Abstract
Introduction
An unmet desire for children may challenge masculine identity and therefore affect sexual self-concept and sexual functioning. The aim of this study was to examine long-term differences in sexual self-concept and sexual dysfunctions between men with fulfilled versus unfulfilled unmet desire for children.
Methods
Data were derived from the Bavarian Men’s Health-Study, a cross-sectional survey including middle-aged men. The unmet desire for children was defined according to the World Health Organization criteria and assessed via structured interviews. Participants completed standardized questionnaires assessing four dimensions of sexual self-concept: toughness, body image, sexual self-esteem, and perceived pressure with regard to sexuality. Sexual dysfunctions—including erectile dysfunction, low sexual desire, premature ejaculation, and delayed ejaculation—were additionally assessed. Participants were categorized according to whether their unmet desire for children had ultimately been fulfilled or remained unfulfilled. To control for potential confounders when comparing dimensions of sexual self-concept (age, body mass index, semen analysis, relationship status, education, and financial situation), a 1:1 propensity score matching was performed. Group differences were analyzed using the Wilcoxon–Mann–Whitney test. Primary outcomes were differences in sexual self-concept and sexual dysfunctions between men with fulfilled versus unfulfilled unmet desire for children.
Results
The final sample comprised 1097 men (mean age 50.6 ± 0.7 years), all with a history of unmet desire for children. The mean age at onset of unmet desire for children was 35.9 ± 6.1 years. Overall, 65.5% of men who had experienced an unmet desire for children ultimately became fathers. After propensity score matching, no significant differences were observed in any dimension of sexual self-concept between men with fulfilled versus unfulfilled unmet desire for children (P > .05). Likewise, the prevalence of sexual dysfunctions did not differ significantly between groups (P > .05).
Discussion
Approximately 15 years after experiencing an unmet desire for children, no differences in sexual self-concept or rates of sexual dysfunctions were observed between men with fulfilled versus unfulfilled unmet desire for children. These findings suggest that, in the long term, reproductive outcomes—such as the fulfillment or non-fulfillment of an unmet desire for children—may only have a modest impact on men’s sexual self-concept and sexual functioning. The findings may contribute to counseling efforts by reducing concerns about potential long-term psychosexual consequences of an unmet desire for children.
Keywords: infertility, desire for children, sexual self-concept, sexual dysfunction, male sexuality, body image, sexual self-esteem, masculinity, erectile dysfunction
Introduction
For many men, the desire for fatherhood represents a central aspect of identity and is closely linked to societal expectations of masculinity. In a German national survey, 56% of men considered fatherhood an essential component of male identity, while more than one-quarter of men with an unfulfilled desire for children reported experiences of stigmatization and social exclusion.1 Infertility, defined by the World Health Organization (WHO) as the inability to achieve pregnancy after at least 12 months of regular unprotected intercourse, affects a substantial proportion of couples worldwide.2
Importantly, this clinical definition encompasses a heterogeneous group of individuals and couples with different underlying causes of infertility. Male factors contribute to approximately half of all infertility cases, either as the sole identifiable cause or in combination with female factors, while in a substantial proportion no clear etiology can be identified.3–5 Regardless of the underlying cause, the experience of an unmet desire for children may constitute a major psychological stressor and disruptive life event. Beyond impaired reproductive function, infertility-related experiences may have broader consequences for men’s psychological well-being, relationships, and perceptions of masculinity. These consequences can be understood within a biopsychosocial framework, in which sexual health and self-concept are shaped by the dynamic interplay of biological factors, psychological processes, individual experiences, and sociocultural influences.1,6–8 Such experiences can challenge established identity structures and may require men to renegotiate aspects of their self-concept, including their sexual self-concept. Identity and self-concept are dynamic constructs shaped by personal experiences, social environments, and culturally dominant ideals of masculinity.1,6–8 The sexual self-concept refers to an individual’s perception and evaluation of their sexual feelings, behaviors, and attributes and represents an important dimension of male sexuality.9–11 While the sexual self-concept comprises numerous dimensions, the present study focused on four dimensions that are particularly relevant in the context of male sexuality: toughness, body image, sexual self-esteem, and perceived pressure with regard to sexuality.12
Although infertility affects both partners, clinical care and public discourse have historically focused primarily on women, contributing to the perception of infertility as predominantly a female issue.13–15 Nevertheless, men experiencing infertility also report emotional distress, stigma, feelings of inadequacy, and impaired self-esteem.16–19 Infertility may further threaten traditional concepts of masculinity, particularly when fertility is closely linked to male identity and sexual competence.20–22 Consistently, previous studies have associated infertility with negative body image, and reduced sexual self-esteem.18,23,24
Beyond changes in self-perception, infertility-related distress may also affect broader aspects of sex life including sexual functioning. Psychological burden, performance pressure, anxiety, and feelings of diminished masculinity have been discussed as contributing factors to sexual dysfunctions such as erectile dysfunction (ED), low sexual desire (LL), or premature ejaculation (PE) among infertile men.25–27 This close and bidirectional relationship between infertility and sex life has recently been conceptualized as the “Inferto-Sex Syndrome”, emphasizing the interrelated nature of reproductive and sexual health.28
Against this background, the present study examines men WHO experienced an initially unmet desire for children according to WHO criteria and investigates the long-term relevance of its outcome—whether fatherhood was ultimately achieved or remained unfulfilled. Specifically, differences in sexual self-concept many years after the onset of infertility-related experiences were analyzed. The present study addressed the following research question: do men whose desire for children ultimately remained unfulfilled differ from men WHO ultimately fulfilled their previous unmet desire for children with regard to long-term sexual self-concept and the prevalence of sexual dysfunctions? To our knowledge, this is the first study to investigate long-term sexual self-concept in men with a history of unmet desire for children stratified by reproductive outcomes.
