The effect of women's sexual functioning on quality of their sexual life.

INTRODUCTION: Considering the high prevalence of sexual dysfunction among women and the role of quality of sexual life in women's life and health, in addition to the important role of sexual function evaluation in measuring quality of life, this study aimed to determine the effect of female sexual function on the quality of sexual life.
MATERIAL AND METHODS: This research was a descriptive and cross-sectional. The population of this study was 420 women from Qazvin in 2020, who were selected by multi-stage sampling. The data collection tool was a demographic questionnaire and Persian version of the Female Sexual Function Assessment questionnaire (FSFI) and Sexual Quality of Life Questionnaire (SQOL-F). Data were analyzed using SPSS 23, and descriptive statistics and logistic regression were applied.
RESULTS: The mean (SD) of sexual function score was 21.56 (4.83) out of 36, therefore, it was at an unfavorable level. Also, the mean (SD) score of sexual quality of life 59.71 (19.21) was out of 108 (moderate). The results of logistic regression test showed that the variables of sexual function, age and level of education of women were the factors affecting the quality of women's sexual life (P < 0.05).
CONCLUSIONS: Young women with lower sexual function, and lower level of education had lower quality of sexual life. Hence, it is necessary to pay more attention to these women in designing educational programs for improving the quality of their sexual life. ©2021 Pacini Editore SRL, Pisa, Italy.

Introduction

Sexual activity is one of the important aspects of human life that can be influenced by personal characteristics, interpersonal relationships, family and socio-cultural circumstances, surrounding environment, history of sexual activity between spouses, in addition to the physical/mental and hormonal health status [1]. Sexual health is one of the main pillars for the stable marital life, hence, having comfortable sexual relations is highly influential in triggering happiness and improving quality of life [2]. Sexual health is the harmony between body, mind and feeling which contributes in shaping social and intellectual dimensions of one’s personality [3, 4].

Sexual function is a part of human life and behavior, and sexual health is strongly intertwined with the individual’s personality [5]. Human sexual function is a process that stands for a combination of different parts and requires coordination between the nervous, vascular and endocrine systems [6]. Normal sexual function is a component of a woman’s sexual and mental health, and changes in this function due to any reason can cause problems in emotions and interpersonal communication that might affect the other functions of women [1]. Sexual function for women is a state of ability to achieve sexual arousal, orgasm and satisfaction, which enhances health and status with a good quality of life [6]. Latest research on sexual health in Iran showed that women had poor sexual function [5]. Also, in Ladari et al. [7] and Tabaghdehi et al. [8] studies, 48.5 and 45.2% of women experienced sexual dysfunction, respectively.

On the other hand, sexual function is defined as a substantial part of health and an integral part of life in order to achieve sexual pleasure, which leads to better health and promoted quality of life [4]. One of the important physical and psychological dimensions of women’s quality of life is their way in practicing sexual life, which is affected by many factors [9].

Quality of sexual life is one of the key issues in the field of sexual and reproductive health. In most studies, sexual dysfunction is the main feature used to investigate the quality of life [10]. In other words, evaluation of sexual function plays a crucial role in measuring quality of life [11, 12]. Nowadays, there is a consensus on the interrelation between the quality of sexual life, and the level of satisfaction, and the level of general quality of life, so that the low quality of sexual life can be an indication to the low general quality of life [10]. The results of studies conducted in Iran and other countries have reported different levels of sexual quality of life among women. Moderate levels of sexual quality of life were reported in the studies of AJ et al. [13] and Kisa et al. [14], while these levels were good in Samimi of et al. [15], Aduloju et al. [16] and Roshan Chesli et al. [17].

Considering the high prevalence of sexual dysfunction among women [10], and its determining role of quality of women’s sexual life [9], in addition to its importance in measuring quality of life [11, 12], this study aimed to determine the effect of women’s sexual function on their quality of sexual life.

Methods

The present study was a descriptive-analytical cross-sectional conducted in 2020 among women referring to health centers in Qazvin. Sampling was done through one-stage cluster method so that at first a list of all comprehensive health centers in Qazvin was prepared. Then, out of these 24 centers, 6 centers from the north, south, and the city center were randomly selected and all women referring to these centers, who met the inclusion criteria, entered the study after obtaining written informed consent, and all eligible women referring to these centers were selected to participate in the study after granting the informed consent.

