Selected aspects of the sexual functioning of women – preliminary studies

Introduction

Human sexuality, and therefore women’s sexuality, is determined by a series of complex aspects, collectively referred to as bio-psycho-social factors [1–5]. Some of them influence the choice of sex, and the orientation or the formation of the centres responsible for controlling sexuality in the foetal phase of life. Human sexual development further consists of several more phases. In the pre-school period, there is already a natural interest among children in all things gender related. Adolescence, on the other hand, involves not only the most important but also rapid biological changes, and in turn the acceleration or eroticisation of the psyche. Once again, literature sources also indicate that women’s sexuality in late life is the area that has received the least attention and, consequently, less research [6]. The division of the sexual response cycle into the phases of desire, arousal, orgasm, and relaxation has made it possible to recognise sexual dysfunctions [7–9] according to the symptoms that appear in them. Among desirability disorders (hypolibidaemia), the most common include hypoactive sexual desire disorder or reduced sexual arousal syndrome. Arousal disorders include lubrication disorders, among others. Orgasmic disorders may include, for example, a lack of a joyful experience. Chronic sexual tension syndrome was one of the relaxation phase disorders [10]. In contrast, pain syndromes that directly relate to female sexual activity include vaginismus, vulvodynia, and dyspareunia [11].
It is worth emphasising the complexity and multidimensionality of the factors and mechanisms connected with sexuality, which should all be taken into account in diagnostics and sexual therapies. Medical aspects are as important as psychological and social factors.
Sexology is a scientific study that is key to human existence, and it is continuously developing. Even though in recent years more attention has been paid to sexual health, this sphere still requires further analyses and exploration. It is popularly believed that sexual health has a significant influence on the overall health of an individual. Not only does it affect the development of their personality, but also their ability to effectively communicate and build satisfying relationships.
One area that requires particular attention is the sexual functioning of women at different ages. Previous studies usually focused on the procreation period, ignoring other stages of female life. Nevertheless, understanding and analysing changes in the sexual sphere across the lifespan of a woman are key when understanding human nature.
It is worth emphasising that socio-demographic factors, such as place of residence, age, marital status, education, and socio-economic conditions have a remarkable influence on the health behaviours of women during the procreation period. However, when analysing the sexual functioning of women of different ages, one should also take into consideration psychosocial, emotional, and cultural variables, which shape this sphere of life.
In light of the above, it is essential to carry out studies on female sexual health, taking into account a variety of aspects of their life and the impact of these issues on society. A holistic approach to sexology is the only way to better understand and support the sexual health of women, thus contributing to the overall wellbeing of society.

Objective of the study, questions, and research hypotheses

The objective of the study was to evaluate female sexual functioning taking into account sociodemographic factors.

1. Does age/place of residence significantly affect sexuality?
2. H0: Age/place of residence significantly affects female sexuality.
3. H1: Age/place of residence does not significantly affect female sexuality.
4. Does painful intercourse determine female sexual activity?
5. H0: Painful intercourse determines female sexual activity.
6. H1: Painful intercourse does not determine female sexual activity.
7. Does obesity affect female sexuality?
8. H0: Obesity affects female sexuality.
9. H1: Obesity does not affect female sexuality.

