Sexual problems among married Nigerian women

Abstract

We interviewed and examined 293 married women, 15–49 years of age, seeking primary care at a teaching hospital in central Nigeria. One or more sexual problems were identified in 71% of women. The proportion of specific sexual problems was 39% for a desire problem, 40% for an arousal problem, 31% for a sex pain problem and 55% for an orgasmic problem. Poor marital communication, lack of foreplay, Islamic religion and advancing age were independently associated with a desire problem. Absence of foreplay was independently associated with an arousal problem. Lack of foreplay, lower abdominal pain, gynaecological conditions, working outside the home and younger age were independently associated with a sex pain problem. The absence of foreplay, poor marital communication and being a housewife were independently associated with an orgasmic problem. Sexual problems are common among married Nigerian women seeking outpatient care.

Introduction

Sexual health, an aspect of reproductive health, encompasses the absence of sexually transmitted diseases and reproductive disorders, control of fertility, avoidance of unwanted pregnancies and sexual expression without exploitation, oppression or abuse.1 Some patients with sexual problems present with physical complaints that have a psychological basis.2 Gynaecological or urological complaints, insomnia, depression, arthralgia and other symptoms may indicate underlying sexual problems. Sexuality is a sensitive area for most persons. Physicians share some of the taboos, embarrassment, shyness and inexperience in discussing sexual matters, often lacking information other than personal experience.3 Although sexually transmitted infections generally are managed appropriately, sexual health usually is not discussed until or unless a problem arises.1

Female sexual dysfunction has been categorized as sexual desire, sexual arousal, orgasmic and sexual pain disorders.4, 5, 6, 7 Psychological and organic factors may contribute to sexual dysfunction. Psychological factors include fear, depression, fatigue, stress, anxiety and beliefs.6 Beliefs about female sexuality are influenced by culture, education and religion. For most of human existence and in many societies, women have been regarded as property and subject to men.8 Organic factors include gynaecological, urological, endocrine and neurological disorders.6, 9, 10

Most studies of sexuality carried out in developing countries concern adolescent reproductive health, contraception or sexually transmitted infections.11, 12 Little is known about sexual problems among married African women. We sought to determine the nature and prevalence of sexual problems among married women in the reproductive age group seeking outpatient care at a Nigerian teaching hospital and to characterize the risk factors for sexual problems.

Methods

We recruited consecutive married women in the reproductive age group (15–49 years) who presented for outpatient medical care at the Jos University Teaching Hospital between February and May 2004. Jos is an urban centre (1991 census population 650 839) located in central Nigeria with approximately equal proportions of Christians and Muslims. The outpatient department of the teaching hospital is staffed by family physicians, and the majority (>95%) of patients are self-referred and seeking primary care. Eligible women were informed about the importance of sexual health to their overall well being and invited to be confidentially interviewed about their sexual health. Women in acute distress or requiring admission were excluded. Written, informed consent was obtained from all women and the study was approved by the ethical committee of the Jos University Teaching Hospital.

Based on our experience of identifying sexual problems among women presenting with somatic complaints, we developed a structured questionnaire with terminology familiar to Nigerian women to determine the prevalence and nature of sexual problems. The 68-item questionnaire was verbally administered in English or Hausa by a female family physician and required 30–45 min to complete. Data were collected about the presenting complaint, the respondent's family background, parity, dates of deliveries, practice of polygamy, contraceptive use, age at marriage, husband's occupation and education, and whether husband lives together with the patient. We sought information about beliefs, desire for sex, pain or difficulty at penetration, vaginal lubrication, satisfaction, orgasm and whether intercourse takes place during pregnancy and breastfeeding. Classification of sexual problems was consistent with Diagnostic and Statistical Manual of Mental Disorder (DSM-IV) criteria,4 except that the criterion of marked distress or interpersonal difficulty was not assessed. Consequently, we use the term ‘problem’, rather than the DSM-IV term ‘disorder’, to classify sexual difficulties. Desire was categorized as none, low, medium or high. Responses of ‘none’ or ‘low’ were considered as a desire problem. An arousal problem was defined as inadequate vaginal lubrication during sexual intercourse. A sex pain problem was characterized by the usual experience of pain during sexual intercourse, which was categorized as deep or superficial. Occurrence of orgasm was categorized as never, rarely, sometimes, usually and always. Responses of ‘never’ or ‘rarely’ were considered as an orgasmic problem.

