
==== Front
Sao Paulo Med J
Sao Paulo Med J
Sao Paulo Med J
São Paulo Medical Journal
1516-3180
1806-9460
Associação Paulista de Medicina - APM

16358099
10.1590/S1516-31802005000500007
Original Article
Prevalence of sexual problems and related help-seeking behaviors among mature adults in Brazil: data from the Global Study of Sexual Attitudes and Behaviors
Prevalência de problemas sexuais e de comportamentos relacionados à busca de ajuda para estes problemas em adultos no Brasil: resultados do estudo global de atitudes e comportamentos sexuaisMoreira Edson Duarte Junior *
Glasser Dale *
dos Santos Djanilson Barbosa *
Gingell Clive *
Address for correspondence: Edson Duarte Moreira Junior Fundação Oswaldo Cruz – Departamento de Epidemiologia e Bioestatística Rua Waldemar Falcão, 121 Salvador (BA) — Brasil — CEP 40295-001 Tel. (+55 71) 356-8781 Ramal 243 Fax (+55 71) 356-2155 E-mail: edson@cpqgm.fiocruz.br
Conflicts of interest: Edson Duarte Moreira Junior is a consultant for Pfizer, Inc.; Dale Glasser is an employee of Pfizer, Inc. and owns Pfizer stock; Djanilson Barbosa dos Santos has no conflict of interest; Clive Gingell is a consultant for Pfizer, Inc.

01 9 2005
2005
123 5 234241
15 12 2004
15 8 2005
19 8 2005
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons license.
ABSTRACT

CONTEXT AND OBJECTIVE:

Relatively little is known about the usual frequency of sexual activity and how older individuals cope with sexual problems. The objective was to study sexual activity, prevalence of sexual problems and related help-seeking behaviors among middle-aged and older men and women in Brazil.

DESIGN AND SETTING:

Population survey, by Fundação Oswaldo Cruz.

METHODS:

Interviews were held with 1,199 Brazilians aged 40-80 years (471 men and 728 women). The standardized questionnaire investigated demographics, general health, sexual behavior, attitudes and beliefs.

RESULTS:

Overall, 92.6% of men and 58.3% of women had had sexual intercourse during the preceding year. More than half of the men and women had done so more than once a week. Early ejaculation (30.3%) was the commonest male sexual problem, followed by inability to reach orgasm (14.0%), erectile difficulties (13.1%) and lack of sexual interest (11.2%). For women, the commonest sexual problems were lubrication difficulties (23.4%) and lack of sexual interest (22.7%). Depression was a significant correlate of sexual problems, for men and women. More women than men had sought help for sexual problem(s) from a healthcare professional.

CONCLUSIONS:

The findings highlight the importance of encouraging greater use of available healthcare services, including consultation with a medical doctor regarding sexual health. This should not only enable men and women to maintain satisfactory sexual function well into their later years, but may also result in overall improvement in the quality of healthcare.

RESUMO

CONTEXTO E OBJETIVO:

A prevalência e os fatores correlatos de desordens sexuais masculinas como disfunção erétil e ejaculação precoce têm sido estudados em muitos países, entretanto, bem menos investigações se ocuparam especificamente dos problemas sexuais femininos. Além disso, relativamente 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 de problemas sexuais e os comportamentos de busca de ajuda relacionados a esses problemas, entre homens e mulheres de meia-idade e mais velhos no Brasil.

TIPO DE ESTUDO:

Inquérito populacional realizado pela Faculdade Oswaldo Cruz. Pesquisa por telefone (discagem aleatória) conduzida no Brasil em 2001 e 2002.

MÉTODOS:

As entrevistas foram baseadas num questionário padronizado, incluindo informações demográficas, 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.

RESULTADOS:

Ao todo, 92,6% dos homens e 58,3% das mulheres referiram alguma atividade sexual no ano que precedeu a entrevista, e mais da metade dos homens e mulheres reportaram atividade sexual mais de uma vez uma semana. Ejaculação precoce (30,3%) foi o problema sexual masculino mais comum, seguido por incapacidade de alcançar o orgasmo (14,0%), dificuldades de ereção (13,1%) e falta de interesse sexual (11,2%). Os problemas sexuais relatados mais freqüentemente por mulheres foram dificuldades de lubrificação (23,4%) e falta de interesse sexual (22,7%). Depressão foi correlacionada significativamente com problemas sexuais nos homens e nas mulheres. Mais mulheres do que homens tinham procurado a 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.

