ORIGINAL CONTRIBUTION
`
`Sexual Dysfunction in the United States
`Prevalence and Predictors
`Edward O. Laumann, PhD
`Anthony Paik, MA
`Raymond C. Rosen, PhD
`
`SEXUAL DYSFUNCTIONS ARE CHAR-
`
`acterized by disturbances in
`sexual desire and in the psycho-
`physiological changes associ-
`ated with the sexual response cycle in
`men and women.1 Despite increasing de-
`mand for clinical services and the po-
`tential impact of these disorders on in-
`terpersonal relationships and quality of
`life,2,3 epidemiologic data are relatively
`scant. Based on the few available com-
`munity studies, it appears that sexual dys-
`functions are highly prevalent in both
`sexes, ranging from 10% to 52% of men
`and 25% to 63% of women.4-6 Data from
`the Massachusetts Male Aging Study7
`(MMAS) showed that 34.8% of men aged
`40 to 70 years had moderate to com-
`plete erectile dysfunction, which was
`strongly related to age, health status, and
`emotional function. Erectile dysfunc-
`tion has been described as an impor-
`tant public health problem by a Na-
`tional Institutes of Health Consensus
`Panel,8 which identified an urgent need
`for population-based data concerning the
`prevalence, determinants, and conse-
`quences of this disorder. Even less is
`known about the epidemiology of fe-
`male sexual dysfunction.
`Professional and public interest in
`sexual dysfunction has recently been
`sparked by developments in several ar-
`eas. First, major advances have oc-
`curred in our understanding of the neu-
`rovascular mechanisms of sexual
`response in men and women.9-11 Sev-
`eral new classes of drugs have been iden-
`tified that offer significant therapeutic po-
`
`See also Patient Page.
`
`Context While recent pharmacological advances have generated increased public
`interest and demand for clinical services regarding erectile dysfunction, epidemiologic
`data on sexual dysfunction are relatively scant for both women and men.
`Objective To assess the prevalence and risk of experiencing sexual dysfunction across
`various social groups and examine the determinants and health consequences of these
`disorders.
`Design Analysis of data from the National Health and Social Life Survey, a probabil-
`ity sample study of sexual behavior in a demographically representative, 1992 cohort
`of US adults.
`Participants A national probability sample of 1749 women and 1410 men aged 18
`to 59 years at the time of the survey.
`Main Outcome Measures Risk of experiencing sexual dysfunction as well as nega-
`tive concomitant outcomes.
`Results Sexual dysfunction is more prevalent for women (43%) than men (31%)
`and is associated with various demographic characteristics, including age and educa-
`tional attainment. Women of different racial groups demonstrate different patterns
`of sexual dysfunction. Differences among men are not as marked but generally con-
`sistent with women. Experience of sexual dysfunction is more likely among women
`and men with poor physical and emotional health. Moreover, sexual dysfunction is
`highly associated with negative experiences in sexual relationships and overall well-
`being.
`Conclusions The results indicate that sexual dysfunction is an important public health
`concern, and emotional problems likely contribute to the experience of these problems.
`www.jama.com
`JAMA. 1999;281:537-544
`
`tential for the treatment of male erectile
`disorder,12-14 while other agents have been
`proposed for sexual desire and orgasm
`disorders.15,16 Availability of these drugs
`could increase dramatically the num-
`ber of patients seeking professional help
`for these problems. Epidemiologic data
`would be of obvious value in develop-
`ing appropriate service delivery and re-
`source allocation models. Additionally,
`changing cultural attitudes and demo-
`graphic shifts in the population have
`highlighted the pervasiveness of sexual
`concerns in all ethnic and age groups.
`The present study addresses these is-
`sues by analyzing data on sexual dysfunc-
`tion from the National Health and Social
`Life Survey (NHSLS), a study of adult
`sexual behavior in the United States.17
`Sampling, data collection, and response
`analysis were all conducted under highly
`
`controlled conditions. This unique data
`source provides extensive information on
`key aspects of sexual behavior, includ-
`ing sexual problems and dysfunction,
`health and lifestyle variables, and socio-
`cultural predictors. Prior analyses of sexual
`dysfunction, using NHSLS data, are lim-
`
`Author Affiliations: Department of Sociology, Uni-
`versity of Chicago, Chicago, Ill (Dr Laumann and Mr
`Paik); and Department of Psychiatry, University of
`Medicine and Denistry of New Jersey—Robert Wood
`Johnson Medical School, Piscataway (Dr Rosen).
`Financial Disclosure: Dr Edward O. Laumann has
`served on the Scientific Advisory Committee to Pfizer
`Inc, New York, NY, in the development of Viagra, a
`medication for erectile dysfunction, since January 1997.
`Dr Rosen has received research and consulting sup-
`port from Pfizer Inc, Merck & Co Inc, West Point, Pa;
`Eli Lilly Co, Indianapolis, Ind; Bristol-Meyers Squibb
`Co, Princeton, NJ; Procter & Gamble, Cincinnati, Ohio;
`and ICOS Corp, Bothell, Wash.
