289

The Epidemiology of Sexual Dysfunctions

Leonard R. DeRogatis, PhD, and Arthur L. Burnett, MD

Center for Sexual Medicine at Sheppard Pratt, Baltimore, MD, USA; Department of Psychiatry, Johns Hopkins University
School of Medicine, Baltimore, MD, USA; Department of Urology, The James Buchanan Brady Urological Institute,
Baltimore, MD, USA; The Johns Hopkins Hospital and The Johns Hopkins University School of Medicine, Baltimore, MD,
USA

DOI: 10.1111/j.1743-6109.2007.00668.x

ABSTRACT

Introduction. Epidemiology can be dened as the population study of the occurrence of health and disease. The
knowledge of the rates of occurrence of sexual dysfunctions and the primary risk factors for these conditions is very
important to assist in assessing the risk and planning treatment and prevention programs in sexual medicine.
Aim. Review modern studies of the prevalence and incidence of sexual dysfunction in an effort to establish a
consensus concerning the frequency of occurrence of these conditions, and review the strengths and liabilities of
design methodology in the eld.
Main Outcome Measure. Review of peer-reviewed literature.
Results. The ndings suggest that sexual dysfunctions are highly prevalent in our society worldwide, and that the
occurrence of sexual dysfunctions increases directly with age for both men and women. There is also a strong support
for the nding that although the frequency of symptoms increases with age, personal distress about those symptoms
appears to diminish as individuals become older. An additional uniform result was that specic medical conditions
and health behaviors represent major risk factors for sexual disorders, and that many of these health conditions also
have a strong positive relationship with age.
Conclusions. Progress has been made concerning both the number and quality of epidemiologic prevalence studies
in sexual medicine; however, there is a paucity of studies of the incidence of these conditions. Because reliable
incidence data are critical for prevention and treatment planning, the design and execution of the incidence trials
should become a high priority for the eld. In addition, repeated calls for the development of a new systematic and
integrated diagnostic system in sexual medicine were also evident, because of the perception by many that the
imprecision of our current diagnostic system represents the rate-limiting step for the epidemiology of the eld.
The review suggests that although much has been accomplished in the past 1520 years, much remains to be done.
DeRogatis LR, and Burnett AL. The epidemiology of sexual dysfunctions. J Sex Med 2008;5:289300.
Key Words. Sexual Dysfunctions; Epidemiology; Prevalence; Incidence; Nosology

Introduction rests on being functional and unimpaired in the

physical, psychologic, and relational aspects of

E pidemiology can be dened as the population

study of the occurrence of health and disease,
with an ultimate goal of maintenance of the former
and prevention of the latter. The oft-quoted state-
ment of the World Health Organization [1] to the
effect that health is a state of complete physical,
mental and social well-being, and not merely the
absence of disease or inrmity, reminds us that
dening health can sometimes be as demanding an
enterprise as a delineating disease. Sexual health
sexual behavior, and conversely, it is almost certain
that each of these facets of sexual behavior makes a
tangible contribution to states in which sexual
function goes awry.
There are numerous reasons why epidemiology
is important to the science of sexual medicine.
Epidemiology offers a powerful set of methods to
potentially address questions about the nature, eti-
ology, prognosis, and treatment of sexual dis-
orders. In part, this is because cases of sexual

2007 International Society for Sexual Medicine J Sex Med 2008;5:289300

290
dysfunction seen in the clinic represent only a
minor fraction of the range of cases of sexual dis-
orders present in the population. Also, because
experimental manipulation of the major determi-
nants of sexual dysfunctions is usually not feasible
or possible, epidemiology contributes exibility of
design that enables the study of the impact of these
factors via alternative methods.
The most fundamental study designs in epide-
miology are referred to as observational studies, and
within this category, a distinction is usually made
between descriptive studies and analytic studies.
Descriptive studies tend to be done when we know
little about the nature, occurrence, or risk factors
of the disorder. The principal goals of such studies
are to establish reliable estimates of the frequency
of the condition in the population under study, and
perhaps generate useful hypotheses about the
conditions etiology. In analytic studies typically,
enough is already known about the disorder and its
potential determinants to enable specic hypoth-
eses to be tested. The identication of the risk
factors of the condition and their causal associa-
tion with the index disorder is the major focus of
analytic studies.
A key aspect of analytic epidemiologic studies is
establishing a relative index of association between
the risk factors and the disorder under consider-
ation, i.e., how convincing are the relationships
between hypothetical risk factors A, B, and C, and
the occurrence of the disorder. The relative
weights of various risk factors are determined by
measures of association which are themselves
established by a number of factors: strength of
association (in terms of exposure/nonexposure and
presence of the condition), temporal relationships
(risk factor antedates disorder), generalizability of
the association (e.g., present in Asians, blacks, Cau-
casians), and specicity of the association (necessity/
sufciency of the risk factor of the disorder).
However, estimating the relative importance of
risk factors can become complicated when the
condition under study is multifactorially deter-
mined, as are the sexual dysfunctions, with either
alternative (A or B or C) or cumulative (A + B + C)
patterns of causation.