KEY WORDS:

Epidemiology
Health surveys
Erec-tile dysfunction
Prevalence
Sex disorders
PALAVRAS-CHAVE:

Epidemiologia
Levantamentos epidemiológicos
Disfunção erétil
Prevalência
Disfunção erétil
Prevalência
Sexualidade
==== Body
pmcINTRODUCTION

The development of several convenient and effective oral treatments for male erectile dysfunction has contributed to the increasing level of interest in the sexual functioning of middle-aged and older adults that has been seen in recent years. Over the last 10 years or so, a large number of studies have investigated the prevalence of sexual problems among middle-aged and elderly people. These studies have tended to focus mainly on the populations of individual countries in Europe,1–5 the United States of America (USA),6–10 and Central and South America.11–15 The prevalence and correlates of the male sexual disorders of erectile dysfunction and early ejaculation have been studied most extensively, while fewer investigations have looked specifically at female sexual problems.16,17 Furthermore, relatively little has been reported about the usual frequency of sexual activity and the value and significance of sexual relationships for older individuals, although the few published studies in this area have concluded that sexual interest and activity persist well into older age.18–20

The published literature on the prevalence and correlates of sexual disorders comprises studies conducted in developed and developing countries that have employed a wide variety of study designs and definitions. This makes it difficult to conduct cross-national comparisons in a scientifically valid manner. Moreover, there are currently no studies that allow a comparison of sexual behavior or help-seeking patterns for sexual problemsacross different countries.

The Global Study of Sexual Attitudes and Behaviors (GSSAB) was a population survey of 27,500 men and women aged 40 to 80 years in 29 countries representing many world regions.21,23 Brazil was one of the countries within this study.

OBJECTIVE

Here, our goal is to report data on sexual activity, the prevalence of sexual problems and related help-seeking behaviors among men and women in the Brazilian cohort of the Global Study of Sexual Attitudes and Behaviors.

METHODS

Type of study

Population survey.

Setting

A computer-assisted telephone interview survey, using random-digit dialing as the sampling design, was carried out in Brazil during 2001 and 2002 (participants were sampled from the five largest cities in Brazil, namely, São Paulo, Rio de Janeiro, Salvador, Belo Horizonte, and Brasília). Respondents were randomly selected by asking for the man or woman in the household aged between 40 and 80 years of age (participants were interviewed by interviewers of the same gender).

A structured questionnaire requested information concerning general health, demographics, relationships, and sexual behavior, attitudes and beliefs. The subjects were asked if they had engaged in sexual intercourse during the previous 12 months, and the presence of sexual dysfunction was assessed by means of two sequential questions. The respondents were first asked whether they had experienced one or more of the sexual problems listed in Tables 2a and 2b for a period of at least two months during the previous year, and those who answered ‘Yes’ were then asked whether they had experienced the problem ‘occasionally’, ‘sometimes’ or ‘frequently’.

Table 2. Age-standardized prevalence of sexual problems by gender in Brazil, according to severity, 2001-2002 (percentage and 95% confidence interval)

	Men (n = 471)	Women (n = 728)	
Early ejaculation	30.3 (26.0, 34.8)		
 Occasional	4.6 (2.8, 7.0)		
 Periodic	14.4 (11.3, 18.1)		
 Frequent	11.2 (8.4, 14.6)		
Lubrication difficulties		23.4 (19.4, 27.7)	
 Occasional		3.5 (2.0, 5.8)	
 Periodic		13.9 (10.8, 17.6)	
 Frequent		5.9 (3.9, 8.6)	
Erectile difficulties	13.1 (10.1, 16.6)		
 Occasional	4.1 (2.5, 6.4)		
 Periodic	6.2 (4.1, 8.9)		
 Frequent	2.8 (1.4, 4.8)		
Lack of sexual interest	11.2 (8.4, 14.6)	22.7 (18.8, 27.0)	
 Occasional	2.8 (1.4, 4.8)	3.8 (2.2, 6.1)	
 Periodic	6.0 (3.9, 8.6)	11.8 (8.9, 15.3)	
 Frequent	2.5 (1.3, 4.5)	7.1 (4.8, 10.0)	
Inability to reach orgasm	14.0 (10.9, 17.6)	22.0 (18.1, 26.2)	
 Occasional	4.4 (2.6, 6.7)	4.5 (2.6, 6.7)	
 Periodic	7.1 (4.9, 9.9)	13.0 (9.9, 16.6)	
 Frequent	2.5 (1.3, 4.5)	4.5 (2.6, 6.7)	
Sex not pleasurable	7.8 (5.5, 10.7)	20.3 (16.6, 24.5)	
 Occasional	3.0 (1.6, 5.0)	4.0 (2.4, 6.4)	
 Periodic	3.2 (1.8, 5.3)	10.4 (7.7, 13.7)	
 Frequent	1.6 (0.6, 3.3)	5.9 (3.9, 8.6)	
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)	
 Periodic	1.8 (0.8, 3.6)	10.6 (7.9, 14.0)	
 Frequent	1.4 (0.5, 3.0)	5.2 (3.3, 7.8)	
Note: based on reports from sexually active respondents (those who had had intercourse within the past year). Percentage in the first row of each panel indicates the overall prevalence of the sexual problem, defined as experiencing the problem for a period 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 the age distribution of the total of sexually active men and women in this sample from Brazil.