`Corresponding Author and Reprints: Edward O. Lau-
`mann, PhD, Department of Sociology, University of
`Chicago, 5848 S University Ave, Chicago, IL 60637
`(e-mail: ob01@midway.uchicago.edu).
`
`©1999 American Medical Association. All rights reserved.
`
`JAMA, February 10, 1999—Vol 281, No. 6 537
`
`Downloaded From: http://jama.jamanetwork.com/ by David Holman on 01/07/2016
`
`MYLAN - EXHIBIT 1012
`
`

`
`SEXUAL DYSFUNCTION IN THE UNITED STATES
`
`ited, presenting basic prevalence rates
`across demographic characteristics and
`indicators of overall health and well-
`being.17(pp368-374) The present study, in con-
`trast, uses multivariate techniques to es-
`timate relative risk (RR) of sexual
`dysfunction for each demographic char-
`acteristic as well as for key risk factors.
`
`METHODS
`Survey
`The NHSLS, conducted in 1992, is a na-
`tional probability sample of 1410 men and
`1749 women between the ages of 18 and
`59 years living in households throughout
`theUnitedStates.Itaccountsforabout97%
`of the population in this age range—
`roughly150millionAmericans.Itexcludes
`peoplelivingingroupquarterssuchasbar-
`racks, college dormitories, and prisons, as
`wellasthosewhodonotknowEnglishwell
`enough to be interviewed. The sample
`completion rate was greater than 79%.
`Checkswithotherhigh-qualitysamples(eg,
`US Census Bureau’s Current Population
`
`Survey) indicated that the NHSLS suc-
`ceeded in producing a truly representative
`sampleofthepopulation.Eachrespondent
`was surveyed in person by experienced in-
`terviewers, who matched respondents on
`various social attributes, for an interview
`averaging 90 minutes. Extensive discus-
`sionofthesamplingdesignandevaluations
`of sample and data quality are found in the
`book by Laumann et al.17(pp35-73,549-605)
`Sexual dysfunction was indexed in this
`study according to 7 dichotomous re-
`sponse items, each measuring presence
`of a critical symptom or problem during
`the past 12 months.17(p660) Response items
`included: (1) lacking desire for sex; (2)
`arousal difficulties (ie, erection problems
`in men, lubrication difficulties in wom-
`en);(3)inabilityachievingclimaxorejacu-
`lation; (4) anxiety about sexual perfor-
`mance; (5) climaxing or ejaculating too
`rapidly; (6) physical pain during inter-
`course; and (7) not finding sex pleasur-
`able. The last 3 items were asked only of
`respondentswhoweresexuallyactivedur-
`
`ing the prior 12-month period. Taken to-
`gether, these items cover the major prob-
`lem areas addressed in the Diagnostic and
`Statistical Manual of Mental Disorders,
`Fourth Edition1 classification of sexual dys-
`function. Self-reports about sexual dys-
`functions, especially in face-to-face inter-
`views, are subject to underreporting bi-
`ases arising from personal concerns about
`social stigmatization. Moreover, there may
`be systematic biases in underreporting
`related to particular attributes of the re-
`spondents. For example, older or less
`educated women or younger Hispanic
`men might be more reluctant to report
`sexual problems. Lack of privacy during
`interviews could also result in underre-
`porting. However, analyses (not reported
`herein) indicate that reporting biases due
`to lack of privacy are negligible in NHSLS
`data.17(pp564-570)
`A latent class analysis (LCA) was used
`to evaluate the syndromal clustering of
`individual sexual symptoms. Latent class
`analysis is a statistical method well suited
`
`Table 1. Prevalence of Dysfunction Items by Demographic Characteristics (Women)*
`Unable to Achieve Orgasm
`Lacked Interest in Sex
`
`Experienced Pain During Sex
`
`Predictors
`
`No. (%)
`1486
`
`154 (32)
`161 (32)
`101 (30)
`53 (27)
`
`264 (29)
`108 (35)
`91 (34)
`
`85 (42)
`149 (33)
`153 (30)
`80 (24)
`
`Adjusted OR
`(95% CI)
`
`Referent
`1.05 (0.78-1.41)
`1.02 (0.73-1.44)
`0.78 (0.52-1.18)
`
`Referent
`1.15 (0.83-1.59)
`1.25 (0.93-1.69)
`
`Referent
`0.70 (0.49-1.00)†
`0.63 (0.44-0.90)†
