The Journal of Sex Research

ISSN: 0022-4499 (Print) 1559-8519 (Online) Journal homepage: http://www.tandfonline.com/loi/hjsr20

A Swiss Longitudinal Study of the Prevalence of, and Overlap Between, Sexual Problems in Men and Women Aged 20 to 50 Years Old Jules Angst, Michael P. Hengartner, Wulf Rössler, Vladeta Ajdacic-Gross & Brigitte Leeners To cite this article: Jules Angst, Michael P. Hengartner, Wulf Rössler, Vladeta Ajdacic-Gross & Brigitte Leeners (2015) A Swiss Longitudinal Study of the Prevalence of, and Overlap Between, Sexual Problems in Men and Women Aged 20 to 50 Years Old, The Journal of Sex Research, 52:8, 949-959, DOI: 10.1080/00224499.2014.1002556 To link to this article: http://dx.doi.org/10.1080/00224499.2014.1002556

Published online: 01 Jul 2015.

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Date: 08 October 2015, At: 02:33

JOURNAL OF SEX RESEARCH, 52(8), 949–959, 2015 Copyright # The Society for the Scientific Study of Sexuality ISSN: 0022-4499 print=1559-8519 online DOI: 10.1080/00224499.2014.1002556

A Swiss Longitudinal Study of the Prevalence of, and Overlap Between, Sexual Problems in Men and Women Aged 20 to 50 Years Old Jules Angst Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich

Michael P. Hengartner

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Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich and Department of Applied Psychology, Zurich University of Applied Sciences

Wulf Ro¨ssler Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich and Institute of Psychiatry, Laboratory of Neuroscience (LIM 27), University of Sao Paulo

Vladeta Ajdacic-Gross Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich

Brigitte Leeners Division of Reproductive Endocrinology, University Hospital Zurich The aim of this study was to obtain data on the development and course of sexual problems and their interrelationships by investigating a representative sample of men and women over a period of 30 years. A representative sample of 299 women selected from the complete electoral register and 292 men selected from screening lists for military service in Zurich, Switzerland, answered questions about their sexuality as part of a series of seven interviews between ages 20 (1979) and 50 (2008). Of the initial sample of 591 participants, 43% (57% of them male) were lost to follow-up. Interviews were conducted using the Structured Psychopathological Interview and Rating of the Social Consequences of Psychological Disturbances for Epidemiology (SPIKE), a semistructured interview. Sexual problems were identified on the basis of the study participants’ self-appraisal. One-year prevalence rates, lifetime risks, and overlap of functional, emotional, and sexual desire problems in men and women were evaluated. The findings confirmed higher lifetime risks in women than in men for any sexual problem (females 67.0%; males 46.0%) and for functional (39.3%; 22.1%), emotional (35.7%; 15.9%), and sexual desire problems (51.6%; 33.3%). While in general men’s sexual problems increased with age, no such association was observed in women. The overlap of all three problems (functional, emotional, and sexual desire) was reported by 16.9% of women but only 5.0% of men. Although there are commonalities, the type but also the development and, in particular, the overlap of sexual problems in women and men are markedly different.

Correspondence should be addressed to Brigitte Leeners, Division of Reproductive Endocrinology, University Hospital Zurich, Frauenklinikstr. 10, CH 8091 Zurich, Switzerland. E-mail: Brigitte.Leeners@ usz.ch Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/hjsr.

Sexual activity is recognized as a human basic need that strongly influences well-being and health in both women and men (Glasier, Gu¨lmezoglu, Schmid, Moreno, & Van Look, 2006; Hooghe, 2012; Laumann et al., 2006; Rosen & Bachmann, 2008; Smith, Pitts, Shelley, Richters, & Ferris, 2007). For example, in one study, sexual activity

