Socio-demographic Determinants of Low Sexual Desire and Hypoactive Sexual Desire Disorder: A Population-based Study in Iran

Abstract

Background

Hypoactive sexual desire disorder (HSDD) is one of the most common types of female sexual dysfunction that can affect women of all ages. It is worth noting that HSDD is different from low sexual desire (LSD) often experienced in daily life [1]. A sexual complaint can only be considered a sexual disorder when the diagnostic and statistical criteria for sexual dysfunctions are met and when that sexual problem has caused personal distress [2].

According to the Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition, Text Revision (DSM-IV-TR), low sexual desire which can cause significant personal distress is the primary indicator of HSDD. However, in the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5), HSDD is categorized under female sexual interest/arousal disorder (FSIAD), which is a controversial reform. Regardless of the benefits of amendment in diagnostic criteria, decades of research based on the DSM-IV-TR criteria for the diagnosis of HSDD has shaped the basis of our understanding of LSD distress primary symptoms, epidemiology, and clinical management [3]. In fact, arguments about the epidemiology of FSIAD have been based on the extrapolation of studies using HSDD rather than FSIAD criteria [4].

The prevalence of LSD in the female population varies from 11% to 53%. However, only 22-65% of these women have reported experiencing LSD-related distress required for the diagnosis of HSDD [5].

Sexual desire is a multi-factorial and multidimensional phenomenon with large individual, couple, cultural, and value differences that need to be addressed properly in studies dealing with this issue [6].  HSDD can root in biological, psychological, sexual, and social factors [7]. Compared to those without HSDD, women suffering from HSDD reported greater sexual and marital dissatisfaction, hopelessness, frustration, anger, loss of femininity, and low self-esteem [8].   

Various studies have yielded different results regarding the socio-demographic factors affecting LSD and HSDD. Some of these studies indicated the increased risk of LSD and HSDD with advancing age [7, 9, 10], whereas in other studies, only LSD has been found to be associated with increasing age (not HSDD) [5]. Understanding the role of socio-demographic factors is essential in screening individuals for LSD and HSDD.

So far, very few international studies have been conducted in this field. Although social determinants of sexual satisfaction in Iranian women have been studied [11], no studies have been conducted in Iran to identify the socio-demographic factors associated with LSD and HSDD among reproductive-age married women. Therefore, we sought to investigate the socio-demographic factors associated with LSD and HSDD. It is hoped that raising awareness regarding this issue among Iranian women could be a major step forward in planning future national policies aimed at promoting women’s sexual and reproductive health.

Methods

Design and data collection

This population-based, cross-sectional study was conducted with a 2-stage cluster sampling design in Sari, Iran. First, the necessary scientific permissions were attained from Mazandaran University of Medical Sciences. Afterwards, approval was obtained from the Ethics Committee of Mazandaran University of Medical Sciences (IR.MAZUMS.REC.94.1734). The results are reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (for checklist, see supplementary information) [12].

Sampling procedure

The 2-stage cluster sampling method was used in this study. For this purpose, we first selected all the healthcare centers of Sari city to ensure maximum heterogeneity. Then, we used the systematic random sampling method to choose women of reproductive age admitting these centers. Based on the probability of selection in proportion to population size (or estimated population size), sample size from each center was determined.  In addition, a list of eligible women was prepared and numbered and a fixed sampling interval was determined. The interval was determined by dividing the population size by the desired sample size. Finally, those meeting the inclusion criteria were contacted and invited to enroll in the study.

Participants

A total of 1000 reproductive-age women from 20 health centers of Sari participated in the study between October 2015 and January 2016. The nature of the study was explained to the participants, and verbal and written informed consent was obtained from them prior to enrollment. It is worth mentioning that none of the study participants was under the age of 16, so there was no need for parental or guardian consent. Also, to help women with LSD or HSDD, they were referred to a sexual health professional team for additional assessment and receiving sexual health education, counseling, and/or treatment interventions.

Participants in this study included reproductive-age women who had been married and living with their sexual partner for at least 6 months and were willing to participate in the study. In addition, women who were pregnant or breastfeeding for the first six months and those who went through premature ovarian failure were excluded from the study.

Outcome measurements

First, the socio-demographic characteristics of the participants, including age, age at first intercourse, number of children, length of marriage, Body Mass Index (BMI), level of satisfaction with income, level of education, level of physical activity, current smoking and alcohol use, were recorded. Subsequently, the participants were asked to fill out the Sexual Interest and Desire Inventory-Female (SIDI-F) and Female Sexual Distress Scale-Revised (FSDS-R).