Logistic regression was used to investigate potential factors associated with selected sexual dysfunction. In these analyses, the presence of a sexual dysfunction was coded only for those respondents who reported experiencing the problem frequently or periodically, while those who indicated that they experienced the problem only occasionally were recorded as indicating no sexual dysfunction.

The subjects who reported that they had experienced a sexual problem were asked whether they had sought help from a number of possible sources. The options included: “Talked to partner”, “Talked to a medical doctor (other than a psychiatrist)”, “Looked for information anonymously (in books/magazines or on the internet)”, “Talked to family member or friend”, “Taken prescription drugs/devices or talked to pharmacist”, “Talked to psychiatrist or psychologist or marriage counselor”, “Talked to a cleric or religious adviser”, “Called a telephone help line” and “Other – please specify”. Respondents could indicate that they had sought help from more than one source.

The subjects with sexual problems who had not consulted a physician were asked why they had not done so, and offered a list of 14 possible reasons (from which they were to check all that applied). The reasons included attitudes and beliefs regarding the sexual problem and the patient-doctor relationship. All respondents (irrespective of whether they reported any sexual problems) were also asked “During a routine office visit or consultation in the past 3 years, has your physician asked you about possible sexual difficulties without you bringing it up first?” (Yes/No) and “Do you think a doctor should routinely ask patients about their sexual function?” (Yes/No). The categorization of household income as “low”, “medium” or “high” was based on the distribution of income in Brazil according to the criteria of the Instituto Brasileiro de Geografia e Estatística.24

The prevalence of a specific characteristic was calculated by dividing the number of cases by the corresponding population. The denominator for the calculation of the prevalence of sexual problem was the number of sexually active people (i.e. at least one episode of intercourse during the previous 12 months). The prevalence estimates were age-standardized using the age distribution of the population of Brazil (by gender when appropriate), and are given with their confidence intervals.25

RESULTS

Characteristics of study population

Overall, 8,637 individuals were contacted, 2,127 of whom were not eligible to participate (outside of the age range). Of the 6,510 eligible individuals, 5,088 refused to participate when the survey topic was introduced, while 223 interrupted the interview. A total of 1,199 individuals (471 men and 728 women) completed the survey, thus giving a response rate of 18.4%. Table 1 presents data on selected characteristics of the study sample, standardized for the age distribution of the population of Brazil in the year 2000. A greater proportion of men (82.6%) than women (54.3%) were married or in an ongoing partnership (Table 1). More than half of the men (57.3%) and about one-third of the women (35.0%) were employed and 66.5% of men and 54.1% of women reported that they were in good or excellent general health.

Table 1. Selected characteristics of the study population, Brazil, 2001-2002 (percentage; age-standardized prevalences)

	Men
(n = 471)	Women
(n = 728)	
Age group (years)	
 40-49	29.9	30.8	
 50-59	32.1	29.8	
 60-69	22.5	21.7	
 70-80	15.5	17.7	
Relationship status	
 Married or ongoing partnership	82.6	54.3	
 Divorced/separated without sex partner	8.9	13.2	
 Widowed without sex partner	4.7	22.0	
 Single without sex partner	3.8	10.6	
Urban residential setting	93.8	97.4	
Education	
 Primary school or less	36.3	47.1	
 Secondary/high school	36.5	35.0	
 At least some college	27.2	17.9	
Household income	
 Low	12.4	23.8	
 Medium	78.5	70.8	
 High	9.2	5.4	
Current employment status	
 Employed	57.3	35.0	
 Unemployed	4.9	3.2	
 Retired	37.8	22.9	
 Homemaker	0	38.9	
Religion	
 Christian/Jewish	89.4	88.7	
 Atheist	3.3	1.3	
 Other, specified	7.3	10.0	
Good to excellent general health *	66.5	54.1	
Intercourse in the last 12 months	92.6	58.3	
Intercourse more than once a week	65.6	57.2	
* Self-reported “good” or “excellent” general health (versus “fair” or “poor”).

