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Original Article

Prevalence and associated risk factors of female sexual


dysfunction among Jordanian women
Maher Elias Maaita1, Basel M. Khreisat1, Omar A. Tasso1,
Nareman Naser Otom1, Bayan M. Aljaafreh1, Gharam M. Abuassaf1
1
Department of Obstetrics and Gynecology, King Hussein Medical Center, Amman, Jordan

A bstract
Background: Female sexual dysfunction (FSD) and the associated risk factors are less studied in the Middle East. This study
is designed to determine the prevalence of FSD and its associated risk factors in Jordan. Materials and Methods: A group
of women were interviewed using detailed questionnaire on several aspects of FSD including desire, arousal, lubrication,
orgasm, satisfaction, and pain disorders. They underwent sociodemographic investigation. Prevalence and risk factors of
FSD are calculated in different age groups. Results: A total of 470 women aged 32.6 ± 9.6 years are included in this study.
Desire problems were detected in 49.4% (232/470) of the studied women, while an arousal problem in 31.9% (150/470)
and lubrication problem in 39.2% (184/470). An orgasm problem was detected in 39.57% (186/470) of the studied women,
while satisfaction problem was detected in 43.82% (206/470) and pain problem during sexual relation in 19.2% (90/470).
There was positive significant correlation between each domain of the FSD and the studied women’s age except pain. FSD
was found to be significant in women with more than four children (83.3%, P < 0.02), those who had been married for more
than 10 years (76.7%, P < 0.02), in women with chronic medical diseases (76.7%, P < 0.02), in unemployed women (76.7%,
P  < 0.02), and in women not using contraception (75.2%, P < 0.005). There was no significant correlation with the level of
education (P < 0.34) and monthly income (P < 0.24). Conclusion: The prevalence of FSD in Jordan is about 64.7%, the desire
disorders are the most prevalent domain of FSD, and age is the most significant risk factor for FSD. Further research is
needed with larger and more comprehensive sample to estimate the magnitude of FSD and to confirm its relationship with
different risk factors.

Keywords: Dysfunction, female, Jordan, risk, sexual

Introduction The sexuality manifestations are complex interactions of


behavioral, intrapsychical, social, and interpersonal factors
Female sexual dysfunction (FSD) and the associated risk factors intervening in its initiation and maintenance.[7]
are less studied in the Middle East.[1‑6]
A normal sexual response is usually followed by characteristics
FSD may be a lifelong problem or acquired later in life after a state of psycho‑physiological expressions, and many physical and
of normal sexual functioning. It takes different forms, including mental changes.[8]
lack of sexual desire, impaired arousal, inability to accomplish
orgasm, and/or pain during sexual activity.[7] The sexual response involves the entire body organs, although
the most characteristic physiological changes occur in the
Address for correspondence: Dr. Basel M. Khreisat, genitalia. Healthy body is required to have effective and pleasant
Department of Obstetrics and Gynecology,
King Hussein Medical Center, Amman, Jordan.
E‑mail: [email protected] This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non-commercially, as long as appropriate credit is
Access this article online given and the new creations are licensed under the identical terms.
Quick Response Code:
Website: For reprints contact: [email protected]
www.jfmpc.com

How to cite this article: Maaita ME, Khreisat BM, Tasso OA, Otom NN,
Aljaafreh BM, Abuassaf GM. Prevalence and associated risk factors of
DOI:
10.4103/jfmpc.jfmpc_200_18 female sexual dysfunction among Jordanian women. J Family Med Prim
Care 2018;7:1488-92.

© 2018 Journal of Family Medicine and Primary Care | Published by Wolters Kluwer ‑ Medknow 1488
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Maaita, et al.: Sexual dysfunction among Jordanian women

sexual response. For this reason, different natures of many body Calculation of the prevalence of sexual dysfunction for each
disorders may adversely affect the satisfactory sexual response.[9] domain and comparison among the groups was done. Therefore,
sexual dysfunction for each domain was considered when
The female sexual cycle is first described by Master and the desire score is  ≤3.3  (range 1–5), an arousal score is  ≤3.4
Johnson in 1966.[10] It is divided into four phases: desire (libido), (range 0–5), lubrication score is  ≤3.4  (range 0–5), an orgasm
arousal (excitement), orgasm, and resolution. Understanding the score is ≤3.4 (range 0–5), satisfaction score is ≤3.8 (range 0–5),
sexual response cycle will help in the evaluation and management and pain score is ≤3.8 (range 0–5). The total score was obtained
of the related disorders.[9] by adding the six domain scores; the range of the total score
was from 2 to 36. Sexual dysfunction was considered when the
No previous studies were conducted in Jordon to estimate the total score was <28. Interviewers (doctors and qualified nurses)
prevalence of FSD and its related risk factors; therefore, this matched respondents on various social attributes in an interview
study is designed to determine the prevalence of FSD and its averaging 35 minutes. The collected data were tabulated and
associated risk factors in Jordan. statistically analyzed using the Statistical Package for Social
Sciences version 20 (Chicago, IL), to determine the prevalence
Materials and Methods of FSD and to predict the associated risk factors in Jordan.