Material and methods

The Polish version of the Female Sexual Function Index (FSFI) questionnaire was used to assess female sexual functioning at puberty. This is the approved standardised questionnaire used to assess female sexual functions over the previous 4 weeks. The questions in the FSFI questionnaire corresponded to 6 different domains such as desire (questions 1, 2), arousal (questions 3, 4, 5, 6), lubrication (questions 7, 8, 9, 10), orgasm (questions 11, 12, 13), satisfaction (questions 14, 15, 16), and pain (questions 17, 18, 19). In contrast, questions 20 and 21 provided information on the satisfaction of a women’s sexual desire. In each domain, sexual function was assessed using a Likert scale. The individual subscales could be scored 0–6 points, except for the questions on desire, where scores ranged 1.2–6.0. After completing the FSFI questionnaire, a woman could have a score of 1.2–36.0 points. Noticeably, the higher the score, the higher her sexuality is rated. Women with sexual disorders scored ≤ 26.55 points [12, 13]. The female sexual function index questionnaire provides credibility, sensitivity, reliability, internal consistency, stability, and repeatability of results assessing disorders of sexual drive, arousal, orgasm, and dyspareunia. The questionnaire can be used in groups that vary in their sexual stage in life, both in the pre- and post-menopausal period. This is also a good tool with regard to psychometrics [14]. Cronbach’s coefficient for this tool is 0.9 [15].
In addition, the FSFI questionnaire was extended to include questions on the following: age, weight, height, year of onset of first menstruation, and any hormonal treatment used. It also featured socio-demographic questions including gender, education, marital status, and place of residence.
Particular attention was also paid to the complete confidentiality and anonymity of the survey. The Female Sexual Function Index questionnaire was made available to respondents exclusively through social media, which undoubtedly influenced the increased interest and openness of women on the topic of sex. The inclusion criteria were women aged 18 years and older who provided their informed consent.
As far as body mass index (BMI) is concerned, the respondents were asked to indicate their body mass and height, i.e. the parameters required for the correct classification. Body mass index is calculated by dividing weight in kilograms by height in metres squared. The optimal and most desired range of BMI in adults is 18.5–24.99. This poses the lowest risk of obesity-related diseases. Class 1 obesity is present when BMI is within 30–34.9 kg/m2, class 2 obesity is BMI of 35–39.9 kg/m2, and class 3 obesity is BMI over 40 kg/m2.
In the descriptive analysis, tables were used to show the number (n) and percentage (%) of responses to each question of the FSFI questionnaire.
The non-parametric Mann-Whitney U test and Spearman’s R-correlation coefficient were used to assess differences in a single trait between the 2 groups.
The study was conducted in accordance with the Declaration of Helsinki and approved by the Bioethics Committee of the Poznań University of Medical Sciences registered under the identification number: 440/2023 of 24 May 2023.

Results

A total of 333 women between the ages of 20 and 65 years took part in the study. The average age of the women surveyed was 38.1 years. The standard deviation was more than 25% of the mean value, indicating an average age variation. Minimum age – 20 years, maximum age – 65 years.
The highest number of women declared a tertiary education, i.e. 267 women (80.2%), and the least amount declared a vocational education, i.e. 5 people (1.5%). There were 199 married women (59.8%), 92 single women (27.6%), and the fewest were separated or widowed women – 4 of each (1.2% of respondents per group).
The average age of sexual initiation was 19.1 years. The standard deviation accounted for more than 14% of the mean value, indicating little variation in the age of first sexual initiation. The minimum age was 14 years, the maximum was 35 years. Most women initiated sexual activity at the age of 18 years – 84 people (25.2%), at the age of 17 years – 54 people (16.2%) and at the age of 20 years – 41 people (12.3%), the smallest amount at the age of 14 years and 35 years – one person each (0.3%). Detailed figures and percentages are shown in Table 1.
The largest number of women indicated that they were not taking contraceptive pills or other hormonal medication – 322 (96.7%). Only one woman (0.3%) indicated that she had her first menstrual period after hormone treatment at the age of 15 years.
Considering BMI, more than half of the female respondents were of a normal weight – 176 women (52.9%). 100 respondents (30.0%) were overweight, but the least amount of women were emaciated – 4 people (1.2%) and with class 3 obesity (Table 1).
For the purposes of further analysis, subjects who were emaciated and underweight formed one underweight group, while subjects with stage I, II, and III obesity formed a separate obese group.
After analysing the sociodemographic data obtained from the female respondents, the focus was on questions exploring their sexuality. The questions of the FSFI questionnaire were related to the last 4 weeks, which the respondent was informed about before completing the questionnaire. In addition, the questionnaire explained the concepts of sexual stimulation, sexual intercourse, sexual activity, and sexual arousal (stimulation).
In terms of the frequency of feeling sexual interest or desire (within 4 weeks), the most respondents indicated several times (less than every other day, approximately once or twice a week) – 167 people (50.2%), the least indicated that very often – 28 people (8.4%), or almost never/never – 26 people (7.8%) (Table 2).
In terms of determining the level of sexual interest or desire (within 4 weeks), most respondents indicated medium – 157 people (47.1%), the least indicated very low or none – 23 people (6.9%), and very high – 22 people (6.6%).
Regarding the frequency of feeling sexually excited (aroused) during intercourse or during other sexual activity (masturbation, self-stimulation) during the 4-week period, the largest number of women indicated being always or almost always sexually aroused – 142 people (42.6%), or usually sexually aroused – 92 people (27.6%) (Table 3).
Regarding the fulfilment of sexual desire, the respondents marked several statements, and a total of 485 responses were recorded. The largest number of women indicated having sexual intercourse with a man (partner) – 255 people, which represented 52.6% of all responses given.

