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Age and Ageing 1996.25285-291
Sexual Desire, Erection, Orgasm and
Ejaculatory Functions and Their Importance
to Elderly Swedish Men: A Population-based
Study
ASGEIR R. HELGASON, JAN ADOLFSSON, PAUL DICKMAN,
STEFAN ARVER, MATS FREDRIKSON, MARIANNE GOTHBERG,
GUNNAR STEINECK
Summary
Relevant information for clinical decision-making in a wide spectrum of diseases includes the extent to which
sexual function is intact, how important it is to preserve sexual capacity and whether waning sexual function
causes distress. Little information is available on elderly men. We aimed to obtain this basic information.
Radiumhemmet's Scale of Sexual Function was posted to 435 randomly selected men aged 50-80 years.
Assessments included sexual desire, erectile capacity, orgasm and ejaculation and to what extent waning sexual
function distressed the men. The questions were answered anonymously.
Information was obtained from 319 men (73%). Of these, 83% stated that sex was 'very important',
'important' or a 'spice to life'. Physiological potency for men aged 50-59, 60-69 and 70-80 amounted to 97%,
76% and 51% respectively. Among the oldest men (70-80 years), 46% reported orgasm at least once a month.
Over 80% of all men who reported some level of erection stated that it was of importance to them to maintain
the present level of erection stiffness. Most men who reported waning sexual function (compared with their
youth) stated that this distressed them.
Sex is important to elderly men. Even among the 70-80-year-olds, an intact sexual desire, erection and
orgasm are common and it is considered important to preserve them. Sexual function should be considered in
the clinical assessment of elderly men.
Key words: Sexual function, Distress, Elderly men.
Background
Since the establishment of the Swedish Association for
Sex Education in 1933 and the introduction of more
liberal laws regarding sexuality and compulsory sex
education in schools in 1955, Sweden has experienced an
increasingly relaxed attitude towards sex. These factors,
accompanied by intensified exposure of sexual issues in
the media, have resulted in a demand from patients and
patient organizations to include assessment of sexual
function in clinical care. Three population-based studies
have been published in which a few aspects of sexual
function have been assessed in elderly men [1—3]. The
study on sexual function recently published in the USA
did not assess the sex life of people over 59 years of age
[4] and no population-based study has analysed the
relationship between different aspects of sexual function and its importance to elderly men. It is therefore
difficult to estimate how different diseases and their
treatment affect sexuality in this patient group and to
what extent diminished sexual function distresses the
patients. Several studies indicate that elderly men
continue to be sexually active throughout their lives.
Masters and Johnson found no upper age limit for sexual
function [5]. Pfeiffer stated that about 70% of men with
an average age of 68 'regularly partake in sexual activity'
[6]. Persson reported that 52% of 70-year-old married
men still engaged in intercourse and roughly 20% more
often than once a month [1]. Helgason et al. [7] found
that most men (median age 70 years) were distressed
when external beam radiation therapy for localized
prostate cancer decreased sexual function. This was
true of all aspects of sexuality assessed: sexual desire,
erection and orgasm.
The aim of the present study was to obtain basic
information on sexual desire, erection, orgasm and
286
A R. HELGASON ET AL.
ejaculatory functions and to assess to what extent a
decline in function distresses elderly men. The data
may be used in clinical decision-making and in the
design of clinical trials for diseases affecting elderly
men, such as prostate cancer and diabetes mellitus.
Subjects and Methods
A questionnaire was mailed to 195 men aged 70—80 years, 155
men aged 60-69 and 85 men aged 50-59, randomly selected
from Stockholm residents from the Swedish Population
Registry. This is made possible by the Swedish civil registration
system, in which each citizen is given a unique identification
number and all citizens are entered into a computerized
population registry. The study was approved by the local
ethics committee.
A letter introducing and explaining the aims of the study
was sent to all men before they received the questionnaire.
The survey was anonymous but the men were asked to supply
their name on a special form and return it separately when
they had completed the questionnaire. This was done in order
to identify those who did not respond. Non-respondents
received two reminding letters and finally, if possible, a
telephone call, assessing the reason for non-response. The
collection of data started in October 1993, and was completed
in April 1994.