Regarding inclusion criteria, women who were referring to health centers in Qazvin, having a spouse and living together for at least one year, sexually-active, not having any chronic debilitating disease, not having a spouse suffering from premature ejaculation or impotence, with no diagnosed mental health problems (according to the participant’s report), finished at least their basic education, and showed willingness to participate in the study. Suffering from genital diseases and/or genital surgery affecting sexual potency, tubectomy, and use of drugs to reduce libido were exclusion criteria in this study. Moreover, incomplete questionnaires were excluded, and non-willingness to take part was considered as exclusion criteria.

One of the study objectives was to assess women’s sexual function. Therefore, according to the results of Maasoumi et al. study [5] and considering P = 0.52 for the frequency of sexual function, as well as using the formula of Cochrane’s sample size and calculating d = 0.05, the estimated sample size was 383. However, non-response rate was considered 10%, thereby, the sample size has been increased to 420.

Data were collected in this study using a questionnaire that included the following:

demographic and contextual information: including age of participant, level of education, employment status, age of first child, age of spouse, spouse’s educational level, duration of marriage, age at marriage, number of weekly sexual intercourses, and use of contraceptives;

the Persian version of the Female Sexual Function Questionnaire (FSFI) was used to assess women’s sexual activity in the last four weeks prior to the study. This questionnaire consists of 19 items; sexual desire (2 items for example: Over the past 4 weeks, how often did you feel sexual desire or interest?), arousal (4 items for example: Over the past 4 weeks, how often did you feel sexually aroused (“turned on”) during sexual activity or intercourse?), orgasm (3 items), sexual pain (3 items for example: Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)?), genital softening (4 items for example: Over the past 4 weeks, how often did you become lubricated (“wet”) during sexual activity or intercourse?) and sexual satisfaction (3 items for example: Over the past 4 weeks, how satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner?).

Each item has 6 choices; ‘I did not have sexual activity = 0’, ‘never = 1’, ‘rarely = 2’, ‘sometimes = 3’, ‘often = 4’ and ‘always = 5.’ The minimum score of the questionnaire was 2, the maximum score was 36, and the cut-off point was 28. In other words, scores higher than the cut-off point indicated desirable sexual performance [18]. The validity and reliability of this instrument in Iran have been assured by Mohammadi et al. as they found the Cronbach’s alpha coefficient in their study was 0.87 [19]. Also in the present study, Cronbach’s alpha coefficient for FSFI was 0.81. Therefore, the Persian version of FSFI is a reliable tool for assessing the sexual performance of Iranian women.

To evaluate the quality of women’s sexual life, the Persian version of the Sexual Quality of Life Questionnaire (SQOL-F) was used. This questionnaire was firstly designed in 1998, and revised and validated in 2005 by Symonds et al. [20]. This questionnaire is composed of 18 questions (for example 3 question: When I think about my sexual life, I find it an enjoyable part of my whole life. I have lost my self-confidence as a sexual partner. When I think about my sexual life, I feel like I have lost something) on a six-point Likert scale (strongly agree = 6, agree = 5, neutral = 4, disagree = 5 and strongly disagree = 6). The minimum score obtained was 18 and the maximum score was 108. The higher scores indicate a better quality of sex life [20]. For judging the results, the references values adopted in that study were classified as follow: (18-36) = poor quality, (37-72) = medium quality and (73-108) = good quality [20-21]. In the present study, the standardized questionnaire in Maasoumi et al. [21] was used. This questionnaire was translated and psychometric in 2013, and the Cronbach’s alpha coefficient was 0.73 and the internal correlation coefficient was 0.88. Also, content validity index and content validity ratio have been reported as 0.91 and 0.84, respectively [21]. In the current study, Cronbach’s alpha coefficient for this questionnaire was 0.76. According to the researchers of the present study, the quality of sexual life was descried as: undesirable when the score was in the range 18-36, and desirable when it was between 37 and 108. Data were analyzed using SPSS software version 23, and the descriptive statistics and logistic regression were applied to show the characteristics of study sample size, and to determine the influential factors on the measures under study, respectively. It should be noted that the quality of sexual life was the dependent variable, and the variables of age, level of education, employment status, age of first child, age of spouse, level of spouse education, duration of marriage, age at marriage, number of sexual intercourses per week, contraceptive use and sexual function, were the independent variables. In addition, the level of significance in this study was considered at p < 0.05.

