The prevalence of sexual problems (SP) and sexual satisfaction and their associations with sex-related perceptions and quality of life (QOL) were investigated by interviewing 3257 and 1568 Chinese adults in Hong Kong by a specially designed computerized telephone-interviewing method. SP was prevalent among male (50.9%) and female (54%) respondents; approximately 50% were dissatisfied with their sexual life. Of respondents, 23.9% of men and 5.9% of women perceived sex as important and 52.5% for men and 33.8% of women reported adequate sexual knowledge. The prevalence of SP ranged from 3.4% (pain) to 29.7% (premature orgasm) for men and 6.9% (anxiety) to 24.7% (lack of interest) for women. Prevalence of erectile and lubrication problems were 9.6 and 23.6%, respectively. Sex-related knowledge, perceived importance of sex, perceived physical health status, sexual satisfaction were predictors of SP. Gender differences and strong cultural influences appear to exist. Moreover, SP and sexual satisfaction were associated with mental health and vitality QOL and overall life satisfaction.
Recent studies have showed that sexual dysfunctions are common in both sexes.1, 2, 3, 4 A study in the US estimated the prevalence of sexual dysfunction (SD) to be 43% among women and 31% among men.5 An analysis of 22 general population surveys conducted in western countries summarized estimates of SD prevalence for men (inability to achieve orgasm: 5%, premature ejaculation: 35%, inhibited sexual excitement: 10–20% and inhibited sexual desire: 1–15%) and for women (inability to achieve orgasm: 5–30% and inhibited sexual desire: 1–35%).6 Similarly, a large-scale international collaboration of multidisciplinary experts reported that 40–45% of adult women and 20–30% of adult men suffer from at least one SD.7 It also reported the following prevalence rates among women: low levels of sexual interest at 17–55%, lubrication difficulties about 8–15%, orgasmic dysfunction at 25% and vaginismus at approximately 6%. The prevalence of erectile dysfunction was reported to be 1–9% among young males under 40 y old and rapidly increased with age to 20–40% among males between the ages of 60–69 y.7
Age, lower education, socioeconomic status, perceived health, diabetes, heart disease and hypertension were found to be important determinants of erectile dysfunction in men.8, 9 SD has also been attributed to other physical, clinical factors and psychological factors.5, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 Research on erectile dysfunction patients indicate that SD has significant adverse effects on both physical and mental health dimensions of quality of life (QOL).20, 21, 22, 23, 24
Sexual dysfunction data for Asian populations are scant and primarily clinic-based.25, 26, 27, 28, 29, 30 Moreover, little is known about the prevailing attitudes and perceptions of sexual problems (SP) or its effects on QOL in Asian populations. Few large-scale, population-based studies on SP have been reported in Chinese population study. The study investigated the prevalence and associated factors of sexual problems and relevant perceptions among Hong Kong Chinese heterosexual adults.
The study population comprised of heterosexual, adult Chinese male and female subjects of age 18–60 y. A random telephone survey was conducted from January to April 2002. Almost 100% of the Hong Kong households have telephones.31 The household member, whose birthday was closest to the day of the interview was invited to participate in the study. All interviews were conducted between 1800 and 2230 hours. Unanswered telephone calls were given at least three attempts before being classified as invalid. A total of 1571 men and 3257 women were interviewed, excluding 55 and 95 homosexual men and women, data obtained for 1516 and 3162 heterosexual men and women were analyzed in the study (Data of homosexual respondents were analyzed in another paper). Verbal informed consent was obtained from the respondents and the ethics approval was obtained from the Survey Ethics Research Committee of the Chinese University of Hong Kong. Participation was voluntary and no compensation was made. The study was sponsored by the Chinese University of Hong Kong.
