Sexuality of Women with Rheumatoid Arthritis in a West African Hospital

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Open Journal of Rheumatology and Autoimmune Diseases, 2021, 11, 152-159
https://www.scirp.org/journal/ojra
ISSN Online: 2164-005X
ISSN Print: 2163-9914
DOI:
10.4236/ojra.2021.114016 Oct. 14, 2021 152 Open Journal of Rheumatology and Autoimmune Diseases
Sexuality of Women with Rheumatoid Arthritis
in a West African Hospital
Aly Badra Kamissoko1, Tayo Nadège Raissa Edikou1, Abdoulaye Barry1, Marina Sanda1,
Kadé Fofana1, Lou Nahan Eunice Irie1, Mamadou Lamine Diallo1,2, Owonayo Oniankitan2
1Department of Rheumatology, Ignace Deen National Hospital, Conakry, Guinea
2Department of Rheumatology, Sylvanus Olympio University Hospital, Lomé, Togo
Abstract
Background:
Rheumatoid arthritis is a chronic autoimmune disease that
causes socio-economic, psychological and sexual problems. It imposes limita-
tions on sexual relationships and these issues are still taboo in African society.
Objective:
The objective is to assess t
he impact of rheumatoid arthritis (RA)
on women’s sexuality at the Ignace Deen National Hospital.
Patients
and
Methods:
This was an analytic case-control study of 8 months (from April 6,
2020 to December 11, 2020). All patients followed for rheumatoid arth
ritis
diagnosed according to 2010 ACR/EULAR criteria for RA had been included.
Results:
One hundred and five women (52 RA patients and 53 controls) were
collected. The two groups were comparable in terms of demographic charac-
teristics. Sexual dysfunction was found in 69.2% of cases versus 35.8% of con-
trols. Women with RA had poorer sexual functioning in the categories of de-
sire, arousal, lubrication, orgasm, satisfaction, and pain of the FSFI score
compared to healthy women (p = 0.01; p = 0.7; p = 0.3; p = 0.8; p = 0.1; and p
= 0.3 respectively). Patients were 4 times more likely to have sexual dysfunc-
tion than healthy individuals and this result was statistically significant with a
p-value less than 0.05.
Conclusion:
Sexual dysfunction was noted in a large
number of RA patients surveyed at the rheumatology department of the Ig-
nace Deen national hospital. A larger study is needed to better assess this is-
sue and seek management solutions.
Keywords
Rheumatoid Arthritis, Sexuality, FSFI, Guinea
1. Introduction
Rheumatoid arthritis (RA) is a chronic and progressive autoimmune disease
How to cite this paper: Kamissoko, A.B.,
Edikou, T.N.R., Barry, A., Sanda, M., Fof
a-
na, K., Irie, L.N.E., Diallo, M.L. and Onia
n-
kitan, O.
(2021)
Sexuality of Women with
Rheumatoid Arthritis in a West African
Hospital
.
Open Journal of Rheumatology
and Autoimmune Diseas
es
,
11
, 152-159.
https://doi.org/10.4236/ojra.2021.114016
Received:
August 13, 2021
Accepted:
October 11, 2021
Published:
October 14, 2021
Copyright © 20
21 by author(s) and
Scientific
Research Publishing Inc.
This work is
licensed under the Creative
Commons Attribution International
License (CC BY
4.0).
http://creativecommons.org/licenses/by/4.0/
Open Access

