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Keywords:

  • Epidemiologic Survey;
  • Sexual Function;
  • Sexual Satisfaction

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. Statement of Authorship
  10. References

Introduction.  It is now increasingly recognized that sexual health is important to overall good health and well-being.

Aim.  The Global Better Sex Survey (GBSS) explored the sexual aspirations and unmet needs of men and women worldwide.

Main Outcome Measures.  Participant responses to survey questions.

Methods.  Data were collected during 2005 in 27 countries by phone, door-to-door, and street-intercept interview. Data were weighted by demographic characteristics to accurately reflect the general population of each country.

Results.  Of the 12,563 respondents (men = 6,291, women = 6,272), 46% of men and 48% of women were younger than 40 years, 41% were 40–59 years, and 11% were 60 years or older. Nearly all men (91%) and women (94%) were married, living with a partner, or in a relationship. All aspects of sex (intercourse, foreplay, orgasm, attraction to partner) were important to men and women. Nearly half (48%) of men surveyed reported some degree of erectile dysfunction (ED). A significant proportion of men (65%) were not very satisfied with their erection hardness (63% of women were not very satisfied with their partner's erection hardness). An association existed between satisfaction with erection hardness and satisfaction with sex life, love and romance, and overall health. Only 7% of men reported using a prescription medication for ED. However, 74% of men were willing to take medication to improve their erections if they thought they had ED; 64% of women would support such a decision.

Conclusions.  The GBSS reports the sexual needs and desires of men and women worldwide. Erectile function and the effect of ED on aspects of the sexual experience emerged as the most pressing concerns among male participants. Mulhall J, King R, Glina S, and Hvidsten K. Importance of and satisfaction with sex among men and women worldwide: Results of the Global Better Sex Survey. J Sex Med 2008;5:788–795.


Introduction

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. Statement of Authorship
  10. References

It is now increasingly recognized that sexual health is important to overall good health and well-being. A recent epidemiological study, the Global Study of Sexual Attitudes and Behavior, has identified the prevalence of sexual problems among mature women and men in 29 countries. While many problematic issues have been identified, erectile dysfunction (ED) has emerged as one of the most prominent sexual health concerns among men, with worldwide prevalence ranging from 13% to 28% of men aged 40 to 80 years old [1]. Current estimates place the number of men who will be affected by ED at 300 million by the year 2025 [2], which may be a conservative prediction because many cases of ED go unreported and untreated [3–5].

While ED has a well-documented impact on physical function, it can also have psychological effects, which can impact both partners; therefore, ED is often described as a couple's problem[6]. Partner support and satisfaction facilitate the successful, long-term treatment of ED, and improvement in erectile function can enhance the emotional well-being and quality of life of both partners [7–13].

Recognizing the impact of ED on sexual health for both men and women, the National Institutes of Health consensus panel on impotence determined that ED is an important public health problem deserving increased research support [14] and recommended that studies be performed to investigate the “perceptions and expectations associated with racial, cultural, ethnic, and societal influences on what constitutes normal male erectile function”[14]. In this report, we present the aggregate results of the Global Better Sex Survey (GBSS), which focused on components important for a satisfying sexual relationship and expectations for oral medications for ED therapy.

Methods

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. Statement of Authorship
  10. References

Questionnaire Development

An expert panel (including authors) made up of urologists, sexual medicine and outcomes research specialists, and research experts from Harris Interactive (Rochester, NY) conducted a systematic literature review to identify important issues related to sexual function and to assist in developing a series of questions focusing on these concepts. These included questions derived from sexual function scales, including validated instruments (Sexual Experience Questionnaire [15], Self-Esteem and Relationship Questionnaire [16], Massachusetts Male Aging ED Assessment [17]) as well as those based on input from the expert panel.

Two surveys, one for men and one for women, were developed to assess prevailing global sexual attitudes and behaviors. Each survey included questions on sexual episodes and satisfaction, attitudes about sex, attitudes about men's sexual health (women: attitudes about men's sexual performance), men's sexual experiences/use of ED medications (women: women's sexual experiences/attitudes/partner's use of ED medications), and demographics.

Subject Recruitment

Because of the highly personal and sensitive nature of the inquiry, it was decided to use the most appropriate and effective mode of data collection in each country rather than to attempt to standardize the data collection method globally. Hence, the sampling and data collection techniques used in each country represent the best effort in each case to achieve the most representative probability sample.

