Sexual behaviour and dysfunction and help-seeking patterns in adults aged 40–80 years in the urban population of Asian countries

Authors


Alfredo Nicolosi, Department of Epidemiology and Medical Informatics, Institute of Biomedical Technologies, National Research Council, Via Fratelli Cervi 93, 20090 Segrate MI, Italy.
e-mail: alfredo.nicolosi@itb.cnr.it

Abstract

OBJECTIVE

To study sexual activity, the prevalence of sexual dysfunction and related help-seeking behaviour among middle-aged and elderly people in Asia.

SUBJECTS AND METHODS

A random population survey was carried out in 2001–2002 among urban residents aged 40–80 years in China, Taiwan, South Korea, Japan, Thailand, Singapore, Malaysia, Indonesia and The Philippines, with interviews based on a standardized questionnaire covering demographic details, health, relationships, and sexual behaviours, attitudes and beliefs. An intercept method of sampling was used in all countries except Japan, where questionnaires were mailed to a sample drawn from telephone directories. Sexual dysfunction was defined as persistent sexual problems.

RESULTS

The questionnaire was completed by 6700 people (3350 men and 3350 women), giving a response rate of 27%. Across all countries, 82% of men and 64% of women had engaged in sexual intercourse during the year preceding the interview. Most of the respondents considered satisfactory sex an essential means of maintaining a relationship. More than 20% of men and 30% of women complained of having at least one sexual dysfunction, although there were marked variations among the countries. The sexual dysfunctions most frequently reported were early ejaculation (20%; 95% confidence interval, CI, 18–21) and erectile dysfunction (15%, 14–17) among men; and a lack of sexual interest (27%, 25–29), lubrication difficulties (24%, 22–25), and an inability to reach orgasm (23%, 22–25) among women. Of the 948 men and 992 women who were sexually active and reported sexual dysfunctions, 45% did sought no help or advice and only 21% sought medical care.

CONCLUSION

Men and women in Asian countries continue to show sexual interest and activity into middle age and beyond. Although sexual dysfunction is prevalent in this age group, several sociocultural and economic factors appear to be preventing individuals from seeking medical help for these problems.

Abbreviations
ED

erectile dysfunction

GSSAB

Global Study of Sexual Attitudes and Behaviours

INTRODUCTION

The recent increase in interest in sexual behaviour and sexual problems of middle-aged and elderly people is, at least in part, a consequence of longer life expectancy and the wider availability of effective and convenient treatments for male erectile dysfunction (ED). The studies that have been conducted to date to explore aspects of sexuality among middle-aged and older adults indicate that interest in sex persists in these age groups [1–4].

In Asia, ED is the only male sexual disorder which has been systematically investigated among middle-aged and elderly people (in Japan, Thailand, Singapore, South Korea, Malaysia and China) [5–10]. No studies focusing specifically on female sexual problems appear to have been carried out in Asian populations, although dyspareunia has been investigated as a symptom of menopause among women in South-east Asian countries [11].

The Global Study of Sexual Attitudes and Behaviours (GSSAB) was a population survey which studied 27 500 women and men, aged 40–80 years, in 29 countries around the world [12,13]. In the present paper we report the results from the nine Asian countries which were involved, and compare sexual behaviour, prevalence of sexual dysfunction, and help-seeking patterns across these countries (Hong Kong was analysed separately from mainland China because their recent history is different and they have a different socio-economic profile).

SUBJECTS AND METHODS

Sampling was based on an intercept method, except for Japan. Individuals were randomly selected and contacted in public areas by a same-gender interviewer who requested that they complete a self-administered questionnaire. Women and men were sampled in similar numbers. Rural areas were not included because of logistical problems. In Japan, names were randomly drawn from the national telephone database and the subjects were mailed a self-completed questionnaire, along with a postage-paid return envelope and an incentive check for US $4.

The questionnaire elicited demographic details, health, relationships, sexual behaviour, attitudes and beliefs. Subjects were asked if they had engaged in sexual intercourse during the past year. The presence of sexual dysfunction was assessed using two sequential questions; the first was “During the last 12 months have you experienced any of the following for a period of 2 months or more?”: ‘Lacked interest in having sex’, ‘Were unable to reach climax (experience orgasm)’; ‘Reached climax (experienced orgasm) too quickly’; ‘Experienced physical pain during intercourse’; ‘Did not find sex pleasurable’; (men only) ‘Had trouble achieving or maintaining an erection’; (women only) ‘Had trouble becoming adequately lubricated’.

