Determinants of Female Sexual Function in Breastfeeding Women

Abstract

Knowledge about the determinants of female sexual function in breastfeeding women is limited. A total of 355 breastfeeding women completed the Female Sexual Function Index (FSFI) and the Qol-8 quality of life questionnaire. FSFI scores decreased in the first six months of breast feeding. There was a positive relationship between FSFI scores and the importance of sex, level of communication, income, quality of life, and receiving brief sexual counseling.

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Journal of Sex & Marital Therapy
ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: https://www.tandfonline.com/loi/usmt20
Determinants of Female Sexual Function in
Breastfeeding Women
Miguel Fuentealba-Torres, Denisse Cartagena-Ramos, Lucia A. S. Lara,
Josilene D. Alves, Antônio C. V. Ramos, Laura T. Campoy, Jonas B. Alonso,
Lucila C. Nascimento & Ricardo A. Arcêncio
To cite this article: Miguel Fuentealba-Torres, Denisse Cartagena-Ramos, Lucia A. S. Lara,
Josilene D. Alves, Antônio C. V. Ramos, Laura T. Campoy, Jonas B. Alonso, Lucila C. Nascimento
& Ricardo A. Arcêncio (2019): Determinants of Female Sexual Function in Breastfeeding Women,
Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2019.1586020
To link to this article: https://doi.org/10.1080/0092623X.2019.1586020
Accepted author version posted online: 05
Mar 2019.
Published online: 11 Apr 2019.
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Determinants of Female Sexual Function in
Breastfeeding Women
Miguel Fuentealba-Torres
a
, Denisse Cartagena-Ramos
a
, Lucia A. S. Lara
b
, Josilene
D. Alves
a
, Ant^
onio C. V. Ramos
a
, Laura T. Campoy
a
, Jonas B. Alonso
c
, Lucila C.
Nascimento
a
, and Ricardo A. Arc^
encio
a
a
Department of Maternal-Infant Nursing and Public Health, University of S~
ao Paulo, Ribeir~
ao Preto, Brazil;
b
Faculty of Medicine of Ribeir~
ao Preto, Department of Gynecology and Obstetrics, University of S~
ao Paulo,
Ribeir~
ao Preto, Brazil;
c
Collage of Nursing, University of S~
ao Paulo, Ribeir~
ao Preto, Brazil
ABSTRACT
Knowledge about the determinants of female sexual function in breast-
feeding women is limited. A total of 355 breastfeeding women completed
the Female Sexual Function Index (FSFI) and the Qol-8 quality of life ques-
tionnaire. FSFI scores decreased in the first six months of breast feeding.
There was a positive relationship between FSFI scores and the importance
of sex, level of communication, income, quality of life, and receiving brief
sexual counseling.
Introduction
The female sexual function (FSF) which is stimulated by the need to increase emotional proxim-
ity, the desire to increase attractiveness and share physical sexual pleasure, or satisfying one’s sex-
ual needs (Basson, 2001; Cooper, Barber, Zhaoyang, & Talley, 2011).
Global analysis of epidemiological studies has indicated that between 40% and 50% of women
report problems in sexual functioning (McCabe et al., 2016). This situation is consistent with cur-
rent reports issued by specialists from different regions of the world in the fourth International
Consultation on Sexual Medicine, in which a high rate for female sexual problems and few thera-
peutic alternatives was evidenced in comparison with the options available for the treatment of
male sexual dysfunction (McCabe et al., 2016).
The determinants of FSF are essential for improving our understanding of the problems
related to FSF as well guiding the clinical anamnesis and early diagnosis of sexual dysfunction,
which will contribute to sexual health policies, mainly in populations with higher risk.
Breastfeeding women present a higher risk of developing problems in sexual functioning, per-
haps due to changes in the levels of estrogen, progesterone, testosterone, follicle stimulating hor-
mone, and luteinizing hormone, but also because of increased oxytocin and prolactin (Leeman &
Rogers, 2012). These changes reduce sex hormone levels, which may increases the chances of
developing hypoactive sexual desire (LaMarre, Paterson, & Gorzalka, 2003; Mcbride & Kwee,
2017; Millheiser, 2012).
Although breastfeeding women are considered at increased risk of developing sexual problems,
the determinants that interfere with FSF of women who breastfeed are poorly understood. The
literature is limited, as has been evidenced by a scoping review protocol that investigated relevant
primary studies (Fuentealba-Torres et al., 2018).
CONTACT Miguel Fuentealba-Torres mfuentealba@usp.br Department of Maternal-Infant Nursing and Public Health,
University of S~
ao Paulo, Ribeir~
ao Preto, 14040-902 Brazil.
ß2019 Taylor & Francis Group, LLC
JOURNAL OF SEX & MARITAL THERAPY
https://doi.org/10.1080/0092623X.2019.1586020

According to the literature review mentioned above, biological, psychological, interpersonal
(Basson, 2000), and social determinants (Solar & Irwin, 2010) can influence FSF. Exploratory
studies have shown that low quality of life is related to problems in sexual functioning. In breast-
feeding women, the perception of quality of life could be particularly diminished due to physical
and emotional overload, fatigue, irritability, and changes in the body, especially during the first
6 months of breastfeeding, due to the free demand for breastfeeding.
