Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Prevalence of women’s sexual problems in the USA

Anthony Paik, Edward O Laumann

Introduction

Since Kinsey’s study of female sexuality,1'2 the epidemiology of women’s sexual problems, generally, and female sexual dysfunction, specifically, have attracted substantial professional interest and controversy. While the underlying reasoning for early epidemiologic studies rested on the paucity of prevalence estimates, the burgeoning literature of today is generating heated debate. Some promote prevalence estimates of women’s sexual problems as identifying an underrecognized, public-health concern;3 others critically assess these estimates as being flawed4 or, more conspiratorially, intended for manufacturing new markets for pharmaceutic companies and clinicians.5,6 Amid the din of scholarly recriminations, both factions share a fundamental assumption: they attach great significance to prevalence estimates, suggesting a need for reviewing how surveys have been used to define, measure, and report the prevalence of both female sexual dysfunction and female sexual problems. Understanding how surveys have been used to develop prevalence estimates can shed light not only on the methodological validity of prevalence estimates vis-à-vis one another, but also on the significance of these estimates for the wider culture.7

The purpose of this chapter is to provide an overview of epidemiologic studies reporting prevalence estimates of female sexual problems in the USA. This chapter is organized as follows. We first review epidemiologic concepts, focusing on issues of definition and classification, measurement, and study validity. Next, we report prevalence data of female sexual problems in the USA. We limit our discussion to prevalence estimates for general populations, which include representative samples or broadly representative clinical samples, such as those drawn from gynecologic or family-practice settings. Lastly, we conclude with a discussion of the methodological limitations of these epidemiologic studies and suggest future directions in this area.

The epidemiology of women’s sexual problems

We draw on a number of concepts from psychiatric epidemiology in this review of the literature. One of the basic epidemiologic measures of outcome occurrence is prevalence, defined as the proportion of a population exhibiting a health condition during a specified time interval.8 While prevalence can refer to any time period, researchers typically distinguish among point (current), period, and lifetime prevalence. However, given the importance of epidemiologic estimates of women’s sexual problems, it is important to recognize that many factors of study design can affect estimated prevalence, making validity an important methodological concern.

An important, related conceptual issue is the definition of the health condition. Despite widespread usage of the term sexual dysfunction among epidemiologic studies, most of these studies rely not on clinical diagnosis of dysfunction, but on selfreports of symptoms of sexual problems. Thus, we use the term sexual dysfunction only when clinically diagnosed, regardless of the terminology used by the epidemiologic study. We use the term sexual problem to refer to reported symptoms, which reflects the latent population in which a subset exhibit manifest sexual dysfunction, but also recognize that many reported symptoms are not necessarily perceived subjectively as problematic or consistent with a dysfunction. Nevertheless, we apply the term sexual problem to reported symptoms, since it is not currently clear whether sexual problems should be exclusively defined by respondents.

The validity of prevalence estimates of women’s sexual problems rests on two fundamental issues. The first deals with a general issue in epidemiology: a study’s overall methodological quality, which can be assessed by various criteria indexing internal and external validity. According to Prins et al.,9 internal validity refers to the quality of a study’s design, which includes assessing data collection procedures, measurement instruments, definition of the health condition, and informativity of reported prevalence; external validity refers to the generalizability of a study, which is affected by the characteristics of the source population, sampling, eligibility criteria, and response rates.

The second issue focuses more specifically on the measurement of women’s sexual problems, which includes topics of definition, classification, and the psychometric properties of measurement instruments. That is, researchers’ decisions about theoretic concepts and the collection of this information via indicators are quite important for the validity of prevalence estimates. The first deals with the theoretic and conceptual models used. Prevalence studies typically adopt one of the prevailing definitional and classification systems for sexual dysfunctions, such as the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, 4th edition (DSM-IV) or the World Health Organization’s International Classification of Diseases (ICD-10). However, we note that there is considerable debate about the appropriateness of these definitions, as well as recent attempts to create international consensus about female sexual dysfunction.1^12 Clearly, the type of definitions used will affect prevalence estimates of women’s sexual problems.

