Female Sexual Dysfunction and Associated Factors Among Married Women in Bahir Dar, Northwest Ethiopia: A Cross‐Sectional Study

ABSTRACT

Background and Aims

Sexual Dysfunction is a hidden factor for countless divorces, which affects 38% of women globally. However, the issue has received less attention and remains under research. Understanding the magnitude and factors associated with Female Sexual Dysfunction is relevant to promoting female sexual and overall health through designing appropriate programs. Hence, this study has assessed the prevalence and factors of Female Sexual Dysfunction among married women of reproductive age.

Methods

A community‐based cross‐sectional study was conducted on 583 married women from February 2023 to March 2023, in Bahir Dar, Northwest Ethiopia. A multi‐stage random sampling was employed. Sexual Dysfunction was measured by the Female Sexual Function Index tool and defined as a score below 23. Data was collected using a structured questionnaire by Kobo Collect software. The data analysis was done using SPSS version 25. Multivariable logistic regression models were used to identify factors. A p value below 0.05 was considered statistically significant.

Results

The prevalence of Sexual Dysfunction was 51.8% (95% CI: 47.80–55.70). The women's age 30–39 (AOR: 1.89, 95% CI: 1.01–3.53), Pregnancy (AOR: 3.29, 95% CI: 1.18–9.14), Depression (AOR: 2.88, 95% CI: 1.62–5.11), Fifty and above age of partner (AOR: 4.91, 95% CI: 1.48–16.28), Circumcised women (AOR 2.28, 95% CI: 1.13–4.59), and Partner's substance use (AOR:7.62, 95% CI: 4.98–11.67) were significantly associated factors for sexual dysfunction.

Conclusion

Female sexual dysfunction is a significant public health problem that has affected more than half of the studied women. Age, Pregnancy, Depression, Circumcision, and partner substance use were factors for female sexual dysfunction. Hence, education and counseling on substance use, circumcision, age, and pregnancy should be emphasized. Early diagnosis and treatment of depression should be encouraged.

Abbreviations

AOR

adjusted odds ratio

EDHS

Ethiopian demographic and health survey

FSAD

female sexual arousal disorder

FSD

female sexual dysfunction

FSFI

female sexual function index

PHQ

patient health questionnaire

1. Introduction

Sexuality is a central aspect of “being human”. Sexual health is more than avoiding diseases and unplanned pregnancies [1]. A healthy sexual life between couples is significantly related to Perceived Relationship Quality Components (PRQC) [2]. Female Sexual Dysfunction (FSD) is characterized by one or more issues with female sexual desire, arousal, orgasm, lubrication, satisfaction, and/or sexual pain/discomfort that cause significant suffering or disturbance in a person's ability to respond sexually or to experience sexual pleasure [3, 4]. Although FSD is more complex and challenging to categorize, evidence shows that it is classified as situational (occurs only in certain circumstances or with certain partners), acquired, lifelong (primary, and secondary), or generalized (occurs in all situations and with all partners) [5, 6].

Sexual dysfunction has six domains or types. The first one is the absence of sexual fantasies, thoughts, and/or desires that cause personal distress, which is known as hypoactive sexual desire disorder (HSDD). The second is Female Sexual Arousal Disorder (FSAD), characterized by a persistent inability to initiate or sustain sexual engagement, and inappropriate lubrication/swelling reaction to sexual excitement [7]. The third domain is orgasmic disorders characterized by a persistent or recurrent difficulty, delay, or absence of obtaining orgasm following adequate sexual stimulation and arousal [8]. The fourth type is sexual pain disorder (dyspareunia), which is characterized by recurrent or persistent genital pain during intercourse [9]. The fifth type is sexual dissatisfaction described as an effective response deriving from one's subjective judgment of the positive and negative qualities linked with one's sexual connection [10].

The Sustainable Development Goal calls for achieving universal access to sexual and reproductive healthcare for all reproductive‐age women by 2030 [11]. However, this goal still seems unachievable in many developing countries, including Ethiopia, because discussing sexual intercourse and sexuality issues is a cultural taboo, and discussions about women's sexual health are generally frowned upon [12, 13, 14]. Most women do not seek care for sexual dysfunctions [15]. In a study done in Egypt, it was reported that most women (84.1%) with sexual problems had not received a professional consultation for their sexual issues. A study in Ethiopia has found that one major cause of divorce was sexual incompatibility [16].

