1 Andrology Australia, Monash Institute of Medical Research, Monash University, Melbourne, Victoria, 2 Prince Henrys Institute of Medical Research, Melbourne, Victoria, 3 Centre for Education & Research on Ageing and School of Public Health, University of Sydney, Sydney, NSW, 4 Department of Medicine, University of Adelaide, Adelaide, SA, 5 Department of Andrology, Concord Hospital, ANZAC Research Institute, University of Sydney, Sydney, NSW and 6 Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Victoria
7 To whom correspondence should be addressed at: Andrology Australia, Monash Institute of Medical Research, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168, Australia. E-mail: carol.holden{at}med.monash.edu.au
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Abstract |
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Key words: ageing/contraception/epidemiology/male infertility/sexuality
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Introduction |
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While young couples often share contraceptive decision-making (Grady et al., 1996), as female fertility declines the best choice of contraception may vary accordingly. While the dual role of condoms to prevent pregnancy and sexually transmitted infections (STI) has particular appeal for younger men with less stable relationships (de Visser and Smith, 2003
), among older couples sterilization via vasectomy is increasingly popular. Australia has among the highest reported vasectomy rates in the world (Schlegel and Goldstein, 1993
) and, although intended as an irreversible procedure, a proportion of men regret sterilization and seek a return of fertility by vasectomy reversal or by using assisted reproductive technologies, usually due to remarriage or death of children (Jequier, 1998
; Holman et al., 2000
).
Understanding the sexual behaviours and fertility needs of older men is necessary for the development of appropriate medical and public health education, services and information targeted to an ageing population. In addition, by exploring attitudes, experiences and knowledge regarding sexual health issues in men as they age may provide insight into the development of education programmes better targeted to younger men.
As part of a national, cross-sectional study investigating male reproductive health (Holden et al., 2005), this study describes the self-reported prevalence of sexual activity, fertility and contraceptive use amongst a representative sample of Australian men aged
40 years. Wider reproductive health issues that concern men are also explored to attempt to understand where health policy and education should be appropriately directed for the older male population who remain sexually active.
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Materials and methods |
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Within each State and Territory, respondents were stratified into four age groups: 4049, 5059, 6069 and 70 years. Sampling continued until a minimum of 1250 men in each age stratum had been surveyed. Recruitment was by random selection of households from the electronic telephone directory (Electronic White Pages, EWP), with over-sampling in some age brackets and geographical regions to ensure proportionate representation. An overall individual response rate of 78% was achieved. Socio-demographic characteristics of the men participating in the study were generally representative of the Australian population (Holden et al., 2005
). The study was approved by the Southern Health Human Research Ethics Committee, Melbourne.
Telephone survey instrument
The computer-assisted telephone instrument (CATI), available at http://www.andrologyaustralia.org/survey/codebook.pdf, included >90 questions focusing on socio-demographic issues (age, marital status, ethnicity, occupation and education), general health and lifestyle, sexual function, fertility, contraception, relationship issues, and knowledge, attitudes and beliefs concerning male reproductive health and its disorders.
All information obtained from the interview was self-report with no check against medical records. Where available, questions from other validated instruments and those used in an Australian context were incorporated.
The Accessibility/Remoteness Index of Australia (ARIA) database (Department of Health and Aged Care and the University of Adelaide, 1999) was used to compare the self-reported prevalence of health behaviours across geographical regions. ARIA measures were grouped into major cities, inner regional, outer regional, remote, and very remote based on distances for each populated location, converted to a continuous measure ranging from 0 for high accessibility to 15 for extreme remoteness.
Statistical analysis
Sample proportions were adjusted for non-responders and weighted according to age and state of residence, with weighting based on the 2001 Census age distribution of Australian men (Australian Bureau of Statistics, 2003) to reflect the original target sample (i.e. 5001, with rounding). Descriptive analyses were performed using SPSS 12.0.1 for Windows software (SPSS Inc., Chicago IL, USA).
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Results |
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At all ages, men desired sexual activity more frequently than presently, including 27.0% of men aged 70 years (Table I). However,
25% of men in the youngest (4049 year) age group and 58% in the oldest (
70 years) age groups reported that their interest in sex had diminished in the 6 months prior to interview (Table I). While changes in frequency, desire and libido were reported in older age groups, reported sexual physical pleasure with a partner did not change with age for those men who remained sexually active (Table I).