The Female Sexual Function Index scale assesses all aspects of a woman’s sexual functioning

The assessment applies to 6 domains: I – desire (Q1 and Q2), II – arousal (Q3, Q4, Q5, and Q6), III – lubrication (Q7, Q8, Q9, and Q10), IV – orgasm (Q11, Q12, and Q13), V – sexual satisfaction (Q14, Q15, and Q16), and VI – pain complaints related to sexuality (Q17, Q18, and Q19). The assessment covers the last 4 weeks.
The highest scores were recorded in the domain of sexual pain complaints (6) with a mean score of 4.94, and sexual satisfaction (5) with a mean score of 4.77. The lowest scores were recorded in the domain of arousal (2) with a mean score of 4.34, and desire (1) with a mean score of 3.5 (Table 4).
The mean score for sexual functioning was 26.53 points. The standard deviation accounted for more than 27% of the mean value, indicating an average variation in results. Minimum score – 2 points, maximum score – 35.4 points (Fig. 1).
The highest average desirability score was recorded in the 20–30 age group with 3.85 points and in the 31–40 age group with 3.73 points, and the lowest in the 51–60 age group with 2.91 points. The highest average arousal score was recorded in the 31–40 age group with 4.56 points and in the 20–30 age group with 4.51 points, and the lowest in the 51–60 age group with 3.67 points. The highest average score for pain related to sexuality was reported by 41–50-year-olds with 5.13 points and 31–40-year-olds with 5.12 points, and the lowest by 51–60-year-olds with 4.42 points. Statistically significant differences were noted between the age of the study group and female sexual functioning in the domain of desire (p = 0.000), arousal (p = 0.001), lubrication (p = 0.028), and general sexual functioning (p = 0.016) (Table 5).
Higher rates of desire, arousal, sexual satisfaction, and pain related to sexuality were reported in the urban group, while in the rural group – lubrication and orgasm. There was a slightly higher rate of women with possible sexual dysfunction (score ≤ 26 points) in the group of rural residents, with 31 respondents (33.3%), than in the group of urban residents, with 75 respondents (31.3%).
When asked about the frequency of experiencing discomfort or pain during sexual intercourse over a 4-week period, 194 respondents (58.3%) indicated a response of almost never or never or several times – 79 respondents (23.7%) experienced discomfort or pain during sexual intercourse. The lowest number of women surveyed answered almost always or always – 8 respondents (2.4%), and those who felt pain or discomfort during most intercourse – 6 respondents (1.8%).
Due to the level of significance (p > 0.05), there were no statistically significant findings between urban and rural residents regarding the results of sexual functioning. Women’s BMI had a statistically significant, low correlation with arousal scores (p < 005) (Fig. 3, Table 6). The highest average desire score was recorded in the underweight group, with 3.96 points, and in the normal range group, with 3.54 points, and the lowest in the obese group, with 3.24 points. The highest average arousal score was recorded in the underweight group – 4.89 points and overweight group – 4.43 points, the lowest in the obese group – 3.82 points.
The highest average lubrication score was recorded in the group in the normal range – 4.62 points and overweight – 4.61 points, the lowest in the underweight group – 4.26 points. The highest average orgasm score was recorded in the underweight group with 4.92 points and the overweight group with 4.52 points, and the lowest in the obese group with 4.2 points. The highest mean sexual satisfaction results were recorded in the normal-range group with 4.87 points and the overweight group with 4.83 points, and the lowest in the obese group with 4.31 points. The highest mean score for pain related to sexuality was recorded in the obese group with 5.18 points and with a normal range of 4.86 points, the lowest in the underweight group with 4.52 points.
The highest rate of women with possible sexual dysfunction (score ≤ 26 points) was in the obese group with 21 (44.7%) and the overweight group with 31 (31.0%), and the lowest in the group with a normal BMI value with 51 (29.0%).

