Abstract
Sexual activity in older people has become a topic of growing interest. The aim of this study is to investigate the effect of physical health and socioeconomic factors on the sexual activity of middle-aged and elderly Taiwanese men. From August 2007 to April 2008, 744 men older than 40 years were enrolled from a free health screening in Kaohsiung, Taiwan. All participants received detailed physical examination and answered questionnaires that collected demographic and lifestyle information, and medical history as well as answered items from the International Prostate Symptoms Score and five-item version of the International Index of Erectile Function (IIEF-5). Overall, 100 (13.4%) participants reported to be sexually inactive in previous 6 months. Older age, lower education levels, loss of a partner, erectile dysfunction, and increased number of comorbidities were found to be independent predictors for sexual inactivity. In conclusion, most middle-aged and elderly Taiwanese men remain sexually active. In addition to erectile dysfunction and loss of a partner, lower education levels and increased number of comorbidities were found to be predictors for sexual inactivity. Further research would need to elucidate whether improvement of those factors could help to preserve sexual activity.
Introduction
Sexuality is a core dimension of life that encompasses partnership, activity, behaviour, attitudes, and function [Citation1]. The concept that older individuals are not sexually desirable, sexually desirous, and sexually capable was a common misconception about ageing and sexuality in the past. This misconception is most likely generated by the gradual and natural decline of sexual function that occurs during the ageing process [Citation2]. Because of dramatic changes in attitudes about sexuality, increases in healthy life expectancy, and the wider availability of effective and convenient treatments for sexual dysfunction, interest in sexuality of middle-aged and elderly adult has increased [Citation2,Citation3]. Sexual expression has been found to be a predictor of general health and demand for medical care in older people, and a healthy sexual life has been shown to improve their quality of life and self-esteem [Citation4,Citation5].
Although sexual problems increase with age, many men and women participate in sexual activity throughout middle age and into their later years [Citation1,Citation6–8]. In the global study of sexual attitudes and behaviours (GSSAB), the first large, multicountry survey to various aspects of sex and relationships, investigating 27,500 men and women aged 40–80 years in 29 countries, more than 80% of male and 66% of female participants reported having sexual intercourse during the 12 months leading up the interview for that study [Citation6–8]. In detail, 93% of the men aged 40–49 years and 53% of those aged 70–80 years reported participation in sexual activity, and among the women, the percentages were 88% and 21%, respectively [Citation6–8]. Recently, in a population-based study involved in 1445 men and 1550 women aged 57–85 years in the United States, 73% of respondents aged 57–64 years, 53% of those aged 65–74 years, and 26% of those aged 75–85 years reported having sexual activity in the previous 12-month period [Citation1]. In this study, men are more likely to be sexually active and have a spousal or other intimate relationship than women in their mid-to-later life [Citation1].
In contrast to western countries, few studies on sexuality or sexual activity have been conducted in Asia [Citation9–11]. It may be owing to a more conservative culture and the recognition of sexuality as a taboo subject for discussion or investigation in Asia [Citation11,Citation12]. In the GSSAB, although sexual interest and activity were widespread among middle-aged and elderly Asian men and women, and persistent into old age, Asian subjects are more male-orientated, more sexually conservative, and less sexually active than western subjects [Citation9]. The results from nine Asian countries in the GSSAB showed that 96.2% of men aged 40–49 years and 49.4% of those aged 70–80 years still had sexual intercourse in the previous 12 months [Citation9].
In Taiwan, although erectile dysfunction has been systematically investigated among middle-aged and elderly men [Citation13,Citation14], little attention has been directed toward their sexual activity. In addition to erectile dysfunction, other sexual problems especially decreased sexual desire would affect sexual activity [Citation15–17]. Studies from other countries also showed that sexual activity of older people would be influenced by cultural, social and lifestyle factors, as well as by physiological factors [Citation1,Citation3,Citation6–8]. The aim of this study is to investigate the prevalence of sexual activity and its predictors, especially physical health and socioeconomic factors, among middle-aged and elderly Taiwanese men.
Methods
From August 2007 to April 2008, a free health screening for men older than 40 years was conducted by the Kaohsiung Medical University Hospital in Kaohsiung, Taiwan [Citation18]. The screening was open to the general male population living in the city of Kaohsiung. At this screening, each participant received a detailed physical examination and answered questionnaires to collect their demographic and lifestyle information, medical history, as well as sexual function and sexual activity in previous 6 months. The study protocol was approved by the Institutional Review Board of the Kaohsiung Medical University Hospital, and all subjects provided informed consent before their participation. Men who had current malignances or major psychiatric disorder were excluded. All participants were assessed by a male interviewer using a structured questionnaire that covered the following aspects.
