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Female sexuality: in three Egyptian cities

Abd El-Rahman, Sherine H.a; Younis, Ihaba; El Awady, Monab

doi: 10.1097/01.XHA.0000439143.35911.19
Original articles
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Background Because of the sensitive nature of the topic, female sexuality is not a common subject in the Egyptian medical literature. The present work aimed to assess domains of sexual functioning (e.g. sexual arousal, orgasm, satisfaction) in an Egyptian sample.

Participants and methods The participants were 313 married women attending or working in Family Planning Centers in three cities; a face-to-face questionnaire was administered to all participants. The questions covered many aspects of female sexuality avoiding topics of taboo, for example homosexuality.

Results Most women had been circumcised. The most common coital frequency was 1–2 and 3–6/week, which decreased during pregnancy, after delivery, and with aging. Most women reported no change in libido throughout the menstrual cycle. Achieving an orgasm was reported frequently by the majority of women and they commonly faked an orgasm if they did not achieve it. Affirmative responses on premarital masturbation and the practice of oral sex were uncommon. The missionary position was the most commonly used position and women were largely satisfied with their sexual life as a whole.

Conclusion Despite economic difficulties, the practice of female genital cutting, and male dominance, the studied women viewed their sexual life positively.

Departments of aDermatology and Andrology

bPublic Health, Faculty of Medicine, Benha University, Benha, Egypt

Correspondence to Sherine H. Abd El-Rahman, MD, Department of Dermatology and Andrology, Faculty of Medicine, Benha University, Benha, Egypt Tel: +20 122 319 6080; fax: +222581705;e-mail: sherineaddo@yahoo.co.uk

Received September 11, 2013

Accepted November 25, 2013

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Introduction

The term sexuality is generally used to refer to a group of concepts and behaviors, including those of sexual identity and preference, attitudes and experiences, activities, and associated thoughts and feelings 1.

Sexual function is an important aspect of quality of life, scarcely investigated in women compared with other quality-of-life areas 2. Women’s sexuality is highly variable and multifaceted, encompassing a number of physiologic, psychological, and interpersonal factors. Although common elements and pathways have been identified, the role of individual differences, learning factors, sociocultural influences, and age in women’s sexual response cannot be overstated. Despite major advances in understanding the neurobiology of the female sexual response, defining normal sexual response in women still remains highly challenging and controversial 3.

Although coital frequency is linked to marital satisfaction, there have been few recent attempts to study the correlation between these in marriages 4.

In Egypt, the topic of female sexuality is not commonly dealt with in the medical literature because of the conservative nature of the society.

The present work aimed to assess domains of sexual functioning (e.g. sexual arousal, orgasm, satisfaction) in an Egyptian sample.

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Participants and methods

This study was carried out over the last 10 months of 2012 and included 313 married women (not younger than 18 years of age and not older than 50 years of age) attending or working in Family Planning Centers in three Egyptian cities: Cairo, Benha (50 km North of Cairo), and Aga (120 km North East of Cairo). All women were currently living with their husbands.

The approval of the medical research ethics committee in Benha Faculty of Medicine was obtained for this study. The nature and aims of the research were explained to all respondents before obtaining their consent. However, because of the specific social and cultural context, the requirement of written informed consents was not applicable and was replaced by verbal witnessed consents. This is because of the fear and suspicion linked to signing any documents. The participants were also informed about their right to refuse participation in the research, and they could withdraw from the study at any time. In addition, the respondents were assured that the information provided would only be used for research purposes.

The method used to collect data was face-to-face interviews by a female doctor. This was done because of the low literacy rate of the women and because some questions had to be explained to the women to obtain the most accurate answers possible. The questionnaire we designed to cover different aspects of sexual activity that a woman may experience but because of the sensitive nature of the topic, some questions were not included, for example sexual identity, homosexuality, premarital intercourse, and extramarital relations. It was considered that asking these questions may either result in refusal to complete the questionnaire or provision of dishonest answers.

These data were tabulated, coded, and then analyzed using the computer program SPSS (statistical package for science, California State University, California) version 19. The t-test was used to test the significance of the difference between two independent sample means. Pearson’s correlation was used to determine the linear relationship between two variables.