Globally, even though sexual dysfunction affects more women (38%) than males (28%), women's sexual issues receive less attention [17]. A worldwide study in 2016 found that 41% of women reported having sexual dysfunction in some way [18]. The prevalence of specific categories of FSD was pain 39.08%, disorders in arousal 48.21%, sexual desire 50.70%, lubrication 37.60%, orgasm 40.16%, and sexual satisfaction 35.02%, making it a major medical problem [19]. FSD was typically lower (40%) in more developed regions such as Europe and North America, compared to developing regions like the Middle East and Africa (62%) [20].

In sub‐Saharan Africa, in 2015, the prevalence of FSD ranged from 46% to 73% [21]. In Ghana, pain during sex is the most commonly reported issue among 72.9% of women [22]. In 2019, a study in Nairobi, Kenya, found that the total prevalence of FSD was 38.7%. Unlike the other African countries, discussing sexual issues is a cultural taboo in Ethiopia, particularly in the study area. As a result, the extent of the problem is underreported. In Ethiopia, FSD is one of the major sexual and reproductive health issues; however, it remains an under‐researched area. A study in 2019 found that 57.1% of the women had a sexual dysfunction [23]. In another study in Ethiopia, only 39% of the participants reported greatest sexual satisfaction [24].

Several factors were identified to be associated with female sexual dysfunction. These include: sociodemographic characteristics, mental health, drugs, chronic diseases, pelvic organ abnormalities, abortion, physical exercise, and substance utilization [25, 26, 27]. Genital mutilation, gender inequality, poor reproductive health conditions, and the view of sex as a means of reproduction (as opposed to pleasure) all contribute to the burden of FSD in developing countries [27]. There may be other factors that may affect women's sexual dysfunction, including a history of sexual abuse, genital mutilation, sociodemographic, lifestyle, and medical issues of their partner [17,26, 27].

In Ethiopia, there are ample studies on men's sexual dysfunction, but there is very limited evidence on FSD. Although it is known to be the hidden factor of countless divorces, it remains an under‐researched and ignored issue. Hence, the objective/aim of this study was to determine the prevalence of FSD among married women of reproductive age in Bahir‐Dar city, northwest Ethiopia. It was also aimed to identify predictor factors of FSD.

2. Methods

2.1. Study Design, Setting, and Period

This study was done in the Bahir‐Dar city administration, which is the capital city of the Amhara regional state, northwest Ethiopia. It was selected randomly among the major cities in the Amhara regional state. The city has six sub‐cities with an estimated total population of 356,757 [28]. A total of 129,687 reproductive‐age women reside in the city [28]. A community‐based cross‐sectional study design was used to assess the prevalence of FSD and associated factors from February 2023 to March 2023.

2.2. Population

All married women of reproductive age residing in the Bahir Dar city administration were the source population. All married women of reproductive age residing in the randomly selected Keble's of Bahir Dar city were the study population.

2.2.1. Inclusion Criteria

Married women who have lived in the city of Bahir Dar for a minimum of 6 months were included in the study.

2.2.2. Exclusion Criteria

The study excluded pregnant women above the second trimester and women who gave birth in the past three months.

2.3. Sample Size Determination

Both double and single population proportion formulas were used to estimate the sample size. The largest sample size was found by using a single population proportion formula, $(n\hspace{0.17em}=\hspace{0.17em}[{\left(Z_{\alpha /2}\right)}^2*P*(1\hspace{0.17em}-\hspace{0.17em}P)]d²)$, by considering the following assumptions; 95% CI where Z _α/2 (reliability coefficient) is 1.96, 5% margin of error, design effect of 1.5, nonresponse rate (5%), and prevalence of FSD in Tigray region (57.1%) [29] giving the final sample size of 622.

2.4. Sampling Procedure

A multistage sampling technique was used to choose the study participants from the target population. There are six sub‐cities in Bahir‐Dar city, and of these, two of the sub‐cities were selected by the lottery method. There are eight kebeles (the smallest administrative units) in these two sub‐cities, and three of the kebeles were selected by lottery method. Then the sample size was proportionally allocated to the selected kebeles. Finally, a systematic random sampling technique was used to select the study participants.

2.5. Study Variable

The dependent variable: Female sexual dysfunction (YES or NO).

The independent variables include: Socio‐demographic characteristics, reproductive and obstetric characteristics, medical factors, and lifestyle‐related factors.

