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Prevalence and Sociodemographic

Predictors of Sexual Problems in
Portugal: A Population-Based Study With
Women Aged 18 to 79 Years
a a
Maria Manuela Peixoto & Pedro Nobre
a
Faculdade de Psicologia e Ciências da Educação, Universidade do
Porto, Porto, Portugal
Accepted author version posted online: 28 Oct 2013.Published
online: 23 Dec 2013.

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To cite this article: Maria Manuela Peixoto & Pedro Nobre (2015) Prevalence and Sociodemographic
Predictors of Sexual Problems in Portugal: A Population-Based Study With Women Aged 18 to 79 Years,
Journal of Sex & Marital Therapy, 41:2, 169-180, DOI: 10.1080/0092623X.2013.842195

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 JOURNAL OF SEX & MARITAL THERAPY, 41(2), 169–180, 2015
Copyright 
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ISSN: 0092-623X print / 1521-0715 online
DOI: 10.1080/0092623X.2013.842195

Prevalence and Sociodemographic Predictors of Sexual

Problems in Portugal: A Population-Based Study With
Women Aged 18 to 79 Years

Maria Manuela Peixoto and Pedro Nobre

Faculdade de Psicologia e Ciências da Educação, Universidade do Porto, Porto, Portugal
Downloaded by [Erciyes University] at 15:46 21 December 2014

Studies on epidemiology of female sexual problems consistently indicate high prevalence rates
worldwide, suggesting that this clinical presentation should be considered as a public health concern.
However, there are no published studies on prevalence of sexual problems in Portugal. The present
study investigated the prevalence, severity, and comorbidity of female sexual problems in a Portuguese
community sample. In addition, the authors assessed the role of sociodemographic predictors of
women’s sexual difficulties. The authors recruited 500 women using quota methods to resemble
the Portuguese population according to its demographic characteristics. Participants answered to the
Female Sexual Function Index and to a sociodemographic questionnaire. Findings indicated that
37.9% of the Portuguese women reported symptoms of sexual problems. Symptoms of lack of sexual
desire was the most frequent sexual difficulty with 25.4% of the women reporting low desire most
times or always, followed by symptoms of orgasmic (16.8%), sexual arousal (15.1%), and lubrication
difficulties (12.9%), dyspareunia (9.8%), and vaginismus (6.6%). Results indicated that age was a
significant predictor of female sexual problems. Results also indicated that symptoms of female
sexual problems are a significant health concern in Portugal, suggesting that public policies should
be developed to promote sexual health.

A large number of prevalence studies conducted worldwide suggest that female sexual problems
constitute a major health problem among community samples, with a significant negative effect
on both women and couples’ sexual satisfaction and well-being (Abdo, Oliveira, Moreira, &
Fittipaldi, 2004; Haavio-Mannila & Kontula, 1997; Ishak, Low, & Othman, 2010; Lau, Cheng,
Wang, & Yang, 2006; Laumann, Paik, & Rosen, 1999; Oniz, Keskinoglu, & Bezircioglu, 2007;
Ponholzer, Roehlich, Racz, Temml, & Madersbacher, 2005; Rosen & Bachmann, 2008; Shifren,
Monz, Russo, Segreti, & Johannes, 2008; Sidi, Puteh, Abdullah, & Midin, 2007; Stulhofer,
Gregurovic, Pikic, & Galic, 2005).
Epidemiological studies have suggested high prevalence rates of sexual problems for men and
women from several countries worldwide (Simons & Carey, 2001). Data indicated prevalence
rates of women’s sexual problems ranging between 26% and 49% (Abdo et al., 2004; Çayan
et al., 2004; Echeverry, Arango, Castro, & Raigosa, 2010; Fugl-Meyer & Sjogren Fugl-Meyer,
1999; Hawton, Gath, & Day, 1994; Ishak et al., 2010; Lau et al., 2006; Laumann et al., 1999;

Address correspondence to Maria Manuela Peixoto, Faculdade de Psicologia e de Ciências da Educação da Univer-
sidade do Porto, Rua Alfredo Allen 4200-135 Porto, Portugal. E-mail: nelinha.peixoto@gmail.com
 170 PEIXOTO AND NOBRE