Relationship Between Epidemiology, Nosology, and
Standardized Methods
In the case of sexual dysfunctions, the large major-
ity of our epidemiologic studies are observational
descriptive in nature, with the reporting of very few
analytic trials. This is so in large measure because
our nosology, or diagnostic system, is relatively
J Sex Med 2008;5:289300
DeRogatis and Burnett
imprecise and our methods are neither standard-
ized nor very clearly articulated. Writing speci-
cally in reference to psychiatric epidemiology,
Allen and his colleagues stated, The availability of
a widely accepted and reliable diagnostic system
is an essential prerequisite to . . . epidemiology.
Further, they made the point, Epidemiologic
research is impossible without clear and consistent
methods of classifying and diagnosing . . . disor-
ders [2]. Imprecise diagnostic denitions result in
imprecise estimates of occurrence rates, and very
much impede meaningful attempts at evaluating
risk factors. Inconsistent methods continually
hamper the attempts of gaining the consensus
estimates of the population rates of dysfunction.
Dunn and her colleagues, referring to their 2002
review of 28 studies of female sexual dysfunction
(FSD) [3], stated, . . . the heterogeneity of studies
ruled out the possibility of formally pooling the
data. Furthermore, this variety of methodology,
study design, and case denitions . . . meant that
giving a reliable overall estimate of the different
sexual problems was not possible (p. 418). Simi-
larly, Hayes and his associates recently concluded
in their review of prevalence studies of FSD, As
measures of sexual dysfunction and time frames
differ between studies, it is still not possible to
determine reliable overall prevalence estimates of
FSD (p. 594) [4].
The large majority of epidemiologic investiga-
tions of sexual dysfunctions have involved esti-
mates of the prevalence of various conditions.
However, it is important to realize that the
methods of data collection in these studies have
been extremely variable, including mailed surveys,
telephone interviews, rarely, scores on validated
test instruments, and even more rarely, in-person
interviews. In the current review, we will limit our
evaluation to studies completed circa 1990 and
thereafter. This is because prevalence data from
earlier studies of sexual dysfunctions tended to use
heterogeneous case denitions, in some cases
focused on symptoms, in others on problems,
and only rarely on formal disorders. The design
methodology also varied enormously in these
earlier trials as was pointed out in Spector and
Careys review of 47 earlier studies in 1990 [5]. An
updated review by Simons and Carey in 2001 sum-
marized the results of 52 FSD studies accom-
plished since the previous review [6]. They were
able to develop a pooled current and 1-year
prevalence estimate of 710% for orgasmic dis-
order; however, they concluded that in spite of
some improvement in standardization, because
Epidemiology of Sexual Dysfunctions
of extreme heterogeneity, it remained difcult
to pool results across studies. They stated,
. . . despite the increased attention in the past
decade to the study of sexual dysfunctions there
appears to have been relatively little methodologi-
cal improvement overall (p. 215).
These problems represent a fundamental limi-
tation for contemporary research in sexual medi-
cine, and while there are appeals to the eld to
effectively address these pervasive issues [7,8], our
current epidemiologic research remains strongly
encumbered by the absence of a more rigorous
diagnostic system and the use of a standardized
methodology.
Practical Matters and Current Standards
Additional factors also inuence attempts to
derive frequency statistics for sexual dysfunctions.
Perhaps of greatest concern is the extent to which
sexual disorders, that essentially require self-
reporting, are perceived to be problematic for the
affected individuals. Affected individuals with
erectile dysfunction (ED), for instance, may not
perceive the disorder to be a problem for them,
either in terms of degree of distress or signicance
as a life-threatening condition. Also, for disorders
associated with social stigmatism, which may be
such for sexual disorders, the presence and extent
of the problem, as reported, may signicantly vary
from their actual occurrences [9]. The inuence of
cultural, religious, and legal norms may impact the
estimations of sexual problems within a commu-
nity of interest. The availability of regular sex part-
ners among surveyed individuals may also affect
the assessments of sexual function. Finally, it is
important to consider the time frame of the
investigation. In the current era of effective oral
medication to treat ED, following the advent of
phosphodiesterase type 5 inhibitor therapy in
1998, there has been an increased public health
awareness surrounding ED and its societal impact,
possibly generating greater acknowledgment and
acceptance of the widespread presence of sexual
disorders.
Epidemiologic research of sexual dysfunctions
has evolved formatively in the direction toward
increasingly rigorous investigative methodology.
Early reports in the literature commonly derived
estimates based on persons having sexual disorders
seen in a hospital, clinic, or doctors ofce. For
instance, patients evaluated in an endocrinology
clinic for diabetes mellitus permitted an opportu-
nity to ascertain the presence and frequency of an
associated sexual disorder such as ED occurring
291
among those with the primary disease state. Such
studies afforded insight into the risk relationship
between a particular sexual disorder and the
primary disease state and further suggested
pathophysiologic mechanisms accounting for the
disorder. However, such studies reect select
populations, and thus, do not serve to describe the
circumstances of the sexual problem as it affects
the broad population. More recently, peer-
reviewed scientic literature has emerged based on
studies that apply contemporary probability-based
sampling strategies, and thus, yield data that are
representative of the population at large. These
reports are believed to offer a rened understand-
ing of the true population frequencies of sexual
dysfunctions, appropriate for advancing meaning-
ful global public health efforts to address them.