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Results

Table 1 presents the answers provided by all responders. Table 2 shows that age and education had a highly statistically significant effect on the prevalence of genital cutting (P≤0.001). Almost all participants with cut genitals were either older than 40 years (98.0%) or illiterate (97.9%), or could only read and write (98.4%). However, genital cutting had a highly statistically significant effect on the ability of women to achieve an orgasm and on the overall satisfaction (P≤0.001). The percentage of anorgasmic women was 22.2% (genital cut group) versus 0.0% (nongenital cut group).

Table 1

Table 1

Table 2

Table 2

Table 3 shows a highly statistically significant effect of age on different aspects of female sexuality (defloration methods, ability to achieve an orgasm, coital frequency, interpersonal sexual behavior, and overall satisfaction). More than half of the participants (53.1%) older than 40 years had received a manual defloration, 42.9% were anorgasmic, and 61.2% had the least coital frequency (<once weekly). Moreover, participants >40 years had the lion’s share regarding negative history of ever being either totally undressed (71.4%) or having an oral sex (87.8%).

Table 3

Table 3

Table 4 shows that education had a highly statistically significant effect on several aspects of female sexuality (P≤0.001). Illiterate women, in comparison with those with a university degree, had the least coital frequency (48.9 vs. 1.4%), anorgasmia (38.3 vs. 0.0%), had been manually deflorated (83.0 vs. 2.8%), and were dissatisfied with their sexual life (66.0 vs. 8.5%).

Table 4

Table 4

Area of residence had a highly statistically significant effect on genital cutting (P≤0.001); 90% of the participants from either Benha or Aga had received genital cutting versus 58.49% from Cairo (Table 5).

Table 5

Table 5

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Discussion

Despite the campaigns in the media and its penalization, female genital cutting (FGC) is still practiced extensively in Egypt (Table 1). The Demographic and Health Survey (EDHS) also showed that 91% of all women in Egypt between the 15 and 49 years of age had undergone FGC, which is not only common among Muslims but also in the Christian community, which constitutes 10% of the Egyptian population 5. Despite a gradual progress, the fight to end FGC in Egypt has become increasingly more difficult.

The prevalence of FGC seems to be decreasing at least in Cairo but not as much in other parts of the country (Table 5). This view is shared by Tag-Eldin et al.6. Improving the educational level seems to be an important step in the fight against FGC (Table 2). This was in contrast to another Egyptian study 7, which reported that school and university education did not disseminate an effective anti-FGC message.

Problems in the domains of achieving an orgasm and satisfaction were significantly higher in participants who had received genital cutting compared with those who had not (Table 2). The same results were also obtained by Anis et al.8. However, it should be taken into consideration that other factors, for example age, may influence the ability to achieve an orgasm (Table 3). The existing literature is conflicting on the effects of FGC on sexual function. European researchers at the World Congress for Sexual Health 9, after studying African women who had been ‘circumcised’, reported that FGC women are also capable of achieving an orgasm. In contrast, Andersson et al.10 reported that FGM reduces women’s sexual quality of life significantly.

Numerous studies on sexual behavior have evaluated the link between the persistence of a sexually active life and advancing age. Degauquier et al.11 reported that there is a decline in sexual interest correlated with the life span. Furthermore, Dana et al. 12 reported that aged women are more concerned about problems related to dyspareunia, decreased arousal and response, decreased frequency of sex, and loss of sexual desire. Our results seem to be in agreement with these results as majority of the participants older than 40 years of age (42.9%) reported inability to achieve an orgasm and 61.2% had the least frequency of sex (<once/week) versus women aged 20 years or less who scored 11.6 and 0%, respectively (Table 3). In contrast, another research reported that sexual dysfunction increased with age in all categories, except achieving an orgasm, with more than half of women aged 18–30 years reporting problems in achieving an orgasm, significantly higher than that for women aged 31–54 years 13.

Sexual frequency is of interest for researchers because it is positively linked to emotional satisfaction and physical pleasure, and couples with greater sexual frequency are less likely to divorce 14. This was in agreement with our results as the group (>40 years) with the least sexual frequency was the most (61.2%) unsatisfied with their lives (Table 3). Our results also showed a significant positive correlation between sexual satisfaction and coital frequency. Brody and Costa 15 also reported that frequency of penile vaginal intercourse was directly associated with sexual satisfaction, health, and well being. This correlation between marital satisfaction and sexual frequency was later explained by Ebstein et al.16, who reported that neurochemicals such as oxytocin and vasopressin, for example, are released during sexual activity and may help to increase social attachment and decrease anxiety.