The questionnaire comprised over 140 questions, including
Radiumhemmet's Scale of Sexual Function and questions
assessing potential risk factors for decreased sexual function.
Radiumhemmet's Scale of Sexual Function was developed
during successive in-depth interviews with over 30 patients
and has been judged by several clinicians to reflect the clinical
interview accurately. It contains 40 questions using from five
to eight ordinal categories as response alternatives and
assesses three global phases of sexuality: desire, erection and
orgasm. Each aspect of sexuality is evaluated with separate
questions measuring frequency and/or intensity. Distress due
to decreased function is assessed for all aspects of sexual
function. The questionnaire is designed so that all men can
relate to all questions, regardless of sexual preference.
The modules designed to assess different aspects of sexual
desire include questions on frequency of sexual dreams,
frequency of sexual thoughts or desires of any kind and the
overall importance of sexuality. Erection is assessed using
questions about the frequency of sexually stimulated erections, morning erections and spontaneous erections. Erection
Table I. Erection stiffness was assessed for sexually aroused
erections, morning erections and spontaneous erections using
the eight category scale below
If you have an erection of any degree, how stiff does your penis
become?
Approximately as in youth—all the time
Approximately as in youth—most of the time
Always sufficient for intercourse
Sufficient for intercourse most of the time
Seldom sufficient for intercourse
Hardly ever sufficient for intercourse
Never sufficient for intercourse
Not relevant, no penis stiffness
^ Potent
^ Impotent
stiffness for all three aspects of erection is compared to
erections in youth. In the present analysis, potency was defined
as erection stiffness 'usually sufficient for intercourse'. Potency
in any of the three stiffness domains was defined as
'physiological potency' (Table I). Finally, erection maintenance
during intercourse and/or masturbation is assessed. Questions
about orgasm frequency, orgasmic pleasure, and ejaculate
volume capture different aspects of orgasm. The importance
of an intact sexual function is assessed for different aspects of
sexuality and the importance of regaining a previous level of
performance is assessed in case of decreased function.
Additional questions assessing frequency of intercourse and
sexual initiatives are also included.
To assess any potential lack of representativeness of the
general population, the prevalence of different diseases in the
present population was compared to available official statistics
for the prevalence of diabetes mellitus, myocardial infarction
and hypertensive disease in Swedish men [8], using indirect
age standardization. Information regarding the prevalence of
prostate cancer in 50-80-year-old men in the Stockholm
region was retrieved from the local Cancer Registry. Where
appropriate, Fisher's exact test was used to test for general
association in two-way tables and the Mantel—Haenszel chisquare test was used to test for trends across age groups.
Results
The questionnaire was returned by 319 men, giving an
overall response rate of 73%. The median age of those
responding was 68 years. The response rate was not
dependent on age. For men aged 50-59, 60-69 and 7080 years the response rates were 73% (62/85), 72% (111/
155) and 73% (142/195), respectively. Four men did not
supply information on age. Wherever possible, all those
not responding were contacted by telephone. Of all
subjects, 33 (8%) of those not responding stated that
they were not interested in participating in any kind of
survey, 17 (4%) could not be reached (living abroad or
address unknown), 14 (3%) stated that they were too
busy to participate but would try to find time, 14 (3%)
had physical impairment (blindness, mental retardation,
'too sick to participate' etc.) and 38 (9%) had a known
address but could not be reached by telephone and
therefore could not be included in this assessment.
The frequency of various sexual functions and
activities is presented in Table II. Sexual dreams
were reported by 65%, sexual desire of any kind by 88%,
sexually aroused erection by 83%, orgasm in intercourse
or masturbation by 83% and orgasm during sleep by
15%. Engagement in intercourse was reported by 71%.
A decline in function was noted in all aspects of
sexuality assessed with increasing age.