A. B. Kamissoko et al.
DOI:
10.4236/ojra.2021.114016 153 Open Journal of Rheumatology and Autoimmune Diseases
characterized by inflammation responsible for joint destruction, leading to func-
tional disability and chronic pain [1]. RA causes socio-economic, psychological
and sexual problems. Sexual problems are common, but also taboo, especially in
African societies [2]. RA imposes limitations on sexual intercourse impacting
sexual desire [3], and the main reasons cited are fatigue and pain [4]. This leads
to a decrease in frequency of sexual intercourse [5]. In Sweden, decreased sexual
desire was found in 62% of women with rheumatoid arthritis [3]. In 2019 in Tu-
nisia, Alia F
et al.
reported a decrease in sexual frequency in 59% of women after
diagnosis of RA [5]. In Senegal, 23.8% of RA patients had a co-wife since the be-
ginning of the disease course [6]. Several Guinean studies have dealt with RA
without addressing the sexual dimension [7] [8] [9] [10]. The objective of this
study was to assess the impact of RA on women’s sexuality at the Ignace Deen
national hospital in Conakry (Guinea).
2. Patients and Methods
This was an analytical case-control study lasting 8 months (from April 6, 2020 to
December 11, 2020) in the rheumatology department of the Ignace Deen nation-
al hospital in Conakry (Guinea). Patients followed for rheumatoid arthritis di-
agnosed according to the ACR/EULAR 2010 criteria [11] were included. We re-
cruited all consenting patients, meeting the selection criteria. Controls were fe-
male volunteers in apparent good health, of the same age range as the cases.
They were recruited among the patients’ companions. One case (women with
RA) was age-matched to a control (volunteer woman in apparent good health).
Not included in the study were:
 Patients with gynecological disease.
 Patients whose partner has suffered from a urological disease.
 Patients with neurological or psychiatric illness.
 Patients on medication that may affect sexual function (antidepressants,
neuroleptics).
 Patients diagnosed with secondary Sjögren’s syndrome.
 For each patient, the following data were collected:
 Qualitative data: employment status, marital status, presence of a co-wife,
education level.
 Quantitative data: age, RA duration, morning stiffness, number of swollen
joints, number of tender joints, number of ankylosed joints, Disease Activity
Score 28 (DAS28) which assesses the activity of rheumatoid arthritis in 28
joints. RA is considered in remission if DAS 28 ≤ 2.6, low active if 2.6 < DAS
28 ≤ 3.2, moderately active if 3.2 < DAS 28 ≤ 5.1 and highly active if DAS
28 > 5.1. The Visual analogue scale (VAS) assesses the intensity of the pa-
tient’s pain on a scale of 0 (no pain) to 10 (unbearable pain). The Health As-
sessment Questionnaire (HAQ) which assesses the functional impact of RA
on the patients’ quality of life. The score varies from 0 (patient maintains ac-
tivities without difficulty) to 3 (patients unable to do activities). The Female
Sexual Function Index (FSFI) score which assesses sexual function in women.

A. B. Kamissoko et al.
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10.4236/ojra.2021.114016 154 Open Journal of Rheumatology and Autoimmune Diseases
FSFI consists of 19 questions divided into six subscales measuring different
aspects of female sexual function. These aspects are desire (Q1 - Q2), arousal
(Q3 - Q6), lubrication (Q7 - Q10), orgasm (Q11 - Q13), satisfaction (Q14 -
Q16) and pain (Q17 - Q19). When FSFI is less than or equal to 26.55, there is
sexual dysfunction [12] [13]. The short form of the FSFI was used. This ver-
sion was based on existing FSFI items (desire, arousal, lubrication, orgasm,
satisfaction and pain). A total score of 19 is diagnostic of sexual dysfunction,
with a maximum score of 30 [14].
2.1. Data Analysis
The results were analysed using Microsoft Excel 2019 and Epi Info 7.2.3.1. Qua-
litative variables were summarised by frequency and percentage, and quantita-
tive variables by mean and standard deviation (SD). Comparisons were made by
using the Pearson correlation test. All tests were two-tailed; the significance level
was set at 5%.
2.2. Ethical Considerations
Informed consent was obtained from the patients and the research protocol was
accepted by the ethics committee of the Ignace Deen national hospital in Cona-
kry.
3. Results
One hundred and five women were registered (53 cases and 53 controls). The
mean age of the patients was 43.3 ± 13.4 (Range: 18 years and 73 years). There
was a predominance of married patients (71.2%) with an average duration of
marriage of 18.6 ± 11.3 years. They had a co-wife in 54.1% of cases. RA patients
were employed in 57.7% of cases (Table 1).
The RA average duration was 6.7 ± 6.2 years. The mean DAS 28 at the time of
evaluation was 4 ± 1.6 (Table 2).
Cases had significant sexual dysfunction (p = 0.00006). The scores used found
that 36 patients (69.2%) and 19 controls (35.8%) had a sexual dysfunction. All
dimensions of sexuality were affected. The lower the mean scores, the more the
domain were impacted. Desire, arousal, lubrication, orgasm, satisfaction and
pain were all lowered in RA patients than in controls. The most affected part was
desire, which was correlated with RA with a p-value of 0.01 (Table 3).
Thirty-seven patients under 50 years had a sexual dysfunction (45.7%) com-
pared to 19 over 50 years. Sexual dysfunction was correlated with patient age
with a p-value < 0.05 (p = 0.0039). The limitation of patients’ quality life, calcu-
lated by the HAQ score was not significantly associated with the occurrence of
sexual dysfunction (p = 0.376) (Table 4).
4. Discussion
This was a case-control study to investigate the sexuality of women with rheu-
matoid arthritis in the rheumatology department of the Ignace Deen national