2.6. Data Collection Tool and Procedure

A structured interviewer‐administered questionnaire was adopted by reviewing different literature [22, 29, 30]. The questionnaire was prepared in English and then it was translated into Amharic version and then translated back to English to check its consistency. A Cronbach's Alpha reliability test to check its reliability was done and the result was 0.93 which implies that the items have good internal consistency.

To evaluate sexual dysfunction, a validated survey Female Sexual Function Index (FSFI) was applied. In the Ethiopian context, this tool was validated and used by a study conducted in Aksum Town, Tigray region, Ethiopia [23]. It is a 19‐item survey that evaluates several aspects of female sexual function with six domains as the following: Desire (items 1, 2), Arousal (items 3–6), Lubrication (items 7–10), Orgasm (items 11–13), Satisfaction (items 14–16) and Pain (items 17–19). Each item score is graded from 0 to 5; 0 means no sexual intercourse, 1 indicates sexual dysfunction, and 5 indicates normal sexual function. Each woman's domain scores are obtained by adding the scores of each woman's questions that encompass the domain and multiplying the summation by the domain factor which is included in the FSFI for each domain. Factors for desire were 0.6, for arousal and lubrication were 0.3, and 0.4 for orgasm, satisfaction, and pain. The overall score was acquired by adding the six domain scores. The total‐scale score range is from 2.0 to 36.0, and the higher scores suggest better sexual function among women [31].

To measure depression, we used the Patient Health Questionnaire (PHQ‐9), a 10‐item tool which measures the depression status of women in the past 2 weeks [32]. To assess substance utilization Ethiopian Demographic and health Survey (EDHS) questions have been applied [33]. Sexual violence has been measured by questions taken from a document called researching violence against women [34].

The questionnaire was pretested and a Cronbach's Alpha reliability test was done to assure the data quality. The data collectors and supervisors were trained for 2 days to ensure the quality of the data. The questionnaire was administered in Amharic (the local language). The supervisors and the principal investigators strictly followed the data collection process. The collected data were reviewed and checked for completeness before data entry.

2.7. Measurement

2.7.1. Female Sexual Dysfunction

Women who scored below 23 on the Female Sexual Function Index tool were considered to have sexual dysfunction [31].

2.7.2. Depression

Those respondents who were found to score ≥ 10 in PHQ‐9 were classified as having depression [32].

2.7.3. Chronic Disease

If the individual is diagnosed to have one of (chronic respiratory diseases like asthma, diabetic mellitus, hypertension, cardiovascular problems, cancer, or another chronic disease), they have been said to be chronically ill [35].

2.7.4. Physical Exercise

when a person engages in activities purposely (walking, jogging) for at least 150 min per week [36].

2.7.5. Sexual Violence

if the woman responds yes to one of the three questions then she is considered a victim [34].

2.7.6. Substance User

If a person uses one of the following;

• ▪Alcohol: A person who consumed alcohol for 6 or more days in the last 30 days was considered a drinker.
• ▪Khat: A person who has chewed Khat for 6 or more days in the last 30 days,
• ▪Tobacco: If a person smokes a cigarette daily, then she/he is considered a smoker [33].

2.8. Data Processing and Analysis

All the questionnaires were collected using Kobo Collect software. The data was exported to SPSS version 25, cleaned, and checked for completeness. A descriptive analysis was done and presented with tables, bar charts, frequencies, and texts.

A Binary logistic regression model has been employed to assess the statistical association between the independent variables and the outcome variable, that is, FSD. Firstly, a bi‐variable logistic regression analysis was done to see the association of each independent variable with the outcome variable. Accordingly, a crude odds ratio (COR) with 95% CI was obtained. Then, variables which had a p value less than 0.25 in the bi‐variable logistic regression analysis were entered into the multivariable logistic regression models to identify the independent effect of the predictor variables on the outcome variable (FSD), by controlling confounding effects. Those variables having a p value of less than 0.05 in the multivariable logistic regression model were considered to have a statistically significant association with FSD. Adjusted Odds Ratio (AOR) with 95% CI has been used as the measure of association.

Multi‐collinearity between each predictor was checked by a variance inflation factor (VIF), the test result was 1.06–2.80. Hosmer–Lemeshow goodness of fit test has also been assessed to check the model, and the result was 0.6.