Of all men who engaged in 'intercourse and/or
masturbation', 79% claimed that they always or nearly
always achieved orgasm, 10% achieved orgasm often,
9% sometimes and 2% never achieved orgasm (not in
table). Among all the men supplying information, 58%
stated that their sexual companion sometimes takes the
initiative to partake in sexual activity and 22% reported
that their sexual companion takes the initiative to
partake in sexual activity at least once per month (not in
table).
SEXUAL FUNCTION IN ELDERLY MEN
287
Table II. Frequency of sexual function, 'during the last few months', among 319 men 50-80 years of age in Stockholm
Times per month
4 oor more1
Age group
(years)
3-4
1-2
Less than once
N<
%
50—80(n = 319)2
Sexual dreams
Sexual desire
Sexual erection
Orgasm
Orgasm in sleep
Intercourse
5
33
32
22
0
14
5
12
16
18
0
14
16
25
21
26
3
22
39
17
14
17
12
21
35
12
17
17
85
29
50—59 (n = 62)
Sexual dreams
Sexual desire
Sexual erection
Orgasm
Orgasm in sleep
Intercourse
11
68
61
61
24
34
10
16
24
21
0
21
28
11
8
13
3
18
38
3
3
3
13
20
13
2
3
2
82
7
60— 69 (n= 111)
Sexual dreams
Sexual desire
Sexual erection
Orgasm
Orgasm in sleep
Intercourse
6
35
35
25
0
17
3
14
15
25
0
17
18
28
26
25
3
24
43
17
13
16
14
21
30
6
11
8
83
21
70—80 (n= 142)
Sexual dreams
Sexual desire
Sexual erection
Orgasm
Orgasm in sleep
Intercourse
3
17
16
4
0
4
4
9
13
11
0
8
8
29
24
31
3
22
37
25
19
23
9
22
48
21
29
31
88
44
The answer alternative in the questionnaire was; 'usually every week'. Four men did not supply information on age and
therefore cannot be included in the age sub-category analysis. Orgasm in sexual acts—no distinction was made between orgasm
in intercourse or during masturbation. 4One man reported orgasm in sleep this frequently. 'Percentages do not add up to 100%
due to rounding.
%potei
Q3
100-.r 9 7 % i ^
82%
75
SO
25
0
76%f—
11
•
•
50-59
60-69
Age
•in
1
•
No restriction
•
Restriction
,• 1
70-80
Figure 1. Percentages of physiologically potent men before
and after excluding any diseases and medication that might
affect sexual function.
In the whole sample of men, 68% reported an
erection stiffness 'sufficient for intercourse most of the
time' during sexually stimulated erection, morning
erection or spontaneous erection (physiological
potency). The level of physiological potency increased
to 77% when the analysis was restricted by excluding
men having taken any prescribed medication during the
previous 12 months and/or reporting prostate cancer,
psychiatric disorders, diabetes mellitus, hyperthyroidism, intermittent claudication, hypertensive disease,
myocardial infarction, Parkinson's disease, epilepsy,
renal disorders or obstructive bronchial disease. Physiological potency decreased with increasing age
(p < 0.001). All men in the youngest category (50-59
years) were physiologically potent after the restriction
but only approximately 60% of the oldest age group
(70-80 years) (Figure 1).
A R. HELGASON ET AL.
288
Table III. The importance of maintaining the present level of sexual function among men 50-80 years of age, reporting any level
of function
Important/very important
Of some importance
Of no importance
50-80
Sexual desire
Erectile capacity
Orgasmic pleasure
Ejaculate volume
46
57
62
37
33
25
22
27
21
18
16
36
50-59
Sexual desire
Erectile capacity
Orgasmic pleasure
Ejaculate volume
75
84
91
50
18
11
5
22
7
5
34
28
60-69
Sexual desire
Erectile capacity
Orgasmic pleasure
Ejaculate volume
48
59
63
37
35
28
26
31
18 4
13
11
31 4
70-80
Sexual desire
Erectile capacity
Orgasmic pleasure
Ejaculate volume
31
42
47
29
39
29
26
26
31 4
29
27
45
Age group
(years)
Stating that waning function would be 'very difficult' or 'difficult to accept'. Stating that they could accept waning function
without 'major difficulties'. Stating that they could accept waning function without 'any difficulties' or that the function had
'very little importance' or 'no importance' to them. Percentages do not add up to 100% due to rounding.
