This article was downloaded by: [Dalhousie University] On: 13 November 2014, At: 03:39 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Survey of the Prevalence of Sexual Dysfunctions in Kurdish Women a
a
b
Modabber Arasteh , Narges Shams Alizadeh , Ebrahim Ghaderi , c
b
d
Fariba Farhadifar , Ronak Nabati & Fardin Gharibi a
Psychology Department, Kurdistan University of Medical Sciences, Sanandaj, Iran b
Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran c
Gynecology Department, Kurdistan University of Medical Sciences, Sanandaj, Iran d
Research Deputy, Kurdistan University of Medical Sciences, Sanandaj, Iran Accepted author version posted online: 14 Nov 2013.Published online: 18 Nov 2013.
To cite this article: Modabber Arasteh, Narges Shams Alizadeh, Ebrahim Ghaderi, Fariba Farhadifar, Ronak Nabati & Fardin Gharibi (2014) Survey of the Prevalence of Sexual Dysfunctions in Kurdish Women, Journal of Sex & Marital Therapy, 40:6, 503-511, DOI: 10.1080/0092623X.2013.776653 To link to this article: http://dx.doi.org/10.1080/0092623X.2013.776653
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
JOURNAL OF SEX & MARITAL THERAPY, 40(6), 503–511, 2014 C Taylor & Francis Group, LLC Copyright ISSN: 0092-623X print / 1521-0715 online DOI: 10.1080/0092623X.2013.776653
Survey of the Prevalence of Sexual Dysfunctions in Kurdish Women Modabber Arasteh and Narges Shams Alizadeh
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Psychology Department, Kurdistan University of Medical Sciences, Sanandaj, Iran
Ebrahim Ghaderi Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
Fariba Farhadifar Gynecology Department, Kurdistan University of Medical Sciences, Sanandaj, Iran
Ronak Nabati Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
Fardin Gharibi Research Deputy, Kurdistan University of Medical Sciences, Sanandaj, Iran
This study evaluates the prevalence of female sexual dysfunctions among Kurdish women. Participants in the study were 196 women between 15 and 55 years of age who attended the gynecological clinic of Be’sat Hospital in Sanandaj Province, Iran. The authors collected relevant data using the Female Sexual Function Index. The mean score was 22.71 (SD = 5). Using a cutoff score of 26.55, the authors found that 151 women (77%) had some sexual dysfunction. Scores declined as patients’ age increased; further, an older age at marriage was associated with a higher score. This study, the first about sexual dysfunctions in Kurdish society, shows that sexual dysfunctions are prevalent among women of this ethnicity. Clinicians should complete further studies to assess the factors contributing to this phenomenon.
INTRODUCTION Sexual dysfunction is defined as dyspareunia, permanent or recurring decline in sexual desire and arousal, or difficulty in achieving an erection and/or orgasm (Basson et al., 2000). Prevalence rates reported in previous studies range from 21% to 98%. Such differences might be ascribed to Address correspondence to Fariba Farhadifar, Gynecology Department, Be’sat Hospital, Keshavarz Ave., Kurdistan, Iran. E-mail: [email protected]