Lindal & Stefansson, 1993; Oksuz & Malhan, 2006; Oniz et al., 2007; Safarinejad, 2006; Shifren
et al., 2008; Sidi et al., 2007; Stulhofer et al., 2005).
Lack of sexual desire is usually pointed as the most frequent sexual problem among women,
with studies indicating prevalence rates ranging from 27% to 70% (Abdo et al., 2004; Çayan
et al., 2004; Hassanin et al., 2010; Ishak et al., 2010; Oksuz & Malhan, 2006; Sidi et al.,
2007). Difficulties in reaching orgasm are also very common in the general population; recent
studies have indicated prevalence percentages ranging from 18% to 61% (Abdo et al., 2004;
Hassanin et al., 2010; Ishak et al., 2010; Lau et al., 2006; Oksuz & Malhan, 2006; Ponholzer
et al., 2005; Safarinejad, 2006; Stulhofer et al., 2005). Studies regarding the prevalence of
female sexual arousal difficulties have indicated some disparity, depending on the diagnostic
criteria used (inclusion or exclusion of subjective indicators of sexual arousal). Community
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studies have indicated prevalence rates ranging from 6% to 36% (Fugl-Meyer & Sjogren Fugl-
Meyer, 1999; Ishak et al., 2010; Laumann et al., 1999; Lindal & Stefansson, 1993; Oksuz &
Malhan, 2006; Ponholzer et al., 2005; Safarinejad, 2006). Regarding sexual pain, studies have
indicated percentages between 2% and 7% for dyspareunia (Barlow et al., 1997; Ernst et al., 1993;
Fugl-Meyer & Sjogren Fugl-Meyer, 1999; Laumann et al., 1999; Lindal & Stefansson, 1993;
Ventegodt, 1998) and prevalence not higher than 1% for vaginismus (Fugl-Meyer & Sjogren
Fugl-Meyer, 1999; Ventegodt, 1998). However, more recent studies suggested a frequency of
64% for dyspareunia (Hassanin, Helmy, Fathalla, & Shahin, 2010), and 42% for vaginismus
(Oniz et al., 2007). Moreover, these findings were found in studies conducted in community
samples from Egypt and Turkey, suggesting that sexual pain is strongly influenced by cultural
factors.
Sociodemographic characteristics, namely age and educational level, have been suggested as
risk factors for female sexual problems. Regarding age, previous studies have indicated a positive
association between aging and prevalence of sexual desire problems, arousal, lubrication, and
orgasmic difficulties On the opposite direction, a negative association with age has been founded
for sexual pain related problems in previous studies (Abdo et al., 2004; Çayan et al., 2004;
Hassanin et al., 2010; Hisasue et al., 2005; Ishak et al., 2010; Oksuz & Malhan, 2006; Parish et al.,
2007; Punholzer et al., 2005; Safarinejad, 2006; Sidi et al., 2007). Besides age, epidemiological
studies have suggested that educational level is also strongly associated with female sexual
problems. Findings have indicated that education play a protective role, with well-educated
women reporting lower levels of sexual problems (Abdo et al., 2004; Çayan et al., 2004; Echeverry
et al., 2010; Safarinejad, 2006; Shifren et al., 2008; Sidi et al., 2007). Regarding marital status,
data remains controversial. Although some studies suggested that married women report less
sexual problems (Laumann et al.,, 1999), other studies suggest the opposite (Safarinejad, 2006).
Moreover, some studies indicate no effect of marital status on the frequency of sexual problems
(Abdo et al., 2004; Echeverry et al., 2010). Overall, findings suggest a possible mediation of
social and cultural factors on the relation between marital status and sexual problems in women.
Regarding the role of relationship length on sexual problems, studies are sparse, but they suggest a
positive association, with women in older relationships reporting higher levels of sexual problems,
even after controlling for age (Hassanin et al., 2010; Ishak et al., 2010; Sidi et al., 2007; Stulhofer
et al., 2005).
Despite the frequency of epidemiological studies, there are no published data on the prevalence
of sexual problems among women from the Portuguese population. Although some research have
been conducted and published with clinical samples (Gomes, Fonseca, & Gomes, 1997; No-
bre, Pinto-Gouveia, & Allen-Gomes, 2006), the nonexistence of community studies prevents the
 PREVALENCE OF FEMALE SEXUAL PROBLEMS IN PORTUGAL 171

estimation of the real dimension of female sexual problems in Portugal. The present study is
aimed at evaluating the prevalence, severity, and comorbidity of female sexual problems in a Por-
tuguese community-based sample. Moreover, we also analyzed the effect of sociodemographics
factors such as age, educational level, marital status, and length of relationship, on female sexual
problems.

