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New
survey on the prevalence of sexual dysfunction and related help-seeking
behaviors among mature adults in the United States of America.
www.medscape.com
From
International Journal of Impotence Research
A
Population-Based Survey of Sexual Activity, Sexual Problems and Associated Help-
seeking Behavior Patterns in Mature Adults in the United States of
America
E.O. Laumann; D.B.
Glasser; R.C.S. Neves; E.D. Moreira Jr.
Published:
07/16/2009
Abstract
and Introduction
Abstract
To
study sexual activity, the prevalence of sexual dysfunction and related
help-seeking behaviors among mature adults in the United States
of America, a telephone survey was conducted in 2001–2002. A total
of 1491 individuals (742 men/749 women) aged 40– 80
years
completed the survey. Overall, 79.4% of men and 69.3% of women had
engaged in sexual intercourse during the 12 months preceding the
interview. Early ejaculation (26.2%) and erectile
difficulties (22.5%) were the most common male sexual problems. A lack of sexual interest
(33.2%) and lubrication difficulties
(21.5%) were the most common female sexual problems. Less than 25% of men and women with a
sexual problem had sought help for
their sexual problem(s) from a health professional. Many men and women in the United States report
continued sexual interest
and activity into middle age and beyond. Although a number of sexual problems are highly prevalent, few people seek medical
help.
Introduction
The
development of convenient and effective oral treatments for male erectile
dysfunction has stimulated an increasing level of interest in the
sexual functioning of middle-aged and older adults. Over
the last decade, many studies have investigated the prevalence of sexual problems
among middle-aged and elderly people. Most
of these studies have involved the populations of industrially developed nations around the
world, particularly in Europe,[1-3]
and in the Americas.[4-12]
The prevalence of the male sexual problems of erectile dysfunction and early
ejaculation and their
related risk factors have been investigated most extensively, whereas fewer studies have focused specifically on female
sexual
dysfunction.13, 14 Moreover, relatively little is known about the average frequency of sexual activity and the importance of sexual
relationships among older men and women, although the few studies that have examined sexuality in mature adults have reported that
sexual
interest and activity persist well into older age.[15,16]
The
published studies of the prevalence and correlates of sexual problems in
developed and developing countries have used a variety of
different study designs and definitions, which makes valid
cross-national comparisons difficult. Moreover, there are currently no related
studies reporting how men or women from different
cultures attempt to manage or overcome their sexual problems, and there are only a
few studies that allow a comparison of
sexual behaviors across different countries.[17]
The
Global Study of Sexual Attitudes and Behaviors (GSSAB) was a population
survey of 27 500 men and women aged 40–80 years in
29 countries representing many world regions.[18-21]
Here, we report the results from the respondents in the United States. In addition to
estimating the prevalence of several sexual problems in men
and women, we sought to investigate the factors associated with these
problems and described the help-seeking behavior
they elicited in this population.
Using
a random-digit dialed sampling design, computer-assisted telephone
interviews were carried out in the United States during 2001 and
2002. Respondents were randomly selected by asking for the man or
woman in the household aged between 40 and 80 years of age
(participants were interviewed by interviewers of the same
gender). Women and men were sampled in approximately equal numbers by
design and verbal consent was obtained from all study
participants. They were also informed about the following issues: (1) all information
obtained would be used in aggregate; (2)
responses were voluntary; (3) the confidentiality and the privacy of their responses were
protected because no personal identifiers were
coded into the interview instruments; (4) no list of respondents was retained; (5) the
protocol was approved by an
institutional review board; and (6) 'refusers' were not called back in an effort to convert them to participating
respondents.
A
structured questionnaire requested information concerning general health,
demographics, relationships and sexual behaviors, attitudes and
beliefs. The subjects were asked if they had engaged in
sexual intercourse during the previous 12 months and the presence of sexual
dysfunction was assessed by means of two sequential
questions. The respondents were first asked whether they had experienced one or
more of the sexual problems listed in Table 2 for a
period of at least 2 months during the previous year, and those who answered 'Yes'
were then asked whether they had experienced
the problem 'occasionally', 'sometimes' or 'frequently'.