Discussion

Sexual health is currently considered an essential element of general health condition and wellbeing worldwide [16–20]. Sexuality is a complex and multidimensional aspect of human life, influenced by a variety of factors, e.g. psychosocial factors.
In recent years, female sexuality has been the subject of scientific research. Although further exploration is required, the actual progress of knowledge on this issue is crucial to understanding the complexity and diversity of factors and mechanisms vital in sexual functioning.
Scientific studies in sexology have been focused on physiological and psychosocial aspects to deliver a comprehensive perspective on this important sphere of female life [21–24]. It should be pointed out that female sexual disorders can manifest themselves in a loss of desire, arousal disorders, difficulty reaching orgasm, or pain during sexual intercourse [25].
In our own studies, 38.7% of the women always or nearly always reached orgasm (climax) during sexual stimulation or intercourse over the previous 4 weeks, 23.4% – most of the time, and 7.5% – nearly never or never. 6.7% of the women declared sexual inactivity. As for difficulty reaching orgasm (climax, maximum sexual arousal) during sexual stimulation (masturbation, self-stimulation) or sexual intercourse in the previous 4 weeks, the largest number of women reported that this was rather easy (50.8%) or easy (18.3%). The smallest number of women stated that this was extremely difficult or impossible (4.2%) and very difficult (1.8%).
In studies by Cabral et al. [26] 67% of the respondents reported sexual dysfunctions at ≤ 26.55, the highest frequency of which was among the women aged 56–65 years. Blümel et al. [27] carried out a study among 7243 women in 11 countries in South America, confirming a high frequency of sexual dysfunction in women aged 40–59 years. In addition, a significant negative impact of age on the frequency of sexual activity, interest therein, and various aspects or sexual responses (e.g. pleasure, arousal, and orgasm) were observed in a longitudinal study carried out among Australians [28].
Low desire in women means a lack of need for or aversion to sexual intercourse. According to DSM-IV-TR (diagnostic and statistical manual of mental disorders), this is a persistent or recurrent aversion to sexual activity that causes discomfort and hinders relationships between partners. Low desire is the most common female sexual disorder, estimated at 5.4–13.6% [29]. In the case of younger women, this can result from interpersonal problems, diseases, depression, medications (namely antidepressants, particularly selective serotonin reuptake inhibitor), contraception, and corticosteroids. The symptoms are often unrecognised as women avoid sexual contact, which can disturb relationships between partners.
A Brazilian study on female sexuality showed that 30% of the women experienced sexual disorders. The most often reported symptoms were a lack of desire (34.6%) and difficulties reaching orgasm (29.3%) [30]. A lot of studies suggest that female sexual functions deteriorate with age [31]. According to Kaiser [32], age-induced changes in sexual activity should be analysed separately from those resulting from diseases common at this stage of life. The studies associate sexual disorders in middle-aged women with a sense of guilt or shame caused by a lack of sexual desire, marriage problems, comorbidities in any partner, and medications that affect libido or performance [31].
Sexual arousal disorder means an inability to fully participate in sexual intercourse and insufficient lubrication of the mucous membranes, which causes distress and hinders relationships between partners. The results of the survey conducted in the United States indicate that 5% of women experience difficulties reaching sexual arousal [29]. In our own studies, as far as the level of sexual arousal during sexual intercourse or other sexual activities (masturbation, self-stimulation) over the previous 4 weeks is concerned, the largest number of women indicated that they were highly aroused, but did not lose contact with reality (51.1%) or were moderately aroused (25.8%), while the smallest number of women declared sexually inactivity (4.2%) or weak or loss of arousal (3.0%). As regards satisfaction with arousal during sexual intercourse or other sexual activities (masturbation, self-stimulation) over the previous 4 weeks, the largest number of women were nearly always or always satisfied (39.0%) or most of the time (33.6%), while the smallest number of women indicated that they were not sexually active (4.8%) or had very low activity or a lack of self-confidence (4.2%).