There is an important knowledge gap regarding FSF among women who breastfeed and con-
sidering that this event is a common practice in this period, it is important for primary studies
to be conducted in this area. It will be necessary not only to develop a diagnostic study but
also to be able to analyze the determinants of FSF using a robust tool for the evaluation of sex-
ual function. The Female Sexual Function Index (FSFI) questionnaire (Rosen et al., 2000) has
been characterized as a gold standard for the evaluation of FSF (Sand, Rosen, Meston, &
Brotto, 2009). Thus, the aim of this study was to identify the determinants of the mean
FSFI score.
Method
Participants
A cross-sectional study was carried out. The study population consisted of 4839 breastfeeding
women from the northeast region of the state of S~
ao Paulo, Brazil. A probabilistic sample was
used, calculated in 355 participants, using an accuracy of 5%, a 95% confidence interval and a
power of 80%.
The inclusion criteria were as follows: women over 18 years old, sexual activity including
penis-vagina relationship, and exclusive, predominant, or complementary breastfeeding until
23 months after delivery. The exclusion criteria were pregnant women breastfeeding, use of anti-
hypertensive drugs, antidepressants, and/or antipsychotics, and an inability to read or understand
the instructions of the research.
Procedure
The data was collected in primary health care facilities. The participants were randomly selected
from lists of medical appointments. The selected participants were invited to participate volun-
tarily, and the objectives, risks, and benefits of the study were explained. The participants
agreed to participate and provided signed informed consent. Data collection was carried out by
trained professionals with clinical experience and the self-applied interviews were held between
June and September 2017. The average time for application of the questionnaire
was 20 minutes.
The study was approved on June 07, 2017 by the Research Ethics Committee of the University
of S~
ao Paulo, under authorization number CAAE 67039517.5.0000.5393, considering the ethical
principles of the Helsinki Declaration (1964).
Measures
Sexual function was evaluated using the FSFI (Rosen et al., 2000), a self-reporting questionnaire
that evaluates FSF in the last four weeks (Rosen et al., 2000). This tool is a gold standard test
(Sand et al., 2009) and has been validated in Brazil (Thiel et al., 2008). The questionnaire consists
of 19 items across six domains of sexual functioning: desire, arousal, lubrication, orgasm, satisfac-
tion, and pain. The scores of each domain are multiplied by a correction factor that standardizes
the total score, which varies from 2 to 36 points, to obtain the total score.
2 M. FUENTEALBA-TORRES ET AL.

Quality of life (QoL) was evaluated using the Eurohis-Qol-8 instrument (Schmidt, M€
uhlan, &
Power, 2006). This is a self-reporting questionnaire that determines self-perceived QoL in the pre-
vious two weeks by evaluating the physical, psychological, social relations and environmental
domains. This questionnaire consists of eight items, with scores ranging from one to five points.
The total score varies from 8 to 40 points. A higher total score of Eurohis-Qol-8 indicates better
QoL. This questionnaire was adapted and validated for the Brazilian context (Rocha, Power,
Bushnell, & Fleck, 2012), and presents evidence of validity, and reliability (Pires, Fleck, Power, &
Da Rocha, 2018).
Women were evaluated using a semi-structured questionnaire to assess sociodemographic
determinants (age, race, marital status, religion, family income, years of study, employment, sex-
ual health counseling), biological determinants (type of birth, chronic illness, perineal trauma,
time of breastfeeding, type of breastfeeding, problems with breastfeeding and problems related to
this process), psychological (importance of sex by women, discomfort with the breasts, resump-
tion of sex, stress) and interpersonal determinants (level of communication between the couple,
time in the relationship, premature ejaculation between the couple). The variable sexual health
counseling was defined as exposure to at least one medical consultation or trained professional,
with the aim of advising women about sexuality after childbirth and attending to possible sexual
complaints by women in this period. Levels of communication between the couple and the
importance of sex and stress were assessed on a Likert scale, with a minimum score of 1 and a
maximum of 5 (Likert, 1932).
Statistical analysis
The database was constructed using double independent typing. A descriptive analysis was devel-
oped by SPSS program version 23.0. The predictive variables of the mean FSFI score were identi-
fied using a regression model of the class of Generalized Additive Models for Location, Scale, and
Shape Models (GAMLSS). These analyses were carried out using the program R, version 3.4.1 (R
Core Team, 2017), using the GAMLSS library (Stasinopoulos & Rigby, 2007).
Frequencies and percentages were calculated for the categorical variables and minimum,
maximum, median, mean, and standard deviation (SD) were estimated for numerical varia-
bles. The study-dependent variable was the total score of the FSFI questionnaire, and the
independent variables were the sociodemographic, clinical, psychological, interpersonal, and
QoL data.
A bivariate analysis was undertaken, crossing the total FSFI score with each independent vari-
able using the Mann-Whitney, Kruskal-Wallis, and Spearman Coefficients. Box plots and scatter
diagrams, plus a Loess curve, were used to analyze the dispersion and to identify a possible func-
tional relationship between the FSFI total score and independent variables.