`0.52 (0.34-0.78)†
`
`No. (%)
`1477
`
`125 (26)
`140 (28)
`72 (22)
`43 (23)
`
`199 (22)
`92 (30)
`85 (32)
`
`67 (34)
`129 (29)
`122 (24)
`59 (18)
`
`Adjusted OR
`(95% CI)
`
`Referent
`1.25 (0.91-1.72)
`0.91 (0.63-1.32)
`0.92 (0.60-1.44)
`
`Referent
`1.45 (1.03-2.05)†
`1.68 (1.23-2.29)†
`
`Referent
`0.79 (0.55-1.15)
`0.62 (0.42-0.90)†
`0.47 (0.30-0.73)†
`
`No. (%)
`1479
`
`99 (21)
`73 (15)
`42 (13)
`16 (8)
`
`132 (14)
`53 (17)
`43 (16)
`
`36 (18)
`77 (17)
`81 (16)
`34 (10)
`
`Adjusted OR
`(95% CI)
`
`Referent
`0.63 (0.44-0.91)†
`0.55 (0.36-0.85)†
`0.31 (0.17-0.56)†
`
`Referent
`0.85 (0.56-1.27)
`1.14 (0.77-1.68)
`
`Referent
`0.95 (0.61-1.51)
`0.85 (0.54-1.34)
`0.55 (0.32-0.95)†
`
`Total
`Age, y
`18-29
`30-39
`40-49
`50-59
`Marital status
`Currently married
`Never married
`Divorced, separated, or
`widowed
`Education
`Less than high school
`High school graduate
`Some college
`College graduate
`Race or ethnicity
`Referent
`178 (16)
`Referent
`275 (24)
`Referent
`324 (29)
`White
`0.61 (0.37-1.02)‡
`27 (13)
`1.12 (0.76-1.65)
`64 (32)
`1.67 (1.16-2.40)†
`90 (44)
`Black
`0.64 (0.36-1.15)
`16 (14)
`0.69 (0.42-1.13)
`25 (22)
`0.90 (0.57-1.40)
`35 (30)
`Hispanic
`0.83 (0.36-1.95)
`9 (19)
`1.41 (0.72-2.78)
`16 (34)
`1.62 (0.86-3.05)
`20 (42)
`Other
`*Data are from National Health and Social Life Survey.17 Estimated ratio of odds of reporting a given symptom for members of the specified group to odds for reference group.
`Derived from logistic regression models performed on respondents with at least 1 partner during the 12-month period prior to the survey. The model includes all predictor vari-
`ables as well as controls for religious affiliation and residence in rural, suburban, or urban areas. Percentages are derived from respondents in each category, and the total number
`represents those who responded to the questions. OR indicates odds ratio; CI, confidence interval.
`†Pⱕ.05.
`‡Pⱕ.10.
`
`538 JAMA, February 10, 1999—Vol 281, No. 6
`
`©1999 American Medical Association. All rights reserved.
`
`Downloaded From: http://jama.jamanetwork.com/ by David Holman on 01/07/2016
`
`

`
`SEXUAL DYSFUNCTION IN THE UNITED STATES
`
`for grouping categorical data into latent
`classes18,19 and has a number of medical
`applications, such as evaluation of diag-
`nostic systems20-23 and generation of epi-
`demiologic estimates using symptom
`data.24,25 Latent class analysis tests
`whether a latent variable, specified as a
`set of mutually exclusive classes, ac-
`counts for observed covariation among
`manifest, categorical variables. A more
`detailed discussion of this method is
`available on request from the authors.
`Since diagnostic criteria for disorders of
`sexual dysfunction involve a complex of
`symptoms, we used LCA for grouping
`symptoms into categories. These catego-
`ries, then, represent a typology of dis-
`orders for sexual dysfunction found in
`the US population, indicating both preva-
`lence and types of symptoms.
`We analyzed only those respondents
`reporting at least 1 partner in the prior
`12-month period. Respondents who were
`sexually inactive during this period were
`excluded. This procedure may limit our
`results because excluded respondents
`
`may have avoided sex because of sexual
`problems. However, this procedure was
`necessary to ensure that each respon-
`dent answered all the symptom items
`since 3 items were asked only of sexu-
`ally active respondents. A total of 139
`men and 238 women were excluded on
`this basis. Excluded men were more
`likely to be single and have lower levels
`of education. We expect that this will bias
`our estimates of prevalence of sexual dys-
`function downward since sexually inac-
`tive men generally reported higher rates
`of symptoms. Excluded women tended
`to be older and single. The exclusion of
`these women is likely to bias our esti-
`mates of the prevalence of sexual dys-
`function upward given that these women
`tended to report lower rates.
