Richard D. Hayes

Definitions/epidemiology/risk factors for sexual dysfunction.

INTRODUCTION Accurate estimates of prevalence/incidence are important in understanding the true burden of male and female sexual dysfunction and in identifying risk factors for prevention efforts. This is the summary of the report by the International Consultation Committee for Sexual Medicine on Definitions/Epidemiology/Risk Factors for Sexual Dysfunction. AIM The main aim of this article is to provide a general overview of the definitions of sexual dysfunction for men and women, the incidence and prevalence rates, and a description of the risk factors identified in large population-based studies. METHODS Literature regarding definitions, descriptive and analytical epidemiology of sexual dysfunction in men and women were selected using evidence-based criteria. For descriptive epidemiological studies, a Prins score of 10 or higher was utilized to identify population-based studies with adequately stringent criteria. This report represents the opinions of eight experts from five countries developed in a consensus process and encompassing a detailed literature review over a 2-year period. MAIN OUTCOME MEASURES The study aims to provide state-of-the-art prevalence and incidence rates reported for each dysfunction and stratified by age and gender. Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. RESULTS A wealth of information is presented on erectile dysfunction, its development through time, and its correlates. The field is still in need of more epidemiological studies on the other mens sexual dysfunction and on all womens sexual dysfunctions. CONCLUSIONS A review of the currently available evidence from epidemiological studies is provided.

ORIGINAL ARTICLESORIGINAL ARTICLES: Definitions/Epidemiology/Risk Factors for Sexual Dysfunction

INTRODUCTION Accurate estimates of prevalence/incidence are important in understanding the true burden of male and female sexual dysfunction and in identifying risk factors for prevention efforts. This is the summary of the report by the International Consultation Committee for Sexual Medicine on Definitions/Epidemiology/Risk Factors for Sexual Dysfunction. AIM The main aim of this article is to provide a general overview of the definitions of sexual dysfunction for men and women, the incidence and prevalence rates, and a description of the risk factors identified in large population-based studies. METHODS Literature regarding definitions, descriptive and analytical epidemiology of sexual dysfunction in men and women were selected using evidence-based criteria. For descriptive epidemiological studies, a Prins score of 10 or higher was utilized to identify population-based studies with adequately stringent criteria. This report represents the opinions of eight experts from five countries developed in a consensus process and encompassing a detailed literature review over a 2-year period. MAIN OUTCOME MEASURES The study aims to provide state-of-the-art prevalence and incidence rates reported for each dysfunction and stratified by age and gender. Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. RESULTS A wealth of information is presented on erectile dysfunction, its development through time, and its correlates. The field is still in need of more epidemiological studies on the other mens sexual dysfunction and on all womens sexual dysfunctions. CONCLUSIONS A review of the currently available evidence from epidemiological studies is provided.

Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London

Objective Despite improving healthcare, the gap in mortality between people with serious mental illness (SMI) and general population persists, especially for younger age groups. The electronic database from a large and comprehensive secondary mental healthcare provider in London was utilized to assess the impact of SMI diagnoses on life expectancy at birth. Method People who were diagnosed with SMI (schizophrenia, schizoaffective disorder, bipolar disorder), substance use disorder, and depressive episode/disorder before the end of 2009 and under active review by the South London and Maudsley NHS Foundation Trust (SLAM) in southeast London during 2007–09 comprised the sample, retrieved by the SLAM Case Register Interactive Search (CRIS) system. We estimated life expectancy at birth for people with SMI and each diagnosis, from national mortality returns between 2007–09, using a life table method. Results A total of 31,719 eligible people, aged 15 years or older, with SMI were analyzed. Among them, 1,370 died during 2007–09. Compared to national figures, all disorders were associated with substantially lower life expectancy: 8.0 to 14.6 life years lost for men and 9.8 to 17.5 life years lost for women. Highest reductions were found for men with schizophrenia (14.6 years lost) and women with schizoaffective disorders (17.5 years lost). Conclusion The impact of serious mental illness on life expectancy is marked and generally higher than similarly calculated impacts of well-recognised adverse exposures such as smoking, diabetes and obesity. Strategies to identify and prevent causes of premature death are urgently required.