Variables with value of p<0.05 or with functional relationship trends with the FSFI’s total
score in the dispersion charts, were inserted into the models of the GAMLSS class. The Akaike
criterion (AIC) was used to select the most appropriate model for the data set provided by the
inserted variables (Akaike, 1974).
Multicollinearity of the independent variables was evaluated using the variance inflation factor
(VIF). The selection of the independent variables for comparison between adjusted models was
performed using the likelihood ratio test (LRT). The non-parametric Fligner-Killen test was then
used to verify the homogeneity of the model variance. Diagnostic graphs of the model were
made, and the Shapiro-Wilk normality test, was applied to the model residues.
The final adjustment of the model showed the predicted values of the means FSFI scores, as
percentages. Graphs of the values predicted by the model were drawn. The graphs were elabo-
rated with the variables adjusted in the model equation. The type I error was set at 0.05 for all
statistical tests. Variables either with a p-value <0.05 or with graphical trends of functional
JOURNAL OF SEX & MARITAL THERAPY 3

relationship between the total FSFI score and numerical variables in the dispersion analysis, were
also inserted to a multiple regression model.
Results
Initially, 372 women were recruited, but five declined to participate (0.01%) and 12 were excluded
because they had difficulty understanding the questionnaires (0.03%); thus, 355 women were
included in the study. Regarding sociodemographic characteristics, the average age was
26.5 ± 6.68 years, income was 450.83 ± 252.41 USD, and length of the relationship was
6.27 ± 4.50 years (Table 1). It was also observed that 34.4% of women were married, 51.3% had a
religion, 60% had 11 years of study, and 31.3% were wage earners.
Table 1 shows the Spearman’s correlation coefficient (S) analysis between independent varia-
bles and the total FSFI score. The communication level score, sex importance level score, stress
level score, and QoL score, had p-values lower than 0.5 (p<0.5), which were inserted in the
GAMLSS regression model.
Table 2, shows the results of a bivariate analysis considering the categorical variables and total
FSFI score. The marital status, perineal trauma, breastfeeding type, breastfeeding problems, dis-
comfort with breasts, premature ejaculation of the partner, and sexual health counseling variables
had p-values lower than 0.5, which were inserted into the GAMLSS regression model.
Per capita income was added into the GAMLSS model, because the quadratic parameters pre-
sented a functional relationship with the FSFI score in the dispersion analysis with the LOESS
curve. Figure 1 shows the functional relationships between the independent variables and the total
score for the FSFI, through dispersion analysis.
The Weibull distribution (WEI3) was selected for each independent variable according to the
AIC criterion. The results of the Shapiro-Wilk test confirmed normality on the residuals of the
model and the adjustment adequacy (W ¼0.99584, p-value ¼0.4717).
Table 3 shows the results of the GAMLSS regression model. Six variables were adjusted in the
final model: per capita income, up to six months breastfeeding, QoL score, sex importance level
score, communication level score, and sexual health counseling.
The model predicted that the mean FSFI score would be reduced by 4.06% in the group of
women who breastfed during the first six months, and conversely, that the mean FSFI score
would increase by 7.54% for each point in the QoL score, about 5.55% for each point in the
importance of sex score, 2.61% for each point in the communication score, and 6.50% in the
group of women who had access to at least one session of sexual health counseling. When the
model considered the quadratic terms of the income per capita variable in its final fit, it predicted
that the mean FSFI score would increase in quadratic form to higher per capita income.
Table 1. Correlation analysis with numeric variables and total scores of the female sexual function index (n ¼355).
Variables Min Max Mean ± DS Median Sp-value
Age, years 18 45 26.5 ± 6.68 25.00 0.05 0.36
Family income, USD
a
491.06 1.473,19 450.83 ± 252.41 1,600.00 0.04 0.44
Per capita income, USD
a
12.40 491.06 116.68 ± 69.19 116.88 0.07 0.17
Relationship time, years 1 28 6.27 ± 4.50 5.00 0.61 2.48
Resumption intercourse, days 1 120 44.96 ± 16.64 42.00 0.07 0.16
Communication level score
b
1 5 3.86 ± 1.25 4.00 0.34 <0.01
‡
Sex importance level score
b
1 5 3.33 ± 1.91 3.00 0.35 <0.01
‡
Stress level score
b
1 5 3.38 ± 1.38 3.00 0.15 0.03
†
Quality of Life score
c
14 40 29.44 ± 4.89 30.00 0.39 <0.01
‡
S¼Spearman’s correlation coefficient; SD ¼Standard deviation.
†
Correlation is significant at the 0.05 level.
‡
Correlation is significant at the 0.01 level.
a
1 Dollar to USD ¼4.07 Brazilian Real/BRL (Date quoted rate: 9/21/2018).
b
Score Likert scale of the one at five points.
c
QoL total score.
4 M. FUENTEALBA-TORRES ET AL.

It is important to emphasize that the model has also adjusted two parameters of dispersion
(per capita income and communication level score), predicting that for each one Real in the per
capita income, the precision of the model is expected to increase by 0.04%, and, by 12.41% for
every extra point at the level of communication.
