create the summary of the findings "MATERIALS AND METHODS
Patients and setting
This cross-sectional study was conducted between January 2012 and August
2013. The study sample consisted of female patients with SCI who had been
referred to the Brain and Spinal Cord Injury Repair Research Center in Tehran,
Iran. Brain and Spinal Cord Injury Repair Research Center is a referral center
for patients with SCI from all over the country. The inclusion criterion were
age 18 years older, married or sexually active within the past 6 months, and
having a SCI at any neurological level for longer than 6 months. Patients with
1Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; 2Department of Neurosurgery Center, Imam
Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran; 3Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia; 4Ain Shams University,
Cairo, Egypt; 5Department of Medicine and Psychiatry, Duke University Medical Center, Durham, NC, USA; 6Social Determinants of Health Research Center, Qazvin University of
Medical Sciences, Qazvin, Iran and 7Department of Public Health, Qazvin University of Medical Sciences, Qazvin, Iran
Correspondence: Dr AH Pakpour, Department of Public Health, Qazvin University of Medical Sciences, Shahid Bahounar BLV, Qazvin 3419759811, Iran.
E-mail: <PRESIDIO_ANONYMIZED_EMAIL_ADDRESS> or <PRESIDIO_ANONYMIZED_EMAIL_ADDRESS>
Received 25 February 2014; revised 10 April 2014; accepted 7 May 2014; published online 17 June 2014
Spinal Cord (2014) 52, 646–649
& 2014 International Spinal Cord Society All rights reserved 1362-4393/14
www.nature.com/sc
major medical diseases, including diabetes mellitus, cardiovascular diseases,
hypertension, rheumatic diseases, kidney disease, severe mental and psychiatric
disorders, substance abuse or pregnant, were excluded from the study. Also
excluded were patients who suffered from cognitive impairment that was
assessed by the Mini-Mental State Exam. Patients were excluded from the
study if they had Mini-Mental State Exam o27. After checking their eligibility
criteria, all potential participants were informed about aims of the study and
asked to read and sign an informed consent form. The study was approved by
the Institutional Review Board of Qazvin University of Medical Sciences.
Measures
Sociodemographic questions included age, educational status, employment
status, living situation and whether or not the participant had children. Also
collected from the medical information were information about the duration
of SCI in months, level of lesion and the reason for the SCI. The neurological
status of the patients (that is, motor and sensory levels impaired by the
SCI) was evaluated using the American Spinal Injury Association (ASIA)
guidelines.10
FSFI
The 19-item FSFI is a multidimensional tool to assess females’ sexuality and
has been used in both clinical and community populations. The measure is
composed of six subscales including sexual desire (two items), arousal (four
items), lubrication (four items), orgasm (three items), satisfaction (three
items) and pain (three items). All subscale scores ranged from 0 to 5 with
higher scores indicating better sexual functioning. Subscale scores are summed
to obtain a total score for the FSFI. Scores of 27 or lower have been identified
as the cutoff for sexual dysfunction.11 The Iranian version of the FSFI has been
found to be a valid and highly reliable tool for detecting sexual dysfunction
among women.9
Hospital anxiety and depression scale (HADS)
The HADS is a self-administered measure of anxiety and depression that
consists of 14 questions divided into two subscale (7 items for anxiety and
7 items for depression). All items are rated on a four-point response scale
ranging from 0 (absence of symptoms) to 3 (severe symptoms). Both anxiety
and depression scales range from 0 to 21 with higher scorers indicating higher
symptoms of distress. The recommended cutoff scores for both anxiety and
depression are: 0–7 (non-case), 8–10 (possible case) and 11–21 (cases). The
HADS has been translated into Persian (Farsi), and its psychometric properties
have been established in Iranian populations.12
Female sexual distress scale-revised (FSDS-R)
The FSDS-R is a 13-item questionnaire that assesses different aspects of sexual
distress in women. All items are rated on a Likert-type-scale ranging from
0 (never) to 4 (always) with higher scores indicating greater sexual distress.
Items are summed to create a total score for the FSDS-R. A score of 11 or
higher is considered the cutoff for women with sexual distress. The Iranian
version of the FSDS-R has acceptable psychometric properties when used in
Iranian women.13
Statistical analysis
A control sample of 1123 Iranian women without SCI was taken from a
previous study.13 Women in the control group did not have any systematic
diseases that might interfere with sexual functioning. The control group was
matched for age, educational status and having children to women with SCI.