Those who answered positively the first question were asked a second question: “For each of these experiences, how often would you say this has occurred during the last 12 months?” and the offered answers were ‘Occasionally’, ‘Sometimes’ and ‘Frequently’. In calculating the prevalence of sexual dysfunctions, we excluded those who reported occasional problems because the term ‘sexual dysfunction’ implies a persistent problem. Those who reported having a sexual dysfunction were asked whether they sought help or advice from a series of sources (respondents could indicate more than one source). In the analysis, the following categories were used: (i) family/social support (talked to the partner, family members or friends, a clergy person or religious advisor, a marriage counsellor); (ii) medical care (talked to a physician, a pharmacist, a psychiatrist or psychologist, used prescribed or unprescribed drugs or devices); (iii) information (looked in books or magazines, on the Internet or called a telephone helpline).

Subjects with sexual dysfunction who did not consult a physician were asked the reason for not doing so. The original, not mutually exclusive answers were: ‘I didn’t think it was very serious’; ‘I thought it was a normal part of getting older’; ‘I didn’t think a doctor could do much for me’; ‘I didn’t think I would be comfortable talking to a doctor’; ‘I don’t have a regular physician’; ‘I’m comfortable the way I am’; ‘I was waiting to see if this problem would go away’; ‘I was worried that a doctor might find something seriously wrong with me’; ‘I didn’t think it was a medical problem’; ‘I didn’t think the doctor would be comfortable discussing sexual problems’; ‘The doctor is a close friend’; ‘The doctor is too young or old’; ‘The doctor is the wrong gender and I’d feel uncomfortable’; ‘It's too costly to see a doctor’. In the analysis, the answers were categorized as: (i) Lack of perception of problem(s) (‘I am comfortable the way I am’, ‘Waiting to see if problem goes away’, ‘Did not think it was very serious’, ‘I was worried that a doctor might find something seriously wrong with me’); (ii) Thinks issue is not a medical problem (‘Normal with ageing’, ‘Do not think it is a medical problem’, ‘Physician cannot do much’); (iii) Embarrassment (‘Not comfortable talking to a physician’, ‘Physician uneasy talking about sex’, ‘Physician is the wrong gender’, ‘Physician is of the wrong age’, ‘Physician is a close friend’); (iv) Problem with access to or affordability of medical care (‘Do not have a regular physician’, ‘Physician is expensive’).

The categorization of household income as ‘low’, ‘medium’ or ‘high’ was based on the distribution of income in each country, to make it possible to compare nations with different absolute mean incomes.

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 sexual dysfunctions was the number of sexually active people (i.e. at least one episode of intercourse during the previous year). The prevalence estimates were age-standardized using the age distribution of the entire study population (by gender when appropriate) and are presented with 95% CI [14].

RESULTS

Overall, 31 495 individuals were contacted, 6420 of whom were not eligible to participate. Of the 25 075 eligible individuals, 15 396 refused to participate at introduction, while 2964 interrupted the interview. A total of 6700 individuals (3350 men and 3350 women) completed the questionnaire, for a response rate of 27% (Table 1). Most subjects in all countries were married, with rates ranging from 57% of women in Thailand to 99% of men in mainland China. More than half of the subjects were employed in all countries except for mainland China, where only 39% of women and 43% of men were employed. The rate of employment in the remaining countries ranged from 53% of men in Hong Kong to 93% of women in South Korea and Taiwan. The proportion of people with a low income was highest in the Philippines (50% of men and 61% of women), while in all other countries ≤ 30% of men and women reported a low income. More than half of the subjects reported that their general health was good or excellent, except in South Korea and Hong Kong, where only 49% and 44% of women, respectively, reported good or excellent health. In all countries except Thailand and Taiwan, more men than women reported good or excellent health.

Table 1.  Characteristics of the Asian population of the GSSAB, 2001–2002 (age-standardized prevalence), the age-standardized prevalence of sexual dysfunctions (only sexually active subjects), and the proportion of men and women with sexual dysfunctions who did not consult a physician, and reasons for not consulting
 ChinaHong KongTaiwanSouth KoreaJapanThailandSingaporeMalaysiaIndonesiaPhilippines
  • *

    All values are percentages, unless otherwise specified; M/W, men/women;

  • Self-reported ‘good’ or ‘excellent’ general health;

  • Reporting sexual intercourse on at least one occasion during the preceding 12 months;

  • ¶Reporting sexual intercourse more than once per week.