Overall, 14% of Australian men had used commercial sex services on at least one occasion in their lives with 2% of men overall having done so in the previous year. Although younger men (4049 years) reported more use of commercial sex services, a few men continue to pay for sex beyond 70 years. Of men who had paid for sex in the 12 months prior to interview, men who had no regular sexual partner in the last 12 months were more likely to use commercial sex services than men who had a regular sexual partner (37% compared with 14% respectively).
Family size and aspirations for paternity
The mean number of children fathered was higher in older age groups ranging from 2.1 in the youngest group (4049 years) to 2.8 in men aged 70 years (Table II). The proportion of men who have fathered six or more children increased across age groups (Table II) and was smallest for those men living in major cities (42%) compared to men living in regional and remote areas (61%).
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While overall concern for not being able to father children in the future was low (4.3% of men aged 40 years), about a third of men without children still wanted or once wished to be fathers, regardless of age (Table II). Of the childless men surveyed,
22% still desired paternity. Another 16% felt they were now too old, being highest in the oldest age group (52%). Of men who considered themselves now too old to have children, three-quarters of these men had once wanted to be fathers (data not shown). Conversely, of the childless men surveyed, 60% of men did not wish to have children plus another 21% who consider themselves too old now, never wished to have children.
Prevalence of infertility
It is not possible to estimate the prevalence of male infertility per se as female factors could not be assessed. However, an age-standardized proportion of 12.2% of Australian men aged 40 years have never fathered children and 7.6% indicated they have tried but been unable to conceive, with a similar proportion having undergone medical tests for infertility (Table II).
Of the 12.2% of men who had never fathered children, it can be derived from the groups that still wish or once wished to be a father (34.3%) that 4.0% of the surveyed population still wish or once wished to be a father. Conversely, of the childless men surveyed who did not wish or never wanted to have children, an age-standardized voluntary infertility rate of 7.7% for the total population surveyed is derived. Hence, among men who did not have children, men were about twice as likely to have chosen to remain child-free than to be involuntarily childless.
Safe sex
Of the men aged 40 years in a current sexual relationship, 9.5% use condoms with their regular sexual partner. However, in regard to STI prevention this study indicates that
41% of Australian men aged
40 years having casual sexual relationships do not use condoms. The proportion of men reporting not using condoms in casual relationships increased in older age groups (Table II).
Two-thirds of men surveyed had ever used condoms, although half of these men reported that condoms interfered with their sexual enjoyment.
While the proportion of men who had ever used condoms did not vary across geographical regions, men were less likely to report using condoms in casual sexual relationships if living in remote Australia (50%) compared to major cities (65%). Men with higher education were also more likely to report using condoms in casual sexual relationships (66% post-secondary compared to 43% below secondary).
Vasectomy
The overall age-adjusted prevalence of vasectomy in men aged 40 years in this survey was 25.1%. The proportion of men who reported a vasectomy was lower in older groups (Table II) with the highest rates (31%) reported in men aged between 40 and 49 years and also in men aged between 50 and 59 years.
An association between vasectomy and region of residence and education levels was also identified. Men were less likely to report having had a vasectomy if living in remote Australia (19%) compared to major cities and regional locations (25%). Men with higher education were also more likely to report having had a vasectomy (28% post-secondary compared to 20% below secondary).
Of vasectomized men surveyed, an age-adjusted proportion of 9.2% of men expressed regret in regard to having had the vasectomy whereas only 1.4% vasectomized men had undertaken vasectomy reversal.
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Discussion |
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Societal changes in the availability of sexual information and greater availability of contraceptive services, fertility treatments and commercial sex services will have affected the prevalence of many outcomes as a function of the decade of birth. With an increasing aged population in developed countries, it is imperative to understand older mens sexual behaviour and concerns to direct education programmes, research, policy and services for both the public and professional communities.
This study confirms previous findings that while the frequency and desire for sexual activity declines with advancing age (Diokno et al., 1990; Jung and Schill, 2004
), many men continue to have a physically satisfactory sexual relationship. An ability to retain sexual activity in later years is an important issue for men with concerns expressed about losing erectile function with age (Helgason et al., 1996
; Holden et al., 2005
). The proportion of middle-aged and older men who reported wanting more sexual activity than they are currently having is almost half of that reported in another large Australian study (Richters et al., 2003
) of wider and mostly younger age range but comparable to that reported in a small population-based study of Swedish men aged 5080 years (Helgason et al., 1996
). While differences in survey methodology and definitions are acknowledged, making comparisons between studies difficult, these discrepancies cannot be readily explained but may in part be related to the context of questioning. Both the MATeS and Swedish studies only recruited older men aged
40 or
50 years respectively, with the focus of questioning in relation to sexual health issues and concerns for older men compared to more general questions in a much wider age range and limited to men aged <60 years with an HIV/AIDS research context (Richters et al., 2003
).
