Prevalence of sexual problems and related help-seeking behaviors ...

Edson Duarte Moreira Junior
Prevalence of sexual problems
Dale Glasser
Djanilson Barbosa dos Santos
TICLE
and related help-seeking behaviors
Clive Gingell
among mature adults in Brazil:
AL AR
n
data from the Global Study
RIGI
of Sexual Attitudes and Behaviors
o
Centro de Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz, and
scientific directorate of Hospital São Rafael, Salvador, Bahia, Brazil
ABSTRACT
InTRoduCTIon
oBJECTIVE
The development of several convenient
Here, our goal is to report data on sexual
CONTEXT AND OBJECTIVE: Relatively lit le is
and effective oral treatments for male erectile
activity, the prevalence of sexual problems and
known about the usual frequency of sexual activ-
dysfunction has contributed to the increasing
related help-seeking behaviors among men and
ity and how older individuals cope with sexual
problems. The objective was to study sexual activ-
level of interest in the sexual functioning of
women in the Brazilian cohort of the Global
ity, prevalence of sexual problems and related
middle-aged and older adults that has been
Study of Sexual Attitudes and Behaviors.
help-seeking behaviors among middle-aged and
seen in recent years. Over the last 10 years or
older men and women in Brazil.
so, a large number of studies have investigated
METHodS
DESIGN AND SETTING: Population survey, by
Fundação Oswaldo Cruz.
the prevalence of sexual problems among
middle-aged and elderly people. These studies
Type of study
METHODS: Interviews were held with 1,199
Brazilians aged 40-80 years (471 men and
have tended to focus mainly on the popula-
Population survey.
728 women). The standardized questionnaire
tions of individual countries in Europe,1-5 the
investigated demographics, general health,
United States of America (USA),6-10 and Cen-
Setting
sexual behavior, attitudes and beliefs.
tral and South America.11-15 The prevalence
A computer-assisted telephone interview
RESULTS: Overall, 92.6% of men and 58.3% of
and correlates of the male sexual disorders
survey, using random-digit dialing as the
women had had sexual intercourse during the
preceding year. More than half of the men and
of erectile dysfunction and early ejaculation
sampling design, was carried out in Brazil
women had done so more than once a week.
have been studied most extensively, while
during 2001 and 2002 (participants were
Early ejaculation (30.3%) was the commonest
fewer investigations have looked specifically
sampled from the five largest cities in Brazil,
male sexual problem, fol owed by inability
to reach orgasm (14.0%), erectile difficulties
at female sexual problems.16,17 Furthermore,
namely, São Paulo, Rio de Janeiro, Salvador,
(13.1%) and lack of sexual interest (11.2%).
relatively little has been reported about the
Belo Horizonte, and Brasília). Respondents
For women, the commonest sexual problems
usual frequency of sexual activity and the
were randomly selected by asking for the man
were lubrication difficulties (23.4%) and lack
of sexual interest (22.7%). Depression was a
value and significance of sexual relation-
or woman in the household aged between 40
significant correlate of sexual problems, for men
ships for older individuals, although the few
and 80 years of age (participants were inter-
and women. More women than men had sought
published studies in this area have concluded
viewed by interviewers of the same gender).
help for sexual problem(s) from a healthcare
that sexual interest and activity persist well
A structured questionnaire requested infor-
professional.
into older age.18-20
mation concerning general health, demograph-
CONCLUSIONS: The findings highlight the
importance of encouraging greater use of avail-
The published literature on the prevalence
ics, relationships, and sexual behavior, attitudes
able healthcare services, including consultation
and correlates of sexual disorders comprises
and beliefs. The subjects were asked if they had
with a medical doctor regarding sexual health.
studies conducted in developed and devel-
engaged in sexual intercourse during the previous
This should not only enable men and women to
oping countries that have employed a wide
12 months, and the presence of sexual dysfunc-
maintain satisfactory sexual function wel into
their later years, but may also result in overall
variety of study designs and definitions. This
tion was assessed by means of two sequential
improvement in the quality of healthcare.
makes it difficult to conduct cross-national
questions. The respondents were first asked
KEY WORDS: Epidemiology. Health surveys. Erec-
comparisons in a scientifically valid manner.
whether they had experienced one or more of the
tile dysfunction. Prevalence. Sex disorders.
Moreover, there are currently no studies that
sexual problems listed in Tables 2a and 2b for a
allow a comparison of sexual behavior or help-
period of at least two months during the previous
seeking patterns for sexual problems across
year, and those who answered ‘Yes’ were then
different countries.
asked whether they had experienced the problem
The Global Study of Sexual Attitudes and
‘occasionally’, ‘sometimes’ or ‘frequently’.
Behaviors (GSSAB) was a population survey
Logistic regression was used to investigate
of 27,500 men and women aged 40 to 80
potential factors associated with selected sexu-
years in 29 countries representing many world
al dysfunction. In these analyses, the presence
regions.21,23 Brazil was one of the countries
of a sexual dysfunction was coded only for
within this study.
those respondents who reported experiencing
Sao Paulo Med J. 2005;123(5):234-41.

