Bron Skinner, PhD

Sexuality is an important part of the total person; integral to health, quality of life, and general well-being. It affects the way we relate to ourselves, our sexual partners, and all other people.¹ A healthy attitude about sexuality can provide numerous benefits, including a link with the future through procreation; a means of pleasure and physical release; a sense of connection to others; a form of gentle, subtle, or intense communication; enhanced feelings of self-worth; and a contribution to self-identity.²

Sexuality also carries risks, especially for women, including unwanted pregnancy, sexually transmitted diseases, and the potential for exploitation. These types of concerns are a common threat to sexual health and have been reported in 50% to 70% of marriages^3,4 and in 75% of couples who seek marital therapy.⁵

As primary health providers, family physicians are in a good position to identify and address patients’ sexual concerns, thereby promoting their overall health and well-being. Physicians, however, frequently do not recognize these concerns during the clinical encounter. Available studies suggest that less than half of patients’ concerns are recognized by their physicians, and it is believed that physicians are generally unaware of the nature and frequency of sexual concerns among their patients.^6,7

The purpose of our study was to describe the frequency and type of the sexual concerns among women attending military outpatient clinics for routine gynecological care. The military medical center was a convenient facility serving a relatively diverse population of American women. Our study also extends the work of previous prevalence studies in clinical settings of sexual concerns by providing a larger sample size.

Methods

We included women who sought routine gynecological care at the Department of Family Practice (DFP) and the Department of Obstetrics and Gynecology (OB/GYN) at Madigan Army Medical Center (MAMC), a large military medical center located in Pierce County, Washington. Beneficiaries of health care at MAMC include active duty service members, active military reserve, retired military members, their families, and eligible employed or retired civilian service members. The DFP and OB/GYN Clinics are the main providers for routine gynecological care of the Madigan military beneficiaries.

We obtained approval for this study from the Human Subjects Review Committee of the Clinical Investigation Department of Madigan Army Medical Center and the Human Subjects Review Committee of the University of Washington.

Our target population consisted of all women who sought routine gynecological care between August 1992 and December 1992 at the DFP (n=525) and between December 1992 and January 1993 at the OB/GYN department (n=1059). We excluded women who were younger than 18 years, unable to understand English, geographically unavailable for follow-up, or who had cognitive dysfunction rendering them unable to complete the questionnaire.

We collected data through waves of questionnaires mailed to all 1584 eligible women. Ninety-six women could not be located, and 8 women were ineligible because of language barriers or cognitive dysfunction. In total, 985 women who sought care in the OB/GYN department and 495 women who sought care from the DFP were located and otherwise eligible for the study (total sample size=1480 women).

Our survey instrument included 95 questions addressing sociodemographic characteristics, aspects of the patient’s sexual history, sources of knowledge about sex, their sexual concerns, and their interest and experience with addressing these concerns with physicians. The 27 types of sexual concerns queried were drawn from the sexuality literature and were measured on a 5-point Likert scale (1=never; 5=always).

We determined the number of sexual concerns per respondent by recoding the Likert scales into dichotomous (yes/no) responses and summing the positive responses. Responses recoded as “yes” included all positive responses on the Likert scale, from “occasionally” to “always.” We also recoded positive responses into “high” and “low” categories to illustrate the distribution by frequency of sexual concerns. Missing data were excluded from analysis. We used descriptive statistics to define the study population.

Results

We received 964 completed questionnaires from 1480 eligible subjects, for a response rate of 65.1%. Demographic data are shown in Table 1. Respondents were 18 to 87 years old (mean=45.4 years, median=44.0 years, standard deviation=16.79). Almost half were exclusively homemakers, and a smaller percentage was employed outside the home. Eighty-five percent of the women in the sample were married.

Sexual Concerns

Almost all respondents, 98.8% (n=952), reported one or more sexual concerns, with a mean of 12.5 concerns per woman. Frequencies of sexual concerns are listed in descending order in Table 2. Single women had more sexual concerns than married women (80.5% vs 71.5% having 10 or more sexual concerns), and widowed women had even fewer (50.8% having 10 or more sexual concerns, (X = 21.97, P=.001). The total number of sexual concerns increased with level of education ( X = 30.42, P <.001) and decreased with increasing age (X=41.90, P=.000). Women who reported concerns about thinking of or having had an affair were more likely to report concerns about having different sexual desires than their partners (X=56.89, P <.000), not having their sexual needs met (X=66.69, P <.000), and their partner having sexual difficulties (X = 42.05, P <.000).