`Analyses performed in this study were
`made by use of logistic and multinomial
`logistic regression. For assessing the preva-
`lence of symptoms across demographic
`characteristics, we performed logistic re-
`gressions for each symptom. This ap-
`proach produced adjusted odds ratios
`
`Sex Not Pleasurable
`
`Anxious About Performance
`
`Trouble Lubricating
`
`(ORs), which indicate the odds that mem-
`bers of a given social group (eg, never mar-
`ried) reported the symptom relative to a
`reference group (eg, currently married),
`while controlling for other demographic
`characteristics. Demographic character-
`istics included respondent’s age, marital
`status, educational attainment level, and
`race and ethnicity. Next, while control-
`ling for these characteristics, we esti-
`mated adjusted ORs using multinomial lo-
`gistic regressions for 3 sets of risk factors,
`each modeled separately in a nonnested
`manner. Risk factors associated with
`health and lifestyle included alcohol con-
`sumption, prior contraction of sexually
`transmitted diseases (STDs), presence of
`urinary tract symptoms, circumcision,
`health status, and experience of emo-
`tional or stress-related problems. Social
`status variables included change in in-
`come level and normative orientation, in-
`dexed by how liberal or conservative re-
`spondents’ attitudes were toward sex. Risk
`factors associated with sexual experi-
`ence included the number of lifetime sex
`partners, frequency of sex, how often re-
`spondents think about sex, frequency of
`masturbation, same sex contact, and ex-
`perience in potentially traumatic events
`such as adult-child contact, forced sexual
`contact, sexual harassment, and abor-
`tion. Finally, we conducted a set of logis-
`tic regressions that used the categories of
`sexual dysfunction as predictor vari-
`ables. These models measured the asso-
`ciation between experience of dysfunc-
`tion categories and quality-of-life
`concomitants, which included being sat-
`isfied personally and in relationships. We
`stress that concomitant outcomes can-
`not be causally linked as an outcome of
`sexual dysfunction. Latent class analyses
`were performed using maximum likeli-
`hood latent structure analysis.26 All logis-
`tic regressions used STATA version 5.0.27
`Information regarding variable construc-
`tion, LCA methods, and data quality are
`available from the authors.
`
`RESULTS
`Prevalence of Sexual Problems
`Use of NHSLS data allows for calculat-
`ing national prevalence estimates of
`sexual problems for adult women and
`
`Adjusted OR
`(95% CI)
`
`Referent
`0.80 (0.58-1.11)
`0.52 (0.35-0.77)†
`0.53 (0.33-0.84)†
`
`Referent
`0.92 (0.65-1.31)
`1.24 (0.89-1.74)
`
`Referent
`0.81 (0.55-1.20)
`0.78 (0.52-1.15)
`0.67 (0.43-1.06)‡
`
`No. (%)
`1482
`
`78 (16)
`57 (11)
`36 (11)
`12 (6)
`
`86 (9)
`55 (18)
`39 (15)
`
`37 (18)
`54 (12)
`59 (12)
`32 (10)
`
`No. (%)
`1479
`
`129 (27)
`118 (24)
`55 (17)
`33 (17)
`
`188 (21)
`79 (25)
`66 (25)
`
`57 (28)
`102 (23)
`115 (23)
`59 (18)
`
`235 (21)
`66 (32)
`23 (20)
`11 (23)
`
`Adjusted OR
`(95% CI)
`
`Referent
`0.71 (0.47-1.08)
`0.73 (0.46-1.18)
`0.40 (0.20-0.79)†
`
`No. (%)
`1475
`
`92 (19)
`91 (18)
`69 (21)
`52 (27)
`
`Adjusted OR
`(95% CI)
`
`Referent
`0.84 (0.59-1.20)
`0.97 (0.66-1.44)
`1.40 (0.91-2.15)
`
`Referent
`1.57 (1.02-2.42)†
`1.59 (1.05-2.41)†
`
`196 (22)
`54 (17)
`51 (19)
`
`Referent
`0.82 (0.56-1.21)
`0.93 (0.66-1.33)
`
`Referent
`0.66 (0.41-1.06)‡
`0.57 (0.35-0.92)†
`0.56 (0.32-0.98)†
`
`31 (15)
`91 (20)
`108 (21)
`72 (22)
`
`253 (22)
`30 (15)
`13 (12)
`8 (17)
`
`Referent
`1.28 (0.81-2.02)
`1.45 (0.92-2.30)
`1.49 (0.91-2.45)
`
`Referent
`0.63 (0.40-1.02)‡
`0.51 (0.27-0.94)†
`0.57 (0.24-1.38)
`
`Referent
`1.42 (0.96-2.11)‡
`0.72 (0.43-1.21)
`0.77 (0.36-1.65)
`
`125 (11)
`33 (16)
`14 (12)
`11 (23)
`
`Referent
`1.18 (0.71-1.95)
`0.86 (0.45-1.65)
`1.68 (0.76-3.72)
`
`©1999 American Medical Association. All rights reserved.
`
`JAMA, February 10, 1999—Vol 281, No. 6 539
`
`Downloaded From: http://jama.jamanetwork.com/ by David Holman on 01/07/2016
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`

`
`SEXUAL DYSFUNCTION IN THE UNITED STATES
`
`men. While NHSLS data on critical
`symptoms do not connote a clinical defi-
`nition of sexual dysfunction, their preva-
`lence does provide important informa-
`tion about their extent and differential
`distribution among the US population.
`TABLE 1 and TABLE 2 analyze the preva-
`lencing sexual problems across selected
`demographic characteristics. For women,
`the prevalence of sexual problems tends
`to decrease with increasing age except for
`those who report trouble lubricating. In-
`creasing age for men is positively asso-
`ciated with experience of erection prob-
`lems and lacking desire for sex. The
`oldest cohort of men (ages 50-59 years)
`is more than 3 times as likely to experi-
`ence erection problems (95% confi-
`dence interval [CI], 1.8-7.0) and to re-
`port low sexual desire (95% CI, 1.6-
`5.4) in comparison to men aged 18 to
`29 years. The prevalence of sexual prob-
`lems also varies significantly across mari-
`tal status. Premarital and postmarital (di-
`vorced, widowed, or separated) statuses
`
`are associated with elevated risk of ex-
`periencing sexual problems. Nonmar-
`ried women are roughly 11⁄2 times more
`likely to have climax problems (95% CI,
`1.0-2.1 and 1.2-2.3, respectively) and
`sexual anxiety (95% CI, 1.0-2.4 and 1.1-
`2.4, respectively) than married women.
`Similarly, nonmarried men report sig-
`nificantly higher rates for most symp-
`toms of sexual dysfunction than mar-
`ried men. Thus, married women and men
`are clearly at lower risk of experiencing
`sexual symptoms than their nonmar-
`ried counterparts.
`High educational attainment is nega-
`tively associated with experience of sexual
`problems for both sexes. These differ-
`ences are especially marked between
`women who do not have high school di-
`plomas and those who have college de-
`grees. Controlling for other demo-
`graphic characteristics, women who have
`graduated from college are roughly half
`as likely to experience low sexual desire
`(95% CI, 0.3-0.8), problems achieving
`
`orgasm (95% CI, 0.3-0.7), sexual pain
`(95% CI, 0.3-1.0), and sexual anxiety
`(95% CI, 0.3-1.0) as women who have
`not graduated from high school. Male
`college graduates are only two thirds
`(95% CI, 0.4-1.0) as likely to report cli-
`maxing too early and half as likely to re-
`port nonpleasurable sex (95% CI, 0.2-
`0.9) and sexual anxiety (95% CI, 0.3-
`0.8) than men who do not have high
`school diplomas. Overall, women and
`men with lower educational attainment
`report less pleasurable sexual experi-
`ence and raised levels of sexual anxiety.
`The association between race and eth-
`nicity and sexual problems is more vari-
`able. Black women tend to have higher
`rates of low sexual desire and experi-
`ence less pleasure compared with white
`women, who are more likely to have
`sexual pain than black women. His-
`panic women, in contrast, consistently
`report lower rates of sexual problems.
`Differences between men are not as
`marked but are generally consistent with
`
`Table 2. Prevalence of Dysfunction Items by Demographic Characteristics (Men)*
`
`Lacked Interest in Sex
`
`Unable to Achieve Orgasm
`
`Climax Too Early
`
`No. (%)
`1246
`
`28 (7)
`28 (7)
`26 (9)
`15 (9)
`
`49 (7)
`31 (8)
`15 (9)
`
`18 (11)
`25 (7)
`32 (8)
`22 (7)
`
`Adjusted OR
`(95% CI)
`
`Referent
`1.31 (0.71-2.40)
`1.79 (0.90-3.55)‡
`1.74 (0.79-3.83)
`
`Referent
`1.55 (0.86-2.79)
`1.29 (0.69-2.39)
`
`Referent
`0.62 (0.31-1.21)
`0.68 (0.35-1.30)
`0.55 (0.27-1.12)‡
`
`No. (%)
`1243
`
`121 (30)
`122 (32)
`83 (28)
`55 (31)
`
`214 (30)
`111 (29)
`54 (32)
`
`61 (38)
`125 (35)
`106 (26)
`87 (27)
`
`Adjusted OR
`(95% CI)
`
`Referent
`1.01 (0.72-1.42)
`0.88 (0.60-1.30)
`0.95 (0.61-1.49)
`
`Referent
`0.95 (0.68-1.33)
`1.12 (0.77-1.62)
`
`Referent
`0.91 (0.61-1.35)
`0.58 (0.39-0.87)†
`0.65 (0.42-1.00)†
`
`Predictors
`
`No. (%)
`1249
`
`56 (14)
`52 (13)
`45 (15)
`30 (17)
`
`77 (11)
`71 (19)
`31 (18)
`
`30 (19)
`42 (12)
`65 (16)
`44 (14)
`
`Adjusted OR
`(95% CI)
`
`Referent
`1.52 (0.95-2.42)‡
`2.11 (1.23-3.64)†
`2.95 (1.60-5.44)†
`
`Referent
`2.75 (1.74-4.36)†
`1.69 (1.05-2.73)†
`
`Referent
`0.61 (0.35-1.05)‡
`0.88 (0.53-1.47)
`0.71 (0.40-1.24)
`
`Total
`Age, y
`18-29
`30-39
`40-49
`50-59
`Marital status
`Currently married
`Never married
`Divorced, separated, or
`widowed
`Education
`Less than high school
`High school graduate
`Some college
`College graduate
`Race or ethnicity
`Referent
`290 (29)
`Referent
`68 (7)
`Referent
`134 (14)
`White
`1.14 (0.75-1.72)
`49 (34)
`1.14 (0.57-2.26)
`13 (9)
`1.13 (0.67-1.90)
`27 (19)
`Black
`0.78 (0.46-1.31)
`25 (27)
`1.24 (0.54-2.83)
`8 (9)
`0.94 (0.47-1.86)
`12 (13)
`Hispanic
`1.63 (0.86-3.09)
`17 (40)
`2.83 (1.24-6.50)†
`8 (19)
`2.02 (0.94-4.32)‡
`10 (24)
`Other
`*Data are from National Health and Social Life Survey.17 Estimated ratio of odds of reporting a given symptom for members of the specified group to odds for reference group.