  • §

    §% of individuals with sexual dysfunctions who did not consult a physician; other categories are not mutually exclusive reasons for not consulting a physician, as reported by those with sexual dysfunctions who did not consult a physician.

Mean (sd) age, years55 (10)55 (11)52 (11)53 (11)57 (11)53 (11)50 (8)52 (10)55 (8)59 (11)
M/W*:
Sample (N)250/250250/250250/250600/600750/750250/250250/250250/250250/250250/250
Married 99/97 80/75 93/88 95/77 98/88 80/57 70/77 85/77 83/64 91/72
Urban residence100/100100/100100/100100/100 78/75100/100100/88 97/93 87/88100/100
Currently employed 43/39 53/73 76/93 80/93 74/92 83/86 77/86 67/75 66/85 70/90
Income level:
Low 23/25 21/27 24/19 25/27 24/30 23/30 25/21 20/27 12/17 50/61
Medium 64/65 41/42 56/63 62/61 49/42 53/41 47/40 73/64 59/61 41/34
High 13/10 38/32 20/18 13/12 27/28 24/29 28/27 7/8 15/11 9/5
Good health 66/58 59/44 67/67 68/49 57/54 57/59 72/65 72/62 73/65 59/50
Hypertension 17/20 21/19 17/15 35/33 21/17 30/16 9/4 10/14 19/21 33/29
Diabetes 4/5 4/8 4/6 31/25 8/5 16/10 11/2 18/13 4/4 15/10
Current smoker 64/5 48/3 54/10 64/5 45/14 38/6 45/8 55/12 66/6 43/20
Sexually active 97/92 77/55 90/76 90/70 78/63 75/44 70/58 63/53 82/54 77/57
Very sexually active 17/11 20/4 25/16 28/15 10/7 35/20 37/31 31/28 24/27 42/23
Sexual dysfunctions, % (95% CI)
Men
Early ejaculation22 (17–28)10 (5–16)13 (8–17)20 (17–24)22 (18–25)23 (14–31)12 (7–16)31 (23–39) 9 (6–12)45 (38–53)
Erection difficulties20 (15–25) 8 (3–13) 9 (5–13)18 (14–21)13 (11–16)29 (21–38) 2 (0–4)28 (20–36)11 (7–15)33 (26–41)
Lack of interest in sex15 (11–20) 8 (3–13)17 (12–22)16 (13–20) 8 (5–10)19 (11–26)11 (6–15)17 (10–24)20 (16–25)29 (22–36)
Inability to achieve orgasm13 (8–17) 8 (2–13)11 (7–16)11 (8–14) 9 (7–11)15 (7–22) 4 (1–7)19 (12–27) 7 (4–10)29 (22–36)
Sex not pleasurable11 (7–15) 3 (0–5) 9 (5–13)10 (8–13) 3 (2–4)12 (5–19) 5 (2–8)20 (12–27) 6 (3–9)22 (15–28)
At least one dysfunction37 (31–43)24 (17–30)32 (26–38)38 (34–42)32 (28–36)49 (40–57)22 (16–28)48 (40–56)27 (22–32)64 (57–72)
Women
Lack of interest in sex21 (16–27)19 (12–27)35 (27–43)17 (14–21)33 (29–38)24 (16–31)19 (13–25)42 (33–51)28 (19–36)50 (41–60)
Inability to achieve orgasm25 (20–31)13 (7–20)21 (14–29)10 (7–12)29 (24–33)27 (19–35)19 (13–25)21 (23–40)22 (14–30)56 (47–65)
Sex not pleasurable23 (17–28)15 (8–22)17 (10–23)20 (16–24)21 (17–25)22 (14–29)10 (5–14)26 (14–37)16 (11–21)42 (33–51)
Lubrication difficulties33 (27–38)15 (8–22)24 (17–32)18 (14–22)30 (25–34)22 (15–30)14 (9–19)36 (27–45)14 (9–18)50 (40–60)
Pain during sexual intercourse13 (9–18) 9 (3–15)23 (16–30)13 (9–16)27 (23–31)20 (12–27) 7 (3–11)33 (25–42)12 (7–16)33 (24–42)
At least one dysfunction45 (38–51)37 (29–45)51 (44–58)35 (31–39)53 (48–58)55 (47–63)32 (25–39)58 (49–67)39 (30–48)82 (75–89)
Physician consultation and reasons for not consulting
Not talked with GP89859597917485659679 (88)
Because of:
lack of perception of problem(s)95969393929984948396 (94)
thinks issue is not a medical problem96938990879979958692 (91)
embarrassment86498277717467966863 (75)
a problem with access  to or affordability of medical care90467658608456778271 (69)

