Prevalence of Sexual Activity and Associated Factors in Men Aged 75 to 95 Years A Cohort Study

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1 Annals of Internal Medicine Original Research Prevalence of Sexual Activity and Associated Factors in Men Aged 75 to 95 Years A Cohort Study Zoë Hyde, MPH; Leon Flicker, MBBS, PhD; Graeme J. Hankey, MD; Osvaldo P. Almeida, MD, PhD; Kieran A. McCaul, MPH, PhD; S.A. Paul Chubb, PhD; and Bu B. Yeap, MBBS, PhD Background: Knowledge about sexuality in elderly persons is limited, and normative data are lacking. Objective: To determine the proportion of older men who are sexually active and to explore factors predictive of sexual activity. Design: Population-based cohort study. Setting: Community-dwelling men from Perth, Western Australia, Australia. Participants: 3274 men aged 75 to 95 years. Measurements: Questionnaires from 1996 to 1999, 2001 to 2004, and 2008 to 2009 assessed social and medical factors. Sex hormones were measured from 2001 to Sexual activity was assessed by questionnaire from 2008 to Results: A total of 2783 men (85.0%) provided data on sexual activity. Sex was considered at least somewhat important by 48.8% (95% CI, 47.0% to 50.6%), and 30.8% (CI, 29.1% to 32.5%) had had at least 1 sexual encounter in the past 12 months. Of the latter, 56.5% were satisfied with the frequency of activity, whereas 43.0% had sex less often than preferred. In cross-sectional analyses, increasing age, partner s lack of interest, partner s physical limitations, osteoporosis, prostate cancer, diabetes, antidepressant use, and -blocker use were independently associated with reduced odds of sexual activity. Living with a partner and having a non English-speaking background were associated with increased odds. In longitudinal analyses, higher testosterone levels were associated with increased odds of being sexually active. Other factors were similar to the cross-sectional model. Limitations: Response bias may have influenced findings because sexuality can be a sensitive topic. Attrition may have resulted in a healthier-than-average sample of older men. Conclusion: One half of elderly men consider sex important, and one third report being sexually active. Men s health problems were associated with lack of sexual activity. Key modifiable risk factors include diabetes, depression, and medication use. Endogenous testosterone levels predict sexual activity, but the role of testosterone therapy remains uncertain. Primary Funding Source: National Health and Medical Research Council of Australia. Ann Intern Med. 2010;153: For author affiliations, see end of text. Since antiquity, sexual activity has largely been considered the purview of the young. Classical depictions of sexuality invoke notions of vigor, youth, and fertility. Venus, the Roman goddess of love, is portrayed as young and nubile, whereas her lover, Mars, is depicted as muscular and virile. In the following centuries, sexuality increasingly fell within the religious sphere, and reproduction was deemed the chief purpose of sexual activity. Beyond the reproductive years, sex was regarded as not only inappropriate but also immoral (1). The conceptualization of older persons as asexual persisted well into the 20th century. Alfred Kinsey s pioneering studies were among the first to challenge this perception, noting that some persons remained sexually active into old age (2). However, the belief that sexuality is not a concern of older persons remains entrenched, and they are often overlooked in sexual health research (3). A recent government report of the health of older Australians made no mention of sexual health (4), and the Australian Longitudinal Study of Health and Relationships, which aims to document the natural history of the sexual and reproductive health of the Australian adult population, did not sample adults older than 64 years (5). Sexuality is an important component of overall wellbeing for both young and older adults (6). Although attitudes persist that older persons are not capable of or lack interest in sex (7), many consider sexuality important and wish to remain sexually active as they age (8, 9). However, epidemiologic data about sexual activity in this age group are scarce, and it is unclear what changes can be expected as part of the aging process. Sexual activity has been demonstrated to decrease with age in both cross-sectional and longitudinal studies (10, 11). These changes parallel the slow but steady decline in androgen levels in men, which peak in early adulthood and decline by 1% to 2% per year thereafter (12). Although a slowly growing body of literature describes the sexual activity and behavior of older persons, normative data are lacking. Many studies comprise persons with sexual dysfunction or are hampered by small sample sizes or large age See also: Print Editors Notes Summary for Patients....I-58 Web-Only Conversion of graphics into slides Downloaded From: This by article a Penn has State been University corrected. Hershey The specific User correction on 02/04/2015 appears on the last page of this document. For original version, click "Original Version (PDF)" in column 2 of the article at American College of Physicians 693