Related to issues of definition and classification is the problem of measurement. Measurement instruments consist of questions, or items, which prompt respondents about symptoms. Sexual problems are assessed in surveys by various questions, in the form of scales or schedules.13 Scales refer to a question or a set of questions (i.e., single vs multiple indicators), with response categories that can be dichotomous, ordered, or continuous, and that are designed to measure a dimension of a trait or domain. In general, the reliability of scales increases with more items. Other researchers use schedules that are designed to assess the presence or absence of a syndrome, such as a sexual dysfunction. Schedules are used to classify individuals as presenting a diagnostic category of a health condition such as a specific sexual dysfunction. The psychometric properties of scales and schedules - their reliability and validity - are an important concern. Reliability of measures refers to the reproducibility of results, while validity refers to the extent to which measurements reflect the theoretic concept of interest.14

An important measurement issue for prevalence estimates is the problem of caseness, which refers to the operationalized criteria, or case criteria, through which researchers designate the existence of a case that meets their theoretic definition of a sexual problem.15 In general, highly restrictive criteria yield lower prevalence estimates and identify more severe cases; however, they may also exclude many individuals who are still being negatively affected by sexual problems.

Below, we apply these epidemiologic concepts in our review of prevalence studies of women’s sexual problems in the USA. We focus on epidemiologic studies of sexual problems, sexual dysfunctions, sexual disorders, or sexual distress. We include studies, published from 1970 to June 2004, which estimated prevalence of one or more sexual problems for general populations in the USA. Thus, we exclude studies utilizing samples comprising only patients with specific health conditions, such as studies focusing on sexual problems among patients with diabetes, cancer, or surgical procedures, for example, or those studying patients at clinics for sexual problems. To increase our coverage, we did include studies relying on samples of women at gynecologic or family-practice clinics, but we focus most of our attention on those employing probability samples. We also exclude studies that lacked systematic sampling criteria, such as recruitment methods based on self-selected volunteers (e.g., responses to magazine advertisements).

We identified prevalence studies of women’s sexual problems by two strategies. We first identified studies in reference lists from existing reviews of the literature.16-20 We then searched MEDLINE (1966-Jun 2004) and PSYCHINFO (1974-Jun 2004), using the search terms epidemiologic or prevalence plus one of the following terms: sexual dysfunction, sexual function disturbances, sex, disorder, psychosexual disorder, dyspareunia, vaginismus, anorgasm, vaginal dry, frigidity, sexual arousal, inhibited sexual desire, hypoactive sexual desire, sexual distress, sexual aversion, orgasmic disorder, inhibited female orgasm, or inhibited sexual desire.

Prevalence studies of sexual problems among US women

Table 2.1.1 lists 15 studies, published in 1970-2004 that produced prevalence estimates of one or more sexual problems among US women in general populations. One paper is listed three times because it presents prevalence estimates from three separate data sets: two community studies and one national study.22 There are currently four national data sets with some information about women’s sexual problems. Two studies, which have representative samples of noninstitutionalized adults, data collected through in-person interviews, and high response rates, are the most generalizable.23'25 The remaining two national studies are less able to be generalized because one22 suffers from sample attrition in a longitudinal cohort, while the other21 has a low response rate (53%) and includes only individuals who meet the following criteria: (1) English is the first language of the respondent, (2) the respondent has been in a heterosexual relationship for 6 months or more, and (3) the respondent is non-Hispanic white or non-Hispanic black.

Seven data sets are used to estimate prevalence for specific communities or regions in the USA. Four of these derive from communities included in the Epidemiologic Catchment Area Study, 1980-5.22,29,30 The external validity of these studies also appears to be superior, with high response rates and the added advantage of being explicitly designed for estimating prevalence of sexual dysfunctions and sexual problems based on Diagnostic and Statistical Manual for Mental Disorders, 3rd edition (DSM- III), criteria. In addition, there are three studies of middle-aged or older women, but all of these appear to have lower external validity for various reasons, including sample attrition in a longitudinal cohort,28 nonrepresentative sampling procedures,27 and high proportion of missing data.26

Table 2.1.1. Epidemiologic studies reporting the prevalence of women's sexual problems in the USA

Study

Mode of Sampling

Response

Data

Sample

administration

Age

rate

Size

Range

Restrictions

National

21Bancroft et al., 2003

Probability

Kinsey Institute Study, 1999-2000

Telephone

53%

987

20-65

English as first language;

>=6 months in a heterosexual relationship; white and black respondents only.