A. B. Kamissoko et al.
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10.4236/ojra.2021.114016 155 Open Journal of Rheumatology and Autoimmune Diseases
Table 1. Socio-demographic characteristics of rheumatoid arthritis patients and controls.
Cases n (%)
Controls n (%)
Age (mean ± standard deviation) 43.3 ± 13.4
36 ± 13
Marital status
Single 7 (13.5)
21 (39.6)
Divorced 2 (3.8)
2 (3.8)
Married 37 (71.2)
27 (50.9)
Widowed 6 (11.5)
3 (5.7)
Duration of marriage 18.6 ± 11.3
17.5 ± 12.7
Co-wife
Yes 20 (54.1)
10 (37)
No 17 (45.9)
17 (63)
Educational stage
Illiterate-Primary 16 (30.8)
8 (15.1)
Secondary-Higher 36 (69.2)
45 (84.9)
Professional status
Employee 30 (57.7)
26 (49.1)
Unemployed 22 (42.3)
27 (50.9)
Table 2. Clinical characteristics of the 52 patients with RA.
n (%) Mean ± SD
RA duration (years) 6.7 ± 6.2
Age of onset (years) 35.9 ± 13.9
Morning stiffness 23.6 ± 21.7
<30 min 26 (55.3)
≥30 min 21 (44.7)
Ankylosed joints 1 ± 2
Tender joints 7 ± 9
Swollen joints 2 ± 3
DAS28 4.0 ± 1.6
VAS 4.0 ± 2.9
HAQ 0.7 ± 0.8
DAS28: Disease activity score 28; VAS: Visual analogue scale; HAQ: Health assessment
questionnaire.
Table 3. Comparison of the overall score and mean scores of the different FSFI domains
between cases and controls.
Cases (n = 52) Controls (n = 53) p-value
RA duration (years) 2.5 ± 1.1 3.0 ± 1.2 0.01

A. B. Kamissoko et al.
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10.4236/ojra.2021.114016 156 Open Journal of Rheumatology and Autoimmune Diseases
Continued
Age of onset (years) 1.5 ± 1.7 2.8 ± 1.9 0.7
Morning stiffness 1.7 ± 2.0 3.2 ± 2.0 0.3
<30 min 1.3 ± 1.8 2.8 ± 1.9 0.8
≥30 min 2.5 ± 1.7 3.7 ± 1.7 0.1
Ankylosed joints 1.7 ± 2.1 3.0 ± 1.9 0.3
Tender joints 11.3 ± 9.4 18.5 ± 9.7 0.0006
Swollen joints
Table 4. Sexual dysfunction by age and HAQ in women with rheumatoid arthritis and in
healthy women.
Age 18 - 50 years
n (%)
Age 51 - 73 years
n (%) p-value
Presence of sexual dysfunction 37 (45.7%) 19 (79.2%) 0.0039
No sexual dysfunction 44 (54.3%) 5 (20.8%)
HAQ* [0 - 1] HAQ* [1 - 3] p-value
Presence of sexual dysfunction 25 (65.8%) 11 (78.6%) 0.376
No sexual dysfunction 13 (34.2%) 3 (21.4%)
hospital in Conakry, Guinea. This study collected hospital data that cannot be
extrapolated to the general population. Our department is the unique rheuma-
tology department in Guinea but the patients do not consult systematically. In
their journey to treatment, they still require a lot to traditional medicine before
coming to medical structures. The consideration by the subject of sexuality as a
taboo in our society was another limitation in collecting data such as talking
about sexuality to a third person especially in Guinea. Interview by a woman
helped to remove this barrier. The frequency of sexual dysfunction in patients
was similar to Moroccan data [15] (71.9% for cases vs. 54% for controls). Simi-
larly, in Turkey, a high frequency of sexual dysfunction was reported [16]. This
high frequency could be explained by the fact that pain, fatigue and stiffness are
the main signs of RA, thus putting sexuality at the bottom of the priority list.
The mean age of the patients was comparable to that of Kars Fertelli T [16] (49.5
± 8.14 years) and Frikha F
et al.
[17] (42.5 ± 5.8 years). This result could be ex-
plained by the fact that, according to literature, RA most often affects women in
the age group between 40 and 60 years [18]. The high frequency of married
women was similar to the data reported by Lin M-C
et al.
[19] (92.9%). This
could be explained by the fact that the religious context of the population for
who marriage is a very important value in the custom. The marriage average
duration was similar to the Egyptian report [20] (18.5 ± 3.5 years; range: 3 and
37 years) and the Tunisian data [17] (17.7 years; range: 2 and 28 years). In our
context, women marry ant a young age. The high co-wife rate has been reported