The variance inflation factor (VIF) did not show the presence of multicollinearity, with values
below 1.5 in all the variables of the model. The LRT test showed that variables improved the pre-
diction of mean FSFI score (AIC ¼20005.81, LRT ¼28.13, p-value <0.001). The Fligner-Killen
test confirmed the independence of errors and also homogeneity in variance. A likelihood ratio
Table 2. Bivariate analysis with total scores for female sexual function index (FSFI) and categorical variables (n ¼355).
Variables n (%) Mean ± SD p-value
Race 0.87
White 100 (28.2) 22.25 ± 1.16
Black 67 (18.9) 21.61 ± 2.11
Brown 146 (41.1) 22.60 ± 0.96
Asian 42 (11.8) 23.95± 2.28
Marital Status 0.04
†
Living as 233 (65.6) 22.11 ± 0.77
Married 122 (34.4) 24.09 ± 1.49
Religion 0.08
No 173 (48.7) 21.39 ± 0.99
Yes 182 (51.3) 23.04 ± 0.90
Years of study 0.96
Up to 8 years of study 113 (31.7) 24.75 ± 0.46
Up to 11 years of study 214 (60.2) 24.64 ± 0.31
12 or more years of study 28 (8.0) 24.91 ± 1.02
Employment 0.12
Employed 111 (31.3) 22.92 ± 1.27
Unemployed or in the home 244 (68.7) 22.21 ± 0.78
Type of delivery 0.74
Cesarean section 125 (35.2) 21.83 ± 1.27
Vaginal delivery 230 (64.8) 22.93 ± 0.80
Chronic Disease 0.26
No 324 (91.3) 22.41 ± 0.73
Yes 31 (8.7) 23.04 ± 2.15
Perineal trauma 0.01
†
No 336 (94.6) 22.67 ± 0.70
Yes 19 (5.4) 21.37 ± 2.69
Breastfeeding type 0.01
‡
Exclusive 126 (35.5) 22.92 ± 0.93
Predominant 53 (14.9) 22.10 ± 1.10
Complementary 176 (49.5) 22.88 ± 1.62
Time of the breastfeeding <0.00
†
>6 months 173 (48.7) 22.57 ± 1.44
<6 months 182 (51.3) 22.48 ± 0.80
Breastfeeding problems <0.00
†
No 309 (87.0) 25.02 ± 0.27
Yes 46 (13.0) 22.50 ± 0.60
Decreased sexual intercourse <0.00
†
No 138 (38.8) 26.82 ± 0.33
Yes 217 (61.2) 23.34 ± 0.32
Discomfort with breasts <0.01
†
No 230 (64.8) 22.68 ± 0.95
Yes 125 35.2 22.24 ± 1.00
Premature ejaculation of the partner 0.01
†
No 228 (64.2) 22.34 ± 0.85
Yes 127 35.8 22.84 ± 1.22
Sexual health counseling <0.00
†
No 263 (74.1) 21.82 ± 0.86
Yes 92 (25.9) 23.78 ± 1.14
SD ¼Standard deviation.
†
p-value <0.05 of Mann-Whitney test.
‡
p-value <0.05 of Kruskal-Wallis test.
JOURNAL OF SEX & MARITAL THERAPY 5

test (LRT) showed that the parameters as a whole improve the prediction of the mean FSFI score.
The t-scores indicated that all variables adjusted in the final model contributed significantly to
the prediction of the mean FSFI score, with values p<0.05. The model explained 35.79% of the
variance, according to R Cox Snell test. The Shapiro-Wilk test showed that the residuals follow a
normal distribution (W ¼0.99687, p-value ¼0.7268) (Figure 2).
The Figure 3 shows the multidimensional graphs of means FSFI scores predicted by the model
according to according to level of importance of sex, communication level, QoL, the breastfeeding
time (greater and less than six months), sexual health counseling and per capita income. The val-
ues for communication level and QoL were set at their averages for all the estimates of the graphs
(3.86 and 29.44, respectively).
In general, the graphs show, in a non-linear manner, that mean FSFI score tend to be higher
among breastfeeding women who receive sexual health counseling, who have per capita incomes
above USD$300, and with higher levels of importance for sex, communication between the couple
and QoL.
Table 3. Predictive model of the female sexual function index mean score.
Mean parameters FSFI Estimates SD TMean 95% CI p-value
Intercept 2.72 0.05 53.53 15.1977 13.7566–16.7899 <0.01
Per capita income 0.32 0.14 2.33 ——0.02
Per capita income (quadratic term) 0.31 0.10 3.11 ——<0.01
Up to six months breastfeeding 0.04 0.01 3.00 0.9594 0.9338–0.9857 <0.01
Quality of life score 0.07 0.01 5.46 1.0754 1.0477–1.1038 <0.01
Sex importance level score 0.03 0.01 5.15 1.0355 1.0218–1.0493 <0.01
Communication level score 0.03 0.01 2.83 1.0261 1.0080–1.0445 <0.01
Sexual health counseling 0.06 0.02 3.71 1.0650 1.0302–1.1010 <0.01
Dispersion parameters FSFI Estimates SD TDispersion 95% CI p-value
Intercept 1.37 0.14 9.97 3.9178 2.9952–5.1246 <0.01
Per capita income 0.00 0.00 2.74 1.0004 1.0001–1.0007 0.01
Communication level score 0.12 0.03 3.63 1.1241 1.0552–1.1975 <0.01
†
p0.05. t: value test; SD: Standard deviation; CI: confidence interval.