22Golding et al., 1998

Longitudinal

cohort

National Study of Health and Life Experiences for Women, 1991

In-person interview

NA

963

21 +

None reported.

23Klassen and Wilsnack, 1986

Probability

Drinking and problem drinking among women, 1981

In-person interview, SAQ

87%

917

21+

None reported.

24 25Laumann et al., 1999

Probability

National Health and Social Life Survey, 1992

In-person interview

79%

1,511

18-59

Sexually active in last year.

Community

26Diokno et al., 1990

Probability

Washtenaw County, MI

Clinical interview

65%

1,956

60+

None reported. Size includes men and women.

27Gold et al., 2000

Random plus snowball

Study of Women's Health across the Nation, 1995-7

Telephone and in-person

NA

16,065

40-55

None reported.

22Golding et al., 1998

Probability

Los Angeles ECA Study, 1980-5

In-person interview

68%

1,428

18+

None reported.

22Golding et al., 1998

Probability

North Carolina ECA Study, 1980-5

In-person interview

79%

1,703

18+

None reported.

28Johannes and Avis, 1997

Longitudinal

cohort

Massachusetts Women's Health Study, 1988-89

In-person interview, SAQ

NA

360

51-62

Initial cohort (1982) was pre-menopause only.

29Johnson et al., 2004

Probability

St Louis ECA Study, 1981-2

In-person interview

87%

1,801

18-96

None reported.

30Samuels et al., 1994

Probability

Eastern Baltimore Mental Health Survey, 1981

Clinical interview

75%

810

18-64

Excluded persons with dementia or delirium.

Clinical

31Bachmann et al., 1989

Consecutive

intercept

Gynecologic clinic

Clinical interview

100%

887

12-78

None reported.

32Jamieson and Steege, 1996

Consecutive

intercept

Five primary care practices, 1993

Self-completed

83%

581

18-45

Sexually active and menstruating.

33Levine and Yost, 1976

Random

Gynecology clinic at a medical center

In-person interview

79%

59

30-39

None reported.

34Nusbaum et al., 2000

Complete

population

Routine gynecologic care at a medical center, 1992-3

Mail

65%

964

18-87

Excluded persons with cognitive dysfunction, poor English, and those unavailable for follow-up.

35Rosen et al., 1993

Unspecified

Outpatient gynecologic service at a medical center

Self-completed

NA

329

18-73

Respondents were in relationships or sexually active.

36Schein et al., 1988

Consecutive

intercept

Primary care clinic

Self-completed

64%

148

18-78

Excludes acutely ill and new patients.

Finally, there are six studies based on clinical samples drawn from women attending gynecologic or family-practice clinics.31-36 While these samples are not representative of a general population in a technical sense, they may reflect the prevalence of sexual problems among women seeking routine medical checkups, particularly gynecologic care. Nevertheless, we believe that these studies have the lowest external validity and tend to recruit women who are, on average, less healthy.

Below we review prevalence estimates, presented in Table 2.1.2, for the following sexual problems identified in the literature: problems with sexual desire and interest; problems with sexual arousal, which includes lubrication difficulties; problems with orgasm; problems with painful sex; and combined measures of sexual dysfunctions. Several studies also assessed several other sexual problems, typically associated with assessments about one’s partnership, but we did not include this information in this review.