A. B. Kamissoko et al.
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10.4236/ojra.2021.114016 157 Open Journal of Rheumatology and Autoimmune Diseases
in Senegal (23.8%) [6]. The symptoms of the disease influence the relationship
between the spouses. This would lead the husband, not satisfied with his sex life
in general to take another wife. The impact of RA on patients’ life quality was
lower than that reported in Turkey [21] (HAQ = 1.3 ± 0.7). This low frequency
could be explained by the fact that most patients are quickly diagnosed and im-
mediately started on treatment. This would significantly reduce the impact of
RA on their quality of life. The moderate disease activity was thought to be re-
lated to the fact that patients most often return to their doctor when they expe-
rience symptoms of the disease. The low sexual desire of RA patients compared
to controls was similar to the data of Aras H
et al.
[22] (cases 2.1 ± 0.9 vs. con-
trols 3.02 ± 0.8). This low sexual desire in female RA patients could be explained
by the cognitive and emotional aspects of sexual desire, which are often altered
during chronic diseases [5]. Sexual arousal in patients was lower than in Tuni-
sian patients [5] (3.27 ± 1.5). This could be due to the decreased libido caused by
RA, always associated with the importance of joint pain, hence a decrease in
arousal [23]. Low sexual lubrication in patients was lower than in Turkey [16]
(cases 3.52 ± 0.99 vs. controls 3.54 ± 1.08). This may be related to the fact that
RA may be accompanied by mucocutaneous dryness. The patients and controls
had a lower orgasm than the Moroccan patients [24] (cases 3.86 ± 1.47 vs. con-
trols 2.70 ± 1.80). This low score comes from fatigue and joint pain that would
prevent patients from experiencing sufficient pleasure during sexual activity.
This concept of orgasm, which can sometimes be difficult to define, was however
well understood by our respondents. Contrary to the parameters described
above, the patients’ sexual satisfaction was comparable to the data of Aras H
et
al.
[22] (cases 2.05 ± 0.9 vs. controls 3.9 ± 1.3). This low sexual satisfaction could
be explained by the patients’ fear of pain related to movements. They would
prefer to shorten the duration of sexual intercourse, which would lead to dissa-
tisfaction [25]. Our patients had more pain during vaginal penetration than
those of Coskun B
et al.
[26] (cases 4.26 ± 1.77 vs. controls 5.50 ± 0.56). The fact
that the patients were not sufficiently lubricated they could experience pain
during vaginal penetration. The high risk of sexual dysfunction in patients with
RA would be related to the main symptom of RA: pain; but also to the psycho-
logical state of patients. There was a correlation between age and sexual dysfunc-
tion which is much more prevalent in young people. This is because in general,
older women are less sexually active than younger ones.
5. Conclusion
Rheumatoid arthritis is chronic inflammatory rheumatism and its symptoms
have a significant impact on the sexuality of women who suffer from that condi-
tion, because of the functional handicap it causes. The absence of studies on this
aspect in Guinea led us to highlight the negative impact of this disease on sex-
uality. A larger study is needed to better assess this issue and seek management
solutions.

A. B. Kamissoko et al.
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10.4236/ojra.2021.114016 158 Open Journal of Rheumatology and Autoimmune Diseases
Conflicts of Interest
The authors declare that they have no conflicts of interest.
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