METHOD

Participants and Procedures

The present study involved 500 women from the general Portuguese population with ages between
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18 and 79 years. Women were recruited across different regions in Portugal, by a research group of
PhD students in psychology, across 2 years. Participants received an explanation about the purpose
of the study and signed an informed consent form. Participants received the questionnaires and
were instructed to answer in private and return them using sealed envelopes. Individuals were not
paid for their participation. The study was approved by an ethics committee from the University
of Trás-os-Montes e Alto Douro. Participants were selected according to quota methods in order
to better reproduce the sociodemographic characteristics of the Portuguese female population
(Spector & Carey, 1990). Data from the Portuguese National Statistics Institute1 were analyzed
for defining the distribution from the general Portuguese population, and six levels of stratification
for age were defined (18 to 24 years, 25 to 34 years, 35 to 44 years, 45 to 54 years, 55 to
64 years, and 65 to 79 years), three levels of marital status (single, married/living together, and
divorced/widowed) and three levels of stratification for educational level (0 to 9 years, 10 to
12 years, and 13 or more years of education). For length of relationship, three groups were
created (0 to 10 years, 10 to 20 years, and 20 or more years of relationship duration). Therefore,
women were selected in order to complete the defined quotas. Demographic characteristics of the
sample are shown in Table 1.

Data Processing and Analysis

Prevalence was estimated for each sexual problem, namely, lack of sexual desire, arousal, lubri-
cation, and orgasmic difficulties, dyspareunia, and vaginismus. Responses to reference questions
from the Female Sexual Function Index (FSFI; Rosen et al., 2000) were used to estimate female
sexual difficulties, however those questions do not specify any clinical diagnosis. Lack of sexual
desire (Item 1):”How often did you feel sexual desire or interest?”; sexual arousal difficulties
(Item 3): “How often did you feel sexually aroused (“turned on”) during sexual activity or inter-
course?”; lubrication difficulties (Item 7):”How often did you become lubricated (“wet”) during
sexual activity or intercourse?”; orgasmic difficulties (Item 11): “When you had sexual stimu-
lation or intercourse, how often did you reach orgasm (climax)?”; and dyspareunia (Item 17):
“How often did you experience discomfort or pain during vaginal penetration?” Last, vaginismus

1According to the National Institute of Statistics, the distribution of women according to age was as follows: 18 to

24 years: 10.5%; 25 to 34 years: 20.9%; 35 to 44 years: 20.2%; 45 to 54 years: 18.2%; 55 to 64 years: 15.2%; 65 to
79 years: 15%. In addition, 58% of women had 0 to 9 years of education; 20% had 10 to 12 years of education, and 22%
had 13 or more years of education.
 172 PEIXOTO AND NOBRE

TABLE 1
Sociodemographic Characteristics of the Sample (N = 500)

n M (SD)

Age (years)
Total 500 44.3 (15.3)
18–24 53 21 (2.0)
25–34 104 29.5 (3.0)
35–44 101 39.7 (2.8)
45–54 91 49.1 (2.8)
55–64 79 58.5 (4.5)
>65 72 67.8 (3.3)
n %
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Marital status
Single 90 18.0
Married/living together 349 69.8
Divorced/widowed 39 7.8
Missing 22 4.4
Educational level (years)
0–9 280 56.0
10–12 93 18.6
13 or more 106 21.2
Missing 21 4.2
Length of the relationship (years)
0–10 172 34.4
10–20 85 17.0
20 or more 154 30.8
Missing 89 17.8

was measured by a specific question added to the original FSFI: “How often did you feel vaginal
muscle contractions that difficult or prevented penetration during sexual activity?” Response to
Items 1, 3, 7, and 11 of the FSFI (Rosen et al., 2000) were inversely scored.
For severity purposes, women who reported experiencing sexual difficulties in most of the
times (more than half of the times) and almost always/always were considered to have moderate
to severe sexual difficulties, while those who reported sexual difficulties about half of the times
were considered to have borderline (transitory) difficulties. Frequency analyzes were conducted
in order to assess prevalence, severity, and comorbidity of sexual problems in women, and 95%
confidence intervals were estimated. However, distress levels and duration criterion were not
assessed, preventing inferences regarding clinical diagnosis of female sexual problems. Logistic
regression analyzes were performed to test the predictor role of sociodemographic characteristics,
namely age, educational level, marital status, and length of the relationship.

