Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Worldwide prevalence and correlates

Jeong-han Kang, Edward O Laumann, Dale B Glasser, Anthony Paik

Introduction

The debate continues on the nature of gender differences in sexual problems.1 One feature of this debate centers on the extent to which biologic, psychosocial, and cultural factors each contribute to these various difficulties. Yet, assessments of their relative influence on the prevalence of sexual problems have been hampered by the lack of systematic, cross-cultural population studies. A recent review of 52 studies on sexual dysfunctions, for example, found that few were based on broadly representative samples, and even fewer included information on multiple sexual problems.2 With most epidemiologic studies focused on North American and Western European populations, findings from other regions of the world are often based on smaller studies involving clinical series or other samples that are not broadly representative. The Global Study of Sexual Attitudes and Behaviors (GSSAB) was recently conducted to investigate health status, as well as attitudes, beliefs, behaviors, and satisfaction regarding sex and relationships among middle- aged and older adults in 29 countries.

The objectives of the current analysis of the GSSAB include the following: (1) to estimate the prevalence of sexual problems among women for five regional clusters; (2) to identify factors that increase the likelihood of reporting selected, common sexual problems by regional cluster.

Methods

The GSSAB is the first large, multicountry survey to study systematically attitudes, beliefs, and behavior regarding sexual relationships among middle-aged and older adults. The survey involved 13 882 women and 13 618 men, aged 40-80 years, in 29 countries, representing many world regions. We selected women of 18 countries for the current analysis (n = 7361) that

will represent regions of the world, excluding Europe and the USA. European countries and the USA have been analyzed in Chapters 2.2 and 2.1, respectively, of this volume. For the purposes of this chapter only, “Western” shall refer to the Western regions, excluding Europe and the USA. In Canada, Australia, New Zealand, and Brazil, samples were based on random-digitdialing, and respondents were selected randomly within households by asking for the person between 40 and 80 years of age with the most recent birthday. Sampling in Middle Eastern countries (Algeria, Egypt, Morocco, and Turkey) employed a door-to-door protocol, where households were selected by random starting points, and study staff contacted every third house in several major cities. In Asian countries (China, Hong Kong [although Hong Kong is part of China, it is listed separately because of its distinct socioeconomic and cultural characteristics], Korea, Indonesia, Malaysia, the Philippines, Singapore, Taiwan, and Thailand), an intercept protocol was employed in major cities. Both the door-to-door and intercept protocols represent accepted survey methods for each country, but are likely to be more reflective of their urban populations. A female sample size of 750 was used in Australia, Turkey, and Japan. A female sample size of 250 was used in New Zealand, Algeria, China, Hong Kong, Taiwan, Indonesia, Malaysia, the Philippines, Singapore, and Thailand. In the remaining countries, the female sample sizes were as follows: Canada, 500; Brazil, 471; Mexico, 252; Egypt, 318; Morocco, 253; and Korea, 600.

In Canada, Australia, New Zealand, and Brazil, telephone interviews were conducted via computer-assisted telephone interview (CATI). Due to the sensitive nature of the topic, refusals were not called back. The door-to-door and intercept protocols employed in Algeria, Egypt, Morocco, Turkey, China, Korea, Taiwan, Indonesia, Malaysia, the Philippines, Singapore, and Thailand used self-completed questionnaires. There were two exceptions to this data collection strategy. In Japan, a mailed, self-completed questionnaire was used, and in Mexico, a mixed-mode method of in-person and telephone interviews was employed. The mean overall response rate was 19%, the mean rate for the telephone interviews being 15%, 30% for the self- completed questionnaires, and 33% for the mailed, self-completed questionnaires used in Japan. Response rate ranged from 8% to 55% in the various countries.

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 only, (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, and (5) ‘refusers’ were not called back in an effort to convert them to participating respondents.

The questionnaire asked for information about demographics, health, relationships, and general satisfaction with life as a whole, as well as individual behavior, practices, attitudes, and beliefs regarding sexuality. The presence of sexual problems was assessed by the following question: “During the last 12 months have you ever experienced any of the following for a period of 2 months or more when you: (1) lacked interest in having sex; (2) were unable to reach climax (experience orgasm); (3) reached climax (experienced orgasm) too quickly; (4) experienced physical pain during sex; (5) did not find sex pleasurable; and (6) had trouble becoming adequately lubricated?” Respondents were permitted to answer yes to all that applied. For those indicating the presence of a specific sexual problem, the relative severity was assessed in a follow-up question: “For each of these experiences, how often would you say this has occurred during the last 12 months? Would you say that this has occurred occasionally, sometimes, or frequently?”

We restricted our analyses to only those respondents who had had intercourse at least once in the year prior to being interviewed. This procedure reduced our sample size to 4705 women and tended to drop older respondents, who were sexually inactive more frequently. Thus, the prevalence of sexual problems was calculated by dividing the total number of selfreports for each problem by the total number of respondents who were sexually active in the year prior to being interviewed. Country-specific data were grouped into clusters, according to geographic proximity, shared cultural backgrounds, and similar modes of data collection. Using the age distribution of the entire sample in the GSSAB for women, we age-standardized the prevalence estimates for each regional cluster.

A number of possible correlates of sexual problems were investigated. These included age, self-reported measures of general health status, current level of physical activity, selfreport of a diagnosed vascular condition (including hypertension, diabetes, heart disease, high cholesterol, and having had a stroke), self-report of a diagnosis of depression, having had a hysterectomy, and whether respondents currently or formerly smoked. Respondents also reported how often they thought about sex - a proxy for their current level of sexual libido - and whether they agreed with the belief that aging reduced sexual desire and/or behavior. Other self-reported measures included educational attainment, whether respondents believed that their religion guided their sexual behavior, experience with divorce and financial problems in the 3-year period prior to being interviewed, the expected time horizon of their current relationships, the frequency of engaging in sex, whether they usually engaged in foreplay, and whether they were sexually exclusive.

We utilized logistic regression in this study. This approach produced adjusted odds ratios (ORs), which indicate the odds of reporting the particular sexual problem among those with a given characteristic (such as poor health) relative to people in a reference category (such as good health), controlling for all other factors in the regression analysis. In these analyses, the presence of a sexual problem included only those respondents who reported “sometimes” or “frequently” having the problem (that is, those who indicated “occasionally” were recoded to indicate no sexual problem). In order to evaluate the validity of pooling a specific country with the others in a regional cluster, we employed a series of interaction models between covariates and country dummy variables to test whether a specific country could be pooled in an analysis. Countries with covariate patterns that were significantly different from the pooled sample were dropped from the analysis (results are available upon request). Thus, we dropped the following countries: (1) Algeria, Taiwan, Indonesia, the Philippines, and Singapore in logistic regressions of orgasm problems; and (2) Mexico, Egypt, Taiwan, and the Philippines in logistic regressions of lubrication difficulties.