Based on recent consensus guidelines, contem-
porary standards of assessment for epidemiologic
studies should apply external and internal valida-
tion [10]. External validity requires the denition
of the source population, description of eligibility
according to such features as age range and
inclusion and exclusion criteria, conrmation of a
response rate of at least 70% of the sample studied,
specication of the study period, and adequate
characterization of the study population (e.g., age,
gender, presence of comorbidities, socioeconomic
status). Internal validity requires prospective data
collection, application of validated (and properly
used) measurement instruments, and statement of
the denition of the sexual disorder under study
(see above).
Measures of the Frequency of Disorder
In order to do science in almost any area of dis-
course, methods must be developed to promote
the quantication of outcomes; in the case of
epidemiology, these measures are focused on the
quantication of disorder occurrence. As raw counts
of occurrence have little meaning, in and of them-
selves, more sophisticated indices have been devel-
oped to reect factors like the reference population,
those at risk, and the period over which observa-
tions were made. Although there are numerous
indicators of the frequency with which disease
occurs, the two fundamental indicators are the
prevalence and incidence of the disorder.
Definition of Prevalence
Prevalence is dened simply as the proportion of
existing cases in a population relative to the total
population at risk at a particular point in time. It
J Sex Med 2008;5:289300
292
essentially communicates the probability that an
individual in the population will have the disorder
at a specic point in time. This form of prevalence
is referred to as point prevalence, as the reference
period is a specic point in time.
Number of existing cases at
a specific time (T1 )
P=
Total population at risk
A second important measure of prevalence is
referred to as period prevalence. This measure of
prevalence enumerates the number of cases of the
condition occurring in the population under study
during a specic period of time (e.g., 6 months, 12
months, lifetime). Period prevalence combines
information on existing cases with occurrences of
new cases of the disorder.
Definition of Incidence
Incidence is dened as the number of new cases of
a particular disorder that develop during a speci-
ed time period. It essentially represents an esti-
mate of the risk of developing the condition during
the specied time window.
Number of new cases during
a specific time period
I=
Total population at risk
Because incidence reects the emergence of new
cases, and thereby a change in health status during
the measurement period, many epidemiologists
feel that it represents a measure that is very well
suited to study risk factors. Prevalence on the other
hand, is a function of both prior incidence and
duration of the index condition. If a condition has a
brief duration, then prevalence tends to be low;
however, if illness duration is chronic, even with a
low incidence rate, cases will accumulate over time
and prevalence will be high relative to incidence.
Currently in sexual medicine, because of the
gradual and uncertain onset of most sexual dysfunc-
tions, the large majority of epidemiologic studies
report occurrence in terms of prevalence data.
Male Sexual Dysfunctions
Prevalence of Male Sexual Dysfunctions
The Massachusetts Male Aging Study (MMAS) is
perhaps recognized as the rst population-based
study offering a determination of the prevalence
rate of ED [11]. This study, which comprised a
sample of 1,800 men surveyed in a Boston, MA
area from 19871989, reported a prevalence rate
J Sex Med 2008;5:289300
DeRogatis and Burnett
of 52% for any level of ED (including minimal,
moderate, and complete presentations) and that of
35% for moderate or complete ED. The study also
documented the relationship of age and ED, deter-
mining that the prevalence rates of complete ED
(no ability to achieve an erection) increased from
5% to 15% for men between the ages of 40 and 70
years. The study comprised mainly of Caucasian
men within this age range only, and thus, it is not
useful to draw conclusions about national varia-
tions in race and ethnicity or the prevalence of ED
in men over the age of 70 years.
The National Health and Social Life Survey, a
cross-sectional interview survey conducted in
1992, which included 1,410 men aged 1859 years
throughout the United States, found that approxi-
mately 10% of the respondents had trouble
maintaining or achieving an erection, and the
prevalence of any form of sexual dysfunction in
men was 31% [12]. The study also evaluated sexual
dysfunctions other than ED including low desire
(approximate overall rate of 15%), and inability to
achieve orgasm (approximate overall rate of 8%).
An age-associated decline in sexual problems was
also conrmed. Compared to the referent group of
men aged 1829, the oldest cohort of men (ages
5059 years) were more than 3.5 times as likely to
experience ED (95% condence interval [CI], 1.8
7.0), nearly three times as likely to experience low
sexual desire (95% CI, 1.65.4), and two times as
likely to experience inability to achieve orgasm
(95% CI, 0.793.83). Climaxing or ejaculating
too rapidly was the most commonly indicated
sexual dysfunction in this study, affecting approxi-
mately 30% of respondents with similar rates
across age groups.
The Health Professions Follow-up Study,
which involved a sample of more than 31,000 men
aged 5390 years surveyed in 1992, found that ED
based on the conservative criteria of poor to very
poor function was 33%, ranging from about 25%
among those younger than 59 years to 61% in
individuals older than 70 years [13]. The study also
demonstrated that many aspects of sexual function
decreased sharply by decade after 50 years of age.
