0 - West - A Systematic Review of The Literature On Female Sexual Dysfunction Prevalence

A Systematic Review of the
Literature on Female Sexual

Dysfunction Prevalence and
Predictors
Suzanne L.West Lisa C. Vinikoor Denniz Zolnoun
University of North Carolina
Interest in human sexuality began in the 18th century, but formal and more rig-
orous studies focused on sexual satisfaction and sexual practices were published
in the early 1900s. Alfred Kinsey's pioneering work on sexuality, in which he
surveyed over 10,000 men and women age 16 and older, began in the late 1930s.
In the mid-1960s. Masters and Johnson published their seminal work charac-
terizing the sexual response cycle. Since then, numerous researchers have
attempted to understand and to quantify "normal" sexual behaviors using sur-
vey techniques. We conducted a systematic review of the published literature on
the prevalence of female sexual dysfunction overall and, more specifically, on
sexual desire disorder, arousal difficulties, anorgasmia, and dyspareunia. The
review also encompassed dysfunction related to the reproductive factors, such
as pregnancy, hysterectomy, and menopause. We included sexual dysfunction
comorbid with diabetes, depression, and antidepressant therapies. In total, 85
studies are summarized in this review, which spans literature from the early
1900s to the present. We performed a quality assessment of each study, defining
quality based on the representativeness of the population studied and the rigor
of the instruments used for assessing sexual dysfunction. Although none of the
85 studies included in the review met both standards of quality, some met one
criterion and not the other Definitions of female sexual dysfunction have been
developed and refined recently, but there is an urgent need to determine mea-
surable outcomes that can be used for future work.
Key Words: dyspareunia, libido, sexual arousal disorder, sexual desire, sex-
ual dysfunction.
Since at least the 18th century, gender differences in relationships,

love, and sexuality have been described by many authors attempting
Suzanne L.West, PhD, MPH, is affiliated with the Cecil G. Sheps Center for Health
Services Research, the Department of Epidemiology, School of Public Health, and the
Department of Obstetrics and Gynecoiogy, School of Medicine, all at the University of
North Carolina, Chapel Hill, NC. Lisa C. Vinikoor, BS, is affiliated with the Cecil G. Sheps
Center for Health Services Research and the Department of Epidemiology, School of Pub-
lic Health at the University of North Carolina. Denniz Zolnoun, MD, MPH, is affiliated
with the Department of Obstetrics and Gynecoiogy, School of Medicine at the University
of North Carolina. The authors wish to thank J. Nikki McKoy for her expert editorial
assistance. Correspondence concerning this article should be addressed to Suzanne L.
West, Cecil G. Sheps Center for Health Services Research, 725 Airport Road, Chapel Hill,
NC 27599-7590. (Sue West@unc.edu)
40
FEMALE SEXUAL DYSFUNCTION 41
to understand the psychopathology of sexual behavior (Johnson,

Wadsworth, Wellings, & Field, 1994). Survey research in this area
hegan in the late 1920s when Hamilton studied marital relationships
(Hamilton & Macgowan, 1929) and Davis (1929) reported on the sex
hfe of 2,200 women from New York City. Since then, Terman (1938)
compared rates of actual and desired intercourse frequency for 800
couples (Terman, 1938), and Kinsey began his notable work that
resulted in two books: Sexual Behavior in the Human Male (Kinsey,
Pomeroy, & Martin, 1948) and Sexual Behavior in the Human Female
(Kinsey, Pomeroy, Martin, & Gebhard, 1953). Soon after Kinsey's pub-
lication on women's sexuality in the United States, Chesser (1956)
provided similar data for English women. Much of tbe older work was
focused on sexual satisfaction, orgasmic ability, and actual and
desired sexual intercourse frequency, as the field was underdeveloped
at that point. However, the study of female sexuality advanced once
Masters and Johnson published Human Sexual Response in 1966 and,
in 1970, their description of the four-phased female sexual response in
Human Sexual Inadequacy. Kaplan's refinement of the Masters and
Johnson characterization several years later (Kaplan, 1977) incorpo-
rated desire so that the response cycle included desire, excitement
(arousal), orgasm, and resolution. This four-phase model, based on
sexual response more characteristic of men (Basson et al., 2003), is
the current foundation for diagnosing sexual problems, according to
the fourth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR), with diagnosis requiring that the sexual prob-
lems cause "marked distress and interpersonal difficulties" (American
Psychiatric Association, 2000a, retrieved January 29, 2005, from
http://online.statref.com.libproxy.Ub.unc.edu/document.aspx?fxid=37
&docid=255).
A conceptualization of female sexual dysfunction was lacking until
the works by Masters and Johnson (1966) and Kaplan (1977) were pub-
lished, so it is not surprising that in studies published before this date
different aspects of sexuality were assessed. Unlike the current litera-
ture that requires authors to condense a tremendous amount of method-
ological description and results into a few journal pages, the early
studies were published as books (Chesser, 1956; Davis, 1929; Gebhard
& Johnson, 1979; Hamilton & Macgowan, 1929; Hite, 1976; Terman,
1938). Because this allowed space for greater elaboration, the popula-
tions were well described, the questionnaires were provided, and
numerous descriptive tables were available. However, this greater
detail also reveals that the authors developed their own questions with
little or no regard for comprehensibility and how question wording
42 S. WEST, L. VINIKOOR, & D. ZOLNOUN
might influence response. Even questions regarding the same construct,

such as a woman's ability to have an orgasm, were phrased differently
in each of the surveys so comparison across surveys is difficult. More-
over, those conducting the surveys did not address the possibility of
response bias due to the sensitive nature of the questions—at times
male physicians administered the questionnaires to female patients
(Rainwater, 1968)—although some questionnaires were self-adminis-
tered (Chesser, 1956; Terman, 1938).
The authors of the early studies recognized that a representative sam-
ple was important for valid results, but this was more in concept than in
reality. Most used some type of convenience sample identifying women or
couples by advertisements, through various organizations (e.g., parent-
teacher associations, church groups, and universities), or through clinic
populations. Only the more recent studies used some random selection
procedure to ensure the collection of data from a representative sample.
In fact, presently, the most frequently cited statistics on female sexual
dysfunction are from the article by Laumann and colleagues who used a
national probability sample derived from household addresses (Lau-
mann, Paik, & Rosen, 1999). However, like earlier studies, the sexual
questions in this survey were newly created and not specifically designed
to identify female sexual dysfunctions in a clinical setting.
About the time that the Laumann (Laumann et al., 1999) study was
published, a revised definition of female sexual dysfunction was devel-
oped by an international group with professional expertise in 10 disci-
plines related to female sexual health (Basson et al., 2000). Although
there were some definitional revisions, the major components of sexual
response, desire, arousal, and orgasm were retained, and a separate cat-
egory for sexual pain disorders was added. More specifically, the sexual
pain disorders were categorized into dyspareunia, vaginismus, and
other sexual pain disorders. Like the DSM, the new consensus defini-
tion requires that any of the components of sexual dysfunction (hypoac-
tive sexual desire disorder, sexual arousal disorder, or orgasmic
disorder) cause the woman personal distress.
This revised definition of female sexual dysfunction has been criti-
cized by many researchers, primarily because of its foundation on the
male sexual response cycle (Basson et al., 2003). The clarification was
an attempt to differentiate sexual problems that were primarily physi-
cal from those that could be attributed more readily to psychological or
relationship issues, or a combination of etiologies. In rethinking wom-
en's sexual response, several important clarifications were suggested.
Uulike the male sexual response cycle, there may not he a progression
from desire to arousal and orgasm in women and desire may not pre-
cede arousal. In addition, female sexual response may change over the
reproductive lifecyele, whicb includes the menstrual cycle, pregnancy,
the postpartum period, and menopause, with fluctuations in response
actually being part of the normal life cycle rather than abnormal psy-
chopathophysiology.
With the proposed modifications in the definition and conceptualiza-
tion of women's sexual dysfunction, a review of the research on preva-
lence of sexual dysfunction and factors that influence the presence of
dysfunction is timely. Reviewing past research ean help inform the needs
of future research. The following are tbe key questions for this review:
(a) What is the prevalence of female sexual dysfunction overall, and as
differentiated into its fonr major components—desire, arousal, orgasmic,
and sexual pain disorders? (b) Do reproductive factors, such as preg-
nancy, hysterectomy and menopause, and family planning influence the
prevalence of female sexual dysfunction? (c) Do comorbidities, such as
diabetes or depression and its treatment, affect sexual functioning.
Methods
We conducted a literature search of the MEDLINE database from
January 1, 1966, to February 11, 2004, using the search terms provided
in Tables 1 and 2. We supplemented this search by hand searching the
bibliographies from review papers and original articles. Hand searching
continued until no previously unidentified publications were found. In
addition, we conducted separate literature searches to identify studies
assessing the prevalence of sexual dysfunction related to pregnancy,
surgical and natural menopause, and family planning, which were done
separately from studies of specific comorbid conditions such as diabetes,
depression and its treatment.
A preliminary review of the literature indicated that there was a
great deal of variability in the key words and Medical Subject Headings
(MeSH) associated with many of the seminal publications on female
sexual function and dysfunction. As indicated in Tables 1 and 2, our
search terms included sexual dysfunction, as well as components of the
sexual response, such as sexual desire, arousal, and orgasm, to address
this variability. For example, we knew from the MeSH documentation
that sexual dysfunction was added to the MeSH dictionary in 1999, so a
complete search would require including each of the individual compo-
nents of the sexual response in addition to dyspareunia.
Our second and third key questions focused on the factors associated
with tbe prevalence of female sexual dysfunction. We determined, a pri-
ori, which reproductive lifecyele events and comorbidities we would
focus on in the review (pregnancy and the postpartum period.
menopause, family planning, depression, and diabetes) and retained

papers that addressed these conditions.
Two of the authors (SLW and LCV) independently reviewed the titles
and abstracts from the literature searches. If either reviewer deter-
mined that a study met the inclusion criteria (Table 3), we retrieved the
full paper for further evaluation. Two of the authors (SLW and LCV)
reviewed the full study to determine final inclusion, adjudicating dis-
agreements by consensus discussion. Papers excluded at this stage were
publications that provided no prevalence data, reviews and commen-
taries, those on gynecologic pain conditions {including vulvar vestibuli-
tis and endometriosis), and those with prevalence rates based on
physicians' estimation.
The relevant information on study population, study population char-
acteristics, eligibility factors, the instrument for measuring sexual dys-
function, method of data collection, prevalence rates, predictors of
sexual problems, and other important miscellaneous information was
ahstracted into the evidence tables by one of the three authors. A second
author checked the accuracy of the abstracted information against the
Table 1
Terms Included in the Sexual Dysfunctions, Psychological Medical Subject Search
Dysfunction, Psychological Sexual
Dysfunctions, Psychological Sexual
Psychological Sexual Dysfunction
Psychological Sexual Dysfunctions
Sexual Dysfunction, Psychological
Psychosexual Disorders
Disorder. Psychosexual
Disorders, Psychosexual
Psychosexual Disorder
Psychosexual Dysfunctions
Dysfunction. Psychosexual
Dysfunctions, Psychosexual
Psychosexual Dysfunction
Frigidity
Hypoactive Sexual Desire Disorder
Orgasmic Disorder
Disorders, Orgasmic
Orgasmic Disorders
Sexual Arousal Disorder
Arousal Disorders, Sexual
Disorders, Sexual Arousal
Sexual Arousal Disorders
Sexual Aversion Disorder
Aversion Disorders. Sexual
Disorders, Sexual Aversion
Sexual Aversion Disorders
Vaginismus
Note. Sexual dysfunctions, psychological was introduced as a MeSH term in 1999.
Table 2
Systematic Search Strategy and Results
Search strategy Re.sults
1 Explode sexual dysfunctions, psychological or explode
sex disorders or explode libido or explode impotence 20,448
2 Limit to human, English, female 6,621
3 Explode epidemiology 8,141
4 Explode prevalence 69.218
5 Combine search 2 and search 4 104
6 Focus on sex disorders/epidemiology 82
7 Limit to human, English, female 51
8 Focus on sexuality/statistics and numerical data 11
9 Sexual dysfunctions, psychological I MeSH I or libido
(MeSH) or dyspareunia (MeSHi or orgasm (MeSH),
limited to English, female, and human 5,379
10 Case-control studies (MeSH), or "cohort" studies (MeSH)
or epidemiologic studies (MeSH) or cross-sectional
studies (MeSH) 427,372
11 Combine searches 9 and 10, limiting to English, female, and
human 55I
12 Combine searches 5 or 7 or 8 or 11 605
original articles. Once a final consistency check was performed to

ensure that all available information from eligible papers was
abstracted, the abstraction was considered complete.
The search resulted in 662 possible papers, consisting of 605 papers
from the literature searches, 47 papers identified from hand-searching,
and 10 papers identified in focused literature searches (see Figure 1).
After reviewing the abstracts and reviewing the full papers retrieved
from the abstract review phase, 85 original studies were included in
this review.
We had three duplicate publications because two authors (Laumann
et a l , 1999; Terman, 1938) published more than one document on each
study. Terman and Laumann et al. published both a journal article and
a detailed description of the study methodology. Two texts were pub-
lished for the Kinsey study (Gebhard & Johnson, 1979; Kinsey et al.,
1953), with one text (Kinsey et ai., 1953) containing the study design
and some summary data and the second text containing most of the
data tables (Gebhard & Johnson, 1979).
Over half of the articles included in this review were identified by
hand-searching the reference lists of eligible articles and review papers.
We reviewed our literature search and the papers that we identified by
hand-searching to determine why so many of the papers were missed
using MEDLINE. We believe that the newness of the Medical Subject
Table 3
Inclusion and Exclusion Criteria
Element Inclusion Exclusion
Databases MEDLINE, PsycINFO, Cochrane Library Other databases
Languages English only Other languages
Populations Humans and females only from randomly Transsexuals, women or
selected populations of women identified couples seeking care for
by random digit dialing, postal codes, sexual dysfunction or
electoral roles, population registers, marital counseling, aberrant
university attendance, etc. behavioral groups, males,
women seeking care for
Women seeking care for gynecological or pelvic pain, vulvar
obstetrical conditions, including vestibulitis, endometriosis,
menopause women being treated for
sexual conditions, animal
studies
Female sexual dysfunction

in women who were sexually
abused or in those with
urinary incontinence.
Study design Case-control studies IMeSH), or "Cohort" Letters and editorials
Studies (MeSH) or Epidemioiogic Studies
(MeSHI or Cross-Sectional Studies (MeSH)
Sample size For general prevalence studies, N > 100
Publication Original articles Reviews, commentaries,
types editorials, letters, case
reports, papers providing the
methods of ongoing studies
Time period From 1900 on
Headings (MeSH) for sexual dysfunction is an important reason for not

finding many of the earlier sexual dysfunction studies. Another likely
reason is that we required a MeSH term identifying the study design
for each study in the search (e.g., cross-sectional study or randomized
controlled trial). However, most of the articles we identified from our
hand searching had no mention of a study design, not even "compara-
tive study." Had we omitted the requirement of study design from our
literature search strategy, we would have identified letters, editorials,
case reports, and many other types of medical literature that would not
provide useful information for this review.
A systematic review of the literature typically includes some assess-
ment of the quality of the individual articles in the review. This can be
done by using quality scales or checklists where "points" are given for
specific study attributes, such as a randomized design or blinding of
assessors to outcome. These methodological factors are only relevant to
Potentially relevant studies as identified by MEDLINE,

