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Thomas HN, Chang CH, Dillon S, Hess R. Sexual Activity in Midlife Women: Importance of Sex Matters. JAMA Intern Med. 2014;174(4):631–633. doi:10.1001/jamainternmed.2013.14402
Sexual function is associated with health-related quality of life (HRQoL).1,2 Understanding the factors that affect aging women’s sexual activity has implications for maintenance of HRQoL in this population.
In this study, we used a longitudinal cohort to examine the factors that predict maintenance of sexual activity among midlife women. We hypothesized that higher sexual function and higher importance of sex at baseline would predict maintenance of sexual activity.
Do Stage Transitions Result in Detectable Effects (STRIDE) is a longitudinal cohort study of women ages 40 to 65 years enrolled in 2005 from a general internal medicine practice. All English-speaking women who completed written informed consent were enrolled. This study was approved by the University of Pittsburgh’s institutional review board. Women completed annual questionnaires regarding demographic variables, menopausal status and symptoms, and medical comorbidities. In year 4 of the study, women completed the Female Sexual Function Index (FSFI).3 Lower scores indicate worse sexual function. Importance of sex was assessed by a single question. Menopausal status was assigned based on self-reported bleeding history. Body mass index and medication use were abstracted from the electronic health record.
The primary outcome was sexual activity at year 8, assessed by the question: “During the past 6 months, have you engaged in any sexual activities with a partner?” Women who did not answer the questions on sexual function or who answered “No sexual activity in the prior 4 weeks” on any FSFI question were excluded.
Descriptive statistics were used to compare sexually active and inactive women at baseline. We used univariable logistic regression models to examine characteristics associated with sexual activity maintenance at study year 8. Variables that may change over time were examined longitudinally using random effects mixed models. Variables that attained clinical or marginal statistical significance (P < .20) were entered into a multivariable model.
A total of 602 women completed study year 4. Of these, 354 women (66.3%) were sexually active and form the baseline group (68 had missing data). At year 8, 228 (85.4%) remained sexually active. The mean FSFI scores among sexually active and inactive women were 22.3 and 21.8, respectively (P = .67). Women who were sexually active at baseline were more likely to be younger, white, highly educated, partnered, and earlier in the menopausal transition (Table 1).
In the multivariable model, white race (odds ratio [OR], 3.09; P = .04), lower body mass index (OR, 0.94; P = .02), and higher importance of sex (OR, 3.21; P = .01) were significant predictors of sexual activity maintenance (Table 2). The FSFI score did not predict maintenance of sexual activity in univariable or multivariable models (P = .65 and P = .98, respectively).
In contrast to prior research, we found that most sexually active midlife women remain sexually active. However, FSFI scores are consistently low in this cohort, with means falling below the cutoff for “sexual dysfunction.” This may be due to problems with the instrument itself. As women age, kissing and intimate touching become more important relative to penetrative intercourse.4,5 The FSFI’s focus on intercourse may not accurately reflect what constitutes satisfying sex in this population, yielding falsely low scores.
Women who reported greater importance of sex had higher maintenance of sexual activity. In contrast, we found that sexual function, as measured by the FSFI, is not associated with maintenance of sexual activity. This suggests that the “quality” of sex does not affect whether a woman will continue to have sex over time. Midlife women have many reasons for engaging in sex that go beyond “quality.”
These findings challenge prior assumptions about female sexual function in midlife. As we study and care for these women, a more nuanced understanding of female sexuality is essential.
Corresponding Author: Holly N. Thomas, MD, Division of General Internal Medicine, Center for Research on Healthcare, University of Pittsburgh, 230 McKee Pl, Ste 600, Pittsburgh, PA 15213 (firstname.lastname@example.org).
Published Online: February 10, 2014. doi:10.1001/jamainternmed.2013.14402.
Author Contributions: Drs Thomas and Hess had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Thomas, Hess.
Acquisition of data: Dillon, Hess.
Analysis and interpretation of data: Thomas, Chang, Hess.
Drafting of the manuscript: Thomas.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Thomas, Chang.
Obtained funding: Hess.
Administrative, technical, and material support: Hess.
Study supervision: Hess.
Conflict of Interest Disclosures: Dr Thomas is a women’s health fellow funded through the Department of Veteran’s Affairs. No other disclosures are reported.
Funding/Support: STRIDE was supported by grant AG024254 from the National Institute of Health’s National Institute on Aging.
Role of the Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Previous Presentation: An earlier version of the data in this study was presented orally at the Society of General Internal Medicine (SGIM) Annual Meeting; April 26, 2013; Denver, Colorado.
Additional Contributions: We gratefully acknowledge the women who participated in STRIDE.
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