Descriptive statistics were used to summarize the characteristics of the sample,
including scores on the FSFI subscales, FSDS-R and HADS. Symptoms of
depression, anxiety, sexual distress and dysfunction were compared between
cases and controls using the w2 test or Student’s t-test. Benjamini and
Hochberg adjustments in the level of statistical significance were made to
control for multiple comparisons.14
A logistic regression model was used to identify correlates of FSD (defined as
an FSFI total score p27) controlling for potential confounders. In this model,
FSD status (FSD¼ 1 and healthy ¼ 2) was the dependent variable, whereas age,
living situation, educational status, work status, ASIA grade, FSDS-R score,
depression and anxiety were entered as independent variables. A forward
selection method was used in the analysis, entering all variables that were
significant in bivariate analyses at Po0.10 into the model at one time.
Multicollinearity was checked by calculating the tolerance collinearity statistics
and the variance inflation factor, where a tolerance less than 0.2 and variance
inflation factor 45 indicate problems.15 All statistical analyses were done using
SPSS, version 16 (SPSS, Chicago, IL, USA).
RESULTS
Of 118 eligible patients with SCI, 13 (11%) declined to participate
because of discomfort over answering questions about sexual functioning, which reflects the highly personal and private nature of
sexual activity in Iran. Average age was 41.0 (10.1) years. Education
level was relatively low, with only 36.2% educated at the secondary
school level. A majority were from urban areas (74.3%). Most
(80.0%) had acquired their SCI from motor vehicle accidents. The
ASIA grade was A in 57.1%, B in 14.3%, C in 9.5%, D in 14.3% and E
in 4.8%. For about half (43%), the site of injury was at the thoracic
Table 1 Sociodemographic and clinical characteristics of the study
population
Patients with SCI (n ¼ 105)
Age, years 41.0 (10.1)
Living situation
Urban 78 (74.3%)
Rural 27 (25.7%)
Education
No school 10 (9.5%)
Primary school 38 (36.2%)
Secondary school 42 (4.0%)
College school or above 15 (14.3%)
Work status
Retired 7 (6.7%)
Employed 10 (9.5%)
Unemployed 88 (83.8%)
Children
No 36 (34.3%)
Yes 69 (65.7%)
ASIA grade
A 60 (57.1%)
B 15 (14.3%)
C 10 (9.5%)
D 15 (14.3%)
E 5 (4.8%)
Lesion level
Cervical 37 (35.2%)
Thoracic 45 (42.9%)
Lumbar-sacral 23 (21.9%)
Etiology of SCI
Fall 9 (8.6%)
Impact of object on the body 12 (11.4%)
Car accident 84 (80.0%)
Abbreviations: ASIA, American Spinal Injury Association; SCI, spinal cord injury.
Female sexual dysfunction in patients with SCI
M Hajiaghababaei et al
647
Spinal Cord
level. Table 1 presents the demographic and clinical characteristics of
the study population.
To assess the impact of age categories on the FSFSI subscales, a oneway analysis of variance with Bonferroni correction was performed.
The results of the analysis of variance indicated that older patients
suffered from more sexual dysfunction compared with younger
patients. Younger patients reported significantly higher scores on
the all FSFSI subscales compared with older patients (Po0.05).
Women with SCI reported significantly higher levels of sexual
dysfunction compared with healthy women in the control sample
(Table 2). Among the FSFSI subscales, lack of vaginal lubrication was
reported more frequent in patients with SCI compared with controls.
The overall prevalence of FSD based on the cutoff score for the FSFI
was 87.6% compared with only 37% of healthy controls (Po0.001).
Sexual distress (FSDS-RX11) was twice as common in women with
SCI compared with controls (52% vs 25%, P ¼ 0.02). Moreover,
women with SCI reported a significantly higher level of sexual distress
compared with healthy controls (Table 2). Combined sexual distress
or sexual dysfunction was present in 48% of patients with SCI
compared with 21% of healthy controls (Po0.01).
The scores on the anxiety and depression subscales of the HADS
are presented in Table 3. Patients with SCI had significantly more
symptoms of anxiety and depression compared with healthy control
women. The prevalence of significant anxiety and depression based on
cutoff scores was found to be 51% and 53%, respectively, in women
with SCI, compared with 26% and 29% in controls (P ¼ 0.015).
Correlates of FDS in bivariate analyses (Po0.1) were age,
education, living situation, work status, ASIA grade, depression and
anxiety. These correlates were entered into the logistic regression
model predicting FDS (Table 4). Sexual dysfunction was significantly
higher in older patients (odds ratio (OR) ¼ 0.945 (95% confidence
interval (CI)¼ 0.897, 0.995) P ¼ 0.033), those with lower education
(OR¼ 0.164 (95% CI¼ 0.050, 0.139) P ¼ 0.003), those with
complete lesions (OR ¼ 0.164 (95% CI¼ 0.078, 0.144) Po0.001),
those with sexual distress (OR¼ 0.920 (95% CI¼ 0.870, 0.973)
P ¼ 0.033), anxiety (OR¼ 0.720 (95% CI¼ 0.623, 0.832) Po0.001)
and depression (OR ¼ 0.669 (95% CI¼ 0.549, 0.814) Po0.001)."