PsyclNFO, Cochrane Collaboration Library ( N = 605)
Excluded
Reason Number
A^< 100 167
Transsexual 97
Not female sexual dysfunction 51
Males 30
Focus on aberrant behavior 23
Reviews or commentaries 22
Other exclusions 59
-treatment ( n = ^8)
-couples/counseling {n = 23)
-case reports (n = 7)
-sexual development in = 3)
-all others { n = 8)
Total 449
Original articles ( ;! = 156),

articles identified by hand-
searching (n ~ 47) and articies
found using separate literature
searches [n = 10) were retrieved
for full review ( n = 213),
Excluded after full paper retrieved and

reviewed
Reason Number
N< 100 24
No prevalence data 38
Gynecological pain or urinary 17
incontinence condition
Not female sexual dysfunction 3
Review, background, letter, 29
comment
Other exclusions 14
-methods or pilot ( n = 2)
-all others ( n = 12)
r Total 125
Final review includes 85 original

studies and 3 duplicate
publications subdivided into
overall FSD and FSD related to
pregnancy/postpartum,
menopause, family planning,
diabetes, and depression.
Figure 1. Flow diagram of study inclusions and exclusions.

randomized controlled trials and not to observational studies that are

the foundation of this review.
A preferred approach is to evaluate quality based on the specific
study characteristics important to the topic under review (West et al.,
2002). For example, in assessing the quality of the literature for studies
of the prevalence of female sexual dysfunction, two components are
important for discussing the validity of the findings. The first is to
understand how the women were recruited into the study, either ran-
domly (using phone numbers or census lists) or by identifying subjects
based on medical visits or procedures, which is also known as conve-
nience sampling. The characteristics of a random sample may be very
different from that for a convenience sample, as will the response rates.
These factors will be discussed later in this review.
The second component relates to how the information on sexual dys-
function was obtained—was it from clinical diagnosis, self-administered
questionnaires, or interviewer administration? If it was from question-
naires, how valid were the questionnaires used for assessing the sexual
components? Thus, in order for a study to be of high quality for this
review, it would have to have both a valid assessment of outcome and a
representative sample.
Results
The results from this systematic review are summarized below begin-
ning with a description of the publications focused on general sexual
dysfunction and then followed by five topic specific discussions of female
sexual dysfunction: (a) during pregnancy and the postpartum period, (b)
after surgical or natural menopause, (c) after abortion or while using
contraceptives, (d) in women with diabetes, and (e) in women with
depresssion or using antidepressant therapy. The studies are summa-
rized in Tables 4-9.
When reading through the results, it will be helpful to refer to these
tables, as they provide detailed descriptions of each study with regard
to how the population was recruited for the study (random versus con-
venience samples), the population characteristics, inclusion and exclu-
sion criteria, data collection methodologies, and results.
General Studies (see Table 4)
Sexual dysfunction. Of the 40 studies focused on the general popula-
tion, over half (n - 22) contained the percentage of women with sexual
dysfunction, sexual difficulties, or having one or more sexual problems
either currently, in the past 3 months, or as a lifetime prevalence. Rates
of any dysfunction were relatively low in women who were inter-
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viewed—11% in married women (Diokno, Brown, & Herzog, 1990) and

20^f in women attending a London clinic (Goldmeier, Judd, & Schroeder,
2000)—and high (91%) when based on self-administered questionnaires
by women seeking care at a military clinic (Nusbaum & Gamble, 2001).
In addition, women were asked about sexual dysfunction over varying
time periods, from current problems to dysfunction lasting for periods
ranging from weeks to years. Only two authors queried whether sexual
dysfunction lasted for an extended period and reported rates of 15% to
20% for overall dysfunction that lasted for 3 months or longer (Mercer
et al., 2003; Najman, Dunne, Boyle, Cook, & Purdie, 2003). Each
researcher's definition of dysfunction or method of ascertainment dif-
fered, as did the populations studied (random versus convenience sam-
ples), so comparisons across studies may be inappropriate.
With regard to factors that influence the prevalence of overall sexual
dysfunction, there is agreement that a woman's relationship with her
partner affects her sexual satisfaction and extent of sexual dysfunction
(Bancroft, Loftus, & Long, 2003; Nazareth, Boynton, & King, 2003). In
addition, hoth physical issues (Ernst, Foldenyi, & Angst, 1993; Fugl-
Meyer & Sjogren Fugl-Meyer, 1999; Laumann et al., 1999; Nazareth et
al., 2003; Richters, Grulich, de Visser, Smith, & Rissel, 2003) and psy-
chiatric prohlems correlated with the prevalence of sexual dysfunction
(Lindal & Stefansson, 1993; Osborn, Hawton, & Gath, 1988). There was
disagreement on the relationship between age and dysfunction, with
dysfunction increasing with age in eight studies (Bachmann, Leiblum,
& Grill, 1989; Fugl-Meyer & Sjogren Fugl-Meyer, 1999; Laumann et al.,
1999; Nazareth et al., 2003; Osborn et al., 1988; Richters et al., 2003;
Rosen, Taylor, Leiblum, & Bachmann, 1993; Ventegodt, 1998) but no
relationship with age reported in three others (Frank, Anderson, &
Rubinstein, 1978; Goldmeier et al., 2000; Read, King, & Watson, 1997).
Whether marriage affects sexual dysfunction prevalence is uncertain:
In two studies unmarried women were more likely to have sexual dys-
function (Laumann et al., 1999; Lindal & Stefansson, 1993), but in a
third, married women were more likely to have sexual dysfunction
(Read etal., 1997).
Sexual desire or interest. As shown in Table 4, researchers have
sought information on sexual desire or interest dysfunctions using
many different terms, including desire disorder, inhibited sexual desire,
low libido, lack of or decreased sexual interest, no desire for intercourse,
altered sexual interest, frequency of sexual thoughts and/or fantasies, as
well as the DSM-IV diagnosis of hypoactiue sexual desire disorder. Of
the 40 general studies reviewed (see Table 4), in 26 (67.5%) desire disor-
ders were addressed. The earliest publication giving the percentage of
women with no interest in sex was that by Hite (Hite, 1976), in which
1% of women indicated no interest in sex. During the period from the
late 1970s until the study by Laumann et al. (1999), the proportion of
women who reported httle or no interest in sex generally ranged from
about 107r to 20^^. No sexual desire was self-reported hy 109f of young
women of low socioeconomic status attending family planning services
{Golden, Golden, Price, & Heinrich, 1977), 12'7/ of women selected from
Copenhagen registries had no interest in sex (Garde & Lunde, 1980h),
and Rosen and colleagues reported that 15.17^ of middle-aged women
attending a gynecologic clinic were never interested in vaginal inter-
course (Rosen et al., 1993). In 2003, five studies were published with
information on sexual interest or desire: one from Austria (clinic-hased),
two from the U.K. (one clinic-based and the other recruited from postal
codes), and two from Australia. Both of the Australian studies used a
random sample of women and reported high rates of desire disorder,
from a low o^ 277c in women 18-29 (Najman et al., 2003) to over 50% in
women 20 and over (Richters et al., 2003). The results of these two stud-
ies also suggest that desire falls with increasing age as shown in two
population-hased Australian studies (Najman et al., 2003; Richters et
al., 2003), but this relationship with age was not observed in a popula-
tion-based study of Danes hy Venetegodt (1998) in which desire disor-
ders increased through ages 30 to 40 but then decreased in the late 40s
and thereafter.
Only four of the studies providing information on sexual desire disor-
ders addressed demographic and social predictors (Kadri, McHichi
Alami, & McHakra Tahiri, 2002; Klusmann, 2002; Rainwater, 1968;
Shokrollahi, Mirmohamadi, Mehrabi, & Babaei, 1999). Longer partner-
ship duration (Klusmann, 2002), spousal dissatisfaction (Shokrollahi et
al., 1999), many children (Kadri et al., 2002), and financial concerns
(Kadri et al., 2002; Rainwater, 1968) were associated with decreased
sexual interest. The data on age and marital status are derived from
Moroccan women and show that younger and unmarried women have
less sexual desire disorder (Kadri et al., 2002).
Sexual arousal or excitement. The extent to which a woman has suffi-
cient lubrication for sexual intercourse is used as an indicator of sexual
arousal or excitement. In most of the 21 studies containing information
on arousal, either arousal, excitement, lubrication, or responsiveness
was reported (see Table 4). Based on the results from the Rosen et al.
(1993) and Dunn, Croft, and Hackett (1998) studies that included both
arousal and lubrication, rates for lubrication difficulties are higher than
those for arousal dysfunction suggesting that one should not equate
lubrication difficulties with arousal dysfunctions. The highest rate of
lubrieation difficulties was reported by Nusbaum and Gamble (76%),

but the question asked how frequently the woman had concerns about
lubrication problems, which addresses the woman's concern about the
problem rather than the actual oceurrence of the problem (Nusbaum &
Gamble, 2001).
Of the 40 general studies evaluated, 12 contained information on
arousal or excitement difficulties (see Table 4). In most of the studies,
the prevalence of arousal disorder was between 20% and 30%, but it
ranged from 3.6% (Nazareth et al., 2003, who used the Brief Sexual
Function Questionnaire to define arousal disorder in a clinic population)
to a high of 48% (Frank et al., 1978, who used a convenience sample of
happily married couples and an unvalidated questionnaire to identify
arousal problems). The study by Frank and colleagues had participation
rates among the different groups that varied 10-fold (5%-50'7r). The
above examples show that the population evaluated and the method of
identifying the arousal disorder, including terminology and question-
naire method, will affect the rates determined. This will be diseussed
further in the section entitled Quality of the Articles.
Other factors that may affect the rates of arousal disorders include
age, sexual attitude, and spousal relationship. Both Najman (Najman et
al, 2003) and Nazareth (Nazareth et a l , 2003) found that arousal dys-
function increased with age, but Nazareth's findings were less robust
than Najman's. Women with a conservative attitude toward sexuality or
whose husbands were dissatisfied with their sexual relationship were
likely to have arousal disorder (ShokroUahi et a l , 1999), although these
findings should be interpreted with caution because the authors pro-
vided little information on study design and participation rates.
Orgasm. Thirty-four of the 40 studies evaluated in this review were
foeused on either anorgasmia or orgasmic difficulties (see Table 4). The
most interesting aspect of the literature on orgasm is its long history of
inclusion in sex research studies, as there are data on orgasm adequacy
beginning in 1938 (Terman, 1938) and on anorgasmia from 1957
(Chesser, 1956).
For anorgasmia, the rates were typically below 20% (Ard, 1977;
Atputharajah, 1987; Bachmann et a l , 1989; Bancroft et a l , 2003;
Chesser, 1956; Fisher, 1973; Frank et al, 1978; Garde & Lunde, 1980a;
Gebhard & Johnson, 1979; Golden et al, 1977; Hite, 1976; Mereer et a l ,
2003; Ventegodt, 1998), although in one study reported rates were as
high as 50% (Goldmeier et al, 2000). In four studies the reported rates
were in the 20% to 40% range (Laumann et a l , 1999; Read et a l , 1997;
Richters et a l , 2003; Rosen et al, 1993). In the studies with rates above
20% that were conducted in the past 5 years, interviewers were typi-
cally used to collect the data (Goldmeier et al., 2000; Laumann et al.,
1999; Read et al., 1997; Richters et al., 2003; ShokroUahi et a l , 1999),
whereas the older studies used self-administrated instruments for data
collection (Ende et al., 1984; Rosen et al., 1993).
In 13 studies, rates of orgasm difficulty or orgasm disorder were pro-
vided without reporting on anorgasmia (Athanasiou, Shaver, & Tavris,
1970; Dunn et al., 1998; Ernst et al.. 1993; Fugl-Meyer & Sjogren Fugl-
Meyer, 1999; Geiss et al., 2003; Kadri et al., 2002; Lindal & Stefansson,
1993; Najman et al., 2003; Nazareth et al., 2003; Nusbaum & Gamble,
2001; Osborn et al., 1988; Schein et al, 1988; Terman, 1938), and in two
studies, both anorgasmia and orgasm difficulty rates were provided
(Frank et a l , 1978; Golden et a l , 1977). The rate of orgasm difficulty
ranged from 20% to 30% on average (Athanasiou et a l , 1970; Dunn et
a l , 1998; Fugl-Meyer & Sjogren Fugl-Meyer, 1999; Geiss et al, 2003;
Najman et al, 2003; Nazareth et al, 2003; Schein et al, 1988; Terman,
1938), with a high outlier of 81% for the study conducted in women
attending a military clinic (Nusbaum & Gamble, 2001). In four studies
orgasm difficulty rates below 20% were reported, and all of these stud-
ies used interviewer-administration for data collection (Ernst et a l ,
1993; Kadri et a l , 2002; Lindal & Stefansson, 1993; Osborn et a l ,
1988), whereas in only two of the eight studies with rates in the 20%-
30% range were interviewer-administered questionnaires used (Fugl-
Meyer & Sjogren Fugl-Meyer, 1999; Najman et a l , 2003). How
interview administration may affect the results is discussed later.
Women with diabetes were at greater risk of anorgasmia (Kadri et
a l , 2002; also see Table 8), as were those who engaged in coitus less fre-
quently and had a more conservative attitude toward sexuality
(ShokroUahi et a l , 1999). Women of Latino descent were less likely to
have orgasmic difficulties compared to either Black or non-Latino White
women (Golden et al, 1977).
Dyspareunia. The prevalence of dyspareunia ranged from 0.9% to
75%, with bimodal frequencies of less than lO7t {Bancroft et a l , 2003;
Danielsson, Sjoberg, Stenlund, & Wikman, 2003; Diokno et a l , 1990;
Ernst et a l , 1993; Fisher, 1973; Fugl-Meyer & Sjogren Fugl-Meyer,
1999; Garde & Lunde, 1980a; Kadri et al, 2002; Lindal & Stefansson,
1993; Mercer et a l , 2003; Nazareth et a l , 2003; Osborn et a l , 1988;
Pepe, Panella, Pepe, D'Agosta, & Pepe, 1989; Rosen et a l , 1993;
ShokroUahi et a l , 1999; Starr & Weiner, 1981; Ventegodt, 1998) and
20% to 30% (Atputharajah, 1987; Ende et al, 1984; Geiss et a l , 2003;
Golden et al, 1977; Laumann et al, 1999; Najman et a l , 2003; Pepe et
a l , 1989; Richters et a l , 2003; Schein et al, 1988). The bimodal nature
of the rates probably reflects many issues, such as the woman's underly-
88 S. WEST. L. VINIKOOR, & D, ZOLNOUN
ing physiological state (e.g., age, pregnancy), as well as study design

