Sexuality is both an individual and social phenomenon, enacted through relationships that are structured and limited by cultural, political and economic forces. Social determinants of health, defined by the CDC (Centers for Disease Control and Prevention) as “conditions in the places where people live, learn, work and play,” are therefore necessarily relevant to sexual health.¹ But any attempt to apply this theory to health care practice is brought up short by questions about which aspects of sexual health are thus influenced, which populations of patients are affected, and which social forces and conditions are most relevant.

A narrative review recently published by Higgins et al critiques the abundance of research examining the effects of various factors on sexual health (including gender, sexual orientation, race, religion and education) for its neglect of “poverty and socioeconomic conditions [which] are largely omitted from this scholarship, despite socioeconomic status being among the largest influences on people’s lived experiences.”² This is an important call to action for sexual health research, but still leaves unanswered how best to study the relevant aspects of socioeconomic status (SES) and their relationship to various clinical conditions.

We offer one response in Kim et al, a cross-sectional study that investigated the relationship between female sexual dysfunction (FSD) and SES using data from the National Health and Nutrition Examination Survey (NHANES), a survey of the U.S. population published by the National Center for Health Statistics of the CDC, from 2007 to 2016.³ NHANES included data about income, which were used to calculate participants’ poverty income ratio (PIR) and quantify SES. It also included a sexual behavior questionnaire, conducted in privacy using a self-interview system to encourage honest responses.

Despite the fact that FSD is well defined with characteristic disease symptoms (including those of sexual desire, arousal, orgasm and dyspareunia),⁴ the sexual behavior questionnaire did not specifically inquire about these; this was in contrast to male sexual dysfunction and erectile dysfunction, about which male NHANES participants were explicitly interrogated. Therefore, we used sexual frequency as a surrogate for female sexual function, and diagnosed FSD in those women whose replies to the question, “In the past 12 months, how many times have you had vaginal or anal sex?” fell within the first quartile of responses, with ≥11 sexual incidents in the past 12 months.

While sexual frequency is certainly an imperfect measure of FSD, it is collected as a key variable in 5 of 7 well-validated scales assessing FSD from direct patient input, and low sexual frequency has been found to be strongly associated with FSD among Western and European nations.^5,6 Therefore, in the absence of any direct questions about symptoms of FSD, sexual frequency was determined to be the best proxy for measuring FSD in the data available. Analysis was conducted using SPSS^® v27 using complex survey design analysis in order to extrapolate the NHANES study population into the national U.S. population.

Figure 1. Sexual frequency of participants.

In total, the analysis included 7,348 NHANES participants from 2007 to 2016, representing 43 million U.S. women aged 20–59 years. Within our population, 26.3% of participants reported sexual frequency of ≥11 times/year (see Figure). We found that patients of lower SES (PIR <2) were twice (OR=1.98; 95% CI=1.25-3.13) as likely to report lower sexual frequency (0-11 times/year) compared to those of higher SES (PIR ≥2), after adjusting for relevant social history, gynecologic history and significant medical conditions (p=0.003; see Table). This demonstrates that lower SES is likely to be associated with FSD among women in the U.S.³

Our study has several clear limitations. In addition to the aforementioned uncertainty regarding the correlation of FSD diagnosis with low sexual frequency, given its cross-sectional and observational design, causality between SES and FSD as measured by low sexual frequency cannot be inferred. Since it relied on a retrospective survey questionnaire for data, this study is subject to recall bias. In addition, we did not adjust for every individual risk factor for FSD, such as history of abortions or sexual abuse, nor could we adjust for relational risk factors to exclude females whose partners have sexual dysfunction.

Notwithstanding these limitations’indeed, even because of them’the study has several noteworthy strengths. Its methodology calls attention to a significant gender inequity: that despite the prevalence of FSD symptoms (present in over 40% of women) exceeding that of male erectile dysfunction,⁷ our national health statistics neglect the former while explicitly concerning themselves with the latter. This systemic, macro-level neglect is mirrored in micro-level clinical encounters, as health care providers often avoid asking female patients about sexual activity and FSD symptoms, even in gynecologic care settings, where they are clearly relevant.⁸ The inclusion of FSD in the AUA Core Curriculum is an important corrective to this bias within urology.

Paradoxically, the relative neglect of female sexual symptoms in clinical practice and national health statistics is inverted within the extant research literature about SES and other social determinants of sexual health, the majority of which is devoted to White women.² By using NHANES, which purposely oversamples from demographics that have been historically overlooked by population surveys including racial and ethnic minorities and elderly adults, we redress some of this bias. However, by focusing exclusively on FSD, our study does recapitulate the historical and habitual tendency of sexual medicine to consider female sexual problems as psychosocial and male sexual dysfunction as biological, when both sexes would be more accurately represented and served by a balanced biopsychosocial approach.⁹

Our study suggests that regular screening for FSD is most warranted by patients of lower SES, particularly women who are 50 years or older, are non-Hispanic Black, and have comorbid diabetes or depressive symptoms, since the association of SES and FSD is stronger in these subgroups. These findings also highlight the importance of having affordable options for the diagnosis and treatment of FSD, as the cost of specialist female sexual health care and treatment can be a significant barrier to access. Asking about symptoms’in our epidemiological surveys, clinical encounters and research’is the principal step and can be a potent force for positive change.¹⁰