Downloaded by [Dalhousie University] at 03:39 13 November 2014
504
M. ARASTEH ET AL.
variation in age; to social, economic, cultural, and environmental factors; and to various cutoff points for the definition of sexual disorders (Abu Ali, Al Hajeri, Khader, Shegem, & Ajlouni, 2008; Amidu et al., 2010; Blumel et al., 2009; Chedraui, Perez-Lopez, San Miguel, & Avila, 2009; Parish, Laumann, Pan, & Hao, 2007; Singh, Tharyan, Kekre, Singh, & Gopalakrishnan, 2009; Vahdaninia, Montazeri, & Goshtasebi, 2009). Previous studies have indicated different origins and causes for female sexual dysfunctions including infertility, pregnancy, aging (Read, 1999), gynecologic surgery in the pelvic area (Zippe, Nandipati, Agarwal, & Raina, 2006), sexual abuse during childhood (Leonard & Follette, 2002), psychosocial factors, and chronic diseases (Ponholzer, Roehlich, Racz, Temml, & Madersbacher, 2005; Watson & Davies, 1997). Furthermore, negative cultural attitudes and emotional problems might contribute to the development of these diseases (Omidvar, Bakouie, & Nasiri Amiri, 2011; Trudel et al., 2010). Experts recognize the importance of sexual function to everyday life; such functioning should therefore play a role in studies concerning quality of life (Ambler, Bieber, & Diamond, 2012). In some cultures, women who are affected by sexual dysfunctions might not be aware of their problems and might not seek counseling and treatment because of cultural and religious barriers (Vahdaninia et al., 2009). Different racial groups might have different patterns of sexual dysfunction (Laumann, Paik, & Rosen, 1999). Social, emotional, and relationship problems might lead to a lack of emotional communication, negative feelings toward sexuality, and higher sexual dysfunction prevalence (Meston & Bradford, 2007; Trudel et al., 2010). Therefore, cultural attitudes are a major determining factor in marital relationships, sex play, and desire declaration. Kurds constitute an Iranian ethnicity living in the Western part of Iran. Sex is a taboo and problematic subject in Kurdish culture. Cultural attitudes common to this ethnicity include a negative attitude toward (a) women who reveal their sexual appetites, (b) women who express their sexual needs freely, (c) women who seek more out of sexual relationships than the fulfillment of men’s sexual needs. Therefore, any assessment of female sexual dysfunctions will lead to a general portrait of the sexual conditions and challenges to be found in Kurdish families. MATERIALS AND METHODS Experimental Procedure The aim of the study was to determine the type and prevalence of sexual dysfunctions faced by Kurdish women. This study was reviewed and approved by the ethics committee of Kurdistan University of Medical Sciences in Sanandaj, Iran. The participants in the study consisted of married women 15–55 years of age, with any sort of complication, who attended the gynecological clinic of Be’sat Hospital in Sanandaj, Iran, in 2010. Women with a history of gynecologic surgery and/or childbirth within the past 6 months were excluded, as were those 56 years of age and older. The sample size was calculated as 196 using the following sample proportion formula (Z1-α/2 2 p(1–p)/d2). Calculation was based on an 85% prevalence of sexual dysfunctions and a precision level of ±5% around the prevalence rate, with a 5% chance of Type I error. Only 5 individuals did not consent to participate in the study, all of whom were replaced by other participants. We used a simple sampling method and continued until we attained the desired sample size.
SEXUAL DYSFUNCTION IN KURDISH WOMEN
505
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Instrument A well-trained impartial Kurdish interviewer explained the aim of the study and obtained a consent form from each subject. She monitored the process of filling out the questionnaires. Whenever patients had difficulty understanding a question, she explained the meaning and goal of the question. The first questionnaire obtained demographic information only. In the next step, we used the Female Sexual Function Index (FSFI; Rosen et al., 2000) to collect relevant data. The validity and reliability of this questionnaire in Iran has been previously confirmed (Mohammadi, Heydari, & Faghihzadeh, 2008). The FSFI consists of 19 items divided into six subdomains including sexual desire, sexual arousal, lubrication, orgasm, satisfaction, and dyspareunia (Rosen et al., 2000). The scores ranged from 2 (poor) to 36 (good). The obtained score for each domain was multiplied by the specific weight of that domain, and the total score was calculated as the sum of all scores of the six domains. Sexual dysfunctions were defined using cutoff scores (Rosen et al., 2000). If a woman’s FSFI total score was less than 26.55, she was classified as having a sexual dysfunction. Cutoff scores on the six domains were as follows: desire dysfunction if the desire domain score was less than 4.28, arousal dysfunction if the arousal domain score was less than 5.08, lubrication dysfunction if the lubrication domain score was less than 5.45, orgasm dysfunction if the orgasm domain score was less than 5.05, satisfaction dysfunction if the satisfaction domain score was less than 5.04, and pain dysfunction if the pain score domain score was less than 5.51. Data Analysis The data were analyzed using the SPSS 11.5. Univariate analysis was performed using chi-square and Fisher’s exact tests for categorical data, the independent t test for quantitative data, and Spearman’s rho for correlation analysis. Variables with p values less than 0.25 in univariate analysis were entered into multiple regression analysis.