Almost all of the men (92.6%) and more than half of the women (58.3%) said that they had had sexual intercourse during the 12 months preceding the interview, and 58.4% of men and 26.1% of women engaged in sexual intercourse more than once a week.

Prevalence of sexual problems

Early ejaculation was by far the most common male sexual problem, and was reported by almost one-third (30.3%) of the sexually active men (most of who said that they experienced this problem periodically or frequently) (Table 2). An inability to reach orgasm, erectile difficulties and a lack of sexual interest were each experienced by approximately 11 to 14% of sexually active men, while a lack of pleasure in sex (7.8%) and pain during sexual intercourse (4.5%) were much less common.

Lubrication difficulties (23.4%) were the most common sexual problem reported by sexually active women in Brazil, closely followed by lack of sexual interest (22.7%) and an inability to reach orgasm (22.0%), while a lack of pleasure in sex and pain during sexual intercourse were experienced by 20.3% and 18.0% of sexually active women, respectively (Table 2). The majority of the women who reported each of these problems said that they experienced it frequently or periodically.

Physical, health, demographic and socioeconomic factors associated with three selected sexual dysfunctions in men and women are summarized in Table 3 (odds ratios from logistic regression). Older age (age 60 to 80 years compared with the referent age of 40 to 49 years) was a significant correlate of lubrication difficulties in women (odds ratio 2.10; p < 0.05). Of the various factors investigated and listed in Table 3, three medical conditions were significantly associated with an increased likelihood of one or more types of male sexual dysfunction (i.e. a sexual problem that was experienced periodically or frequently), while only one of the factors was a significant correlate of sexual dysfunction in women. A diagnosis of depression was a significant correlate of erectile difficulties (odds ratio 3.02; p < 0.01), and early ejaculation (odds ratio 1.98; p < 0.05) among men, and of a lack of sexual interest in both men (odds ratio 4.37; p < 0.001) and women (odds ratio 1.68; p < 0.05). Diagnoses of hypertension and prostate disease were significant correlates of early ejaculation (odds ratio 1.95; p < 0.05) and a lack of sexual interest (odds ratio 2.77; p < 0.05), respectively.

Table 3. Factors associated with sexual dysfunction by gender, Brazil, 2001-2002

	Men	Women	
	Early
ejaculation	Lack of sexual
interest	Erectile
difficulties	Inability to
reach orgasm	Lack of sexual
interest	Lubrication
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.

Help-seeking behavior

The prevalence of selected help-seeking behavior for sexual problems in Brazil is summarized in Table 4. Of the respondents who were sexually active and reported experiencing at least one sexual problem, 41.3% of men and 29.7% of women had not sought any help or advice (i.e. no action taken). Patterns of help-seeking behavior showed some differences between men and women in Brazil. More than twice as many women (44.0%) as men (21.2%) reported talking to a medical doctor about their sexual problem(s). However, overall, about half of the women (53.1%) and almost three-quarters of the men (72.1%) had sought no help from a health professional. Talking to their partner was a similarly popular course of action among men and women (42.3% and 41.4%, respectively), while women were more likely than men to talk to a friend or family member (25.3% versus 10.6%) and to seek information from an anonymous source such as books and magazines, telephone help-lines or the internet (18.3% versus 12.0%). Few men (3.8%) and women (6.2%) reported seeking help from a member of the clergy or other religious adviser.

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.

Factors associated with seeking medical help for sexual problems

A number of physical, socioeconomic and attitudinal factors that might be associated with seeking medical help for sexual problems were investigated using logistic regression and the results (odds ratios) for men and women in Brazil are summarized in Table 5. Women with a high or medium household income were more likely than those with a low income to seek medical help for sexual problems (odds ratio 2.18; p < 0.05), but income was not a significant factor for men. None of the male sexual problems investigated were significantly associated with seeking medical help, but among women lubrication difficulty was a significant correlate of seeking medical help (odds ratio 2.66; p < 0.01). Having been asked by a doctor about possible sexual difficulties during a routine visit in the past three years was a significant correlate of seeking medical help for sexual problems for both men (odds ratio 4.72; p < 0.01) and women (odds ratio 1.92; p < 0.05) in Brazil. Sexual attitudes and beliefs that were significantly associated with seeking medical help for sexual problems were: among women, thinking that a doctor should routinely ask patients about sexual problems (odds ratio 2.44; p < 0.05); and among men, being somewhat or very dissatisfied with their sexual function (odds ratio 3.16; p < 0.05) and believing that sex is an extremely or very important part of life (odds ratio 2.79; p < 0.05).