Four hundred seventy Jordanian women who attended King Mean and standard deviation were used to represent numerical
Hussein Medical Center in Amman, Jordan, were recruited in variables, whereas number and percentage were used to represent
this cross‑sectional, descriptive study from September 2017 to categorical variables. Independent Student’s t‑test was used
January 2018. The study was approved by the ethical committee for numeric parametric variables, and Chi‑square test used for
of the Royal Medical Services, and women were recruited in this categorical variables analysis. P < 0.05 was considered statistically
study after informed written consent. significant.

Women with severe medical or psychiatric illnesses, divorced, or Sample size


widowed were excluded from this study. The required data were The required sample size was calculated using G Power software
collected through face‑to‑face interview with each participant version 3.17 for sample size calculation (Heinrich‑Heine‑Universität,
by female doctor or qualified nurse using Arabic translation of Düsseldorf, Germany), setting α‑error probability at 0.05,
female sexual function index (FSFI).[11] power  (1−β error probability) at 0.95%, and effective sample
size (w) at 0.3. The effective sample includes more than 110 women
Subjects were divided into six age groups, including ages less than needed to produce a statistically acceptable figure.
18, 19–29, 30–39, 40–49, 50–59, and 60–69 years. Demographic
characteristics were collected using questionnaire including the Results
following: age of the husband, occupational status, average
income, level of education, parity, use of any medications, Four hundred seventy Jordanian women were recruited in this
duration of relationship, contraception use, and the past medical study and the sociodemographic data of the studied women
and/or surgical history. were listed in Table 1. The sexual dysfunction was detected in
304 (64.7%) of the studied women [Table 1].
The Arabic translation of FSFI questionnaire was used to evaluate
FSD. The FSFI[12] is a brief, 19‑item self‑report measure of FSD FSD was significantly low in women <18 years (4/304 women
that provides scores on six domains of sexual function as well as with FSD compared to 6/166 women without FSD, P = 0.02)
a total score. The domains assessed in the questionnaire include and significantly high in women ≥40–69 years (65/304 with FSD
the following: desire (2 items), arousal (4 items), lubrication compared to 13/166 women without FSD, P = 0.03; Table 2).
(4 items), orgasm (3 items), satisfaction (3 items), and pain
(3 items). The questionnaire assessed sexual function or disorders FSD was significantly high in women who had more than 4
which had occurred during the past 4 weeks. Sexual desire was children [30 (83.3%), P < 0.02]; their husbands were more
assessed by asking two questions about frequency and desire level. than 40 years of age [98 (81.7%), P = 0.002]; had been
Arousal was assessed by asking four questions about frequency, married for more than 10 years [112 (76.7%), P < 0.02]; were
level, confidence, and satisfaction. Lubrication was assessed by unemployed [127 (76.7%), P < 0.02]; had medical problems
asking four questions about frequency, difficulty, frequency of such as hypertension, diabetes mellitus, and ischemic heart
maintaining lubrication, and difficulty in maintaining lubrication. disease [70 (76.7%), P < 0.02]; used medication [62 (86.1%),
Orgasm was assessed by asking three questions about frequency, P < 0.006]; and did not use contraceptives [151 (75.2%), P < 0.005].
difficulty, and satisfaction. Satisfaction was assessed by asking There were no significant correlations between FSD and the level
three questions about the amount of closeness with partner, of education (P < 0.34) or monthly income (P < 0.24) [Table 3].
sexual relationship, and overall sex life. Pain was assessed by
asking three questions about pain frequency during vaginal Desire problems were detected in 49.4% (232/470) of the
penetration and pain frequency following vaginal penetration. studied women, while an arousal problem was detected in

Journal of Family Medicine and Primary Care 1489 Volume 7 : Issue 6 : November-December 2018
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Maaita, et al.: Sexual dysfunction among Jordanian women