In the Americas, Europe, Malaysia, South Korea, Israel, and Australia, the survey was conducted by telephone using random digit dialing. In the Asian region, survey methods employed a random street intercept where subjects were either questioned face-to-face or asked to complete the survey on paper. In Arab countries, participants were often referred by other willing participants, and administered a self-completed survey. Most survey completers received nominal (≤$25) compensation for participation in the form of money, coupons, or gift cards. Respondents were adults (25–74 years of age) who had sexual intercourse at least once in the previous 12 months. Women must have had heterosexual intercourse.

Statistical Analysis

Weighting Within a Country

If data were available for a sexually active population within a given country, the sample was weighted to reflect the sexually active population of the country. If data pertaining to the sexually active population were not available, but it was estimated that at least 80% of the adults of the country are sexually active, then the survey was weighted to reflect the general population. Weighting factors included age, sex, ethnicity, education, region, marital status, socioeconomic and employment status, and household size. Samples were not weighted if data were unavailable for the sexually active population, the incidence/percentage of sexually active adults was unknown, or if <80% of the adult population was sexually active.

Aggregate Weights

The aggregate data of all 27 countries were weighted by the population size of the individual countries to accurately reflect the proportional differences in population size between countries. In addition, a self-weighting design was used to set sample country population sizes that reflected the population size of the country compared with other sampled countries, with larger samples (1,000 or 2,000) for larger countries and smaller samples (500 or less) for smaller countries. In figures, the unweighted bases for men and women are displayed to reflect the true sample size.

Results

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. Statement of Authorship
  10. References

Responder Characteristics

The GBSS was a one-time, cross-sectional epidemiologic survey conducted in 2005 in six geographic regions (Table 1): the Americas, Europe, Asia, Oceania, the Middle East, and Africa. Cooperation rates varied substantially between countries. This type of discrepancy is for the most part attributable to the data collection method used in each country (e.g., phone recruit to a mail survey in South Korea vs. street intercept in Hong Kong). In total, 12,563 people (6,291 men and 6,272 women) participated in the GBSS (Table 2). Nearly half of the survey participants were younger than 40 years of age, and the majority of participants were married.

Table 1.  Participating regions and countries in the Global Better Sex Survey
 Male completersFemale completersCooperation rate (%)
AmericasBrazil50250126.3
Canada25025019.9
Mexico25025019.3
United States1,0041,00311.3
EuropeFrance25025112.2
Germany25125126.3
Italy25025024.4
Spain25025013.0
Switzerland12512645.5
Turkey1271258.1
United Kingdom25025013.8
AsiaHong Kong12512596.7
Indonesia26225777.3
Japan5005009.6
Malaysia12812532.0
South Korea2542552.2
Singapore12512592.9
Taiwan2502506.1
Thailand13212571.9
OceaniaAustralia12512510.6
Middle EastIsrael1261259.6
Kuwait12512542.3
Lebanon12512550.7
United Arab Emirates12512750.1
AfricaEgypt12512581.6
Morocco13012539.5
South Africa12512662.2
Total 6,2916,272 
 12,563 
Table 2.  Demographic characteristics of respondents to the Global Better Sex Survey
 MenWomen
N6,2916,272
Age, years (%)
 ≥601210
 40–594141
 ≤394648
 Unknown12
Marital status (%)
 Married7076
 Living with a partner56
 Single, divorced, separated, or widowedIn a relationship1612
Not in a relationship85
 Unknown11

Importance of Sex

Analysis of the compiled data revealed that all aspects of sex (e.g., intercourse, foreplay, ability to achieve orgasm, attraction to partner) are very important to men and women (Figure 1). The aspect of the sexual experience that was most highly regarded by men and women was feeling attracted to one's partner, with 71% of women and 72% of men reporting that attraction to their partner was very important to them. Nearly all of the men (97%) and women (94%) agreed that it is important to give their partner pleasure during sex.

image

Figure 1. Importance of sex to men and women. Men and women were asked to rate the importance of several aspects of the sexual experience. The proportions of men and women were determined for those who responded that different aspects of the sexual experience were 1, not at all important (or disagree strongly); 2, not too important (or disagree somewhat); 3, somewhat important (or somewhat agree); or 4, very important (or strongly agree); and for those who were not sure or declined to answer. The unweighted bases for men and women are displayed to reflect the true sample size. ♀ = women; ♂ = men.

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Satisfaction with Sex

More than half of all respondents (58% of women, 57% of men) were not fully satisfied with their sex life, and approximately one-quarter (24%) of women and more than one-third (36%) of men indicated that they were having less than the right amount of sex. In the 4 weeks before the interview, 47% of women and men reported having sexual intercourse one to five times, and 13% of women and 9% of men did not engage in sexual intercourse.