The interviewer first confirmed that the respondents were Chinese. Some nonsensitive questions (Part I) were then asked in order to establish rapport and facilitate the asking of subsequent more sensitive questions (Part II). In Part II, questions were prerecorded in a computerized phone system (the ‘Dot-line’ service), and respondents only needed to key in their responses. Interviewers were of both genders but the voice asking the prerecorded questions was female. Respondents were connected to the ‘Dot-line’ and the interviewer left the line after connection was made. Respondents were ensured about confidentiality and anonymity. Colloquial Cantonese was used since almost all respondents (94.9% of the population in Hong Kong) are Cantonese.32 Some researchers have suggested that telephone interviewing is a preferred method of collecting sensitive data. This particular method has been validated;31, 33, 34 it reduces reporting bias when compared to the conventional telephone interview method. This method also has been used in a number of other local studies.35, 36, 37, 38 The response rate was approximately 50%.
Questions regarding self-reported SP were adapted from a study conducted in the US, following the Diagnostic and Statistical Manual of Mental Disorders IV classification of SD.5 Respondents were asked whether they had experienced any of the following SP for at least three consecutive months over the past year (yes/no answer): lack of sexual pleasure, inability to have an orgasm, lack of interest in sex, feelings of anxiety, pain, premature orgasm (men only), trouble in erection (men only) and trouble with lubrication (women only).
The respondent's background information and perceptions about sex were also measured (Table 1). QOL data were measured by the Mental Health and Vitality subscales from the Chinese version of the Short Form-36 Health Survey (SF-36), these scales have been validated locally.39
Age- and gender-specific prevalence for individual and overall SP categories were reported and odds ratios (ORs) for gender differences, adjusted for age were derived. Univariate ORs were also derived to identify factors that were associated with sex-related perceptions, individual and overall SP categories as well as whether or not the respondent had at least one sexual problem (SP) and whether he/she felt bothered by having an SP. Univariately significant ORs (P<0.05) were used as candidate variables for the multivariate stepwise logistic regression analyses. All statistical analyses were conducted with SPSS version 11.0.1.
The background characteristics of the study participants are described in Table 1. Approximately 44% of the male and female respondents were of age 40–59 y; approximately 60% of the male and 70% of the female subjects had an educational attainment of secondary school or lower. Over one-half of the male (52.3%) and two-thirds of the female subjects (65%) were married or cohabitating with their partner and about 74 and 45%, respectively, were employed full-time. Around half of the respondents perceived their health to be fair or poor and about 10% of them had been diagnosed with one of the following chronic diseases: diabetes, heart disease or hypertension.
Perceptions related to sex
Men were more likely than women to believe that sexual life is very important to them (23.9 versus 5.9%, P<0.001, Table 1) and to feel that they were adequately knowledgeable about sex (52.5 versus 33.8%, P<0.001, Table 1), but men and women were equally likely to feel satisfied with their sexual life (51.7% of men and 49.5% of women, P=0.166, Table 1).
The univariate and multivariate analyses predicting perceived adequacy of sexual knowledge, perceived importance of sex and satisfaction with sexual life are summarized in Table 2. The multivariate analysis showed that those who were not currently married, sexually nonactive in the past year, divorced or widowed, perceived a fair/poor health status, reported lower life satisfaction, had lower mental health QOL or lower vitality QOL and were less likely than others to feel satisfied with their sexual life (Table 2).
Prevalence of SP
Half of all males (51%, 95% CI: 48.4–53.5%) reported at least one SP (27.9 and 13.1%, respectively, had ≥2 and ≥3 SP). The prevalence of the individual SP ranged from 3.4% (pain) to 29.7% (premature orgasm). Over half of all female respondents (53%, 95% CI: 51.5–55.0%) reported at least one SP (34.5 and 18.7%, respectively, reported ≥2 and ≥3 SP). The female prevalence of the individual SP ranged from 6.9% (anxiety) to 24.7% (lack of interest). In general, the prevalence of SP increased with age (Table 2). Adjusting for age, prevalence of individual SP categories were higher among women than among men (P<0.05, see Table 3). The prevalence of SP among sexually active respondents are put in parentheses in Table 3 and are comparable to those obtained for all respondents (Table 3). In the study sample, 81.0% of the male and 65.1% of the female respondents reported themselves being sexually active in the last 12 months. The age-specific prevalence for being sexually active is shown in Table 3. Male respondents were more likely than female respondents to be sexually active in the last year (OR=0.37, P<0.001, Table 3).
