The study investigates prevalence of sexual dysfunction (SD), sexual satisfaction and their correlates in the rural female population in China. An anonymous cross-sectional study was carried out in a random sample of 1178 married of age 20–39 years in Dengfeng County, Henan, China. The prevalence of having at least one SD was 43 and 38% of the respondents were satisfied with their sexual life; 64.0% thought that sex was not important to them; and 85.7% believed that they do not have adequate sex-related knowledge. Having SD and high sexual satisfaction were associated with high mental health or vitality quality of life scores and better perceived health status. Other independent predictors of SD included sociodemographic variables, biological variables, life style factors and masturbation. It is concluded that SD was prevalent among the studied women and were associated with mental health. The sexual health among married women needs to be improved in rural China.
The prevalence of sexual dysfunction (SD) were reported for the United Status female general population1 (anxiety or inhibition during sexual activity: 38.1%; lack of sexual pleasure: 16.3%; difficulty in achieving orgasm: 15.4%; lack of lubrication: 13.6%; painful intercourse: 11.3%). In England, the overall prevalence of SD was 41% among women (orgasmic dysfunction 27%, dyspareunia 18%, vaginal dryness 28%, problems with arousal 17%, inhibited enjoyment 18%).2 Spector and Carey3 reviewed 23 studies and reported current prevalence for inhibited female orgasm to be 5–10%.3 Another study in the United States showed that SD was more prevalent among women (43%) than among men (31%).
SD could be influenced by disease conditions and psychological problems.4, 5, 6 In Zurich, SD was found in 26% of the normal population, 45% of nontreated depressed patients and 63% of treated depressed patients.7 A large proportion of the population in China are living in rural areas (63.91%).8 Yet, no relevant studies have been reported.
The study investigates the prevalence of female SD, sexual satisfaction and perceptions related to SD in a rural China younger female adult population. Factors that are associated with SD and sexual satisfaction were also identified.
A study was conducted in the Dengfeng County of the Hunan Province, during August through November 2003. Denfeng has an area of about 1200 km2; 90% of the 0.62 million residents lived in rural areas. The study population comprised married women who were of age 20–40 years.
First, five of the 17 rural districts in Dengfeng were randomly selected. In all, 10 villages were then randomly selected from the villages of these five districts. The 10 sampled villages have a total of about 4100 eligible women, which made up the sampling frame of this study (a list of all married women was being kept by the local Family Planning Unit), from which 1300 women were randomly selected. They were visited at home by a female fieldworker accompanied by a staff of the local family planning unit. The study was implemented by the fieldworkers who were a member of the research team (not a member of the local Family Planning Unit). With informed consent, a total of 1198 women aged 20–39 years participated in the survey (a response rate: 92.2%); 24 women (2%) were sexually nonactive and were excluded from the analysis. Ethics approval was obtained from the National Family Planning Institute of China. The anonymous and structured questionnaire were self-administered by 85% of the respondents, the rest was filled in the questionnaire with assistance obtained from the fieldworker. Privacy and confidentiality were ensured.
The SD questions were based on DSM-IV definitions,9 including six categories of SD occurring in the past 12 months10, 11 (questions asked included: whether you had physical pain during intercourse in the last 12 months, whether you lacked desire for sex in the last 12 months, whether you had lubrication difficulties in the last 12 months, whether you were inability achieving climax in the last 12 months, whether you were anxious about sexual performance in the last 12 months and whether you found sex not pleasurable in the last 12 months).
Background characteristics (see Table 2), variables related to sexual and reproductive characteristics (see Table 3), perceived physical health status and perceived sexual satisfaction were measured. Mental health and vitality quality of life (QOL) scores, using SF36 subscales,12, 13 were also measured (Table 4).
Age-specific prevalence of SD was derived and was tabulated by relevant factors. χ2-test, odds ratios (OR) obtained from logistic regression models, adjusting for age, ages at marriage and education level were calculated. Multivariate stepwise regression models, using variables that were statistically significant in previous analyses as input, were also performed. Data analysis was performed using SPSS for Windows Release 11.0.1 (SPSS Inc., Chicago, USA).
Background characteristics of respondents
The frequency distribution of socioeconomic characteristics, smoking and alcohol use and various reproductive variables were summarized in Tables 1, 2 and 3. Of the respondents, 67% of them reported a coital frequency of ⩾2 times per week and 4% self-reported that they had masturbated in the last 12 months; 36% of them perceived sexual life to be important and 86% perceived their sexual knowledge to be inadequate (Table 3). Around 50% of the respondents perceived their physical health to be excellent or very good (Table 4).
