of women of a similar age range reported in one local study [4] and much lower than the figure of 43% reported for American women aged below 59 years [1]. Furthermore, this study has also found that the prevalence of six domains of FSD ranges from 8.4% to 10.6%; this prevalence range is lower than that previously found among Hong Kong women (11.7–16.3%) [4] and much lower than the reported prevalence rates for Iranian women (26.7– 37.0%) and Japanese women (12.5–29.7%) [10,18]. The lower prevalence rate of FSD in our sample may be due to the fact that our study was based on a population-based survey rather than a hospitalbased survey [6] and also the relatively younger age of our respondents compared with those in previous studies [1,10]. Second, multiple logistic regressions were performed to analyze the risk factors for six domains of FSD, and it was found that education was negatively associated with lack of interest in sex, which is consistent with previous findings that indicated that a lower level of education is a risk factor for sexual dysfunction [19,20]. Having children was found to be a protective factor for physical pain during sex. Compared with the women from lowincome families, the women coming from a middle-income reported less orgasm delay, which is similar to the finding that unemployment is a risk factor for orgasm delay [4]. Similar with previous findings [14,21], our study found that poor physical health, lower frequency of sex, and abortion history are risk factors for different domains of FSD. Regarding sexual attitudes, either neutral or traditional attitudes to sex were found to be associated with nearly all domains of FSD (the exception being orgasm delay), which confirms the previous finding of one local study [4] and suggests the necessity for professionals to promote liberal attitudes in women’s sexual health service delivery. Consistent with one previous study [22], marital J Sex Med 2015;12:738–745
744 dissatisfaction was found to be a risk factor for lack of interest in sex and not finding sex pleasurable, which further confirms the significance of mutual passion and intimacy during lovemaking [23]. Third, this study has shown that four domains (lack interest in sex, not finding sex pleasurable, lubrication difficulties, and inability to achieve orgasm) of FSD are positively associated with life dissatisfaction as well as sex dissatisfaction, which is consistent with previous finding that sexual dysfunction adversely affects women’s quality of life [10,15]. However, orgasm delay and physical pain during sex were not found to be associated with either life dissatisfaction or sex dissatisfaction. Sex was once a taboo in Chinese culture [24], and women were expected to be passive in sexual behavior and were inhibited from sexual agency [25]. It is highly possible that women experiencing orgasm delay or physical pain during sex may regard these as normal parts of the sexual process. However, the associations between orgasm delay and physical pain and women’s quality of life should be investigated further. There are several limitations to this study that should be noted. First, considering this study’s large-scale community survey, the measurement of FSD was simply based on self-report of six dimensions of FSD instead of formal clinical diagnosis by trained professionals. To capture the rich dimensions of FSD, it is necessary to adopt a wellvalidated international scale, such as the Female Sexual Function Index. Furthermore, the diagnostic parameter of sex-related personal distress should be included in the next community survey on reproductive-aged Chinese women in Hong Kong. Second, all the participants were married at the time of the survey; single or divorced women were excluded from our survey. Meanwhile, all of these married women were young and middleaged, and thus our results may lead to an underestimation of the prevalence rate of FSD in the whole population. Therefore, the results from this study cannot be generalized to all women in Hong Kong. Third, although most of the risk factors were identified from previous studies, due to the cross-sectional design of this study, cause and effect were not separated from each other in time, and so may only produce the correlates of FSD. In other words, it is also possible that some risk factors might be the consequences of FSD: for example, physical health and marital dissatisfaction may be the results of FSD. Providing evidence for the valid risk factors of FSD requires a longitudinal design in future studies. J Sex Med 2015;12:738–745
Zhang et al. Conclusion
Using a population-based sample, this study contributes to our understanding of FSD in a nonWestern context in several ways: First, it shows that FSD is also a prevalent phenomenon among reproductive-aged Chinese married women in Hong Kong, although the prevalence rate is relatively lower compared with previous studies, and this deserves more academic and clinical attention. Second, the results of this study show that multiple factors including low education and income, average or poor health, lower frequency of sex, abortion history, traditional attitudes toward sex, and marital dissatisfaction are risk factors for sexual dysfunction. Therefore, the prevention of FSD can start from these risk factors to design relevant programs. Third, the study shows that most domains of FSD (except for orgasm delay and physical pain during sex) have severe consequences on married women’s life satisfaction and sexual satisfaction; thus, the professionals in women’s sexual health should keep in mind that not all symptoms of sexual dysfunction play similar negative roles in Chinese married women’s life quality. Corresponding Author: Huiping Zhang, PhD, Department of Social Work, Renmin University of China, No.59, Zhongguancun Street, Haidian District, Beijing 100872, China. Tel: 86-18611727250; Fax: 86-10-82502546; E-mail: [email protected] Conflict of Interest: The author(s) report no conflicts of interest.
Statement of Authorship
Category 1 (a) Conception and Design Huiping Zhang; Paul S.F. Yip (b) Acquisition of Data Susan Fan; Paul S.F. Yip (c) Analysis and Interpretation of Data Huiping Zhang; Paul S.F. Yip
Category 2 (a) Drafting the Article Huiping Zhang (b) Revising It for Intellectual Content Huiping Zhang; Susan Fan; Paul S.F. Yip
Category 3 (a) Final Approval of the Completed Article Susan Fan; Paul S.F. Yip
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