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Prevalence Rates of Sexual Difficulties and Associated Distress in Heterosexual Men and Women: Results From an Internet Survey in Flanders a

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Lies Hendrickx , Luk Gijs & Paul Enzlin

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Institute for Family and Sexuality Studies, Department of Development and Regeneration , University of Leuven Published online: 28 Oct 2013.

To cite this article: Lies Hendrickx , Luk Gijs & Paul Enzlin (2014) Prevalence Rates of Sexual Difficulties and Associated Distress in Heterosexual Men and Women: Results From an Internet Survey in Flanders, The Journal of Sex Research, 51:1, 1-12, DOI: 10.1080/00224499.2013.819065 To link to this article: http://dx.doi.org/10.1080/00224499.2013.819065

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JOURNAL OF SEX RESEARCH, 51(1), 1–12, 2014 Copyright # The Society for the Scientific Study of Sexuality ISSN: 0022-4499 print=1559-8519 online DOI: 10.1080/00224499.2013.819065

ARTICLES

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Prevalence Rates of Sexual Difficulties and Associated Distress in Heterosexual Men and Women: Results From an Internet Survey in Flanders Lies Hendrickx, Luk Gijs, and Paul Enzlin Institute for Family and Sexuality Studies, Department of Development and Regeneration, University of Leuven As most epidemiological surveys on sexual problems have not included assessment of associated distress, the principal aim of this study was to provide prevalence estimates of both DSM-IV-TR-defined (American Psychiatric Association [APA], 2000) and less commonly assessed sexual difficulties and dysfunction (e.g., lack of responsive sexual desire, lack of subjective arousal). A secondary aim was to obtain information about comorbidity between sexual desire and sexual arousal difficulties=dysfunction. This study comprised an online survey completed by 35,132 heterosexual Flemish men and women (aged 16 to 74 years). Results indicated that sexual dysfunctions were far less common than sexual difficulties, and some uncommonly assessed sexual problems (e.g., ‘‘lack of responsive desire’’ in women; ‘‘hyperactive sexual desire’’ in men) were quite prevalent. In women, there was a high comorbidity between ‘‘lack of spontaneous sexual desire’’ and ‘‘lack of responsive sexual desire’’; between ‘‘lack of genital arousal’’ and ‘‘lack of subjective sexual arousal’’; and between sexual desire and sexual arousal difficulties=dysfunctions. The implications of these findings for epidemiological research on sexual dysfunction and for the newly defined DSM-5 Female Sexual Interest=Arousal Disorder (APA, 2013) are discussed.

Introduction Since the publication of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (APA, 1994), there have been a number of population-based studies of sexual problems (e.g., Christensen et al., 2011; Fugl-Meyer & Fugl-Meyer, 1999; Laumann, Gagnon, Michael, & Michaels, 1994). Despite the stipulation of the DSM-IV (APA, 1994) that a diagnosis of a sexual dysfunction should be based on the presence of both symptoms related to sexual desire, sexual arousal, orgasm, and=or sexual pain and distress We would like to thank the collaborators of Ook getest op mensen from the Flemish public broadcasting company (VRT) who provided us the unique opportunity to undertake this online survey. We are especially grateful to Berten Baert, Maarten Boone, Hendrik Dacquin, Niels Laukens, and Jeroen van Aert for their help in data acquisition. Correspondence should be addressed to Lies Hendrickx, Institute for Family and Sexuality Studies, Department of Development and Regeneration, KU Leuven, Kapucijnenvoer 33 blok g – bus 7001, 3000 Leuven, Belgium. E-mail: [email protected]

about the symptoms, most studies, with few exceptions (e.g., Bancroft, Loftus, & Long, 2003; Christensen et al., 2011; Fugl-Meyer & Fugl-Meyer, 1999), have not included a measure of distress. In this article, the term sexual difficulty is used to refer to impairments in sexual function, regardless of the level of sexual distress. Sexual dysfunction will be used to describe impairments in sexual function that are also distressing to the individual. Tables 1 and 2 present a summary of populationbased epidemiological surveys carried out in Western countries (Europe, North America, and Australia) (Fugl-Meyer et al., 2010; Lewis et al., 2004; Simons & Carey, 2001; West et al., 2008). In men, prevalence rates of sexual difficulties varied from 3.2% to 24.9% for hypoactive sexual desire, from 5% to 26% for erectile difficulty, from 0.8% to 8.3% for absent or delayed orgasm, from 4.9% to 28.5% for premature ejaculation (PE), and from 0% to 3% for dyspareunia. Fewer studies have reported prevalence rates of sexual dysfunctions, rendering a prevalence rate of 6% for hypoactive sexual

HENDRICKX, GIJS, AND ENZLIN

Table 1.

Prevalence of Specific Sexual Difficulties=Dysfunctions in Men

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Study Sexual difficulty (%) Laumann et al. (1994) Dunn et al. (1998) Ventegodt (1998) Fugl-Meyer & Fugl-Meyer (1999) Richters et al. (2003) Rosen et al. (2004) (Europe) Rosen et al. (2004) (United States) Porst et al. (2007) (Europe) Porst et al. (2007) (United States) Træen & Stigum (2010) Træen & Stigum (2010) Christensen et al. (2011) Sexual dysfunction (%) Fugl-Meyer & Fugl-Meyer (1999) Christensen et al. (2011)

N

Age

Hypoactive Sexual Desire

Erectile Difficulty

Absent or Delayed Orgasm

Premature Ejaculation

Dyspareunia

1,346 789 753 1,475

18–59 18–75 18–88 18–74

15.8 — 3.2 16

10.4 26 5.4 5

8.3 — 0.8 2

28.5 14 4.9 9

3 — 0.4 1

Population-based Convenience sample Convenience sample

10,173 10,729 9,384

16–59 20–75 20–75

24.9 — —

9.5 10–13 22

6.3 — —

23.8 — —

2.4 — —

Convenience sample Convenience sample

4,124 8,009

18–70 18–70

— —

9.7–14.6 18.3

— —

20–20.3 24

—

Population-based Convenience sample Population-based

941 902 2,120

18–59 18–67
16

11–13

9

3–7

26–27

2

—

7

4

10

0

Population-based

1,475

18–74

6

3.4

1.1

4.4

(0.6)