Problems with sexual desire/interest

We identified eight studies published since 1970 that reported estimates, ranging from 7% current to 31% lifetime prevalence, for problems with sexual desire or sexual interest. Population- based estimates of lifetime prevalence for problems with sexual desire/interest among adult women are 11% in a study using the Diagnostic Interview Schedule for DSM-III (DIS-III)29 and 31% in a study using simple dichotomous measures to measure the proportion of women who have never been interested in or never enjoyed sex (5%) and those who experienced this problem after an initial period of enjoyable sex (26%).23 The one clinic-based study reported a lifetime prevalence of concern about low sexual desire at 29%.34 In contrast, a national survey of adult women, which also used a simple dichotomous measure, reported a 1-year prevalence for lack of interest in sex for several months to be 31%;24 however, a latent structure model presented in the appendices of this paper, which was reported in detail elsewhere because of space limitations,25 categorized 22% of women nationally as having low desire. In terms of current prevalence, a national study reported that 7% of women nationally had never thought about sex in the last month,21 while clinic-based estimates were 10-21%.31,32,36

Variation in estimated period-specific prevalence appears to reflect differences in measurement and operational criteria.

Table 2.1.2. Prevalence of Women's Sexual Problems by Type and Prevalence Period

Response Criteria for Overall

Study Definition of Problem or Question category problem designation Prevalence Comments

Problems with Sexual Desire/Interest Prevalence - current-last 2 months

31Bachmann et al., 1989

Problem/difficulty with desire

Open-ended

Positive response

21%

 

4Bancroft et al., 2003

Frequency of thinking about sex in the last month

3-point scale

Never

7%

 

32Jamieson and Steege, 1996

Currently experiencing less interest in sex

NA

NA

10%

 

36Schein et al., 1988 Multiple items for sexual desire or libido

Prevalence - last 3-12 months

NA

NA

18%

14% of sample lack sexual desire with partner

24Laumann et al., 1999

Lacked interest for several months last year

Dichotomous

Positive response

31%

 

25Laumann et al., 2001

Low desire

Probabilistic

Latent structure modeling

22%

 

Prevalence - ever

29Johnson et al., 2004

Lack of pleasure with sex for several months and importance of sex

Dichotomous w/ probes

DIS for DSM-III criteria

11%

Excludes problems due to medical conditions or medication

23Klassen and Wilsnack, 1986

No interest or enjoyment ever

Dichotomous

Positive response

5%

Designated as a “primary" sexual dysfunction

Table 2.1.2. (Continued)

Study

Definition of Problem or Question

Response

category

Criteria for problem designation

Overall

Prevalence Comments

23Klassen and Wilsnack, 1986

Initially enjoyable sex; no interest or enjoyment for two months or more ever

Dichotomous

Positive response

26%

Designated as a “secondary" sexual dysfunction

34Nusbaum et al., 2000

Sexual concerns about lack of interest

5-point scale

High frequency (unspecified)

29%

 

Problems with Arousal/Lubrication

       

Prevalence - current-last 2 months

       

31Bachmann et al., 1989

Problem/difficulty with arousal, lubrication, or anxiety

Open-ended

Positive response

13%

 

4Bancroft et al., 2003

Sum of three items measuring arousal in the last month

4-point scale

NA

12%

 

4Bancroft et al., 2003

No lubrication or reported vaginal dryness during intercourse

Dichotomous

Positive response

31%

 

27Gold et al., 2000

Vaginal dryness in the last 2 weeks

Dichotomous

Positive response

13%

 

32Jamieson and Steege, 1996

Currently experiencing less pleasure with sex

NA

NA

2%

 

36Schein et al., 1988

Multiple items for arousal problems with partner

NA

NA

50%

22% of sample have arousal problems during masturbation

Prevalence - last 3-12 months

       

24Laumann et al., 1999

Sex not pleasurable for several months last year

Dichotomous

Positive response

23%

 

24Laumann et al., 1999

Trouble lubricating for several months last year

Dichotomous

Positive response

20%

 

25Laumann et al., 2001

Arousal problems

Probabilistic

Latent structure modeling

14%

 

Prevalence - ever 29Johnson et al., 2004

Trouble becoming aroused for 2 months or more

Dichotomous w/ probes

DIS for DSM-III criteria

4%

Excludes problems due to medical conditions or medication

33Levine and Yost, 1976

Problems with arousal

NA

NA

12%

 

