# Silent Struggles: Sexual Dysfunction Among Breast Cancer Survivors From Three Tertiary Hospitals in Tunisia

## TL;DR

This study finds that most breast cancer survivors in Tunisia experience sexual dysfunction, with treatments like surgery and radiotherapy worsening the issue.

## Contribution

The study is the first to report on sexual dysfunction among breast cancer survivors in Tunisia using a validated Arabic version of the FSFI.

## Key findings

- 87% of breast cancer survivors in Tunisia experience sexual dysfunction.
- Radical surgery, radiotherapy, and hormonotherapy are significantly associated with higher rates of sexual dysfunction.
- Desire and arousal are the most commonly affected domains of sexual function.

## Abstract

Background

Breast cancer is the most common malignancy among women worldwide and the leading cause of cancer-related mortality. While survival rates have improved, the impact of breast cancer and its treatments on female sexual health remains underexplored, particularly in North African populations.

Objective

The objective of this study is to assess the prevalence and determinants of sexual dysfunction among women in remission after treatment for non-metastatic breast cancer in Tunisia.

Methods

We conducted a descriptive, cross-sectional multicenter study (November-December 2024) including 200 sexually active women in remission from non-metastatic breast cancer recruited from three tertiary hospitals in Tunisia. Sexual function was assessed using the validated Arabic version of the Female Sexual Function Index (FSFI-19). Sociodemographic, clinical, and treatment variables were collected and analyzed with standard statistical tests; sexual dysfunction was defined as a total FSFI score ≤26.55.

Results

The mean age was 50.3 ± 23.2 years; 74% were aged 41-67 years. Most women (83%) underwent surgery, 92% chemotherapy, 80% radiotherapy, and 55% hormonotherapy; only 10% had breast reconstruction. The mean FSFI score was 18.3 ± 11.6, with 87% of participants meeting criteria for sexual dysfunction. Desire (59%) and arousal (59.5%) were the most impaired domains, while 43% reported lubrication difficulties, 50% had orgasmic dysfunction, and 56.5% had dyspareunia. Overall, 74.5% of participants reported sexual dissatisfaction. Analytically, sexual dysfunction was more frequent after radical surgery compared to conservative surgery (91% vs. 78%, p=0.04), and among women receiving radiotherapy (92% vs. 76%, p=0.02) or hormonotherapy (94% vs. 78%, p=0.01). Radiotherapy was associated with more lubrication difficulties and sexual pain, while hormonotherapy mainly impaired desire and lubrication. No significant differences were observed for chemotherapy.

Conclusion

Sexual dysfunction is highly prevalent among Tunisian breast cancer survivors, particularly affecting desire and arousal. Specific treatments, especially radical surgery, radiotherapy, and hormonotherapy, exacerbate sexual impairments. Systematic assessment of sexual health using validated instruments such as the FSFI should be integrated into routine oncology follow-up. Multidisciplinary, culturally adapted interventions are urgently needed to address the physical, psychological, and relational dimensions of survivorship care.