General characteristics and overall health
Information on age, education levels, occupation, and marital or relationship status were obtained. Participants who were married or cohabiting at the time of the survey or who reported to having a romantic, intimate, or sexual partner were referred to as having a partner [Citation1]. Information on participants’ medical histories was obtained based on self-reports of medical conditions, including diabetes mellitus, hypertension, hyperlipidaemia, cardiovascular disease, stroke and spinal cord injury. Questions regarding smoking and alcohol use were also included. A participant was classified as an alcohol drinker or a cigarette smoker if he regularly consumed any alcoholic beverage at least once per week or smoked ≥10 cigarettes per week, respectively, for at least 6 months [Citation18,Citation19]. Current drinkers or smokers were those who were drinking or smoking at the above frequency within 1 year before the screening. Former drinkers or smokers were defined as those who had stopped drinking or smoking for at least 1 year before the screening [Citation18,Citation19].
Lower urinary tract symptoms
Each subject was also asked to grade the severity of their lower urinary tract symptoms (LUTS) using the Chinese version of the International Prostate Symptoms Score [Citation20]. The severity of LUTS was classified into three categories according to the total symptom score as mild (score 0 to 7), moderate (score 8–19), and severe (score 20–35). Subjects with moderate to severe symptoms were defined as having significant symptoms of LUTS [Citation20].
Sexual problems and sexual activity
Because of the sensitive nature of sexual problems and sexual activity, especially for older Taiwanese people whose thinking was more likely to be traditional, each participant was self-assessed with the help of those questions at the end of questionnaire. Efforts were also made to protect their privacy. The information about erectile function and sexual desire in previous 6 months was initially assessed by direct questionings (‘Did you have any problem in erectile function? Yes or No’ and ‘Did you feel deceased interest in sex? Yes or No’). They then responded to an abridged, five-item version of the International Index of Erectile Function (IIEF-5), as self-reported ED may be underreported in Taiwan [Citation14]. If a participant responded that he had problem in erectile function or the total score of IIEF-5 below 22, he was defined as having erectile dysfunction. Because sexual intercourse is found to be the main sexual activity if any in which older Taiwanese men participate [Citation10], we assume that it will be more closely associated with satisfaction in the sexual lives and general lives of these men as well as physical and mental health than other sexual behaviours [Citation21]. All participants were asked about their frequency of sexual intercourse in previous 1 month first. For those who answered no sexual intercourse in previous 1 month, they would be asked whether they had sexual intercourse in previous 6 months. If a participant reported to have no sexual intercourse in previous 6 months, he was defined as being sexually inactive [Citation11].
Physical measurements
Each participant also received physical measurements of blood pressure, body weight (kg), and height (cm). Body mass index [BMI (kg/m2)] was calculated as body weight divided by the square of body height. Normal weight, overweight, and obesity were defined as a BMI of <24, 24 to <27, and 27 or higher, respectively according to the Taiwanese definition [Citation18,Citation22].
Statistical analysis
Data are expressed as mean ± standard deviation unless otherwise indicated. Quantitative variables were compared using Student's t test, and qualitative variables were compared using the chi-square test or Fisher's exact test. Any factors with significant association with the condition of sexual activity in the initial analyses were further examined in multiple logistic regression analysis. The Statistical Package for Social Sciences, version 12.0 (SPSS, Chicago, Illinois) was used for statistical analyses. A p < 0.05 was considered significant.
Results
Of the 819 men participating in the health screening, 75 subjects excluded due to current malignancies(14 cases), major psychiatric disorders (5 cases), and incomplete evaluation (56 cases), leaving 744 subjects with the mean age of 57.4 ± 6.6 years (range: 43–87 years). Forty-seven of 56 incompletely evaluated subjects were reluctant to answer questions about their sexual function and sexual activity. The baseline characteristics and sociodemographic data of the study population are summarised in .
Table I. Baseline characteristics of subjects (n = 744).
In our study population, 404 (54.3%) participants reported to have erectile dysfunction and 389 (52.3%) felt their sexual desire decreased (). Both prevalence of erectile dysfunction and decreased sexual desire were increased with age and were especially high in those over the age of 60. One hundred (13.4%) participants reported being sexually inactive in previous 6 months, especially in those over the age of 60, including 24.1% of participants aged 60–69 years and 51.2% of those aged 70 years or older.
