Female genital mutilation: cultural and psychological implications

Female genital mutilation (FGM) is widely practised in several regions of the world. It is often associated with physical, psychological, sexual and social sequelae. Migration of persons from cultures that actively practice FGM to the UK and other Western countries increases the chances that clinicians will be faced with patients who have undergone this procedure. Clinical presentations often occur against a background of differences in culture and social identity, which may pose a challenge to any form of intervention. Perceptions of normalcy, human rights violation and gender roles may also differ. This paper discusses historical, cultural, gender and identity issues associated with FGM and its psychological and sexual implications.

A literature review on vulvodynia and distress

 Distress about a sexual problem is a necessary part of diagnosing female sexual dysfunction. It is an important way to distinguish between a sexual problem and normal sexual variation and has implications for treatment seeking, motivation for therapy and prognosis. The concept of distress, however, has not been clearly defined and is complex and poorly understood. Furthermore, there has been limited research into distress related to genital pain disorders. This paper explores the concept of distress within the field of vulvodynia research, specifically the distress that results from genital pain. Due to the limited research into distress relating specifically to genital pain this review will contextualise the available literature within the larger context of distress related to other female sexual dysfunctions. The discussion includes the current and future Diagnostic and Statistical Manual definitions for genital pain, as well as general definitions of distress. It also explores distress in the genital pain and general female sexual dysfunction literature and discusses its diagnostic, research and clinical implications.

Reducing harmful traditional practices in Adjibar, Ethiopia : lessons learned from the Adjibar safe motherhood project

This paper assesses the impact of the Adjibar Safe Motherhood Project and derives lessons of value to future interventions. Amongst the participatory qualitative methods used were 15 group discussions, eight semi-structured interviews, a number of opportunistic informal discussions and observation. The information gathering was complemented by a detailed review of project documents. Field visits for data collection took place over a six day period in March 2005. The project was effective in raising awareness about maternal health, and the social, economic and health consequences of various harmful traditional practices (HTPs). It has also mobilised the community to monitor and report HTPs and has strengthened referral systems for counselling, support and treatment. A number of effective strategies were identified as having contributed to project success. These are presented using the framework offered by the Ottawa Charter for Health Promotion which presents five areas of public health action: developing personal skills; strengthening community action; building healthy public policy; re-orienting health services; and, creating supportive environments. This evaluation contributes to and strengthens the expanding body of literature about effective development practices to reduce HTPs. It demonstrates that addressing HTPs takes time and long term investment; both are necessary to enable better understanding of the social and cultural reasons for HTPs before attempting to address them, and to build the community trust necessary to overcome the natural resistance to challenging such deeply entrenched practices. The project also highlighted the importance of developing a multi pronged strategy based on engagement with a broad range of stakeholders and supportive legislation.

The impact of study design on prevalence estimates of female sexual dysfunction

Introduction, objectives Despite increasing research, the true prevalence of Female Sexual Dysfunction (FSD) remains a contentious issue. Previous research suggests that aspects of study design affect the reported prevalence of FSD. We compare commonly used instruments for assessing FSD. Methods A random sample of 240 Australian women aged 20-70 participated in this population based, cross-sectional study. A questionnaire mailed to women across Australia included four instruments for assessing FSD. The Sexual Function Questionnaire combined with the Female Sexual Distress Scale (SFQ-FSDS) was employed as a standard, validated instrument. Alternative instruments were the SFQ alone and two modified versions of a set of questions originally developed by Laumann et al. Results When assessed by the SFQ-FSDS, prevalence estimates (and 95% confidence intervals) of Hypoactive Sexual Desire Disorder, Female Sexual Arousal Disorder (genital subtype), Female Orgasmic Disorder, and Dysparunia were 16%(11-20%), 8%(4-11%), 9%(6-13%), 2%(0.1-3%) respectively. The prevalence estimates of these same disorders obtained using alternative instruments were 32-55%, 17-35%, 17-33% and 3-25% respectively. The sensitivity of alternative instruments varied widely (0 to 1.0). Specificities ranged from 0.51 to 0.99. Positive predictive values ranged from 0 to 0.57. Negative predictive values were all above 0.90. Changing the time span for recalling sexual experiences in an instrument altered the prevalence estimates, sensitivity and specificity. 32% of women with low desire, 31% with low genital arousal, 36% with orgasm difficulty and 57% with sexual pain were sexually distressed. Conclusion Over a third of women who were classified as suffering FSD by alternative instruments did not have FSD when assessed by SFQ-FSDS. Alternative instruments produced substantially higher prevalence estimates of FSD and identified different groups of women. Consequently, the instruments researchers choose to assess FSD may affect both the prevalence estimates and risk factors they report.