SIDI-F was designed by Clayton et al. in 2006 and consists of 13 items plus 5 diagnostic items. The probable score for each individual falls within 0 to 51, with higher scores indicating higher sexual desire. The reliability of this tool was proved to be excellent, and the internal consistency of this tool was established with the Cronbach's alpha coefficient of 0.90.  The validity of this tool was also examined by correlating it with other valid instruments of sexual function [13]. Moreover, the validity and reliability of the Persian version of this tool have been assessed in Iran. The internal consistency of the Persian version was confirmed with the Cronbach's alpha coefficient of 0.90, and the test-retest method with a two-week interval proved the proper reliability of this tool [14].

FSDS-R was used for the assessment of personal distress, which is key for the diagnosis of HSDD. FSDS-R comprises of 13 items rated based on a 5-point Likert scale ranging from 0 (never) to 4 (always), with higher scores (11 and above) indicating greater sexual distress. The original version of the FSDS-R has shown acceptable reliability with the Cronbach’s alpha falling within the range of 0.87 to 0.93 and a high test-retest reliability (with the internal correlation coefficient ranging between 74% and 86%). For determining the reliability of the Persian version of FSDS-R, internal consistency and reliability were assessed using the test-retest method. Furthermore, Cronbach’s alpha coefficient was determined as a measure of internal consistency, while its reliability was assessed using test-retest measurement (repeatability index). The homogeneity of 70% and higher was considered acceptable. Using the test-retest method, internal consistency and reliability were calculated to be >0.70. Therefore, the Persian version of FSDS-R is considered a valid and reliable tool for assessing distress related to sexual dysfunction in Iranian women and can be used for screening patients with HSDD [15].      

Women with low sexual desire (SIDI-F score ≤ 33.0) and sexually-related personal distress (FSDS-R score ≥11) were classified as having HSDD. When accompanied by personally-related sexual distress, this score provides a robust definition of HSDD for use in an epidemiologic context.

Statistical methods

In a study of women aged 20–60 years from 28 cities of Iran, the prevalence of sexual desire problems was found 35% (p= 35%) using the Female Sexual Functioning Index (FSFI) [16]. With an estimated precision of 3% (d =0.03), confidence level of 95% (α) (Z = 1.96), and a nonresponse rate of 10%, the standard sample size was estimated at 1000 women.

Statistical analyses were performed using SPSS, version 18. The normal distribution of the data was confirmed, and mean and SD values were obtained using descriptive statistics. The socio-demographic factors associated with LSD and HSDD were then identified using the Chi-squared test. A P-value of lower than 0.20 in the Chi-squared test was adopted as representing the critical level for the selection of variables. Those variables with a P-value greater than 0.20 were maintained as adjusting factors in the multivariate logistic regression analysis [17].

Multivariate regression analysis was conducted to analyze the relationship between the socio-demographic variables and HSDD and LSD. P-value of less than 0.05 was considered statistically significant.

Results

A total of 1000 women of reproductive age (15 to 49 years with the mean age of 32.09±7.33 years) were enrolled in this study. The socio-demographic characteristics and their correlation with LSD and HSDD are shown in Table 1. All of the socio-demographic characteristics were significantly associated with LSD and HSDD, except for alcohol consumption and physical activity which were only associated with LSD.

Table 1. Socio-demographic characteristics of study participants & chi-square test results for predictors of LSD & HSDD among women of reproductive age

The results of logistic regression regarding the association between the socio-demographic variables and LSD and HSDD are presented in Table 2. As demonstrated, our results suggest that the odds of LSD and HSDD are 50-60% lower in women with age at first intercourse ≥ 21 ([OR:0.56; 95% CI:0.3-0.9] and [OR:0.4; 95% CI:0.2-0.7], respectively) than women with first intercourse between 9-17 years of age.

Table 2. Odds ratios from multivariate logistic regression examining factors associated with LSD & HSDD in women of reproductive age 

The odds of LSD were 3 and 2 times higher among women aged 35-40 years (OR:2.1; 95% CI:1.2-3.7) and those over 40 years of age (OR:3.1; 95% CI:1.6-5.8) than women under 30 years of age. However, age was not a factor associated with HSDD.

Moreover, women with BMI ≥ 30 were at 1.8-fold greater risk for LSD compared with women having BMI > 25 (OR:1.8; 95% CI:1.1-2.8). However, women's BMI was not related to HSDD.

The odds of reporting LSD and HSDD were approximately 2.4 and 3.2 times higher in women with 10 years or more spent in marriage compared with women who had been married for less than 2 years ([OR:2.4; 95% CI:1.1-5.4] and [OR:3.2; 95% CI:1.0-9.6], respectively).