Sexual disorders related to pain during intercourse are divided into 2 categories: dyspareunia and vaginismus. DSM-IV-TR defines dyspareunia as persistent pain during intercourse, caused by a lack of lubrication of the mucous membranes and hindering relationships between partners. Vaginismus is a recurrent contraction of muscles of the distal third of the vagina, which hinders sexual intercourse. Dyspareunia is common, particularly among women after menopause (8–22%) [33]. Recent studies suggest that this pain results from sexuality rather than from sexual function disorder. Vaginal pain is often caused by vulval vestibule pain, insufficient lubrication, or vaginismus. A lack of desire and arousal disorders can increase pain because the former often causes physical discomfort. Though uncommon (1–6%), vaginismus can result from fear of pain.
Female sexual disorders can occur at any age, but they are more likely during middle age or menopause [34, 35]. The results of a study carried out by Safarinejad revealed that 31.5% of Iranian women aged 20–60 years suffer from sexual dysfunctions [36]. Considering female education, Cabral et al. [24] proved that 78.9% of women with low levels of education exhibited a higher rate of sexual dysfunctions. De Lorenzi et al. [37] observed that higher education facilitates access to information and reduces the level of anxiety. In our own studies, the highest rate of possible sexual dysfunction (≤ 26 pts) was noted among women aged 51–62 years (52.8%) and 41–50 years (33.6%), while the lowest was at the age of 31–40 years (26.2%). A slightly higher rate of possible sexual dysfunction (≤ 26 pts) was recorded among women living in villages (33.3%) than among those living in cities – 75 women (31.3%).
The causes of long-term lack of sexual activity are often cited as fatigue, overwork, poor general health, alcohol abuse, or deterioration of a relationship [38]. The most commonly reported sexual disorders by women are arousal disorders. Of the complaints of pain related to sexuality, 13% of women complain of dyspareunia and 2% complain of vaginismus [39].
Analysis of the available research material shows that there is a statistical relationship between demographics such as age and women’s sexuality. The correlation between the 2 variables was calculated using Spearman’s R correlation coefficient, where age remained in low correlation with the results of several of the 6 domains. The negative correlation of domains such as desire, arousal, lubrication and general sexual functioning tells us that the higher the age of the woman, the lower the score for the domains listed. Carranza- Lira et al. [40] reported a significant decrease in FSFI scores between the ages 50–54 years, indicating that age may be important in sexual life. In the group of women between 40–44 years of age, sexual function was more prominent in terms of desire, arousal, and lubrication. In terms of orgasm and pain experienced during intercourse, the group of women aged 45–49 years scored lower, and greater sexual dysfunction was observed in women over 50 years of age. In a study by Safdar et al. [38], female respondents under 40 years of age had significantly lower satisfaction scores than respondents over 40 years of age.
A study in 2019, carried out using the Polish version of the FSFI among mature women undergoing a preventive gynaecological examination, indicated a statistically significant correlation between age and FSFI [39].
It confirmed the negative correlation of the following domains: desire, arousal, and lubrication. Thus, the older the woman, the lower the score obtained for the domains listed. At the same time, the results of the same research showed, on the one hand, that the sexual sphere is still a taboo subject for some women, and on the other hand, they make it possible to see how indicators such as age, weight, height, age of first menstruation, hormonal treatment, clinical hyperandrogenism, or sexual initiation affect a woman’s sexual desire. They also allow women to recognise current sexual dysfunctions, but also to evaluate their sexuality [39].
Further analysis of the study material shows another statistical relationship between BMI and the arousal domain. Body mass index remains in low correlation with arousal domain scores (p < 0.05). This means that the higher a woman’s BMI, the lower the score obtained for the arousal domain.
In another 2017 study by Sinica et al., also using the Polish version of the FSFI questionnaire, conducted on a group of women without a history of sexual abuse or other forms of domestic violence in childhood, a low negative correlation between BMI and the arousal domain was confirmed. At the same time, this means that as BMI increases, arousal in women decreases. This study also demonstrates once again that the FSFI questionnaire is an essential tool for women’s sexological diagnosis of sexual dysfunction [41].
