The sexual dysfunctions encompass a variety of disorders that are characterized by disturbances in the various phases of the sexual response cycle of desire, arousal, orgasm and resolution, as well as sex-related pain disorders [1,2]. Reviews and studies have shown that sexual dysfunction can arise as a result of physical or mental illness [3- 6], or through the effects of medication [7]. Sexual dysfunctions have a major impact on life satisfaction, sexual satisfaction, mental health and partnership [8-11], Female sexual function disorders are very prevalent, with a prevalence of over 40% [5,11]. In international studies in which standardized screenings were applied, such as the Female Sexual Function Index (FSFI) [12], the estimated prevalence is between 24% and 43% [13,14]. An American study among female students reported 63% [15]. The prevalence of sexual desire dysfunctions in women is reported to be between 17% and 55%; for dyspareunia the determined values are 14-27%, for orgasm disorders 16-25% and for excitement and lubrication problems 8-15%, that for sexually active women lies between 21-28% [5]. The prevalence of male sexual dysfunction is reported as 20- 30%, with the strongest evidence-based results for erectile dysfunction. Using the cut-off values of the International Index of Erectile Function (IIEF-5) a prevalence of 21% in men between the ages 40-80 years has been determined. The incidence of erectile dysfunction increases steadily according to age. In European studies, prevalence rates of up to 10% are reported among the under 40-year-olds, 20-30% in the age group of 40-59, 20-40% aged between 60-69 and 50-75% aged between 70-80 [5]. The differences in prevalence are based on the fact that, on the one hand, operationalization is not always easy and, on the other, various forms of sexual dysfunctions can overlap. In clinical practice, there should be a distinction made between sexual problems and sexual dysfunction. Sexual dysfunctions are characterized by an impairment of the sexual function, psychological stress or serious relationship problems. The first signs of sexual dysfunction should also be taken seriously because they can be the indicators of an underlying chronic disease [5,16,17]. Nevertheless, the issue of sexuality is rarely addressed by physicians and often neglected in medical care [18,19]. The aim of our study was to determine the occurrence of sexual dysfunction in women and erectile dysfunction in men between the ages of 18 and 40, by applying the FSFI and IIEF. Furthermore, the objective was to examine the connection between sexual dysfunction and health-related quality of life, sexual satisfaction, relationship satisfaction, health status and depression, as this is of great relevance to medical care. Finally, the intent was to assess whether and if so, when and in what form, sexual anamneses and the treatment of sexual problems have already been implemented in medical care.

The survey was carried out among 801 patients aged between 18- 40. All patients were in primary care and received at least some form of medical treatment, such as for minor illnesses or infections, or having had a routine check-up or vaccinations. It was conducted as an empirical online study on sexual attitudes, behavior and disorders, using SoSci- Survey software. The software SoSci-Survey [20] ensured a high level of data protection, while also guaranteeing a reliable dissemination of the survey information. In addition to social-demographic data, sexual disorders, health-related quality of life, sexual satisfaction, partnership satisfaction, health and depression and individually experienced health care were also assessed. Sexual dysfunctions should be examined in patients aged between 18-40 and the medical health care from the patient's perspective. For patients in this age group, it is less likely to experience the effects of multimorbidity [21]. In female sexual dysfunction it is often difficult to view the individual sexual dysfunctions separately from each other. Consequently, it was essential to choose a valid instrument for identifying the various sexual impairments, which would provide a cut-off value to measure a sexual dysfunction. Recruitment and data collection took place from September 2014 to February 2015. The study was conducted in accordance with the "Declaration of Helsinki", the guidelines of Good Clinical Practice and was approved by the institutional review board of the University Hospital Jena.

Measure

Sociodemography, health status and partnership satisfaction: The socio-demographic data was collected in accordance with the recommendations of the Working Group "Epidemiological Methods" in the German Working Community Epidemiology of the GMDS and the DGSMP [22]. The assessment of health and the partnership satisfaction was based on a visual analogue scale of 0 to 100 in accordance with the EuroQuol [23].

Sexual dysfunction: The Female Sexual Function Index (FSFI) [12,24] is an internationally validated 19-item self-assessment questionnaire with six subscales: desire, subjective arousal, lubrication, orgasm, satisfaction and pain. The model explained 78.43% of the variance and the subscales showed good internal constancy values (Cronbach's alpha: 0.75-0.95). The FSFI has been validated in women with sexual arousal disorders, libido problems and orgasm disorders. The cut-off value is 26.55 [25].

