Afrane et al. World Journal of Pharmaceutical Research
PREVALENCE AND SELF-MANAGEMENT OF FEMALE SEXUAL
DYSFUNCTION AMONG WOMEN IN SIX REGIONS OF GHANA: A
CROSS-SECTIONAL STUDY
Barima A. Afrane1, Irene A. Kretchy1*, Emelia P. Imbeah1,Joseph A. Sarkodie2, Philip Debrah3, Franklin Acheampong4, Samuel Oppong1 and Patrick Amoateng5
1
Department of Pharmacy Practice and Clinical Pharmacy, School of Pharmacy, University
of Ghana, College of Health Sciences, Legon.
2
Department of Pharmacognosy and Herbal Medicine, School of Pharmacy, University of
Ghana, College of Health Sciences, Legon.
3
Department of Pharmaceutics and Microbiology, School of Pharmacy, University of Ghana,
College of Health Sciences, Legon.
4
Department of Pharmacy, Korle-Bu Teaching Hospital, Accra.
5
Department of Pharmacology and Toxicology, School of Pharmacy, University of Ghana,
College of Health Sciences, Legon.
ABSTRACT
Background: Female sexual dysfunction (FSD) is widespread and a relevant health condition among women. Few women seek medical
care, yet, the patronage of female sex-enhancing agents from the
pharmacies, chemical and herbal shops have increased in recent times.
The study sought to determine the prevalence and self-management of
FSD among Ghanaian women. Methods: A community-based cross-sectional study was conducted using structured questionnaires to elicit
descriptive accounts of sexual experiences, help-seeking behaviours
and measures taken to manage the sexual problems. Two hundred and
seven (207) sexually active women aged 18 years and above were
interviewed from six out of the ten regions in Ghana. Results: The majority of the respondents were married (53.1%), had tertiary
education (74.4%) and were within the ages of 18-29 (52.4%). Of all the respondents, 44.3%
were not aware of FSD. The overall prevalence of FSD was 45.6%. The most prevalent
sexual problems were pain during sex (72.9%), lubrication difficulties (72.3%), arousal
Volume 5, Issue 3, 241-254. Research Article ISSN 2277– 7105
Article Received on 08 Jan 2016,
Revised on 28 Jan 2016, Accepted on 18 Feb 2016
*Correspondence for
Author
Dr. Irene A. Kretchy
Department of Pharmacy
Practice and Clinical
Pharmacy, School
of Pharmacy, University
of Ghana, College of
disorder (70.3%), desire disorder (54.2%) and sexual dissatisfaction (27.1%). Only 22.5% of
the respondents with FSD sought formal medical help. The reasons for not seeking formal
help included the perception that FSD was normal (50.0%), personal embarrassment (19.2%)
and time constraints (15.4%). About 57% of the respondents had self-managed at least one
sexual problem. Counselling (31.2%), use of vaginal lubricants (24.1%) and sex and
relationship strategies (23.4%) were the most cited options for managing FSD. Overall,
85.0% of women perceived the management options were effective. Only 1% of the
respondents experienced side effects (vaginal itching) when vaginal lubricants and vaginal
herbal preparations were employed. Conclusion: Women in Ghana experience female sexual
dysfunction making it a health concern requiring recognition and intervention.
KEYWORDS: Female Sexual Dysfunction; Help-Seeking Behaviour; Ghana; Women.
INTRODUCTION
Sexual dysfunction is a widespread and relevant public health problem occurring commonly
in women than in men (Lauman et al, 2005). Marthol et al. (2004) defined sexual dysfunction
as disturbances in sexual desire with psycho-physiological changes that characterize the
sexual response and cause marked distress and interpersonal difficulty. Female Sexual
Dysfunction (FSD) has been used to depict various sexual problems such as low sexual desire
or interest, reduced arousal, orgasmic difficulties and pain during sex (Marthol et al, 2004).
Female sexual dysfunction is multifactorial in terms of etiology. It may be caused by
psychological, physiological and sociological factors (Phillips, 2000). FSD is widespread and
affects women in different countries, cultures and age groups. In Ghana, the prevalence of
FSD has reported previously as 72.8% (Ramage, 2007).