(e.g., question wording), the period of observation queried (e.g., ever, the
past year), or the duration of dyspareunia. For example, in the study by
Mercer and colleagues (Mercer et al., 2003), the questionnaire
addressed pain that lasted 1 month or more (11.8%), as well as pain
lasting 6 months or more (3.4%).
In four studies, reported prevalence rates of dyspareunia were much
higher than in the other 25 studies containing dyspareunia rates (Bach-
mann et al., 1989; Dunn et al., 1998; Hite, 1976; Nushaum & Gamble,
2001). The most likely reason for these higher rates is question wording
that asked whether the woman ever had any type of pain accompanying
sex. Laumann and colleagues (1999) found that pain differed hy age,
with the highest likelihood of pain in the 18-29 year age group (21%),
decreasing to an average of 14% in the 30 to 49 year age group, and 8%
in those over 50. Laumann's question asked whether the woman had
pain during sex, where the pain lasted for several months or more over
the past 12 months. This dichotomous question required women to
think about two issues, the past 12 months and whether the pain lasted
for several months or more. If the women failed to contemplate whether
the pain lasted for an extended period of time and only thought about
whether she had pain the past 12 months, we would expect higher rates
of dyspareunia.
Dyspareunia was positively related to hypertension, depressive
symptoms, and sleep disorders (Kadri et al., 2002) but negatively associ-
ated with age (Danielsson et al., 2003; Laumann et al., 1999; Najman et
al., 2003; Richters et al., 2003; Ventegodt, 1998). Shokrollahi and col-
leagues reported that spousal dissatisfaction was associated with dys-
pareunia, but the relationship was not very strong (Shokrollahi et al.,
1999).
Sexual Dysfunction During Pregnancy and the Postpartum Period (see

Table 5)
The studies of dysfunction related to pregnancy focus on specific sex-

ual components, such as interest, arousal, orgasm, and pain, and do not
provide data on the prevalence of sexual dysfunction in general. With
the exception of dyspareunia, the predictors of sexual dysfunction dur-
ing pregnancy and the postpartum period were not specific by sexual
component. According to Bogren (1991), different factors affected sexual
desire, frequency, and satisfaction during pregnancy, typically with a
negative relationship. With regard to sexual desire, women with a
higher educational attainment, mental symptoms during pregnancy,
and worry about the pregnancy outcome had reduced sexual desire.
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Similarly, sexual frequency was reduced in married women during the

first and third trimesters, and in depressed women through all
trimesters. Depression influenced sexual satisfaction through all the
trimesters, hut women over age 25 had decreased satisfaction during
the third trimester. With regard to resuming sexual activity, women
over age 35 resumed 2.5 weeks later than those under age 25 years, and
non-White women resumed activity a little over a week later than did
White women. Women who were breastfeeding resumed sexual activity
about a week earlier than those who were not breastfeeding fSignorello,
Harlow, Cbekos, & Repke, 2001).
Sexual desire or interest. Information on sexual interest during preg-
nancy and/or the postpartum period was provided in seven studies (Bar-
rett et al., 1999, 2000; Bogren, 1991; Ellis & Hewat, 1985; Oboro &
Tahowei, 2002; Rohson, Brant, & Kumar, 1981; Sayle, Savitz, Thorp,
Hertz-Picciotto, & Wilcox, 2001), and in two studies tbe focus was solely
on pregnancy (Bogren, 1991; Sayle et al., 2001), one providing informa-
tion for desire disorder during pregnancy and in the postpartum period
(Robson et al., 1981). In four studies, information on the postpartum
period only was provided (Barrett et al., 1999, 2000; Ellis &. Hewat,
1985; Oboro & Tahowei, 2002). In all of the studies, women's interest lev-
els were compared to levels prior to pregnancy. In all three studies in
wbich sexual desire during pregnancy was evaluated, a reduced interest
in sex was found (Bogren, 1991; Rohson et al., 1981; Sayle et al., 2001),
witb the proportion of women with decreased sexual desire ranging from
57^7, to 75% in tbe tbird trimester (Bogren, 1991; Sayle et al., 2001).
In all five studies containing data on sexual interest during tbe post-
partum period, sexual interest was found to be low after delivery (Bar-
rett et al., 1999, 2000; Ellis & Hewat, 1985; Oboro & Tahowei, 2002;
Rohson et al., 1981), with approximately 23%-57'^ of women reporting
reduced sexual interest when measured at 3 months postpartum. At 6
months, reduced sexual interest was reported by 21%-37% of women.
Sexual arousal or excitement. Of the tbree studies providing informa-
tion on sexual arousal during the postpartum period (Barrett et al.,
1999, 2000; Oboro & Tahowei, 2002), only Ohoro and Tahowei provided
information on lubrication problems at 6-weeks postpartum (51%); by 3-
and 6-months postpartum, the proportion of women reporting lubrica-
tion problems was 29%, and 13%, respectively (Barrett et al., 1999,
2000; Oboro & Tabowei, 2002).
Orgasm. In two studies, rates of orgasm during pregnancy were
reported (Rohson et al., 1981; Sayle et al., 2001), and in five studies
orgasm difficulties during the postpartum period were reported (Barrett
et al., 1999, 2000; Oboro & Tabowei, 2002; Robson et al., 1981; Sig-
norello et al., 2001). The ability to experience orgasm decreased over the
pregnancy, with approximately 609^ of women experiencing orgasm
through the second trimester (Sayle et al., 2001). Robson et al. reported
t h a t only 26% of t h e women still h a v i n g i n t e r c o u r s e in t h e t h i r d
trimester experienced orgasm at least half of the time.
As with sexual desire, the ability to reach orgasm improved during
the postpartum period. At 6 weeks postpartum, 41'>( of women had diffi-
culty with orgasm (Oboro & Tabowei, 2002). The percentage decreased to
15%-23% by 6 months postpartum (Barrett et a l , 1999, 2000; Oboro &
Tabowei, 2002). At 6 months postpartum, women with an intact per-
ineum or first degree perineal t e a r were more likely to experience
orgasm as compared to those with either a second degree perineal
trauma or a third to fourth degree laceration (Signorello et al., 2001).
Dyspareunia. Rates of dyspareunia were reported in six studies, and
all of them were focused on the postpartum period (Barrett et al., 1999,
2000; Grant et a l , 2001; Oboro & Tabowei, 2002; Signorello et a l , 2001;
Sleep & Grant, 1987). Approximately 20%-50% of women indicated
painful intercourse at 3 months postpartum, but this decreased to 10%-
20% at 6 months. Signorello and colleagues (2001) reported t h a t t h e
n u m b e r of women affected by d y s p a r e u n i a d u r i n g t h e p o s t p a r t u m
period was related to the degree of perineal t r a u m a sustained during
the birth. Compared to women with either a second or third/fourth
degree tear, women with an intact or first degree perineal tear had less
severe d y s p a r e u n i a a n d were less likely to have d y s p a r e u n i a at 6
months postpartum. However, whether the repair was a two versus a
three stage repair of an episiotomy, or first degree perineal laceration,
did not affect dyspareunia when first resuming sexual activity or at 1
year after resuming activity (Grant et a l , 2001).
Female Sexual Dysfunction in Natural and Surgical Menopause (see

Table 6)
Sexual dysfunction. Estimates of the prevalence of sexual dysfunction
by menopausal status were provided in three recent studies: one of peri-
and postmenopausal women in Santiago, Chile (Castelo-Branco et a l ,
2003); another of women from The Netherlands having either a total
vaginal, subtotal, or total abdominal hysterectomy for benign conditions
(Roovers, van der Bom, van der Vaart, & Heintz, 2003); and the third of
natural and surgical menopause in women from Australia {Denner-
stein, Randolph, Taffe, Dudley, & Burger, 2002), The prevalence of sex-
ual dysfunction in Chilean women was 51.3%, pooling over age and
menopausal status. The authors found that dysfunction was lower for
women in good health, for those who used hormone replacement ther-
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apy, and in more educated women. They also reported that sexual dys-
function increased as women aged and became menopausal. Roovers
and colleagues showed a 40%-50% reduction in sexual dysfunction for
some women, regardless of surgical procedure, but others developed
dysfunction after the surgery. Dennerstein and colleagues used the Per-
sonal Experiences Questionnaire (Dennerstein et al., 2002), for which a
sum of < 7 was considered indicative of sexual dysfunction. Compared to
women in early menopausal transition, during which 42% of women
were considered to have sexual dysfunction, 88% of postmenopausal
women had dysfunction.
It is difficult to interpret the results of these studies. Castelo-Branco
et al. (2003) and Roovers et al. (2003) used convenience samples, but
Dennerstein (2000) used a representative sample. Also, results were
pooled over menopausal status, and the type of hysterectomy was evalu-
ated without comparison to natural menopause. Further, a question-
naire score was used to measure sexual dysfunction. Besides these
issues, how ovarian function might influence dysfunction was not con-
sidered (i.e., the authors of the convenience sample studies did not
stratify their results by presence or absence of oophorectomy).
Sexual desire or interest. Of the 11 studies containing information on
sexual interest related to menopause or hysterectomy (see Table 6), only
Nappi and colleagues (Nappi, Verde, Polatti, Genazzani, & Zara, 2002)
and Hallstrom (1979) focused solely on naturally menopausal women,
although Dennerstein and colleagues (Dennerstein, Smith, Morse, &
Burger, 1994) provided results stratified by surgical versus natural
menopause and oophorectomy status. In the other studies, comparisons
were made between women with a hysterectomy and either women
prior to a hysterectomy (Carranza-Lira, Murillo-Uribe, Martinez Trejo,
& Santos-Gonzalez, 1997; Dennerstein et al., 1994; Kilkku, Gronroos,
Hirvonen, & Rauramo, 1983; Rhodes, Kjerulff, Langenberg, & Guzinski,
1999; Virtanen et al., 1993} or women with n a t u r a l menopause
(Chiechi, Granieri, Lohascio, Ferreri, & Loizzi, 1997). Castelo-Branco et
al. did not provide rates of reduced interest differentiated by type of
menopause.
The study by Dennerstein and colleagues (1994) is particularly infor-
mative, as they provided estimates of increased, decreased, and no
change in sexual interest, stratified by type of menopause and oophorec-
tomy status. The rate of reduced sexual desire was highest in naturally
menopausal women, followed by surgically menopausal women who had
had an oophorectomy and perimenopausal women. Likewise, the study
by Hallstrom (1979) was also informative. Although sexual interest
appears to decrease with age in several of the studies, Hallstrom con-
trolled for age when evaluating menopausal transitions and showed that
levels of sexual desire are related to biological factors rather than age.
The studies of surgical menopause must he evaluated carefully
because of the interrelationship between health issues and relation-
ship factors. Besides the physical issues, such as why the hysterec-
tomy was done, authors typically evaluate dysfunction subsequent to
hysterectomy without regard to oophorectomy status, or relationship
factors. In many of the studies, levels of postsurgery sexual interest
are compared to presurgery rates that are often done when the woman
is symptomatic and in need of corrective surgery. In a study of pre-
dominantly younger women, in which only IVTr of the women were >
50 years of age, Rhodes et al. (1999) found that hysterectomy is associ-
ated with increased sexual interest, perhaps because the potential for
pregnancy is no longer a concern. Similarly, Virtanen et al. (1993)
reported a slight improvement in interest with time since hysterec-
tomy, but age and oophoreetomy status were not considered. Rates of
sexual interest at 6 or 12 months postsurgery were not affected by
how the hysterectomy was done (abdominal or supravaginal) or hy
oophoreetomy status. Regardless of the type of menopause, women
who had dyspareunia were more prone to decreased sexual desire
than women without dyspareunia (Chieehi et al., 1997), as were
women with psychological problems (Avis, Stellato, Crawford,
Johannes, & Longcope, 2000; Nappi et al., 2002; Rhodes et al., 1999).
Considering all of the studies providing data on sexual interest, the
fmdings are complex and difficult to interpret. We discussed some of the
findings from these studies here, but Table 6 is more informative as, in
it, we contrast study designs and measurement issues, and we provide
data on all the outcomes evaluated. In addition, there are several recent
reviews focusing on menopause and sexuality issues (Dennerstein,
Alexander, & Kotz, 2003; Farrell & Kieser, 2000; Maas, Weijenborg, &
ter Kuile, 2003; McCoy, 1998).
Sexual arousal or excitement. Reviewing the findings of the eight
studies in which data were collected on arousal or excitement difficul-
ties in naturally or surgically menopausal women, the general conclu-
sion is that arousal problems (and lubrication insufficiency) tend to
increase with age and with progression through the perimenopausal
transition (Avis et al., 2000; Castelo-Branco et al., 2003; Chen & Ho,
1999; Malacara et al., 2002; Nappi et a l , 2002; Rhodes et al., 1999;
Roovers et al., 2003). Malacara and colleagues (2002) found no differ-
ences in vaginal dryness by urban or rural location in Mexico, but there
were differences among the three geographic locations, with the pre-
menopausal women from the Yucatan having much less of a problem
with dryness than those from Guanajuato or Coahuila. Whether this is