We sought information on possible psychological risk factors of sexual problems including marital communication, causes of conflicts, the husband's beliefs about women and his attitude towards the respondent. We inquired about age at first intercourse, female circumcision, history of forced sex, lifetime number of sexual partners and whether another partner had satisfied the patient more than her current partner. Organic risk factors were evaluated including chronic medical illness, pelvic or abdominal pain, vaginal discharge or pruritus, previous gynaecological diagnoses and current medications. We sought information about somatic symptoms often reported by Nigerian women which have no clear organic cause, like difficulty in initiating or sustaining sleep, early morning awakening, crawling sensations in the body and movement in the abdomen.

Physical examination included blood pressure, weight, height and abdominal examination. Pelvic examination focused on evidence of circumcision, vulvovaginal abnormalities, discharge, tight introitus, cervical motion tenderness, uterine size, adnexal enlargement and tenderness. Additional investigations were performed as clinically indicated.

Data were entered, checked and analysed in Epi Info 3.02 (CDC, Atlanta, GA, USA). χ2analysis was used to compare categorical variables and obtain unadjusted odds ratios in univariate analysis. Logistic regression analysis was used to simultaneously control for characteristics that were significantly associated with sexual problems in the univariate analyses. Adjusted odds ratios are reported for factors that remained significant in logistic regression. A P-value less than 0.05 was considered significant.

Results

A total of 299 women were approached to participate. Six (2%) declined consent: four considered themselves too old for sex (38–42 years) and two Muslim women said their religion did not allow them to discuss sexual matters. The 293 respondents ranged in age from 17 to 49 years, with a mean (±s.d.) age of 31±8 years (Table 1). Over one-quarter had no formal education and 31% had only primary education.

Table 1 Characteristics of 293 Nigerian women

About one-third (32%) of the women were in a polygamous setting, which was more frequent among Muslims than Christians (odds ratio (OR) 7.0; 95% confidence interval (CI) 3.8–13). Muslim women were younger (15.9±2.6 years) than Christian women at first intercourse (18.4±3.3 years; P<0.001). The mean age at marriage was 18±4 years, and uneducated women were more likely to marry early (12.5; 5.3–30).

The most common frequency of intercourse was 1–2 per week (41%). Ten per cent of women had had no intercourse within the preceding 6 months. A minority (29%) used contraception. Most women (79%) engaged in foreplay, and 92% believed sex was meant to be enjoyed by women. Foreplay was significantly associated with satisfaction (P<0.001) and orgasm (P<0.001). Over one-third (35.3%) had no sex education before marriage, and their first source of information about sex was their husbands. A minority (32%) of women refrained from sex during breastfeeding, because they believed it would make their baby sick or to prevent pregnancy.

Most women (94%) had marital conflicts (Table 2), and 23% reported they did not communicate openly with their husbands. The majority (57%) had been forced by their husbands to have sex, and 17% had been forced by other men (primarily relatives) to have sex before marriage. Interpersonal conflicts with other wives affected the relationships of married women with their husbands (Box 1).

Table 2 Primary causes of marital conflict in 293 Nigerian women
Box 1 Representative statements by Nigerian women of sexual difficulties

Only three (1%) women had a sexual problem (all dyspareunia) as their presenting complaint (Table 3). No organic cause could be identified for 33% of the presenting complaints. Abnormal vaginal discharge (24%) was the most common gynaecological complaint. A diagnosis of human immunodeficiency virus (HIV) infection was reported by three women (1%). Fifty-two (18%) women were on medication, antihypertensives (13%) being most common.

Table 3 Physical symptoms and findings

Circumcision was reported by 38% of women, involving a portion of the clitoris during infancy. Two were circumcised as teenagers or young adults with excision of the clitoris and labia minora, which was confirmed by examination. Of 35 women with abnormal vaginal discharge, 21 had candidiasis by microscopy or culture. Of 13 non-pregnant women with uterine enlargement, ultrasound confirmed fibroids in 10. One woman with adnexal tenderness had a tubo-ovarian abscess identified by ultrasound.