ETHICAL CONSIDERATIONS

Ethical approval was granted by the Vice Chancellor for Research and Technology at Qazvin University of Medical Sciences (IR.QUMS.REC.1399.077). An introductory letter was sent to the health centers in Qazvin explaining the nature and study objectives, and presenting the study questionnaires. Confidentiality of collected information was assured for the officials of the comprehensive health centers as well as the participating women.

Results

A total of 420 women with mean (SD) age 33.14 (4.59) years were included in the study (the response rate was 100%). Of them, 59.5% (n = 250) were under 30 years old, 43.8% (n = 184) were housewives, and 47.4% (n = 199) were holding bachelor degree or higher. Table I shows the other sociodemographic characteristics of the participating women.

Tab. I.

Demographic and contextual characteristics of the study participants.

#	Variable		Frequency
			(n)	(%)
1.	Age (years)	Under 30	170	40.5
		30 or above	250	59.5
2.	Educational level	Elementary	45	10.7
		Middle school	32	7.6
		Diploma	47	11.2
		Associate degree	97	23.1
		Bachelor and higher	199	47.4
3.	Employment status	Housewife	184	43.8
		Unemployed	47	11.2
		Employee	131	31.2
		Self-employed	58	13.8
4.	Age of first child (years)	< 10	150	35.7
		10-20	139	33.1
		> 20	131	31.2
5.	Age of spouse (years)	< 35	196	46.7
		≥ 35	224	53.3
6.	Educational level of spouse	Elementary	44	10.5
		Middle	31	7.4
		Diploma	59	14
		Associate degree	89	21.2
		Bachelor and higher	197	46.9
7.	Marriage duration (years)	< 10	149	35.5
		10-20	140	33.3
		> 20	131	31.2
8.	Age at marriage (years)	< 25	188	44.7
		25-35	162	38.6
		> 35	70	16.7
9.	Sexual intercourses per week	0	82	19.5
		1	113	26.9
		2-3	134	31.9
		≥ 4	91	21.7
10.	Use of contraceptives	Yes	226	53.8
		No	194	46.2

The results showed that the mean (SD) score of sexual performance of female participants was 21.56 (4.83) out of 36, and this indicated an unfavorable level. Also, 59.3% (n = 249) and 40.7% (n = 171) experienced poor and good sexual function, respectively. The mean (SD) score of quality of sexual life of the participants was 59.71 (19.21) was out of 108 points, and lied in the moderate level. In addition, 25.5% (n = 107) had poor quality of sex life, while, 60% (n = 252) and 14.5% (n = 61) reported moderate and good quality of sexual life, respectively.

Table II illustrates the results of logistic regression which sought to determine the factors affecting the quality of sexual life of women in the study. The results revealed that age, level of education and sexual function were the most influential factors on the quality of women’s sexual life (p < 0.05):

Tab. II.

Factors affecting the quality of women’s sexual life based on logistic regression analysis.

#	Variable		Significance level	OR
1.	Age		0.025	0.104
2.	Educational level	Elementary	0.017
		Middle school	0.447	0.217
		Diploma	0.258	0.616
		Associate degree	0.031	0.258
		Bachelor and higher	0.021	1.586
3.	Employment status	Housewife	0.366
		Unemployed	0.744	0.584
		Employee	0.599	0.249
		Self-employed	0.312	0.125
4.	Age of first child (years)	< 10	0.325
		10-20	0.086	12.288
		> 20	0.586	4.347
5.	Age of spouse		0.181	1.214
	Educational level of spouse	Elementary	0.753	0.133
		Middle	0.512	0.222
		Diploma	0.799	0.219
		Associate degree	0.847	0.334
		Bachelor and higher	0.745	0.211
7.	Marriage duration (years)	< 10	0.788
		10-20	0.941	0.447
		> 20	0.957	1.458
8.	Age at marriage (years)	< 25	0.081
		25-35	0.093	2.111
		> 35	0.884	0.254
9.	Sexual intercourses per week	0	0.061
		1	0.873	0.258
		2-3	0.071	3.245
		≥ 4	0.062	2.554
10.	Sexual activity		0.009	3.221
11.	Use of contraceptives		0.588	2.471
12.	Intercept		1.000	6.23

Age variable was one of the factors affecting the quality of women’s sexual life (p = 0.024); so that the chance of having a desirable quality of sex life in women aged ≥ 30 was 1.104 times higher than women < 30 years old. Also, the level of education was also an influential factor on the quality of women’s sexual life (p = 0.017); so that the women with bachelor’s and higher education, and post-diploma education had a desirable quality of sex life 1.586 and 1.258, respectively, higher than those with elementary education. Meantime the variable of sexual functioning significantly affected the quality of women’s sexual life of (p = 0.009), thus, the women with good sexual performance was 3.221 times better than women with poor sexual performance regarding quality of sexual life.