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

Attitudes and beliefs about diagnosis and treatment of sexual problems

By far the most common reason cited by men and women in Brazil for not consulting a doctor about a sexual problem was a belief that it is a normal part of aging, or being comfortable as he/she is (81.7% of men and 85.6% of women) (Table 6). However, thinking the problem was not very serious or waiting for it to go away (59.1% of men and 69.9% of women); feelings of discomfort or embarrassment about talking to a doctor (52.4% of men and 60.8% of women); and thinking it was not a medical problem or that a doctor could not do much to help (57.9% of men and 58.8% of women), were all cited by more than half of all respondents (Table 6). Lack of access to or affordability of medical care was also cited as a reason by about half of the men (54.9%) and women (46.4%). Few respondents in Brazil had been asked by a doctor about possible sexual difficulties during a routine visit in the past 3 years (13.6% of men and 19.8% of women) but more than three-quarters of men (85.4%) and women (76.9%) thought that a doctor should routinely ask patients about their sexual function.

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.

DISCUSSION

The Global Study of Sexual Attitudes and Behaviors has obtained population-level data on sexual attitudes and behaviors from middle-aged and older adults in 29 countries in a manner that allows direct comparisons of the results from different countries and regions. The large, cross-national sample and the use of a common method of data collection represent two major strengths of this study. Here, we have focused specifically on the sexual activity, prevalence of sexual problems and associated help-seeking behavior among men and women in Brazil. The standardized, structured questionnaire was administered using computer-assisted telephone interviews. This method was chosen in preference to face-to-face interviews to avoid causing respondents undue embarrassment when talking about private and sensitive issues, and to minimize the likelihood that they might feel obliged to give “socially desirable” answers.26

Only sexual problems that were experienced periodically or frequently (i.e. those that persisted with moderate to higher frequency) were considered to be “dysfunctions”.27 This is essentially equivalent to using two sequential screening tests, and minimizes the risk of false positive responses. It is likely, therefore, that the prevalence of sexual dysfunction may be under-reported in the Global Study of Sexual Attitudes and Behaviors, in comparison with studies that used more sensitive, but less specific, methods. Published studies on the prevalence of male erectile dysfunction in Brazil have highlighted the need to consider the severity or frequency of a sexual dysfunction when comparing reports from apparently similar study samples. Two population-based surveys conducted in Brazil, one in the northeast13 and the other in the southeast,14 reported a prevalence of moderate or complete erectile dysfunction of 14.4% and 12.0%, respectively, among Brazilian men aged 40 to 70 years. Likewise, in a national survey in Brazil, the prevalence of moderate or complete erectile dysfunction was 14.7%.12 These estimates are similar to what was observed in the GSSAB Brazilian cohort, in which the overall age-standardized prevalence of erectile difficulties was 13.8% (9.8% experienced the problem frequently or periodically).

The overall response rate in Brazil (18.4%) was low, but the prevalence of a number of self-reported health conditions, including hypertension, diabetes and smoking in GSSAB was comparable with published values.28–31 This suggests that refusal to participate in this study was most probably due simply to an unwillingness to undergo a telephone interview and the modest response rate is therefore unlikely to have introduced a bias in the estimates of the prevalence of sexual behaviors and problems. It also appears to indicate that the study population was broadly representative of the Brazilian population. This assumption is further supported by the observation that the prevalence of erectile difficulties among men in the Brazilian cohort of the GSSAB was comparable to what has been reported in published studies, which have focused on the prevalence of moderate or severe erectile dys-function among Brazilian men aged between 40 and 70 years.13,14,32