2.9. Ethical Approval and Consent to Participate

A written ethical approval letter was obtained from the Bahir Dar University Research Ethics Review Committee. Written consent was asked from each study participant and their husbands before data collection. For those participants who were unable to read the consent, a verbal explanation was given to them and their consent was recorded by the data collectors. They were informed about the objective of the study, the confidentiality of their data, and the right to refuse participation.

3. Results

3.1. Socio‐Demographic Characteristics

A total of 583 married women of reproductive age participated in the study which gives a response rate of 93.7%. In this study, 484 (83%) participants were orthodox Christians. The mean age of the study participants was 31.5, SD: 7.1. More than one‐third 198 (34.8%) of the married women have an educational status of Degree and above, and 183 (31%) of the participants work in governmental institutions. Nearly half, 275 (47.2%) of the participant's partners' educational status was Degree and above (Table 1).

Table 1.

Socio‐demographic characteristics of married women of reproductive age, in Bahir Dar city, northwest Ethiopia, 2023.

Variable	Category	Frequency	Percent
Age	19–29	270	46.3
	30–39	217	37.3
	40–49	96	16.4
Religion	Orthodox	484	83
	Protestant	57	9.8
	Othera	42	7.2
Education	Grade 1–8	47	8.1
	Grade 9–12	182	31.2
	College/diploma	156	26.8
	Degree/above	198	33.9
Occupation	Housewife	166	28.5
	Merchant	185	31.7
	Government employee	209	35.8
	Othersb	23	3.9
Age at marriage	15–24	386	66.2
	25–34	188	32.2
	35–44	9	1.5
Partner age	20–29	98	16.8
	30–39	254	43.6
	40–49	157	26.9
	≥ 50	74	12.7
Partner education level	Grade 1–8	35	6
	Grade 9–12	120	20.6
	College/diploma	153	26.2
	Degree/above	275	47.2
Partner occupation	Merchant	247	42.4
	Government employee	259	44.4
	Othersb	77	13.2

^aMuslims and Catholics.

^bNGO and daily laborers.

3.2. Lifestyle Related Characteristics

Of the total study participants, 100 (18.4%) were substance users. More than half, 321 (55.7%), of the participants' partners were substance users. Regarding physical activity, 16 (2.7%) of the study participants and 50 (8.6%) of their partners perform physical activity (Table 2).

Table 2.

Lifestyle‐related characteristics of married women of reproductive age, in Bahir Dar city, northwest Ethiopia, 2023 (N = 583).

Variable	Category	Frequency	Percent
Alcohol drinking	Yes	107	18.4
Khat chewing	Yes	11	1.9
Cigarette smoking	Yes	13	2.2
Substance utilization	Yes	107	18.4
Partners alcohol drinking	Yes	280	48.03
Partners khat chewing	Yes	59	10.1
Partners cigarette smoking	Yes	59	10.1
Substance utilization	Yes	321	55.7
Women physical activity	Yes	16	2.7
Partners physical activity	Yes	50	8.6
Nutrition status for women	Good	488	83.7
	Poor	95	16.3

3.3. Reproductive, Obstetrics, and Medical Characteristics

Among the participants, 37 (6.3%) were pregnant. Of the study participants, 454 (77.9%) have children. Regarding contraceptive utilization 360 (61.7%) claimed to use contraceptives. A total of 171 (29.3%) had a history of violence. The proportion of women who have been circumcised was 87 (14.9%). Of the total participants, 132 (22.6%) had a history of abortion. Of the participants who have a child 248 (54.6%) of mothers had last born baby delivery a history of spontaneous vaginal delivery (SVD). The study revealed that 41 (7%) and 91 (15%) of women and their partners had chronic diseases, respectively. Of the study participants 147 (25.2%) women faced depression in the past 2 weeks before the survey (Table 3).

Table 3.

Reproductive, obstetric, and medical characteristics of married women of reproductive age, in Bahir Dar city, northwest Ethiopia, 2023.