Population-based

2,120


16

—

5

2

7

0.1

Study Sample

Population-based Population-based Population-based Population-based

Note. Brackets indicate that the number from which percentage is computed is < 50.

desire disorder (HSDD), 3.4% to 5% for erectile dysfunction (ED), 1.1% to 2% for absent or delayed orgasm as a sexual dysfunction, 4.4% to 7% for PE as a sexual dysfunction, and less than 1% for dyspareunia as a sexual dysfunction (see Table 1). In women, prevalence rates for sexual difficulties have varied from 7.2% to 54.8% for hypoactive sexual desire, from 11% to 31.2% for lubrication difficulties, from 6.8% to 28.6% for absent or delayed orgasm, and from 3.1% to 20.3% for dyspareunia. With regard to sexual dysfunctions, prevalence rates varied from 2.5% to 14.2% for HSDD in women, from 5.1% to 7.5% for FSAD (female sexual arousal disorder, including problems with lubrication), from 3.1% to 9.9% for female orgasmic disorder (FOD or absent or delayed orgasm), and from 1% to 4.1% for dyspareunia (see Table 2). In their review on the prevalence of sexual difficulties in men and women, Fugl-Meyer et al. (2010) concluded that about 20% to 30% of adult men and 40% to 45% of adult women have at least one sexual difficulty. Despite the growing number of population-based studies (see Tables 1 and 2), the prevalence rates cited by FuglMeyer et al. (2010) should be interpreted with caution because studies differed in sample selection, in definitions, and in measurements of sexual problems, which hinder comparison of prevalence rates across studies and countries. Some prevalence studies did not use representative or population-based data but relied on clinical samples (e.g., Nobre, Pinto-Gouveia, & Gomes, 2006). Furthermore, study populations often differed in age range, 2

with some studies including a broad age range (e.g., 16 to 70 years old), while others focused on a more restricted age range (e.g., 40 to 80 years old). Another issue is the use of different definitions for sexual problems and the use of different questionnaires with single- or multi-item questions and different reference periods (e.g., four weeks, six months, one year) to assess sexual problems. Moreover, some studies did not include a measurement of distress. Nevertheless, studies that did include a measure of distress yielded substantially lower prevalence rates of sexual dysfunctions (e.g., Fugl-Meyer & Fugl-Meyer, 1999). This implies that not all individuals are distressed by an impairment in sexual function. Another limitation is that almost all epidemiological studies were restricted to assessing prevalence of sexual difficulties and=or sexual dysfunctions that were described in DSM-IV-TR (APA, 2000). However, many authors have suggested revising the criteria for sexual dysfunctions, particularly with regard to female sexual disorder (e.g., Basson, 2000; Binik, 2010a; 2010b; Brotto, 2010a, 2010b, 2010c; Graham, 2010a, 2010b; Kleinplatz, 2012; Tiefer, Hall, & Tavris, 2002). Other authors have commented on the proposals for DSM-5 female sexual disorders (e.g., DeRogatis, Clayton, Rosen, Sand, & Pyke, 2011; DeRogatis et al., 2010). This literature generally pertains to female sexual disorders and suggests that several new criteria should be evaluated in research (e.g., Basson, 2000; Binik, 2010a, 2010b; Brotto, 2010a, 2010b, 2010c; DeRogatis et al., 2010; Graham, 2010a, 2010b; Kleinplatz, 2012; Tiefer et al., 2002). In view of the critique that the diagnosis

PREVALENCE AND DISTRESS IN SEXUAL DIFFICULTIES

Table 2.

Prevalence of Specific Sexual Difficulties=Dysfunctions in Women

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Study Sexual difficulty (%) Laumann et al. (1994) Dunn et al. (1998) Ventegodt (1998) Fugl-Meyer & Fugl-Meyer (1999) Bancroft et al. (2003) Richters et al. (2003) Shifren et al. (2008) West et al. (2008) Weiss & Brody (2009) Træen & Stigum (2010) Træen & Stigum (2010) Christensen et al. (2011) Sexual dysfunction (%) Fugl-Meyer & Fugl-Meyer (1999) Bancroft et al. (2003) Shifren et al. (2008) West et al. (2008) Weiss & Brody (2009) Christensen et al. (2011)

Study Sample

Population-based Population-based Population-based Population-based Population-based Population-based Convenience sample Population-based Convenience sample Population-based Convenience sample Population-based Population-based Population-based Convenience sample Convenience sample Convenience sample Population-based

N

Age

Hypoactive Sexual Desire

Lubrication Difficulty

Absent or Delayed Orgasm

Dyspareunia

1,622 657 741 1,335

18–59 18–75 18–88 18–74

33.4 — 11.2 33

18.8 28 — 12

24.1 27 6.8 22

14.4 18 3.1 6

987 9,134 31,581 2,207 903 1,353 769 2,295

20–65 16–56 18–102 30–70 15–88 18–59 18–67
16

7.2 54.8 37.7 36.2 17.8 37–42

31.2 23.9 25.3 — — 19–21

9.3 28.6 21.1 — — 23–26

3.3 20.3 — — — 9

—

11

15

4

1,335

18–74

14.2

7.5

9.9

4.1

987 31,581 2,207 903 2,295

20–65 18–102 30–70 15–88
16

(2.5) 9.5 8.3 7.5 —

6.5 5.1 — — 7

3.1 4.6 — — 6

1 — — — 3

Note. Brackets indicate that the number from which percentage is computed is < 50.

