Disclosures Neither John Tomlinson and Linford Fernandes have conflicts of interest. Within the last three years, Kevan Wylie has received honoraria, research grants and support to attend medical conferences and meetings from Astra Zeneca, Bayer Schering Pharma, Boehringer Ingelheim, imedicare, Ipsen, Janssen-Cilag, J&J, Meda Pharmaceuticals, Pfizer, Procter and Gamble, Prostrakan and Durex/SSL. Neither he nor any immediate family member has a current financial arrangement or affiliation with any organization(s) that may have a direct financial interest in the subject matter of the guideline.
John M. Tomlinson, 26 Church LaneHolybourne,AltonHampshireGU34 4HD, UK Tel.: +1420 82210Email: email@example.com
Introduction: Sexual problems are relatively common in the community. The under-reporting of such problems calls for alternative ways of getting a true perspective of the prevalence of sexual dysfunction.
Aim: To assess and investigate the concerns, ages and nationality of male users of a electronic helpline using it over 2 years (2009–2010).
Methods: Detailed records were kept of all emails and telephone calls to the helpline which included administrative and clinical queries. The clinical calls and some of the emails were answered by the administrator, while the majority of the emails were answered by a physician. This presentation will deal with the users who emailed for assistance with male sexual dysfunction. (n = 673).
Results: The helpline received a total of 6142 calls over the period of investigation, including administrative and press calls. Men accounted for 88% of the callers about sexual dysfunction. Erectile dysfunction accounted for 68% of the complaints by men who used the e-mail service. Premature ejaculation, loss of sex drive, genital problems and masturbation worries were other concerns that were received. A large number of men from the Middle East and the Indian sub-continent used the email service, mostly for premature ejaculation and masturbation worries, related to their arranged marriage.
Conclusions: We found confirmation that the commonest sexual complaints in men were of erectile dysfunction and loss of sex drive. Significant correlations were identified between the types of sexual dysfunction and the age and ethnicity of the men who presented with them.
Telephone helpliness have been set up to provide advice to people anonymously who suffer from sexual dysfunction as many people don't report any problems to their doctors.
An email helpline is a useful way for people to receive professional advice on sexual concerns. It has helped elicit different patterns of sexual health concerns in the community.
Sexual problems are relatively common in the community (1), although a substantial proportion of people suffering with sexual problems, difficulties or dysfunctions do not seek advice from a clinician or specialist. For those who do seek help, there is little in the form of a well-defined protocol for general practitioners to refer to when dealing with such patients, even if they are already suffering from a comorbid condition like coronary heart disease (2,3). Among men, the likelihood of reporting a concern regarding their sexual health varies with time, with only half of those suffering from a sexual condition reporting it within a year (4). The under-reporting of such problems calls for alternative ways to get a true perspective of the prevalence of sexual dysfunction in the population.
Increasingly, the use of telephone helplines have become common place, although recent evidence would suggest that their users are more often men, aged between 26 and 35 years who have not sought help from elsewhere (5). This Italian group reported the most common sexual difficulties among men as erectile dysfunction and premature ejaculation.
There is a number of reports in the literature about the development of telephone helplines, (6–10) although there is very limited evidence of the use of electronic mail to help patients with sexual problems (11,12).
In the United Kingdom, the Impotence Association was set up as a charity in 1995 to assist patients with sexual problems as an additional or alternative resource, and to direct contact with medical practitioners, sex therapists or other professionals with expertise in the field. With time, the UK charity changed its name to the Sexual Dysfunction Association to encompass women’s and couple’s problems as well as those affecting men, and extending the remit beyond erectile dysfunction. More recently, in keeping with a more positive approach to facilitate patient information, the charity was renamed as the Sexual Advice Association.
From the outset, a telephone helpline has been provided by the charity, although only very limited data were collected in the early years. Since 2007, the Association has been able to offer personalised responses to email enquiries in addition to both the telephone service and the advice sheets on their Internet web base. As data had not previously been gathered, they started to be collected from early 2008. The period between 2009 and 2010 has been used in this study to identify a typical period of e-mail requests to the charity.