---

235
the problem frequently or periodically, while
magazines or on the internet)”, “Talked to
they had not done so, and offered a list of
those who indicated that they experienced the
family member or friend”, “Taken prescrip-
14 possible reasons (from which they were to
problem only occasionally were recorded as
tion drugs/devices or talked to pharmacist”,
check all that applied). The reasons included
indicating no sexual dysfunction.
“Talked to psychiatrist or psychologist or
attitudes and beliefs regarding the sexual
The subjects who reported that they had
marriage counselor”, “Talked to a cleric or
problem and the patient-doctor relationship.
experienced a sexual problem were asked
religious adviser”, “Called a telephone help
All respondents (irrespective of whether they
whether they had sought help from a number
line” and “Other – please specify”. Respon-
reported any sexual problems) were also asked
of possible sources. The options included:
dents could indicate that they had sought
“During a routine office visit or consultation
“Talked to partner”, “Talked to a medical
help from more than one source.
in the past 3 years, has your physician asked
doctor (other than a psychiatrist)”, “Looked
The subjects with sexual problems who
you about possible sexual difficulties without
for information anonymously (in books/
had not consulted a physician were asked why
you bringing it up first?” (Yes/No) and “Do
you think a doctor should routinely ask pa-
tients about their sexual function?” (Yes/No).
Table 1. Selected characteristics of the study population, Brazil, 2001–2002 (per-
The categorization of household income as
centage; age-standardized prevalences)
“low”, “medium” or “high” was based on the
Men
Women
distribution of income in Brazil according
(n = 471)
(n = 728)
to the criteria of the Instituto Brasileiro de
Age group (years)
Geografia e Estatística.24
The prevalence of a specific characteristic
40–49
29.9
30.8
was calculated by dividing the number of cases
50–59
32.1
29.8
by the corresponding population. The denomi-
60–69
22.5
21.7
nator for the calculation of the prevalence of
sexual problem was the number of sexually
70–80
15.5
17.7
active people (i.e. at least one episode of inter-
Relationship status
course during the previous 12 months). The
Married or ongoing partnership
82.6
54.3
prevalence estimates were age-standardized
using the age distribution of the population of
Divorced/separated without sex partner
8.9
13.2
Brazil (by gender when appropriate), and are
Widowed without sex partner
4.7
22.0
given with their confidence intervals.25
Single without sex partner
3.8
10.6
Urban residential setting
93.8
97.4
RESuLTS
Education
Characteristics of
study population
Primary school or less
36.3
47.1
Overall, 8,637 individuals were con-
Secondary/high school
36.5
35.0
tacted, 2,127 of whom were not eligible to
At least some college
27.2
17.9
participate (outside of the age range). Of the
Household income
6,510 eligible individuals, 5,088 refused to
participate when the survey topic was intro-
Low
12.4
23.8
duced, while 223 interrupted the interview.
Medium
78.5
70.8
A total of 1,199 individuals (471 men and
High
9.2
5.4
728 women) completed the survey, thus giv-
ing a response rate of 18.4%. Table 1 presents
Current employment status
data on selected characteristics of the study
Employed
57.3
35.0
sample, standardized for the age distribution
Unemployed
4.9
3.2
of the population of Brazil in the year 2000.
A greater proportion of men (82.6%) than
Retired
37.8
22.9
women (54.3%) were married or in an ongo-
Homemaker
0
38.9
ing partnership (Table 1). More than half of
Religion
the men (57.3%) and about one-third of the
women (35.0%) were employed and 66.5% of
Christian/Jewish
89.4
88.7
men and 54.1% of women reported that they
Atheist
3.3
1.3
were in good or excellent general health.
Other, specified
7.3
10.0
Almost all of the men (92.6%) and more
than half of the women (58.3%) said that
Good to excellent general health*
66.5
54.1
they had had sexual intercourse during the 12
Intercourse in the last 12 months
92.6
58.3
months preceding the interview, and 58.4%
Intercourse more than once a week
65.6
57.2
of men and 26.1% of women engaged in
*Self-reported “good” or “excellent” general health (versus “fair” or “poor”).
sexual intercourse more than once a week.
Sao Paulo Med J. 2005;123(5):234-41.