34Nusbaum et al., 2000

Sexual concerns about lubrication

5-point scale

High frequency (unspecified)

19%

 

35Rosen et al., 1993

Lack of pleasure with sexual activity

5-point scale

50% of the time or more

20%

 

35Rosen et al., 1993

Lack of lubrication

5-point scale

50% of the time or more

23%

 

Orgasm Problems

         

Prevalence - current-last 2 months

       

31Bachmann et al., 1989

Problem/difficulty with anorgasmia

Open-ended

Positive response

4%

 

Table 2.1.2. (Continued)

Study

Definition of Problem or Question

Response

category

Criteria for problem designation

Overall

Prevalence Comments

‘Bancroft et al., 2003

Frequency of orgasm in the last month

Count

NA

9%

 

32Jamieson and Steege, 1996

Decreased frequency of orgasm

NA

NA

8%

 

36Schein et al., 1988

Multiple items for orgasm problems with partner

NA

NA

18%

15% of sample have orgasm problems during masturbation

Prevalence - last 3-12 months

       

28Johannes and Avis, 1997

Difficulty reaching orgasm during the last 6 months

5-point scale

More than 25% of the time

41%

 

24Laumann et al., 1999

Inability to orgasm for several months last year

Dichotomous

Positive response

25%

 

Prevalence - ever 29Johnson et al., 2004

Bothered by inability to experience orgasm for several months

Dichotomous w/ probes

DIS for DSM-III criteria

16%

Excludes problems due to medical conditions or medication

23Klassen and Wilsnack, 1986

No orgasms ever with partner

Dichotomous

Positive response

5%

Designated as a “primary" sexual dysfunction

23Klassen and Wilsnack, 1986

Initially able to orgasm; inability to orgasm for two months or more ever

Dichotomous

Positive response

18%

Designated as a “secondary" sexual dysfunction

23Klassen and Wilsnack, 1986

Reaching orgasm

6-point scale

25% of the time or less

25%

 

33Levine and Yost, 1976

Inability to achieve orgasms

NA

NA

5%

 

34Nusbaum et al., 2000

Sexual concerns about orgasm difficulties

5-point scale

High frequency (unspecified)

26%

 

35Rosen et al., 1993

Difficulty reaching orgasm

5-point scale

50% of the time or more

30%

 

Problems with Pain during/after Sex

       

Prevalence - current-last 2 months

       

31Bachmann et al., 1989

Problem/difficulty with pain during sex

Open-ended

Positive response

48%

 

‘Bancroft et al., 2003

Pain during sex 50% of the time or more in the last month

Dichotomous

Positive response

3%

 

26Diokno et al., 1990

Pain with intercourse

Dichotomous

Positive response

13%

Only n =164

32Jamieson and Steege, 1996

Currently experiencing pain during/after sex

4-point scale

NA

45%

 

36Schein et al., 1988

Multiple items for dyspareunia

NA

NA

21%

 

Prevalence - last 3-12 months

       

28Johannes and Avis, 1997

Pain during the last 6 months

5-point scale

More than 25% of the time

13%

 

24Laumann et al., 1999

Pain during sex for several months last year

Dichotomous

Positive response

15%

 

Table 2.1.2. (Continued)

Study

Definition of Problem or Question

Response

category

Criteria for problem designation

Overall

Prevalence Comments

25Laumann et al., 2001

Pain

Probabilistic

Latent structure modeling

7%

 

Prevalence - ever 32Jamieson and Steege, 1996

Pain for more than 1 year duration

NA

NA

20%

 

29Johnson et al., 2004

Sexual relations ever physically painful

Dichotomous w/ probes

DIS for DSM-III criteria

19%

Excludes problems due to medical conditions or medication

23Klassen and Wilsnack, 1986

Sexual relations have been sometimes so painful to prevent intercourse

Dichotomous

Positive response

17%

Designated as a “primary" sexual dysfunction

23Klassen and Wilsnack, 1986

Sexual relations sometimes physically painful

Dichotomous

Positive response

36%

Designated as a “secondary" sexual dysfunction

34Nusbaum et al., 2000

Sexual concerns about dyspareunia

5-point scale

High frequency (unspecified)