of HSDD in the DSM-IV-TR (APA, 2000) focused too much on spontaneous desire (e.g., Basson, 2000), the current study assessed not only spontaneous desire but also sexual desire in response to the initiative of the partner. A lack of subjective sexual arousal has seldom been assessed in surveys, although it has been shown that, in women, correlations between genital response and subjective sexual arousal are often low (Chivers, Seto, Lalumie`re, Laan, & Grimbos, 2010). Furthermore, too much desire and early orgasm in women have been assessed only rarely in surveys. Nevertheless, these problems seem to cause distress as women with these problems are seen in our clinical practice. Because these problems are not well recognized in the literature and thus not well known by clinicians, women confronted with these sexual difficulties may feel very ‘‘abnormal.’’ Therefore, we believe that to better understand these uncommonly assessed sexual difficulties and sexual dysfunctions more empirical input is needed. Based on the limitations of previous studies, the aims of this study were threefold. The first aim was to provide prevalence estimates of the APA (2000) DSM-IV-TRdefined sexual difficulties and sexual dysfunctions. The second aim was to provide prevalence estimates of newly defined but uncommonly assessed sexual dysfunctions in heterosexual men and women, such as hyperactive sexual desire (i.e., too much sexual desire), lack of responsive desire (i.e., lack of the ability to respond with sexual desire to sexual initiatives of the partner), lack of subjective arousal (i.e., lack of the subjective feeling of being

aroused), early orgasm in women, retrograde ejaculation (i.e., when semen that would normally be ejaculated via the urethra is redirected to the urinary bladder), and lack of a forceful propulsive ejaculation in men (i.e., partial ejaculatory incompetence, in which semen seeps out of the penis). The third aim of this study was to provide an estimate of comorbidity of spontaneous and responsive desire difficulties=dysfunctions, of genital and subjective arousal difficulties= dysfunctions, and of arousal and desire difficulties= dysfunctions in women. Method Participants In total, 37,921 Flemish people completed an Internet-based survey with questions on their gender, age, relationship status, sexual orientation, and on the presence of sexual difficulties and sexual distress. During the process of data cleaning, 7,545 cases were deleted based on the following exclusion criteria: In 4,170 cases, participants were excluded due to (a) incomplete data (N ¼ 100); (b) double or triple use of IP addresses (N ¼ 1,379); (c) not self-identifying as a heterosexual (N ¼ 2,570), and (d) age not between 16 and 74 years old (N ¼ 121). Furthermore, based on the 5% trimmed mean of time needed to complete the survey, the data of respondents that took an unusually short or long time to complete 3

HENDRICKX, GIJS, AND ENZLIN

Table 3.

Example of the Questions Used in SFS

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Question Question 1. ‘‘During the past 4 weeks, did you have too little desire for sex, too little desire for sexual activities, too little sexual fantasies or erotic thoughts (¼too little sexual desire)?’’

0. 1. 2. 3.

(If Question 1 > 0) If I have too little desire, I experience this as:

1. No or a mild problem 2. A moderate problem 3. A severe or extreme problem

(If Question 1 > 0 and participant has a steady partner) If I have too little desire, my partner experiences this as:

1. No or a mild problem 2. A moderate problem 3. A severe or extreme problem

(If Question 1 > 0 and participant has a steady partner) If I have too little desire, I experience this in my relationship as:

1. No or a mild problem 2. A moderate problem 3. A severe or extreme problem

the questionnaire were omitted (N ¼ 3,375).1 After deleting the data from surveys of participants that were not completed within the 90% interquartile range of duration time, this left 30,378 participants, who took between 2.5 and 8.5 minutes to complete the questionnaire. Measures Demographics. Men and women were asked to indicate their gender (man=woman), current age (in years), and whether they had a steady partner (yes=no). Sexual orientation. Sexual orientation was measured based on self-identification. Participants were asked to indicate whether they identified as heterosexual, bisexual, homosexual=lesbian, or asexual. Sexual function and sexual distress. Impaired sexual function and sexual distress associated with impaired sexual function were assessed by means of the Sexual Functioning Scale (SFS). The SFS is an extended version of the Short Sexual Functioning Scale (SSFS) developed by Enzlin et al. (2012). The SFS covers not only all sexual dysfunctions included in the DSM-IVTR (APA, 2000) but also problems with increased sexual desire, absence of or decreased responsive sexual desire, absence of or decreased subjective arousal, early orgasm in women, retrograde ejaculation, and lack of a forceful propulsive ejaculation. The presence of each sexual difficulty was scored on a 4-point scale with

1

The trimmed mean is a procedure to trim down the ends of a distribution, thereby removing the outliers that skew and bias the mean. The trimmed mean produces accurate results even when the distribution is not symmetrical (Field, 2009). In this study, the 5% trimmed mean of duration was 266 seconds, which came close to the median duration of 250 seconds.

4

Scale I I I I

did not have too little desire had mildly too little desire had moderately too little desire had severely or extremely too little desire

the following response choices: 0 (No), 1 (Mild), 2 (Moderate), 3 (Severe or extreme). To determine the clinical significance of these sexual difficulties, participants who had scores of
2 on any of the previous items were asked to evaluate how distressing each sexual difficulty was. Participants were asked whether they themselves experienced distress due to the sexual difficulty (personal distress), whether according to them their partners experienced distress because of the sexual difficulty (partner distress), and whether the sexual difficulty caused distress in their relationships (relational distress). Each type of distress was scored 1 (No or mild distress), 2 (Moderate distress) or 3 (Severe or extreme distress). If respondents had partners, distress was considered to be present if they had a sum score of
5 (i.e., moderate levels of distress on at least two types of distress or severe=extreme distress on at least one type of distress). For respondents without partners, only the item referring to ‘‘personal distress’’ was used; distress was considered to be present when personal distress generated a score of
2 (moderate or severe=extreme personal distress). For instance, HSDD was based on the questions found in Table 3.

Procedure An Internet-based survey was developed and promoted with the help of Ook getest op mensen (‘‘Also tested on people’’), a television program that is broadcast by the Flemish public broadcasting company (VRT), where health-related questions are discussed by scientific experts. In this context, we had the unique opportunity to conduct this study about aspects of sexual life among residents of Flanders (i.e., the Dutch speaking part of Belgium). The survey was posted online and could be completed between January 18–30, 2012. During that period, the public broadcasting company used various media (television, radio, online) to further

PREVALENCE AND DISTRESS IN SEXUAL DIFFICULTIES

promote this study and to invite people to complete the online questionnaire. The episode in which the results of the study were presented was watched by 866,069 of the 2,600,000 households (33.3%) in Flanders (Statistics Belgium, n.d.). To further contextualize this online survey, in 2010, 77% of all Flemish households had access to the Internet and thus would have been able to complete the online survey (Research Department of the Flemish Government, n.d.).

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Data Analysis As this study was based on a large convenience sample, the data were weighted by gender and age to make the sample as representative as possible of the population of Flanders aged 16 to 74. This weighting procedure meant that for all analyses a sample of 35,132 participants was used. Statistical analyses, in this case student’s t-test and chi-square tests, were performed using SPSS (version 18.0, Chicago, IL).