Table 1: Sociodemographic and marital characteristics of Table 2: Prevalence of female sexual dysfunction
the studied population, and the use of contraceptives according to the age group of the study participants
Variables Value (%) Age of the studied Women without Women with Total P
Age (years) 32.6±9.4 population (years) FSD, n (%) FSD, n (%)
Studied population according to sexual dysfunction <18 6 (60.0) 4 (40.0) 10 (100.0) 0.02
Without sexual dysfunction 166 (35.3) 19‑29 90 (43.7) 116 (56.3) 206 (100.0) 0.1
With sexual dysfunction 304 (64.7) 30‑39 57 (32.4) 119 (67.6) 176 (100.0) 0.2
Studied population according to age (years), n (%) ≥40‑69 13 (16.7) 65 (83.4) 78 (100.0) 0.03
≥18 10 (2.1) Total 166 304 470
19‑29 206 (43.8) Data are presented as n (%) and the Chi‑square test used for statistical analysis. FSD: Female sexual
dysfunction
30‑39 176 (37.4)
40‑49 56 (11.9)
50‑59 14 (3.0) Discussion
60‑69 8 (1.7)
Studied population according to parity, n (%) This study was conducted to determine the prevalence of FSD
0‑4 398 (84.7) and its associated risk factors in Jordan. Sexuality is a crucial issue
5‑20 72 (15.3) in enhancing marital relationships. In Jordanian society, like any
Studied population according to the age of the other Arabic society, talking about sexual disorders is sensitive
husband (years), n (%) and may lead to improper assessment.[2]
<40 350 (74.5)
≥40 120 (25.5) All studies conducted in the Middle East to assess the sexual
Studied population according to the level of education, disorders are not comprehensive to discuss all the possible risk
n (%)
factors of FSD.[1,2,4]
Primary school 52 (11.1)
Secondary school 94 (20.0)
Diploma 94 (20.0)
In this study, we tried to assess the prevalence of FSD and
Bachelor 228 (48.5) some of its related risk factors using data collected from three
Master 2 (0.4) different areas in Amman, the capital city of Jordan, where
Studied population according to the average income, nearly half of the people in Jordan live and represent different
n (%) socioeconomic levels.
<500 84 (17.9)
≥500 386 (82.1) In this study, FSD is recorded in 64.7% of the studied
Studied population according to the occupational status, women (age range 18–69 years) which is higher than that reported
n (%)
by Laumann et al.,[3] who reported FSD in 43% of their studied
Employed 298 (63.4)
women (1.749 women investigated, living throughout USA).[3]
Unemployed 172 (36.6)
Studied population according to the duration of
relationship, n (%) The prevalence of FSD in a Turkish study conducted by Cayan
<10 324 (68.9) et al.[4] ranged from 22% in women aged 18–27 years to 66%
≥10 146 (31.1) in those aged 48–57 years. Jaafarpour et al.[13] reported 46.2%
Studied population according to their medical and prevalence of FSD in an Iranian study.
surgical history, n (%)
No 392 (83.4) In this study, the desire problems were detected in 49.4% (232/470)
Yes 78 (16.6) of the studied women, while an arousal problem was detected in
Studied population according to their medication, n (%)
31.9% (150/470) and the lubrication problem in 39.2% (184/470).
No 398 (84.7)
An orgasm problem was detected in 39.57% (186/470) of the
Yes 72 (15.3)
Studied population according to contraceptive use, n (%)
studied women, while the satisfaction problem was detected in
No 202 (43.0) 43.82% (206/470) and pain problem during sexual relation in
Yes 268 (57.0) 19.2% (90/470).
Data are presented as n (%) or mean±SD. SD: Standard deviation
Cayan et al.[4] reported desire problems in 60% of their studied
31.9% (150/470) and lubrication problem in 39.2% (184/470). women, arousal problems in 43%, lubrication problems in 38%,
An orgasm problem was detected in 39.57% (186/470) of the and orgasmic problems in 46%, which indicate that the results of
studied women, while the satisfaction problem was detected this study are consistent with what was reported by Cayan et al.[4]
in 43.82% (206/470) and pain problem during sexual relation
in 19.2%  (90/470). There was positive significant correlation In addition, Castelo‑Branco et al.[14] conducted a study on
between each domain of the FSD and the studied women’s age 534 healthy women (52 ± 6 years) to assess FSD, and they
except pain [Table 4]. reported desire disorders in 38%, arousal disorders in 32%,

Journal of Family Medicine and Primary Care 1490 Volume 7 : Issue 6 : November-December 2018
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Maaita, et al.: Sexual dysfunction among Jordanian women

orgasmic disorders in 25%, and dyspareunia in 33% of the pain (all domains of the FSD increased with the increased
studied women. women’s age). Levine et al. [16] previously confirmed this
correlation in their study.
Age is the most important factor for FSD[14‑17]; in this study,
participants with FSD were significantly older than 50 years of Parity and duration of marriage have negative correlation with
age (100%, P < 0.01), and they all have domains of FSD except FSD,[2] and this study and other previous studies showed that
dyspareunia which was less in their age group compared to others. women with more children had higher sexual disorders.[18,19] Other
This can be explained by the less frequent intercourse and/or sexual studies failed to confirm this relationship.[20,21]
relation in their age group compared to other younger age groups.
Makkii and Yazdi[22] recommended designing valid surveys on
In this study, there was positive significant correlation between large samples to overcome the inconsistency in the results of
each domain of the FSD and the studied women’s age except the effect of parity on FSD.