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was the highest rated daily activity leading to happiness (Kahneman, Krueger, Schkade, Schwarz, & Stone, 2004). In addition to general happiness, sexual activity is strongly correlated with being happy in one’s relationship (Mitchell et al., 2013). Nevertheless, about twothirds of women and one-third of men avoid sexual activity when they experience sexual problems (Hooghe, 2012; Mercer et al., 2003). There is consistent evidence that sexual disorders are common in both men and women. In an Australian randomly selected sample 55.0% of the men and 60.5% of the women reported at least one sexual problem in the year prior to the study period (Najman, Dunne, Boyle, Cook, & Purdie, 2003). Another study using a representative Australian sample and computer-assisted telephone interviews showed that 24.9% of the men and 54.8% of the women aged 16 to 59 years experienced lack of interest in having sex, making it the most frequently reported sexual difficulty (Richters, Grulich, de Visser, Smith, & Rissel, 2003). More recent data from Australia reported prevalences of 66% in women and 34% in men for at least one sexual difficulty at the time of the investigation (Smith et al., 2012; Smith et al., 2013). In the U.S. National Health and Social Life Survey (Laumann, Paik, & Rosen, 1999), 43% of the women and 31% of the men reported one or more sexual problems over the previous 12 months (Laumann et al., 1999). Data from Europe show comparable prevalences. In a representative Danish sample 30% of women and 27% of men reported a current sexual problem (Ventegodt, 1998), and in a Swedish sample 47% of women and 23% of men reported a sexual problem in the previous year (Fugl-Meyer & Sjogren, 1999). In a representative Finnish study the prevalence rate for female sexual dysfunction was 32.6% (Witting et al., 2008). The recent U.K. National Survey of Sexual Attitudes and Lifestyles (Natsal) survey found prevalences for at least one sexual problem in the past year of 41.6% in men and 51.2% in women (Mitchell et al., 2013). However, solid information from representative community studies on sexual behavior and difficulties is still rather limited (Beutel, Sto¨bel-Richter, & Bra¨hler, 2008; Hayes, Dennerstein, Bennett, Sidat, et al., 2008; Laumann et al., 2005; Laumann et al., 1999; Richters et al., 2003; Simons & Carey, 2001). Due to large methodological differences—for example, samples studied, data collection, age ranges investigated, time span addressed, and definitions of sexual dysfunction— available studies are difficult to compare and as a result no final conclusions on the prevalence of sexual problems can be drawn. Also, there are virtually no longitudinal studies following the development and course of sexual problems, and those which have been done cover a rather short time span (Dennerstein, Guthrie, Hayes, DeRogatis, & Lehert, 2008; Lewis et al., 2010; Smith et al., 2012; Smith et al., 2013). Previous surveys 950

have rarely assessed distress about sexual difficulties; although when distress has been assessed this markedly reduces prevalence rates of sexual problems (Beutel et al., 2008; Laumann et al., 1999; Smith et al., 2012; Smith et al., 2013). In the current study distress associated with sexual problems was assessed. While it is generally accepted that there is a comorbidity between sexual disorders, for example, desire and arousal disorders (Lewis et al., 2010; Witting et al., 2008), the evaluation of the association of different types of sexual problems has been limited. Although there are few representative samples comparing sexual problems in women and men, according to available literature prevalences of the most frequent sexual problems seem to differ between men and women (Laumann et al., 1999; Lewis et al., 2010; Richters et al., 2003; Ventegodt, 1998). For example, lack of desire is reported more often by women than by men (Fugl-Meyer & Sjogren, 1999; Richters et al., 2003; Ventegodt, 1998). In agreement with these observations, the U.K. Natsal survey reported an imbalance in the level of sexual interest between partners (Mitchell et al., 2013). In summary, we currently do not know how sexual problems longitudinally develop, how strong the comorbidity is in different sexual problems, and whether there are differences in comorbidity patterns between men and women. To better understand and address sexual problems in men, women, and couples, more information on such associations is needed. In the recent Natsal survey (Mitchell et al., 2013), low sexual function was associated with increased age for both men and women. While there was a clear association between age and sexual problems such as erectile dysfunction (ED) and lubrication difficulties, the relationship between age and other functional as well as emotional sexual problems was less clear (Fugl-Meyer & Sjogren, 1999; Laumann et al., 1999; Leeners, Hengartner, Ajdacic-Gross, Ro¨ssler, & Angst, 2015; Richters et al., 2003; Simons & Carey, 2001; Ventegodt, 1998). Data on the longitudinal development of sexual problems open new opportunities to gain insight on the type and degree of age-related factors that influence sexual problems, which might be missed in cohort cross-sectional studies. Given the increased availability of successful psychosexual and pharmacological treatments, a better understanding of the prevalences and associations of sexual problems in the general population would likely allow improved treatment.