Erection Hardness and Sexual Confidence

Although 95% of men and 88% of women reported that it is important to be able to achieve and maintain an erection for a good sexual experience, only 38% of men were very satisfied with their erection hardness (36% of women were very satisfied with their partner's erection hardness) (Figure 2). In an analysis of attitudes about men's sexual performance, 90% of women and 91% of men believed that a man's confidence in his sexual ability is critical to having a good love relationship (Figure 1).

image

Figure 2. Importance of and satisfaction with erection hardness. The importance of getting and maintaining an erection and satisfaction with erection hardness was reported by 12,563 men and women. Possible responses for importance of getting and maintaining an erection were 1, not at all important; 2, not too important; 3, somewhat important; or 4, very important. Possible responses for satisfaction with erection hardness were 1, very dissatisfied; 2, dissatisfied; 3, satisfied; or 4, very satisfied. The unweighted bases for men and women are displayed to reflect the true sample size. ♀ = women; ♂ = men.

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Association Between Erection Hardness and Overall Health

For men and women who had sex within the previous 4 weeks, there existed an association between satisfaction with erection hardness and satisfaction with sex life, love and romance, and overall health (Figure 3). In general, respondents who indicated low satisfaction with erection hardness were less likely to be satisfied with their sex life, love and romance, and overall health. The majority of men who were very satisfied with their erection hardness and women who were very satisfied with their partner's erection hardness were also very satisfied with their sex life, love and romance, and overall health.

image

Figure 3. Association between erection hardness and satisfaction with sex life, love and romance, and overall health. The association between satisfaction with sex life, love and romance, and overall health was determined for men who reported that they were less than satisfied, satisfied, or very satisfied with their erection hardness and for women who reported that they were less than satisfied, satisfied, or very satisfied with their partner's erection hardness. The responses for the 11,078 men and women who had had sex within the previous 4 weeks were 1 = very dissatisfied, 2 = somewhat dissatisfied, 3 = neither satisfied nor dissatisfied, 4 = somewhat satisfied, and 5 = very satisfied. The unweighted bases for men and women are displayed to reflect the true sample size.

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Desire to Improve Erectile Function

Among male respondents to the GBSS who had not taken a prescription medication for ED in the previous 4 weeks, 48% reported some degree of ED (responses of usually [mild ED, 36%], sometimes [moderate ED, 10%], or never [severe ED, 2%] being able to get and keep an erection good enough for sex). Among men categorized as having mild, moderate, and severe ED, 25%, 34%, and 35%, respectively, were interested in improving their sexual experience. In addition, 67% of these men worried that it was their fault and more than half (53%) reported that it made them hesitant to initiate sex in the future when they were unable to get or keep an erection. However, among all respondents to the GBSS, only 7% of men reported using a prescription medication for ED in the previous 4 weeks. Of these men, the majority (56%) had been using a prescription medication for ED for ≤1 year.

Prescription Medication for ED

Among the men who had not taken a prescription medication for ED, 74% said they would be willing to do so if they thought they had ED, and 68% would do so if they thought it would make sex better; 64% of women would support that decision. Of the men who had used a prescription medication for ED, nearly one-quarter of the men (22%) used the medication every or almost every time (nearly one-third, 32%, of the women reported that their partner used an ED medication every time or almost every time), and 87% of men and 79% of female partners reported that the ED treatment has allowed them to have better sex. The majority of men and women reported that the ED medication had improved the hardness of erections, the reliability in achieving an erection, the duration of erections, and pleasure from sexual activity (Figure 4).

image

Figure 4. Improvement in sexual performance among men with erectile dysfunction (ED) who took a prescription medication for ED within the past 4 weeks. Men with ED (N = 530) and female partners of men with ED (N = 311) were asked to what extent the prescription medication that the men were taking for their ED improved various aspects of sexual performance within the past 4 weeks. Response options were 1 = not improved at all, 2 = not improved much, 3 = improved somewhat, 4 = improved a great deal. The unweighted bases for men and women are displayed to reflect the true sample size. ♀ = women; ♂ = men.