Pain during mammography: implications for breast screening programmes

Pain experienced during mammography can deter women from attending for breast cancer screening. Review of the current literature on pain experienced during mammography reveals three main areas of interest: reports of the frequency of pain, identification of predictors of pain and strategies for responding to pain. Implications of this literature for breast screening programmes include the need for appropriate measurements of pain during mammography that are valid for screening populations, a further understanding of organizational factors involved in screening programmes that may be predictors of pain and for the development of valid strategies for responding to pain within breast screening programmes.

Patellar tendons with normal imaging and pain: change in imaging and pain status over volleyball season

Objective: Patellar tendon injury commonly presents as abnormal imaging with pain or abnormal imaging without pain. Normal imaging with pain has also been reported clinically, but little is known about the behavior of these tendons over time. This study investigated the behavior of tendons with normal imaging and pain over a volleyball season.

Design: Prospective study.

Setting: Institutional.

Participants: One hundred and one male and female volleyball players.

Main outcome measurements: At the beginning and end of the season ultrasound determined imaging status and the single leg decline squat test determined pain. The imaging and pain status at follow-up of tendons with normal imaging and pain at baseline was reported and contrasted to the imaging and pain status of the other patellar tendon injuries.

Results: Tendons with normal imaging and pain [relative risk (RR) 15.1], abnormal imaging without pain (RR 14.6), and abnormal imaging with pain (RR 51.5) had a greater risk of having abnormal imaging with pain at the end of the season when compared with normal tendons (P < 0.01). Among tendons with normal imaging and pain at baseline, 27% had abnormal imaging without pain and 21% contained abnormal imaging with pain at the end of the season.

Conclusions: Patellar tendons with normal imaging and pain at the beginning of a volleyball season are equally as likely to have abnormal imaging and pain at the end of the season as tendons with abnormal imaging without pain. Normal imaging with pain may represent a clinically relevant patellar tendon injury.

Prevalence of genital human papillomavirus DNA in a sample of senior school-aged women in the Australian Capital Territory

Background: A strong association between persistent infection with oncogenic types of human papillomavirus (HPV) and cervical cancer is well established. Small numbers of international studies examining adolescent HPV infection and the risk factors associated are published, but there is currently no evidence on the prevalence and risk factors for HPV in an Australian, sexually active female adolescent population. Methods: To provide prevalence and risk factors for HPV in a female sexually active, senior high school population in the Australian Capital Territory (ACT), a convenience sample of 161, 16–19-year-old females attending a senior high school was evaluated. The sample formed part of a larger sample recruited for a study of sexually transmitted infections and blood-borne viruses in senior high school students. A clinical record was used to collect information about sexual and other risk behaviours, while self-collected vaginal swabs were tested for HPV DNA detection and genotyping using polymerase chain reaction. Results: The prevalence of HPV DNA in this sample overall was 11.2%, with multiple genotypes in 38%. No statistically significant associations were found between HPV DNA and the number of male partners, age of coitarche, time since first sexually active, condom use, smoking or alcohol intake. Conclusions: This is the first Australian study that has examined the prevalence and risk factors for genital HPV in this demographic group. The prevalence of HPV infection is slightly lower than reported in similar age groups overseas and is lower than other Australian studies in older women and those attending sexual health centres. Of HPV-positive young women, high-risk genotypes were found in over half, with more than one-third of HPV existing as multiple genotypes. Large community-based prevalence studies are needed to guide the development of recommendations for the vaccination of young women against HPV and to support other health promotion initiatives.