RESULTS In the present study, the mean age was 31.6 years (SD = 8.4 years); the median number of abortions was 0 (range = 0–4); the median number of gravidity was 1 (range = 0–8); and the average age at marriage was 19.5 years (SD = 3.8 years). The mean FSFI score was 22.71 years (SD = 5 years). Using the cutoff score of 26.55, 77% of the participants were classified as having a sexual dysfunction. The most prevalent dysfunction was pain, reported by 95.9% of participants (Table 1). All participants were classified with at least one dysfunction and the majority were classified with multiple dysfunctions (Table 2). Other analyses (Table 3) showed that the highest level of sexual dysfunction prevalence was found among illiterate subjects (91.7%, 95% CI [74.1%, 97.7%]). Correlational analyses showed that as age increased, sexual dysfunctions became more prevalent (Table 4). Multiple regression showed that only the participants’ ages and the age at marriages were related to the overall FSFI score. Every 1-year increase in age was associated with a 0.28
506
M. ARASTEH ET AL.
TABLE 1 Mean Scores and Standard Deviations in FSFI Domains and Frequency (%) of Sexual Dysfunction Item
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Desire Arousal Lubrication Orgasm Satisfaction Pain Total score
M
SD
n
%
3.67 3.25 4.93 4.04 4.91 2.58 22.71
1.2 1.4 1.3 1.2 1.0 1.4 5.0
129 173 140 149 85 188 151
65.8 88.3 71.4 76.0 43.4 95.9 77.0
decrease in FSFI scores, whereas each 1-year increase in age at marriage was associated with a 0.25 improvement in FSFI scores (Table 5). DISCUSSION In this study, the prevalence of sexual dysfunctions was calculated as 77%. The highest prevalence in subdomain categories was found in intercourse pain and arousal dysfunction. One factor in the high prevalence of sexual dysfunction in our study might be that the women under analysis were all attending a gynecological clinic. Therefore, the health problems that initially brought them to the clinic could be a variable in these results. Conducting a population-based study might result in more accurate results; however, because of cultural and religious limitations, it is not yet possible to conduct such a study in Iran and in the Kurdistan province. Although the prevalence of sexual dysfunctions is high, satisfaction dysfunction is less common, perhaps because of low expectations in a culture where women do not enjoy high levels of sexual satisfaction. In contrast, the participants were selected from patients attending a gynecological clinic; thus, they did not constitute a typical population sample, so the high rate of dysfunction in the pain subdomain might be the result of sampling bias. TABLE 2 Number of Dysfunctional Domains Reported by Participants Number of FSFI domain scores per participant that are classified as a dysfunction
n
%
Lower
Upper
1 2 3 4 5 6
7 21 18 39 61 50
3.6 10.7 9.2 19.9 31.1 25.5
1.7 7.1 5.9 14.9 25.0 19.9
7.2 15.8 14.0 26.0 37.9 32.0
Participants
Note. FSFI = Female Sexual Function Index.