Figure 1. Graphics of relationships between total score FSFI and independent variables. A, C, D, E ¼Functional relationship by
Loess curve. B, F ¼Relationship by box charts.
6 M. FUENTEALBA-TORRES ET AL.

Discussion
The study aimed to identify the determinants of the mean FSFI score in breastfeeding women.
The findings revealed that per capita income, breastfeeding for up to six months, level of QoL,
level of sexual importance, level of communication, sexual health counseling and per capita
income are determinants of the mean FSFI score.
Figure 2. Diagnosis graphics of waste model.
JOURNAL OF SEX & MARITAL THERAPY 7

Figure 3. Predictive graphs of the FSFI mean score according to level of importance of sex, communication level, QoL, breast-
feeding time, sexual health counseling and per capita income.
8 M. FUENTEALBA-TORRES ET AL.

The FSF is influenced by socioeconomic status, because the mean FSFI scores were signifi-
cantly lower among women with lower incomes. Per capita income is a social determinant associ-
ated with poverty and social inequality, which has a negative impact on the general health of
people, as well as on sexual health (Solar & Irwin, 2010). Low socioeconomic status interferes
with women’s mental health, affecting sexual responsiveness (Kingsberg et al., 2017), increasing
dissatisfaction in the relationship (Khajehei, Doherty, Tilley, & Sauer, 2015) and increasing vul-
nerability to develop problems with sexual function. It is advisable to carefully evaluate the sexual
functioning of low-income patients, because they are vulnerable to developing sexual dysfunction.
This study indicates that evaluation of QoL is relevant for the comprehensive assessment of
sexual health during breastfeeding because significantly lower FSFI scores were evidenced among
women with lower QoL. Previous studies suggest that a low perception of QoL could increases
the risk of female sexual problems (Hisasue et al., 2005; Laumann, Paik, & Rosen, 1999). Stress,
associated with demands for baby care, emotional overload, lack of sleep and fatigue (Mcbride &
Kwee, 2017; McDonald, Woolhouse, & Brown, 2015; Millheiser, 2012), can impact the perception
of QoL in women who practice breastfeeding. In addition, sexual QoL could be affected due to
increased vaginal dryness (Khajehei et al., 2015; Redelman, 2017), and the appearance of dyspar-
eunia in vaginal intercourse (Alligood-Percoco, Kjerulff, & Repke, 2016; Lagaert, Weyers, Van
Kerrebroeck, & Elaut, 2017). Despite this background, knowledge of the effect of low QoL in the
FSF is limited among women who breastfeed. The evidence found in this study predicts that the
FSF improves when the perception of QoL is high. Clinical evaluation of QoL and FSF among
breastfeeding women is recommended.
Multivariate FSFI analyses predicted that mean scores would be lower in the first 6 months of
lactation. In this period, the interest of the woman in maintaining sexual relations with the couple
may decrease, as, on many occasions, the woman is focused exclusively on breastfeeding
(Adanikin, Awoleke, Adeyiolu, Alao, & Adanikin, 2015; Barrett et al., 2000). A recently published
study reported significantly lower FSFI scores among women who exclusively breastfeed (Matthies
et al., 2019). In addition, in this period, the delay in the resumption of sexual relations has been
reported (Brtnicka, Weiss, & Zverina, 2009; Rowland, Foxcroft, Hopman, & Patel, 2005), along
with a decrease in the frequency of sexual relations (Matthies et al., 2019; van Anders, Hipp, &
Kane Low, 2013) and a decrease in sexual desire (Khajehei et al., 2015; Leeman & Rogers, 2012).
The study also showed that lower scores for the level of perceived importance of sexual rela-
tions correlated with lower average FSFI scores. Although this variable has not been investigated
in depth, one study indicated that the importance of sex is significantly lower in women who
breastfeed, compared with those who have stopped breastfeeding (Trutnovsky, Haas, Lang, &
Petru, 2006). The low importance of sex has a multifactorial origin and may be influenced by psy-
chosocial factors such as adjustment to becoming a mother, resentment of role changes, emotional
connection with the baby (Woolhouse, McDonald, & Brown, 2012) and by the practical need to
breastfeed frequently (Leeman & Rogers, 2012). Changes in body image such as weight gain after
childbirth, changes in the shape and function of the breasts, or the appearance of stretch marks or
scars on the skin (Ahn, Sohn, & Yoo, 2010; Barrett et al., 2000) can interfere with the sexual
motivation system (Bancroft & Graham, 2011) and contribute to the decrease in sexual interest.