Patients can contact the Sexual Advice Association by phone or by electronic mail (e-mail). All telephone calls to the Association are answered by the administrator, who is a chartered psychologist and who works on Mondays, Wednesdays and Fridays for a total of 24 h. She also separates the administrative calls such as Press enquiries, from the e-mails from patients.
An answer is offered directly over the phone to the patient and to those telephone calls with a query, which she can answer herself. Where this immediate response can be given, it is often accompanied with the advice to consult web-based information sheets on the Association’s website or contact their general practitioner. Those who she feels need more specific medical information are passed on to one of the Trustees.
There are seven of these, each with a specific expertise. These are a cardiologist, an urologist, a psychiatrist, a gynaecologist, a general practitioner, a sexual health clinic nurse practitioner, a psychotherapist and a business woman.
Where she is uncertain about the advice to give, the administrator will forward the e-mail to the Trustee with specialist knowledge and expertise in male sexual dysfunction (JT). He attempts to answer them within 48–74 h or acknowledges them with a request for a more detailed history.
Where queries are sent in by or about women, e-mails are sent to the appropriate Trustee. These are not dealt with by direct response to the patient, but by offering advice to the administrator for her to send on to the enquirer.
All e-mail requests about male-related problems sent to the specialist physician about male-related problems during 2009 and 2010 (No. 673) were reviewed, and data were collated.
All the statistical analysis was carried out in Statistical Package for the Social Sciences (SPSS) version 17 (IBM Corporation, Somers, NY, USA).
The primary way people found out about the helpline was through the Sexual Dysfunction Association website. Over 2009 and 2010, the website registered 200,385 visitors in total. The majority of these visitors were from Great Britain with 135,370 visitors. A total of 19,789 visits were from people in the United States. Other countries that had significant numbers of users were Singapore (1240), Canada (2905) and India (4019).
Telephone calls received
The helpline received a total of 6142 telephone calls over the period of investigation (2009–2010), including administrative and press calls. Eighty eight percent of the telephone calls were about sexual dysfunction in men. The number of telephone calls for different sexual dysfunction concerns is outlined in Table 1. Some telephone callers complained of multiple problems like erectile dysfunction and loss of sex drive. Therefore, the number of concerns exceeds the total number of calls for men and women. The telephone callers were dealt with and advised on the management of their problems by the helpline administrator herself and were directed towards sources that would help further, such as the fact sheets on the helpline website. Where the problem was thought to have a medical cause, the telephone caller was advised to visit their doctor, and in the case of a telephone call from within the UK, callers might have been referred on to specialists.
Table 1. Demographics and presenting problems of callers to the helpline 2009–2010. Totals exceed concerns as some callers complained of multiple problems
Telephone calls received
Total calls received
Low sex drive
Non-specified sexual dysfunction
Low sex drive
Other (e.g. pregnancy, STDs)
Along with the 6142 telephone calls, the Sexual Advice Association helpline received a total of 4703 e-mails over the period of investigation, 2120 of which were about administrative issues. There were 87 e-mails that were from the press asking for information about the work done by the Association or with a specific sexual query. There were 67 e-mails from health professionals, usually concerning the role of the helpline.
Calculation of the use of either a telephone call or an e-mail by age was not possible, because phone callers were often reluctant to say their age and many e-mailers had to be prompted two or three times, especially the ones from outside the UK.
The total number of e-mail enquiries from patients received over the period of investigation in 2009 and 2010 and the type of sexual problems reported by men and women are shown in Tables 2 and 3 respectively. These show e-mails with clinical problems only, most of which were dealt with by the helpline administrator. Some of the e-mails were from the partners of men suffering from a particular problem. In a few of these cases, it was not clear whether the woman e-mailing had informed her partner previously that she was writing for advice because she felt he had a problem. From the nature of the correspondence, the suspicion was that some women who e-mailed might not have talked to their partner about their concern.