Table II. The prevalence of sexual dysfunction and sexual inactivity in different age groups.
compares the clinical characteristics of the subjects reported sexual activity in previous 6 months with those did not. Men who were older (63.4 ± 9.4 years vs. 56.4 ± 5.5 years, p < 0.001), had lost a partner (14.0% vs. 2.8%, p < 0.001), had lower education levels (primary school or less: 20% vs. 3%, p < 0.001), were not currently employed (47.0% vs. 15.4%, p < 0.001), reported erectile dysfunction (79.0% vs. 50.5%, p < 0.001) or reported decreased sexual desire (67.0% vs. 50.0%, p = 0.002), and had more comorbidities (1.72 ± 1.19 vs. 1.03 ± 0.98, p < 0.001) were significantly more likely to report no sexual activity in previous 6 months than their counterparts. A significantly greater percentage of those reporting no sexual activity had comorbidities such as diabetes mellitus (30.0% vs. 7.1%, p < 0.001), hypertension (43.0% vs. 24.5%, p < 0.001), cardiovascular diseases (21.0% vs. 7.3%, p < 0.001), stroke (8.0% vs. 0.6%, p < 0.001) and LUTS (57.0% vs. 45.3%, p = 0.03). The prevalence of substances use (current smoking and current alcohol drinking) was not significantly different between those with and without sexual activity.
Table III. The comparison of clinical characteristics between the participants with and without sexual activity.
Finally, multiple logistic regression analysis was performed to evaluate those factors which had significant association with sexual activity in the initial analyses, including age, marital or relationship status, education levels, working status, erectile dysfunction, decreased sexual desire, and the number of comorbidities (). It revealed that older age, lower education levels, loss of a partner, erectile dysfunction, and increased number of comorbidities were all independent predictors for sexual inactivity in previous 6 months. In addition, loss of a partner [odds ratio (OR) = 6.83, 95% confidence interval (CI) = 2.91–16.04, p < 0.001] and education levels of primary school or less (OR = 6.54, 95% CI = 2.85–15.00, p < 0.001) were two most important predictors for sexual inactivity in ageing Taiwanese men. Decreased sexual desire and working status are no longer to be significant predictors for sexual inactivity after adjusting for other covariates.
Table IV. The predictive factors for sexual inactivity in multiple logistic regression analysis.
Discussion
In a sample of ageing Taiwanese men from this community-based study, we found that most participants (86.6%) are still sexually active in their mid to later life, though more than half reported to have erectile dysfunction (54.3%) or decreased sexual desire (52.3%). In addition to older age and erectile dysfunction, lower education levels, loss of a partner, and increased number of comorbidities were found to be independent predictors for decreased sexual activity in ageing Taiwanese men.
In this study, the prevalence of sexual inactivity in previous 6 months were 7.1%, 7.4%, 24.1% and 51.2% in participants with the age of 40–49 years, 50–59 years, 60–69 years, and 70 years or older, respectively. The prevalence was increased with age, and was especially in those over the age of 60. In the previous study of Wang et al. [Citation10] with a sample of elderly adults over age 65 in Taipei, Taiwan, 59.5% male participants were sexually inactive in the previous 12 months, and the result was similar to our finding. Another study conducted in Hong Kong found that 69.3% elderly Chinese men over age 65 were sexually inactive in the previous 6 months [Citation11].
This study also found that sexual function, including erectile function and sexual desire, also decreased with age, especially in those over the age of 60. Previous cross-sectional studies have reported strong aged-related declines in all aspects of sexual function [Citation5,Citation6,Citation23], and one longitudinal study, the Massachusetts Male Ageing study (MMAS), reported a nonlinear age-related change in sexual intercourse, sexual desire and erectile function [Citation24]. In MMAS, there was significant reduction in sexual function in their oldest age group (60–70), though other variables indirectly related to age such as partner availability, health status, and sexual attitudes might also play a role in that nolinear decline [Citation24].
Sexuality play an important role in the maintaining the intimate relationship [Citation25]. Therefore, many older people who have no partner or have lost their partners tend to become uninterested in sex. Although the impact of age on the availability of a spouse or other intimate partner seemed to be marked among women, a substantial portion of men lose their partners in their mid to later life [Citation1,Citation15]. In addition to age, loss of a partner was also noted as an important predictor of sexual inactivity in ageing Germanic men [Citation15,Citation26].