For the sample as a whole, 57.1% (n=550) reported concerns about having exposure in one or more of the areas of sexual, emotional, or physical abuse during their lifetime. Nearly half, 42.0% (n=398), reported concerns about sexual coercion at some point in their lives, and 43.6% (n=412), reported concerns about having been physically or emotionally abused.

Discussion

Our study confirms that sexual concerns are virtually universal among women, and since many of these sexual concerns have health implications, it reinforces the public health importance of this domain.⁸ In our study, 98.8% reported one or more sexual concerns, a higher percentage than in previous studies that have indicated a prevalence of one or more sexual concerns ranging from 53% (n=228)⁹ to 75% (n=212).¹⁰ The greater prevalence of sexual concerns in our study may be in part because of the broader range of sexual concerns queried by our instrument. Thus, our study substantiates the ubiquity of sexual concerns and underscores the potential importance of addressing sexual issues in the clinical encounter. A much lower percentage of women in the general population^8,11 are reported as having specific sexual concerns: dyspareunia (14.4%), preorgasmic (24.1%), lack of interest (33.4%), and difficulty lubricating (18.8%). Our results may indicate a higher prevalence for women who are seeking health care, supporting the case for physicians’ active inquiries about sexual concerns. Many sexual concerns are potentially treatable by physicians.

Nearly half of our respondents reported a concern about sexual coercion at some point in their lives, a percentage very similar (47.6% to 57%) to that of a recent report of lifetime prevalence of sexual victimization of women.¹² Survey data for the general population11 revealed that 22% of women aged 18 to 59 years reported being forced to have sex by a man, and 17% of women reported having been sexually touched when they were children. The higher percentage in our study may be because these women are more likely to seek health care or because of the much broader age range of our respondents.

Limitations

A weakness of our study is that the results may not be generalizable to other patient populations. Although this study sample of military beneficiaries is undoubtedly different from a random sample of women from the general population, there is no reason to believe that these differences are so great as to alter our main findings and conclusions. For example, compared with the 1990 census data from the state of Washington, the study sample had a similar age distribution and only a small difference in racial composition. Most notable, our sample had substantially fewer (2.4%) single, never married women in comparison with the state (20.8%), a difference that would probably result in our underestimation of the prevalence of sexual concerns. Our study does provide a better sample across all income groups than previous studies, which tended to include more upper-class and middle-class subjects.

Conclusions

The response rate of 65%, considered excellent for a self-report mail survey dealing with a sensitive subject,¹³ indicates that the topic of sexual concerns is important. Our results study suggest the prevalence of sexual concerns is high and varied among a large sample of typical US women. These data highlight the sexual health care needs of women and describe some of their details. What is clear from these results is that in a reasonably large sample of women with ready access to gynecological care, a broad range of sexual health concerns is common across all ages. Sexuality is an integral part of health, quality of life, and general well-being, and primary care physicians should be trained and prepared to address these sexual concerns.

Acknowledgments

We would like to thank the women who participated in this study, who shared very personal information with the understanding it would be used for physician education about sexual health.

Sexuality is an important part of the total person; integral to health, quality of life, and general well-being. It affects the way we relate to ourselves, our sexual partners, and all other people.¹ A healthy attitude about sexuality can provide numerous benefits, including a link with the future through procreation; a means of pleasure and physical release; a sense of connection to others; a form of gentle, subtle, or intense communication; enhanced feelings of self-worth; and a contribution to self-identity.²

Sexuality also carries risks, especially for women, including unwanted pregnancy, sexually transmitted diseases, and the potential for exploitation. These types of concerns are a common threat to sexual health and have been reported in 50% to 70% of marriages^3,4 and in 75% of couples who seek marital therapy.⁵

As primary health providers, family physicians are in a good position to identify and address patients’ sexual concerns, thereby promoting their overall health and well-being. Physicians, however, frequently do not recognize these concerns during the clinical encounter. Available studies suggest that less than half of patients’ concerns are recognized by their physicians, and it is believed that physicians are generally unaware of the nature and frequency of sexual concerns among their patients.^6,7

The purpose of our study was to describe the frequency and type of the sexual concerns among women attending military outpatient clinics for routine gynecological care. The military medical center was a convenient facility serving a relatively diverse population of American women. Our study also extends the work of previous prevalence studies in clinical settings of sexual concerns by providing a larger sample size.