Results Descriptives The final weighted sample consisted of 35,132 heterosexual participants (50.1% men and 49.9% women). The mean age of the sample was 39.06  14.7 years. Men (41.9  14.8 years) were significantly older than women (36.18  14 years) (t (35,020.278) ¼ 37.5, p < .001), which could be explained by the lower number of men in the youngest age groups and the higher number of men in the oldest age groups. The majority of the participants (89.5%) had a steady partner at the time of the survey (Table 4).

Table 4. Age Distribution and Relationship Status of Participants Demographic Age 16–19 years 20–24 years 25–29 years 30–34 years 35–39 years 40–44 years 45–49 years 50–54 years 55–59 years 60–64 years 65–69 years 70–74 years Steady partner Yes No

Men N (%) (N ¼ 17,598)

881 1,839 1,654 1,712 1,822 2,061 1,781 1,668 1,583 1,444 610 543

(5.0) (10.5) (9.4) (9.7) (10.4) (11.7) (10.1) (9.5) (9.0) (8.2) (3.5) (3.1)

15,842 (90.0) 1,756 (10.0)

Women N (%) (N ¼ 17,534)

1,453 3,228 2,250 2,321 1,520 1,700 1,468 1,392 866 805 381 150

(8.3) (18.4) (12.8) (13.2) (8.7) (9.7) (8.4) (7.9) (4.9) (4.6) (2.2) (0.9)

15,641 (89.2) 1,893 (10.8)

Prevalence of Sexual Difficulties and Sexual Dysfunctions In this article, sexual difficulties are defined as impairments in sexual function, regardless of the presence of distress. A sexual difficulty was considered present when individuals reported a moderate or severe=extreme impairment in sexual functioning. Sexual dysfunctions were defined as sexual difficulties that are associated with (moderate or severe=extreme) distress. When taking into account only sexual difficulties related to the DSM-IV-TR (APA, 2000), 23.3% of men and 39.9% of women were classified as having at least one sexual difficulty (v2(1, N ¼ 35,130) ¼ 1126.647, p < .001), and 11.3% of men and 20.2% of women were classified as having at least one sexual dysfunction (v2(1, N ¼ 35,131) ¼ 521.86, p < .001) (Tables 4 and 5). When the less commonly assessed sexual difficulties were included, prevalence rates increased to 47.5% of men being classified as having at least one sexual difficulty and 20.5% being classified as having at least one sexual dysfunction (v2(1, N ¼ 35,129) ¼ 7.857, p < .01; Table 5). In women, 49.2% were classified as having sexual difficulties, while 24.4% were classified as having at least one sexual dysfunction (v2(1, N ¼ 35,131) ¼ 71.877, p < .001; Table 6).

Sexual Difficulties and Sexual Dysfunctions in Men The prevalence rates of sexual difficulties and sexual dysfunctions in men are presented in Table 5. Besides providing prevalence estimates of sexual difficulties and sexual dysfunctions, Table 5 also presents the level of severity on impairment of several aspects of sexual functioning on a 4-point scale, ranging from No impairment in sexual functioning to Severe or extreme impairment in sexual functioning. Almost 30% of all men were classified as having the sexual difficulty hyperactive sexual desire. Hyperactive sexual desire was the most common sexual dysfunction in men, with almost 10% of men classified as having hyperactive sexual desire (see Table 5). Also, 12% of men were classified as having the sexual difficulty PE. The second most common sexual dysfunction in men was PE: almost 6% of all men were classified as having PE. In all, 8% of men were classified as having an erectile difficulty, and nearly 5% of men were classified as having ED. Only 3.4% of men were classified as having the sexual difficulty lack of subjective arousal, and 1.9% were classified as distressed by this lack of subjective arousal (i.e., classified as having a sexual dysfunction); 4% of men were classified as having a lack of responsive sexual desire as a sexual difficulty. Even less prevalent was responsive desire as a sexual dysfunction, with 2.3% of men classified as lacking desire, even in response to a partner taking initiative, and 4% of men classified as having hypoactive (spontaneous) sexual desire 5

HENDRICKX, GIJS, AND ENZLIN

Table 5.

Levels of Severity and Prevalence Rates of Sexual Difficulties=Dysfunctions in 17,598 Men Presence of an Impaired Sexual Function (%)

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Condition Sexual aversion Hyperactive sexual desire Hypoactive sexual desire Lack of responsive desired Erectile difficultye Lack of subjective arousal Absent=delayed orgasm Premature ejaculation Retrograde ejaculation Lack of a forceful propulsive ejaculation Dyspareuniaf At least one sexual difficulty=dysfunction At least one DSM-defined sexual difficulty=dysfunctiong

Prevalence of (%)

No (Score ¼ 0)

Mild (Score ¼ 1)

Moderate (Score ¼ 2)

Severe (Score ¼ 3)

Sexual Difficultya

Sexual Dysfunctionb

96.7 36.8 85.9 84.9 70.2 84.1 92.2 73.4 98.3 91.5 98.0

2.4 35.5 9.9 11.0 21.5 12.5 4.7 14.4 0.9 4.8 1.7

0.6 23.4 3.4 3.2 6.3 2.6 2.3 10.5 0.4 3.4 0.3

0.3 4.3 0.9 0.8 2.0 0.8 0.7 1.7 0.4 0.4 0.0

0.9 27.7 4.4c 4.1c 8.3 3.4 3.0 12.2 0.8 3.8 0.3 47.7 23.3

0.5 9.7 1.6 2.3 4.8 1.9 1.2 5.7 0.2 0.6 0.2 20.5 11.3

a

Sexual difficulty denotes moderately or severely impaired sexual function (score
2 on difficulty questions). Sexual dysfunction denotes moderately or severely impaired sexual function that caused moderate or severe distress (score on sexual difficulty question
2) AND (if partner: score
5 on three types of distress; if no partner: score
2 on personal distress). c Due to rounding issues, the total percentage of the sexual difficulties is not the exact sum of prevalence of moderately and severely impaired sexual function. d The prevalence rate of lack of responsive desire is based on the data of men with a partner (N ¼ 15,842). e Erectile difficulty was defined as ‘‘difficulty in attaining and=or maintaining an erection sufficient for penetration.’’ f Prevalence of dyspareunia in men was calculated on N ¼ 16,175. Men who could not or never penetrate their partner have been left out (unclear whether this was due to pain in men or pain in women). g DSM-IV-TR-defined sexual difficulties included sexual aversion, hypoactive sexual desire, erectile difficulty, absent=delayed orgasm, premature ejaculation, and dyspareunia. b

as a sexual difficulty. HSDD (as a sexual dysfunction) was less prevalent, with only 1.6% of men classified with this dysfunction. The sexual difficulty ‘‘lack of a forceful Table 6.

propulsive ejaculation’’ was relatively uncommon in men (3.8%), and only 0.6% of men were classified as having this particular sexual dysfunction. The sexual

Prevalence Rates of Sexual Difficulties=Dysfunctions in 17,535 Women Presence of an Impaired Sexual Function (%)

Condition Sexual aversion Hyperactive sexual desire Hypoactive sexual desire Lack of responsive desirec Lubrication difficultyd Lack of subjective arousal Absent=delayed orgasm Early orgasm Dyspareunia At least one sexual difficulty=dysfunction At least one DSM-IV-TR-defined sexual difficulty=dysfunctionf a

Prevalence of (%)

No (Score ¼ 0)

Mild (Score ¼ 1)

Moderate (Score ¼ 2)

Severe (Score ¼ 3)

Sexual Difficultya

Sexual Dysfunctionb

85.2 69.6 56.3 52.4 57.1 66.4 61.2 93.1 87.9

11.7 20.6 24.3 33.9 30.5 24.1 18.7 5.1 7.7

2.6 8.4 15.3 11.4 9.3 7.1 11.8 1.7 4.0

0.5 1.4 4.0 2.3 3.1 2.5 8.3 0.1 0.3

3.1 9.8 19.3 13.7 12.4 9.6 20.1 1.8 4.4e 49.2 39.9

2.3 1.7 10.3 9.4 7.0 6.4 6.9 0.4 3.2 24.3 20.2

Sexual difficulty denotes moderately or severely impaired sexual function (score
2 on difficulty questions). Sexual dysfunction denotes moderately or severely impaired sexual function that caused moderate or severe distress (score on sexual difficulty question
2) AND (if partner: score
5 on three types of distress; if no partner: score
2 on personal distress). c The prevalence rate of lack of responsive desire is based on the data of women with a partner (N ¼ 15,641). d Lubrication difficulty was defined as ‘‘difficulty attaining and=or maintaining lubrication.’’ e Due to rounding issues, the total percentage of the sexual difficulties is not the exact sum of prevalence of moderately and severely impaired sexual function. f DSM-IV-TR-defined sexual difficulties included sexual aversion, hypoactive sexual desire, lubrication difficulty, absent=delayed orgasm, and dyspareunia. b

6

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PREVALENCE AND DISTRESS IN SEXUAL DIFFICULTIES

difficulty ‘‘no or delayed orgasm’’ was also uncommon in men (3%), as was ‘‘no or delayed orgasm’’ as a sexual dysfunction, with a prevalence of 1.2% (see Table 5). The sexual difficulties sexual aversion (0.9%), retrograde ejaculation (0.8%), and dyspareunia (0.3%) were much less prevalent than other previously mentioned sexual difficulties. Sexual aversion, retrograde ejaculation, and dyspareunia as sexual dysfunctions were also very uncommon, with prevalence rates of 0.5%, 0.2%, and 0.2%, respectively.

sexual aversion as a sexual dysfunction. The sexual difficulty hyperactive sexual desire was quite common: Nearly 10% of all women were classified as having this difficulty. However, experiencing distress because of hypersexual desire (as a sexual dysfunction) was uncommon: Only 1.7% of all women were classified as having such a dysfunction. Finally, the sexual difficulty early orgasm was relatively uncommon in women (1.8%), and even fewer women were classified as having early orgasm as a sexual dysfunction (0.4%).

Sexual Difficulties and Sexual Dysfunctions in Women

Comorbidity of Sexual Difficulties and Dysfunctions in Women

The prevalence rates of sexual difficulties and sexual dysfunctions of women in our sample are presented in Table 6: 19% of women were classified as having the sexual difficulty hypoactive sexual desire. Sexual desire disorders were most prevalent in women, with about 10% of women classified as having these sexual dysfunctions; 10% of women were classified as having HSDD. Almost 14% of women were classified as having the sexual difficulty lack of responsive desire, and 9% of women were classified as having the sexual dysfunction lack of responsive desire. In all, 12% of women were classified as having the sexual difficulty lack of lubrication, and 7% of women were classified as having FSAD. One in five women were classified as having the sexual difficulty ‘‘absent or delayed orgasm’’; thus, this problem was very common. However, only 6.9% of women were classified as having absent or delayed orgasm as a sexual dysfunction. Almost 10% of women were classified as having the sexual difficulty lack of subjective arousal, whereas 6.4% of women were classified as having lack of subjective arousal as a sexual dysfunction. The sexual difficulty dyspareunia was much less prevalent: Only 4.4% of all women were classified with this. Even fewer women (3.2%) were classified as having dyspareunia as a sexual dysfunction; in addition, 3% of women were classified as having the sexual difficulty sexual aversion, and 2% of women were classified as having

Comorbidity of hypoactive sexual desire and lack of responsive sexual desire. Overall, 19.3% of women were classified as having the sexual difficulty hypoactive sexual desire, and 13.7% were classified as having a lack of responsive desire (see Table 6). High comorbidity rates were found between hypoactive sexual desire and lack of responsive desire as sexual difficulties (depending on the sexual difficulty used as reference category, between 44% and 66%) and as sexual dysfunctions (depending on the sexual dysfunction used as reference category between 51% and 61%) (see Table 7). Converting the comorbidity into prevalence rates, this means that in women with a partner, 9.1% were classified as having both the sexual difficulties low spontaneous and responsive sexual desire, and 5.8% were classified as having both low spontaneous and responsive sexual desire as sexual dysfunctions (see Table 8). Comorbidity of genital sexual arousal and subjective sexual arousal. The comorbidity of lack of genital arousal and lack of subjective arousal was quite high (between 39% and 50% for difficulties; between 41% and 44% for sexual dysfunctions) (see Table 7). However, converting these rates into prevalence rates, ‘‘pure genital sexual arousal’’ difficulty (i.e., genital sexual arousal difficulty alone without subjective sexual arousal

Table 7. Comorbidity of Low Sexual Desire and Low Sexual Arousal Difficulties=Dysfunctions in Women With a Partner (N ¼ 15,641) Sexual Difficulties Lack Lack Lack Lack

of of of of

spontaneous sexual desire responsive sexual desire genital arousal subjective arousal

Sexual Dysfunctions HSDD Lack of responsive sexual desire FSAD Lack of subjective arousal

Lack of Spontaneous Sexual Desire (%)

Lack of Responsive Sexual Desire (%)

Lack of Genital Arousal (%)

Lack of Subjective Arousal (%)

N

— 66.3 49.1 69.4

43.7 — 40.8 63.6

30.1 38.0 — 49.5

33.2 46.2 38.6 —

3,254 2,143 1,997 1,557

HSDD (%)

Lack of Responsive Sexual Desire (%)

FSAD (%)

Lack of Subjective Arousal (%)

N

— 61.2 40.0 58.2

50.8 — 43.2 62.3

24.9 32.4 — 43.6

34.0 43.9 40.9 —

1,768 1,468 1,100 1,033

7

HENDRICKX, GIJS, AND ENZLIN

Table 8. Prevalence of Pure Desire and Arousal Difficulties=Dysfunctions in Women With a Partner, Divided Into Subtypes (N ¼ 15,641) Type of Arousal Difficulty Sexual Difficulties: Type of Desire Difficulty d

Pure spontaneous desire Pure responsive desiree Combination of both typesf No lack of desire Total

Pure Genital (%)a

Pure Subjective (%)b

Combination of Both Types (%)c

No Lack of Arousal (%)

1.6 0.6 0.9 4.8 7.9

1.2 0.6 1.9 1.3 5.0

0.7 0.6 3.1 0.5 4.9

8.3 2.8 3.2 68.0 82.3

Total 11.7g 4.6 9.1 74.6

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Type of Arousal Dysfunction Sexual Dysfunctions: Type of Desire Dysfunction d

Pure spontaneous desire Pure responsive desiree Combination of both typesf No lack of desire Total

Pure Genital (%)

a

Pure Subjective (%) b

Combination of Both Types (%)c

No Lack of Arousal (%)

0.6 0.5 1.4 1.2 3.7

0.2 0.5 1.6 0.5 2.8

4.3 2.2 2.2 80.6 89.3

0.5 0.4 0.5 2.7 4.1

Total 5.6 3.6 5.8h 85.0

a

Women reporting a lack of genital sexual arousal but not a lack of subjective sexual arousal. Women reporting a lack of subjective sexual arousal but not a lack of genital sexual arousal. c Women reporting both a lack of genital sexual arousal and a lack of subjective sexual arousal. d Women reporting a lack of spontaneous sexual desire but not a lack of responsive sexual desire. e Women reporting a lack of responsive sexual desire but not a lack of spontaneous sexual desire. f Women reporting both a lack of spontaneous sexual desire and a lack of responsive sexual desire. g Total percentage is slightly different from the sum of ‘‘pure spontaneous desire difficulty’’ components because cell percentages have been rounded. h Total percentage is slightly different from the sum of ‘‘combination of both types of desire dysfunction’’ components because cell percentages have been rounded. b

difficulty) was most common (7.9%), followed by ‘‘pure subjective sexual arousal’’ difficulty (i.e., subjective sexual arousal difficulty alone without genital sexual arousal difficulty; 5.0%), and then by a combination of these two kinds of arousal difficulties (4.9%). In terms of a sexual dysfunction, ‘‘pure genital arousal’’ dysfunction (i.e., genital sexual arousal dysfunction alone without subjective sexual arousal dysfunction; 4.1%) was most common, followed by ‘‘pure subjective arousal’’ dysfunction (i.e., subjective sexual arousal dysfunction alone without genital sexual arousal dysfunction; 3.7%), and 2.8% of women were classified as having a combination of both kinds of arousal problems (Table 8). Comorbidity of sexual desire and sexual arousal. Women in our study who were classified as having a sexual desire or sexual arousal difficulty were also often classified as having another sexual arousal or sexual desire difficulty. This type of comorbidity varied from approximately 30% to nearly 70%, depending on the sexual difficulty that was regarded as the reference category (see Table 7). Similarly, the comorbidity of sexual desire and sexual arousal as sexual dysfunctions was very high, again varying between nearly 25% and 62%, depending on the reference category (see Table 7). Translating these comorbidity rates into comorbidity prevalence rates, Table 8 indicates that 8

11.2% of women with a partner were classified as having a desire difficulty as well as an arousal difficulty, and 6.2% were classified as having both a desire dysfunction and an arousal dysfunction.

Discussion The present study was based on an online survey completed by 35,132 heterosexual Flemish men and women. In men, the most common sexual difficulties were hyperactive sexual desire (27.7%), premature ejaculation (12.2%) and erectile difficulty (8.3%), while the prevalence of each of these types of sexual dysfunction (i.e., including distress), dropped to 9.7%, 5.7%, and 4.8%, respectively. In women, the most common sexual difficulties were absent or delayed orgasm (20.1%), hypoactive sexual desire (19.3%), lack of responsive desire (13.7%), and lubrication difficulties (12.4%), while the prevalence of these sexual dysfunctions (i.e., including distress) were less common, with ‘‘low desire dysfunctions’’ (i.e., HSDD and responsive sexual desire disorder) most common (both present in about 10%), followed by FSAD (7%), absent or delayed orgasm (6.9%), and a distressing lack of subjective arousal (6.4%). Another aim of this study was to provide data on comorbidity of sexual desire and sexual arousal

PREVALENCE AND DISTRESS IN SEXUAL DIFFICULTIES

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difficulties and dysfunctions in women. The present study yielded high comorbidity rates between the sexual difficulties lack of spontaneous desire and lack of responsive desire in women (between 44% and 66%), as well as between lubrication difficulty and lack of subjective arousal (between 39% and 50%). For the sexual dysfunctions HSDD and lack of spontaneous desire and the sexual dysfunctions FSAD and lack of subjective arousal, high comorbidity was also observed (between 51% and 61% and between 41% and 44%, respectively). Furthermore, there was evidence of high rates of comorbidity between female sexual desire and sexual arousal difficulties (between 30% and 69%) and arousal dysfunctions (between 25% and 62%). Sexual Difficulties and DSM-IV-TR-Identified Sexual Dysfunctions Prevalence rates in the overall sample. In our study, significantly more women (approximately 40%) than men (about 23%) were classified as having at least one of the APA’s (2000) DSM-IV-TR-defined sexual difficulties. Despite the caution needed when comparing prevalence rates from different studies using different methods, this result seems consistent with other studies that have reported higher prevalence rates of sexual difficulties and sexual dysfunction in women than in men (Fugl-Meyer & Fugl-Meyer, 1999; Laumann et al., 1994; Richters, Grulich, de Visser, Smith, & Rissel, 2003; Træen & Stigum, 2010; Ventegodt, 1998). The prevalence rates found in the present study are also in line with the findings in most epidemiological research suggesting that 40% to 45% of women and 20% to 30% of men report at least one sexual difficulty (Fugl-Meyer et al., 2010; Mercer et al., 2003). To assess sexual dysfunctions as described in DSMIV-TR (APA, 2000), the present study also measured sexual distress. Compared with estimates of sexual difficulties, prevalence estimates of sexual dysfunctions clearly dropped—to 20% of women and 11% of men reporting at least one sexual dysfunction. Only two studies provided an overall estimate of sexual dysfunctions in both men and women (Fugl-Meyer & FuglMeyer, 1999; Christensen et al., 2011). Fugl-Meyer and Fugl-Meyer (1999) found a gender difference similar to the current study. Christensen et al. (2011) did not find any gender difference, which is probably due to the fact that they did not assess hypoactive sexual desire dysfunction, which is relatively prevalent in women. Specific prevalence rates in men and women. The specific rates for sexual difficulties in men and women found in this study illustrate how prevalence rates of sexual difficulties—and thus also those of sexual dysfunctions—are prone to variability, depending on the definition and severity criteria used (Hayes, Dennerstein, Bennett, & Fairley, 2008). For example, if the current

study had included ‘‘mildly impaired sexual functioning’’ to determine the rates of sexual difficulties, the prevalence rates of all sexual difficulties would be considerably higher. Because of this problem, and because the prevalence rates found here were based on a convenience sample (weighting was limited to two factors, i.e., gender and age), comparison of the prevalence rates found in this study with those reported in other population-based studies is difficult. Uncommonly Assessed Sexual Difficulties and Sexual Dysfunctions Comparison of prevalence rates of uncommonly assessed sexual difficulties and sexual dysfunctions is difficult because they have rarely been considered in previous epidemiological research. Nevertheless, empirical research on these uncommonly assessed sexual difficulties and dysfunction is sorely needed. For example, the DSM-5’s female sexual interest=arousal disorder (FSIAD) (APA, 2013) provoked discussion in the literature on desire and arousal dysfunctions in women (e.g., DeRogatis et al., 2010), but few empirical studies have obtained data on the prevalence of responsive desire and subjective arousal (Brotto, Bitzer, Laan, Leiblum, & Luria, 2010). The current study may contribute to this debate by providing empirical data on these uncommonly assessed difficulties and dysfunctions. Spontaneous and responsive desire disorders in women. In DSM-IV-TR, a diagnosis of HSDD was based on ‘‘deficient (or absent) sexual fantasies and desire for sexual activity’’ (APA, 2000, p. 498). However, in the past decade the validity of these diagnostic criteria for HSDD has been a subject of debate; based on international consensus conferences (Basson et al., 2003; Basson et al., 2004), it was proposed that a lack of responsive desire should also be included in diagnostic criteria for HSDD. In these proposals, a diagnosis of HSDD should be considered only when both spontaneous and responsive sexual desire are reduced=absent (Basson et al., 2004). In the current study, 19.3% of women were classified as having ‘‘hypoactive sexual desire’’ difficulty and 13.7% of women were classified as having ‘‘lack of responsive desire’’ difficulty. However, when a diagnosis of desire difficulty required the presence of both a ‘‘lack of spontaneous sexual desire’’ and ‘‘a lack of responsive desire,’’ prevalence rates dropped to 9.1%. Similarly, the prevalence rates of HSDD plus responsive desire dysfunction dropped to 5.8%, while the prevalence rate of HSDD was 10.3% and that of ‘‘lack of responsive desire’’ dysfunction was 9.4%. The sexual dysfunctions subcommittee of the DSM-5 Workgroup on Sexual and Gender Identity Disorders considered the suggestions made by Basson et al. (2003; 2004) to avoid pathologizing women who report a lack of spontaneous sexual desire in the 9

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presence of intact responsive sexual desire, or vice versa, and included both criteria in the diagnostic criteria for FSIAD. However, DSM-5 does not require that both diagnostic criteria be present for a diagnosis of FSIAD to be made (Brotto, 2010a). Lubrication and subjective arousal disorders in women. Another criticism about the DSM-IV-TR (APA, 2000) classification of female sexual disorders (FSDs) concerns the diagnostic criteria for FSAD. It has been shown that genital arousal (vaginal lubrication) and the feeling of being aroused (subjective arousal) do not always correlate highly in women (for a review, see Chivers et al., 2010). Therefore, it has been suggested that there are several subtypes of female sexual arousal disorders in women (Basson et al., 2003; Basson et al., 2004; Brotto et al., 2010). Despite the suggestion that different types of sexual arousal problems (pure genital, pure subjective, or combined) can be differentiated and the assumption that the combined type is the most common clinical presentation, prevalence estimates for these subtypes are still lacking (Brotto et al., 2010). In the present study, about 40% of women who were classified as having difficulty with genital arousal were also classified as having difficulty with subjective arousal. Also, about 40% of women with FSAD also were classified as having a subjective arousal dysfunction. This means that some women had only a genital arousal difficulty=FSAD, and other women had only a subjective arousal difficulty=dysfunction. Our study also included prevalence estimates of both lubrication difficulties and lack of subjective arousal, and these indicated that more women were classified as having a pure genital arousal difficulty=dysfunction (7.9%=4.1%) or a pure subjective arousal difficulty=dysfunction (5%=3.7%) than the combination of both (4.9% sexual difficulty; 2.8% sexual dysfunction). This finding is clearly in contrast to the assumption in clinical practice, where the combination type is thought to be most common (Brotto et al., 2010). The current data suggest DSM-5 should have included three subtypes of female arousal disorders and should include both subjective or genital arousal (and distress) as sufficient criteria to diagnose arousal disorders in women. In the DSM-5, the diagnosis of FSIAD is made based on a polythetic approach, including criteria of genital and nongenital physical sexual arousal (A.6) and subjective arousal (A.4) (Brotto, 2010a). However, in clinical practice a diagnosis of FSIAD does not enable a clinician to differentiate between the three types of sexual arousal disorders (i.e., DSM-5 does not provide subtypes within the diagnosis of FSIAD). In view of the current study’s findings that an equal number of women are classified as having pure genital dysfunctions as pure subjective arousal dysfunctions, and that these are slightly more prevalent than the combined dysfunctions, we believe it is still important to differentiate between these subtypes. 10

Female sexual interest=arousal disorder. The current study is one of the first to provide empirical data on the decision to merge the categories of female sexual desire and arousal disorders in DSM-5 (Brotto, 2010a; Graham, 2010b). Because there is evidence that desire and arousal are not separate constructs (i.e., women find it hard to differentiate between them) (Brotto, Heiman, & Tolman, 2009; Mitchell, Wellings, & Graham, 2012), and there is a high comorbidity between them, desire and arousal disorders in women are merged in the DSM-5 (Brotto, 2010a). In line with the DSM-5 FSIAD diagnosis, the current study revealed that many women with HSDD also can be classified as having sexual arousal dysfunctions, and vice versa. However, despite these high comorbidity rates, in the current study more women were classified as having desire difficulties= dysfunctions alone (14.3% and 8.7%, respectively) than having a combination of desire and arousal difficulties= dysfunctions (11.2% and 6.2%, respectively). Moreover, some women also were classified as having arousal difficulties=arousal dysfunctions only (6.6% and 4.4%, respectively). The fact that in this study many women could be classified as having either a desire disorder alone without an arousal disorder or vice versa is, we believe, an indirect suggestion that when completing a questionnaire about sexual difficulties=dysfunctions some women—or at least some of those with a sexual disorder—are able to refer to sexual desire or sexual arousal as distinct categories. Although the study did not provide data on the DSM-50 s criteria A.5 of FSIAD—‘‘absent=reduced sexual interest=arousal in response to any internal or external sexual=erotic cues (e.g., written, verbal, visual)’’ (APA, 2013, p. 433)—we believe the current findings suggest that DSM-5 runs the risk of not diagnosing some women with FSIAD, although they would be diagnosed with HSDD or FSAD when using DSM-IV-TR (APA, 2000). Therefore, we argue for more empirical research to validate the new DSM-5 category FSIAD and in particular to study to what extent DSM-5 will underdiagnose women who experience problems with sexual desire alone or problems with sexual arousal alone (for an analogous argument, see also Clayton, DeRogatis, Rosen, & Pyke, 2012a, 2012b; DeRogatis et al., 2011). Strengths, Limitations, and Conclusions A clear limitation of the present Internet-based study is that the results are based on a convenience sampling procedure; therefore, we cannot conclude that the sample was representative of the (Flemish) population. Nevertheless, we believe that a strength of the current study is that it was based on a very large sample (N ¼ 35,132) of Flemish heterosexual men and women which probably provides enough variation in the data. Moreover, attempts were made to overcome the disadvantage of this sampling strategy as much as possible.

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PREVALENCE AND DISTRESS IN SEXUAL DIFFICULTIES

For example, we believe that the quality of the data was improved by stringent selection of participants, keeping only those relying on one IP address, resulting in a reduction of the sample with roughly 7,000 cases deleted. The use of a weighting procedure on the data based on gender and age was also done in an attempt to increase the representativeness of the data. Therefore, we believe that although the reported data are not based on a random sample, the prevalence estimates presented here are quite relevant estimates of sexual difficulties and dysfunctions. Furthermore, by including severity of sexual difficulties (and associated prevalence rates), we believe comparison with prevalence rates found in other studies with those presented here will be facilitated. The inclusion of a (multidimensional) measurement of distress enabled comparison of rates of sexual difficulties and clinically significant sexual dysfunctions and supported previous studies that have deemed it crucial to differentiate between sexual difficulties and sexual dysfunctions. Also, the inclusion of uncommonly assessed sexual difficulties and sexual dysfunctions generated new empirical data, especially with regard to sexual desire and sexual arousal dysfunctions in women. Last, we consider it an advantage that being sexually active was not a necessary condition for a person to be included in this study. Experiencing a sexual difficulty or sexual dysfunction could be the reason why people are not sexually active (Christensen et al., 2011). Future research should include non–sexually active participants in population-based studies on sexual difficulties and sexual dysfunctions. Furthermore, researchers should try to distinguish between those individuals who are avoiding sexual activity because of experience of sexual difficulties or dysfunctions versus those who are inactive for other reasons. In addition to the major limitation of the convenience sample, another shortcoming in this study was the time frame used to assess sexual difficulties=dysfunctions, which was the past four weeks. In studies where the duration of sexual problems has been assessed, the prevalence rates of more persistent problems dropped considerably compared with problems experienced only in the past four weeks (e.g., Mercer et al., 2003). Therefore, to ameliorate estimates of prevalence of persistent sexual difficulties=dysfunctions, it would have been useful to have asked participants how long they had been experiencing the sexual difficulty=dysfunction and considered only those participants who had experienced problems for at least several months as having a sexual difficulty=dysfunction. In conclusion, this study clearly confirms once more that the way sexual dysfunctions are defined and measured (e.g., severity, with or without distress) has a profound impact on prevalence rates of sexual dysfunctions found in research. To provide more comparable data, in future research the diagnostic criteria of the DSM should be used in studies on

prevalence rates of sexual dysfunctions. Finally, this study revealed that uncommonly assessed sexual difficulties=dysfunctions seem to be quite common and therefore should also be assessed in future research to provide a more nuanced and=or refined picture of prevalence estimates of sexual problems.

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