a study artifact or a true finding is unclear because similar findings
were not found in postmenopausal women. With regard to hysterec-
tomy, Roovers et al. (2003) and Rhodes et al. (1999) found a reduction in
vaginal dryness after surgery in those with this problem prior to hys-
terectomy. Few women who had not had arousal problems prior to
surgery developed them after surgery. Thakar, Ayers, Clarkson, Stan-
ton, and Manyounda (2002) found no differences in vaginal lubrication
comparing pre- and postsurgery values or by type of hysterectomy.
Without controlling for age and reason for hysterectomy, the differences
between the studies are not informative.
In none of the hysterectomy studies did the authors differentiate
between women who did and did not have an oophorectomy at the same
time as the hysterectomy. Failure to provide this information is unfortu-
nate because ovarian function is likely to be driving the sexual dysfunc-
tion rather than hysterectomy per se. Increasing age, depression, and
psychosocial factors are the most frequently reported predictors of
arousal dysfunction.
Orgasm. Information on orgasm was provided in several studies,
some comparing the frequency of or ability to have an orgasm before
and after hysterectomy (Helstrom, Lundberg, Sorbom, & Backstrom,
1993; Kilkku et al., 1983; Rhodes et al., 1999; Roovers et al., 2003; Vir-
tanen et al., 1993). Others described problems with orgasm overall or by
age and/or menopausal status (Avis et al., 2000; Castelo-Branco et a l ,
2003; Chen & Ho, 1999; Kilkku et al., 1983; Rhodes et al., 1999; Roovers
et al., 2003; Virtanen et al., 1993). The average proportion of naturally
menopausal women who had problems with orgasm ranges from
approximately 37.2% in a population with mean age 53.8 (Avis et al.,
2000) to as high as 58% in a study of 45- to 55-year-old women (Chen &
Ho, 1999). Castelo-Branco and colleagues suggest that the ability to
experience orgasm decreases with age. Given the other life stressors
and personal health factors that appear as women age, in addition to
relationship issues (loss of a partner or poor partner health), it is diffi-
cult not only to separate but also to quantify the potentially indepen-
dent effects of age, ovarian function, psychosocial issues, and partner
factors (Dennerstein et a l , 2003; McCoy, 1998).
Rhodes et a l , (1999) and Roovers et a l , (2003) reported that orgasm
difficulties decreased after hysterectomy by approximately 15%, with
the indication for hysterectomy given as a "benign condition." Kilkku
(1983) suggested that rates of orgasm difficulty in those who had a
supravaginal hysterectomy was slightly superior to those in woman who
had an abdominal hysterectomy, but the results were not statistically
significant. Without adequate control for the conditions for which hys-
terectomy was indicated, understanding the true effect of hysterectomy
on orgasm is prohlematic. Hysterectomies in premenopausal women are
typically performed for abnormal bleeding, hormone imbalance, or
fibroids, whereas uterine prolapse is the leading reason for hysterec-
tomy in postmenopausal women (Maas et al., 2003). Thus, it is impor-
tant to evaluate orgasm controlling for why the surgery was done.
Further, women may or may not have an oophorectomy when they are
hysterectomized, but researchers may not differentiate between women
who do and do not have ovaries. This differentiation may become more
important as we determine whether hysterectomy without an oophorec-
tomy promotes ovarian failure (Maas et al., 2003).
The predictors of orgasm difficulties include age (Avis et al., 2000;
Rhodes et al., 1999), vaginal dryness (Avis et al., 2000), recent bladder
infection (Avis et al., 2000), depression, (Rhodes et al., 1999), and bilat-
eral oophorectomy (Kilkku et al., 1983; Rhodes et al., 1999).
Dyspareunia. Almost all of the natural or surgical menopause studies
contained some information on dyspareunia. Dyspareunia increased with
age (Castelo-Branco et al, 2003; Nappi et al., 2002), with 11.1% of 40- to
44-year-old women and 45% of the 55-60-year-olds experiencing dyspare-
unia. However, pain was shown to decrease with hysterectomy (Kilkku,
1983; Rhodes et al., 1999; Hoovers et al., 2003; Virtanen et al, 1993) and,
more specifically, with time since hysterectomy (Kilkku, 1983; Virtanen et
al, 1993). Comparing the rates of dyspareunia across studies of women
who are menopausal and/or who had a hysterectomy is very difficult
because many of the women having a hysterectomy have pain conditions
as the indication for the hysterectomy.
With regard to predictors of dyspareunia, women with low sexual
interest were at higher risk for dyspareunia than those without low sex-
ual interest. Chiechi et al. (1997) reported that 40.7% of women with
low sexual interest had dyspareunia, whereas only 11.7% of women who
did not report low sexual interest had dyspareunia. Duration of
menopause status (Malacara et al., 2002; Nappi et al., 2002), age
(Malacara et al., 2002; Rhodes et al., 1999), body mass index (Malacara
et al, 2002), depression (Nappi et al., 2002), and recent urinary infec-
tion are associated with the prevalence of dyspareunia (Avis et al.,
2000). Whether women had a bilateral salpingo-oophorcctomy did not
correlate with dyspareunia subsequent to the hysterectomy (Denner-
stein et al., 1994; Kilkku, 1983).
Family Planning (see Table 7)
Sexual dysfunction. In the only study providing information on over-
130 S. WEST, L. VINIKOOR, & D, ZOLNOUN
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all sexual dysfunction, Bianchi-Demicheli et al. (2002) reported that

31% of women had at least one problem with either desire, orgasm,
vaginal dryness, or dyspareunia after a pregnancy termination. Ban-
croft and Graham have conducted several experimental studies in
which women were randomly assigned to hormonal contraception
groups, but the study populations were too small for inclusion in this
review (Graham, Ramos, Bancroft, Maglaya, & Farley, 1995; Sanders,
Graham, Bass, & Bancroft, 2001).
Sexual desire or interest. Most of the studies included in this section
of the review focused on increases or decreases in sexual interest in
relation to family planning options, such as contraception, pregnancy
termination, or sterilization. Sexual interest was unchanged for more
than 50% of the women who had tubal sterilizations, ranging from
51% (Jackson & Lander, 1980) to 80% (Costello, Hillis, Marchbanks,
Jamieson, & Peterson, 2002). In many of the family planning studies,
increased sexual interest as a result of surgery or contraception was
reported, with increased desire ranging from 9% in women who had
pregnancy terminations (Bianchi-Demicheli et al., 2002) to 34% in
tubal sterilizations (Punnonen & Erkkola, 1984), but in many studies
there were women who reported decreases in sexual interest, from
very few women (1%) to a sizable number (22%), regardless of which
method of family planning was used (Bianchi-Demicheli et al., 2002;
Confmo, Ismajovich, Rudick, Yedwab, & David, 1983; Costello et al.,
2002; Jackson & Lander, 1980; Kjer, 1990; Mafakhkharul Islam,
Begum, & Keramat Ali, 1991; Punnonen & Erkkola, 1984; van Coever-
den de Groot et al., 1980). The predictors of reduced sexual interest
included anxiety (Bianchi-Demicheli et al., 2002), regret of steriliza-
tion (Costello et al., 2002; Kjer, 1990), and ethnicity. For example, 45%
of the indigenous people of New Zealand (the Maori) had reduced sex-
ual desire compared with 10% of the Europeans (Jackson & Lander,
1980).
Sexual arousal or excitement. As with desire, some women reported
an increase (13%) in sexual arousal, and others reported a decrease
(9%) in sexual arousal as measured by vaginal lubrication in those who
had undergone pregnancy terminations (Bianchi-Demicheli et al.,
2002). In a study by Kjer (1990), 3% of women complained of arousal
problems 4 to 8 years poststerilization. Anxiety and regret of steriliza-
tion were predictors of arousal problems (Bianchi-Demicheli et al.,
2002; Kjer, 1990).
Orgasm. Most women reported no change in rates of orgasm disorder
associated with pregnancy termination (72%), although 2% reported an
increase in orgasm disorder, and 17% reported a decrease in orgasm dis-
order (Bianchi-Demicheli et al., 2002). Predictors of orgasmic problems

included anxiety, fatigue, and sadness.
Dyspareunia. The three studies in this section of the review in which
dyspareunia was ascertained vary on family planning method evaluated,
including intrauterine device (Confino et al., 1983), tubal sterilization
(Punnonen and Erkkola, 1984), and pregnancy termination (Bianchi-
Demicheli et al., 2002), as well as type of intrauterine device (Confino et
al., 1983). In the study of tubal sterilizations, Punnonen and Erkkola
(1984) reported no dyspareunia 2-3 years afler surgery in 85% of women.
Ten percent of women experienced no change, and only a very small per-
centage had an increase or decrease in pain. In an intrauterine device
study, Confino et al. (1983) found more dyspareunia in users of the Cop-
per-T as compared with the OM-GA Cu device, but, as this paper was
published in 1983, the devices studied have, in all likelihood, heen
improved and refined. The differentiation between the two devices for
sexual dysfunction is likely to be irrelevant today. For pregnancy termi-
nations, more women exhibited a greater increase in dyspareunia than a
decrease, but the numbers were not large.
Diabetes (see Table 8)

We identified three studies in which sexual dysfunction among diabetics
was described, including one of only Type 1 diabetics (Enzlin, Mathieu,
Van Den Bruel, Vanderschueren, & Demyttenaere, 2003), another on Type
2 diabetic women (Erol et al., 2002), and a third that was based on pre-
dominantly Type 2 diabetics with a small proportion (5%) of Type 1 diabet-
ics (Wandell & Brorsson, 2000). Sexual dysfunction was reported by 27% of
Type 1 diabetics, many of whom had poor marital relationships. Women
complaining of sexual interest and arousal dysfunctions in particular had
more depressive symptoms. Erol and colleagues compared women with
Type 2 diabetes to a control group without diabetes. More women with
Type 2 diabetes exhibited sexual dysfunction for libido, clitoral sensation,
orgasm, and vaginal discomfort. Similarly, Wandell and Brorsson reported
lower sexual function scores for diabetic patients compared to a random
sample of the population for libido, arousal, and orgasm.
In Type 1 diabetics, sexual dysfunction was not related to age, body-
mass index, duration of diabetes, or hemoglobin (HbAlc) levels (Enzlin
et al., 2003). For Type 2 diabetics, desire disorder was associated with
current cardiovascular and psychiatric health, whereas arousal disorder
was associated only with psychiatric disease, and orgasm was related to
age (Wandell & Brorsson, 2000). According to Erol et al. (2003), body
mass index, diabetes duration, and HbAlc were not associated with sex-
ual dysfunction for Type 2 diabetes.
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Depression (see Table 9)

To address our third key question, whether the prevalence of female
sexual dysfunction was associated with comorbidities, we sought studies
containing prevalence information in depressed persons, some of whom
were treated with antidepressants. Although the literature on sexual
dysfunction in depressed patients seems large, there are few studies in
which information is provided for at least 100 individuals who are
depressed and the rates of dysfunction are not confounded by treatment
effects. More specifically, we focused on studies in which there was base-
line information on sexual dysfunction prior to treatment initiation.
The literature on drug-induced sexual dysfunction is large, and a full
review is beyond the scope of this paper. We refer interested readers to
a recent paper by Montgomery, Baldwin, and Riley, (2002), who pro-
vided a review of the antidepressant-induced sexual dysfunction litera-
ture, which includes studies from 1978 until 1999.
Sexual dysfunction. In two randomized controlled trials (Ekselius &
von Knorring, 2001; Michelson, Schmidt, Lee, & Tepner, 2001) and two
observational studies (Keller Ashton, Hamer, & Rosen, 1997; Montejo,
Llorca, Izquierdo, & Rico-Villademoros, 2001), the prevalence of sexual
dysfunction in depressed patients was reported. Although it is unclear
whether the women in the study by Michelson et al. had received anti-
depressants previously, 69.3% of depressed women initiating fluoxetine
therapy had sexual dysfunction, and at week 13 of the open-label fluox-
etine therapy phase, 67.5% still had sexual dysfunction. Women whose
depression symptoms improved were enrolled in a 25-week double-blind
continuation phase comparing fluoxetine (20 mg daily or 90 mg weekly)
to placebo. At the end of the 25-week phase, 46.9% of women still had
sexual dysfunction. Thus, sexual dysfunction is comorbid with
untreated depression, and treatment of depression with fluoxetine does
improve both depression and sexual dysfunction in certain women.
What cannot be disentangled is whether the improvement in depression
symptoms resulted in enhanced sexual function or whether the
improved depression and sexual dysfunction symptoms were indepen-
dent but potentiated by fluoxetine therapy.
In their clinical trial, Ekselius and Von Knorring (2001) found a
47.6% and 46.6% basehne rate of sexual dysfunction in the women ran-
domized to sertraline and citalopram, respectively, with both groups
having a 1-week drug washout prior to beginning therapy. The rates of
sexual dysfunction after 24 weeks of therapy were 23.8% in the sertra-
line group and 31.0% in the citalopram group, which was not statisti-
cally significantly different between the two drugs or between baseline
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FEMALE SEXUAL DYSEUNCTION 149
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and 24 weeks. Although the authors provided haseline rates after a

washout period, it is unclear whether assessing sexual dysfunction
prevalence after a washout period equates with measuring a prevalence
rate in women who had never received antidepressant therapy.
In two of the three ohservational studies, the focus was to identify
whether initial treatment with antidepressants was associated with
sexual dysfunction (Keller Ashton et al., 1997; Montejo et al., 2001).
Widely divergent rates were found. In a prospective study carried out in
psychiatrists' offices, Montejo and colleagues reported an incidence rate
of 56.9% in women with no prior sexual dysfunction who were treated
for depression. Keller Ashton and colleagues reported a 13.89^' rate from
a retrospective review of depression clinic charts of patients referred
from primary care practitioners and psychiatrists. Angst (1998)
reported that sexual dysfunction was higher in depressed women, some
of whom may be treated with antidepressants or psychotherapy, com-
pared to nondepressed women. Older individuals and those who were
married tended to have a greater prevalence of sexual dysfunction;
there were no differences in sexual dysfunction by type of serotonin
reuptake inhibitor (Keller Ashton et al., 1997).
Sexual desire or interest. Besides the studies in which overall sexual
dysfunction was evaluated (Ekselius & von Knorring, 2001; Keller Ash-
ton et al., 1997; Michelson et al., 2001; Montejo et al., 2001), these, and
an additional study, contained information on sexual interest (Bonier-
bale, Lancon, & Tignol, 2003). Michelson and colleagues reported that
at the start of their Phase I clinical trial, 73.99? reported minimal to
severe problems with low sexual interest prior to fluoxetine therapy. At
the start of Phase II, 50.3% of women had low sexual interest, and at
the end of Phase II, 26.4%, 47.3%, and 26.3% of women had improved,
unchanged, and worsened sexual interest, respectively. Ekselius and
colleagues evaluated sexual interest in women treated for depression
who were put through a 1- to 5-week (fluoxetine group) washout period
to assess "untreated" sexual dysfunction, and found that 50*^ of women
had reduced sexual interest at baseline (Ekselius & von Knorring,
2001). After 24 weeks of sertraline or citalopram treatment in women
without sexual dysfunction at baseline, 11.8% developed low desire
(Ekselius & von Knorring, 2001). Montejo and colleagues (2001) did not
specify the proportion of women who developed decreased sexual desire
after beginning antidepressant therapy but found that the severity of
desire disorder was high after initiating therapy.
Angst (1998) reported similar proportions of depressed and nonde-
pressed women with decreased libido, although the depressed women
included those who were and were not receiving therapy. Bonierbale et
al. (2003) reported that 55% of depressed women had low sexual inter-
est, but 64% of these women were using antidepressants at the time of
data collection. Although the studies described above provide some
information on the relative contribution of depression and its treatment
to the prevalence of sexual desire disorder, more work is needed to tease
apart the effect of depression on sexual desire separately from the effect
of antidepressants, as well as to understand the interaction among
these two conditions and antidepressant exposure.
Sexual arousal or excitement. Four studies contained information on
arousal (Keller Ashton et al., 1997) or vaginal lubrication associated
with depression or its treatment (Bonierbale et al., 2003; Michelson et
al., 2001; Montejo et al., 2001). Keller Ashton reported that 7.1% of
women reported arousal problems while taking selective serotonin reup-
take inhibitors. The proportion of women who reported problems with
vaginal lubrication ranged from a low of 19c to approximately 20%, with
most researchers combining the women who were and who were not
using antidepressants. Lubrication difficulties were reported by 42.8%
of women prior to starting antidepressant therapy and decreased to
26.5% after 13 weeks of fluoxetine (Michelson et al., 2001). It is unclear
from this study whether women were newly diagnosed with depression
and just starting treatment or if they were just starting a new episode
of treatment. The severity of lubrication problems was in the nil to mild
range in women who did not have sexual dysfunction prior to starting
antidepressant therapy (Montejo et al., 2001). As with the other compo-
nents of sexual dysfunction, it is important to delineate whether sexual
arousal problems result from the underlying disease, depression, or its
treatment.
Orgasm. Five studies contained data on problems with orgasm (see
Table 91. Of tbe women who had antidepressant-associated sexual dys-
function, 59% complained about orgasm difficulties (Keller Ashton et
al., 1997). Delayed orgasm occurred in 15% of depressed women, most of
whom were currently being treated with antidepressants (Bonierbale et
al., 2003). Of the women with no orgasmic dysfunction after the
washout period, 14.3% reported orgasmic dysfunction after 24 weeks of
either sertraline or citalopram therapy (Ekselius & von Knorring,
2001). Impaired orgasm was present in 62.1% of women prior to treat-
ment and in 44.6% of women after 13 weeks of fluoxetine therapy
(Michelson et al., 2001). Rather than presenting the rates of orgasmic
difficulties, Montejo and colleagues (2001) asked women to rate the
average intensity of delayed or absent orgasm on a scale from zero (no
problem) to three (severe problem). The average was 2.2 for delayed
orgasm and 1.7 for anorgasmia due to antidepressant use.
Dyspareunia. Only Bonierbale et al. (2003) evaluated the relation-