2 Original Research Sexual Activity in Older Men Context Data about sexuality and aging are scarce. Contribution This study surveyed Australian men aged 75 to 95 years about social and medical factors 3 times over 13 years and measured hormone levels and sexual activity at the second and third surveys, respectively. About one third of men reported at least 1 sexual encounter in the past year. Increasing age, lower testosterone levels, partner s disinterest or physical limitations, osteoporosis, prostate cancer, diabetes, and use of antidepressants or -blockers were associated with lack of sexual activity. Caution The study cohort may be healthier than other elderly male populations. Implication This study identifies medical factors related to absence of sexual activity in older men. The Editors ranges, and few have focused on persons older than 70 years (9, 13, 14). We therefore designed our study to explore sexuality in a population-based cohort of 3274 community-dwelling men aged 75 to 95 years. We aimed to determine the proportion of older men who are sexually active and explore the social, physical, and hormonal factors predictive of sexual activity in this age group. We hypothesized that psychosocial factors and medical comorbid conditions would be major determinants of sexual activity but that testosterone levels would remain a predictor after adjustment for these factors. METHODS Setting and Participants The HIMS (Health In Men Study) is a longitudinal study of community-dwelling men living in Perth, Western Australia, Australia, who were originally recruited in a trial of screening for abdominal aortic aneurysm (15). In 1995, men aged 65 years or older were randomly selected from the electoral roll (enrollment to vote is compulsory). From 1996 to 1999 (wave 1), men attended a clinic and completed a questionnaire, providing a range of demographic and clinical data. Approximately 5 years later, surviving men were invited to participate in a follow-up study. From 2001 to 2004 (wave 2), 5585 completed a second questionnaire; 4263 of these attended a clinic, in which early morning sera was obtained from 4249 men. From 2008 to 2009 (wave 3), questionnaires were mailed to 7445 surviving men, of which 3274 were returned (Figure 1). Clinical assessments were not performed at wave 3. The Human Research Ethics Committee of the University of Western Australia approved the study. Biochemical Assessment Blood samples were collected at wave 2 from 8:00 a.m. to 10:30 a.m. Biochemical assays were done in the biochemistry departments of Royal Perth Hospital and Fremantle Hospital, as reported elsewhere (16). Serum total testosterone, sex hormone binding globulin, and luteinizing hormone levels were determined by chemiluminescent immunoassays on an Immulite 2000 analyzer (Diagnostic Products, Biomediq, Doncaster, Victoria, Australia). Free testosterone (the fraction not bound to sex hormone binding globulin or albumin) was estimated by using mass action equations (17). Of the 4249 men who provided sera at wave 2, 4165 (98.0%) had testosterone, sex hormone binding globulin, and luteinizing hormone successfully assayed. Assessment of Sexual Activity At wave 3, participants were asked to self-report the number of persons (including men and women) with whom they had been sexually active in the past 5 years, how often they had had sex in the past 12 months (did not have sex, 1 time per week, 2 to 3 times per month, or 1 time per month), how satisfied they were with the frequency of sexual activity in the past 12 months (more often than liked, about as often as liked, or less often than liked), and how important a part of their lives sex was now (extremely, very, moderately, somewhat, or not at all). We defined sex and sexual activity as any mutually voluntary activity with another person that involves sexual contact, regardless of whether intercourse or orgasm occurs, as per 1 of the largest studies of sexuality in elderly persons to date (10). Participants who did not have sex in the past 12 months were prompted to state a reason. Participants were also asked about their lifetime sexual behavior (only with women, with men and women, only with men, or with no one). Medical Comorbid Conditions Medical comorbid conditions were assessed from selfreported questionnaire data provided at all 3 time points, from biochemical measurements at wave 2, and from medical records obtained through the Western Australian Data Linkage System (18). The system provides electronic linkage to the state s population health data collections and comprises records from the death registry, cancer registry, and hospital morbidity data system (which includes all separations for public and private hospitals in the state dating from 1970). Other Items of Interest Men were asked about the highest level of education achieved at wave 1, alcohol use at wave 3, and smoking status at all 3 time points. Participants were also asked to complete the 15-item Geriatric Depression Scale at wave 2 and the depression module of the 9-item Patient Health December 2010 Annals of Internal Medicine Volume 153 Number 11

3 Sexual Activity in Older Men Original Research Figure 1. Study flow diagram. Men 65 y or older randomly selected from electoral roll and invited to study (n = ) Excluded (n = 456) Previous scan or operation for abdominal aortic aneurysm: 328 Should not have been invited, too young: 118 Could not scan aorta: 10 Out of town (n = 238) Unwell (n = 609) Returned to sender (n = 543) Did not respond (n = 5303) Attended clinic and completed W1 questionnaire (n = ) Died before invitation to follow-up (n = 1263) Invited to follow-up study (n = ) Died after invitation (n = 155) Unable to attend (n = 331) Unwell (n = 572) Returned to sender (n = 1000) Did not respond (n = 3297) Attended clinic and completed W2 questionnaire (n = 4263) Completed W2 questionnaire only (n = 1322) Died before invitation to follow-up (n = 3340) Invited to follow-up study (n = 7445) Died after invitation (n = 126) Returned to sender (n = 173) Unwell (n = 230) Withdrew (n = 361) Did not respond (n = 3281) Completed W3 questionnaire (n = 3274) The study spans 14 y, from 1995 to W wave. Questionnaire at wave 3. Possible scores range from 0 to 15 on the Geriatric Depression Scale, and 0 to 27 on the Patient Health Questionnaire, with higher scores indicating greater severity of symptoms (19, 20). A Geriatric Depression Scale score of 7 or greater or a Patient Health Questionnaire score of 10 or greater was considered to indicate clinically relevant depressive symptoms. Statistical Analysis We used Stata, version 11.0 (StataCorp, College Station, Texas 2009), to analyze the data. The Cuzik test for 7 December 2010 Annals of Internal Medicine Volume 153 Number