10%

 

35Rosen et al., 1993

Painful intercourse

5-point scale

50% of the time or more

11%

 

Other problems

         

Prevalence - current-last 2 months

       

31Bachmann et al., 1989

Problem/difficulty with vaginismus

Open-ended

Positive response

6%

 

4Bancroft et al., 2003

Distress about sexuality in the last 4 weeks

4-point scale

Moderate and a great deal

15%

 

36Schein et al., 1988

Multiple items for being frightened about sex

NA

NA

4%

 

Prevalence - last 3-12 months

       

24Laumann et al., 1999

Anxiety about performance for several months last year

Dichotomous

Positive response

12%

 

Prevalence - ever 35Rosen et al., 1993

Anxiety or inhibition with sexual activity

5-point scale

50% of the time or more

23%

 

35Rosen et al., 1993

Vaginismus

5-point scale

50% of the time or more

12%

 

Combined measures of sexual problems

       

Prevalence - current-last 2 months

       

4Bancroft et al., 2003

Interest, arousal, lubrication, orgasm, or pain

Dichotomous

One or more

45%

 

32Jamieson and Steege, 1996

Decreased orgasm, pleasure, interest, or frequency

NA

One or more

22%

 

30Samuels et al., 1981

Any sexual dysfunction - DSM-III

Psychiatric

examination

Clinical diagnosis

3%

No gender-specific prevalence

Table 2.1.1. (Continued)

Study

Definition of Problem or Question

Response

category

Criteria for problem designation

Overall

Prevalence Comments

Prevalence - ever 29Johnson et al., 2004

Desire, arousal, orgasm or pain ever

Dichotomous w/ probes

One or more

33%

Excludes problems due to medical conditions or medication

23Klassen and Wilsnack, 1986

Desire, orgasm, or vaginismus

Cumulative score (0-3)

One or more

35%

Designated as “primary" sexual dysfunctions

22Golding et al., 1998

Pain or sex not pleasurable for several months ever

Dichotomous

One or more

28%

LA-ECA

22Golding et al., 1998

Pain or sex not pleasurable for several months ever

Dichotomous

One or more

18%

NC-ECA

22Golding et al., 1998

Pain or no interest in sex ever

Dichotomous

One or more

56%

NSHLEW

NA = not available; LA-ECA = Los Angeles Epidemiological Catchment Area; NC-ECA = North Caroline Epidemiological Catchment Area; NSHLEW = National Study of Health and Life Experiences in Women

Studies employing single items with dichotomous response categories,23,24 as opposed to gradated scales or multiple measures, tended to generate the largest prevalence estimates. Similarly, clinic-based estimates were generally higher than those reported in population-based studies. In terms of operational criteria, most of these studies use researcher-defined criteria for designating sexual problems and did not report asking whether respondents perceived these symptoms or conditions as problems. Only two studies used multiple questions to designate caseness: one study used the Diagnostic Interview Schedule III algorithms, which were specifically designed to estimate prevalence of inhibited sexual desire as defined by DSM-III,29 while the other used a latent structure model fitted to actual response patterns.25 These two studies are not only highly generalizable, but also offer superior measures for psychometric properties, suggesting that 11-22% of adult women nationally experienced difficulties or problems with sexual desire for several months. Overall, 5% of women nationally have never been interested in sex, and 11-22% have had low desire for several months. Nevertheless, there appears to be a need for scales or schedules that include fine-grained response options, multiple items, and assessment of whether respondents’ view a reported symptom of low desire as problematic.

Problems with sexual arousal, including lubrication difficulties

Ten studies reported prevalence estimates for problems with excitement, lubrication difficulties, or arousal in general. Prevalence estimates for problems with excitement or pleasure are 2% currently,32 a 1-year prevalence of 23%,24 and a lifetime prevalence of 20%.35 For lubrication difficulties or vaginal dryness, prevalence estimates are 13-31% currently,21,27 a 1-year prevalence of 20%,24 and a lifetime prevalence of 19-23%.34,35 Unfortunately, there are no population-based estimates of life time prevalence for either problems with excitement/pleasure or lubrication difficulties/vaginal dryness.