ship between depression and dyspareunia, reporting that 11% of
depressed women, some of whom were treated for depression experi-
enced genital pain.
Quality of the Articles
Our findings on the quality of the studies are summarized in Table
10. We had two criteria to judge study quality: (a) use of a valid assess-
ment of sexual dysfunction (i.e., a measurement tool that was con-
structed using appropriate psychometric techniques [Lohr et al.. 1996])
and (b) evaluation of sexual dysfunction in a representative sample of
the population in which all individuals in a population were eligible to
be selected, yet selection was done randomly. This is in contrast with a
convenience sample, such as women seeking care from certain clinicians
or having surgery at particular hospitals.
With regard to the first criterion, the authors of five studies appeared
to use a valid assessment of outcome in that the questionnaires ade-
quately discriminated between who did and who did not have sexual
dysfunction (Bonierbale et al., 2003; Ekseiius & von Knorring, 2001;
Enzlin et al., 2003; Montejo et al., 2001; Schein et al., 1988). However,
their samples were clinic-based, which makes it more difficult to gener-
alize their results to the population as a whole. Women who seek care
may be different from those who do not in ways that are related to sex-
ual dysfunction. As a result, these six studies do not meet our criterion
concerning the representativeness of the sample.
Tbere were eight studies in which a representative sample of women
was drawn (Bancroft et al., 2003; Fugl-Meyer & Sjogren Fugl-Meyer,
1999; Laumann et aL, 1999; Lindal & Stefansson, 1993; Mercer et al.,
2003; Najman et al., 2003; Richters et al., 2003; Ventegodt, 1998). In two
of tbese, a partially valid assessment of outcome was used (Lindal &. Ste-
fansson, 1993; Ventegodt, 1998). Ventegodt did some reliability testing 13
months after tbe initial survey and found correlations in the 0.6 to 0.9
range, although information on whicb sexual problems bad lower correla-
tions witb previous information was not provided. Lindal and Stefansson
measured sexual dysfunction using tbe Diagnostic Interview Scbedule
IIIA (DIS-IIIA; American Psycbiatric Association, 2000b), a validated
diagnostic tool for identifying psycbiatric disorders in tbe general popula-
tion. However, tbis diagnostic tool assesses orgasm and pain only, not sex-
ual desire and arousal difficulties. A furtber concern is t h a t the
Diagnostic Interview Scbedule IIIA (DIS; American Psycbiatric Associa-
tion, 2000b) was translated into Icelandic, and it is unclear wbetber tbe
autbors evaluated tbe measurement properties of tbe translated instru-
Table 10
Validity of Outcome Assessment and Representativeness of the Population for Each of the
Studies Included in the Review
Validity of outcome assessment Population-Based study
Partially
Valid valid Unknown
assessment assessment validity of Some Clinic-
of outcome of outcome assessment Yes caveats based Unclear
General sexual dysfunction
Bancroft etal., 2003
Daniels.s(m et al, 2003
Geiss etal., 2003
Mercer et al., 2003
Najman et al.. 2003
Nazareth et al., 2003 Brief
Sexual
Function
Questionnaire
adapted
for women
Richters et al., 2003
Kadri et al., 2002
Klusmann, 2002
Nusbaum &
Gamble, 2001
Goldmeier etal.. 2000
Fugl-Meyer &
Sjogren Fugl-
Meyer, 1999
Laumann ct al., 1999 •
Shokrnllahi
et al., 1999 BISF-W
not valid
according to •
Daker-White
Dunn etal.. 1998
Ventegodt, 1998 •
Read et al., 1997 GRISS
adapted for • /
women
Ernst et al., 1993
Lindal &
Stefansson. 1993 Used the
DIS-IIIA
translated
into
Icelandic
Rosen et ah, 1993 BISF-W
not valid
according to
Daker-White
Raboch & Raboch, 1992 • /
Diokno et al., 1990 • /
Bachmann etal., 1989 •

Pepe etal., 1989 •
Osborn et al., 1988
Scheinetal., 1988
Atputharajah, 1987
Ende et al., 1984
Table 10 continued on following page.

Table 10
Studies Included in the Review (continued)
Component Validity of outcome assessment Population-Based study
Partially
Valid valid Unknown
Starr & Weiner, 1981
Garde & Lunde, 1980
Gebhard & Jobnson,
1979 and
Kinsey et al. 1953
Frank e t a l . 1978
Ard, 1977
Golden et al, 1977
Hite, 1976
Fisber, 1973
Atbanasiou, 1970
Rainwater. 1968
Chesser. 1956
Terman. 1938. 1951
Pregnancy and the postpartum period
Morofetal, 2003
Oboro & Tabowei, 2002
Grant e t a l . 2001
Sayle et al, 2001
Signorello e t a l , 2001
Barrett et al, 2000
Barrett et al. 1999
Bogren, 1991
Sleep & Grant. 1987
Ellis & Hewat. 1985
Robsonetal. 1981
Menopause and hysterectomy
Castelo-Branco et al,
2003
Roovers et al, 2003
Dennerstein et al. 2002;
Dennerstein et al. 1994
Malacara et al, 2002
Nappi et al, 2002
Tbakar et al, 2002 •
Avis et al, 2000 Sexual
activity
questionnaire
used which
is not valid
according to
Daker-White
Ho, 1999 •
Rhodes et a l , 1999
Carranza-Lira
et al, 1997
Chiechi e t a l , 1997 Ascertain-
ment by a
Table 10 conljnued on folluwing page.

Table 10
Studies Included in the Review (continued)
Component Validity of outcome assessment Population-Based study
Partially
Valid valid Unknown
Huertaetal., 1995
Helstrometal. 1993
Virtanenetal., 1993
Kilkku, 1983;
Kilkkuetal., 1983
Hallstrom, 1979
Family planning
Bianchi-Demicheli
et al,, 2002
Costello et al., 2002
Mafakhkharul
Islam etal., 1991
Kjer, 1990
Punnonen & Erkkola,
1984
Confino et al,, 1983
Jackson & Lander,
1980
Van Coeverden
de Groot et al., 1980
Diabetes
Enzlin et al., 2003 Utvalg for
Kliniske
Undersogelaer
Side Effect Scale
lUKU-SESl
Erol etal,, 2002 Index of
Femalf Sexual
Function (IFSF)
Questionnaire
Wandell &
Brorsson, 2000
Depression
Bonierbale
et al., 2003 Arizona Sexua!
Experience Scale
EkseliuH & Von
Knorring, 2001 Utvalg for
Kliniske
Undersogelser
Side Effect Scale
lUKU-SES)
Michelson
etal.. 2001
Montejo
etal., 2001 Psychotropic-
related sexual
dysfunction
questionnaire
Angst 1998
Keller Ashton
et al., 1997
ment prior to its use. In tbe remaining seven studies using representative
samples, questionnaires that were developed specifically for tbe study
were used. Tbe authors provided little information on questionnaire
pretesting or tbe measurement properties of tbe questionnaire.
Tbe remaining 70 studies were tbose that used convenience samples
and did not assess sexual dysfunction using validated measurement
tools. Tbe metbodological issues described subsequently provide a dis-
cussion of wby tbese two elements of quality are important for tbe
papers included in tbis review.
Methodological Issues in Studying Female Sexual Dysfunction

Catalogued in Tables 4-9 are 85 papers tbat contain information rele-
vant to sexual dysfunction overall, or its components, sucb as sexual
desire, sexual arousal, orgasm, or dyspareunia. Most of tbe data
describe tbe prevalence rate of sexual dysfunction or its components,
wbicb is computed by taking the total number of persons known to bave
tbe problem at any point in time divided by tbe population from wbich
those witb tbe problem are derived (Last, 1995). Tbis is in contrast witb
tbe incidence rate, wbicb represents tbe number of individuals who
develop or begin to manifest tbe condition in a given period of time
divided by tbe population wbo could develop tbe condition in tbis period
of time (i.e., tbe population at risk of manifesting tbe condition). Calcu-
lating an incidence rate is more difficult tban calculating a prevalence
rate because tbe incidence computation requires a time dimension; one
has to identify a population of women wbo do not bave sexual dysfunc-
tion, who are then followed for tbe development of dysfunction over a
particular time period.
In tbis review, tbere are only two studies (Ekselius & von Knorring,
2001; Montejo et al., 2001) that contain data on tbe onset of sexual dys-
function, and tbese two studies focus on tbe onset of sexual disorders
related to antidepressant use. Ekselius and von Knorring were able to
compute the incidence of sexual dysfunction occurring 24 weeks after
the initiation of antidepressant therapy because they used tbe same
questionnaire at botb time periods. Tbe design of tbe study by Montejo
and colleagues was less robust for calculating incidence as all individu-
als in tbe study were already taking either antidepressants and/or ben-
zodiazepines wben tbey were queried about sexual dysfunction. Tbe
researchers required tbat tbe individuals bave normal sexual function
prior to medication use as assessed by recall, not derived in a standard-
ized manner prior to initiation of tbe study.
As will become apparent in tbe later metbodological discussions, tbe
primary criticism of the study by Montejo and colleagues (2001) is tbe
uncertainty of the denominator, which may have been subject to selec-

tion and/or information bias. Because they included only those individu-
als who reported normal sexual function prior to antidepressant use,
and normalcy was not measured objectively (information bias), the sam-
ple included in the study may be biased. Selection and information bias
will be discussed in more depth below.
Selection Bias In Studies Of Sexual Dysfunction
Selection bias is a systematic error arising from the way participants
are selected for a study and factors that affect study participation
(Rothman, 2002). As discussed earher, determining disease burden (i.e.,
research that derives a prevalence, incidence, or mortality rate)
requires both a numerator and a denominator. The numerator is a
count of the number of individuals with the disease of interest, whereas
the denominator is the population from which the cases (numerator)
were derived, some of whom will have sexual dysfunction and the
remainder will not.
The most robust prevalence rates will involve an entire population or
will randomly sample from the entire population so that the population
sampled for the study will be as similar as possible to the true popula-
tion for which the prevalence rate is thought to apply—this minimizes
selection bias. There were several examples of population-based studies
in Table 4, in which women were identified by random digit dialing
(Bancroft et al., 2003; Laumann et al., 1999; Richters et al., 2003; Ven-
tegodt, 1998), from electoral rolls (Najman et al., 2003), population reg-
isters (Fugl-Meyer & Sjogren Fugl-Meyer, 1999; Kadri et al., 2002;
Lindal & Stefansson, 1993), address files (Mercer et al., 2003), and con-
scripts (Ernst et al., 1993). Although not every woman lives in a house-
hold with a telephone {bias for random digit dialing) or was registered
to vote (bias for electoral rolls), small numbers of women may be miss-
ing from the study population (numerator and denominator). Despite
these small omissions, the prevalence rates developed from these stud-
ies will have a valid and definable denominator. The validity of the
numerator (i.e., women who have sexual dysfunction) will be discussed
below under information bias.
Table 4 contains many studies from clinical populations, as well as
recruitment from outpatient gynecology clinics. A major concern about
rates that are derived from clinical populations is whether all ages, eth-
nicities, disease states, socioeconomic levels, and so forth have the same
probability of being included in the study. For example, if the women
who do not seek care by general practitioners (Dunn et al., 1998;
Nazareth et al., 2003; Read et a l , 1997) are more hkely to have sexual
158 S. WEST, L, VINIKOOR, & D, ZOLNOUN
dysfunction, then the rate of sexual function from these studies would
he lower t h a n in studies in which all women could be queried on sexual
dysfunction. For clinic-based studies, it is important to realize t h a t
women who seek care may be different from those who do not for rea-
sons such as chronic illness, ability to pay for care, availability of trans-
portation, and other reasons associated with health and health services.
Thus, the prevalence rates from clinic populations may be biased unless
some type of selection procedure was used t h a t allowed all women to
have an approximately equal chance of being selected for the study.
Using a clinic-based population is not invalid, but the onus is on the
researchers to acknowledge the potential for selection bias in their
results and to interpret their findings accordingly.
The difficult part about selection bias is t h a t it cannot be observed
from the results of the study (Rothman, 2002) except by comparing cer-
tain population characteristics, such as age, gender, or geographic loca-
tion, to data from other sources that are known to be true probability
samples, such as the National Health and Nutrition Examination Study
(NHANES) (National Center for Health Statistics, 2004). Laumann et
al. (1999) compared the age, gender, education, marital status, race/eth-
nicity, religious affiliation, and overall health between individuals in
the National Health and Social Life Survey (NHSLS) to those from the
Current Population Survey, the General Social Survey, and the National
Survey of Family and Households and found some differences but noth-
ing that suggested their sample was very different from those other sur-
veys. For samples derived from medical practices, r e s e a r c h e r s can
compare the demographics of the study sample to t h a t for the entire
practice to evaluate whether selection bias may have occurred.
From the perspective of selecting samples for research, some of the
most fascinating studies were those published more t h a n 20 years ago
(Ard, 1977; Athanasiou et al, 1970; Chesser, 1956; Fisher, 1973; Frank
et al., 1978; Garde & Lunde, 1980a; Gebhard & Johnson, 1979; Golden
et al., 1977; Hite, 1976; Rainwater, 1968; Starr & Weiner, 1981; Terman,
1938). Many of these researchers recruited women from a variety of dif-
ferent sources, not one of which encompassed an entire population. For
example, Kinsey sought to identify a large and heterogeneous sample of
individuals so t h a t the sexual information derived would represent a
diverse population (Kinsey et al., 1953). For this reason, he included
university students and faculty; individuals in mental hospitals and
prisons; those with specific religious, union, or professional affiliations;
as well as homosexuals, transvestites, transsexuals, and prostitutes. He
felt that defining a sample that would be representative of the popula-
tion would be too complex and difficult. As a result, the Kinsey data are
very rich but cannot provide true prevalence rates. The studies by Starr
and Weiner, Frank et al., Hite, Rainwater, and Terman included women
from church groups, university alumnae, and women's clubs. Some
focused on married couples to control for the opportunity for sexual
activity (Ard, 1977; Frank et al., 1978) Others had more definable popu-
lations, but they were still not generalizable to the population as a
whole (Ard, 1977; Chesser, 1956; Fisher, 1973; Garde & Lunde, 1980a;
Golden etal., 1977).
Regardless of the recruitment strategy, if participation rates were
low, then the estimate of sexual dysfunction may be biased. It is possi-
ble that those who did participate may be different than those who did
not, but more importantly, the direction of bias may not be predictable.
It could be that women who are more comfortable with their sexuality
and who have less sexual dysfunction are more likely to participate in
studies of sexual dysfunction, which would mean that the estimates for
sexual dysfunction are biased downward. However, if women who have
sexual dysfunction are more likely to participate, then the prevalence
estimates might be biased upwards. Of the studies done more than 20
years ago, only the Garde and Lunde (1980a) study had a somewhat
definable population and a 94*7^ participation rate, which provides some
reassurance about the validity of their sample (American Association
for Public Opinion Research [APOR], 2000).
Another important caveat for addressing selection bias and the valid-
ity of the prevalence rates reflects the computation of response or par-
ticipation rates. In 2000, the American Association for Public Opinion
Research published a document providing standard definitions and
methods for computing response rates from national probability sam-
ples, in which response rate is defined as, "the number of (people who)
complete interviews divided by the number of eligible (people) in the
sample (AAPOR, 2000) The word, eligible is an important qualifying
term because it defines who is part of the denominator. As several of the
studies included in this review would be considered national probability
samples (Bancroft et al., 2003; Fugl-Meyer & Sjogren Fugl-Meyer, 1999;
Laumann et al., 1999; Lindal & Stefansson, 1993; Mercer et al., 2003;
Najman et al., 2003; Richters et al., 2003; Ventegodt, 1998), how they
determined their response rate is germane to this review. Several of the
researchers were able to enumerate an entire population using electoral
rolls (Najman et al., 2003), population registers (Fugl-Meyer & Sjogren
Fugl-Meyer, 1999; Lindal & Stefansson, 1993; Ventegodt, 1998), or a
multistage area probability sample, in which every woman in the study
population would be of known eligibility and could be included in the
study {Laumann et al., 1999). The multistage area probability sample
tbat was used by Laumann and colleagues was based on a sample frame
developed in 1980 by tbe Survey Researcb Center of tbe University of
Micbigan and tbe National Opinion Researcb Center (SRC/NORC) tbat
allows tbe identification of bousebolds. Once a bousebold was identified,
a randomly selected individual within the household provided tbe sur-
vey data.
In contrast, studies tbat involve random digit dialing bave an added
complexity because tbere will be numerous bousebolds for wbicb eligi-
bility information cannot be derived. This is because people bang up
before eligibility can be ascertained, or no one ever answers tbe phone
(Bancroft et al., 2003; Mercer et a l , 2003; Ricbters et al., 2003).
Wbetber and bow tbese telepbone numbers witb unknown eligibility
are incorporated into tbe response rate will affect its magnitude. To
incorporate tbe numbers with unknown eligibility, one must estimate
tbe proportion of bousebold telepbone numbers wbere no information
on eligibility is available even tbougb tbere may be one or more eligible
individuals for tbe study (unknown eligibility). The smaller tbe
unknown eligibility estimate, tbe bigber tbe response rate. Altbougb
not specified directly, tbe 53.1% response rate in tbe study by Bancroft
and colleagues probably took into account unknown eligibility because a
well-recognized survey researcb firm collected tbe data, suggesting the
response rate was computed appropriately. For tbe Ricbters et al. and
Mercer et al. studies, bowever, it is not clear from the metbods section
of tbeir publications wbetber unknown eligibility was taken into
account for deriving tbeir response rates of 77.6^^ and 65.4*7^, respec-
tively. Tbese rates are relatively bigb compared to current response
rates in the United States.
Information Bias In Studies of Sexual Dysfunction

