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3rd International Consultation on Sexual Medicine - Paris

Co-Sponsored by
International Consultation on Urological Diseases (ICUD)
International Society for Sexual Medicine (ISSM)

Edition 2010

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The great tragedy of science :

The slaying of a beautiful hypothesis by an ugly fact
Thomas Huxley (85s895)

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The Third International Consultation on Sexual Medicine (ICSM), which took place on July 10 to July 13, 2009 at the
Palais de Congres in Paris, France was organized under the auspices of the International Consultation on Urological
Diseases and the International Society for Sexual Medicine (ISSM). This year’s ICSM was a truly memorable scientiic
event full of impressive discoveries, never before seen studies backed by robust data and an overwhelming interest
from the audience. After having watched and listened to each and every one of the presentations given during the four
day meeting, we are pleased to afirm that the ield of Sexual Medicine for both Men and Women is making enormous
progress. This well deserved success is due to the dedication, perseverance and hard work done by the renowned
experts in the ield who sellessly devote their time, intellect and energy to promoting the results and indings obtained
by their studies.
To successfully carry out a meeting and publication as important as this, careful preparation was necessary. In early
2008, Chairman Francesco Montorsi, Secretary Saad Khoury, Honorary President Tom Lue and Vice Chairs; Ganesan
Adaikan, Rosemary Basson, Edgardo Becher, Anita Clayton, François Giuliano, Ira Sharlip all met together in person or
by phone conference in Paris with the ISSM ofice representatives to brainstorm on how a reference such as the Recom--
mendations for Sexual Medicine should be developed. Much thought and consideration went into deciding what topics
should be considered as chapters and how the meeting and eventual publication would be organized.
Choosing the Chairpersons, Members and Consultants was not an easy task as the experts in these ields are many
and each very distinguished. The identiication of the members of all the committees started from a very rigorous as--
sessment of the chairpersons and members of the 2003 Consultation as we clearly wanted to have on board again all
those who had given a substantial contribution to that meeting and were still available to actively participate this further
In addition, a very extensive PubMed search and a thorough evaluation of the scientiic programmes of the most impor--
tant international scientiic meetings devoted to sexual medicine served to identify the names of the top experts from
the ive continents.
The topics that were discussed in the 2003 Consultation served as the basis to build the programme of the 2009
meeting. We considered the advances done in the ield during the last six years and we identiied all the areas which
deserved to be speciically investigated by the experts of the new Consultation. In the end, we were able to produce a
table of contents composed of 25 Chapters covering a vast spectrum of the critical topics concerning aspects of sexual
medicine for both men and women.
The lists of topics and experts were then matched and the committees were formed. Although a few of those on each
of our “wish lists” could not be included due to economic restraints, we were able to guarantee the participation of 186
experts to the inal program.
The preparatory meetings held at the various major national meetings, the ISSM in Brussels and the American Urologi--
cal Association 2009 annual meeting in Chicago, were essential to understand how each chapter was progressing and
what the next steps should be. These meetings allowed everyone to inally meet face-to-face under the same roof to
streamline ideas and inal recommendations of their respective chapters. We were impressed to see the close collabo--
ration the committees had with one another to make sure that ideas were shared without overlap.
The work of the various committees was indeed very hard and was witnessed by the exchange of a huge number of
emails aimed at discussing the contents of the various chapters. We are very pleased to inform you that we were always
able to touch with our hands the enthusiasm and passion for science shown by the chairs and members of the com--
mittees. Sometimes there were strong views which would be contrasting but at the end it was always possible to ind a
general consensus and the inal editing of the chapters text was overall very smooth.
In Paris, the presentations of the committees were really top quality and it was clear to the audience that a huge amount
of work was behind the slides that were shown. The discussion sessions were always very lively and many ideas that
came out of these were used to improve the inal text of the chapters.
In the end, we believe that our objective to create and update a set of standards from evidence based studies and years
of research has been reached. This gratifying accomplishment could not have been made without the support from the
previously mentioned organizations, the various sponsors and the ambitious staff of the Consultation.
We are grateful to everyone involved and especially to Ira Sharlip who was instrumental in maintaining the necessary
geographical balance when identifying the top experts and also in obtaining funding for the meeting; to Tom Lue and all
the Vice Chairs who were extremely active during all the preparatory phases and to David Casalod and his team who
were the responsible persons for the very eficient logistics.
We are convinced that these contributions will be key in advancing our knowledge in the ield of sexual medicine and
ultimately in improving the care of our patients.


Chairman, ICSM Assistant to the Chairman, ICSM Secretary, ICSM

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Some of the members of the International

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Committees Paris, France

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F. Montorsi, A. Clayton,
r. Basson, F. Giuliano,
G. Adaikan S. Khoury,
E. Becher, I. Sharlip


(Alphabetical order - Chair persons in bold)

Lastname Firstname Country Committee Dai Yutain China 13

Abdo Carmita Brazil 17 Davis Susan Australia 23
Adams Michael Canada 8 Dean John UK 4
Ahn Tai Young South Korea 17 Dennerstein Lorraine Australia 21
Akkus Emre Turkey 12 Derogatis Leonard USA 6
Althof Stanley USA 3 Donatucci Craig USA 19
Amar Edouard France 5 Eardley Ian UK 19
Andersson Karl-Eric Sweden 11 El Sakka Ahmed Saudi Arabia 8
Angulo Javier Spain 13 El-Meliegy Amr Egypt 19
Anis Tarek Egypt 8 Faria Geraldo Brazil 18
Argiolas Antonio Italy 11 Fisher William Canada 21
Assalian Pierre Canada 3 Fugl Meyer Kerstin Sweden 2
Avis Nancy USA 23 Georgiadis Janniko Netherlands 22
Barada Jamie USA 12 Ghanem Hussein Egypt 15
Basson Rosemary Canada 9 Giraldi Annamaria Denmark 22
Bella Anthony Canada 20 Giuliano François France 7
Binik Irv M. Canada 25 Glasser Dale USA 2
Bitzer Johanes Switzerland 24 Glina Sidney Brazil 1
Bivalacqua Trinity USA 15 Goldmeier David UK 10
Bohm-Starke Nina Sweden 25 Goldstein Irwin USA 11
Briganti Alberto Italy 20 Gonzalez Cadavid Nestor USA 16
Brock Gerald Canada 20 Granot Michal Israel 25
Broderick Gregory USA 15 Graziottin Alessandra Italy 25
Brotto Lori Canada 24 Guay Andre USA 14
Burnett Arthur USA 11 Hackett Geoff UK 5
Buvat Jacques France 14 Hatzichristou Dimitris Greece 6
Calomirescu Nicolae Romania 5 Hatzimouratidis Kostas Greece 19
Carrier Serge Canada 12 Hayes Richard United Kingdom 2
Carson Culley USA 18 Hedlund Peter Sweden 7
Chen Juza Israel 17 Hellstrom Wayne USA 18
Chevret-Measson Marie France 3 Hisasue Shin-ichi Japan 7
Chitaley Kanchan USA 13 Incrocci Luca Netherlands 9
Chivers Meredith Canada 22 Jackson Graham UK 8
Christ George USA 11 Jannini Emmanuele Italy 17
Clayton Anita USA 21 Juenemann Klaus Peter Germany 20
Corbin Jackie USA 19 Kadioglu Ates Turkey 15
Corona Giovanni Italy 2 Kaufman Joel M. USA 14
Costabile Ray USA 20 Kim Edward USA 8
Dabees Khaled Egypt 4 Kim Noel USA 13

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Kimoto Yasusuke Japan 5 Ramlachan Prithy South Africa 5
Kingsberg Sheryl USA 21 Rees Peter Canada 9
Krishnamurti Sudhakar India 18 Rellini Alessandra Italy 2
Krychman Michael USA 9 Richardson Daniel UK 10
Laan Ellen Netherlands 24 Rivero Miguel Argentina 5
Labrie Fernand Canada 23 Rosen Raymond USA 6
Laumann Edward USA 2 Rosner William USA 23
Lebret Thierry France 16 Rowland David L. USA 17
Lee Sung Won South Korea 19 Rubio-Aurioles Eusebio Mexico 4
Leiblum Sandra USA 3 Sadeghi Nejad Hossein USA 10
Leiblum Sandra USA 24 Sadovsky Richard USA 9
Levin Roy UK 22 Salonia Andrea Italy 22
Levine Lawrence USA 16 Schover Leslie USA 9
Lewis Ron USA 2 Schulman Claude Belgium 14
Low Wah Yun Malaysia 6 Schultheiss Dirk Germany 1
Lue Tom USA 13 Seftel Allen USA 12
Luria Mijal Israel 24 Segraves Taylor USA 2
Maggi Mario Italy 14 Shabsigh Ridwan USA 5
Maravilla Ken USA 22 Shamloul Rany Canada 15
Marson Leslie USA 7 Shifren Jan USA 23
Martin Morales Antonio Spain 9 Simonelli Chiara Italy 3
McCabe Marita Australia 3 Simonsen Ulf Denmark 13
McCarthy Margaret USA 22 Sohn Michael Germany 16
Sotomayor De
McCullough Andrew USA 20
Zava Mariano Mexico 6
McMahon Chris Australia 17
Srilatha Balasubramanian Singapore 7
McVary Kevin USA 19
Stief Christian Germany 13
Melman Arnold USA 12
Symonds Tara UK 6
Meryn Siegfried Austria 5
Tan Hui Meng Malaysia 14
Meuleman Eric Netherlands 6
Teloken Claudio Brazil 12
Miner Martin USA 8
Tiefer Leonore USA 4
Minhas Suks UK 18
Torres Luis Otavio Brazil 5
Mirone Vincenzo Italy 16
Uckert Stefan Germany 13
Moncada Ignacio Spain 18
Ugarte y Romano Fernando Mexico 4
Montague Karl USA 18
Usta Mustafa Turkey 16
Montejo Angel Luis Spain 9
Van Lankveld Jacques Netherlands 25
Montorsi Piero Italy 8
Vardi Yoram Israel 6
Moreira Edson Brazil 2
Vardi Yoram Israel 12
Morgentaler Abraham USA 14
Virag Ronald France 1
Mullhall John USA 20
Vlachopoulos Charalambos Greece 8
Munarriz Ricardo USA 19
Wagner Gorm Denmark 1
Nappi Rossella Italy 23
Waldinger Marcel Netherlands 17
Nehra Ajay USA 15
Wallen Kim USA 7
O’Connell Helen Australia 22
Wang Run USA 9
O’Leary Michael USA 6
Wasserman Marlene South Africa 10
Paick Jae-Seung South Korea 13
Weidner Wolfgang Germany 10
Parish Sharon USA 4
Weijmar Schultz Willibrord Netherlands 25
Park Kwangsung South Korea 11
Wespes Eric Belgium 13
Park Nam Cheol South Korea 12
Wesselmann Ursula USA 25
Perelman Michael USA 21
Wierman Margaret USA 23
Perovic Sava Serbia 16
Wylie Kevan UK 3
Pfaus Jim Canada 7
Wyllie Mike UK 12
Porst Hartmut Germany 12
Xin ZhongCheng China 11
Pukall Caroline Canada 25
Yassin Aksam Germany 14
Pyke Robert USA 21
Zitzman Michael Germany 14
Ralph David UK 16

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1. Historical highlights of sexual dysfunctions in men 7. Experimental models for the study of female and
and women male sexual function
DIrK Schultheiss, Germany BALASUBRAMANIAN Srilatha, Singapore
GOrM Wagner, Denmark FrANçOIS Giuliano, France
SIDNEy Glina, Brazil KIM Wallen, uSA
JIM Pfaus, Canada
2. Deinitions, classiication and epidemiology of LESLIE Marson, USA
sexual dysfunction PETTER Hedlund, Sweden
ALESSANDRA Rellini, Italy SHIN-ICHI Hisaue, Japan
DALE Glasser, USA
EDSoN Moreira, Brazil 8. Cardiovascular aspects of sexual medicine
EDWARD Laumann, USA AHMED El Sakka, Saudi Arabia
GIoVANNI Corona, Italy CHARALAMBoS Vlachopoulos, Greece
KErSTIN FuGL Meyer, Sweden EDWARD Kim, USA
rON Lewis, uSA GrAHAM Jackson, uK
TAyLoR Segraves, USA PIErO Montorsi, Italy
WILLIAM Fisher, Canada MICHAEL Adams, Canada
TAREK Anis, Egypt
3. Psycological and interpersonal dimensions of
sexual function and dysfunction 9. Sexual function in chronic illness and cancer
CHIARA Simonelli, Italy ANGEL LUIS Montejo, Spain
KEVAN Wylie, UK ANToNIo MARTIN Morales, Spain
MARIE Chevret-Measson, France LESLIE Schover, USA
MArITA McCabe, Australia LuCA Incrocci, Netherlands
PIERRE Assalian, Canada MICHAEL Krychman, USA
SANDRA Leiblum, USA PETER Rees, Canada
rOSEMAry Basson, Canada
STANLEy Althof, uSA
4. Ethical, socio-cultural and educational aspects of 10. Sexually transmitted diseases and sexual function
sexual medicine DAVID Goldmeier, UK
EUSEBIo Rubio-Aurioles, Mexico HOSSEIN SADEGHI Nejad, uSA
FERNANDo Ugarte y Romano, Mexico LUCIA o’Sullivan, Canada
JOHN Dean, uK MArLENE Wasserman, South Africa
KHALED Dabees, Egypt WOLFGANG Weidner, Germany
LEoNoRE Tiefer, USA
SHARoN Parish, USA 11. Future treatment targets for sexual dysfunctions
ANToNIo Argiolas, Italy
5. Economic aspects of sexual dysfunction ArTHur Burnett, uSA
CARoLyN Earle, Australia GEoRGE Christ, USA
IrWIN Goldstein, uSA
GEOFF Hackett, uK
KARL-ERIC Andersson, Sweden
LUIS otavio Torres, Brazil
NICoLAE Calomirescu, Romania
PRITHy Ramlachan, South Africa 12. Standards for clinical trials in male sexual
rIDWAN Shabsigh, uSA dysfunctions
SIEGFRIED Meryn, Austria ALLEN Seftel, USA
yASUSUKE Kimoto, Japan ARNoLD Melman, USA
CLAUDIo Teloken, Brazil
6. Clinical evaluation and symptom scales: sexual EMRE Akkus, Turkey
dysfunction assessment HArTMuT Porst, Germany
DIMITrIS Hatzichristou, Greece JAMIE Barada, USA
ERIC Meuleman, Netherlands MIKE Wyllie, UK
LEoNARD Derogatis, USA NAM CHEoL Park, South Korea
MARIANo Sotomayor De Zava, Mexico SERGE Carrier, Canada
MICHAEL o’Leary, USA yOrAM Vardi, Israel
rAyMOND rosen, uSA 13. Physiology and pathophysiology of Men’s Sexual
TARA Symonds, UK Arousal and Penile Erection
WAH yun Low, Malaysia CHrISTIAN Stief, Germany
yoRAM Vardi, Israel ERIC Wespes, Belgium

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TOM Lue, uSA ALBERTo Briganti, Italy
JAE-SEUNG Paick, South Korea ANDREW McCullough, USA
JAVIER Angulo, Spain ANTHoNy Bella, Canada
KANCHAN Chitaley, USA GErALD Brock, Canada
JOHN Mullhall, uSA
RAy Costabile, USA
STEPHAN Uckert, Germany
ULF Simonsen, Denmark 21. Standards for clinical trials in sexual dysfunctions
yUTAIN Dai, China of women: research designs and outcomes
14. Endocrine aspects of male sexual dysfunction ANDRE Guay, USA
ABRAHAM Morgentaler, USA ANITA Clayton, uSA
ANDRE Guay, USA LoRRAINE Dennerstein, Australia
CLAUDE Schulman, Belgium MICHAEL Perelman, USA
HUI MENG Tan, Malaysia SHERyL Kingsberg, USA
JACquES Buvat, France
JoEL M. Kaufman, USA 22. Physiology of women’s sexual function and patho--
LUIZ oTAVIo Torres, Brazil physiology of women’s sexual dysfunction
MArIO Maggi, Italy ANDrEA Salonia, Italy
MICHAEL Zitzman, Germany ANNAMArIA Giraldi, Denmark
HELEN o’Connell, Australia
15. Priapism JANNIKo Georgiadis, Netherlands
AJAy Nehra, USA KEN Maravilla, USA
ATES Kadioglu, Turkey MARGARET McCarthy, USA
GrEGOry Broderick, uSA MEREDITH Chivers, Canada
HUSSEIN Ghanem, Egypt Roy Levine, USA
RANy Shamloul, Canada
TRINITy Bivalacqua, USA 23. Endocrine aspects of women’s sexual dysfunction
FERNAND Labrie, Canada
16. La Peyronie’s Disease, penile trauma and gender JAN Shifren, USA
reassignment surgery MArGArET Wierman, uSA
DAVID ralph, uK NANCy Avis, USA
LAWrENCE Levine, uSA rOSSELLA Nappi, Italy
MICHAEL Sohn, Germany SUSAN Davis, Australia
MUSTAFA Usta, Turkey WIEBKE Arlt, UK
SAVA Perovic, Serbia
24. Women’s sexual desire and arousal disorders
THIERRy Lebret, France
ELLEN Laan, Netherlands
VINCENZo Mirone, Italy
JoHANES Bitzer, Switzerland
17. Disorders of orgasm and ejaculation in men LOrI Brotto, Canada
CARMITA Abdo, Brazil MIJAL Luria, Israel
CHrIS McMahon, Australia SANDRA Leiblum, USA
DAVID L. rowland, uSA 25. Women’s sexual pain disorders
EMMANUELE Jannini, Italy ALESSANDRA Graziottin, Italy
JUZA Chen, Israel CARoLINE Pukall, Canada
MARCEL Waldinger, Netherlands IRV M. Binik, Canada
TAI young Ahn, South Korea JACquES VAN Lankveld, Netherlands
18. Implants, mechanical devices and vascular surgery MICHAL Granot, Israel
for erectile dysfunction NINA Bohm-Starke, Sweden
CULLEy Carson, USA URSULA Wesselmann, USA
GERALDo Faria, Brazil WILLIBRORD WEIJMAR Schultz, Netherlands
IGNACIo Moncada, Spain 26. Summary of the recommendations on Sexual Dys--
KArL Montague, uSA functions in Men
SUKS Minhas, UK
SUDHAKAR Krishnamurti, India 27. Summary of the recommendations for Women’s
WAyNE Hellstrom, uSA Sexual Dysfunction
19. Pharmacotherapy for erectile dysfunction RoSEMARy BASSoN MD,
KoSTAS Hatzimouratidis, Greece
RICARDo Munarriz, USA
SUN WON Lee, South Korea
20. Sexual rehabilitation after treatment for prostate

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eVIdeNCe – BASed MedICINe oVerVIew oF THe MAIN STePS For
INTrODuCTION 2.2 How papers are analysed?
The International Consultation on Urological Diseases (ICUD) Papers published in peer reviewed journals have differing
is a non-governmental organization registered with the World quality and level of evidence.
Health Organisation (WHO). In the last ten years Consultations Each committee will rate the included papers according to
have been organised on BPH, Prostate Cancer, Urinary Stone
levels of evidence (see below).
Disease, Nosocomial Infections, Erectile Dysfunction and
Urinary Incontinence. These consultations have looked at The level (strength) of evidence provided by an individual
published evidence and produced recommendations at four study depends on the ability of the study design to minimise
levels; highly recommended, recommended, optional and not the possibility of bias and to maximise attribution.
recommended. This method has been useful but the ICUD is inluenced by:
believes that there should be more explicit statements of the
levels of evidence that generate the subsequent grades of • the type of study
recommendations. The hierarchy of study types are:
The Agency for Health Care Policy and Research - Systematic reviews and meta-analysis of randomised
(AHCPR) have used speciied evidence levels to justify controlled trials
recommendations for the investigation and treatment of a - Randomised controlled trials
variety of conditions. The oxford Centre for Evidence Based
Medicine have produced a widely accepted adaptation of the - Non-randomised cohort studies
work of AHCPR. (June 5th 2001 http://minerva.minervation. - Case control studies
com/cebm/docs/levels.html). The ICUD has examined the
- Case series
oxford guidelines and discussed with the oxford group
their applicability to the Consultations organised by ICUD. It - Expert opinion
is highly desirable that the recommendations made by the • how well the study was designed and carried out
Consultations follow an accepted grading system supported
by explicit levels of evidence. Failure to give due attention to key aspects of study
methodology increase the risk of bias or confounding factors,
The ICUD proposes that future consultations should use a and thus reduces the study’s reliability.
modiied version of the Oxford system which can be directly
‘mapped’ onto the oxford system. The use of standard check lists is recommended to insure
that all relevant aspects are considered and that a consistent
1. 1st Step: Deine the speciic questions or statements approach is used in the methodological assessment of the
that the recommendations are supposed to address. evidence.
2. 2nd Step: Analyse and rate (level of evidence) the The objective of the check list is to give a quality rating for
relevant papers published in the literature. individual studies.
The analysis of the literature is an important step in preparing
• how well the study was reported
recommendations and their guarantee of quality.
The ICUD has adopted the CoNSoRT statement and its
2.1 What papers should be included in the analysis?
widely accepted check list. The CoNSoRT statement and
• Papers published, or accepted for publication in the peer the checklist are available at
reviewed issues of journals.
http: //www.consort-statement.org
• The committee should do its best to search for papers
accepted for publication by the peer reviewed journals in 2.3 How papers are rated?
the relevant ield but not yet published. Papers are rated following a «Level of Evidence scale».
• Abstracts published in peer review journals should be ICUD has modiied the Oxford Center for Evidence-Based
identiied. If of suficient interest the author(s) should Medicine levels of evidence.
be asked for full details of methodology and results. The The levels of evidence scales vary between types of studies
relevant committee members can then ‘peer review’ the (ie therapy, diagnosis, differential diagnosis/symptom
data, and if the data conirms the details in the abstract, prevalence study).
then that abstract may be included, with an explanatory
footnote. This is a complex issue – it may actually increase the Oxford Center for Evidence-Based Medicine Website:
publication bias as “uninteresting” abstracts commonly do http://minerva.minervation.com/cebm/docs/ levels.html
not progress to full publication. 3. 3rd Step: Synthesis of the evidence
• Papers published in non peer reviewed supplements will After the selection of the papers and the rating of the level
not be included. of evidence of each study, the next step is to compile a
An exhaustive list should be obtained through: summary of the individual studies and the overall direction of
I.the major databases covering the last ten years (e.g. the evidence in an Evidence Table.
Medline, Embase, Cochrane Library, Biosis, Science 4. 4th Step: Considered judgment (integration of
Citation Index) individual clinical expertise)
II. the table of contents of the major journals of urology and Having completed a rigorous and objective synthesis of the
other relevant journals, for the last three months, to take evidence base, the committee must then make a judgement
into account the possible delay in the indexation of the as to the grade of the recommendation on the basis of this
published papers in the databases. evidence. This requires the exercise of judgement based on
It is expected that the highly experienced and expert clinical experience as well as knowledge of the evidence and
committee members provide additional assurance that no the methods used to generate it. Evidence based medicine
important study would be missed using this review process. requires the integration


First pages.indd 10 8/25/2010 12:49:36 PM

of individual clinical expertise with best available external 6.2 Grades of Recommendation
clinical evidence from systematic research. Without the The ICUD will use the four grades from the oxford system.
former, practice quickly becomes tyrannised by evidence, for As with levels of evidence the grades of evidence may apply
even excellent external evidence may be inapplicable to, or either positively (do the procedure) or negatively (don’t do the
inappropriate for, an individual patient: without current best procedure). Where there is disparity of evidence, for example
evidence, practice quickly becomes out of date. Although it if there were three well conducted RCT’s indicating that Drug
is not practical to lay our “rules” for exercising judgement, A was superior to placebo, but one RCT whose results show
guideline development groups are asked to consider the no difference, then there has to be an individual judgement
evidence in terms of quantity, quality, and consistency; as to the grade of recommendation given and the rationale
applicability; generalisability; and clinical impact. explained.
5. 5th Step: Final Grading • Grade A recommendation usually depends on consistent
The grading of the recommendation is intended to strike an level 1 evidence and often means that the recommenda--
appropriate balance between incorporating the complexity of tion is effectively mandatory and placed within a clinical care
type and quality of the evidence and maintaining clarity for pathway. However, there will be occasions where excellent
guideline users. evidence (level 1) does not lead to a Grade A recommenda--
tion, for example, if the therapy is prohibitively expensive,
The recommendations for grading follow the oxford Centre dangerous or unethical. Grade A recommendation can
for Evidence-Based Medicine. follow from Level 2 evidence. However, a Grade A recom--
The levels of evidence shown below have again been mendation needs a greater body of evidence if based on
modiied in the light of previous consultations. There are now anything except Level 1 evidence
4 levels of evidence instead of 5. • Grade B recommendation usually depends on consistent
The grades of recommendation have not been reduced and a level 2 and or 3 studies, or ‘majority evidence’ from RCT’s.
“no recommendation possible” grade has been added. • Grade C recommendation usually depends on level 4
6. Levels of Evidence and Grades of recommendation studies or ‘majority evidence’ from level 2/3 studies or Dephi
Therapeutic Interventions processed expert opinion.
All interventions should be judged by the body of evidence • Grade D “No recommendation possible” would be used
for their eficacy, tolerability, safety, clinical effectiveness and where the evidence is inadequate or conlicting and when
cost effectiveness. It is accepted that at present little data expert opinion is delivered without a formal analytical
exists on cost effectiveness for most interventions. process, such as by Dephi.
6.1 Levels of Evidence 7. Levels of Evidence and Grades of recommendation
for Methods of Assessment and Investigation
Firstly, it should be stated that any level of evidence may be
positive (the therapy works) or negative (the therapy doesn’t From initial discussions with the oxford group it is clear that
work). A level of evidence is given to each individual study. application of levels of evidence/grades of recommendation
for diagnostic techniques is much more complex than for
• Level 1 evidence (incorporates oxford 1a, 1b) usually interventions.
involves meta-anaylsis of trials (RCTs) or a good quality
The ICUD recommend, that, as a minimum, any test
randomised controlled trial, or ‘all or none’ studies in which
no treatment is not an option, for example in vesicovaginal should be subjected to three questions:
istula. 1. does the test have good technical performance, for
• Level 2 evidence (incorporates oxford 2a, 2b and 2c) example, do three aliquots of the same urine sample give
includes “low” quality RCT (e.g. < 80% follow up) or the same result when subjected to ‘stix’ testing?
metaanalysis (with homogeneity) of good quality prospective 2. Does the test have good diagnostic performance, ideally
‘cohort studies’. These may include a single group when against a “gold standard” measure?
individuals who develop the condition are compared with 3. Does the test have good therapeutic performance, that is,
others from within the original cohort group. There can be does the use of the test alter clinical management, does
parallel cohorts, where those with the condition in the irst the use of the test improve outcome?
group are compared with those in the second group.
For the third component (therapeutic performance) the same
• Level 3 evidence (incorporates oxford 3a, 3b and 4) approach can be used as for section 6.
8. Levels of Evidence and Grades of recommendation
good quality retrospective ‘case-control studies’ where for Basic Science and Epidemiology Studies
a group of patients who have a condition are matched The proposed ICUD system does not easily it into these
appropriately (e.g. for age, sex etc) with control individuals areas of science. Further research needs to be carried out,
who do not have the condition. in order to develop explicit levels of evidence that can lead
good quality ‘case series’ where a complete group of patients to recommendations as to the soundness of data in these
all, with the same condition/disease/therapeutic intervention, important aspects of medicine.
are described, without a comparison control group. CONCLuSION
• Level 4 evidence (incorporates oxford 4) includes expert The ICuD believes that its consultations should follow
opinion were the pinion is based not on evidence but on the ICuD system of levels of evidence and grades of
‘irst principles’ (e.g. physiological or anatomical) or bench recommendation, where possible. This system can be
research. The Delphi process can be used to give ‘expert mapped to the Oxford system.
opinion’ greater authority. In the Delphi process a series of There are aspects to the icuD system that require further
questions are posed to a panel; the answers are collected research and development, particularly diagnostic
into a series of ‘options’; the options are serially ranked; performance and cost effectiveness, and also factors
if a 75% agreement is reached then a Delphi consensus such as patient preference.
statement can be made. P. Abrams, S Khoury, A. Grant 19/1/04

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- Foreword
- Members of the committees
- Evidence Based Medicine overview
- Contents
Committee 1: Historical highlights of sexual dysfunctions in men and women
Sidney Glina, Brazil, Dirk Schultheiss, Germany, Gorm Wagner, Denmark
Committee 2: Deinitions, classiication and epidemiology of sexual dysfunction
Kerstin Fugl Meyer, Sweden, ron Lewis, uSA, Giovanni Corona, Italy,
William Fisher, Canada, Edward Laumann, USA, Edson Moreira, Brazil,
Alessandra Rellini, Italy, Taylor Segraves, USA, Consultant Dale Glasser, USA
Committee 3: Psychological and interpersonal dimensions of sexual function and
Stanley Althof, uSA, Marita McCabe, Australia, Pierre Assalian, Canada,
Marie Chevret-Measson, France, Sandra Leiblum, USA, Chiara Simonelli, Italy, Kevan Wylie, UK
Committee 4: Ethical, socio-cultural and educational aspects of sexual medicine
John Dean, uK, Khaled Dabees, Egypt, Sharon Parish, USA, Eusebio Rubio-Aurioles, Mexico
Leonore Tiefer, USA, Consultant Fernando Ugarte y Romano, Mexico
Committee 5: Economic aspects of sexual dysfunction
Geoff Hackett, uK, ridwan Shabsigh, uSA, Nicolae Calomirescu, Romania,
Yasusuke Kimoto, Japan, Siegfried Meryn, Austria, Luis Otavio Torres, Brazil,
Consultants Carolyn Earle, Australia, Prithy, Ramlachan, South Africa
Committee 6: Clinical evaluation and symptom scales: sexual dysfunction
Dimitris Hatzichristou, Greece, raymond rosen, uSA, Leonard Derogatis, USA,
Eric Meuleman, Netherlands, Michael O’Leary, USA, Yoram Vardi, Israel,
Wah Yun Low, Malaysia, Consultants Mariano Sotomayor De Zava, Mexico, Tara Symonds, UK
Committee 7: Experimental models for the study of female and male sexual function
François Giuliano, France, Kim Wallen, uSA, Petter Hedlund, Sweden, Leslie Marson, USA,
Jim Pfaus, Canada, Balasubramanian Srilatha,Singapore, Consultant Shin-ichi Hisaue, Japan
Committee 8: Cardiovascular aspects of sexual medicine
Graham Jackson, uK, Piero Montorsi, Italy, Michael Adams, Canada, Tarek Anis, Egypt
Ahmed El Sakka, Saudi Arabia, Charalambos Vlachopoulos, Greece,
Consultant Edward Kim, USA
Committee 9: Sexual function in chronic illness and cancer
rosemary Basson, Canada, Luca Incrocci, Netherlands, Michael Krychman, USA,
Angel Luis Montejo, Spain, Antonio Martin Morales, Spain, Peter Rees, Canada,
Leslie Schover, USA, Run Wang, USA
Committee 10: Sexually transmitted diseases and sexual function
Hossein Sadeghi Nejad, uSA, Marlene Wasserman, South Africa, David Goldmeier, UK,
Lucia O’Sullivan, Canada, Wolfgang Weidner, Germany
Committee 11: Future treatment targets for sexual dysfunctions
Arthur Burnett, uSA, Irwin Goldstein, uSA, Karl-Eric Andersson, Sweden,
Antonio Argiolas, Italy, George Christ, USA, ZhongCheng Xin, China
Committee 12: Standards for clinical trials in male sexual dysfunctions
Hartmut Porst, Germany, yoram Vardi, Israel, Emre Akkus, Turkey, Jamie Barada, USA,
Serge Carrier, Canada, Arnold Melman, USA, Nam Cheol Park, South Korea, Allen Seftel, USA
Claudio Teloken, Brazil, Mike Wyllie, UK

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Committee 13: Physiology and pathophysiology of Men’s Sexual Arousal and Penile Erection
Tom Lue, uSA, Christian Stief, Germany, Javier Angulo, Spain, Yutain Dai, China,
Noel Kim, USA, Stephan Uckert, Germany, Eric Wespes, Belgium,
Consultants Kanchan Chitaley, USA, Jae-Seung Paick, South Korea, Ulf Simonsen, Denmark
Committee 14: Endocrine aspects of male sexual dysfunction
Jacques Buvat, france, mario maggi, italy, Abraham Morgentaler, USA,
Claude Schulman, Belgium, Michael Zitzman, Germany, Consultants Andre Guay, USA,
Joel M. Kaufman, USA, Hui Meng Tan, Malaysia, Luiz Otavio Torres, Brazil
Committee 15: Priapism
Gregory Broderick, uSA, Ates Kadioglu, Turkey, Trinity Bivalacqua, USA,
Hussein Ghanem, Egypt, Ajay Nehra, USA, Rany Shamloul, Canada
Committee 16: La Peyronie’s Disease, penile trauma and gender reassignment surgery
Lawrence Levine, uSA, David ralph, uK, Thierry Lebret, France, Vincenzo Mirone, Italy
Michael Sohn, Germany, Consultants Nestor Gonzalez Cadavid, USA, Sava Perovic, Serbia
Mustafa Usta, Turkey
Committee 17: Disorders of orgasm and ejaculation in men
Chris McMahon, Australia, David L. rowland, uSA, Carmita Abdo, Brazil, Juza Chen, Israel
Emmanuele Jannini, Italy, Marcel Waldinger, Netherlands, Consultant Tai Young Ahn, South Korea
Committee 18: Implants, mechanical devices and vascular surgery for erectile dysfunction
Wayne Hellstrom, uSA, Karl Montague, uSA, Culley Carson, USA, Sudhakar Krishnamurti, India
Suks Minhas, UK, Ignacio Moncada, Spain, Consultant Geraldo Faria, Brazil
Committee 19: Pharmacotherapy for erectile dysfunction
Craig Donatucci, uSA, Ian Eardley, uK, Jackie Corbin, USA, Kostas Hatzimouratidis, Greece
Kevin McVary, USA, Consultants Ricardo Munarriz, USA, Sun Won Lee, South Korea
Committee 20: Sexual rehabilitation after treatment for prostate cancer
Gerald Brock, Canada, John Mullhall, uSA, Alberto Briganti, Italy,
Klaus Peter Juenemann, Germany, Andrew McCullough, USA,
Consultants Anthony Bella, Canada, Ray Costabile, USA
Committee 21: Standards for clinical trials in sexual dysfunctions of women: research
designs and outcomes assessment
Anita Clayton, uSA, Lorraine Dennerstein, Australia, Andre Guay, USA, Sheryl Kingsberg, USA
Michael Perelman, USA
Committee 22: Physiology of women’s sexual function and pathophysiology of
women’s sexual dysfunction
Annamaria Giraldi, Denmark, Andrea Salonia, Italy, Meredith Chivers, Canada,
Janniko Georgiadis, Netherlands, Ken Maravilla, USA, Margaret McCarthy, USA,
Helen O’Connell, Australia, Consultant Roy Levine, USA
Committee 23: Endocrine aspects of women’s sexual dysfunction
rossella Nappi, Italy, Margaret Wierman, uSA, Wiebke Arlt, UK, Nancy Avis, USA,
Susan Davis, Australia, Fernand Labrie, Canada, William Rosner, USA, Jan Shifren, USA
Committee 24: Women’s sexual desire and arousal disorders
Lori Brotto, Canada, Johanes Bitzer, Switzerland, Ellen Laan, Netherlands, Sandra Leiblum, USA
Mijal Luria, Israel
Committee 25: Women’s sexual pain disorders
Jacques van lankveld, netherlands, Irv M. Binik, Canada, Michal Granot, Israel,
Alessandra Graziottin, Italy, Willibrord Weijmar Schultz, Netherlands,
Consultants Nina Bohm-Starke, Sweden, Caroline Pukall, Canada, Ursula Wesselmann, USA
Committee 26: Summary of the Recommendations on Sexual Dysfunctions in Men
Committee 27: Summary of the Recommendations for Women’s Sexual Dysfunction

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Committee 01

of Sexual Medicine


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of Sexual Medicine


of botanics and was irst adopted in the title of a

I. INTrODuCTION German monography by August Henschel “Von
der Sexualität der Planzen (On the sexuality of
plants)” in 1820 [1]. After its transfer to human
sexuality the term was primarily reserved for the
Today we have a clear concept of sexual medicine
aspect of reproduction and not for sexual desire
and how to deine this medical discipline. But
and emotionality. Even Paolo Mantegazza was still
historically the uniication of sexuality and medicine
talking of love (amore) when he was referring to the
was not a given condition. Medicine was mainly
sexual relation of two individuals. He never used the
focused on human reproduction and how to prevent
terms sexual or sexuality. However this changed in
and treat sexually transmitted diseases (STD).
the late 19th century and culminated in the 2nd half
Hardly any other aspect would have met the interest
of the 20th century by even reducing the term to the
of medical doctors for centuries. Perhaps the irst true abridged version sex.
medicalization of sexuality, i.e. the fusion of medicine
and sexuality, was the dreadful anti-masturbation Sexology (“Sexualwissenschaft”): According
campaign led by doctors, beginning with Tissot, to Sigusch [1] the term sexology appeared irst in
since the middle of the 18th century. Therefore, we a book entitled “Sexology as the philosophy of life:
have chosen this period as the starting point for this implying social organization and government” written
article and only included the respective development by Elizabeth Osgood Goodrich Willard and published
before that time in some aspects. in Chicago, Illinois, in 1867. It is a parafeministic
monography with religious fundamentalistic tendency
We would like to point out that his article can only relecting the human female and male interaction.
highlight developments and milestones of sexual In a lecture on “The woman´s question” from 1885
medicine and is not intended to be encyclopaedic. and published in 1888 the English mathematician,
The historical primary literature has not been refer-- statistician and eugenicist Karl Pearson asked for a
enced extensively, but the reader is referred to se-- “real science of sexualogy”.
lected secondary literature sources that will provide In the German literature the equivalent term
detailed information on each respective topic. More-- Sexualwissenschaft was popularized by the
over, the focus is on the medical perspective rather dermatologist Iwan Bloch from Berlin in his famous
than on the interdisciplinary aspect that deines the book “Das Sexualleben unserer Zeit (The sexual
discipline of sexology. life in our time)” oficially published in 1907, but
actually already on the market in fall 1906 [2]. A
clear deinition of the interdisciplinary approach
II. TErMINOLOGy of sexology is stated in this work. However,
Sigmund Freud had used the same term earlier
Sexuality: Before the 18th century only the adjective in 1898 in an essay dealing with the importance
sexual (Latin: sexualis) was used in the sense of of sexual events for the development of neurosis,
“belonging to the sex or gender”. To our knowledge but without earning the same or even any public
the noun sexuality appeared after 1800 in the ield recognition. So did the writer Karl Vanselow in 1904


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and the sexologist Magnus Hirschfeld in 1906 [1]. Spiritual and Physical Advice to those who have
“Sexualwissenschaft” was initially translated literally already injured themselves by this abominable
as “Sexual Science” but was rapidly transformed practice.” that experienced several re-editions and
more adequately in “Sexology”. The subsequent translations and resulted in a irst public awareness
development of sexology after 1907 and reference for a new medical entity, i.e. masturbation which also
of later authors to the text of Bloch underline the included involuntary seminal loss often referred to
importance of his book. Another founding milestone as spermatorrhoea. This publication was indeed the
not only in terms of terminology is the journal beginning of an anti-masturbation campaign that
“Zeitschrift für Sexualwissenschaft (Journal for lasted until the mid- 20th Century. It was not only a
Sexual Science)” founded in January 1908. Neither socio-cultural and religious issue but increasingly
the introducing article “Über Sexualwissenschaft gained interest of medical doctors.
(On Sexual Science)” written by the journal´s editor
In 1758 the Swiss physician Simon Auguste Da--
Magnus Hirschfeld [3], nor another contribution
vid Tissot (1728-1797) published a book entitled
in the journal´s irst issue “Bemerkungen zur
“L’Onanisme, Dissertation sur les Maladies produ--
Nomenklatur der Sexualwissenschaft (Remarks on
ites par la Masturbation” (“Onanism, Treatise on the
the Nomenclature of Sexual Science)” mentioned
Diseases produced by Masturbation”) (Fig. 1).
the term sexual medicine [4].
Sexual Medicine: However, the above
mentioned irst issue of the journal “Zeitschrift für
Sexualwissenschaft” does contain an article entitled
“Forensische Sexualmedizin (Forensic Sexual
Medicine)” written by the lawyer Joh. Werthauer from
Berlin [5]. The article is only reviewing legal cases
that include some kind of sexual act or misconduct.
Therefore, the modern deinition of sexual medicine
is in no way indicated in this publication. Although
aspects of sexuality in medicine were addressed by
many physicians and sexologists in the following
decades the term sexual medicine was not
established before the 1970´s. It is quite dificult to
identify the exact time or even person who deserves
the credit for introducing the term in its modern
deinition. One interesting question in this context
(Fig.1) Simon Auguste David Tissot (portrait and
might be the shift from the understanding of “Clinical frontispiece of his publication from 1758.
Sexology” towards “Sexual Medicine”. In 1972
Volkmar Sigusch from Germany published a book
“Ergebnisse zur Sexualmedizin (Results for Sexual
With this writing the young medical doctor from
Medicine)” in which he deines this new academic
Lausanne became the most inluential medical
speciality but also complains about the fact that
propagandist of the alleged dangers of masturbation.
medical faculties and the majority of the medical
For more than 150 years, the fear of «masturbatory
community are still unwilling to accept the developing
insanity» remained a dominant theme of disease
discipline of sexual medicine [6]. Since April 1972 the
prevention and adolescent sexual education. As
German journal “Sexualmedizin” and one year later
outlined above Tissot was not the irst to imagine
the “British Journal of Sexual Medicine” were the irst
that nocturnal emissions and masturbation were a
periodicals literally dedicated to the new discipline
medical problem, but he deinitely anthologized and
and several monographies and textbooks including
summarized earlier thoughts on this subject. Tissot’s
the term sexual medicine in their title were published
work helped reshape medicine’s attitude towards
in the 2nd half of the 1970´s [7].
sexuality and provided an additional scientiic basis
upon which the process of pathologization of sexual
III. “THE TrEATMENT OF ONANISM” anatomy and sexual functions could proceed.
- THE FIrST SySTEMATIC Tissot’s primary contribution was not as an innovator
but as a skilful collator and editor of independently
MEDICALIzATION OF SExuALITy expressed, roughly contemporary medical views
on masturbation. His highly original argument was
Around 1712 an anonymous author, most likely carefully constructed and supported by references
the quack doctor and medical pornographer John to earlier authorities, such as Galen, Aretaeus,
Marten [8], published the pamphlet “Onania; or, the Celsus, Boerhaave, Gaubius, Koempf, Sennert,
Heinous Sin of Self Pollution, and all its Frightful Regis, Craanem, Zimmermann, G.M. Wepfer, and
Consequences, in both SEXES Considered, with Veslin. Going through many editions, each of which


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allowed Tissot to make additions, emendations,
and annotations, his erudite book created the partly
inaccurate impression that there existed a powerful
consensus among the respectable and leading
European doctors, in harmony with the views of
classical authors, that masturbation was a dangerous
disease and gathering threat to human welfare.
Tissot had a major impact on the development of
the professional anti-masturbation movement from
the second half of the eighteenth century onwards.
Physicians adopted his theories and invented a
wide array of severe surgical, medical, dietary,
and behavioral therapies for the prevention of
masturbation over the next 150 years.
(Fig.2) Isaac Baker Brown (portrait and frontispiece
Especially in the United States, where an
of his publication from 1866)
unregulated organization of the medical profession
pushed doctors towards radicalism and extremism in
theory and practice, circumcision — in some cases
of insanity, epilepsy, catalepsy, and hysteria in fe--
executed without anaesthesia in order to combine
males» from 1866 inally resulted in the downfall of
“treatment” with punishment — became the most
Baker Brown [12] (Fig.2).
common surgical intervention against masturbation
in boys during the 19th and 20th centuries. Some Closure of the introitus vaginae as part of “female
authors conclude that “extremist religion, and circumcision” procedures is also called inibulation
extreme anti-sexualism and anti-phallacism provided and done with the intention to alter women´s sexual
a fertile ground for the acceptance of an obviously activity. This procedure is still practiced in some
anti-phallic, intentionally destructive surgery” [9]. African and Muslim cultures today.
Preputial inibulation, i.e. avoiding retraction of the In conclusion the widespread medicalization and
foreskin by generally piercing the distal part with pathologization of masturbation following Tissot´s
a metal clasp or ring, was also employed as a publication “l’Onanisme, Dissertation sur les
means of controlling male sexuality since antiquity. Maladies Produites par la Masturbation” resulted in
It experienced a revival during the Victorian Era the fact that medical doctors for the irst time became
as another clinical weapon in the medical war increasingly engaged in issues of human sexuality.
on masturbation. Although circumcision was the Although inglorious in many aspects this part of
most commonly employed means of preventing history must be considered as one origin of sexual
masturbation in the United States and Britain, medicine.
inibulation was frequently employed as an alternative
procedure, being used in mental institutions and
orphan asylums and receiving endorsement from IV. SELECTED EArLy PIONEErS
leading medical authorities [10]. OF SExOLOGy
Even vasectomy was used to treat excessive
masturbation. The irst use of vasectomy by the In Europe of 19th century sexual subjects were
physician Harry Sharp, later a well-known protagonist considered taboo and repression was the main
of eugenic sterilization in the US, in 1899 was on position towards them. However many scientists and
a 19 year male who had complained of excessive thinkers brought up new ideas about sexuality during
masturbation. Following the surgery, the patient is this period and in the irst part of 20th century.
reported to have acquired a higher intellectual level
It is generally assumed that modern sexual medicine
in addition to reduced masturbation [11].
was founded by German psychiatrists and derma--
All these medical theories and resulting treatments tologists. However Paolo Mantegazza (1831-1910)
were not only focused on male children, adolescents (Fig.3), an Italian professor of pathology and an--
and adults but were also adapted to female sexual-- thropology, was probably the founder of the modern
ity, especially masturbation and nymphomania. The sexual medicine. Decades before the studies of e.g.
most extreme example probably occurred in Victo-- Albert Moll and Havelock Ellis, he had developed ex--
rian England when the renowned gynaecological perimental work and had formulated new sexual the--
surgeon Isaac Baker Brown (1811-1873) suggested ories, founding a new science, which Mantegazza
and performed clidoridectomy for the treatment of called “science of embrace”; curiously he referred to
various nervous disorders. The public dispute on his love (amore) when he was talking of sexual relation.
respective book «On the curability of certain forms He never used the term sexual. Besides his interest

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(Fig.3) Paolo Mantegazza (Fig.5) Richard Freiherr von Krafft-Ebing (portrait
together with his wife and frontispiece of his
publication from 1886).