Several studies reported prevalence estimates for arousal problems in general, which were all tapped with multiple items. In terms of lifetime prevalence, a community study, which used the DIS-III, estimated 4% prevalence of difficulty in becoming aroused for 2 months or more.29 In contrast, a national study reported a 1-year prevalence of 14% for arousal problems among women.25 Another national study reported that 12% of women were currently experiencing arousal problems,21 while clinic- based estimates were 12-50%.31,33,36

Prevalence estimates for arousal problems are also limited in several ways. Most researchers use varying definitions to tap arousal problems. Moreover, single-item measures of specific symptoms, such as lubrication difficulties or vaginal dryness, tend to be more liberal than multiple-indicator assessments of arousal problems. Among the three population-based studies assessing arousal problems, measurement strategies vary: one study employed a simple count procedure with no reported psychometric properties;21 not surprisingly, the constructed arousal measure had no concurrent validity. Alternatively, the other two studies used the DIS-III29 and a concurrently validated, latent-structure modeling approach,25 respectively, suggesting that the prevalence of arousal problems among US women runs from 4%, based on DSM-III criteria, to 14% more generally.

Problems with infrequent orgasms

Eleven studies reported prevalence figures for infrequent orgasm or difficulty in reaching orgasm in the range 4-41%. In terms of lifetime prevalence, one population-based study, using DSM-III criteria, estimated that 16% of women were bothered by inability to experience orgasm for several months,29 while another reported that 5% of women nationally have never had an orgasm; another 18% had this problem for 2 months or more, and 25% had trouble reaching orgasm more than 50% of the time.23 Three clinical studies reported estimates of 5% for inability to reach orgasm,33 26% for concern about orgasm difficulty,34 and 30% for difficulty in reaching orgasm more than 50% of the time.35 Similarly, another national study estimated a 1-year prevalence of 25% for reported inability to orgasm for several months.24 In contrast, a community study reported a 1-year prevalence of 41% for orgasm problems,28 but this high estimate appears to reflect the narrow age range of older women (ages 51-62) included in this study. For current prevalence, a national study estimated orgasm problems among 9% of women,21 while clinic-based studies ranged from 4% to 18%.31,32,36

In general, definition, measurement, and operational criteria of orgasm problems across these studies were quite heterogeneous. Some researchers assessed orgasm problems by asking about the frequency of orgasm and used ordered scales for response categories; others assessed the presence of orgasm problems with dichotomous measures. However, none of these studies appear to have investigated whether respondents viewed reported inability to orgasm as problematic. Only one population-based study used multiple items from the DIS-III to designate the presence of orgasm problems;29 thus, its estimate of 16% appears to be the best available. Another study also generated an important baseline estimate: 5% of women nationally have never had an orgasm.23

Problems with pain during/after sex

Eleven studies reported prevalence estimates of 3-48% for pain during or after sex. Lifetime estimates from population-based studies were 17% and 19%,9,23 while clinic-based studies reported prevalence of 10-20%.32,34,35 Six-month prevalence was reported as 13%,28 while another study reporting 1-year prevalence found that 15% of women reported pain during sex for several months,24 but classified only 7% by the study’s latent structure model.25 In terms of current prevalence, two population-based studies reported estimates of 3% and 13%,21,26 while estimates from clinic- based studies were much higher at 21-48%.31,32,36

Variation in reported estimates appears to reflect methodological differences. Studies using single-item indicators generated higher prevalence estimates; moreover, dichotomous indicators appear to yield higher estimates than ordered scales. In terms of operational criteria, most of these studies again used researcher-defined criteria. Two population-based studies with high external validity did use multiple measures to designate caseness: one study used the DIS-III and produced an estimated prevalence of 19%,29 while the other used a latent structure model that classified 7% of women as having pain with sex.25 Thus, these two estimates suggest a range of 7-19% for pain with sex.