Women with moderate and high levels of satisfaction with income showed lower odds of LSD ([OR:0.5; 95% CI:0.3-0.7] and [OR:0.4; 95% CI:0.2-0.8], respectively) and HSDD ([OR:0.5; 95% CI:0.3-0.8] and [OR:0.1; 95% CI:0.06-0.5], respectively).

Among personal habits, alcohol consumption and high level of physical activity were associated with lower levels of LSD ([OR: 0.4; 95% CI: 0.2-0.8] and [OR: 0.5; 95% CI: 0.3-0.9], respectively). But, these variables were not associated with HSDD. Regarding alcohol consumption, World Health Organization has stated alcohol consumption rate is low in most Muslim countries, including Iran [18]. In a systematic review by Chegeni et al. [19], alcohol consumption among women was reported to vary from 0.2% to 21%. Consistently, in the present study, only about 6% of the participants mentioned alcohol consumption (at least once in the last month). Since these participants were chosen from among women visiting health centers in one city, they do not represent women in the whole country, which precludes the generalization of this finding to the whole population.

Among the meaningful factors affecting LSD, age < 40 (P < 0.001), BMI (P < 0.01), and satisfaction with income level (P < 0.05) showed the most significant relationships. However, the most important factors affecting HSDD were age at first intercourse, satisfaction with income level, and increased length of marriage (P < .05), which can indicate the importance of socio-cultural factors in the intensity of HSDD.

Discussion

The present study was conducted to determine the socio-demographic factors associated with LSD and HSDD. Based on previous studies, women’s sexual interest/desire disorder can be best described as lack of sexual thoughts or fantasies, absence of responsive desire, and diminished or absent feeling of sexual desire or interest. That is to say, this disorder is linked with abnormally low or absent sexual drive or lack of incentive to become sexually aroused [20, 21].

In relation to the length of marriage variable, the present study demonstrated that by adjusting other variables, as the length of time spent in marriage increased, the risk of LSD and HSDD also elevated. Therefore, after 10 years or more of marriage, the possibility of having LSD and HSDD in women would be 2.4 and 3.2 times higher than women who have been married for less than two years. Similar to the findings of the present study, many other studies have confirmed the inverse relationship between the length of marriage and sexual desire problems. The results of another study conducted among 356 women aged 20-70 years indicated that women who had been in relationships lasting for 20-29 years experienced higher levels of disaffection compared to women who had been in a relationship for less than five years [32]. Pfaus's review also signified that after controlling for the age variable, women's sexual desire had a significant inverse relationship with marriage duration [33]. Kim (2013) also reported that women with HSDD who had been in long-term relationships tended to have lower scores for sexual desire [34]. Therefore, these findings show the necessity of adopt preventive interventions with the aim of promoting couples′ sexual health over the course of their married life.

In this nationally representative sample, age at first intercourse was also identified as a factor associated with both LSD and HSDD, such that having the first sexual intercourse at a very young age can be considered a risk factor for LSD and HSDD. According to the results of Abdo et al.  [7] in Brazil, women whose age at first intercourse was more than or equal to 21 were 1.5 times more likely to experience HSDD compared to women whose first intercourse was between 9 and 17 years of age. On the other hand, in a study by Safarinejad et al. [16] in Iran, it was found that lower age at marriage significantly contributed to sexual problems. The discrepant findings of these studies can be due to the differences in the geographical location of the communities under study and participants’ cultural and attitudinal differences regarding the appropriate age of the first intercourse. In European societies, women usually experience their first intercourse at a very young age, but in Iran any extramarital intimate relationship (specially the sexual type) between men and women is socially, culturally, legally, and religiously forbidden.

Controlling for other socio-demographic variables revealed that increased satisfaction with monthly income decreased the possibility of having LSD and HSDD; thus, satisfaction with income acts as a protective factor against developing HSDD. It appears that satisfaction with income level lowers the risk of LSD and HSDD through decreasing tensions and stress in women’s lives. This finding is in line with the results obtained by Ghanbarzadeh et al. [35], which signified financial problems as a significant preventive factor against LSD in women. Results obtained from another study also revealed that the emergence of sexual desire problems in the face of financial dependency is highly probable [16]. In a study conducted among 1000 married women aged 16-49 years in Egypt, it was demonstrated that most of the participants believed that LSD is associated with socio-economic conditions such as economic stressors and low income [36]. In contrast, a study conducted in China showed that by controlling variables such as age, level of education, and age at marriage, increased average monthly income in women resulted in improved sexual relationship [37]. It can only be justified by the fact that financial dependence on the spouse causes false interest in couples to have intercourse.