One or more sexual problems were identified in 71% (95% CI 66–76%) of women (Table 4). A desire problem was present in 39% (34–45%), an arousal problem in 40% (34–46%), a sex pain problem in 31% (26–36%) and an orgasmic problem in 55% (49–61%). Selected risk factors and their association with sexual problems are shown in Table 5. Women with poor marital communication (OR 2.9; 95% CI 1.6–5.0), early morning awakening (2.5; 1.5–4.1), chronic medical conditions (2.3; 1.2–4.3), bodily crawling sensations (2.4; 1.4–4.3) and advancing age (P<0.01) were at increased risk of a desire problem. A desire problem occurred less frequently in women with formal education (0.42; 0.25–0.71) and among those who engaged in foreplay (0.19; 0.11–0.35). In logistic regression, poor marital communication (adjusted OR 2.4; 1.3–4.6), lack of foreplay (3.7; 1.9–7.1), Islamic religion (2.0; 1.1–3.5) and advancing age (P<0.001) were independently associated with a desire problem.

Table 4 Specific sexual problems and concerns
Table 5 Sexual problems and risk factors

An arousal problem was more likely in women from a polygamous setting (1.9, 1.1–3.1), with chronic medical conditions (2.0; 1.1–3.7), using medication (2.0; 1.1–3.6), with early morning awakening (2.2; 1.4–3.6) and with bodily crawling sensations (2.2; 1.2–3.8). An arousal problem occurred less frequently in those with formal education (0.38; 0.23–0.65) and who engaged in foreplay (0.08; 0.04–0.17). However, in a logistic regression controlling for variables associated with an arousal problem in the univariate analysis, only absence of foreplay was independently associated with an arousal problem (adjusted OR 10; 4.8–21).

The frequency of a sex pain problem was greater among those with lower abdominal pain (4.6; 2.4–8.6), gynaecological conditions (3.0; 1.2–8.0), abnormal vaginal discharge (2.3, 1.3–3.9) and lack of foreplay (4.0; 2.2–7.1). Contraceptive users had a lower risk of a sex pain problem (0.53; 0.29–0.95). Variables independently associated with a sex pain problem in logistic regression were lack of foreplay (adjusted OR 6.9; 3.4–14), lower abdominal pain (6.5; 3.2–13), gynaecological conditions (4.6; 1.5–14), work outside the home (2.2; 1.2–4.0) and younger age (P=0.02). Those with a sex pain problem were also more likely to have a desire problem (OR 4.4; 2.6–7.4), an arousal problem (2.2; 1.3–3.7) and an orgasmic problem (3.9; 2.2–6.9).

Risk factors for an orgasmic problem included being Muslim (1.9; 1.2–3.0), poor marital communication (2.7; 1.5–4.9), polygamy (1.8, 1.1–3.0), being a housewife (1.7; 1.1–2.7), no formal education (2.0; 1.1–3.1), early morning awakening (2.1; 1.3–3.5), bodily crawling sensations (1.9; 1.1–3.4) and forced sexual intercourse by the husband (1.7; 1.1–2.8). Contraceptive use was associated with a reduced frequency of orgasmic problems (0.63; 0.38–1.0). Variables that independently predicted an orgasmic problem in logistic regression were absence of foreplay (adjusted OR 11; 4.6–27), poor marital communication (2.1; 1.1–4.0) and being a housewife (1.8; 1.1–2.9).

Women with some formal education were more likely to communicate openly with their husbands (1.9; 1.0–3.3), engage in foreplay (4.6; 2.5–8.2), use contraception (2.4; 1.2–4.5) and marry at an older age (median 19 vs 15 years; P<0.001). Women who had been forced by their husbands to have sex married at younger ages than those who had not (median 17 vs 19 years; P<0.001). Female circumcision was not associated with any sexual problem. The frequency of coitus was significantly lower (P<0.001) in those with all sexual problems, except pain problems, than in those without any problem.

Discussion

Sexual problems were common among married Nigerian women seeking outpatient medical care, with 71% having one or more sexual problems. The proportion of specific sexual problems ranged from 31% for a sex pain problem to 55% for an orgasmic problem. To our knowledge, this is the first study to describe the prevalence and nature of sexual problems in married African women. The study comprised women from many tribes and cultures in Nigeria. We found that poor marital communication, lack of foreplay, unexplained somatic symptoms and lower abdominal pain were often associated with sexual problems.