95% CI
SEXUAL DYSFUNCTION IN KURDISH WOMEN
507
TABLE 3 Comparison of Sexual Dysfunction Prevalence in Some Groups Participants
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Variable Religion Sunnite Shiite Residency Urban Rural Education Uneducated Primary Secondary High school College Work status Housewife Not a housewife Forced marriage Yes No Divorced Yes No Husband aloofness Yes No Family planning for birth control Yes No Episiotomy history Yes No Sex phobia Yes No Ovarian cyst Yes No Age group (years) 40 Religious morality Yes No Caesarian history Yes No
Sexual dysfunction
n
%
n
%
p
170 26
86.7 13.3
129 22
75.9 84.6
.324†
166 30
84.7 15.3
131 20
78.9 66.7
.142
24 36 40 42 54
12.2 18.4 20.4 21.3 27.6
22 30 26 29 44
91.7 83.3 65.0 69.0 81.9
.050
151 45
77.0 33.0
111 40
73.5 88.9
.031†
10 186
5.1 94.9
10 141
100.0 75.8
.120†
7 189
3.6 96.4
3 148
42.9 78.3
.050†
51 145
26.0 74.0
39 112
76.5 77.2
.910
135 61
68.9 31.1
106 45
78.5 73.8
.464
86 110
43.9 56.1
67 84
77.9 76.4
.799
21 175
10.7 89.3
18 134
81.0 76.6
.788†
22 174
11.2 88.4
12 139
54.5 79.9
.008
96 59 41
49.0 30.1 20.9
64 48 41
66.7 81.4 20.9
20 176
10.2 89.8
17 134
85.0 76.1
.575†
43 108
28.5 71.5
33 79
76.7 73.1
.650
†Fisher exact test was used for analysis. Others were analyzed by chi-square test.
.001
508
M. ARASTEH ET AL.
TABLE 4 Correlation Between FSFI Domain and Some Demographic Variables
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Domain Desire Arousal Lubrication Orgasm Satisfaction Pain Total score Frequency of domains dysfunction
Age
Age at marriage
Marriage duration
Gravidity
Education
−.319(< .001)† −.287(< .001)† −.282(< .001)† −.283(< .001)† −.376(< .001)† −.106(.14) −.436(< .001)† .308(< .001)†
.089(.221) .200(.006)† .137(.6) .144(.048)† −.185(.011)† −.276(< .001)† .109(.135) −.021(.773)
−.309(< .001)† −.323(< .001)† −.282(< .001)† −.287(< .001)† −.402(< .001)† .001(.99) −.417(< .001)† .277(< .001)†
−.246(.001)† −.245(.001)† −.110(.125) −.109(.129) −.232(.001)† −.105(.830) −.244(.001)† .162(.023)†
.118(.101)† .187(.009)† .130(.07) .174(.015)† −.319(< .001)† −.204(.004)† .173(.016)† −.134(.061)
Note. Spearman’s rho was used to correlation analysis. FSFI = Female Sexual Function Index. †Statistically significant. p value is indicated in the parentheses.
Results of the multivariate analysis showed that advancing age is associated with the increased prevalence of sexual dysfunctions, whereas high age at marriage was associated with a lower risk of sexual dysfunctions. It should be noted that aging is associated with hormonal changes. Moreover, the participants hailed from a society in which sexual activities are limited before marriage. Therefore, the participants enjoy sex more after marriage more than before, and they experience higher levels of satisfaction. In contrast, it is probable that marriage at younger ages leads to lower levels of satisfaction because of limited sexual knowledge, forced marriages, and lack of physiological capabilities. The mean FSFI score was less than that found in previous studies. Varying cultures, study settings, and emotional distress can lead to differences in FSFI scores (Blumel et al., 2009; Bond
TABLE 5 Analysis of Multiple Regression With FSFI Score as Dependent Variables and Some Variables as Independent Variables Unstandardized coefficient Variable Constant Age Residency Education Work status Gravidity Age at marriage
95% CI for B
β
SE
Standardized coefficient
Lower
Upper
p
23.857 −0.282 1.090 0.425 −1.404 0.353 0.247
2.711 0.063 0.992 0.368 1.048 0.287 0.111
−.474 .080 .118 −.120 .124 .190
18.509 −0.407 −0.868 0.302 −3.472 −0.214 0.027
29.205 −0.158 3.048 1.152 0.663 0.920 0.466
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Survey of the Prevalence of Sexual Dysfunctions in Kurdish Women a
a
b
Modabber Arasteh , Narges Shams Alizadeh , Ebrahim Ghaderi , c
b
d
Fariba Farhadifar , Ronak Nabati & Fardin Gharibi a
Psychology Department, Kurdistan University of Medical Sciences, Sanandaj, Iran b
Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran c
Gynecology Department, Kurdistan University of Medical Sciences, Sanandaj, Iran d
Research Deputy, Kurdistan University of Medical Sciences, Sanandaj, Iran Accepted author version posted online: 14 Nov 2013.Published online: 18 Nov 2013.