The impact of patient sex on paramedic pain management in the prehospital setting

Objective: The aim of this study was to establish the impact of patient sex on the provision of analgesia by paramedics for patients reporting pain in the prehospital setting.
Methods: This retrospective cohort study of paramedic patient care records included all adult patients with a Glasgow Coma Score higher than 12 transported to hospital by ambulance in a major metropolitan area over a 7-day period in 2005. Data collected included demographics, patient report of pain and its type and severity, provision of analgesia by paramedics, and type of analgesia provided. The outcomes of interest were sex differences in the provision of analgesia. Data analysis was by descriptive statistics, χ2 test, and logistic regression.
Results: Of the 3357 patients transported in the study period, 1766 (53%) reported pain; this forms the study sample. Fifty-two percent were female, median age was 61 years, and median initial pain score (on a 0-10 verbal numeric rating scale) was 6. Forty-five percent of patients reporting pain did not receive analgesia (791/1766) (95% confidence interval [CI], 43%-47%), with no significant difference between sexes (P = .93). There were, however, significant sex differences in the type of analgesia administered, with males more likely to receive morphine (17%; 95% CI, 15%-20%) than females (13%; 95% CI, 11%-15%) (P = .01). The difference remains significant when controlled for type of pain, age, and pain severity (odds ratio, 0.61, 95% CI, 0.44-0.84).
Conclusion: Sex is not associated with the rate of paramedic-initiated analgesia, but is associated with differences in the type of analgesia administered.

What can prevalence studies tell us about female sexual difficulty and dysfunction?

Introduction. Many recent studies have investigated the prevalence of female sexual difficulty/dysfunction.
Aim. Investigate female sexual difficulty/dysfunction using data from prevalence studies.
Methods. We reviewed published prevalence studies excluding those that had not included each category of sexual difficulty (desire, arousal, orgasm, and pain), were based on convenience sampling, or had a response rate <50% or a sample size <100.
Main Outcome Measures. For each study we used the prevalence of any sexual difficulty as the denominator and calculated the proportion of women reporting each type of difficulty. For each category of sexual difficulty we used the prevalence of that difficulty lasting 1 month or more as the denominator and calculated the proportion of difficulties lasting several months or more and 6 months or more.
Results. Only 11 of 1,248 studies identified met our inclusion criteria. These studies used different measures of sexual dysfunction, so generating a simple summary prevalence was not possible. However, we observed consistent patterns in the published data. Among women with any sexual difficulty, on average, 64% (range 16–75%) experienced desire difficulty, 35% (range 16– 48%) experienced orgasm difficulty, 31% (range 12–64%) experienced arousal difficulty, and 26% (range 7–58%) experienced sexual pain. Of the sexual difficulties that occurred for 1 month or more in the previous year, 62–89% persisted for at least several months and 25–28% persisted for 6 months or more. Two studies investigated distress. Only a proportion of women with sexual difficulty were distressed by it (21–67%).
Conclusions. Desire difficulty is the most common sexual difficulty experienced by women. While the majority of difficulties last for less than 6 months, up to a third persist for 6 months or more. Sexual difficulties do not always cause distress. Consequently, prevalence estimates will vary depending on the time frame specified by researchers and whether distress is included in these estimates.

Are aspects of study design associated with the reported prevalence of female sexual difficulties?

Objective: To investigate associations between the prevalence of sexual  difficulties reported in published studies and design features of those studies to determine if differences in design contribute to variation in prevalence estimates.
Design: Systematic review, multivariate analysis.
Setting: Studies published internationally in English.
Patient(s): Not applicable.
Intervention(s): None.
Main Outcome Measure(s): Prevalence estimates of difficulty with desire, arousal, orgasm, and sexual pain reported in published studies.
Result(s): Our systematic literature search identified 1,380 publications. Fifty-five studies met our inclusion criteria (reporting prevalence, sample size and response rate, sample size greater than 100, not clinic based). Reported prevalence of sexual difficulty varied across studies (up to tenfold). Eleven aspects of research conduct in these studies were included in our multivariate analysis as explanatory variables. Five aspects of study design and conduct (data collection procedures, inclusion criteria, duration of sexual difficulty recorded, sample size, and response rate) were associated with the reported prevalence of at least one type of sexual difficulty independently of likely predictors of true variation in prevalence: study location, study year, and age range of participants.
Conclusion(s): This review provides evidence that study design may influence reported prevalence estimates of female sexual difficulties and contribute to the wide variation in published estimates.