Results

Table 2.3.1 presents the prevalence of sexual problems of 2 months’ or more duration, subdivided by frequency of occurrence. In most cases, the reported prevalence of sexual problems was higher in East Asia and Southeast Asia than in the other regions of the world. Lack of interest in sex and inability to reach orgasm were the most common sexual problems across the five regions, ranging from 28% to 43% and 22% to 41%, respectively. Lubrication difficulties were relatively common and showed similar prevalence across most regions, with the notable exceptions of East Asia and Southeast Asia, where the prevalence was approximately 10 percentage points higher than that reported in other regions. We analyzed factors associated with the likelihood of reporting sexual problems among women. We focused on more severe problems: only those respondents indicating a periodic (sometimes) or frequent sexual problem in the 12 months prior to being interviewed were coded as having that particular problem (that is, those who indicated “occasionally” were recoded to indicate no sexual problem). Here we present detailed analyses of two selected problems: the inability to reach orgasm and lubrication difficulties.

Table 2.3.2 presents logistic-regression results for factors associated with the likelihood of reporting an inability to reach orgasm. Age does not appear to be systematically associated with this problem, although several regions show some positive associations. Poor health tends to increase the likelihood of orgasm difficulties, most prominently in the “Western” regions (OR =1.7) and Asian (OR =1.5 for East Asia and OR = 2.0 for Southeast Asia) populations. In contrast, thinking about sex is associated with a decreased likelihood of this problem. Most other factors, including physical inactivity, vascular diseases, having had a hysterectomy, smoking, and belief that aging reduces sexual interest or activity, show inconsistent associations. Financial problems and depression consistently show positive associations; however, few of the odds ratios reach statistical significance. Relationship characteristics, such as partnership status, the frequency of sex, and foreplay, are generally nonsignificant, although women who have low expectations about the future viability of their relationship(s) are consistently more likely to report this problem.

Table 2.3.1. Prevalence (%) of women's sexual problems by region and severity

 

Lack of sexual interest

Inability to reach orgasm

Orgasm too quickly

Pain during sex

Sex not pleasurable

Lubrication

difficulties

"West"a

33.6 (30.3, 36.9)

25.0 (22.0, 27.9)

9.2 (7.4, 11.0)

12.1 (10.0, 14.2)

19.8 (17.0, 22.6)

27.8 (24.7, 30.8)

Occasionally

12.1 (9.8, 14.4)

8.6 (6.6, 10.5)

4.5 (3.3, 5.7)

4.0 (2.8, 5.1)

6.9 (5.1,8.7)

7.0 (5.3, 8.8)

Periodically

13.9 (11.5, 16.3)

11.2 (9.0, 13.4)

3.8 (2.5, 5.0)

5.5 (3.9, 7.1)

9.0 (7.0, 11.0)

11.6 (9.4, 13.9)

Frequently

7.3 (5.5, 9.1)

4.6 (3.3, 5.9)

0.8 (0.3, 1.3)

2.5 (1.6, 3.5)

3.6 (2.5, 4.8)

9.1 (7.1, 11.0)

Central/South Americab

28.1 (24.1, 32.2)

22.4 (18.7, 26.1)

18.3 (14.9, 21.8)

16.6 (13.4, 19.8)

19.5 (16.1, 22.9)

22.5 (18.8, 26.3)

Occasionally

7.8 (5.4, 10.5)

6.7 (4.5, 8.9)

5.0 (3.1,6.8)

2.6 (1.4, 3.9)

5.6 (3.5, 7.7)

4.3 (2.4, 6.2)

Periodically

12.8 (9.8, 15.8)

12.1 (9.2, 14.9)

9.6 (6.8, 12.3)

8.4 (6.1, 10.6)

8.8 (6.5, 11.1)

11.7 (8.9, 14.5)

Frequently

7.4 (5.0, 9.8)

3.7 (2.0, 5.3)

3.8 (2.3, 5.4)

5.6 (3.4, 7.9)

5.2 (3.3, 7.0)

6.5 (4.3, 8.7)

Middle Eastc

43.4 (38.6, 48.3)

23.0 (18.4, 27.7)

10.0 (6.9, 13.1)

21.0 (16.2, 25.8)

31.0 (26.1, 36.0)

23.0 (18.1, 27.8)

Occasionally

14.3 (11.0, 17.6)

6.1 (4.7, 7.6)

3.8 (2.7, 5.0)

6.6 (5.1,8.1)

9.2 (6.1, 12.3)

10.7 (6.8, 14.6)

Periodically

18.3 (13.7, 22.8)

10.9 (7.7, 14.0)

5.2 (2.3, 8.0)

9.0 (5.2, 12.8)

13.6 (10.4, 16.9)

7.0 (5.4, 8.5)

Frequently

10.9 (6.6, 15.2)

6.0 (2.4, 9.7)

1.0 (0.5, 1.6)

5.4 (1.7, 9.0)

8.2 (4.4, 12.0)

5.3 (1.7, 9.0)

East Asiad

34.8 (32.0, 37.7)

32.3 (29.5, 35.1)

17.6 (15.2, 20.0)

31.6 (28.8, 34.4)

29.7 (26.9, 32.4)

37.9 (35.0, 40.7)

Occasionally

7.4 (5.8, 9.0)

9.0 (7.4, 10.7)

6.2 (4.7, 7.7)

11.2 (9.3, 13.0)

8.6 (6.9, 10.2)

10.1 (8.4, 11.8)

Periodically

13.8 (11.8, 15.9)

11.9 (10.0, 13.9)

7.0 (5.4, 8.6)

11.8 (9.8, 13.9)

10.4 (8.6, 12.1)

15.6 (13.4, 17.9)

Frequently

13.6 (11.4, 15.9)

11.3 (9.3, 13.3)

4.3 (3.0, 5.6)

8.6 (6.7, 10.5)

10.7 (8.7, 12.8)

12.1 (9.9, 14.3)

Southeast Asiae

43.3 (38.1, 48.6)

41.2 (36.0, 46.4)

26.3 (21.4, 31.2)

29.2 (24.1, 34.3)

35.9 (31.0, 40.7)

34.2 (28.9, 39.5)

Occasionally

9.5 (5.6, 13.4)

7.3 (4.4, 10.3)

6.6 (3.0, 10.3)

6.7 (3.3, 10.1)

8.2 (4.7, 11.7)

6.5 (3.6, 9.4)

Periodically

23.7 (19.1,28.4)

26.8 (21.7, 31.9)

17.7 (13.3, 22.1)

19.8 (14.9, 24.6)

22.9 (18.2, 27.7)

20.7 (16.1, 25.2)

Frequently

10.1 (6.3, 13.9)

7.1 (4.1, 10.2)

2.0 (0.0, 4.3)

2.7 (1.3, 4.1)

4.7 (2.8, 6.7)

7.1 (3.6, 10.6)

Note: based on reports from sexually active respondents. 95% confidence intervals in parentheses. Percentage in the first row of each region panel indicates the regional average of sexual dysfunction, defined as an experience of dysfunction for a period of 2 months or more. The difference between the regional average and the sum of the three levels of severity of sexual dysfunction indicates the proportion who failed to specify the level of severity. All prevalences are adjusted according to the age distribution of the total of sexually active women in the GSSAB survey.