A diagnosis of depression was a significant correlate of a lack of sexual interest for both genders, and of erectile difficulties and early ejaculation among men in the GSSAB Brazilian cohort. A lack of sexual interest was also significantly associated with prostate disease and early ejaculation with a diagnosis of hypertension. Interestingly, none of the reported medical conditions, apart from depression, were significant correlates of sexual problems among Brazilian women in the GSSAB. Comorbidity between erectile dysfunction and depression is known to exist but the precise nature of the relationship between these conditions is not clear.33 While it is possible that the distress of erectile dysfunction may contribute to the development of depressive illness, it is also possible that depressive illness may lead to erectile difficulties. Moreover, it is important that the possible role of antidepressant treatments is considered when investigating the copresence of depression and sexual dysfunction. Sexual dysfunction is a well-recognized side effect of antidepressant therapy. However, different agents may be associated with different rates of dysfunction.34–36 Selective serotonin reuptake inhibitors (SSRIs) have been reported to be associated with particularly high rates of sexual dysfunction and, while men report higher rates of sexual side effects from SSRIs than do women, women seem to experience more severe dysfunction with these agents.35,37 A significant association between depression and erectile dysfunction among men in Brazil has been reported previously.12–14 However, the data from GSSAB indicate that depression is also associated with other male sexual problems, namely early ejaculation and a lack of sexual interest. Despite the correlation between sexual problems and depression, the relationship is most probably bi-directional, i.e. sexual problems may follow depression, while depression may be a consequence of sexual dysfunction. We cannot discern the causal direction in these cross-sectional data. The association between depression and sexual dysfunction warrants further investigation because depression is highly prevalent in Brazil and other Latin American countries, possibly due at least in part to social factors such as violence that are especially present in medium and large cities.38 (For logistical reasons, the Brazilian sample in GSSAB was drawn primarily from urban areas.)

The GSSAB data indicate that feeling that the problem is not severe, or not being bothered by the problem, may be deterring men and women in Brazil from discussing their sexual difficulties with their doctor. Furthermore, it appears that doctors in Brazil rarely ask patients about their sexual health during a routine consultation, even though the vast majority of men and women would appreciate this and it would appear to encourage medical help-seeking for sexual problems. Untreated sexual problems can greatly impair a patient's enjoyment of their sexual life and it is important that physicians, especially primary care physicians, ask patients about possible sexual difficulties during routine visits.39 This should result in improved sexual functioning for the patient and an enhanced physician-patient relationship and greater professional satisfaction.

Socioeconomic factors also influence patterns of help-seeking behavior for sexual problems among mature men and women in Brazil. Our findings indicate that women with a medium or high household income were significantly more likely to seek help than women from low-income households. Furthermore, a lack of access to or affordability of medical care was cited by about one-half of all respondents, both men and women, as a reason for not seeking medical help for sexual problems. A recent cross-sectional study performed in Rio Grande do Sul, Brazil, showed that only 37% of the study sample had a regular doctor and that this was directly associated with income.40 The authors also found that individuals with a regular physician tended to have better access to a range of health services and they recommended encouraging people to consult with a regular doctor as a means of improving the quality of and access to healthcare services, particularly among the poorest individuals. Improving the care available to older adults with low income may be especially important, as a study of the influence of socioeconomic circumstances on health has demonstrated that, among a representative sample of the Brazilian population aged 65 years or older, lower income was associated with worse health and physical functioning, and less frequent use of medical services.41

CONCLUSIONS

We conclude that, although middle-aged and elderly men and women in Brazil continue to show sexual interest and activity, a number of sexual problems are highly prevalent. Only a minority of the men and women who experience sexual difficulties seek medical help: this may be partly because they do not perceive such problems as potentially treatable medical conditions, or because they do not have access to or cannot afford medical care. The findings from GSSAB highlight the importance of encouraging greater use of the available healthcare services, including consultation with a medical doctor on matters of sexual health. This should not only enable men and women to maintain satisfactory sexual function well into their later years, but may also result in an overall improvement in the quality of healthcare, particularly among poorer individuals.

Acknowledgement:

The authors acknowledge the contribution of their colleagues on the study's international advisory board: Gerald Brock (Canada), Jacques Buvat (France), Uwe Hartmann (Germany), Sae-Chul Kim (Korea), Rosie King (Australia), Edward Laumann (USA), Bernard Levinson (South Africa), Ken Marumo (Japan), Alfredo Nicolosi (Italy) and Ferruh Simsek (Turkey).

Edson Duarte Moreira Junior, MD, PhD. Centro de Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz, and scientific directorate of Hospital São Rafael, Salvador, Bahia, Brazil.

Dale Glasser, MD. Pfizer Inc, New York, United States of America.