Variable	Category	Frequency	Percent
Pregnancy	Yes	37	6.3
	No	546	94.7
Contraceptive use	Yes	360	61.7
	No	223	38.3
Types of contraceptives	Oral contraceptive	206	57.2
	Implanon	66	18.3
	Injection	52	14.4
	IUCD	19	5.2
	Other	17	4.7
Parity	No	129	22.1
	< 3	395	67.8
	≥ 4	59	10.1
Extended postpartum period	Yes	110	18.9
	No	473	81.1
History of delivery	Spontaneous vaginal delivery	248	54.6
	Cesarean section	116	25.5
	Instrumental	90	19.8
Circumcision	Yes	87	14.9
	No	496	85.1
Gynecological problems	Yes	103	17.7
	No	480	82.3
Abortion history	Yes	132	22.6
	No	451	77.4
Sexual violence	Yes	171	29.3
	No	412	70.7
Chronic disease in women	Yes	41	7.03
	No	542	92.96
Chronic disease in partner	Yes	91	15.6
	No	492	84.4
Medication in women	Yes	19	3.3
	No	564	96.7
Medication in partner	Yes	47	8.1
	No	536	91.9
Depression	Yes	147	25.2
	No	436	74.8

3.4. Prevalence of Female Sexual Dysfunction

As shown in Figure 1 below, 302 (51.8%) (95% CI: 47.8%–55.7%) of married women of reproductive age were found to have sexual dysfunction. Lubrication disorder was the most common sexual disorder among women (53.9%), followed by pain disorder (48.5%) (Figure 1).

Figure 1.

Distribution of sexual domains among married women of reproductive age with and without FSD, in Bahir Dar, northwest Ethiopia, 2023.

3.5. Factors Associated With Female Sexual Dysfunction

Twenty‐two variables were included in the bivariate analysis. Depression, age of women, age of partner, pregnancy, partner education, circumcision, gynecological problems, abortion, nutrition, sexual violence, substance utilization of partner, and history of delivery were associated with the FSD at a p value below 0.25. These variables were candidates for multivariable logistic regression. Of the 12 variables that were included in the multivariable analysis. However, only women aged between 30 and 39, pregnant, depressed, partners with the age of 50 and above, women who were circumcised, and partner substance use show a significant association with the outcome variable.

In this study, depression was significantly associated with female sexual dysfunction. Women with depression were almost three times (AOR: 2.88, 95% CI: 1.62–5.11) more likely to be affected by sexual dysfunction than those without it. Women in the age group of 30–39 years were twice (AOR: 1.89, 95% CI: 1.01–3.53) more likely to be affected by female sexual dysfunction compared to those in the age group of 19–29. The finding showed that women whose husbands utilize substances have nearly eight times (AOR: 7.62, 95% CI: 4.98–11.67) higher chance of being affected by dysfunction than those whose husbands do not utilize substances. Additionally, Women who are pregnant are almost three times (AOR: 3.29, 95% CI: 1.18–9.14) more likely to be affected by dysfunction than those who are not.

There is no statistical difference between women who have a history of abortion and those who don't have a history of abortion. On the other hand, the age of the husband of a woman who has female sexual dysfunction was significantly higher than that of the other group. Those women with a husband aged 50 years and above were almost five times (AOR: 4.910, 95% CI: 1.48–16.28) more likely to be sexually dysfunctional than those whose husbands were aged 20–29 years old. History of delivery was not statistically significantly associated with FSD, but those women who were circumcised had twice the (AOR: 2.28, 95% CI: 1.13–4.59) chance of being sexually dysfunctional than their counterparts (Table 4).

Table 4.

Bivariate and multi‐variable logistic regression analysis of factors associated with FSD among married women of reproductive age, in Bahir Dar city, northwest Ethiopia, 2023.

Variable	Category	Female sexual dysfunction		COR (95% CI)	AOR (95% CI)
		Yes	No
Depression	Yes	113	33	4.49 (2.91–6.91)	2.88 (1.62–5.11)*
	No	189	248	(1)	(1)
Age of women	19–29	117	153	(1)	(1)
	30–39	130	87	1.95 (1.35–2.80)	1.89 (1.01–3.53)*
	40–49	55	41	1.75 (1.09–2.80)	0.88 (0.33–2.35)
Age of partner	20–29	36	62	(1)	(1)
	30–39	126	128	1.69 (1.05–2.73)	1.30 (0.68–2.50)
	40–49	89	68	2.25 (1.34–3.78)	1.85 (0.76–4.50)
	>/50	51	23	3.81 (2.01–7.25)	4.91 (1.48–16.28)*
Pregnancy	Yes	30	7	4.31 (1.86–9.99)	3.29 (1.18–9.14)*
	No	272	274	(1)	(1)
Circumcision	Yes	66	21	3.46 (2.05–5.83)	2.28 (1.13–4.59)*
	No	236	260	(1)	(1)
Gynecological problems	Yes	69	34	2.15 (1.37–3.36)	0.90 (0.48–1.69)
	No	233	247	(1)	(1)
Abortion history	Yes	96	36	3.17 (2.07–4.85)	1.57 (0.87–2.82)
	No	206	245	(1)	(1)
Nutrition status of women	Yes	235	253	(1)	(1)
	No	67	28	2.57 (1.60–4.14)	1.75 (0.92–3.33)
Sexual violence	Yes	121	50	3.08 (2.10–4.52)	1.61 (0.96–2.71)
	No	181	231	(1)	(1)
Partner substance use	Yes	238	83	8.87 (5.70–12.05)	7.62 (4.98–11.67)*
	No	64	198	(1)	(1)
History of delivery	None	60	69	0.69 (0.40–1.19)	1.06 (0.49–2.28)
	Instrumental	118	130	0.72 (0.44–1.17)	0.87 (0.47–1.61)
	CS	74	42	1.41 (0.80–2.47)	1.73 (0.85–3.53)
	SVD	50	40	(1)	(1)