Although not life threatening, FSD can have profound effects on the physical and mental
well-being of women. It may contribute to infertility, low self-esteem and emotional burden
and can have overwhelming effects on their relationships with their sexual partners (Amidu et
al, 2010).
Generally, little is known about the help-seeking behaviour of women with sexual problems
and how such women self-manage their condition. Past studies have also shown that only a
small proportion of women with sexual problems seek medical attention (Brock et al, 2006;
Despite the reported high prevalence of female sexual dysfunction in Ghana and the likely
complications it may have on women, the Standard Treatment Guidelines of Ghana gives no
procedures for the assessment and management of women with sexual problems.
Furthermore, little is known about the help-seeking behaviour of women with FSD and the
measures taken by these women to manage their condition(s). Therefore, this study sought to
1. Assess the level of awareness of FSD among women. 2. Assess the help-seeking behaviour
of women with FSD, 3. Identify the measures taken by these women to manage FSD and 4.
Evaluate the perceived effectiveness, safety and adverse effects, if any, associated with these
remedies.
METHODS
Study Design and Setting
A community-based cross-sectional study was conducted in six regions in Ghana namely;
Greater Accra, Ashanti, Western, Central, Brong-Ahafo and Eastern regions. These six
regions are densely populated and were chosen to allow for generalization of results for the
entire country.
Participants
This study approached 305 women, aged 18 years and above, selected randomly from the six
regions irrespective of religious, social and educational backgrounds. Only women in
heterosexual relationships were included in the study. Women who were not sexually active
were excluded. The minimum sample size was determined by the sample size formula; N= Z2 P (1-P)/d2, where P is the highest prevalence rate of 72.8% as reported by(Ramage 2007), Z is the confidence level of 95% (1.96), d is the allowed error of 0.05 (Naing et al, 2006).
Data Collection Tools
A questionnaire comprising of questions on the background of respondents (age, marital
status, highest level of education, occupation, region and religious affiliation), self-reported
FSD, help-seeking behaviour and the treatment/management options for FSD was employed
in this study.
Self-reported sexual problems of desire, arousal, lubrication, orgasm, satisfaction and pain
were measured with the Female Sexual Function Index (FSFI). This tool consisted of 19
questions covering 6 domains namely; desire (Q1-Q2), arousal (Q3-Q6), lubrication
developed based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for female sexual arousal disorder (FSAD), it been shown to discriminate
reliably between FSAD and the other five domains as well as the full scale score (Rosen et al,
2000). Internal consistency of 0.89-0.96 (Cronbach‟s alpha) and test-retest reliabilities
(Cohen‟s kappa) of 0.79-0.86 have been reported to be within the acceptable range (Rosen et
al, 2000). In this study, response to each question related to the previous 3 months and were
scored either from 0 (no sexual activity) or 1 (indicative of dysfunction) to 5 (suggestive of
normal sexual activity).
Help-seeking behaviour among women with FSD was assessed by asking the question: "Have
you ever sought any help from healthcare professionals for your problem?" A list of
healthcare providers was given and more than one option could be selected. „Formal Help‟
was used to represent help sought from healthcare providers such as
obstetricians/gynecologists, general medical practitioners, psychiatrists, psychologists,
pharmacists, nurses, whereas „Informal Help‟ was used to designate help from persons other
than healthcare providers (sexual partners, friends, co-workers, family members etc.).
Reasons for not seeking professional help was then explored.
The final section of the questionnaire explored the options available for self-managing female
sexual dysfunction in the country and the responses noted.
Women who could not read and understand the English language were interviewed in Twi
(the dominant local language). The data collection tool was pre-tested on a sample of 20
respondents and found to be reliable with a Cronbach‟s alpha of 0.81. In addition, responses
in the local language version were professionally translated from Twi to English to ensure
that the exact responses were conveyed in both languages. Averagely, each interview lasted
about 20 minutes.