Main Outcome Measures

Demographics Questionnaire

Participants answered to a brief sociodemographic questionnaire assessing age, level of edu-

cation, marital status, and length of the relationship.
 PREVALENCE OF FEMALE SEXUAL PROBLEMS IN PORTUGAL 173

FSFI

The FSFI (Rosen et al., 2000) is a 19-item instrument, easily administered and scored, providing
detailed information on the major dimensions of sexual functioning. A principal component
analysis identified six factors: sexual interest/desire, sexual arousal, lubrication, orgasm, sexual
satisfaction, and sexual pain. The measure presents acceptable test–retest reliability (r = .79 to r =
.86), internal consistency (Cronbach’s alpha values of .82 and higher), and validity (demonstrated
by significant mean difference scores between a clinical and a control group; Rosen et al., 2000).
The measure allows the calculation of specific indexes for each dimension as well a sexual
function index (calculated through the sum of the specific dimensional indexes), with higher
scores indicating greater levels of sexual functioning (desire: 1.2–6, arousal: 0–6, lubrication:
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0–6, orgasm: 0–6, global satisfaction: 0.8–6, pain: 0–6, total: 2–36). One item was added to the
measure in order to specifically assess the frequency of vaginismus. On the basis of the answers
to this item, an index of vaginismus was calculated with scores ranging from 0 to 6 (higher scores
indicating lower levels of vaginismus). The Portuguese version also presented good psychometric
properties, with high internal consistency (Cronbach’s alpha values were between .88 and .93),
as well as convergent and discriminant validity (Pechorro, Diniz, Almeida, & Vieira, 2009).
Items 1, 3, 7, 11, and 17 from FSFI (Rosen et al., 2000) were used to analyze female
sexual problems, namely lack of sexual desire, arousal, lubrication and orgasm difficulties, and
dyspareunia, respectively. Vaginismus was assessed using a specific question added (“How often
did you feel vaginal muscle contractions that difficult or prevented penetration during sexual
activity?”).

RESULTS

PREVALENCE AND SEVERITY OF SEXUAL PROBLEMS IN WOMEN

A significant percentage of sexually active women reported complaint in different areas of sexual
functioning (see Table 2). A total of 175 women (37.9%) scored below the FSFI cutoff score of
26.5 proposed by Wiegel, Meston, and Rosen (2005) suggesting the presence of sexual problems.
Lack of sexual desire was the most common sexual difficulty, with 25.4% of the women (95%
CI [21.6, 29.2]) reporting lack of interest in involving themselves in sexual activity most times
or almost always/always (75% or more of the occasions). In addition, 29.2% of the women
(95% CI [25.2, 33.2]) reported lack of sexual desire in about half of the times (50%). Orgasmic
difficulties were the second most common sexual problem, with 16.8% of the women (95%
CI [13.5, 20.1]) reporting difficulties in reaching orgasm most times or almost always/always
(75% or more). Moreover, 19.4% of the women (95% CI [16.0, 22.9]) experienced difficulties in
reaching orgasm in about half of the times (50%). Sexual arousal difficulties showed a similar
pattern to orgasmic difficulties with 15.1% (95% CI [12.0, 18.2]) of women reporting having
problems feeling sexually aroused most times or almost always/always (at least 75%) and 19.5%
(95% CI [16.0, 23.0]) in about half of the times (50%). Lubrication difficulties were reported
by 12.9% of the women (95% CI [10.0, 15.8]), as a moderate to severe problem (most times to
always: 75% or more), while, additional 17.2% (95% CI [13.9, 20.5]) reported having troubles
lubricating in about half of the times (50%). Regarding dyspareunia, 9.8% of the women (95%
 174 PEIXOTO AND NOBRE

TABLE 2
Frequency of Female Sexual Problems

Almost More About Less Almost No

always/ than half half the than half never/ sexual
always the time time the time never Total activityc Totalc
Sexual problems n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Lack sexual desirea 50 (10.0) 77 (15.4) 146 (29.2) 111 (22.2) 116 (23.2) 500 (100) Not apply Not apply
Sexual arousal difficultiesa 23 (4.8) 49 (10.3) 93 (19.5) 128 (26.8) 184 (38.6) 477 (100) 23 (4.6) 500 (100)
Lubrication difficultiesa 20 (4.3) 40 (8.6) 80 (17.2) 117 (25.1) 209 (44.8) 466 (100) 34 (6.8) 500 (100)
Orgasmic difficultiesa 30 (6.5) 48 (10.3) 90 (19.4) 117 (25.2) 180 (38.7) 465 (100) 35 (7.0) 500 (100)
Dyspareunia 13 (2.8) 33 (7.0) 88 (18.7) 143 (30.4) 193 (41.1) 470 (100) 30 (6.0) 500 (100)
Vaginismusb 13 (2.8) 18 (3.8) 63 (13.5) 108 (23.1) 266 (56.8) 468 (100) 32 (6.4) 500 (100)
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Note. Participants who indicated not having sexual activity in the 4 weeks before the completion of the questionnaire
were excluded from the analysis (except for desire difficulties).
aAnswers to Items 1, 3, 7, and 11 of the Female Sexual Function Index (scored in reverse order).
bAnswer to an additional item assessing the frequency of vaginismus.
cNumber and frequency of women when participants that indicated not having sexual activity in the 4 weeks before

the completion of the questionnaire were included.