To cite this article: Modabber Arasteh, Narges Shams Alizadeh, Ebrahim Ghaderi, Fariba Farhadifar, Ronak Nabati & Fardin Gharibi (2014) Survey of the Prevalence of Sexual Dysfunctions in Kurdish Women, Journal of Sex & Marital Therapy, 40:6, 503-511, DOI: 10.1080/0092623X.2013.776653 To link to this article: http://dx.doi.org/10.1080/0092623X.2013.776653
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
JOURNAL OF SEX & MARITAL THERAPY, 40(6), 503–511, 2014 C Taylor & Francis Group, LLC Copyright ISSN: 0092-623X print / 1521-0715 online DOI: 10.1080/0092623X.2013.776653
Survey of the Prevalence of Sexual Dysfunctions in Kurdish Women Modabber Arasteh and Narges Shams Alizadeh
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Psychology Department, Kurdistan University of Medical Sciences, Sanandaj, Iran
Ebrahim Ghaderi Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
Fariba Farhadifar Gynecology Department, Kurdistan University of Medical Sciences, Sanandaj, Iran
Ronak Nabati Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
Fardin Gharibi Research Deputy, Kurdistan University of Medical Sciences, Sanandaj, Iran
This study evaluates the prevalence of female sexual dysfunctions among Kurdish women. Participants in the study were 196 women between 15 and 55 years of age who attended the gynecological clinic of Be’sat Hospital in Sanandaj Province, Iran. The authors collected relevant data using the Female Sexual Function Index. The mean score was 22.71 (SD = 5). Using a cutoff score of 26.55, the authors found that 151 women (77%) had some sexual dysfunction. Scores declined as patients’ age increased; further, an older age at marriage was associated with a higher score. This study, the first about sexual dysfunctions in Kurdish society, shows that sexual dysfunctions are prevalent among women of this ethnicity. Clinicians should complete further studies to assess the factors contributing to this phenomenon.
INTRODUCTION Sexual dysfunction is defined as dyspareunia, permanent or recurring decline in sexual desire and arousal, or difficulty in achieving an erection and/or orgasm (Basson et al., 2000). Prevalence rates reported in previous studies range from 21% to 98%. Such differences might be ascribed to Address correspondence to Fariba Farhadifar, Gynecology Department, Be’sat Hospital, Keshavarz Ave., Kurdistan, Iran. E-mail: [email protected]