Methods

We included women who sought routine gynecological care at the Department of Family Practice (DFP) and the Department of Obstetrics and Gynecology (OB/GYN) at Madigan Army Medical Center (MAMC), a large military medical center located in Pierce County, Washington. Beneficiaries of health care at MAMC include active duty service members, active military reserve, retired military members, their families, and eligible employed or retired civilian service members. The DFP and OB/GYN Clinics are the main providers for routine gynecological care of the Madigan military beneficiaries.

We obtained approval for this study from the Human Subjects Review Committee of the Clinical Investigation Department of Madigan Army Medical Center and the Human Subjects Review Committee of the University of Washington.

Our target population consisted of all women who sought routine gynecological care between August 1992 and December 1992 at the DFP (n=525) and between December 1992 and January 1993 at the OB/GYN department (n=1059). We excluded women who were younger than 18 years, unable to understand English, geographically unavailable for follow-up, or who had cognitive dysfunction rendering them unable to complete the questionnaire.

We collected data through waves of questionnaires mailed to all 1584 eligible women. Ninety-six women could not be located, and 8 women were ineligible because of language barriers or cognitive dysfunction. In total, 985 women who sought care in the OB/GYN department and 495 women who sought care from the DFP were located and otherwise eligible for the study (total sample size=1480 women).

Our survey instrument included 95 questions addressing sociodemographic characteristics, aspects of the patient’s sexual history, sources of knowledge about sex, their sexual concerns, and their interest and experience with addressing these concerns with physicians. The 27 types of sexual concerns queried were drawn from the sexuality literature and were measured on a 5-point Likert scale (1=never; 5=always).

We determined the number of sexual concerns per respondent by recoding the Likert scales into dichotomous (yes/no) responses and summing the positive responses. Responses recoded as “yes” included all positive responses on the Likert scale, from “occasionally” to “always.” We also recoded positive responses into “high” and “low” categories to illustrate the distribution by frequency of sexual concerns. Missing data were excluded from analysis. We used descriptive statistics to define the study population.

Results

We received 964 completed questionnaires from 1480 eligible subjects, for a response rate of 65.1%. Demographic data are shown in Table 1. Respondents were 18 to 87 years old (mean=45.4 years, median=44.0 years, standard deviation=16.79). Almost half were exclusively homemakers, and a smaller percentage was employed outside the home. Eighty-five percent of the women in the sample were married.

Sexual Concerns

Almost all respondents, 98.8% (n=952), reported one or more sexual concerns, with a mean of 12.5 concerns per woman. Frequencies of sexual concerns are listed in descending order in Table 2. Single women had more sexual concerns than married women (80.5% vs 71.5% having 10 or more sexual concerns), and widowed women had even fewer (50.8% having 10 or more sexual concerns, (X = 21.97, P=.001). The total number of sexual concerns increased with level of education ( X = 30.42, P <.001) and decreased with increasing age (X=41.90, P=.000). Women who reported concerns about thinking of or having had an affair were more likely to report concerns about having different sexual desires than their partners (X=56.89, P <.000), not having their sexual needs met (X=66.69, P <.000), and their partner having sexual difficulties (X = 42.05, P <.000).

For the sample as a whole, 57.1% (n=550) reported concerns about having exposure in one or more of the areas of sexual, emotional, or physical abuse during their lifetime. Nearly half, 42.0% (n=398), reported concerns about sexual coercion at some point in their lives, and 43.6% (n=412), reported concerns about having been physically or emotionally abused.

Discussion

Our study confirms that sexual concerns are virtually universal among women, and since many of these sexual concerns have health implications, it reinforces the public health importance of this domain.⁸ In our study, 98.8% reported one or more sexual concerns, a higher percentage than in previous studies that have indicated a prevalence of one or more sexual concerns ranging from 53% (n=228)⁹ to 75% (n=212).¹⁰ The greater prevalence of sexual concerns in our study may be in part because of the broader range of sexual concerns queried by our instrument. Thus, our study substantiates the ubiquity of sexual concerns and underscores the potential importance of addressing sexual issues in the clinical encounter. A much lower percentage of women in the general population^8,11 are reported as having specific sexual concerns: dyspareunia (14.4%), preorgasmic (24.1%), lack of interest (33.4%), and difficulty lubricating (18.8%). Our results may indicate a higher prevalence for women who are seeking health care, supporting the case for physicians’ active inquiries about sexual concerns. Many sexual concerns are potentially treatable by physicians.

Nearly half of our respondents reported a concern about sexual coercion at some point in their lives, a percentage very similar (47.6% to 57%) to that of a recent report of lifetime prevalence of sexual victimization of women.¹² Survey data for the general population11 revealed that 22% of women aged 18 to 59 years reported being forced to have sex by a man, and 17% of women reported having been sexually touched when they were children. The higher percentage in our study may be because these women are more likely to seek health care or because of the much broader age range of our respondents.