Ethics
Permission to conduct the study was given by the research committee of School of Pharmacy,
University of Ghana. The study was strictly voluntary. Written and verbal (for women who
could not read) informed consent were sought from the respondents. Participants were not
required to supply any information that would reveal their identities. Data provided by all the
Data Analysis
Data obtained by the FSFI were analyzed by first obtaining domain scores for the 6 domains
as outlined in the computational formula by Rosen et al. (2000). This was done by adding the
scores of the individual questions that made up the domain and by multiplying the sum by the
domain factor provided in the FSFI for each domain. The full scale score (for overall sexual
dysfunction) was obtained by adding the 6 domain scores. Data on the sexual dysfunction,
help-seeking behaviour and management options for FSD were analyzed using the 20th
version of the Statistical Package for Social Sciences (SPSS). Graphical displays such as
frequency tables were used to describe the data.
RESULTS
Out of the 305 women who consented to the study, 207 (67.9%) completed their
questionnaires.
Characteristics of Respondents
The majority of the respondents (52.4%) were between the ages of 18 and 29 years, 53%
were married, 87% had attained a minimum of secondary school education and 95.2% were
Christians. Most of the participants came from the Brong Ahafo region (Table 1).
Level of Awareness, Definition and Possible Causes of FSD
Almost half of the respondents (44.3%) were unaware of FSD (Table 2). Out of the women
who reported having knowledge of FSD (50.7%), 16.9% gave wrong definitions. The
majority of the women understood FSD as pain or discomfort during sex (41.7%),
disturbance in the normal sexual response (30.2%) and lack of desire for sex (24%).
Prominent among the possible causes of FSD cited were stress (30.9%), medical and
hereditary conditions (20.2%), previous sexual abuse (16%), unpreparedness (8.5%), and
ageing (8.5%).
Experience of FSD and Help-seeking Behaviour of Women with FSD
Almost half of the respondent (45.6%) had female sexual dysfunction. Many of them had
experienced at least one problem with sex. Pain during sex was the most reported sexual
problem (72.9%), followed by lubrication difficulties (72.3%), arousal disorder (70.3%),
desire disorder (69.7%), orgasmic disorder (54.2%) and sexual dissatisfaction (27.1%) (Table
Most of the women who reported experiencing sexual problems did not seek any help for
their condition (49.3%). Out of those who sought help, only 22.5% disclosed their condition
to healthcare providers (formal help). Reasons for not seeking formal help included the
thought that experiencing sexual problems was normal (50.0%), personal discomfort and
embarrassment (19.3%), time constraints (15.4%), lack of privacy during hospital visits
(14.4%) and the notion that healthcare providers cannot solve sexual problems. Most of the
women who sought formal and informal help consulted gynecologists and sexual partners
respectively (Table 3).
Self-management of FSD: Measures, Perceived Effectiveness and Side Effects
More than half of the respondents (56.5%) had self-managed at least one sexual problem. The
most cited measures taken by women to self-manage their condition included seeking
informal counsel (31.2%) and the use of vaginal lubricants (24.1%) whereas others resorted
to the use of herbal preparations (5.7%), sex toys (2.1%), vibrators (2.1%), hormonal therapy
(2.1%) and aphrodisiacs (1.4%).
On the whole, more than half of the women who employed these measures saw them to be
effective and safe (Figure 1 and Figure 2) except for complains about vaginal irritation.
Vaginal lubricants greatly reduced pain during sex; Aphrodisiacs increased satisfaction with
sex; sex toys and mechanical aids increased desire for sex and enhanced orgasm whereas
counseling enhanced orgasm and improved the relationship between users and their sexual
partners.
Table 1: Socio-demographic Characteristics of Respondents.
Variable Frequency Percentage
Age
18-29 108 52.4
30-39 55 26.7
40-49 24 11.7
50 and above 19 9.2
Marital Status
Single 110 53.1
Married 89 43.0
Divorced 6 2.9
Widowed 2 1.0
Religious Affiliation
Christian 197 95.6
Muslim 9.0 4.4
Region
Greater Accra 43 20.8
Ashanti 13 6.3
Western 26 12.6
Central 41 19.8
Brong-Ahafo 44 21.3
Eastern 40 19.3
Educational Level
No Education 3 1.4
Primary 9 4.3
Secondary 26 12.6
Tertiary 154 74.4
Post Graduate 15 7.2
[image:7.595.165.429.68.261.2]
Table 2: Awareness of FSD, Definition and Possible Causes.