Of the men with any degree of erection stiffness who
engaged in sexual activity, 14% stated that their erection
always or nearly always ended prematurely, 12% stated
that it often ended prematurely, 46% that it sometimes
did and 28% stated that their erection never ended
prematurely during sexual activity (not in table).
In the whole sample, 46% of the men stated that it
was 'important' or 'very important' to maintain their
present level of sexual desire, 57% said the same about
erection, 62% about preserving their present level of
orgasmic pleasure and 37% stated that it was 'important' or 'very important' to preserve their present
level of ejaculate volume (Table III). Of all men still
able to achieve orgasm, 58% claimed that it was
'important' or 'very important' to maintain this
function (not in table).
Compared with their youth, most of the men
reported waning function in all aspects of sexuality
assessed, with the exception of sexual desire—where
half of all men still maintained their prime time function
(Table IV). After excluding men reporting any diseases
or medications that may affect sexual function, the
percentage of all men reporting no decrease in function,
compared with their youth, increased for sexual desire,
erectile capacity, orgasmic pleasure and ejaculate
volume to 58%, 28%, 43% and 31%, respectively (not
in table). Of those with decreased sexual desire, 20% felt
that this was 'unfortunate' or 'very unfortunate'.
Decreased erection capacity, orgasmic pleasure and
ejaculate volume had the same effect on 38%, 35% and
14%, respectively (Table IV). A decrease in orgasmic
pleasure was highly correlated with decreased ejaculate
volume (p < 0.001) (not in table).
Of all men reporting decreased function, 15% stated
that it was 'important' or 'very important' to regain the
previous level of ejaculate volume, 33% claimed it was
'important' or 'very important' to regain the previous
level of sexual desire, 38% felt the same about orgasmic
pleasure and 39% about erectile capacity (Figure 2). It
• Very
Important
• important
•Ofiome
Importance
111 Of no
Importance
Figure 2. Percentages of all men (50—80 years of age) reporting
decreased function, compared with their youth, assessing the
importance of regaining their previous level of function.
SEXUAL FUNCTION IN ELDERLY MEN
289
Table IV. Reported feelings about waning sexual function, compared with their youth, among 319 men 50-80 years of age in
Stockholm
Age group (years)
Reporting waning
function in:
n
Unfortunate or
very unfortunate
%
Disagreeable1
%
Little or no
relevance
%
No decrease
in function
%
50-80
Sexual desire
Erectile capacity
Orgasmic pleasure
Ejaculate volume
3193
160
238
212
235
20
38
35
14
35
28
30
21
45
34
35
65
504
25
33
26
50-59
Sexual desire
Erectile capacity
Orgasmic pleasure
Ejaculate volume
62
20
40
30
36
30
35
43
6
30
38
33
17
40
285
23 s
78s
68
35
52
42
60-69
Sexual desire
Erectile capacity
Orgasmic pleasure
Ejaculate volume
111
51
83
72
86
18
41
31
9
43
25
33
24
39
34
36
665
54
25
35
23
70-80
Sexual desire
Erectile capacity
Orgasmic pleasure
Ejaculate volume
142
87
114
108
111
18
37
35
21
32
27
27
20
495
36
38
59
39
20
24
22
Percentage of men reporting decreased function. Percentage of all men supplying information. Four did not supply
information on age and are not included in the age sub-category analysis. 4Eight men reported an increase in sexual desire
compared to youth. One man reported an increase in erection stiffness and one man reported an increase in orgasmic pleasure.
Percentages do not add up to 100% due to rounding.
was 'important' or 'very important' for 40% to regain
the previous level of capacity to have intercourse (not in
figure).
