Objective: To identify the predictors of female extramarital sexual intercourse EMSI.

Methods: This analytical cross-sectional study was carried out between January 15th and April 30th, 2018. Women who reported engaging in EMSI or not were recruited.

Sociodemographic variables were recorded. Fisher exact test, t-test and logistic regression were used for comparison. P<0.05 was considered statistically significant.

Results: Fifty six women engaged in EMSI and 154 not. Significant factors associated with EMSI were daily thinking about having SI (aOR 47.18, 95%CI 2.67-833.08), sexual dissatisfaction (aOR 44.14, 95%CI 3.77-517.15), physical distance between the couple (aOR 21.58, 95%CI 2.50-186.57), previous sexual partners ≥4 (aOR 20.90, 95%CI 2.04- 214.43), female level of education above husband’s own (aOR 10.42, 95%CI 1.27-85.79) and lack of dialogue within the couple (aOR 5.71, 95%CI 1.26-25.97). Twenty two (39.3%) women practicing EMSI contracted sexually transmitted infections (STI) including AIDS.

Conclusion: EMSI exposed women to STI including AIDS.

• Daily thinking about sexual intercourse; Physical distance between the couple; Female extramarital sexual intercourse; More than four previous sexual partners; Sexual dissatisfaction

NKWABONG E, FOTIO BANHATIO IF, NSANGOU MM (2021) Factors Associated with Female Extramarital Sexual Relationships in a Sub- Saharan African Country. JSM Sexual Med 5(3): 1076.

Amid couples, sexual intercourse is a duty for both partners, especially when they are married. Sexual intercourse shows love and the share of intimacy between the partners. Women who do not have sexual intercourse have poorer mental health such as lower quality of life [1]. During weddings, both partners more often promise each other not to have extramarital sexual intercourse (EMSI).

The magnitude of EMSI is not well known in our country given that it is a taboo subject. Many women do not like to discuss about this topic. EMSI is considered by many as a betrayal of relationship commitment, given that both partners promised faithfulness to each other [2]. Male EMSI is usually tolerated by the partner [3], but this is not the case for female EMSI [4].

The frequency of EMSI varies worldwide. One study carried out in Uganda reported a frequency of female EMSI of 2.9% [5]. Around 20% of married women in USA engaged in EMSI over the course of their relationships [6].

Predictors of EMSI might vary from a country to another. Known predictors include poverty, alcoholism, drug dependency, physical separation, sexlessness and sexual dissatisfaction [1,7- 10]. Indeed, 43.8% of financially vulnerable women in Iran had EMSI [7]. Moreover, spontaneous or unplanned sexual intercourse under the influence of alcohol has been largely reported [7,11,12].

Female EMSI might be associated with increased risk of unwanted pregnancies. The latter can lead to clandestine abortions, therefore with risk of maternal deaths, especially in settings where abortion is still law-restricted. It may also favor sexual transmissible infections (STI) [13,14]. EMSI may also lead to physical violence or may threaten couple stability [9,15]. Also, a case of death due to acute cardiac failure following extramarital sexual activity of a woman with hypertensive chronic cardiovascular disease has been reported [16].

Despite these numerous consequences, EMSI continues to be practiced by women. Some other predictors might be found in our country. We hypothesized that EMSI might be due to poverty. Identifying the predictors might help in reducing its frequency and, therefore, the consequences associated to it. No study in Cameroon has been carried out on female EMSI practice, hence this study which aimed at identifying the factors associated with its practice in our environment as well as the reasons giving by women who practice it.

This cross-sectional analytical study was carried out in Cameroon between January 15th and April 30th, 2018 in a Yaoundé University Teaching Hospital, a District Hospital and in seven women’s associations. Married women attending antenatal care, gynecologic consultation or attending the different associations took part in this study. Women who reported engaging in EMSI, who could present their marriage certificate if requested, were recruited as well as those who did not. Women cohabiting with men but without being legally married were excluded as well as those with incompletely filled questionnaire. A written informed consent was obtained from each woman. This study was approved by the Cameroon national ethics committee.

The variables recorded anonymously and with confidentiality on an self-administered pretested questionnaire both in French and in English included maternal age, maternal age at wedding, age at 1st sexual intercourse, husband’s age, couple’s level of education, couple’s monthly income, number of days of absence of the husband per week, number of previous sexual partners before being married, frequency of sexual intercourse before marriage, sexual satisfaction (the woman reported satisfaction when pleasure or orgasm occurred during sexual intercourse), daily thinking about having sexual intercourse (SI), poor dialogue or relationship within the couple (lack of discussion about issues concerning the couple or their families), physical distance of the husband (husband living in another town) and woman alcohol consumption. No interpretation was needed because the questions were simple to understand. These variables were chosen because we assumed that they could favor EMSI practice. Other variables recorded were adverse events associated with EMSI practice and the husband’s behavior if informed about his wife’s EMSI practice. EMSI is a shameful condition for a woman to reveal it publicly. A survey conducted in USA revealed a 1.1% rate of EMSI in a face-to-face dialogue, but when using a computer, up to 6.1% revealed their engagement in EMSI [17]. That is why each participant had to fill the anonymous questionnaire in an isolated place, to fold it up before dropping it into a box. All the questionnaires were collected only at the end of the day.

The necessary sample size was calculated as needing at least 44 cases of women practicing EMSI, using the following formula: N=P×(1-P)×(Zα/D)2 [18] where P was the percentage of women practicing EMSI in Uganda (2.9%) [5], Zα=1.96 corresponding to a type I error of 5% and D=0.05 is the degree of precision

Variables of women practicing EMSI were compared to those of women not practicing it. Data were analyzed using SPSS 20.0. Fisher’s exact test was used to compare categorical variables and t-test to compare continuous variables. Logistic regression analysis was undertaken to control for potential confounders. The level of significance was P<0.05.