Variable Frequency Percentage
Knowledge of FSD
Yes 103 50.7
No 90 44.3
Not sure 14 6.76
Definition of FSD
Lack of desire for sex 23 24.0
Pain/Discomfort during sex 40 41.7
Disturbance in normal sexual response 29 30.2
Not sure 4 4.2
Causes
Stress 29 30.9
Medical or Hereditary 19 20.2
Previous Sexual Abuse 25 16.0
Ageing 8 8.5
Unpreparedness 8 8.5
Others 15 16
Table 3: Experience of FSD and Help-Seeking Behaviour of women with Self-Reported FSD.
Variable Frequency Percentage
FSD prevalence
Sexual Dysfunction 94 45.6
No Sexual Dysfunction 112 54.4
*Common Sexual Problems
Desire Disorder 74 69.7
Arousal Disorder 76 70.3
Lubrication Difficulties 85 72.3
Orgasmic Disorder 60 54.2
Sexual dissatisfaction 22 27.1
Sexual Pain 86 72.9
Formal 43 22.5
Informal 77 43.5
None 102 49.3
Type of Formal Help Sought
Gynecologist 23 60.5
General Practitioner 7 18.4
Psychiatrist 1 2.6
Nurse 10 26.3
Pharmacist 5 13.2
Source of Informal Help
Spouse/ partner 47 58.0
Friends 41 50.6
Family members 5 6.2
Co-workers 9 11.1
*Reasons for not Seeking Formal Help
Personal discomfort/embarrassment 20 19.2
Health provider cannot help 11 10.6
Time Constraints 16 15.4
Perception that it was normal 52 50.0
Others 15 14.4
*Multiple responses.
Table 4: Self-Management of FSD; Measures, Perceived Effectiveness and Side Effects.
Variable Frequency Percentage
Self-Managed FSD
Yes 117 56.52
No 90 43.48
Self-management measures
Vaginal Lubricants 34 24.1
Aphrodisiacs 2 1.4
Sex toys 3 2.1
Mechanical aids 3 2.1
Counselling 44 31.2
Psyching oneself 3 2.1
Books, TV sex program 2 1.4
Avoiding stress 2 1.4
Abstaining from sex 2 1.4
Sitting over hot water 1 0.7
Topical local anesthetics 1 0.7
Hormone replacement therapy 3 2.1 Sex and Relationship therapy 33 23.4
Figure 1: Perceived effectiveness of management options for FSD.
Figure 2: Perceived Benefits of Management Options for FSD.
DISCUSSION
Generally, research has shown that unlike male sexual dysfunction, female sexual
dysfunction is a topic that is least talked about in various societies (Gott et al, 2004; Shifren
et al, 2008). Consequently, more than half of the respondents in this study were ignorant of
FSD. Some (10.6%) of the women who reported that they were aware of FSD also gave
completely wrong descriptions and definitions for female sexual dysfunction. The perception
that it is a taboo for women to openly discuss sexual issues and the fact that most studies have
only focused on male sexual problems may have accounted for the significant unawareness of
[image:9.595.151.445.315.529.2]this topic among Ghanaian women and the public as a whole. Such educative programs may
be held on the media, at public gatherings, or at the community level and must focus on
normal and abnormal female sexuality, causes of FSD, treatment options available for FSD
and options for seeking help.
With documented evidence suggesting that FSD is as a result of several causes (Laumann et
al, 2005; Potter, 2007; Ramage, 2006), results from this study also revealed several possible
factors that may cause female sexual problems. Most of the cited causes cut across four main
areas namely, psychological (past sexual abuse, fear), physical (medical conditions),
emotional (stress, anxiety, depression) and aging. Stress, the most cited cause of FSD in this
study (30.9%), has also been shown to cause a decrease in sexual desire, arousal and orgasm
(Hamilton et al, 2013; Zollman et al, 2003).
The prevalence of FSD in this study was found to be 45.6% thus, affirming the existence of
FSD among Ghanaian women in such a proportion that should not be overlooked. However,
the prevalence of FSD in this study was relatively lower than that obtained by Amidu and his
colleagues (2010) in a work done in Kumasi (72.8%) using the Golombok Rust Inventory of
Sexual Function (GRISS) Scale. The difference in the prevalence could be attributed to
differences in the number of participants, geographical locations, the time period for the
study and the scales employed in measuring FSD.