4 Original Research Sexual Activity in Older Men Table 1. Characteristics of the Study Population at Survey Wave 3 (2008 to 2009)* Characteristic Value Age, n (%) y 1315 (40.2) y 1335 (40.8) y 514 (15.7) y 110 (3.3) Marital status, n (%) Married 2373 (72.5) De facto (marriage-like) 44 (1.3) Separated 40 (1.2) Divorced 139 (4.3) Widowed 522 (15.9) Never married 85 (2.6) Missing data 71 (2.2) Living with a partner, n (%) 2405 (74.3) Education level, n (%) Primary school or no school 450 (13.7) Some high school 1176 (35.9) High school 909 (27.8) Tertiary qualification 737 (22.5) Missing data 2 (0.1) Non English-speaking background, n (%) 439 (13.4) Mean body mass index (SD), kg/m (3.5) Mean Geriatric Depression Scale score (SD) 1.9 (2.0) Mean Patient Health Questionnaire score (SD) 2.8 (4.2) Tobacco use, n (%) Lifetime nonsmoker 1074 (32.8) Current or former smoker 2200 (67.2) Alcohol use, n (%) Nondrinker 1193 (36.4) 1 14 drinks/wk 1633 (49.9) drinks/wk 309 (9.4) 29 drinks/wk 98 (3.0) Missing data 41 (1.3) Comorbid conditions, n (%) Dyslipidemia 2342 (71.5) Diabetes mellitus 668 (20.4) Prostate cancer 515 (15.7) Benign prostatic hypertrophy 1112 (34.0) Prostatectomy 1037 (31.7) Coronary heart disease 1326 (40.5) Stroke or transient ischemic attack 538 (16.4) Hypertension 2000 (61.1) Osteoporosis 308 (9.4) Medication use, n (%) -Blockers 333 (10.2) -Blockers 803 (24.5) Diuretics 692 (21.1) Antidepressants 277 (8.5) Neuroleptics 42 (1.3) Mean sex hormone levels (SD) Total testosterone nmol/l 15.5 (5.6) ng/dl (161.5) Free testosterone, pg/ml 81.3 (28.7) Sex hormone binding globulin, nmol/l 41.5 (15.7) Luteinizing hormone, IU/L 5.4 (4.5) * Based on 3274 participants. Sex hormone data were collected at wave 2 (2001 to 2004) and are presented for 1744 men without prostate cancer or previous orchidectomy and not receiving gonadotropin-releasing hormone agonist analogues, antiandrogen therapy, or testosterone supplementation. trend was used to assess trends across groups (for example, proportion of sexually active men, by age). Predictors of sexual activity (having at least 1 sexual encounter in the past 12 months) were explored with logistic regression, following the methodology outlined by Hosmer and Lemeshow (21). We explored predictors in 2 models: a crosssectional model using all men without missing data (n 2758) and a longitudinal model comprising only men with sex hormone data. Of the 4165 men with sex hormone data at wave 2, 2145 attended wave 3. From these, we excluded 401 men with prostate cancer or men who had undergone orchidectomy or were receiving gonadotropinreleasing hormone analogues, antiandrogen therapy, or testosterone supplementation. We excluded a further 244 men with missing data for sexual activity or other responses, leaving 1500 for analysis in the longitudinal model. We initially explored univariate associations between social, physical, and hormonal factors that we considered plausibly associated with sexual activity. We then entered all variables associated with sexual activity into a multivariate model and used the Wald statistic to identify potential candidates for removal. Covariates with very large P values were removed. Of the remaining variables, we retained those that we considered a priori to be important, regardless of statistical significance, and examined the effects of removing the rest sequentially by using the Bayesian information criterion to assess model fit at each step. To assess the validity of our final model, we compared it with the results of a bootstrapped stepwise model, in which all possible covariates were entered. We aimed to ensure that the variables we had chosen were selected in 80% or more of the stepwise models. Model fit was assessed with Hosmer Lemeshow goodness-of-fit tests and with receiver-operating characteristic curves. The area under the curve exceeded 0.8 for the final cross-sectional and longitudinal multivariate models, indicating excellent discriminability. Hormone values were entered into longitudinal analyses as Z scores, placing them on a common, metric-free scale. Odds ratios reflect the effect of a 1-SD increase in hormone level. Role of the Funding Source The National Health and Medical Research Council of Australia, MBF Foundation of Australia, and the Sylvia and Charles Viertel Charitable Foundation funded this research. The funding sources had no role in the design of the study, analysis and interpretation of the data, drafting of the manuscript, or the decision to submit the manuscript for publication. RESULTS Most participants (75.5%) were married or in a marriage-like relationship, and most (74.3%) lived with a partner (Table 1). Medical conditions that could interfere with sexual function were relatively common; prostate cancer had been diagnosed in 15.7%, and 31.7% of partici December 2010 Annals of Internal Medicine Volume 153 Number 11