Methods
Study design and participants
This cross-sectional study was conducted as part of the Bavarian Men’s Health (BMH)-Study between April 2020 and March 2023. The BMH-Study is an ongoing German study which focuses on various aspects of male physical, mental, and sexual health in a large, population-based sample of 50-year-old men. The participants complete standardized questionnaires, undergo a clinical interview and a brief physical examination. Data on sociodemographic factors, lifestyle, general health, sexual behavior, sexual dysfunctions, and psychosocial parameters are collected. A detailed description of the BMH-Study has been published previously.29
Participants were included if they reported a history of unmet desire for children (definition according to the WHO) during the physician interview, and if they completed at least one set of items related to one dimension of the sexual self-concept. Men were excluded if they had undergone bilateral orchiectomy, if information on their sexual orientation was missing, or if they identified as homosexual. Furthermore, men who did not provide information on, or were uncertain about, the results of a semen analysis previously conducted in the context of their unmet desire for children were excluded (Figure 1). All data were collected through standardized questionnaires and face-to-face interviews conducted by trained physicians. The study was approved by the Ethics Committee (Approval Number: 69920SSR). All men were fully informed about the study procedure and provided written informed consent before their enrollment.
Figure 1.
Flowchart of sampling procedure and exclusion criteria. This figure shows how the final sample for this analysis was selected. Out of 5855 participants, n = 1097 were subsequently identified for this analysis.
Variables
Parameters regarding the unmet desire of children
The presence of a current or past unmet desire for children was assessed during the physician interview, based on the WHO definition of infertility.2 During the physician interview men were asked whether they had ever experienced an unmet desire for children. If so, they were further asked whether this desire had remained unfulfilled for more than 12 months despite regular, unprotected intercourse without achieving a pregnancy. Participants were asked to specify the age at onset of unmet desire and whether the intention for having children had ultimately been fulfilled or not. Based on this information, participants were categorized into the groups “fulfilled” and “unfulfilled unmet desire for children” for subsequent analyses. In the context, men reporting an unmet desire for children were asked whether a semen analysis had been conducted and, if so, whether any pathological abnormalities had been identified. For the purpose of this analysis, the responses were categorized as follows: no semen analysis, abnormal semen analysis, or normal semen analysis. Moreover, the use of assisted reproductive techniques (ART) was assessed. Both semen analysis results and ART use were based solely on self-reported information. No verification through medical records or documentation of past semen analyses was performed.
Sociodemographic, lifestyle, and psychological parameter
Sociodemographic variables included age, duration of partnership (in months), presence of children and/or multiples (twins or triplets), level of education, employment status, and self-perceived economic situation. Lifestyle factors included smoking, alcohol consumption, physical activity, body mass index (BMI), and waist circumference. These variables were assessed via structured physician interviews and standardized questionnaires, as described in previous publications.29 Symptoms of depression and anxiety were assessed using the German version of the two-question screening tools: Patient Health Questionnaire (PHQ-2) and Generalized Anxiety Disorder (GAD-2).30 Both measures are rated on a 4-point Likert scale (0–3). A summary score ≥ 3 indicates clinical levels of depression or anxiety symptoms, respectively. These measures have proven reliable and valid in previous studies.30
Sexual behavior
Sexual behavior focused on sexual orientation, frequency of partnered sexual activity as well as frequency of solo-masturbation within the last three months. Details of group categorizations are provided in (Table 1).29
Table 1.