Risk factors for female sexual dysfunction in the general population: exploring factors associated with low sexual function and sexual distress.

INTRODUCTION No previous population-based studies have used validated instruments to measure female sexual dysfunction (FSD) in Australian women across a broad age range. AIM To estimate prevalence and explore factors associated with the components of FSD. MAIN OUTCOME MEASURES Sexual Function Questionnaire measured low sexual function. Female Sexual Distress Scale measured sexual distress. Methods. Multivariate analysis of postal survey data from a random sample of 356 women aged 20-70 years. RESULTS Low desire was more likely to occur in women in relationships for 20-29 years (odds ratio 3.7, 95% confidence intervals 1.1-12.8) and less likely in women reporting greater satisfaction with their partner as a lover (0.3, 0.1-0.9) or who placed greater importance on sex (0.1, 0.03-0.3). Low genital arousal was more likely among women who were perimenopausal (4.4, 1.2-15.7), postmenopausal (5.3, 1.6-17.7), or depressed (2.5, 1.1-5.3), and was less likely in women taking hormone therapy (0.2, 0.04-0.7), more educated (0.5, 0.3-0.96), in their 30s (0.2, 0.1-0.7) or 40s (0.2, 0.1-0.7), or placed greater importance on sex (0.2, 0.05-0.5). Low orgasmic function was less likely in women who were in their 30s (0.3, 0.1-0.8) or who placed greater importance on sex (0.3, 0.1-0.7). Sexual distress was positively associated with depression (3.1, 1.2-7.8) and was inversely associated with better communication of sexual needs (0.2, 0.05-0.5). Results were adjusted for other covariates including age, psychological, socioeconomic, physiological, and relationship factors. CONCLUSIONS Relationship factors were more important to low desire than age or menopause, whereas physiological and psychological factors were more important to low genital arousal and low orgasmic function than relationship factors. Sexual distress was associated with both psychological and relationship factors.

What is the "true" prevalence of female sexual dysfunctions and does the way we assess these conditions have an impact?

INTRODUCTION A wide range of prevalence estimates of female sexual dysfunctions (FSD) have been reported. AIM Compare instruments used to assess FSD to determine if differences between instruments contribute to variation in reported prevalence. MAIN OUTCOME MEASURES Sexual Function Questionnaire combined with Female Sexual Distress Scale (SFQ-FSDS) was our gold standard, validated instrument for assessing FSD. Alternatives were SFQ alone and two sets of simple questions adapted from Laumann et al. 1994. Methods. A postal survey was administered to a random sample of 356 Australian women aged 20 to 70 years. RESULTS When assessed by SFQ-FSDS, prevalence estimates (95% confidence intervals) of hypoactive sexual desire disorder, sexual arousal disorder (lubrication), orgasmic disorder, and dyspareunia were 16% (12% to 20%), 7% (5% to 11%), 8% (6% to 12%), and 1% (0.5% to 3%), respectively. Prevalence estimates varied across alternative instruments for these disorders: 32% to 58%, 16% to 32%, 16% to 33%, and 3% to 23%, respectively. Compared with SFQ-FSDS alternative instruments produced higher estimates of desire, arousal and orgasm disorders and displayed a range of sensitivities (0.25 to 1.0), specificities (0.48 to 0.99), positive predictive values (0.01 to 0.56), and negative predictive values (0.95 to 1.0) across the disorders investigated. Kappa statistics comparing SFQ-FSDS and alternative instruments ranged from 0 to 0.71 but were predominantly 0.44 or less. Changing recall from previous month to 1 month or more in the previous year produced higher estimates for all disorders investigated. Including sexual distress produced lower estimates for desire, arousal, and orgasm disorders. CONCLUSIONS Prevalence estimates of FSD varied substantially across instruments. Relatively low positive predictive values and kappa statistics combined with a broad range of sensitivities and specificities indicated that different instruments identified different subgroups. Consequently, the instruments researchers choose when assessing FSD may affect prevalence estimates and risk factors they report.

ORIGINAL RESEARCH—EPIDEMIOLOGY: What can Prevalence Studies Tell Us about Female Sexual Difficulty and Dysfunction?