Logistic
regression was used to investigate potential factors associated with a
selected sexual dysfunction. In these analyses, the presence
of a sexual dysfunction was coded only for those respondents who
reported experiencing the problem frequently or periodically, whereas
those who indicated that they experienced the
problem only occasionally were recoded to indicate no sexual dysfunction.
The
subjects who reported that they had experienced a sexual problem were
asked whether they had sought help from a number of
possible sources. The options included: 'Talked to partner', 'Talked to a
medical doctor (other than a psychiatrist)', 'Looked for information
anonymously (in books/magazines or on the internet)', 'Talked
to family member or friend', 'Taken prescription drugs/devices or talked to
pharmacist', 'Talked to psychiatrist or
psychologist or marriage counsellor', 'Talked to a clergy person or religious adviser', 'Called a
telephone help line', 'Other—please
specify'. Respondents could indicate that they had sought help from more than one source.
The
subjects with sexual problems who had not consulted a physician were asked
why they had not done so, and offered a list of 14
possible reasons (from which they were to check all that applied). The
reasons included attitudes and beliefs regarding the sexual problem
and the patient–doctor relationship. All respondents
(irrespective of whether they reported any sexual problems) were also asked. 'During a
routine office visit or consultation in the
past 3 years, has your physician asked you about possible sexual difficulties without you bringing it
up first?' (Yes/No) and 'Do
you think a doctor should routinely ask patients about their sexual function?' (Yes/No).
The
categorization of household income as 'low', 'medium' or 'high' was based
on the distribution of income in the United States.
The
prevalence of a specific characteristic was calculated by dividing the
number of cases by the corresponding population. The denominator for the calculation of the prevalence of a sexual problem was
the number of sexually active people (that is, at least one episode
of intercourse during the previous 12 months). The prevalence
estimates are given with their confidence intervals.
Characteristics
of the Study Population
Overall,
19,377 individuals in the United States were contacted, 2817 of whom were
not eligible to participate. Of the 16,560 eligible
individuals, a total of 1491 individuals (742 men and 749 women)
completed the survey, for a response rate of 9.0%. The high attrition rate
is, in part, attributable to the protocol which
stipulated that in the interest of preserving respondents' anonymity, no call backs were
permitted to find better times for interviews or to try to
persuade 'refusers' to participate.
Table
1 presents selected characteristics of the study sample. A large
proportion of the subjects were married or involved in an ongoing
partnership (64.8% of men and 62.0% of women). The majority of the
men (61.0%) and women (68.5%) were employed and, overall,
about 75% of men and women reported that they were in good
or excellent general health.
[ ]
Table
1. Selected Characteristics (%) of the Study Sample, USA, 2001–2002
Approximately
80% of men and 70% of women said that they had had sexual intercourse
during the 12 months preceding the interview,
whereas about one-third of men (35.4%) and more than
one-quarter of women (27.8%) engaged in sexual intercourse regularly (that is,
more than once a week).
Prevalence
of Sexual Problems
Particularly
ejaculation was the most common male sexual problem, and was reported by
26.2% of the sexually active men in the United
States (approximately half of whom said that they experienced this problem
periodically or frequently) ( Table 2 ). Erectile difficulty was the
second most common male sexual problem in the US sample, reported
by 22.5% of sexually active men (12.4% said that they experienced
this problem periodically or frequently), followed by a
lack of sexual interest, which was reported by 18.1% of sexually active men (8.1%
said that they experienced this problem
periodically or frequently). The other sexual problems investigated (an inability to reach orgasm, a
lack of sexual pleasure and
pain during sexual intercourse) were experienced somewhat less frequently, particularly pain during intercourse,
which was reported
by only 3.1% of sexually active men in the United States.
Table
2. Prevalence of Sexual Problems in Men and Women in the USA by Severity,
2001–2002
Lack
of sexual interest (33.2%) was the most common sexual problem reported by
sexually active women in the United States, followed by
difficulty becoming adequately lubricated (21.5%), an
inability to reach orgasm (20.7%) and a lack of sexual pleasure (19.7%) ( Table 2 ).