(Fig.4) Conrad Eckhard (portrait and illustration (Fig.6) Sigmund Freud (portrait and frontispiece of
from his publication from 1863). his publication from 1905 / 2nd edition 1910).

on physiology of «nervous» states (the beginning one of the irst monographies to study sexual topics
of neurophysiology) and the action of drugs (e.g. as clitoral orgasm and female sexual pleasure,
cocaine), Mantegazza wrote about female sexuality, consideration of the mental states of sexual offenders,
sexuality in children, masturbation, erectile dysfunc-- and homosexuality. In contrast to the popular and
tion, vaginism, and male and female infertility. He scientiic belief at that time, Krafft-Ebing was one
had tried gonad transplantations in frogs and he had of the irst authors to point out that homosexuals did
measured the blood low and temperature increase not suffer from mental illness or perversion [15].
during penile erection [13].
Through the discovery and development of psycho--
Even before Mantegazza, scientists in Europe stud-- analysis as an important psychotherapeutic school
ied sexual function without considering this as a new Sigmund Freud (1856-1939) (Fig.6) from Vienna
ield of its own in science or medicine. One outstand-- had also great inluence on sexology, and his famous
ing representative is Conrad Eckhard (1822-1905), “Three Essays on the Theory of Sexuality” from 1905
a German physiologist from Giessen, who followed is considered as his boldest and most impressing
the transformation that scientiic medicine underwent contribution. According to Hartmann: “It was Freud’s
in the 19th century. He conducted basic anatomical intention to establish psychoanalysis not only as a
and physiological research on the erection process part of the medical science but as a comprehensive
in animals and showed that it was possible to pro-- heuristic method that should make a new and unique
duce an erection through electrical stimulation of contribution to the understanding of the conditio hu--
the nervous structures of the brain and spinal cord. mana. By its transversal approach the psychoanaly--
He described the “nervi erigentes” and claimed that sis could contribute new concepts to many ields of
erection did not depend only on venous congestion, knowledge and performed a profound inluence on
the general belief at his time [14] (Fig.4). literature, philosophy and forming art” [16].

richard Freiherr von Krafft-Ebing (1840-1902) The most eminent person of a group of sexologists
(Fig.5) was an Austrian-German psychiatrist. His working in Berlin before 1933 was Magnus
main work was “Psychopathia Sexualis” (1886), Hirschfeld (1868-1935) (Fig.7). He founded the the

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(Fig.7) Magnus Hirschfeld (portrait and his Institute
of Sexology).

irst «gay rights organization» “Wissenschaftlich-

humanitäre Komitee” (Scientiic Humanitarian
Committee) in 1897 dedicated to the scientiic study
of homosexuality. In 1908 he edited the irst journal
for sexology “Zeitschrift für Sexualwissenschaft”
in Berlin. Although this monthly journal was only
published for one year, sexology was formally
launched and quickly developed into an academic
speciality. In 1914 Iwan Bloch and Albert Eulenburg
re-started the “Zeitschrift für Sexualwissenschaft” (Fig.8) Henry Havelock Ellis
as the oficial organ of the newly founded «Ärztliche
Gesellschaft für Sexualwissenschaft und Eugenik”
of Sex”, died in 1935 in Nice, France [http://www2.
(Medical Society for Sexology and Eugenics). As
they state in their preface to the journal, it intended
Sexology/history_of_sexology.html] [14].
to serve «the study of medical, natural, and cultural
problems of sexology». By organizing the irst Henry Havelock Ellis (1859-1939) (Fig.8), an Eng--
“International Congress of Sexology” in Berlin in lish physician who had never practiced medicine,
1921, Magnus Hirschfeld initiated an international devoted his life to scientiic studies of sexual sub--
cooperation of sexologists. In 1928, he co-founded jects. He was a supporter of sexual liberation and
the “World League for Sexual Reform” together with was one of the irst modern thinkers to challenge Vic--
Havelock Ellis and Auguste Forel. Among his many torian taboos against the open and objective discus--
publications was one of the irst comprehensive sion of sex. His interest in human biology ended on
textbooks of sexology entitled «Geschlechtskunde» the six volume “Studies in the Psychology of Sex”,
(Sexual Knowledge) in 5 volumes published between published between 1897 and 1910. Those books
1926 and 1930. Hirschfeld was also the pioneer caused a huge controversy and were banned for
of educational sexual movies. His most important many years. However, it is considered a comprehen--
project was the establishment of the “Institut für sive masterpiece of human sexual biology, behav--
Sexualwissenschaften” (Institute of Sexology) in iour, and attitudes. Ellis viewed sexual activity as the
1919. It was a place for public information and healthy and natural expression of love, and he be--
education, treatment of patients and scientiic came known as a champion of women’s rights and
research located in the centre of Berlin. Many of sex education [http://adbonline.anu.edu.au/biogs/
scientist worked at the institute, most of them like A040139b.htm][17].
Hirschfeld himself were Jewish, e.g. Felix Abraham
and Ludwig Levy-Lenz (transsexual surgery), Arthur Harry Benjamin (1885-1986) (Fig.9) was born in
Kronfeld (psychiatrist), and Bernhard Schapiro (irst Berlin but developed his clinical and scientiic re--
hormonal treatment of cryptorchidism). Due to the search in the USA where he moved to in 1914. His
political circumstances in Germany the institute and special interest was hormonal research but his main
its co-workers increasingly came under pressure. work was devoted to what he himself later described
Hirschfeld left Germany in 1930 for a world tour giving as «transsexualism». He was a pioneer in the re--
lectures and studying sexology in foreign countries. search and in the understanding of the transsexual
He never returned to his home country. In 1933 phenomena, treated many patients, and opened a
the institute in Berlin was plundered and its library new area of research, at a time when even wearing
destroyed by the national socialists. Hirschfeld, clothes associated with the opposite sex in public
according to an American newspaper “The Einstein was often illegal [1].

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Historically, sexually transmitted diseases (SDT) are

the major link between sexuality and the medical
profession since antiquity and until the 20th century
and were commonly addressed as venereal diseases
until the 1990s. Veneris is the Latin genitive form of
the name Venus, the Roman goddess of love. Social
disease was another euphemism [19]. Gonorrhoea
was described by the ancient Egyptians, and was
recognized by Greek and Roman medical writers
[19]. Syphilis was apparently brought to Europe by
Christopher Columbus’ sailors on their return from
(Fig.9) Harry Benjamin America; others argue that it originated in the Old
World. An archeological ind of the bones of an
Essex woman suggested that she had advanced
Ernst Gräfenberg (1881–1957) (Fig.10) was an-- syphilis, between 1300 and 1450. This would predate
other German-born physician who imigrated to the Columbus’ voyage of 1492 [20, 21].
USA during World War II. He is known for develop--
In October 1495 French soldiers of King Charles VIII
ing the intrauterine device (IUD), and for his studies
coming back from Naples arrived in Lyons and the
on the role of the woman’s urethra in orgasm, de--
soldiers suffering from syphilis were treated in the
scribing the controversial female ejaculation and an
Hospital hôtel-Dieu, which became the irst French
erogenous zone where the urethra is nearest to the
Hospital to treat syphilitic patients. This hospital had
vaginal wall, which was later named the Grafenberg
been founded in 542 and at the beginning it was a
spot or G-spot by John D. Perry and Beverly Whipple
place to receive and assist the poor and pilgrims and
in his honour [18].
in the middle of the 15th century it received infectious
patients during some epidemic periods. For three
centuries the Hospital hôtel-Dieu tried to move away
syphilitic patients and it succeeded in 1802 as the
Hospital L’Antiquaille was built [22].
The prevalence and spread of these diseases
was exacerbated by war and growing of the cities.
By the Middle Ages both gonorrhoea and syphilis
were widespread. The term syphilis was not part
of the English language until 1717, following the
translation of an Italian work, it was called the pox.
The clap refered to gonorrhoea, from the old French
word clapier, meaning a brothel. The etymology of
gonorrhoea is probably from the Greek for seed low
in that it was assumed that the urethral discharge
was semen [21].
During years both diseases were considered just
one, many authors believed that the symptoms of
gonorrhoea were the early stages of syphilis. This
(Fig.10) Ernst Gräfenberg. view was substantiated by the British surgeon John
Hunter, who self-injected his own penis with material
taken from a patient with gonorrhoea in 1767. On
developing the signs of syphilis he concluded the
two infections were the same, although he did not
Benjamin and Gräfenberg are prominent represen--
realize that the patient actually suffered from both
tatives of what could be called the American link to
infections at the same time [19, 21].
Europe. Having left Germany at different times and
for different reasons, they both built up a career in In 1793, Benjamin Bell, an Edinburgh surgeon
the U.S. and were part of the medical community re-- conirmed that the diseases were distinct as a
starting the discipline of sexology after it´s complete result of experimentation on medical students. The
destruction in Europe between 1933 and 1945. eminent Guy’s surgeon Sir Astley Cooper recognized

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the two diseases as distinct and in 1824 he wrote concerning prostitution, prevention and therapy
in The Lancet «a man who gives mercury (a drug of infectious diseases: three years later a new
used to treat syphilis) in gonorrhoea deserves to be regulation was established which partly restored the
logged out of the profession because he must be 1861 law [24].
quite ignorant of the principle in which the disease
In 1864 the English Parliament passed the
is cured» [21].
“Contagious Diseases Act”. This legislation allowed
In the middle of the 19th century a French physician, policeman to arrest prostitutes in ports and army
Philippe Ricord determined the three stages — towns and bring them in to have compulsory checks
primary, secondary, and tertiary — of syphilis. Shortly for venereal disease. If the women were suffering
afterwards Rudolph Virchow established that syphilis from sexually transmitted diseases they were placed
was spread through the body by the blood, explaining in a locked hospital until cured. It was claimed that
the known cardiovascular, muscular, and psychiatric this was the best way to protect men from infected
complications. At the turn of the 20th century up to a women. Many of the women arrested were not
third of inmates in mental asylums were reckoned to prostitutes but they still were forced to go to the police
be suffering form tertiary syphilis [19]. station to undergo a humiliating medical examination.
A vociferous campaign was mounted by women>s
The main orthodox treatment for syphilis from the
groups, civil rights activists, and members of the
Middle Ages until the early years of the 20th century
medical profession, and the Acts were repealed in
consisted of the application of a mercury ointment.
1886 [19, 21].
However, during the 17th through to the 20th centuries
many useless “miraculous” treatments to cure the During the First World War, with a great movement of
disease had appeared to exploit the sufferers [19]. the troops, STDs became very common. USA Army
lost nearly 7 million person-days and discharged
Curiously, the legendary Giacomo Casanova was
more than 10,000 men because of STDs. Only the
said to have invented the condom, fashioned from
great inluenza pandemic of 1918–1919 accounted
a sheep’s intestine, not as a contraceptive but as
for more loss of duty during that war. The STDs
protection against syphilis. However he might have
remained a signiicant threat in the early years
used it with this intention but condoms appear in
of World War II, prompting the American War
some of the pictures of “A Harlot>s Progress” by
Department to embark on a massive educational
William Hogarth (1697-1764). This series of paintings
and prophylactic campaign. Numerous posters
was completed in 1731, when Casanova would have
were produced, warning soldiers and sailors of the
been 6 years old [21].
dangers of excessively sexual behavior [25].
During the nineteenth century an increasing number of
Advances against the diseases were notably im--
public health measures, usually aimed at prostitutes,
proved by the discovery of their causative microor--
were taken to prevent or control the spread of
ganisms. That of gonorrhoea was found in 1879 and
STDs. The publication in 1847 of Regulations for
that of syphilis in 1905. Shortly after this the German
the repression of the excesses of prostitution in
bacteriologist Paul Ehrlich announced the eficiacy
Madrid inaugurated an era of regulated prostitution
of Salvarsan, an arsenic-based treatment for syphi--
in Spain. In view of the spread of prostitution and
lis. The development of the sulpha drugs and more
venereal diseases, police measures, and especially
potent antibiotics provided a wider range of effective
medical measures were both considered in the
drugs against these diseases [19]. The discovery
development of these regulations, which had irst
that penicillin can treat syphilis has revolutionized
been proposed by the Count of Cabarrús in 1792.
its management [21]. With the discovery of antibiot--
Although completely conidential, the new system
ics, a large number of sexually transmitted diseases
of regulations, drawn up in 1847, set the stage for
became easily curable, and this, combined with ef--
the wide-reaching regulation of prostitution that
fective public health campaigns against STDs, and
came into effect in several cities in Spain during
the recognition of the importance of contact tracing
and after the mid-19th century, and which included
in treating STDs a great advance was made in the
city residence and periodic health surveillance for
control of those diseases. By tracing the sexual part--
prostitutes [23]. ners of infected individuals, testing them for infec--
In 1861 in Italy a repressive law was passed against tion, treating the infected and tracing their contacts
prostitution to reduce syphilis transmission. After the in turn, STD clinics could be very effective at sup--
constitution of the Kingdom of Italy there began a pressing infections in the general population [http://
debate on this law which was harsh on prostitutes family.jrank].
and failed to resolve the health problem in question. Herpes (from the Greek, to creep) is another STD
In 1880, in Italy, studies were promoted under the with a long history. Herodotus, a Roman physician,
aegis of a royal commission to understand the social described cold sores in the second century, and
situation of prostitution and the epidemic spread genital herpes was irst described by John Astruc,
of syphilis. In 1888 Crispi issued new regulations a French physician in the 18th century, Shortly


comitte 01.indd 25 8/25/2010 12:51:10 PM

thereafter, other physicians noted that genital herpes endocrine tissue. When grafting testicles of cocks
often aflicted a patient shortly after the onset of into the abdominal cavity of hens he was actually
syphilis or gonorrhea [http://family.jrank].
In the 1980s, AIDS (Acquired Immunodeiciency
Syndrome) emerged into the public consciousness
showing that the battle against STDs were not com--
pletely won. AIDS was irst reported June 5, 1981,
when the U.S. Centers for Disease Control (CDC)
recorded a cluster of Pneumocystis carinii pneumo--
nia in ive homosexual men in Los Angeles [26]. In
the beginning, the disease was called GRID Gay-
related immune deiciency by the public. The CDC
called it the “the 4H disease,” because the disease
was prevalent in four communities Haitians, homo-- (Fig.11) John Hunter (portrait and frontispiece of his
sexuals, hemophiliacs, and heroin users. In 1982 publication from 1786)
AIDS was introduced for the irst time. In this year
epidemiologic data deined that contamination oc--
curred by sexual, blood and mother-to-child trans--
mission. In 1983 Human Immunodeiciency Virus,
HIV, was aisled in Pasteur Institute in Paris [27].


OF THE TESTICLES AND THE (Fig.12) Arnold Berthold (portrait and original pas--
DISCOVEry OF ANDrOGENS sage from his publication from 1849)

Ancient knowledges on testicle function: Tales far more interested in the technique of grafting and
and myths about aphrodisiacs and especially tissue acceptance than the secondary effects on
extracts from testicular tissue or blood were reported sex characteristics. In 1849, Arnold Berthold (1801-
from ancient times up to the present. As early as 1863) again made the connection between male
140 BC Sushruta of India advocated the ingestion sexual and behavioural characteristics and a sub--
of testis tissue for the cure of impotence. A vague stance secreted by the testes and concluded that
foreshadow of the endocrine function of the testis transplanted testes affect behavioural and sexual
was speculated by Aretaeus of Cappadocia (2nd till characteristics by secreting a substance into the
3rd century A.D.) and more vigorously in 1775 by blood stream (Fig 12). In Vienna the physiologist Eu--
de Bordeu. They proposed that each organ of the gen Steinach (1861-1944) started experiments with
body produced a substance, which was secreted testicular transplantation in animals at the turn of the
into the blood to regulate bodily function [28]. On the century in order to study the sexual differentiation
other hand the appearance of castrates with their and the hormonal function of the gonads [28, 29].
typical body composition and characteristics can be
looked at as an interesting in vivo model of androgen rejuvenation and early “modern” organotherapy:
depletion at all periods of history. Some of them, In 1889 Charles Edouard Brown-Séquard (1817-
especially some castrati singers of the baroque 1894) reported the rejuvenating effects of self-
period, are reported of having been actively involved administered subcutaneous injections of a mixture
in love affairs and sexual activities. of extracts from sperm, testicular tissue and venous
blood of young and vigorous dogs and guinea pigs
Study of sexual differentiation: It was not until (Fig.13). Although based on a placebo effect, this can
the 1930s, however, that testosterone, the primary be considered the birth of modern clinical androgen
androgen responsible for male physiology and be-- therapy. In his theory of «autoplastic» treatment
haviour, was biochemically identiied. Prior to that, of aging Eugen Steinach (Fig.14) postulated an
many attempts were made to study the sexual dif-- increased incretory hormonal production following
ferentiation of male and female individuals and to the cessation of the secretory output of the gonads
slow or reverse the effects of aging in men and to after surgical ligation of the seminal ducts. With
rejuvenate them. As early as 1767, John Hunter help from the urologist Robert Lichtenstern he
(1728-1793) (Fig.11) performed irst documented successfully performed this surgical procedure in
testicular transplantation experiments in animals a human patient for the irst time in 1918, resulting
and hereby opened the door to transplantation of in a vasectomy boom over the next two decades

comitte 01.indd 26 8/25/2010 12:51:13 PM

therapy», in which extracts from a variety of animal
tissues were used to treat diseases and counter the
effects of aging. Organotherapy remained popular
until the early 20th century, when modern endocrinol--
ogy emerged as a scientiic discipline [30].
Discovery of androgens in the 1930’s: Ernest
Starling and William Hardy irst coined the term
«hormone» in 1905. Pezard in 1912 reported that
(Fig.13) Charles Edouard Brown-Séquard (portrait
aqueous extract of pig testes maintained the comb
and title of his publication from 1889).
and wattles of the capon. 18 years later, Gallagher
and Koch developed the response in the capon into
a quantitative assay procedure, which was adopted
with minor modiications by most laboratories as the
standard assay procedure for male hormone activ--
ity. As early as 1927, Lemuel Clyde McGee demon--
strated the isolation of a biologically active extract of
the lipid fraction of bull testicles. In 1933 McCullagh
and co-workers reported in a very elegant paper that
extracts from blood, urine or spinal luid of men by
using the chick comb assay for measuring andro--
genic activities are useful for treatment of the male
hypogonadism. The authors called the substance
which is produced in the testes “Androtin”. The mag--
(Fig.14) Eugen Steinach (portrait and illustration of nitude of the problem faced by steroid chemists has
effects of vasectomy on the genital organs). been illustrated by the fact that labor-intensive ex--
tracts from up to 100g of testes were required for
a positive result in the so-called chick comb bioas--
say. It is not surprising, therefore, that 15 mg of the
especially to counter the effects of aging in «middle-
irst known androgen – androsterone – was isolated
aged, listless individuals». Steinach nicely summarized
under the leadership of Adolf Butenandt (Fig.15) -
the results of his scientiic life in his late biography: “It
in his age of 28 years - from 15000-25000 liters of
has frequently been said that a man is as old as his
policemen’s urine in 1931. The name of this relative--
blood vessels. One may have greater justiication for
ly weak urinary 5α-reduced androgen comes from
saying that a man is as old as his endocrine glands.”
“andro” = male, “ster” = sterol, and “one” = ketone.
In the 1920‘s one of the main protagonists of tes-- The chemical synthesis of androsterone was per--
ticular transplantation in Europe was Serge Voronoff formed by Leopold Ruzicka (Fig.16) and cowork--
(1866-1951) who grafted slices of primate testis to ers 3 years later. The Japanese Ogata and Hirano
the capsule of human recipient’s testes. He claimed – not enough acknowledged by the Europeans and
to have treated 300 patients and that hormonal se-- Americans – found in 1934 that the androgen from
cretion lasted for about 1-2 years, then decreased the urine ( Butenandt’s androsterone) is not identical
due to ibrosis of the graft. Testicular homotransplan-- with the androgen extracted from boar testes. The
tation had been reported earlier in very few hypogo-- androgenic properties of this crystal hormone were
nadal patients in America by Frank Lydston in 1914 more active than any of the testicular preparations
and V. D. Lespinasse in 1915. None of these was that have been reported heretofore.
performed with vascular anastomoses.
The methods proposed by Brown-Séquard, Stein--
ach, and Voronoff were widely popular in their time
throughout Europe and North America, despite nev--
er undergoing rigorous validation. Voronoff’s grafting
technique, which was enthusiastically adopted in
many countries for agricultural and medical purpos--
es, was later proved to be scientiically unfounded.
Steinach’s theories were also widely popular in their
time and scores of men underwent Steinach opera--
tions, including Sigmund Freud and the Irish poet
William Butler Yeats. Brown-Séquard’s miraculous
results were not reproducible and most likely the
result of a placebo effect. Nevertheless, his report
gave rise to the lucrative industry known as «organo-- (Fig.15) Adolf Butenandt (Fig.16) Leopold Ruzicka

comitte 01.indd 27 8/25/2010 12:51:19 PM

One year later, Karoly David, Elizabeth Dingemanse,
Janos Freud, and Ernst Laqueur reported the isola--
tion of the main secretion product from the testes
and the main androgen in the blood, testosterone,
from several tons of bull testes. The term “testoster--
one”, coined by this Dutch group, combines “testo”
= testes, “ster” = sterol, and “one” = ketone. In the Societal attitudes towards same-sex relationships
same year, the chemical synthesis of testosterone have varied over time and place, from strong
was published by altogether three groups from Ger-- repression until acceptance. Many times the ight for
many, Netherland, and Switzerland led by Adolf Bu-- liberation of homosexualism crossed with research
tenandt, Ernst Laqueur, and Leopold Ruzicka. Ru-- and studies on sexual function. The increasing
zicka and Butenandt were offered the 1939 Nobel scientiic interest in homosexuality in the 19th century
Prize for chemistry for their work, but Butenandt was can be interpreted as one promotor for scientists,
forced by the Nazi government to decline the honour including medical doctors, to investigate medical
[28, 31, 32]. issues and questions related to sexuality in general
and by doing so creating the new ield of sexology
Substitution therapy with testosterone: and later sexual medicine.
The biochemical identiication and synthesis of
testosterone and other steroid hormones was a In many cultures sodomy has been considered as a
“conditio sine qua non” for the further development transgression against divine law or a crime against
of modern endocrinology and the basis for a rational nature. However sexual relationships among same
therapy with sexual hormones. The irst years sex have been known for thousands of years and in
obviously implied a too generous application of every continent. It was an accepted practice in Africa
this new therapeutic option especially in regard to and Americas before the European conquerors
the problem of the “Climacteric in aging male” as arrived and repressed those activities. Homosexuality
was hinted at by an editorial in the “Journal of the in China, has been recorded since approximately 600
American Medical Association (JAMA)” in 1942 [33]: BC. In Japan it has been documented for over one
“Recently many reports have appeared in medical thousand years and was an integral part of Buddhist
journals claiming that a climacteric occurs in middle monastic life and the samurai tradition. Similarly,
aged men. Brochures circulated by pharmaceutical in Thailand, has been a feature of Thai society for
manufacturers depict the woeful course of aging many centuries, and Thai kings had male as well as
man. None too subtly these brochures recommend female lovers.
that male hormonal substance, like a veritable
elixir of youth, may prevent or compensate for the Throughout most of the history of ancient Israel,
otherwise inevitable decline. What of the postulated intercourse between males was condemned outright
occurrence of a climacteric in men?” In the following as an «abomination» and Mosaic Law demanded
years systematic studies like “The male climacteric, the death penalty for those men who «lie with a man
it symptomatology, diagnosis and treatment: use as with a woman». In Greece male homosexuality
of urinary gonadotropins, therapeutic test with was part of a normal man’s love life, besides the
testosterone propionate and testicular biopsies in heterosexual relationships. Plato praised its beneits
delineating the male climacteric from psychoneurosis in his early writings but in his late works proposed
and psychogenic impotence” from 1944 (Fig.17) inally its prohibition [35]. In Crete homosexuality was,
opened the door for modern research projects in the according to Aristotle, oficially supported as a
ield of “androgen deiciency in the aging male” [34]. “population control tactic” [36].

(Fig.17) Elevated gonadotropins in “Male

Climacteric” reported in JAMA 1944.


comitte 01.indd 28 8/25/2010 12:51:21 PM

In Ancient Rome there were common relationships in the Middle East, Africa, Asia, the Caribbean and
between older free men and slaves or freed youths. the South Paciic, outlaw homosexuality. In six
Many roman emperors had male lovers. Christian-- countries, homosexual behavior is still punishable
ity followed the Hebrew tradition of condemnation of with life imprisonment and in ten with death penalty
male sexual intercourse and certain forms of sexual [http://www.ilga.org/statehomophobia/World_legal_
relations between men and women, labeling both as wrap_up_survey_November2006].
sodomy [37]. In the year 528, the emperor Justinian
I, responding to an outbreak of pederasty among the
Christian clergy, issued a law which made castration
the punishment for sodomy.
During the Renaissance, Florence and Venice were Contraceptive methods have a long history and dif--
famous for their widespread practice of homosexual ferent levels of societal acceptance, depending upon
love. However, at that time, the authorities, under the cultural, religious, and political background.
aegis of the Oficers of the Night court, were pros--
ecuting, ining, and imprisoning a good portion of the Prehistoric societies had a slow population growing
homosexual practitioners. In the Europe of the 17th although they had total fertility rates of 4 to 6 [41].
and 18th century repression had gained strength and Approximately half the children who were born died
executions for sodomy continued in the Netherlands before they could reproduce. Furthermore puberty
until 1803, and in England until 1835. was in the upper teens, babies were breastfed for
3–4 years, which spaced pregnancies. With the irst
Between 1864 and 1880 Karl Heinrich Ulrichs urban civilizations and settled agriculture, puberty
published a series of twelve books, entitled “Research began at an earlier age and breastfeeding was often
on the Riddle of Man-Manly Love”. In 1867 he shortened or supplementary food introduced earlier
became the irst self-proclaimed homosexual person than in primitive societies. This increased the rate of
to speak out publicly in defense of homosexuality fertility. Nowadays if a couple initiates sexual inter--
when he pleaded at the Congress of German Jurists course when the woman is 20 years old or younger
in Munich for a resolution urging the repeal of anti- and continues at least until her menopause, without
homosexual laws. “Sexual Inversion” by Havelock artiicially limiting fertility, she can expect to conceive
Ellis, published in 1896, challenged theories that and carry to term an average of 10 live-born children
homosexuality was abnormal, as well as stereotypes, [42, 43]. Sooner or later, all human societies have to
and insisted on the ubiquity of homosexuality and its adopt restraints on family size [43].
association with intellectual and artistic achievement
[38]. Magnus Hirschfeld created the Scientiic There are references of contraceptive methods in
Humanitarian Committee, which campaigned from many historical records [43]. Written records survive
1897 to 1933 against anti-sodomy laws in Germany. from the Egyptian Ebers Papyrus (1550 BC), the Latin
Richard Freiherr von Krafft-Ebing probably was works of Pliny the Elder (23–79 AD) and Dioscorides
one of the irst heterosexual professionals to see (De materia medica, c. 58–64 AD), and the Greek
homosexuals as normal people with a different writings of Soranus (Gynecology, c. 100 AD). During
sexuality [39]. the lowering of Arabic medicine in the 10th century,
a variety of contraceptive recommendations were
In the 1950s in the United States, homosexuality was detailed, particularly in the works of Al-Razi (Rhazes,
taboo and many politicians treated the homosexual d. 923 or 924 AD, Quintessence of Experience),
as a symbol of antinationalism. Senator Joseph All ibn Abbas (d. 994 AD, The Royal Book), and
McCarthy used accusations of homosexuality to Avicenna (Ibn Sina, d. 1037 AD) [43].
stigmatize his opponents. Although there is societal
tolerance to homosexuality, in 2001, 51% of the The evidence of ancient contraceptive knowledge,
general public declared that «homosexual behavior» methods of birth control which are used before
was morally wrong. conception, is very large. A list of contraceptive
methods include: withdrawal by the male (coitus
Homosexual relationships were decriminalized in interruptus); melting suppositories designed to form
many European countries such as Poland in 1932, a barrier over the cervix; diaphragms, caps, or other
Denmark in 1933, Sweden in 1944, and the United devices which are inserted into the vagina over the
Kingdom in 1967, but a turning point was reached cervix and withdrawn after intercourse; intrauterine
in 1973 when the American Psychiatric Association devices; douching after intercourse designed to kill
removed homosexuality from the Diagnostic and or drive out the sperm; condoms; and varieties of the
Statistical Manual of Mental Disorders, thus negating rhythm methods. The main new acquisition was the
its previous deinition of homosexuality as a clinical birth control pill introduced in 1960 [43].
mental disorder [40]. In 1977, discrimination based
on sexual orientation was prohibited for the irst It were the ancient Greeks who irst realized that
time in Canada, extended to many other countries male and female union caused pregnancy and since
during the 1980s. However, many countries today then many contraceptive methods have been used


comitte 01.indd 29 8/25/2010 12:51:21 PM

with varying degrees of success. Probably the oldest condoms were openly sold in drugstores, pubs and
methods of contraception (aside from abstinence of other businesses throughout the world. In 1844,
vaginal intercourse) are coitus interruptus, lactational, rubber was invented, and condoms were able to be
certain barrier methods, and herbal remedies [44]. mass-produced for the irst time, making them ac--
cessible to a wider population [43].
There are historic records of Egyptian women using
a pessary (a vaginal suppository) made of various At the beginning of 19th century female barrier meth--
acidic substances and lubricated with honey, oil or ods were well established. In 1838, in Europe, Wilde
beeswax, which may have been somewhat effective proposed the cervical cap and later Mensinger ad--
at killing sperm or blocking its passage through the vised a diaphragm without spermicide. By 1915,
female genital tract [http://www.mnsu.edu/emuseum/ Rutgers proposed the use of diaphragms with sper--
prehistory/egypt/dailylife/midwifery.htm]. However, micides and individual itting by a physician [43].
it is important to note that the sperm cell was not At that time, attempts were made to block the cervix
discovered until the late 17th century, so those with metal pessaries. The devices required an intra--
methods were completely empiric at that time. uterine portion to hold them in place, and sometimes
Another kind of pessary was a solid object to block they broke, when it was noted that they still acted as
the cervix. This method was popular in pre-industrial successful contraceptives. In 1909, Richter, in a Ger--
societies, especially Africa; here women used plugs man medical journal, described a lexible ring made
of chopped grass or cloth. Balls of bamboo tissue of silk that he placed in the uteri of women seek--
paper were used by Japanese prostitutes, wool ing contraceptive help. By 1923, Proust claimed to
by Islamic and Greek women, linen rags by Slavic have distributed 23,000 intrauterine devices (IUDs).
women. The sponge used by Ancient Jews was At about the same time, Grafenberg presented IUDs
considered the most effective contraceptive in use of silk and later of silver wire [46]
until the development of the diaphragm. The sea The biologic possibility of imitating early pregnancy
sponge was wrapped in silk with a string attached [45]. to inhibit ovulation was well understood by the
During the 2nd century A.D., Greek gynecologists ad-- Austrian physiologist Haberlandt when he published
vised women to spread substances such as ginger or a series of papers, beginning in 1921, on what
olive oil around the vagina to prevent pregnancy [45]. he called “hormonal sterilization.” Ovaries from
pregnant does were transplanted into nonpregnant
Coitus interruptus, where man withdraws his penis rabbits, rendering them infertile for several months.
before the ejaculation, was practiced in Africa, Aus-- By 1927, Haberlandt was exploring the possibility
tralasia, the Middle East, and in Europe. Though of oral contraception, and he collaborated with
condemned by Judaism and Roman Catholicism, its a pharmaceutical irm in Budapest to produce a
practice was common enough in Medieval Europe preparation called “Infecundin» [43].
and later [42].
In 1959, the irst hormonal birth control pill, “Envoid”,
Coitus obstructus was a method recommended in was approved by the FDA for contraception. Though
several Sanskrit texts which required pressing on very effective, this early birth control pill produced
the urethra on its scrotal part; the pressure could major side effects, such as blood clots and high blood
prevent semen low through the urethra forcing it into pressure. By the 1980s, low dose pills were widely
the bladder. Coitus reservatus is a method whereby available with fewer side effects and high eficacy.
the male avoids ejaculation entirely. This method In the 1990s, the “Depo-Provera” hormone injection
was used by the Hindus [43]. was created, and was able to prevent pregnancy
for several months at a time. In 1999, the FDA
The rhythm methods (based on calculating the wom-- approved “Plan B” (the morning after pill) for sale
an’s fertile period and abstaining from intercourse by prescription only. This emergency contraceptive
during it) have been used since the 19th century. gives women the chance to prevent pregnancy
However the female fertility cycle was completely after having unprotected sex, and can be used as a
understood in 1920. Before that time it was common backup if contraception methods fail. By 2003, “Plan
believe that ovulation occurred either during men-- B” was available over-the-counter throughout the
struation or just before it, which made this a very in-- U.S.A [47].
nefective contraceptive method earlier on [43].
Sir Astley Cooper experimented with vasectomy in
Condoms had been known since the 17th century dogs in 1830, Harrison recommended the operation
and were made from animal intestines. Initially it was as a cure for enlarged prostate in 1889. Male
fully advocated in campaigns against sexual trans-- medical sterilization was irst carried out in Indiana
mitted diseases, but in the 1920’s and 1930’s it was in 1899 and spread in the USA until 22 states had
the second contraceptive method used in USA, after sterilization laws in 1929 based on genetic and
coitus interruptus [43]. Leather and linen versions eugenic indications. In the same year, Switzerland
were used early on. By the start of the 19th century, was the irst country in Europe with a sterilization


comitte 01.indd 30 8/25/2010 12:51:21 PM

law; Denmark introduced a test law which became fat. In modern times, women have been reported to
inal in 1935. Between 1933 and 1945 the totalitarian use turpentine, castor oil, tansy tea, quinine water
regimes used forced sterilization for genetic in which a rusty nail has been soaked, horseradish,
diseases and on undesired races. Only in the 1950’s ginger, epsom salts, ammonia, mustard, gin with iron
family planning was introduced as a basis for male ilings, rosemary, lavender, and opium [45, 50].
sterilization, initially in Asian countries [11]. Aside from internal abortifacients, women have at--
tempted external methods such as severe exercise,
Tubal ligation for female sterilization was irst pro-- heavy lifting, climbing trees, hot baths, jumping and
posed by Blundell in 1823 in London. Lungren was shaking. As late as the 20th century, Jewish women
the irst to ligate a woman’s tube in 1880 in Toledo, of the Manhattan Lower East Side attempted to
Ohio, USA. In 1936 in Switzerland, Bosch performed abort by sitting over a pot of steam (or hot stewed
the irst laparoscopic tubal occlusion as a method for onions), a technique described in an 8th century San--
sterilization. Prior to the 1960s, female sterilization skrit source [50].
in the United States was generally performed only
for medical indications (when additional pregnancies The majority of women before the 19th century and
would be hazardous to the mother). Many centers many in the 19th century did not consider abortion a
used a formula (endorsed by the American College sin. Until the early part of the century, there were no
of Obstetricians and Gynecologists until 1969) in laws against abortions done in the irst few months
which age multiplied by parity had to be greater than of pregnancy. Prior to the 19th century, Protestants
or equal to 120 before elective sterilization could be and Catholics held abortion permissible until
considered [48, 49]. ‘quickening’—the moment the fetus was believed to
gain life [45].
Infanticide, the killing of newborn babies, was the
most universal solution to periodic overpopulation Massage abortion is a technology that has been
in pre-industrial societies. It was used to control described in Burma, Thailand, Malaysia, the
population and, at times, the sex ratio where the Philippines, and Indonesia. The procedure is
sexual division of labor dictated. Some groups usually attempted when the woman is 12–20 weeks
practiced infanticide because, in the absence of pregnant. She lies on her back with her knees drawn
medical techniques, it was less risky and painful up and the traditional birth attendant attempts to ix
than abortion. Among some Australian tribes and the uterus and then presses as hard as possible
among the Cheyenne and other Northern Plain with her ingers, the heel of her bare foot, or even
Indians, infanticide was practiced so the tribe could the wood pestle used to grind rice. This practice still
maintain its mobility. The Pima of Arizona practiced occurs tens of thousands of times a year in this part
infanticide when a child was born after the death of of Asia [51].
its father—thereby relieving the mother of the added
A number of methods were available for performing
economic burden [45]. It is signiicant to note that
abortion in the 19th century. The operation of dilation
infanticide was not just a ‘primitive’ practice; Aristotle
and curettage was established and, as early as 1863,
and Plato recommended it for eugenic reasons.
Simpson described a procedure for “dry cupping” the
And if infanticide is not acceptable today, it may be
uterus. Today it would be called vacuum aspiration.
because we have better birth control methods [45].
Vacuum aspiration using a hand-held syringe and a
Infanticide and abortion were considered criminal
lexible plastic cannula was irst described by Kar--
practices during the 18th and 19th centuries and
man and Potts in 1972 [52].
their practice is documented in the transcripts of
trials and in newspapers. This evidence suggests The acceptance of a contraceptive behavior (which
that both practices were widespread. Three cases of included contraceptive methods, abortion techniques
infanticide have been found reported in the Maryland and sometimes infanticide) over tome depended
Gazette on one day in 1761 [45]. upon cultural, economical and religious background.
Women have wanted to abort undesired pregnancies Abortion has not always been seen as a sin or a
since ancient times. A standard method of inducing crime. It presented an easier moral problem for the
abortion (ancient and modern) is the abortifacient ancients than today, because they assumed that life
or potion. Abortifacients are part of a folk culture of started after birth. In the Roman Empire there was
herbal medicine handed down among women for an incentive to have small families. The custom that
thousands of years. In German folk medicine mar-- required the equal division of the estate among one’s
joram, thyme, parsely and lavender in tea form were children was the main reason usually advanced to
used. The root of worm fern was used by German explain why Roman families were so small. Even
and French women and was also prescribed by a the intermittent attempts of the state to encourage
Greek physician in the time of Nero; in French it was population growth proved futile [36].
called the “prostitute root”. Other ancient recipes
called for a paste of mashed ants, foam from camels’ Christianity propagated the idea that the child was
mouths, tail hairs of blacktail deer dissolved in bear sent by God and, unlike other religions, made few

comitte 01.indd 31 8/25/2010 12:51:22 PM

concessions to the social realities that justiied the contraceptives. An international survey of contracep--
avoidance of pregnancy. If one had too many chil-- tive users found that 33 per cent had been sterilized,
dren it had to be viewed as a cross to bear [36]. 20 per cent employed the oral contraceptive, 15 per
cent the IUD and 10 per cent the condom [36].
Some idea of Medieval attitudes towards contracep--
tion can be obtained from the Penitentials—the reli--
gious compilations used by many priests as a frame-- Ix. MALE SExuAL DySFuNCTION
work for their work in the confessional. Sexual sin
exceeded all others in the Penitentials. Noonan has The crucial function in male sexuality is penile
categorized the sexual content of Penitentials from erection. Besides different forms of ejaculatory
the 6th to 11th century. A nocturnal ejaculation war-- disorders, penile deformities and other hypoactive
ranted 7 days’ fasting, while contraception, fellatio, and hyperactive sexual dysfunctions, the male
and anal intercourse attracted penances from 3–15 erection has always been of main interest in medicine
years. Religious records are supplemented by civil and therefore the below overview will concentrate on
cases from 14th and 15th century Venice. Men guilty this aspect [14, 55, 56].
of homosexual anal intercourse were being burned
alive between the Columns of Justice in St. Mark’s Early physiology and pathophysiology of male
Square. But anal intercourse in marriage was also erection:
sometimes prosecuted with exile for a few years. Rug--
In “De aëre aquis et locis” Hippocrates (5th-4th century
giero concluded anal intercourse was a form of birth
BC) described the high incidence of impotence and
control that was practiced by some people at every
infertility in the people of the Scythians and explained
social level, from nobility to humble ishermen. In the
it by continuous perineal trauma due to excessive
Penitentials, the punishment for abortion was some--
horse riding. Aristotle (384 till 322 BC) - like the
times less than that for contraception and was simi--
other Greek authors - outlined the physiological
lar to that for coitus interruptus, although St. Jerome
concept of “pneuma” (= wind, air) as the initiator of
was particularly uncharitable in describing women
who died from attempting an abortion as a “threefold
murderess: as suicides, as adulteress to their heav-- In respect to Arabian medicine the famous Avicenna
enly bridegroom Christ and as murderess of their (980-1037 AD) - also known as Abu Ali al-Hussein
still unborn child” [53, 54]. In 1557, Henri II declared Ibn Abdallah Ibn Sina or “Medicorum princeps
that any concealed pregnancy that ended with the (Prince of Physicians)” – was perhaps rather a
death of the child would be presumed to be murder. philosopher than a physician. Although his notes on
A similar statue was passed in England in 1624 [36]. anatomy and physiology of the genital tract are full
By 1860, the U.S. had banned all abortions except of errors he was a very subtle observer of human
those deemed necessary to save a woman>s life. sexual behaviour, especially when writing about the
In 1873, Congress passed the Comstock Act, which difference between male and female orgasm.
made any and all forms of contraception illegal. The Leonardo da Vinci (1452-1519) – the great artist
ban also prohibited anyone from providing informa-- and genius of the Renaissance - can not only be
tion about birth control or abortion. In 1918, a woman considered as the founder of modern medical
named Margaret Sanger was charged under this Act illustration but was also the irst author to describe
with providing information on contraceptive devices. the increased blood inlow to the penis as the cause
She appealed and won, with the courts inding that of erection. He drew this conclusion from his own
contraception was necessary to protect a woman>s observations and dissections in human corpses.
health. Sanger would go on to found Planned Par--
enthood in the 1930’s [36, 43]. Although the “Musculi erectores penis” (i.e. Mm.
bulbospongiosi and ischiocavernosi) had already
Based on Sanger’s victory and other challenges, the been described by Galen in the 2nd century AD, this
Comstock laws were repealed at both the state and knowledge was lost at the time of Costanzo Varolio
federal levels during the 1930’s. It took another 40 (1543-1575), who re-discovered them and gave an
years before women won the right to choose abor-- astonishingly correct description of the mechanisms
tion as a method of contraception. From 1860 to of erection.
1973, abortion was illegal in the U.S., with few ex--
ceptions. The landmark Supreme Court case of Roe The book “De la generation de l´homme” (On the
v. Wade in 1973 found that laws prohibiting abortion generation of man), written by the master of French
were unconstitutional. This ruling gave women the Renaissance surgery Ambroise Paré (1510-1590)
right to choose abortion in the U.S. freely within the in 1573, constitutes a real guide to good sexual
irst trimester [36]. practices. In this book Paré described in very vivid
language and with many details how to perform
By the 1980s, something like 90 per cent of married sexual intercourse to ensure the greatest chances of
couples in most western countries were employing fertilization and moreover how to diagnose

comitte 01.indd 32 8/25/2010 12:51:22 PM

(Fig.20) Conrad Eckhard (portrait and illustration
(Fig.18) Regnier de Graaf (portrait and illustration from his publication from 1863).
of the penis from his publication from 1668).

he clearly deined an impotence depending on the

mind and an organic impotence as “from want of
proper correspondence between the actions of the
different organs”.
In 1863 the German physiologist Conrad Eckhard
(1822-1905) (Fig.20) from Giessen published his
results on animal experiments inducing penile
erections by applying electrical stimulation at different
levels of the nervous system (also see above).
More detailed contributions on the neurophysiology
of erection were made by J.N. Langley and H.K.
Anderson from England in the mid 1890’s.