For age groups 5359 years, 6069 years, 7079
years, and older than 80 years, respectively, very
good overall sexual function was 44%, 25%, 8%,
and 2%; very good sexual desire was 34%, 24%,
12%, and 6%; and very good ability to reach
orgasm was 51%, 33%, 13%, and 4%. The study
also reported the extent to which sexual function is
a big problem, with percentages for the respec-
tive age groups of 3%, 7%, 13%, and 19%.
Epidemiology of Sexual Dysfunctions
A report based on the release of the 20012002
National Health and Nutrition Examination
Survey (NHANES), a population-based survey
comprising of 2,126 men from 20 to greater than
75 years of age representing broad racial and
ethnic groups in the United States, established an
18.4% ED prevalence rate, based on self-reporting
of being sometimes able or never able to keep an
erection adequate for sexual intercourse [14]. An
age relationship with ED was shown, with a preva-
lence of ED, as previously dened, found to
increase steadily from 6.5% in men aged 2039
years to 77.5% in those 75 years and older. The
percentage of the participants with the most severe
ED, measured by reporting being never able to
maintain an erection, increased from 2% to 47%
between the indicated age categories. Hispanic
men reported ED at approximately twice the rate
as Caucasians (12.5% vs. 4.9%), after controlling
for other ED-related factors such as diabetes,
obesity, and hypertension [14]. Modiable risk
factors independently associated with ED included
diabetes mellitus (odds ratio [OR], 2.69), obesity
(OR, 1.60), current smoking (OR, 1.74), and
hypertension (OR, 1.56).
A separate analysis of the 20012002 NHANES
database, corroborated the aforementioned analy-
sis, also establishing 18.4% ED prevalence rate for
the United States male population [15]. Further
analysis of the cardiovascular risk factors estab-
lished age-adjusted ED prevalence rates of 38.6%
(95% CI, 28.749.5) among men with diabetes
mellitus, 15.1% (95% CI, 10.620.9) and 27.7%
(95% CI, 21.435.0) among men with treated and
untreated hypertension, respectively, 24.7% (95%
CI, 18.132.7) among men with a history of car-
diovascular disease, 17.0% (95% CI, 14.320.1)
among men with hypercholesterolemia, 19.6%
(95% CI, 13.926.8) among men with history of
benign prostate enlargement, and 23.3% (95% CI,
20.027.0) and 12.6% (95% CI, 9.816.2) among
men performing no physical activity and vigorous
physical activity, respectively.
Another nationally representative survey, the
Male Attitudes Regarding Sexual Health Survey,
conducted in 20012002, included men older than
40 years of age and oversampled minority indi-
viduals. In this study, the estimated prevalence of
moderate or severe ED, dened as a response of
sometimes or never to the question, How Incidence of Male Sexual Dysfunctions
would you describe your ability to get and keep an
erection adequate for satisfactory intercourse?
was 22.0% (95% CI 19.424.6) overall [16]. ED
prevalence rates were 21.9% (95% CI, 18.824.9)
293
among 901 non-Hispanic white men, 24.4% (95%
CI, 18.430.5) among 596 non-Hispanic black
men, and 19.9% (95% CI, 13.925.9) among
676 Hispanic men. The study found that rates
increased with age, diabetes, hypertension, and
moderate or severe lower urinary tract symptoms.
Additional studies have recently been con-
ducted afrming the global extent of male sexual
disorders. The Global Survey of Sexual Attitudes
and Behavior represented a collection of data of
more than 27,000 men and women aged 4080
years conducted between 2001 and 2002 in 29
countries [17]. Early ejaculation was the most
commonly reported dysfunction in men occurring
at a 14% (95% CI, 1415) rate, having the greatest
frequency in Asia, Central/South America, and
non-European Western countries. Erectile dif-
culties were the second most frequent dysfunc-
tion in men, reported as an overall rate of 10%
(95% CI, 910), with the greatest rates in Asian
countries. An age-dependent decline in all male
sexual functions including lack of sexual interest
and inability to reach orgasm was conrmed in this
study.
The Mens Attitudes to Life Events and Sexu-
ality Study, a survey conducted in 2001 of more
than 27,500 randomly recruited men aged 2075
years in eight countries including the United
States, the United Kingdom, Germany, France,
Italy, Spain, Mexico, and Brazil, produced an
overall ED prevalence rate of 16% [18]. Similar
to prior discussed studies, the prevalence of
ED increased with increasing age and the pre-
sence of comorbid conditions such as cardio-
vascular disease, hypertension, dyslipidemia, and
depression.
Overall, notwithstanding variations in deni-
tions, methodology and study populations, these
reports substantiate the global presence and extent
of sexual dysfunctions in men. ED has been the
most thoroughly studied dysfunction, with an esti-
mated overall prevalence rate that ranges between
10% and 20% worldwide. Racial/ethnic and geo-
graphic analyses afrm the signicance that one in
ve men experience ED. However, other sexual
dysfunctions are also common. The studies have
also afrmed the correlates of age and comorbid
health conditions with various sexual dysfunctions.
Few epidemiologic studies exist which address
the incidence of male sexual dysfunctions. Such
studies are valuable to assess the risk and plan
treatment and prevention strategies. Longitudinal
J Sex Med 2008;5:289300
294
results of the MMAS with follow-up through 1997
have offered population-based incidence data
for ED [19]. The crude ED incidence rate was
25.9 cases/1,000 man-years (95% CI, 22.529.9)
among men aged 4069 years. The annual inci-
dence rate increased with each decade of life: 12.4
cases/1,000 for men aged 4049 years (95% CI,
9.016.9); 29.8 cases/1,000 for men aged 5059
years (95% CI, 24.037.0); and 46.4 cases/1,000
for men aged 6069 years (95% CI, 36.958.4).