5 Sexual Activity in Older Men Original Research pants had undergone at least a partial prostatectomy. Lifetime sexual behavior was reported by 85.9% of men (n 2811). Most men reported sex only with women (96.5%; n 2712), 1.3% (n 35) with men and women, and 0.5% (n 12) with men only; 1.9% (n 52) reported that they had never been sexually active with anyone. Sexual Activity Most men (85.0%; n 2783) provided data on sexual activity (Table 2). Of these, 857 (30.8% [95% CI, 29.1% to 32.5%]) had sex at least once in the past 12 months. Slightly more men (89.5%; n 2930) reported the importance they attached to sex. Almost half (48.8% [CI, 47.0% to 50.6%]) described sex as at least a somewhat important part of their life. Of the 857 men who reported they were sexually active, 95.7% (n 820) described how satisfied they were with the frequency of sexual activity. Most (56.5%; n 463) were satisfied, whereas 43.0% (n 353) had sex less often than liked. Four men (0.5%) reported having sex more often than preferred. The number of sexual partners in the past 5 years was reported by 2602 men (79.5%); the median response was 1 partner (interquartile range, 0 to 1; range, 0 to 40). Sexual Activity, by Age As Figure 2 shows, the proportion of men engaging in sexual activity decreased with advancing age (Z 9.50; P 0.001). Among men aged 75 to 79 years, 39.6% were sexually active (CI, 36.7% to 42.4%), whereas only 11.0% (CI, 4.2% to 17.8%) aged 90 to 95 years had sex in the past 12 months. Figure 3 shows that the importance men attached to sex was also lower with increasing age (Z 11.38; P Table 2. Importance of, Frequency of, and Satisfaction With Sexual Activity in the 12 Months Before Survey Wave 3 (2008 to 2009) Variable Participants, n (%) Importance of sex Extremely 79 (2.4) Very 293 (9.0) Moderately 693 (21.2) Somewhat 365 (11.1) Not at all 1500 (45.8) Missing data 344 (10.5) Frequency of sexual activity Did not have sex 1926 (58.8) 1 time/wk 169 (5.2) 2 3 times/mo 253 (7.7) 1 time/mo 435 (13.3) Missing data 491 (15.0) Satisfaction with frequency of sex in sexually active men (n 857) More often than liked 4 (0.5) About right 463 (54.0) Less often than liked 353 (41.2) Missing data 37 (4.3) Proportion of Participants, % Figure 2. Proportion of men who engaged in sexual activity in the 12 months before survey wave 3 (2008 to 2009), by age group Age, y Based on data from 2783 men; of these, 1145 were aged 75 to 79 y, 1120 were aged 80 to 84 y, 436 were aged 85 to 89 y, and 82 were aged 90 y. Errors bars indicate 95% CIs ). Sex was described as at least somewhat important by 59.0% (CI, 56.2% to 61.8%) of men aged 75 to 79 years but by only 20.9% (CI, 12.5% to 29.3%) of men aged 90 to 95 years. The 1926 men who had not engaged in sexual activity were prompted to state a reason. More than 1 reason could be given. Lack of interest was reported by 40.5% (n 780), physical problems or limitations by 48.4% (n 932), lack of a partner by 20.9% (n 402), grieving by 4.1% (n 78), and concern that children or family members would not approve by 2.3% (n 44). Lack of interest by the partner or physical problems or limitations of the partner were cited by 39.5% (n 761) and 22.9% (n 441), respectively. Other reasons were given by 5.6% (n 108); the most common were age (n 68), medication use (n 13), and celibacy for religious reasons (n 7). Cross-sectional Associations With Sexual Activity Univariate logistic regression was performed to determine factors associated with sexual activity in the past 12 months. Associations were observed for a large number of variables, which were then entered into a multivariate model (Table 3). After adjustment, increasing age, lack of interest in sex by the partner, physical limitations of the partner, osteoporosis, prostate cancer, diabetes, antidepressant use, and -blocker use were associated with decreased odds of sexual activity in the past 12 months. Living with a partner and having a non English-speaking background were associated with increased odds. 7 December 2010 Annals of Internal Medicine Volume 153 Number

6 Original Research Sexual Activity in Older Men Proportion of Participants, % Figure 3. Importance of sex at survey wave 3 (2008 to 2009), by age group Not at all Somewhat Moderately Very + Extremely Age, y Based on data from 2930 men; of these, 1192 were aged 75 to 79 y, 1194 were aged 80 to 84 y, 453 were aged 85 to 89 y, and 91 were aged 90 y. Longitudinal Associations With Sexual Activity Longitudinal factors associated with sexual activity were explored in men with sex hormone data that were collected at wave 2. As shown in Table 4, several factors were associated with sexual activity in univariate analyses. After adjustment, increasing age, lack of interest in sex by the partner, physical limitations of the partner, diabetes, and antidepressant use were associated with reduced odds of sexual activity. Living with a partner, having a non English-speaking background, and having higher free testosterone levels were associated with increased odds. For each 1-SD increase in free testosterone levels, the odds of having had sex in the past 12 months increased by 20%. Total testosterone level was also independently associated with sexual activity, with an effect size similar to that of free testosterone levels (data not shown), but the latter seemed to be the better predictor and, for this reason, was selected in the final model. DISCUSSION In this study of men aged 75 to 95 years, a substantial proportion were sexually active and considered sex to be