(Fig.19) John Hunter (portrait and frontispiece of Conservative treatment:

his publication from 1786) Aphrodisiacs have been adopted for the treatment
of all kinds of sexual dysfunction since ancient times
pregnancy, how to follow pregnancy and inally how and are still in use in our days.
to conduct delivery. In 1896 the chemist Leopold Spiegel (1865-1927)
In his “Tractus de virorum organis generationi from Berlin performed chemical characterization of
inservientibus, de clysteribus et de usu siphonis in yohimbine from the bark of the African yohimbe tree.
anantomia“ (1668) the Dutch physician regnier de He was well aware of the aphrodisiac effect that the
Graaf (1641-1673) (Fig.18) succeeded in causing bark was said to have in its country of origin and
an erection in a corpse by injecting water into the clinical application followed immediately in Europe.
hypogastric artery. At that time a very meaningful
example of experimental science.
Although the “Nodus penis” had been described
centuries before, Francois de LaPeyronie (1678-
1747) gave the irst extended clinical report on the
disease named after him in his article “Sur quelques
obstacles qui s’opposent à l’éjaculation naturelle
de la semence“ (On some obstacles to the natural
ejaculation of the semen) from 1743. In his opinion
the plaque was predominantly caused by venereal
The famous surgeon and anatomist John Hunter
(1728-1793) (Fig.19) from London is well-known
for his contributions on venereal diseases, the
prostate and urethral strictures. He also dedicated
an interesting chapter on impotence in his book “A (Fig.21) Sigmund Freud (portrait and frontispiece of
Treatise on the Venereal Disease” (1786) in which his publication from 1905 / 2nd edition 1910).

comitte 01.indd 33 8/25/2010 12:51:25 PM

Spiegel patented his chemical discovery in the UK in
1900 an this resulted in a more then 100 years story of
oral drug treatment of erectile dysfunction especially
in psychogenic and mild organic disorders.
The essay with the remarkable title ӆber die
allgemeinste Erniedrigung des Liebeslebens
(The most prevalent form of degradation in erotic
life)” was published in 1912 and is one of the few
publications in which Sigmund Freud (1856-1939)
(Fig.21) deals directly with male erection disorders.
Here he introduced the term “psychical impotence”
into his writings and stressed the high prevalence
of this condition which is manifested by “a refusal
of the sexual organs” to execute the sexual act
[16]. Historically, there was a certain negative
impact of Freudism through the resulting focus on (Fig.22) Otto Lederer (patent with technical drawing
a psychogenic understanding of sexual dysfunction. for his vacuum device from 1913).
Especially in erectile dysfunction organic concepts
of pathophysiology as well as new approaches of in 1971 – was fundamental for the understanding of
somatic therapy were inhibited for many decades. the irst effective oral treatment of erectile dysfunction
The irst milestone in effective medical treatment with PDE-5-inhibitors at the end of the 20th century.
of severe organic erectile dysfunction was the
Vaccuum constriction devices:
intracavernous injection of vasoactive drugs. By
accident the French vascular surgeon ronald The curative application of negative pressure to
Virag from Paris discovered the proerectile effect of different parts of the body was well established in 19th
papaverine during a revascularization surgery of the century medicine. The American physician John King
penis and suggested therapeutic injection into the was the irst to suggest a continuous and repeated
corpus cavernosum in 1982. application of a vacuum device to the penis for the cure
of impotence in 1874. Finally, the Viennese physician
One year later Giles S. Brindley reported a list of Otto Lederer (1872-1944/45) made the signiicant
experiments where he described the possibility of improvement of adding a compression ring to the
getting an eficient erection through what he called use of the vacuum device to facilitate an on-demand
“cavernosal alpha-blockade”. He reported that large erection in 1913 (Fig.22); long before Geddings
doses of oral phenoxybenzamine caused penile D. Osbon constructed his modern device in 1960.
tumescence that lasted for 24 to 48 hours. He
also produced erections with parenteral and penile Surgical treatment:
injection of phentolamine and phenoxybenzamine.
Ambroise Paré (1510-1590) suggested an “artiicial
He proposed the therapeutical use of intracavernous
penis” made of a wooden pipe or tube for patients
injection for patients with erectile dysfunction and
after traumatic penile amputation in order to facilitate
he stated that intracavernous injection could be a
a proper micturition in the standing position. Although
diagnostic tool; he believed that a good response
not intended for sexual activities one might call this
could rule-out a vascular cause, but not a neurogenic
device a 16th century “penile prosthesis” as per
one. Brindley also made history with his dramatic
deinition a prosthesis – in contrast to an implant -
presentation of the effect of intracavernous injection
replaces the whole organ or part of the body.
of the alpha-receptor antagonist phenoxybenzamine
into his own penis at the 1983 meeting of the In 1873 the Italian physician Francesco Parona
American Urological Association (AUA) [57]. (1842-1907) injected the varicous dorsal penile vein
of an impotent young patient with hypertonic saline
Finally, Adrian W. zorgniotti from New York in order to cause sclerosis and by this reduce the
introduced drug combination of papaverine and excessive venous outlow. More then two decades
phentolamine in 1985 [58]. after this irst case report several American doctors
started performing surgical dorsal vein ligation or
With his biochemical research, as outlined in the
resection as e.g. Frank Lydston in 1908.
paper “Fractionation and characterization of a cyclic
adenine ribonucleotide formed by tissue” from Since the early 1930´s Oswald S. Lowsley
1958, the American Earl W. Sutherland (1915- (1884-1955) (Fig.23) from New York was the main
1974) discovered the physiological signiicance of protagonist of surgical treatment for corporoveno-
cyclic nucleotides in the regulation of cell and tissue occlusive dysfunction. He combined simple dorsal
function. This basic knowledge – for which he was vein plication with a surgically more advanced
awarded the Nobel Prize in Medicine and Physiology perineal crural technique in which he plicated the

comitte 01.indd 34 8/25/2010 12:51:27 PM

bulbocavernous and ischiocavernous muscles with
several mattress sutures.
The irst penile implant to facilitate an erection was
used in a phalloplasty procedure performed by the
Russian surgeon Nikolaj A. Bogaraz (1874-1952)
(Fig.24) in 1936. He used the patient´s rip cartilage
and in later years he even performed this operation
in patients with morphologic intact penis but suffering
from erectile dysfunction [59].
In 1948 the French surgeon rené Leriche (1879-
1955) (Fig.25) irstly mentioned arterial vascular (Fig.23) Oswald S. Lowsley (portrait and illustration
impotence in thrombotic obliteration of the aortic of plication of ischiocavernous muscles)
bifurcation, a syndrome he had already described in
detail in the 1920’s and which today is named after
him. During the following time several strategies
were outlined to save or reconstruct the internal iliac
artery during abdomino-pelvic vascular surgery to
maintain or restore erectile function.
In 1973 Václav Michal from Prague reported the
irst microsurgical treatment of vascular erectile
dysfunction by performing a revascularization
with direct anastomosis of the inferior epigastric
artery to the corpus cavernosum. He was one of
the irst researchers to observe that failure of the
hemodynamics of erection played an important role
in the pathogenesis of impotence in many patients.
He also discussed the use of phallo-arteriography
with saline-illed erection to visualize the proximal (Fig.24) Nikolaj A. Bogaraz (Portrait and result after
phalloplasty with rip cartilige)
arterial disease. In the 1980’s further techniques
were introduced later by Michal himself, as well as
by ronald Virag from Paris and Dieter Hauri from
Texas, together with his colleagues William E. Brad--
The very breakthrough of penile implant surgery was ley and Gerald W. Timm when they implanted the
initiated by F. Brantley Scott (Fig.26) from Houston, irst silicone inlatable device on February 2nd, 1973.

(Fig.25) René Leriche (portrait and publication from 1923).


comitte 01.indd 35 8/25/2010 12:51:32 PM

(Fig.26) F. Brantley Scott (portrait and illustration of irst inlatable penile implant from 1973)

This was one the irst effective treatments of erectile Kinsey obtained a grant from the “National Council’s
dysfunction. The authors were very imaginative for Committee for Research in the Problems of Sex”,
that time, describing a completely new concept, in-- which was at the time funded by the Rockefeller
stead of rods, using inlatable cylinders which could Foundation. He assembled a multidisciplinary re--
be illed – on the man`s demand - through pressing search team that included Clyde E. Martin, a student
a pump positioned subcutaneously in the scrotum, assistant who became a research associate; Wardell
transferring the luid from a reservoir implanted in B.Pomeroy, a clinical psychologist; and Paul H. Geb--
the Retzius space to the cylinders promoting pe-- hard, an anthropologist. Kinsey and his colleagues
nile rigidity. This device – the basis of the modern established the “Institute for Sex Research” in 1947
ones - had had an extraordinary evolution since this as a separate, nonproit organization.
publication in 1973. Scott is also recognized for the
Kinsey published «Sexual Behavior In The Human
creation the urinary artiicial sphincter which revolu--
Male» in 1948, which came to be known as the
tionized the treatment of urinary incontinence [60].
«Kinsey Report». It sold more than 250,000 copies
and was translated into a dozen languages. In 1953
x. SExuAL MEDICINE AS A TruE the Institute published “Sexual Behavior In The
Human Female”, which also sold more than 250,000
SPECIALITy AFTEr WOrLD WAr II copies and was translated into several languages.
These two reports sharply challenged many myths
After World War II and mainly after Kinsey´s
about sexual behavior in American society and
reports the ield of Sexual Medicine experienced a
revealed indings on various previously taboo topics,
fast development. It is impossible to cover all the
such as extramarital sexuality, homosexuality,
individuals who contributed to that research, but four
bisexuality, oral sex, masturbation, and prostitution.
of the early pioneers from the 1950’s and 1960’s
Only relatively few male individuals with erectile
should be cited in detail.
dysfunction were analyzed. Although those studies
Alfred Kinsey: were devoted only to white, young Americans
they contributed strongly for the change of sexual
Alfred Charles Kinsey (1894–1956) can be con-- behaviour in the USA in the second part of the
sidered the pioneer in the quantitative and epide-- 20th century. Despite the wide-spread acceptance
miologic study of human sexuality collecting sexual of the scientiic study of sexuality in U.S. society,
histories from a large number of men and women, conservative forces continued to attack the work
resulting in a inal sample of around 18,000. His in-- pioneered by Kinsey as well as on-going studies by
terest in human sexuality fortuitously began when in the Institute for Sexual Research, which resulted in
1938 he was responsible for a course on marriage at the suspension of the research grants and ended
the University of Indiana and found that little survey up the work [http://www.pbs.org/wgbh/amex/kinsey/
research was available on human sexuality. In 1941, peopleevents/p_kinsey.html] [1].

comitte 01.indd 36 8/25/2010 12:51:33 PM

Giuseppe Conti: William Masters and Virginia Johnson:
The Italian anatomist Giuseppe Conti from Padua was William Howell Masters (1915-2001) was one the
a pioneer in scholarly research into erectile function. irst to study the anatomy and physiology of human
His seminal report “L’erection du penis humain et sexuality in the laboratory, and the publication of
ses bases morphologico-vasculaires” (The erection the reports on his indings created much interest
of the human penis and its’ morphologico-vascular and criticism. Since then, he and his colleague and
basis) was published in 1952 and represents one of wife, Virginia Eshelman Johnson (born 1925), have
the earliest attempts to scientiically and precisely become well-known as researchers and therapists in
characterize penile hemodynamics and structure as the ield of human sexuality, and together they have
they relate to the phenomenon of erection. established the Reproduction Biology Center and
later the Masters and Johnson Institute in St. Louis,
Conti found that the penile arteries contained Missouri.
areas of subintimal longitudinal smooth muscle
that protruded into the lumen. Busche referred to In 1954 Masters started his research on human
these structures as “Polsterkissen”; i.e. cushions sexual response. He was concerned that the medical
or polsters near branch points of the deep penile profession had too little information on sexuality to
artery. Based on composition and location Conti understand clients’ problems. As Kinsey had based
postulated that these structures permitted selective his research on case histories, interviews, and
shunting of arterial blood to either “nutritive” arteries secondhand data, Masters decided to study human
or anastomotic arteries that communicated with the sexual stimulation using measuring technology in a
cavernous spaces. Depending on their opening laboratory situation.
or closing an erection or detumescence would In 1956 he hired Virginia Johnson, a sociology
result. This theory persisted until 1980. Counter student, to help in the interviewing and screening
to his contemporaries, Conti proposed that rather of volunteers. The study was conducted over an
than a single mechanism, a number of events are eleven-year period with 382 women and 312 men
responsible for penile erections. Speciically, he participating. Masters and Johnson described a four-
hypothesized that the interplay of arterial inlow with phased cycle relating to male and female sexual
the shunting of blood into the corpora cavernosal responses. To measure physiological changes, they
spaces and the obstruction of venous outlow used electroencephalographs, electrocardiographs,
resulted in the engorgement of the penis [61]. color cinematography, and biochemical studies. They
estimated that they had observed «10,000 complete
James Semans: cycles of sexual response». Their indings about
female sexual arousal described the mechanisms
James H. Semans (1910-2005), a Duke University of vaginal lubrication and orgasm and proved that
surgeon and urologist combined a career as a leading some women were capable of being multiorgasmic.
medical scientist and physician with a passion for
the arts and charitable causes. He was a pioneer in In 1966 Masters and Johnson published “Human
rehabilitative and urinary surgery. Sexual Response” and in 1970 “Human Sexual
Inadequacy”, where they discussed sexual problems
The cultural climate of the southern United States
such as impotence [14].
in the immediate period after World War II was quite
reserved and conservative, not in a political sense, Epilogue
but in a social sense. Deeply religious and very
homogeneous the south was not progressive in any Around 1970 many physicians were dealing with
sense, particularly when it comes to sexual matters. issues of sexual medicine and the term itself and it´s
In this environment Semans published in 1956 modern deinition became established in the medical
a classical article on the treatment of premature community, as has been outlined in the introducing
ejaculation. He was the irst to describe a direct, chapter on terminology of this article (see above).
behavioral treatment for premature ejaculation, the Several societies had already been or were about to
stop-start technique. be founded in the ield of sexology at that time [7].
A key event for the formation of another important
This article is one the irst major open discussion of society was the “First International Conference on
the behavioral issues surrounding sexual dysfunction Corpus Cavernosum Revascularization” in New York
to appear in the literature. For the irst he pointed in October 1978. Adrian W. Zorgniotti, a visionary
out that premature ejaculation could lead to erectile urologist from the Cabrini Medical Center in New
dysfunction. The paper consists of an observational York, identiied and invited experts on vasculogenic
series of cases, each discussed individually which impotence from all over the world for this meeting.
together form the basis for a recommend technique From the subsequent activities and meetings of this
to decrease the stimulation leading to a retarded group arose the “International Society of Impotence
ejaculation [62]. Research” (ISIR), that later opened it´s arms to other

comitte 01.indd 37 8/25/2010 12:51:34 PM

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48) Peterson HB, Pollack AE, Warshaw JS. Tubal sterilization. 58) Lizza EF. Adrian Walton Zorgniotti (1925-1994): Renaissance
In: Rock JA, Thompson JD, eds. Te Linde>s Operative urologist. J Sex Med 2005;2:272-277.
Gynecology. 8th ed. Philadelphia, Pa: Lippincott-Raven; 59) Schultheiss D, Gabouev AI, Jonas U. Nikolaj A. Bogoraz
1997. p. 529-47. (1874-1952): pioneer of phalloplasty and penile implant
49) Piccinino LJ, Mosher WD. Trends in contraceptive use in surgery. J Sex Med 2005;2:139-146.
the United States: 1982-1995. Fam Plann Perspect. Jan- 60) Glina S, Montague DK, Torres LO, Mulcahy JJ. Management
Feb 1998;30:4-10, 46. of erectile impotence: use of inlatable prosthesis. J Sex
50) Himes, NE. Medical History Of Contraception. Rajsons; 2002. Med. 2008;5:2494-2497.

51) Potts M, Graff M, Taing J: Thousand-year-old depictions 61) Glina S, Lewis RW, Steers WD, Lue TF. Erection of the
of massage abortion. J Fam Plann Reprod Health Care. human penis and its morphological and vascular basis by
2007;33:233-4. Guiseppe Conti. J Sex Med 2008;5:262-267.

52) Karman H, Potts M: Very early abortion using syringe as a 62) Glina S, Abdo CH, Waldinger MD, Althof SE, Mc Mahon
vacuum source. Lancet 1972 May 13;1(7759):1051-2. C, Salonia A, Donatucci C.Premature ejaculation: a new
approach by James H. Semans. J Sex Med 2007;4:831-837.
53) Noonan JT: Contraception: A History of Its Treatment by the
Catholic Theologians and Canonists. Cambridge: Harvard 63) Lewis R, Wagner G. History of the International Society
University Press; 1967. of Sexual Medicine (ISSM) – the beginnings. J Sex Med
54) Ruggiero G: The Boundaries of Eros: Sex Crime and Sexuality in
Renaissance Venice. Oxford: Oxford University Press; 1985.


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comitte 01.indd 40 8/25/2010 12:51:34 PM

Committee 2

Deinitions, classiication,
and epidemiology of Sexual




comitte 2.indd 41 8/25/2010 12:52:40 PM

TaBle of conTenTS

I. general inTroDucTion iV. DeScriPTiVe ePiDemiologY

1. inciDence of Sexual DYSfuncTionS

ii. inTroDucTion To DefiniTionS of in men

Sexual DYSfuncTionS 2. inciDence of Sexual DYSfuncTionS

in Women
3. PreValence of Sexual
DYSfuncTionS in Women anD men
iii. DefiniTionS of Sexual 4. PreValence of Women’S Sexual
DYSfuncTion from ThiS DYSfuncTionS
conSulTaTion 5. PreValence of men’S Sexual
1. DefiniTionS of Sexual DYSfuncTionS
in Women V. analYTical ePiDemiologY
2. DefiniTion of Sexual DYSfuncTionS
in men 1. riSk facTorS for Women
3. claSSificaTion of SeVeriTY 2. riSk facTorS for men


comitte 2.indd 42 8/25/2010 12:52:40 PM

Deinitions, classiication,
and epidemiology of Sexual

disentangle true population effects from differences

I. general inTroDucTion in reported prevalence that are simply due to
inconsistent use of deinitions. For example, where
researchers follow DSM-IV deinitions [1] then only
Epidemiological data are the basis for assessing persons who experience both sexual dysfunction
the impact of a condition on a given society. The per se and sexual distress are classed as having a
two components of epidemiology, descriptive sexual dysfunction. [2-4] Studies that only measure
epidemiology (incidence and prevalence by persons, sexual function per se are likely to report higher
place and time) and analytical epidemiology (the prevalence estimates compared to studies based
search for disease or condition risk that may serve strictly on DSM-IV deinitions. Those reading the
to increase prospects for prevention) are the main literature might erroneously conclude that the higher
components for this chapter, in addition to deining prevalence is due to population differences when in
the sexual disorders in women and men. Incidence fact a large part of the difference in prevalence may
is deined as the number of new cases with a certain simply be due to the inconsistent use of deinitions.
condition during a speciic time period in relation
to the size of the population studied. Prevalence Thus, a uniform nomenclature including categorizations
characterizes the proportion of a given population as well as quantiications is necessary in order to pave
that at a given time has the condition. Therefore, it is the road for valid and reliable: 1) comparative studies
important that epidemiological studies are reasonably between nations and regions 2) identiication of risk
valid, and particularly that they cover representative factors/co-morbidities 3) primary and secondary
samples. In case of sexual dysfunctions, incidence preventions and 4) evidence based interventions.
and prevalence are usually measured using self- A major thrust of this and the last [5] consultation
reports. Lack of consensus in deinition of the was to use evidence based medicine standards for
condition and in scaling does, however, lead to inclusion of material analysed and cited. [6] For the
considerable problems for comparing incidence summary of descriptive epidemiology, this committee
and prevalence of sexual conditions described in has adhered to the classiication of epidemiological
different investigations. Different methodological validity described by Prins et al [7], who identiied 15
rationales, such as the time period studied (1 month, dichotomizable (yes/no) points for being recognized
3 months, 6 months, 1 year, life-time), different age as valid from the prevalence or incidence point of
strata included and (self-) selection biases are other view (see Table 1). In this chapter only nationally or
problems in comparative analysis. Some reports regionally representative studies published in peer-
included only one particular sexual dysfunction, reviewed journal or in books, and judged to be al
most prominently for studies of erectile dysfunction, least reasonably valid, i.e. reaching at least 10 of 15
while some include different conditions in both possible yes-answers on the Prins et al assessment,
genders, making it possible to perform cross-gender are included. Articles cited in the analytical section
epidemiological calculations. This heterogeneity are mainly scored 10 or higher using the evidence
in the literature means that we are often unable to based criteria. [6]


comitte 2.indd 43 8/25/2010 12:52:40 PM

Table 1. Criteria for the methodolical quality assessment of prevalence studies- one point for yes to lower case

External validity
Source population
(a) Does the method to select and invite participants result in a study population that covers the complete
population or a random sample?
Description of the eligibility criteria
(b) Is the age range speciied?
(c) Are inclusion and exclusion criteria speciied?
Participants and nonresponders
(d) Is the response rate > 70%, or is the information on nonresponders suficient to make inference on the
representativeness of the study population?
Description of the study period
(e) Is the study period speciied?
Description of the study population
(f) Are important population characteristicsa speciied?

Internal validity
Data collection
(g) Are the data prospectively collected?
Measurement instrument (questionnaire, interview, additional)
(h) Is the measurement instrument validated?
(i) Is the period covered by the measurement instrument speciied?
Deinition of diseasesb
(j) Is a deinition of the disease stated?
Reported prevalences
(k) Are age-speciic and gender-speciic prevalences reported?
(l) Are possible correlates of diseaseb reported?

(m) Is the method of data collection properly described (interview, questionnaire, additional measurement)?
(n) Are the questions and answer possibilities stated?
(o) Are the reported prevalence rates reproducible?

a Two or more of: (i) age distribution; (ii) relevant comorbidity; (iii) lifestyle factors (eg smoking and alcohol consumption); and (iv)
socio-economic data (eg income, education level, marital status)
b Disease equals erectile dysfunction in this interview

recommendation 1 : ii. inTroDucTion To DefiniTionS

of Sexual DYSfuncTionS
In rating level of evidence for epidemiological
studies, there is probably a need to expand the
point allowed for percentage of responders. The At present, the two most widely used sets of deinitions
current score of 1 for percentage of 70% or greater of sexual dysfunctions are those given by the World
is probably too narrow for modern epidemiological Health Organization (WHO), 1980 [8] in the ICD-10,
studies. We may wish to have more lexibility for and by the American Psychiatric Association, (DSM-
this point such as maximum points for 70% and IV) in 1994. [1] In sexual medicine, the ICD-10 has
greater, mid-range for 40-70%, low-range for 20- mainly been used within somatic care and the DSM-
40%, and subtraction point for those with response IV psychological/model. Both sets of deinitions are
rate of less that 20%. grade c. mainly built upon the physiological model of genital


comitte 2.indd 44 8/25/2010 12:52:40 PM

responses and symptoms disturbing coital intercourse for women’s sexual dysfunctions incorporating both
irst described by Masters and Johnson [9]; later physiological and psychological pathophysiologies
modiied by Kaplan. [10] Both sets add to the sexual and personal distress. An important feature of the
response “cycle” in which, for women, vaginismus is DSM-IV and the Basson et al sets of deinitions is a
included. Both sets regard sexual dysfunctions (ICD- classiication into lifelong vs. acquired (after a period
10)/disorders (DSM-IV) as involving combinations of of “normal” functioning). Moreover, the DSM-IV calls
physical and psychological constituents but believe attention to another dimension, namely whether the
it possible to separate these. dysfunction is generalized (occurring in different
situations) vs. situational (occurring only in certain
A basic feature of the ICD-10deintions is that sexual situations). It is underlined that the clinical evalua--
function per se is deined as the various ways in tion should include etiological factors. There is a dis--
which an individual is able to participate in a sexual cussion on the adequacy of the ICD-10 and DSM-
relationship as he or she wishes. The ICD-10 uses IV deinatory systems which to many experts, and
deinatory categories, which are sub-categorized perhaps particularly pertaining to women’s sexual--
into organic (N-series) and non-organic (F-series) ity, appear too “medicalized” [14] ironically labeled
dysfunctions; but several inconsistencies are built biological innocence. Leiblum [15] and Basson [16]
into the system. For example, female arousal from the perspective of women’s sexuality criticize
disorder is described in terms of vaginal physiological the concept of a linearly progressing sequential De--
response; while for the men, satisfactory intercourse sire à Arousal à orgasm model which does not
is included in the ED-deinition. The ICD-10 does regard women’s sexuality. They suggest that many
not include delayed ejaculation as a category by cases of impaired sexual response or interest are
itself, presumably regarding retarded ejaculation as not dysfunctions per se, but are adaptive reactions
equivalent to lack of orgasm. to problems in sexual relationships. [17] It has also
been suggested [18] that women’s sexual dysfunc--
The DSM-IV has two deined (A and B) categories tions may be best conceptualized as a global inhibi--
describing psychogenically based disorders: The A tion of sexual response due to intrapersonal factors,
category focuses on deining sexual disorders per se. an inhibition which may also be true for male sexual
The common denominator of all being: “persistent or disorders. In epidemiological research it has been
recurrent”. It is explicitly pointed out that each disorder found that, for women and men alike, all sexual dys--
must be separated from a dysfunction exclusively functions are generally signiicantly associated. [19-
due to a general medical condition or a substance- 21] Hence, whereas deinitions from a classiicatory
induced sexual dysfunction. Here, a set of subtypes and differential diagnostic point of view are neces--
is introduced. The latter set of deinitions is valid only sary, it appears unsound to assume that one sexual
if the dysfunction is fully explained by the medical disorder per se can, a priori, be expected to be a
condition or the physical effects of a substance/drug,
solitary phenomenon for any given individual.
respectively. When combinations of psychological
and organic conditions are judged to be causal for
a certain dysfunction, the DSM-IV advocates the A number of serious problems can arise for
subtype: “due to combined factors”. The B category research when presumed etiology is incorporated
of the DSM-IV deinitions add to all dysfunctions, a into deinitions. While it is important to recognise
distress dimension: The disturbance causes marked that sexual problems can stem from a wide range
distress or interpersonal dificulty”. These A and B of causes, this approach of including – or excluding
sets of deinitions enable distinguishing a dysfunction – possible etiology in the deinition of sexual
per se from its emotional impact (but only if marked) dysfunction may undermine research aimed at
– intra- as well as interpersonally. The B category improving our understanding of women’s and men’s
does not leave a possibility for inclusion of mild or sexuality. Problems arise because including etiology
sporadically occurring distress. The DSM-IV has in the deinition means that the case deinition is
been criticized for its lack of operational criteria inextricably entangled with the potential risk factors
for the diagnosis of sexual dysfunction. [11] It has of interest. This makes it dificult to undertake a
been suggested that criteria specifying severity and valid analysis of risk factors or demonstrate causal
duration be added in order to distinguish sexual relationships between these risk factors and sexual
disorders requiring medical intervention from transient responses. For example there is evidence that
alterations in sexual function related to life stress relationship factors play a very important role in
or relationship dificulties. [12] These alterations female sexual responses. [2] We therefore might
should lead to more homogenous groups for clinical be tempted to exclude low sexual function that is a
research and to revised estimates of the prevalence
product of a poor relationship from our deinition of
of sexual dysfunction in the general population. At
FSD. If we did, we would not be able to assess the
this time, the criteria for the sexual dysfunctions are
impact of poor relationships on FSD because couples
being evaluated for DSM-V and ICD-11.
with poor relationships who experienced sexual
Some years ago a consensus panel [13] recom-- dificulties would no longer be classiied as having
mended a new diagnostic and classiication system FSD. If we include various relationship factors as


comitte 2.indd 45 8/25/2010 12:52:41 PM

part of sexual dysfunction deinitions in this way then b) The area of sexual arousal disorder is divided into
it will not be possible to assess the impact of these three subtypes. genital sexual arousal dysfunctions
relationship factors in future epidemiological studies. are absent or impaired genital sexual arousal; self-
Furthermore, while certain factors may appear report may include minimal vulval swelling or vaginal
particularly important today this may change in the lubrication from any type of sexual stimulation and
future or between populations. Currently much of the reduced sexual sensation from caressing genitalia.
literature relating to FSD, and to some extent to MSD, Subjective sexual excitement still occurs from
is based on western populations. The etiological non-genital sexual stimuli. Subjective sexual
factors that are important in western societies may arousal dysfunction is the absence of or markedly
be very different to those in other cultures. In some diminished feelings of sexual arousal, (sexual
instances it is not clear whether factors associated excitement and sexual pleasure), from any type of
with FSD are the cause or the consequence of sexual stimulation. Vaginal lubrication or other signs
the sexual dificulties. Consequently we could of physical response still occur. combined genital
run the risk of including in the deinitions of sexual and subjective arousal dysfunction is absence of
dysfunctions factors that are actually a consequence or markedly diminished feelings of sexual arousal
of FSD rather then part of the etiology or factors that (sexual excitement and sexual pleasure) from any
are simply markers for the true underlying causes type of sexual stimulation as well as complaints of
that we have not yet fully investigated. absent or impaired genital sexual arousal (vulval
swelling, lubrication).
recommendation 2. :
c) Persistent genital arousal dysfunction is
There is a need to recognize that deinitions spontaneous, intrusive and unwanted genital arousal
for sexual dysfunction may be different for (i.e. tingling, throbbing, pulsating) in the absence
epidemiological studies versus those needed for of sexual interest and desire. Any awareness of
clinical applications. Epidemiology studies may subjective arousal is typically but not invariably
ask the incidence or prevalence of a disorder in unpleasant. The arousal is unrelieved by one or
a community but for clinical deinitions further more orgasms and the feeling or arousal persists for
expansion such as duration and severity may need hours or days.
to be part of the deined disease evaluated and
treated. The latter in epidemiological studies go d) Orgasmic dysfunction in women is lack of
beyond the per se deinition of the disorder itself. orgasm, markedly diminished intensity of orgasmic
There is a need to keep these parallel as possible. sensations or marked delay of orgasm from any kind
grade c. of stimulation. There is a self-report of (high) sexual
arousal/excitement in this disorder.
iii. DefiniTionS of Sexual e) Dyspareunia is persistent or recurrent pain with
DYSfuncTion from ThiS attempted or complete vaginal entry and /or penile
conSulTaTion vaginal intercourse. Vaginismus is the persistent or
recurrent dificulties of the woman to allow vaginal
on the basis of these deliberations, this committee entry of a penis, a inger and/or any object, despite
has selected the following deinitions. These do the women’s expressed wish to do so. There is often
not generally separate organic from psychological (phobic) avoidance and anticipation/fear of pain.
caused dysfunctions which should (if adequate) Structural or other physical abnormalities must be
be clariied through the etiology and they are not ruled out/addressed.
mutually exclusive.
For clinical studies and relevance to clinical
1. DefiniTionS of Sexual DYSfuncTionS situations, various descriptors are recommended
in Women for the various sexual dysfunctions in women and
The deinitions of sexual dysfunction in women men. They include degree of distress scales, life-
came primarily from deliberations by the work by long or acquired status, situational or generalized
Basson et al [22] and the members of chapter 16 of occurrence, and other relevant conditional states.
this consultation. 2. DefiniTion of Sexual DYSfuncTionS
a) Sexual interest/desire dysfunctions are in men
diminished or absent feeling of sexual interest or
a) Sexual interest/desire dysfunction has to some
desire, absent sexual thoughts or fantasies and a
extent been neglected in epidemiological research
lack of responsive desire. Motivation (here deined
but is quite commonly seen in clinical practice. This
as reasons/incentives), for attempting to become
committee suggests a deinition identical to the one
sexually aroused are scarce or absent. Sexual
for women (see above).
aversion disorder is anxiety and/or disgust at
the anticipation of/or attempt to have any sexual b) Erectile dysfunction (ED) is deined as the
activity. consistent or recurrent inability of a man to attain


comitte 2.indd 46 8/25/2010 12:52:41 PM

and/or maintain penile erection suficient for sexual per se and for dysfunction-caused distress. This
activity. A 3-months minimum duration is accepted scale has been trichotomized: No dysfunction (nev--
for establishment of the diagnosis. In some instances er), Mild dysfunction (hardly ever, rather rarely) and
of trauma or surgically induced ED (e.g. post radical Manifest dysfunction (rather often, often, always,
prostatectomy), the diagnosis may be given prior to nearly always).
3 months. objective testing (or partner reports) may
The common mode used in population-based
be used to support the diagnosis of ED, but these
epidemiological research is single variables, each
measures cannot substitute for the patient’s self-
intended to cover one particular sexual dysfunction.
report in classifying the dysfunction or establishing the
The possible adequacy of using single question self-
assessment was looked upon by Derby et al [28],
c) In August, 2007, the International Society for who found close correlations between the prevalence
Sexual Medicine (ISSM) convened a panel of experts of erectile dysfunction, tapped simultaneously by the
to review criteria for premature ejaculation. This panel IIEF erection domain, three erectile domain items of
proposed the following evidence-based deinition of the BSMFI [29] and the one four grade (No, Mild,
lifelong premature ejaculation : “ejaculation which Moderate, Complete) item used by Feldman et al [26]
always or nearly always occurs prior to or within in their now classical treatise of the prevalence of ED.
about one minute of vaginal penetration, and the
During recent decades different clinically well
inability to delay ejaculation on all or nearly all vaginal
validated questionnaires, some examples being for
penetrations, and negative personal consequences
men the IIEF [30] and for women FSFI [31], have
such as distress, bother , frustration and/or the
been introduced. Furthermore, aggregated scores
avoidance of sexual intimacy.” The panel concluded
have been questioned [32-33] as a summed score
that there was insuficient evidence to propose
may obscure a sexual aspirations-achievement
deinitions for acquired premature ejaculation [23].
gap within pertinent sub-domains. Furthermore,
Recommendation 3. : newer scales for measuring FSD have some
advantages over single item questions. Recently, the
This committee recommends using the ISSM Standardization Committee of International Society
derived deinition (from the convened panel of for sexual Medicine has completed a thorough
experts) for life-long premature ejaculation as the review of the questionnaires constructed to assess
new epidemiological deinition. grade B. female and male sexual function. (in preparation)
of the questionnaires taken into consideration, for
d) Anejaculation is the absence of ejaculation women the FSDS [34] and the SFQ [35-36] were
during orgasm. recommended for both clinical and research use.
Problems can arise when single questions are
e) Orgasmic dysfunction is inability to achieve an used in epidemiological studies. For example in a
orgasm, markedly diminished intensity of orgasmic
number of studies respondents are simply asked
sensations or marked delay of orgasm during any
to report problems (or dificulties) with sexual
kind of sexual stimulation. There is a self-report of desire that occurred for one month or more in
(high) sexual arousal/excitement in this disorder previous 12 months. [20,37-38] . Both distress (i.e.
and orgasmic dysfunction can occur together with problem or dificulty) and sexual function (desire)
ejaculatory function. components are therefore combined into the one
f) Dyspareunia is persistent or recurrent genital question. This makes it dificult to separate out the
pain during sexual activities. relative contribution of distress versus low function
or recognize which factors are associated with the
3. claSSificaTion of SeVeriTY each of these two components. Moreover, we cannot
be sure to what extent distress has been taken into
To make studies comparable, it seems to be of im--
account in participant responses or whether some
portance not only to have uniform deinitions but also
participants have incorporated distress in their
to use uniform scales. The two grade scales (yes/
answers and others have not.
no), for example used by Laumann et al [20], Kadri
et al [24], and Smith et al [25], may be too rigorously Overall, it appears that the ield lacks questionnaires
undifferentiated and may lead to exaggeration of able to measure sexual function for women not in a
the severity of any given dysfunction. In the USA, relationship and no questionnaire has been further
a four-graded (No/Mild/Moderate/Complete) scale validated on non-heterosexual women, although
has been used [26], while in Sweden [27] in another some preliminary data exists on the FSFI in lesbian
large prevalence study a 6-graded scale (Never / women. Although several epidemiological studies
Hardly ever / Rather rarely / Rather / often Never have used single items to assess sexual function in
/ hardly ever / Rather rarely/rather often / often/Al-- different domains, currently there is a lack of empirical
ways, Nearly always) has been used applying single evidence for the discriminant validity of single-item
questions both for characterization of dysfunction measures of sexual dysfunction in women.


comitte 2.indd 47 8/25/2010 12:52:41 PM

We now have good evidence that a single item dysfunction there are ive population-based studies
question can produce very different prevalence that describe the incidence of erectile dysfunction,
estimates than a validated multi-item scale when two from the USA [47-48], one from Brazil [49], one
measuring FSD. In recent study prevalence estimates from the Netherlands [50], and one from Finland
produced by simple non-validated questions were [51, 52] (See Tables 2 and 3.) Two other papers
compared against those obtained using validated have been identiied that report on incidence in a
multi-item scales in the one sample of women. [39] preventive medical care clinic in the USA [53] or in a
When instruments with the same recall (the previous group of general practices in the UK [54]. The most
month) were examined side by side, simple questions important conclusion that can be drawn from these
produced signiicantly different prevalence estimates studies is that incidence is strongly associated with
for desire, arousal, orgasm and pain disorders age. In the study from the UK the incidence of ED
compared to the validated multi-item scales that varied between 8-10 cases per 1000 man years in
incorporated sexual distress. [39] Furthermore, that the period 1999-2000 (in men aged 40-79). This
investigation provided evidence that compared to incidence had more than doubled from about 4
validated multi-item scales, simple questions identify cases per 1000 man years in the period 1996-1997,
different sub-groups of women as experiencing FSD. that is, before the introduction of Sildenail.
[39] Compared to a single question, validated, multi-
The irst published, population-based study on
item scales such as the FSFI, [31] and PFSF [40-
incidence came from the MMAS (Massachusetts
41] that simply examine sexual function have the
Male Aging Study) [47]; the participants were
advantage of being able to examine both frequency
predominantly white. Analyses were performed on
and intensity of sexual experiences with out asking
847 ED-free men at baseline (with a baseline age
women to self diagnose or guess what is normal
between 40 and 69 years; average 52.2 years). After
sexual function. Some multi-item scales [36] have
an average follow-up of 8.8 years a crude incidence
the added advantage of providing cut off scores for a
rate of 26 cases per 1000 man-years was found
number of different sub-categories (or sub-domains)
(95% CI: 22.9-29.9). The annual incidence rate
of sexual function. These instruments have been
increased with each decade of age (table 2). The
translated into a variety of different languages [42-
age-adjusted risk for ED was higher for men with
43] and are beginning to be more widely used in
lower education, diabetes, treated heart disease,
epidemiological, observational studies. [44]
and treated hypertension.
Although self-reported questionnaires such as The Brazilian study was conducted in the city of
IIEF, FSFI and BSMFI have demonstrated their Salvador, the third largest city of the country, with
utility for the evaluation of male and female sexual a racially diverse population. [49]Analyses were
dysfunctions, they do not provide any pathogenetic performed on 428 ED-free men at baseline (with a
information. SIEDy (Structured Interview on baseline age between 40 and 69 years; 53% of the
Erectile Dysfunction) is the only case history tool men were below the age of 50 at baseline). After
suficiently validated for this purpose. [45] This is an average follow-up of 2 years (range 1.7-2.3) a
a 13-item structured interview composed of three crude incidence rate of 65.6 cases per 1000 man-
scales, which identify and quantify three domains years was found (95% CI: 49.6-85.2). The annual
simultaneously present in ED patients (organic: incidence rate increased with each decade of age
Scale 1, relational: Scale 2 and intrapsychic: Scale (table 2). The age-adjusted risk for ED was higher
3). organic, relational, and intrapsychic factors are for men with lower education, diabetes, treated
often to be found together and mutually interacting heart disease, treated hypertension, depression and
in ED patients. Hence, an anamnestic instrument benign prostatic hyperplasia. Based on an analysis
which simultaneously and quantitatively evaluates of baseline characteristics of men in the study, the
them can provide an interesting option to overview authors conclude that the analysis sample was
them. In addition, SIEDY can predict with 70% similar to the sample of men lost to follow-up.
sensitivity and speciicity the presence of an organic
In Europe, the Krimpen study was conducted in the
component of ED. SIEDy is therefore a unique,
town of Krimpen aan den IJssel (The Netherlands),
validated anamnestic and diagnostic instrument
this is a commuter town near Rotterdam with a
available to physician confronting ED. [46]
predominantly Caucasian population. [50] Analyses
were performed on 1458 “clinically-relevant-ED”-
free men and 1432 ED-free men (see table 2. for
iV. DeScriPTiVe ePiDemiologY deinitions of ED) at baseline (with a baseline age
between 50 and 78 years; therefore, in comparison
1. inciDence of Sexual DYSfuncTionS with the other two studies, all men were above
the age of 50 at baseline). Inasmuch as this study
in men
consisted of a baseline measurement and 2 follow-
There are few epidemiological surveys addressing up measurements after an average of 2.1 and 4.2
the incidence of sexual disorders. For erectile years, respectively, it was possible to determine


comitte 2.indd 48 8/25/2010 12:52:42 PM

comitte 2.indd 49

Table 2. Incidence rates of erectile dysfunction in population based cohort studies.