Risk factors for female sexual dysfunction in the general population : exploring factors associated with low sexual function and sexual distress

Introduction. No previous population-based studies have used validated instruments to measure female sexual dysfunction (FSD) in Australian women across a broad age range.
Aim. To estimate prevalence and explore factors associated with the  components of FSD.
Main Outcome Measures. Sexual Function Questionnaire measured low sexual function. Female Sexual Distress Scale measured sexual distress.
Methods. Multivariate analysis of postal survey data from a random sample of 356 women aged 20–70 years.
Results. Low desire was more likely to occur in women in relationships for 20–29 years (odds ratio 3.7, 95% confidence intervals 1.1–12.8) and less likely in women reporting greater satisfaction with their partner as a lover (0.3, 0.1–0.9) or who placed greater importance on sex (0.1, 0.03–0.3). Low genital arousal was more likely among women who were perimenopausal (4.4, 1.2–15.7), postmenopausal (5.3, 1.6–17.7), or depressed (2.5, 1.1–5.3), and was less likely in women taking hormone therapy (0.2, 0.04–0.7), more educated (0.5, 0.3–0.96), in their 30s (0.2, 0.1–0.7) or 40s (0.2, 0.1–0.7), or placed greater importance on sex (0.2, 0.05–0.5). Low orgasmic function was less likely in women who were in their 30s (0.3, 0.1–0.8) or who placed greater importance on sex (0.3, 0.1–0.7). Sexual distress was positively associated with depression (3.1, 1.2–7.8) and was inversely associated with better communication of sexual needs (0.2, 0.05–0.5). Results were adjusted for other covariates including age, psychological, socioeconomic, physiological, and relationship factors.
Conclusions. Relationship factors were more important to low desire than age or menopause, whereas physiological and psychological factors were more important to low genital arousal and low orgasmic function than relationship factors. Sexual distress was associated with both psychological and relationship factors.

Modeling response rates in surveys of female sexual difficulty and dysfunction

INTRODUCTION: Studies that address sensitive topics, such as female sexual difficulty and dysfunction, often achieve poor response rates that can bias  results. Factors that affect response rates to studies in this area are not well characterized.
AIM: To model the response rate in studies investigating the prevalence of female sexual difficulty and dysfunction.
METHODS: Databases were searched for English-language, prevalence studies using the search terms: sexual difficulties/dysfunction, woman/women/female, prevalence, and cross-sectional. Studies that did not report response rates or were clinic-based were excluded. A multiple linear regression model was constructed.
MAIN OUTCOME MEASURES: Published response rates.
RESULTS: A total of 1,380 publications were identified, and 54 of these met our inclusion criteria. Our model explained 58% of the variance in response rates of studies investigating the prevalence of difficulty with desire, arousal, orgasm, or sexual pain (R(2) = 0.581, P = 0.027). This model was based on study design variables, study year, location, and the reported prevalence of each type of sexual difficulty. More recent studies (beta = -1.05, P = 0.037) and studies that only included women over 50 years of age (beta = -31.11, P = 0.007) had lower response rates. The use of face-to-face interviews was associated with a higher response rate (beta = 20.51, P = 0.036). Studies that did not include questions regarding desire difficulties achieved higher response rates than those that did include questions on desire difficulty (beta = 23.70, P = 0.034).
CONCLUSION: Response rates in prevalence studies addressing female sexual difficulty and dysfunction are frequently low and have decreased by an average of just over 1% per anum since the late 60s. Participation may improve by conducting interviews in person. Studies that investigate a broad range of ages may be less representative of older women, due to a poorer response in older age groups. Lower response rates in studies that investigate desire difficulty suggest that sexual desire is a particularly sensitive topic.

Experiences of Australian professional female tennis players returning to competition from injury

Background: This study examined the experiences of professional female tennis players returning to competition from injury.

Methods: In a study commissioned by Tennis Australia, 55 Australian professional female tennis players responded anonymously to a questionnaire developed for the purposes of this study. The questionnaire consisted of open and closed questions that assessed a player’s attribution style, the occurrence and effect of minor and major injuries, frequency and type of treatment sought, attitudinal chances following injury and preventative injury factors.

Results: The quantitative and qualitative analyses of participants’ responses revealed players generally displayed an internal attribution style with the majority of minor injuries involving lower limb injuries (attributed to playing on hard surfaces). Players reported these injuries were addressed in a variety of ways including self-treatment. The majority of severe injuries were upper limb/shoulder and these were generally treated at tournament sites with some requiring surgery.

Conclusions: Players adopted a range of measures to assist recovery from severe injury including the services of health professionals. In further findings, a player’s attribution style was not a predictive variable, except in terms of the number of tournaments missed for minor injuries. Implications of the study’s results and future research directions for cross-cultural studies are highlighted.