Table 2. E-mails received over 2009–2010 from men with different presenting problems. (P) = number of e-mails received from the partner
Low sex drive
Other (e.g. STDs, genital problems etc.)
Total (including e-mails from the partner)
Referral to a medical specialist (usually a trustee)
Table 3. E-mails received over 2009–2010 from men with different presenting problems. (P) = number of e-mails received from the partner
Non-specified sexual dysfunction
Low sex drive
Total (including e-mails received from the partner)
Referral to a medical specialist (usually a trustee)
Those e-mails from men who needed an in-depth reply, were forwarded to the physician specialising in male sexual dysfunction, with a total of 673 being received over the 2 years. The analyses in this article will focus primarily on these 673 e-mails from men. The demographics of these clinical contacts over the 2 years and the most common concerns reported are shown in Table 4. The helpline referred a total of 335 patients, who were residents in the UK, to the College of Sexual and Relationship Therapists (COSRT) over the 2 years.
Table 4. Number of e-mails received by specialist physician from men presenting with different problems
E-mails concerning male sexual dysfunction
No. e-mails (%)
Below 40 years
Above 40 years
Country of origin
Erectile dysfunction (ED)
Premature ejaculation (PE)
Loss of sex drive
The number of people presenting with different sexual problems remained similar over the 2 years. There were approximately equal numbers of people above and below 40 years of age using the service. The number of those from outside UK remains constant at about a quarter of the number of patients.
Age as a factor in sexual problems
Increasing age has been identified as a strong risk factor for the development of sexual dysfunction, taking account of the comorbidities and increase in prescription drug use that goes with advancing age (13). Therefore, the contacts over the 2 years were stratified by age when analysing sexual concern problems. The percentage of contacts in each age group is shown in Figure 1.
The largest number of contacts was from people who were between 21 and 30 years old. The percentage of contacts who were concerned with erectile dysfunction in each age group is shown in Figure 2.
Erectile dysfunction was by far the most common concern with 461 (69%) contacts reporting some problem either achieving and/or maintaining an erection. This figure shows an increase in the complaints regarding erectile dysfunction with increasing age. Patients over 40 years of age were significantly more likely to complain of symptoms concerned with erectile dysfunction than those younger than 40 years (OR = 3.12) (95% CI = 2.13, 4.59). Patients with erectile dysfunction from the UK had a mean age of 47 years, whereas those from outside the UK had a mean age of 37 years.
Premature ejaculation was another concern that troubled 81 (12%) men. The number of concerns over premature ejaculation in the different age groups is shown in Figure 3.
The number of enquires about premature ejaculation was much greater in younger men aged 40 or less, compared with those over 40 (OR = 4.55) (95% CI = 2.56, 8.33).
The other major concern was the loss of sex drive experienced by 113 (17%) contacts. Figure 4 illustrates the significance of age in the incidence of a decrease in sex drive.
The majority of concerns were from the middle-aged, with younger men not reporting a change. Once again, it was more common for people over 40 years to report a noticeable decrease in their sex drive (OR = 1.68) (95% CI = 1.09, 2.58).
Ethnicity as a factor in sexual problems
The helpline received a substantial number of e-mails from people outside the UK with sexual problems. Of the 156 (25%) e-mails from outside the UK, the largest groups were from India or Pakistan, with a total of 71 patients. Altogether, enquiries came from 20 different countries from as far afield as Saudi Arabia, Afghanistan, Zimbabwe, Bulgaria and Australia. Once again erectile dysfunction and premature ejaculation were the most common issues reported by correspondents.