an important part of their life. The older men were, the less likely they were to be sexually active, but sex remained at least somewhat important to one fifth of men aged 90 to 95 years, refuting the stereotype of the asexual older person. Of those who were sexually active, more than 40% were dissatisfied with the frequency of sexual activity, preferring sex more frequently. Having a partner who is capable of and interested in sex is an important determinant of whether older men are sexually active, but men s health problems seem to be the primary reason for ceasing sexual activity. Consistent with previous studies, we found the proportion of men who were sexually active to decrease with advancing age. However, older persons tend to hold more conservative attitudes toward sex than their younger counterparts (22), so this finding may reflect some degree of cohort and period bias. Only longitudinal studies can establish the true age effect. The cross-sectional and longitudinal associations between diabetes and sexual inactivity are unsurprising. The link between diabetes and sexual dysfunction is well established and probably reflects neuropathy, endothelial dysfunction, and decreased levels of nitric oxide, which is essential to erectile response (23). The relatively strong associations observed for antidepressant use are also consistent with the literature. Impaired libido is a common sequela of depression and is thought to reflect changes in limbic neurotransmitters (23, 24). Although antidepressant medication can alleviate depression, it may worsen sexual dysfunction. In particular, selective serotonin reuptake inhibitors are often associated with decreased libido and anorgasmia (24). Similarly, the cross-sectional association between -blockers and sexual inactivity could also reflect underlying morbidity or may be largely attributable to these agents (25). Given that independent associations were not observed for other antihypertensive agents, the latter seems most likely. Although -blockers may cause sexual dysfunction, older patients may not voice concerns about sexual side effects with clinicians. A perception that sex is less important to older persons may lead to patients feeling that their concerns will be trivialized or that sexual side effects are unavoidable. Given that a substantial proportion of older men want to remain sexually active as they age, clinicians should counsel patients about potential sexual side effects of medications and suggest alternative agents where appropriate. Of interest, prostatectomy was not independently associated with decreased odds of sexual activity in either the cross-sectional or longitudinal multivariate model, perhaps reflecting improvements in surgical technique. The negative association between prostate cancer and sexual activity could reflect a more invasive surgical procedure but most likely reflects the effect of hormonal intervention, which is well known to adversely affect libido and erectile function (26). An important and novel finding of our study was the moderate longitudinal association between free testosterone levels and subsequent sexual activity. Endogenous testosterone levels seem to be an independent predictor of sexual activity in men, presumably mediated through libido (27). Nevertheless, the role of testosterone therapy in the treatment of sexual dysfunction is unclear (28). Although desire and erectile function have been shown to improve in hypogonadal men who receive testosterone, men with testosterone levels in the normal range obtain little benefit (29, 30). However, many trials of testosterone therapy have not been sufficiently powered to detect small December 2010 Annals of Internal Medicine Volume 153 Number 11

7 Sexual Activity in Older Men Original Research to moderate effects. Large-scale studies are needed to determine whether interventions that increase testosterone levels in older men can improve sexual interest and activity. Our findings are similar to previous studies of sexuality in middle-aged and older men, which we identified through a MEDLINE search of studies published in English (keywords included sex, sexuality, sexual activity, elderly, older, geriatric, and aging). Lindau and colleagues (10) conducted a cross-sectional study of 3005 community-dwelling adults (including 1455 men) from the United States. Sexual activity in the past 12 months was reported by 84%, 67%, and 39% of men aged 57 to 64 years, 65 to 74 years, and 75 to 85 years, respectively. Among men, diabetes was associated with lack of sexual desire and with erectile dysfunction but was not associated with sexual activity. Araujo and coworkers (11) studied 1085 men from the population-based Massachusetts Male Aging Study. Participants were aged 40 to 70 years at baseline and received follow-up 7 to 10 years later. The number of times per month that the participants had sex decreased by less than 1 time for those aged 40 to 49 years, 2 times for those aged 50 to 59 years, and 3 times for men aged 60 to 70 years. Measures of sexual desire and satisfaction also declined with age. Potential mechanisms under- Table 3. Cross-sectional Logistic Regression Analyses of Factors Associated With Sexual Activity in the 12 Months Before Survey Wave 3 (2008 to 2009) in 2758 Men With Complete Data* Variable Univariate Analysis Multivariate Analysis Odds Ratio (95% CI) P Value Odds Ratio (95% CI) P Value Age 0.88 ( ) ( ) Education level Tertiary qualification 1.00 (reference) High school 1.01 ( ) Some high school 0.93 ( ) Primary school or no school 0.90 ( ) Body mass index Underweight ( 