Sociodemographic, lifestyle, psychological and sexuality characteristics for the entire study sample of men with a current or past unmet desire for children (n = 1097) and comparison between the “fulfilled” (n = 718) and the “unfulfilled” (n = 379) group.
| Unmet desire for children | |||||||
|---|---|---|---|---|---|---|---|
| Entire sample (n = 1097; 100%) | Fulfilled (n = 718; 65.5%) | Unfulfilled (n = 379; 34.5%) | P-value | ||||
| Parameters regarding the unmet desire for children | |||||||
| Age at onset of unmet desire for children, years, mean (±SD) | 35.9 (±6.1) | 35.0 (±5.8) | 37.9 (±6.4) | <.001 | |||
| Duration of the unmet desire for children, years, mean (±SD) | 3.2 (±3.1) | 2.7 (±2.2) | 4.2 (±4.4) | <.001 | |||
| Semen analysis, % (n) | .311 | ||||||
| Yes | 82.2 | (902) | 83.3 | (596) | 77.8 | (256) | |
| Abnormal results | 50.8 | (458) | 41.0 | (294) | 43.3 | (164) | |
| Normal results | 49.2 | (444) | 42.1 | (302) | 37.5 | (142) | |
| No | 17.8 | (195) | 17.0 | (122) | 19.3 | (73) | |
| Assisted reproduction techniques, % (n) | <.001 | ||||||
| Yes | 28.9 | (317) | 34.5 | (248) | 18.2 | (69) | |
| No | 71.1 | (780) | 65.5 | (470) | 81.8 | (310) | |
| Sociodemographic factors | |||||||
| Age at survey, years, mean (±SD) | 50.6 (±0.7) | 50.6 (±0.7) | 50.6 (±0.9) | .713 | |||
| Partnership, % (n) | .003 | ||||||
| Yes | 95.1 | (1043) | 96.5 | (693) | 92.4 | (350) | |
| No | 4.9 | (54) | 3.5 | (25) | 7.7 | (29) | |
| Duration of partnership, % (n) | .0014 | ||||||
| >0–5 | 6.2 | (64) | 4.5 | (31) | 9.6 | (33) | |
| >5 | 93.8 | (970) | 95.5 | (658) | 90.4 | (312) | |
| Number of children, % (n) | <.001 | ||||||
| 0 | 29.0 | (318) | 0 | (0) | 83.9 | (318) | |
| 1 | 26.5 | (291) | 34.7 | (249) | 11.1 | (42) | |
| ≥2 | 44.5 | (488) | 65.3 | (469) | 5.0 | (19) | |
| Multiples, % (n) | <.001 | ||||||
| Yes | 5.3 | (58) | 7.9 | (57) | 0.3 | (1) | |
| No | 94.7 | (1039) | 92.1 | (661) | 99.7 | (378) | |
| Level of education, % (n) | .472 | ||||||
| Low | 7.2 | (79) | 6.8 | (49) | 7.9 | (30) | |
| Intermediate | 17.8 | (195) | 17.0 | (122) | 19.3 | (73) | |
| High | 75.0 | (823) | 76.2 | (547) | 72.8 | (276) | |
| Employment status, % (n) | .286 | ||||||
| Full-time employed | 92.2 | (1011) | 92.8 | (666) | 91.0 | 345 | |
| Part-time employed | 5.2 | (57) | 5.3 | (37) | 5.3 | 20 | |
| Not employed (Not seeking work) | 2.6 | (29) | 2.1 | (15) | 3.7 | 14 | |
| Self-perceived economic situation, % (n) | .958 | ||||||
| (Very) good | 84.8 | (929) | 84.9 | (609) | 84.4 | 320 | |
| Satisfactory | 13.8 | (151) | 13.7 | (98) | 14.0 | 53 | |
| Less good/poor | 1.5 | (16) | 1.4 | (10) | 1.6 | 6 | |
| Lifestyle factors | |||||||
| Smoking, % (n) | .674 | ||||||
| Non-smoker | 57.5 | (627) | 57.0 | (407) | 58.4 | (220) | |
| Former smoker | 32.1 | (350) | 32.9 | (235) | 30.5 | (115) | |
| Current smoker | 10.5 | (114) | 10.1 | (72) | 11.1 | (42) | |
| Alcohol consumption, % (n) | .211 | ||||||
| Low | 17.2 | (183) | 18.1 | (126) | 15.5 | 57 | |
| Moderate | 77.9 | (829) | 77.7 | (540) | 78.3 | 289 | |
| Excessive | 4.9 | (52) | 4.2 | (29) | 6.2 | 23 | |
| Physical activity, % (n) | .312 | ||||||
| ≤1 time/week | 14.2 | (155) | 15.3 | (109) | 12.1 | (46) | |
| 2−5 times/week | 61.5 | (670) | 60.2 | (428) | 63.9 | (242) | |