Information bias is a systematic error in tbat tbe information col-
lected from study subjects is incorrect (Kotbman, 2002). Information
bias directly affects tbe computation of tbe prevalence of sexual dys-
function by affecting botb tbe numerator and denominator of tbe preva-
lence rate. Tbe denominator consists of all persons queried about tbeir
sexual dysfunction, some of wbom will bave problems and others who
will not. Tbe numerator consists of only tbose persons with sexual dys-
function. Computing tbe numerator correctly is more important for tbe
magnitude of the prevalence rate, but a correct denominator is critical
as well.
Tbe number of women wbo do and who do not bave sexual dysfunc-
tion can be derived either by clinical evaluation using appropriate crite-
ria, sucb as tbe DSM-IV-TR (American Psychiatric Association, 2000a)
and instruments such as the DIS-HIA (American Psychiatric Associa-

tion, 2000b) that are validated for diagnosing psychosocial problems, or
by using disease-specific questionnaires. If there is high interrater relia-
bility between clinicians using the DSM criteria for assessing sexual
dysfunction, then the numerator and denominator data should be valid.
Clinical assessment instruments such as the DIS were developed as
standardized tools to assess psychiatric problems and should provide
valid numerator and denominator data as well. There are several fac-
tors that can contribute to information bias in identifying women with
and without sexual dysfunction using disease-specific questionnaires.
These include inadequate cognitive testing and pretesting of question-
naires, use of questionnaires that do not meet certain criteria for relia-
bility and validity, and methods of questionnaire administration.
For survey research that involves questionnaires, one of the most
important reasons for incorrect data occurs when the questionnaire has
been inadequately developed and insufficiently pretested. In fact, Kin-
sey did not want to rely on previous questionnaires but "wished to start
afresh, unencumbered by the assumptions and presuppositions of previ-
ous researchers" (Gebhard & Johnson, 1979, p. 11), In addition, he
chose to avoid attitudinal questions and focused on behaviors because
he felt that the hehaviors represented attitudes more accurately than
opinions.
Kinsey, like many others, asked subjects to think back over long peri-
ods of time (sometimes years) to answer questions regarding when they
first learned about sexual issues such as coitus, pregnancy, and so forth.
Recall accuracy is known to he faulty over time (West et al.. 1995), Inad-
equate pretesting may result in questions that are so ambiguous that
participants do not interpret them correctly, or more importantly, in a
standardized way. There was very little information from the puhlica-
tions on pretesting or reliability assessment (replication of measure-
ment) of the questionnaires that were specifically developed for the
studies included in this review.
According to a recent review by Daker-White (2002), there are few
questionnaires for assessing female sexual dysfunction that are specific
for women and that meet three minimum standards: validity, internal
consistency, and reproducibility. For many of the studies included in this
review, the questions used to determine the prevalence of sexual dys-
function appeared to be developed for the study, and none of the
researchers used one of the validated instruments considered adequate
by Daker-White, Although Read and colleagues (1997) used the Golom-
hok Rust Inventory of Sexual Satisfaction (GRISS), and Nazareth and
colleagues (2003) used the Brief Sexual Function Questionnaire, they
botb adapted tbe instruments for use witb women. It did not appear
tbat in eitber study tbe additional testing required to ensure its contin-
ued validity in switcbing from a male- to a female-focused instrument
were conducted. Sbokrollabi et al. (1999) and Rosen et al. (1993) used
tbe Brief Index of Sexual Functioning for Women (BISF-W), but Daker-
White did not consider tbis a well-validated questionnaire.
Laumann, Gagnon, Micbaei, and Micbaels (1994) developed tbe ques-
tionnaire tbat was used for the NHSLS witb tbe belp of an advisory
panel consisting of experts in fields such as survey researcb, demogra-
phy, epidemiology, sexually transmitted infections, drug use, and sexual
dysfunction. However, tbere is no mention in eitber tbe text (Laumann
et al., 1994) or tbe paper (Laumann et al., 1999) concerning the pretest-
ing of the questionnaire prior to use. Some of tbe questions from tbe
NHSLS were used by Najman et al., (2003). Mercer et al. (2003), and
Ricbters et al. (2003), and Castelo-Branco et al. (2003) used a Spanisb
translation of tbis questionnaire. Tbe NHSLS questionnaire was devel-
oped for the United States population, and its use witb individuals in
Australia, New Soutb Wales, tbe United Kingdom, or Spain may not be
appropriate witbout furtber pretesting and cultural adaptation.
Tbe metbod of questionnaire administration may affect tbe accuracy
of data. The interviewers may be uncomfortable witb tbe questionnaire
topic and impart tbis unease to tbe participant wbo tben alters ber
response. Proper interviewer training is important so tbat interviewers
do not lead or suggest a n s w e r s for the p a r t i c i p a n t . Many of tbe
researchers included in tbis review recruited tbeir patients from clinical
populations. If tbe women were interviewed by a clinician about a sensi-
tive topic, sucb as sexual dysfunction, tbey may be embarrassed or ner-
vous and provide an acceptable ratber tban an accurate response.
Correctly identifying individuals witb sexual dysfunction requires
minimizing information bias tbat can result from poor study design,
including unvalidated questionnaires and improper questionnaire
administration. In none of the studies we reviewed did investigators use
psycbometrically valid instruments tbat could discriminate between
women wbo do and wbo do not have sexual dysfunction based on tbe
DSM-IV criteria.
Outcomes Studied
Tbe literature on sexual function and dysfunction spans at least 75
years, beginning witb Karen Davis's study publisbed in 1929 entitled.
Factors in the Sex Life of Tiventy-Two Hundred Women. Altbough tbe
title of tbe study suggested useful information for tbis review, we did
not include it because tbere was no information on sexual function otber
than masturbation and experiencing orgasm during masturbation. The

next earliest study was that done by Terman, published in 1938 and
entitled Psychological Factors in Marital Happiness. We were able to
include this study because Terman provided some information on sexual
dysfunction, namely orgasm adequacy. In fact, most of the studies pub-
lished prior to Masters and Johnson's Human Sexual Response (1966)
were focused on the frequency of orgasm and some measure of sexual
satisfaction or enjoyment (Athanasiou, 1970; Chesser, 1956; Rainwater,
1968; Terman, 1938), According to our review, the publishing of The
Hite Report: A Nationwide Study on Female Sexuality in 1976 (Hite,
1976) marked the first publication in which data on desire and pain, as
well as orgasm, were provided. Publications since that time have typi-
cally provided information on sexual dysfunction overall, and/or sexual
desire, arousal, orgasm, and pain or some variant of these sexual com-
ponents.
Although all of the studies included in this review contain some esti-
mate of the prevalence of sexual dysfunction, the definitions used are
highly variable, which limits opportunities to compare across studies.
For example, for desire disorders, the following illustrate some of the
definitions used in the review: a period of several months in the pre-
ceeding 12 months where the woman lacked interest (Laumann et al.,
1999; Najman et al., 2003; Richters et al., 2003); lack or loss of sexual
desire when the problem was present all or almost all of the time
(Nazareth et al., 2003); always or often having hypoactive sexual desire
disorder as defined by the DSM-IV criteria (Kadri et al,, 2002); occa-
sional lack of desire (Klusmann, 2002); no desire for intercourse
(ShokroUahi et al,, 1999); avoidance (Read et al., 1997); impaired sexual
interest (Osborn et al,, 1988); lack of biologic drive, which is separate
from motivational problems (Schein et al., 1988); and frequency of desir-
ing sexual relations per week (Starr & Weiner, 1981). All of the defini-
tions include sexual interest or desire (or its converse, aversion), but the
primary difference among the definitions was quantifying the persis-
tence of the problem over some time period. For reasons of comparabil-
ity, it would be useful to consider developing a standard definition of
sexual dysfunction and its four components that includes both a defini-
tion of persistence and a threshold duration that could be used in clini-
cal diagnosis and questionnaire development (see Tables 4-9).
What this would require is coming to some agreement on what con-
stitutes "persistent," "recurrent," and "marked distress" as the DSM-IV-
TR criteria for hypoactive sexual desire disorder, female sexual arousal
disorder, orgasmic disorder, and dyspareunia include these terms for
diagnosing these conditions (Davis, 1929; American Psychiatric Associa-
164 S. WEST, L. VINIKOOR, & I). ZOLNOUN
tion, 2000a). Uniform outcome definitions have been developed for alco-
holism to standardize treatment studies of alcohol dependence and
problem drinking. The sentinel outcome measure selected was the per-
centage of heavy drinking days, which is consuming > 5 drinks per day
for men and > 4 drinks per day for women {Allen, 2003). Until this out-
come measure was determined, researchers would measure different
drinking patterns, such as the number of drinking (or nondrinking)
days in a specific period, the time to first drink, or the number of stan-
dard drinks per drinking day. A standard definition can be useful for
clinical purposes as well as for outcomes of clinical trials.
Developing standardized outcome definitions and using these defini-
tions in the development of sexual dysfunction questionnaires will
enhance our ability to compare across studies and time periods. If, as a
field, we do choose to standardize outcome definitions to facilitate com-
parison across studies and to improve measurement in clinical trials,
there are two important caveats to consider. First, the standardized out-
come should not be selected based on a particular intervention under
study. Second, the outcome selected should have solid psychometric
properties with regard to reliability, validity, and sensitivity to mean-
ingful change in subject response due to treatment (Allen, 2003). As
sexual dysfunction and behavior gain more visibility in the scientific
and lay press, there needs to be parallel development of tools to assess
its development, severity, and quality of life implications.
Discussion
The researchers who have sought information on female sexuality
have spanned 75 years and many cultures. This systematic review
includes data from women in Austria, Australia, Canada, Chile, China,
the Czech Republic, Denmark, France, Germany, Iceland, Iran, Italy,
Mexico, Morocco, New South Wales, Nigeria, Singapore, Sweden, the
United Kingdom, and the United States. The studies contain informa-
tion from the general population and convenience samples of general
practice patients or specialized clinical groups.
The early studies (from 1920 until 1970) provided information on
women's satisfaction and enjoyment of sex along with their ability to
experience orgasm. The very earliest study was by Davis (1929), and
the questions on sexuality focused on frequency and pleasure from mas-
turbation and experience of orgasm with no information on intercourse,
even from married women. During this early period, the research on
women's sexuality paralleled what was known for men, a likely reason
for the focus being on orgasm and sexual satisfaction. With the publish-
ing of the Masters and Johnson (1966) work, researchers in sexuality
subsequently began to address the components of the sexual response