Our own research, on the other hand, shows that there is no statistical relationship between demographics such as place of residence and women’s sexuality. The non-parametric Mann-Whitney U test was used here to assess differences in women’s sexuality according to urban/rural residence. Due to the significance (p > 0.05) for all 6 domains, there were no statistically significant relationships between urban and rural residents regarding the results of sexual functioning. The same study also indicates that BMI has no effect on domains such as desire, lubrication, orgasm, sexual satisfaction, sexual pain complaints, and overall sexual functioning (p > 0.05). In comparison, the aforementioned 2019 study by Jarząbek-Bielecka et al. showed slightly different results [1]. They indicated a weak negative correlation between women’s BMI and the domains of desire and sexual satisfaction. Consequently, the higher the BMI of women, the lower the scores obtained for the domains of desire and sexual satisfaction [39].
From the analysis of our own research, it is also worth noting the mean scores of women’s sexual functioning and individual domains. The mean score for sexual functioning was 26.53 points, while the minimum score was 2 points, and the maximum score was 35.4 points. The highest results were recorded in the domain of sexual pain complaints, with a mean score of 4.94 and sexual satisfaction with a mean score of 4.77. In contrast, the lowest results were recorded in the domains of arousal, with an average of 4.34 points, and desire, with an average of 3.5 points.
In the studies conducted in Poland, the average score of sexual functioning in women with basic sexual education was higher (28.0 pts) than in those without sexual education (23.6 pts).
The best results for women with sexual education were recorded in the domains of arousal, with a mean score of 4.8 points, and sexual satisfaction, with a mean score of 4.8 points. For women without sex education, the highest scores were recorded in the domains of sexual satisfaction, with 4.6 points, and sexual pain complaints, with 4.3 points. In contrast, the lowest result for women with sex education was recorded in the domain of desire, with an average of 4.3 points. For women without sex education, the lowest results were recorded in the domains of arousal and orgasm – 3.7 points, and desire – 3.4 points [39].
Based on our own research and the results of general sexual functioning, we can summarise that 31.8% of the women interviewed had sexual dysfunctions. In contrast, 68.2% were women who lacked sexual dysfunction. The prevalence of sexual dysfunction in women is influenced by sociodemographic factors such as age and BMI.
The results of our own research clearly show that thanks to the FSFI questionnaire, women are able to identify problems related to their sexuality themselves and clearly assess its quality.
The pilot character of the study should be highlighted. Although this study has its strong points, e.g. reliable data and a starting point for further studies, it also has some significant limitations, such as a small study group, and insufficient information on gynaecological and systemic diseases, which affect the general credibility and possibility to generalise the results. The development of knowledge on female sexuality is dynamic and includes physiological, psychosocial, and social aspects, which is why it is worth continuing studies to better understand this complex sphere of life and adjust the therapeutic and educational approach to individual needs.

Conclusions

There is a statistical relationship between demographics such as age and female sexuality. Age was in low correlation with the results of domains such as desire, arousal, lubrication and overall sexual functioning. There is a statistical relationship between BMI and the arousal domain, which remained in low correlation with each other. There is no statistical relationship between demographics such as place of residence and women’s sexuality. Body mass index does not statistically affect domains such as desire, lubrication, orgasm, sexual satisfaction, sexual pain complaints, and general sexual functioning.

Disclosure

1. The study was conducted in accordance with the Declaration of Helsinki and approved by the Bioethics Committee of the Poznan University of Medical Sciences, registered under the identification number: 440/2023 of 24 May 2023.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References