 It is noteworthy that despite the non-significant P-value for the level of education variable (secondary category), a high odds ratio was observed for this variable (OR:3; 95% CI:0.9-9.6). This result could be due to the limited number of cases with HSDD in the primary-illiterate category (4 cases). Therefore, the level of education should not be disregarded while assessing and managing HSDD.

One of the strengths of this study was the fact that it was conducted among a large cohort of women of reproductive age visiting all health centers in Sari city, Iran. Furthermore, since sexual distress is an essential factor in identifying HSDD, Sexual Interest and Desire Inventory-Female (SIDI-F) as well as Female Sexual Distress Scale-Revised (FSDS-R) were used for the diagnosis of HSDD.

The present study also had some limitations that need to be addressed. As we know, the etiology of LSD or HSDD is complex and multifactorial. Thus, we could not consider all the factors affecting sexual desire such as personal circumstances (e.g., psychosexual, physical, and biological factors) and relational conditions [38]. It is worth noting that the sexual response cycle is a concept of psychophysiological alteration, and any attempt to stage the female sex response, although useful, is artificial [39]. Other possible comorbidities such as having difficulty in getting aroused or lubricated, having difficulty in reaching orgasm, feeling pain during or after intercourse, and experiencing vaginal dryness should also be addressed while assessing female sexual desire problems, which were not measured in the study at hand.

In the same vein, Kim et al. [34] reported a significant association between sexual desire and other domains of female sexual function, indicating the need to examine other sexual disorders in the evaluation of sexual desire because components of women’s sex response often overlap with each other, such that sexual desire interacts with and partially overlaps with mental arousal [23]. Basson [40] also proposed that the onset of responsive desire is accompanied by sexual arousal to some extent, which shows that sexual desire and sexual arousal are probably a unitary concept, as in DSM-5 they are categorized under FSIAD [3].

Moreover, our study disregarded the role of the relationship between women and their sexual partner, which is an essential aspect in determining female sexual functioning, including sexual desire. It seems questions such as the stability of the relationship, satisfaction with it, and sexual and general health of the partner can be used to identify people with low sexual desire and subsequent sexual distress.

In line with this statement, many studies have shown that male partner sexual dysfunctions, especially erectile dysfunction and premature ejaculation, have a negative impact on female sexual desire, and women whose partners had a sexual dysfunction reported lower sexual desire [41-44]. Therefore, it is important to note that clinicians should evaluate the sexual function of both partners, which encompasses several dimensions and needs an interdisciplinary approach.

Another limitation of this study was its target group. Participants in this study were limited to women of reproductive age (15-49 years) who were not menopausal, pregnant, or breastfeeding. Thus, more extensive studies need to be conducted in order to gain a deeper insight into other factors involved in this issue and collect further information on the sexual desire status of women in other groups such as pregnant, lactating, and menopausal women.

Conclusions

In short, while there are some common factors contributing to both LSD and HSDD, the socio-demographic factors associated with LSD and HSDD are different. The difference in research populations, sample sizes, and applied tools for evaluating LSD and HSDD can justify the discrepant results reported in various studies.

Abbreviations

LSD: Low Sexual Desire; HSDD: Hypoactive Sexual Desire Disorder; DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition, Text Revision; DSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition; BMI: Body Mass Index; FSIAD: Female Sexual Interest/Arousal Disorder; SIDI-F: Sexual Interest and Desire Inventory-Female; FSDS-R: Female Sexual Distress Scale-Revised.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Mazandaran University of Medical Sciences, Sari, Iran (grant number: 1734). Written informed consent was obtained from the participants before conducting this study. Since all the participants were over the age of 16, there was no need for parental or guardian consent.

Consent for publication

Not applicable.

Availability of data and material

The raw data produced in this study are not available publicly due to the likelihood of being used in future analyses, but they can be accessed through the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding was received for this study.

Authors’ contributions

MM conceived the idea and wrote the proposal, participated in the data collection process, analyzed data, and drafted the paper. ZH approved the proposal with some revisions, participated in data analysis, and reviewed the manuscript in the role of Supervisor. MM critically reviewed the data analysis and interpretation. SK and MP contributed to the revisions of the manuscript. All the authors approved the final version of the manuscript.

Acknowledgements

This study has been supported by Mazandaran University of Medical Sciences as part of a Master’s thesis for a degree in Midwifery Counseling. Hereby, the authors would like to thank the Ethics Committee of Mazandaran University of Medical Sciences and the participants involved in the study.

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