Sex Disabil (2010) 28:275–285

DOI 10.1007/s11195-010-9161-9

ORIGINAL PAPER

The Effect of Family Planning Methods Used by Women

of Reproductive Age on Their Sexual Life

Ebru Gabalci • Fusun Terzioglu

Published online: 6 April 2010

 Springer Science+Business Media, LLC 2010

Abstract The family planning (FP) methods used by women of reproductive age can
have negative or positive influences on the sex lives of couples. Couples should be aware
of the effects of the FP method they use on their sex lives to be able to improve the quality.
This descriptive study was carried out to determine the effects of contraceptive methods on
the sex lives of women. The study was conducted at the Family Planning Center and
Gynecology Clinics of an Obstetrics and Gynecology and Children’s Hospital. The sam-
pling comprised of 366 women who had applied to these centers. Data collection forms
generated based on the literature and the Arizona Sexual Experience Scale (ASEX) were
used as data collection tools. The average ASEX scores were similar for women using the
withdrawal method as a traditional method (:13.75), RIA as a modern method (:13.93),
condoms (:13.30), and oral contraceptives (:13.37), were found to be similar (p [ 0.05).
Since the average scores of ASEX were higher than 11, problems in sexual life were
determined at high levels. The difference between ASEX average scores and duration of
family planning, problems due to the method, duration of marriage, number of pregnancies
and living infants, frequency of sexual intercourse, communication between partners, and
self-declared sexual perception; was statistically significant (p \ 0.05). The study found
higher than normal average ASEX scores and we therefore suggest counseling services,
provided by healthcare staff, on sexual health and family planning that include information
on FP methods and their effects on sex life.

Keywords Family planning
Sexuality
Effect of family

planning methods on the sex life
Turkey

E. Gabalci (&)
F. Terzioglu

Department of Obstetric and Gynecology Nursing, Faculty of Health Sciences,
Institute of Health Sciences, Hacettepe University, Sihhiye, Ankara, Turkey
e-mail: egabalci@hacettepe.edu.tr
F. Terzioglu
e-mail: fusun@hacettepe.edu.tr

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276 Sex Disabil (2010) 28:275–285

Introduction

Women’s health has recently become a topic of importance throughout the world as it is an
important determinant of both child and family health. Family health depends on the
fulfillment of physical, psychological and social needs of family members, their partici-
pation in social life and fulfillment of their individual roles and responsibilities [1].
An important factor determining the happiness and stability of the smallest unit of a
society, the family, is a healthy sexual life in couples. A healthy sexual life depends
primarily on maintenance of a regular relationship between an individual’s private and
social life and his/her reproductive activity and sexuality, absence of fears and wrong
beliefs that can affect one’s sexual life and avoidance of organic disorders, dysfunctions
and inadequacies that can have an impact on the sexual life and reproductive functions
[2, 3].
In this respect, sexuality between couples can be affected by their psychosocial
development, the community’s system of values, gender-specific roles and expectations.
When women do not have the right to control their own sexual functions, sexuality
becomes a duty rather than being a basic need and a source of happiness. Family planning
methods that are used for the purpose of controlling reproductive functions enable couples
to live their sexuality freely [2, 4].
The decision about the choice of the family planning method can be influenced by the
individual’s personality and his/her understandings and behavior regarding sexuality [5].
The factors affecting couples’ use of modern or traditional family planning methods are the
dependability of the method, its side-effects, reusability, hormonal content, preference of
the spouse, extent of knowledge about the method, the female’s health [6–8] and her
beliefs [9]. In addition, the choice of the method can depend on its effects on the sexual life
of the couple. In the literature, it is frequently emphasized that matters on sexuality and
family planning can’t be independent of each other and the effect of the intended or
used family planning method on individuals’ sexual life, should not be underestimated
[6–8, 10].
The family planning method used can have certain positive or negative effects on the
sexual life of couples. While couples are in the process of deciding on which method to
choose, the nurse should also consider the impact of the method on the sexual life of the
couple as a part of his/her responsibilities as a consultant transferring knowledge and
information on sexuality and family planning matters [11]. Nurses, as public health
members, can help improve the quality of a couples’ sexual life by guiding the couple to
choose the best-suited family planning method and its correct use.