а Includes Australia, Canada, and New Zealand (n = 1044).

b Includes Brazil and Mexico (n =588).

c Includes Algeria, Egypt, Morocco, and Turkey (n =967).

d Includes China, Hong Kong, Japan, Korea, and Taiwan (n = 1417).

e Includes Indonesia, Malaysia, Philippines, Singapore, and Thailand (n = 689).

Table 2.3.3 presents logistic-regression results for factors associated with the likelihood of reporting lubrication difficulties. Increasing age shows a curvilinear association with the likelihood of reporting this problem in all the world regions except for Southeast Asia and South America. Women aged 5059 years in comparison with those aged 40-49 years are roughly twice as likely to report lubrication difficulties across several regions, including the “West” (Western regions excluding the USA or European countries) (OR = 1.9), East Asia (OR = 2.2), and the Middle East (OR = 2.6). However, their counterparts, who are 70-80 years old, are no more likely to report this problem than the youngest cohort in the “West” or Central/South America. Most physical status factors are not associated with lubrication difficulties. With the exception of southern Europe, belief in religion guiding sex is associated with consistently raised odds ratios, although statistical significance at 5% is seen only in East Asia. Women with lower educational attainment are less likely to report problems with lubrication in several world regions. Moreover, women who have been diagnosed with depression in the past are greater than one and one-half times more likely to report this problem in “Western” (OR= 1.6), Central/South American (OR =1.8), Middle Eastern (OR =1.6), and Southeast Asian (OR = 1.6) country clusters.

Table 2.3.2. Factors associated with women’s inability to reach orgasm by region

 

“West”

C/S America

Middle East

East Asia

SE Asia

Age (years)

40-49

Referent

Referent

Referent

Referent

Referent

50-59

1.6* (1.0, 2.6)

0.7 (0.4, 1.3)

2.7* (1.5, 5.0)

1.1 (0.8, 1.7)

1.4 (0.5, 3.4)

60-69

1.2 (0.6, 2.2)

1.3 (0.6, 2.9)

2.8* (1.4, 5.7)

1.1 (0.7, 1.8)

3.1+ (0.9, 10.7)

70-80

0.6 (0.2, 2.1)

0.3+ (0.1, 1.2)

3.9 (0.8, 20.3)

0.8 (0.4, 1.7)

n.a.

Education

at least some college

Referent

Referent

Referent

Referent

Referent

secondary/high school

0.8 (0.5, 1.2)

1.6 (0.7, 3.6)

1.1 (0.5, 2.2)

1.3 (0.9, 2.0)

0.7 (0.3, 1.8)

primary school or less

1.6 (0.4, 6.5)

1.8 (0.8, 3.9)

1.7 (0.6, 2.7)

1.2 (0.7, 2.2)

0.3* (0.1, 0.9)

Divorce in past 3 years

0.7 (0.3, 2.0)

1.4 (0.2, 13.0)

1.7 (0.6, 5.2)

0.7 (0.1, 3.7)

1.2 (0.3, 4.9)

Financial problems in last 3 years

1.5 (0.9, 2.6)

1.1 (0.6, 1.9)

1.1 (0.6, 2.0)

0.7 (0.4, 1.2)

2.8* (1.2, 6.2)

Fair/Poor overall health (vs good)

1.7+ (1.0, 2.9)

0.9 (0.5, 1.6)

1.4 (0.7, 2.6)

1.5* (1.1, 2.1)

2.0+ (0.9, 4.3)

Level of physical activity

average and above

Referent

Referent

Referent

Referent

Referent

lower than average

1.1 (0.7, 1.9)

0.4* (0.1, 1.0)

1.8 (0.8, 3.8)

0.9 (0.6, 1.4)

2.2* (1.0, 4.6)

Vascular diseases

1.1 (0.7, 1.7)

1.7+ (1.0, 3.0)

0.8 (0.4, 1.3)

1.1 (0.8, 1.6)

1.0 (0.3, 2.9)

Hysterectomy

0.7 (0.5, 1.2)

0.8 (0.4, 1.5)

1.1 (0.5, 2.6)

1.0 (0.6, 1.9)

0.4* (0.2, 1.0)

Depression diagnosed

1.4 (0.8, 2.2)

1.7+ (1.0, 3.1)

1.3 (0.7, 2.3)

1.2 (0.6, 2.5)

2.7+ (0.8, 8.7)

Smoking

never

Referent

Referent

Referent

Referent

Referent

smoked before

1.4 (0.9, 2.2)

1.1 (0.6, 2.1)

1.7 (0.8, 3.5)

0.6 (0.3, 1.2)

1.7 (0.3, 9.4)

currently smoking

2.0* (1.2, 3.5)

1.1 (0.5, 2.0)

2.0* (1.1, 3.6)

1.0 (0.6, 1.8)

0.6 (0.2, 2.1)

Belief that aging reduces sex interest/activity

1.3 (0.8, 2.2)

0.9 (0.5, 1.5)

0.8 (0.5, 1.4)

1.3+ (1.0, 1.8)

0.6 (0.3, 1.5)

Belief in religion guiding sex

1.3 (0.9, 2.0)

1.6 (0.9, 2.7)

1.0 (0.6, 1.8)

1.2 (0.7, 2.1)

1.9 (0.8, 4.4)

Partnership status

exclusive and committed

Referent

Referent

Referent

Referent

Referent

exclusive but not committed

1.3 (0.7, 2.4)

0.3+ (0.1, 1.1)

0.2 (0.0, 1.8)

0.4 (0.1, 1.6)

0.1* (0.0, 0.7)

nonexclusive

1.5 (0.3, 7.6)

0.4 (0.1, 1.8)

0.3+ (0.1, 1.2)

1.3 (0.6, 3.0)

0.6 (0.1, 2.7)

Future of the relationship

high hope

Referent

Referent

Referent

Referent

Referent

worried

4.5* (2.2, 9.1)

2.2+ (1.0, 5.0)

1.3 (0.5, 3.8)

1.7+ (1.0, 2.8)

1.1 (0.3, 3.3)

no future

1.8 (0.7, 5.0)

2.4* (1.0, 5.4)

2.9+ (0.8, 8.7)

2.9* (1.5, 5.5)

0.3 (0.1, 2.1)

Frequency of sexual relationship

several times per week

Referent

Referent

Referent

Referent

Referent

two to three times per month

1.3 (0.8, 2.0)

1.0 (0.5, 1.7)

1.1 (0.6, 1.9)

1.4 (0.8, 2.2)

0.8 (0.3, 2.1)

less than monthly

1.0 (0.5, 1.8)

1.1 (0.4, 2.8)

1.2 (0.4, 3.1)

1.3 (0.7, 2.3)

0.8 (0.2, 3.0)

Usually doesn’t engage in foreplay

1.5 (0.7, 2.9)

2.1* (1.2, 3.8)

0.8 (0.4, 1.5)

1.6* (1.1, 2.3)

1.3 (0.5, 3.8)

Thinking of sex

never or < 1/month

Referent

Referent

Referent

Referent

Referent

a few times/month

0.6 (0.3, 1.2)

0.8 (0.4, 1.6)

0.6 (0.3, 1.1)

0.6* (0.4, 0.9)

0.6 (0.2, 1.5)

a few times/week

0.4* (0.2, 0.9)

0.5 (0.1, 1.8)

0.6 (0.2, 2.4)

n.a.