In an overall assessment of the 'importance of sex',
13% of all the men aged 50-80 stated that sex was 'very
important' to them, 29% that sex was 'important', 41%
that sex was 'a spice to life' and 17% that they could 'live
without' or 'never think of sex. T h e importance of sex
decreased with increasing age and 28% of the oldest
men (70-80 years) stated that sex was of no importance
to them (Figure 3).
Among all the men, 85% had a 'steady partner', 6%
AGE
70-80
n-142
60-69
n-111
QVery
important
B Important
{£ Spice to life
HCan live without
nevertiblnkof
50-59
n-62
1o
20
30
40
50 60
7U 80
90 100
Figure 3. Overall importance of sexuality in different age
groups. (Four men not supplying information on age are
excluded from the age subgroup analysis.)
had been without a partner for less than 5 years and 8%
for more than 5 years. Three men (1%) reported that
they never had a steady partner.
Of all men, 53% stated that they would have
intercourse more often if they had a willing sexual
partner. Of those, 29% stated that they would have
intercourse 'a little more often' and 24% that they
would have intercourse 'more often' or 'much more
often'. Of the men with partners, 33% stated they would
have intercourse 'a little more often' and 26% that they
would have intercourse 'more often' or 'much more
often' if their partner was more interested in sexual
intercourse (not in table).
There was little difference between the prevalence of
diseases in the present population and the general
Swedish male population in the same age group where
information was available. In the general population
the prevalence of prostate cancer is 2%, diabetes
mellitus 5% and myocardial infarction 13%. However,
there was an over-representation of men with a history
of hypertensive disease in the present population. The
prevalence was 21% compared with an expected
prevalence of 15%, obtained by applying the agespecific general population rates to the current sample
(indirect standardization).
290
A R. HELGASON ET AL.
Discussion
The results of the present study leave little doubt
that intact sexual function is common among elderly
men, even among those 70-80 years old. Only 17%
of all men regarded sex as a trivial part of their life.
Among those with intact sexual function, a substantial
number regarded it important to preserve their current
sexual capacity. Moreover, it is clear that waning
sexual function distressed a substantial proportion of
the men.
In the present study, 88% of all men reported some
sexual desire. In an Israeli study of men with a mean
age of 71.8 years, 86% reported some sexual desire [9].
We know of only one population-based study in which
aspects of sexual desire are included [1]. On assessing
the frequency of sexual dreams in 70-year-old males
and females, the author reported that 8% of the men
still participating in intercourse and 5% of the men not
participating in intercourse reported having sexual
dreams.
Of all men in the present study, 68% appeared to be
capable of achieving erectile stiffness 'usually sufficient
for intercourse'. The 32% prevalence of 'physiological
impotence' in the present study population corresponds
well with our previous findings of a 34% prevalence of
impotence in men before the diagnosis of prostate
cancer [7]. Although the erectile capacity decreased
with increasing age, 51% of the oldest men (70-80
years) were still 'physiologically potent'. We define the
term 'physiological potency' as the physiological ability
to achieve an erection usually sufficient to engage in
intercourse in at least one of three erection assessments
(sexually stimulated, morning or spontaneous). The
men graded their erection stiffness on an eight-category
scale for each of the three erection domains. Physiological potency appeared to depend on physical health
and medication. However, the percentage of 'potent'
men decreased with increasing age. This finding
could not be explained by the diseases and medication
about which we retrieved information. Other potentially important factors, such as hormonal deficiency
and vascular or neural damage, were not considered.
Assessments of psychological factors like stress,
anxiety, depression or boredom which may inhibit
practical use of the physiological ability to have an
erection were not relevant to the present analysis. No
assessment of smoking habits and alcohol consumption
was included in the analysis. A recent study [2] has
reported that 'current cigarette smoking exacerbated
the risk of impotence associated with cardiovascular
diseases and medications', but the authors found no
'general effect of current cigarette smoking'. They
further reported the effect of 'excessive alcohol consumption' on 'minimal impotence' to be small, if any.