The age-adjusted risk was found to be higher for
men with lower education, diabetes, heart disease,
and hypertension.
The MMAS database was also used to examine
coronary risk factors that may predict the devel-
opment of ED in a healthy subsample of men
free of ED or vascular disease at baseline [20].
Among several risk variables, cigarette smoking,
cigar smoking, passive exposure to cigarette
smoke, and overweight status were signicant
predictors of incident ED.
A side analysis of the recently conducted Pros-
tate Cancer Prevention Trial has also produced
incidence data for ED [21]. The trial, which began
in 1994, consisting of more than 18,800 men aged
55 years or older, was designed to assess whether
nasteride would reduce the prevalence of prostate
cancer over a period of 7 years. Among 9,457 men
randomized to the placebo group, 2,420 men (57%)
of 4,247 men without ED at study entry reported
incident ED after 5 years, and this rate increased to
65% at 7 years. Interestingly, the study showed that
incident or prevalent ED generated a hazard ratio
of 1.45 (95% CI, 1.251.69) for subsequent cardio-
vascular events, which is estimated to be in the
range of risk associated with current smoking or a
family history of myocardial infarction.
Female Sexual Dysfunction
Nosology of FSDs
Before reviewing the epidemiologic studies of
FSD, it is relevant that we rst briey review the
diagnostic system currently in use to classify these
conditions. The nosology utilized in the FSDs has
been based on a traditional four-phase model of
the female sexual response cycle put forward by
Masters and Johnson in 1970 [22]. Subsequently,
Kaplan modied the paradigm slightly to focus on
the three principal phases of desire, arousal and
orgasm [23]. This model then formed the basis for
the American Psychiatric Associations Diagnostic
and Statistical Manual of Mental Disorders, fourth
version (DSM-IV) system [24]. In 1998, the sys-
J Sex Med 2008;5:289300
DeRogatis and Burnett
tem was further modied slightly as a result of
the American Foundation of Urologic Disease
(AFUD) international consensus conference on
FSD [25]. Major diagnostic categories delineated
at the AFUD conference were hypoactive sexual
desire disorder (HSDD), female sexual arousal dis-
order, orgasmic disorder, and sexual pain disor-
ders. This fourfold classication is essentially
descriptive in nature, based entirely on clinical
phenomenology, with no basis in pathophysiology
or etiology. In addition, in the DSM-IV and
AFUD systems, sexually related personal distress
must be manifest before a diagnosis can be made.
As the distress criterion was only adopted in recent
years, the case denitions of earlier studies where,
distress was not a diagnostic criterion, are not
comparable to those of recent research. Also, judg-
ments as to whether or not the condition has
existed for the patients lifetime or been acquired,
and whether it is situational or generalized in nature
are aspects of the contemporary nosology.
Beyond these considerations, there are a
number of other inuences that can have an
impact on clinical judgment in an FSD condition,
causing its precise nature to be unclear and obscur-
ing the appropriate diagnosis. A brief inventory of
these factors is listed below:
The symptoms from various categories are often
comorbid.
Personal distress levels may be difcult to
estimate.
Age is a differential factor in the prevalence of
FSD.
Menopausal status must be factored into
judgments.
The partners sexual health and presence must
be considered.
Depression and its treatment are frequent con-
comitants of FSD.
The duration and severity of the disorders are
often highly variable.
Premorbid sexual functioning can be difcult to
assess.
Prevalence of FSDs
Probably the most frequently quoted recent study
addressing the occurrence of FSD is that of
Lauman et al. (1999) [12] reporting on data from
the National Health and Social Life Survey con-
ducted in 1992. These investigators reported on
the risk of experiencing sexual dysfunction based
on a national probability sample of 1,749 women
between the ages of 18 and 59, based on in-person
Epidemiology of Sexual Dysfunctions
surveys. They observed an overall endorsement
rate for sexual problems among women at 43%;
with approximately 32% indicating problems with
a lack of interest in sex. A latent class analysis on
the sample generated four principal categories of
which low sexual desire was one, with a preva-
lence rate of 22%. Arousal problems had a preva-
lence of 14%, with sexual pain disorders endorsed
by 7% of the sample. It is important to note that
these rates are based on a survey instrument and
not on a clinical diagnosis, and while some data
were generated concerning the anxiety that the
respondents felt about their sexual problems, there
was no measurement of sexually related personal
distress.
Reporting on a sample of 703 Viennese women,
using a questionnaire designed specically for
the study, Ponholzer and his colleagues observed
somewhat similar results [26]. Approximately 22%
of the sample indicated problems with low sexual
desire; however, 35% of the women endorsed
arousal problems, and 39% reported orgasmic dif-
culties. Sexual pain disorders were reported by
12.8% of the sample. Age proved to be a substan-
tial risk factor for increased rates of FSD. Observ-
ing a similar rate, Addis and associates [27] found
that lack of sexual interest was endorsed by
23.2% of a midlife random sample of Kaiser
Permanente members, while 40% of a multiethnic
sample who comprised the Study of Womens
Health Across the Nation cohort endorsed low
sexual desire in a questionnaire assessment [28].