---

236
Prevalence of
41.3% of men and 29.7% of women had
men (3.8%) and women (6.2%) reported
sexual problems
not sought any help or advice (i.e. no action
seeking help from a member of the clergy or
Early ejaculation was by far the most com-
taken). Patterns of help-seeking behavior
other religious adviser.
mon male sexual problem, and was reported
showed some differences between men and
Factors associated with
by almost one-third (30.3%) of the sexually
women in Brazil. More than twice as many
seeking medical help for
active men (most of who said that they experi-
women (44.0%) as men (21.2%) reported
sexual problems
enced this problem periodically or frequently)
talking to a medical doctor about their sexual
(Table 2). An inability to reach orgasm, erectile
problem(s). However, overall, about half of
A number of physical, socioeconomic
difficulties and a lack of sexual interest were
the women (53.1%) and almost three-quar-
and attitudinal factors that might be associ-
each experienced by approximately 11 to 14%
ters of the men (72.1%) had sought no help
ated with seeking medical help for sexual
of sexually active men, while a lack of pleasure
from a health professional. Talking to their
problems were investigated using logistic
in sex (7.8%) and pain during sexual inter-
partner was a similarly popular course of
regression and the results (odds ratios) for
course (4.5%) were much less common.
action among men and women (42.3% and
men and women in Brazil are summarized
Lubrication difficulties (23.4%) were the
41.4%, respectively), while women were more
in Table 5. Women with a high or medium
most common sexual problem reported by
likely than men to talk to a friend or family
household income were more likely than
sexually active women in Brazil, closely fol-
member (25.3% versus 10.6%) and to seek
those with a low income to seek medical
lowed by lack of sexual interest (22.7%) and
information from an anonymous source such
help for sexual problems (odds ratio 2.18;
an inability to reach orgasm (22.0%), while a
as books and magazines, telephone help-lines
p < 0.05), but income was not a significant
lack of pleasure in sex and pain during sexual
or the internet (18.3% versus 12.0%). Few
factor for men. None of the male sexual
intercourse were experienced by 20.3% and
18.0% of sexually active women, respectively
Table 2. Age-standardized prevalence of sexual problems by gender in Brazil,
(Table 2). The majority of the women who
according to severity, 2001–2002 (percentage and 95% confidence interval)
reported each of these problems said that they
experienced it frequently or periodically.
Men (n = 471)
Women (n = 728)
Physical, health, demographic and so-
Early ejaculation
30.3 (26.0, 34.8)
cioeconomic factors associated with three
Occasional
4.6 (2.8, 7.0)
selected sexual dysfunctions in men and
Periodic
14.4 (11.3, 18.1)
women are summarized in Table 3 (odds
Frequent
11.2 (8.4, 14.6)
ratios from logistic regression). Older age
(age 60 to 80 years compared with the
Lubrication difficulties
23.4 (19.4, 27.7)
referent age of 40 to 49 years) was a sig-
Occasional
3.5 (2.0, 5.8)
nificant correlate of lubrication difficulties
Periodic
13.9 (10.8, 17.6)
in women (odds ratio 2.10; p < 0.05). Of
Frequent
5.9 (3.9, 8.6)
the various factors investigated and listed
Erectile difficulties
13.1 (10.1, 16.6)
in Table 3, three medical conditions were
Occasional
4.1 (2.5, 6.4)
significantly associated with an increased
Periodic
6.2 (4.1, 8.9)
likelihood of one or more types of male
Frequent
2.8 (1.4, 4.8)
sexual dysfunction (i.e. a sexual problem
Lack of sexual interest
11.2 (8.4, 14.6)
22.7 (18.8, 27.0)
that was experienced periodically or fre-
quently), while only one of the factors was
Occasional
2.8 (1.4, 4.8)
3.8 (2.2, 6.1)
a significant correlate of sexual dysfunction
Periodic
6.0 (3.9, 8.6)
11.8 (8.9, 15.3)
in women. A diagnosis of depression was a
Frequent
2.5 (1.3, 4.5)
7.1 (4.8, 10.0)
significant correlate of erectile difficulties
Inability to reach orgasm
14.0 (10.9, 17.6)
22.0 (18.1, 26.2)
(odds ratio 3.02; p < 0.01), and early ejacula-
Occasional
4.4 (2.6, 6.7)
4.5 (2.6, 6.7)
tion (odds ratio 1.98; p < 0.05) among men,
Periodic
7.1 (4.9, 9.9)
13.0 (9.9, 16.6)
and of a lack of sexual interest in both men
Frequent
2.5 (1.3, 4.5)
4.5 (2.6, 6.7)
(odds ratio 4.37; p < 0.001) and women
Sex not pleasurable
7.8 (5.5, 10.7)
20.3 (16.6, 24.5)
(odds ratio 1.68; p < 0.05). Diagnoses of
Occasional
3.0 (1.6, 5.0)
4.0 (2.4, 6.4)
hypertension and prostate disease were signifi-
cant correlates of early ejaculation (odds ratio
Periodic
3.2 (1.8, 5.3)
10.4 (7.7, 13.7)
1.95; p < 0.05) and a lack of sexual interest
Frequent
1.6 (0.6, 3.3)
5.9 (3.9, 8.6)
(odds ratio 2.77; p < 0.05), respectively.
Pain during sex
4.6 (2.8, 7.0)
18.0 (14.4, 22.0)
Occasional
1.4 (0.5, 3.0)
2.1 (1.0, 4.0)
Help-seeking behavior
Periodic
1.8 (0.8, 3.6)
10.6 (7.9, 14.0)
The prevalence of selected help-seeking
Frequent
1.4 (0.5, 3.0)
5.2 (3.3, 7.8)
behavior for sexual problems in Brazil is
Note: based on reports from sexually active respondents (those who had had intercourse within the past year). Percentage in the
summarized in Table 4. Of the respondents
first row of each panel indicates the overall prevalence of the sexual problem, defined as experiencing the problem for a period
who were sexually active and reported
of two months or more. The difference between the overall prevalence and the sum of the three levels of severity of each sexual
problem indicates the proportion that failed to specify the level of severity. All prevalence estimates are adjusted according to
experiencing at least one sexual problem,
the age distribution of the total of sexually active men and women in this sample from Brazil.
Sao Paulo Med J. 2005;123(5):234-41.

---

237
Table 3. Factors associated with sexual dysfunction by gender, Brazil, 2001–2002
Men
Women
Early
Lack of
Erectile
Inability to
Lack of
Lubrication
ejaculation
sexual interest
difficulties
reach orgasm
sexual interest
difficulties
Age
40–49
Referent
Referent
Referent
Referent
Referent
Referent
50–59
0.70 (0.40, 1.24)
1.10 (0.40, 2.98)
0.67 (0.26, 1.73)
0.69 (0.40, 1.19)
0.68 (0.40, 1.18)
0.92 (0.54, 1.58)
60–80
0.60 (0.33, 1.09)
1.56 (0.59, 4.14)
1.04 (0.42, 2.55)
0.44 (0.24, 1.13)
0.73 (0.42, 1.27)
2.10 (1.13, 3.91)*
Level of physical activity
average and above
Referent
Referent
Referent
Referent
Referent
Referent
lower than average
1.20 (0.66, 2.16)
0.77 (0.29, 2.07)
0.90 (0.37, 2.23)
0.85 (0.46, 1.57)
1.49 (0.88, 2.50)
0.99 (0.54, 1.80)
Smoking
never
Referent
Referent
Referent
Referent
Referent
Referent
currently + smoked before
1.13 (0.70, 1.84)
1.21 (0.57, 2.59)
1.37 (0.65, 2.88)
0.72 (0.45, 1.14)
0.84 (0.54, 1.31)
0.71 (0.45, 1.14)
Education
primary school or less
Referent
Referent
Referent
Referent
Referent
Referent
secondary/some college
0.70 (0.43, 1.12)
0.83 (0.40, 1.76)
0.74 (0.37, 1.74)
1.06 (0.65, 1.72)
1.44 (0.90, 2.31)
1.11 (0.68, 1.82)
Household income
low
Referent
Referent
Referent
Referent
Referent
Referent
medium and high
0.69 (0.37, 1.32)
0.78 (0.29, 2.10)
1.34 (0.47, 3.84)
0.88 (0.51, 1.52)
0.81 (0.48, 1.35)
1.28 (0.71, 2.32)
Medical Conditions
Depression diagnosed
1.98 (1.04, 3.78)*
4.37 (1.93, 9.86)‡
3.02 (1.35, 6.73)†
1.50 (0.91, 2.46)
1.68 (1.06, 2.67)*
1.51 (0.92, 2.50)
Hypertension diagnosed
1.95 (1.17, 3.25)*
0.52 (0.21, 1.26)
1.81 (0.86, 3.79)
1.55 (0.94, 2.57)
1.00 (0.61, 1.63)
0.90 (0.53, 1.53)
Diabetes diagnosed
1.13 (0.50, 2.60)
1.53 (0.50, 4.73)
2.15 (0.81, 5.65)
1.23 (0.55, 2.75)
1.00 (0.45, 2.19)
1.00 (0.42, 2.46)
Heart disease
0.98 (0.51, 1.90)
1.79 (0.72, 4.46)
1.66 (0.72, 3.81)
0.98 (0.49, 1.99)
1.73 (0.94, 3.21)
1.37 (0.67, 2.81)
Prostate disease
1.58 (0.74, 3.37)
2.77 (1.10, 6.92)*
1.79 (0.68, 4.70)
Note: In the odds ratios from logistic regression (and 95% confidence intervals) of these analyses, the presence of a sexual dysfunction included only those respondents who reported having
experienced the problem “sometimes” or “frequently” (i.e. those who indicated “occasionally” were recorded as indicating no sexual problem). Based on reports from sexually active subjects.
*p < 0.05; †p < 0.01; ‡p < 0.001.
Table 4. Prevalence of selected help seeking behaviors for sexual problems by gender, Brazil, 2001–2002

% (95% confidence interval)
Men
Talked to partner
42.3 (35.5, 49.3)
Talked to medical doctor
21.2 (15.8, 27.3)
Taken drugs/used devices or talked to pharmacist
18.8 (13.7, 24.7)
Looked for information anonymously (in books/magazines or via telephone help-line/internet)
12.0 (7.9, 17.2)
Talked to family member/friend
10.6 (6.7, 15.6)
Talked to psychiatrist, psychologist or marriage counselor
6.7 (3.7, 11.0)
Talked to a cleric or religious adviser
3.8 (1.7, 7.4)
Sought no help from a health professional
72.1 (65.5, 78.1)
No action taken
41.3 (34.6, 48.4)
Women
Talked to medical doctor
44.0 (38.0, 50.1)
Talked to partner
41.4 (35.5, 47.5)
Talked to family member/friend
25.3 (20.2, 30.9)
Taken drugs/used devices or talked to pharmacist
22.7 (17.9, 28.1)
Looked for information anonymously (in books/magazines or via telephone help-line/internet)
18.3 (13.9, 23.4)
Talked to psychiatrist, psychologist or marriage counselor
8.4 (5.4, 12.4)
Talked to a cleric or religious adviser
6.2 (3.7, 9.8)
Sought no help from a health professional
53.1 (47.0, 59.2)
No action taken
29.7 (24.5, 35.3)
Note: based on reports from respondents complaining of at least one sexual problem. All prevalences are adjusted according to the age distribution of the total of sexually active men and women
in this sample from Brazil.
Sao Paulo Med J. 2005;123(5):234-41.

---

238
problems investigated were significantly
Attitudes and beliefs about
sible sexual difficulties during a routine visit in
associated with seeking medical help, but
diagnosis and treatment of
the past 3 years (13.6% of men and 19.8% of
among women lubrication difficulty was
sexual problems
women) but more than three-quarters of men
a significant correlate of seeking medical
By far the most common reason cited by
(85.4%) and women (76.9%) thought that
help (odds ratio 2.66; p < 0.01). Having
men and women in Brazil for not consulting a
a doctor should routinely ask patients about
been asked by a doctor about possible sexual
doctor about a sexual problem was a belief that
their sexual function.
difficulties during a routine visit in the past
it is a normal part of aging, or being comfort-
three years was a significant correlate of seek-
able as he/she is (81.7% of men and 85.6%
dISCuSSIon
ing medical help for sexual problems for both
of women) (Table 6). However, thinking the
The Global Study of Sexual Attitudes
men (odds ratio 4.72; p < 0.01) and women
problem was not very serious or waiting for
and Behaviors has obtained population-level
(odds ratio 1.92; p < 0.05) in Brazil. Sexual
it to go away (59.1% of men and 69.9% of
data on sexual attitudes and behaviors from
attitudes and beliefs that were significantly
women); feelings of discomfort or embarrass-
middle-aged and older adults in 29 countries
associated with seeking medical help for
ment about talking to a doctor (52.4% of men
in a manner that allows direct comparisons
sexual problems were: among women,
and 60.8% of women); and thinking it was not
of the results from different countries and
thinking that a doctor should routinely
a medical problem or that a doctor could not
regions. The large, cross-national sample and
ask patients about sexual problems (odds
do much to help (57.9% of men and 58.8%
the use of a common method of data collection
ratio 2.44; p < 0.05); and among men, be-
of women), were all cited by more than half
represent two major strengths of this study.
ing somewhat or very dissatisfied with their
of all respondents (Table 6). Lack of access to
Here, we have focused specifically on the sex-
sexual function (odds ratio 3.16; p < 0.05)
or affordability of medical care was also cited
ual activity, prevalence of sexual problems and
and believing that sex is an extremely or
as a reason by about half of the men (54.9%)
associated help-seeking behavior among men
very important part of life (odds ratio 2.79;
and women (46.4%). Few respondents in
and women in Brazil. The standardized, struc-
p < 0.05).
Brazil had been asked by a doctor about pos-
tured questionnaire was administered using
Table 5. Factors associated with seeking medical help for sexual problems by gender, Brazil, 2001–2002

Men
Women
Age (years)
40–49
Reference
Reference
50–59
1.48 (0.51, 4.27)
1.12 (0.58, 2.16)
60–69
2.18 (0.70, 6.72)
0.93 (0.41, 2.08)
70–80
2.53 (0.72, 8.94)
0.46 (0.13, 1.65)
Education
Primary school or less
Reference
Reference
Secondary/high school
1.60 (0.57, 4.49)
1.46 (0.76, 2.80)
At least some college
1.74 (0.55, 5.94)
1.86 (0.83, 4.17)
High/medium household income (versus low)
1.00 (0.29, 3.51)
2.18 (1.1, 4.72)*
Sexual problems
Erectile difficulties
1.37 (0.60, 3.16)
Early ejaculation
0.54 (0.22, 1.30)
Lack of sexual interest
1.17 (0.49, 2.82)
0.69 (0.38, 1.25)
Inability to reach orgasm
1.00 (0.56, 180)
Lubrication difficulties
2.66 (1.48, 4.79)†
General sexual Attitudes
Have been asked by a doctor about possible sexual difficulties in a routine visit in the past three years
4.72 (1.72, 12.98)†
1.92 (1.09, 3.70)*
Think a doctor should routinely ask patients about sexual function
0.93 (0.27, 3.27)
2.44 (1.05, 5.67)*
Very/somewhat dissatisfied with sexual function
3.16 (1.1, 9.89)*
1.77 (0.89, 3.54)
Belief that decreased ability to perform sexually would significantly affect self-esteem
1.10 (0.47, 2.59)
0.88 (0.49, 1.59)
Belief that sex is a extremely/very important part of overall life
2.79 (1.10, 7.11)*
0.91 (0.30, 2.78)
Think it is OK to use medical treatment for sexual problems
1.08 (0.35, 3.33)
0.71 (0.31, 1.63)
Think that older people no longer want/have sex
1.12 (0.48, 2.65)
0.61 (0.34, 1.11)
Belief in religion guiding sex
0.79 (0.33, 1.90)
1.06 (0.60, 1.86)
Note: odds ratios from logistic regression (and 95% confidence intervals). Based on reports from respondents complaining of at least one sexual problem. *p < 0.05; †p < 0.01
Sao Paulo Med J. 2005;123(5):234-41.