0.2 (0.0, 4.1)

Chi-square

95.6

46.2

78.0

96.4

42.7

d.f.

27

26

27

27

25

Observations

928

531

749

1159

235

Note: odds ratios from logistic regression and their 95% confidence intervals in parenthesis. Based on reports from sexually active women. Country differences in each region controlled.

“West" includes Australia, Canada, and New Zealand.

Central/South America includes Brazil and Mexico.

Middle East includes Egypt, Morocco, and Turkey.

East Asia includes China, Hong Kong, Korea, and Japan.

Southeast Asia includes Malaysia and Thailand.

*p < 0.05; +p < 0.10.

Table 2.3.3. Factors associated with women's lubrication difficulties by region

 

“West”

C/S America

Middle East

East Asia

 

SE Asia

Age (years)

40-49

Referent

Referent

Referent

Referent

 

Referent

50-59

1.9* (1.2, 2.8)

1.0 (0.5, 1.9)

2.6* (1.3, 5.0)

2.2* (1.5, 3.3)

0.7

(0.4, 1.3)

60-69

1.7+ (0.9, 2.9)

1.6 (0.7, 4.0)

3.2* (1.4, 6.9)

3.3* (2.0, 5.3)

0.9

(0.4, 2.1)

70-80

1.0 (0.4, 2.5)

0.6 (0.1, 2.8)

4.6+ (0.9, 23.4)

3.0* (1.4, 6.5)

 

n.a.

Education

at least some college

Referent

Referent

Referent

Referent

 

Referent

secondary/high school

0.7+ (0.5, 1.1)

1.1 (0.5, 2.3)

0.6 (0.2, 1.5)

1.0 (0.7, 1.6)

0.7

(0.4, 1.1)

primary school or less

1.4 (0.4, 4.6)

0.8 (0.4, 1.7)

0.5+ (0.3, 1.1)

1.0 (0.6, 1.8)

0.5*

(0.2, 1.0)

Divorce in past 3 years

0.4 (0.1, 1.4)

n.a.

n.a.

1.2 (0.2, 6.8)

2.1

(0.7, 6.2)

Financial problems in last 3 years

0.8 (0.5, 1.3)

1.1 (0.6, 2.0)

1.4 (0.6, 3.0)

1.2 (0.8, 2.0)

2.0*

(1.2, 3.5)

Fair/poor overall health (vs good)

1.3 (0.8, 2.2)

0.7 (0.3, 1.2)

1.7+ (0.9, 3.2)

1.5* (1.1, 2.0)

1.4

(0.8, 2.5)

Level of physical activity

average and above

Referent

Referent

Referent

Referent

 

Referent

lower than average

1.0 (0.6, 1.7)

0.9 (0.4, 2.1)

1.7 (0.9, 3.6)

1.1 (0.7, 1.7)

2.0*

(1.2, 3.3)

Vascular diseases

1.2 (0.8, 1.7)

1.0 (0.6, 1.8)

0.5* (0.3, 0.9)

0.9 (0.6, 1.3)

0.9

(0.5, 1.7)

Hysterectomy

0.8 (0.5, 1.2)

1.1 (0.5, 2.1)

0.8 (0.3, 2.1)

1.2 (0.6, 2.2)

0.8

(0.3, 1.9)

Depression diagnosed

1.6* (1.0, 2.6)

1.8+ (1.0, 3.4)

1.6 (0.8, 3.3)

1.2 (0.5, 2.7)

1.6

(0.7, 3.6)

Smoking

never

Referent

Referent

Referent

Referent

 

Referent

smoked before

0.9 (0.6, 1.3)

1.0 (0.5, 1.9)

2.5* (1.1, 5.5)

0.6 (0.3, 1.2)

1.2

(0.4, 3.8)

currently smoking

1.5+ (0.9, 2.5)

0.6 (0.3, 1.4)

1.5 (0.7, 3.1)

1.3 (0.7, 2.4)

1.3

(0.6, 3.0)

Belief that aging reduces sex interest/activity

1.2 (0.7, 1.8)

1.1 (0.6, 1.9)

1.0 (0.6, 1.8)

1.4* (1.0, 2.0)

1.3

(0.8, 2.1)

Belief in religion guiding sex

1.4+ (1.0, 2.0)

1.6 (0.9, 2.9)

1.4 (0.8, 2.7)

1.7* (1.0, 2.9)

1.7+

(0.9, 2.9)

Partnership status

exclusive and committed

Referent

Referent

Referent

Referent

 

Referent

exclusive but not committed

0.8 (0.4, 1.6)

0.3+ (0.1, 1.0)

0.7 (0.1, 4.0)

0.3 (0.1, 1.4)

0.9

(0.2, 4.0)

nonexclusive

0.5 (0.1, 3.7)

0.4 (0.1, 1.8)

2.0 (0.5, 8.6)

1.0 (0.4, 2.5)

1.1

(0.4, 3.1)

Future of the relationship

high hope

Referent

Referent

Referent

Referent

 

Referent

worried

3.5* (1.8, 6.9)

1.9 (0.8, 4.4)

1.2 (0.4, 3.5)

1.0 (0.5, 1.8)

1.0

(0.4, 2.7)

no future

1.0 (0.3, 3.9)

1.7 (0.6, 4.8)

1.0 (0.2, 4.9)

1.6 (0.8, 3.1)

0.4

(0.1, 3.1)

Frequency of sexual relationship

several times per week

Referent

Referent

Referent

Referent

 

Referent

two to three times per month

1.4+ (1.0, 2.2)

1.6 (0.9, 2.9)

1.0 (0.5, 1.9)

1.0 (0.6, 1.6)

0.9

(0.5, 1.6)

less than monthly

1.6+ (0.9, 2.8)

1.3 (0.4, 4.1)

1.6 (0.7, 3.8)

1.2 (0.7, 2.1)

0.7

(0.3, 1.5)

Usually doesn’t engage in foreplay

1.1 (0.6, 1.9)

1.1 (0.5, 2.1)

1.1 (0.6, 2.0)

1.4* (1.0, 2.1)

0.9

(0.5, 1.7)

Thinking of sex

never or < 1/month

Referent

Referent

Referent

Referent

 

Referent

a few times/month

0.5* (0.3, 1.0)

1.2 (0.5, 2.9)

0.7 (0.4, 1.4)

0.9 (0.6, 1.3)

0.8

(0.4, 1.4)

a few times/week

0.5+ (0.2, 1.0)

0.5 (0.1, 1.9)

0.7 (0.2, 2.8)

0.7 (0.1, 4.7)

0.5

(0.1, 2.2)

Chi-square

90.4

26.7

53.9

116.2

 

39.9

d.f.