Overall, most men and women reported that they had had sexual intercourse during the 12 months preceding the interview, but there was considerable variation among countries, with the highest rates of sexual activity reported among men in mainland China (97%), South Korea and Taiwan (both 90%) and the lowest among women in Thailand (44%), Malaysia (53%) and Indonesia (54%). The proportion of the sample that was sexually active declined with age in both men and women. Among men, 92.6% of those aged 40–49 years reported that they had had sexual intercourse during the past 12 months, compared with 49.4% of those aged 70–80 years. There was a greater age effect among women (85.0% at 40–49 years and 18.4% at 70–80 years). The proportion of respondents who engaged in sexual intercourse regularly, i.e. more than once a week, also varied widely among the countries (10–42% of men and 4–31% of women).

More than half of the men aged up to 69 years, and > 25% aged 70–80 years, reported that they thought about sexual activity a few times per month or per week (Fig. 1). About 10% of men aged 40–49 years thought about sex every day, but this proportion decreased steadily with age. Two-thirds of the women up to the age of 49 years reported thinking about sex a few times per month or per week, but this figure declined to < 10% in the oldest group of women. A much higher proportion of women than men reported that they never thought about sex (at all ages).

Figure 1.

Frequency of thinking about sexual activity in the Asian population of the GSSAB, 2001–2002 (never or < 1/month, red; few times/month or /week, green; every day, light red).

PREVALENCE OF SEXUAL DYSFUNCTIONS

Overall, early ejaculation (20%), erectile difficulties (15%), and lack of interest in sex (14%) were the most commonly reported sexual dysfunctions among men. Early ejaculation was reported most frequently in The Philippines (45% of sexually active men) and Malaysia (31%), and least often in Indonesia (9%) and Hong Kong (10%) (Table 1). Difficulties with erection were also reported most frequently in the Philippines (33%), and high rates were reported also in Thailand (29%) and Malaysia (28%).

Lack of interest in sex (27%), lubrication difficulties (24%), inability to reach orgasm (23%) and lack of pleasure in sex (20%) were the problems most frequently reported by women. However, there were substantial differences between the countries, with the highest rates reported in the Philippines (>40% of women reported each of these four dysfunctions) and the lowest in Hong Kong, South Korea and Singapore (≤20% of women reported each of these four dysfunctions). Physical pain during intercourse was reported by women somewhat less frequently than the other dysfunctions.

In all countries, > 20% of men and > 30% of women complained of at least one sexual dysfunction, but there were marked variations among the countries, with the lowest rates reported in Singapore (22% of men and 32% of women) and the highest in The Philippines (64% of men and 82% of women).

HELP-SEEKING BEHAVIOUR

Of the 948 men and 992 women who were sexually active and reported periodic and frequent sexual problems, 45% sought no help or advice for their problem (the results were almost identical for men and women), 43% of cases used family or social support, 21% sought medical care, and 26% looked for information in the media (the total is > 100% because multiple answers were allowed) (Fig. 2). The people of East Asia (China, Hong Kong, Taiwan, South Korea and Japan) were the least likely to take any action. In the South-east Asian countries many more people reported making use of family/social and other forms of support.

Figure 2.

Help-seeking behaviour of men and women with sexual dysfunction in the Asian population of the GSSAB, 2001–2002 (no action, green; partner/family/social support, red; health care, light green; information sources, light red).

Most (88%) of men and women with periodic and frequent sexual problems (defined here as sexual dysfunction) had not talked to a doctor about these problems (Table 1). There was substantial variability among the different countries in this respect, with the highest rates of not consulting in South Korea and Indonesia (97% and 96%, respectively) and the lowest in Malaysia (65%). Overall, the lack of perception of their problem or the belief that the problem is not a medical issue were the most common reasons cited by men and women for not consulting a doctor about their sexual problem (Table 1). Embarrassment and problems with access to, or affordability of, medical care were also cited as reasons by a substantial proportion of respondents in all countries.

DISCUSSION

This is the first study to report data on sexual behaviour and the prevalence of sexual dysfunction among middle-aged and older men and women from several Asian countries, in a way that allows comparisons among them. A major strength of this study lies in the cross-national population sample and the use of a common method of data collection. Face-to-face interviews were not used because they may give rise to embarrassment when talking about very private and sensitive issues, or might induce respondents to give socially desirable answers about particular behaviours or attitudes [15]. We defined dysfunction as only those sexual problems that persisted with moderate to high frequency [16]. This method essentially equates to the use of two sequential screening tests, and thus minimizes the risk of false-positive responses. Therefore, it seems likely that the prevalence of sexual dysfunction may have be underestimated in the present study in comparison with studies using more sensitive (and less specific) methods.