No other study has assessed the importance of intact
orgasm pleasure and ejaculate volume in this age group
of men. A minority of all men with a decreased ejaculate
volume reported that this distressed them, whereas a
majority of the men were distressed by reduced
orgasmic pleasure. However, there was a strong significant relationship between decreased orgasm pleasure
and decreased ejaculate volume. It is therefore possible
that a decreased ejaculate volume is partly responsible for
the observed decrease in orgasmic pleasure.
As many as 71% of all the men still had sexual
intercourse. Antonovsky et al. reported a similar
proportion of men with a corresponding mean age
still engaging in intercourse [9]. In the present study,
most men with or without steady partners stated that
they would have intercourse more often if they had
access to a willing sexual partner.
There was no direct assessment of the frequency of
masturbation in the present study. However, orgasm,
of any origin, at least once a month was reported to be
much more frequent than intercourse in all age groups.
This may indicate a relatively high frequency of
masturbation since only a small proportion of the men
reported orgasm during sleep. In a previous Swedish
population-based study of men and women aged 60-80
years, assessing some aspects of sexual function, 51% of
the men stated that they masturbated and as many as
28% masturbated at least once a month. Unfortunately
the response rate was only 32.3%, compromising the
generality of the results [3].
When interpreting the results presented in Table IV
it must be considered that all degrees of waning
function are presented. Men experiencing a slight
decrease in function would not necessarily be expected
to experience that as a major problem.
It was decided not to obtain information from the
regular partner in the assessment of sexual functioning.
The use of information from a partner to calibrate selfassessments of sexual functioning may not be valid. For
example, the men may be more able or willing to
achieve erection and orgasm in masturbation or with
someone other than their partner. Furthermore, the
partner may be ignorant of such activities.
A potential serious source of bias includes a lack of
representativeness of the general population among the
men participating in the study [10]. The representativeness of the study population may be assessed by
comparing the prevalence of different diseases assessed
in the study with the prevalence in the general
population. The proportion of men with different
diseases assessed in the present study is in good
agreement with the prevalence in the general
Swedish population of men in this age group. If
anything, the proportion of men with different diseases
in the present study tended to be higher than the disease
prevalence according to official statistics. However, the
observed over-representation of hypertension in the
present population may be due to varying definitions.
In the present study, the men were asked if they had
ever been diagnosed with 'hypertension', whereas the
official statistics refer to the proportion of men
reporting a chronic hypertensive disease. Nevertheless,
there is no indication that selection of healthy individuals in the investigated population would explain the
results.
SEXUAL FUNCTION IN ELDERLY MEN
291
aging men and women: an Israeli study. Behav Health
Aging \9W;2:\5\-(>\.
Most elderly Swedish men continue to be sexually
active and consider sexual function to be important.
The findings warrant consideration of sexual function
in clinical decision-making and the design of clinical
trials in elderly men.
10. Steineck G, Ahlbom A. A definition of bias founded on the
concept of the study base. Epidemiology 1992;3:477-82.
Acknowledgements
We thank Professor Peter Ekman at the Department of
Urology, Karolinska Hospital in Stockholm, for his valuable
assistance and the Swedish Cancer Society and the Stockholm
Cancer Foundation for financial support.
A. R. Helgason#f, P. DickmanJ, G. Steineck*
Centre of Oncology and Departments of Cancer Prevention
and Cancer Epidemiology, Radiumhemmet,
Karolinska Hospital, S171 76 Stockholm, Sweden
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Authors' addresses
J. Adolfsson
Department of Urology,
S. Arver
Department of Molecular Medicine and Department of
Gynaecology and Obstetrics,
Karolinska Hospital, Stockholm, Sweden
M. Fredrickson
Department of Clinical Psychology, Uppsala University,
Uppsala, Sweden
M. Gothberg
Swedish Association for Sexual Education (RFSU),
The RFSU Clinic, Stockholm, Sweden
•Address correspondence to A. R. Helgason and G. Steineck,
Department of Cancer Epidemiology
flcelandic Cancer Society, Reykjavik, Iceland
^Present address Department of Statistics, University of
Newcastle, Australia
Received in revised form 23 January 1996