Of 234 married women who took part in this study, 24 (10.3%) questionnaires were poorly filled and were excluded, 56 reported engaging in EMSI. The variables of these 56 women were compared to those of the 154 women without EMSI. Some variables are shown in Table 1.

Women whose educational level was above that of their husband had more EMSI practice (16/56 or 28.6% vs. 21/154 or 13.6%, OR 2.53, 95%CI 1.20-5.31, P=0.012).

Moreover, women who had daily thoughts about having SI had more EMSI practice (30/56 or 53.6% vs. 14/154 or 9.1%, OR 11.54, 95%CI 5.40-24.67, P<0.001).

Also, women who claimed not to be sexually satisfied by their husband practiced more EMSI (24/56 or 42.8% vs. 7/154 or 4.5%, OR 15.75, 95%CI 6.25-39.70, P<0.001). Furthermore, when

there was a lack of dialogue within the couple, women were more prone to EMSI (28/56 or 50% vs. 44/154 or 28.6%, OR 2.50, 95%CI 1.33-4.69, P=0.003).

Couple’s physical distance from each other exposed women to EMSI practice (16/56 or 28.6% vs. 11/154 or 7.1%, OR 5.20, 95%CI 2.23-12.09, P<0.001). Women who claimed to have 

financial constraints practiced more EMSI (13/56 or 23.2¨% vs. 27/154 or 17.5%, OR 1.42, 95%CI 0.67-3.00), but the difference was statistically insignificant (P=0.230).

Table 2 shows the distribution of number of sexual partners before marriage amongst the population under study. Other sociodemographic variables are found in Table 3, while Table 4 reveals the factors associated with EMSI practice after logistic regression.

Protective factors for EMSI were absence of sexual intercourse before wedding (3 or 5.3% vs. 39 or 25.3%, OR 0.17, 95%CI 0.04-0.56, P<0.001), or practice of less than two sexual intercourses weekly before wedding (11/53 or 20.7% vs. 70/115 or 60.8%, OR 0.17, 95%CI 0.08-0.36, P<0.001), first sexual intercourse ≥20 years old (6 or 10.7% vs. 73 or 47.4%, OR 0.13, 95%CI 0.05-0.33,P<0.001) and age difference between partners between 5 and 9 years (17 or 30.4% vs. 75 or 48.7%, OR 0.46, 95%CI 0.24-0.88, P=0.013).

The main adverse event encountered by women with EMSI practice was STI (Table 5). Twelve women (21.4%) had unwanted pregnancies with 10 clandestine abortions performed (10/12 or 83.3%). The two other women carried their pregnancy to term.

Among these 56 women, 24 (42.9%) were suspected by their husbands of having EMSI. This led to violence within the couple in 18 cases/24 (75%) and divorce request in two cases (8.3%).

Our study found practice of EMSI amongst married women who participated to this survey. The factors that favored its practice were the fact of daily thinking about having SI, sexual dissatisfaction, physical distance between couples, previous sexual partners number ≥4, female educational level above husband’s own and lack of dialogue within the couple.

We found no association between EMSI practice and woman’s age, age at wedding or at first sexual intercourse, husband’s age, polygamy, age difference between the two partners, alcohol or tobacco consumption, couple’s monthly income or frequency of sexual intercourse before marriage. Other researchers in Iran and in Kenya noticed that financial constraint was a predictor of EMSI [7,8].

Contrarily, women who had daily thoughts about having SI were more prone to EMSI. Thinking about sexual intercourse might cause excitation and increase the necessity of having EMSI. Women should avoid thinking about sexual intercourse when their partners are absent. Instead, they should be encouraged to think about other aspects of life.

Sexual dissatisfaction also exposed to EMSI practice in our study. This has already been noticed in USA [9]. Good quality sexual intercourse improves mental health and quality of life [1].

Women who were far from their husbands were also prone to have EMSI, as already observed in Kenya and USA [8,10]. This can be attributed to the absence of sexual intercourse which is a predictor of EMSI [1].

Women who had four or more sexual partners before getting married were exposed to EMSI practice. This might be explained by the fact that once married, a sexually unsatisfied married woman might try to meet an ex-sexual partner. This was observed in USA too [12].

We also found that women whose educational level was higher than that of their husbands were exposed to EMSI practice. This might be related to the underestimation of their husband’s intellectual capability and a tendency to look for more educated men. Moreover, if she is very qualified and jobless, she might use EMSI to have some favors. Studies should be carried out to verify this hypothesis.

Finally, a lack of dialogue was also a predictor of EMSI. This might be explained by the fact that if a woman cannot communicate with her husband to explain for instance her sexual desire or other problems, she might have the tendency of finding somebody else with whom she can communicate. This has been observed in USA [9].

Women who practiced EMSI in our series were exposed to clandestine abortion from unwanted pregnancies. Some others had STI as observed in Papua New Guinea [14], violence as seen in Malawi [15], or to divorce as noticed in USA [10,12].

The limitations of our study is our incapacity to estimate the number of women who refused to take part to this survey or to verify the authenticity of all of the answers given, especially when it concerned the number of sexual partners. Moreover, our wide confidence interval of some variables shows our small sample size with the true estimates of EMSI difficult to know. Therefore, similar studies with larger sample size should be carried out. Finally, this study reflects EMSI in a part of the country and not in the whole country or the whole town.

Our study showed that EMSI is present in our environment. It was associated with spread of STI including AIDS, unwanted pregnancies and clandestine abortions. We should take into considerations all the predictors found in this study if we want to reduce the magnitude of this event.

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