Limitations

A weakness of our study is that the results may not be generalizable to other patient populations. Although this study sample of military beneficiaries is undoubtedly different from a random sample of women from the general population, there is no reason to believe that these differences are so great as to alter our main findings and conclusions. For example, compared with the 1990 census data from the state of Washington, the study sample had a similar age distribution and only a small difference in racial composition. Most notable, our sample had substantially fewer (2.4%) single, never married women in comparison with the state (20.8%), a difference that would probably result in our underestimation of the prevalence of sexual concerns. Our study does provide a better sample across all income groups than previous studies, which tended to include more upper-class and middle-class subjects.

Conclusions

The response rate of 65%, considered excellent for a self-report mail survey dealing with a sensitive subject,¹³ indicates that the topic of sexual concerns is important. Our results study suggest the prevalence of sexual concerns is high and varied among a large sample of typical US women. These data highlight the sexual health care needs of women and describe some of their details. What is clear from these results is that in a reasonably large sample of women with ready access to gynecological care, a broad range of sexual health concerns is common across all ages. Sexuality is an integral part of health, quality of life, and general well-being, and primary care physicians should be trained and prepared to address these sexual concerns.

Acknowledgments

We would like to thank the women who participated in this study, who shared very personal information with the understanding it would be used for physician education about sexual health.

Sexuality is an important part of the total person; integral to health, quality of life, and general well-being. It affects the way we relate to ourselves, our sexual partners, and all other people.¹ A healthy attitude about sexuality can provide numerous benefits, including a link with the future through procreation; a means of pleasure and physical release; a sense of connection to others; a form of gentle, subtle, or intense communication; enhanced feelings of self-worth; and a contribution to self-identity.²

Sexuality also carries risks, especially for women, including unwanted pregnancy, sexually transmitted diseases, and the potential for exploitation. These types of concerns are a common threat to sexual health and have been reported in 50% to 70% of marriages^3,4 and in 75% of couples who seek marital therapy.⁵

As primary health providers, family physicians are in a good position to identify and address patients’ sexual concerns, thereby promoting their overall health and well-being. Physicians, however, frequently do not recognize these concerns during the clinical encounter. Available studies suggest that less than half of patients’ concerns are recognized by their physicians, and it is believed that physicians are generally unaware of the nature and frequency of sexual concerns among their patients.^6,7

The purpose of our study was to describe the frequency and type of the sexual concerns among women attending military outpatient clinics for routine gynecological care. The military medical center was a convenient facility serving a relatively diverse population of American women. Our study also extends the work of previous prevalence studies in clinical settings of sexual concerns by providing a larger sample size.

Methods

We included women who sought routine gynecological care at the Department of Family Practice (DFP) and the Department of Obstetrics and Gynecology (OB/GYN) at Madigan Army Medical Center (MAMC), a large military medical center located in Pierce County, Washington. Beneficiaries of health care at MAMC include active duty service members, active military reserve, retired military members, their families, and eligible employed or retired civilian service members. The DFP and OB/GYN Clinics are the main providers for routine gynecological care of the Madigan military beneficiaries.

We obtained approval for this study from the Human Subjects Review Committee of the Clinical Investigation Department of Madigan Army Medical Center and the Human Subjects Review Committee of the University of Washington.

Our target population consisted of all women who sought routine gynecological care between August 1992 and December 1992 at the DFP (n=525) and between December 1992 and January 1993 at the OB/GYN department (n=1059). We excluded women who were younger than 18 years, unable to understand English, geographically unavailable for follow-up, or who had cognitive dysfunction rendering them unable to complete the questionnaire.

We collected data through waves of questionnaires mailed to all 1584 eligible women. Ninety-six women could not be located, and 8 women were ineligible because of language barriers or cognitive dysfunction. In total, 985 women who sought care in the OB/GYN department and 495 women who sought care from the DFP were located and otherwise eligible for the study (total sample size=1480 women).

Our survey instrument included 95 questions addressing sociodemographic characteristics, aspects of the patient’s sexual history, sources of knowledge about sex, their sexual concerns, and their interest and experience with addressing these concerns with physicians. The 27 types of sexual concerns queried were drawn from the sexuality literature and were measured on a 5-point Likert scale (1=never; 5=always).