Older adults often lack information about sexuality, and sex education may have not been included in standard curriculum during the formative or even college years of many of today's older adults [Citation25]. In a previous study of Wang et al. [Citation10], they found that higher education levels, positive sexual attitude and knowledge, were significant predictors for Taiwanese people to be sexually active over age 65. One German community survey also reported similar association between education levels and sexual activity [Citation15]. Older people with higher education levels may have more opportunities to receive accurate information about sexuality, so they may have more positive sexual attitude and knowledge, and tend be sexually active when they enter their mid-later life.
Previous studies have showed that sexual dysfunction will increase the risk of sexual inactivity and is closely associated with poor health [Citation11,Citation13,Citation23,Citation27,Citation28]. The GSSAB found that sexual difficulties were relatively common among adults worldwide and chronic illness could influence levels of sexual activity [Citation6–8]. Recently, Lindau et al. [Citation1] noted that sexuality was closely linked to health at older ages, more so for men than for women. In their study, participants in good physical health were more likely to have a spousal or other intimate relationship and were more likely to be sexually active [Citation1]. After controlling for other covariates including sexual function and partnership, we still found that increased number of comorbidities was an independent predictor for sexual inactivity in ageing Taiwanese men. In addition to adequate sexual function and the existence of sexual partner, sexual activity like sexual intercourse may be more physically demanding than other sexual behaviours, and could reflect the condition of physical health. In the previous study of Chen et al. [Citation29], they also found that sexual activity was inversely related to all-cause mortality in elderly Taiwanese men after controlling for age and other confounding factors. In clinical practice, ageing men who reported to decline the frequency of sexual intercourse should also be considered as a warning sign for poor health. Further investigation of the possibility of coexisted chronic illness should be done.
Sexual health is increasingly recognised as an important quality of life concern for older people. In addition to sexual function and physical health, socioeconomic factors could also influence sexual activity [Citation6–8]. The Asian population, especially those in the East Asian countries like Taiwan and China, has been reported to be more conservative regarding sex and less sexually active than other populations due to culture factors [Citation9–11]. In a sample of ageing Taiwanese men from this community-based study, we found that socioeconomic factors, especially lower education levels and loss of a partner, posed higher risk for men to be sexually inactive than poor health and sexual dysfunction. In addition to suggestion of healthier lifestyles to maintain physical health and sexual function, our findings suggested that persistent education of sexual health may be more important to help Taiwanese men to preserve their sexual activity when they enter mid to later life [Citation10].
There are some limitations in this study. First, our data was based on community-dwelling men participated in a free health screening. Although the screening was open to the general male population, some selection bias may exist. Nonetheless, the baseline characteristics and health conditions in our study population were similar to other large community-based and population-based studies conducted in Taiwan [Citation29,Citation30]. Accordingly, our data could provide an opportunity to evaluate the possible prevalence of and predictors for sexual inactivity in ageing Taiwanese men. Second, we didn't evaluate other sexual activities like oral sex and masturbation, because those questions may be more sensitive and reluctant to discuss in Chinese culture, especially for older Taiwanese men whose thinking was more likely to be traditional [Citation10]. Further large comprehensive and multicentre studies from different part of Taiwan may still need to confirm our preliminary results and may consider evaluating other forms of sexual activities in ageing Taiwanese men, and their reasons for sexual inactivity, as well as the impacts on quality of life.
In conclusion, most ageing Taiwanese men were still sexually active in their mid to later life, although the prevalence of sexual inactivity increased with age. In addition to older age and erectile dysfunction, lower education levels, loss of a partner and increased number of comorbidities were all independent predictors for sexual inactivity. Further research would need to elucidate whether improvement of those factors, like persistent education of sexual health to older people, especially to those with lower education levels or change of lifestyle to prevent chronic illness, could help to preserve sexual activity. Physicians should also note that sexual inactivity could be a warning sign for poor health in clinical practice.
Acknowledgements
This study was supported by grants from the Taiwan National Science Council (NSC 98-2314-B-037-030-MY3; NSC 97-2314-B-037-32; NSC 97-2314-B-037-031), Kaohsiung Medical University Hospital (KMUH97-7R22), Kaohsung Medical University (97-CCH-KMU-01), and Kaohsiung Municipal Hsiao-Kang Hospital (kmhk-96-009; kmhk-97-008). We thank Ms. Chao-Shih Chen for her help to hold the healthy screening and Mr. James Steed for editing this manuscript.
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