The present response rate (27%) was not high, but the prevalence of self-reported general health, and hypertension, diabetes and smoking, reported by respondents is consistent with the respective age- and gender-specific national values [17–22]. We assume that the main reason for refusal was a general unavailability to participate in a survey (61% of the eligible contacts refused participation at introduction, and if they are excluded the response rate would be 69%). This suggests that the low response rate is unlikely to have introduced a bias in the estimates of the prevalence of sexual behaviours and dysfunctions.

Sexual interest and activity were widespread among middle-aged and elderly Asian men and women, and persist into old age. However, in comparison with men and women from ‘Western’ regions involved in the GSSAB (including Europe and North America) [13,14], the responses from Asian subjects indicate that they are more sexually conservative, more male-orientated and less sexually active. Although the frequency of sexual intercourse is lower in Asia than in the West, the satisfaction rate with the sexual frequency among Asian people is comparable with that of Western subjects.

The prevalence of sexual dysfunction was quite high, but only a small proportion of affected people sought medical care. This is in contrast with the reported general attitude of expecting healthcare for sexual problems, and it reveals that there are substantial barriers (cultural or financial) which are hampering people from seeking and obtaining the desired medical attention.

Within these general observations, there is considerable variability among the different countries and between East Asian and South-east Asian regions. The predominant cultural and religious influences may influence sexual attitudes and behaviours. For example, in East Asia (China, Taiwan, Japan and Korea) a Confucian cultural background predominates, while in South-east Asia, people have a Buddhist (Thailand), Muslim (Malaysia, Indonesia) or Catholic (The Philippines) background. It is particularly striking that the highest rates of all sexual dysfunctions in both men and women were found in The Philippines. Further analysis of the data is required to elucidate which factors may be contributing to the risk of sexual dysfunction in this sample, for although the lowest income levels were reported in The Philippines, and rates of self-reporting of good/excellent general health were also fairly low, other factors that might be expected to affect sexual function, e.g. levels of education and employment level, and the frequency of intercourse, were all moderate to high. The prevalence of diabetes, hypertension and tobacco use were correlated with the prevalence of sexual dysfunction. It is noticeable that the countries in which the prevalence of hypertension and diabetes was highest among men (South Korea, Thailand, Indonesia), also reported the highest rates of erectile difficulties.

The pattern of help-seeking behaviours showed substantial differences between East and South-east Asian countries. In the East Asian countries (China, Taiwan, South Korea and Japan) most people took no action, while in South-east Asian countries help was most often sought from partner, family or other source of social support. Reasons for not seeking medical help also varied widely among countries, although lack of perception of a problem and the belief that sexual dysfunction is not a medical issue featured strongly in all countries. Cultural factors influencing how comfortable people are about discussing sexual problems also clearly played a role, as ‘embarrassment’ was cited as a reason for not consulting in almost all cases in Malaysia (96.3%) but in less than half (49.0%) of cases in Hong Kong. Problems with affordability or accessibility of medical care were most common in China, Indonesia and Thailand, and least common in Hong Kong, Singapore and Japan. These findings appear to be generally in keeping with the observed socio-economic profiles of these countries, as indicated by level of income and education.

From the findings of this study, we conclude that men and women in Asian countries continue to show sexual interest and activity into middle age and beyond. However, sexual dysfunction is prevalent in this age group, and several sociocultural and economic factors appear to be preventing individuals from seeking medical help for these problems. Further research is required to fully understand which factors are most important in the individual countries. Once there is a clearer indication of the barriers that are preventing men and women from obtaining the care they need, efforts can be made to provide suitable educational, economic and social support.

ACKNOWLEDGEMENTS

The authors acknowledge the contribution of their colleagues on the international advisory board for this study: Gerald Brock (Canada), Jacques Buvat (France), Clive Gingell (UK), Uwe Hartmann (Germany), Rosie King (Australia), Bernard Levinson (South Africa), Edson Moreira (Brazil), Ferruh Simsek (Turkey). Source of support: The Global Study of Sexual Attitudes and Behaviours was funded by Pfizer Inc.

CONFLICT OF INTEREST

Dale B. Glasser is an employee of sponsor. Source of funding: Pfizer.

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