Authors Johannes et al 47. Moreira et al. 49. Schouten et al 50. Shiri et al 51, 52.
(MMAStudy) (Krimpen study)
Geographic Massachusetts Salvador (Brazil) Krimpen aan den Ijssel (The Netherlands) Finland
location (USA)
Population type Random Random All men registered in all general practices in Krimpen Men living in Tampere or
population sample population sample surrounding municipalities from
national population register
Age range of 40-69 40-70 50-78 50-75
Eligibility criteria Men with No cancer of prostate or bladder, radical prostatectomy, No institutionalized patients
sexual partner neurogenic bladder disease or negative advice by GP
Method of At home interview At home interview Self-administered questionnaire handed in at visit Mailed Self-administered
assessment to health center / Clinic questionnaire
Response rate 52% 92% 50% 62%
Baseline: 77% (8.8 y) 83% (2 y) 78% (2.1y) / 62% (4.2y) 46% (5 y)

Differences Participants more Men in analysis Participants more LUTS and better health status compared Men without follow-up were
Non-responders heart disease sample similar to 261 non-responders questioned older and more frequently had
and cancer to loss to follow-up a history of chronic disease
Study design Cohort study Cohort study Cohort study Cohort Study Two question
Instrument Validated single Validated single Validated single assessment question assessment for obtaining
assessment assessment (scale: 4 grades) and maintaining erection
question question (scaled: 4 grades)
(scale: 4 grades) (scale: 4 grades)
Deinition of ED Sometimes or Sometimes or Erections with severely reduced rigidity or erection NIH deinition: inability to
never able to never able to not possible achieve or maintain erection
suficient for satisfactory
get and keep an get and keep an sexual function.
erection adequate erection adequate Scale 3 grades:
for satisfactory for satisfactory Minimal: some dificulties
8/25/2010 12:52:42 PM

sexual intercourse sexual intercourse Moderate: fairly/frequent

Complete: intercourse
does not succeed at all
comitte 2.indd 50

Table 2. Incidence rates of erectile dysfunction in population based cohort studies. (Continued)

Authors Johannes et al 47. Moreira et Schouten et al 50. Shiri et al 51, 52.

al. 49.
(MMA Study) (Krimpen study)
Alternative NA NA Clinically relevant ED (including concern): Erections with reduced rigidity, NA
deinition of severely reduced rigidity or erection not possible and quite a problem or a
ED serious problem for the man
Erections with severely reduced rigidity or erection not possible and a bit of
a problem, quite a problem or a serious problem for the man
Time period 1987-89,1995-97 1998-2000 NS 1994-1999
Mean follow-up 8.8 (?-?) 2 (1.7-2.3) 2.1 (1.8-3.3) 4.2 (3.6-5.8) 5
(range) yrs.
ED Clin.relevant ED ED Clin.relevant ED
Person years 7475 853 2135 2174 3180 3259 NS
of follow-up
Crude 25.9 65.6 32.8 28.1 19.2 14.1 All 39 (34-45)

(22.5-29.9) (49.6- (28.0-38.4) (23.9-32.9) (16.1-22.9) (11.7-17.0) Min127 (110-148)
Cases / 1000 85.2)
person years Mod 41 (36-47)
(95% CI) Comp 18 (15-22)

Age speciic 40-49 y 12.4 40-49 y 50-55 y ALL 22 (17-29)

incidence rates 33.3 Min 96 (77-120)
50-59 y 29.8 50-59 y 21.2 50-59 y 25.3 50-59 y 10.1 50-59 y 11.4
Cases/1000 50-59 y Mod 23 (18-29)
60-69 y 46.4 53.7 60-69 y 34.0 60-69 y 28.9 60-69 y 23.9 60-69 y 14.7
person years Comp 5 (3-8)
60-69 y 70-78 y 96.6 70-78 y 39.1 70-78 y 64.4 70-78 y 26.8
60-65y All 49 (40-60)
Min 166 (131-209)
Mod 51 (41-62)
Comp 23(17-30)
70-75y All 84 (64-110)
Min 187 (129-271)
8/25/2010 12:52:42 PM

Mod 92 (70-120)
Comp 52 (39-69)
Table 3 . Sexual function incidence (1996–2004) without prevalent cases for men in the Olmsted County
Study of Urinary Symptoms and Health Status among Men [48]

Erectile dysfunction
Age (yrs) Incident cases Person-years Incidence/1,000 man-years 95% CI
40-49 8 1,328 6 3, 12
50-59 54 4,406 12 9, 16
60-69 88 2,346 38 30, 46
70+ 102 866 118 96, 143
40+ 252 8,946 28 25, 32
Low libido
Age (yrs) Incident cases Person-years Incidence/1,000 man-years 95% CI
40-49 13 1,333 10 5, 17
50-59 94 4,211 22 18, 27
60-69 98 2,269 43 35, 33
70+ 96 813 118 96, 144
40+ 301 8,626 35 31, 39
Ejaculatory dysfunction
Age (yrs) Incident cases Person-years Incidence/1,000 man-years 95% CI
40-49 5 1,354 4 1, 9
50-59 41 4,481 9 7, 12
60-69 75 2,552 29 23,37
70+ 110 1,065 103 85, 124
40+ 231 9,452 24 21, 28
Perceived sexual problems
Age (yrs) Incident cases Person-years Incidence/1,000 man-years 95% CI
40-49 9 1,362 7 3, 13
50-59 37 4,495 8 6, 11
60-69 88 2,145 41 33, 51
70+ 75 1,174 64 50,80
40+ 155 9,815 16 13, 18
Low sexual satisfaction
Age (yrs) Incident cases Person-years Incidence/1,000 man-years 95% CI
40-49 28 1,242 23 15, 33
50-59 119 3,796 31 26, 38
60-69 88 2,145 41 33, 51
70+ 75 1,174 64 50, 80
40+ 310 8,357 37 33, 41


comitte 2.indd 51 8/25/2010 12:52:43 PM

incidence rates based on two different follow-up in all sexual function domains compared to men
periods. After an average follow-up of 2.1 years who did not have ED at baseline. other baseline
(range 1.8-3.3), a crude incidence rate of 32.8 cases characteristics, including education level; smoking
per 1000 man-years was found (95% CI: 28.0-38.4). status; and presence of diabetes, hypertension,
Furthermore, after an average follow-up of 4.2 years or coronary heart disease, were not signiicantly
(range 3.6-5.8) a crude incidence rate of 19.2 cases associated with the rate of decline in sexual function.
per 1000 man-years was found (95% CI: 16.1-22.9). Change in erectile function was signiicantly
The annual incidence rate increased with each correlated with change in all other sexual function
decade of age (table 2). domains. Correlations among changes in erectile
function, sexual drive, and ejaculatory function were
In this study, an attempt was made to determine
consistent across age groups. However, signiicantly
the incidence rate of “clinically relevant”- ED which
smaller correlations between these measures, and
means that “concern” of the man was considered
sexual satisfaction and problem assessment were
in the deinition. This analysis showed that the age-
observed among older men, suggesting that while
speciic incidence rates as compared to the rates
sexual function may worsen among these men, older
based on the usual deinition of ED, were higher in
men may be less likely to perceive this as a problem
the men aged 50-59, slightly lower in men between
and be dissatisied compared to younger men.
60 and 69, but considerably lower in men above 70
years of age (table 2.). Based on an analysis of It is clear that there are large differences in
lost to follow-up cases, the authors conclude that the incidence rates between these studies. Some of
inluence of this problem on age-speciic incidence the differences can be explained by the design of
rates is negligible. the different studies. A younger baseline age (such
as in the MMAS and Brazil study compared to the
In another European study a target population of
Krimpen study) would result in a population that is
3152 men born in 1924, 1934, or 1944 residing in
on average healthier. Surveys conducted as at home
Tampere, Finland, or 11 surrounding municipalities
interviews might result in a baseline population that
received by mail a questionnaire during the irst
is less healthy than in a study where the men have
quarter of 1994 with two questions regarding
to make an effort to visit a health center or clinic.
erectile dysfunction, trouble getting an erection
An eligibility criterion such as in involvements with a
or maintaining the erection once intercourse had
sexual partner (MMAS) also theoretically results in a
begun. [51, 52] A similar questionnaire was sent in
potentially healthier baseline population. Differences
May, 1999. Analyses were performed on 1442 (46%)
in socio-economic status (SES) between studies
men responding at both time periods and answering
the erectile questions. The erectile dysfunction have probably played an important contribution
was stratiied into minimum (some dificulty in to the variance in incident rates. In Brazil, more
obtaining and/or maintaining erection), moderate than one third of the men had less than 4 years of
(fairly frequently) or complete (intercourse does not education. It is well known that level of education is
succeed at all). Incidence rates varied for age groups a good proxy for SES.
and types of ED as shown in Table 2. The effect of The comparison of the different follow-up periods
age showed increasing incidence of ED and in this
in the Krimpen study highlights that a longer follow-
study diabetes was a major predictor of ED.
up leads to decrease of the crude incidence rate.
The most recent study was a longitudinal study of There are several reasons why this is the case. ED
a group of men in the Olmsted County Study from may be a self-limiting problem in some men. After
Mayo clinic. [48] Men who had a history of prostate a longer follow-up, more men may have died or
or bladder surgery, urethral surgery or stricture, or have become so ill that they cannot participate any
medical or other neurological conditions that could further, leaving a healthier population for the follow-
affect normal urinary function were excluded. These up measurements.
men were studied biennially from 1996 (when the
brief male sexual function inventory (BSMSF) was The above-mentioned factors and biases may work
irst used in this population study) to 2004. Incidence in one direction or the other, making it very dificult
rates for sexual dysfunctions were expressed as to compare studies in which one or more of the
incidence per 1000 person years. of the 2,213 men factors or biases may be at work. It is clear that it
(mean age at baseline 58.39 years) who participated is impossible to identify “THE” incidence of ED. The
in the Olmsted county study, 1827 men (83%) had most important common theme of the studies is the
complete data on sexual function. The person-years fact that incidence increases with age but also that
of follow-up ranged from 8,357 years for the sexual concern in men above 60 and certainly above 70 is
satisfaction domain to 9,815 years for the sexual generally less, explaining the decreasing incidence
problem assessment domain. Incidence data were of “Clinically-relevant”- ED. But there is also a
stratiied for decades of age from 40 years to 70 censoring problem- differential mortality of the sick
plus years. Results are shown in Table 3. Men who and less-well purges the older population of the
had ED at baseline experienced smaller declines potentially interested.


comitte 2.indd 52 8/25/2010 12:52:43 PM

In the Krimpen study the crude incidence of 14.1 methods stated above. All of the articles included
cases per 1000 person years for “Clinically relevant”- in the tables furnish evidence at the Ib hierarchical
ED after a follow-up of 4.2 years is strikingly similar level. [6] There is, by and large, (in spite of different
to the incidence of ED (8-10 cases per 1000 man numbers of dysfunctions registered, different
years) that was recorded in general practices in the classiications of severity and different age strata
UK in men aged 40-79 years, which is somewhat studied) reasonably valid descriptive epidemiological
younger than the Krimpen population. [54] The crude data indicating that about 40-45% of adult women
incidence rates for ED were very similar between the and 20-30% of adult men have at least one manifest
two studies from the United States but both included (as opposed to mild – i.e. sporadically occurring – or
men who were mostly Caucasian. [47, 48] However none) sexual dysfunction deined according to the
the two year incidence rate for clinically relevant ED DSM-IV A- category. Assuming an approximately
from the Netherlands was also very similar to these even distribution in societies worldwide, this means
latter studies. [50] that about one third of all adults, at least in the
western hemisphere where these investigations
2. inciDence of Sexual DYSfuncTionS were conducted, have a manifest sexual dysfunction
in Women per se.
In the early 1990’s, about 45% of Finnish women and 4. PreValence of Women’S Sexual
40% of men aged 18-74 reported decreased sexual DYSfuncTionS
desires during the past 5 years. [55] This incidence
was closely age-related as less than 20% of women An overview of the reasonably valid studies on
and men among those younger than 25 but 70-80% prevalence of women’s sexual dysfunctions, when
of those aged 55-74 reported decreased desire. feasible, dichotomized into mild/sporadic (MiD) and
Similar 5-year incidence (40% of women and 36% manifest (MaD) is given in table 4 which includes
of men) was found in the mid 1990’s in Sweden. [56] investigations with a reported response rate ≥ 40%.
In the latter investigation, 11% of women and 5% Among these eighteen descriptive epidemiological
of men reported markedly decreased desire. one studies seven were from Europe, four from the USA,
explanation for this decrease may be that with longer three from Australia, and one each from Canada, Iran,
Morocco, and Puerto Rico. There were pronounced
duration of partnership, desire tends to decrease [57]
methodological differences between these studies.
and, as discussed in chapter 24, sexual desire, to
Thus, ten used face-to-face interviews. Five of
a greater degree than sexual interest, may be seen
the studies used mail questionnaires. Telephone
as a partner-related aspect of sexuality, not really
interviews of varying length were utilized in three
separable from arousal.
studies. While interviews, whether face-to-face or by
recommendation 4. : telephone for pragmatic reasons, can be regarded
reliable [25.], there is in the literature some doubt
There is a need for more incidence studies, from about the reliability of mailed questionnaires. A main
all regions of the world, for sexual dysfunction in reason for this is that a mailed questionnaire may be
men and women, even more so for all types of answered in consensus between partners. Such a
dysfunctions in women and other that ED in men. questionnaire may also yield a relatively low response
grade c. rate. However, it is also possible that interviewees
may be particularly prone to social desirability bias,
3. PreValence of Sexual where the presence of an interviewer results in
DYSfuncTionS in Women anD men respondents being more likely to give answers that
they think will be socially acceptable.
As mentioned above, prevalence tables for sexual
dysfunctions for women and men, Tables 4-6, were Another dificulty is the difference in the age strata
constructed from reports in peer review journal studied. As can be seen in table 4, the Icelandic
articles or books which met strict inclusion criteria investigation covered a very narrow age span –
of at least 10 of 15 possible assessment points from but included half the population at this age. Some
the Prins et al article. [7] one of the chairmen of this focused only on elderly women while others cover
committee and at least one other of the members of an age span from the teens and up to old age. Two
the committee have screened all to meet the criteria. studies, the Finnish and the Swedish, from the
The literature was located through data-bases, the sample selection and deinatory points of view, can
two previous chapters on epidemiology of Sexual be regarded as twins. However, these two countries
Dysfunction from the past consensus consultations are neighbors with rather small total populations.
[5, 58], and surveys from Spector and Carey (1990) Even the time frame of having had sexual functions/
[59], Simons and Carey (2001) [60], Lewis [61], dysfunctions differs considerably. Thus, while some
Kubin et al. [62] and Melman and Gingell. [63] A studies describe life long prevalence, others address
few of the references were found by crosschecking the past year or even briefer periods (as three months
the bibliographies from the articles sourced by the or last month).


comitte 2.indd 53 8/25/2010 12:52:43 PM

comitte 2.indd 54

Table 4. Reasonably Valid epidemiological investigations of prevalence of women’s sexual dysfunctions. Prins score at least 10, response-rate at least 40%.

Authors, Country/ Method Age n (% Validity Desire (D) Arousal (A) Orgasm Dyspareunia Vaginismus
Performed/ Regional Scale years respons. score Interest (I) Lubrica-tion
published National steps Approx. (Prins) MiD/MaD MiD/MaD MiD/MaD MiD/MaD
Osborn et al 64. GB/R Interview 35-59 436 12 I-/17% L-/17% -/16% -/8% -
NG/1988 5 (72%)
Lindal, ICL/N Interview 55-57 417 14 D16% 6%* 4%** 3% -
Stefansson 2 (75%)
Kontula, Haavio- FI/N Interview 18-74 1146 13-14 D-/35% L-/15% 63%/30% 30%/7% -
Manilla 55
6 (78%)
Barlow et al 67. GB/R Interview >55 2011 10 - L-/8% - 2% -
1993/1997 2
Johannes, Avis 68. USA/R Telephone 51-62 349 (82%) 10 - - -/41% -/13% -

1988-89/1997 3
Group ACSF FR/N Telephone 18-69 1137 11 D55%/8% - 44%/11% 43%/5% -
Bajos et al 4
Laumann et al20. USA/N Interview 18-59 1486 13 I-/32% L-/21% -/26% -/16% -
1992/1994,1999 2
Fugl-Meyer SE/N Interview 18-74 1475 13-14 I 54%/33% L 49%/13% 60%/22% 33%/6% 5%/1%
group65. (59%)
Kadri et al24. MO/R Interview >20 465 (94%) 10 D-/18% -/8% -/12% -/8% -/6%
NG/2002 5
Richters et al37. AU/N Telephone 16-59 8280 13 I-/55% L-/24% -/29% -/20% -
2000-01/2003 2
8/25/2010 12:52:44 PM

Johnson et al USA Interview 18-96 1802 13 D-/11% A-/4% -/16% -/19% -
comitte 2.indd 55

Table 4. Reasonably Valid epidemiological investigations of prevalence of women’s sexual dysfunctions. Prins score at least 10, response-rate at least 40%.

Authors, Country/ Method Age n (% Validity Desire (D) Arousal (A) Orgasm Dyspareunia Vaginismus
Performed/ Regional Scale years respons. score Interest (I) Lubrica-tion
published National steps Approx. (Prins) MiD/MaD MiD/MaD MiD/MaD MiD/MaD
Gruszecki et al 76. Canada Mailquest 15-44 1575 12 D 41%/- - -/23% -/14% -
Dennerstein et AU Mailquest 18-74 1356 13 D-/9% - - - -
al 73. (70%)
Safarinejad 75. Iran/N Interview 20-60 2424 13 D/I 35%* A 30%* -/37% 27%*
NG/2006 5 L 34%*
Eplov et al 74. DK/N Interview 16-67 4917 13 D 53%/19% - - - -
2007 3
Hayes et al 39. AU/N 20-70 12 D-/16% A-/7% -/8% -/1%

Shifren et al 70. USA Mailquest 18-102 31581 14 D-/39% A-/26% -/21% - -
2008 2
Avellanet et al 72. Puerto Mailquest 40-59 919 (55%) 12 D* 41% - - - -
2008 1

MiD = mild, sporadically occurring dysfunction. MaD = manifest dysfunction occurring at least quite often. NG = Not given. *excitement **anorgasmia
8/25/2010 12:52:44 PM
Also deinitions and classiication of severity vary (of 18-74 year olds [27, 68, 71, 73] Hayes et al [2]
considerably ranging from DSM-III or DSM-IV found 16% of Australian women with manifest desire
based face-to-face interviews which post hoc are dysfunction and a Danish study by Eplov et al [74],
transformed into a yes/no dichotomy and up to found that 19% of women 16-67 year old have a
strictly structured questions applying 4, 5, or 6 manifest desire dysfunction. Greater desire levels
graded scales. Regardless of the method used, were found in younger women, physically active,
there appears to be reasonable consensus at the unmarried, with no children under 15 years, in good
turn of the century [20, 65, 70] that the prevalence physical and mental health and without medication.
of women who report at least one manifest sexual Concerning age related desire dysfunction the
dysfunction is in the order of about 40-50%. Swedish prevalence (11%) doubled to 22% in those
50-65 years of age and again doubled to 47% in the
a) Interest/Desire 66-74 year olds. These numbers appear to agree
As pointed out in chapter 24, the deined category rather well with those reported in Iceland [66] and in
“desire” is probably not separable from the Morocco [24], while in France [69] clearly fewer have
psychological aspects of arousal – yet another manifest, but 55% have mild desire dysfunction.
argument for universal consensus. Furthermore, b) Arousal and Lubrication
interest and desire seems to be equivalent for
several authors. As previously mentioned, the traditional biologic
deinition of arousal nearly exclusively covers
Using different methods and scaling, descriptive genital events, foremost lubrication. However, these
epidemiological investigations have found that the genital events may not at all be accompanied by
prevalence of manifest low level of sexual interest psychosexual pleasure (i.e. “arousal”). The obvious
varies between 17% (GB) in 35-59 year old women need of redeining arousal in relation to desire is
[64] through 33-35% (USA 18-59 years old, Sweden discussed in chapter 24.
18-74 years old, Iran 20-60 years old) [20, 65, 75]
and up to 55% in Australia [37.]. Neither in the USA Using the DSM-IV deinition, 16% of 55-57 year
[20] nor in Sweden [56] is there an age dependency old Icelandic women were found to have low levels
up to the age of about 60-65. In Australia 16-19 of excitement [66]. Furthermore, arousal disorder
year old teenagers had signiicantly lower level of was found to have occurred in 26% of American
sexual interest dysfunction than older cohorts. A (aged 18-102) and in 30% of Iranian (aged 20-
major difference between the USA and Sweden in 60) women. However, most valid epidemiological
this respect was that the oldest Swedish women research has focused on genital response in terms
had considerably higher prevalence than the 18-59 of vaginal dryness/insuficient lubrication. Even
year old USA women but clearly lower prevalence in this aspect, there are considerable differences
among the youngest women. In Sweden, 54% of the between epidemiological data (table 4). Generally,
18-74 year old women reported mild (sporadically manifest lubrication dysfunction is prevalent in 8-
occurring) dysfunction during the preceding year. 15%, while Laumann et al [20] and Richters et
This is very close to the French 55% prevalence [69] al [37] reported this to be the case in 21-28% of
of mild desire dysfunction. Both those with manifest sexually active women. These investigations used
and those with mild dysfunctions had signiicantly a dichotomous yes/no scale. Safarinejad [75] found
lower level of overall sexual satisfaction than had 34% of lubrication dysfunction in Iranian women.
Öberg et al [27] found that 49% of Swedish women
those with none of these dysfunctions [27].
aged 18-65 years had mild (sporadically occurring)
Low level of sexual desire was reported in Puerto lubrication insuficiency. Some studies have
Rico in as much as 41% of 40-59 year old women evidenced that with increasing age, in particular age
[72]; however, the deinition utilized by the authors >50 years, lubrication insuficiency becomes more
does not provide enough information to determine prevalent [64, 68], while others have not found age
whether symptoms were mild or manifest. This “loss dependency in this respect [20].
of libido” was associated with greater symptoms of
c) Orgasm
depression. Manifest low desire dysfunction was
reported in as much as 39% in the large scale The prevalence of manifest orgasmic dysfunction
investigation of American women 18-102 years varies considerable in the available epidemiological
old [70] and in 35% of Finnish women aged 18-74 reports. Again, this may to a great extent be due to
[55]. Shifren et al. [70] found desire dysfunction de facto incompatibilities of reports. Nevertheless,
to be more prevalent in the 45-64 age-cohorts. In it appears that in Australia [37.], Sweden [65], the
this study 15-25% of women younger than 55 had USA [20, 70, 71] and Canada [76] the prevalence
this dysfunction; but the prevalence increased to of manifest orgasmic dysfunction is about 16-
about 50% in women aged 55-74. Lower levels of 25% and in Iran as high as 37% [75]. In most of
manifest desire dysfunction – about 10% - were these countries, age dependency has not been
reported from Sweden, France, USA, and Australia traced; while in Australia for about the same overall


comitte 2.indd 56 8/25/2010 12:52:44 PM

prevalence, 50-59 year old women were more likely appears to emerge at older age. It is, therefore not
to report orgasmic dysfunction than were those aged surprising that the elderly population of men, with
between 16 and 49 years. An age-dependency was greater prevalence of, for instance, ED (see below)
also found in the Iranian sample. Also, in the USA is not more sexually distressed than their younger
orgasmic dysfunction was more prevalent among peers. In Australia [37], Argentina [82], Southeast
women 45 or older. A somewhat higher prevalence Asia [85], Korea [94], and Italy [92], a clearly higher
of orgasmic dysfunction (30%) has been reported prevalence of desire/interest dysfunction, without any
from Finland [55]. A signiicant higher prevalence pronounced age effect, of about 25% was reported
(41%) of manifest orgasmic dysfunction among by 16-59 and 40-80 year old men. In the study from
51-62 year old women has been reported from the Netherlands [100], a very high incidence of desire
Massachusetts [68]. In other studies [24, 39, 64, 68, problems were reported, 41-58% from ages 58-78
71], the prevalence of manifest orgasmic dysfunction years. Generally dysfunction of sexual desire/drive
is much lower (11-16%), while that of mild orgasmic is much less prevalent than dysfunction of interest,
dysfunction is remarkably high (about 60%) in the whether life-long (France [69] and Iceland [66]) or
two Nordic countries, where identical methodology during the past year (Sweden [65]) or so. However,
were used. Thus, in these two countries, more than at higher ages (50-65 and >70) both Panser et al [77],
80% of all sexually active women aged 18-74, age the Swedes [65] have demonstrated sharp increase
independently; report some degree of orgasmic also in this prevalence. A national random sampled
dysfunction. population of men in China reported a prevalence
rate of 53% at anytime within the previous year
In Swedish women it was found that women reached and 11% for persistent lack of interest for the most
orgasm more easily through stimulation of both part increasing with age. [84] In summary the
clitoris and vagina, and furthermore, experienced populations’ level of sexual interest appears quite
women reported more pleasurable orgasms during stable from the late teens and up to about 60, where
intercourse when the penis was in the vagina. after it decreases markedly. The same may be true
During masturbation a small minority stimulated only for sexual desire/drive which may in many men,
the vagina. For American women use of marijuana however, start to decline already around the starts of
and alcohol was associated with greater orgasmic their 6th decade of life. In general studies reported in
problems.[71] this chapter since the last consultation for prevalence
d) Dyspareunia and Vaginismus of desire/interest have been reported for 40-80 year
olds without age adjustment to range from 8 to 18%
These conditions are discussed in Chapter 25. around the world except for the citations presented
The syndromes are clearly less prevalent in the above. (See Table 5)
general population. Thus, 6% of the Moroccan [24]
and Swedish [64] women reported some degree of b) Ejaculation Dysfunctions
vaginismus, which does not appear to be related to Ejaculation is distinct from orgasm, which is a purely
age. The prevalence of manifest dyspareunia has cerebral cortical event. If current understanding
been reported as low as 1% in Australian women of ejaculation is limited, the knowledge regarding
[72] and 2% in elderly British women [66] while orgasm remains even more obscure. It is not until
another studies [20, 37, 68, 71, 75, 76] found that very recent time that is was accepted that ejaculatory
dyspareunia prevailed in as many as 14-27%. Mild disorders may have a neurobiological origin rather
(sporadically occurring) dyspareunia is 4-8 fold more than being a pure psychological issue. [102]
common than is manifest. Several investigations have
described increasing dyspareunia with increasing We have been able to locate [22] descriptive
age [21, 65, 78] while in Australia the opposite has epidemiological investigations of ejaculatory
been found with a systematic decrease of reported disturbances fulilling our validity criteria. These are
physical pain during intercourse from the age of 30 given in table 5. The prevalence varies from 8%
years and onwards [37]. and up to 30% for all age groups covered by the
tabulated data for early or premature ejaculation.
5. PreValence of men’S Sexual Two exceptions to this were a prevalence of 55%
DYSfuncTionS in 50 to 59 year old men in one US study [20] and a
very low prevalence in 18-75 year olds surveyed in
a) Desire/Interest
London where the rate of 3.7% was seen [81]. The
Altogether we have identiied 24 epidemiologically 15% life-time prevalence found in France [69] covers
valid reports (table 5) that include men’s interest 5% who often had experienced ejaculation prior to
and/or desire. Whereas in Sweden [65] and the penetration and 10% who often had ejaculated too
USA [20] the prevalence of low or decreased level rapidly after vaginal intromission. The 2-3 fold higher
of sexual interest during the last 12 months by and prevalence expressed as “climax too early” and still
large are remarkably similar and age independent higher for 50-59 year old men reported from the USA
up to the age of about 60 years, a sharp increase may be a result of the dichotomous scale (yes/no)


comitte 2.indd 57 8/25/2010 12:52:44 PM

comitte 2.indd 58

Table 5. Valid epidemiological investigations (arranged according to publication year) of prevalence of men’s sexual dysfunctions.
Erectile dysfunction not included.
Authors (s) Country n Method Age Desire (D) Early Delayed Orgasm Dyspareunia Other
Performed/ Regional Interest (I) Ejaculation Ejaculation
Published National

Lindal, Stefanson66 Iceland/N 405 Interview 55-57 (D) 4% - - 1% - -


Panser et al77 USA/R 2115 Interview (sex drive)

1989-90/ 40-79 6% - - - - -
1995 40-49 0.6%
³70 26%
Kontula, Haavio- Finland/N 1104 Interview 18-74 (D) 1%
18-24 5% - - - 1%
25-34 2% - - - 1%

35-44 5% - - - 1% -
45-54 13% - - - 1%
55-64 14% - - - 10%
65-74 23% - - - 5%
Groupe ACFS France/N 1335 Telephone 18-69 3% 10% 4% 7% 5% -
Bajos et al 1991-
Dunn et al 78 Great 789 Mailed 18-75 - 14% - - - -
Britain/? question-
1996/1998 naire (3 mths)
31% (ever)
Laumann USA/N 1249 Interview 18-59 (I) 16% 31% - 8% -
et al 18-29 14% 30% - 10% -
1992/1999 30-39 13% 32% - 8% - -
8/25/2010 12:52:45 PM

40-49 15% 28% - 9% -

50-59 17% 55% - 6% -
comitte 2.indd 59

Table 5. Valid epidemiological investigations (arranged according to publication year) of prevalence of men’s sexual dysfunctions.
Erectile dysfunction not included. (continued)
Authors (s) Country n Method Age Desire (D) Early Delayed Orgasm Dyspareunia Other
Performed/ Regional Interest (I) Ejaculation Ejaculation
Published National
Fugl-Meyer Sweden/N 1475 Interview (D)/(I)
Fugl-Meyer65 18-74 3%/16% 9% 2% - 1%
1996/1999 18-24 1%/6% 4% 4% - <1%
25-34 2%/16% 7% 0 - <1% -
35-49 1%/15% 8% 2% - <1%
50-65 22%/18% 8% 3% - <1%
66-74 4%/41% 14% 10% - <1%
Blanker et al79 Nether-lands/R 1605 Questionnaire 50-78 - 13% - - 1% -
Richters et al37 Australia/N 8517 Telephone 16-59 (I) 25% - - - -
2000-01/2003 16-19 25% - - - -
20-29 20% - - - -
30-39 22% - - - - -

40-49 29% - - - -
50-59 32% - - - -
Rosen et al80 US/ All CS/SAQ 50-59 28.7%
2001/2003 Europe: 12,815 60-69 55.4%
UK Eur 70-80 73.8%
10,900 All 46.2%
Europe 45.3%
Nazareth London (UK) 447 CS/SAQ 18-75 6.7 (4.6 3.7 (2.1 2.4 (1.2 1.1 (0.4
– 9.4)% – 5.7)% – 4.4)% – 2.6)%
et al81
not reported/2003
8/25/2010 12:52:45 PM
comitte 2.indd 60

Table 5. Valid epidemiological investigations (arranged according to publication year) of prevalence of men’s sexual dysfunctions.
Erectile dysfunction not included. (continued)

Authors (s) Country n Method Age Desire (D) Early Delayed Orgasm Dyspareunia Other

Performed/ Regional Interest (I) Ejaculation Ejaculation

Published National

Nolazco et al82 Argentina/R 2715 Interview by 34.97 23.8% 28.3% 14.1% - - -

Enzlin et al83 Belgium 799 CS/SAQ 40-49 2.7% - - 1.8% -

1999 /2004 50-59 4.7%

60-69 9.9%
8/25/2010 12:52:45 PM
comitte 2.indd 61

Table 5. Valid epidemiological investigations (arranged according to publication year) of prevalence of men’s sexual dysfunctions.
Erectile dysfunction not included. (continued)

Authors (s) Country n Method Age Desire (D) Early Delayed Orgasm Dyspareunia Other
Performed/ Regional Interest (I) Ejaculation Ejaculation
Published National

Nicolosi Northern Europe 13618 CS/SAQ All

et al85 Austria/Belgium (19%) 40-49 7% 13% 5%
1997-1998/2004 Germany/Sweden 50-59 9% 14% 6%
UK 60-69 12% 17% 11%
70-80 16% 18% 17%
Southern Europe
40-80 9(9-10)% 14(14-15)% 7(7-8)%
Non-European West
North. 7(6-8)% 10(9-11)% 5(4-6)%
Australia/Canada New Europe
Zealand South Africa/US

Central/South America South. 6(5-7)% 13(12-15)% 7(6-8)%

Middle East
Algeria/Egypt/ Europe 9(8-11)% 16(14-17)% 8(7-9)%
East Asia
China/Hong Kong/Japan/ South.
Amer. 9(7-11)% 22(19-25)% 8(6-11)%
Southeast Asia
Malaysia/ Middle East
13(11-15)% 8 (7-10)% 7(6-9)%
Singapore/ East Asia
Thailand 12(11-14)% 19 (17-21)% 10(9-12)%
SE Asia
8/25/2010 12:52:46 PM

20(17-23)% 25 (22-29)% 15(13-18)%

comitte 2.indd 62

Table 5. Valid epidemiological investigations (arranged according to publication year) of prevalence of men’s sexual dysfunctions.
Erectile dysfunction not included. (continued)

Authors (s) Country n Method Age Desire (D) Early Delayed Orgasm Dyspareunia Other

Performed/ Regional Interest (I) Ejaculation Ejaculation

Published National

Moreira et al86 Brazil/N 471 Computer- 40-80 11.2% 30.3% - 14.0% 4.6% -
2005 interview
Moreira et al87 Germany/N 750 Computer- 40-80 8.1 15.4 - 5.6 1.8 -

Moreira et al88 Spain/N 750 Computer- 40-80 16.9 31.2 - 15.3 3.6 -
Nickel et al89 Europe, Latin 5096 Questionnaire Mean 65.2 - - - - - Painful
America, ejaculation
Middle East, 16.8%
Asia, Canada
Oksuz et al90 Turkey 2288 Survey/ 15-60 7.3% - - - - -

2004/2005 SAQ
8/25/2010 12:52:46 PM
comitte 2.indd 63

Table 5. Valid epidemiological investigations (arranged according to publication year) of prevalence of men’s sexual dysfunctions.
Erectile dysfunction not included. (continued)

Authors (s) Country n Method Age Desire (D) Early Delayed Orgasm Dyspareunia Other
Performed/ Regional Interest (I) Ejaculation Ejaculation
Published National

Stulhofer Croatia 888 RPS ≤39 - 15.7% - - - -

et al 30-49 10.9%
2004/2005 50-59 3.6%
60-69 6.9%
70-79 12.5%
Corona et al92 Italy 1563 Interview/SAQ 18-88 35.9% - - - - -

Basile-Fasolo Italy 12558 Survey/ <40 - 31.8% - - - -

et al93

SAQ 40-49 17.6%

50-59 25.7%
³60 24.8%
Moreira et al94 Korean/N 600 Intercept 40-80 28.3 32.7 - 19.3 6.1 -
2001-2002/ Protocols

Brock et al95 Canada/N 500 Computer- 40-80 15.2 22.5 - 11.8 4.4 -
2001-2002/2006 telephone
interview survey
Parish et al84 China/N 1,261 Computer- 20-64 53 anytime last 69% anytime - 52% last year 25% anytime Performance
assisted year last year last year
interview 5% > 2 Anxiety
11% > 2 months 8% > 2 mths. months 2% > 2
months 49% last year
8/25/2010 12:52:46 PM

4% > 2 months
Moreira et al96 UK and 4500 Comp.assttele 40-80 15.1 19.8 - 13.7 2.9 -
2001-2002/2008 Europe/N interview
comitte 2.indd 64

Table 5. Valid epidemiological investigations (arranged according to publication year) of prevalence of men’s sexual dysfunctions.
Erectile dysfunction not included. (continued)

Authors (s) Country

Desire (D) Early Delayed
Performed/ Regional n Method Age Orgasm Dyspareunia Other
Interest (I) Ejaculation Ejaculation
Published National
Moreira et al97 Australia/N 750 Computer- 40-80 17.5 23.3 - 13.9 2.7 -
interview survey
Laumann et al98 USA/N 742 Computer- 40-80 18.0 26.2 - 12.4 3.1 -
interview survey
Andersen Denmark 863 RPS 20-45 3% 24% - 2% - -

et al99


Korfage Nether- 3893 CS/SAQ 58-61 40.8% - - - - -

et al100 lands 62-64 41.4%

1993-1999/2008 65-67 46.1

68-70 51.5%

71-78 57.7%
Corona et al101 Italy 2437 Interview/SAQ 51.9 ± 25.9% 4.4% - - -

2001-2007/2008 13.0
8/25/2010 12:52:46 PM
used by Laumann et al [20] while the European evidence based deinition. This committee proposed
investigations used pluri-step scales. However more that lifelong PE in heterosexual men be deined as
recent surveys reported in Table 5 from the last ejaculation which always or nearly always occurs
consultation have shown higher prevalence rates prior to or approximately one minute after vaginal
for early or premature ejaculation from around the penetration on all or nearly all vaginal penetrations
world and particularly from Asia and Latin America. with negative personal consequences.[23] It is
An exception was the study from China in which recommended that future research adopt this
a rate of persistent premature ejaculation was 8% deinition. There is insuficient data at this time to
(> 2 months), a rate of 69% of any occurrence of precisely deine acquired PE or PE in other sexual
the complaint within the previous year. In a recent activities.
study not shown on the Table 5 Ahn et al reported
from Korea in 1,570 men aged 40-79 years of age. A c) orgasm
prevalence rate of 24.9% for not being able to control
It is, at least in men, quite dificult to assess the
their ejaculation time, further broken down based on
prevalence of orgasmic dysfunction. The simple
self-reported intravaginal ejaculation latency time a
reason being that, in contrast to many men with
rate of 11% for a 2 minute cutoff time and 33.1% for
complete spinal cord injury, some men may be unable
a 5 minute cutoff time increasing signiicantly with
to distinguish between ejaculation and orgasm. In
aging. [103] Still fewer investigators have reported
on the prevalence of delayed ejaculation. [64, 68, the USA 8% age independently reported that they
80, 82, 84, 101] (See Table 5) Rates for this disorder had been unable to achieve orgasm (cf table 5)
vary from 1 to 10%. during the last year. [20] A much lower prevalence
(<1%) was reported in 55-57 year old Icelandic men
It is, in fact, probable that many men who have [66] ; while in France [69] the (life-time) prevalence of
dificulties in maintaining an erection during vaginal men’s orgasmic dysfunction was (7%). Since the last
intercourse also report delayed ejaculation. Hence consultation 13 of the 23 published prevalence data
the already relatively low reported prevalence may for male dysfunctions other than ED have reported
be exaggerated. These prevalence studies applied orgasm problem analysis in their surveys. Most of
various frequently non-validated deinitions of and the studies report a prevalence rates in the range
methodologies for evaluation of early ejaculation. of 11.8-19.4%. (See Table 5) Nicolosi’s world-wide
However, it should be emphasized that normative report showed 5-8% for all areas of the world except
data on ejaculation latency time obtained by the for East and Southeast Asia where the prevalence
stopwatch method in the general male population was 10-15%. [85] Five of the surveys reported lower
are mandatory to really establish the prevalence of rates, Nazareth from London reported a prevalence
early ejaculation. Obviously, an accurate deinition rate of 2.4% [81], Enzlin from Belgium, a rate of 1.8%
of early ejaculation is necessary, not only for clinical
[83], Moreira from Germany, a rate of 5.6% [87],
diagnosis and treatment, but also for comparing data
Corona from Italy, a rate of 4.4% [101], and Parish
from different studies and performing epidemiological
studies. [102] Unfortunately, there is a real paucity from China a rate of 5% [84]. This last study reported
of studies dealing with either clinical or non-clinical a rate of 52% for occurring anytime in the previous
samples from which we can really drew valid igures year versus the 5% rate for persistent greater than 2
in keeping with the Prins’ criteria listed elsewhere. month’s occurrence.
Since deinitions regarding ejaculatory, orgasmic
and desire disorders in males, broadly known and
d) Dyspareunia
accepted, were lacking, this “scenario” was in some The prevalence of genital pain in men during
way expected. sexual intercourse has only been fragmentarily
one of the problems of surveys regarding early studied (table 5). In France [69] 5% of the adult
ejaculation is the inconsistency of how the condition male population (of 18 to about 70 years) report
is deined. Some investigators have deined PE that they at least quite often suffer such pain. This
as ejaculation which occurs within one minute of rate from 3-6% was reported in seven studies [see
vaginal penetration whereas others have deined PE Table 5] Clearly lower prevalence of 1% -2% have
as ejaculation which occurs within seven minutes of been found in Finland [55], Sweden [65], China [84],
penetration.[23] Other investigators have deined the Netherlands [79], London [81], and Germany
premature ejaculation based on the number of thrusts [87]. The China study reported a rate of 25% when
between vaginal penetration and ejaculation[104] or occurring anytime within the previous year but only
sense of control over ejaculation[105]. Giuliano et al 2% for persistent greater than 2 month’s occurrence
[106] proposed that PE be deined by a combination [84]. With this low prevalence it is hardly surprising
of direct measures of ejaculatory latency and patient that no age-dependency of men’s dyspareunia has
reported outcomes. In 2007, the International Society been found. Nickel and al reported a prevalence rate
for Sexual Medicine convened an international panel of painful ejaculation on a world survey of 16.8%.
to review current evidence and to recommend an [89]


comitte 2.indd 65 8/25/2010 12:52:47 PM

e) Erectile Dysfunction the studies, since that particular description is so
varied. The deinition of ED used for the particular
Tables 6a-f. are compilations of the data from 59 study and reported on the table is included in table
studies around the world regarding prevalence of ED 6 A-F. The reader can see that the deinition of ED
(male sexual arousal dysfunction) from 1993 to 2009. varied among the studies and thus comparison
At the time of the irst consultation on ED there were between studies is from the beginning hampered.
very few studies that would meet this more stringent Time period covered by the questions about ED
evidence based criteria. In fact, 24 studies in this varied from one month to one year, and 10 of the
table were presented in the last chapter, only six studies did not specify a time period questioned
were included in the irst consultation chapter. [5, 58] about ED.
There continues to be a better global representation.
Again it should be stressed that in order to adhere Most were random population studies, some
to the most scientiically valid studies to be included stratiied by age or region. The Japanese study
only those studies that obtained a Prins score of 10 or from Masumori included all men 40-79 years of
above are included in these tables. There have been age in a ishing village with 42.3% participating the
several other epidemiologic studies that have been study. [107] In the study from Denmark reported by
published regarding prevalence of ED but they do Solstad and Hertoft [112-113], all men of the age
not meet this standard for scientiic validity. The Prins of 51 year from selected communities were sent
scores are included in Table 6 in the irst columns so questionnaires with an 81% response rate. Five of
that the readers can be aware of those with higher the studies were from general practice (GP) settings;
scientiic validity. There are 5 studies from Asia and three that included all men registered in the general
4 from Australia (Table 6A. and B). There are 30 practice. These three included one from the United
studies from Europe (6C), 7 papers from South and Kingdom, 40 years and older, with a 65% response
Central America, 7 from North America, and 6 studies rate [117], one from the Netherlands, 50-75 years of
classiied as worldwide representing data collected age, with a 47% response [79, 124-125], and one
in different regions of the world and published as from Wales, UK, 55-75 years of age, with a 50%
a single paper. For the European studies; 4 each response rate [127]. Two of the other studies were
were from the Netherlands and the United Kingdom, random population studies of the GP registrations,
3 each from Finland, France and Germany, 2 each one from the United Kingdom, 18-75 years of age,
from Denmark, Sweden, Spain and one each from with a 39% response [78, 119] and one from Italy, age
Italy, Belgium, Turkey, Croatia, and Portugal. Two of 18 years and older, with a 82% response rate [120].
the studies were European multinational. Most of the The percentage of response was determined from
Latin American studies were from Brazil except one data presented in the paper or chapter regarding the
study from Columbia, Venezuela, and Ecuador. The eligible number who were scheduled to be screened
North American studies were all from the US except and ranged from 17 to 82%. Only eight of the ifty-
one Canadian report. nine were under 500 participants in number. Eight
of the studies reported no differences between
Design of the studies included survey questionnaire responders and non-responders and another 12 did
only (survey) or cross-sectional study with additional report differences as summarized in the table. Thirty-
measurements (CS) and the table shows 30 of nine did not address this issue.
the former and 28 of the latter. Richter’s data from
Australia was conducted by telephone and was All the studies which were stratiied by age showed
a single question only. [37] Self-administered rising prevalence of ED as the population aged.
questionnaires was the instrument used in 40 of Two of the Asian studies showed doubling of the
the survey designed studies and interviews in the prevalence rate at age 60-70 with almost another
remaining 19 of these. In the cross-sectional studies doubling at age 70-79 years. [107-108] The study not
all studies used the instrument of self-administered stratifying from Korea reported a 31.9% prevalence
questionnaires except one study from Wales [127] rate for ages 40-80 which seemed to represent a
which used an interview. A unique feature of a study mean of the stratiied studies. [94] The more recent
from Denmark was that 100 of the men who had not Korean report stratiied by age showed a tripling of
reported ED on the self-administered questionnaire the prevalence for the 60-69 age group compared
were subsequently interviewed in an ofice setting to those younger whether self reported or scored by
and seven of these reported at the interview ED of IIEF. [103] In that same study using IIEF-5 diagnosis
a signiicant nature, thus increasing the original 4% of <17 as deining ED tripled the self-reported ED
percentage of ED in this group of 51 year old Danish in the younger age groups and the total group and
doubled it for the older age groups.(see Table 6a)
males by 7% in these 100 men. [112, 113]
one of the Australian reports did not show much of
However, as in the case for women’s dysfunctions, a difference in prevalence over stratiication from
there is great variety in methodologies of the studies. 16-59 years until age 40 was reached and then the
The authors of this chapter have eliminated many prevalence was low for the 40-49 and 50-59 year
reported categories of mild ED reported in some of decades of 13 and 19%.[37] The other stratifying for


comitte 2.indd 66 8/25/2010 12:52:47 PM

comitte 2.indd 67

Table 6A. Asian Prevalence of Erectile Dysfunction.