The study indicates that the level of communication is a predictor of FSFI scores, showing
lower scores among women who perceive poor communication in the couple’s relationship. It has
been shown that a high level of communication improves FSF (Lianjun et al., 2011; MacNeil &
Byers, 2005; Montesi, Fauber, Gordon, & Heimberg, 2011), contributes to the well-being of the
couple, stimulates the need for emotional closeness, and contributes to the development of sexual
motivation in women who breastfeed (Convery & Spatz, 2009). A recently published survey indi-
cated that an adequate level of communication improves sexual performance and increases the
frequency of sexual relations (Zhang et al., 2018). Good communication with the couple has been
associated with a higher level of intimacy, satisfaction in the relationship (Ahlborg, Dahl€
of, &
JOURNAL OF SEX & MARITAL THERAPY 9

Hallberg, 2005) and an increase in well-being in the couple’s relationship (Convery & Spatz,
2009). In contrast, poor communication has been linked to higher rates of sexual dissatisfaction
(Blair, Pukall, Smith, & Cappell, 2015), higher incidence of marital problems (Connolly, Thorp, &
Pahel, 2005) and a fear of experiencing genital pain during vaginal sex (Blair et al., 2015).
Strengthening communication can positively impact the intimacy of the couple (McCabe &
Connaughton, 2017) and can improve the female sexual response (Lianjun et al., 2011; Montesi
et al., 2011). In the clinical interview, it is advisable to consult about the communication and guide
the couple in a timely manner to seek specialized help when there are communication problems.
The findings indicate that sexual health counseling is a protective factor for FSF and show that
the average FSFI scores improve when women receive sexual health counseling. Sexual health
counseling prepares women and their partners to face possible changes in female sexual response
during breastfeeding. Because women are exposed to an increased risk of developing sexual dys-
function after childbirth, it is advisable for health professionals to expand sexual health counsel-
ing activities spatially during the period of breastfeeding. Guidance on the use of vaginal
lubricants among breastfeeding women (Leeman & Rogers, 2012; Millheiser, 2012) can help to
decrease the decrease in vaginal lubrication and can prevent the occurrence of dyspareunia. To
prevent the occurrence of problems in the sexual function of women who breastfeed, it is recom-
mended that sexual health counseling begins early in pregnancy, continues in the postnatal period
and that the monitoring of sexual problems extends throughout the period of breastfeeding.
Although this study identified some determinants of FSF during breastfeeding, further evi-
dence is needed. In future studies evaluating the FSF post-partum, it is recommended that FSF
analyses, for the group of women who practice breastfeeding, be performed separately. This could
help to more clearly identify those factors that intervene in the FSF of women who breastfeed
and avoid the development of incorrect conclusions, because breastfeeding could be a confounder
for the measures of association.
Conclusions
The determinants of FSFI should be carefully evaluated among breastfeeding women because they are
characterized by a sophisticated interrelation between the variables level of income per capita, quality of
life, the first six months of lactation, the level of importance of sex, and communication with the couple.
Sexual health counseling is an important determinant for improving sexuality in breastfeeding women.
Funding
This research was funded by the Coordination for the Improvement of Higher Education
Personnel (CAPES) and the National Council for Scientific and Technological Development
(CNPq), Program PEC-PG, Processes numbers 9243143 and 9191134.
Disclosure statement
No potential conflict of interest was reported by the author(s).
ORCID
Miguel Fuentealba-Torres http://orcid.org/0000-0003-4343-6341
Denisse Cartagena-Ramos http://orcid.org/0000-0002-8828-2190
Lucila C. Nascimento http://orcid.org/0000-0002-7900-7111
10 M. FUENTEALBA-TORRES ET AL.

References
Adanikin, A. I., Awoleke, J. O., Adeyiolu, A., Alao, O., & Adanikin, P. O. (2015). Resumption of intercourse after
childbirth in southwest Nigeria. The European Journal of Contraception & Reproductive Health Care,20(4),
241–248. doi:10.3109/13625187.2014.971742
Ahlborg, T., Dahl€
of, L., & Hallberg, L. R. (2005). Quality of the intimate and sexual relationship in first-time
parents six months after delivery. Journal of Sex Research,42(2), 167–174. doi:10.1080/00224490509552270
Ahn, Y., Sohn, M., & Yoo, E. (2010). Breast functions perceived by Korean mothers: Infant nutrition and female
sexuality. Western Journal of Nursing Research,32(3), 363–378. doi:10.1177/0193945909349252
Akaike, H. (1974). A new look at the statistical model identification. IEEE Transactions on Automatic Control,
19(6), 716–723. doi:10.1109/TAC.1974.1100705
Alligood-Percoco, N. R., Kjerulff, K. H., & Repke, J. T. (2016). Risk factors for dyspareunia after first childbirth.
Obstetrics and Gynecology,128(3), 512–518. doi:10.1097/AOG.0000000000001590
Bancroft, J., & Graham, C. (2011). The varied nature of women’s sexuality: Unresolved issues and a theoretical
approach. Hormones and Behavior,59(5), 717–729. doi:10.1016/j.yhbeh.2011.01.005
Barrett, G., Pendry, E., Peacock, J., Victor, C., Thakar, R., & Manyonda, I. (2000). Women’s sexual health after
childbirth. BJOG: An International Journal of Obstetrics and Gynaecology,107(2), 186–195. doi:10.1111/j.1471-
0528.2000.tb11689.x
Basson, R. (2000). The female sexual response: A different model. Journal of Sex & Marital Therapy,26(1), 51–65.
doi:10.1080/009262300278641
Basson, R. (2001). Using a different model for female sexual response to address women’s problematic low sexual
desire. Journal of Sex & Marital Therapy,27(5), 395–403. doi:10.1080/713846827
Blair, K. L., Pukall, C. F., Smith, K. B., & Cappell, J. (2015). Differential associations of communication and love in
heterosexual, lesbian, and bisexual women’s perceptions and experiences of chronic vulvar and pelvic pain.