27

24

26

28

 

27

Observations

928

374

694

1167

 

548

Note: odds ratios from logistic regression and their 95% confidence intervals in parenthesis. Based on reports from sexually active women. Country differences in each region controlled.

“West" includes Australia, Canada, and New Zealand.

Central/South America includes Brazil.

Middle East includes Algeria, Morocco and Turkey.

East Asia includes China, Hong Kong, Korea, and Japan.

Southeast Asia includes Indonesia, Malaysia, Singapore, and Thailand.

*p < 0.05; +p < 0.10.

We also examined several additional sexual problems by logistic regression, including a lack of interest in sex (Table 2.3.4) , pain during sex (Table 2.3.5), and nonpleasurable sex (Table 2.3.6). Lack of interest in sex is associated with the belief that aging reduces sexual desire and activity (OR 1.2— 1.8), thinking about sex infrequently (thinking about sex more frequently is associated with OR 0.3-1.0), depression (OR 1.3-1.6), low expectations about the future of the relationship (lower expectations are associated with OR of 1.3— 3.6 in all regions except Southeast Asia [OR = 0.5]), and infrequent sex (less frequent sex is associated with OR of 1.0— 3.1 within all regions except East Asia [OR = 0.9]) (Table 2.3.4) . Factors associated with pain during sex include younger age (the effect shows considerable variability between regions), poor health (OR 1.0—1.7), infrequent sex (OR 1.1— 2.4), and low expectations about the future of the relationship (there was some variability between regions; however, lower expectations were usually associated with increasing likelihood of the problem [Table 2.3.5]). With respect to nonpleasurable sex among women, thinking about sex infrequently (with thinking of sex never or less than once a month as the referent, sexually active women who thought about sex at least a few times a month had OR of 0.1—0.7), the belief that aging reduces sexual interest or activity (OR 1.3—1.8 in all regions except Central South America [OR = 0.9]), depression (OR 1.0—3.9), and low expectations about the future of their relationship (OR from 1.0 to 4.7 in all regions except Southeast Asia [OR = 0.9]) all elevate the likelihood of reporting this problem (Table 2.3.6).

Discussion

In this research, we have examined a number of factors that may be contributory in the etiology of sexual problems in women. The unique strength of this study is its cross-cultural emphasis. With a sample drawn from 18 countries, we identified several factors that increased the likelihood of a sexual problem in multiple regions of the world. So, for example, the significant effects of age and depression across world regions support both physiologic and psychologic arguments about the etiology of sexual problems. The GSSAB also provides extensive variation with respect to sexual attitudes, beliefs, and behaviors, and we observed many effects that were significant only in certain regions of the world. Future research should investigate the significance of these contingent effects.

While the prevalence of most sexual problems tends to increase with age,3—7 we found that older age, net of other factors, consistently increased the likelihood of most sexual problems among men, but not women (results for men are not presented here).8 Only lubrication difficulties were positively associated with older age. Studies in elderly individuals have indicated that the effects of aging may be of less importance if the effects of the relationship are taken into account.9 Since the more physiologic sexual problems clearly have a significant biologic component, it is not surprising that lubrication difficulties are associated with increased age.9 However, this study does demonstrate that aging effects are more relevant to men then women.

Mental health and stress are also thought to influence sexual function. In the GSSAB, depression was associated with the likelihood of lubrication difficulties in some regions of the world, while stress from financial problems was positively associated with the inability to reach orgasm among women. We also found some evidence that education was positively associated with the likelihood of lubrication problems. Thus, the findings of the current analyses demonstrated some effects of psychosocial context in terms of the significance of stressful events, education level, and the occurrence of depression. Previous studies have reported that depression, stress, and emotional problems can be related to a reduced interest in sex as well as other sexual problems.3,5 Socioeconomic factors have also been shown to have an effect on sexual function in both women and men.3

Relationship issues also play a role in the etiology of sexual problems.10—13 In relationships in which partners show that they care for one another in everyday matters and communicate effectively about their sexual needs, one would anticipate a relatively low risk of sexual problems. In contrast, where there are difficulties in the overall relationship, one would expect this to have a negative impact on sexual function. In the current analysis, low expectations about the future of the relationship increased the likelihood of an inability to reach orgasm among women. Finally, having infrequent sex also increased the likelihood of lubrication difficulties.

The GSSAB has a number of limitations. Methodological issues regarding the study include potentially systematic biases arising from several causes: (1) differences in recruitment of samples and administration of surveys across countries, (2) challenges associated with achieving accurate, valid translations of the survey instrument in multiple languages to ensure the comparability of questions and responses, (3) the adequacy of pooling diverse population samples into regional clusters that are sufficiently homogeneous for comparative statistical analysis, (4) variation in the quality of the country-specific survey organizations across countries, and (5) the attainment of modest response rates.

Thus, while these data are broadly inclusive, they may not be truly representative of each country’s entire adult and older populations because of the relatively modest response rates attained in the countries with the random-digit-dialing protocol and because the door-to-door and intercept protocols drew heavily on urban populations. In general, low completion rates can be of concern because they may be indicative of possible selection bias in the way subjects are recruited, and these issues raise some questions about the accuracy of our prevalence estimates. Prior research has concluded that different modes of administration (telephone and personal survey) resulted in few differences in reports of sexual behaviour.14 We have also tested the effects of the different modes of interview used in the GSSAB and found no effect.15

Table 2.3.4. Factors associated with the lack of interest in having sex among women by region

 

 

“West”

C/S America

Middle East

East Asia

 

SE Asia

Age (years)

40-49

Referent

Referent

Referent

Referent

 

Referent

50-59

1.2 (0.8, 1.8)

0.8 (0.4, 1.3)

1.1 (0.7, 1.8)

1.6** (1.1, 2.4)

1.5

(0.8, 3.0)

60-69

1.0 (0.6, 1.7)

1.7 (0.9, 3.3)

1.5 (0.8, 2.7)

1.8* (1.1, 2.8)

1.1

(0.4, 2.9)

70-80

0.5 (0.2, 1.2)

0.8 (0.3, 2.0)

2.7+ (1.0, 7.5)

1.3 (0.7, 2.3)

1.8

(0.4, 7.3)

Education

 

 

 

 

 

 

at least some college

Referent

Referent

Referent

Referent

 

Referent

secondary/high school

0.8 (0.5, 1.1)

1.5 (0.7, 3.2)

1.2 (0.7, 2.3)

1.2 (0.8, 1.8)

0.6+

(0.3, 1.1)

primary school or less

0.5 (0.2, 1.6)

1.4 (0.7, 3.0)

0.8 (0.5, 1.4)

1.2 (0.8, 2.0)

0.4*

(0.2, 0.9)

Divorce in past 3 years

0.6 (0.2, 1.6)

1.2 (0.2, 8.1)

0.9 (0.3, 3.0)

0.9 (0.1, 6.0)

n.a.