We determined the number of sexual concerns per respondent by recoding the Likert scales into dichotomous (yes/no) responses and summing the positive responses. Responses recoded as “yes” included all positive responses on the Likert scale, from “occasionally” to “always.” We also recoded positive responses into “high” and “low” categories to illustrate the distribution by frequency of sexual concerns. Missing data were excluded from analysis. We used descriptive statistics to define the study population.

Results

We received 964 completed questionnaires from 1480 eligible subjects, for a response rate of 65.1%. Demographic data are shown in Table 1. Respondents were 18 to 87 years old (mean=45.4 years, median=44.0 years, standard deviation=16.79). Almost half were exclusively homemakers, and a smaller percentage was employed outside the home. Eighty-five percent of the women in the sample were married.

Sexual Concerns

Almost all respondents, 98.8% (n=952), reported one or more sexual concerns, with a mean of 12.5 concerns per woman. Frequencies of sexual concerns are listed in descending order in Table 2. Single women had more sexual concerns than married women (80.5% vs 71.5% having 10 or more sexual concerns), and widowed women had even fewer (50.8% having 10 or more sexual concerns, (X = 21.97, P=.001). The total number of sexual concerns increased with level of education ( X = 30.42, P <.001) and decreased with increasing age (X=41.90, P=.000). Women who reported concerns about thinking of or having had an affair were more likely to report concerns about having different sexual desires than their partners (X=56.89, P <.000), not having their sexual needs met (X=66.69, P <.000), and their partner having sexual difficulties (X = 42.05, P <.000).

For the sample as a whole, 57.1% (n=550) reported concerns about having exposure in one or more of the areas of sexual, emotional, or physical abuse during their lifetime. Nearly half, 42.0% (n=398), reported concerns about sexual coercion at some point in their lives, and 43.6% (n=412), reported concerns about having been physically or emotionally abused.

Discussion

Our study confirms that sexual concerns are virtually universal among women, and since many of these sexual concerns have health implications, it reinforces the public health importance of this domain.⁸ In our study, 98.8% reported one or more sexual concerns, a higher percentage than in previous studies that have indicated a prevalence of one or more sexual concerns ranging from 53% (n=228)⁹ to 75% (n=212).¹⁰ The greater prevalence of sexual concerns in our study may be in part because of the broader range of sexual concerns queried by our instrument. Thus, our study substantiates the ubiquity of sexual concerns and underscores the potential importance of addressing sexual issues in the clinical encounter. A much lower percentage of women in the general population^8,11 are reported as having specific sexual concerns: dyspareunia (14.4%), preorgasmic (24.1%), lack of interest (33.4%), and difficulty lubricating (18.8%). Our results may indicate a higher prevalence for women who are seeking health care, supporting the case for physicians’ active inquiries about sexual concerns. Many sexual concerns are potentially treatable by physicians.

Nearly half of our respondents reported a concern about sexual coercion at some point in their lives, a percentage very similar (47.6% to 57%) to that of a recent report of lifetime prevalence of sexual victimization of women.¹² Survey data for the general population11 revealed that 22% of women aged 18 to 59 years reported being forced to have sex by a man, and 17% of women reported having been sexually touched when they were children. The higher percentage in our study may be because these women are more likely to seek health care or because of the much broader age range of our respondents.

Limitations

A weakness of our study is that the results may not be generalizable to other patient populations. Although this study sample of military beneficiaries is undoubtedly different from a random sample of women from the general population, there is no reason to believe that these differences are so great as to alter our main findings and conclusions. For example, compared with the 1990 census data from the state of Washington, the study sample had a similar age distribution and only a small difference in racial composition. Most notable, our sample had substantially fewer (2.4%) single, never married women in comparison with the state (20.8%), a difference that would probably result in our underestimation of the prevalence of sexual concerns. Our study does provide a better sample across all income groups than previous studies, which tended to include more upper-class and middle-class subjects.

Conclusions

The response rate of 65%, considered excellent for a self-report mail survey dealing with a sensitive subject,¹³ indicates that the topic of sexual concerns is important. Our results study suggest the prevalence of sexual concerns is high and varied among a large sample of typical US women. These data highlight the sexual health care needs of women and describe some of their details. What is clear from these results is that in a reasonably large sample of women with ready access to gynecological care, a broad range of sexual health concerns is common across all ages. Sexuality is an integral part of health, quality of life, and general well-being, and primary care physicians should be trained and prepared to address these sexual concerns.

Acknowledgments

We would like to thank the women who participated in this study, who shared very personal information with the understanding it would be used for physician education about sexual health.