Author(s)/ Year/ Number

Age of Differences/
Published/ (Prins Country of study Population Type Eligibility Criteria
participants (% respondents) Nonresponders

Masumori, et al. Japan All men in a ishing 40-79 No prostate or bladder 289 (46.8%) NS
1999107 village cancer or surgery,
42.3% analyzed
(10) anti- androgen, CVA or
neurogenic bladder

Kongkanand Thailand Region stratiied RPS 40-70 NS 1250 NS


Moreira et al. 2001- Korean RPS 40-80 40 to 80 years 600 (32.5%) NS


Parish et al. 1999- China Region stratiied RPS 20-64 Sexually active within 1,261 (76%) NS
2000/200784 stable relationship

Ahn et al.102 Korea Region stratiied RPS 40-79 All men 1,570 Similar(stat. sigf.) to
2004/2007 population published
(12) in Nat Health and
Nutrition Survey
8/25/2010 12:52:47 PM

( ) Prins Score
comitte 2.indd 68

Table 6A. Asian Prevalence of Erectile Dysfunction (continued)

Prevalence Rate
Prevalence Rate
Authors/Date Published Design/Instrument Deinition of ED Time Period Percentage
Age (years)
(CI 95%)

Masumori, et al. CS/SAQ Ability to have an One month 40-49 15 (6-28)

erection when stimulated
1999 107 50-59 23 (14-35)
none or little of the time
60-69 39 (30-49)

70-79 71 (59082)

Kongkanand Survey/Interview Sometimes or never Six months 40-49 7 (5-9)

able to achieve or keep
2000 108 50-59 22 (18-26)
erections good enough
for intercourse 60-70 49 (42-56)

Moreira et al. 2001-

Had trouble achieving or
2002/2006 94 Survey/SAQ One year 31.9 (27.9,; 36.0)
maintaining an erection

Age stratiication by bar

Parish et al. 1999-2000/ Dificulty achieving and
One year and persistent graph only therefore raw 52-58% last year
200784 Survey/ Interview trouble maintaining an
(> 2 months) percentages by age not 5-8% persistent

40-79 13.4 SR / 32.4 IIEF

40-49 4.2 SR / 17 IIEF

Ahn et al.102 Survey/Interview by Self reported (SR) and
50-59 13 SR / 29.5 IIEF
2004/2007 questionnaire IIEF-5 < 17 deined ED
60-60 30.1 SR / 62 IIEF
8/25/2010 12:52:47 PM

70-79 41.1 SR / 84.4 IIEF

comitte 2.indd 69

Table 6B. Australian Prevalence of Erectile Dysfunction

Author(s)/ Year/
Number Differences/
Published/ (Prins Country of study Population Type Age of participants Eligibility Criteria
(% respondents) Nonresponders

Pinnock South Australia Probability population 40+ NS 371 (49.8%) Compared to 374
sample nonresponders
1999109, 110
– Similar

Richters et al. Australia Weighted RPS >40 NS 8367 (57) No difference from
general population
2000-01/2003 37 Nationally
(13) representative

Moreira et al. 2001- Australia RPS 40-80 40 to 80 years 750 (16.9%) NS

Chew et al. 2001- Western Australia RPS 20-99 Voter enrollment 1,580 (37) No difference from
2002/2008 general population
8/25/2010 12:52:47 PM
comitte 2.indd 70

Table 6B. Australian Prevalence of Erectile Dysfunction (continued)

Prevalence Rate Prevalence Rate

Authors/Date Published Design/Instrument Deinition of ED Time Period Age (years) Percentage
(CI 95%)
Pinnock Survey/SAQ Erections inadequate for Three months 40-49 6 (3-11)
1999 109, 110 50-59 12 (6-19)
(13) 60-69 41 (29-53)
70-79 63 (49-76)
80+ 81 (54-96)

Richters et al Telephone Last 3 months 16-59 10%

2000-01/200 Single question 16-19 4%
(13) 20-29 5%

30-39 5%
40-49 13%
50-59 19%
Moreira et al. / 2001-
2002/2008 97 Had trouble achieving or
Survey/Interview One year 21.1 (20.4; 21.9)
maintaining an erection
20->80 40.3
20-29 15.7
30-39 8.7
Chew et al. 2001-2002/2008
40-49 12.9
Survey/questionnaire IIEF-5 <22
(12) 50-59 31.6
60-69 52.4
8/25/2010 12:52:48 PM

70-79 69.4
>80 68.2
comitte 2.indd 71

Table 6c. european Prevalence of erectile Dysfunction

Author(s)/ Year/ Country of Age of Number

Population Type Eligibility Criteria Differences/ Nonresponders
Published/ (Prins Score) study participants (% respondents)

Solstad, Hertoft Denmark All men in selected 51 NS 439 (81) Comparison with other Danish
112, 113
communes samples/ different employment
1993 status
Kontula, Finland Nationally 18-74 N/S 996 (68) Small socio-demographic
representative RPS differences
(13 - 14)
Helgason, et al. Sweden Stratiied by age RPS 50-80 Born in Sweden, no prostate 315 (72) Participants more hypertension;
cancer prostate cancer, diabetes
1996114, 115 mellitus and myocardial
(13) infarction similar

McFarlane, et al. 1996116 France Stratiied by region 50-80 No previous urethral or 1734 (53) NS
RPS bladder disease, prostate
cancer, radiotherapy to
prostate or pelvis area

Groupe ACSF France Nationally 18-69 N/S 1335 (<50% ?) NS

Bajos et al
Frankel, et al. United All men registered in 40+ Ambulant, no prostate 423 (65) NS
Kingdom general practice cancer or surgery, urinary
1998117 problems secondary to
(10) surgery, neurologic damage
Koskimaki et al Finland Stratiied birth cohart 50, 60, 70 Not in an institution 1983 (63) NS
8/25/2010 12:52:48 PM

comitte 2.indd 72

Table 6c. european Prevalence of erectile Dysfunction

Author(s)/ Year/ Country of Age of Number Differences/

Population Type Eligibility Criteria
Published/ (Prins Score) study participants (% respondents) Nonresponders

Dunn, et al. United Kingdom Stratiied by age 18-75 NS 780 (39) NS

78, 119
and gender, random
1998 sample from general
(11) practice registers
Fugl-Meyer Sweden 18-74 RPS Living in Sweden, 1288 (52%) Compared to all
it mentally and nonresponders:
1999 physically participants younger
Parazzini Italy Random sample of 18+ NS 2010 (82) NS
general practice
Braun, et al. Germany Age and marital status 30-80 NS 4489 (56) Comparison with German
stratiied RPS

socioeconomic data
2000 – similar

Meuleman Netherlands Age stratiied RPS 40-79 Dutch-speaking 1233 (70) Participants more
symptoms and more
2001 married compared to 45
Boyle, et al.123 NR interview

Blanker, et al. Netherlands All men registered in 50-75 No cancer of prostate 1605 (47) Participants more
general practice or bladder, radical LUTS and better health
2001 79, 124, 125 prostatectomy, status compared to
(13) neurogenic bladder 261 nonresponders
disease or negative questioned
advice by GP

Martin-Morales, et al. 2001 Spain Age, community, 25-70 Non-institutionalized 2467 (75) NS
8/25/2010 12:52:48 PM

population density
stratiied RPS
comitte 2.indd 73

Table 6c. european Prevalence of erectile Dysfunction

Author(s)/ Year/ Age of Number

Country of study Population Type Eligibility Criteria Differences/ Nonresponders
Published/ (Prins Score) participants (% respondents)

Green, et al. Wales, UK All men registered in 11 55-70 NS 2027 (50) Compared to census data,
general practices more married

Mak et al. 2002 128 Belgium Random population 40-69 Men living in two 799 (47.6%) NS
sample comparable Belgian
(10) urban areas

Shiri et al., 2003 129 Shiri Finland Stratiied/birth cohort 50-75 Men living in Tampere 2198 (70%) NS

et al. 2004 130 or surrounding


Nazareth et al. 2003 81 London (UK) Men and women 18-75 People attending 1512 (71%) NS
registered in general general practitioner visit
(10) 447 men

De Boer et al. 2004 131 Netherlands Men registered in general 18-91 Men able to complete 2117(38%) NS
practice questionnaire, not
mentally retarded, and
Dutch speaking
8/25/2010 12:52:48 PM
comitte 2.indd 74

Table 6C. European Prevalence of Erectile Dysfunction

Author(s)/ Year/ Number

Age of Differences/
Published/ (Prins Country of study Population Type Eligibility Criteria
participants (% respondents) Nonresponders

Oksuz et al. Turkey Membership list of 15-60 Men registered on the 2288 (72%) NS
the Turkish health membership list of the Turkish
2005 website health website

Stulhofer et al. 2005 91 Croatia RPS 35-84 People living in private 615 (69%) NS

Moreira et al. 2001-

Spain RPS 40-80 40 to 80 years 750 (23%) NS
2005 88

Moreira et al. 2001-
Germany RPS 40-80 40 to 80 years 750 (17.4%) NS
2005 87
May et al. Germany RPS 18-79 Men living in a well established 3124 (31.2%) NS
Teles et al. Portugal RPS 40-69 Men attending a visit or 3.067 (81.3%) NS
accompanying patients in
2008 primary healthcare centres

Andersen et al. Denmark RPS 20-45 People born and living in 863 (26%) NS
8/25/2010 12:52:48 PM

comitte 2.indd 75

Table 6C. European Prevalence of Erectile Dysfunction

Author(s)/ Year/ Number

Age of
Published/ (Prins Country of study Population Type Eligibility Criteria (% Differences/ Nonresponders
Score) respondents)

Korfage et al. Netherlands Men in the Eur. 58-78 Men without 3893 (81%) NS
Randomized study on prostate cancer
2008. screening for Prostate diagnosis
(10) Cancer

Moreira et al.
20012002/200896 UK and Europe RPS 40-80 40 to 80 years 750 (17%) NS

Buvat et al. 2001-

2002/2009 134 France RPS 40-80 40 to 80 years 750 (23.8%) NS

Corona et al. 8 centres from the RPS 40-80 Randomly 3,369 (40%) No difference in reported general
European Union recruited from health, and number of morbidities
2009 in preparation population between participating or not in
Florence (Italy) registers the study
Leuven (Belgium)
Lodz (Poland)
Malmo (Sweden)
Manchester (UK)
Santiago de
Compostela (Spain),
8/25/2010 12:52:48 PM

Szeged (Hungary)
Tartu (Estonia).
comitte 2.indd 76

Table 6C. European Prevalence of Erectile Dysfunction (continued)

Prevalence Rate
Prevalence Rate
Authors/Date Published Design/Instrument Deinition of ED Time Period Percentage
Age (years)
(CI 95%)

Solstad, Hertoff CS/SAQ Impaired erection sexual One year 51 4 (2-6) [In a separate
intercourse impossible interview of 100 of
1993112, 113 – more that few occasions original group +7%]

Kontula, Penis does not become One year 18-74 6%

erect or loses rigidity
Haavio-Manilla Survey/ Interview during intercourse quite 18-24 1%
1992/9555 often, almost constantly 25-34 0%
(13 - 14)

35-44 1%
45-54 7%
55-64 16%
65-74 32%

Helgason, et al. Survey/SAQ Erectile stiffness seldom, Few months 50-59 3 (0-11)
114, 115
hardly ever or never
1996 suficient for intercourse 60-69 24 (1-33)
(13) 70-80 49 (41-58)

McFarlane, et al. Survey/SAQ Dificulty in having an Month 50-59 20 (17-23)

erection each time or
1996 some time 60-69 33 (29-37)
(12) 70-79 38 (33-43)
8/25/2010 12:52:49 PM
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Table 6C. European Prevalence of Erectile Dysfunction (continued)

Prevalence Rate
Authors/Date Published Design/Instrument Deinition of ED Time Period Prevalence Rate Percentage
Age (years) (CI 95%)
Groupe ACSF Survey/ Interview Often not, erection Lifetime 18-69 7%
Bajos et al
Frankel, et al. CS/SAQ Erections – rigidity reduced, severely reduced or NS 40-49 9 (5-14)
1998 50-59 29 (21-38)
(10) 60-69 57 (46-67)
70-79 79 (65-90)
Koskimaki, et al. Survey/SAQ Moderate or complete ED, often dificulties with NS 50 12 (10-15)
erection (obtain/maintain) during sexual intercourse

1998118 or none 60 24 (21-28)

(10) 70 49 (44-53)
Dunn, et al. Survey/SAQ Dificulty in getting or maintaining an erection Three months 18-75 Ed last 3 months – 26
199878, 119 Lifetime
Lifetime – 39 (35-42)
Fugl-Meyer Survey/Interview Penis does not become or lose rigidity during One year 18-24 3 (1-6)
intercourse quite often, nearly all the time or all the
1998 65 25-34 2 (1-4)
(13) 35-49 3 (1-4)
50-65 2 (1-4)
66-74 24 (17-33)
Parazzini Survey/Interview Ability to attain and maintain erection suficient for NS 18-29 2 (1-6)
satisfactory sexual performance
2000 120 30-39 2 (1-4)
(10) 40-49 5 (3-8)
8/25/2010 12:52:49 PM

50-59 16 (12-21)
60-69 27 (22-34)
70+ 48 (39-61
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Table 6C. European Prevalence of Erectile Dysfunction (continued)

Prevalence Rate
Prevalence Rate
Authors/Date Published Design/Instrument Deinition of ED Time Period Percentage
Age (years)
(CI 95%)
Braun, et al. Survey/SAQ ED is greater than 17 of rating scale NS 30-39 2 (2-3)
2000 121 40-49 10 (8-12)
(11) 50-59 16 (13-18)
60-69 34 (32-37)
70-76 53 (48-58)
Mueleman Survey/SAQ Problems attaining or maintaining NS 40-49 6 (3-10)
an erection hard enough for sexual
2001 122 intercourse 50-59 9 (6-12)
Boyle, et al 60-69 22 (18-26)
(15) 70-79 38 (32-44)
Blanker, et al. CS-SAQ No erections or erections of severely NS 50-54 3 (1-5)

reduced rigidity
2001, 79, 124, 125 55-59 5 (3-8)
(13) 60-64 11 (8-14)
65-69 19 (14-23)
70-78 26 (19-33)
Martin-Morales, et al. Survey/SAQ Moderate to severe incapacity for NS 25-39 2 (1-3)
2001 126 erection on single questions
40-49 3 (2-5)
50-59 8 (5-10)
60-70 21 (18-25)
Green, et al. CS/Interview Complete erectile dysfunction – never NS 55-60 7 (?)
able to attain an erection suficient for
2001 127 satisfactory sexual activity 61-65 13
(10) 66-70 22
Mak al. 128 CS/SAQ Erectile function domain score of IIEF Eight months 40-49 19.4%
8/25/2010 12:52:49 PM

< 26
Eur Urol 2002 50-59 39.8%
(10) 60-69 65.9%
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Table 6C. European Prevalence of Erectile Dysfunction (continued)

Prevalence Rate
Authors/Date Prevalence Rate
Design/Instrument Deinition of ED Time Period Percentage
Published Age (years)
(CI 95%)
Shiri et al. 2003 129 Survey/SAQ NIH deinition: inability to achieve or maintain Four months 50 67%
erection suficient for satisfactory sexual function
and 55 68%
Shiri et al. 2004 130 60 74%
2004 65 85%
(12) 70 85%
75 89%
Nazareth et al. CS/SAQ ICD-10 diagnostic classiication: No erection or penis NS 18-75 8.8(6.4-11.8)%
too soft for penetration
2003 81
NIH deinition: inability to achieve or maintain

De Boer et al. CS/SAQ NS 18-30 4.0(1.8-6.3)

erection suficient for satisfactory sexual function
2004 131 31-40 5.6 (3.5-7.6)
(11) 41-50 13.7 (10.8-16.5)
51-60 23.7 (19.5-27.8)
61-70 40.0 (32.9-47.0)
71-80 41.9 (33.6-50.2)
>80 33.3 (17.9-48.7)
Oksuz et al. Survey/SAQ Florida Sexual History Questionnaire: erectile Two months 15-60 59.7%
function score ≤22
2005 90
Stulhofer et al. CS/SAQ Dificulty in obtaining/maintaining erection Two months ≤39 5.8%
2005 91 30-49 7.0%
(10) 50-59 17.7%
8/25/2010 12:52:49 PM

60-69 17.8%
70-79 30.0%
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Table 6C. European Prevalence of Erectile Dysfunction (continued)

Prevalence Rate
Prevalence Rate
Authors/Date Published Design/Instrument Deinition of ED Time Period Percentage
Age (years)
(CI 95%)
Moreira et al.
Had trouble achieving
2001-2002/200588 Survey/Interview One year 12.7 (9.8; 14.6
or maintaining an erection
Moreira et al.
Had trouble achieving
2001-2002/200587 Survey/Interview One year 7.9 (5.6; 9.9)
or maintaining an erection
May et al. CS/SAQ Erectile function domain score Three months 18-29 9.4%
2007 132 of IIEF < 26 30-39 10.1%
(11) 40-49 15.5%
50-59 39.1%

60-69 67.4%
70-79 88.7%
Teles et al. CS/SAQ Erectile function domain score Seven months 40-49 30%
2008 133 of IIEF < 26 50-59 50%
(11) 60-69 70%

Andersen et al. CS/SAQ Erection inadequate to obtain One year 20-45 6%

or maintain sexual intercourse
2008 almost all the time or quite often

Korfage et al. CS/SAQ Problems with getting Five months 58-61 12.0%
2008 or maintaining erection 62-64 14.6%
(10) 65-67 18.4%
8/25/2010 12:52:49 PM

68-70 21.9%
71-78 26.3%
comitte 2.indd 81

Table 6C. European Prevalence of Erectile Dysfunction (continued)

Prevalence Rate
Authors/Date Prevalence Rate
Design/Instrument Deinition of ED Time Period Percentage
Published Age (years)
(CI 95%)

Moreira et al. 2001-

2002/200896 Had trouble achieving or maintaining an
Survey/Interview One year 17.8 (14.4; 21.3)

Buvat et al. 2001-

2002/2009 134 Had trouble achieving or maintaining an
Survey/Interview One year 15.0 (12.2; 18.2)

Corona et al. CS/SAQ Sometimes or never able to get or keep an Two years 40-49 6%
erection suficient for sexual intercourse
2009 50-59 19%
in preparation 60-69 38%
(14) >70 64%
8/25/2010 12:52:50 PM
comitte 2.indd 82

Table 6D. latin america Prevalence of erectile Dysfunction

Author(s)/ Year/
Age of Number (%
Published/ Country of study Population Type Eligibility Criteria Differences/ Nonresponders
participants respondents)
(Prins Score)

Moreira et al.
1998/ 2002 136 Random population
Brazil/ R 40 - 70 40 - 70 years 602 (92) NS
sample (RPS)

All men
Rhoden et al. participating in
1998 / 2002 137 Brazil/ R a free screening 45 - 90 ? 965 (90.1) -
(11) program for
prostate cancer

Moreira et al. The participants in the study

1999 -2000/ 2002 had higher educational
138 Brazil/ R RPS 40 - 70 40 - 70 years 342 (91.2)
attainment than the average
(14) Brazilian men

Moreira et al. The nonresponders were similar

2000/ 2001 139 Community based to participants in regard to age,
Brazil/ N ³ 18 ³ 18 years 1170 (91)
sample education, and prevalence of
(13) medical conditions

Morillo et al.
2002 140 Venezuela, Ecuador/ RPS ³ 40 ³ 40 years 1963 (82) NS
8/25/2010 12:52:50 PM

comitte 2.indd 83

Table 6D. latin america Prevalence of erectile Dysfunction

Author(s)/ Year/
Number (% Differences/
Published/ (Prins Country of study Population Type Age of participants Eligibility Criteria
respondents) Nonresponders

Moreira et al. 2001 Brazil/ N RPS 40 - 80 40 - 80 years 471 (18) NS

- 2002/ 2005 86

De Almeida Claro et Brazil/ R RPS ³ 20 ³ 20 years 2000 (?) Participants had higher
al. 2006 141 educational achievement

8/25/2010 12:52:50 PM
comitte 2.indd 84

Table 6D. latin america Prevalence of erectile Dysfunction (continued)

Author(s)/ Year/
Prevalence Rate
Published/ (Prins Design/ Instrument Deinition of ED Time Period Prevalence Rate Percentage (CI 95%)
Age (years)
Moreira et al. Survey/Interview Sometimes or never able to get Six months 40-49 9.9%
1998/ 2002 136 and keep an erection adequate for 50-59 11.8%
satisfactory sexual intercourse 60-70 31.7%
Rhoden et al. Survey/SAQ IIEF-5 (scores <21) Four weeks 40-49 36.4%
1998 / 2002 137 50-59 42.5%
60-69 58.1%
(11) 70-79 79.4%
>80 100%
Moreira et al. Survey/SAQ Sometimes or never able to get Six months 40-49 3.5%
1999 -2000/ 2002 and keep an erection adequate for 50-59 16.7%
satisfactory sexual intercourse 60-70 39.6%


Moreira et al. Survey/SAQ Sometimes or never able to get One month 18-39 9.4%
and keep an erection adequate for 40-49 15.5%

2000/ 2001 satisfactory sexual intercourse 50-59 22.1%
60-69 37.0%
(13) >70 39.6%

Morillo et al. Survey/Interview Sometimes or never able to get Four weeks Colombia Ecuador Venezuela
and keep an erection adequate for 40-49 36.2% 32.8% 38.5%
2002 satisfactory sexual intercourse 50-59 40.0% 50.0% 51.7%
60-69 75.2% 73.0% 74.7%
(14) 70-79 78.4% 82.1% 81.7%
>79 84.1% 92.3% 92.2%

Moreira et al. Survey/Interview Had trouble achieving or maintaining One year 40-80 13.1%
2001 - 2002/ an erection
2005 86
De Almeida Claro Survey/Interview IIEF Four weeks 20-30 0.2%
et al. 31-40 0.2%
8/25/2010 12:52:50 PM

41-50 1.0%
2006 141 51-60 2.8%
> 61 7.0%
comitte 2.indd 85

Table 6e. north american Prevalence of erectile Dysfunction

Author(s)/ Year/ Number

Country Age of Differences /
Published/ Population Type Eligibility Criteria
of study participants (% respondents) Nonresponders
(Prins Score)
Feldman, et al. USA Random population 40-70 Men with sexual partner 1290 (40?) Participants more heart
199426, 28, 142, 143 sample (RPS) disease and cancer


Panser, et al. USA RPS 40-79 No prostate or bladder 2115 (55) Participants more
cancer, low back surgery, urological disease, chronic
1995 CVA neurogenic bladder disease similar
(12) or antiandrogen use

Laumann, USA RPS 18-59 Not from barracks, college 1244 (70) NS
et al. dorms or prisons, English
speaking, at least one
199920. partner in previous year

Ansong, et al. USA Age stratiied RPS 50-76 NS 1408 (27) Questionnaire to non-
responders – 21/110
2000 prevalence of ED similar

Bacon, et al.2003 145 USA Health professionals 53-90 31742 (25) NS


Brock et al. 2001-

2002/2006 95 Canada RPS 40-80 40 to 80 years 500 (9.7%) NS

Laumann et al. 2001-

2002/2009 98 USA RPS 40-80 40 to 80 years 742 (9.0%) NS
8/25/2010 12:52:50 PM
comitte 2.indd 86

Table 6e. north american Prevalence of erectile Dysfunction (continued)

Prevalence Rate
Authors/Date Prevalence Rate
Design/Instrument Deinition of ED Time Period Percentage
Published Age (years)
(CI 95%)

Feldman, et al. CS/SAQ Sometimes able or never able to get and Six months 40 23 (?)
26, 28, 142, 143
keep an erection for sexual intercourse
1994+ 50 32
(13) 60 40
70 49

Panser, et al. Survey/SAQ Constant inability to have erection when Month 40-49 1 (0-1)
sexually stimulated
1995 50-59 6 (4-8)
(12) 60-69 22 (18-26)

70-79 44 (38-51)
Laumann, et al. Survey/Interview Trouble maintaining or achieving an erection Year 18-29 7 (5-10)
199920. 30-39 9 (6-12)
(12) 40-49 11 (8-15)
50-59 18 (13-26)
Ansong, et al. Survey/SAQ Recurrent inability to attain of maintain Six months 50-54 26 (20-32)
erection for satisfactory intercourse
2000 144 55-59 35 (29-41)
(10) 60-64 47 (40-53)
65-69 58 (54-66)
70-76 69 (62-75)
Bacon, et al. 145 Survey/SAQ Poor or very poor 2000 <60 10
2003 Ability to have and maintain erection 60-69 26
adequate for intercourse
8/25/2010 12:52:51 PM

(10) 70-79 50
>79 60
comitte 2.indd 87

Table 6e. north american Prevalence of erectile Dysfunction (continued)

Prevalence Rate
Authors/Date Prevalence Rate
Design/Instrument Deinition of ED Time Period Percentage
Published Age (years)
(CI 95%)

Brock et al. / 2001-

2002/2006 95 Had trouble achieving or maintaining an
Survey/Interview One year 16.0 (12.5; 19.9)

Laumann et al. 2001-

2002/200998 Had trouble achieving or maintaining an
Survey/Interview One year 22.5 (19.6; 25.7)
8/25/2010 12:52:51 PM
comitte 2.indd 88

Table 6F. Worldwide Prevalence of Erectile Dysfunction

Author(s)/ Year/ Number

Published/ (Prins Country of study Population Type Age of Eligibility Differences/
participants Criteria (% respondents) Nonresponders
Rosen et al. 2003 80 US/ Random population 50-80 Householder All NS
(12) Europe: sample 12.815 (36.8%)
UK (RPS) Europe
France 10,900

Nicolosi et al. Brazil Random population 40-70 Householder Total number 2513 NS
2003 146 Italy sample Brazil (92%)
(11) Japan (RPS) Italy (72%)
Malaysia Japan (51%)

Malaysia (16%)
Rosen et al. US, Brazil, Mexico/ Random population 25-75 NS All NS
2004 147 Europe: sample 27,839
(10) UK (RPS) US 9284(45%)
Germany Mexico 2735
France (55%)
Italy Brazil 5091
Spain (51%)
Europe UK2053(48%)
Germany 3040
France 2053
Italy 2130
8/25/2010 12:52:51 PM

Spain 1453
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Table 6F. Worldwide Prevalence of Erectile Dysfunction

Author(s)/ Year/ Population Age of Number Differences/

Country of study Eligibility Criteria
Published/ (Prins Score) Type participants (% respondents) Nonresponders

Nicolosi et al. 2004 85 Northern Europe Random 40-80 Men and women 27500 (19%)
Austria/Belgium/Germany/Sweden/UK population householder
(11) sample 13618 men

Southern Europe

Non-European West
Australia/Canada/ New Zealand/
South Africa/US

Central/South American


Middle East

East Asia

Southeast Asia

Shabsig et al. US/Germany/UK/France/ItalySpain Men registered 20-75 Men attending 28691 NS

in general general practice,
2005 practice family practice or
(10) general internal
medicine visit
8/25/2010 12:52:51 PM

Laumann et al. 2001-2002/ Random

2005 149 World* population 40-80 40 to 80 years 13750 (19%) NS
(14) sample (RPS)
comitte 2.indd 90

Table 6F. Worldwide Prevalence of Erectile Dysfunction (continued)

Prevalence Rate
Prevalence Rate
Authors/Date Published Design/Instrument Deinition of ED Time Period Percentage
Age (years)
(CI 95%)

50-59 30.8%
60-69 55.1%
Reduced or no erection
Rosen et al. 2003 80 70-80 76.0%
CS/SAQ according to Danish Four months
(12) Prostatic Symptom Score
All countries 48.9%
Europe 45.3%
Nicolosi et al. Survey/ SAQ Sometimes or never able Nine months 40-70 Brazil (15.5%)
to maintain erection to
2003 146 complete sexual intercourse Italy (17.2%)
(11) Japan (34.5%)

Malaysia (22.4%)
Rosen et al. 2004 147 Survey/Interview Erection dificulties Three months 20-29 8%
(10) 30-39 11%
40-49 15%
50-59 22%
60-69 30%
70-75 37%

All 16%

US 22%
Brazil 14%
Mexico 14%
UK 13%
Germany 13%
France 11%
8/25/2010 12:52:51 PM

Italy 13%
Spain 10%
comitte 2.indd 91

Table 6F. Worldwide Prevalence of Erectile Dysfunction (continued)

Prevalence Rate
Authors/Date Prevalence Rate
Design/Instrument Deinition of ED Time Period Percentage
Published Age (years)
(CI 95%)
Nicolosi et al. 2004 85 CS/SAQ Trouble in achieving or Two months or more in All countries
maintaining erection previous years 40-49 5.0%
50-59 9.0%
60-69 15.2%
70-80 22.0%
Total 40-80 10 (9-10)%

Northern Europe 8(7-9)%

Southern Europe 8 (7-9)%
Non-European West 11 (10-13%)
American 9 (6-11)%

Middle East 8 (6-10)%

East Asia 15 (13-17)%
Southeast Asia 22 (18-25)%
Shabsig et al. 2005 Survey/SAQ Dificulty in getting or Seven months 30-75 US (25%)
keeping erection France (13%)
(10) Germany (22%)
Italy (12%)
Spain (12%)
UK (19%)
Laumann et al. Survey/Interview or Had trouble achieving One year 13 (12; 15) in Northern Europe
/2001-2002/2005 149 SAQ or maintaining an 13 (11; 14) in Southern Europe
erection 21 (19; 22) in Non-European
14 (11; 16) in Central/South
14 (12; 16) in Middle East
27 (25; 29) in East Asia
8/25/2010 12:52:51 PM

28 (25; 32) in South East Asia

older ages showed marked increasing rates with each quoted up to age 70 where rates varied from 26 to
of the three decades beginning with age 60. [109- 42%. [79, 100, 122-125, 131] In the Korfage study
110] The study that did not stratify for age reported a age stratiication ranged from three to eight years
21.1 % prevalence rate for ages 40-80 years again and was reported for different age groups beginning
relecting a blend of the stratiied studies. [97] The with age 58 and ending with age 78 years. For the
most recent report from western Australia [111] had ive different age groups prevalence rates varied
a older age range in their study and reported an from 12 to 26.3 %. [100]
overall prevalence rate of 40.3%, almost 4 times the In the three studies from France two were non
prevalence from the other age stratiied study with an randomized, the study reporting on ages 18 to
overall rate of 10% [37]. In the younger age groups 69 years was 7% prevalence rate and the study
the former study reported higher rates for ED until reporting on ages 40 to 80 years was 15%. [68, 134]
the decade of 40-49 where the rates were almost the In the study stratiied for age by decades beginning
same but in the next decade again the former study at age 50 the prevalence rates were 20%, 33%,
reported higher rates. (See Table 6B) and 38% for each of the ensuing decades. [116] Of
Prevalence studies from Europe were dificult to the 3 studies from Germany one was not reported
compare. (See Table 6c) In the Scandinavian stratiied for age but reported a 7.9% prevalence rate
studies, the prevalence seemed to rise sharply after for ED over the last year for ages 40-80 years. [87]
the age of 65 years, with rates of 20% or greater The two studies stratiied by age showed prevalence
after this age and this rate doubling when reaching rates in the teens for those 49 years and younger.
the age of 70 years or older. The only exception to For each ensuing decade though rates were half as
this trend was the study from Finland where much much in the Braun study compared to the May study.
[121, 132] In the two studies from Spain, the one not
higher prevalence rates were reported beginning
stratiied for age showed a prevalence rate of ED
with age 50 and continuing with an upward slope
of 12.7% for ages 40-80 years. [88] In the stratiied
for every ive year cohorts. [129-130] This study
for age study rates were low until the decade of 60-
used the NIH deinition for ED and inquired about
70 years were the rate of 21 % was reported. [126]
activity the previous four months The prevalence
In the single study from Belgium the rates doubled
of ED before the age of 61 years in the continental
every decade from 40 to 69 years from 19.4% to
northern European studies were generally quite low
65.9%. [128] In the study from Croatia the prevalence
except for the study mentioned above. In a recent rate for ED was low before age 50 but stayed about
study by Corona 8 centers from the European Union 18% from ages 50 to 69 years and almost doubled
participated in the study 9. [135] (See Table 6c). to 30% age 70 and beyond. [91] In the single study
Prevalence rates tripled from the decades in the 40’s from Portugal prevalence rates for ED were high
to 50’s and doubled for each succeeding 10 year beginning with 30% for the 40 to 49 year decade
cohort. Moreira’s study from the UK and Europe did to 50% to 70% for the next two decades. [133] For
not stratify for age and reported a prevalence rate for the single Italian study rates were very low before
ED of about 18%. [96] age 50 but were reported as 16%, 27% and48% for
In two studies from the United Kingdom not stratiied the three decades beginning at age 50 years. [120]
for age prevalence rates were quite different although In the single Turkish study the unstratiied for age
similar ages (18-75 years were reported), 8.8% and prevalence rate for those 15 to 60 year of age was
26% respectively. [78, 81, 119] Dunn’s study asked almost 60%. [90]
for lifelong compared to last three months prevalence There were seven studies from Latin America,
for ED and the rates increased for the former to 39% almost all from Brazil. (See Table 6D) In the single
from 26%. [78, 119] In the other two studies from the report from three non Brazilian countries, Columbia,
United Kingdom, both derived again from general Ecuador, and Venezuela, the prevalence rates
practice groups there was a marked difference in for each of four decades beginning at age 40 and
prevalence rates for ED although for one group the ending as age 79 from each of the three countries
deinition was for complete erectile failure and one were almost the same with a 33 to 38.5% for the
was dificulty in attaining and maintaining an erection irst decade, 40-50% for the next, increasing by
and were stratiied for different age ranges. The about 25% for the 60-69 years of age decade to 73-
prevalence rates for the stricter deinition ranged 75%, increasing about another 5% until age beyond
from 7 to 22% for the three periods stratiied from 79 where rates ranged from 84 to 93%. [140] In the
age 55 to 70 years of age. [127] For the less strict 6 studies reporting on more than 300 patients, the
deinition prevalence rates ranged from 9 to79% from prevalence rates for ED were not stratiied for age in
four decades reported, ages 40-79 years. [117] one study and the prevalence rate in that study was
13.1% for ages 40-80 years. [86] The four random
In the four studies from the Netherlands stratiication population and community based population studies
by age was different in all papers but in general reported prevalence rates for ED in the teens before
prevalence rates for ages before 60 were in the age 50, varying from low of about 12% to 22% in the
teens and increased after that for each age period decade of 50-59 (with one exception mentioned in the


comitte 2.indd 92 8/25/2010 12:52:52 PM

next sentence), increasing from about 32% to 58% well as 5 European countries. Including all of the
in the decade ages 60 to 69 years. [136, 138,139, countries the prevalence rates for Ed were stratiied
141] In one study of 2000 men prevalence rates by ive decades and a single six year group of 70-
were much lower than the other random population 75 years of age. Rates were in the teens for the
studies using the IIEF as deining ED from 0.2% three decades beginning with age 20 through age
beginning with age 20-40 years of age, 1% for those 49 years. For the next two decades beginning with
41 to 50 years of age, about 3% for 51 to 60 years of age 50 to 69 years prevalence rates of 22 and 30%
age and 7% in those greater than 60 years of age. were reported with a prevalence rate of 37% for
[141] In a study of 965 men participating in a free the six years of 70 to 75. Overall prevalence rate
screening program for prostate cancer, ages 45 to was 16% and the individual rates from the seven
90 years using IIEF-5 of scores below 21 as deining countries except the US were below this rate with
ED rates of prevalence for the disorder were much the overall prevalence rate of ED in the US of 22%,
higher in this group from almost 37% for those 40 half again the total group rate and double to 8%
to 49 years of age, increasing by 5.5% for the next above the other countries. [147] In a second study
decade and by just beyond 20% for those 60 to 69 from Nicolosi et al regional prevalence rates for age
years of age. For those 70 to 79 years of age the 40 to 80 years from around the world were reported.
rate was 79.4% and 100% for those 80 and above. Rates were stratiied for age for all of the countries
[137] Rates were higher when IIEF scores were and were low before age 60, were reported as 15.2%
used to deine ED. for the seventh decade of life and 22% above age 70
In the studies from the United States, ( see Table 6e), years. The regional prevalence rates were similar for
the methods used and populations varied but two of all of the regions and ranged from 8 to 15% except
the studies showed fairly consistent prevalence rates for Southeast Asia where the prevalence rate was
for the various ages, the Massachusetts Male Aging almost double to 22%. [85] Shabsig et al reported
Study (MMAS) and the study from Ansong. [26, 28, in 2005 non-stratiied for age prevalence rates for
142-143] The Laumann data included men who were ED from a large number of men from the US and
younger and reported less than half the prevalence ive European countries. The rates for France, Italy,
rate for the men 50 to 59 years of age compared to and Spain were similar, 12 or 13 %, while the UK,
the other two studies from the United States. [20] Germany, and the US were higher, 19, 22, and 25
The Olmsted County study from the United States % respectively. [148] In the same year Lauman
also showed a lower prevalence rate by a large reported prevalence rates in a large number of men
amount for the ages 40-59 and half the prevalence from various regions of the world. The rates were
rate for the decades 60-69 years but similar rates 13 to 14% in Northern Europe, Southern Europe,
for the decades 70-79 as the MMAS data. [77] In Central/South America, and the Middle East. In non-
the 3 studies reported from North America that were European West the rate was higher at 21% but again
not part of the last chapter two were not stratiied as shown above in the Nicolosi studies the highest
for age and prevalence rates were 16 and 22.5% prevalence rates for ED were in two regions in Asia,
for ages 40 to 80 years of age. [95, 98]One study 27% in East Asia and 28% in Southeast Asia. [149]
reported prevalence data from a survey of health
The same tools and methods were used in a United
professionals and semistratiied by age with the
States study and a Japanese survey. [77, 107]
following prevalence rates for those less that 60
years of age, those 60 to 69 years of age, those 70 Thus these two could possibly provide for the best
to 79 years of age and those greater than 79 years of comparison between two cultures. The Japanese
age of 10, 26, 50 and 60% respectively. [145] study showed almost double the prevalence rate for the
four decades reported on compared to the American
There are 6 studies classiied as world-wide reports. study. In contrast, the study from Thailand showed
(see Table 6f) The irst was a study by Rosen et al half of the prevalence rate for the age group 40-49
that included the US and 6 European countries. The years compared to the Japanese study but almost
prevalence rates were stratiied for three decades equal rates for the other older decades reported.
beginning with age 50 years and through age 80
and were about 31%, 55%, and 76% respectively. one important issue to be addressed in future research
The overall rates were similar for all countries and is the validity and reliability of self-report data on ED
Europe only. [80] Nicolosi et al compared prevalence generated in response to a single question (e.g.,
rates in Brazil, Italy and two Asian regions in 40 to the NHSLS’s [20] question, “During the last twelve
70 years of age. These were not age stratiied and months has there been periods of several months or
the prevalence rates of 15 and 17% were similar more when you…had trouble achieving or maintaining
for the non-Asian studies and were higher in Asia, erection?”) when compared to results from the well
22.4% in Malaysia and 34.% in Japan. [146] Rosen used validated, multi-item International Index for
et al in a second world-wide study again compared Erectile Function (IIEF), [30] which is, of course,
prevalence rates in the US, Brazil, and Mexico as also a scale based on self-reports. The question of


comitte 2.indd 93 8/25/2010 12:52:52 PM

which of the two instruments may be more useful prevalence rates. Most of the world show a rather
and accurate for large population studies remains high rate from 20-40% for the ages 60-69 years,
controversial. A good correlation of each criterion some increasing after age 65 years, except for most
in population samples has been reported. [28] A of the Scandinavian reports where the age of 70
single self assessment direct question to evaluate years and older is the decade of major prevalence
ED was applied to the population based samples of rate change except the one report from Finland that
the MMAS follow-up evaluation, in addition to the showed high rates beginning at age 50. [129-130]
Brief Male Sexual Function Inventory (BMSFI) and Almost all of the reports show high prevalence rates
the IIEF. Prevalence was similar to that determined for those men in their 70’s and 80’s, ranging from 50
on the IIEF, agreement was moderate (0.56 to 0.58 ) to 100% prevalence of ED in these decades.
and association with previously identiied risk factors
were similar for each classiication. The single Recommendation 5. :
question correlated well with these other measures There is a need for more prevalence and incidence
(r= 0.71 to 0.78, p<0.001). However the incidence of data studies on sexual dysfunctions in men and
subjects not classiied due to missing data was 9% women from Africa, India, and Asia. grade c.
on the MMAS single question, 8% on the BMSFI,
and 18% on the IIEF. Based on these data, the Recommendation 6. :
direct self-assessment question may be a practical
tool for population studies, in which detailed clinical Prevalence and incidence studies need to be
measures of ED are impractical. more parallel in data collected and meet as many
standards as possible [7]- duration for disorder
The Global Survey of Sexual Attitudes and Behavior
screened for should be at least three months or
(GSSAB) [85, 149] have reported prevalence data
more. Researchers should include severity scales
based on two items, the irst item corresponding
for the disorder in the survey. grade c.
exactly to the NHSLS question while the second asks
if the respondent has reported a problem of achieving Recommendation 7. :
and maintaining an erection for two months or more,
he is then asked, “how often would you say this has There is a need to study the effect of excluding
occurred during the last 12 months?” The choices non-sexually active individual from the prevalence
are either occasionally, sometimes, or frequently. data reports. grade c.
The GSSAB regarded only respondents reporting
periodic, i.e. sometimes or frequently, dificulties as h) Concurrence of sexual dysfunction
indicating moderate or severe ED. Across 7 world Both in the descriptive and analytical epidemiological
regions, between 22% and 44% reported only literature there is very little on simultaneous
having occasional problems with ED of several occurrence of different sexual dysfunctions within
months duration. These respondents were excluded and across genders. In French men, aged 18-69, it
from the prevalence estimates of having ED. Various has been reported that 7% of those with manifest ED
systematic review of population-based estimates of
also are early ejaculators. [150] In an older sample
sexual dysfunction note the considerable variation in
(50-78 year olds) from the Netherlands about 50%
the items asked to establish the presence of ED in
of the men with early ejaculation also reported
the respondent (see Table 6a-f.) and the resulting
ED. [79] To which extent this simply indicates that
dificulties posed in establishing the comparability of
incapacity to maintain erection is a sequel to early
the estimates across studies. [7, 60] It is imperative
ejaculation remains to be analyzed. From France it
that research evaluating the relative eficacy of
has been reported that 37% of 18-70 year old men
different measurement strategies be undertaken to
with ED have lost their “libido”. [21] It has been
establish recommended “best practice” for future
found in a Swedish study that within both genders
studies. Consideration of “best practice” should be
(aged 18-74) nearly all own sexual dysfunctions
mindful that useful epidemiological data can often
are closely associated (generally at a p level of <
be generated with brief questions that would not
0.001). [19] The only exception is that for the men
be especially effective in identifying more narrowly
with early or delayed ejaculation quite logically
deined clinical conditions.
were not signiicantly correlated. Moreover, a high
In summary, the prevalence of erectile dysfunction degree of cross-gender concurrence was found. In
on a world wide basis shows a great deal of variation fact all women’s dysfunctions studied were closely
but the way the information is collected, the way the (p <0.005- 0.001) coherent with all male partners’
population is sampled, the tools used for the survey, functions/dysfunctions as perceived by the women.
and, most importantly, the way ED is deined vary Men’s sexual dysfunctions had precisely the same
greatly. Below the age of 40 years the prevalence close associations with men’s perceptions of their
is 1-10%. In the decades from 40-49 the prevalence female partner’s functions/dysfunctions. These
ranges from 2-9% to as high 15%. The 50-59 year indings irmly suggest that it is important to think in
age group showed the greatest range of reported terms of sexual partner relationship, none the least in


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therapy- pharmacological or psychotherapeutic. [151]
Laumann et al also examined the co-occurrence of V. analYTical ePiDemiologY
dysfunctions for the set of dysfunctions discussed in
the latent class analysis, but the actual percentages
of overlap were not given in the article. [21]
1. riSk facTorS for Women
g) Sexual dysfunctions and personal distress:
In this part, we shall irst address women’s sexuality
It is of paramount importance to know to what extent in relation to health issues. Subsequently indings
sexual dysfunctions are accompanied by distress. relating social and demographic factors to sexual
Commonly overall level of sexual distress is function will be discussed. Besides the investigations
nowadays measured by one single question or by referred to, we have not been able to locate reliable
an aggregative questionnaire such as the FSDS (the and reasonably evidence-based investigations of
Female Sexual Distress Scale) [34, 70]. Given the risk factors for women’s sexual functions. Thus,
close coherence of different sexual dysfunctions the need for more research concerning women’s
– intrapersonal as well as interpersonal – we sexuality must be underlined. When dealing with
have here chose to focus on the extent to which risk factors, co-morbidities and socio-demographic
speciic dysfunctions lead to dysfunctional distress items, descriptive epidemiology gives best
(personal problems). Among women and men with evidence. However, analytical epidemiology may
manifest dysfunction per se generally less than be an adequate way to identify the relative risk of
half experience that it is accompanied by manifest sexual dysfunction caused by (sets of) medically
personal distress (Table 7). Moreover, only small or psychologically identiied particular diagnostic
minorities of those with mild/sporadic dysfunction categories.
report manifest distress. In Sweden 26% and 17% of
women and men reported at least one distressing self
recommendation 8:
or partner’s sexual dysfunction. However, among the
manifestly personally distressed, the vast majority
were not satisied with their sexual lives. This can be There clearly is a need for more analytical
compared with the sexual satisfaction rate of 55% epidemiological studies about women’s sexual
in the total population. [19] In general agreement dysfunctions. grade c.
with this and deining sexual distress (one overall
pluri-item aggregated variable) using the FSDS a) General Health-related risk factors
[71] have found that 22% of women in the USA
aged 18 and above reported sexual distress. This Richters et al [37] found that, compared with women
is about half of the 43% who had an – age adjusted with excellent health, those reporting good, fair
– sexual dysfunction. However, these authors did or poor health were more likely to have a sexual
not explicitly ask for distress caused by speciic dysfunction. Signiicant odds ratios were 1.9, 3.1
sexual dysfunctions. Measuring women’s sexual and 5.7 for those with good, fair or poor health,
distress using the FSDS, Rosen et al [152] have respectively. Simultaneously Laumann et al. [20]
reported that among women with low sexual desire and Fugl-Meyer & Fugl-Meyer [65] reported that less
level of distress decreased with higher age and -than good health leads to greater risks of sexual
those in partner relationship had relatively high level dysfunctions concerning desire/sexual interest
of distress as had those with arousal and orgasmic and genital pain. Self-reported health and levels
dysfunctions. Furthermore Bancroft et al., [153] found of physical activities have been conirmed to be
that neither relative frequency of sexual thoughts, an important correlate of sexual function, as more
frequency of orgasm, nor lubrication problems were orgasm problems were found among women who
predictors for women having signiicant or manifest reported no physical activity [154], and higher level
versus no, or mild versus no distress concerning of sexual desire among those who reported higher
their own sexuality. They further reported that the self-perceived health and more physical exercise.
best predictor of sexual distress was relatively low [74] Perceived poor health was also a predictor
emotional well-being. In reasonable consensus with for women’s sexual desire, arousal, orgasm and
other studies Öberg and Fugl-Meyer [154] conirmed dyspareunia. [70, 71, 154]
that low level of satisfaction with partner relationship
is closely associated with women’s manifestly b) Diabetes
distressing dysfunction of sexual interest, lubrication
and orgasm. However, the causality is unclear. Thus, Kadri et al [24] in their descriptive epidemiological
a distressing sexual dysfunction may be caused by study of Moroccan women reported (univariate)
a disharmonious partner relationship but a sexual signiicant associations for diabetes with orgasmic
dysfunction may contribute to a not satisfying partner dysfunction, dyspareunia and sexual aversion. Also
relationship. Danish women with diabetes have been found to have


comitte 2.indd 95 8/25/2010 12:52:52 PM

Table 7. Relationship Between Sexual Dysfunction, Personal Distress, and Sexual Satisfaction

Manifest dysfunction
Manifest dysfunction Sexually satisied (in % )
(in %) accompanied
among those personally
Per se % by manifest personal
Low Sexual Interest
33 43 18

Low Sexual Interest

16 38 13

Lubricative insuff.
12 63 20

Erectile dysfunction
5 69 25

22 45 15
dysfunction (W)