Neither of these studies assessed distress associ-
ated with the desire problem. Paralleling these
estimates, the Global Study of Sexual Attitudes
and Behavior found rates of lack of interest
ranging from 24% to 43% in different regions of
the world [29]. However, Segraves and Woodard
pointed out that as only approximately 50% of
women who admit to having a sexual problem also
report being distressed about it, rates of diagnos-
able sexual dysfunction, as dened by contempo-
rary standards, will be considerably less than the
observed 2443% [30].
A number of recent reviews have been pub-
lished on the epidemiology of FSD that have
proved to be very informative. Dunn and her asso-
ciates published a review in 2004 of 28 studies on
selected categories of sexual dysfunction, and also
addressed the persistent methodological problems
associated with FSD research [3]. Unfortunately,
of the major FSD diagnostic categories, only
orgasmic and pain disorders were included in their
report. Overall estimates suggested a rate of 25%
295
for orgasmic disorder, and the 1-year prevalence of
female sexual pain disorders had a prevalence of
between 1% and 21%. The nature of the relation-
ship between pain prevalence and age proved
controversial, with some studies showing a direct
relationship between age and pain prevalence, and
others suggesting that the relationship is inverse.
Additional instructive reviews have also been
published within the past several years. Lewis and
his associates [31] accomplished a review which
covered both male and female dysfunctions, as well
as prominent risk factors. They concluded that
estimates of the prevalence of low sexual interest
among women in the studies they reviewed
showed high variability, ranging from 17% to
55%. They appear to distinguish between low
interest and low desire, which they characterize
as having a prevalence of 10% in women up to 49
years of age, and then increasing to 22% among
the 50- to 65-year-old group. Arousal/lubrication
disorders were found to range between 8% and
28%. They found high variability in estimates of
female orgasmic dysfunction with rates generally
clustering around 25%, but reported two Nordic
studies in which over 80% of women endorsed
problems with orgasm to some degree. Pain disor-
ders also proved highly variable with a low esti-
mated prevalence of 2% in an elderly British
population and some estimates as high as 1820%
in several British and Australian studies.
Hayes and his colleagues at the University of
Melbourne in Australia published a thoughtful
methodologic review on the epidemiology of
female dysfunctions in 2006 [32]. Their report also
considered the duration of the conditions in those
studies that reported such data. The review found
desire disorder to be the most prevalent FSD con-
dition with a mean of 64% and a range of 1675%.
Desire problems were followed by orgasmic dif-
culties at 35%, range 1648%, and arousal disor-
ders at 31%, range 1264%. On average, 26% of
respondents reported pain disorders, with a range
of from 758%. Of the studies they reviewed,
only two (Fugl-Meyer and Fugl-Meyer [33] and
Bancroft et al. [34]) investigated the presence of
sexually related personal distress, which ranged
from 2167%.
An interesting trio of studies was published very
recently (20062007) based on the Womens
International Study of Health and Sexuality
(WISHeS), which was conducted in 1999 and
2000 via mail survey and personal interview on a
large cross-sectional market research database of
4,517 women aged 2070 years. The participants
J Sex Med 2008;5:289300
296
included women from the United States, the
United Kingdom, Germany, France, and Italy.
These reports are somewhat unique because vali-
dated self-report questionnaires, the Prole of
Female Sexual Functioning (PFSF) [35] and the
Personal Distress Scale (PDS) [36], were utilized
as the case-dening criteria. Dennerstein et al.
[37] focused their report on the prevalence of
HSDD in menopausal women from the four
European countries. Score on the PFSF Desire
scale were used to identify those individuals with
low desire, while scores on the PDS determined
women with high manifest distress. The sample
was partitioned into premenopausal women, sur-
gically menopausal women aged 2049, surgically
menopausal women aged 5070, and naturally
menopausal women. Rates of low sexual desire
were 16%, 29%, 46%, and 42%, respectively.
However, when distress levels were factored in to
determining cases of HSDD, the rates became
7%, 16%, 12%, and 9%. These estimates were
contrasted with those reported by Fugl-Meyer and
Fugl-Meyer [33] based on a Swedish sample, one-
third of whom indicated they suffered from low
desire, but only 43% of whom were distressed by
it. The estimate of HSDD in that sample was 14%.
Using the same database, Hayes and his associ-
ates [38] analyzed the data looking at the relation-
ship between HSDD and aging. Partitioning the
sample into European and American respondents,
rates of low desire progressed from 11% among
20- to 29-year-olds to 53% among women in the
6070 age group among Europeans and from 22%
to 32% among comparable American samples. In
both samples, there was a denite increase in rates
of low sexual desire associated with age. Concomi-
tantly, the nature of the relationship between age
and distress was inverse, falling from 65% to 22%
among Europeans, and 67% to 37% across the age
range among American women. This disordinal
relationship between low sexual desire and sexual
distress resulted in a nonsignicant relationship
between age and HSDD across the age range, with
prevalence estimates ranging from 6% to 13% in
Europe, and from 12% to 19% in the United
States.