The frequency of sexual problems and concerns may be greater among married Nigerian women presenting for care than in other parts of the world. In a study of London general practices, 40% of women received at least one diagnosis of sexual dysfunction by conservative International Classification of Diseases (ICD)-10 criteria, but only 3–4% had sexual difficulties identified in their practice records.13 In a large telephone survey in Australia, 55% of women lacked interest in sex, 20% experienced pain during intercourse and 29% failed to have orgasm.14 In a probability sample of the US population, 22% of women had low sexual desire, 14% had arousal problems, 7% had sexual pain and 26% were unable to achieve orgasm.15

Few studies of female sexual dysfunction have been carried out in non-Western countries. In Turkish women, 48% had a desire problem, 36% an arousal problem, 43% a pain problem and 43% an orgasm problem.16 In a large population survey of Iranian women, 35% had desire disorders, 30% arousal disorders, 27% pain disorders and 37% orgasmic disorders.17 In a population survey of rural Chinese women, 25% had desire disorders, 26% arousal disorders, 21% pain disorders and 31% orgasmic disorders.18 These varying prevalence rates likely reflect differing methodologies and populations.

As expected, relationship problems were associated with sexual difficulties. Many clinicians believe that the couple, rather than the woman, is the correct focus for assessing dysfunction.19 Some sexual problems could potentially be ameliorated, because they were associated with poor marital communication, lack of foreplay and low educational attainment. We found a direct relationship between educational attainment and engagement in foreplay, which was strongly associated with sexual satisfaction and orgasm. Some uneducated respondents admitted that they felt inhibited when their husbands wanted to engage in foreplay. Lower educational attainment has been associated with sexual dysfunction in other studies15, 17 and may account for the high prevalence of sexual problems in Nigerian women.

Contraceptive users experienced orgasm more frequently than non-users. Contraceptive use has been associated with increased frequency of sexual activity in rural Nigerian women.20 An increased frequency of sexual intercourse has been associated with a lower risk of desire and arousal disorders,15 although this may simply indicate that women with sexual dysfunction are less likely to engage in sexual activity. Users of contraceptive were also less likely to be abstinent during breastfeeding than non-users. The cultural proscription of intercourse during breast feeding has been associated with increased extramarital sexual encounters by men.21

One strength of our study was the high response rate, with less than 2% of the women declining to participate. A female family physician was able to make women more comfortable to discuss their sexual problems and concerns,10 reducing potential bias. However, cultural restrictions and the traditional inhibitions in discussing sexual matters could have reduced the reporting of sexual problems.

Although we did not fully utilize the DSM-IV criteria for the diagnosis of sexual dysfunction (e.g. absence of sexual fantasies), the aspects of sexual dysfunction we explored were culturally relevant. There have recently been calls to redefine women's sexual dysfunction, because the traditional DSM-IV criteria are at variance with current concepts of women's sexual response.19, 22 We did not assess the DSM-IV criterion of ‘marked distress or interpersonal difficulty’ resulting from sexual dysfunction and our questionnaire was not psychometrically validated. In addition, the DSM-IV criteria for orgasmic disorder require sexual excitement sufficient for normal orgasm. The absence of foreplay in 21% of women suggests inadequate sexual stimulation to permit orgasm for many women. These factors would likely have resulted in lower prevalence estimates of sexual disorders based on strict DSM-IV criteria.

As this was a descriptive study, the association of risk factors with specific sexual problems is based on an exploratory analysis, which must be regarded as preliminary and requires confirmation. Because the study population comprised married women presenting for medical care, it may not be representative of women in the community. Women seeking medical care may have minor and major illnesses and take medications that predispose them to sexual problems.7, 9 Thus, they are not representative of the general population of women who do not seek care. However, they do reflect the population of women primary care providers in Africa are likely to encounter. Most women in this study had little education and low income, and thus this study may not be representative of Nigerians with higher education and income. However, most African women do not have secondary education, so the education and social class of women in this study still represent a large proportion of African women.

Sexual difficulties are common among married Nigerian women presenting for outpatient care. Many women are prepared to talk about sexual issues, if their physicians raise the topic. Appropriate counselling and sexual health education could potentially reduce the burden and prevalence of sexual problems. Furthermore, addressing sexual problems among married couples may provide an additional avenue for tackling the HIV/AIDS epidemic. These possibilities merit further investigation.

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Correspondence to T Thacher.

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Ojomu, F., Thacher, T. & Obadofin, M. Sexual problems among married Nigerian women. Int J Impot Res 19, 310–316 (2007) doi:10.1038/sj.ijir.3901524

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Keywords

  • Africa
  • reproductive health
  • culture
  • dysfunction
  • religion
  • risk factors

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