Female sexual dysfunction (FSD) is an important component of sexual health. The Biopsychosocial Model of Care (BPSM) defines sexual dysfunction as a complex interaction of biological (genetics, pathology, physiology), social (socio-economical, cultural, environmental, and relational) and psychological (emotions, thoughts and behavioural) factors. Few South African studies have investigated the above factors and if they influence FSD.
The aim of this study was to examine the biopsychosocial factors (exposures) and if they are associated with sexual dysfunction in self-identified females in Gauteng, South Africa, during 2013-2023. 
Biopsychosocial factors (exposures) included: socio-cultural factors such as employment, relationship status, alcohol consumption, smoking, number of children, number of sexual partners, sexual orientation and exercise;  psychological factors such as concern about having a STI, concern about low sex drive, concern about orgasm; and biomedical factors such as age, number of pregnancies, regularity of menstruation period, hormone replacement therapy, contraception, fertility treatment, pain, hysterectomy, menopausal status, previous infections, bladder and bowel symptoms, comorbidities, and menopausal status.

Clinical records from self-identified females (binary, cisgender, transgender, non-binary, agender, or gender-queer) were accessed from two sexual health clinics. These were exported to Microsoft Excel and Stata Version 18.0. A cross-sectional design was assembled to analyse a convenient sample of 1,595 patient records. Prevalence and associations were examined by different biopsychosocial exposure variables and FSD, as measured with the Female Sexual Function Index, using inferential statistics, prevalence ratios, and multivariate logistic regression models.

The prevalence estimate of FSD was 84.17% (N = 1595). Stratified prevalence estimates of FSD by factors such as concern about sex drive, orgasm, or sexually transmitted infections, were > 90%.  Prevalence ratios amongst all factors varied between 0.87-1.34. Pain during sex (AOR = 6.02, p = 0.000), concern about sex drive (AOR = 6.48, p = 0.000) and orgasm (AOR = 5.22, p = 0.000), number of sexual partners (AOR = 0.61, p = 0.000) and relationship status (AOR = 0.17, p = 0.005) were found to be significantly associated with FSD. In addition, factors such as contraception use (OR = 1.33, p = 0.048), urinary symptoms (OR = 2.22, p = 0.000), concern about STI (OR = 0.37, p = 0.000), and doing exercise (OR = 0.56, p = 0.000) were also associated with FSD and adjusted for in the final regression model. No interactions between variables were found.

The period prevalence of clinically relevant FSD in our sample is higher than many reported prevalence rates for FSD in mid- and low-income countries.
Stratified by biomedical factor, some of the highest prevalences of FSD was noted in those who experienced pain during sex and in those who experienced urinary frequency. Urinary incontinence can directly affect sexual function due to leaking during intercourse, or indirectly due to consequent avoiding of intercourse due to fear of leaking. The concern is that approximately 25-45% of women will experience some form of urinary incontinence symptoms in their lifetime and perhaps FSD based on this assumption.
The inclusion of factors such as contraception, urinary frequency, concern about STI and exercise in a final regression model, are supported by previous studies that found significant associations between these factors and FSD. Differences in associated factors when compared to existing literature, may speak to the complexity and biopsychosocial specificity of factors associated with FSD.

The results suggest that several biopsychosocial factors are associated with FSD and that FSD is multifactorial (Figure 1). The study made a unique contribution to the body of knowledge by including self-identified females. Future research should focus on longitudinal, cohort and/or intervention studies to determine not only association, but also temporality and ultimately causation.