Also, using the WISHeS dataset, Graziottin
[39] estimated the prevalence of desire, arousal and
orgasmic disorders based upon PFSF and PDS
case denition criteria. She observed a signicant
intercountry variation, with the highest rates of
dysfunction in Germany and the United Kingdom,
and the lowest rates in Italy and France. As an
example, low desire was reported by 21% of
J Sex Med 2008;5:289300
DeRogatis and Burnett
French women and 28% of Italians, while rates
were 36% and 34% in Germany and the United
Kingdom. Data on arousal and orgasmic disorders
were similar, demonstrating the potential for con-
siderable intercultural variation. As was empha-
sized in the previous report, there was a strong
relationship between prevalence and age across all
dysfunctional categories. Graziottin subsequently
went on to review the implications of these data
for clinical assessment, and explored etiologic dif-
ferentiation and prognostic implications.
Incidence of FSDs
Because of some of the complexities outlined
above, there are only a few published incidence
studies of FSDs. Kontula and Haavio-Mannila
published the results of a 5-year incidence study in
a Finnish population, 1874 years old [40]. The
investigation was focused on low sexual desire
which was endorsed by 45% of the women. This
rate was highly age dependent; however, as the rate
among women less than 25 was approximately
20%, the incidence among women over 55 was
7080%. A similar 40% incidence of low desire
was reported by Fugl-Myer in a 5-year incidence
study in a Swedish population. A more detailed
evaluation revealed that 11% of the sample
reported suffering from severe reduction of
sexual desire [41].
Discussion
After decades of tentative data on rates of occur-
rence, rendered indistinct by imprecise diagnostic
denitions and uncertain science, recent epide-
miologic research has established some ndings
that appear consistent and reliable. For example,
there is now little doubt that sexual dysfunctions,
in both males and females, have a substantial
prevalence in the United States and throughout
the world, and that there is a relatively unambigu-
ous relationship between frequency of dysfunction
and age in both men and women.
Depending on age demarcation and severity
of the condition under evaluation, rates of ED
have been consistently observed to increase from
approximately 2.5 to 4.0 times as age progresses
from men in their 20s to men in their 70s. Overall
rates of ED ranged from 10% to 20%, with the
majority of studies reporting an overall rate closer
to 20%. The ndings suggest that rapid ejaculation
(RE) is the most prevalent male dysfunction with
rates of occurrence ranging from 14% to 30%;
however, RE does not show a systematic relation-
Epidemiology of Sexual Dysfunctions
ship with age, and rates are relatively constant
across the adult lifespan. A much less systematic
review has been available for the other male sexual
dysfunctions, such as low sexual desire and inhib-
ited ejaculation, although there also appears to be a
signicant relationship between prevalence and age
for these conditions as well.
Among studies of women, low sexual desire was
the most prevalent of the dysfunctions, and this
appears to be so across the age range, including
both premenopausal and postmenopausal women.
There are some data to suggest that surgically
menopausal women may have a higher prevalence
than naturally menopausal women, which may be
related to lower levels of androgens in this group.
Generally speaking, low sexual desire systemati-
cally increases with progressing age, with occur-
rence observed to be two to four times greater in
oldest vs. youngest cohorts. The overall frequency
of reported low sexual desire did vary considerably
depending on the composition of the sample, with
reported frequencies ranging from 10% to 64%.
Several studies reported an overall prevalence of
22%, with other studies reporting very similar
rates for one or more subgroups. Although con-
servative compared to some ndings, there
appears to be a consensus for a rate of 2025% for
low sexual desire.
A confounding issue involves the necessary
presence of manifest personal distress in both the
DSM-IV and AFUD systems required to make a
formal sexual diagnosis, including one of HSDD.
This nosologic innovation creates problems from
an epidemiologic perspective, because although
clinical manifestations of low desire have a direct
linear relationship with age, personal distress
shows a strong inverse relationship. The result of
this disordinal interaction between low desire and
personal distress across age is that most studies
report rates of HSDD as constant throughout the
age range even though problems with low desire
clearly increase with age. Also, with the introduc-
tion of personal distress as an obligatory diagnostic
criterion, there is now a major inconsistency
between the case denitions used in current epi-
demiologic studies, and studies completed in
earlier periods.
Another very uniform nding, in the case of
males and females, is that certain medical and
health conditions are reliably identied risk factors
for sexual dysfunction. Specically in the case of
ED for men, diabetes, cardiovascular disorders,
hypertension, dyslipidemia, obesity, smoking, and
prostate disorders all show a positive relationship
297
with the occurrence of ED. Among women, there
are also substantive relationships between health
factors and rates of sexual dysfunction. Chronic
illnesses and poor general health status tend to be
associated with higher occurrences of sexual dys-
function among women. In terms of specic con-
ditions, diabetes, breast cancer, lower urinary tract
problems, surgical removal of the ovaries, multiple
sclerosis, and clinical depression have all been
consistently found to show signicant associations
with FSD. Although prevalence estimates vary
with gender, age, illness duration, illness severity,
and case denition, there is a clear evidence for
sexual liability associated with a number of highly
prevalent medical conditions. It should be noted in
addition, that many of these medical disorders
have a strong independent association with age,
which makes age an even more insidious risk factor
for sexual dysfunction.