Djanilson Barbosa dos Santos, MSc. Centro de Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz and scientific directorate of Hospital São Rafael, Salvador, Bahia, Brazil.

Clive Gingell, FRCS. Bristol Urological Institute, Southmead Hospital, Bristol, England, for the Global Study of Sexual Attitudes and Behaviors (GSSAB) Investigators’ Group.

Sources of funding:

The Global Study of Sexual Attitudes and Behaviors was funded by Pfizer, Inc.

Centro de Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz, and scientific directorate of Hospital São Rafael, Salvador, Bahia, Brazil
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REFERENCES

1 Giuliano F Chevret-Measson M Tsatsaris A Reitz C Murino M Thonneau P Prevalence of erectile dysfunction in France: results of an epidemiological survey of a representative sample of 1004 men Eur Urol 2002 42 4 382 389 12361905
2 Martin-Morales A Sanchez-Cruz JJ Saenz de Tejada I Rodriguez-Vela L Jimenez-Cruz JF Burgos-Rodriguez R Prevalence and independent risk factors for erectile dysfunction in Spain: results of the Epidemiologia de la Disfuncion Erectil Masculina Study J Urol 2001 166 2 569 574 discussion 574-5 11458070
3 Blanker MH Bosch JL Groeneveld FP Erectile and ejaculatory dysfunction in a community-based sample of men 50 to 78 years old: prevalence, concern, and relation to sexual activity Urology 2001 57 4 763 768 11306400
4 Helgason AR Adolfsson J Dickman P Sexual desire, erection, orgasm and ejaculatory functions and their importance to elderly Swedish men: a population-based study Age Ageing 1996 25 4 285 291 8831873
5 Dunn KM Croft PR Hackett GI Sexual problems: a study of the prevalence and need for care in the general population Fam Pract 1998 15 6 519 524 10078790
6 Feldman HA Goldstein I Hatzichristou DG Krane RJ McKinlay JB Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study JJ Urol 1994 151 1 54 61
7 Panser LA Rhodes T Girman CJ Sexual function of men Sexual function of men ages 40 to 79 years: the Olmsted County Study of Urinary Symptoms and Health Status Among Men J Am Geriatr Soc 1995 43 10 1107 1111 7560700
8 Laumann EO Paik A Rosen RC Sexual dysfunction dysfunction in the United States: prevalence and predictors JAMA 1999 281 6 537 544 10022110
9 Ansong KS Lewis C Jenkins P Bell J Epidemiology of erectile dysfunction: a community-based study in rural New York State Ann Epidemiol 2000 10 5 293 296 10942877
10 Bacon CG Mittleman MA Kawachi I Giovannucci E Glasser DB Rimm EB Sexual function in men older than 50 years of Sexual function in men older than 50 years of age: results from the health professionals follow-up study Ann Intern Med 2003 139 3 161 168 12899583
11 Ugarte y Romano F Barroso AJ Prevalencia de disfunción eréctil en México y factores de riesgo asociados Rev Mex Urologia 2001 61 2 63 76
12 Moreira ED Jr Abdo CH Torres EB Lisboa Lobo CF Fittipaldi JA Prevalence and correlates of erectile dysfunction: results of the Prevalence and correlates of erectile dysfunction: results of the Brazilian study of sexual behavior Urology 2001 58 4 583 588 11597544
13 Moreira ED Jr Lisboa Lobo CF Villa M Nicolosi A Glasser DB Prevalence and correlates of erectile dysfunction in Salvador, northeastern Brazil: a population-based study Int J Impot Res 2002 14 Suppl 2 S3 S9 12161762
14 Moreira ED Jr Bestane WJ Bartolo EB Fittipaldi JA Prevalence and determinants of erectile dysfunction in Santos, southeastern Brazil Sao Paulo Med J 2002 120 2 49 54 11994773
15 Nolazco C Bellora O Lopez M Prevalence of of sexual dysfunctions in Argentina Int J Impot Res 2004 16 1 69 72 14963474
16 Osborn M Hawton K Gath D Sexual dysfunction among middle aged women in the community Br Med J (Clin Res Ed) 1988 296 6627 959 962
17 Barlow DH Cardozo LD Francis RM Urogenital ageing and its effect on sexual health in older British women Br J Obstet Gynecol 1997 104 1 87 91
18 Schiavi RC Rehman J Sexuality and aging Urol Clin North Urol Clin North Am 1995 22 4 711 726 7483124