| ≥6 times/week | 24.3 | (265) | 24.5 | (174) | 24.0 | (91) | |
| Waist circumference (cm), MW (±SD) | 97.5 (±11.9) | 97.7 (±11.8) | 97.1 (±12.2) | ||||
| Waist circumference (cm), % (n) | .283 | ||||||
| ≤94 | 43.6 | (475) | 42.4 | (302) | 45.9 | (173) | |
| >94–≤102 | 27.7 | (302) | 28.1 | (200) | 27.1 | (102) | |
| >102 | 28.7 | (313) | 29.6 | (211) | 27.1 | (102) | |
| BMI (kg/m2), MW (±SD) | 26.8 (±4.1) | 26.9 (±3.9) | 26.8 (±4.5) | ||||
| BMI (kg/m2), % (n) | .480 | ||||||
| <25 | 35.9 | (391) | 34.6 | (247) | 38.2 | (144) | |
| 25–<30 | 46.4 | (506) | 48.7 | (347) | 42.2 | (159) | |
| ≥30 | 17.7 | (193) | 16.7 | (119) | 19.6 | (74) | |
| Psychological factors | |||||||
| Screening for symptoms of depression (PHQ-2), % (n) | .655 | ||||||
| Negative (<3) | 95.3 | (1035) | 95.5 | (679) | 94.9 | (356) | |
| Positive (≥3) | 4.7 | (51) | 4.5 | (32) | 5.1 | (19) | |
| Screening symptoms of anxiety (GAD-2), % (n) | .540 | ||||||
| Negative (<3) | 95.5 | (1037) | 95.8 | (682) | 94.9 | (355) | |
| Positive (≥3) | 4.5 | (49) | 4.2 | (30) | 5.1 | (19) | |
| Sexual behavior | |||||||
| Sexual orientation | .665 | ||||||
| (Rather) Heterosexual | 99.4 | (714) | 99.7 | (378) | |||
| Bisexual | 0.6 | (4) | 0.3 | (1) | |||
| Partnered sexual activityc, +, % (n) | .607 | ||||||
| No | 13.7 | (149) | 13.2 | (94) | 14.8 | (55) | |
| Up to one time/month | 23.3 | (253) | 23.2 | (165) | 23.6 | (88) | |
| A few times/month to one time/week | 43.8 | (475) | 45.2 | (322) | 41.0 | (153) | |
| 2–3 times/week | 15.9 | (173) | 15.6 | (111) | 16.6 | (62) | |
| ≥4 times/week | 3.2 | (35) | 2.8 | (20) | 4.0 | (15) | |
| Solo-masturbationd, +, % (n) | .589 | ||||||
| No | 10.3 | (107) | 10.1 | (69) | 10.6 | (38) | |
| Up to one time/month | 21.7 | (226) | 20.4 | (140) | 24.0 | (86) | |
| A few times/month to one time/week | 37.6 | (393) | 37.9 | (260) | 37.2 | (133) | |
| 2–3 times/week | 22.4 | (234) | 23.6 | (162) | 20.1 | (72) | |
| ≥4 times/week | 8.1 | (84) | 8.0 | (55) | 8.1 | (29) | |
Abbreviations: BMI: body mass index, PHQ-2: Patient Health Questionnaire; GAD-2: Generalized Anxiety Disorder.
Dimensions of the sexual self-concept
Four dimensions of the sexual self-concept were assessed: toughness, body image, sexual self-esteem, and perceived pressure with regard to sexuality.
Toughness
Toughness was measured using three items from the “Toughness Norm” subscale of the German version of the Male Role Norms Scale (MRNS): “Nobody respects a man very much who frequently talks about his worries, fears, and problems”, “When a man is feeling a little pain he should try not to let it show very much”, and “I think a young man should try to become physically tough, even if he’s not big”. Responses were rated on a 5-point Likert scale (1 = fully disagree to 5 = fully agree). Higher scores indicate higher approval of toughness as one aspect of masculinity.31,32 Cronbach’s α = 0.66.
Body image
Body image was assessed using three items from the Dresden Body Image Inventory (DKB-35) potentially relating to sexuality: “I like my body”, “I enjoy showing my body”, and “I have pleasant and intense feelings of my body in sexuality”. Participants rated each item on a 5-point Likert scale, (1 = not at all to 5 = completely).33 Higher scores indicate a more positive body image. Cronbach’s α was 0.62.
Sexual self-esteem
Sexual self-esteem was assessed using three items: “During sex, I am a good lover”, “During sex, I pay attention to my partner’s desires”, and “During sex, I am imaginative”. The participants rated each item on a 5-point Likert scale (1 = not at all to 5 = completely). Higher scores represent higher sexual self-esteem. Cronbach’s α was 0.69.12
Perceived pressure with regard to sexuality
Perceived pressure with regard to sexuality was assessed by four questions: “I have the impression that nowadays, too much is expected from men during sex”, “With regards to sexuality, I feel put under pressure”, “I often panic about living up to the expectations of being a man during sex”, “I worry whether I correspond to the public image of a ‘real man’”.34 The response options ranged from 1 (not at all) to 5 (completely), with higher scores indicating greater perceived pressure with regard to sexuality of men.34 Cronbach’s α was 0.73.
Sexual dysfunctions
Erectile dysfunction
ED was assessed using the German version of the International Index of Erectile Function—Erectile Function (IIEF-EF) and the Erection Hardness Score (EHS).35 ED was defined as an IIEF-EF Score < 26 or, in case of no sexual intercourse in the past 4 weeks, by an EHS < 4.12,35
Low sexual desire
LL was assessed using a question from a previous German study on sexual desire: “How often have you felt sexual desire during the past 4 weeks?”36 The answers provided were “very frequently”, “frequently”, “occasionally”, “rarely”, and “very rarely/never”, the latter two answers defined as LL.29
PE and delayed ejaculation
PE and delayed ejaculation (DE) were assessed using the Sexual Complaints Screener for Men (SCS-M).37 For both conditions, participants first completed a symptom-specific screening item referring to the previous 6 months. For PE, participants were asked: “Some men cannot control their sexual excitement so that they ejaculate before or shortly (within approximately 2 min) after penetration. Has this happened to you during the last 6 months?”. For DE, participants were asked: “Some men have difficulty ejaculating or reaching orgasm during sexual activity. Has this happened to you during the last 6 months?” Response options for both items were: “no sexual activity”, “never/almost never”, “rarely”, “sometimes”, “often”, and “almost all the time/almost always”. Participants who reported symptoms additionally rated the degree to which this constituted a personal problem (“not at all a problem”, “a very small problem”, “some problem”, “a considerable problem”, “a very great problem”). Following previous studies based on data from the BMH-Study, PE and DE were categorized and dichotomized into absence versus presence of symptoms (“no” vs “yes”), with PE “yes”.29
Statistical analysis
A descriptive analysis was conducted for the total sample, covering sociodemographic variables, lifestyle factors, aspects of sexual behavior and sexual dysfunctions, as well as variables related to the unmet desire for children. The aforementioned variables were descriptively analyzed for men with a “fulfilled” and an “unfulfilled unmet desire for children”, and compared between these groups. For the comparison of categorical variables, Chi-square tests or Fisher’s exact tests were performed. For continuous variables (BMI, waist circumference, age at the time of the survey/onset of unfulfilled desire for children, sexual self-concept dimensions) the Wilcoxon–Mann–Whitney test was used. To reduce the influence of potential confounding variables between the groups, a 1:1 propensity score matching was carried out each of the included dimensions of the sexual self-concept. Propensity scores were estimated using logistic regression, including predefined covariates that were selected a priori based on evidence from the literature. These variables were chosen because they have been reported in previous studies to be associated with sexual self-concept or to represent potential confounding factors influencing the outcome: educational level, self-perceived economic status, BMI, presence and duration of a partnership, and the results of a semen analysis (normal vs. abnormal). Using the logit-transformed propensity score a 1:1 matching was performed, employing a greedy nearest-neighbor algorithm with a caliper width of 0.2 standard deviations and exact matching for categorical variables. The balance of variables after matching was assessed using standardized differences. Subsequently, differences between the groups “fulfilled” vs. “unfulfilled unmet desire for children” regarding the four dimensions of sexual self-concept were tested using the Wilcoxon–Mann–Whitney test.
The significance level was set at α = 0.05. All statistical tests were two-sided, exploratory, and performed at the 0.05 level of significance. Data analyses were conducted using the Statistical Analysis System (SAS), version 9.4 (SAS Institute Inc., Cary, NC, USA).
Results
Study population characteristics
A total of 1097 men who reported a history of an unmet desire for children were included in this analysis (Figure 1). At the time of the survey, the mean age was 50.6 ± 0.7 years. Most participants (95.1%) were in a partnership, and 71.0% reported having children. The majority were employed full-time (92.2%) and rated their economic situation as (very) good (84.8%). A large proportion were either overweight (46.4%) or obese (17.7%), and more than half had a waist circumference greater than 94 cm (56.4%). The majority of men identified as heterosexual 99.4%. 62.9% reported having partnered sexual activity at least a few times per month and 68.1% reported performing solo-masturbation at least a few times per month (Table 1).