Interestingly, the prevalence of sexual problems from the contacts within the UK and those outside the UK showed a significant difference. Men from the UK with erectile dysfunction were significantly more likely to make contact than men from outside the UK (OR = 1.69) (95% CI = 1.15, 2.44). This was also true of concerns because of loss of sex drive, which were more likely to come from men in the UK (OR = 2.74) (95% CI = 1.49, 5.05). However, premature ejaculation was more commonly reported by those who were from outside the UK, in particular from the Indian subcontinent (OR = 3.63) (95% CI = 2.21, 5.95).
Other sexual problems
The helpline received e-mails from people reporting a range of other sexual problems. Sixty five enquiries reported problems around masturbation, with more enquiries coming from outside the UK (38, mostly Muslims – calculated by e-mail address, name, country or the writer’s admission) compared with 27 within the UK. Concerns over masturbation in 25% of the men (usually worries that ‘excessive’ masturbation in adolescence was the cause of their problem) were from those in their 20s with the number of queries decreasing in the older age groups.
Eighty two patients reported genital problems with anxieties about a bend in their erection and penis size. Of the e-mails, 47 were from the UK, whereas 29 were from outside the UK. The other six patients did not specify their country. Patients younger than 40 years were significantly more likely to report concerns regarding their genitals, such as bends in the penis or penis size, than those over 40 years. The majority of genital concerns, 47 (70%) were from those under 40 years of age (OR = 2.43) (95% CI = 1.41, 4.20).
A total of 377 (56%) of the patients were advised on management of their problem. This included trying new medication like PDE5 inhibitors, different techniques for counteracting their problems and in many cases reassurance, where patients were overly anxious about them. The remaining patients were advised to get a medical check, report to their doctor for specific tests or were referred elsewhere
Based on the symptoms reported, 153 (23%) patients were advised to have their testosterone levels measured. The percentage of patients recommended for a check based on their age is shown in Figure 5. Several of these patients had other chronic diseases like diabetes or heart disease that are known to be comorbid conditions for symptoms like erectile dysfunction (14,15).
Forty two percent of the contacts over 40 years old, diabetics or those with heart disease, were advised to have their testosterone levels tested. This emphasises the likelihood of sexual problems (erectile dysfunction, loss of sex drive, so-called ‘Viagra failure’) being linked to lower testosterone levels with increasing age. A total of 178 (26%) contacts were referred back to their GP to get a medical check, have an appropriate blood test, try a new drug (such as a PDE5 inhibitor) or make changes to their existing medication. The limitations of email contact were shown up by the difficulty in finding whether the patient actually went for the tests and later, if they did, of obtaining precise results.
Twenty six patients were referred to the COSRT, a national specialist charity for sexual and relationship therapy.
Throughout the period that the data were collected, a log was kept if possible, of the response rate to advice given by the administrator or physician. This included responses, where patients thanked the physician after receiving advice or successfully overcoming their problem. A total of 271 (40.3%) patients responded once or more to the initial request for a more detailed history, followed by advice given by the physician. The response rate improved in 2010 with more people responding to correspondence than in 2009. Over the period of investigation, a total of 991 e-mail replies were sent to patients with advice on management, although some patients wrote back and requested further information, requiring multiple e-mails.
An interesting point with regard to response rate is that the younger people were more likely to reply or thank the helpline administrator or physician than older contacts as shown in Figure 6. One possible explanation for this might be that older contacts might have just accepted the advice given, given up more easily, disliked giving a more detailed answer to questions about their problem or had seen the advice given as something not worth going through with. Another is that the younger men, especially those in their teens, were glad not to have had to see a doctor face-to-face, and were grateful for the anonymity. Furthermore, access to technology needs to be taken into account as well. Older contacts might not have checked their e-mail accounts as regularly as younger contacts who might have had more frequent access to the Internet.