Aims The aim of this study was to obtain new data on the development and course of sexual problems, such as functional and=or emotional sexual problems, as well as lack of sexual desire and their interrelationships by investigating a representative population sample of men and women over a period of 30 years. We provide

PREVALENCE AND ASSOCIATIONS OF SEXUAL PROBLEMS

data on the prevalences of these sexual problems in seven age categories and a comparison of these prevalence rates, as well as their overlap, in both genders.

Method

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Sampling The Zurich Study started with a cohort of 4,547 participants (2,201 men and 2,346 women) representative of the general population in the canton of Zurich in Switzerland, who were screened in 1978 with the Symptom Checklist 90-R (DeRogatis, 1977) when the men were 19 and the women 20 years old. The male and female participants were sampled with different approaches. Every Swiss male is screened for military service at age 19; thus, conscripts within a defined catchment area comprise its complete male population of that age. With the consent of the military authorities, but independently of their screening procedure, we randomly selected 50% of all male conscripts of the canton of Zurich of this age group. Each participant received a letter signed by the research leader guaranteeing that any personal information was to be used solely for research purposes, would be kept confidential, and would in no circumstances be disclosed to the military authorities. The refusal rate of the original male screening sample was 0.2%; a further 0.4% of the 50% selected randomly completed the questionnaires, including the SCL-90 R, but declined to give their names and addresses, resulting in an overall refusal rate of 0.3%. The screening procedure was performed concurrently with military medical examinations but in a separate room. It was emphasized that participation was voluntary. After agreement to study participation, interviews were conducted independently from military procedures. Many participants had to be excluded because they were not born in 1959 (coming a second or third time for recruitment or prematurely), so the final male sample was reduced to 2,201 participants. Female participants were identified from the complete electoral register of the canton of Zurich. Again, 50% of them were randomly selected and received questionnaires by mail, of which 75% responded. A subsample of 591 participants (292 men, 299 women), representing 2,600 people of the same age, was selected for interview. We applied a stratification procedure to enrich the interview sample with cases at risk for the development of psychiatric syndromes. Stratification was based on a cut-off value of the SCL-90-R Global Severity Index (GSI) score, which was obtained in the initial screening phase, as specified previously. The GSI is a global measure that assesses the severity of psychopathology. The GSI cut-off values were 1.57 and 1.89 for males and females, respectively. This means that two-thirds of the final interview sample comprised randomly drawn

high scorers (defined by the 85th percentile or above on SCL-90-R GSI scores) from the screening sample of 4,547 participants, while the remaining one-third were randomly selected from the rest of the screening sample (GSI scores below the 85th percentile). Such a two-phase procedure, consisting of initial screening and subsequent interview with a stratified subsample, is fairly common in epidemiological research (Dunn, Pickles, Tansella, & Va´zquez-Barquero, 1999). All together, seven interview waves have been conducted as follows: in 1979 (N ¼ 591, 292 males=299 females), 1981 (N ¼ 456, 220= 236), 1986 (N ¼ 457, 225=232), 1988 (N ¼ 424, 200=224), 1993 (N ¼ 407, 192=215), 1999 (N ¼ 367, 162=205), and 2008 (N ¼ 335, 144=191); the overall response rate was 57% at the final interview. Of the 335 persons lost to follow-up, 57% were men and 43% were women. The initial allocation to the two groups, above and below the 85th percentile of the GSI, remained stable throughout the study, although the dropouts were rather more frequent among the extremely high and low scorers on the GSI (Eich et al., 2003). We repeated the dropout analyses for the final interview in 2008, where we found no significant difference between participants who had left and those who remained in the study in regard to socioeconomic status and education; there were also no differences in initial psychological symptom patterns, as assessed by the SCL-90-R. There was, however, a moderate bias: there were more male than female dropouts (OR ¼ 1.82; 95% CI ¼ 1.31–2.53; p < 0.001); and also among dropouts 72% were single, while among those who remained in the study over 30 years only 25% were single. The ethics committee of the canton of Zurich, Switzerland, approved the study. Measures and Procedure Symptom checklist (SCL 90-R). The SCL-90-R is a self-report questionnaire designed to identify psychological symptom patterns of psychiatric and medical patients (DeRogatis, 1977). Respondents are asked to report the extent to which they have experienced various psychological symptoms within the past seven days on a 5-point Likert scale ranging from 0 (Not at all) to 4 (Extremely). There are nine symptom subscales: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, phobic anxiety, psychoticism, paranoid ideation, and hostility. Overall, SCL-90-R subscale scores have demonstrated excellent internal consistency (alpha ¼ .77–.90) and test–retest reliability (r ¼ .78–.90) (Payne, 1985). Structured psychopathological interview and rating of the social consequences of psychological disturbances for epidemiology. Interviews were conducted by trained psychologists=psychiatrists using SPIKE (Angst, DoblerMikola, & Binder, 1984) at the participant’s home or 951

¨ SSLER, AJDACIC-GROSS, AND LEENERS ANGST, HENGARTNER, RO

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at the research laboratory of the Psychiatric University Hospital in Zurich. The SPIKE is a semistructured interview, which was developed for epidemiological surveys in psychiatric research and collects data on sociodemographic factors, somatic syndromes, psychopathology, substance use, medication, health services, impairment, and social activity (for more information, see Angst et al., 1984). Validity and reliability of SPIKE was good for mood and anxiety disorders but was not assessed specifically for sexual problems. Sexual problems. Sexual problems were one area discussed during the two- to three-hour interview, which covered approximately 30 psychiatric and somatic health topics. All seven interviews from 1979 to 2008 (interviewees aged 20–21 to 49–50) assessed functional problems (e.g., ED, lack of lubrication) and emotional problems with sex (e.g., shame, inhibitions) in both male and female participants. Reduced desire was assessed at five of the seven interview waves (1986–2008; interviewees aged 27–28 to 49–50). The presence of a sexual problem as well as the perception as a functional=emotional problem or a lack of sexual desire, including the perception that this was a problem, was based on the participants’ subjective self-appraisal; in other words, the sexual problem was defined by the participant. The questions were worded as follows: ‘‘Did you have sexual problems during the past twelve months?’’ If this screening question was endorsed, participants were additionally asked whether, according to their personal evaluation, those problems related to ‘‘functional problems’’ or ‘‘emotional problems’’ and, from 1986 on, also to ‘‘reduced sexual desire.’’ The wording of these questions was as follows: ‘‘Do you think this problem is functional=emotional?’’ and ‘‘Do you suffer from lack of sexual desire?’’ In other words, these answer categories did not differentiate among specific conditions. A sexual problem was defined on a 0 to 100 scale of subjective distress as Mild (0 to 30), Moderate (31 to 60), or Severe (61 to 100). Statistical Analysis To obtain estimates representative of the general population, prevalence and cumulative incidence rates were weighted to adjust for the sample stratification. The weighting factor was determined according to the probability of the lower- and higher-scorer stratum— in other words, 66% of the 15% of highest scoring persons on the GSI, resulting in a factor of 11.3 for participants from the remaining 85th percentile rank. By this means we obtained estimates representative for the general population of the canton of Zurich. Sex differences in weighted prevalence rates were analyzed with Wald v2 tests using the SURVEYFREQ procedure of SAS version 9 for Windows. This procedure uses probability weights to compute unbiased 952

standard errors and corresponding confidence intervals. Associations between different forms of sexual problems and within-subject effects of age=time were analyzed with a series of generalized estimating equations (GEEs) using SPSS 20 for Macintosh. These analyses were introduced to fit regression models that account for within-subject correlation, which is an inherent part of longitudinal studies that rely on repeated measures (Zeger, Liang, & Albert, 1988). All sexual problems were alternately regressed on one another. A weighting variable (high versus low scorers) was included in each model to account for the sample stratification. Intercept and slope were included in all GEE models, which is a standard procedure on longitudinal analysis (Twisk, 2013). To avoid having any constraints on the covariance structure, the within-subject covariance structure was specified with the ‘‘unstructured’’ correlation type. All analyses applied two-tailed significance testing. Main Outcome Measures The main outcome measures were one-year prevalence rates and cumulative incidence rates for any sexual problem; reduced sexual desire; and emotional and functional sexual problems in women and men, assessed over a 30-year longitudinal period.

Results Out of 224 women and 200 men that participated in the assessment wave in 1988 at age 30, 76.8% of the women and 68.5% of the men were ever married up to the last assessment in 2008 at age 50. Overall, 27.7% of the women and 15.5% of the men were ever divorced. In all, 67% of the women and 52% of the men had children. A low, intermediate, and high education level was reported by 31.2%, 37.7%, and 31.2% of the women and 34.0%, 38.7%, and 27.2% of the men, respectively. Finally, the weighted cumulative 12-month prevalence rates of mood disorders in this sample were 44.6% for women and 42.1% for men; and for an anxiety disorder, 54.4% for women and 33.3% for men. Figure 1 shows the weighted prevalence of any sexual problem. Significant gender differences—more mild, but in particular more moderate and severe problems—in women compared with men were observed at age 20–21 (v2 ¼ 12.980, df ¼ 3, p ¼ 0.005) and 22–23 (v2 ¼ 14.811, df ¼ 3, p ¼ 0.002). There was a peak in mild symptoms in men at the age of 49. The prevalence of any sexual problem varied significantly over time in men (v2 ¼ 36.509, df ¼ 1, p < 0.001) but not in women (v2 ¼ 1.274, df ¼ 1, p ¼ 0.259). The cumulative incidence for any sexual problem, which may also be conceived as lifetime risk, was 67.0% in women and 46.0% in men. In our sample distress related to sexual problems was also highest when females were 21 (mean of 60.0 on a

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PREVALENCE AND ASSOCIATIONS OF SEXUAL PROBLEMS

Figure 1. a. One-year prevalence rates of any sexual problem in men. b. One-year prevalence rates of any sexual problem in women.

scale from 0 to 100) and decreased steadily up to the age of 41 (mean of 32.2). At age 50, however, distress was again somewhat higher than at age 41 (mean of 40.0). Figures 2a through 2c summarize weighted one-year prevalence rates of functional, emotional, and sexual desire problems. The prevalence rates of functional problems increased more than fivefold between the ages of 20 and 49 in men (3.1% to 16.6%) and threefold in the corresponding period in women (6.0% to 18.3%). Only at the age of 40–41 was the prevalence of functional problems higher in women (v2 ¼ 4.395, df ¼ 1, p ¼ 0.037). The prevalence of functional problems varied significantly over time in both men (v2 ¼ 29.667, df ¼ 1, p < 0.001) and women (v2 ¼ 5.680, df ¼ 1, p ¼ 0.017), increasing substantially in both with age. The cumulative incidence rates for men and women were 22.1% and 39.3%, respectively. Emotional problems were significantly more prevalent in women than in men at the ages of 20–21 (v2 ¼ 10.707, df ¼ 1, p ¼ 0.001) and 22–23 (v2 ¼ 10.387, df ¼ 1, p ¼ 0.001), and although statistically not significant, twice as common among women (10.8% versus 5.3%) at 27–28; thereafter the rates were similar. Interestingly, the one-year prevalence in women declined steadily from ages 21 (15.9%) to 50 (4.6%), whereas in men the annual prevalence of emotional problems varied less over the study period (average prevalence ¼ 4.0%). Variation over time was again significant in both males (v2 ¼ 7.164, df ¼ 1, p ¼ 0.007) and

Figure 2. a. One-year prevalence rates of functional problems. b. One-year prevalence rates of emotional problems. c. One-year prevalence rates of reduced sexual desire.

females (v2 ¼ 34.268, df ¼ 1, p ¼ 0.000). The cumulative incidence rate for emotional problems in men was 15.9%, about half that in women (35.7%). Finally, reduced desire was overall again more prevalent in women than in men, although this difference was statistically significant only at ages 27–28 (v2 ¼ 6.581, df ¼ 1, p ¼ 0.011) and 40–41 (v2 ¼ 8.120, df ¼ 1, p ¼ 0.005). The pattern was not consistent in men and women; intriguingly, reduced sexual desire was reported by men substantially less and by women substantially more frequently at the age of 40–41. The prevalence of lack of desire did not vary significantly over time in men (v2 ¼ 3.657, df ¼ 1, p ¼ 0.056) 953

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¨ SSLER, AJDACIC-GROSS, AND LEENERS ANGST, HENGARTNER, RO

sexual desire associated with functional problems (5.9%); the rates of the different association patterns were very similar (range: 2.9%–7.9%). In women, on the other hand, those patterns diverged considerably. The overlap of all three problems was much stronger in women (16.9%) than in men (5.0%). The repeated associations between different forms of sexual problems in men and women estimated with GEE are presented in Table 1. For each of the sexual problems investigated (dependent variables), we tested in both men and women whether the presence of the other two sexual problems (predictors) showed any significant association with regard to repeated co-occurrence. In women lack of desire was strongly predicted by emotional problems (OR ¼ 27.6, p < 0.001) and functional problems (OR ¼ 48.2, p < 0.001). In men the strongest association was found between emotional problems and functional problems (OR ¼ 17.2, p < 0.001).

Discussion

Figure 3. a. Lifetime overlap of sexual problems: men ages 20 to 49 (N ¼ 292). b. Lifetime overlap of sexual problems: women ages 21 to 50 (N ¼ 299).

and women (v2 ¼ 0.000, df ¼ 1, p ¼ 0.992). The cumulative incidence rate was again clearly higher in women (51.6%) than in men (33.3%). Figure 3 presents the lifetime overlap of lack of desire, emotional and functional problems according to gender (weighted data). Men most commonly experienced reduced sexual desire alone (7.9%) and reduced

Table 1.

Our results from a representative community study show significantly higher lifetime risks for sexual difficulties as well as a stronger lifetime overlap of sexual problems in women than in men. The one-year prevalence for any female sexual problems ranged from 19.4% at age 28 up to 32.9% at age 41, which is higher than the one-year prevalence of 19% found by Dennerstein and colleagues (2008) at age 45 to 55 but well below the 53.8% to 76.1% found in population-based samples (Hayes, Dennerstein, Bennett, Sidat, et al., 2008; Mercer et al., 2003; Richters et al., 2003). Due to methodological differences, for example, the collection of information by personal or computer-assisted telephone interview or questionnaires, reported female prevalences in a large American convenience sample of different age groups ranged from 25% to 76% (Laumann et al., 1999; Moreira, Brock, et al., 2005). Thus, our results for women compare well to those found in other community samples. The one-year prevalence for any

Associations Between Sexual Problems According to Repeated Co-Occurrence Males

Predictor Dependent variable: Reduced desire Emotional problems Functional problems Emotional problems Reduced desire Functional problems Functional problems Reduced desire Emotional problems

OR (95% CI)

Sig.

OR (95% CI)

Sig.

12.00 (4.25; 33.91) 9.73 (4.69; 20.17)

A Swiss Longitudinal Study of the Prevalence of, and Overlap Between, Sexual Problems in Men and Women Aged 20 to 50 Years Old.

The aim of this study was to obtain data on the development and course of sexual problems and their interrelationships by investigating a representati...
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