Prevalence of SD
The prevalence of individual types of SD ranged from 20.7 (pain: 95% CI=18.4–23.0%) to 30.5% (no climax: 95% CI=27.9–33.1%). Those who were in their 30s were more likely than those who were in their 20s to have SD in most of the items (OR ranged from 1.52 to 1.86, P<0.01, see Table 1), except for pain and finding sex not pleasurable. Among all respondents, 43% (95% CI=40.5–46.2%) reported having at least one of the six studied SD and 36% (95% CI=33.2–38.7) reported having more than one SD; statistically significant age differences were observed (see Table 1).
Factors associated with individual SD
Adjusting for age and age at marriage, years of education were associated with all but one type of SD (except finding sex not pleasurable) (adjusted OR=1.43–1.98, P<0.05, Table 2). Adjusting for age at marriage and education, younger age was associated with lack of sexual interest and lubrication problems (adjusted OR=0.39–0.64, P<0.05).
Adjusting for age, education and age at marriage, higher income (adjusted OR=1.46–3.45) and sharing a bedroom with other nonspouse family members (adjusted OR=1.34–5.69) were associated with all six types of SD. Smokers and drinkers were more likely than others to be unable to achieve orgasm (adjusted OR=5.26 and 2.36, P<0.05, respectively). Similarly, adjusted for age, education level and age at marriage, those who reported poorer physical health condition (adjusted OR=2.02–2.88) and lower mental health QOL or vitality QOL (adjusted OR=2.09–50.44) were associated with all types of SD (see Table 4).
With similar statistical adjustments, experience of pregnancy (adjusted OR=1.75–2.28, P<0.05), artificial abortion (adjusted OR=2.14, P<0.05), older age at menarche (adjusted OR=1.96–3.68) and use of IUD (adjusted OR=1.50–1.77, P<0.05), ever having cervical erosion, RTI or menstrual disorder (adjusted OR=2.68–144) were associated with various types of SD. Those who had masturbated in the last 12 months (adjusted OR=1.81–2.69, Table 4), currently pregnant women (adjusted OR=0.17 and 0.32, respectively, Table 3), and who believed sexual life is important were less likely to report SD (adjusted OR=0.25–0.36). Adequate sexual knowledge was not associated with any of the six types of SD (Table 4).
Factors predicting at least one SD (multivariate analysis)
The results of the stepwise logistic regression model, using age and all significant variables listed in Tables 2, 3 and 4 as input variables showed that higher average annual income per family member, alcohol consumption, higher age at menarche, ever having contracted RTI, having masturbated in the last 6 months, perceiving an average or poor general physical health status and lower vitality QOL scores were all significantly and independently associated with having at least one SD (adjusted OR=2.53–38.00, P<0.01, Table 5). Further, those perceiving that sexual life is important were less likely than others to have at least one SD (adjusted OR=0.48, P<0.001, Table 5). Age and whether sharing bedroom with other nonspouse members were marginally significant in the model (P=0.055 and 0.056, respectively) (Table 5).
Satisfaction with one's sexual life
Of all respondents, 39% of the respondents stated that they were satisfied with their sexual life. Older age, higher income, perceiving sexual life as important, perceiving adequate sexual knowledge, perceiving better physical health status and better mental health QOL were associated with better sexual satisfaction, both univariately (OR=1.38–7.24) and multivariately (adjusted OR=1.32–4.30) (Table 6) (vitality QOL was univariately but not multivariately significant). All six SD were univariately associated with one's lower sexual satisfaction (adjusted OR=0.33–0.69). Pain in sex (adjusted OR=0.57, 95% CI: 0.34–0.93) and finding sex not pleasurable (adjusted OR=0.48, 95% CI: 0.31–0.75) were multivariately associated with sexual satisfaction (but not anxiety, inability to have orgasm, lack of interest in sex and lubrication problems).
Seeking consultation from doctors
Among those with SD, about 12.4% sought consultation from doctors, ranging from 9.1% for the lubrication problem to 14.2% for lack of orgasm (data not tabulated).
It is seen that 43.4% of all respondents self-reported having at least one SD; such figure is comparable with those obtained from the United States,10 Europe2, 14 and Iran.15 Yet, our sample consisted of younger adults and international data may not be easily comparable.16 All the studied SD were associated with lower sexual satisfaction (OR=0.33–0.69). Such an association was also reported in other studies.17
The prevalence for the six studied SD ranged from 20.3% (pain) to 30.5% (no orgasm), and therefore no particular type of SD was dominant. When women enter their 30s, the odds for having different types of SD increased moderately (OR=1.52–1.86). The age effect remains in the multivariate analysis for predicting at least one SD. It is expected that SD among those of age above 40 years would even be higher.