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Discussion

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. Statement of Authorship
  10. References

From multinational, aggregate data, it was determined that all aspects of the sexual experience were important to men and women. However, a significant proportion of men and women were not completely satisfied with their sex life, and there was a desire for improvement across both sexes. Nearly half of the men reported some degree of ED, and dissatisfaction with erection hardness emerged as the predominant complaint, with regard to erectile function. Recent findings from an international study panel proposed treating patients with ED to their full erectile potential as an appropriate treatment goal for ED therapy, and recognized maximal erection hardness as the “starting point that may ultimately lead to overall sexual satisfaction”[18].

In this study, men and women who were very satisfied with erection hardness were also very satisfied with their sex life and love and romance. Interestingly, satisfaction with erection hardness was also linked with satisfaction with overall health for men and women. Studies indicate that erectile function can be an indicator of vascular health [19], and recent epidemiologic reports reveal that ED is associated with chronic diseases and may predict the severity and prognosis of cardiovascular disease [20–23]. Saigal et al. reported that the prevalence of ED among men aged ≥20 years was 18% and that obesity, hypertension, smoking, and diabetes were associated with an increased risk of ED (odds ratio range, 1.56–2.69) [23]. Among men 40 to 80 years old visiting a primary care physician, the prevalence of ED was 49% and was associated with an increased risk of developing cardiovascular disease or diabetes [20]. Among men who underwent cardiac stress testing (average age was 59 years), 54% had ED, and these men were more likely than men without ED to have heart disease, diabetes, and hypertension [22].

Studies have shown that as a man's erectile function and sexual satisfaction improve, so too does his partner's sexual satisfaction [11,13,24–26]. These findings are supported by the GBSS in which men who had taken a prescription medication for ED and their partners both agreed that treatment has allowed them to have better sex.

In the GBSS, almost half of the total population of men reported that they cannot always get and keep an erection good enough for sex, indicating that they have some degree of ED. Although the majority of men reported a willingness to take a prescription medication if they thought they had ED, a decision that would be supported by the majority of women, very few had taken a medication for ED. These data reveal that although men and women report deficits in erectile function and sexual satisfaction, barriers remain to ED diagnosis and treatment. Similar discrepancies between the prevalence of ED symptoms and receipt of ED medications have been reported in a number of studies, e.g., in a population-based study, Eardley et al. [27] reported that ED was present in 32% of men and 26% of male partners of women surveyed; however, only 15% of men with self-reported ED and 6% of male partners with ED had received treatment.

There are limitations to the GBSS. The most appropriate and effective mode of data collection in each country was used rather than a standardized data collection method globally. Consequently, it is possible that to some degree country-by-country differences in findings are attributable to differences in data collection mode. For example, the anonymity provided by telephone interviews may have resulted in more candid responses than face-to-face interviews. The responses to intimate questions, such as those in the GBSS, may differ between participants who were initially hesitant to answer and those who willingly volunteered answers. However, the country-by-country variance may also be attributable to cultural differences between countries—which impact such factors as who qualifies for the survey by virtue of having sex, who chooses to participate in the survey, and how participants actually answer the questionnaire.

This survey is also limited by the number of questions which focused on erectile function, to the exclusion of other sexual problems that occur in men and women. However, the focus on erectile function allows for a more in-depth analysis of this problem and the ramifications of this disorder for men and women, globally.

Conclusion

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. Statement of Authorship
  10. References

The GBSS reports the sexual needs and desires of men and women worldwide and focuses on the effect of ED on aspects of the male and female sexual experience.

Acknowledgments

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. Statement of Authorship
  10. References

This study was funded by Pfizer Inc. Editorial assistance was provided by Susan DeRocco, PhD, and Janet E. Matsuura, PhD, at Complete Healthcare Communications, Inc., and was funded by Pfizer Inc, New York, NY.

Statement of Authorship

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. Statement of Authorship
  10. References

Category 1

  • (a)
    Conception and Design
    • John P. Mulhall; Rosie King; Sidney Glina; Kyle Hvidsten

  • (b)
    Acquisition of Data
    • John P. Mulhall; Rosie King; Sidney Glina; Kyle Hvidsten

  • (c)
    Analysis an Interpretation of Data
    • John P. Mulhall; Rosie King; Sidney Glina; Kyle Hvidsten

Category 2

  • (a)
    Drafting the Manuscript
    • John P. Mulhall; Rosie King; Sidney Glina; Kyle Hvidsten

  • (b)
    Revising It for Intellectual Content
    • John P. Mulhall; Rosie King; Sidney Glina; Kyle Hvidsten

Category 3

  • (a)
    Final Approval of the Completed Manuscript
    • John P. Mulhall; Rosie King; Sidney Glina; Kyle Hvidsten

References

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. Statement of Authorship
  10. References
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