Early ejaculation (M) 9 47 35

Delayed ejaculation
2 55 24

Dyspareunia (W) 6 69 18

Dyspareunia (M) 1 58 24

Vaginismus (W) 1 92 17

low sexual desire signiicantly more often than non- on the replicability of the results. In a larger study
diabetic women [74]. In a well-controlled age matched conducted in a nationally representative sample of
analytical study Enzlin et al. reached the conclusion women in the USA, heart disease was not associated
that sexual problems are frequent in women with with sexual dysfunctions. [70] The relationship
diabetes mellitus. Among the sexual function between vaso-congestion and sexual dysfunctions
variables, “libido”, lubrication, orgasm and genital remains poorly understood in women. In a large
pain only decreased lubrication was signiicantly scale, well-controlled analytic study Duncan et al.
(univariately) associated with being diabetic. [155] [158] reported that hypertension (univariately) was
Moreover, women with “more” diabetic complications associated with decreased lubricative function and
reported signiicantly more sexual dysfunctions. with orgasmic dysfunction. Among all the different
However, more recent large epidemiological studies aspects of women’s sexual function studied by Dunn
conducted on women representative of the US 2005 et al. [119] medication with antihypertensive drugs
census, Brazilian women, and Australian women, did was a signiicant negative predictor (Odds ratios 0.3)
not ind a signiicant relationship between diabetes of orgasmic function. Moreover, Hanon et al [159]
and desire, arousal, or orgasm. [37, 70, 156-157] described that 41% of treated hypertensive women
(aged 58±12) experienced decreased sexual interest
c) Cardio-vascular diseases during treatment.
In a convenience sample of Korean women aged 40
d) Urinary tract diseases
to 80, women with a heart disease were 5.75 times
more likely to have problems reaching an orgasm Stress urinary incontinence has been found by
in the previous 2 months than women without heart Osborn et al. [64] to negatively inluence all aspects
disease [94]. However, the response rate in this of women’s sexual function (sexual interest, desire,
study was very low (33%) which raises questions arousal, lubrication, orgasm) and to be signiicantly


comitte 2.indd 96 8/25/2010 12:52:53 PM

correlated with dyspareunia and vaginismus. In a (odds ratios 2.2-2.9) with SSRIs (selective serotonin
small scale analytical investigation [160.] urinary re-uptake inhibitors) or venlafaxine than with buprion
stress incontinence was (univariately) signiicantly or netazodone in women and men on monotherapy.
associated with sexual interest, lubricative Moreover, the WHo collaboration center for
insuficiency, orgasmic dysfunction and dyspareunia. international drug monitoring has reported that out
Along these lines, Laumann et al. found that having of a total of nearly 215,000 reported adverse effects
urinary tract symptoms were predictors of lubrication of antidepressant during the period 1968-1997, 5000
insuficiency, orgasmic dysfunction, and dyspareunia were sexual in nature. [164] Using the somewhat
while ever having had STI (sexually transmitted outdated response cycle phase deinitions, about
infections) was a negative predictor for sexual 1500 adverse reactions were related to each of
interests and for lubricative function [20]. the “desire” and “excitement phases”, while 200
occurred during the “phase of orgasm”. The most
e) Gynaecological factors
typical female SSRI adverse reaction was orgasmic
Hysterectomy has in a few epidemiological studies dysfunction. Although the sheer number of reports to
been found to affect women’s sexuality. the WHo is great, these anecdotal reports cannot be
taken as evidence.
Dennerstein et al. [73] found that 16% of surgical
menopausal women had low sexual desire
compared to 7% of menstruating women and the g) Social stressors as risk factors
former being more likely to feel distressed. Hormonal Some epidemiological investigations have
therapy improved levels of desire but did not change addressed the impact of sexual abuse on women’s
distress. Furthermore, Shifren et al. [70] reported, sexual behaviour and it has been clearly shown that
despite desire, arousal and orgasm function were women’s current sexual life can be detrimentally
lower among women who were hysterectomized. inluenced by abuse. [20, 38, 74, 119, 165, 166]
Similarly, McPherson found that sexual arousal, but Studies that ask people to self-identify as sexual
not vaginal dryness, was impaired in women who abuse survivors usually report lower rates of sexual
received hysterectomy as compared to women with abuse as compared to studies that utilize behavioural
oophorectomy. [161] deinitions. [167] Having ever been sexually forced
f) Psychiatric/psychological factors by a man predicts low levels of desire and greater
arousal disorder in American women. Also, having
There is little doubt that part of the psychological ever been sexually harassed predicted arousal
distress experienced by individuals with mood disorder and sexual pain [20]. In Sweden, 12% of
or anxiety disorders affects sexual function. 18-74 year old women had at some time of their life
Unfortunately, research on the epidemiology of sexual been sexually abused [165]. Women with a history
dysfunction has yet to provide information on the of sexual abuse had a signiicantly higher number of
commonality between psychological vulnerabilities sexual dysfunctions than had women with no history
that are associated with sexual disorders. By latent of abuse and nearly all different types of sexual
class analysis Laumann et al. [20] deducted that abuse were signiicantly (univariately) associated
emotional problems or stress are sizeable predictors with orgasmic dysfunction. Having been genitally
of low desire, arousal disorder and sexual pain (all abused was also signiicantly associated with low
three deined according to the DSM-IV). level of sexual interest. Satisfaction with sexual life
Ten years ago Dunn et al [119] demonstrated was lower in those who had been abused and, in
signiicant likelihoods (Odds ratios ranging from particular, if abused more than once. Furthermore,
1.8-4.5) depression and anxiety to predict all their data from the same representative Swedish sample
investigated parameters: arousal, insuficient showed that obesity was not associated with a
lubrication, orgasmic dysfunction and dyspareunia. history of sexual abuse and sexual satisfaction. In
Accumulating evidence [64, 70-72, 74] conirmed Moroccan women [24] having been sexually abused
these associations between anxiety and depression negatively inluenced sexual interest. Interestingly,
with sexual dysfunction. An interesting study by only one study reported rates of sexual function
Sievert et al [162], however with a response rate of among men with a history of child sexual abuse [38]
only 29%, found that loss of desire for women under and they found a less strong relationship between
the age of 40 correlated with depression symptoms; sexual abuse and sexual function compared to the
for women in the age-cohort 40 to 60 with menopausal relationship observed in women.
symptoms and for those older than 60 with somatic
Incidences of emotional and physical abuse during
and psychological problems – a mutual denominator
childhood are highly comorbid with a history of sexual
could be mood changes/depressive symptoms.
abuse and some studies have found initial evidence
The effect of different antidepressants giving negative of a stronger relationship between emotional and
“changes in sexual function” were, by Clayton et al physical abuse and sexual function as compared to
[163.], found to be signiicantly more likely to occur sexual abuse [168]. No epidemiological studies that


comitte 2.indd 97 8/25/2010 12:52:53 PM

we know of have examined this research question levels of sexual interest/desire and of ED than are
which requires the simultaneous assessment of those who have a steady partner relationship. In the
different types of childhood trauma along with USA relatively low level of educational attainment is
measures of sexual function. associated with early ejaculation. [20]

Being single is (univariately) associated with The Health Professional Follow-up Study (HPFS) is
dysfunctions of sexual interest, vaginal lubrication, a cohort of male dentists, optometrists, osteopaths,
orgasm and with dyspareunia [65]. Low levels of podiatrists, pharmacists, and veterinarians in
sexual interest, arousal, orgasm and also dyspareunia the United States who responded to a mailed
are signiicantly most common in women with marital questionnaire in 1986 (original response rate 32%).
dificulties [64, 119]. There is a close relationship This U.S. study of prevalence and risk factors for
between male partner’s sexual dysfunctions erectile dysfunction found a 10-fold difference in
and women’s own dysfunctions; particularly if relative risk for erectile dysfunction associated with
distressing [19]. Furthermore, low levels of overall older age, regardless of health status or previous
sexual satisfaction and satisfaction with partner erectile function. [145] Follow-up questionnaires
relationship predict low level of satisfaction with life were mailed every two years. At the time of the 2000
as a whole. (See Table 7) In a large-scale-analytical questionnaire, 43,235 men, age 53 to 90 years,
epidemiological investigation of a gynaecological were alive and actively participating in the study.
sample, Raboch and Raboch reported that a The questionnaire was mailed up to four times to
number of “intra-familiar” aspects of life (early loss non-respondents with a response rate of 79%. This
of mother and father, not having a happy childhood, group of 31,742 health professionals, with no known
history of prostate cancer, ranged in age from 53 to
having three or more siblings or not having a happy
90 years at the time of the 2000 questionnaire. Men
marriage) univariately were signiicant features of
in the oldest age group were less likely to be married,
women with orgasmic dysfunction, in particular if
smoke, or engage in physical activity and were more
the dysfunction caused personal distress [169].
likely than younger men to have comorbid conditions.
In Morocco, relatively low education is common in
When men with prostate cancer were excluded, the
women with low level of sexual interest [24]. This is
age-standardized prevalence of erectile dysfunction
also the case in the USA [20] and in Eastern Europe
in the previous 3 months was 33%. Men with a healthy
[169] for orgasmic dysfunction and, additionally, in
lifestyle and no chronic disease had the lowest risk
the USA for dyspareunia [20]. In the USA women
for erectile dysfunction; the greatest difference
with more than 20% inancial household decrease
was seen for men 65 to 79 years of age. Comorbid
during the year prior to the investigation have low
conditions, such as diabetes, cancer, stroke, and
level off interest and lubrication and also relatively
hypertension, were also associated with increased
high prevalence of dyspareunia [20]. Furthermore,
risk for erectile dysfunction, whereas physical
stress at work or unemployment have been reported
activity, leanness, moderate alcohol consumption,
to accompany low sexual desire in women [170,171]
and not smoking were associated with decreased
but was associated with a higher desire of foreplay
risk. Men included in this study had lower rates of
in French women. [171]
obesity and less diabetes than same-age men in
2. riSk facTorS for men the general population. In addition, participants in
our study were more likely to be white, have higher
a) Age, Health and Social Related Risk Factors educational attainment, have higher incomes, and
Less than good overall health is likely to concur with have better health care access than similar-age men
men’s low level of sexual interest/desire and with ED in the general population. Therefore, the indings
[20, 65] Furthermore, Laumann et al [20] identiied a probably relect a more favorable proile for sexual
(signiicant) odds ratio of 2.4 for the likelihood of poor function across the life course compared with the
general population. The study found an inverse
to fair health being a predictor of early ejaculation.
association between physical activity and erectile
Also Richters et al [37] reported that Australian
dysfunction. The study also found that younger men
men who are not in excellent or good health are
(<60 years of age) beneit more from exercise than
most likely to have a sexual dysfunction (not further
older men (>80 years of age).
speciied). Having been sexually touched before
puberty predicts lower level of interest/desire (odds The National Social Life, Health, and Aging Project
ratios 2.2), ED (odds ratios 3.1) and early ejaculation (NSHAP) is a nationally representative US probability
(odds ratios 1.8). [20] Moreover, men who ever have sample of 1,550 women and 1,455 men aged 57-85
forced a woman sexually are more likely (odds ratios at the time of an interview. In this report the weighted
3.5) to have ED than are those who never have done response rate was 75.5%. [172] Data on sexual
so. Neither of these two descriptive investigations problems were collected through seven dichotomous
has found ejaculatory disturbance correlates of response items inquiring about sexual problems
sexual abuse. Both in the USA [20] and in Sweden experienced over several months during the previous
[65] partnerless men are more likely to have low 12 months. Items asked included lack of interest in


comitte 2.indd 98 8/25/2010 12:52:53 PM

sex, arousal problems, too early climaxing, inability Cross-sectional analysis of data from 2126 adult
to obtain an orgasm, pain during sex, unplesurable male participants in the 2001-2002 US National
sex, and performance anxiety. There was little if Health and Nutrition Examination Survey (NHANES).
any increase in sexual problems with age for either Erectile dysfunction assessed by a single question
gender except for orgasm and erectile problems in during a self-paced, computer-assisted self-
men- both positively correlated with age. Hispanic interview. These data are nationally representative
women reported (oR=2.4) more reports of sexual of the noninstitutionalized adult male population
pain compared to white women. Black men are more in the US. [174] The overall prevalence of erectile
than twice as likely to report lack of sexual interest dysfunction in men aged 20 years and greater was
and premature climax (oR 2.3 and 2.90), and almost 18.4% (95% conidence interval [CI], 16.2-20.7),
four times (oR=3.8) likely to report lack of sexual suggesting that erectile dysfunction affects 18 million
pleasure as white men. Lack of pleasure is sharply men (95% CI, 16-20) in the US. The prevalence of
lower among widowed or never married (oR=0.1) erectile dysfunction was highly positively related
than married men while divorced and separated men to age but was also particularly high among men
report twice as likely complaints (oR=2.0). Reports with one or more cardiovascular risk factors,
of anorgasmia and lack of sexual pleasure decline men with hypertension, and men with a history of
with men’s higher education in contrast to erectile cardiovascular disease, even after age adjustment.
problems which are sharply elevated (oR=1.9) Among men with diabetes, the crude prevalence
among men with some college education. Health of erectile dysfunction was 51.3% (95% CI, 41.9-
conditions strongly affect the likelihood of sexual 60.7). In multivariable analyses, erectile dysfunction
problems in women but less among men, except an was signiicantly and independently associated
association between any lifetime history of STD’s with diabetes, lower attained education, and lack of
and non pleasurable sex (OR=5.4) and between physical activity.
urinary tract syndrome and erectile problems (oR=
3.7). Poor mental health is associated with both The National Health and Nutrition Examination
women’s and men’s reports of sexual problems; Survey collect data by household interview. The
anxiety raising lack of sexual pleasure for men and sample design is a stratiied, multistage, probability
women and depression selectively associated with sample of clusters of persons representing the
men’s anorgasmia and erectile problems. Finally, civilian noninstitutionalized population. Data include
satisfaction in a relationship was associated with medical histories in which speciic queries are made
fewer sexual problems. In the healthier, older regarding urological symptoms (including ED). [175]
respondents age patterns suggested maintenance These items were selected for analysis in 3566 men,
of sexual capacity rather than decline. Increasing 20 years and older. In men 20 years and older, ED
biological age does not result in more sexual affected almost 1 in 5 respondents. Hispanic men
problems for either sex except for men’s erectile were more likely to report ED (odds ratio [OR], 1.89),
and orgasmic problems. Sexual problems among after controlling for other factors. The prevalence
the elderly seemed more a response to stressors of ED increased dramatically with advanced age;
in multiple domains of life from physical health to 77.5% of men 75 years and older were affected.
features of an intimate relationship. In addition, there were several modiiable risk
Most epidemiological studies on ED underrepresented factors that were independently associated with ED,
minority groups. In a cross-sectional population- including diabetes mellitus (oR, 2.69), obesity (oR,
based survey conducted between May, 2001 and 1.60), current smoking (OR, 1.74), and hypertension
January, 2002 facilitated equivalent representation (OR, 1.56).
was achieved for non-Hispanic whites (N=901), non-
hispanic blacks (N=596) and Hispanic males (N=676) In the Boston Area Community Health (BACH)
40 years and older by using targeted phone lists to Survey ED was assessed in 2,301 men aged 30-
oversample the minority. [173] Overall prevalence 79 using the 5-item IIEF-5 (deining ED as a score
rate for ED was 22%; 21.2% for whites, 24.4% < 16). [176]Overall prevalence of ED was 20.7%
for blacks and 19.9% for Hispanics, all categories with a higher rate among blacks (24.9%) and
increasing with older age. overall sampled ED Hispanics (25.3%) compared to whites (18.1%),
probability increased with diabetes, hypertension, even after adjusting for age, comorbid conditions,
and moderate or severe lower urinary tract and behavioral risk factors. However after controlling
symptoms (LUTS); in whites >70 years of age and for socio-economic factors the association between
diabetes; in blacks with severe LUTS; in Hispanics race/ethnicity and ED disappeared.
greater than age 60, moderate LUTS, hypertension, b) Smoking or Other Tobacco Use
and depression. Probability of ED decreased with
level of exercise, higher level of education overall; It is logical to assume that erectile function, a process
in blacks with exercise, good relationship quality and which relies on normal arterial vascular performance
lower level of alcohol intake; in Hispanics with high to operate correctly, would be adversely affected
school or college education. by cigarette smoking. A recent review on cigarette


comitte 2.indd 99 8/25/2010 12:52:54 PM

smoking and erectile dysfunction appeared in 2008. smokers. Ex-smokers had an odds ratio of 1.6 (95%
[177] In that article epidemiological and clinical data conidence interval 1.2-2.3). The authors also found
as well as a discussion of causative factors are well the association of smoking and ED risk to be present
reviewed. In a previous literature review, McVary et in men without a history of any cardiovascular
al presented the results of an exhaustive review of disease, cardiopathy, hypertension diabetes and
the literature conducted by the Subcommittee on neuropathy. Nicolosi et al studied the epidemiology
Smoking and ED of the Socioeconomic Committee of ED in four countries. [146] The countries that were
of the Sexual Medical Society of North America. included in the study were Brazil, Italy, Japan and
[178] These authors found strong indirect evidence Malaysia. From each country, a random sample
that smoking may affect erections. Their conclusions of approximately 600 men between the ages of 40
were: “Available evidence on the association and 70 were interviewed. The authors found an
of smoking with ED is not complete insofar as odds ratio of ED of 2.12 (95% conidence interval
association is likely due to the consistency of the 1.26-3.56) in men who smoke >30 cigarettes/day
relationship of smoking and endothelial disease, compared to men who did not smoke. Bartolotti et al
and the strength of the association of ED with other reported on 9670 diabetic men who were categorized
endothelial disease”. as: never smokers (30%), current smokers (30%),
or ex-smokers (40%). [181] These participants
Tengs and osgood performed a complete Meta were randomly selected from 178 different diabetic
analysis of available literature over the last 20 years centers in Italy. The effect of age was considered
prior to 2001 by searching MEDLINE to identify the when the results were analyzed. These researchers
prevalence of smoking among impotent men. [179] found that current smoker had an odds ratio of ED
These authors reviewed over 1000 articles and of 1.4 (95% conidence interval 1.3-1.6) compared
identiied 19 that reported the smoking habits of 3819 to never smokers and ex-smokers had an odds ratio
men. They found that 16 of these articles, including of 1.5 (95% conidence interval 1.3-1.6) compared to
the 6 largest studies, found the prevalence of never smokers. The authors further found that in ex-
smoking to be higher than in the general population. smokers, the risk of ED was inversely related to the
Their meta-analysis revealed that 40% of impotent number of years since the patient quit smoking.
men were current smokers, which they compared to
28% of men in the general population. These authors A recent epidemiological study of high evidenced-
concluded that: “Based on almost 2 decades of based criteria attempted to identify the association
evidence, tobacco use is an important risk factor for between cigarette smoking and ED and further
impotence. Anti-tobacco advertisements featuring analyzed the data by adjusting for presence or
impotence as a reason to avoid or cease tobacco absence of cardiovascular disease. [182] The
use are well grounded in scientiic fact”. Western Australia Men’s Health Study (WAMHS) is
based on a stratiied sample of the male population
In the previous consultation there were two articles obtained from the Western Australia (WA) electoral roll
cited that did not ind increased risk for ED in for June 2001. This publication was based on 1,580
association with smoking. Mak et al performed a participants who had returned their questionnaires
population-based study in Belgium. [128] These and included smoking data and year of birth (89.3%
investigations interviewed a random sample of the of those returning the questionnaire). The report
population, which included 799 men aged 40 – 70 demonstrated statistically signiicant increases in the
years. They did not ind a correlation between smoking odds of ED among current smokers compared with
and ED, either in current smokers or in ex-smokers. never smokers even after adjustment for age and
Similarly, Morillo et al reported on the prevalence of cardiovascular disease. Although not statistically
ED in Columbia, Ecuador and Venezuela. [140] This signiicant, the corresponding odds among ever
study questioned 1946 randomly selected men aged smokers and former smokers were also increased
49 and older. Using univariate analysis, the authors implying a possible adverse effect of previous
did not ind any association of cigarette smoking with smoking on erectile function. Cardiovascular disease
ED. did not confound the relationship between smoking
and ED. This study also suggested that cessation of
There were two studies in cross-sectional
smoking before middle age may avoid the increase
populations and one in a special clinical population
in the risk of ED.
of diabetics included in the last consensus chapter
that found a positive correlation between smoking Most studies who report on the association of
and ED. Mirone et al performed a cross-sectional smoking and ED contain populations with other
study on the prevalence and risk factors for ED in diseases that are clear risk factors for ED. However,
the general population in Italy. [180] This random a study of 7,684 Chinese men showed that smoking
sample included 2010 men from the practices of was associated with ED in men without clinical
143 general practitioners. The researchers found vascular disease. [183] The same study also
that current smokers had an odds ratio of ED of 1.7 demonstrated increased odds of those men who
(95% conidence interval 1.2-2.4) compared to never smoked more than 20 cigarettes per day. A. dose


comitte 2.indd 100 8/25/2010 12:52:54 PM

related association has been also reported in other excellent discussion of the methodological limitations
studies. [184, 185] It has also been shown that the of published research and make suggestions
magnitude of the association between smoking and for changes to produce more reliable and useful
ED decreases across increasingly older age groups, information [203]. Whitehead and Klyde reviewed a
suggesting that smoking may have a more apparent large amount of the associations between ED and
impaction on erectile function in young rather than diabetes mellitus in their literature review of 1990
older smokers. [186] [189]. Some of their observations are reported in
Table 8.
Thus it would appear that the preponderance of
evidence available at this time would identify cigarette
In a separate paper from the Health Professionals
smoking as an independent risk factor for ED. We
Follow-up Study (HPFS) included in the prevalence
have, on the other hand, not identiied descriptive
of ED table, Bacon et al report on the association of
or analytical literature which links smoking to other
type and duration of diabetes with ED in this large
male sexual dysfunctions or to any female sexual
cohort of men [204]. Men with diabetes had an age-
dysfunctions. Those of us who are clinicians, should
adjusted relative risk of 1.32 (95% CI 1.3-1.4) for
use and expand this information to enlighten our
having ED compared to men without diabetes. Men
patients and to encourage them to add ED to the
with type 2 diabetes had an increasingly greater
long list of reasons why they should strive to quit
risk of ED with increased duration since diagnosis,
particularly for men diagnosed >20 years previously.
c) Diabetes Mellitus In 178 diabetic centers in Italy, data was collected
using interviews regarding erectile dysfunction in
From the Netherlands, Enzlin et al reported that men 9,868 men [205]. The patients ranged in age from 20
with complications of type I diabetes had signiicantly to 69 years. The prevalence of ED was 35.8% for the
greater prevalence of decreased desire than had entire group, ranging from 4.6% for men 20-29 years
those without complications [187]. This was also of age to 45.5% for men 60-69 years of age. For men
the case for prevalence of orgasmic dysfunction. with insulin dependent diabetes mellitus, diabetes
Diabetes mellitus has also been associated with present for over ten years, with fair or poor control
retrograde and anejaculation. [188] based on glycosylated hemoglobin 7.5-9% and > 9%
respectively, those managed with agents other than
Erectile dysfunction has been reported to occur in diet control, and history of diabetes mellitus-related
at least 35-90% of men with diabetes mellitus with arterial, renal, or retinal disease and neuropathy and
the onset of ED occurring in an earlier age (10 to 15 those who were smokers, all showed a higher odds
years before) than those without diabetes mellitus ratio for ED.
[189-202]. In the MMAS study, the age-adjusted
probability of complete ED was three times higher in A subset of 1,010 of these men from the Italian
men who reported having treated diabetes mellitus group above without ED at baseline were followed
than those without diabetes. [26] prospectively for 2.8 years to determine the incidence
of ED associated with diabetes [206]. The crude
Weinhardt and Carey in 1996 published a incidence rate was 68 cases per 1000 men years
comprehensive review of empirical literature, (95% CI 59-77). The incidence of ED increased
regarding the prevalence of ED among men with with increasing age, duration of diabetes, and
diabetes mellitus; they suggest that 26-35% of deteriorating metabolic control. The rate was higher
diabetic men will develop ED. They present an for type 2 than in type 1. The relative risk increased

Table 8. associations of Diabetes mellitus (Dm) with erectile Dysfunction

- Erectile Dysfunction is usually present within 10 years of diagnosis of DM

- Usually occurs at a younger age group in insulin dependent DM
- ED may be irst sign of DM in as high as 12 % of cases in males
- Poorly controlled DM may produce a reversible temporary ED once controlled
- ED in almost all patients with DM related neuropathy
- DM macrovascular complications related to age of patient
- DM microvascular complications related to duration of DM and glycemic control

Whitehead and Klyde. Clin Geriatric Med 1990, 6:771-795.


comitte 2.indd 101 8/25/2010 12:52:54 PM

also with obliterative arterial disease of the lower legs, Prospective Cardiovascular Munster studies [213]
ischemic heart disease, renal disease, autonomic have clearly demonstrated that overweight and
neuropathy, sensation and motor neuropathy, and obesity are independent factors associated with an
diabetic foot and retinal disease. The Massachusetts increased mortality in men and that this is due largely
Male Aging study reported ED incidence of 51 to coronary atherosclerosis or other cardiovascular
cases/ 1000 man years [28]. Also, the incidence rate diseases. Moreover, the same studies have shown
of erectile dysfunction is higher for each decade of that the prevalence of obesity has dramatically
diabetic men compared to non-diabetics, up to twice increased both in the US [211, 212] and Europe [213]
expected in the general population without diabetes creating a new important burden for the medical
mellitus. community.
Diabetic men with sexual dysfunction, including ED, The link between obesity and male potency dates
are older and have a longer duration of diabetes back to the Byzantine era, when it was thought that a
[199, 200, 204, 205]. ED in men with diabetes is large stomach impaired a man’s ability to have sexual
more severe and associated with poorer quality intercourse. [214] So far, however, the association
of life [175, 194] and poor glycemic control [200]. between obesity, sedentary lifestyle and erectile
Hyperlipidemia, hypertension, and obesity are dysfunction (ED) has not been completely clariied.
conditions common in diabetic men and also [215, 216] Baseline data from the Massachusetts
independent risk factors for ED. Male Aging Study (MMAS) failed to ind any
association between BMI and ED. [26] More recently,
Interestinlgy, Gazzaruso et al. [207] reported that
cross-sectional analysis of data from the NHANES
ED itself could be considered the most eficient
survey [174], involving 2126 non-institutionalized
predictor of silent coronary artery disease in a
men representative of the US adult male population,
diabetic population, independently of glycometabolic
demonstrated an attenuated association between
control and ED severity. In particular, among a
obesity and ED after adjustment for cardiovascular
consecutive series of 160 subjects with apparently
risk factors. However, longitudinal studies have
non-complicated type 2 diabetes, they demonstrated
clearly demonstrated a direct association between
that the prevalence of ED was 7-fold higher (35% vs
these conditions at baseline and the subsequent
7%) in subjects with silent coronary artery disease.
development of ED. [49, 217] In particular, the Health
Similar results were conirmed during longitudinal
Professionals Follow up Study [145], including 22,086
studies by the same group [208] and other authors.
US health professional men, showed that after a 14-
[209] Accordingly, Corona et al. demonstrated that year follow-up study period, ED was most likely to
penile vascular insuficiency was inversely related occur in men who were obese (OR=1.7[1.5-2]) and
to the risk of silent coronary artery diseases in the who lived a sedentary lifestyle (OR= 0.7[] for
diabetic population. [210] subjects with physical activity greater than 32.6 vs.
In a recent publication, Rosen and others report an less than 2.7 METs/week). In addition, prospective
analysis of risk factors in a subset of 373 men of data from the MMAS demonstrated that cigarette
the Look AHEAD trial of type 2 diabetes [199]. Of smoking and BMI signiicantly predicted the risk of
these 373 men 268 were sexually active (68.7%). developing ED even after controlling for confounding
About 75% of these 373 men had mild, moderate, factors. [28, 218]
or severe ED using the erectile function domain of yet how obesity affects ED is not entirely clear. Early
the IIEF (65% of the sexually active men). Of the endothelial dysfunction and impaired nitric oxide
sexually active men 42.5% had consulted with a synthesis, necessary for stimulating smooth muscle
physician about sexual problems. Only 7.3% of the relaxation and increased blood low which is in turn
sexually active men had severe ED. Risk factors necessary for erection, have been considered the
inluencing ED were the following: the existence major associated pathogenetic issues. [215-216,
of metabolic syndrome, hypertension history, and 219-220] Corona et al. [214] recently conirmed
other cardiovascular disease. Men with improved this hypothesis in a large cross-sectional trial
levels of itness were about 40% less likely to have including 2,435 male patients seeking treatment
ED. Cardiorespiratory itness was measured by a at an outpatient clinic for sexual dysfunction
symptom-limited graded exercise treadmill test to between 2001 and 2007. The results of this study
voluntary exhaustion [199]. showed that obesity was signiicantly associated
d) Obesity metabolic syndrome and erectile with a higher physical contribution to ED, while
there was no difference seen among relational or
psychological determinants. As the severity level of
Until the last decade, the risk associated with over- obesity increased, penile blood low decreased (one
weight and obesity had been widely underestimated. half of patients with morbid obesity had pathological
Large prospective epidemiological investigations penile blood low). In addition, as previously reported
including the Framingham [211], the National Health [215-216, 219-220], an inverse association between
and Nutrition Examination Surveys [212] and the testosterone levels and BMI was also found. In these


comitte 2.indd 102 8/25/2010 12:52:54 PM

patients, hypogonadism can exacerbate sexual also be predictive of MetS with an unadjusted relative
dysfunction because of its typical symptoms, such risk of 1.35. [231] The prevalence of ED in subjects
as decreased sexual desire and mood disturbances with MetS ranges from 27% [232] to 80% [233] strictly
[214-216, 219-220] This evidence might be a useful associated with the number of MetS components
motivator for men to improve their health-related and the endothelial function impairment. [215-216,
lifestyle choices. Accordingly, Esposito et al. [221] 229-230]
in a randomized trial in obese men, has shown that
In particular, among subjects with ED, those with
decreasing BMI and increasing exercise signiicantly
MetS are characterized by the worst erectile function,
improved ED in approximately a third of cases
(essentially due to impairment in penile blood low)
suggesting that lifestyle changes can reverse ED.
and report a prevalent dificulty in obtaining vs.
Kratzik et al [222] demonstrated that the risk of severe
maintaining erection, a gradual onset of the disorder,
ED is decreased by 82.9% for males with physical
and a decreased number of nocturnal erections, all
activity of at least 3000 Kcal/week. In addition, the
of which were demonstrated to be associated more
same authors reported that an energy expenditure
of as little as 1000 Kcal/week signiicantly reduces with an organic than a psychogenic origin of ED.
the existing risk of ED. Some examples would be [234-236] Corona et al., [234-236] demonstrated
bicycling 4 miles (6.4 km) in 15 minutes, social that elevated blood pressure and hyperglycaemia,
dancing for 30 minutes, running 1.5 miles (2.4 km) in which are well known cardiovascular risk factors,
15 minutes or gardening for 30-45 minutes. [222] are associated with impaired penile vascular low
to a greater extent than the other components of
Furthermore, a Mediterranean diet based on olive MetS. The association between hypogonadism
oil as the major fat source and including more and MetS is emerging even in subjects with ED.
ish, legumes, vegetables and fruits have been [215-216, 219-220, 229-230] Abdominal adiposity
recommended as an extremely successful and and hyperglycaemia [215-216, 219-220, 229-230]
conservative way to treat obesity since the time of represent the most important factors involved in
Greco-Roman writers. [223] A large body of evidence the pathogenesis of hypogonadism in MetS. The
has demonstrated that a greater adherence to a presence of hypogonadism in men with MetS
Mediterranean diet is associated with a signiicant increased symptoms of sexual dysfunction such as
improvement in health status, as well as a signiicant low sexual desire. [215-216]
reduction in overall and cardiovascular disease
mortality. [224] Hence, in line with these data, the Recommendation 9:
protective role of a Mediterranean diet on erectile There is still a question whether obesity and the
function is not surprising. [225] In addition, both metabolic syndrome per se are additional risk
clinical and experimental studies have conirmed factors for erectile dysfunction or that the diseases
that combining physical exercise with the reduction cardiovascular and diabetes themselves that are
of caloric intake provides additional beneits to part of these conditions are the risk factors that
erectile function. [226] account for this association. Further research is
needed to answer this question. Grade C.
Recently, it has been reported that central obesity
(high waist circumference) may be a better predictor c) Cardiovascular Disease and Hypertension
of increased cardiovascular risk than obesity per se
[227] Although this issue is under debate, Cornier Endothelial dysfunction is a condition present in
et al [228] demonstrated that waistline should be many cases of erectile dysfunction and thus there
considered at least the best predictor of medical is a common etiologic pathway for other vascular
care costs. Central obesity is a key element of disease states, such as cerebrovascular accidents,
metabolic syndrome (MetS), a cluster of metabolic myocardial infarction, heart disease, hypertension,
abnormalities related to a state of insulin resistance hyperlipidemia, low serum levels of high density
and an increased risk of developing cardiovascular lipoproteins (HDL), arteriosclerosis, and peripheral
and metabolic diseases [216, 227] Although several vascular disease and thus an association with
deinitions for MetS have been proposed [216], the these other conditions is to be expected. Wabrek
criteria deined by the National Cholesterol Education and Burshell reported that 64% of 131 men, aged
Program-Third Adult Treatment Panel (NCEP-ATPIII) 31 to 86 years, hospitalized for acute myocardial
are the most widely used in clinical practice and infarction were impotent. [237] Sjögren and Fugl-
research. Recently it has been demonstrated that Meyer reported an 18% prevalence of ED in 49
not only the individual components of MetS but also men before experiencing a myocardial infarction
MetS itself is signiicantly associated with ED. [215- compared to a prevalence of 45% after the event,
216, 229-230] In addition, prospective data from the with a 43% new onset or increase in ED in this group
Massachusetts Male Aging Study in a population- of men. [238] These authors also found that low level
based cohort observed at three different time points of sexual desire increased after myocardial infarction
over approximately 15 years showed that ED could from 14% to 35% and orgasmic problems from 4%


comitte 2.indd 103 8/25/2010 12:52:55 PM

to 25%. In fact 21% reported anorgasmia after the signiicantly higher among men with hypertension
myocardial infarction. In another study ED was (OR= 1.47), ischemic heart disease (OR=1.8), and
present prior to myocardial infarction (MI) in 64% stroke (OR=1.47). With these latter three conditions
of 131 men and before coronary bypass surgery and peripheral arterial disease in combination in
in 57% of 130 men [239]. In still another study of patients grouped together as cardiovascular disease
132 men attending day case angiography, 40% had the odds ratio was 1.85. The age-adjusted odds
experienced ED before their coronary diagnosis had for severe ED (IIEF-5 <8) was 2.62 in men with
been made. [240] In addition, Montorsi et al. [241] peripheral vascular disease with no signiicant odds
demonstrated that , in subjects with angiographically ratio for ED in general ( IIEF-5< 22). When diabetes
document coronary artery disease, ED becomes mellitus, hypertension, and hyperlipidemic were
evident prior to angina symptoms in almost 70% of present in the same patient the odds ration of ED was
the cases, with a mean interval of more than three 3.21. The authors concluded that the relevance and
years. Accordingly, Thompson et al. [242] , in the importance of careful cardiovascular risk evaluation
Prostate Cancer Prevention Trial, reported that in men with ED could not be overemphasized. The
incident ED was associated with a 25% increase authors also emphasized that the associations
in risk of subsequent CV events, during a nine year described in this paper are cross-sectional and that
follow-up, after an adjustment for confounders. data concerning the interval between the onset of
ED and the diagnosis of signiicant cardiovascular
Treated heart disease (worse in smokers), treated
events or recognition of biomedical risk factors were
hypertension (again, worse in smokers), and low
unable to be addressed thus making the temporal
serum levels of HDLs were signiicantly correlated
relationship between ED and cardiovascular disease
with impotence in the MMAS report. [26] Values of
and risk factors unanswered.
HDL more than 90 mg/dL were associated with no
probability of complete ED and conversely when the Recommendation 10. :
level of HDL dropped to 30 mg/dL the probability of
complete ED was 16%. Complete ED was present Although the association of ED and Cardiovascular
in 15% of men with treated hypertension and this disease and risk factors are well established there is
incidence was associated with the duration and a need for longitudinal studies in patients who have
severity of the hypertension in the MMAS report, manifest ED or cardiovascular disease and do not
as well hypertension increasing the age-adjusted have the opposite manifest associated condition in
incidence of ED. In another study the prevalence of order to establish a temporal relationship between
ED was not increased among hypertensive and pre these two entities. grade c.
hypertensive men compared with normotensive men
aged 25-40 years. [243] These authors concluded f) Hormonal or Endocrine
that it takes years for hypertension to cause ED in this
The effect of androgens on desire/interest and sexual
generally healthy and younger group of men. Wei et
behavior is well established but few reports show
al [53] found that a high level of total cholesterol and
direct end organ, corpora cavernosa, dependency on
a low level of HDL are important risk factors for ED.
androgens, except the early growth and development
In an analysis of the two MMAS studies of 1987-89
of the male reproductive tract. [248-250] Carani et al
and 1995-97, it is suggested that ED and coronary
[251] did show increased rigidity as measured by rigi-
heart disease share some behaviorally modiiable
scan in eugonadal men treated with androgens but
determinants in men who are free of manifest ED or
no change in frequency of NPT associated events
predisposing illness at baseline. [244]
nor duration of circumference change, suggesting
Since the last publication of this chapter there has an enhancement of corpora cavernosal function
been a stress on the association of cardiovascular in response to androgens. In a study by Becker
disease and risk factors and ED. It is now thought et al, [252] systemic and cavernous plasma levels
that ED may be a harbinger of silent coexistent or of testosterone were found to be elevated during
subsequent coronary artery disease. [245, 246] erection and with laccidity and detumescence
Almost all of the cross-sectional studies tabulated in states, cavernous levels were signiicantly lower
Tables 6A-F that collected data on coexistent cardiac than systemic levels suggesting corporeal binding of
disease or risk factors found increased prevalence testosterone in the cavernous spaces.
of ED compared to those without these risk factors.
Primary or secondary hypogonadism is often
In a recent cross-sectional observational study the associated with erectile failure but not always.
intimate nexus between ED and cardiovascular This may be due to a low threshold of androgens
disease was presented. [247] In a group of 1,514 necessary for cavernosal tissue function, perhaps
men with an age range of 20-99 years cardio- even at levels that can be maintained by the adrenal
vascular risk factors were more prevalent with androgens in the face of lack of testicular androgens.
increasing age and among participants with ED [253, 254] Hormonal dependency for erection seems
and severe ED. The age-adjusted odds of Ed were to vary for erections produced by different situations,


comitte 2.indd 104 8/25/2010 12:52:55 PM

during rapid eye movement sleep, with visual sex Severe hyperprolactinemia (PRL > 735 mU/L or 35
stimulation, or fantasy or sexual situation induced ng/mL) but nor milder form has a negative impact
erections. [255-257] Severe low levels are necessary on sexual function, impairing sexual desire - as well
to suppress sleep-related erections, with moderate as erectile function - and testosterone production.
low levels affecting sexual situation with partner [266-268] In particular, it has been reported that
erections, and erections induced by visual sex in subjects with sexual dysfunction, a severely
stimulation not showing much androgen dependency. reduced libido is associated with a 10-fold increase
An article that demonstrates this last point and also in the prevalence of severe hyperprolactinemia.
the variation in androgen dependency for different [270] A PRL-induced hypogonadism could explain,
types of erection was that by Greenstein et al in 1995. only partially, this association [266-268] since PRL
[258] Four, all who had surgical castration, of sixteen plays also a direct role in the control of male sexual
men who were surgically or medically castrate, had desire. Accordingly in hypogonadal subjects with
erection produced by a visual sexually stimulated
hyperprolactinemia, prolactin-lowering drugs are
ilm, and none were able to have erectile activity
able to restore both testosterone levels and libido
in a partner sexually induced situation. These four
[268], while testosterone replacement therapy is
men had signiicantly, but yet still at castrate levels,
not as effective. [270] The relationship between
higher levels of testosterone than the men unable to
respond to the visual stimulation. Similarly Bancroft hyperprolactinemia and erectile function is under
and Wu [259] had shown that androgen replacement debate. Some Authors have suggested a possible
in hypogonadal men improved erectile response to pathogenetic link between severe erectile dysfunction
fantasy (as well as reported sexual acts per week at (ED) and severe hyperprolactinemia [271] although
home) but erections in response to erotic ilms were even negative associations have been reported.
not signiicantly different from normal controls either [269, 272] In addition, controlled studies evaluating
before or after androgen treatment. Another study the effect of dopamine agonists on ED subjects with
showed the futility of using testosterone therapy in hyperprolactinemia were inconclusive. [268]
those patients with testosterone in the low range of
normal to improve erectile function and suggests g) Urinary tract diseases and Lower Urinary
that testosterone has to be at extremely low levels to Tract Symptoms (LUTS)
effect sexually related erections or nocturnal sleep
erections. [260] Chronic renal failure is a risk factor for ED. [273]
There were two high Prins score studies that looked
As far as epidemiological studies go, the MMAS study at ED in patients seen in dialysis clinics and rates
constitutes the largest male endocrine database for ED were high for all ages almost all above 50%
available, by including reliable measurement of 17
however stratiied. [274, 275] In the USA general
hormones. Interestingly, testosterone (total, free,
urinary tract symptoms predicted ED (odds ratio:
or albumin bound) or dihydrotestosterone (DHT)
levels did not signiicantly correlate with erectile 3.1), but not other investigated parameters (desire,
dysfunction. Of the 17 hormones measured, none, ejaculation) of male sexual function. [20] These
with the exception of dehydroepiandrosterone sulfate indings principally agree with those of Blanker
(DHEAS), correlated with erectile dysfunction. et al from the Netherlands. [79] The latter also, in
DHEAS levels of 0.5 mgm/ml were associated with their sample of 50-78 year old men identiied lower
a high probability of complete ED (16%) compared urinary tract symptoms (LUTS) as concurrent with
to DHEAS levels of 5 and 10 mgm/ml (6.5% and ejaculatory dysfunction – deined as no ejaculation
3.4% respectively). [26, 254] However probabilities or signiicantly reduced ejaculatory volume - The
of complete impotence increased as DHEAS levels odds ratios for the likelihood of moderate and severe
decreased while the overall and moderate ED LUTS as compared with no such symptoms to concur
probabilities remained unchanged. Such patterns with ejaculatory dysfunction being as high as 3.8 and
support the hypothesis that minimally impotent men 7.8, respectively.
may become completely impotent if their DHEAS
levels decrease from 10 to 0.5 mgm/ml level. Despite A number of studies from clinical and community
this evidence, Placebo controlled, randomized double populations have shown that the prevalence of ED
blind studies have shown that DHEA administration and reduced sexual desire along with other types
is not useful for improving sexual dysfunction in men. of sexual dysfunction is greater in men with LUTS.
[261, 262] [276-282] Most of these studies have also shown
The weak relationship between low T and ED that the presence of LUTS is an independent risk
is supported by results from both human and factor for sexual dysfunction. Moreover there is a
animal studies. [263, 264] Rhoden et al [265] on positive correlation between severity of LUTS and
a consecutive large series of almost 1000 elderly severity of ED. [276, 277, 279, 281] Decreased
subjects, with or without ED, have documented a sexual satisfaction as well as sexual activity are
lack of association between T and International associated with increasing severity of LUTS. [276,
Index of Erectile Function (IIEF-5). 277] Recently there was a report in the literature


comitte 2.indd 105 8/25/2010 12:52:55 PM

of the irst multinational population-based study the clinical literature to be consensus that between
to evaluate the relationship among those with half and two thirds of male stroke patients develop
overactive bladder (oAB) and ED, and also sexual ED. Both early and delayed ejaculation have been
quality of life. [283] 502 cases of OAB were matched described to emerge after stroke; but within in a very
with 502 controls. Reduced sexual activity was 14% wide latitude. [291, 292]To which extent the profound
in cases versus 4% in controls. Those with OAB sexual dysfunctions in these patients mainly are
were signiicantly more likely to have ED than were results of poor coping or are mainly somatogenic still
controls (OR 1.5). Signiicantly more of those with remains to be elucidated.
OAB (15%) reported decreased enjoyment of sexual
activity because of urinary symptoms relative to Erectile dysfunction occurs in 90% of patients with
controls (2%). The perceived impact of OAB on the multiple system atrophy, being the irst symptom in
frequency of sexual activity, sexual enjoyment, and 37% of the cases. [294] Other diseases and chronic
satisfaction appeared most pronounced in cases disorders reported to have a risk for ED include
with urinary incontinence. sleep apnea, chronic obstructive lung disease [295]
,scleroderma [296] ,and Peyronie’s disease. [297]
An excellent epidemiological study from Finland In a recent epidemiologic study of 70 patients who
established the bothersomeness of LUTS symptoms were candidates for a liver transplantation 52 (74%)
and the prevalence of ED. [284] The target population had ED using IIEF-5 criteria. [298] This article is a
were samples from Tampere and surrounding good review of previous studies of this same link and
municipalities in Finland in 1999. Cohorts of men discussion of the possible etiologic reasons for this
born in 1924, 1934, and 1944 comprised those association along with a review of effect of coexistent
studied. Adjusted odds ratios of ED were 2.6 for men other medical conditions and social factors effecting
with LUTS total scores of 11-19 compared to those this association.
without LUTS and 4.4 for those with scores of 20 or
more comparing the two groups. For bother scores Fitzgerald and others [299] remind all of the need
even low bother were signiicantly associated with to be aware of the effect of chronic disease on
ED. all urologic disorders including LUTS and ED.
In bivariate analyses, most urologic and sexual
h) Other Chronic Diseases
symptoms were associated with type II diabetes,
Polyneuropathy, which commonly involves cardiac disease, hypertension, and depression.
autonomous dysfunction is another source of However, in multivariate models adjusting for all four
sexual dysfunction, particularly ED and ejaculatory illnesses, gender, race/ethnicity, age, alcohol intake,
dysfunction [285] Thus, Vardi et al reported a 38% smoking, physical activity, and body mass index there
coincidence of polyneuropathy and ED in diabetics were fewer signiicant associations. It was found that
and a 10% coincidence of the two in non-diabetics. all urologic symptoms were signiicantly related to at
[286] Among other neurological conditions which may least one illness, with depression increasing the odds
lead to male sexual dysfunctions are Parkinson’s of all urologic and sexual symptoms studied. Urinary
disease. In these patients, decreased sexual desire tract specialists and sexual health professionals
and ED are common for still unknown reasons. should consider factors outside the urinary tract
[287-289] However, treatment with dopaminergic that may be contributing to urologic symptoms. It
substance have been observed to increase level of remains unknown whether treatment of medical
interest/desire. Even the pathogenesis of the often and psychological illnesses can result in meaningful
reported ED is to date unclear. There is good clinical improvement in urologic symptoms, or conversely,
evidence that other chronic neurological disorders whether urinary tract symptoms can provide valuable
may affect sexual function. Thus, in seizure free insight into an individual’s overall health status.
periods, epilepsy can be associated with reduced
sexual interest/desire and with ED. [285, 289] In a i) Surgery and Trauma
review article of genitourinary conditions associated
Spinal cord injury patients are obviously at
with patients with multiple sclerosis the incidence of
an increased risk for erectile and ejaculatory
ED was reported to be 40-80%, usually occurring a
(anejaculation) dysfunctions with central induced
half decade to a decade after onset of the progressive
erectile activity possible in those with lower spinal
disorder. [290] In multiple sclerosis, ejaculatory
cord injury and relexogenic erection possible in
dysfunction may, according to clinical reports, prevail
those with upper cord injury. Besides leading to
in about 50% as the disorder progresses. [289]
fertility problems (the incidence of male spinal cord
In the USA Monga et al [291] In a retrospective study injury peaks at ages 15-30) these dysfunctions are
found a three fold increased prevalence of low sexual among the most pronounced problems for the future
desire after stroke. Others have identiied clearly quality of life in the quadriplegic or paraplegic men
smaller post-stroke changes in sexual interest/desire. (for an overview see reference [285]). There is – to
[292, 293] In some contrast there appears throughout some extent anecdotal – data showing that both