CI [7.2, 12.4]) in the sample reported discomfort or pain during vaginal penetration most times
or almost always/always (75% or more), whereas 18.7% (95% CI [15.3, 22.1]) indicated having
this problem in about half of the times (50%). Last, vaginismus was reported by 6.6% of the
sample (95% CI [4.4, 8.8]) has occurring in most sexual occasions or almost always/always
(75% or more), while additional 13.5% of the women (95% CI [10.5, 16.5]) indicated having this
complain in about half of the sexual episodes (50%) involving penile-vaginal penetration.
In addition, 4.6% (23 women) reported having no sexual activity and 7.6% (35 women)
reported no attempt to have penile-vaginal penetration, over the past 4 weeks. Although women
who reported no sexual activity on the prior 4 weeks were included in the study, they were
excluded from the analysis regarding the prevalence of sexual problems.

Comorbidity Among Sexual Difficulties

Findings indicated moderate to high rates of comorbidity among sexual problems (see Table 3).
Lack of sexual desire was the most frequent additional complaint reported by women in the
sample and was found in 81.3% of women with sexual arousal difficulties, 71.9% of women
with lubrication problems, 61.3% of women with orgasmic complaint, 48.2% of women with
vaginismus, and 45.4% of women with sexual pain. Sexual arousal difficulties were reported as
an additional problem by 71.9% of women with lubrication difficulties, 57.3% of women with
orgasmic complains, and 49.5% of women with lack of sexual desire. Lubrication difficulties were
founded as an additional complaint in 69.5% of women with sexual arousal difficulties, 56% of
women with orgasmic difficulties, and 42.3% of women with lack of sexual desire. Additional
orgasmic complains were present in 73.7% and 72.8% of the women with lubrication and sexual
arousal difficulties, respectively; and in 47.4% of women with lack of sexual desire. Dyspareunia
as an additional complaint was found in 72.4% of women with vaginismus. Last, 47.7% of the
women with dyspareunia also reported vaginismus as an additional sexual problem.
 PREVALENCE OF FEMALE SEXUAL PROBLEMS IN PORTUGAL 175

TABLE 3
Comorbidity of Female Sexual Problems

Secondary sexual problema

Lack sexual Sexual arousal Lubrication Orgasmic
desire difficulties difficulties difficulties Dyspareunia Vaginismus
Principal sexual problema % % % % % %

Lack sexual desireab — 49.5 42.3 47.4 20.6 14.4

Sexual arousal difficultiesab 81.3 — 69.5 72.8 27.1 13.6
Lubrication difficultiesab 71.9 71.9 — 73.7 19.3 12.2
Orgasmic difficulties ab 61.3 57.3 56.0 — 21.3 14.7
Dyspareuniaa 45.4 36.3 25 36.3 — 47.7
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Vaginismusac 48.2 27.5 24.1 37.9 72.4 —

Note. Subjects that indicated not having sexual activity in the 4 weeks before the completion of the questionnaire
were excluded from the analysis.
aAnswers for lack of sexual desire, sexual arousal difficulties, lubrication difficulties and orgasmic difficulties,

dyspareunia, and vaginismus scored 75% of the times or more.

bAnswers to Items 1, 3, 7, and 11 of the Female Sexual Function Index (scored in reverse order).
cAnswer to an additional item assessing the frequency of vaginismus.

Sociodemographic Predictors of Sexual Problems

To explore the effect of sociodemographic factors on female sexual difficulties, we performed

a binary logistic regression. The model included four demographic dimensions as independent
variables—categorical variables (age, educational level, marital status, and length of relationship)
and each category of sexual difficulties (lack of sexual desire, arousal difficulties, lubrication dif-
ficulties, orgasmic difficulties, dyspareunia and vaginismus), as well as global sexual difficulties
(assessed by the FSFI cutoff; Wiegel et al., 2005) were used as dependent variables. As shown
in Table 4, controlling for all other sociodemographic variables, age was the strongest sociode-
mographic predictor of global sexual problems with older women: 45 to 54 years of age (OR =
7.18, 95 CI [1.8, 29.2]), 55 to 64 years of age (OR = 12.1, 95 CI [2.7, 54.3]), and older than
65 years (OR = 25.1, 95 CI [4.6, 135.7]) reporting more probability of presenting overall sexual
difficulties, compared with women 18 to 24 years of age. Lack of sexual desire was significantly
more likely to be reported by women 55 to 64 years of age (OR = 6.25, 95 CI [1.04, 37.6]) and
older than 65 years (OR = 8.79, 95 CI [1.36, 56.7]), when compared with women 18 to 24 years
old. Moreover, women older than 65 years of age were eight times more likely to report orgasmic
difficulties (OR = 8.0, 95 CI [1.2, 53.7]) than were women aged 18 to 24 years.
Regarding educational level, women with 10 to 12 years of education (OR = 0.4, 95 CI [0.2,
0.79]) and with 13 or more years of education (OR = 0.51, 95 CI [0.26, 0.99]) had significantly
lower probability of presenting overall sexual difficulties compared with less educated women (0
to 9 years of education). For length of the relationship, women involved in relationships for 10
to 20 years (OR = 0.24, 95 CI [0.07, 0.87]) and for more than 20 years (OR = .29, 95 CI [0.1,
0.84]) had significantly lower probability of reporting lubrication problems, when compared with
women in relationships for less than 10 years. length. For arousal difficulties, dyspareunia, and
vaginismus no significant predictors were found regarding sociodemographic predictors.
 Downloaded by [Erciyes University] at 15:46 21 December 2014

176
TABLE 4
Statistics for Binary Logistic Regression With Different Dependent Variables and Sociodemographic Characteristics as Categorical Variables

Lack of sexual Sexual arousal Lubrication Orgasmic Sexual

desireab difficultiesab difficultiesab difficultiesab Dyspareuniaa Vaginismusac difficultiesd
(n = 410) (n = 400) (n = 394) (n = 394) (n = 397) (n = 396) (n = 393)
Variable OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p
Age (years) 18–24 Reference Reference Reference Reference Reference Reference Reference
25–34 1.51 (0.33–6.93) ns 0.68 (0.13–3.44) ns 0.51 (0.08–3.22) ns 1.07 (0.25–4.5) ns 0.27 (0.02–3.24) ns 0.69 (0.03–14.8) ns 2.85 (0.88–9.24) ns
35–44 0.86 (0.15–4.93) ns 0.18 (0.02–1.70) ns 0.21 (0.02–2.23) ns 0.93 (0.16–5.32) ns 0.17 (0.01–2.50) ns 0.37 (0.01–10.1) ns 3.36 (0.86–13.12) ns
45–54 2.91 (0.51–16.52) ns 1.81 (0.25–13.10) ns 2.15 (0.23–20.56) ns 1.7 (0.29–9.96) ns 0.42 (0.03–6.17) ns 0.67 (0.02–18.30) ns 7.18 (1.80–29.20) ∗ ∗
55–64 6.25 (1.04–37.60) ∗ 2.44 (0.30–19.62) ns 4.23 (0.39–45.70) ns 2.31 (0.35–15.4) ns 0.66 (0.04–10.52) ns 1.1 (0.04–31.80) ns 12.1 (2.70–54.30) ∗ ∗ ∗
∗
>65 8.79 (1.36–56.70) ∗ 3.1 (0.36–25.90) ns 9.3 (0.82–105.50) ns 8.0 (1.20–53.70) 0.65 (0.04–11.30) ns 0.86 (0.03–26.84) ns 25.1 (4.60–135.7) ∗ ∗ ∗
Educational level (years) 0–9
∗∗
10–12 0.92 (0.44–1.96) ns 0.49 (0.16–1.48) ns 0.34 (0.09–1.35) ns 0.34 (0.11–1.07) ns 1.29 (0.49–3.39) ns 0.42 (0.10–1.70) ns 0.4 (0.20–0.79)
∗
13 or more 0.6 (0.27–1.35) ns 0.71 (0.27–1.88) ns 0.7 (0.24–2.10) ns 1.08 (0.47–2.50) ns 0.46 (0.12–1.74) ns 0.00 (0.00–0.00) ns 0.51 (0.26–0.99)
Marital status single
Married/living together 2.33 (0.67–8.11) ns 1.79 (0.42–7.70) ns 3.94 (0.76–20.39) ns 1.04 (0.31–3.41) ns 5.86 (0.61–56.80) ns 1.16 (0.14–9.83) ns 0.74 (0.3–1.81) ns
Divorced/widowed 1.22 (0.24–6.15) ns 0.46 (0.05–4.20) ns 0.41 (0.03–50.40) ns 0.69 (0.11–4.25) ns 1.75 (0.07–41.70) ns 0.78 (0.04–16.01) ns 0.3 (0.08–1.17) ns
Length of relationship (years) 0–10
∗
10–20 0.71 (0.31–1.60) ns 0.45 (0.14–1.50) ns 0.24 (0.07–0.87) 0.67 (0.28–1.61) ns 1.13 (0.37–3.41) ns 2.33 (0.64–8.50) ns 0.62 (0.32–1.20) ns
∗
20 or more 1.17 (0.54–2.60) ns 1.04 (0.39–2.80) ns 0.29 (0.10–0.84) 0.45 (0.18–1.15) ns 1.66 (0.54–5.10) ns 1.5 (0.36–6.22) ns 0.8 (0.40–1.60) ns

Note. Subjects that indicated not having sexual activity in the 4 weeks before the completion of the questionnaire were excluded from the analysis.
∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.
aLack of sexual desire, sexual arousal difficulties, lubrication difficulties, orgasmic difficulties, dyspareunia, and vaginismus scored 75% of the times or more.
bAnswers to Items 1, 3, 7, and 11 of the Female Sexual Function Index (scored in reverse order).
cAnswer to an additional item assessing the frequency of vaginismus.
dSexual difficulties were assessed according to Female Sexual Function Index cutoff (<26.5).
 PREVALENCE OF FEMALE SEXUAL PROBLEMS IN PORTUGAL 177

DISCUSSION

The present study was aimed at evaluating the prevalence, severity, and comorbidity of female
sexual problems in a Portuguese community sample. Overall, findings suggested that sexual
problems were a significant concern among Portuguese women, with over a third (37.9%) of
the Portuguese women reporting symptoms of sexual problems. In view of the fact that distress
levels were not evaluated, female sexual problems reported could be overestimated. Current data
was consistent with previous findings about prevalence rates of women’s sexual problems (Abdo
et al., 2004; Çayan et al., 2004; Echeverry et al., 2010; Fugl-Meyer & Sjogren Fugl-Meyer,
1999; Hawton et al., 1994; Ishak et al., 2010; Lau et al., 2006; Lindal & Stefansson, 1993;
Oksuz & Malhan, 2006; Oniz et al., 2007; Shifren et al., 2008; Sidi et al., 2007; Stulhofer et al.,
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2005).
In the present study, 23 (4.6%) and 35 (7%) of the women reported not having had sexual
activity and/or sexual intercourse during the past four weeks, respectively. This result could be
due to a low pattern of sexual activity frequency or due to avoiding sexual contact because of
sexual problems experienced previously. Although the methodology used does not allow inferring
or assigning a clinical diagnosis of sexual problems, or its etiology, it provides a global overview
of sexual functioning in a community based sample of Portuguese women. A wide range of
difficulties were assessed, namely symptoms of lack of sexual desire, arousal, orgasmic and
lubrication difficulties, dyspareunia, and vaginismus. Our findings were consistent with previous
research, suggesting symptoms of lack of sexual desire as the most frequent complaint in women
from our community sample (Çayan et al., 2004; Ernst, Foldenyi, & Angst, 1993; Fugl-Meyer
& Sjogren Fugl-Meyer, 1999; Hassanin et al., 2010; Hawton et al., 1994; Ishak et al., 2010;
Laumann et al., 1999; Lindal & Stefansson, 1993; Oksuz & Malhan, 2006; Ventegodt, 1998; Sidi
et al., 2007). The present findings could be explained by parenting educational styles, common
across Latin and mainly Catholic countries, which influenced sexual beliefs, namely the belief
that women should not show sexual interest (Nobre & Pinto-Gouveia, 2006). Implications for
intervention should be addressed, namely an investment on sexual education policies.
Results on the association among sexual problems suggested that symptoms of lack of sexual
desire was the most frequent additional complain in women presenting other sexual problems.
This was particularly evident for women with sexual arousal problems which also indicated low
sexual desire in 81% of the cases. This strong association between low desire and arousal problems
is in line with comorbidity studies and recent findings suggesting that desire and arousal share
common latent factors (Carvalho, Vieira, & Nobre, 2012). Moreover, this finding gives some
support for the new diagnostic criteria for sexual problems in the DSM-5, which merged sexual
desire/interest and sexual arousal disorders into one diagnostic category (Brotto, 2010; Graham,
2010).
Overall, the range of comorbidities was moderate to high among symptoms of lack of sexual
desire, arousal, lubrication, and orgasmic difficulties, suggesting a global pattern of overlapping
within female sexual problems consistent with previous findings (Lauman et al., 1999; Nobre et al.,
2006; Simons & Carey, 2001; Wiegel et al., 2005). Symptoms of dyspareunia and vaginismus
were strongly related to each other but relatively independent from other sexual difficulties, except
low desire. This finding is also congruent with data suggesting that dyspareunia and vaginismus
share common latent factors (Carvalho et al., 2012) and with the new DSM-5 that merged the two
clinical entities (Binik, 2010a, 2010b).
 178 PEIXOTO AND NOBRE

Regarding sociodemographic predictors of female sexual problems, binary logistic regression

analyzes showed that age was the strongest predictor of sexual problems, namely symptoms of
lack of sexual desire, orgasmic disorder, and global sexual functioning even when controlling for
all other sociodemographic variables. The global pattern suggest that sexual problems increase
with age, particularly in women older than 55 years of age, which is consistent with the literature
(Abdo et al., 2004; Çayan et al., 2004; Hassanin et al., 2010; Hisasue et al., 2005; Ishak et al.,
2010; Oksuz, & Malhan, 2006; Parish et al., 2007; Ponholzer et al., 2005; Safarinejad, 2006;
Sidi et al., 2007). However this pattern is not common to all sexual problems. The prevalence of
vaginismus and dyspareunia seems to be relatively independent from age (with younger women
presenting relatively higher rates compared with older women). This finding is consistent with
Lauman and colleagues (1999) study that indicated a trend for pain disorders to decrease with age.
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Moreover, according to a recent study (Hayes et al., 2008), level of sexual distress experienced
may have a stronger effect on female sexual difficulties, even when compared with age.
Regarding the role of education, our findings indicated a positive effect on sexual functioning.
Women with lower educational levels reported significantly more overall sexual problems in line
with previous findings (Abdo et al., 2004; Çayan et al., 2004; Echeverry et al., 2010; Safarinejad,
2006; Shifren et al., 2008; Sidi et al., 2007). One possible explanation for this result may be
related to the lower accessibility of less educated women to relevant information regarding
anatomy and physiology of female sexual response, as well as to higher levels of inadequate
sexual beliefs (Nobre, 2009; Nobre & Pinto-Gouveia, 2006; 2008a, 2008b). Marital status was
the only sociodemographic predictor that did not present a significant effect on female sexual
difficulties, which was consistent with some previous studies (Abdo et al., 2004; Echeverry et al.,
2010). The present finding suggested that, independent from marital status, women reported
similar sexual problems. For length of the relationship, findings indicated that women in longer
relationships reported fewer problems regarding lubrication. This finding suggests that women
in longer relationships may be more able to respond physiologically to sexual stimulation from
the partners, regardless of their age.
The present study presents some limitations that should be acknowledged. Although the sample
was constituted to represent the sociodemographic characteristics of the Portuguese population,
we used a nonrandom method. For that reason, sampling biases should be considered. The
FSFI (Rosen et al., 2000) is a self-reported measure that aims to assess female sexual function.
For the estimate of prevalence rates, specific questions from the FSFI (Rosen et al., 2000) were
selected, and consequently personal distress and interpersonal interference were not evaluated, and
temporal criteria was based only on reported complains during the previous 4 weeks. Therefore,
clinical diagnosis cannot be inferred. Moreover, the assessment of sexual difficulties was based
on self-reported problems, which could add self-bias related to dysfunctional sexual beliefs about
sexual performance (Nobre & Pinto-Gouveia, 2006).
Regardless of the referred limitations, the present study reveals that a significant percentage
of Portuguese women experience sexual difficulties, suggesting that this should be considered as
a public health concern. Although no information about personal distress was collected, negative
consequences in women’s lifestyle related to sexual difficulties are well-known. The overlapping
between desire, sexual arousal, lubrication, and orgasmic problems suggests that mechanisms
related to female sexual response are complex and may have common etiological factors inter-
acting. Overall, aging was associated to higher difficulties related to sexual functioning, whereas
education was associated to less global sexual problems. Important clinical implications should be
addressed and self-perceived sexual problems should be noticed. Moreover, this study represents
 PREVALENCE OF FEMALE SEXUAL PROBLEMS IN PORTUGAL 179

a preliminary assessment of female sexual problems in a Portuguese community sample. Further

investigation using clinical interviews and including the new DSM-5 criteria (symptoms, severity
criteria, distress, and duration criteria) should be conducted to further explore the prevalence of
female sexual problems as well as other psychosocial and medical predictors.

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