At least one-half of the women who reported each of
these problems said that she experienced it frequently or
periodically. The other
sexual problem investigated was pain during sexual
intercourse, which was experienced by 12.7% of sexually active women.
Table
2. Prevalence of Sexual Problems in Men and Women in the USA by Severity,
2001–2002
Physical/health,
demographic and socioeconomic factors associated with three selected
sexual dysfunctions in men and women are
summarized in Table 3 (odds ratios (OR) from logistic regression). Older
age (age 60–80 years compared with the referent age of 40–49
years) was a significant correlate of erectile difficulties in men
(OR 2.19, P≤0.05) and lubrication difficulties in women (OR 2.56, P≤0.01),
whereas the age range of 50–59 years (the age at which many
women experience the menopause) was associated with an inability to reach
orgasm in women (OR 2.45 compared with the
referent of 40–49 years, P≤0.05). A lower than average level of physical activity was a
significant correlate of lack of sexual
interest in both men (OR 2.13, P≤0.05) and women (OR 1.76, P≤0.05). The impact of a diagnosis of
a number of common health conditions
were investigated and it was observed that depression was significantly associated with a lack of
sexual interest in
both men (OR 3.19, P≤0.01) and women (OR 2.08, P≤0.01), erectile difficulties in men (OR 2.61, P≤0.01) and
lubrication
difficulties (OR 2.42, P≤0.01) and an inability to reach orgasm (OR 2.73, P≤0.01) in women. Among men, a diagnosis of
prostate
disease was associated with a lack of sexual interest (OR 2.56, P≤0.05).
Table
3. Factors Associated With Sexual Problems by Gender, USA, 2001–2002
Help-seeking
Behavior
The
prevalence of selected help-seeking behaviors for sexual problems in the
United States is summarized in Table 4 . Of the respondents
who were sexually active and reported experiencing at least
one sexual problem, 45.2% of men and 43.9% of women did not take any
action (that is, they had not sought any help or advice).
A slightly greater proportion of men (21.9%) than women (16.1%) reported talking
to a medical doctor about their sexual problem(s),
but overall the majority of men (75.7%) and women (79.7%) had sought no help from a
health professional. Patterns of
help-seeking behaviors were generally similar for men and women in the United States and talking to their
partner was the most usual
action taken by both men and women (43.3 and 43.4%, respectively).
Table
4. Prevalence of Selected Help-seeking Behaviors for Sexual Problems by
Gender, USA, 2001–2002
Factors
Associated With Seeking Medical Help for Sexual Problems
Some
factors that might be associated with seeking medical help for sexual
problems were investigated using logistic regression and the
findings for both men and women in the United States are summarized in
Table 5 . A significant effect of age was seen only in men at age
60–69 years (OR 5.2, P≤0.01), compared with the referent group
aged 40–49 years. Certain sexual problems were associated with a
greater likelihood of seeking medical help. Erectile
difficulties in men (OR 5.29, P≤0.001) and lubrication difficulties in women (OR 2.09,
P≤0.05) were significant correlates of
seeking medical help for sexual problems. A number of sexual beliefs and attitudes were significant
correlates of seeking
medical help for sexual problems. In men, these were 'being very or somewhat dissatisfied with their own sexual
functioning' (OR 2.94,
P≤0.01), 'a belief that decreased sexual ability would significantly affect their own self-esteem' (OR 2.69, P≤0.05)
and
'thinking that it is acceptable to use medical treatment for sexual problems' (OR 13.52, P≤0.01). In women, having been asked by a
doctor
about possible sexual difficulties during a routine visit in the past 3 years (OR 2.23, P≤0.05), and thinking that a doctor should
routinely ask patients about sexual function (OR 3.55, P≤0.05) were significantly correlated with seeking medical help for sexual
problems.