Factors associated with having at least one SP
For males, factors associated with having at least one SP included older age (OR=1.53), having inadequate sex-related knowledge (OR=1.65), having lower overall life satisfaction (OR=1.91) and having lower mental health QOL (OR=1.55). For female subjects, relevant factors include age (OR=1.41), perception that sex is not important (OR=2.01), inadequate sex-related knowledge (OR=1.41), lower overall life satisfaction (OR=1.57), lower mental health (OR=1.78) and lower vitality QOL (OR=1.35) (Table 4). Univariate associations are also reported in Table 4.
Factors associated with individual categories of SP (multivariate analysis)
For men, age, divorced status, having one of the three chronic diseases, fair or poor perceived general health status, inadequate sex-related knowledge and perceived importance of sex, low mental health QOL and lack of vitality QOL were associated with various types of SP (Table 5). For females, multivariate analyses showed that age, marital status, fair/poor perceived health status, inadequate sex-related knowledge, dissatisfaction with sexual life, general life satisfaction, lower mental health QOL and lower vitality QOL were associated with different SP categories (Table 6).
Whether felt much bothered by at least one SP among sexually active respondents
About 21.8 and 23.6% of all male and female respondents, respectively, felt very bothered by at least one of the studied SP; corresponding figures were 25.1 and 30.8% for sexually active male and female respondents, respectively (P>0.05). The age trends were significant for sexually active males but not for sexually active females (Table 3). Among sexually active male respondents, the seven forms of SP were all univariately associated with being much bothered by SP (OR=6.03–13.6). However, the associations were strongest for erectile dysfunction (OR=10.2) and anxiety (OR=13.6) among men, and anxiety (OR=9.31), lack of pleasure (OR=9.65) and lubrication problems (OR=6.58) for female subjects (Table 6).
Among sexually active males who had at least one SP, multivariate analysis revealed that inadequate sexual knowledge (OR=3.45) and anxiety about sexual intercourse (OR=7.49) were associated with being bothered by SP (Table 4), whereas among their female counterparts, being married (OR=1.99), inadequate knowledge of sex (OR=2.03), lubrication problems (OR=2.40), lack of pleasure (OR=2.73) and anxiety (OR=2.91) were associated with being bothered by SP (Table 4).
Approximately one-half of all male and female respondents reported having at least one of the studied SP, out of which about 50% felt much bothered by the SP. The prevalence of SP was substantially higher than the 43% of women and 31% of men living in the US.5 Lack of pleasure was far more prevalent among Hong Kong male (15.4%) and female (25%) subjects as compared to US male (8.4%) and female (5.7%) subjects. (Stringent criteria of having an SP for at least three consecutive months in the last 12 months was used for this study.) Caution, however, should be made when comparisons are made across studies.40
Having at least one SP was significantly associated with lower overall life satisfaction and worse mental health QOL for both genders, and worse vitality QOL in women. Only about half of the respondents were satisfied sexually; sexual satisfaction was also significantly associated with better overall life satisfaction and QOL. Women's mental health QOL, unlike in their male counterparts, was associated with all six of the SP studied. The causal direction is not certain. It is possible that SP are more consequential to women than to men; it is also possible that women's SP were more affected by their mental health status. Analyzing only those with SP, univariately, both men and women who were bothered by SP were more likely than others to have lower overall life satisfaction scores, lower mental health and lower vitality QOL scores. Sexual health and QOL are hence closely interrelated to one another. Perceived physical health was also independently associated with sexual satisfaction and various individual SP. Univariately, chronic physical disease was significantly associated with SP (some individual SP and overall) among men and women. After adjusting for age and other variables, anxiety SP among men is still significantly associated with chronic physical disease. Hence, physical health may also be related to sexual health.