Similar rates of paid sex are reported in the comparable 4059 year age group in our study to previous Australian (Rissel et al., 2003b) and international (Leridon et al., 1998
; Johnson et al., 2001
) studies. Our study lends some support to the hypothesis that commercial sex services help men without a regular partner for sexual activity but this may account for only a part of such sexual activity (Pitts et al., 2004
). The lack of information about the clients of commercial sex services makes it hard to know what proportion of all clients these older single men represent. While adding some information, our study highlights how little is known about the motivation, needs and experience of male clients, including older men, of commercial sex services, for which further research is required.
The decline in the mean number of children, and in families with more than six children, fathered by men in this survey reflects the demographic transition to smaller families in the second half of the 20th century (Australian Bureau of Statistics, 2005). The higher lifetime prevalence of infertility testing in younger men is most likely due to the greater awareness, availability and utilization of fertility services in recent years, rather than any increase in infertility per se (Akre et al., 1999
; Balasch, 2000
). The involuntary infertility rate of 7.6% is the best estimate that can be provided for intractable infertility across the whole study, while it seems that
8% of men never seek to be fathers, which is similar to studies undertaken in men aged 2039 years (11%) (Weston et al., 2004
).
Few studies have previously explored contraceptive issues in older men (Wulff and Lalos, 2004). Condom usage for contraception or for STI prevention needs to be distinguished with regard to their objectives, required reliability of use and risks of failure, and the age-specific conditions they aim to prevent (Wulff and Lalos, 2004
). Condom use for contraception among couples of reproductive age varies widely in popularity with higher rates of usage in economically developed countries such as Australia (United Nations Population Division, 2003
). Due to the decline in female fertility around mid-adult life, condom usage among men aged >50 years is predominately for STI prevention apart from the minority with younger, pre-menopausal wives (de Visser and Smith, 2003
). Together with the very high rates of vasectomy, these observations reflect the fact that Australian men are keen to be involved in family planning. The failure of many men involved in casual sexual relationships to use condoms is apparent despite a continuing emphasis on safe sex practices for all men in the community considered at risk of STI infection from casual partners (Wallace and Carlin, 2001
).
The vasectomy rate of just over 30% in 4059 year olds is, together with New Zealand with a prevalence of 44% among men aged 4074 years (Sneyd et al., 2001), the highest in the world, exceeding those of other comparably economically developed Western countries such as USA (11%) and The Netherlands (11%) (Schlegel and Goldstein, 1993
). The high vasectomy rate in Australian men may reflect the procedures excellent safety and efficacy record, the wide availability of vasectomy services at a low cost on the national health scheme, and willingness of Australian men to take family planning responsibility (Grady et al., 1996
; Schwingl and Guess, 2000
). Vasectomy regret was relatively high (9%), with a vasectomy reversal rate of 1.4%. This discrepancy probably reflects a range of reasons for regret including adverse effects (pain, masculine self-image, ambivalence about family size) and renewed desire for paternity due to remarriage or loss of children (Jequier, 1998
; Schwingl and Guess, 2000
). The major determinants of vasectomy reversal are young age and non-paternity at time of vasectomy (Holman et al., 2000
). Further studies are needed to ensure that appropriate education is undertaken and properly informed consent is obtained before undertaking this significant surgical intervention. Above all, this highlights the need for reversible male contraceptives of comparably high efficacy to modern female methods so that men can participate more effectively in reliable family planning without undergoing premature sterilization that permanently sacrifices decades of future potential fertility.
The findings from this study have implications for improving a variety of professional education services and community attitudes towards sexuality in older people. While sexual problems may impact on psychological health and well-being, even though age may influence this effect (Hinchliff and Gott, 2004), few men discuss or seek treatment for sexual health problems (Rosen et al., 2004
; Holden et al., 2005
). This may in part be related to perceived communication barriers that prevent patients comfortably discussing sexual health problems with a medical practitioner (Gott and Hinchliff, 2003
; Gott et al., 2004
). With a stereotypic image of older people being sexually inactive, improved research, education and policy is needed to ensure that age-related barriers to seeking information and treatment for reproductive health issues do not persist for older men.
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Acknowledgements |
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Submitted on June 8, 2005; resubmitted on August 15, 2005; accepted on August 18, 2005.