Chronic diseases such as hypertension, diabetes mellitus, and


Table 3: The potential risk factors for female sexual
ischemic heart diseases were generally not strongly correlated to
dysfunction
FSD in some studies,[23] while in this research we found significant
Potential risk Sexual dysfunction χ2 P
relationship between FSD and chronic diseases (89.7%,
factor (total 304 women), n (%)
P < 0.001).
Parity
≤4 244/304 (80.3) 9.4 <0.05
>4 60/304 (19.7)
In addition, previous studies showed positive association among
Age of husband depression, anxiety, and FSD.[24]
≤40 206/304 (67.8) 9.8 <0.02
>40 98/304 (32.2) Data regarding the effect of contraception on FSD are conflicting,
Level of education as there are no randomized controlled trials to compare the
Middle 106/304 (34.9) 2.3 <0.34 effect of different methods of contraception (hormonal and
Higher 198/304 (65.1) non‑hormonal methods) on FSD.
Income
≤500 62/304 (20.4) 2.9 <0.24 A decrease in sexual interest in women using some birth control
>500 242/304 (79.6) methods was reported by a prospective cohort study,[25] which
Occupation was the largest to address this issue. It compared women
No 127/304 (41.8) 8.7 <0.05
who used copper intrauterine device (IUD) with women
Yes 177/304 (58.2)
using other hormonal methods; a decrease in interest was
Duration of
relationship found in women using estrogen–progestin vaginal ring, depot
≤10 192/304 (63.2) 9.6 <0.05 medroxyprogesterone, and progestin implant. There was no
>10 112/304 (36.8) effect on sexual interest in women using estrogen–progestin
Medical history oral contraceptives, progestin IUD, or estrogen–progestin
Free 234/304 (77) 10.2 <0.05 patch. In general, the data of this study showed more sexual
Present 70/304 (23) dysfunction in those who did not use contraception (75.2%,
Medication P < 0.005).
No 241/304 (79.3) 9.3 <0.05
Yes 63/304 (20.7) The prevalence of FSD is high in this study and we have to
Use of contraction acknowledge the fact that FSD is a problem in our society. We
No 151/304 (49.7) 8.3 <0.05 need to have clear pathways to refer these patients for further
Yes 153/304 (50.3)
Data are presented as n (%) and the Chi‑square test used for statistical analysis. FSD: Female sexual
management. Unfortunately, we do not have sexual therapists
dysfunction in Jordan to treat these patients and some of them are managed

Table 4: The domain score of each sexual dimension of each studied group
Parameters ≥18 (n=10) 19‑29 (n=206) 30‑39 (n=176) 40‑49 (n=56) 50‑59 (n=14) 60‑69 (n=8) P Total scores (mean±SD) Total, n (%)
Desire 4.12±1.07 3.94±1.37 3.60±0.00 3.26±1.22 2.9±0.78 1.1±0.30 0.05 3.15±0.91 232 (49.4)
Arousal 4.2±0.82 3.84±1.24 4.3±0.89 3.02±1.6 1.9±1.76 0.00±0.00 0.001 2.87±1.57 150 (31.9)
Orgasm 5.11±1.26 5.04±1.32 4.57±1.65 3.60±1.90 1.89±1.68 0.00±0.00 0.01 3.37±1.30 186 (39.57)
Pain 1.90±2.03 2.02±2.19 2.14±2.19 2.23±2.35 2.27±2.29 3.36±2.15 0.005 2.32±2.21 90 (19.15)
Lubrication 5.52±1.73 5.14±1.49 4.72±1.66 4.16±1.97 2.57±2.24 0.00±0.00 0.001 3.69±1.53 184 (39.15)
Satisfaction 5.37±0.31 5.52±0.66 4.66±1.92 4.11±2.10 2.91±2.18 1.20±0.00 0.05 3.96±1.36 206 (43.82)
Overall 26.22±7.22 25.5±8.27 23.99±8.31 20.38±11.14 14.44±10.93 5.66±2.45 0.05 19.36±8.71 304 (64.7)
Data are presented as mean±SD or n (%). Student’s t‑test used for statistical analysis. SD: Standard deviation

Journal of Family Medicine and Primary Care 1491 Volume 7 : Issue 6 : November-December 2018
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Maaita, et al.: Sexual dysfunction among Jordanian women

by general gynecologists or psychiatrists who are not trained in 8. Hisasue S, Kumamoto Y, Sato Y, Masumori N, Horita H,
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Journal of Family Medicine and Primary Care 1492 Volume 7 : Issue 6 : November-December 2018

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