cycle. Schein and colleagues (1988) were the first to address the four
components of the response cycle: desire, arousal, orgasm, and dyspare-
unia along with sexual satisfaction.
From the 1990s forward, numerous authors have addressed overall sex-
ual dysfunction and its components. It is unfortunate, however, that no
measurable case definition exists for sexual dysfunction broadly defined or
for its individual components. The 2000 report from the International Con-
sensus Development Conference contained definitions and classifications
of female sexual dysfunction that were based on the general structure of
the DSM-IV-TR (American Psychiatric Association, 2000a) and the Inter-
national Classification of Disease-10 (Basson et al., 2000; World Health
Organization, 1992), but what constitutes a persistent problem is still
unresolved and judged by the clinician treating the woman.
An additional challenge in the field of sexual dysfunction research is
that the definitions of disorder are focused on the female genital
response and do not consider psychological or subjective sexual desire,
arousal, and satisfaction (Basson et al., 2003). This puts the emphasis
on physical factors rather than the interplay between the physical, psy-
chological, and emotional aspects of sexual response. As researchers in
the field of female sexual dysfunction, we need to resolve whether the
measurement of sexual dysfunction will include consideration of both
the genital response and the psychological aspect of the sexual relation-
ship. If we include physical, psychological, and perhaps relationship fac-
tors in the definition, how will these be measured?
As seen in Tables 4-9 and in the methodological issues described in
the results section, there is a wide variation in the definitions used by
each of the authors. For an affirmative response in the NHSLS, Lau-
mann et al. (1994, 1999) required that the problem last at least for a
period of several months during the past 12 months. The sexual dys-
function questions from the NHSLS were also used in three other stud-
ies, including one that translated the instrument into Spanish, but the
populations were all different—the United Kingdom, Spain, and two
different surveys from Australia. Thus, the similarity of questions
enhances comparability because the study definitions are the same, but
the question of cultural adaptation remains. Contrasting rates from
studies of widely varying populations that used many different ways of
defining and ascertaining sexual dysfunction is problematic. Future
work might focus on standardizing definitions along with studying dys-
function in representative populations.
With the exception of studies of depression and its treatment, there
was very little attention paid to the use of standard or validated instru-
ments in the studies of comorbid conditions. For most of the studies, the
questions were developed de novo for the research project with little, if
any, reliability or validity assessment. However, we must acknowledge
that the literature search for these comorbid conditions may not have
been as thorough as for the general studies, and we may be missing
some important research.
Besides the comorbid conditions affecting the prevalence of female
sexual dysfunction, we also identified demographic factors that migbt
influence these rates, such as age and relationship factors. The most dif-
ficult issue to discern is the interrelationships among age, the pre-
menopausal transition, and tbe duration of the sexual relationship, and
their independent and combined effects on the prevalence of sexual dys-
function. Only a new, large, and carefully designed study will be able to
address these interrelationships, as none of the studies included in this
review have done so.
We faced numerous difficulties in identifying the literature for this
systematic review. Our preliminary searches identified only a small por-
tion of the eligible literature, and many of the studies we included were
ascertained by hand-searching bibliographies of review articles and
other prevalence papers. For this reason, we may have missed some
studies that would have been pertinent to the review. Likewise, we did
not do a thorough review of the literature to identify all studies
addressing comorbidities associated with female sexual dysfunction.
The literature on comorbidities provided additional insight into female
sexual dysfunction issues that may be relevant for future research.
The Future
Sexual function and dysfunction are not static as there are changes
over time with age, duration of the sexual relationship, and the peri-
menopausal transition. In his study of 19- to 32-year-olds at German
universities, Klusmann (2002) found that sexual satisfaction decreased
in both men and women with increasing duration of the relationship.
More intriguing was the fact that the desire to have sex often was simi-
lar across relationship duration for males but decreased for females. In
contrast, the desire to be tender was high and stable across relationship
duration in females but decreased in males. Future work will need to
disentangle the affects of age, hormonal status, relationship compatibil-
ity, and duration using well-validated measures of sexual dysfunction
and representative populations.
With all of the research that has been done in this field to date, none
of the studies meet the quality criteria set forth for prevalence studies
(i.e., a well-defined and representative sample and a validated assess-
ment of sexual dysfunction). The major problem is that there are few
well-validated instruments based on the current definitions and that
are appropriate for use in the female population. The second problem is
the difficulty and expense involved in conducting these large popula-
tion-based studies. Finally, little is known about the importance of sex-
ual dysfunction to the individual and/or society. For the individual with
sexual dysfunction, there is a personal cost to her and her partner with
respect to their relationship. But there may be a societal cost as well, as
reflected in divorce rates, domestic violence, single-parent families, and
future relationships. These ancillary costs are rarely measured, but
without a better understanding of their magnitude, female sexual dys-
function, as a health outcome, will continue to be underappreciated, to
the detriment of the individual or society.
References
Allen, J. P. (2003). Measuring outcome in interventions for aicoho! dependence and prob-
lem drinkinp: Executive summary of a conference sponsored by the National Institute
on Alcohol Abuse and Alcoholism. Alcoholism, Clinical and Experimental Research, 27,
16.57-1660.
American Association for Public Opinion Research. (2000). Standard definitions: Final
dispositions of case codes and outcome rates for .surveys. Lenexa, Kansas: Author
American Psychiatric Association. (2000a). Diagnostic and statistical manual of mental
disorders-text revision fourth edition (DSM-IV-TR). Washington, DC: Author. Retrieved
January 29, 2005, from http://online.statref.com.libproxy.lib.unc.edu/document.aspx?
fxid=37&docid-255
American Psychiatric Association. l2000bl. Handbook of psychiatric measures. Washing-
ton, DC: Author.
Angst, J. (19981. Sexual problems in healthy and depressed persons. International Clini-
cal Psychopharmacotogy, 13iSuppl. 6), Sl-4.
Ard, B. (19771. Sex in lasting marriage: A longitudinal study. The Journal of Sex Research,
13, 274-285.
Athanasiou. R., Shaver, P.. & Tavris, C. i 1970, July). Sex. Psychology Today. 4, 39-51.
Atputharajah, V. (1987). Some aspects of sexual knowledge and sexual behaviour of local
women. Results of a survey—XII. Sexual problems and concerns. Singapore Medical
Journal. 28, 509-512.
Avis, N. E., Stellato. R.. Crawford. S., Johannes. C. & Longcope, C. 12000). Is there an
association between menopause status and sexual functioning? Menopause. 7, 297-309.
Bachmann, G. A., Leiblum, S. R.. & Grill, J. (1989). Brief sexual inquiry in gynecologic
practice. Obstetrics and Gynecology, 73, 425-427.
Bancroft. J., Loftus, J.. & Long, J. S. (2003). Distress about sex: A national survey of
women in heterosexual relationships. Archives of Sexual Behavior, 32, 193-208.
Barrett. G., Pendry, E., Peacock, J.. Victor, C, Thakar. R.. & Manyonda, I. (1999). Women's
sexuality after childbirth: A pilot study. Archives of Sexual Behavior, 28, 179-191.
Barrett. G,. Pendry. E.. Peacock, J.. Victor. C, Thakar. R., & Manyonda. I. (2000). Women's
sexual health after childbirth. BJOG: An International Journal of Obstetrics and
Gynaecology, 107, 186-195.
Basson. R., Berman, J.. Burnett, A.. Derogatis. L.. Ferguson. D.. Fourcroy. J.. et al. (2000).
Report of the International Consensus Development Conference on Female Sexual
Dysfunction: Definitions and classifications. The Journal of Urology, 163, 888-893.
Basson. R., Leiblum, S., Brotto, L., Derogatis, L., Fourcroy, J., Fugl-Meyer, K., et al.
168 S. WEST, L. VINIKOOR. & D, ZOLNOUN
(2003). Definitions of women's sexual dysfunction reconsidered: Advocating expansion

and revision. Journal of Psychosomatic Obstetrics and Gynaecology, 24. 221-229.
Bianchi-Demicheli, F., Perrin, E., Ludicke, F., Bianchi, P. G., Chatton, D., & Campana, A.
(2002). Termination of pregnancy and women's sexuality. Gynecologic and Obstetric
Investigation, 53, 48-53.
Bogren, L. Y. (19911. Changes in sexuality in women and men during pregnancy. Archives
of Sexual Behavior. 20, 35-45.
Bonierbale, M., Lancon, C, & Tignol, J. (2003). The ELIXIR study: Evaluation of sexual
dysfunction in 4,557 depressed patients in France. Current Medical Research and
Opinion. 19. 114-124.
Carranza-Lira. S.. Murillo-Uribc, A., Martinez Trejo, N,, & Santos-Gonzalez, J. (1997).
Changes in symptomatology, hormones, lipids. and bone density after hysterectomy.
International Journal of Fertility and Women's Medicine. 42, 43-47.
Castelo-Branco, C, Blumel, J. E., Araya, H., Riquelme, R., Castro, G., Haya, J., et al.
(2003). Prevalence of sexual dysfunction in a cohort of middle-aged women: Influences
of menopause and hormone replacement therapy. Journal of Obstetrics and Gynaecol-
ogy. 23. 426-430.
Chen, J.. & Ho, S. C. (1999). Contraceptive status and sexual function of climacteric Chi-
nese women. Contraception. 59, 85-90.
Chesser. E. (1956), The .sexual, marital, and family relationships of the English woman.
London: London Hutchinsons Medical Publications.
Chiechi, L. M., Granieri, M., Lobascio, A., Ferreri, R., & Loizzi, P. (1997). Sexuality in the
climacterium. Clinical and experimental obstetrics & gynecology, 24, 158-159.
Confino, E., Ismajovich, B., Rudick, A., Yedwab, G., & David, M. P. (1983). Comparison
between OM-GA Cu and Copper-T IUCDs. Contraception, 28, 521-525,
Costello, C, Hiliis, S. D., Marchbanks, P, A., Jamieson, D, J., & Peterson, H. B. 12002). The
effect of interval tubal sterilization on sexual interest and pleasure. Obstetrics and
gynecology, 100, 511-517.
Daker-White, G. (2002). Reliable and valid self-report outcome measures in sexual
(dys)function: A systematic review. Archives of Sexual Behavior. 31, 197-209.
Danielsson, I., Sjoberg, I.. Stenlund, H., & Wikman, M, (2003). Prevalence and incidence
of prolonged and severe dyspareunia in women: Results from a population study. Scan-
dinavian Journal of Public Health, 31, 113-118.
Davis, K. (1929). Factors in the nex life of twenty-two hundred women. NY: Harper.
Dennerstein, L., Alexander, J. L., & Kotz, K, (2003). The menopause and sexual functioning:
A review of the population-based studies. Annual Review of Sex Research, 14, 64-82,
Dennerstein, L., Randolph, J., Taffe, J., Dudley, E,, & Burger, H. (2002), Hormones, mood,
sexuality, and the menopausal transition. Fertility and Sterility, 77(Suppl. 4), S42-48.
Dennerstein, L., Smith, A. M., Morse, C. A., & Burger, H, G. (1994). Sexuality and the
menopause. Journal of Psychosomatic Obstetrics and Gynaecology, 15, 59-66,
Diokno, A. C, Brown, M. B,, & Herzog, A. R. (1990). Sexual function in the elderly.
Archives of Internal Medicine, 150, 197-200.
Dunn, K. M., Croft, P R,, & Hackett. G. I. (1998). Sexual problems: A study of the preva-
lence and need for health care in the general population. Family Practice, 15, 519-524.
Ekselius, L., & von Knorring, L. (2001). Effect on sexual function of long-term treatment
with selective serotonin reuptake inhibitors in depressed patients treated in primary
care. Journal of Clinical Psychophannacology, 21, 154-160.
Ellis, D. J., & Hewat, R. J. (1985). Mothers' postpartum perceptions of spousal relation-
ships. Journal of Obstetric. Gynecologic, and Neonatal Nursing, 14, 140-146.
Ende, J., Rockwell, S., & Glasgow. M, (1984). The sexual history in general medicine prac-
tice. Archives of Internal Medicine, 144, 558-561.
Enzlin, P., Mathieu, C, Van Den Bruel, A., Vanderschueren, D.. & Demyttenaere, K.
(2003). Prevalence and predictors of sexual dysfunction in patients with type 1 dia-
betes. Diabetes Care, 26, 409-414.
Emst. C, Foldenyi, M., & Angst, J. (1993). The Zurich Study: XXL Sexual dysfunctions
and disturbances in young adults. Data of a longitudinal epidemiological study. Euro-
pean Archives of Psychiatry and Clinical Neuroscience, 243, 179-188.
Erol. B.. Tefekli. A.. Ozbey, L, Salman. F., Dincag, N., Kadioglu, A., et al. (20021. Sexual
dysfunction in type 11 diabetic females: A comparative study. Journal of Sex & Marital
Therapy, 2S( Suppl. 1), 55-62.
Farrell, S. A., & Kieser, K. (2000). Sexuality after hysterectomy. Obstetrics and Gynecol-
ogy, 95, 1045-1051.
Fisher, S. (19731. The female orgasm. New York: Basic Books.
Frank, E., Anderson, C, & Rubinstein, D. (1978). F"requency of sexual dysfunction in "nor-
mal" couples. The New England Journal of Medicine, 299, 111-115.
Fugl-Meyer, A. R., & Sjogren Fugl-Meyer, K. (1999). Sexual disabilities, problems and sat-
isfaction in 18-74 year old Swedes. Scandinavian Journal of Sexology, 2, 79-105.
Garde. K., & Lunde, L (1980a). Female sexual behaviour. A study in a random sample of
40-year-old women. Maturitas, 2, 225-240.
Garde, K., & Lunde, L 11980b). Social background and social status: Influence on female
sexual behavior, a random sample of 40-year-old women. Maturitas, 2, 241-246.
Gebhard. P., & Johnson, A. (1979). The Kinsey data: Marginal tabulations of the 1963-
1983 Interviews conducted by the Institute for Sex Research. Philadelphia: W.B. Saun-
ders.
Geiss, I. M., Umek, W. H., Dungl. A., Sam. C, Riss. P., & Hanzal, E. <2003). Prevalence of
female sexual dysfunction in gynecologic and urogynecologic patients according to the
international consensus classification. Urology. 62, 514-518.
Golden. J.. Golden, M., Price, S., & Heinrich, A. (1977). The sexual problems of family
planning clinic patients as viewed by the patients and the staff. Family Planning Per-
spectives, 9, 25-29.
Goldmeier, D.. Judd, A., & Schroeder, K. (2000). Prevalence of sexual dysfunction in new
heterosexual attenders at a central London genitourinary medicine clinic in 1998. Sex-
ually Transmitted Infections. 76. 208-209.
Graham, C. A.. Ramos, R.. Bancroft, J., Maglaya, C, & Farley, T. M. (1995). The effects of
steroidal contraceptives on the well-being and sexuality of women: A double-blind,
placebo-controlled, two-centre study of combined and progestogen-only methods. Con-
traception. 52, 363-369.
Grant. A., Gordon, B., Mackrodat. C, Fern, E., Truesdale, A., & Ayers, S. (2001). The
Ipswich childbirth study: One year follow up of alternative methods used in perineal
repair. BJOG: An International Journal of Obstetrics and Gynaecology, 108, 34-40.
Hallstrom, T. (1979). Sexuality of women in middle age: The Goteborg study. Journal of
Biosocial Science. 11, 165-175.
Hamilton, G. V., & Macgowan, K, (1929). What is wrong with marriage? New York: A. & C.
Boni.
Helstrom. L., Lundberg, P. O., Sorbom, D., & Backstrom, T. (1993). Sexuality after hys-
terectomy: A factor analysis of women's sexual lives before and after subtotal hysterec-
tomy. Obstetrics and Gynecology. 81, 357-362.
Hite, S. (1976). The Hite report: A nationwide study of female sexuality. New York: Dell.
Huerta, R., Mena, A., Malacara. J. M., & de Leon, J. D. (1995). Symptoms at the
menopausal and premenopausal years: Their relationship with insulin, glucose, corti-
sol, FSH, prolactin, obesity and attitudes towards sexuality. Psychoneuroendocrinology,
20, 851-864.
Jackson, P., & Lander, J. L. (1980). Female sterilisation: A five-year follow-up in Auck-
land. The New Zealand Medical Journal, 91, 140-143.
Johnson, A. M., Wadsworth, J., Wellings, K., & Field, J. (1994). Sexual attitudes and
lifestyles. Oxford, UK: Blackwell Scientific Publications.
Kadri. N., McHichi Alami, K. H., & McHakra Tahiri, S. (2002). Sexual dysfunction in women:
Population based epidemiological study. Archives of Women's Mental Health, 5, 59-63.
Kaplan, H. S. 11977). Hypoactive sexual desire. Journal of Sex & Marital Therapy, 3, 3-9.
Keller Ashton, A., Hamer, R., & Rosen, R. C. (1997). Serotonin reuptake inhibitor-induced
sexual dysfunction and its treatment: A large-scale retrospective study of 596 psychi-
atric outpatients. Journal of Sex & Marital Therapy, 23. 165-175.
Kennedy, S. H., Dickens, S. E., Eiafeld, B. S., & Bagby, R. M. (1999). Sexual dysfunction
before antidepressant therapy in major depression. Journal of Affective Disorders, 56,
201-208.
Kilkku. P. (1983). Supravaginal uterine amputation vs. hysterectomy. Effects on coital fre-
quency and dyspareunia. Affo Obstetricia et Gynecohgica Scandinavica, 62. 141-145.
Kilkku, P., Gronroos, M., Hirvonen. T., & Rauramo. L. 11983). Supravaginal uterine ampu-
tation vs. hysterectomy. Effects on libido and orgasm. Acta Obstetricia et Gynecologica
Scandinavica. 62, 147-152.
Kinsey, A. C, Pomeroy. W. B.. & Martin, C. E. (1948). Sexual behavior in the human male,
Philadelphia: W.B. Saunders.
Kinsey, A. C, Pomeroy, W. B., Martin, C. E., & Gebhard, P. H. (1953). Sexual behavior in
the human female, Philadelphia; W.B. Saunders.
Kjer, J. J. (1990). Sexual adjustment to tubal sterilization. European Journal of Obstetrics,
Gynecohgy, and Reproductive. Biology, 35, 211-214.
Klusmann, D. (2002). Sexual motivation and the duration of partnership. Archives; of Sex-
ual Behavior, 31. 275-287.
Last, J. M. (Ed.). (1995). A dictionary of epidemiology (3rd ed.l. New York: Oxford Univer-
sity Press.
Laumann, E. O., Gagnon, J. H., Michael, R. T, & Michaels. S. (1994). The social organization
of sexuality: Sexual practices in the United States. Chicago: University of Chicago Press.
Laumann. E. O., Paik. A., & Rosen. R. C. (19991. Sexual dysfunction in the United States:
Prevalence and predictors. JAMA: The Journal of the American Medical Association,
2Si, 537-544.
Lindal. E., & Stefansson, J. G. 11993). The lifetime prevalence of psychosexual dysfunction
among 55 to 57-year-olds in Iceland. Social Psychiatry and Psychiatric Epidemiology,
28, 91-95.
Lohr, K. N., Aaronson. N. K., Alonso, J., Burnam, M. A., Patrick, D. L., Perrin, E. B.. et al.
(1996). Evaluating quality-of-life and health status instruments: Development of scien-
tific review criteria. Clinical Therapy, 18. 979-992.
Maas, C. P., Weijenborg. P. T, & ter Kuile, M. M. (2003). The effect of hysterectomy on sex-
ual functioning. Annual Review of Sex Research, 14, 83-113.
Mafakhkharul Islam, A. I., Begum, A., & Keramat Ali, S. M. (1991). Psychosomatic effects
of permanent sterilization. Bangladesh Medical Research Couneil bulletin, 17, 17-22.
Malacara, J. M., Canto de Cetina, T., Bassol, S.. Gonzalez. N.. Cacique, L., Vera-Ramirez,
M. L., et al. (2002). Symptoms at pre- and postmenopause in rural and urban women
from three states of Mexico. Maturitaf:, 43, 11-19.
Masters. W. H.. & Johnson, V. (1966). Human sexual response. Boston: Little. Brown.
Masters, W. H., & Johnson, V. (1970). Hunian sexual inadequacy. Boston: Little, Brown.
McCoy. N. L. (1998). Methodological problems in the study of sexuality and the
menopause. Maturitas, 29, 51-60.
Mercer. C. H., Fenton, K. A., Johnson. A. M., Wellings, K.. Macdowall, W., McManus. S., et
al. 120031. Sexual function problems and help seeking behaviour in Britain: National
probability sample survey. British Medical Journal (Clinical research ed.), 327, 426-427.
Michelson, D., Schmidt, M.. Lee. J.. & Tepner, R. (20011. Changes in sexual function dur-
ing acute and six-month lluoxetine therapy: A prospective assessment. Journal of Sex
& Marital Therapy, 27. 289-302.
Montejo, A. L., Llorca. G., Izquierdo, J. A., & Rico-Villademoros, F. (2001). Incidence of
sexual dysfunction associated with antidepressant agents: A prospective multicenter
study of 1022 outpatients. Spanish Working Group for the Study of Psychotropic-
Related Sexual Dysfunction. The Journal of Clinical Psychiatry, 62(Suppl. 3), 10-21.
Montgomery, S. A., Baldwin, D. S.. & Riley, A. (2002). Antidepressant medications: A