The most prevalent areas of sexual difficulties were pain during sex/dyspareunia (72.9%),
followed by lubrication difficulties (72.3%), arousal difficulties (70.3%), desire difficulties
(69.7%) and orgasmic difficulties (54.2%). Sexual dissatisfaction was the least reported
sexual problem. These disorders have also been reported with dyspareunia being cited as the
most prevalent sexual problem (Mercer et al, 2003).
With the high prevalence rates of sexual problems recorded, one would expect more women
with sexual problems to seek medical attention. However, similar to findings of related
studies, nearly one-half of the participants with self-reported sexual problems did not seek
any kind of help for their problems (Nicolosi et al, 2004; Shifren et al, 2008). Perhaps these
women did not seek help because they thought sexual problems were normal and there was
no need worrying about their condition so long as they were able to satisfy the sexual needs
the help-seeking behaviour of women experiencing sexual problems depends on the
perceived severity of the problem.
Of the women who sought help, a high proportion (43.5%) opted for informal help (i.e. they
discussed their problems with sexual partners, friends, co-workers and family members)
whereas 22.5% sought formal help (i.e. they confided in healthcare providers such as general
practitioners, gynecologists, pharmacists, and nurses). Studies conducted by Shifren et al.
(2008) and Mercer et al. (2003) showed similar results. The most cited reasons for not
seeking formal help were the perception that FSD was normal and part of life, personal
discomfort or embarrassment and time constraints. The lack of privacy during hospital visits
and the belief that healthcare providers could not be of help were also cited by a substantial
portion of the respondents which is consistent with other studies (Gott et al, 2004; Shifren et
al 2008). There is therefore the need to educate women on the complications of FSD and the
benefits that can be obtained from seeking formal help. Women could be given some privacy
during hospital visits in order to encourage them to discuss their problems freely.
Furthermore, healthcare providers could be educated on ways of initiating healthy sexual
conversations with their female patients without making them feel uncomfortable and shy.
More than half of the participants in this study had self-managed their problems. This agrees
with the finding of the study conducted by Danquah et al (2011) in Ghana where 46% of the
respondents were reported to have used a myriad of sex enhancing agents for decreased
libido, female orgasmic disorder and vaginal tightening.
The most reported measures for self-managing FSD in this study were informal counseling
(32%), the use of vaginal lubricants (24.1%) and sex and relationship strategies (23.4%).
Prolonged foreplay, caressing, change in sexual positions and effective communications were
the most employed sex and relationship strategies by women in managing sexual problems.
Few women also employed other measures such as sex toys, mechanical aids, topical local
anesthetics, hormone replacement therapy, and herbal preparations. Comparable with other
studies, most of the users of these options (>60%) perceived them to be effective in managing
sexual problems (Pereira et al, 2013; Ramage 2006). Among the users of these options, a
user of vaginal lubricants and a user of topical (vaginal) herbal preparations, complained of
vaginal irritation and itching. Certain herb-based lubricants are known to contain extracts of
aloe and lavender, which may be responsible for the irritations or allergic reactions. The
vaginal irritations in some susceptible users has been attributed to the product osmolality
(Adriaens et al, 2008). None of the users of the other management options reported any side
or adverse effects. Thus, suggesting that these measures could be used to manage FSD with
little or no problems. Primary healthcare providers could therefore be educated on these
management options to enable them offer counseling and education to women who complain
of sexual problems.
The findings from this study are preliminary thus, leaving room for researchers to further
examine and explore other possible aspects of FSD.
CONCLUSION
Female sexual dysfunction (FSD) is prevalent in the Ghanaian society. Most women with
sexual dysfunction either do nothing about their condition or self-manage them. There is thus,
the need for public education programs to educate women on the causes and effects of FSD
as well as the options available for treating sexual problems. Healthcare providers could also
be trained on how to assess, diagnose and manage FSD appropriately. Additionally, health
providers such as pharmacists (particularly community pharmacists), doctors and nurses
could include education on FSD to their routine management of women in order to improve
female sexual health in general.