`Derived from logistic regression models performed on respondents with at least 1 partner during the 12-month period prior to the survey. The model includes all predictor vari-
`ables as well as controls for religious affiliation and residence in rural, suburban, or urban areas. Percentages are derived from respondents in each category, and the total number
`represents those who responded to the questions. OR indicates odds ratio; CI, confidence interval.
`†Pⱕ.05.
`‡Pⱕ.10.
`
`540 JAMA, February 10, 1999—Vol 281, No. 6
`
`©1999 American Medical Association. All rights reserved.
`
`Downloaded From: http://jama.jamanetwork.com/ by David Holman on 01/07/2016
`
`

`
`SEXUAL DYSFUNCTION IN THE UNITED STATES
`
`what women experience. Indeed, al-
`though the effects of race and ethnicity
`are fairly modest among both sexes,
`blacks appear more likely to have sexual
`problems while Hispanics are less likely
`to have sexual problems, across the cat-
`egories of sexual dysfunction.
`
`Latent Class Analysis
`The results of LCA allow for analyzing risk
`factors and quality-of-life concomitants in
`relation to categories of sexual dysfunc-
`tion, rather than individual symptoms.
`Analyses presented in TABLE 3, TABLE 4,
`and TABLE 5 use the results of LCA instead
`of individual symptoms. These results
`indicate that the clustering of symptoms
`according to syndrome can be repre-
`sented by 4 categories for women as well
`as for men. Latent class analysis also esti-
`mates the size of each class as a propor-
`tion of the total sample, a result corre-
`sponding to prevalence of categories of
`sexual dysfunction in the US population.
`Finally, LCA identifies each class’s symp-
`
`toms, indicating the likelihood that
`respondents in that class will exhibit
`a given symptom, thus providing re-
`searchers with information about what
`elements characterize each category.
`Although not equivalent to clinical diag-
`nosis, this approach offers a statistical rep-
`resentation of sexual dysfunction.
`For women, the 4 categories identi-
`fied by LCA roughly correspond to ma-
`jor disorders of sexual dysfunction as out-
`lined by the Diagnostic and Statistical
`Manual of Mental Disorders, Fourth Edi-
`tion.1 These include an unaffected group
`(58% prevalence), a low sexual desire cat-
`egory (22% prevalence), a category for
`arousal problems (14% prevalence), and
`a group with sexual pain (7% preva-
`lence). Similarly, a large proportion of
`men (70% prevalence) constitutes an
`unaffected population. The remaining
`categories consist of premature ejacula-
`tion (21% prevalence), erectile dysfunc-
`tion (5% prevalence), and low sexual de-
`sire (5% prevalence). Overall, the results
`
`Sex Not Pleasurable
`
`Anxious About Performance
`
`Trouble Maintaining or
`Achieving an Erection
`
`No. (%)
`1246
`
`39 (10)
`30 (8)
`25 (9)
`10 (6)
`
`41 (6)
`40 (11)
`21 (13)
`
`22 (14)
`21 (6)
`39 (9)
`21 (6)
`
`70 (7)
`23 (16)
`7 (8)
`4 (9)
`
`Adjusted OR
`(95% CI)
`
`Referent
`0.95 (0.54-1.69)
`1.04 (0.54-2.01)
`0.73 (0.31-1.69)
`
`Referent
`1.80 (1.02-3.18)†
`2.27 (1.27-4.04)
`
`Referent
`0.35 (0.17-0.68)†
`0.59 (0.32-1.08)‡
`0.44 (0.22-0.88)†
`
`No. (%)
`1247
`
`77 (19)
`65 (17)
`55 (19)
`25 (14)
`
`98 (14)
`78 (21)
`45 (26)
`
`37 (23)
`65 (18)
`77 (19)
`41 (13)
`
`Adjusted OR
`(95% CI)
`
`Referent
`0.98 (0.65-1.48)
`1.09 (0.68-1.75)
`0.87 (0.49-1.54)
`
`Referent
`1.71 (1.14-2.56)†
`2.29 (1.51-3.48)†
`
`Referent
`0.68 (0.42-1.10)
`0.70 (0.44-1.13)
`0.49 (0.28-0.83)†
`
`Referent
`2.33 (1.29-4.20)†
`0.95 (0.40-2.29)
`1.29 (0.44-3.82)
`
`173 (18)
`35 (24)
`5 (5)
`9 (21)
`
`Referent
`1.22 (0.76-1.95)
`0.24 (0.09-0.61)†
`1.33 (0.61-2.90)
`
`No. (%)
`1244
`
`30 (7)
`35 (9)
`31 (11)
`31 (18)
`
`65 (9)
`37 (10)
`24 (14)
`
`21 (13)
`32 (9)
`43 (10)
`31 (10)
`
`98 (10)
`19 (13)
`5 (5)
`5 (12)
`
`Adjusted OR
`(95% CI)
`
`Referent
`1.46 (0.84-2.57)
`1.84 (0.97-3.47)‡
`3.59 (1.84-7.00)†
`
`Referent
`1.73 (1.00-2.97)†
`1.61 (0.96-2.71)‡
`
`Referent
`0.64 (0.34-1.18)
`0.76 (0.42-1.38)
`0.66 (0.35-1.26)
`
`Referent
`1.21 (0.67-2.17)
`0.53 (0.20-1.39)
`1.17 (0.44-3.12)
`
`of LCA show that the total prevalence of
`sexual dysfunction is higher for women
`than men (43% vs 31%).