19 Matthias RE Lubben JE Atchison KA Schweitzer SO Sexual Sexual activity and satisfaction among very old adults: results from a community-dwelling Medicare population survey Gerontolo-gist 1997 37 1 6 14
20 Gott M Hinchliff S How important is sex in later life? The views of older people Soc Sci Med 2003 56 8 1617 1628 12639579
21 Laumann EO Nicolosi A Glasser DB Sexual problems Sexual problems among women and men aged 40 to 80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors Int J Impot Res 2005 17 1 39 57 15215881
22 Nicolosi A Laumann EO Glasser DB Sexual behaviour and sexual dysfunctions after age 40: the global study of sexual attitudes and behaviors Urology 2004 64 5 991 997 15533492
23 Moreira ED Jr Brock G Glasser DB Help-seeking behaviour for sexual problems: the global study of sexual attitudes and behaviors Int J Clin Pract 2005 59 1 6 16 15707457
24 Instituto Brasileiro de Geografia e Estatística Pesquisa de orçamentos familiares - POF 2002-2003 Disponível em URL: http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/pof/2002/default.shtm Acessado em: 2005 (Aug 19)
25 Gardner MJ Altman DG Confidence intervals rather than P values: estimation rather than hypothesis testing Br Med J (Clin Res Ed) 1986 292 6522 746 750
26 Analysis of sexual behaviour in France (ACSF) A comparison between two modes of investigation: telephone survey and face-to-face survey. ASCF principal investigators and their associates AIDS 1992 6 3 315 323 1567577
27 Moynihan R The making of a disease: female sexual dysfunction BMJ 2003 326 7379 45 47 12511464
28 Lima-Costa MF Barreto SM Uchoa E Firmo JO Vidigal PG Guerra HL The Bambui Health and Aging Study (BHAS): prevalence of risk factors and use of preventive health care services Rev Panam Salud Publica 2001 9 4 219 227 11418968
29 Guimaraes AC Hypertension in Brazil J Hum Hypertens 2002 16 Suppl 1 S7 S10
30 Torquato MT Montenegro RM Junior Viana LA Prevalence of diabetes mellitus and impaired glucose tolerance in the urban population aged 30–69 years in Ribeirão Preto (São Paulo), Brazil Sao Paulo Med J 2003 121 6 224 230 14989137
31 Ala L Gill G Gurgel R Cuevas L Evidence for affluence-related hypertension in urban Brazil J Hum Hypertens 2004 18 11 775 779 15215877
32 Nicolosi A Moreira ED Jr Shirai M Bin Mohd Tambi MI Glasser DB Epidemiology of erectile dysfunction in four Epidemiology of erectile dysfunction in four countries: cross-national study of the prevalence and correlates of erectile dysfunction Urology 2003 61 1 201 206 12559296
33 Seidman SN Exploring the relationship between depression and erectile dysfunction in aging men J Clin Psychiatry 2002 63 Suppl 5 5 12 discussion 23-5
34 Gregorian RS Golden KA Bahce A Goodman C Kwong WJ Khan ZM Antidepressant-induced sexual dysfunction Ann Pharmacother 2002 36 10 1577 1589 12243609
35 Clayton AH Pradko JF Croft HA Prevalence of sexual dysfunction among newer antidepressants J Clin Psychiatry 2002 63 4 357 366 12000211
36 Montgomery SA Baldwin DS Riley A Antidepressant medications: a review of the evidence for drug-induced sexual dysfunction J Affect Disord 2002 69 1-3 119 140 12103459
37 Hensley PL Nurnberg HG SSRI sexual dysfunction: a female perspective J Sex Marital Ther 2002 28 Suppl 1 143 153 11898696
38 Jorge MR Depression in Brazil and other Latin American countries Seishin Shinkeigaku Zasshi 2003 105 1 9 16 12701207
39 Sadovsky R Integrating erectile dysfunction treatment into primary care practice Am J Med 2000 109 Suppl 9A 22S 28S discussion 29S-30S 11137499
40 Mendoza-Sassi R Béria JU Prevalence of having a regular Prevalence of having a regular doctor, associated factors, and the effect on health services utilization: a population-based study in Southern Brazil Cad Saúde Pública 2003 19 5 1257 1266 14666207
41 Lima-Costa MF Barreto S Giatti L Uchôa E Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Socioeconomic circumstances and health among the brazilian elderly: a study using data from a National Household Survey] Cad Saúde Pública 2003 19 3 745 757 12806478