 

Financial problems in last 3 years

1.2 (0.7, 1.9)

1.2 (0.8, 2.0)

1.7* (1.0, 2.8)

1.1 (0.7, 1.8)

2.0*

(1.0, 4.0)

Fair/poor overall health (vs good)

1.3 (0.8, 2.1)

0.9 (0.5, 1.5)

1.0 (0.6, 1.6)

1.6** (1.2, 2.1)

2.3**

(1.3, 4.3)

Level of physical activity

 

 

 

 

 

 

average and above

Referent

Referent

Referent

Referent

 

Referent

lower than average

1.2 (0.7, 1.9)

1.3 (0.7, 2.4)

1.7* (1.0, 3.0)

1.1 (0.8, 1.6)

0.9

(0.5, 1.8)

Vascular diseases

1.2 (0.8, 1.7)

1.2 (0.7, 2.0)

1.0 (0.6, 1.5)

1.0 (0.7, 1.4)

2.1*

(1.1, 4.0)

Hysterectomy

1.3 (0.8, 2.0)

0.8 (0.5, 1.5)

1.1 (0.6, 2.1)

0.9 (0.5, 1.7)

0.3*

(0.1, 0.9)

Depression diagnosed

1.5+ (1.0, 2.4)

1.6+ (1.0, 2.7)

1.5+ (1.0, 2.4)

1.3 (0.5, 3.2)

1.3

(0.5, 3.8)

Smoking

 

 

 

 

 

 

never

Referent

Referent

Referent

Referent

 

Referent

smoked before

1.0 (0.7, 1.6)

1.1 (0.7, 1.9)

1.2 (0.6, 2.5)

1.3 (0.8, 2.2)

1.4

(0.3, 7.7)

currently smoking

1.6+ (1.0, 2.4)

0.8 (0.5, 1.4)

1.3 (0.8, 2.1)

0.8 (0.4, 1.3)

0.4+

(0.2, 1.1)

Belief that aging reduces sex interest/activity

1.7* (1.1, 2.5)

1.5+ (0.9, 2.4)

1.2 (0.8, 1.8)

1.7** (1.3, 2.4)

1.3

(0.7, 2.4)

Belief in religion guiding sex

1.2 (0.8, 1.7)

1.1 (0.7, 1.8)

1.1 (0.7, 1.7)

1.6 (0.9, 2.9)

3.2*

(1.3, 8.0)

Partnership status

 

 

 

 

 

 

exclusive and committed

Referent

Referent

Referent

Referent

 

Referent

exclusive but not committed

0.6 (0.3, 1.3)

0.8 (0.3, 1.8)

0.9 (0.3, 3.0)

0.5 (0.2, 1.5)

n.a.

 

non-exclusive

0.4 (0.0, 3.4)

0.5 (0.1, 2.2)

0.9 (0.2, 4.1)

0.6 (0.3, 1.5)

1.3

(0.3, 5.0)

Future of the relationship

 

 

 

 

 

 

high hope

Referent

Referent

Referent

Referent

 

Referent

worried

3.6** (1.7, 7.6)

2.2* (1.1, 4.3)

1.6 (0.6, 4.2)

1.3 (0.7, 2.4)

0.5

(0.1, 2.5)

no future

3.6** (1.8, 7.4)

2.4* (1.2, 4.9)

1.9 (0.7, 4.7)

3.1** (1.6, 6.0)

1.3 (0.1, 25.2)

Frequency of sexual relationship

 

 

 

 

 

 

several times per week

Referent

Referent

Referent

Referent

 

Referent

two to three times per month

2.3** (1.6, 3.4)

1.1 (0.7, 1.9)

1.8** (1.2, 2.8)

0.8 (0.5, 1.2)

1.6

(0.8, 2.9)

less than monthly

2.7** (1.6, 4.4)

1.5 (0.7, 3.2)

3.1** (1.5, 6.5)

0.9 (0.6, 1.4)

1.0

(0.4, 2.5)

Usually doesn’t engage in foreplay

1.7+ (0.9, 3.1)

1.4 (0.8, 2.4)

0.9 (0.6, 1.5)

1.1 (0.7, 1.6)

1.3

(0.7, 2.8)

Thinking of sex

 

 

 

 

 

 

never or < 1/month

Referent

Referent

Referent

Referent

 

Referent

a few times/month

0.4** (0.3, 0.7)

0.6 (0.4, 1.1)

0.6* (0.4, 0.9)

0.3** (0.2, 0.5)

1.0

(0.5, 2.0)

a few times/week

0.3** (0.1, 0.5)

0.3+ (0.1, 1.2)

0.4+ (0.1, 1.1)

0.7 (0.3, 1.6)

0.2+

(0.0, 1.3)

Chi-square

124.56

49.56

68.77

173.36

 

78.94

d.f.

27

26

26

28

 

24

Observations

1011

599

668

1144

 

356

Note: Odds ratios from logistic regression and their 95% confidence intervals in parenthesis. Based on reports from sexually active women. Country differences in each region controlled.

“West" includes Australia, Canada, and New Zealand;

East Asia includes China, Hong Kong, Taiwan, and Japan;

Southeast Asia includes Indonesia and Malaysia;

South America includes Brazil and Mexico;

Mid-east includes Algeria and Turkey.

+p ≤ 0.10; * p ≤ 0.05; ** p ≤ 0.01.

Table 2.3.5. Factors associated with pain during sex among women by region

 

 

“West”

C/S America

Middle East

East Asia

 

SE Asia

Age (years)

40-49

Referent

Referent

Referent

Referent

 

Referent

50-59

0.5+ (0.3, 1.0)

0.8 (0.4, 1.6)

1.0 (0.5, 1.9)

1.1 (0.7, 1.6)

2.1*

(1.1, 4.0)

60-69

0.8 (0.3, 1.9)

1.2 (0.5, 2.9)

0.9 (0.4, 2.0)

1.3 (0.8, 2.1)

1.5

(0.7, 3.5)

70-80

n.a.