---

239
Table 6. Attitudes, behaviors and beliefs about diagnosis of and treatment for sexual problem by gender, Brazil, 2001–2002

% (95% confidence interval)
Men
Reasons for not consulting a doctor about the sexual problem experienced:*
Normal with aging/I am comfortable the way I am
81.7 (74.9, 87.3)
Did not think it was very serious/Waiting to see if problem goes away
59.1 (51.2, 66.7)
Doctor cannot do much/Do not think it is a medical problem
57.9 (50.0, 65.6)
Do not have a regular physician/Doctor is expensive
54.9 (46.9, 62.6)
Not comfortable talking to a MD/MD is a close friend/MD is the wrong gender
52.4 (44.5, 60.3)
Doctor uneasy to talk about sex
25.6 (19.1, 33.0)
Have been asked by a doctor about possible sexual difficulties in a routine visit in the past three years†
13.6 (10.6, 17.0)
Think a doctor should routinely ask patients about their sexual function†
85.4 (81.8, 88.4)
Women
Reasons for not consulting a doctor about the sexual problem experienced:*
Normal with aging/I am comfortable the way I am
85.6 (79.0, 90.8)
Did not think it was very serious/Waiting to see if problem goes away
69.9 (62.0, 77.0)
Not comfortable talking to a MD/MD is a close friend/MD is the wrong gender
60.8 (52.6, 68.6)
Doctor cannot do much/Do not think it is a medical problem
58.8 (50.6, 66.7)
Do not have a regular physician/Doctor is expensive
46.4 (38.3, 54.6)
Doctor uneasy to talk about sex
22.2 (15.9, 29.6)
Have been asked by a doctor about possible sexual difficulties in a routine visit in the past three years†
19.8 (16.9, 22.9)
Think a doctor should routinely ask patients about their sexual function†
76.9 (73.7, 79.9)
*Based on reports from respondents complaining of at least one sexual problem who have not consulted a doctor. †Based on all respondents. All prevalences are adjusted according to the age
distribution of the total of sexually active men and women in this sample from Brazil. MD = medical doctor.
computer-assisted telephone interviews. This
standardized prevalence of erectile difficulties
were significant correlates of sexual problems
method was chosen in preference to face-to-
was 13.8% (9.8% experienced the problem
among Brazilian women in the GSSAB. Co-
face interviews to avoid causing respondents
frequently or periodically).
morbidity between erectile dysfunction and
undue embarrassment when talking about
The overall response rate in Brazil (18.4%)
depression is known to exist but the precise
private and sensitive issues, and to minimize
was low, but the prevalence of a number of
nature of the relationship between these condi-
the likelihood that they might feel obliged to
self-reported health conditions, including hy-
tions is not clear.33 While it is possible that the
give “socially desirable” answers.26
pertension, diabetes and smoking in GSSAB
distress of erectile dysfunction may contribute
Only sexual problems that were experi-
was comparable with published values.28-31
to the development of depressive illness, it is
enced periodically or frequently (i.e. those that
This suggests that refusal to participate in
also possible that depressive illness may lead to
persisted with moderate to higher frequency)
this study was most probably due simply to
erectile difficulties. Moreover, it is important
were considered to be “dysfunctions”.27 This is
an unwillingness to undergo a telephone inter-
that the possible role of antidepressant treat-
essentially equivalent to using two sequential
view and the modest response rate is therefore
ments is considered when investigating the
screening tests, and minimizes the risk of false
unlikely to have introduced a bias in the esti-
copresence of depression and sexual dysfunc-
positive responses. It is likely, therefore, that
mates of the prevalence of sexual behaviors and
tion. Sexual dysfunction is a well-recognized
the prevalence of sexual dysfunction may be
problems. It also appears to indicate that the
side effect of antidepressant therapy. However,
under-reported in the Global Study of Sexual
study population was broadly representative
different agents may be associated with dif-
Attitudes and Behaviors, in comparison with
of the Brazilian population. This assumption
ferent rates of dysfunction.34-36 Selective sero-
studies that used more sensitive, but less
is further supported by the observation that
tonin reuptake inhibitors (SSRIs) have been
specific, methods. Published studies on the
the prevalence of erectile difficulties among
reported to be associated with particularly
prevalence of male erectile dysfunction in
men in the Brazilian cohort of the GSSAB
high rates of sexual dysfunction and, while
Brazil have highlighted the need to consider
was comparable to what has been reported in
men report higher rates of sexual side effects
the severity or frequency of a sexual dysfunc-
published studies, which have focused on the
from SSRIs than do women, women seem to
tion when comparing reports from apparently
prevalence of moderate or severe erectile dys-
experience more severe dysfunction with these
similar study samples. Two population-based
function among Brazilian men aged between
agents.35,37 A significant association between
surveys conducted in Brazil, one in the north-
40 and 70 years.13,14,32
depression and erectile dysfunction among
east13 and the other in the southeast,14 reported
A diagnosis of depression was a significant
men in Brazil has been reported previously.12-14
a prevalence of moderate or complete erectile
correlate of a lack of sexual interest for both
However, the data from GSSAB indicate that
dysfunction of 14.4% and 12.0%, respectively,
genders, and of erectile difficulties and early
depression is also associated with other male
among Brazilian men aged 40 to 70 years.
ejaculation among men in the GSSAB Brazil-
sexual problems, namely early ejaculation and
Likewise, in a national survey in Brazil, the
ian cohort. A lack of sexual interest was also
a lack of sexual interest. Despite the correlation
prevalence of moderate or complete erectile
significantly associated with prostate disease
between sexual problems and depression, the
dysfunction was 14.7%.12 These estimates are
and early ejaculation with a diagnosis of hy-
relationship is most probably bi-directional,
similar to what was observed in the GSSAB
pertension. Interestingly, none of the reported
i.e. sexual problems may follow depression,
Brazilian cohort, in which the overall age-
medical conditions, apart from depression,
while depression may be a consequence of
Sao Paulo Med J. 2005;123(5):234-41.

---

240
sexual dysfunction. We cannot discern the
physician-patient relationship and greater
of socioeconomic circumstances on health
causal direction in these cross-sectional data.
professional satisfaction.
has demonstrated that, among a representative
The association between depression and sexual
Socioeconomic factors also influence
sample of the Brazilian population aged 65 years
dysfunction warrants further investigation
patterns of help-seeking behavior for sexual
or older, lower income was associated with
because depression is highly prevalent in
problems among mature men and women
worse health and physical functioning, and
Brazil and other Latin American countries,
in Brazil. Our findings indicate that women
less frequent use of medical services.41
possibly due at least in part to social factors
with a medium or high household income
such as violence that are especially present
were significantly more likely to seek help
ConCLuSIonS
in medium and large cities.38 (For logistical
than women from low-income households.
We conclude that, although middle-
reasons, the Brazilian sample in GSSAB was
Furthermore, a lack of access to or afford-
aged and elderly men and women in Brazil
drawn primarily from urban areas.)
ability of medical care was cited by about
continue to show sexual interest and activ-
The GSSAB data indicate that feeling that
one-half of all respondents, both men and
ity, a number of sexual problems are highly
the problem is not severe, or not being bothered
women, as a reason for not seeking medical
prevalent. Only a minority of the men and
by the problem, may be deterring men and
help for sexual problems. A recent cross-
women who experience sexual difficulties
women in Brazil from discussing their sexual
sectional study performed in Rio Grande
seek medical help: this may be partly because
difficulties with their doctor. Furthermore, it
do Sul, Brazil, showed that only 37% of the
they do not perceive such problems as poten-
appears that doctors in Brazil rarely ask patients
study sample had a regular doctor and that
tially treatable medical conditions, or because
about their sexual health during a routine con-
this was directly associated with income.40
they do not have access to or cannot afford
sultation, even though the vast majority of men
The authors also found that individuals with
medical care. The findings from GSSAB
and women would appreciate this and it would
a regular physician tended to have better
highlight the importance of encouraging
appear to encourage medical help-seeking for
access to a range of health services and they
greater use of the available healthcare services,
sexual problems. Untreated sexual problems
recommended encouraging people to consult
including consultation with a medical doctor
can greatly impair a patient’s enjoyment of their
with a regular doctor as a means of improv-
on matters of sexual health. This should not
sexual life and it is important that physicians,
ing the quality of and access to healthcare
only enable men and women to maintain
especially primary care physicians, ask patients
services, particularly among the poorest
satisfactory sexual function well into their
about possible sexual difficulties during routine
individuals. Improving the care available to
later years, but may also result in an overall
visits.39 This should result in improved sexual
older adults with low income may be espe-
improvement in the quality of healthcare,
functioning for the patient and an enhanced
cially important, as a study of the influence
particularly among poorer individuals.
REFEREnCES
1. Giuliano F, Chevret-Measson M, Tsatsaris A, Reitz C, Murino
7. Panser LA, Rhodes T, Girman CJ, et al. Sexual
S
function
exual
of
function men
of men
14. Moreira ED Jr, Bestane WJ, Bartolo EB, Fittipaldi JA. Prevalence
M, Thonneau P. Prevalence of erectile dysfunction in France:
ages 40 to 79 years: the Olmsted County Study of Urinary
and determinants of erectile dysfunction in Santos, southeastern
results of an epidemiological survey of a representative sample
Symptoms and Health Status Among Men. JJ Am
Am Geriatr
Geriatr Soc.
Soc.
Brazil. Sao
S
Paulo
ao P
Med
aulo M
J. 2002;120(2):49-54.
ed J. 2002;120(2):49-54.
of 1004 men. Eur Urol. 2002;42(4):382-9.
1995;43(10):1107–11.
15. Nolazco C, Bellora O, Lopez M, et al. Prevalence off
2. Martin-Morales A, Sanchez-Cruz JJ, Saenz de Tejada I, Rodri-
8. Laumann EO, Paik A, Rosen RC. Sexual dysfunctionn
sexual dysfunctions in Argentina. Int J Impot Res.
guez-Vela L, Jimenez-Cruz JF, Burgos-Rodriguez R. Prevalence
in the United States: prevalence and predictors. JAMA.
2004;16(1):69-72.
and independent risk factors for erectile dysfunction in Spain:
1999;281(6):537-44.
16. Osborn M, Hawton K, Gath D. Sexual dysfunction among
results of the Epidemiologia de la Disfuncion Erectil Masculina
9. Ansong KS, Lewis C, Jenkins P, Bell J. Epidemiology of erectile
middle aged women in the community. Br Med J (Clin Res
Study. J Urol. 2001;166(2):569-74; discussion 574-5.
dysfunction: a community-based study in rural New York State.
Ed). 1988;296(6627):959-62.
3. Blanker MH, Bosch JL, Groeneveld FP, et al. Erectile and
Ann Epidemiol. 2000;10(5):293-6.
17. Barlow DH, Cardozo LD, Francis RM, et al. Urogenital age-
ejaculatory dysfunction in a community-based sample of men
10. Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Glasser
ing and its effect on sexual health in older British women. Br J
50 to 78 years old: prevalence, concern, and relation to sexual
DB, Rimm EB. Sexual
S
function
exual
in
function men
in
older
men
than
older
50
than
y
50 ears
y
of
ears of
Obstet Gynecol. 1997;104(1):87-91.
activity. Urology. 2001;57(4):763-8.
age: results from the health professionals follow-up study. Ann
18. Schiavi RC, Rehman J. Sexuality and aging. Ur
U ol
rol Clin
Clin Nor
N th
th
4. Helgason AR, Adolfsson J, Dickman P, et al. Sexual desire,
Intern Med. 2003;139(3):161-8.
Am. 1995;22(4):711-26.
erection, orgasm and ejaculatory functions and their importance
11. Ugarte y Romano F, Barroso AJ. Prevalencia de disfunción eréctil
19. Matthias RE, Lubben JE, Atchison KA, Schweitzer SO. Sexual
Sexual
to elderly Swedish men: a population-based study. Age Ageing.
en México y factores de riesgo asociados. Rev
Rev Mex
Mex Ur
U ologia.
rologia.
activity and satisfaction among very old adults: results from a
1996;25(4):285-91.
2001;61(2):63-76.
community-dwelling Medicare population survey. Gerontolo-
5. Dunn KM, Croft PR, Hackett GI. Sexual problems: a study of
12. Moreira ED Jr, Abdo CH, Torres EB, Lisboa Lobo CF, Fittipaldi
gist. 1997;37(1):6-14.
the prevalence and need for care in the general population. Fam
JA. Pr
P e
r v
e a
v l
a e
l n
e c
n e
c a
n
a d
n c
o
c r
o r
r e
r l
e a
l t
a e
t s
e o
f
o e
r
e e
r c
e t
c itlie
l d
y
d s
y f
s u
f n
u c
n t
c ito
i n
o :
n r e
r s
e u
s l
u tls
t o
f
o t h
t e
he
20. Gott M, Hinchliff S. How important is sex in later life? The
Pract. 1998;15(6):519-24.
Brazilian study of sexual behavior. Urology. 2001;58(4):583-8.
views of older people. Soc
S
Sci Med.
oc Sci M
2003;56(8):1617–28.
ed. 2003;56(8):1617–28.
6. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ,
13. Moreira ED Jr, Lisboa Lobo CF, Villa M, Nicolosi A, Glasser
21. Laumann EO, Nicolosi A, Glasser DB, et al. Sexual
Sexual problems
problems
McKinlay JB. Impotence and its medical and psychosocial
DB. Prevalence and correlates of erectile dysfunction in Salvador,
among women and men aged 40 to 80 y: prevalence and cor-
correlates: results of the Massachusetts Male Aging Study. JJ
northeastern Brazil: a population-based study. Int J Impot Res.
relates identified in the Global Study of Sexual Attitudes and
Urol. 1994;151(1):54-61.
2002;14(Suppl 2):S3-9.
Behaviors. Int J Impot Res. 2005;17(1):39-57.
Sao Paulo Med J. 2005;123(5):234-41.