18.5 kg/m 2 ) 0.09 ( ) Normal ( kg/m 2 ) 1.00 (reference) Overweight ( kg/m 2 ) 1.04 ( ) Obese ( 30 kg/m 2 ) 0.85 ( ) Living with a partner 2.24 ( ) ( ) Partner lacks interest in sex 0.12 ( ) ( ) Partner has physical limitations 0.22 ( ) ( ) Non English-speaking background 1.57 ( ) ( ) Arthritis 0.85 ( ) Osteoporosis 0.59 ( ) ( ) Coronary heart disease 0.72 ( ) Stroke or transient ischemic attack 0.73 ( ) Heart failure 0.56 ( ) Atrial fibrillation 0.73 ( ) Sleep apnea 1.20 ( ) Insomnia 0.89 ( ) Pulmonary disease 0.94 ( ) Benign prostatic hypertrophy 1.09 ( ) Prostate cancer 0.43 ( ) ( ) Prostatectomy 0.76 ( ) Other cancer in past 5 y 0.83 ( ) Dementia 0.71 ( ) Leg ulcer 0.56 ( ) Eye disorder 0.77 ( ) Epilepsy 0.58 ( ) Parkinson disease 0.41 ( ) Thyroid disorder 0.87 ( ) Irritable bowel syndrome 0.87 ( ) Hypertension 0.93 ( ) Diabetes mellitus 0.77 ( ) ( ) Dyslipidemia 0.85 ( ) Patient Health Questionnaire score ( ) Antidepressant use 0.45 ( ) ( ) Neuroleptic use 1.35 ( ) Blocker use 0.76 ( ) Blocker use 0.71 ( ) ( ) Diuretic use 0.66 ( ) Ever smoked 0.81 ( ) Drinks alcohol 1.14 ( ) * All variables were measured at wave 3, except educational attainment, which was measured at wave December 2010 Annals of Internal Medicine Volume 153 Number

8 Original Research Sexual Activity in Older Men Table 4. Longitudinal Logistic Regression Analyses of Factors Measured at Survey Wave 2 (2001 to 2004) and Their Association With Sexual Activity in the 12 Months Before Survey Wave 3 (2008 to 2009) in 1500 Men With Sex Hormone Data* Variable Univariate Analysis Multivariate Analysis Odds Ratio (95% CI) P Value Odds Ratio (95% CI) P Value Age 0.89 ( ) ( ) Education level Tertiary qualification 1.00 (reference) High school 0.86 ( ) Some high school 0.87 ( ) Primary school or no school 0.81 ( ) Body mass index Normal ( kg/m 2 ) 1.00 (reference) Overweight ( kg/m 2 ) 1.01 ( ) Obese ( 30 kg/m 2 ) 0.58 ( ) Living with a partner 2.33 ( ) ( ) Partner lacks interest in sex 0.11 ( ) ( ) Partner has physical limitations 0.18 ( ) ( ) Non English-speaking background 1.71 ( ) ( ) Arthritis 0.81 ( ) Osteoporosis 0.59 ( ) Coronary heart disease 0.80 ( ) Stroke or transient ischemic attack 0.72 ( ) Insomnia 0.85 ( ) Pulmonary disease 0.91 ( ) Prostatectomy 0.76 ( ) Cancer (not prostate) in past 5 y 1.05 ( ) Dementia 0.65 ( ) Hypertension 0.68 ( ) Diabetes mellitus 0.68 ( ) ( ) Dyslipidemia 0.80 ( ) Geriatric Depression Scale score ( ) Antidepressant use 0.39 ( ) ( ) Neuroleptic use 0.59 ( ) Blocker use 0.93 ( ) Blocker use 0.85 ( ) Diuretic use 0.73 ( ) Ever smoked 0.77 ( ) Total testosterone 1.15 ( ) Free testosterone 1.18 ( ) ( ) Sex hormone binding globulin 0.99 ( ) Luteinizing hormone 0.83 ( ) * Hormonal variables were entered into the models as Z scores; odds ratios indicate the effect of a 1-SD increase in hormone level. All variables were measured at wave 2, except educational attainment (which was measured at wave 1) and those marked with a dagger. Measured at wave 3. lying these changes were not explored by the investigators. Beckman and colleagues (31) reported the results of a series of cross-sectional, population-based surveys of 1506 adults (of whom 560 were men) aged 70 years from Gothenburg, Sweden. Men were sampled from 1971 to 1972, 1976 to 1977, and 2000 to Sexual intercourse in the past 12 months was reported by 47%, 48%, and 66% of men in the first, second, and third surveys, respectively. Of those not sexually active in the final survey, 64% reported this was because of their lack of desire or capability, whereas 30% cited their partner s lack of desire or capability. The remaining 6% did not have a partner. The researchers concluded that the male partner was largely the determining factor in whether an older heterosexual couple continues to be sexually active. Strengths of our study include large sample size; composition of randomly selected, community-dwelling men; and comprehensive assessment of medical comorbid conditions. In particular, use of the Western Australian Data Linkage System enhanced detection of medical conditions and surgical procedures that might affect sexual function, such as prostate cancer and prostatectomy. Limitations may include recall and response bias, survivorship effects, possible underrepresentation of men from low socioeconomic backgrounds, and cultural and linguistically diverse groups. Random sampling strategies are likely to underrepresent such hard-to-reach persons unless oversampling is used (32). We did not have the opportunity to collect serial blood samples to assess hormone levels over time. However, blood sampling at a single time point offers a reasonable estimate of prevailing testosterone levels (33). The questions assessing sexual behavior were simple and did not require detailed answers, in hopes of minimizing recall bias. Although analysts were blinded to participants iden December 2010 Annals of Internal Medicine Volume 153 Number 11