Beyond age and health status, there are a
number of other risk factors for sexual dysfunction
that have been explicitly identied in recent years.
Although we will not systematically review the
body of evidence here, there is a very clear conr-
mation that specic categories of prescribed medi-
cations have a high risk of dysfunction associated
with them. In particular, psychiatric drugs such as
antidepressants and antipsychotics have a clearly
demonstrated liability for sexual problems, as
do antihypertensives, some anticonvulsants, and
H2-blockers. There is also an evidence that certain
specic drugs (e.g., digoxin) foster sexual problems
in some individuals [42]. We must conclude from
these data that not only do certain medical condi-
tions place an individual at increased risk for sexual
problems, but that in certain instances, our choice
of treatment can make an independent contribu-
tion to risk for sexual dysfunction as well.
It is impossible to contradict the fact that de-
nite advances have been made in our knowledge
of the population occurrence of sexual dysfunc-
tions, almost exclusively in terms of the preva-
lence of these conditions. We must remain
cognizant of the fact, however, that we still have
much work ahead of us in establishing a rigorous
epidemiology of sexual medicine. A very signi-
cant deciency in the eld concerns the paucity
of studies of the incidence of sexual dysfunctions.
This is because, in a large measure, of the fact
that incidence estimates require longitudinal
assessment across time, thereby involving expen-
sive and time-consuming trials. We cannot do a
reasonable job of estimating the risk and institut-
ing sexual health prevention programs, however,
J Sex Med 2008;5:289300
298
unless we know when, where, and in whom new
sexual liabilities emerge. This is probably a goal
that can be tackled most expeditiously by federal
agencies.
As has previously been stated, precise epidemi-
ology is very much dependent on rigorous no-
sology or diagnostic nomenclature, which we
currently do not have in place. Serious efforts must
be made in the eld to establish a uniform nosol-
ogy, with consistent denitions of dysfunctions for
both men and women. The new nomenclature
should be free of any specic theoretical orienta-
tion, and be acceptable to a sizeable enough pro-
portion of clinicians in sexual medicine to establish
a meaningful diagnostic convention. Only when
this is accomplished will we be able to do careful
analytic epidemiology addressing specic risk
factors and their degree of association with sexual
dysfunctions. Until this step is taken, no matter
how rigorous our clinical trial designs, we will
remain in a half a loaf position because we will
lack unied, meaningful denitions of the diag-
nostic entities we seek to evaluate.
Beyond what has already been said, we want to
emphasize that we believe strongly that any new
diagnostic system should include measurements of
severity and duration of dysfunction if we are to
optimize knowledge in the eld. Such assessments
do not have to be complex, with a simple ordinal
Likert scale of mild, moderate, severe enabling us to take the next important scientic
reecting severity and duration recorded in
months/years. These measurements would greatly
increase the utility of current reports of lifetime
vs. acquired, which provide the minimal infor-
mation that duration was either continuous or
noncontinuous. Severity assessments will also
help establish whether the nature of the condition
is more likely to be transitory and remitting, or
enduring and profound, and will also help reduce
variation in our estimates of occurrence by render-
ing trial samples more homogeneous.
Conclusion
The current review of the epidemiology of sexual
dysfunctions has documented specic clear results
that have emerged consistently for both men and
women. Within both genders, there is little doubt
that sexual dysfunctions are highly prevalent in our
society, and that the prevalence of sexual dysfunc-
tions increases directly with age. There are also
strong data to support the ancillary nding that
while the frequency of dysfunctional symptoms
increases with age, personal distress about those
J Sex Med 2008;5:289300
DeRogatis and Burnett
symptoms has an inverse relationship with matu-
ration. Distress appears reduced as individuals
become older. Another very reliable nding is that
certain medical conditions and health behaviors
represent major risk factors for sexual disorders,
and that many of these health conditions also have
a strong positive relationship with age. Therefore,
we must conclude that age should be assigned dual
impact as a risk factor, both directly through the
maturation process, and indirectly through its
relationship with specic medical conditions,
strongly suspected to be etiologic agents for sexual
disorders.
Although we have observed improvement in
both the number and quality of epidemiologic
prevalence studies in sexual medicine, there is a
dearth of studies of the incidence of these condi-
tions. These studies are important for the preven-
tion and treatment planning regarding sexual
disorders, and their development and execution
should become a top priority for the eld. We have
also observed repeated calls for the development of
a new systematic and integrated diagnostic system
in sexual medicine, because the poor quality of our
current nosology is viewed by many as the rate-
limiting step for the epidemiology of the eld.
Analytic studies designed to rigorously evaluate
the risk factors can only be accomplished if our
case denitions are uniform and reliable, thereby
steps. It appears reasonable to conclude from the
current review that although much has been
accomplished in the past two decades, a great deal
remains to be done.
Corresponding Author: Leonard R. DeRogatis, PhD,
Center for Sexual Medicine at Sheppard Pratt, 6501 N.
Charles Street, Baltimore, MD 21285-6815, USA. Tel:
410-938-4336; Fax: 410-938-4340; E-mail: lderogatis@
sheppardpratt.org
Conict of Interest: None declared.
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