^* p value below 0.05.

4. Discussion

This study has assessed the prevalence of sexual dysfunction and associated factors among married women of reproductive age in Bahir Dar city. The prevalence of sexual dysfunction among married women of reproductive age was 51.8% with 95% CI (47.8%, 55.7%). This is in line with a study conducted in Egypt 53.1%, Ghana 48.3%, and Beijing, China 50% [22, 29, 37]. However, this finding is lower than that of a study conducted in Aksum, Ethiopia (57.1%) [23]. This may be due to the fact that in this study, only married women have participated, while the study from Aksum involved all women of reproductive age. On the other hand, the finding of this study is lower than a study conducted in Egypt, 61.2% [38], and in Palestine, 61% [39]. This is because these studies included women above the age of 49. Women in menopause are most likely to be affected by female sexual dysfunction [29, 40].

This finding is higher than the study done in Nairobi Kenya, which was 38.1% [30], and Hong Kong which was 25.6% [41]. This variation may be due to the difference in the study period, possible socioeconomic factors including women education, women autonomy, and cultural taboo on discussing and reporting sexual issues. In addition, use of hormonal contraceptive among the respondent may be related with the observed variation.

In this study, the lubrication‐related disorder was the most predominant (53.9%) domain of sexual dysfunction, followed by pain 48.5%. Vaginal dryness or lack of lubrication could result from certain health conditions or treatments for health conditions such as childbirth, birth control pills, cancer treatments and not being sexually aroused [42, 43, 44]. In this study and other similar studies in the Gaza Strip, Palestine, pain‐related FSD was common among married women, accounting for 79% [39]. While a study in Elfayoum, Egypt found that the most commonest (58.5%) dysfunction was orgasm‐related dysfunction [38]. The difference may be due to different socio‐cultural, economic backgrounds, and medical factors.

In this study, different factors were found to be associated with FSD. Female circumcision is the cause of pain or dyspareunia and lack of lubrication [23]. This study has revealed that FSD has been reported to be more prevalent among women in the age group of 30–39 years. Similar to the studies in Jordan, Ethiopia, and Egypt, FSD increases with age [23, 29, 40, 45]. This is justifiable as women age, less estrogen is produced and also a small amount of testosterone is produced starting when women are in their 30 s as a result, tissues become inflamed and irritated due to low production of estrogen which leads to atrophic vaginitis then these changes will cause pain during sexual activity that involves penetration not only this but also vaginal secretions will decrease which provides less lubrication during sexual intercourse [6].

Those women with older husbands have a higher likelihood of experiencing sexual dysfunction compared to those women with husbands aged below 50 years old. This finding is in line with studies done in Egypt, Elfayoum City, which states that there was a statistically significant negative correlation between FSFI score and husband age [38]. The resemblance of the results is defensible because male sexual dysfunction is a common condition that affects more than 50% of males between the ages of 40 and 70 [46]. It has been proposed that pleasurable penile–vaginal sex requires a sufficient erection as a requirement, which leads to increased levels of sexual satisfaction in women [45].

Based on our findings, pregnant females had statistically significantly lower FSFI scores than non‐pregnant females. Similar to a study conducted in Brazil, the frequency of sexual dysfunctions increased with pregnancy [47]. According to studies throughout pregnancy, sexual function declines and worsens because of hormonal changes [48, 49]. However, the results were not consistent with a study from Egypt, which states that pregnant females had higher FSFI scores [37]. A study indicates that women's sexual interests vary according to their gestational age [50]. This could be explained as there may be differences in the gestational age of pregnant women who were included in this study.