INTRODUCTION Many recent studies have investigated the prevalence of female sexual difficulty/dysfunction. AIM Investigate female sexual difficulty/dysfunction using data from prevalence studies. METHODS We reviewed published prevalence studies excluding those that had not included each category of sexual difficulty (desire, arousal, orgasm, and pain), were based on convenience sampling, or had a response rate <50% or a sample size <100. Main Outcome Measures. For each study we used the prevalence of any sexual difficulty as the denominator and calculated the proportion of women reporting each type of difficulty. For each category of sexual difficulty we used the prevalence of that difficulty lasting 1 month or more as the denominator and calculated the proportion of difficulties lasting several months or more and 6 months or more. RESULTS Only 11 of 1,248 studies identified met our inclusion criteria. These studies used different measures of sexual dysfunction, so generating a simple summary prevalence was not possible. However, we observed consistent patterns in the published data. Among women with any sexual difficulty, on average, 64% (range 16-75%) experienced desire difficulty, 35% (range 16- 48%) experienced orgasm difficulty, 31% (range 12-64%) experienced arousal difficulty, and 26% (range 7-58%) experienced sexual pain. Of the sexual difficulties that occurred for 1 month or more in the previous year, 62-89% persisted for at least several months and 25-28% persisted for 6 months or more. Two studies investigated distress. Only a proportion of women with sexual difficulty were distressed by it (21-67%). CONCLUSIONS Desire difficulty is the most common sexual difficulty experienced by women. While the majority of difficulties last for less than 6 months, up to a third persist for 6 months or more. Sexual difficulties do not always cause distress. Consequently, prevalence estimates will vary depending on the time frame specified by researchers and whether distress is included in these estimates.

Antibody to Herpes Simplex Virus Type 2 as a Marker of Sexual Risk Behavior in Rural Tanzania

A serosurvey was conducted in a random sample of 259 women and 231 men in 12 rural communities in Mwanza Region, Tanzania, using a type-specific ELISA for Herpes simplex virus type 2 (HSV-2) infection. Seroprevalence rose steeply with age to approximately 75% in women >=25 years old and 60% in men >=30. After adjusting for age and residence, HSV-2 prevalence was higher in women who were married, in a polygamous marriage, Treponema pallidum hemagglutination assay (TPHA)-positive, had more lifetime sex partners, or who had not traveled. Prevalence was higher in men who were married, had lived elsewhere, had more lifetime partners, had used condoms, or were TPHA-positive. HSV-2 infection was significantly associated with recent history of genital ulcer. The association between HSV-2 infection and lifetime sex partners was strongest in those <25 years old in both sexes. This association supports the use of HSV-2 serology as a marker of risk behavior in this population, particularly among young people.

ORIGINAL RESEARCH—EPIDEMIOLOGYORIGINAL RESEARCH—EPIDEMIOLOGY: What can Prevalence Studies Tell Us about Female Sexual Difficulty and Dysfunction?

INTRODUCTION Many recent studies have investigated the prevalence of female sexual difficulty/dysfunction. AIM Investigate female sexual difficulty/dysfunction using data from prevalence studies. METHODS We reviewed published prevalence studies excluding those that had not included each category of sexual difficulty (desire, arousal, orgasm, and pain), were based on convenience sampling, or had a response rate <50% or a sample size <100. Main Outcome Measures. For each study we used the prevalence of any sexual difficulty as the denominator and calculated the proportion of women reporting each type of difficulty. For each category of sexual difficulty we used the prevalence of that difficulty lasting 1 month or more as the denominator and calculated the proportion of difficulties lasting several months or more and 6 months or more. RESULTS Only 11 of 1,248 studies identified met our inclusion criteria. These studies used different measures of sexual dysfunction, so generating a simple summary prevalence was not possible. However, we observed consistent patterns in the published data. Among women with any sexual difficulty, on average, 64% (range 16-75%) experienced desire difficulty, 35% (range 16- 48%) experienced orgasm difficulty, 31% (range 12-64%) experienced arousal difficulty, and 26% (range 7-58%) experienced sexual pain. Of the sexual difficulties that occurred for 1 month or more in the previous year, 62-89% persisted for at least several months and 25-28% persisted for 6 months or more. Two studies investigated distress. Only a proportion of women with sexual difficulty were distressed by it (21-67%). CONCLUSIONS Desire difficulty is the most common sexual difficulty experienced by women. While the majority of difficulties last for less than 6 months, up to a third persist for 6 months or more. Sexual difficulties do not always cause distress. Consequently, prevalence estimates will vary depending on the time frame specified by researchers and whether distress is included in these estimates.