The International Index of Erectile Function (IIEF-5) [26] is a short 5-item self-description tool to measure erectile dysfunction. The internal consistency values are very good (Cronbach's alpha: 0.73-0.99). The total sum of the IIEF-5 is between 5 and 25. The clinical cut-off is 21.

Health-related quality of life: The SF-12 [27] is an established short measuring instrument for recording the health-related quality of life. The two subscales "mental health" and "physical health" can be reliably evaluated with the 12 items on the eight subscales, role physical, role emotional, physical function, social function, mental health, vitality, pain and general health.

Sexual satisfaction: The NSSS-SD [28], German version: New Sexual Satisfaction Scale - Short is a 12-item short instrument for measuring sexual satisfaction on a 5-stage Likert scale [29]. The total value is between 12 and 60. The value for the internal consistency is 0.92.

Depression: The PHQ-9 (Patient Health Questionnaire-9) [30,31] is one of the best screening tools for a reliably measuring the severity of depression by means of 9 items on a 4-point rating scale. The range is between 0 and 27. PHQ-9 scores between 5 and 9 represent a mild, between 10-14 a moderate and between 15-27 a severe depression [32].

Questions about sexual anamnesis and treatment: The patients’ experiences with the health care system were measured with the help of individual items. They were asked whether a complete sexual anamnesis had been carried out with regard to their sex history, use of contraceptives and sexual dysfunctions and if so, which medical specialists had done this.

Data analysis: The patient characteristics were analysed descriptively and the group differences were analysed by means of variance analyses, indicating the confidence intervals. For data analysis, SPSS 21.0 was used at a fixed level of significance of alpha=0.05.

The socio-demographic variables of the total sample of 801 patients are shown in Table 1. Patients between the ages of 18 and 40 were included in the analysis; the average age was 66.3 (SD=8.3). All patients reported to have received at least some form of medical treatment, such as for minor illnesses or infections, or having had a routine check-up or vaccinations.

Table 1: Characteristics of the sample (N=801).

On the basis of the FSFI values (MW=25.9, SD=8.2) a sexual dysfunction was found in 211 (35.6%) women, 351 (59.3%) had no clinically relevant values and 30 values were missing (5.1%). In the group of men who participated, clinically relevant erectile dysfunction was found in 59 subjects (28.2%) with respect to IIEF-5 (MW=21.1; SD=6.2). 150 (71.8%) had no clinically relevant values. There were highly significant differences between the groups with and without male or female sexual dysfunction in terms of health-related quality of life, sexual satisfaction, relationship satisfaction, health status and depression. The mean values, standard deviations and confidence intervals with regard to the presence of a sexual dysfunction are shown in Tables 2 and 3. The surveyed women and men with sexual dysfunction stated they have significantly lower values of health-related quality of life, sexual satisfaction, partnership satisfaction and health and a significantly higher level of depression.

Table 2: Differences between the groups calculated according to the FSFI (sexual dysfunction) in women in terms of health-related quality of life, sexual satisfaction, relationship satisfaction, health and depression.

Table 3: Group differences calculated according to the IIEF-5 (erectile dysfunction) in men in terms of health-related quality of life, sexual satisfaction, relationship satisfaction, health status and depression.

Sexual anamnesis and medical care from the patient's perspective

85.1% of women (n=504) stated that they had never had a complete sexual anamnesis (questions regarding the date of their first menstruation, contraceptives and possible problems during sexual intercourse). In the cases of female patients with a complete sexual anamnesis (14.9%, n=88), the anamnesis had been performed in 85 (14.4%) of the women by a gynecologist, in two women by the general practitioner (0.3%) and in one case by the psychotherapist (0.2%). In the cases of 205 men (98.1%) a complete sexual anamnesis had never been performed. In three cases the sexual anamnesis had been performed by a general practitioner (1.4%) and in one case by an urologist (0.5%). 91.4% (n=191) of the men had never been questioned about contraception in primary care. 81.8% (n=484) of women and 87.6% (n=183) of the men had never been asked about sexual problems or dysfunctions. Table 4 provides information about questions asked during sexual anamnesis in primary care.

Table 4: Questions asked during sexual anamnesis in primary care.