Journal of Sex and Marital Therapy,41(5), 498–524. doi:10.1080/0092623X.2014.931315
Brtnicka, H., Weiss, P., & Zverina, J. (2009). Human sexuality during pregnancy and the postpartum period.
Bratislavske Lekarske Listy,110(7), 427–431.
Connolly, A., Thorp, J., & Pahel, L. (2005). Effects of pregnancy and childbirth on postpartum sexual function: A
longitudinal prospective study. International Urogynecology Journal,16(4), 263–267. doi:10.1007/s00192-005-
1293-6
Convery, K. M., & Spatz, D. L. (2009). Sexuality & breastfeeding: What do you know? MCN: The American
Journal of Maternal Child Nursing,34(4), 218–223. doi:10.1097/01.NMC.0000357913.87734.af
Cooper, M. L., Barber, L. L., Zhaoyang, R., & Talley, A. E. (2011). Motivational pursuits in the context of human
sexual relationships. Journal of Personality,79(6), 1333–1368. doi:10.1111/j.1467-6494.2010.00713.x
Fuentealba-Torres, M., Cartagena-Ramos, D., Sierra, J. C., Lara, L. A., Okano, S. P., Berra, T. Z., …Arc^
encio,
R. A. (2018). What are the factors that contribute to the development of sexual dysfunction in breastfeeding
women? A systematic scoping review protocol. BMJ Open,8(8), e022863. doi:10.1136/bmjopen-2018-022863
Hisasue, S-I., Kumamoto, Y., Sato, Y., Masumori, N., Horita, H., Kato, R., …Itoh, N. (2005). Prevalence of female
sexual dysfunction symptoms and its relationship to quality of life: A Japanese female cohort study. Urology,
65(1), 143–148. doi:10.1016/j.urology.2004.08.003
Khajehei, M., Doherty, M., Tilley, P. J. M., & Sauer, K. (2015). Prevalence and risk factors of sexual dysfunction in
postpartum Australian women. The Journal of Sexual Medicine,12(6), 1415–1426. doi:10.1111/jsm.12901
Kingsberg, S. A., Althof, S., Simon, J. A., Bradford, A., Bitzer, J., Carvalho, J., …Shifrin, J. L. (2017). Female sex-
ual dysfunction: Medical and psychological treatments, committee 14. Journal of Sexual Medicine,14(12),
1463–1491. doi:10.1016/j.jsxm.2017.05.018
Lagaert, L., Weyers, S., Van Kerrebroeck, H., & Elaut, E. (2017). Postpartum dyspareunia and sexual functioning:
A prospective cohort study. The European Journal of Contraception & Reproductive Health Care,22(3), 200–206.
doi:10.1080/13625187.2017.1315938
LaMarre, A. K., Paterson, L. Q., & Gorzalka, B. B. (2003). Breastfeeding and postpartum maternal sexual function-
ing: A review. Canadian Journal of Human Sexuality,12(3–4):151–168.
Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States: Prevalence and predic-
tors. JAMA,281(6), 537–544.
Leeman, L. M., & Rogers, R. G. (2012). Sex after childbirth: Postpartum sexual function. Obstetrics and Gynecology,
119(3), 647–655. doi:10.1097/AOG.0b013e3182479611
Lianjun, P., Aixia, Z., Zhong, W., Feng, P., Li, B., & Xiaona, Y. (2011). Risk factors for low sexual function among
urban Chinese women: A hospital-based investigation. Journal of Sexual Medicine,8(8), 2299–2304. doi:10.1111/
j.1743-6109.2011.02313.x
Likert, R. (1932). A technique for the measurement of attitudes. Archives of Psychology,22(140), 1–55.