Thinking that older people no longer want/have sex had quite a different effect for men and women. Although
among women, this belief was
associated with an increasing likelihood of seeking medical help for sexual problems (OR
3.14, P≤0.01), men with this belief were less
likely to seek medical help (OR 0.36, P≤0.05).
]
Table
5. Factors Associated With Seeking Medical Help for Sexual Problems by
Gender, USA, 2001–2002
Attitudes
and Beliefs About Diagnosis and Treatment of Sexual Problems
The
most common reasons cited among respondents in the United States for not
consulting a doctor about a sexual problem were thinking
it was not very serious or waiting for the problem to go away
(36.3% of men and 38.1% of women) and a belief that it is a normal part of
aging or being comfortable as he/she is (25.4% of men and
28.2% of women) ( Table 6 ). Lack of access to or affordability of medical
care and embarrassment about discussing sexual
problems with their medical doctor were cited as a reason by less than 5% of men and
women, whereas a lack of belief that a sexual
problem is a treatable medical condition was cited by about 15% of men and women. Few
respondents in the United States had been
asked by a doctor about possible sexual difficulties during a routine visit in the past 3 years
(11.5% of men and 15.0% of
women) but more than one-half of men (59.2%) and women (54.0%) thought that a doctor should routinely
ask patients about their
sexual function.
]
Table
6. Attitudes, Behaviors and Beliefs About Diagnosis of and Treatment for
Sexual Problems by Gender, USA,
2001–2002
In
this study, we report population-level data from middle-aged and older men
and women in the United States concerning sexual behavior,
the prevalence of sexual problems and associated help-seeking behaviors. The large cross-national population sample and the use of a
common method of data collection represent two major
strengths of the GSSAB. Face-to-face interviews were not used to avoid causing
respondents undue embarrassment when talking
about private and sensitive issues, and to minimize the likelihood of respondents feeling
obliged to give 'socially desirable'
answers.[22]
Only a sexual problem that persisted with moderate to higher frequency was considered to
be a 'dysfunction'. This method is
essentially equivalent to using two sequential screening tests, and minimizes the risk of false-positive
responses. It is likely,
therefore, that the prevalence of sexual dysfunction may be under-reported in the GSSAB in comparison with studies
that used more
sensitive, but less specific methods.
The
overall response rate in the United States (9.0%) was low, but similar to
other countries in our study, namely, Austria, Canada,
Germany, Spain, Italy, United Kingdom and Israel (<12%); and somewhat
lower than the response rate in Australia, New Zealand,
Sweden, France and Belgium (14–17%). In the data available, we did not
find any of the characteristics to be correlated to participation in
the survey. Although it is true that low completion
rates can serve as a flag for the possibility of systematic biases in sample coverage, it by
no means guarantees or necessitates it. The
prevalence of self-reported health conditions such as hypertension, diabetes and smoking in the
GSSAB (these data are not shown
here) was comparable with published values.[23-25] This suggests that contacts refused to participate in
the study due to a
general unwillingness to undergo a telephone interview, regardless of the subject matter and is therefore unlikely to have
introduced a bias in the estimates of the prevalence of sexual behaviors and problems. It also appears to indicate that the study
population
was broadly representative of the US population. This assumption is further supported by the observation that the prevalence of
erectile
dysfunction among men in the US cohort of the GSSAB is comparable to values reported in published studies that were
conducted in the
United States among men aged 50 years or older in rural Central New York State,5 and among US health
professionals.[6]
The prevalence
of other sexual problems in our survey is also comparable to those yielded by the analysis of data from
the National Health and Social Life
Survey, a probability sample study of sexual behavior in a demographically representative cohort
of US adults.[4]
In this study, an inability
to reach orgasm, a lack of sexual interest and sex not pleasurable was reported by
22, 29 and 11% of the women and by 9, 16 and 7% of
the men, respectively.
Some
well-known risk factors (for example, smoking, diabetes, and so on) did
not seem to affect sexual function/problems in our survey.
