The Connection Between General and Sexual Health

On the following pages, the Deutsches Ärzteblatt publishes two studies on questions of sexual health and how it is connected to sexual activity and sexual satisfaction. While both being based on the same German study population, they approach the topic of sexual dysfunction from different angles (1, 2).

Sexual dysfunction as a harbinger

Since the publication of the report “Health Status of Men in Germany” (Gesundheitliche Lage der Männer in Deutschland), the body of evidence indicating that sexual dysfunction, especially erectile dysfunction in men, is a harbinger of ischemic heart disease and as such requires diagnostic work-up, has been growing (3). Sexual dysfunction can be associated with cardiovascular disease, diabetes mellitus and neurological disorders (4). Only one in five men seeks medical help (5). Conversely, physical and mental illnesses can have a significant negative effect on sexual activity and sexual satisfaction—and sexuality, if perceived as satisfying, has a significant positive impact on quality of life (6).

Raising awareness in the medical community

The aim of the recent German Health and Sexuality Survey (GeSiD, Gesundheit und Sexualität in Deutschland) is to collect representative population-based data on how sexuality and health are interrelated in men and women and, at the same time, raise awareness of this relevant issue within the medical community (1). Thus, this study, which was funded by the German Federal Center for Health Education (BZgA, Bundeszentrale für gesundheitliche Aufklärung), was initiated, since sexual dysfunction plays a minor role in everyday clinical practice—and this in all age groups.

Both of the articles in the Deutsche Ärzteblatt are based on one nationwide survey in Germany, investigating a random sample of 4955 women and men with regard to sexual activity, sexual satisfaction, general health status, chronic disease and impairments, as well as multimorbidity.

The focus of the GeSiD study was on the connection between physical and mental health on the one hand and sexual activity and sexual satisfaction on the other hand in a German-speaking residential population aged between 18 and 75 years. It was found that with increasing age the health status deteriorated and sexual dysfunction increased. The age groups with the highest level of sexual activity in men and women were the age groups 35 to 46 years and 25 to 36 years, respectively, with the current activity typically being associated with relationship duration and health status, but also with whether or not the respondents were living in a stable relationship.

New classification

The study by Briken et al. (2) is a substudy of the GeSiD and was developed against the backdrop of the new 11^th Revision of the International Classification of Diseases (ICD-11), coming into effect in 2022. In the revised classification, the division into physical and non-physical sexual dysfunction is abandoned and both types are combined in the chapter “Conditions Related to Sexual Health” and divided into four main groupings. For a sexual problem to become a sexual dysfunction, additional qualifying variables, such as duration, symptom severity and distress, are required as morbidity criteria. For the general population in Germany, no up-to-date prevalence estimates have been available previously. Their study fills this gap in our knowledge by providing for Germany a prevalence estimate based on the new ICD-11 criteria for sexual dysfunction, taking into account the morbidity criteria and age.

The results of the two studies show a decrease in sexual activity and sexual satisfaction in respondents (male and female) rating their health status as moderate or poor or living with chronic disease or impairment which has a limiting effect on their sexuality. Interestingly, no significant associations between the age of the respondents and their sexual satisfaction were found, while duration and status of the relationship played a key role.

Integrating sexual health questions into the medical history

Using a German population sample, the two studies showed an association between diseases and impairment of sexuality. Hence the need for integrating questions on sexual health into the medical history of patients, and not just when sexually transmitted infections (STIs) or sexual dysfunction are present. Here, it is important to break the taboo around this topic and raise awareness of sexual health issues among doctors already during their training and continuing education and teach them the skills required for addressing these very personal aspects of life in order to lower the threshold among both doctors and patients.

Agreement with international studies

These data are highly relevant for early detection and prevention and not limited to sexual dysfunction. Recently, epidemiological studies from Scandinavian countries have shown that severe male infertility, typically diagnosed and treated in middle-aged men, is strongly associated with severe diseases (cancer, cardiovascular disease, neurological disease) later in life (7, 8). Likewise, male infertility is still shrouded in taboo and neatly fits in with the overall theme of reproductive health and its importance for general health.