13.7% (n=81) of women and 7.7 (n=16) of men were previously treated for sexual problems. Among the women with a sexual dysfunction according to FSFI, 84.8% (n=179) were not treated. And 93.2% (n=55) of men with clinically relevant erectile dysfunction are also untreated.

Sexual dysfunctions are not uncommon in early adulthood and have a significant influence on the patients' sexual satisfaction and quality of life. Nevertheless, this is often disregarded in medical care. The results of this present study correspond with the figures of other studies [5,11], in that they show high levels of sexual dysfunction, even though the prevalence differences and standard deviation are great [33]. Many studies set the starting age for measuring sexual dysfunction at 40 [5], although the increase in sexual dysfunction in elderly patients is more the result of age-related morbidity rather than of normal aging processes [34]. Sexual dysfunctions often have a negative impact on the quality of life and result in a high level of suffering for the patient. In the present study, men and women with sexual dysfunction reported significantly lower values in health-related quality of life (mental health), sexual satisfaction, partnership satisfaction and health status on the one hand, as well as higher levels in depression on the other. These results are consistent with recent studies [8-11], but some of the relationships may be bidirectional [35]. Depression is often associated with sexual dysfunction and sexual dysfunction can also lead to depression [35]. The results of the sexual anamnestic questions are also consistent with references in specialist literature, according to which sexuality is rarely addressed by doctors [18,19,36]. The reasons for this are: first of all, coyness or modesty; secondly, the feeling of not being adequately prepared or trained for a “sex talk”; thirdly, the assumption that a person’s sexual history is irrelevant in relation to the patient’s major medical problems; and last of all, time issues [19]. Moreover, less than 20% of men and 15% of women discuss their sexual problems with their doctor, which is partly due to lack of awareness and a sense of shame [37]. This situation can become problematic when physicians feel just as uneasy about the matter and do not initiate the conversation about sexuality. As a result of these factors, sexual dysfunctions often go undiagnosed. In the present study 84.8% of women and 91.2% of men with a sexual dysfunction are untreated. There is confirmation of this in specialist literature, according to which sexual dysfunctions are generally underdiagnosed and are treated either with delay or not at all [38]. However, many patients want to talk to the doctor about sexual problems [39]. In our study, more than half of the patients said that they wished their doctor would instigate such a conversation. This is in line with the results of a German study, in which 54% of women and almost 45% of men think the doctor should routinely screen some aspects of sexual function [37]. On an international level, recommendations are increasingly being made to GPs (doctors in general and family medicine), who are routinely responsible as key gatekeepers in the health care system, to address the main issues concerning sexual health [19]. The questions related to the patients’ sex history could be efficiently integrated into their general check-up routine, when asking questions about their current complaints or prescribed medication. It would be easy to say, e.g. "Many people with diabetes notice a change in their sexual function. Have you noticed any of these changes yourself?" A straightforward approach and a common-sense attitude when it comes to sexual anamnesis and routine screening would be of great advantage to both patient and doctor.

Online surveys are sometimes criticized for allegedly posing the danger of misrepresentation, although they do have the advantage of reaching a diverse group of people, especially adolescents and young adults. The sometimes-feared risk of distortion of facts has so far never been ascertained in any comparative study [40]. This type of study is even considered to be particularly suitable for research studies in the area of sexual research [41] since it reduces social inhibitions and promotes openness in sensitive topics [42]. Often online surveys are not considered to be representative, as Internet users nowadays can still differ from the non-users. However, the age effect described in scientific publications could be reduced to a minimum since the present age group also corresponds to the main user group of the 18-to-40-year-olds. Nevertheless, there is the restriction that it is not a representative study. In next studies data on medications and chronic diseases should be asked. Another limitation of the study is that, while for men there is a specific sexual dysfunction (erectile dysfunction), for women there is only a score for probability calculation to diagnose a sexual dysfunction. This is due to the fact that, particularly in women, individual sexual functional disorders are often not clearly identifiable, though the classification systems [43] increasingly make allowances for this. Furthermore, we only have the subjective patient information to evaluate the health care services. With the aid of representative surveys and the back-up of health care data (supplied by doctors and health insurances) we will obtain a more insightful representation, as well as a more comprehensive assessment of the kind of health care situations of patients with sexual dysfunctions.

Sexual concerns and dysfunctions have a major impact on our quality of life. Therefore, they should be routinely queried in the context of medical examinations. For example, when prescribing medicines, side effects may be referred to sexuality. And the GP should see himself as a conversation partner for sexual health.

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