!" #$ % !" &&'(& !" )*&'+' ,-.- -- /+*0 ! " "##$ %&'%$ ( ) ( ( * +! ( , -. / 0 ) . 1) 2. "##$. 3 4 ( 5 6 578 ). 0 ) . . $%. 9# . . :8; <%7$$=79">%7". 3 ' / ) ( ( 6 7 ). / ( ) %" ( $ ( ?( ) 7 ) ) ( . @ ( ( ?( ( ( ( ( ( . , ' A 7 ( %&&$ ) %>7B= +$<C ( ) - ) %<<9 ) ( D ? . ( ( ( 7 ) %>79$ . : & ( = ( 97) A ) ( ( ; ?,?, ( ( . , ' , ( ) ( ( ( . ( ) ( ( 7 ). ! ( 7 ) ( ( ( ( ( (. / ? ( + - 3) E ) . / ( + ) - ( ( ( ) ( 7 ). , ( 7 ) 7 ) (7 ) ( (( ( ?( . F ( 6 ( ( . : (( 7 ) A ) 6 ( ) ( 7 ). 5 ( @( ( 0 ) !" # " $ % &'(" " )*+&,-. " G 2 1) "##$ :; %9$%79"#9 :8; <%7$$=79">%7" ' ''' 7$>=& + '?? ..? H I ' ''' 7$>=&- ORIGINAL PAPERS This dissertation is based on the following original papers, which will be referred to in Roman numerals: I Öberg K, Fugl-Meyer KS, Fugl-Meyer AR. On sexual well-being in sexually abused Swedish women: epidemiological aspects. Sex Relat Ther 2002; 17: 329-341. II Öberg K, Fugl-Meyer AR, Fugl-Meyer KS. On categorization and quantification of women’s sexual dysfunctions: An epidemiological approach. Int J Impotence Res 2004; 16: 261-269. III Öberg K and Sjögren Fugl-Meyer K. On Swedish women’s distressing sexual dysfunctions: Some concomitant conditions and life satisfaction. J Sex Med 2005; 2: 169-180. IV Sjögren Fugl-Meyer K, Öberg K, Lundberg PO, Lewin B, Fugl-Meyer AR. On orgasm, sexual behavior and erotic perceptions in 18-74 year- old Swedish women. In manuscript. CONTENTS AIMS ..............................................................................................................7 BACKGROUND ............................................................................................8 Conceptual Deliberations ...........................................................................8 A Conceptual Model ................................................................................10 SUBJECTS AND METHODS .....................................................................20 Setting ......................................................................................................20 Sample......................................................................................................20 Procedure..................................................................................................22 Methodological Considerations................................................................29 Statistics ...................................................................................................31 MAIN RESULTS..........................................................................................34 I ................................................................................................................34 II ...............................................................................................................35 III..............................................................................................................36 IV..............................................................................................................39 Post Scriptum ...........................................................................................41 GENERAL DISCUSSION ...........................................................................43 ACKNOWLEDGEMENTS..........................................................................52 REFERENCES .............................................................................................54 ABBREVIATIONS NoD No sexual dysfunction per se NoDD No distressing sexual dysfunction MiD Mild sexual dysfunction per se MiDD Mild distressing sexual dysfunction MaD Manifest sexual dysfunction per se MaDD Manifest distressing sexual dysfunction LiSat-11 Life satisfaction checklist encompassing 11 items CI Confidence interval OR Odds ratio AIMS The overall aim of this dissertation is: To identify pertinent conditions for sexual well-being in adult Swedish women. The particular objectives of the four studies are: I To describe the prevalence of life-time sexual abuse in women, aged 18-74, and to relate sexual abuse to sexual dysfunction per se and to level of sexual satisfaction. II To describe and to classify degrees of sexual functions/dysfunctions per se and personal distress caused by them, in 18-65 year-old women, in relation to some socio-demographic characteristics and to level of sexual satisfaction. III To identify in 18-65 year old women the likelihood of co-occurrence of distressing sexual dysfunctions with different domains of life satisfaction and with a chosen set of contextual variables. IV To describe levels of orgasmic function in 18-74 year-old women, in relation to some life-time sexual behaviors and erotic perceptions. 7 BACKGROUND Exactly a century ago in “Three essays on the theory of sexuality”, Freud (1) stated that sexuality is an essential drive in the life of the human being. But, why would the scientific community seek epidemiological knowledge about sexuality and the sexual behaviour of human beings besides out of pure curiosity? With the introduction of psychotherapeutic rationales and methods for alleviating sexual problems and, in the last three decades with the development of drugs intended to restore sexual functions –at least in men- a need for knowing the incidence and prevalence of sexual dysfunctions has emerged. This knowledge is essential to decisions in public health about dimensioning treatment resources and primary or secondary measures for preventing sexual dysfunctions. Indeed, sexuality is not only a private issue, but a matter of public health: the World Health Organization emphasizes the right of people to have “the highest attainable standard of health in relation to sexuality, including access to sexual and reproductive health care services” (2). In today’s therapeutic practices whether psychological, medical or eclectic, evidence-based knowledge about human sexuality is needed. There is, however, a deplorable lack of epidemiological data, particularly concerning the conditions of women’s sexual life (3). Conceptual Deliberations This dissertation focuses on conditions for Swedish women’s sexual well- being. I open with a brief discussion of the concept of sexuality, moving on to other central concepts of this thesis. Sexuality: According to Foucault (4), the concept of sexuality did not exist in antiquity since sexuality was an integral of human conduct. The first use of the term sexuality appeared in the year 1800, suggesting that it came into existence with modern society (5). Foucault (6) emphasizes that the political, economic and technical changes that came about with industrialization led to the conceptualization of sexuality as a discrete area of human experience. Today the Oxford Advanced Learners dictionary defines sexuality as “the 8 quality of being sexual or having sex.” Besides denoting female or male biology, sex is defined as “sexual activity and everything connected with it” (7). In the year 2002 the WHO, in a Technical Consultation on Sexual Health, discussed definitions of sex, sexuality and sexual health and arrived at the following broad working definition: “Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction”(2). It thus appears that the term “sexuality” has no distinct ontology but can be regarded as a social construct. Since the social construction of sexuality operates within spheres of power (8) it facilitates societal control over sexual praxis. Epidemiological research in sexual medicine/sexology is clearly important, but may unfortunately lead to normative definitions of sexuality and sexual practices. Knowledge can even facilitate control of sexuality by political forces in for example, patriarchal societies (9). The WHO (2) further says that: “sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles, and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, cultural, political, ethical, legal, historical and religious and spiritual factors”. Sexual health is defined by the WHO (2) as a state of physical, emotional, mental and social well-being related to sexuality, and not simply as an absence of disease, dysfunction or infirmity. For good sexual health, sexual rights must be recognized as prerequisite. Sexual rights include the right of all persons to be free of coercion, discrimination and violence and to have access to sexual and reproductive health care services. Whether sexual rights can be demonstrated empirically has been discussed by an expert-group (10). Its conclusion is that the definition given above permits identification of a certain minimum to be achieved. A major focus of this dissertation lies upon the term sexual dysfunction, a somewhat