The demographics of people calling the helpline over the 2 years showed considerable uniformity as shown in Tables 2, 3 and 4. Erectile dysfunction, premature ejaculation and loss of sex drive were the commonest problems reported. This is in keeping with the trend that erectile dysfunction and premature ejaculation are the most frequent self-reported sexual concerns among men (7,16). Almost half the e-mails every month were handled by the administrator. These usually involved one-off queries rather than persistent symptoms and the large number may be because of the fact that an e-mail service is relatively anonymous, allowing for one-off enquiries. A substantial, but unquantified number of patients had not sought help before, and the e-mail helpline was their first contact with a healthcare professional. This has been shown to be the case with other European countries with callers to a helpline being for the most part young men who had not spoken to anyone else about their problems before (5).
The fact that female partners contacted the helpline on behalf of their partner is interesting, as studies indicate that only half of those with erectile dysfunction or premature ejaculation have ever discussed the condition with their partner (4). The proportion of patients who have discussed their sexual problem with their partner and a doctor increases with the duration of the problem, with people more likely to seek help for condition lasting longer than a year. Most men with premature ejaculation do not seek assistance from their doctor, and most of those who do, are not satisfied with the results (17).
Interestingly, those who suffered from erectile dysfunction were significantly more likely to report a decrease in their libido as well, with 20% of people who reported erectile dysfunction also reporting a loss in sex drive (OR = 2.27) (95% CI = 1.37, 3.76). It has been shown that erectile dysfunction is strongly associated with premature ejaculation and a loss of sexual desire (18). However, there was not a significant correlation between people suffering from premature ejaculation and a decreased libido.
Another significant factor in reporting sexual problems was ethnicity. A large number of contacts especially from the Indian subcontinent reported premature ejaculation as being a significant concern. Interestingly, these were mostly young Muslim men. This trend is supported by a recent study that focused on the aetiology of premature ejaculation being linked to the country of origin (19). That study found that some racial groups are more susceptible to premature ejaculation, particularly men from the Indian subcontinent. One reason they put forward for this finding is that some races are more ‘sexually restrained’ than others. In particular, in Middle Eastern and Asian cultures, young men are more likely to refrain from sexual intercourse before marriage.
In 2010, 24 (6.2%) contacts reported as being either in or expecting an imminent arranged marriage. A significant number of these men also reported premature ejaculation as a concern (OR = 3.95) (95% CI = 1.59, 9.80). This could be a factor that highlights a relationship between country of origin and premature ejaculation, as most of these men were from outside the UK. Furthermore, this finding is supported by a recent study that found that men in arranged marriages were significantly more likely to have concerns regarding premature ejaculation (20). Reasons put forward for this correlation include no previous sex before marriage, anxious first sexual experiences, previous sex outside of marriage, religion and pressure from family (21).
Our helpline has been shown to be effective in highlighting the concerns of men and women regarding their sexual health. It has been used as a counselling service, where feedback has been given after initial contact from the concerned person. Such helplines are used extensively for different issues ranging from smoking cessation to depression.
The question of cost-effectiveness in a charitable organisation is often asked, and the answer seems to be that charities depend on a lot of goodwill from their Trustees and helpers and in this case, apart from the Administrator who is paid for 3 days a week, everyone else is not paid. The physician who replies to the e-mails has recently retired from being the Director of a very active men’s sexual health clinic and does the work for the charity pro bono in his spare time.
However, although this is an international helpline, there are relatively few of them. The increased global coverage by an international helpline can be effective in increasing access in countries, where such a service is not available. As shown in the results, people who contact a helpline from different countries vary in age and ethnicity, and so the helpline must have the expertise to provide tailored advice to the individual contacts. Therefore, it is advantageous to have a common standard of counselling or feedback, which can be provided by a global service.
Telephone advice lines are an established source of support for patients with sexual problems. E-mail advice and counselling is an increasingly important and effective resource to elicit answers anonymously that otherwise might remain hidden. It can therefore be a useful link between the health-care system and people coping with problems that are not usually picked up in routine medical consultations, especially with men who are embarrassed and who feel they cannot discuss their sexual difficulties face-to-face with someone whom they may know, such as their own doctor.