9 Sexual Activity in Older Men Original Research tities, our study was not anonymous, and this may have encouraged response bias. Sexuality is a sensitive topic for many and is subject to various social, religious, and legal norms. Participants may therefore be reluctant to report socially censured behaviors (32). We also asked participants about sexual activity and satisfaction with sex in terms of frequency, which may not correlate with measures of quality. Given attrition over successive waves of the study, it is also likely that our results reflect some degree of survivorship bias. Rates of chronic medical conditions are similar to those reported in other studies of elderly persons, but our results are probably best considered representative of relatively healthy, community-dwelling men, rather than elderly men generally. We also cannot exclude the possibility of nonresponse bias, in which men with less liberal sexual attitudes were perhaps less likely to answer the sexual activity questions. The number of men who considered sex at least somewhat important was greater than the number who were sexually active in all age groups, suggesting that a substantial proportion of older men may have unmet sexual needs. Addressing risk factors, such as depression, diabetes, and medication use may improve sexual activity but will not benefit partnerless men. These findings highlight the need for further multidisciplinary research to explore how older men can achieve sexual fulfillment when they are widowed or when their partners are incapable of or uninterested in sex. In conclusion, although older men are less likely than their younger counterparts to be sexually active, sex remains important to many older men, even in the 10th decade of life. Men s health problems were associated with reduced likelihood of being sexually active, suggesting that these problems are the main reason that older men cease sexual activity. Potentially modifiable risk factors include diabetes, depression, and medication use. Endogenous testosterone levels seem to predict sexual activity after adjustment for social factors and medical comorbid conditions, but it is unclear what role testosterone therapy may have in improving sexual function in older men. Given the difficulty establishing causality in observational studies, further research is required to explore this question. From Western Australian Centre for Health and Ageing, Centre for Medical Research, Western Australian Institute for Medical Research, School of Medicine and Pharmacology, School of Psychiatry and Clinical Neurosciences, University of Western Australia, Crawley; Royal Perth Hospital, Perth; and Fremantle Hospital, Fremantle, Western Australia, Australia. Acknowledgment: The authors thank Tricia Knox and the staff of the Departments of Biochemistry, PathWest, Royal Perth and Fremantle Hospitals, Western Australia, Australia, for their assistance in performing the hormone assays; Peter Feddema, DPC-Biomediq, Doncaster, Victoria, Australia, for his assistance with sourcing hormone assay kits and reagents; and the staff and management of Shenton Park Hospital, Shenton Park, Western Australia, Australia, for providing space in which to conduct follow-up clinics. The authors especially thank all the men who participated in the study and the research assistants who helped with data collection. Grant Support: By grants , , , , and from the National Health and Medical Research Council of Australia and grant DS from the MBF Foundation of Australia. Ms. Hyde is supported by a National Health and Medical Research Council Biomedical Postgraduate Scholarship. Hormone assays were funded by a Clinical Investigator Award to Dr. Yeap from the Sylvia and Charles Viertel Charitable Foundation, New South Wales, Australia. Potential Conflicts of Interest: Disclosures can be viewed at M Reproducible Research Statement: Study protocol and data set: Not available. Statistical code: Available from Ms. Hyde ( , Requests for Single Reprints: Zoë Hyde, MPH, Western Australian Centre for Health and Ageing (M570), University of Western Australia, 35 Stirling Highway, Crawley, Western Australia 6009, Australia; , zoe@sexologyresearch.org. Current author addresses and author contributions are available at References 1. Covey HC. Perceptions and attitudes toward sexuality of the elderly during the Middle Ages. Gerontologist. 1989;29: [PMID: ] 2. Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Male. Philadelphia: WB Saunders; Gott M, Hinchliff S, Galena E. General practitioner attitudes to discussing sexual health issues with older people. Soc Sci Med. 2004;58: [PMID: ] 4. Australian Institute of Health and Welfare. Older Australia at a Glance. 4th ed. Canberra: Australian Institute of Health and Welfare; Smith AM, Pitts MK, Shelley JM, Richters J, Ferris J. The Australian longitudinal study of health and relationships. BMC Public Health. 2007;7:139. [PMID: ] 6. Comfort A, Dial LK. Sexuality and aging. An overview. Clin Geriatr Med. 1991;7:1-7. [PMID: ] 7. Andrews CN, Piterman L. Sex and the older man GP perceptions and management. Aust Fam Physician. 2007;36: [PMID: ] 8. Jung A, Schill WB. Male sexuality with advancing age. Eur J Obstet Gynecol Reprod Biol. 2004;113: [PMID: ] 9. Gott M, Hinchliff S. How important is sex in later life? The views of older people. Soc Sci Med. 2003;56: [PMID: ] 10. Lindau ST, Schumm LP, Laumann EO, Levinson W, O Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med. 2007;357: [PMID: ] 11. Araujo AB, Mohr BA, McKinlay JB. Changes in sexual function in middleaged and older men: longitudinal data from the Massachusetts Male Aging Study. J Am Geriatr Soc. 2004;52: [PMID: ] 12. Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR; Baltimore Longitudinal Study of Aging. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. Baltimore Longitudinal Study of Aging. J Clin Endocrinol Metab. 2001;86: [PMID: ] 13. Smith LJ, Mulhall JP, Deveci S, Monaghan N, Reid MC. Sex after seventy: a pilot study of sexual function in older persons. J Sex Med. 2007;4: [PMID: ] 14. Ginsberg TB, Pomerantz SC, Kramer-Feeley V. Sexuality in older adults: behaviours and preferences. Age Ageing. 2005;34: [PMID: ] 15. Norman PE, Flicker L, Almeida OP, Hankey GJ, Hyde Z, Jamrozik K. Cohort Profile: The Health In Men Study (HIMS). Int J Epidemiol. 2009;38: 7 December 2010 Annals of Internal Medicine Volume 153 Number