Purpose of the Study

The aim of this study was to evaluate the effect of family planning methods (those that
would enable the continuation of a safe and happy sexual life and permit freedom of choice
of reproducing) on the sexual lives of women of reproductive age.

Individuals and Method

The study was conducted in the Family Planning Center and Gynecology Outpatients of
Obstetrics and Gynecology and Children’s Hospital in Ordu/Turkey was selected as the
study site, the sample size consisted of 366 women who attended this center, were made

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between November and December, 2007. Since the study aimed to evaluate the effect of
our country’s four most widely used family planning methods [withdrawal, intrauterine
device (IUD), condoms and oral contraceptive] on the sexual lives of women, inclusion of
equal numbers of individuals for each method used was intended. In brief, a total of 366
individuals (92, 92, 92 and 90 that used condoms, IUD, withdrawal and oral contracep-
tives, respectively) were selected by a simple random sampling method. Face to face
interviewing and filling in the data collection form took approximately 10 and 15 min per
women.
Individuals that fulfilled the following Sample Selection Criteria were included in the
study:
1. Between the ages of 15 and 49,
2. Sexually active,
3. At least primary school graduate,
4. No psychiatric problems,
5. Not in menopause,
6. Used at least one family planning method (withdrawal, IUD, condom and oral
contraceptive) in the last 6 months
Data was collected using a Descriptive Data Form and the Arizona Sexual Experience
Scale. The Data Collection Form was composed of various sections: the first section
included socio-demographic characteristics (age, education level, education level of the
spouse, employment, social security, etc.), the second section included characteristics
related to sexual life (frequency of sexual intercourse, communication between spouses,
emotional closeness, sexual perceptions about self, etc.), and the third section was com-
posed of questions related to the family planning method used and its effects on sexual life
(the FP method used, problems related to the method used, problems encountered, the
impact of the method on sexual life, etc.).
The Arizona Sexual Experience Scale was developed to scan and identify problems
encountered in the sexual lives of the individuals in a brief and simple way. Although it
was initially used for the identification of sexual problems in patients with depression, it
was later also applied to various disease groups and to healthy individuals for scanning
purposes. The scale, comprised of 5 questions, is a Likert type self-evaluation scale with
male or female-specific tests. The female-specific test contains questions on sexual arousal,
psychological stimulation, physiological stimulation (vaginal lubrication), capacity to
reach orgasm and satisfaction following an orgasm, in this order. These questions fulfill the
current DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) and ICD-10
(International Classification of Disease) sexual dysfunction diagnosis criteria. Upon
grading of each question from 1 to 6, a total score ranging from 5 to 30 is obtained. Low
scores indicate a strong sexual response that is satisfactory, while high scores signify
sexual dysfunction [12]. The validity and dependability of the Turkish version of this test,
which was originally developed by Mc Gauhey CA, was tested in 2004 by Soykan and a
cut-off point of ‘‘11’’ was determined to be a good indicator of sexual dysfunction that
provides scale validity [13].

Ethical Consideration

For this study official and ethical approval from the relevant institutions were obtained
(date 31.10.2007, Tracking No: B 104 ISM 452 0015/2522). The participants were

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informed about the aim and method of the study, their written consents were obtained, and
that they have the right to withdraw at any point of the study.

Study Limitations

This study has a number of limitations. First, the study included women using modern
(IUD, contraceptives and condom) and traditional (withdrawal) FP methods. The other
methods were not considered in this study. Second, the spouses of the women included in
the study were not evaluated by the male form of the sexual life scale and hence the results
of this study contain only female-related statements. Therefore, generalization of the
results is limited.

Data Analysis

The results were analyzed using the Statistical Package for Social Sciences (SPSS) for
Windows 11.5 software.
The dependent variable of the study was the level of influence in the sexual lives of the
women. The independent variables were the age, level of education, level of education of
the spouse, employment, presence or absence of social security, income level, family
structure, number of pregnancies, number of births and the family planning method used.
Percentage calculation, Pearson chi square, analysis of variance and test for significance
of difference between standard error of means were used for data analysis.
The following criteria were used for data evaluation using the Arizona Sexual Expe-
rience Scale [13]:
• 11 and above; Probability of identification of sexual problems, 52%,
• 11 and below; Probability of identification of sexual problems is quite low.

Findings

Table 1 presents the Arizona Sexual Experience Scale (ASEX) score averages of women
according to their FP methods. The table shows that the ASEX scores of all women were
above 11 (x: 13.59), indicating a high possibility for the identification of problems in their
sexual lives. The ASEX score average of women using IUD ( x: 13.93) were higher than the
ASEX average scores for other methods. Statistical comparison of the difference between
the methods used and ASEX score averages were insignificant (p [ 0.05).
Table 2 presents the Arizona Sexual Experience Scale (ASEX) score averages of
women according to the impact of the FP method on their sexual lives.

Table 1 The Arizona Sexual

Method ASEX score Statistical analysis
Experience Scale (ASEX) score
averages x ± SD
averages of women according to
their FP methods
Withdrawal 13.75 ± 3.87 F: 0.547; p: 0.651
Intrauterine device 13.93 ± 3.94
Condom 13.30 ± 3.54
Oral contraceptive 13.37 ± 4.18
General average 13.59 ± 3.88

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Among women using the withdrawal method, ASEX score averages of women
reporting a negative effect on sexual satisfaction ( x: 14.80), sexual desire (
x: 14.63) and
frequency of sexual intercourse ( x: 14.86) were higher than those reporting no negative
effects on sexual satisfaction (
x: 12.64), sexual desire (
x: 13, 62) and frequency of sexual
intercourse (
x: 13, 53). Statistically, only the difference between the effect of the with-
drawal method on sexual satisfaction and the ASEX score averages was significant
(p \ 0.05). The difference between the effect of the withdrawal method on sexual desire
and frequency of sexual intercourse and the ASEX score averages were not significant
(p [ 0.05). All women using intra uterine devices (IUD) reported that IUD use had no
negative effects on sexual satisfaction (x: 13.93), sexual desire (
x: 13.93) or frequency of
sexual intercourse (x: 13.92). Among women using the condom method, ASEX score
averages of women reporting a negative effect on sexual satisfaction ( x: 14.66), sexual
desire (
x: 13.25) and frequency of sexual intercourse ( x: 13.62) were higher than those
reporting no negative effects on their sex lives, however, the difference was not significant
(p [ 0.05). Among women using the oral contraceptive method, ASEX score averages of
women reporting a negative effect on sexual desire ( x: 16.42) and frequency of sexual
intercourse (
x: 15.58) were higher than those reporting no negative effects on their sex
lives. This difference was statistically significant (p \ 0.05), whereas the difference
between the effect on sexual satisfaction and the ASEX score averages was not (p [ 0.05).

Table 2 The Arizona Sexual Experience Scale (ASEX) score averages of women according to the impact
of the FP method on their sexual lives n: 366
The impact of the method ASEX score averages
on sexual life
Sexual satisfaction Sexual desire Sexual intercourse
x ± SD x ± SD frequency x ± SD

Withdrawal
Positive effect – – –
Negative effect 14.80 ± 3.65 14.63 ± 3.85 14.86 ± 4.37
No effect 12.64 ± 3.82 13.62 ± 3.88 13.53 ± 3.76
Statistical analysis F: 7.69 p: 0.007 F: 0.65 p: 0.422 F: 1.49 p: 0.225
IUD
Positive effect – – –
Negative effect – – –
No effect 13.93 ± 3.94 13.93 ± 3.94 13.92 ± 3.92
Condom
Positive effect 12.92 ± 2.65 – 13.50 ± 3.53
Negative effect 14.66 ± 2.94 13.25 ± 1.48 13.62 ± 1.68
No effect 13.32 ± 3.84 13.21 ± 3.76 13.26 ± 3.70
Statistical analysis F: 0.58 p: 0.559 F: 0.003 p: 0.955 F: 0.03 p: 0.962
Oral contraceptive
Positive effecta 12.50 ± 3.53 13.18 ± 4.24 10.75 ± 2.63
Negative effectb – 16.42 ± 3.45 15.58 ± 2.74
No effectc 13.39 ± 4.21 12.71 ± 4.06 13.45 ± 4.39
Statistical analysis F: 0.08 p: 0.766 F: 4.88 p: 0.010 F: 4.35 p: 0.016
Difference: b - c Difference: a - b
Bold characters are statistically significant. Superscript indicators are point to difference among variable

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The table also shows that all women using withdrawal, IUD and oral contraceptives had
ASEX score averages above normal according to the level of effect on sex life.
Table 3 presents the Arizona Sexual Experience Scale (ASEX) score averages of
women according to their socio-demographic characteristics. The ASEX score averages of
women that were 31 and above ( x: 15.43) were higher than those of other age groups and
the difference between them was significant (p \ 0.05).
According to their level of education, the ASEX score averages of primary school
graduates ( x: 14.42) were higher than the graduates of secondary school ( x: 13.77) or high
school and above ( x: 12.99). The statistical analysis of the difference between the level of
education and the ASEX score averages was significant (p \ 0.05).
According to their level of income, the ASEX score averages of women within
the ‘‘average’’ income level group ( x: 14.42) were higher than those within the ‘‘low’’
(
x: 13.76) or ‘‘high’’ ( x: 12.02) income groups and the difference between them was
statistically significant (p \ 0.05).

Table 3 The Arizona Sexual Experience Scale (ASEX) score averages of women according to their socio-
demographic characteristics n: 366
Socio-demographic characteristics N ASEX score averages x ± SD

Age
Below 20a 11 10.45 ± 2.84
Between 21 and 25b 69 11.89 ± 3.51
Between 26 and 30c 111 13.13 ± 3.44
31 and aboved 175 15.43 ± 3.85
Statistical analysis F*: 9.81 p: 0.001
Difference; between a and d, b and d and c and d
Level of education
Primarya 140 14.42 ± 3.89
Secondaryb 75 13.77 ± 3.68
High school and abovec 151 12.99 ± 3.98
Statistical analysis F*: 5.74 p: 0.001
Difference; between a and c
Income level
Gooda 85 12.35 ± 4.06
Averageb 268 13.97 ± 3.74
Lowc 13 13.76 ± 4.02
Statistical analysis F*: 5.86 p: 0.001
Difference; between a and b
Duration of marriage
5 years and belowa 109 12.03 ± 3.57
Between 6 and 10 yearsb 85 12.67 ± 3.12
11 years and abovec 172 15.03 ± 3.90
Statistical analysis F*: 26.16 p: 0.001
Difference; between a and c, b and c
* Analysis of variance
** Test for significance of difference between standard error of means
Superscript indicators are point to difference among variable

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The ASEX score averages of women married for 11 years and above ( x: 15.03) were
higher than the ASEX score averages of women that were married for 5 years and below
(
x: 12.03) or between 6 and 10 years ( x: 12.67). The statistical analysis of the difference
between the duration of marriage and the ASEX score averages, was significant (p \ 0.05).
Table 4 presents the Arizona Sexual Experience Scale (ASEX) score averages of
women according to their properties related to marriage and sex life. The ASEX score
averages of women having sex 1–2 times per week ( x: 14.58) were higher than those
having sex 3–4 times per week ( x: 13.35) or 5 times and above ( x: 9.88). The difference
between the frequency of sexual intercourse and the ASEX score averages were statisti-
cally significant (p \ 0.05).
The ASEX score averages of women describing their relationship with the spouse
as ‘‘good’’ (x: 12.60) were lower than those describing the relationship as ‘‘average’’
( x: 17.72) and the difference was statistically significant (p \ 0.05).
x: 15.04) or ‘‘bad’’ (

Table 4 The Arizona Sexual Experience Scale (ASEX) score averages of women according to their
properties related to marriage and sex life
Properties related to marriage and sexual life N ASEX score averages x ± SD

Frequency of sexual intercourse (weeks)

1–2a 147 14.58 ± 4.15
3–4b 192 13.35 ± 3.37
5 and abovec 27 9.88 ± 3.29
Statistical analysis F*: 19.16 p: 0.001
Difference; between a and b,
b and c, a and c
Communication with the spouse
Gooda 283 12.60 ± 3.63
Averageb 65 15.04 ± 3.24
Badc 18 17.72 ± 4.84
Statistical analysis F*: 18.22 p: 0.001
Difference; between a and b,
b and c, a and c
Perception of self in terms of sexuality
Attractivea 255 12.23 ± 3.30
Unwillingb 78 16.46 ± 3.48
Coldc 33 17.27 ± 2.78
Statistical analysis F*: 71.45 p: 0.001
Difference; between a and b,
a and c
Reaction of spouse upon rejection***
Positive 176 12.67 ± 3.66
Negative 112 14.51 ± 4.00
Statistical analysis t** : -4.05 p: 0.001

* Analysis of variance
** Test for significance of difference between standard error of means
*** This question was answered only by those that rejected relation when they were unwilling (n: 288)

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The ASEX score averages of women describing themselves sexually ‘‘attractive’’

(
x: 12.23) were lower than those describing themselves as ‘‘unwilling’’ (
x: 16.46) or ‘‘cold’’
x: 17.27) and the difference was statistically significant (p \ 0.05).
(
Among women that rejected relation when unwilling, the ASEX score averages of those
whose spouses reacted positively ( x: 12.67) were lower than the women whose spouses
x: 14.51) and the difference was statistically significant (p \ 0.05).
reacted negatively (

Discussion

Family planning improves family health and prosperity and through its influence on
couples’ decision in having children, contributes to the socio-economic development of the
country [1, 8].
Studies conducted reveal that the FP methods used by couples can have both positive
(oral contraceptives [14, 15] and negative effects [16–18] on their sexual lives. Contrary to
this, there are other studies where no negative effects could be determined [19, 20].
In this study, an important fraction of women whose spouses used the traditional with-
drawal method reported that the withdrawal method had no effect on sexual satisfaction
(48.9%), sexual desire (80%) or frequency of relation (83.6%). However, for the same
method, other women reported negative effects on satisfaction (51%), sexual desire (11.9%)
or frequency of sexual intercourse (16.3%). In literature, the withdrawal method was reported
to have negative effects on sexual satisfaction in couples, due to the cessation of the plateau
phase of the relation [21–23]. Our finding that the majority of women using the withdrawal
method reported no difficulties in their sex lives related to the used method is of note.
In our study, women using IUD as one of the modern FP methods reported no signif-
icant changes in their sex lives (sexual satisfaction, sexual desire and sexual intercourse).
Other studies also found no IUD-related negative effects on sexual life but complaints
about method related side effects (menorrhage, infections, pregnancy, dislocation of IUD,
etc.) were observed [21, 22]. These results suggest that IUD use is terminated by women
due to its side effects and not because of an influence on their sexual lives.
When the effect of oral contraceptives on the sex life of women was analyzed, the
majority of women reported no effect on sexual satisfaction (97.7%), sexual desire (66.6%)
or frequency of sexual intercourse (73.3%). A fraction of the women that used oral con-
traceptives reported increased sexual desire (17.7%) or frequency of sexual intercourse
(13.3%), whereas another fraction reported decreases in sexual satisfaction (2.2%), sexual
desire (15.5%) or frequency of sexual intercourse (13.3%). A study by Yanikkerem found
the reason for termination of oral contraceptive use to be the side effects [17]. The reports
by Sanders et al. [18] and Sabatini et al. [24] have identified oral contraceptive use as a
negative effector of sexual life (decreased sexual desire). In contrast, Oddens [25] and
Guida et al. [15] found a positive effect (increase in sexual desire and fantasies). These
results suggest that similar to IUD use, contraceptive use is terminated by women due to its
side effects and not because of a negative influence on their sexual lives.
The sexual life of the women included in this study was evaluated using the Arizona
Sexual Experience Scale (ASEX). In our country, a score of 11 or above using the ASEX
scale is considered to be a cut-off score where the probability of identification of sexual
problems is 52% [13]. According to the FP methods (withdrawal, IUD, condom, OC) used
in the last 6 months, the received ASEX score averages were similar and above normal
(p [ 0,05). Similarly, a study by Yilmaz [2], found that the effect of the FP method
(withdrawal, IUD, condom, OC) used on sexual functions was statistically insignificant.

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Although the majority of women reported no adverse effects for the FP method used on
their sex lives and had no complaints, the high ASEX scores found in this study suggest
that women cannot adequately address issues related to sexual life.
Age is an important factor affecting the sex life. With the advance of age, the frequency
of sexual relation decreases and difficulties in sexual stimulation can occur [26]. Herein, it
was determined that the ASEX score averages increased with the advance of age, indi-
cating that the probability of experiencing difficulties in sexual life increased (p \ 0.05). A
similar study also found a negative impact of aging on sexual life [2]. With the advance of
age and decrease in estrogen levels, the experienced physiological changes (vaginal dry-
ness, vaginal atrophy, loss of arousal, loss of sexual desire, etc.), perception of self as
unattractive and appearance of chronic diseases and physical difficulties may result in
negative effects on sexual life [27].
The level of education is an important factor determining the perception of sexual life
and in women. A high education level increases the socio-cultural and economical status of
an individual, improves his/her problem solving and self-expression abilities and enables
him/her to be more open about subjects related with sexuality [28]. When the level of
education of women and their ASEX score averages were compared, the ASEX score
averages of primary school graduates ( x: 14.42) were found to be higher than those
graduated from secondary school ( x: 13.77) and high school and above ( x: 12.99)
(p \ 0.05). The study by Yilmaz [2] also demonstrated a negative effect of lower edu-
cation level on sexual life. In contrast, the study by Guvel found no negative effect of
education level on sexual life [29]. These results suggest that higher education level may
contribute to the perception and meaning of sexuality.
Similarly, the ASEX score averages of women describing their income levels as ‘‘good’’
(
x: 12.35), ‘‘average’’ ( x: 13.76) were found to be high (p \ 0.05).
x: 13.97) or ‘‘bad’’ (
However, the scores of women describing their income levels as ‘‘average’’ and ‘‘bad’’
were higher than those considered to be of ‘‘good’’ income level. While these results point
to presence of problems in sexual lives of all groups, those belonging to the ‘‘average and
bad’’ income levels may experience more problems due to possible additional socioeco-
nomic difficulties.
Married life is influenced by the male and female health, their perceptions of sexuality
and sexual life, their roles and expectations as a male and a female and their satisfactions or
dissatisfactions experienced as a result of these [28, 30]. A strong and happy marriage is
possible when two different personalities complete each other, which means psychological,
social and sexual compatibility. A good communication between the man and the woman
and compatibility in sexual life ensures a happy married life and enables satisfaction in
sexual life [29, 30]. In our study we found that the score averages of women describing
their communication with their spouse as ‘‘bad’’ ( x: 17.72) was higher than those with
‘‘good’’ communication between spouses ( x: 1,260) (p \ 0.05). Other studies also found a
strong correlation between a happy marriage and sexual compatibility and revealed that an
unsuccessful sexual life leads to incompatibility between couples [2, 28]. The results of
this study also suggest that a good communication between couples improves compatibility
in married and sexual life.
When ASEX score averages of women were compared according to their perception of
self, the ASEX score averages of women describing themselves as ‘‘unwilling’’ ( x: 16.46)
and ‘‘cold’’ (x: 17.27) were higher than those describing themselves as ‘‘attractive’’
x: 12.23) (p \ 0.05). This result indicates that the way women describe themselves in
(
terms of sexuality (unwilling, cold), has a negative impact on their sex life and increases
the possibility of identification of problems related to sexual life. Similarly, when the

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ASEX score averages of women were compared according to their frequency of having
sex, the ASEX score averages of women having sex 1–2 times per week ( x: 14.58) were
determined to be higher than those having sex 5 times or above per week ( x: 9.88)
(p \ 0.05). It is known that sexual willingness and frequency of sex shows a parallel and
affects sexual satisfaction [31]. This result suggests that the way women perceive them-
selves sexually affect their sexual willingness and the frequency of sexual relation.

Conclusion

In conclusion, the women included in our study have reported no significant negative
effects of FP methods they use on their sexual lives. In contrast, their ASEX score averages
were determined to be high. This result suggests that these women have problems in their
sexual lives but are not aware of them, or can not voice these issues since their expectations
related to their sexual lives is low. Furthermore, the study also identified socio-
demographic characteristics and properties related to married life as influencing factors on
the sexual lives of women. In this respect, when evaluating sexual life, a question-based
approach may not be adequate and a thorough investigation of sexual life is required.

Suggestions

Under the light of these findings, the following suggestions are made: 1—couples should
be informed about the effect of FP methods on sex life, 2—consultation services for sexual
health should be initiated in places where no such services are available and should be
expanded, 3—these services should be integrated within the context of reproductive health
consultancy services. Furthermore, we suggest that the effect of other FP methods that
were not included in this study on sex life and the effect of FP methods on sexual lives of
men should be evaluated in studies with large sample numbers.

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