0.6 (0.1, 2.4)

1.9 (0.5, 7.9)

1.1 (0.5, 2.1)

1.1

(0.4, 3.0)

Education

 

 

 

 

 

 

at least some college

Referent

Referent

Referent

Referent

 

Referent

secondary/high school

1.0 (0.5, 1.9)

1.2 (0.5, 2.5)

0.9 (0.4, 2.1)

1.0 (0.7, 1.5)

0.7

(0.4, 1.3)

primary school or less

0.5 (0.0, 6.2)

0.7 (0.3, 1.6)

1.1 (0.5, 2.1)

1.2 (0.7, 2.1)

0.5

(0.2, 1.2)

Divorce in past 3 years

0.2 (0.0, 2.0)

0.7 (0.1, 7.4)

1.1 (0.3, 4.4)

1.7 (0.4, 7.2)

0.3

(0.0, 3.4)

Financial problems in last 3 years

1.7 (0.8, 3.5)

2.2* (1.2, 4.0)

1.0 (0.5, 1.9)

1.6* (1.0, 2.5)

1.1

(0.6, 2.1)

Fair/poor overall health (vs good)

1.7 (0.8, 3.4)

1.1 (0.6, 2.2)

0.9 (0.5, 1.9)

1.6** (1.2, 2.3)

1.6

(0.9, 2.7)

Level of physical activity

 

 

 

 

 

 

average and above

Referent

Referent

Referent

Referent

 

Referent

lower than average

0.8 (0.4, 1.8)

0.5 (0.2, 1.3)

2.0* (1.1, 3.7)

0.8 (0.5, 1.2)

2.2*

(1.1, 4.4)

Vascular diseases

1.0 (0.5, 1.7)

1.3 (0.7, 2.5)

1.4 (0.7, 2.7)

1.1 (0.8, 1.5)

1.4

(0.8, 2.4)

Hysterectomy

0.4** (0.2, 0.8)

1.5 (0.7, 3.0)

0.4* (0.2, 0.9)

1.2 (0.7, 2.2)

0.1**

(0.0, 0.3)

Depression diagnosed

1.5 (0.7, 3.1)

1.5 (0.7, 2.9)

1.6 (0.8, 3.1)

1.3 (0.6, 2.9)

1.8

(0.8, 3.9)

Smoking

 

 

 

 

 

 

never

Referent

Referent

Referent

Referent

 

Referent

smoked before

1.6 (0.8, 3.1)

1.1 (0.6, 2.2)

1.1 (0.5, 2.7)

0.4* (0.2, 0.8)

0.6

(0.2, 2.1)

currently smoking

1.1 (0.5, 2.6)

1.2 (0.5, 2.5)

1.0 (0.5, 1.9)

1.0 (0.6, 1.7)

0.3*

(0.1, 0.9)

Belief that aging reduces sex interest/activity

1.9+ (0.9, 3.8)

0.5* (0.3, 1.0)

0.6+ (0.4, 1.1)

1.1 (0.8, 1.6)

0.8

(0.5, 1.5)

Belief in religion guiding sex

1.6 (0.8, 2.9)

1.7 (0.9, 3.2)

1.5 (0.8, 2.8)

0.9 (0.5, 1.7)

3.5**

(1.5, 8.1)

Partnership status

 

 

 

 

 

 

exclusive and committed

Referent

Referent

Referent

Referent

 

Referent

exclusive but not committed

1.3 (0.5, 3.4)

0.3* (0.1, 1.0)

1.6 (0.5, 5.5)

0.7 (0.2, 1.9)

0.7

(0.1, 4.6)

nonexclusive

3.1 (0.3, 29.1)

1.9 (0.5, 6.9)

1.4 (0.3, 6.3)

0.4 (0.1, 1.7)

1.5

(0.4, 6.5)

Future of the relationship

 

 

 

 

 

 

high hope

Referent

Referent

Referent

Referent

 

Referent

worried

3.4* (1.2, 9.3)

1.5 (0.6, 3.6)

2.4+ (0.9, 6.3)

0.8 (0.4, 1.4)

1.3

(0.4, 4.4)

no future

2.9+ (0.8, 9.8)

0.7 (0.2, 2.0)

0.5 (0.1, 2.4)

1.3 (0.7, 2.5)

1.7

(0.4, 6.5)

Frequency of sexual relationship

 

 

 

 

 

 

several times per week

Referent

Referent

Referent

Referent

 

Referent

two to three times per month

1.4 (0.7, 2.6)

2.4* (1.2, 4.5)

1.1 (0.6, 2.0)

1.2 (0.8, 1.9)

1.2

(0.6, 2.2)

less than monthly

1.4 (0.6, 3.4)

1.7 (0.5, 5.4)

1.3 (0.5, 3.3)

1.6* (1.0, 2.4)

1.2

(0.6, 2.4)

Usually doesn’t engage in foreplay

1.8 (0.8, 4.2)

1.1 (0.5, 2.5)

0.8 (0.5, 1.6)

1.3 (0.9, 1.9)

0.8

(0.4, 1.6)

Thinking of sex

 

 

 

 

 

 

never or < 1/month

Referent

Referent

Referent

Referent

 

Referent

a few times/month

0.7 (0.3, 1.6)

0.6 (0.3, 1.3)

1.0 (0.5, 1.8)

0.8 (0.5, 1.2)

1.5

(0.8, 2.9)

a few times/week

0.5 (0.2, 1.4)

0.4 (0.1, 1.5)

0.2 (0.0, 2.0)

n.a.

5.7**

(1.7, 19.5)

Chi-square

50.7

44.0

49.1

99.2

 

80.2

d.f.

25

25

27

27

 

27

Observations

815

430

840

1366

 

531

Note: Odds ratios from logistic regression and their 95% confidence intervals in parenthesis. Based on reports from sexually active women. Country differences in each region controlled.

“West" includes Australia and Canada;

East Asia includes China, Hong Kong, Korea, and Japan;

Southeast Asia includes Indonesia, Philippine, and Malaysia;

South America includes Brazil;

Mid-east includes Algeria, Morocco, and Turkey.

+ p ≤ 0.10; * p ≤ 0.05; **p ≤ 0.01.

 

Table 2.3.6. Factors associated with finding sex nonpleasurable among women by region

   

"West"

C/S America

Mideast

East Asia

 

SE Asia

Age (years)

             

40-49

 

Referent

Referent

Referent

Referent

 

Referent

50-59

1.2

(0.7, 2.0)

0.8 (0.4, 1.7)

1.1 (0.7, 1.8)

1.3 (0.9, 1.9)

1.0

(0.6, 1.9)

60-69

1.6

(0.8, 3.1)

1.0 (0.4, 2.6)

1.5 (0.8, 2.7)

1.4 (0.9, 2.3)

0.5

(0.2, 1.2)

70-80

0.7

(0.2, 2.5)

 

0.9 (0.2, 4.5)

0.9 (0.4, 2.0)

1.3

(0.1, 18.7)

Education

             

at least some college

 

Referent

Referent

Referent

Referent

 

Referent

secondary/high school

0.8

(0.5, 1.2)

1.7 (0.7, 3.8)

1.1 (0.5, 2.0)

1.1 (0.7, 1.6)

0.5*

(0.3, 0.9)

primary school or less

0.8

(0.2, 3.7)

0.6 (0.2, 1.5)

1.0 (0.6, 1.6)

1.4 (0.8, 2.4)

0.4*

(0.2, 0.9)

Divorce in past 3 years

0.9

(0.3, 3.0)

 

0.6 (0.1,2.1)

1.0 (0.2, 3.9)

0.6

(0.2, 2.4)