comitte 2.indd 106 8/25/2010 12:52:55 PM

men and women with complete spinal cord injury and Depression Scale (HAD) [308] Dunn et al [119]
rostrally to peripheral genital innervation levels can found that anxiety, but not depression, signiicantly
experience orgasm elicited by stimulation of non- predicted early ejaculation. Suppression and
genital body areas and the majority of the men seem expression of anger indicate higher probabilities
to have only minor dysfunction, if at all, concerning of moderate and complete ED [26]. Independently
sexual interest/desire. Surgery or trauma affecting of medication, Araujo et al [142] demonstrated
any level of neurologic control of erection or that that depression is closely associated (odds ratios
interfering with the arterial supply of the corpora 2.0) with ED and as discussed elsewhere in this
cavernosal tissue are unquestionably risk factors chapter many antidepressants may lead to sexual
for erectile dysfunction. DePalma has reviewed the dysfunctions. This is particularly true for SSRIs, which
impact of vascular surgery on ED.[300] are nowadays used for delaying early ejaculation.
From clinical experience, it is well established that ED k) Medications and Recreational Drugs
and anejaculation are common after prostatectomy.
Erectile dysfunction due to prescription medications
There is, however, astonishingly little epidemiological
is sometimes dificult to prove and is probably
data on this subject. Some four years ago Stanford
often under-reported. In the MMAS, a statistically
et al [301] reported a high incidence (about 60%) of
signiicant correlation between ED and vasodilators,
post radical prostatectomy ED; whether or not the
anti-hypertensives, cardiac and hypoglycemic
surgical intervention had been nerve-sparing. other
agents was noted. [26] However when the second
reports show higher retention of erectile activity after
analysis of the population was made in 1995-97,
bilateral nerve sparing surgery in the younger male
adjustments for comorbidities and health behaviors
and in those with strong erectile activity before the
attenuated some medication associations with ED
surgery [302, 303]. Radiation therapy to the pelvis
with only nonthiazide diuretics and benzodiazepines
also is a source of damage to nerves involved in
remaining statistically signiicant for association
erectile and ejaculatory functions [304] while sexual
with prevalent ED. [309] Meinhardt and his co-
functions remain stable after treatment for benign
authors have reviewed the inluence of medication
prostatic hyperplasia. [305]. of erectile dysfunction in some detail. [310]
Schrader et al in 2 studies showed a weak association Major classes of prescription drugs commonly
between some parameters of erectile function and reported to be associated with ED are histamine-2
bike riding. [306, 307] In the irst study 17 bicyclist receptor antagonists, hormones, anticholinergics,
men were compared to 5 non-cycling controls with psychotropics and certain cytotoxic medications.
nocturnal penile tumescence studies (NPT). The Whether one type of anti-hypertensive agent is
only difference between the groups was a statistical less likely to be associated with ED than another is
difference in the percentage of sleep time erections, dificult to pin down since the prevalence of ED is
27.1± 9.7% vs 42.8 ± 17.56 (p=.008). [306] Although often an association with the hypertension condition
traditional seats seem to clearly produce sensory as well. This debate is well discussed in two articles.
deicits from prolonged bicycle riding, ED defects [311-312] In an experimental rodent animal model of
are weakly supported by evidenced based data. hypertension, data suggested that renin-angiotension
In the second study from Schrader et al, data system inhibition by enalapril, an angiotension
regarding erectile function was available for 64 to 70 converting enzyme inhibitor, may at least partially
of 90 men who were studied at baseline, at which normalize penile vascular structure. [313] Calcium
time traditional bicycle seats were used compared channel blockers and alpha adrenergic blocker
to using a no- nose saddle. This was a non-group theoretically may be the best alternatives, along
controlled study with each man serving as his own with the angio-tension converting enzyme inhibitors,
control over the six months of the study. IIEF-5 was in attempting to reverse ED when associated with
statistically better after 6 months (score of 29.12 vs other anti-hypertensive agents. Rosen and others
29.61 p= 0.015) – 72.7% of oficers scored a perfect review sexual dysfunction problems with the
30 at baseline compared to 84.9% at 6 months. No selective serotonin reuptake inhibitors (SSRIs). [314]
changes were noted in NPT data. [307] Trazadone is one antidepressant that is unlikely
to be associated with ED and in fact has a risk of
j) Psychiatric/psychological risk factors associated priapism. [317] In general, it is suggested
that antipsychotics with strong alpha-I receptor
It is well established that disorders of the psyche
afinity properties be considered as substitutes for
may concur with male sexual dysfunction. There is
other prescription psychotropic drugs associated
valid epidemiological data on this subject. In the USA
with ED. Life style related risk factors for ED include
[20] emotional problems or stress were signiicant
chronic alcoholism and chronic use of marijuana,
predictors of low level of desire (odds ratios 3.2),
codeine, meperidine, methadone and heroin. [315]
ED (odds ratios 3.6) and early ejaculation (odds
ratios 2.3). The association of ED with depression There are three recent reviews of the effects of
is well established. [26] Using the Hospital Anxiety psychiatric drugs on sexual function [316-318]


comitte 2.indd 107 8/25/2010 12:52:56 PM

Tricyclic antidepressant and mono-amine oxidase population. [331] Other chronic disease states were
inhibitors have been shown to be associated with not present in this population at baseline, including
delayed ejaculation in double-bind studies [319, 320] men treated for heart disease or diabetes, history
Similarly, studies have shown that selective serotonin of prostate cancer, or those with incomplete data
reuptake inhibitors (SSRIs) as well as venlafaxine are regarding chronic disease risk factors. The results
associated with anorgasmia and decreased libido. of this analysis showed that a change in smoking
There is some evidence that a small number of men status or change in heavy alcohol consumption did
may experience erectile dysfunction as the result of not decrease the incidence of ED. The average age
SSRI therapy. [321, 322] Duloxetine [323], bupropion at baseline in this population was 52 years of age
[324] and nefazodone [325] have low rates of sexual and changes in tissue may not have been possible
dysfunction. Most studies are consistent in inding to reverse by middle age changes. Men originally
that traditional antipsychotic drugs (for example, obese at baseline seemed to have a higher incidence
haloperidol, thioridazine) are associated with high of ED regardless of the follow-up status. Sedentary
rates of ejaculatory delay, decreased libido and /or behavior status was associated with developing ED
erectile dificulties.[326] Risperidone also has a high with the highest risk of dysfunction for those who
rate of sexual dysfunction. [327] Quetiapine and had maintained a sedentary life-style. The lowest
olanzapine, appear to have lower rates of sexual level of risk for ED, for all factors analyzed, was in
side effects. [328] Most of the antipsychotic drugs those subjects who initiated physical activity after
and some antidepressants have been reported to qualifying as sedentary at baseline. Increasing
be associated with priapism in isolated cases. The physical activity, even in these men in their 40’s and
largest number of case reports concern thioridazine 50’s, is effective for reversing other cardiovascular
and trazodone. [329] disease risk associations and this study seems to
demonstrate a similar beneit for decreasing the
Corona et al. recently explored the relationship
chance of developing ED. Another lesson to be
between the use of selective serotonin reuptake
taken from this study is that modiiable risk factors
inhibitors (SSRIs), non-SSRIs antidepressants and
may require earlier intervention than middle age.
benzodiazepines (BDZ), hormonal parameters and
reported sexual dysfunction on consecutive series There a very few data that support the notion that
of 2040 attending their unit for sexual dysfunction treatment of lifestyle risk factors may improve
[330] The current use of SSRIs was associated with ED. Esposito et al [332], in 2009 published a
a 1.7 fold risk for any degree of hypoactive sexual prospective behavior modiication study in which
desire (HSD), while the risk increased to two-fold 209 subjects were randomly assigned to one of two
when moderate/severe HSD was considered. treatment groups. 104 men randomly assigned to
Patients reporting the use of SSRIs showed lower the intervention program received detailed advice
frequency of intercourse and higher sense of guilt about how to reduce body weight, improve quality
with masturbation. In addition, the use of SSRIs was of diet and increase physical activity. The control
associated with a signiicant impairment of erectile group of 105 subjects was given general information
function and 3.4 fold risk of delayed ejaculation. about healthy food choices and general guidance
Conversely, a lack of signiicant association was on increasing their level of physical activity. IIEF-
observed among BDZ or non-SSRI antidepressant 5 scores were similar for both groups at the onset
users and all the aforementioned life-stressors and of the study. At baseline 35% of the subjects and
relational parameters. 38% of the control group had normal erectile
function. After two years these igures were 58
l) The effects of modiication of risk factors
subjects in the intervention group and 40 subjects in
Using data from the reassessment (1995-97) of the control group showing a signiicantly (P=0.015)
a portion of the population without ED at baseline improvement in erectile function. The conclusion of
in the original MMAS study population (1987- this study was that it was possible to achieve and
89), an attempt was made to assess the effect improve erectile function in men at risk by means of
of modiication of certain risk factors associated non-pharmacological intervention aiming at weight
with ED as decreasing the incidence of ED in this loss and increasing physical activity.


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Committee 3

Psychological and
Interpersonal Dimensions
of Sexual Function
and Dysfunction


Committee Members:


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Psychological and
Interpersonal Dimensions
of Sexual Function and Dysfunction



dysfunctional rather than healthy sexuality. Finally,

there is a paucity of well-controlled, large-scale
outcome research documenting the eficacy of sex
To most individuals, it seems obvious that
psychological and interpersonal factors play a major
role in both the etiology and maintenance of sexual I. THE INHErENT TENSION
problems. The ways in which love and affection
are expressed in one’s family of origin, the unique BETWEEN EVIDENCED-BASED
and sometimes traumatic sexual experiences one rESEArCH AND PSyCHOTHErAPy
has growing up, the religious, cultural and societal
It must be noted at the outset that there is an inherent
messages one receives about sex from peers,
tension between evidence-based medicine and
teachers, relatives and the ever-increasing impact
the art and science of psychotherapy/sex therapy.
of the media on one’s beliefs and behavior clearly
Psychotherapy, as it is generally practiced, is more
play a role in shaping attitudes and promoting sexual
relational, symbolic and dynamic than other ields
health or dysfunction. More signiicantly, individual
of medicine or therapy. The relationship style and
vulnerability to sexual disruption stems from
personality of both the practitioner and the patient
personality and constitutional/ biological dispositions
contribute signiicantly to treatment outcome as
to psychiatric and medical illness, medication,
well as the therapeutic process itself. other factors
surgery as well as the inability to develop and sustain
that cannot readily be quantiied or manualized and
intimate relationships.
contribute to positive outcomes [1] include such
This chapter will review the most signiicant things as the placebo factors that enhance hope and
psychological and interpersonal dimensions expectancy [2], extra-therapeutic factors such as
contributing to sexual health. other chapters will client motivation and chance events (e.g., meeting
provide more of a focus on the biological aspects a new partner), relationship comfort between the
of sexual function and dysfunction. We will consider client and therapist and inally, the degree to which
the predisposing, precipitating, maintaining and the model and structure of therapy conform to the
contextual factors involved in sexual dysfunction client’s expectations.
as well as the success of conventional and
Laboratory research is important, but does not
newer techniques of psychological treatment in
easily translate into clearly prescribed clinical
the alleviation of these disorders. Finally, we will
interventions that enhance sexual life. Having an
recommend a treatment model that offers a greater
array of evidence-based behavioral interventions
likelihood of success- an integrated biopsychosocial
(e.g. directed masturbation) available is important,
model that fully acknowledges the dynamic interplay
but how, when, and under what circumstances they
between our mind and bodies.
are applied to speciic sets of patients by a particular
There is a dearth of high level evidence-based therapist represent the elusive and creative aspects
studies in this area. The observations concerning of psychotherapy. While we know that distracting
developmental factors impeding or facilitating thoughts usually interfere with sexual arousal, it is
sexual health are primarily theoretical, clinical and not always obvious how to help clients re-focus on a
anecdotal- with the emphasis on accounting for sexual situation when they experience performance


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anxiety or negative thoughts. Sex therapy, in variety of predisposing, precipitating maintaining and
actual practice, is usually an idiosyncratic blend of contextual factors [3] (See Table 1). Predisposing
interventions and interpretations, utilizing behavioral, factors include both constitutional and prior life
relational, psychoanalytic and cognitive psychology experiences that contribute to a person’s vulnerability
concepts. Evidence-based medicine cannot fully for dysfunction. Predisposing factors are quite varied
capture the art of psychotherapy. Nonetheless, it and may include a history of childhood or adult sexual
may help delineate the eficacy of speciic clinical abuse or violence, anatomical deformity, chronic
interventions. illness, etc. However, these factors alone are rarely
suficient to create sexual dysfunction [4].
Precipitating factors include those more immediate
THErAPy factors that can propel a person from adequate
Sex therapy is a specialized form of psychotherapy response to dysfunctional response. They include
that draws upon an array of technical interventions such things as separation or divorce, a humiliating
known to effectively treat male and female sexual sexual experience, a mutilating surgery and biological
dysfunctions (e.g., in the case of female anorgasmia, events such as illnesses, or medications or surgeries
directed masturbation). Treatment may be conducted with sexual side effects.
in an individual, couples or group format depending Maintaining factors such as relationship conlict,
upon the initial problem, the judgment of the therapist loss of sexual conidence, performance anxiety,
and the motivation of both partners. and lack of privacy or medications that negatively
Psychosexual evaluation goes beyond traditional affect sexual function may prolong and exacerbate
psychological assessment to examine the patient’s problems, irrespective of the original predisposing or
or couple’s sexual history, current sexual practices, precipitating conditions.
relationship quality and history, emotional health Contextual factors encompass the present day
and contextual factors (e.g., young children, chronic stresses and demands that impinge on the individual
illness, inancial concerns, etc.) currently inluencing or couple. These include such diverse issues as
their lives. Usually, a thorough psychosexual and serious inancial struggles, unemployment, fatigue
developmental history is taken as well in order to from childrearing, or the burdens of caretaking for a
identify past experiences that may be contributing sick parent, child or partner, etc. They also include
to the presenting sexual or emotional problem (e.g., environmental factors such as partners working
past sexual trauma; an over-sexualizing parent). It different shifts and not having suficient privacy.
is important to assess all of the relevant medical The contextual issues are usually leeting but can
and biological factors that may also be contributory become chronic and do impact on sexual function.
to the development or maintenance of the current Each of these domains contributes to both the
dificulty. individual’s and the couples’ ability to sustain an
active and satisfying sexual life or to develop and
Sexual therapy techniques comprise behavioral/
maintain sexual dysfunction.
cognitive interventions as well as psychodynamic,
systems relationship and educational interventions 1. PrEDISPOSING FACTOrS -
(e.g., reading, videotapes, illustrations, anatomical CONSTITuTIONAL FACTOrS
models). Effective comprehensive treatment may
involve collaboration with other specialists such Constitutional factors are inborn biological and
as urologists, gynecologists, endocrinologists, psychological traits that inluence sexual interest
family practice physicians, internists, cardiologists, levels and response tendencies. They may be
neurologists, nurse practitioners, physician created by genomically-based anatomical, hormonal,
assistants, or physical therapists. Individuals vascular and neurological characteristics. How
trained and qualiied as sex therapists may include constitutional factors lead to variations in desire,
physicians, psychologists, social workers, nurses, arousal, orgasm and pleasure from sex is not known
physical therapists and marriage and family with any precision, yet research suggests that each
therapists. of these factors can either enhance or impede later
sexual performance and satisfaction. For example,
B. ETIOLOGICAL BACKGrOuND intersex children who are born with ambiguous
genitalia are likely to experience more sexual
OF SExuAL DySFuNCTION problems in later life than those children born with
normal genitalia [5].
Sexual dysfunction is typically inluenced by a Psychological development is an on-going process


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that begins before birth and continues throughout life. a child of that gender. Gender conformity throughout
over time, individuals either develop or fail to develop childhood is an early developmental marker for
numerous sexual and interpersonal capacities, adolescent heterosexuality [7]. Childhood gender
including the ability to love. The developmental nonconformity predicts adolescent and adult
processes that organize healthy sexuality, while not homosexuality with greater accuracy in boys than it
clearly understood, do not appear to be sexual per does in girls [8]. Erotic fantasy often appears in the
se. The quality of attachments to parents, and the 10th year of life in both genders [9] . These fantasies
ability of caretakers to identify and satisfy the child’s relect the formation of the child’s gender identity,
needs interact with constitutional and temperamental sexual orientation and their preferred sexual “script”
forces to foster sexual comfort and identity [6] . In e.g., what the individual wants to do with another
fact, our understanding of sexual development is and what they want done to them [10]. Sexually
conceptual and descriptive and is largely devoid of atypical adolescents may become gay or lesbian
sophisticated evidence-based studies. and in extreme instances may be diagnosed as
having a gender identity disorder (transsexualism)
a) Gender identity development
or a paraphilia (such as voyeurism, exhibitionism,
Each child develops a gender identity—that is, a fetishism, sadism, masochism, pedophilia) [11].
sense of self as either a boy or a girl and an increasing Although there is much speculation about the
preference for play, dress, and peer companionship speciic developmental factors that organize
that is perceived by adults as typical or atypical for children’s gender identity, orientation, and sexual

Table 1: Etiological model for understanding sexual function and dysfunction

1. Anatomical deformities, e.g., intersex conditions
2. Hormonal irregularities
3. Temperament, e.g., shyness vs. impulsivity; inhibition/excitation
4. Physical resiliency
5. Personality traits, e.g., obsessive- compulsive vs. histrionic
1. Problematical attachment/experiences with parents or parental surrogates
2. Exposure to physical, sexual coercion, violence
3. Surgical intervention/medical illness
4. Event based or process-based trauma
5. Early sexual experiences, e.g., irst intercourse
6. Sexual abuse
7. Religious/cultural messages, expectations, constraints


l. Life-stage stressors such as divorce, separation, loss of partner, inidelity, menopausal complaints
2. Infertility or post-partum experiences
3. Humiliating sexual encounters/experiences
4. Depression/anxiety
5. Relationship discord
6. Substance abuse


1. Ongoing interpersonal conlict
2. Stress- emotional, occupational, personal
3. Acute/chronic illness/health problems
4. Medications, substance abuse
5. Loss of sexual self-conidence, performance anxiety
6. Body image concerns


1. Present day stresses and demands- inancial burdens, unemployment, caretaking of parents, children or
partner, fatigue from childrearing
2. Environmental constraints- lack of privacy, time, partners working different shifts
3. Repeated unsuccessful attempts to conceive children, artiicially assisted attempts to conceive


comitte 3.indd 123 8/25/2010 12:54:18 PM

scripts, research has been unable to clarify these c) Puberty
developmental processes precisely [12].
Despite the long-held assumption that puberty
b) Trauma- Event and process based trauma provides the crucial trigger for the onset of sexual
feelings, more recent research suggests that it is the
Two types of developmental factors are thought to
maturation of the adrenal glands and secretion of
increase the likelihood of sexual dysfunction: event-
adrenal hormones around age 10 that appear to be
based trauma (single episode) and process-based
associated with the development of sexual attraction,
trauma (on-going interactions or behaviors) with
thoughts and emotions which get shaped by cultural
caregivers [13]. It is reasonable to assume that the
expectations of sexuality [12]. For both girls and
remote inluences that create sexual dysfunction
boys, there is a positive correlation between plasma
during the adult years do so by triggering old trauma/
testosterone levels and increased interest in sex,
or anxiety-laden memories, which in the present, are
although this association is more dramatic in boys
experienced as sexual anxiety.
than in girls [15].
What follows are two examples of developmental
As their bodies are changing during adolescence,
experiences that inluence sexual behavior; the irst
boys and girls receive multiple cultural messages
is an example of an event-based trauma, the second
about how men and women do (or should) express,
of a process based, conlict.
experience and manage their sexual feelings.
If a 12-year-old girl is raped by a stranger, a decade Notions of men as “naturally” sexually aggressive
later when she participates in an entirely consensual and women as “naturally” passive may be socially
sexual intimacy, she may be too frightened to enjoy reinforced with the consequence that both boys and
her sexual experience. We label her childhood girls follow prescribed sociosexual scripts, i.e. men
victimization as a traumatic developmental factor are sexual initiators and women are sexual gate-
contributing to, or causing her adult sexual keepers [16]. Social pressures appear to have a
dysfunction. The terror she experienced during the more signiicant inluence in determining the sexual
rape may not have been suficiently processed, behavior of young women than young men. In fact,
understood or resolved. She is not free to enjoy women are considered to be more “erotically plastic”
present-day desired sexual experiences because of than men and hence to be more amenable to gender
remnants from the past trauma. and sexual cultural prohibitions and expectations
[17]. This may help explain why women tend to have
A man avoids sexual intercourse with his wife a higher incidence of sexual problems as adults than
because he prefers the “safety” of masturbation.
do men [18].
Growing up, he experienced his mother as intrusive
and over-bearing. He recognizes the hostility he d. Impact and initiation of irst intercourse
bears toward his mother, but is unable to appreciate
that his avoidance of his wife is related to his inability Although age of irst intercourse and the emotional
to psychologically separate his wife from his critical aspect of the experience are thought to contribute
mother. to later sexual functioning, research to date on how
the sexual debut relates to adult sexual functioning
Most predisposing factors to sexual dysfunction are has been limited and contradictory. Woo and Brotto
not event-based. Rather, they are process-based, [19] studied Euro-Canadian and Asian-Canadian
typically involving the ongoing relationship with university students. In the overall sample, older
one’s caretakers. For instance, growing up with
age of irst intercourse was associated with more
parents who express no warmth, do not touch their
sexual problems as an adult, including more sexual
child affectionately, and refuse to acknowledge his/
infrequency, sexual avoidance, and non-sensuality.
her feelings can inhibit healthy intimate relationships
as an adult as well as undermine the child’s self- Among the women, Asian-Canadians reported
respect. Negative relationships in childhood may higher scores on the Vaginismus and Anorgasmia
delay or inhibit healthy adult sexual development. measures, whereas the ethnic groups did not differ on
the male-speciic measures of sexual complaints.
Clinicians elucidate the developmental factors that
predispose a patient to current sexual dysfunction Udry and Billy [20] sampled 1400 Caucasian
on a case-by-case basis. our ideas tend to be based adolescent virgins and studied which hormonal and
on retrospective patient self-reports [14] and are not social variables predicted the initiation of adolescents’
“evidence based”. Nonetheless they seem helpful sexual activity. They found that for males, free
in illuminating both the patient’s and clinician’s testosterone level rather than social variables was
understanding of the problem. Event and process correlated with the initiation of irst coitus, while for
based trauma may explain what enables one person females, hormones had no direct effect but most of
who has suffered adverse circumstances such the social variables did. These included their friends’
as unemployment, marital conlict, or an affair, to sexual activity, grades, deviance, religiosity, sexual
become dysfunctional while others under similar permissiveness, parents’ educational level and locus
circumstances do not. of control.


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In a qualitative study of adolescent girls’ irst one of the major problems in studying CSA is the
intercourse, Thompson [21] found that the majority lack of agreement on the deinition and description
of girls in her research remembered their irst coital of sexual abuse. Deinitions of sexual abuse vary
experience as painful and unpleasant. In response, considerably across countries, cultures and research
many girls decided to postpone further intercourse for articles. Without understanding the “meaning” of
one or more years. The girls who remembered and the behavior to the individuals involved, its putative
interpreted the experience positively had mothers impact on later sexual function and dysfunction
who had talked to them about their sexuality in cannot be fully appreciated. For instance, sibling
positive ways, had encouraged them to pay attention “incest” may or may not be considered normative,
to their own desire (or lack of it) and had socialized depending on the cultural context.
them to expect satisfying sexual experiences.
In a well-conducted epidemiological study of sexual
While the relationship of negative irst experiences
well-being in sexually abused Swedish women, oberg,
to the development of later sexual problems has
Fugl-Meyer and Fugl-Meyer [26] deined abuse as
not been well researched, it is an area that merits
forced situations or acts that were perceived as sexual
attention. Clinically, it is often reported that traumatic
and 11 different abusive acts, ranging from forced
or humiliating sexual initiation and coitus may be
exhibition of one’s genitals to vaginal intercourse.
associated with later sexual anxiety, aversion and
The national representative sample consisted of
1,335 Swedish women aged 18-74. Twelve percent
3. SExuAL ABuSE AND SExuAL of Swedish women reported being abused at least
DySFuNCTION once during their lifetime, with the most common
types of abuse being vaginal penetration and genital
Childhood sexual abuse, a signiicant contributing manipulation by the perpetrator. About half of the
factor to sexual dysfunction, may even be more abused women had been abused more than once.
dificult to discuss with patients than a current Nearly all types of sexual abuse were signiicantly
sexual problem. It is important to ask about sexual
associated with orgasmic problems, and the women
abuse because of its impact not only on gynecologic
who had experienced forced vaginal penetration,
complaints but also on adult mental health
genital manipulation, cunnilingus or being forced
to perform fellatio also had a lower level of sexual
Recent studies have demonstrated child sexual interest than non-victims of abuse. Fellatio and
abuse survivors report a lifetime history of multiple genital manipulation were signiicantly associated
exposures to various trauma and higher levels with a higher prevalence of vaginismus. Those
of mental health symptoms. Sexual violence is who had been sexually victimized more than once
associated with increased risk of posttraumatic had signiicantly lower levels of sexual interest and
stress disorder and depression [22]. The inluence of anorgasmia than women who had been abused only
early sexual abuse on later adult sexual functioning once. Moreover, 81% of the women who had been
has been found to pertain in particular to problems in abused more than once reported one dysfunction.
sexual desire, arousal, orgasm and sexual pain. Finally, sexually abused women had lower levels of
Meston et al. [23] showed that the relationship sexual well-being than non-abused women.
between child sexual abuse and negative sexual
In a recent follow-up study of the long-term impact of
affect was independent from symptoms of depression
CSA, 77 sexually abused and 89 comparison women
and anxiety, suggesting that the impact of child sexual
abuse on sexual self- schemas may be independent (mean age = 20.41, SD = 3.38) were assessed 10
from the impact that the abuse may have in other years after disclosure in a longitudinal, prospective
areas of the survivor’s life. In a review article on study [27]. These investigators found that abused
factors predisposing women to chronic pelvic pain, women were more preoccupied with sex, younger
sexual abuse was associated with dyspareunia and at irst voluntary intercourse, more likely to have
also to non-cyclical pelvic pain [24]. been teen mothers, and endorsed lower birth control
eficacy than comparison participants
Rellini [25] attempted to create a theoretical model
of understanding the sexual problems of women The impact of sexual trauma on male sexual
who experienced childhood sexual abuse (CSA). function has received relatively little attention, and
When exposed to sexual stimuli, CSA survivors there is some inconsistency in the studies reported
experienced more inhibitory responses and less to date. Although studies comparing the impact of
excitatory responses than women in a control victimization in men and women show a greater
group. Conversely, in situations when sexual stimuli effect in women [28, 29], negative consequences
were not present, CSA survivors showed a greater have been found in men as well. In a questionnaire
excitation of sexual responses than women in the study of 301 men in a nonclinical sample, sexual
non-CSA group. Additionally, CSA survivors showed victimization, sexual abuse and dysfunctional family
a potential dificulty inhibiting intrusive sexual background were predictive of premature ejaculation
thoughts. and sexual desire disorder. However, long lasting


comitte 3.indd 125 8/25/2010 12:54:19 PM

adverse familial relationships had a greater impact objective fact, but rather rigid (Western) standards,
on these disorders than sexual abuse per se [30]. culturally imposed, about the importance of being
Methodological factors that may affect outcome in young, thin and beautiful. There is little empirical
these studies have included the deinition of sexual research examining the degree to which an
abuse [31], whether or not an age discrepancy excessive focus on body image interferes with, or
between offender and victim is required in deining contributes to sexual dysfunction, per se, but clinical
childhood abuse [32], and whether sexual abuse observations suggest that these preoccupations
has occurred as a single incident or as repeated serve as a distraction during sexual exchange.
victimization [33]. Changes in the appearance of one’s body have
Sexual abuse is considered a salient risk factor for also been linked to changes in sexual response.
later adult sexual dysfunction, increased prevalence For example, female patients who have undergone
of high- risk sexual behavior and increased adult treatments involving body – altering surgeries (e.g.
psychopathology [34, 35]. For instance, a recent for cancer) show a decrease in sexual arousal and
study [36] of 1490 women revealed that one-third interest post-surgery. Women who have undergone
were survivors of sexual abuse involving penetration. psychotherapy for eating disorders that include
Overall, regression analysis indicated a signiicant body – altering components (e.g; weight loss) show
relationship between early sexual abuse and later enhanced sexual responses following treatment[46].
participation in risky sexual behavior as an adult. The Faith and Schare [47] examined the relationship
earlier that the abuse occurred, the greater impact it between excessive self-focus on bodily appearance
had on the likelihood of engaging in adult risk-taking and sexual function. They found that negative
sexual behaviors. Since child and adolescent sexual body image was related to lower levels of sexual
abuse is a global phenomenon with equal incidence experience when sexual attitudes and knowledge
reported in such diverse countries as Brazil, Chile, as well as global psychological adjustment were
Mexico, Israel, Palestine, Sierra Leone, South Africa, held constant. This was an observational study
Sweden and Switzerland, it is important to screen using measures of general body image and sexual
for its presence during the initial evaluation of both experience rather than a well-controlled study.
men and women [35, 37-41]. Observing or being
It should be noted that cultural standards of female
the recipient of physical violence during childhood is
beauty and desirability vary considerably cross-
another risk factor for sexual dysfunction. It has been
culturally. While thinness is socially valued in
related to a heightened neurophysiological response
Western countries, more full-bodied women are
to perceived threat (startle response), disruption of
considered sexually desirable in other regions of the
trust, and impairment in self-esteem and personal
world. Comfort and self-acceptance with one’s body,
autonomy [42]. Not only do many young people live
irrespective of the degree to which it mirrors cultural
with violence in intimate relationships, but youth
stereotypes, is believed to be a salient contributory
everywhere are exposed to media images of violent
factor to overall sexual health and function.
situations in which people abuse power and control.
These early experiences may predispose individuals 5. VuLNErABILITy AND rISK FACTOrS
to later dificulties with intimate relationships [43]. INFLuENCING SExuAL HEALTH &
Chronic and troubling dyspareunia was reported by DySFuNCTION
37% of a sample of 409 women with a past history of Space does not permit a thorough inventory of
sexual coercion and physical partner abuse and 75% all of the many constitutional and developmental
reported various sexual dysfunctions [44]. Notably, factors that may predispose an individual to later
only a small number of women had ever discussed sexual problems. Sufice it to say that an individual’s
these concerns with their physician [45]. vulnerability to later sexual dysfunction is determined
4. BODy IMAGE AND SExuAL FuNCTION by the ratio of risk vs. protective factors as well as their
personal resiliency. In general, one’s vulnerability
Body image appears to be an important factor to sexual dysfunction is increased by having more
contributing to sexual self-conidence for both men risk factors lasting for longer periods accompanied
and women. It may function as a predisposing, by greater coercisiveness than a single negative or
precipitating or even maintaining factor for the traumatic episode [48].
development of sexual dificulties since it impacts
Resiliency is a psychological attribute that describes
both early experiences, (e.g., of being teased), and
the individual’s ability to cope with signiicant
later sexual experiences with partners.
adversity or stress in ways that are not only effective,
Men tend to worry about penis size, while women but result in their enhanced ability to confront and
tend to worry about body shape and weight. Many master future adversity [49]. When stress factors are
women are sexually self-conscious and many greater than the individual’s protective factors, then
avoid sex when they feel overweight or physically even resilient individuals may be overwhelmed and
undesirable. often, these feelings are not based on develop sexual problems.


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Recent advances in immunology and neuroscience other partner. Therefore, partner issues function
are elucidating the links between emotions and as precipitating and maintaining factors. The
disease, between the brain and the immune system following section explores this topic in detail and
and the mind and body. “With sophisticated new also provides a review of the relationships between
genetic and mathematical modeling techniques, anxiety, depression, sexual conidence and sexual
we can determine what part of our stress dysfunction.
responsiveness we are born with, and how much is
under environmental control. These sorts of theories I. rOLE OF THE PArTNEr
will help us understand not only the reasons for
individual differences in stress responsiveness, but Studies have begun to clarify the dynamic and
will also point the way to develop new behavioral reciprocal relationship of one partner’s sexual function,
strategies that can change the set point of different sexual satisfaction, physical and mental health to the
individual’s stress responses [50]”. other partner’s sexual health and satisfaction. The
partner’s role as a precipitating or maintaining factor
has been overshadowed by focusing on individual
medical or psychological factors or the impact of
Negative developmental experiences such as the quality of the relationship upon sexual function.
problematic attachments, neglectful or critical parents, This section will review the indings on partner
restrictive upbringing, sexual and physical abuse issues as precipitating and maintaining factors in
and violence, traumatic early sexual experiences male and female sexual dysfunction. Two caveats:
as well as a variety of constitutional vulnerabilities 1) we recognize that not all sexual behavior occurs
are associated with a greater prevalence of sexual in relationships and 2) the data are derived solely
dysfunctions and dificulties in adult life. While from studies with heterosexual couples. Clearly,
some individuals appear less vulnerable and more more research is needed with gay/lesbian couples to
resilient in the face of stressors, others are more characterize the inluence of the each partner on the
susceptible. More research is needed on factors that other’s sexual function and satisfaction.
increase personal resiliency and contribute to the
development of healthy sexuality. 1. SExuAL FuNCTION AND SATISFACTION
a) Erectile dysfunction (ED)

Precipitating factors are those that trigger sexual Several randomized, placebo-controlled trials of men
problems. For any single individual, it is impossible to with ED who are treated with phosphodiesterase
predict which factors under what circumstances may type 5 inhibitors (PDE5i’s) have evaluated the
impair sexual desire or performance. Nonetheless, sexual function of female partners at baseline and
an individual’s vulnerability to a particular set of end of treatment (see Table 2) [51-53]. Fisher et al.
circumstances can precipitate sexual dysfunction. studied 293 women whose male partners had ED
For instance, suffering humiliation from one’s spouse and were receiving either vardenail or placebo [54].
Following the onset of ED 36% of women reported
may cause one man to lose his erection while another
a decrease in sexual desire; 31% noted that their
man may be unaffected. Similarly, in response to
ability to experience orgasm declined; 46% had
the discovery of a partner’s inidelity, one woman
decreased sexual satisfaction and; the frequency of
may lose sexual desire while another may become
lovemaking also signiicantly decreased. Greenstein
more sexually driven. While initially a precipitating
et al. [55] evaluated 113 female partners of men
event may be problematic and distressing, it need with ED attending a sexual dysfunction clinic. Fifty-
not necessarily lead to a diagnosable dysfunction ive percent of these partners reported having some
long term. However, repetitive problematic sexual form of sexual disorder, mostly orgasmic problems
experiences damage self-conidence and ultimately and decreased sexual desire
are pathonomic for sexual dysfunction, even in
reasonably resilient individuals. often, there is not Shabsigh et al. [56] investigated the prevalence of
a clear distinction between either predisposing and female sexual dysfunction (FSD), urinary symptoms,
precipitating factors or precipitating and maintaining and depressive symptoms in female partners of
factors. As a predisposing factor, anxiety can increase men presenting with ED. Women completed the
an individual’s vulnerability to sexual dysfunction. It Brief Index of Sexual Function for Women, Centers
can also serve as a maintaining factor leading to for Epidemiologic Studies-Depression, (CES-D), a
sexual avoidance or arousal inhibition. demographics questionnaire and general medical
questionnaire. of the 50 women who completed
Partners’ physical, emotional and sexual health the questionnaires, sexual dysfunction symptoms
can affect the sexual and emotional health of the included: anxiety/inhibition (26%), hypoactive sexual


comitte 3.indd 127 8/25/2010 12:54:20 PM

Table 2: Impact of erectile dysfunction on the female partner

N of Level of
Author, year Methods Summary results
subjects evidence
Fisher, 200554 293partners Internet questionnaires, Sexual frequency and sexual
frequency sexual activity satisfaction less frequent after ED
sexual experience before Women with partners who were 2
and after development currently using PDE5 inhibitors had
of partner’s ED and with a more satisfying sexual experience
PDE5 than those whose partners did not
use a PDE5 inhibitor.
Goldstein, 200557 229 couples Randomized, double- Vardenail increased multiple
blind, placebo-controlled domains of women’s sexual
Vardenail/Placebo trial function, except pain and a marked 1
FSFI ,mSLqq-qoL for improvement in sexual quality of life
female partners of female partners
Fisher, 200551 197 couples Randomized, double- Vardenail increased QOL and
bind, placebo-controlled each FSFI domains. Partners’ total
Vardenail/Placebo trial mSLQQ-QOL score in the vardenail 1
FSFI, question qoL group was double of the placebo
Huntermark, 96 couples Randomized, double- No difference between the 2 groups
2007375 bind, placebo-controlled with regard to relationship functioning
Vardenail/Placebo trial 1
Dyadic Adjustment Scale
Chevret- 57 couples Prospective, open-labeled ISL sexual life satisfaction score was
Méasson, clinical trial Sildenail, low at baseline and increased with
200953 context close to routine a highly signiicant change in each 2
clinical practice domain: desire, satisfaction with her
Index of Sexual Life, sexual life, general life satisfaction
Heiman, 200758 155 couples Randomized, double- Greater improvement in q3,in sexual
blind, placebo-controlled function. And in Sexual satisfaction
Sildenail trial measures 1
1/ FePEDS Q3 The interdependence of sexual
2/SFQ, FSFI, EDITS- function and satisfaction between
Partner members of couple is demonstrated

Cayan, 200460 87 with Female sexual function After treatment of male ED,
partners evaluated with FSFI. signiicant improvement in sexual
38 ED partner Men evaluated with IIEF arousal, lubrication, orgasm and 4
13 ED partner satisfaction in female partners
17 penile
Conaglen H, 100 couples Sildenail or tadalail for a 79.2% of the women preferred
2008376 12-week phase, followed their partners’ use of tadalail, while
by another 12-week period 15.6% preferred sildenail. Women’s 4
using the alternate drug. reasons are: relaxed, satisfying,
Female partners interview longer-lasting sexual experiences
at baseline, midpoint, and
end of study


comitte 3.indd 128 8/25/2010 12:54:20 PM

desire (20%), arousal/lubrication dificulty (30%), associated with men’s poorer dyadic adjustment.
orgasmic dificulty (24%), dyspareunia (18%), and Additionally, all 4 negative attribution dimensions
sexual dissatisfaction (34%). Urinary symptoms and higher levels of women’s pain intensity predicted
of frequency and urgency were reported by 36%. increased levels of psychological distress in men.
Depressive symptoms were present in 44%.
Speckens et al. [67, 68] investigated female partners
Goldstein et al. [57] reported that after men received of men with ED where no organic cause could be
12 weeks of treatment with vardenail, the female found and partners of men with organically based
partners demonstrated signiicant improvements in ED. They compared the partner’s views on the
total Female Sexual Function Index (FSFI) score as relationships, sexual function, sexual attitudes,
well as sexual desire, subjective arousal, lubrication, and psychological adjustment. Vaginismus and
orgasm and satisfaction sub-domain scores. dyspareunia which preceded the onset of ED were
Chevret-Measson et al. [53] reported signiicantly more common in the partners of men with nonorganic
improved scores on the Life Satisfaction Scale ED as were relationship problems. The authors
for women whose male partners were receiving concluded that female sexual dysfunction, high
sildenail. Similar improvements in female partners sexual interest and relationship problems contribute
sexual function, treatment satisfaction and sexual to the onset, exacerbation and maintenance of non-
satisfaction following the man’s treatment with organic ED.
PDE5is are described by others [58-60].
The associations between desire discrepancies and
Chevret-Measson [53] suggested that studies much
sexual and relationship satisfaction in heterosexual
closer to “real life” and clinical practice with a broader
dating couples (N = 72) were examined by Davies
population than men and their partners in clinical
et al. [68]. Women whose sexual desire level was
trials are necessary to assess the global therapeutic
lower than their partners’ endorsed lower levels of
approach in a context close to normal practice.
relationship adjustment relative to women whose
b) Premature ejaculation desire was either greater than or similar to their
The impact of premature ejaculation (PE) upon partners’.
partners was documented by Riley and Riley in a d) Impact of illness on partner sexual function
retrospective audit of their medical records [61].
Approximately 50% of female patients with sexual Chronic Prostatitis/Chronic Pelvic Pain Syndrome
problems, such as ‘not enjoying sex’ or anorgasmia, (CP/CPPS) is a common condition in men involving
had partners with PE either at the onset of their pelvic pain and sexual dysfunction. Smith et al. [69]
problem or at some time in the relationship. Hartmann sought to identify potential predictors of sexual and
et al. [62] reported that 27% of dysfunctional men, relationship function among couples with CP/CPPS,
including those with PE, were unsure of the capacity and to examine associations among pain, sexual,
and frequency of their partners’ orgasm, compared and relationship variables. Men completed the
to 4% of functional men. In contrast to Riley and International Index of Erectile Function (IIEF) and
Riley and Hartmann studies, Byers [63] and Revicki a subscale of the Multidimensional Pain Inventory.
[64] found less impact of PE on female partners Female partners were administered to the FSFI,
sexual function although all studies found women and all participants received the Golombok-Rust
had diminished sexual satisfaction. Inventory of Sexual Satisfaction and the Dyadic
Adjustment Scale. Couples’ sexual function, sexual
c) Female sexual dysfunction satisfaction, and relationship adjustment were all
Witting and colleagues [65] investigated the signiicantly associated. Patient sexual function was
association between female sexual dysfunction, predicted by patient sexual satisfaction and female
distress and partner compatibility. The two main sexual function, whereas female sexual function was
complaints of women were “too little foreplay” (42%) predicted by female sexual satisfaction and patient
and “partner is more interested in sex than you” relationship adjustment. Pain severity signiicantly
(35%). The women experiencing distress on the predicted sexual and relationship functioning among
Female Sexual Distress Scale (FSDS) or having couples. However, multiple regression models
a sexual dysfunction as determined by the FSFI revealed that sexual and relationship variables
reported more incompatibility with their partner were the strongest predictors of patient and partner
compared with functional women. functioning, over and above pain severity.
Jodoin[66] asked 46 male partners of women with Harden et al. [70] sought to examine how quality
provoked vulvodynia to complete the Attributional of life, self-eficacy and appraisal of the illness
Style questionnaire-Partner Version, Brief Symptom experience vary among men with prostate cancer
Inventory, Dyadic Adjustment Scale, Sexual History and their partners according to age. They divided
Form and Global Measure of Sexual Satisfaction. the sample into three categories: middle age (50-
The men’s global and stable negative attributions 64); young-old (65-74); and old-old (75-84). Middle
were related to lower sexual satisfaction whereas, aged spouses reported the most distress related to
higher levels of internal and global attribution were sexual changes in their husbands. Spouses in both


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the middle age and old-old group had more bother genesis of sexual disorders has been examined
related to hormone therapy than the young-old in several clinical studies as shown in Table 3. A
spouses. Couper et al. [71] performed a review of review by Norton & Jehu [76] reported high levels of
the literature from 1994-2005 regarding psychosocial anxiety in sexually dysfunctional individuals [77-84],
factors impacting the patient and partner. They found which varied in amount and quality. Some studies
that partners report more distress than patients, found higher levels of sexually related anxiety, but
yet believe that patients are the more distressed. no differences in social or general anxiety [81, 82,
The focus of concern of patients is on their sexual 85, 86].
function which not shared to an equal degree by
their partners.
a) Anxiety and female sexual dysfunction
The relationship between anxiety levels and female
McCabe et al. [72] examined the impact of multiple
sexual dysfunction has not been extensively studied.
sclerosis (MS) on sexuality and relationships among
While most of the existing research has focused on
111 males and females with MS. The results indicated
anxiety in women with diagnosed sexual dysfunction,
that MS had a negative impact on sexual functioning
other research has studied the incidence of sexual
among men and women: only 35.4% of men and
dificulties in women with anxiety disorders compared
20.4% of women were not experiencing any form of
to non-anxious women.
sexual dysfunction. The most common dysfunction
for men was ED, and for women was hypoactive Murphy and Sullivan [87] compared sexually aversive
sexual desire. Surprisingly, the majority of men and women to sexually functional women and found that
women did not express concern about their sexual the aversive group experienced heightened levels of
problems. Perhaps they expect these problems to ‘acute’ anxiety related both to sexual and non-sexual
be an inevitable consequence of developing MS. spheres. In addition, the sexually aversive women
McCabe [73] examined the difference in sexual reported dificulty with identity, self-acceptance
dysfunction between 381 people with MS and 291 and feelings of inadequacy in most psychosocial
people from the general population. Males with MS areas. Leiblum et al. [88] found that women with
demonstrated higher levels of sexual dysfucntion persistent genital arousal (PGA) were more likely
than males in the general population; however the than non-PGA women to experience a range of
only difference between females with MS and those anxiety symptoms (e.g., panic attacks, obsessive
from the general population was that MS females compulsive disorder).
reported higher levels of numbness in their genital
Kaplan [89, 90] believed that performance anxiety
was the critical element in sexual avoidance, which
These studies consistently demonstrate the reached panic proportions for some individuals. She
interdependence of sexual function between reported that a signiicant number of ‘sexaphobic’
partners. Speciically, they suggest that dysfunction patients had a dual diagnosis of sexual and panic
in one partner tends to cause problems for the other disorder. In fact, women with panic disorder have
and that improvement in function in one partner been found to have lower sexual desire than healthy
tends to have a positive effect on the other. The data controls [91].
strongly argue that clinicians take a biopsychosocial
Campillo et al. [92] compared anxiety and depression
approach to the treatment of sexual dysfunctions
levels in women with and without sexual disorders and
and include evaluation of the partner if possible.
found higher levels of trait anxiety and depression in
the sexually dysfunctional women. Trudel et al. [93]
II. THE rOLE OF ANxIETy examined the role of anxiety, depression and marital
adjustment in 20 couples with low desire in one or
IN SExuAL FuNCTION AND both partners. The results indicated that the sexually
DySFuNCTION dysfunctional subjects had low levels of depressive
mood but moderate levels of anxiety.
Anxiety played a signiicant role in early
psychodynamic formulations of sexual dysfunction b) Anxiety and male sexual dysfunction
and later became the foundation for the etiological
concepts of sex therapy established by Masters Feil and Richter-Appelt[86] compared beliefs and
and Johnson [74] and Helen Kaplan [75]. Kaplan anxiety in ED patients and sexually functional men
believed that sexually related anxiety became and found that men with ED reported a signiicantly
the inal common pathway through which multiple higher degree of sexual anxiety but no difference in
psychopathogens led to sexual dysfunction. general or social anxiety. In addition, the subjective
feeling of eficacy and personal competency was
1. rESEArCH STuDIES ON ANxIETy AND lower in the ED group.
In another study [94], 41 ED-patients completed the
The role of anxiety as a key etiological agent in the State-Trait-Anxiety-Index (STAI) and the International


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Table 3: Empirical studies on the relationship between anxiety and sexual dysfunction:

Level of
Author N Methodology results
Cooper, 1968 77 54 “Impotent” and ejaculatory disorders 37% were rated cured or improved. 2
patients treated for 1 year Anxiety was most prominent in
acute onset erectile dysfunction and
premature ejaculation.
Cooper, 196879 53 Examined men with diagnoses of While patients with premature 2
‘impotence’ or ejaculatory disorder ejaculation had the highest anxiety
and investigated them clinically and scores, the scores for all groups fell
with a neuroticism scale within the normal range. ‘Neurotic
anxiety’ was a signiicant factor in
minority of sexual dysfunctions.
Cooper, 196978 49 Examined prevalence of ‘coital 94% experienced some degree of 2
anxiety’ in patients with sexual coital anxiety which was interpreted
dysfunctions in a psychiatric clinic as causal. Coital anxiety was seen
with self-rated levels of anxiety and as a special form of anxiety with only
relation to the irst manifestation of weak association to other ‘neurotic’
the sexual symptoms anxieties.
Derogatis, 197980 87 Forty-seven male and 40 female Both male and female patients showed 3
dysfunctional patients were higher levels of psychological distress
evaluated on the Derogatis Sexual and dysphoric affect than normal. The
Functioning Inventory (DSFI) most pronounced elevations were
and compared to a group of 200 found on depression and anxiety.
Kockott, 198081 42 Examined 42 patients and 24 In subjects with situational erectile 2
controls with semi-standardized dysfunctions high levels of anxiety
interviews and 5 psychological were found. The results demonstrated
scales an important functional role of
anxiety in the maintenance of sexual
Kockott,198082 42 Examined psychophysiological In patients with primary psychogenic 2
parameters upon viewing of an erectile dysfunction, all parameters
erotic ilm in 42 patients and 24 were lower than in the controls
controls indicating that anxiety may act
detrimentally on genital arousal
Munjack, 197883 35 Personality proiles of ejaculatory Both premature and retarded 2
dysfunction patients were measured ejaculators were found to be
on various standardized inventories more anxious, depressed and
and compared to a group of normal psychologically disturbed.
Munjack, 198184 90 Personality proiles of erectile Results showed that sexually 2
dysfunction patients were dysfunctional patients were more
measured on various standardized pervasively disturbed than control
inventories and compared to a subjects. While depression scores
group of psychiatric patients and a were signiicantly higher, anxiety
group of normal controls. scores were not conclusively elevated
on all scales, but only on a subset.
Fahrner, 198385 86 41 female and 45 male sexual Results indicated that general 3
dysfunction patient’s levels of social nonassertiveness is not a common
insecurity and self-uncertainty were symptom of sexual disorders. Rather,
measured on two standardized insecurity is restricted to speciic areas
psychological inventories relevant to sexual functioning.