The result of this study found that depression was positively significantly associated with female sexual dysfunction. This makes it in line with a study conducted in Tigray, Ethiopia [23]. The similarity is supported by a paper done in 2019, which states that the most common identifiable predictor of sexual dysfunction in women is depression. Depression is a well‐known cause of a generalized decrease in interest, motivation, and enjoyment in life, with specific effects on sexual interest and activity [23, 51].

Substance use by the partner was found to be a significant factor for FSD. This is in line with other similar studies, which stated that alcohol and smoking have a positive correlation with sexual dysfunction. Sexual dysfunction is related to initiation, change in dose, or stopping of a substance or drug [20, 29]. This is anticipated given that smoking may reduce the perfusion of central and peripheral tissues, raise the risk of genital vascular stiffness, impair sexual function, and result in erectile dysfunction in males. It is anticipated because, as mentioned above, erectile difficulties affect women's sexual dysfunction [45]. Circumcised women were found to be more sexually dysfunctional than uncircumcised women. Other similar studies also identified female genital mutilation as one of the factors for sexual dysfunction [20, 38, 52]. This is because female genital mutilation removes a significant number of nerve cells around the genital area, which results in low sexual enjoyment [53]. However, a study in Egypt stated that there was no significant difference in experiencing sexual dysfunction between circumcised and uncircumcised women. This may be due to the small number of circumcised women included in the study [29].

5. Strengths and Limitations of the Study

Some of the strengths of this study include the use of validated tools, such as the Female Sexual Function Index (FSFI) and the Patient Health Questionnaire (PHQ‐9), to assess Female Sexual Dysfunction (FSD), which enhances the internal validity of the findings. Additionally, a larger sample size was employed to improve the generalizability of the results. Comprehensive statistical analyses were also conducted to identify factors associated with FSD, further strengthening the robustness of the study.

Regarding the limitations, one possible limitation of our study is that discussing sexual issues is a cultural taboo in Ethiopia, which may have led to social desirability bias and the potential for underreporting or misreporting of sensitive information. However, the authors made efforts to mitigate this by ensuring confidentiality and conducting data collection (interviews) in a highly private setting. Respondents were encouraged to speak freely, and female data collectors were also involved to help create a more comfortable environment. Given these considerations, future studies on similar topics should prioritize maintaining privacy and confidentiality to minimize biases and improve the accuracy of responses. The study assessed the substance utilization of the partner side since it's difficult to measure their substance utilization status by their wife due to privacy issues, it would be better if the data collection were held when both couples were available.

Another limitation of our study is the use of a cross‐sectional design, which limits our ability to establish causal relationships between FSD and the identified factors. To better understand the causal pathways, the authors recommend that future studies employ longitudinal designs. This study did not include direct data from male partners; instead, the authors gathered information about male partners from female respondents. Therefore, future studies should collect data directly from male partners to gain a more comprehensive understanding of the factors influencing FSD.

6. Conclusions and Recommendations

The results of this study concluded that FSD is a significant public health problem that affects more than half of the studied women. Women aged 30–39 years, being pregnant, having depression, ≥ 50 years of partner age, circumcised women, and partner substance use were significantly associated factors for FSD. According to the findings, the most common FSD domain that affects more than half of women is a lack of lubrication. Hence, this study suggests that education and counseling on substance use, circumcision, age, and pregnancy should be emphasized in national, regional, and local health programs. Additionally, early diagnosis and treatment of depression should be encouraged. Finally, future studies should include multiple regions of Ethiopia to enhance the generalizability of the findings and facilitate comparisons across regions, as well as between urban and rural areas. Additionally, we recommend that future research examine FSD separately among pregnant and postpartum women to provide a more accurate and focused analysis of this often overlooked segment of the population.

Author Contributions

Heaven Haile: conceptualization, investigation, methodology, formal analysis, project administration, writing – original draft, and data curation. Dabere Nigatu: methodology, writing – review and editing, validation, supervision, and software. Zemenu Shiferaw Yadita: writing – review and editing, validation, software, supervision, and methodology.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author Zemenu Shiferaw Yadita affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

All data supporting the findings are submitted with the manuscript. The data set for this article is openly accessible without restriction, upon request to the corresponding author.