Checking the bride’s virginity by manual defloration is an essential ceremony, especially in rural Egypt. However, the procedure differs by region. Ahmed et al.17 described two types of procedures to check virginity: Othmannlley or Afrangy (the modern type) and El Dokhla El Balady (the traditional hand defloration). This tradition seems to be declining as the percentage of wives deflorated manually in the age group of 20 years or younger was nearly half that in wives older than 41 years of age (Table 3). Education is an important factor in eradicating this tradition (Table 4). Another factor is the heightened religious rituals observed in Egypt over the past two decades that prohibit genital exposure unless there is a very strong reason.

The conservative nature of the Egyptian society in general and that of women in particular is evident from some of the results of the present study. Most women refused to answer questions about anal sex, most women denied the practice of oral sex (even calling it disgusting), and almost 45% of women reported that they either do not or infrequently become totally undressed during intercourse (Table 1). The small percentage (7.35%) of women admitting to premarital masturbation compared with 36.8% in Britain 18 and 48% in the USA 19 may be explained by the fact that the present study used a face-to-face interview that may have made women hesitate to speak about, let alone admit to, masturbation. Urbanization seems to have an effect on this conservative behavior as women who admitted to premarital masturbation, those who stated that they practiced oral sex, and those who stated that they become totally undressed during intercourse were mainly from Cairo (an urban area) than Benha (a semi-urban area) and Aga (a rural area).

Bullivant et al. 20 proposed the term ‘sexual phase’ of the cycle to describe the 6-day period, beginning 3 days before the luteinizing hormone surge, in which they observed a stronger sexual desire and more sexual fantasies in the women they studied. They suggested that this is because of a dynamic interaction between estrogens and progesterones. This relation between time of the cycle and libido is comparable with our findings, where 49.6% of women reported an increase in libido after menstruation or during midcycle (Table 1). Haselton et al.21 used a sample of 30 partnered women photographed at high and low fertility cycle phases, and noted that readily observable behaviors – self-grooming and ornamentation through attractive choice of dress – increase during the fertile phase of the ovulatory cycle. Sexual interest was strongly associated with well being, suggesting that variations in well being have a powerful effect on sexuality in the majority of women.

The decline in sexuality, during pregnancy and postpartum, observed in the present study (Table 1) was also observed by Lamont 22, who added that pregnancy and breastfeeding can affect sexual functioning. The timing and nature of sexual relations during these periods should be a part of the medical advice that both partners receive.

The percentage of anorgasmic women (18.9%) was close to the one found in another Egyptian study (16.9%) 23 and in a French study (15.5%) 24, but was discrepant from another study in Iran 25 and Ghana 26, which reported 26.3 and 74.9%, respectively. The percentage of anorgasmic women reported in this study is probably not the actual percentage because of the face-to-face interview we conducted. Also, an interesting finding in the present study is that 75.3% of women admitted to faking an orgasm to avoid problems with their husbands. This is further evidenced by our finding that 81.2% of the women reported that they could frequently or infrequently achieve an orgasm but only 65.5% were satisfied with their sexual life as a whole (Table 1). Muehlenhard and Shippee 27 also noted that 50–60% of women reported faking an orgasm. Kaighobadi et al.28 suggested that faking an orgasm may be a form of mate retention practiced by women to prevent a partner’s infidelity or defection from the relationship.

In our study, Pearson’s correlation analysis showed that sexual satisfaction was significantly correlated with frequency of ability to achieve an orgasm. Costa and Brody 29 reported that penile vaginal orgasm is frequency correlated positively with PRQC dimensions (Perceived relationship Quality Components: satisfaction, intimacy, trust, passion and love. Furthermore, Tao and Brody 30 reported that sexual satisfaction was associated with the frequency of penile vaginal intercourse and the orgasm resulting from it.

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Conclusion

Our results shed new light on an area of marriage – sex – that has received relatively little attention. Women’s sexuality may be affected by biological events (e.g. puberty, childbirth, menopause, and aging), by their own psychology/psychological health, by their ethnicity and culture, and by their sexual orientation.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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Keywords:

female genital cutting; female sexuality; sexual frequency; sexuality in midlife

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