MacNeil, S., & Byers, E. S. (2005). Dyadic assessment of sexual self-disclosure and sexual satisfaction in heterosex-
ual dating couples. Journal of Social and Personal Relationships,22(2), 169–181. doi:10.1177/0265407505050942
JOURNAL OF SEX & MARITAL THERAPY 11

Matthies, L. M., Wallwiener, M., Sohn, C., Reck, C., M€
uller, M., & Wallwiener, S. (2019). The influence of partner-
ship quality and breastfeeding on postpartum female sexual function. Archives of Gynecology and Obstetrics,
299(1), 69–77. doi:10.1007/s00404-018-4925-z
Mcbride, H. L., & Kwee, J. L. (2017). Sex after baby: Women’s sexual function in the postpartum period. Current
Sexual Health Reports,9(3), 142–149. doi:10.1007/s11930-017-0116-3
McCabe, M. P., & Connaughton, C. (2017). Sexual dysfunction and relationship stress: How does this association
vary for men and women? Current Opinion in Psychology,13,81–84. doi:10.1016/j.copsyc.2016.05.007
McCabe, M. P., Sharlip, I. D., Lewis, R., Atalla, E., Balon, R., Fisher, A. D., …Segraves, R. T. (2016). Incidence
and prevalence of sexual dysfunction in women and men: A consensus statement from the fourth international
consultation on sexual medicine 2015. The Journal of Sexual Medicine,13(2), 144–152. doi:10.1016/
j.jsxm.2015.12.034
McDonald, E., Woolhouse, H., & Brown, S. J. (2015). Consultation about sexual health issues in the year after
childbirth: A cohort study. Birth,42(4), 354–361. doi:10.1111/birt.12193
Millheiser, L. (2012). Female sexual function during pregnancy and postpartum. The Journal of Sexual Medicine,
9(2), 635–636. doi:10.1111/j.1743-6109.2011.02637.x
Montesi, J. L., Fauber, R. L., Gordon, E. A., & Heimberg, R. G. (2011). The specific importance of communicating
about sex to couples’sexual and overall relationship satisfaction. Journal of Social and Personal Relationships,
28(5), 591–609. doi:10.1177/0265407510386833
Pires, A. C., Fleck, M. P., Power, M., & Da Rocha, N. S. (2018). Psychometric properties of the EUROHIS-QOL 8-
item index (WHOQOL-8) in a Brazilian sample. Revista Brasileira de Psiquiatria,40(3), 249–255. doi:10.1590/
1516-4446-2017-2297
R Core Team. (2017). R: A language and environment for statistical computing. R Foundation for Statistical
Computing. Retrieved September 1, 2018, from https://www.r-project.org/.
Redelman, M. (2017). A clinical perspective on sexuality with pregnancy and postpartum. International Journal of
Reproduction, Fertility & Sexual Health,04(03), 105–109. doi:10.19070/2377-1887-1700018
Rocha, N. S. D., Power, M. J., Bushnell, D. M., & Fleck, M. P. (2012). The EUROHIS-QOL 8-item index:
Comparative psychometric properties to its parent WHOQOL-BREF. Value in Health,15(3), 449–457. doi:
10.1016/j.jval.2011.11.035
Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., …D’Agostino, R. J. (2000). The female
sexual function index (FSFI): A multidimensional self-report instrument for the assessment of female sexual
function. Journal of Sex & Marital Therapy,26(2), 191–208. doi:10.1080/009262300278597
Rowland, M., Foxcroft, L., Hopman, W. M., & Patel, R. (2005). Breastfeeding and sexuality immediately post par-
tum. Canadian Family Physician Medecin de Famille Canadien,51(10), 1366–1367.
Sand, M., Rosen, R., Meston, C., & Brotto, L. A. (2009). The female sexual function index (FSFI): A potential “gold
standard”measure for assessing therapeutically-induced change in female sexual function. Fertility and Sterility,
92(3), S129. doi:10.1016/j.fertnstert.2009.07.1173
Schmidt, S., M€
uhlan, H., & Power, M. (2006). The EUROHIS-QOL 8-item index: Psychometric results of a cross-
cultural field study. European Journal of Public Health,16(4), 420–428. doi:10.1093/eurpub/cki155
Solar, O., & Irwin, A. (2010). A conceptual framework for action on the social determinants of health. Social deter-
minants of health discussion paper 2 (policy and practice), pp. 1–79. Retrieved from http://www.who.int/social_
determinants/publications/9789241500852/en/.
Stasinopoulos, D. M., & Rigby, R. A. (2007). Generalized additive models for location scale and shape (GAMLSS)
in R.Journal of Statistical Software,23(7), 1–46. doi:10.18637/jss.v023.i07
Thiel, R. d. R. C., Dambros, M., Palma, P. C. R., Thiel, M., Riccetto, C. L. Z., & Ramos, M. D F. (2008). Traduc¸~
ao
para portugu^
es, adaptac¸~
ao cultural e validac¸~
ao do female sexual function index. Revista Brasileira de Ginecologia
e Obstetr
ıcia,30(10), 504–510. doi:10.1590/S0100-72032008001000005
Trutnovsky, G., Haas, J., Lang, U., & Petru, E. (2006). Women’s perception of sexuality during pregnancy and after
birth. The Australian and New Zealand Journal of Obstetrics and Gynaecology,46(4), 282–287. doi:10.1111/
j.1479-828X.2006.00592.x
van Anders, S. M., Hipp, L. E., & Kane Low, L. (2013). Exploring co-parent experiences of sexuality in the first 3
months after birth. The Journal of Sexual Medicine,10(8), 1988–1999. doi:10.1111/jsm.12194
Woolhouse, H., McDonald, E., & Brown, S. (2012). Women’s experiences of sex and intimacy after childbirth:
Making the adjustment to motherhood. Journal of Psychosomatic Obstetrics and Gynaecology,33(4), 185–190.
doi:10.3109/0167482X.2012.720314
Zhang, J., Wu, J., Li, Y., Zhou, Y., Li, Y., Zhao, R., …Chen, J. (2018). Influence factors of sexual activity for
internal migrants in China. Sexual Medicine,6(2), 97–107. doi:10.1016/j.esxm.2018.01.006
12 M. FUENTEALBA-TORRES ET AL.