---

241
22. Nicolosi A, Laumann EO, Glasser DB, et al. Sexual behaviour
31. Ala L, Gil G, Gurgel R, Cuevas L. Evidence for affluence-related
41. Lima-Costa MF, Barreto S, Giatti L, Uchôa E. Desigualdade
and sexual dysfunctions after age 40: the global study of sexual
hypertension in urban Brazil. J H
u
H m
u H
y
H p
y e
p r
e t
r e
t n
e s
n .s 2
0
2 0
0 4
0 ;
4 18
1 (
8 1
( 1
1 )
1 7
) 7
7 5
7 -
5 9
- .
9
social e saúde entre idosos brasileiros: um estudo baseado na
attitudes and behaviors. Urology. 2004;64(5):991–7.
32. Nicolosi A, Moreira ED Jr, Shirai M, Bin Mohd Tambi MI,
Pesquisa Nacional por Amostra de Domicílios. �S
� o
S c
o i
c o
i e
o c
e o
c n
o o
n m
o i
m c
ic
23. Moreira ED Jr, Brock G, Glasser DB, et al. Help-seeking be-
Glasser DB. Epidemiology of erectile dysfunction in fourr
circumstances and health among the brazilian elderly: a study
haviour for sexual problems: the global study of sexual attitudes
countries: cross-national study of the prevalence and correlates
using data from a National Household Survey]. Cad Saúde
and behaviors. Int
I J Clin Pract.
nt J Clin P
2005;59(1):6-16.
ract. 2005;59(1):6-16.
of erectile dysfunction. Urology. 2003;61(1):201-6.
Pública. 2003;19(3):745-57.
24. Instituto Brasileiro de Geografia e Estatística. Pesquisa de
33. Seidman SN. Exploring the relationship between depression
orçamentos familiares - POF 2002-2003. Disponível em URL:
and erectile dysfunction in aging men. J Clin Psychiatry.
http://www.ibge.gov.br/home/estatistica/populacao/condica-
2002;63(Suppl 5):5-12; discussion 23-5.
odevida/pof/2002/default.shtm. Acessado em: 2005 (Aug 19).
34. Gregorian RS, Golden KA, Bahce A, Goodman C, Kwong WJ,
25. Gardner MJ, Altman DG. Confidence intervals rather than P
Khan ZM. Antidepressant-induced sexual dysfunction. Ann
values: estimation rather than hypothesis testing. Br Med J (Clin
Pharmacother. 2002;36(10):1577–89.
Res. Ed). 1986;292(6522):746-50.
35. Clayton AH, Pradko JF, Croft HA, et al. Prevalence of sexual
26. Analysis of sexual behaviour in France (ACSF). A comparison
dysfunction among newer antidepressants. J Clin Psychiatry.
between two modes of investigation: telephone survey and face-
2002;63(4):357-66.
to-face survey. ASCF principal investigators and their associates.
36. Montgomery SA, Baldwin DS, Riley A. Antidepressant
Acknowledgement: The authors acknowledge the contribu-
AIDS. 1992;6(3):315-23.
medications: a review of the evidence for drug-induced sexual
tion of their colleagues on the study’s international advisory
board: Gerald Brock (Canada), Jacques Buvat (France),
27. Moynihan R. The making of a disease: female sexual dysfunc-
dysfunction. J Affect Disord. 2002;69(1-3):119-40.
Uwe Hartmann (Germany), Sae-Chul Kim (Korea), Rosie
tion. BMJ. 2003;326(7379):45-7.
BMJ. 2003;326(7379):45-7.
37. Hensley PL, Nurnberg HG. SSRI sexual dysfunction: a female
King (Australia), Edward Laumann (USA), Bernard Levinson
28. Lima-Costa MF, Barreto SM, Uchoa E, Firmo JO, Vidigal PG,
perspective. J Sex Marital Ther. 2002;28(Suppl 1):143-53.
(South Africa), Ken Marumo (Japan), Alfredo Nicolosi (Italy)
Guerra HL. The
The Bambui
Bambui Health
Health and
and Aging
Aging Study
Study (BHAS):
(BHAS):
38. Jorge MR. Depression in Brazil and other Latin American
and Ferruh Simsek (Turkey).
prevalence of risk factors and use of preventive health care
countries. Seishin Shinkeigaku Zasshi. 2003;105(1):9-16.
Sources of funding: The Global Study of Sexual At itudes and
Behaviors was funded by Pfizer, Inc.
services. Rev Panam Salud Publica. 2001;9(4):219–27.
39. Sadovsky R. Integrating erectile dysfunction treatment into pri-
Conflicts of interest: Edson Duarte Moreira Junior is a con-
29. Guimaraes AC. Hypertension in Brazil. J Hum Hypertens.
mary care practice. Am J Med. 2000;109(Suppl 9A):22S–8S;
sultant for Pfizer, Inc.; Dale Glasser is an employee of Pfizer,
2002;16(Suppl 1):S7–S10.
discussion 29S-30S.
Inc. and owns Pfizer stock; Djanilson Barbosa dos Santos
30. Torquato MT, Montenegro Junior RM, Viana LA, et al.
40. Mendoza-Sassi R, Béria JU. Pre
P valence of having a regularr
has no conflict of interest; Clive Gingell is a consultant for
Prevalence of diabetes mellitus and impaired glucose tolerance
doctor, associated factors, and the effect on health services
Pfizer, Inc.
Date of first submission: December 15, 2004
in the urban population aged 30–69 years in Ribeirão Preto
utilization: a population-based study in Southern Brazil. Cad
Cad
Last received: August 15, 2005
(São Paulo), Brazil. Sao Paulo Med J. 2003;121(6):224-30.
Saúde Pública. 2003;19(5):1257-66.
Accepted: August 19, 2005
AuTHoR InFoRMATIon
RESuMo
Prevalência de problemas sexuais e de comportamentos relacionados à busca de ajuda para estes problemas
Edson Duarte Moreira Junior, MD, PhD. Centro de
em adultos no Brasil: resultados do estudo global de atitudes e comportamentos sexuais
Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz, and
scientific directorate of Hospital São Rafael, Salvador,
CONTEXTO E OBJETIVO: A prevalência e os fatores correlatos de desordens sexuais masculinas como
Bahia, Brazil.
disfunção erétil e ejaculação precoce têm sido estudados em muitos países, entretanto, bem menos
Dale Glasser, MD. Pfizer Inc, New York, United States
investigações se ocuparam especificamente dos problemas sexuais femininos. Além disso, relativamente
of America.
pouco se sabe sobre a freqüência usual da atividade sexual e sobre como indivíduos mais velhos tentam
lidar com seus problemas sexuais. O objetivo deste estudo foi estudar a atividade sexual, a prevalência
Djanilson Barbosa dos Santos, MSc. Centro de
de problemas sexuais e os comportamentos de busca de ajuda relacionados a esses problemas, entre
Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz and
scientific directorate of Hospital São Rafael, Salvador,
homens e mulheres de meia-idade e mais velhos no Brasil.
Bahia, Brazil.
TIPO DE ESTUDO: Inquérito populacional realizado pela Faculdade Oswaldo Cruz. Pesquisa por telefone
Clive Gingell, FRCS. Bristol Urological Institute, Southmead
(discagem aleatória) conduzida no Brasil em 2001 e 2002.
Hospital, Bristol, England, for the Global Study of Sexual
MÉTODOS: As entrevistas foram baseadas num questionário padronizado, incluindo informações demográ-
Attitudes and Behaviors (GSSAB) Investigators’ Group.
ficas, saúde em geral, e comportamentos, atitudes e crenças sexuais. Um total de 1.199 indivíduos no
Brasil (471 homens e 728 mulheres) de 40 a 80 anos completou o inquérito.
Address for correspondence:
RESULTADOS: Ao todo, 92,6% dos homens e 58,3% das mulheres referiram alguma atividade sexual no ano
Edson Duarte Moreira Junior
que precedeu a entrevista, e mais da metade dos homens e mulheres reportaram atividade sexual mais de
Fundação Oswaldo Cruz – Departamento de Epide-
uma vez uma semana. Ejaculação precoce (30,3%) foi o problema sexual masculino mais comum, seguido
miologia e Bioestatística
por incapacidade de alcançar o orgasmo (14,0%), dificuldades de ereção (13,1%) e falta de interesse
Rua Waldemar Falcão, 121
sexual (11,2%). Os problemas sexuais relatados mais freqüentemente por mulheres foram dificuldades de
Salvador (BA) — Brasil — CEP 40295-001
lubrificação (23,4%) e falta de interesse sexual (22,7%). Depressão foi correlacionada significativamente
Tel. (+55 71) 356-8781 Ramal 243
com problemas sexuais nos homens e nas mulheres. Mais mulheres do que homens tinham procurado a
Fax (+55 71) 356-2155
E-mail: edson@cpqgm.fiocruz.br
ajuda de um profissional de saúde para seu problema(s) sexual(is).
CONCLUSÕES: Os achados do GSSAB destacam a importância de encorajar o maior uso dos serviços
de saúde disponíveis, incluindo consultas médicas sobre queixas ligadas à saúde sexual. Isso deverá não
somente possibilitar que homens e mulheres mantenham uma função sexual satisfatória até idades mais
avançadas, mas também poderá resultar numa melhora geral da qualidade da assistência à saúde.
PALAVRAS-CHAVE: Epidemiologia. Levantamentos epidemiológicos. Disfunção erétil. Prevalência..
Copyright © 2005, Associação Paulista de Medicina
Sexualidade.
Sao Paulo Med J. 2005;123(5):234-41.

---