Downloaded by [Dalhousie University] at 03:39 13 November 2014
504
M. ARASTEH ET AL.
variation in age; to social, economic, cultural, and environmental factors; and to various cutoff points for the definition of sexual disorders (Abu Ali, Al Hajeri, Khader, Shegem, & Ajlouni, 2008; Amidu et al., 2010; Blumel et al., 2009; Chedraui, Perez-Lopez, San Miguel, & Avila, 2009; Parish, Laumann, Pan, & Hao, 2007; Singh, Tharyan, Kekre, Singh, & Gopalakrishnan, 2009; Vahdaninia, Montazeri, & Goshtasebi, 2009). Previous studies have indicated different origins and causes for female sexual dysfunctions including infertility, pregnancy, aging (Read, 1999), gynecologic surgery in the pelvic area (Zippe, Nandipati, Agarwal, & Raina, 2006), sexual abuse during childhood (Leonard & Follette, 2002), psychosocial factors, and chronic diseases (Ponholzer, Roehlich, Racz, Temml, & Madersbacher, 2005; Watson & Davies, 1997). Furthermore, negative cultural attitudes and emotional problems might contribute to the development of these diseases (Omidvar, Bakouie, & Nasiri Amiri, 2011; Trudel et al., 2010). Experts recognize the importance of sexual function to everyday life; such functioning should therefore play a role in studies concerning quality of life (Ambler, Bieber, & Diamond, 2012). In some cultures, women who are affected by sexual dysfunctions might not be aware of their problems and might not seek counseling and treatment because of cultural and religious barriers (Vahdaninia et al., 2009). Different racial groups might have different patterns of sexual dysfunction (Laumann, Paik, & Rosen, 1999). Social, emotional, and relationship problems might lead to a lack of emotional communication, negative feelings toward sexuality, and higher sexual dysfunction prevalence (Meston & Bradford, 2007; Trudel et al., 2010). Therefore, cultural attitudes are a major determining factor in marital relationships, sex play, and desire declaration. Kurds constitute an Iranian ethnicity living in the Western part of Iran. Sex is a taboo and problematic subject in Kurdish culture. Cultural attitudes common to this ethnicity include a negative attitude toward (a) women who reveal their sexual appetites, (b) women who express their sexual needs freely, (c) women who seek more out of sexual relationships than the fulfillment of men’s sexual needs. Therefore, any assessment of female sexual dysfunctions will lead to a general portrait of the sexual conditions and challenges to be found in Kurdish families. MATERIALS AND METHODS Experimental Procedure The aim of the study was to determine the type and prevalence of sexual dysfunctions faced by Kurdish women. This study was reviewed and approved by the ethics committee of Kurdistan University of Medical Sciences in Sanandaj, Iran. The participants in the study consisted of married women 15–55 years of age, with any sort of complication, who attended the gynecological clinic of Be’sat Hospital in Sanandaj, Iran, in 2010. Women with a history of gynecologic surgery and/or childbirth within the past 6 months were excluded, as were those 56 years of age and older. The sample size was calculated as 196 using the following sample proportion formula (Z1-α/2 2 p(1–p)/d2). Calculation was based on an 85% prevalence of sexual dysfunctions and a precision level of ±5% around the prevalence rate, with a 5% chance of Type I error. Only 5 individuals did not consent to participate in the study, all of whom were replaced by other participants. We used a simple sampling method and continued until we attained the desired sample size.
SEXUAL DYSFUNCTION IN KURDISH WOMEN
505
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Instrument A well-trained impartial Kurdish interviewer explained the aim of the study and obtained a consent form from each subject. She monitored the process of filling out the questionnaires. Whenever patients had difficulty understanding a question, she explained the meaning and goal of the question. The first questionnaire obtained demographic information only. In the next step, we used the Female Sexual Function Index (FSFI; Rosen et al., 2000) to collect relevant data. The validity and reliability of this questionnaire in Iran has been previously confirmed (Mohammadi, Heydari, & Faghihzadeh, 2008). The FSFI consists of 19 items divided into six subdomains including sexual desire, sexual arousal, lubrication, orgasm, satisfaction, and dyspareunia (Rosen et al., 2000). The scores ranged from 2 (poor) to 36 (good). The obtained score for each domain was multiplied by the specific weight of that domain, and the total score was calculated as the sum of all scores of the six domains. Sexual dysfunctions were defined using cutoff scores (Rosen et al., 2000). If a woman’s FSFI total score was less than 26.55, she was classified as having a sexual dysfunction. Cutoff scores on the six domains were as follows: desire dysfunction if the desire domain score was less than 4.28, arousal dysfunction if the arousal domain score was less than 5.08, lubrication dysfunction if the lubrication domain score was less than 5.45, orgasm dysfunction if the orgasm domain score was less than 5.05, satisfaction dysfunction if the satisfaction domain score was less than 5.04, and pain dysfunction if the pain score domain score was less than 5.51. Data Analysis The data were analyzed using the SPSS 11.5. Univariate analysis was performed using chi-square and Fisher’s exact tests for categorical data, the independent t test for quantitative data, and Spearman’s rho for correlation analysis. Variables with p values less than 0.25 in univariate analysis were entered into multiple regression analysis.