10 Original Research Sexual Activity in Older Men [PMID: ] 16. Yeap BB, Almeida OP, Hyde Z, Norman PE, Chubb SA, Jamrozik K, et al. In men older than 70 years, total testosterone remains stable while free testosterone declines with age. The Health in Men Study. Eur J Endocrinol. 2007;156: [PMID: ] 17. Vermeulen A, Verdonck L, Kaufman JM. A critical evaluation of simple methods for the estimation of free testosterone in serum. J Clin Endocrinol Metab. 1999;84: [PMID: ] 18. Holman CD, Bass AJ, Rouse IL, Hobbs MS. Population-based linkage of health records in Western Australia: development of a health services research linked database. Aust N Z J Public Health. 1999;23: [PMID: ] 19. Almeida OP, Almeida SA. Short versions of the geriatric depression scale: a study of their validity for the diagnosis of a major depressive episode according to ICD-10 and DSM-IV. Int J Geriatr Psychiatry. 1999;14: [PMID: ] 20. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16: [PMID: ] 21. Hosmer DW, Lemeshow S. Applied Logistic Regression. New York: J Wiley; Waite LJ, Laumann EO, Das A, Schumm LP. Sexuality: measures of partnerships, practices, attitudes, and problems in the National Social Life, Health, and Aging Study. J Gerontol B Psychol Sci Soc Sci. 2009;64 Suppl 1:i [PMID: ] 23. Wylie K, Kenney G. Sexual dysfunction and the ageing male. Maturitas. 2010;65:23-7. [PMID: ] 24. Clayton AH, Montejo AL. Major depressive disorder, antidepressants, and sexual dysfunction. J Clin Psychiatry. 2006;67 Suppl 6:33-7. [PMID: ] 25. Ko DT, Hebert PR, Coffey CS, Sedrakyan A, Curtis JP, Krumholz HM. Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction. JAMA. 2002;288: [PMID: ] 26. Schwandt A, Garcia JA. Complications of androgen deprivation therapy in prostate cancer. Curr Opin Urol. 2009;19: [PMID: ] 27. Mitchell Harman S. Testosterone, sexuality, and erectile function in aging men. J Androl. 2003;24:S42-5. [PMID: ] 28. Yeap BB. Are declining testosterone levels a major risk factor for ill-health in aging men? Int J Impot Res. 2009;21: [PMID: ] 29. Isidori AM, Giannetta E, Gianfrilli D, Greco EA, Bonifacio V, Aversa A, et al. Effects of testosterone on sexual function in men: results of a meta-analysis. Clin Endocrinol (Oxf). 2005;63: [PMID: ] 30. Boloña ER, Uraga MV, Haddad RM, Tracz MJ, Sideras K, Kennedy CC, et al. Testosterone use in men with sexual dysfunction: a systematic review and meta-analysis of randomized placebo-controlled trials. Mayo Clin Proc. 2007;82: [PMID: ] 31. Beckman N, Waern M, Gustafson D, Skoog I. Secular trends in self reported sexual activity and satisfaction in Swedish 70 year olds: cross sectional survey of four populations, BMJ. 2008;337:a279. [PMID: ] 32. Fenton KA, Johnson AM, McManus S, Erens B. Measuring sexual behaviour: methodological challenges in survey research. Sex Transm Infect. 2001;77: [PMID: ] 33. Vermeulen A, Verdonck G. Representativeness of a single point plasma testosterone level for the long term hormonal milieu in men. J Clin Endocrinol Metab. 1992;74: [PMID: ] FAST-TRACK REVIEW Annals will consider manuscripts of high quality for expedited review and early publication (Fast Track) if they have findings that are likely to affect practice immediately and if they are judged valid. We give priority to fast-tracking large clinical trials with clinical outcomes. Authors wishing to fast-track their articles should contact Senior Deputy Editor Dr. Cynthia Mulrow ( , cynthiam@acponline.org) and provide an electronic version of their manuscript along with a request and justification for expedited review December 2010 Annals of Internal Medicine Volume 153 Number 11

11 Current Author Addresses: Ms. Hyde and Drs. Flicker, Almeida, and McCaul: Western Australian Centre for Health and Ageing (M570), University of Western Australia, 35 Stirling Highway, Crawley, Western Australia 6009, Australia. Dr. Hankey: Royal Perth Hospital, GPO Box X2213, Perth, Western Australia 6001, Australia. Drs. Chubb and Yeap: Fremantle Hospital, PO Box 480, Fremantle, Western Australia 6959, Australia. Author Contributions: Conception and design: Z. Hyde, G.J. Hankey, O.P. Almeida, K.A. McCaul, B.B. Yeap. Analysis and interpretation of the data: Z. Hyde, L. Flicker, K.A. Mc- Caul, B.B. Yeap. Drafting of the article: Z. Hyde, G.J. Hankey. Critical revision of the article for important intellectual content: Z. Hyde, L. Flicker, G.J. Hankey, O.P. Almeida, K.A. McCaul, S.A.P. Chubb, B.B. Yeap. Final approval of the article: Z. Hyde, L. Flicker, G.J. Hankey, O.P. Almeida, K.A. McCaul, S.A.P. Chubb, B.B. Yeap. Provision of study materials or patients: L. Flicker, B.B. Yeap. Statistical expertise: Z. Hyde, L. Flicker, K.A. McCaul. Obtaining of funding: L. Flicker, G.J. Hankey, O.P. Almeida, B.B. Yeap. Administrative, technical, or logistic support: L. Flicker, K.A. McCaul, S.A.P. Chubb, B.B. Yeap. Collection and assembly of data: Z. Hyde, L. Flicker, O.P. Almeida, S.A.P. Chubb, B.B. Yeap. W December 2010 Annals of Internal Medicine Volume 153 Number 11

12 CORRECTION: SEXUAL ACTIVITY IN MEN AGED 75 TO 95 YEARS In the recent article by Hyde and colleagues (1), the unit of measure for sex hormone-binding globulin in Table 1 should be nmol/l, not g/ml. This has been corrected in the online version. Reference 1. Hyde Z, Flicker L, Hankey GJ, Almeida OP, McCaul KA, Chubb SAP, et al. Prevalence of sexual activity and associated factors in men aged 75 to 95 years: a cohort study. Ann Intern Med. 2010;153: