13.3% of participants reported an ‘always regular’ coital relationship, 28% ‘mostly regular’, 24% ‘variable’, 13.6% ‘mostly irregular’, and 21.1% ‘always irregular’, the latter three grades grouped together into 58.7% with irregular coitus. Irregular coitus was a possible risk factor for ED (odds ratio 3.95, 95% CI 2.8–5.5) as well as for PE (odds ratio 1.86, 95% CI 1.38–2.51).
28.8% reported the use of one or more contraceptive measure for birth control in the form of condoms (39.2%), vasectomy (37.8%), female contraceptive pills (17.5%), coitus interruptus (9.1%), safe period (7%), intrauterine device (IUD) (4.9%), and other in 2.8% including hysterectomy and female patch. Collectively, female contraceptives were used by 25.2%.
The highest rate of satisfaction with the contraceptive measure used was detected with IUD, followed by vasectomy, female contraceptive pills, safe period, coitus interruptus, and least of all condoms.
The USA is a cosmopolitan country encompassing a wide diversity of ethnicities, cultures, and attitudes. However, every community – USA included – have common values and characteristics despite the diversity. This is why we restricted our analysis to those who have lived most of their lives in USA such that they are imprinted to the largest extent possible by some common values, in comparison with recent immigrants, who would better be analyzed in the context of their countries and cultures of origin. We also recognized the language barrier that distinguishes two distinct populations, English-speaking and Spanish-speaking, among others. This report focuses on the former, which constitutes the largest group.
The results at hand show that a considerable proportion of participants (63.4%) were married. However, the age of marriage seems to be relatively advanced, mostly among those above the age of 50. Marriage was not associated with a higher risk for ED or PE. However, the longer DCR was associated with a higher prevalence of PE. This was not a consequence of aging as there was no significant difference in age among individuals with DCR more than 10 years with PE and those not. This is in agreement with other reports that deny an effect for age on ejaculatory control 5. Thus, couples with a longer DCR (mostly the married) should be made aware of the treatment options for PE, possibly by family physicians and/or mass media.
Utility of PDEi’s was highest among widowers, which could be explained by the fact that this group had individuals of the oldest age relative to other groups. However, recreational use in the absence of ED was highest among the married, possibly explained by the decrease in the IIEF score with the longer DCR, although not to the extent of causing frank ED. This subtle decrease in erectile power could be the motivation for PDEi utilization. Similar motivation for recreational use was reported by other investigators where PDEi’s were used to have a harder and longer lasting erection, higher coital frequency, and to prevent sexual failure 6. The above-mentioned ‘longer lasting erection’ could also be in line with the slightly higher prevalence of PE among those with a longer DCR, although PE is not a formal indication for the management of PE.
Monthly frequency of sexual intercourse in USA was less than that reported in the Middle East 7 (8.7±9.3 vs. 13.2±11.5). However, this is influenced by the older average age of participants in USA (52.38±14.5 vs. 35.2±7.6 years in the Middle East). Comparison of respective age groups showed similar coital frequency in USA (Table 2) and the Middle East (from 14.5±12.4 in the ‘18–39 years’ age group, down to 10.1±7.3 in the ‘40–49 years’ group, and 9.1±6.2 in the ‘50–59 years’ group). Overall, both regions coincide in this domain. Frequency of sexual intercourse is known to decrease with age 7. This was reproduced in the American population with a decrease from approximately three times per week in the 18–39 years age group to approximately once a week in the above 60 group. Still, the expectations for what a normal coital frequency should be were much higher than the actual frequency in both regions. These findings may set the internationally acceptable normal frequency of sexual intercourse in various age groups, important to alleviate concerns that may lead to unnecessary utilization of erection-enhancing medications. Longer IELT along with higher coital frequencies can be explained by the close spacing, which decreases sexual craving and consequently modulates the drive for ejaculation and ejaculatory control. However, the positive correlation between IIEF and coital frequency could be attributed to the effect of better erectile function on coital frequency and probably not vice versa. The same explanation may apply to the mutual effect of irregular coital activity on erectile function and ejaculatory control, where irregularity could predispose to PE, whereas ED could lead to irregularity of coital activity.
Contraception was resorted to at a much lower rate in USA than was in the Middle East 5 (28.8 and 56%, respectively), reflecting the population problem in the latter. In USA, condoms were the most frequently used, although least preferred. Dislike for condoms was also detected in the Middle East, although matching a low frequency of use 5. The second most practiced contraception was vasectomy, although, in contrast to condoms, was associated with a high satisfaction rate in USA. This is in contrast to the Middle East, where vasectomy was extremely rare 5. The high frequency and satisfaction rates with vasectomy reflect the freedom and independence conferred, without the need for on-demand contraception. Still, condoms came first in frequency of use despite dissatisfaction, possibly because of their added benefit in the domain of safe sex. This shift to condoms was reported since 1998, where the decrease in pill and diaphragm use and the increase in reliance on condoms suggested that concerns about HIV and other sexually transmitted diseases were changing patterns of method use 8.
However, men in both USA and the Middle East favored female contraceptive measures the most, although resorted to in variable proportions. Contraceptive pills were both favored and frequently utilized by couples in USA and the Middle East. However, although IUD was associated with the highest satisfaction rate in both the USA and the Middle East, it was among the least utilized in USA and the most utilized in the Middle East. It seems that men in USA and the Middle East generally prefer the female partner to take over the responsibility of contraception, in which case, satisfaction with the contraceptive measure is highest. In USA, men prefer the independence conferred by non-on-demand methods such as IUD and vasectomy.
In USA, as of the year 2011, the majority of English-speaking men above the age of 50 are married, although the age of marriage seems to be toward the fourth to fifth decades. Men with a longer duration of a coital relationship (years) are relatively vulnerable to PE, which should be discussed by the family physician, general practitioner, and in the mass media if it is to be addressed appropriately. Married men were more prone to use PDEi’s for recreational purposes, despite lack of formal ED. Coital frequency is almost the same in USA and the Middle East, ranging from approximately three times per week in the 18–39 years age group to approximately once a week in the above 60 group. Regular and closely spaced coital activity was associated with better ejaculatory control. It seems that men in USA and the Middle East generally prefer the female partner to take over the responsibility of contraception, in which case, satisfaction with the contraceptive measure is highest. In USA, men prefer the independence conferred by non-on-demand methods such as IUD and vasectomy.
Conflicts of interest
There are no conflicts of interest.
1. Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Peñ BM.Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction.Int J Impot Res1999;11:319–326.
2. Symonds T, Perelman MA, Althof S, Giuliano F, Martin M, May K, et al..Development and validation of a premature ejaculation diagnostic tool.Eur Urol2007;52:565–573.
4. Ahmad O, Boschi-Pinto C, Lopez A, Murray C, Lozano R, Inoue M.Age standardization of rates2001.Geneva:WHO.
5. Shaeer O, Shaeer K.The Global Online Sexuality Survey
(GOSS): ejaculatory function, penile anatomy, and contraceptive usage among Arabic-speaking internet
users in the Middle East.J Sex Med2012;9:425–433.
6. Bechara A, Casabé A, De Bonis W, Helien A, Bertolino MV.Recreational use of phosphodiesterase type 5 inhibitors by healthy young men.J Sex Med2010;7:3736–3742.
7. Shaeer O, Shaeer K.The global online sexuality survey
(GOSS): erectile dysfunction among Arabic-speaking internet
users in the Middle East.J Sex Med2011;8:2152–2163.
8. Piccinino LJ, Mosher WD.Trends in contraceptive use in the United States: 1982–1995.Fam Plann Perspect1998;30:4–10+46.
condom; contraception; epidemiology; frequency; Internet; marriage; survey; USA