On average, the experience of an unmet desire for children had occurred at the mean age of 35.9 (±6.1) therefore on average 15 years prior to the survey, with an average duration of the unmet desire for children of 3.2 (±3.1) years within the overall cohort. More than 80% of the men had undergone a semen analysis as part of the initial diagnostic workup, with nearly half of these assessments revealing pathological findings. Approximately one in five participants reported that no semen analysis had been conducted during the diagnostic evaluation of their unmet desire of children. Around 30% of men in the whole study sample of men with an unmet desire for children reported the usage of ART (Table 1). With regard to sexual dysfunctions within the entire study sample, 18.8 % of men had ED, 7.8 % reported LL, 6.9 % reported PE, and 1.2 % DE (Table 2).
Table 2.
Sexual dysfunctions in the entire study sample of men with an unmet desire for children (n = 1097) and comparison between the “fulfilled” (n = 718) and the “unfulfilled” (n = 379) group.
| Unmet desire for children | ||||
|---|---|---|---|---|
| Entire sample (n = 1097; 100%) | Fulfilled (n = 718; 65.5%) | Unfulfilled (n = 379; 34.5%) | P-value | |
| Sexual dysfunctions | ||||
| Erectile dysfunction, % (n) | .187 | |||
| Yes | 18.8 (201) | 17.6(124) | 20.9 (77) | |
| No | 81.2 (871) | 82.4 (580) | 79.1 (291) | |
| Low sexual desire, % (n) | ||||
| Yes | 7.8 (83) | 7.1 (50) | 9.1 (33) | .264 |
| No | 92.2 (982) | 92.9 (651) | 90.9 (331) | |
| Premature ejaculation, % (n) | ||||
| Yes | 6.88 (65) | 7.89 (49) | 4.5 (16) | .088 |
| No | 93.12 (880) | 92.11 (572) | 95.1(308) | |
| Delayed ejaculation, % (n) | ||||
| Yes | 1.2 (12) | 0.9 (6) | 1.8 (6) | .358 |
| No | 98.8 (969) | 99.1 (637) | 98.2 (332) | |
Comparison of men with and without fulfillment of an unmet desire of children
In 65.6% of the men (718/1097), the previously unmet desire for children had been fulfilled, while in 34.5% (379/1097) it remained unfulfilled. Men whose desire for children had been fulfilled were, on average, younger at the onset of the unmet desire for children compared to those whose desire remained unfulfilled. Men with successful realization of the unmet desire for children reported more often the usage of ART compared to men without successful realization (P < .001). They were also more likely to be in a partnership at the time of the survey and had a higher likelihood of having multiples (all P < .05). No significant differences were found between the two groups regarding whether a semen analysis had been performed, or whether the results were normal or abnormal. Furthermore, there were no differences between the groups in terms of lifestyle factors, sexual behavior, or level of symptoms of depression or anxiety (all P > .05; Table 1). Likewise, the prevalence of sexual dysfunctions did not differ significantly between the two groups (all P > .05; Table 2).
Comparison of the sexual self-concept between men with and without fulfillment of an unmet desire for children after propensity score matching
After propensity score matching, the comparative analyses were based on matched samples of n = 630 participants for toughness, n = 626 for body image, n = 588 for sexual self-esteem, and n = 606 for perceived pressure with regard to sexuality. No significant differences were observed between men whose previously unmet desire for children had been fulfilled and those for whom it remained unfulfilled across any of the assessed dimensions of sexual self-concept (all P > .05, effect sizes toughness r = 0.001, body image r = 0.020, sexual self-esteem r = 0.059 und for perceived pressure with regard to sexuality r = 0.062) (Figure 2).
Figure 2.
Frequency distribution of the responses on the 5-point Likert scale for each of the four dimensions of the sexual self-concept, comparing the fulfilled and unfulfilled group, after 1:1 propensity score matching (all P > .05).
Discussion
Despite the high global prevalence of unmet desire for children, its long-term psychological and sexual consequences in men remain insufficiently studied. While previous research has primarily focused on women, the male perspective is still underrepresented especially in terms of the long-term impact on the sexual self-concept.13,15 This study therefore examined whether dimensions of the sexual self-concept including toughness, body image, sexual self-esteem, and perceived pressure with regard to sexuality differ between men whose desire for children was fulfilled and those for whom it remained unfulfilled as well as sexual dysfunctions in the long term.