ACKNOWLEDGEMENTS
The authors wish to thank all the women who participated in this study and the school
authorities at School of Pharmacy, University of Ghana, Legon.
REFERENCES
1. Laumann, E.O, Nicolosi, A., Glasser, D.B, Paik, A., Gingell, C., Moreira, E., Wang, T.
(2005). “Sexual problems among women and men aged 40–80 y: prevalence and
correlates identified in the Global Study of Sexual Attitudes and Behaviors”. International
Journal of Impotence Research, 5: 39–57.
2. Marthol, H., Hilz, M.J. (2004). “Female Sexual Dysfunction: A Systematic Overview of
Classification, Pathophysiology, Diagnosis and Treatment”. Fortschritte der Neurol
Psychiatr, 72: 121–135.
3. Phillips, N.A. (2000). “Female sexual dysfunction: evaluation and treatment”. Am Fam
Physician, 62: 127–136, 141–142.
5. Amidu, N., Owiredu, W.K.B.A., Woode, E., Appiah, R., Quaye, L., Gyasi-Sarpong, C.K.
(2010). “Sexual dysfunction among Ghanaian men presenting with various medical
conditions”. Reprod Biol Endocrinol, 8: 118.
6. Jaafarpour, M., Khani, A., Khajavikhan, J., Suhrabi, Z. (2013). “Female sexual
dysfunction: prevalence and risk factors”. J Clin Diagn Res., 7: 2877–80.
7. Brock, G., Moreira, E.D., Glasser, D.B., Gingell, C. (2006). “Sexual disorders and
associated helpseeking behaviours in Canada”. Can J Urol, 13: 2953–2961.
8. Shifren, J.L., Monz, B.U., Russo, P.A., Segreti, A., Johannes, C.B. (2008). „Sexual
problems and distress in United States women: prevalence and correlates”. Obstet
Gynecol, 112: 970–978.
9. Naing, L., Winn, T., Rusli, B.N. (2006). “Practical Issues in Calculating the Sample Size
for Prevalence Studies”. Arch Orofac Sci., 1: 9–14.
10.Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., Ferguson, D.,
D‟ Agostino, Jr R. (2000). “The Female Sexual Function Index (FSFI): a
multidimensional self-report instrument for the assessment of female sexual function”. J
Sex Marital Ther, 26: 191–208.
11.Gott, M., Hinchliff, S., Galena, E. (2004). “General practitioner attitudes to discussing
sexual health issues with older people”. Social Science and Medicine, 2093–2103.
12.Potter, J.E. (2007). “A 60-year-old woman with sexual difficulties”. JAMA, 297:
620-633.
13.Ramage, M. (2006). “Female sexual dysfunction”. Women‟s Health Medicine, 84–88.
14.Zollman, G., Rellini, A., Desrocher, D. (2003). “The mediating effect of daily stress on
the sexual arousal function of women with a history of childhood sexual abuse”. J Sex
Marital Ther, 39: 176–92.
15.Hamilton, L.D., Meston, C.M. (2013). “Chronic stress and sexual function in women”. J
Sex Med, 10: 2443–54.
16.Mercer, C.H., Fenton, K.A., Johnson, A.M., Wellings, K., Mcdowall, W., Mcmanus, S.,
Nanchahal, K., Erens, B. (2003). “Sexual function problems and help seeking behaviour
in Britain: national probability sample survey”. BMJ, 327: 427-7.
17.Nicolosi, A., Laumann, E.O., Glasser, D.B., Moreira, E.D., Paik, A., Gingell, C. (2004).
“Sexual behavior and sexual dysfunctions after age 40: The global study of sexual
18.Danquah, C.A., Kuffuor, G.A., Anto, B.P., Nimako, K.A. (2011). “The indiscriminate use
of sex enhancing products among Ghanaians: Prevalence and potential risk”. Adv Appl
Sci Res., 2: 350–359.
19.Pereira, V.M., Arias-Carrión, O., Machado, S., Nardi, A.E., Silva, A.C. (2013). “Sex
therapy for female sexual dysfunction”. Int Arch Med, 6: 37.
20.Adriaens, E., Remon, J.P. (2008). “Mucosal irritation potential of personal lubricants
relates to product osmolality as detected by the slug mucosal irritation assay”. Sex