This may be due to the limited power of our study, and to possible
misclassification of the diagnosis of medical conditions as we had to rely
on self-report. Despite that, we found that depression
was a significant correlate of a number of sexual problems in both men and women in
the United States. Comorbidity between male
erectile dysfunction and depression is known to be high but the nature of the relationship
between the two conditions is unclear.[26,27]
Although the distress of erectile dysfunction may contribute to the development of depression,
it is also possible that
depressive illness may lead to erectile difficulties. There have been data from a prospective study suggesting that the
incidence of
erectile dysfunction is increased among men with depression.28 When considering the co-presence of depression and sexual
dysfunction, the
possible role of antidepressant treatments should not be overlooked. Sexual dysfunction is a common side effect of
antidepressant therapy; however, the reported rates of dysfunction may vary between different agents.[29,30]
The selective serotonin
reuptake inhibitors appear to be associated with
especially high rates of sexual dysfunction and whereas men taking selective serotonin
reuptake inhibitors report higher rates of sexual side effects than women, the dysfunction experienced by women seems to be more
severe.[29,31]
Finally, just as cardiovascular problems are good markers for sexual problems (and vice versa), our data suggest that
depression can be investigated in a similar way, that is, physicians who note that their patients are depressed may want to inquire
about their
sexual function and patients who are having problems with sex should be queried about their mood state.
Our
findings indicate that feeling that the problem was not severe, or not
being bothered by the problem may be deterring men and women
in the United States from raising the subject of their sexual
difficulties with their doctor. Furthermore, they show that doctors in the United
States rarely ask patients about their sexual health
during a routine consultation, even though this would be welcomed by the majority of
men and women and would appear to encourage
medical help-seeking for sexual problems, at least in women. If left untreated, sexual
problems can greatly diminish a patient's
quality of life and it is important that physicians— especially
primary care physicians—incorporate
questions about sexual functioning
into their routine patient work-ups.32 If handled sensitively, this should result not only in improved
functioning for the
patient but also an enhanced physician–patient relationship and greater professional satisfaction.
In
conclusion, these findings indicate that middle-aged and elderly men and
women in the United States continue to show sexual interest and
activity, in spite of the high prevalence of several sexual
dysfunctions. Few of the men and women who experience sexual difficulties seek
medical help; this may be due in part to
believing that the problem was not serious and/or not being bothered by the problem. Appropriate
educational initiatives, aimed at both
patients and healthcare professionals, may help to increase awareness and understanding of sexual
health issues and help them to
identify and overcome potential barriers that their patients' might have in discussing and seeking help for
sexual problems, thereby
enabling more older adults to continue to enjoy a fulfilling sexual life.
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Authors
and Disclosures
E.O.
Laumann,1
D.B.
Glasser,2
R.C.S.
Neves,3
and E.D.
Moreira Jr.
3
for the GSSAB Investigators' Group
1Department
of Sociology, University of Chicago, Chicago, USA
2Pfizer
Inc., New York, NY, USA
3Gonçalo
Moniz Research Center, Oswaldo Cruz Foundation, Salvador, Brazil
Conflict
of Interest
Edward
O Laumann and Edson D Moreira Jr are consultants for Pfizer Inc. Dale B
Glasseran is an employee and stockowner of Pfizer Inc.
Raimundo C S Neves—none.
Acknowledgements
We
acknowledge the contribution of our colleagues on the study's
International Advisory Board: Alfredo Nicolosi (Italy), Bernard Levinson
(South Africa), Clive Gingell (UK), Ferruh Simsek (Turkey),
Gerald Brock (Canada), Jacques Buvat (France), Ken Marumo (Japan),
Rosie King (Australia), Sae-Chul Kim (Korea) and Uwe
Hartmann (Germany). The Global Study of Sexual Attitudes and Behaviors was
funded by Pfizer Inc.
Correspondence:
Dr ED Moreira Jr, Unit of Epidemiology and Biostatistics, Oswald Cruz
Foundation, Rua Waldemar Falcão 121,
Salvador, Bahia 40.295-001, Brazil. E-mail:
edson@bahia.fiocruz.br
Int
J Impot Res. 2009;21(3):171–178 © 2009 Nature Publishing Group
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