Sociodemographic factors
With regard to the assessed sociodemographic factors, men with an unfulfilled unmet desire for children were older at the onset of their desire for children, were less likely to be in a relationship and more often in shorter relationships at the time of the survey. These findings align with evidence linking advanced paternal age to reduced fertility and lower success rates in both natural and assisted conception.38,39 The lower partnership rates may reflect barriers to parenthood due to lack of a suitable partner, while prolonged infertility may itself strain relationships and contribute to separation, especially in couples with poor communication or avoidant coping strategies.18,40
Sexual dysfunctions
The rates of sexual dysfunctions including ED, LL, PE, and DE observed in this study are comparable to those reported in previous population-based studies.36,41–43 Previous research has suggested that male infertility and male sexual dysfunctions often coexist and may mutually reinforce one another through psychosexual, sociocultural, and relationship-related mechanisms.27,28,44 In this context, men experiencing infertility-related distress frequently report psychosocial stress, which may worsen sexual functioning and potentially affect hormonal and reproductive processes.44 Based on these findings, it could have been assumed that men whose desire for children ultimately remained unfulfilled would also show higher rates of long-term sexual dysfunctions following the experience of an unmet desire for children. However, no significant differences between the groups were observed in the present study. Importantly, the present analyses did not only assess ED, LL, and PE, which have been investigated in the context of infertility, but also DE. Although DE has so far received comparatively little attention in infertility research, it has likewise been discussed as a potentially relevant sexual dysfunctions among men experiencing infertility-related stress and reproductive difficulties.44
Sexual self-esteem and body image
In contrast to prior studies reporting impaired sexual self-esteem and body image in infertile men, no differences were observed between groups in the present study.8,23,45 A key explanation may be the long-time interval since the experience of unmet desire for children in this study in comparison with the aforementioned studies which surveyed men at the time of their clinical work-up and treatment at fertility clinics. The average of approximately 15 years since the onset of the unmet desire for children may have allowed for psychological adaptation, emotional processing, and the development of alternative life goals, thereby buffering long-term effects.
In addition relational and behavioral factors also shape body image and sexual self-esteem.46 The majority of men in this analysis reported stable relationships and regular partnered sexual activity, factors that likely contributed to the overall positive evaluations of body image and sexual self-esteem in the current sample.
Perceived pressure with regard to sexuality and toughness
In addition to body image and sexual self-esteem, perceived pressure with regard to sexuality and toughness were assessed as further dimensions of the sexual self-concept. As outlined in the introduction, an unfulfilled desire for children can represent a significant psychological and physical stressor for men, affecting various aspects of life, including self-identity.13,15 In societal narratives and media representations, fertility is often closely tied to masculinity.22 As a result, the inability to achieve fatherhood may lead to a disrupted or incomplete sense of traditional masculine identity.1,20,21 Interestingly, in the current study, perceived pressure with regard to sexuality was low across the entire sample, and no significant differences were observed between the fulfilled and unfulfilled groups. Both groups also demonstrated only moderate endorsement of toughness as an aspect of traditional masculine ideals. These findings may reflect, in contrast to the aforementioned studies,1,20,21 a shift from a more traditional understanding to a more modern understanding of masculinity, including factors like less endorsement of toughness, but also a decoupling of reproductive capacity from male identity as discussed in other studies.47
Symptoms of depression and anxiety
Existing studies indicate elevated infertility-specific anxiety during diagnosis and treatment initiation.14 In the current study, which focused on long-term differences between men with fulfilled versus unfulfilled desire for children, no significant group differences were found regarding symptoms of depression or anxiety. This finding is consistent with previous long-term follow-up research showing that several aspects of quality of life improved over time in infertile men and that fathering a child did not significantly influence long-term quality of life.48 Another study conducted 20 to 23 years after IVF treatment found that most men were in good mental health, although childless participants reported a higher risk of psychological symptoms.49 This discrepancy may be explained by the higher proportion of men in stable relationships in our sample (in this study 95.1 % versus 88% in49). Since single participants reported more symptoms of depression and anxiety, relationship status may offer more psychological protection than parenthood itself in the long term.49
Strengths and limitations
This study has both strengths and limitations. A notable strength is the use of propensity score matching, which increases the likelihood of detecting potential differences primarily attributable to the fulfillment or non-fulfillment of the desire for children while adjusting for other relevant factors, including sociodemographic characteristics, lifestyle factors, and the self-reported result of the semen analysis. Importantly, several of the matching variables are themselves known to be associated with differences in sexual self-concept and sexual functioning. Thus, matching on these characteristics reduces the likelihood that observed group differences are due to confounding factors rather than the long-term experience of fulfilled versus unfulfilled fatherhood itself.
Previous research has suggested that men who perceive themselves as the cause of infertility (ie, male-factor infertility) may experience greater infertility-related distress, which also could affect aspects of sexual self-concept. To account for this potential source of confounding, we matched participants according to their self-reported semen analysis results, thereby considering men’s subjective perception of their fertility status.48
Semen analysis results and reproductive experiences were based on participants’ self-reports and were not verified against medical records. Therefore, recall bias and potential misclassification cannot be excluded and should be considered when interpreting the findings. However, this approach was a deliberate methodological choice, as the present study focused on psychological outcomes and aimed to capture the subjective perception and interpretation of fertility-related information. Men’s perception of their semen quality (eg, whether they perceived their semen analysis as normal or abnormal) may be particularly relevant for long-term well-being and dimensions of sexual self-concept, potentially having a stronger influence than objective medical parameters alone.