Financial problems in last 3 years

2.2**

(1.3, 3.8)

1.1 (0.6, 2.0)

1.4 (0.9, 2.4)

1.0 (0.6, 1.6)

1.6+

(0.9, 3.0)

Fair/poor overall health (vs good) Level of physical activity

1.9*

(1.0, 3.7)

1.3 (0.6, 2.7)

0.9 (0.6, 1.5)

1.3+ (1.0, 1.8)

1.4

(0.8, 2.3)

average and above

 

Referent

Referent

Referent

Referent

 

Referent

lower than average

1.0

(0.5, 2.0)

1.9 (0.8, 4.6)

2.9** (1.7, 5.1)

1.3 (0.9, 2.0)

2.5**

(1.5, 4.2)

Vascular diseases

0.7

(0.5, 1.2)

0.9 (0.5, 1.8)

1.4 (0.9, 2.2)

1.1 (0.8, 1.5)

1.2

(0.7, 2.2)

Hysterectomy

1.3

(0.7, 2.2)

1.1 (0.5, 2.4)

1.7 (0.8, 3.7)

1.0 (0.6, 1.7)

0.8

(0.4, 1.9)

Depression diagnosed Smoking

1.1

(0.6, 2.0)

1.0 (0.5, 1.9)

1.9** (1.2, 3.2)

1.6 (0.8, 3.2)

3.9**

(1.5, 10.2)

never

 

Referent

Referent

Referent

Referent

 

Referent

smoked before

1.4

(0.9, 2.3)

0.8 (0.4, 1.7)

1.0 (0.5, 2.0)

0.6 (0.3, 1.2)

2.7

(0.8, 9.2)

currently smoking

1.4

(0.8, 2.5)

0.9 (0.4, 2.1)

1.0 (0.6, 1.7)

1.1 (0.6, 2.0)

1.4

(0.6, 3.0)

Belief that aging reduces sex interest/activity

1.8*

(1.1, 3.1)

0.9 (0.5, 1.9)

1.3 (0.8, 2.1)

1.4* (1.0, 1.9)

1.3

(0.7, 2.2)

Belief in religion guiding sex

1.4

(0.9, 2.2)

0.8 (0.4, 1.6)

0.9 (0.6, 1.5)

1.6+ (1.0, 2.5)

1.0

(0.6, 1.9)

Partnership status

             

exclusive and committed

 

Referent

Referent

Referent

Referent

 

Referent

exclusive but not committed

0.7

(0.4, 1.4)

0.1* (0.0, 0.7)

2.1 (0.8, 5.9)

0.7 (0.2, 2.4)

0.8

(0.3, 2.5)

non-exclusive

2.4 (0.4, 14.1)

1.2 (0.4, 3.4)

1.1 (0.3, 4.1)

1.8 (0.8, 3.8)

0.7

(0.2, 2.1)

Future of the relationship

             

high hope

 

Referent

Referent

Referent

Referent

 

Referent

worried

4.7**

(2.3, 9.9)

2.1 (0.8, 5.6)

1.0 (0.4, 2.6)

2.4** (1.4, 4.0)

0.8

(0.3, 2.5)

no future

1.4

(0.4, 5.3)

1.4 (0.5, 4.3)

1.2 (0.4, 3.8)

3.3** (1.7, 6.3)

3.4+

(0.9, 12.5)

Frequency of sexual relationship

             

several times per week

 

Referent

Referent

Referent

Referent

 

Referent

two to three times per month

1.6+

(0.9, 2.6)

1.2 (0.6, 2.6)

1.9** (1.2, 3.1)

1.1 (0.7, 1.6)

0.6+

(0.3, 1.1)

less than monthly

2.0*

(1.0, 3.9)

1.6 (0.5, 5.3)

1.9+ (0.9, 4.0)

0.8 (0.4, 1.4)

1.0

(0.4, 2.1)

Usually doesn't engage in foreplay Thinking of sex

1.0

(0.4, 2.1)

3.4** (1.6, 7.2)

0.9 (0.6, 1.5)

1.8** (1.3, 2.5)

1.6+

(0.9, 2.9)

never or < 1/month

 

Referent

Referent

Referent

Referent

 

Referent

a few times/month

0.3**

(0.2, 0.7)

0.5 (0.2, 1.2)

0.7+ (0.4, 1.1)

0.5** (0.4, 0.8)

0.7

(0.3, 1.3)

a few times/week

0.2**

(0.1,0.6)

0.1* (0.0, 0.8)

0.2* (0.0, 0.8)

0.6 (0.2, 2.3)

0.4

(0.1, 1.4)

Chi-square

 

104.5

43.6

80.8

107.0

 

65.0

d.f.

 

27

23

27

29

 

28

Observations

 

928

351

719

1357

 

550

Note: Odds ratios from logistic regression and their 95% confidence intervals in parenthesis. Based on reports from sexually active women. Country differences in each region controlled.

“West" includes Australia, Canada, and New Zealand;

East Asia includes China, Hong Kong, Taiwan, Korea, and Japan;

Southeast Asia includes Indonesia, Malaysia, Thailand, and Singapore;

South America includes Brazil;

Mideast includes Algeria, Morocco, and Turkey.

+ p ≤ 0.10; * p ≤ 0.05; ** p ≤ 0.01.

As in all cross-sectional surveys, the causal direction of many covariates is not clear. For example, when we observe an association between overall health or depression and a sexual problem, we cannot discern the causal direction in these crosssectional data. All of our measures are self-reported, and many are based on responses to single items; however, in a multicountry survey of this size, it would not be feasible to include physical examinations. Hence, there is likely to be considerable classification error, which is most likely reflected in the relatively modest sizes of many ORs. Self-reports of sexual conditions and other health conditions are likely to underestimate the true prevalence because the subject may not be aware, may not recall, or may choose not to disclose that she has the prob- lem/condition in question. A subject is unlikely to report a problem/condition that she does not have.

A number of sexual problems were found to be frequent in this large sample of women aged 40-80 years. Among those problems, lack of interest in sex and inability to reach orgasm were the most common across the world regions we investigated. In comparing those regions, Asian regions show the highest prevalence rates across various sexual problems. In terms of risk factors, physical, social/emotional, and relationship factors were all found to have a significant impact on the prevalence of one or more sexual problems. In addition, we observed an important gender difference: increasing age was less consistently associated with sexual problems among women.

Acknowledgments

The GSSAB was funded by Pfizer Inc. We acknowledge the contribution of our colleagues in this study, namely, Alfredo Nicolosi (Italy), Clive Gingell (UK), Edson Moreira (Brazil), and Tianfu Wang (China) for the GSSAB Investigators’ Group, and the international advisory board for this study, namely, Jacques Buvat (France), Gerald Brock (Canada), Uwe Hartmann (Germany), Sae-Chul Kim (Korea), Rosie King (Australia), Bernard Levinson (South Africa), Ken Marumo (Japan), and Ferruh Simsek (Turkey).

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