Unlike, employment status, age of the first child, age of spouse, level of spouse education, duration of marriage, age at marriage, number of sexual intercourses per week and use of contraceptives have led to statistically non-significant differences in the quality of women’s sexual life.

Discussion

The aim of this study was to determine the effect of women’s sexual function from in Qazvin, Iran on their quality of sexual life. The results of the present study showed that the quality of sexual life of participating women was moderate, and was in line with the results of Kisa et al. [14], Aj et al. [13] and Sezgin et al. [22] studies, but inconsistent with the results of Samimi et al. [15], Maasoumi et al. [21] and Roshan Chesli and Et al. [17] and Ahmadian Chashemi et al. [23] and Aduloju et al. [16]. In the abovementioned studies, the quality of women’s sexual life was at a good level. The potential reasons for this discrepancy could be attributed to the difference in the research community, context and employment status of women in these studies compared to the present one, in which the majority of women were housewives, while in the aforementioned studies, most of them were employees. The nature of work is also one of the important factors that can affect the quality of life and, consequently, the quality of sexual life [15].

The results of the present study demonstrated that the sexual performance of participating women was an unfavorable. Considering the average level of quality of sexual life and its relationship between with sexual function in this study, it was assumed that sexual functioning will be also moderate. Thereby, this indicates that in addition to sexual functioning, there are some other confounders might influence the quality of sexual life of women under study. In the study of Maasoumi et al., the sexual performance of the participating women was also unfavorable [5]. The results of Kingsberg [24] and Aslan [25] studies were consistent with the results of the present study as well. Conversely, Sahebalzamani et al. [26] and Karamidehkordi [27] stated that the majority of participants in their studies had good sexual functioning. One of the reasons for this difference can be owned to the variation in the statistical population, cultural conditions and tools used. Furthermore, embarrassment of women to talk about sexual issues, lack of clear understanding sexual-related issues, and the paucity of studies in this domain, can be other reasons for this discrepancy.

In the current study, age was one of the factors affecting the quality of sexual life of women. It is noteworthy that age can led to differences in couples’ sexual performance and, consequently, the quality of women’s sexual life by making changes in sexual feelings and desires, sexual harmony, body shape, sexual ability and health status. These results were consistent with the studies of Beigi et al. [28] and Shahraki et al. [29]. Similarly, Samimi et al. believed that the role of age is prominent in the sexual functioning and quality of sexual life, and this role cannot be ignored [15].

The educational level of women was one also an influential factor on the quality of women’s sexual life. Science and knowledge play a role in the growth and intellect of individuals. It also affects the way people behave and how they socially interact with each other in general and with their family members in particular. Therefore, this can justify the contribution of education level in improving the quality of women’s sex life, which in turn were consistent with the results of various studies in the literature [28, 30-33].

The effect of sexual functioning on the quality of sexual life of women was also notable. This can be associated with the relationship between sexual desire and the impact on individual, social and family relationships; and this ultimately affects the quality of life of women and consequently the quality of their sexual life. Moreover, both sexual functioning and quality of sexual life focus on sexual issues, therefore, existence of this relationship is conceivable. These results were in line with the results of studies carried out by Nazarpour et al. [34], Chedraui et al. [35], Nappi et al. [36], Nicolosi et al. [37] and Ambler et al. [38].

To the best of our knowledge, the present study was the first to examine the relationship between sexual functioning and quality of women’s sexual life. The most important limitation of this study was the lack of previous which in turn limited the comparability, and drew attention toward the necessity of conducting further studies in the future. Additionally, self-report in completing the questionnaire is not expected to provide accurate information about the participant. Also, the relatively small sample size was another limitation. Furthermore, the results of the study cannot be generalizable as it was conducted only among selected women of several comprehensive health centers in one province, Qazvin. Accordingly, further researches on a larger scale are recommended on women in this city and other cities, especially in rural areas.

Conclusions

Overall, the results of the present study showed that the quality of sexual life and sexual functioning among the participating women were moderate and unfavorable, respectively. Also, variables including; age, level of women’s education and sexual performance were factors affecting the quality of women’s sexual life. Therefore, there is a compelling need to design and implement the necessary training to improve the quality of sexual life among these women, especially those younger women with weak sexual functioning, and lower level of education.