review of the evidence for drug-induced sexual dysfunction. Journal of Affective Disor-
ders. 69, 119-140.
Morof, D.. Barrett, G., Peacock, J., Victor. C. R., & Manyonda, I. (2003). Postnatal depres-
sion and sexual health after childbirth. Obstetrics and Gynecology, 102. 1318-1325.
Najman, J. M., Dunne, M. P.. Boyle. F M., Cook, M. D., & Purdie, D. M. (2003). Sexual
dysfunction in the Australian population. Australian Family Physician, 32, 951-954.
Nappi. R. E., Verde, J. B., Polatti, F.. Genazzani, A. R.. & Zara, C. (2002). Self-reported
sexual symptoms in women attending menopause clinics. Gynecologic and Obstetric
Investigation. 53. 18M87.
National Center for Health Statistics. (2004, June 22). National Health and Nutrition
Examination Survey. Retrieved July 10, 2004, from http://www.cdc.gov/nchs/nhanes
Nazareth, L, Boynton, P., & King, M. (2003). Problems with sexual function in people
attending London general practitioners: Cross sectional study. British Medical Journal
(Clinical research ed.), .527. 423.
Nusbaum. M. R., & Gamble, G. (2001). The prevalence and importance of sexual concerns
among female military beneficiaries. Military Medicine. 166. 208-210.
Oboro, V. O., & Tabowei, T O. (2002). Sexual function after childbirth in Nigerian women.
International Journal of Gynaecology and Obstetrics, 78, 249-250.
Osborn, M., Hawton, K., & Gath, D. (1988). Sexual dysfunction among middle aged
women in the community. British Medical Journal (Clinical research ed.), 296. 959-
962.
Pepe, F, Panella, M., Pepe, G., D'Agosta, S., & Pepe, P. (1989). Frequency of sexual dys-
functions among Roman Catholic women. Family Practice, 6. 16-18.
Punnonen, R., & Erkkola. R. (1984). Late complications of taparoscopic clip sterilization.
Acta Obstetricia et Gynecologica Scandinavica, 63, 149-151.
Raboch, J.. & Raboch. J. (1992). Infrequent orgasms in women. Journal uf Sex & Marital
Therapy, 18, 114-120.
Rainwater, L. (1968), Some aspects of lower class sexual behavior. Medical Aspects of
Human Sexuality. 2. 15-25.
Read, S.. King, M., & Watson, J. (1997). Sexual dysfunction in primary medical care:
Prevalence, characteristics and detection by the general practitioner. Journal of Public
Health Medicine. 19, 387-391.
Rhodes, J. C, Kjerulff, K. H., Langenberg, P. W., & Guzinski, G. M. (1999). Hysterectomy
and sexual functioning. JAMA: The Journal of the American Medical Association, 282,
1934-1941.
Richters, J.. Grutich, A. E., de Visser, R. O., Smith, A. M., & Rissel, C. E. (2003), Sex in
Australia: Sexual difficulties in a representative sample of adults. Australian and New
Zealand Journal of Public Health. 27, 164-170.
Robson. K. M., Brant, H. A., & Kumar, R. (1981). Maternal sexuality during first preg-
nancy and after childbirth. British Journal of Obstetrics and Gynaecology. 88, 882-889.
Roovers, J. P., van der Bom, J. G., van der Vaart. C. H., & Heintz, A. P. (2003). Hysterec-
tomy and sexual well-being: Prospective observational study of vaginal hysterectomy,
subtotal abdominal hysterectomy, and total abdominal hysterectomy. British Medical
Journal (Clinical research ed.), 327, 774-778.
Rosen. R. C, Taylor, J. F., Leiblum, S. R.. & Bachmann. G. A. (1993). Prevalence of sexual
dysfunction in women: Results of a survey study of 329 women in an outpatient gyne-
cological clinic. Journal of Sex & Marital Therapy. 19, 17M88.
Rothman, K. J. (2002). Epidemiology: An introduction. New York: Oxford University
Press.
Sanders, S. A., Graham, C. A., Bass, J. L., & Bancroft, J. (2001). A prospective study of the
effects of oral contraceptives on sexuality and well-being and their relationship to dis-
continuation. Contraception, 64, 51-58.
Sayle, A. E., Savitz, D. A., Thorp, J. M. J., Hertz-Picciotto. L, & Wilcox, A. J. (2001). Sexual
activity during late pregnancy and risk of pretenn delivery. Obstetrics and Gynecology,
97. 283-289.
Schein, M,, Zyzanski, S. J.. Levine, S., Medalie, J. H., Dickman, R. L., & Alemagno, S. A.
(1988). The frequency of sexual problems among family practice patients. The Family
Practice Reaearch Journal. 7. 122-134.
ShokroUahi, P., Mirmohamadi, M., Mehrabi, F., & Babaei, G. (1999). Prevalence of sexual
dysfunction in women seeking services at family planning centers in Tehran. Journal
of Sex & Marital Therapy. 25, 211-215.
Signorello. L. B., Harlow. B, L., Chekos. A. K.. & Repke. J. T (2001). Postpartum sexual
functioning and its relationship to perineal trauma: A retrospective cohort study of
primiparous women. Amvrican Journal of Obstetrics and Gynecology, 184, 881-888; dis-
cussion 888-890.
Sleep. J., & Grant, A. (19871. West Berkshire perineal management trial: Three year fol-
low up. British Medical Journal (Clinical research ed.), 295, 749-751,
Starr. B. D., & Weiner, M. B. (1981). The Starr-Weiner report on sex and sexuality in
mature years. Briarcliff Manor, NY: Stein & Day.
STRAW. (20011. Executive summary: Stage of Reproductive Aging Workshop (STRAW).
Menopause, 8. 402-407.
Terman, L. (1938). Pnychologieal factors in marital happiness. New York: McGraw-Hill.
Terman, L. (19511. Correlates of orgasm adequacy in a group of 556 wives. Journal of Psy-
chology, 32, 115-172.
Thakar, R., Ayers, S., Clarkson. P., Stanton, S-, & Manyonda, I, (2002). Outcomes after
total versus subtotal abdominal hysterectomy. The New England Journal of Medicine,
347. 1318-1325.
van Coeverden de Groot, H. A., Gunston, K. D., Davey D. A., Vader, C. G., Coetzee, E. J., &
Sapire, K. E. (1980). Laparoscopic sterilization on a day-case basis. South African Med-
ical Journal, 58, 61-64.
Ventegodt, S. (1998). Sex and the quality of life in Denmark. Archives of Sexual Behavior.
27, 295-307.
Virtanen, H.. Makinen, J., Tenho, T, Kiilholma. P.. Pitkanen. Y., & Hirvonen, T. (1993).
Effects of abdominal hysterectomy on urinary and sexual symptoms. British Journal of
Urology. 72, 868-872.
Wandell, P. E., & Brorsson. B. (2000). Assessing sexual functioning in patients with
chronic disorders by using a generic health-related quality of life questionnaire. Qual-
ity of Life Research, 9. 1081-1092.
West, S. L., King. V. J.. Carey, T. S., Lohr, K. N., McKoy, N., Sutton, S., et al. (2002). Sys-
tems to rate the strength of scientific evidence. Rockville, MD: Agency for Healthcare
Research and Quality.
West, S, L., Savitz, D. A., Koch. G.. Strom, B. L., Guess. H. A.. & Hartzema, A. (1995).
Recall accuracy for prescription medications: Self-report compared with database
. American Journal of Epidemiology, 142, 1103-1112,

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A Systematic Review of the

Literature on Female Sexual

Since at least the 18th century, gender differences in relationships,

to understand the psychopathology of sexual behavior (Johnson,

might influence response. Even questions regarding the same construct,

menopause, family planning, depression, and diabetes) and retained

original articles. Once a final consistency check was performed to

Female sexual dysfunction

Headings (MeSH) for sexual dysfunction is an important reason for not

Potentially relevant studies as identified by MEDLINE,

Original articles ( ;! = 156),

Excluded after full paper retrieved and

Final review includes 85 original

Figure 1. Flow diagram of study inclusions and exclusions.

randomized controlled trials and not to observational studies that are

OO QOO < O O OOO P-OO

i CO 1> Tf- <o o o

.y"? 'c"« D-p .E c

3=^ ^-Hb e>"

viewed—11% in married women (Diokno, Brown, & Herzog, 1990) and

lubrieation difficulties was reported by Nusbaum and Gamble (76%),

ing physiological state (e.g., age, pregnancy), as well as study design

Sexual Dysfunction During Pregnancy and the Postpartum Period (see

The studies of dysfunction related to pregnancy focus on specific sex-

2SI -i - 3r£-5 -= J2-S-S

.re the 3^ 36th

f*^ O^ (-^ r-^ CJ r^ r-i 5C ^

Similarly, sexual frequency was reduced in married women during the

Female Sexual Dysfunction in Natural and Surgical Menopause (see

-" '7. ^ -c,2

1 cfiOO COO & OO

'a a> >> 3 3

with dryness than those from Guanajuato or Coahuila. Whether this is

EH fe, > U T3 'n I

all sexual dysfunction, Bianchi-Demicheli et al. (2002) reported that

order (Bianchi-Demicheli et al., 2002). Predictors of orgasmic problems

Diabetes (see Table 8)

K'D ^ n rr re ' ^ •—^ ^

Depression (see Table 9)

and 24 weeks. Although the authors provided haseline rates after a

Dyspareunia. Only Bonierbale et al. (2003) evaluated the relation-

Diokno et al., 1990 • /

Bachmann etal., 1989 •

Table 10 continued on following page.

Table 10 conljnued on folluwing page.

Methodological Issues in Studying Female Sexual Dysfunction

uncertainty of the denominator, which may have been subject to selec-

Information Bias In Studies of Sexual Dysfunction

and instruments such as the DIS-HIA (American Psychiatric Associa-

than masturbation and experiencing orgasm during masturbation. The

subsequently began to address the components of the sexual response

(2003). Definitions of women's sexual dysfunction reconsidered: Advocating expansion

Montgomery, S. A., Baldwin, D. S.. & Riley, A. (2002). Antidepressant medications: A

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