RESULTS In the present study, the mean age was 31.6 years (SD = 8.4 years); the median number of abortions was 0 (range = 0–4); the median number of gravidity was 1 (range = 0–8); and the average age at marriage was 19.5 years (SD = 3.8 years). The mean FSFI score was 22.71 years (SD = 5 years). Using the cutoff score of 26.55, 77% of the participants were classified as having a sexual dysfunction. The most prevalent dysfunction was pain, reported by 95.9% of participants (Table 1). All participants were classified with at least one dysfunction and the majority were classified with multiple dysfunctions (Table 2). Other analyses (Table 3) showed that the highest level of sexual dysfunction prevalence was found among illiterate subjects (91.7%, 95% CI [74.1%, 97.7%]). Correlational analyses showed that as age increased, sexual dysfunctions became more prevalent (Table 4). Multiple regression showed that only the participants’ ages and the age at marriages were related to the overall FSFI score. Every 1-year increase in age was associated with a 0.28
506
M. ARASTEH ET AL.
TABLE 1 Mean Scores and Standard Deviations in FSFI Domains and Frequency (%) of Sexual Dysfunction Item
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Desire Arousal Lubrication Orgasm Satisfaction Pain Total score
M
SD
n
%
3.67 3.25 4.93 4.04 4.91 2.58 22.71
1.2 1.4 1.3 1.2 1.0 1.4 5.0
129 173 140 149 85 188 151
65.8 88.3 71.4 76.0 43.4 95.9 77.0
decrease in FSFI scores, whereas each 1-year increase in age at marriage was associated with a 0.25 improvement in FSFI scores (Table 5). DISCUSSION In this study, the prevalence of sexual dysfunctions was calculated as 77%. The highest prevalence in subdomain categories was found in intercourse pain and arousal dysfunction. One factor in the high prevalence of sexual dysfunction in our study might be that the women under analysis were all attending a gynecological clinic. Therefore, the health problems that initially brought them to the clinic could be a variable in these results. Conducting a population-based study might result in more accurate results; however, because of cultural and religious limitations, it is not yet possible to conduct such a study in Iran and in the Kurdistan province. Although the prevalence of sexual dysfunctions is high, satisfaction dysfunction is less common, perhaps because of low expectations in a culture where women do not enjoy high levels of sexual satisfaction. In contrast, the participants were selected from patients attending a gynecological clinic; thus, they did not constitute a typical population sample, so the high rate of dysfunction in the pain subdomain might be the result of sampling bias. TABLE 2 Number of Dysfunctional Domains Reported by Participants Number of FSFI domain scores per participant that are classified as a dysfunction
n
%
Lower
Upper
1 2 3 4 5 6
7 21 18 39 61 50
3.6 10.7 9.2 19.9 31.1 25.5
1.7 7.1 5.9 14.9 25.0 19.9
7.2 15.8 14.0 26.0 37.9 32.0
Participants
Note. FSFI = Female Sexual Function Index.