Pain and lack of interest remained multivariately significant in predicting sexual satisfaction. Treatment and counseling for SD are hence important to enhance sexual satisfaction. Yet, only 12.4% of those with SD consulted a doctor. The low prevalence may be due to limited accessibility to relevant services. However, the traditional Chinese culture, which discourages discussing sex-related issues with others, and/or the lack of sex-related knowledge, etc., may also prohibit service seeking.
Further, both sexual satisfaction and having at least one SD were significantly associated with mental health and vitality QOL measures and perceived physical health status. Sexual health, physical and mental health may therefore be inter-related. The causal directions needs to be clarified.18, 19
Only 38.7% of the respondents were satisfied with their sexual life, while 64.0% of the respondents stated that sexual life was not important to them. Sexual well-being may therefore have been under-emphasized by females in rural China. It is speculated that the male-dominant traditional Chinese culture, which is still very intact in rural China, may have been suppressing women for seeking sexual pleasure. It is interesting to see that women with some SD (including no orgasm, pain and lubrication, lack of interest and anxiety) were more likely than others to have higher (instead of lower) coital frequency. It is possible that sexual activities may have been demanded by the husband of these women having SD, even if the wife was not finding sex enjoyable. Such would be an interesting research topic.
Further, 85.7% of the respondents expressed that they did not possess adequate sexual knowledge. Sexual knowledge, although not significantly associated with SD, was significantly associated with sexual satisfaction. As expected, not much promotion of sexual health has been noticed in rural China, but such in fact is very much warranted.
It is seen that income and education level were associated with SD; income remained statistically significant in the multivariate analysis in predicting at least one SD. It is speculated that the women with better education or income may have a different lifestyle. They may have found greater difficulties to conform with the traditional male-dominant Chinese culture. The prevalence of smoking and drinking alcohol were low for the sampled rural women. However, these life style factors predicted SD. These gave some support to other studies reporting similar associations.20, 21
The current study further found that Chinese women with late menarche (13–14 vs ⩽12 years) were at high risk of having SD (multivariate analysis), which is supported by another study.22 Associations were found between SD and RTI, cervical erosion, menstrual disorders and use of IUD, which have not been well documented in the literature.
A particularly interesting finding is that living arrangement (sharing a room with other nonspouse family members) was associated with SD. Such an arrangement is very common in rural China (over 60% in our sample), and is possibly also common in other developing countries. Privacy for sex is hence an issue for SD in developing countries. According to our research, such has not been investigated.
Those perceiving importance of sexual life was less likely than others to have SD and more likely to be satisfied with their life in general. However, 64.0% of the respondents expressed that sex is not important to them, as compared to lower corresponding figures observed in the Western populations.14, 23 It is possible that those who feel sex to be important would pay more attention to their sexual life, such as communicating with their husband or expressing their needs, thus lowering the chance of having SD. It is also possible that those with SD may deny their needs or to justify their unfulfilled needs by ‘believing’ sex is not important to them. Cognitive dissonance would therefore be reduced.24 It is also possible that as a result of being socialized by the traditional Chinese culture that tends to suppress sexual pleasure among women, females consciously or subconsciously, downplayed their perceived importance of sex. Since this is an important predictor of SD and sexual satisfaction, education should promote the perceived importance of sexual health, and to encourage women in rural China to express their feelings over sexual matters. Again, such are speculations and further studies are required.
There are additional signs that sexual health of women living in rural China has not been optimal, as many of them were having SD, inadequate sexual knowledge, lower satisfaction with their sexual life or were seeing sexual life as being not important to them, although SD and sexual health were, however, in fact, associated with mental health and vitality aspects of QOL.25 Further, few of those women suffering from SD, however, sought treatments.
The study has a few limitations. The data were self-reported. Self-reported SD data have, however, been used in other similar studies.10, 26 In addition, these figures would have been underestimated if reporting bias were prevalent. Second, associations rather than causal relationships have been reported as this is a cross-sectional study. Third, China is a vast country and the results obtained from a locality may not be representative. Further, the prevalence of older adult women has not been studied.
Results of this study showed that determinants of SD are multidimensional, including sociodemographic factors, life style factors (such as alcohol consumption, artificial abortion, contraception device), living arrangement, biological characteristics (such as age at menarche and menstruation problems), perceptions (such as importance of sex), sexual knowledge, physical health status and QOL, etc. Multidisciplinary efforts to promote sexual health are much warranted.
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