Overall prevalence of sexual problems

Several studies reported prevalence estimates for other sexual problems, such as anxiety about sex or vaginismus, and for combined measures of female sexual problems; we focus on the latter in this section. One study analyzed three different probability samples22 and reported lifetime prevalence estimates of 18% and 28% for pain during sex or nonpleasurable sex, and 56% for pain during sex or lack of interest in sex. Two population-based surveys, using similar instruments, estimated that 33%29 and 35%23 of women have experienced a problem with desire, arousal, orgasm, or pain. One national study estimated a 1-month prevalence of 45% for experiencing a current sexual problem;29 however, this study reported no concurrent validity in their measures of sexual problems. Nevertheless, it is important to remember that these proportions reflect the percentage of women reporting symptoms. It is not clear whether women view these symptoms as problematic, or, more importantly, whether a trained clinician would view these symptoms as dysfunctional. Indeed, one population-based study that incorporated a psychiatric examination in its study design found that only 3% of men and women had a clinically diagnosed sexual dysfunction,30 by DSM-III criteria, suggesting that roughly 1 in 10 cases of reported sexual problems actually exhibits female sexual dysfunction. However, it would be misleading to assume that those cases of sexual problems that do not meet the criteria for female sexual dysfunction are not problematic.

Finally, these combined measures raise the issue of copresence of symptoms. An important epidemiologic question centers on the extent to which reported symptoms are copresent. Only one study reports the extent to which symptoms are cop- resent.25 This study reported an oft-cited prevalence of 43% for sexual problems among adult women; however, this statistic actually represents the size of three classes, low desire (22%), arousal problems (14%), and pain (7%), which are constituted by patterns of copresent symptoms. Future research should be devoted to investigating these patterns by more fine-grained measures than simple dichotomous indicators.

Conclusion

We reviewed 15 studies of general populations reporting prevalence estimates of sexual problems among adult women in the USA. Studies with high internal and external validity presented estimates of 5-22% for problems with sexual desire, 4-14% for problems with arousal, 5-16% for orgasm problems, and 7-19% for problems with painful sex. In general, these estimates are approximately the same or slightly higher than prevalence estimates reported in several population-based studies of northern European women, which were 5-16% for low desire, 6-8% for arousal problems, 4-10% for orgasm problems, and 3-18% for sexual pain.18 Our review also identified four studies, which have not been listed in prior reviews, reporting prevalence estimates based on epidemiologic catchment area data, which was collected with the DIS-III as well as through clinical examination.

However, we strongly emphasize that reported sexual problems in almost all epidemiologic studies do not connote clinical diagnosis of female sexual dysfunction. As we mentioned above, one population-based study, which did not report gender-specific prevalence but did use clinical diagnosis, found an overall prevalence of 3% for any sexual dysfunction in the general population as defined by DSM-III criteria. Thus, most epidemiologic results should be viewed as the latent population of women with sexual problems in which a subset exhibits manifest female sexual dysfunction. Nevertheless, there is still an association between certain sexual problems and negative health outcomes when the former are specified carefully.

Continuing methodological heterogeneity appears to be producing wide variation in estimates. First, there appears to be a strong need for consistent definitions of sexual problems, an issue that continues to produce disagreement despite attempts to produce an international consensus.10-12 Important omissions in many studies’ definitions of sexual problems are assessments of whether the respondent views a particular symptom as a problem and whether a symptoms is recurrent or frequent. Second, there is a widespread use of measures with unknown psychometric properties. Standardization in schedules and scales as well as use of multiple items would certainly increase the validity of these measures. Researchers also need to demonstrate that their measures of sexual problems have concurrent validity.

Finally, several issues require increased attention. Further investigation needs to be done on the copresence of symptoms. Moreover, researchers should devote more attention to relational contexts when assessing sexual problems. Many studies assessed the prevalence of problems with desire, arousal, orgasm, and pain without investigating the nature of the corresponding sexual relationships. Thus, overall, as demand for epidemiologic analyses has increased in recent years, our review has shown that many prevalence studies of women’s sexual problems are limited by methodological and substantive issues.

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