All-cause mortality among people with serious mental illness (SMI), substance use disorders, and depressive disorders in southeast London: a cohort study.

BackgroundHigher mortality has been found for people with serious mental illness (SMI, including schizophrenia, schizoaffective disorders, and bipolar affective disorder) at all age groups. Our aim was to characterize vulnerable groups for excess mortality among people with SMI, substance use disorders, depressive episode, and recurrent depressive disorder.MethodsA case register was developed at the South London and Maudsley National Health Services Foundation Trust (NHS SLAM), accessing full electronic clinical records on over 150,000 mental health service users as a well-defined cohort since 2006. The Case Register Interactive Search (CRIS) system enabled searching and retrieval of anonymised information since 2008. Deaths were identified by regular national tracing returns after 2006. Standardized mortality ratios (SMRs) were calculated for the period 2007 to 2009 using SLAM records for this period and the expected number of deaths from age-specific mortality statistics for the England and Wales population in 2008. Data were stratified by gender, ethnicity, and specific mental disorders.ResultsA total of 31,719 cases, aged 15 years old or more, active between 2007-2009 and with mental disorders of interest prior to 2009 were detected in the SLAM case register. SMRs were 2.15 (95% CI: 1.95-2.36) for all SMI with genders combined, 1.89 (1.64-2.17) for women and 2.47 (2.17-2.80) for men. In addition, highest mortality risk was found for substance use disorders (SMR = 4.17; 95% CI: 3.75-4.64). Age- and gender-standardised mortality ratios by ethnic group revealed huge fluctuations, and SMRs for all disorders diminished in strength with age. The main limitation was the setting of secondary mental health care provider in SLAM.ConclusionsSubstantially higher mortality persists in people with serious mental illness, substance use disorders and depressive disorders. Furthermore, mortality risk differs substantially with age, diagnosis, gender and ethnicity. Further research into specific risk groups is required.

Improved treatment services significantly reduce the prevalence of sexually transmitted diseases in rural Tanzania: results of a randomized controlled trial.

Objective:To evaluate the impact of improved case management for sexually transmitted diseases (STD) at the primary health care level on the incidence and prevalence of STD. Design:Community-randomized controlled trial. Setting:Mwanza region, Tanzania. Subjects:A random cohort of about 1000 adults aged 15–54 years from each of 12 communities, in six matched pairs. One member of each pair was assigned at random to receive the intervention, and the others served as a comparison community. This cohort was surveyed at baseline and at follow-up 2 years later. About 100 antenatal clinic attenders were also studied in each community on two occasions: the first shortly after the implementation of the intervention, and the second approximately 1 year later. Intervention:Improved services were established for the management of STD, using the syndromic approach, in rural health units. Results:A total of 12 534 individuals were enrolled in the cohort study, of whom 8844 (71%) were seen again 2 years later. The prevalence of serological syphilis (rapid plasma reagin titre ≥1:8, Treponema pallidum haemagglutinin assay positive) was 6.2% in both intervention and comparison communities at baseline. At follow-up it was 5.0% in the intervention community and 7.0% in the comparison community [adjusted relative risk (RR), 0.71; 95% confidence interval (CI), 0.54–0.93; P < 0.02]. The prevalence of urethritis in males did not differ significantly between intervention and comparison groups at follow-up, but the prevalence of symptomatic urethritis was reduced by about 50% (adjusted RR, 0.51; 95% CI, 0.24–1.10; P = 0.08). There was no significant difference between the groups in the incidence of self-reported STD symptoms over the last year of the follow-up period, or in the prevalence of any STD in antenatal clinic attenders. Conclusion:The reduction in HIV incidence previously reported in this intervention study can be attributed to a reduction in the duration, and hence the prevalence of symptomatic STD.