Men were much more likely than women to regard sex as being important to them (24 versus 6%) and to perceive themselves having an adequate level of sexual knowledge (53 versus 34%). Perception about the importance of sex is an independent predictor for having at least one SP for women but not for men. Moreover, several SP were also more common among female than in male subjects. The observed gender differences may be reflecting the traditional, male-dominant Chinese culture that is repressive towards sexual pleasure-seeking in women but not in men. Yet, the absolute percentages of men perceiving sex to be important or having adequate sexual knowledge were still relatively low. The conservative social climate may not be conducive for discussion or promotion of sexual health.
The prevalence of erectile dysfunction of 9.6% is comparable to the approximately 10% prevalence found in western countries.1 Erectile problems were significantly associated with being bothered by SP, mental health QOL and vitality QOL. In fact, it is the only male SP that was associated with mental health QOL (Table 5). It should be noted that potency is often seen as a symbol of manhood.
Women were significantly less interested in sex than men. Relatedly, unlike women, men's perception of the importance of sex did not diminish with age. A large proportion of older, married couples may have a discordant level of interest in sex. Further research on the importance of this disparity is warranted.
Lubrication problems and lack of interest were the two most prevalent SP among women (each affecting about 25% of women). These figures were somewhat higher than the prevalence reported in the West.5 Among sexually active women, those who were married were less likely than others to have pain but were more likely to have lubrication problems, lack of orgasm and lack of interest or pleasure from sex. Married women with SP were also more likely than their nonmarried counterparts to feel bothered by SP. Sex among married women may have become routine.
One half of all respondents felt that their sexual knowledge was inadequate. Education level predicted perceived adequacy of sexual knowledge. Sexual knowledge was an independent predictor of different categories of SP (and having ≥1 SP), sexual satisfaction, QOL as well as whether being bothered by having an SP. It is hence important to promote sex-related knowledge in the general population. Although socioeconomic differences have been shown to be significant predictors of SP in other studies,5 education level was univariately but not multivariately significant in predicting whether or not the respondent had at least one SP and whether the respondent reported being bothered by an SP. It is likely that the educational effects were moderated by other variables such as perceived adequacy of sex-related knowledge.
The study has several limitations. Firstly, SP are self-reported rather than being obtained from clinical assessments, but self-reported data on SP have been used in numerous published studies.2, 5, 9 The results may be subject to reporting bias although a validated data collection method has been used to reduce the bias.33, 41 Telephone surveys may also result in selection bias but the method has been used in many local studies41 as it reduces embarrassment. Living quarters in Hong Kong are typically small and household surveys may not be able to maintain privacy. The Chinese culture, particularly aspects related to sex, is still intact in Hong Kong. Yet, the Hong Kong data may still be quite different from those of mainland China as other cultural aspects still differ substantially. Further studies in other Chinese population are still warranted. Despite these limitations, the study has a relatively large sample size and is one of the few large-scale studies conducted for Chinese populations.
In summary, the prevalence of SP, not being satisfied with sexual life and being bothered by SP were high among both men and women in Hong Kong. These were in turn correlated with several dimensions of life satisfaction and QOL, as well as perceived physical health. Further research should clarify the causal direction between QOL, physical health and sexual health. Gender differences and cultural influences were noticeable and need to be taken into account in promotion of sexual health. The conservative Chinese cultural context does not seem conducive for good sexual health. Sexual knowledge of the general public is largely inadequate but it is an important predictor of sexual well-being. Empowerment and sex education efforts are hence required. Perceptions such as perceived importance of sex were also a significant predictor of SP. Public health efforts to change relevant perceptions and to provide appropriate treatment services are also much warranted.
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Cite this article
Lau, J., Kim, J. & Tsui, HY. Prevalence of male and female sexual problems, perceptions related to sex and association with quality of life in a Chinese population: a population-based study. Int J Impot Res 17, 494–505 (2005). https://doi.org/10.1038/sj.ijir.3901342
- quality of life
- sexual dysfunction
- Hong Kong
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