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Table 3: Empirical studies on the relationship between anxiety and sexual dysfunction (continued)

Level of
Author N Methodology results
Feil, 200286 90 The relationship between erectile Signiicant differences with respect 3
functioning, self-esteem, and to beliefs concerning control and
general sexual skills was determined personal competency which proved
in a group of sexually dysfunctional to be lower in dysfunctional subjects.
patients and compared to normal Sexually dysfunctional men also had
controls. higher levels of anxiety pertaining
speciically to sociosexual situations,
but did not exhibit higher levels of
general insecurity.
Murphy, 198187 20 Twenty women diagnosed The groups differed signiicantly on 3
as sexually aversive and 35 anxiety and self-concept proiles
controls were compared on the indicating that sexually aversive
dimensions anxiety, self-concept, women experience higher levels of
and sociosexual information anxiety and have more dificulty with
with a battery of psychological identity and self-acceptance.
Lieblum, 2007249 156 Women were recruited for a web- Women with PGA compared to non- 2
based study of persistent sexual PGA women were more likely to
arousal (PGA). be depressed and more anxious,
report panic attacks and obsessive
compulsive symptoms.
Kaplan, 1995161 414 Summarizes the sexual dysfunction Of the 414 patients that met the criteria 3
diagnoses and associated disorders for sexual aversion disorder, 35% had
of all 5,580 patients seen in the concomitant diagnoses of anxiety
human sexuality programs in which disorder. The incidence of anxiety
the author was involved between disorders in the remaining diagnostic
1972 and 1992. groups was 10%.
Van Minnen, 27 The sexual functioning of 27 women Both patient groups were found to 2
200091 with panic disorders was compared have lower sexual desire and lower
to the sexual functioning of 17 frequency of sexual contact and in
women with obsessive-compulsive anxiety patients, hypoactive sexual
disorders and 34 controls on a desire or sexual aversion disorders
number of self-report instruments. were more frequent than in controls.
Patients with anxiety disorders are
more at risk of sexual dysfunctions
and do not corroborate the indings
from experimental studies that anxiety
may facilitate sexual arousal.
Campillo,199992 200 The study evaluated the hypothesis Signiicantly higher levels of 2
that sexual disorders are signiicantly depression and trait anxiety in the
related to emotional problems. 200 patient group, associated to sexual
sexually dysfunctional women fears, lack of sexual information, or
were compared with 184 controls sexual traumas.
on two standardized psychological
Trudel, 199793 20 Twenty couples with low desire The low desire subjects showed 2
problems were compared with normal levels of depression and
20 control couples on several moderate levels of anxiety.
psychological measures including
the Beck Depression Inventory and
an anxiety scale (IPAT).
Mallis, 200294 41 Patients with erectile dysfunctions Results showed that 93,5% had 3
(ED) were administered the State- noticeable state anxiety and 90,5%
Trait-Anxiety-Inventory (STAI) and elevated trait anxiety. While there was
underwent a clinical psychiatric no signiicant relationship between
evaluation. ED severity and state anxiety, patients
with severe ED had higher levels of
trait anxiety.


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Table 3: Empirical studies on the relationship between anxiety and sexual dysfunction (continued)

Level of
Author N Methodology results
Mas, 200295 78 The inluence of personality Trait anxiety as measured by the 3
characteristics on the erectile STAI proved to be a highly signiicant
response to intracavernosal injections predictor of the erectile response,
was determined in 78 patients with even when controlling for the severity
erectile dysfunctions. of the ED.
Corona, 200896 1388 This study was designed to examine The indings demonstrated that 3
the relationship between psychiatric depression was associated with
symptoms and ED among men hypoactive sexual desire ((HSD),
presenting for treatment of ED. whereas high levels of obsessive-
compulsive symptoms were associated
with a lower prevalence of HSD.
Lykins, 200698 1062 The association between depressed Most women experienced a negative 3
mood and sexual -interest assessed association between depression/
in 663 college females, and the anxiety and sexual function. A small
results compared to the association number experienced a positive
among 399 college men. association. In general men were
more likely to demonstrate a positive
association between negative mood
and sexual functioning
Sugimori, 1419 The study was designed to determine There was a strong association 3
200599 the relationship between ED and between depression and ED among
depression/anxiety among 1419 men from 45-54 years, and between
Japanese men aged 40-64 years. anxiety and ED for men from 50-54
Rosen,2008100 - Eleven studies related to management The evidence suggests that PE is 4
or treatment of premature ejaculation associated with negative psychological
were reviewed to determine the and quality of life consequences for
psychological factors associated with the man, as well as having negative
the disorder. associations with his relationship.
Beggs, 1987105 19 In 19 sexually functional women, Results showed signiicant increases 3
genital sexual arousal during sexual in genital arousal in both conditions,
anxiety stimuli was compared to but increases in the pleasure condition
sexual arousal in response to sexual were signiicantly greater than those
pleasure stimuli. in the anxiety condition, thud providing
support for a functional role of anxiety
in sexual dysfunction.
Palace, 1990106 16 In 16 sexually dysfunctional women Anxiety preexposure enhanced 2
and 16 controls, the effects of sexual genital, but not subjective, arousal
anxiety on physiological and subjective in both groups. Functional subjects
sexual arousal were determined reported higher levels of genital
under 2 stimulus conditions: an arousal in both conditions. The results
anxiety-evoking and neutral-control suggest that anxiety may enhance
preexposure stimulus, each paired sexual arousal through the facilitation
with a sexually arousing stimulus. of sympathetic activation.
Meston, 1995108 35 The effects of sympathetic activation In 35 sexually functional women, 3
following acute exercise on the effects of acute exercise on
physiological and subjective sexual physiological and subjective sexual
arousal in women arousal were determined. Acute
exercise signiicantly increased genital
responses to an erotic stimulus, thus
providing support for a facilitatory role
of sympathetic activation for female
sexual arousal.
Meston, 1996109 36 The study examined the time course While acute exercise had no effect on 3
of the effect of acute exercise on sexual arousal 5min post-exercise, it
female sexual arousal in a group of signiicantly increased genital arousal
36 sexually functional women. after 15min and yielded marginal
increases at 30min post-exercise.
There were no effects of acute
exercise on subjective arousal.
Meston, 1998110 20 In 20 sexually functional women, The results indicate that ephedrine 3
the effect of the alpha and beta- signiicantly increased physiological,
adrenergic agonist ephedrine on but not subjective, responses to
genital and subjective sexual arousal erotic stimuli and seems to be able
was examined. to facilitate the initial stages of
physiologic arousal in women.


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Index of Erectile Functioning (IIEF). The majority of and dysfunctional subjects [101]. Contrary to
men had high levels of state anxiety as well as trait the indings from clinical studies that indicate an
anxiety, but only trait anxiety correlated statistically inhibition effect of anxiety, the laboratory evidence
with the severity of the erectile disorder. The authors has indicated that anxiety (as induced in the lab
concluded that anxiety as a personality factor could setting) either facilitates or does not affect sexual
act either as an etiological substrate of ED or as a arousal in functional subjects. The evidence for
precipitant for this dysfunction. sexually dysfunctional subjects is mixed.
With the same questionnaire, Mas et al. [95] Barlow [102] has offered a theoretical model
examined the inluence of personality factors on explaining why anxiety may operate differentially in
the erectile response to intracavernosal injections functional vs. dysfunctional individuals. His model
in 78 patients. When controlling for the severity of emphasizes the role of cognitive interference in
the ED through IIEF-scores, trait anxiety proved to male sexual dysfunction. In general, what appears to
be a highly signiicant predictor of injection eficacy. distinguish functional from dysfunctional responding
A number of recent studies have supported these is a difference in selective attention and distractibility.
associations between ED and anxiety [96-99]. There What sex therapists consider performance demand,
have been few recent articles that have examined fear of inadequacy or spectatoring are all forms of
the relationship between anxiety and other types situation-speciic, task-irrelevant, cognitive activities
of male sexual dysfunction. However, Althof and which distract dysfunctional individuals from task-
Rosen [100] concluded in their review article that the relevant processing of stimuli in a sexual context
evidence that was available suggested a relationship, [103].
not necessarily causal, between anxiety and PE.
In summary, the cognitive-information processing
c) Summary: Anxiety in sexually dysfunctional models of sexual anxiety assert that sexual arousal
men and women is dependent upon ‘task-relevant’ processing of a
sexual stimulus. In sexually dysfunctional subjects,
From these results it can be concluded that the sexual stimuli induce a performance demand, which
majority of sexually dysfunctional individuals exhibit in turn leads to a shift of attentional focus away from
heightened levels of anxiety suggesting a central the sexual content of a situation, inhibiting arousal.
role of anxiety in the subjective experience and
maintenance of sexual disorders. Correlational Lab studies show that subjective and physiological
evidence exists for the relationship between ED and sexual responses are inluenced by different
anxiety. However this does not imply causality. It is mechanisms. Anxiety inluences genital responses,
also not clear if it is generalized anxiety, or anxiety but not subjective responses. Attentional focus
that is more closely related to the sexual content that seems inluential in cognitive processing [104].
is more strongly related to sexual dysfunction in men
a) The laboratory evidence for women
and women.
For women, the relationship between anxiety and
sexual performance has received limited research
ANxIETy INTErFErES WITH SExuAL attention. However, the literature that is available
PErFOrMANCE suggests that activation of the sympathetic nervous
The central role of anxiety reported by sex therapists system (including anxiety provoking stimuli) facilitates
has been challenged by a number of sophisticated genital sexual arousal in sexually functional women
laboratory studies aimed at unraveling the sequence and in women with low sexual desire (but not in
of cognitive-affective processes during sexual women with orgasmic disorder) [105-110]. overall,
arousal in dysfunctional and functional men and, to the evidence for the role of anxiety in sexually
a lesser extent, women. In these studies, anxiety is dysfunctional women is mixed, with the suggestion
induced either by shock threat or by performance that it is more negative than facilitory [111].
demand, sometimes combined with a special Table 3 summarizes the signiicant clinical
distraction condition. Sexual arousal is assessed with implications of anxiety as it relates to sexual
psychophysiological (penile tumescence or vaginal behavior.
photoplethysmography) and subjective (lever,
questionnaires, rating scales) measures. Special 3. IMPLICATIONS
attention is paid to differences between sexually
The laboratory studies on the relationship between
functional and dysfunctional subjects. Subsequent
anxiety, distraction, general sympathetic activation
studies also examined the role of sympathetic
and sexual response have convincingly shown
activation (SNS activation) such as exercise or other
that anxiety is not universally disruptive to sexual
functioning. In addition, results indicate that
Laboratory data indicate that the sexual arousal the anxiety – sexual response relationship is
process operates differently in sexually functional complex and that the term ‘anxiety’ is too broad for


comitte 3.indd 134 8/25/2010 12:54:22 PM

comprehensively describing the variety of factors lifetime history of psychopathology in patients
that can disrupt sexual arousal and functioning. presenting with desire disorders. Forty-six subjects
The available evidence indicates that the level and (22 men and 24 women) were compared to 36
the nature of anxiety and its history are important matched controls, utilizing clinical interviews, SCL-
determinants. Whereas moderate levels and 90-R and an instrument assessing lifetime affective
relatively ‘safe’ settings may catalyze sexual arousal, and schizophrenic disorders. Although none of the
higher levels, less feelings of personal control or a patients manifested any clinical affective disorder at
longer history of anxiety very likely impair sexual the time of assessment, the proportion of low desire
functioning [91]. patients with histories of major and intermittent
depression was almost twice as high as that of control
subjects. Moreover, in 88% of the men and 100%
III. DEPrESSION AND SExuAL of the women, the initial depressive episode almost
FuNCTION always preceded or coincided with the development
of inhibited sexual desire. Hayes et al. [119] also
The relationship between depression and sexual found that depression was a strong predictor of
functioning is of considerable interest to clinicians and arousal and orgasmic dysfunction among women.
researchers since both affective and sexual disorders Interestingly, Lykins et al. [98] found that depression
are highly prevalent, are believed to exhibit a marked was more strongly associated with lower sexual
co-morbidity and might even share a common desire in men than in women. Schreiner-Engel
etiology [112, 113]. It is generally agreed that the and Schiavi [118] suggested that a past history of
relationship between depressive mood and sexual depression may contribute to the pathogenesis
dysfunction is bi-directional and further complicated of low desire or that both disorders result from the
by the sexual side effects of antidepressants [114]. same underlying condition.
Depression has a powerful impact on all aspects of
male and female sexual response: desire, arousal one of the most recent and intriguing studies looking
and orgasm. Examining sexual function in 134 at the relationship between depression and sexual
depressed men and women who were not taking function in women was that of Frohlich and Meston
antidepressant medication, researchers reported [120]. These researchers studied 47 college women
with low Beck Depression Inventory (BDI) scores
that 42% of the men reported a decrease in sexual
(non-depressed) and compared them to 47 women
drive; a similar percentage had a decrease in interest
with clinically signiicant BDI scores. Results showed
in sexually explicit material, sexual fantasies and
that the depressed group reported more desire for
masturbation. Twenty-six percent of the men were
solitary sexual activity, e.g., masturbation than did
not sexually active in the month prior to assessment.
the control group but there was no difference in
Of those who were sexually active, 34% stated that the two depression groups in desire for sex with
their erection was less vigorous, 46% were unable a partner. The depressed group reported a higher
to sustain an erection, 12% reported PE and 23% frequency of problems with arousal, orgasm and
reported delayed ejaculation [115]. pain, less satisfaction, and less pleasure. The authors
1. DEPrESSION AND SExuAL FuNCTION IN speculated that greater desire for masturbation in
MEN AND WOMEN the depressed women’s group might relect the
wish for a reliable form of pleasure. It remains to
The most common sexual pattern associated with be established whether similar results would be
depression is loss or reduction of sexual interest obtained with a population of male students.
and/or sexual arousal. Beck [116] found low sexual
Table 4 provides an overview of the studies that
interest in 61% of severe depressives compared
have been conducted looking at sexual dysfunction
with 27% of non-depressed controls. Both Derogatis
in men and women.
et al. [117] and Schreiner-Engel and Schiavi [118]
examined the prevalence of acute psychiatric 2. DEPrESSION AND ErECTILE
symptoms and lifetime psychopathology in men and DySFuNCTION
women with different sexual dysfunctions. Derogatis
conducted a psychiatric interview and administered Many of the recent studies have focused on the
the Symptom Checklist 90 Revised (SCL-90R) association between depression and ED. Data from
to a sample of 325 patients (199 men and 126 the Massachusetts Male Aging Study [121] showed
women). Men with ED had speciic elevations on that depression and anger were highly correlated
the depression dimension of the SCL-90R. Similarly, with ED. Nearly all men with symptoms of major
depressive disorder (MDD) had some degree of
anorgasmic women and women with sexual pain
ED[122]. Based on logistic regression analyses
disorders also had major elevations of the SCL-90R
that controlled for other potential predictors of ED,
depression scale relecting dysthymia and feelings
moderate-to-complete ED was 1.82 times more
of self-depreciation.
likely in those who exhibited depressive symptoms
Schreiner-Engel and Schiavi [118] studied the compared to those who did not.


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Table 4: Empirical studies on the relationship between depression and sexual dysfunction

Level of
Author N Methodology results Evidence
Kennedy, 134 Examined sexual function in 42% of the men reported reduced sexual desire, 3
1999115 depressed men and women not 46% erectile problems, 12% experienced PE
taking antidepressant medication and 23% experienced retarded ejaculation.
Beck, 966 A depression inventory was Loss of libido was found in 27% of nondepressed 3
1967116 administered to 966 psychiatric patients as compared to 61% of patients with
patients and the incidence of ‘loss severe, 58% with moderate, and 38% with mild
of libido’ was determined in relation depressive symptoms. Loss of libido correlated
to the degree of depression highly with loss of appetite, and loss of interest
in other people.
Derogatis, 325 199 male and 126 female Abnormal levels of psychological distress and 3
1981117 patients seeking treatment for between one third and one half of the sample
sexual dysfunction underwent were assigned psychiatric diagnoses. Men with
a psychiatric evaluation and ED had speciic elevations on the depression
completed a symptom checklist scale. Women complaining of anorgasmia and
(SCL-90-R). sexual pain disorders also exhibited marked
signs of depression and self depreciation.
Schreiner- 46 The lifetime history of None of the patients showed any clinical affective 3
Engel, psychopathology in 22 male and disorder, the proportion of patients with histories
1986118 24 female low desire patients was of major and intermittent depression was twice
compared to 36 matched controls as high as that of controls. In 88% of men and
on various measures. 100% of women, the initial depressive episode
preceded or coincided with the development of
low desire. Results suggest a common etiology
of both disorders.
Hayes,119 356 Study was designed to estimate Low desire was more frequent in women in 3
2008 prevalence and factors associated relationships for 20-29 years. Depression was
with FSD in Australian women. associated with low arousal and high distress.
Frolich, 94 Compared sexual function among Women with depressive symptoms reported 2
2002120 47 women with depressive more problems with sexual desire, arousal,
symptoms not receiving medication orgasm, pain, and less sexual satisfaction and
to 47 aged matched controls. pleasure.
Feldman, 1709 Normative data on the prevalence The combined prevalence of minimal, moderate 2
1994294 of ED, and its physiological and and complete impotence was 52%. The
psychosocial correlates in a prevalence of complete impotence tripled from 5
general population are provided. to 15% between subject ages 40 and 70 years.
The Massachusetts Male Aging Subject age was the variable most strongly
Study was a community based, associated with impotence. After adjustment
random sample observational for age, a higher probability of impotence was
survey of noninstitutionalized men directly correlated with indexes of anger and
40 to 70 years old conducted in the depression.
Boston area. A self-administered
sexual activity questionnaire
was used to characterize erectile
Araujo, 1265 Data from the Massachusetts Male After controlling for potential confounding 2
1998122 Aging Study were reanalyzed to variables, nearly all men with symptoms of major
determine if ED is associated with depressive disorder were found to have some
depressive symptoms. degree of ED. Moderate to complete ED was
almost twice as likely on those who exhibited
depressive symptoms, indicating a robust and
independent relationship between depression
and ED.
Shabsigh, 120 120 men who presented with Patients with ED (either alone or in combination) 3
1998124 either ED only, BPH (benign were 2.6 times more likely to report depressive
prostatic hyperplasia) only, or with symptoms than patients with BPH only. ED
both problems were screened for patients with depressive symptoms also had
depressive symptoms. lower libido. It was concluded that ED is
associated with high incidence of depressive
symptoms, regardless of other variables such
as age or comorbidities.
Strand, 120 120 ED patients were screened Results showed that only a subset of patients 3
2002126 for depressive symptoms (12%) fulilled the categorical diagnosis
which were determined either of depressive disorder. When measured
categorically (DSM-IV diagnosis of dimensionally with the BSI, however, the patients
depressive disorder: yes or no) or had signiicant elevations of depression and
dimensionally as the score on the other dysphoric affects indicating a signiicant
Brief Symptom Inventory (BSI). degree of emotional distress.


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Assalian writes that men with ED may become 3. SuMMAry
depressed because of their sexual dysfunction and
because of the secondary effects that ED may have In summary, the empirical evidence conirms a
on the relationship [123]. In men who present with prominent role of depression in sexual dysfunction.
one of these two problems it is crucial to ask about While the exact direction of causality is dificult
the other because of their frequent coexistence. The to ascertain, the data not only indicate a close
effective management of depressed men with ED correlational relationship between depression
often involves treating both conditions concurrently. and sexual disorders but also support a functional
signiicance of mood disorders in causing and
Shabsigh et al. [124] studied 120 men who presented maintaining sexual dysfunction. Compared to
to a urologic clinic with ED, benign prostatic functional controls, sexually dysfunctional men and
hyperplasia (BPH), or both. Rates of depression in women exhibit both higher levels of acute depressive
the ED group, the ED and BPH group, and the BPH symptoms and a markedly higher lifetime prevalence
group alone were respectively 54%, 56% and 21%. of affective disorders. All of the studies reported
Patients with ED and depression were more likely have been at levels 3,4 and 5 of evidence and
to discontinue (intracavernosal injection or vacuum) consequently, more randomized controlled research
treatment than ED patients without depressive is needed.
symptoms. In a later review, Shabsigh et al. [125]
stressed that ED and depression have a signiicant Further, we recommend that assessment of anxiety
negative impact on the quality of life of patients and and depression should be included as part of the
their partners. initial evaluation in individuals presenting with sexual
complaints and dysfunctions. An attempt should be
Strand et al. [126] screened a cohort of 120 men made to ascertain whether the anxiety/depression is
who sought evaluation at a sexual behaviors clinic a consequence or a cause of the sexual complaint.
for depressive symptoms which were determined If a pre-existing acute depression exists, it should
either categorically (DSM-IV diagnosis of depressive be treated along with the sexual problem. Some
disorder: yes or no) or dimensionally as individual research suggests that relief of the sexual problem
scores on the Brief Symptom Inventory (BSI). is associated with relief of depression [129]. The role
Utilizing DSM-IV criteria for depression, only a small, of anti-depressants and anti-anxiety medications
but by no means insigniicant, subset of men (12%) as contributory factors to the sexual dysfunction
qualiied for a diagnosis of depressive disorder, but should be evaluated and if implicated, a change in
when distress was measured dimensionally the
medication(s) may be indicated.
group demonstrated signiicantly elevated levels
among all dimensions, including depression. These
results indicate high levels of emotional distress IV. OTHEr PErSONALITy
in ED patients similar to those found by Derogatis
et al. [117]. Sugimori et al. [99] found that among
middle aged men (45-59 years) there was a strong DySFuNCTION
association between ED and depression. Corona et
Hoyer et al [130] reported on the relationship
al. [96] demonstrated that among men, depression
between patients seeking treatment for mental health
was also related to low levels of sexual desire.
concerns and sexual dysfunction at an outpatient
Seidman [127] suggested that ED and the accompanying clinic. Pre-treatment, of the 451 patients seeking
psychosocial distress may stimulate the development psychotherapy, mostly for anxiety and depression,
of depressive illness in vulnerable individuals, or 68% of females and 54% of males reported at least
that depression might cause ED. It is likely that one sexual complaint. Following treatment that did
the relationship between depression and ED is bi- not focus on sexual dysfunction, those in remission,
directional. or those who had a positive response to therapy,
Finally, the results of a large-scale study of 4557 demonstrated a 26% reduction in sexual symptoms.
depressed patients in France found high rates of Patients who did not respond to therapy had a 4%
sexual dysfunction [128]. Patients with DSM-IV major reduction in sexual symptoms. The authors suggest
depressive episodes but no previous diagnosis of that clinicians treating patients with anxiety and
sexual dysfunction were studied. Evaluation included depression be aware of the high rate of sexual
both questionnaire (the Arizona Sexual Experience dysfunction and consider augmenting treatment by
Scale) and physician observation. overall, the also treating their sexual dysfunction.
researchers found that 35% of the participants 1. OBSESSIVE-COMPuLSIVE DISOrDErS
spontaneously reported sexual problems and 69%
indicated problems when asked by the physician.
The frequency of sexual dysfunction was higher There are a few reports examining the association
in patients treated with antidepressants than in between obsessive-compulsive disorder (OCD) and
untreated patients (71% and 65% respectively). sexual dysfunction. Independent studies [131-134]


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suggest that approximately 50% of individuals with and arousability but is not associated with marital/
OCD report sexual problems and that 60% to 73% sexual satisfaction [135].
of OCD individuals are dissatisied with their sexual
While Van Minnen and Kampman [91] believe OBSESSIVE-COMPuLSIVE, BOrDErLINE
that OCD develops as a reaction to severe sexual AND HISTrIONIC PErSONALITy
conlicts within the patients or in their family of origin, DISOrDErS
Staebler et al. [134] did not ind any differences in
the sexual history of OCD patients or patients with It appears that personality disorders are often
panic or depressive disorders. associated with dificulties in intimacy, sexual desire,
and pair-bonding. However, the empirical evidence
A variety of research studies suggest that OCD may is too limited to draw conclusions regarding causal
be a speciic risk factor for sexual dificulties. For relationships between any speciic personality
instance, in a descriptive study of 44 OCD patients, disorder and sexual dysfunction. The available
Rasmussen and Tsuang [133] reported that 32% had information consistently indicates higher levels of
sexual impulses that conlicted with their values. In psychological distress and a substantial overlap
a comparable study, 36% of the sample patients had with symptoms of mental disorders in sexually
sexual obsessions [131]. A recent study of women dysfunctional patient samples. The problems most
with persistent genital arousal disorder (PGAD) often identiied in sexually dysfunctional individuals
found that they were more likely than non-PGA are mood and anxiety disorders, and deicits in
women to evidence high levels of panic attacks and self-esteem and self-regulation, with some studies
OCD [88]. Corona et al. [96], in contrast, found that indicating that women are more affected by these
high levels of OCD symptoms were associated with factors than men.
a lower prevalence of HSDD in men. Clearly, more
However, conclusions based on the data currently
research is needed to better understand the role of
available are seriously limited on methodological
OCD in the development and maintenance of sexual
grounds. A wide array of heterogeneous instruments
dysfunction in men and women.
ranging from unvalidated global measures of
2. HISTrIONIC PErSONALITy DISOrDErS psychopathology to more reined and validated
AND SExuAL DySFuNCTION instruments including interviews have been used
to establish diagnostic criteria. In addition, in some
There is a marked lack of research regarding the studies, mixed diagnostic groups and small samples
sexual attitudes, behavior, and relationships of were used, while others did not employ matched
patients with histrionic personality disorders. Apt and control groups.
Hurlbert [135] compared a sample of women with
histrionic personality disorder (HPD) with a matched
sample of controls (aged 24-31 years). Women V. OTHEr PrECIPITATING
with HPD were found to have signiicantly lower FACTOrS FOr SExuAL FuNCTION
sexual assertiveness, greater erotophobic attitudes AND DySFuNCTION
toward sex, lower self-esteem, and greater marital
dissatisfaction. They also had signiicantly greater In addition to the disorders described above, there
sexual preoccupations, lower sexual desire, more are a wide array of precipitating factors that may
sexual boredom, greater orgasmic dysfunction, “tip the balance” from satisfactory sexual function to
and were more likely to enter into an extramarital dysfunction. Among these factors (but by no means
affair. Apt and Hurlbert concluded that, although all) are life stage stressors such as childbirth, infertility,
these patients are inordinately concerned with their divorce or loss, unemployment, extra-relationship
physical attractiveness and sexual appeal, their affairs, humiliating or traumatic sexual experiences,
sexual behavior varies widely and tends to run the partner sexual inadequacy or clumsiness and most
gamut from unresponsive to promiscuous. signiicantly, relationship discord. Space limitations
3. BOrDErLINE PErSONALITy DISOrDEr preclude a discussion of all of these factors, so we will
AND SExuAL DySFuNCTION focus on the most important, namely interpersonal
and relationship contributions.
Similar to the study above, Hurlbert [136] found that
women with borderline personality disorder showed VI. ANGEr ASSOCIATED WITH
higher sexual self-esteem and sexual assertiveness
compared to controls but also a greater likelihood of
having extra-marital affairs. Sensation seeking, often In assessing individuals and couples with sexual
associated with narcissistic personality disorders, problems, clinicians often identify the presence of
has been associated with increased sexual desire anger in the individuals and relationship. Kinsey


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pointed out the striking similarities between the who are in poor relationships may express their
physiological responses during sex and the bodily lack of relationship satisfaction by avoiding sexual
reactions that accompany the experience of anger interactions and restricting their range of sexual
[137]. This similarity was also noted in primate experience and intimacy. Among men, however,
studies where MacLean [138] showed that sexual relationship problems did not appear signiicantly
and aggressive responses are in extremely close related to sexual dysfunction, but the level of
proximity to each other in the limbic system of the arguments did. Men with HSDD evidenced more
brain. Several clinicians speculated that sexual dificulties than non-HSDD men in their level of
dysfunction may be a means of expressing anger at relationship functioning by demonstrating increased
the partner [139, 140]. Additionally, Kaplan [75] stated arguments and lower sexual satisfaction. Donahey
that the partner rejection, power struggles and sexual and Carroll [144] reported similar indings: female
sabotage create dysfunction rather than pleasure. clients with HSDD demonstrated lower levels of
Sex therapy cannot be conducted separately from relationship satisfaction than male clients with HSDD.
an examination of the couple’s hostility. Exploration Kelly et al. [145] also found that among couples where
of anger must be pursued if treatment is to be the female was experiencing orgasmic disorder, the
successful in the longer term [141]. couples experienced poorer communication than
control couples who did not experience any sexual
dysfunction. Roffe and Britt [146] found evidence for
high levels of hostility among couples seeking sex
OF SExuAL FuNCTION AND therapy. They also found that lack of expressiveness
DySFuNCTION and low levels of affection within the relationship
contributed to sexual dysfunction. Although there
Clinically, it has been observed that sexual problems has been limited research conducted on the
are sometimes the cause and sometimes the result relationship of men with PE, Rosen and Althof [100]
of dysfunctional or unsatisfactory relationships. found that PE impacted on both the men and their
These observations generally stem from clinical partners. The impact of sexual dysfunction on the
data rather than controlled research with community relationship is well illustrated in a study conducted
samples. Often it is dificult to determine which came by Oberg and Fugl-Meyer [147], who found that the
irst- a non-intimate and non-loving relationship, or major predictors of female sexual dysfunction were
low sexual desire and/or performance problems dissatisfaction with the relationship and partner
leading to partner avoidance and antipathy. The sexual dysfunction.
research literature is conlicting, and often dificult An interesting inding by Smith et al. [69, 148] was
to interpret since couples begin therapy with varying that the partners of men with Chronic Prostatites/
degrees of relationship satisfaction or dissatisfaction. Chronic Pelvic Pain Syndrome also experienced low
An early study found that sexual and relationship levels of sexual functioning and sexual satisfaction,
satisfaction were independent domains [142] (see as well as poor relationship functioning. In fact,
Table 5). Heiman et. al. [142] reported that sexual male sexual functioning signiicantly predicted the
satisfaction remained intact in a non-clinical sample sexual functioning of their female partner. Atwood
of 110 couples even when a sexual dysfunction et al. [149] also emphasized the importance of the
was present, although the majority of the research couple relationship in both the development and
literature shows a correlation between sexual maintenance of ED. Clinicians and researchers have
problems and relationship problems. noted that these relationship problems are often not
well addressed in the resolution of sexual dysfunction
Most studies that have examined the impact of in both men and women [150].
interpersonal issues on sexual function have used
There are methodological problems associated
a correlational study design rather than randomized
with most of the research exploring the interaction
controls trials, limiting the extent to which causative
between sexual and relationship function and
statements and generalizations may be drawn. satisfaction. Many of the studies consist of small,
non-representative samples, lack a no-treatment
control group, provide inadequate assessment of the
I. rELATIONSHIP DyNAMICS speciic sexual dysfunction(s) and fail to adequately
AND SExuAL DySFuNCTION assess the couple’s relationship. More signiicantly,
IN MEN AND WOMEN it is dificult to determine to what extent the sexual
complaints led to lower relationship satisfaction or
McCabe and Cobain[143] found that global deicits the conlict in the relationship resulted in poorer
in the current relationship were more likely to occur sexual function and satisfaction. Finally, the reported
among sexually dysfunctional women than sexually association between relationship maladjustment
functional women, but found no differences between and sexual dysfunction is confounded in studies of
the two groups in communication or number of “clinical populations” rather than population-based
arguments. These authors believe that women studies.


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Table 5: Studies on interpersonal dimensions of sexual function and dysfunction

Number of Based
Author Treatment Method Summary of Study Findings
Subjects Medicine
Heiman, 110 Survey of non-clinical respondents Sexual and relationship functioning 3
1986142 are independent domains
McCabe 343 Compared 114 dysfunctional males Dysfunctional females were more 3
1998143 and 84 dysfunctional females likely than functional females to
with 43 functional males and 102 experience negative events in
functional females on individual adolescence, poorer relationship
and relationship factors. and more negative attitudes to sex.
Dysfunctional males were more likely
than functional males to experience
Donahey, 66 Hypoactive sexual desire men were Women were more likely to 3
1993144 compared to women in relation to experience problems in relationships
psychological and relationship and psychological functioning
functioning. compared to men.
Kelly, 47 couples Compared (a) couples with no Group b evidenced poorer 2
2006377 physical problems, females had communication patterns in their
sexual problems, (b) couples with relationship than either of the other
no physical or sexual problems, two groups.
(c) couples with physical and no
sexual problems.
Roff, 492 246 couples seeking sexual Three types of marital interactions 3
1981146 dysfunction therapy were compared were identiied: high hostility by wife
on their marital interactions or husband, inhibited response by
husband, affection expressed by
both partners
oberg , 926 Survey of non-sexually active Low levels of satisfaction with 3
2005147 Swedish women aged 18-65 years the relationship and male sexual
in a heterosexual relationship dysfunction predicted sexual
dysfunction in the female partner
Smith , 75 couples Compared sexual and relationship Men with CP/CPPS evidenced 2
200769 functioning of 38 men with Chronic higher sexual dysfunction than
Prostatitis/Chronic Pelvic pain control men partners of men with
Syndrome and their partners to 37 CP/CPPS reported more sexual
control men and their partners. pain vaginismes and depressive
symptoms than control females.
Pietropento, 400 Physicians were surveyed to There was considerable disagreement 3
1986163 determine the prevalence of in the prevalence of ISD, but there
inhibited sexual desire among their was a general consensus that ISD
patients. was associated with the quality of
marital relationships.
Herlbert , 57 Compared the effectiveness of The treatment was generally found 2
1993164 two group interventions using to be effective for both treatment
orgasmic training in the treatment groups; the couples only group
of hypoactive sexual desire: showed some evidence of greater
women were assigned to women improvement than the women only
only group, couples group, or wait group.
list control group.
Zimmer, 48 Compared the effectiveness of Both treatment groups showed 2
1987165 sex therapy alone, sex therapy improvement in their sexual
and marital therapy to a control symptoms. However, the combined
condition. sex and marital therapy group
demonstrated the greatest
Macphee, 98 49 couples where the woman was The group receiving marital therapy 3
1995166 experiencing ISD were assigned made modest improvements in their
to either Emotion focused Therapy levels of sexual desire and reductions
group or a control group. in levels of depression. Lower initial
levels of marital distress resulted in
greater treatment gains.


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Table 5: Studies on interpersonal dimensions of sexual function and dysfunction (continued).

Number of Based
Author Treatment Method Summary of Study Findings
Subjects Medicine
Stuart, 90 Compared 59 married women The ISD group demonstrated poorer 3
1987167 with inhibited sexual desire to 39 functioning in the areas of sexual
married women with normal sexual history, marital, functioning, and
desire. other aspects of sexual functioning.
Trudel, 80 Evaluated differences in dyadic HSD was found to be associated with 3
200593 adjustment between 20 couples a range of relationship problems, but
with HSD, and 20 couples without causality could not be determined.
this condition.
Hurlbert , 66 Evaluated whether relationship Relationship factors were strongly 3
2005169 dynamics or other aspects of associated with sexual desire and
sexual functioning predict sexual psychosocial functioning. other
desire and psychosocial functioning aspects of sexual functioning were
among 66 women with hyposexual strongly associated with psychosocial
desire. functioning
Leiblum , - Review of literature related to the Lack of sexual desire is the most 4
2002170 experience of sexual dysfunction common sexual complaint among
among menopausal women. post-menopausal women. This may
be due to biological changes, as well
as psychological and relationship
McCabe, 343 198 dysfunctional men and women Dysfunctional men were lower than 3
1997171 were compared to 145 functional functional men for all aspects of
men and women in relation to their intimacy; this difference only applied
levels of intimacy and quality of for social and recreational intimacy
life. among women. quality of life was
lower for dysfunction women than
functional women. This difference
did not apply to men
Davies, 72 couples Sexual desire discrepancies and Women whose sexual desire was 3
199968 their relationship to sexual and lower than their partners’ evidenced
relationship functioning were lower levels of relationship
examined in 72 dating couples. adjustment compared to women with
the same or higher levels of sexual
desire compared to their partner.
Klusman, 1865 Survey of German students aged Sexual activity and satisfaction 3
2002173 19-32 who were involved in a decline with length of relationship
heterosexual, steady relationship. in both men and women; sexual
Investigated the relationship desire declines in women; desire
between sexual motivation and for tenderness declines in men but
length of relationship. increases in women.


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of dyadic adjustment than couples without HSDD
II. rELATIONSHIP DyNAMICS AND [168]. Similarly, Trudel, Landry and Larose[93]
found that compared to controls, couples in which
HyPOACTIVE SExuAL DESIrE one partner was diagnosed with HSDD obtained
HSDD is one of the most perplexing, prevalent and lower adjustment scores on the Marital Happiness
etiologically complex of all the sexual dysfunctions. Scale. Hurlbert et al. [169] found that the relationship
It is generally found to be more common in women between HSDD and relationship functioning was
than in men [151-153]. In men it is often confounded stronger for women than for men.
with arousal and erectile problems, making it dificult
A large scale health and sexuality survey of 2,050
to determine the primary diagnosis. There is a
pre-, peri-, and postmenopausal women between the
considerable overlap between desire, arousal and
ages of 20-70 found that those women who reported
orgasmic dificulties for both men and women.
lowered levels of sexual desire also reported more
Interpersonal factors are frequently cited as one of relationship dissatisfaction, lower frequencies of
the causal determinants of low sexual desire. Social- sexual activity, fewer orgasms and more distress
developmental theories e.g., Scharff’s [154] object [170].
relations perspective; differentiation theories; (e.g.,
McCabe [171] observed that individuals with
Schnarch [155]), and cognitive behavioral theories
HSDD reported lower levels of intimacy and lower
( e.g., Pridal & LoPiccolo [156]), address the role of
satisfaction with the quality of the intimacy in their
relationship factors as either inhibiting or facilitating
lives than controls. Davies et al. [172] examined
the experience of sexual desire.
discrepancies between partners’ levels of sexual
Most theories describe HSDD as emerging from desire, and found that for both husbands and wives,
an interaction between individual and dyadic individuals who felt that there was a discrepancy
characteristics. Notable examples are Talmadge and between their own and their partner’s desire reported
Talmadge’s [157] relational model, and Rosen and lower relationship satisfaction.
Leiblum’s [158] sexual scripting paradigm. Zilbergeld
In stable long-term relationships, sexual frequency
and Ellison[159] and others [155] have theorized
declines over time, although satisfaction may
that sexual dysfunction, particularly HSDD, serve as
continue to remain high. Even among young adults,
a “distance regulator” in a relationship. If a couple
sexual frequency declines over time. Klusmann [173],
is fearful that too much intimacy will lead to fusion
for example, reported changes in sexual interest in
and lack of individual differentiation, one or both
students between 19 and 32 years of age who were
partners may attempt to create distance, often
in “steady partnerships.” He found that both sexual
through sexual apathy. Even approaches that do
activity and sexual satisfaction declined over time
not view relationship issues as central to sexual
but that desire decreased only in women. Desire
desire recognize the role of the current relationship
for tenderness decreased in men but increased in
in maintaining the individual determinants of the
women over that period.
disorder [160].
It is generally agreed that, at the very least, the
cooperation of the partner without HSDD is essential III. THE IMPACT OF rELATIONSHIP
for the successful treatment of desire disorders [161], THErAPy ON SExuAL
[162]. In fact, 73% of surveyed physicians endorsed DySFuNCTION
the belief that sex therapy or psychotherapy with both
members of the couple is the best form of treatment Wiederman [174] suggests that treatment focused
for most cases of inhibited sexual desire[163]. solely on the sexual dysfunction is likely to fail if
Further, there is empirical evidence indicating that the underlying relationship dynamics are ignored.
sex therapy with the couple is more eficacious He maintained that without treating the problematic
than treating the HSDD patient alone [164], that relationship, enhanced sexual function is likely to be
combined marital and sex therapy approaches are temporary or that other psychological symptoms in
more eficacious than sex therapy alone for couples one or both partners will develop in order to maintain
with HSDD [165], and that women with HSDD show homeostasis. At present, there is limited empirical
modest improvement in desire and other aspects research to either support or refute this view.
of sexual functioning following brief marital therapy
In a comprehensive review of treatments for
sexual dysfunction, Besharat [175] highlighted the
There is research supporting the observation that importance of communication and conlict resolution
low sexual desire is associated with lower levels of strategies as well as resolution of systemic issues in
relationship satisfaction and adjustment, both for the relationship. While there are conlicting indings,
individuals with low desire and their partners [167]. the preponderance of evidence suggests that
For example, couples with HSDD have poorer levels therapy, which speciically addresses relationship


comitte 3.indd 142 8/25/2010 12:54:24 PM

issues, will be more successful than therapy that only to lead to a satisfying sexual relationship unless
focuses on the resolution of the sexual dysfunction. relationship issues were also addressed. These
The existing research supports the observation that issues include feelings of insecurity that develop as
the quality of the relationship plays an important role a result of the sexual dysfunction, as well as anger
in the outcome of sex therapy [176]. and disappointment. Returning to an active sexual