`
`Risk Factors
`Tables 3 and 4 present multinomial lo-
`gistic regressions on categories of sexual
`dysfunction. Adjusted ORs indicate the
`relative risk of experiencing a given cat-
`egory of sexual dysfunction vs reporting
`no problems for each risk factor, while
`controlling for other characteristics. With
`regard to health and lifestyle risk factors,
`those who experience emotional or stress-
`related problems are more likely to ex-
`perience sexual dysfunctions defined in
`each of the categories. In contrast, health
`problems affect women and men differ-
`ently. Men with poor health have el-
`evated risk for all categories of sexual dys-
`function, whereas this factor is only
`associated with sexual pain for women.
`The presence of urinary tract symptoms
`appears to impact sexual function only (eg,
`arousal and pain disorders for women or
`erectile dysfunction for men). Finally, hav-
`ing had an STD, moderate to high alco-
`hol consumption, and circumcision gen-
`erally do not result in increased odds of
`experiencing sexual dysfunction.
`Social status variables, which measure
`an individual’s socioeconomic and nor-
`mative position relative to other persons,
`assess how sociocultural position affects
`sexualfunction.Deteriorationineconomic
`position, indexed by falling household in-
`come, is generally associated with a mod-
`est increase in risk for all categories of
`sexual dysfunction for women but only
`erectile dysfunction for men. Normative
`orientation does not appear to have any
`impact on sexual dysfunction for wom-
`en; men with liberal attitudes about sex,
`in contrast, are approximately 13⁄4 times
`morelikelytoexperienceprematureejacu-
`lation (95% CI, 1.2-2.5).
`Finally, various aspects of sexual ex-
`perience result in an increased risk of
`sexual dysfunction. Sexual history, in-
`dicated by having more than 5 lifetime
`partners and by masturbation prac-
`tices, does not increase relative risk for
`either women or men. Women with low
`sexual activity or interests, however, have
`elevated risk for low sexual desire and
`
`©1999 American Medical Association. All rights reserved.
`
`JAMA, February 10, 1999—Vol 281, No. 6 541
`
`Downloaded From: http://jama.jamanetwork.com/ by David Holman on 01/07/2016
`
`

`
`SEXUAL DYSFUNCTION IN THE UNITED STATES
`
`arousal disorders. Men do not exhibit
`similar associations. The impact of po-
`tentially traumatic sexual events is mark-
`edly different for women and men.
`Women respondents reporting any same-
`sex activity are not at higher risk for
`sexual dysfunction, while men are. Men
`reporting any same-sex activity are more
`than twice as likely to experience pre-
`mature ejaculation (95% CI, 1.2-3.9) and
`low sexual desire (95% CI, 1.1-5.7) than
`men who have not. Arousal disorder ap-
`pears to be highly associated in women
`who have experienced sexual victimiza-
`tion through adult-child contact or forced
`sexual contact. Similarly, male victims of
`adult-child contact are 3 times as likely
`to experience erectile dysfunction (95%
`CI, 1.5-6.6) and approximately 2 times
`as likely to experience premature ejacu-
`
`lation (95% CI, 1.2-2.9) and low sexual
`desire (95% CI, 1.1-4.6) than those who
`have not been victims of adult-child con-
`tact. Finally, men who have sexually as-
`saulted women are 31⁄2 times as likely to
`report erectile dysfunction (95% CI, 1.0-
`12.0). Indeed, traumatic sexual acts con-
`tinue to exert profound effects on sexual
`functioning, some effects lasting many
`years beyond the occurrence of the origi-
`nal event.