95% CI
SEXUAL DYSFUNCTION IN KURDISH WOMEN
507
TABLE 3 Comparison of Sexual Dysfunction Prevalence in Some Groups Participants
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Variable Religion Sunnite Shiite Residency Urban Rural Education Uneducated Primary Secondary High school College Work status Housewife Not a housewife Forced marriage Yes No Divorced Yes No Husband aloofness Yes No Family planning for birth control Yes No Episiotomy history Yes No Sex phobia Yes No Ovarian cyst Yes No Age group (years) 40 Religious morality Yes No Caesarian history Yes No
Sexual dysfunction
n
%
n
%
p
170 26
86.7 13.3
129 22
75.9 84.6
.324†
166 30
84.7 15.3
131 20
78.9 66.7
.142
24 36 40 42 54
12.2 18.4 20.4 21.3 27.6
22 30 26 29 44
91.7 83.3 65.0 69.0 81.9
.050
151 45
77.0 33.0
111 40
73.5 88.9
.031†
10 186
5.1 94.9
10 141
100.0 75.8
.120†
7 189
3.6 96.4
3 148
42.9 78.3
.050†
51 145
26.0 74.0
39 112
76.5 77.2
.910
135 61
68.9 31.1
106 45
78.5 73.8
.464
86 110
43.9 56.1
67 84
77.9 76.4
.799
21 175
10.7 89.3
18 134
81.0 76.6
.788†
22 174
11.2 88.4
12 139
54.5 79.9
.008
96 59 41
49.0 30.1 20.9
64 48 41
66.7 81.4 20.9
20 176
10.2 89.8
17 134
85.0 76.1
.575†
43 108
28.5 71.5
33 79
76.7 73.1
.650
†Fisher exact test was used for analysis. Others were analyzed by chi-square test.
.001
508
M. ARASTEH ET AL.
TABLE 4 Correlation Between FSFI Domain and Some Demographic Variables
Downloaded by [Dalhousie University] at 03:39 13 November 2014
Domain Desire Arousal Lubrication Orgasm Satisfaction Pain Total score Frequency of domains dysfunction
Age
Age at marriage
Marriage duration
Gravidity
Education
−.319(< .001)† −.287(< .001)† −.282(< .001)† −.283(< .001)† −.376(< .001)† −.106(.14) −.436(< .001)† .308(< .001)†
.089(.221) .200(.006)† .137(.6) .144(.048)† −.185(.011)† −.276(< .001)† .109(.135) −.021(.773)
−.309(< .001)† −.323(< .001)† −.282(< .001)† −.287(< .001)† −.402(< .001)† .001(.99) −.417(< .001)† .277(< .001)†
−.246(.001)† −.245(.001)† −.110(.125) −.109(.129) −.232(.001)† −.105(.830) −.244(.001)† .162(.023)†
.118(.101)† .187(.009)† .130(.07) .174(.015)† −.319(< .001)† −.204(.004)† .173(.016)† −.134(.061)
Note. Spearman’s rho was used to correlation analysis. FSFI = Female Sexual Function Index. †Statistically significant. p value is indicated in the parentheses.
Results of the multivariate analysis showed that advancing age is associated with the increased prevalence of sexual dysfunctions, whereas high age at marriage was associated with a lower risk of sexual dysfunctions. It should be noted that aging is associated with hormonal changes. Moreover, the participants hailed from a society in which sexual activities are limited before marriage. Therefore, the participants enjoy sex more after marriage more than before, and they experience higher levels of satisfaction. In contrast, it is probable that marriage at younger ages leads to lower levels of satisfaction because of limited sexual knowledge, forced marriages, and lack of physiological capabilities. The mean FSFI score was less than that found in previous studies. Varying cultures, study settings, and emotional distress can lead to differences in FSFI scores (Blumel et al., 2009; Bond
TABLE 5 Analysis of Multiple Regression With FSFI Score as Dependent Variables and Some Variables as Independent Variables Unstandardized coefficient Variable Constant Age Residency Education Work status Gravidity Age at marriage
95% CI for B
β
SE
Standardized coefficient
Lower
Upper
p
23.857 −0.282 1.090 0.425 −1.404 0.353 0.247
2.711 0.063 0.992 0.368 1.048 0.287 0.111
−.474 .080 .118 −.120 .124 .190
18.509 −0.407 −0.868 0.302 −3.472 −0.214 0.027
29.205 −0.158 3.048 1.152 0.663 0.920 0.466