As this study focused on the psychological relevance of fulfilled versus unfulfilled unmet desire for children, subgroup analyses according to infertility etiology, primary versus secondary infertility, or the use of ART were not performed. Another limitation is the absence of assessments prior to or at the onset of the unmet desire for children, limiting causal interpretations regarding the impact of fulfillment versus non-fulfillment over time.
Furthermore, the present study was conducted in a cohort of 50-year-old men residing in Bavaria, Germany, and was based on a single survey wave. Therefore, the findings may not be directly generalizable to other age groups, younger or older generations, or populations with different sociocultural backgrounds.
Future longitudinal studies are needed to better understand temporal changes in sexual self-concept and sexuality across the course of infertility experiences and their long-term outcomes. In addition, including both partners may provide further insights, as infertility and sexuality are inherently couple-based phenomena shaped by dyadic interactions and shared experiences.
Conclusion
In the long term, no differences in sexual self-concept were observed between men with fulfilled versus unfulfilled desire for children. Neither did the two groups differ with regard to rates of sexual dysfunctions. These findings suggest that reproductive outcomes may have only a modest impact on sexual self-concept and sexual functioning and should be interpreted within a broader biopsychosocial framework. This perspective may help improve counseling by reducing concerns about lasting psychosexual consequences of the experience of an unmet desire for children.
Acknowledgments
The authors thank all men who participated in the BMH-Study.
Contributor Information
Lilly J Schmalbrock, Technical University of Munich, School of Medicine and Health, Department of Urology, Technical University of Munich University Hospital, Munich 81675, Germany.
Valeska C Schlöder, Technical University of Munich, School of Medicine and Health, Department of Urology, Technical University of Munich University Hospital, Munich 81675, Germany.
Frank-Michael Köhn, Andrologicum Munich, Burgstraße, Munich 80331, Germany.
Victoria A Goeldner, Technical University of Munich, School of Medicine and Health, Department of Urology, Technical University of Munich University Hospital, Munich 81675, Germany.
Stefan Schiele, Technical University of Munich, School of Medicine and Health, Department of Urology, Technical University of Munich University Hospital, Munich 81675, Germany.
Helga Schulwitz, Technical University of Munich, School of Medicine and Health, Department of Urology, Technical University of Munich University Hospital, Munich 81675, Germany.
Andreas Dinkel, Technical University of Munich, School of Medicine and Health, Department of Psychosomatic Medicine and Psychotherapy, Technical University of Munich University Hospital, Munich 81675, Germany.
Martina Kron, Institute of Epidemiology and Medical Biometrics, University of Ulm, Ulm 89075, Germany.
Jürgen E Gschwend, Technical University of Munich, School of Medicine and Health, Department of Urology, Technical University of Munich University Hospital, Munich 81675, Germany.
Kathleen Herkommer, Technical University of Munich, School of Medicine and Health, Department of Urology, Technical University of Munich University Hospital, Munich 81675, Germany.
Author contributions
Conceptualization: Lilly J. Schmalbrock, Andreas Dinkel, Kathleen Herkommer; data curation: Lilly J. Schmalbrock, Valeska C. Schlöder, Stefan Schiele, Martina Kron, and Helga Schulwitz; formal analysis: Lilly J. Schmalbrock, Valeska C. Schlöder, Stefan Schiele, Martina Kron, and Helga Schulwitz; investigation: Lilly J. Schmalbrock, Valeska C. Schlöder, and Kathleen Herkommer; methodology: Andreas Dinkel and Kathleen Herkommer; project administration: Jürgen E. Gschwend and Kathleen Herkommer; resources: Jürgen E. Gschwend and Kathleen Herkommer; software: Stefan Schiele, Martina Kron, and Helga Schulwitz; supervision: Andreas Dinkel, Kathleen Herkommer, and Frank-Michael Köhn; validation: Lilly J. Schmalbrock, Frank-Michael Köhn, Andreas Dinkel, Stefan Schiele, Martina Kron, Victoria A. Goeldner, and Helga Schulwitz; visualization: Lilly J. Schmalbrock, and Valeska C. Schlöder; writing—original draft: Lilly J. Schmalbrock and Kathleen Herkommer; writing—review & editing: Valeska C. Schlöder, Frank-Michael Köhn, Andreas Dinkel, Stefan Schiele, Martina Kron, Victoria A. Goeldner, and Helga Schulwitz; funding acquisition: Jürgen E. Gschwend and Kathleen Herkommer.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
All authors declare no conflicts of interest.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.