`
`Quality-of-Life Concomitants
`The experience of sexual dysfunction is
`highly associated with a number of un-
`satisfying personal experiences and rela-
`tionships. Table 5 highlights the associa-
`tions of categories of sexual dysfunction
`with emotional and physical satisfaction
`with sexual partners and with feelings of
`
`Table 3. Latent Classes of Sexual Dysfunction by Risk Factors (Women)*
`Adjusted OR (95% CI)
`
`Low Desire
`
`Arousal Disorder
`
`Sexual Pain
`
`0.46 (0.15-1.39)
`1.44 (1.02-2.03)†
`1.19 (0.89-1.59)
`1.44 (0.94-2.20)‡
`2.70 (2.04-3.58)†
`
`0.87 (0.24-3.21)
`1.45 (0.95-2.23)‡
`4.02 (2.75-5.89)†
`1.61 (0.94-2.73)‡
`4.65 (3.22-6.71)†
`
`0.58 (0.07-4.66)
`1.23 (0.65-2.33)
`7.61 (4.06-14.26)†
`3.35 (1.70-6.63)†
`1.82 (1.05-3.13)†
`
`Referent
`1.12 (0.84-1.51)
`1.66 (1.12-2.47)†
`1.25 (0.95-1.66)
`
`Referent
`0.88 (0.60-1.30)
`1.58 (0.99-2.54)‡
`1.36 (0.96-1.94)‡
`
`Referent
`1.02 (0.57-1.83)
`2.22 (1.13-4.36)†
`0.83 (0.48-1.43)
`
`Predictors
`Health and lifestyle (n = 1381)
`Daily alcohol consumption
`STD ever
`Urinary tract symptom
`Poor to fair health
`Emotional problems or stress
`Social status (n = 1460)
`Household income (1988-1991),
`% change
`1-20 Increase
`0-20 Decrease
`⬎20 Decrease
`Liberal attitudes about sex
`Sexual experience (n = 1248)
`ⱖ5 Lifetime partners
`Sex frequency no more than
`once monthly
`Thinks about sex less than
`once weekly
`Masturbation at least once
`monthly
`1.16 (0.35-3.81)
`0.47 (0.17-1.33)
`0.93 (0.43-2.01)
`Any same sex activity ever
`1.01 (0.51-2.01)
`1.22 (0.77-1.92)
`1.34 (0.91-1.97)
`Had an abortion ever
`1.64 (0.93-2.89)‡
`1.44 (0.98-2.12)‡
`1.17 (0.85-1.61)
`Sexually harassed ever
`1.13 (0.56-2.28)
`1.73 (1.11-2.71)†
`1.16 (0.77-1.75)
`Sexually touched before puberty
`1.05 (0.53-2.08)
`2.01 (1.31-3.07)†
`1.45 (0.98-2.12)‡
`Sexually forced by a man ever
`*Data are from National Health and Social Life Survey.17 Estimated ratio of odds of membership in a given latent class
`for members of the specified group to odds for reference group in the default latent class of having no problems.
`Derived from multinomial logistic regression models performed on respondents with at least 1 partner during the
`12-month period prior to the survey. Three models were run separately for each sex (health and lifestyle, social
`status, and sexual experience). Predictor variables, in addition to those listed for health, lifestyle, and sexual history,
`included age, marital status, education, race and ethnicity, religion, and place of residence. OR indicates odds ratio;
`CI, confidence interval; and STD, sexually transmitted disease.
`†Pⱕ.05.
`‡Pⱕ.10.
`
`0.98 (0.68-1.41)
`2.29 (1.57-3.32)†
`
`1.29 (0.84-1.98)
`2.28 (1.43-3.63)†
`
`1.25 (0.66-2.36)
`0.94 (0.41-2.12)
`
`2.37 (1.74-3.25)†
`
`1.47 (0.98-2.21)‡
`
`1.35 (0.73-2.48)
`
`1.10 (0.75-1.60)
`
`1.41 (0.90-2.20)
`
`1.36 (0.71-2.58)
`
`general happiness. However, no causal or-
`der should be assumed since quality-of-
`life indicators are concomitant out-
`comes of sexual dysfunction. For women,
`all categories of sexual dysfunction—
`low sexual desire, arousal disorder, sexual
`pain—have strong positive associations
`with low feelings of physical and emo-
`tional satisfaction and low feelings of hap-
`piness. Similar to women, men with erec-
`tile dysfunction and low sexual desire
`experience diminished quality of life, but
`those with premature ejaculation are not
`affected. In brief, experience of sexual dys-
`function is generally associated with poor
`quality of life; however, these negative out-
`comes appear to be more extensive and
`possibly more severe for women than
`men. In an examination of help-seeking
`behavior (analysis not shown here, but
`available on request), we found that
`roughly 10% and 20% of these afflicted
`men and women, respectively, sought
`medical consultation for their sexual prob-
`lems.
`
`COMMENT
`Demographic factors such as age are
`strongly predictive of sexual difficul-
`ties, particularly erectile dysfunction.
`Sexual problems are most common
`among young women and older men.
`Several factors may explain these differ-
`ential rates. Since young women are more
`likely to be single, their sexual activities
`involve higher rates of partner turnover
`as well as periodic spells of