Prevalence of sexual problems and related help-seeking behaviors among mature adults in Brazil: data from the Global Study of Sexual Attitudes and Behaviors

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.


ABSTRACT InTRoduCTIon
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.2][13][14][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][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 helpseeking patterns for sexual problems across 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. 21,23Brazil 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.

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'.
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 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.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. 24he 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

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.
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.

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.

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  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.

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 pos-sible 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.

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  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 method was chosen in preference to face-toface 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. 26nly sexual problems that were experienced periodically or frequently (i.e.those that persisted with moderate to higher frequency) were considered to be "dysfunctions". 27This 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 northeast 13 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%. 12These 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).
][30][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 dysfunction among Brazilian men aged between 40 and 70 years. 13,14,32 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][35][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][13][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 REFEREnCES 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. 39This 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 crosssectional 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. 40he 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 middleaged 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.

of sexual problems and related help-seeking behaviors among mature adults in Brazil: data from the Global Study of Sexual Attitudes and Behaviors Centro
de Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz, and scientific directorate of Hospital São Rafael, Salvador, Bahia, Brazil 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.

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

Table 4 .
Prevalence of selected help seeking behaviors for sexual problems by gender,Brazil, 2001-2002

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