February 2004, Vol 26, No. 2 |
Original Articles
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Study on knowledge, attitude and sexual behaviour among the Chinese elderly males in Hong KongC C N Chan 陳正年，K S Ho 何健生，L C L Heung 香子翎，W M Chan 陳慧敏 HK Pract 2004;26:64-73 Summary Objective: To study the sexual behaviour, knowledge and attitude towards sex in elderly males and to evaluate the need for sex related health education. Design: A cross-sectional survey. Subjects: 528 Chinese elderly males, aged 65 and above attending 5 designated Elderly Health Centers (EHCs) of the Department of Health, HKSAR. Main outcome measures: The demographics of the participants, their sexual behaviour, knowledge and attitudes about sex. Results: Among 528 respondents, 66.1% (n=349) reported having sexual desire in the past one year. 52.3% (n=276) were sexually active and engaged in one or more relationships with females in the past year. Among those married/cohabited respondents, the percentage expressing satisfaction (more than half of the occasions) during sexual intercourse with their wife, girl friend (if any), and commercial sex workers (if any) in the past one year were 69.7%, 64.3 and 83.3% respectively. Among those sexually active respondents (n=276), the percentage using condoms (more than half of the occasions) during sexual intercourse with wife and girlfriend were 3% and 25% respectively. On the other hand, 36% engaged with commercial sex workers did not use condoms consistently. Masturbation had been prasticed by 15% (n=79) of all the respondents in the past one year. For those who were sexually active in the last year (n=276), 27% (n=75) expressed difficulty in maintaining erection in more than half of the circumstances during sexual intercourse and 6.8% (n=19) had complete erectile dysfunction. 5% (n=26) had during the past one year taken drugs (including Chinese or Western medicine other than Sildenafil) to boost sexual performance. 6% (n=32) of all respondents who had ever had sex in their lifetime reported using Sildenafil while 6.3% (n=2) of these users had underlying coronary heart disease. 58.1% (n=307) of these respondents did not know that there was a risk in taking Sildenafil in coronary heart disease. 41.3% (n=218) of all respondents considered sexual intercourse was harmful to elders' health. There was a discrepancy on the attitudes among elderly males on sexual need as compared to female elders and about 44.7% had sexual problem with their wives. Conclusion: This study provides information on sexual knowledge, attitude and behaviour about sex among elderly males. In contrast to many myths about sex and ageing, we show that quite a substantial proportion of elderly males remain sexually active. Society should not regard sex as a taboo for the elderly and more health education both to elders themselves and carers on the correct knowledge and attitude towards sex in the elderly is needed. Keywords: Elderly male, sexual desire and activity, health education 摘要 目的：探討男長者的性行為，性知識和對性的態度，以及評估性健康教育的需求。 設計：橫切面調查。 對象：528位曾使用香港特別行政區政府衛生署轄下五間指定長者健康中心的服務，年齡在65歲或以上的中國籍男長者。 測量內容：參加者的人口統計學資料，他們的性行為、性知識和對性的態度。 結果：在528位回應者中，66.1%（n=349)表示在過去一年曾有性慾。52.3%（n=276）在過去一年曾與一位或多位女性維持性關係。在已婚或同居的回應者中，表示在與妻子、情人和性工作者性交時有滿足感的（半數以上），分別有69.7%、64.3%和83.3%。在性活躍的回應者中，(n=276)，與妻子和情人性交時採用避孕套（半數以上）的比率，分別是3%和25%。27%（n=75）表示在超過一半的性交時有維持勃起的困難。6.8%（n=19）更有完全勃起機能障礙。而36%在與性工作者性接觸時不會慣性使用避孕套。15%的回應者（n=79）在過去一年內曾有手淫。5%（n=26）在過去一年內，曾服用除昔多芬外的中西藥物來增進性表現。在所有曾有性經驗的回應中，6%（n=32）曾服用昔多芬。當中，6.3%（n=2）的服用者患有冠心病。在所有回應者中，58.1%（n=307）不知道昔多芬可能會對冠心病構成危險。41.3%（n=218）認為性交會損害長者的健康。在比較男長者和女長者在性需要的看法，他們是有不同的態度。約44.7%跟妻子在性愛方面出現問題。 結論：此調查提供有關男長者的性知識、性態度和性行為的資料。相對於很多關於性和衰老的誤解，我們顯示相當比例的男長者在性方面仍然活躍。社會不應將性定為長者的禁忌，而應對長者和護理者提供更多關於正確性知識和態度的健康教育。 主要詞彙：男長者，性慾和性行為，健康教育 Introduction Sexual activity is a component of the well-being of an individual. It is also basic to human relations. Although the physiological changes of ageing affect the sexual response cycle, an overseas study has shown that sexual interest is still preserved in older persons.1 There was no age difference in sexual enjoyment and satisfaction.2 It was also found that elders in western countries had a moderate amount of knowledge and permissive attitudes on sexuality.3 The general attitude of the social environment does not take note of the sexual needs of the elderly.4 When older men show the same kind of sexual interest as younger men, these men would be labelled as "dirty old men". Guilt and anxiety could compel these older adults to suppress their desire. A lack of understanding from health care professionals affects the elders' willingness to talk about their sexual problems. Literature search has revealed little study on sexual behaviour of old people, either internationally or locally. Most studies are on adolescents and adults below the age of 60. So far there is no local study on the knowledge, behaviour and attitudes of sex life focusing on elderly people. In addition, the sexual risk-taking behaviour is another health concern. In US, Leigh et al (1993) reported 9% of those aged 60-69 and 80% of participants over 70 reported having more than two partners during the past five years.5 There is also some evidence showing that older people within UK engage in sexual-related risk-taking behaviour.6 In Hong Kong, there are a few studies on sexual-related risk behaviour of Chinese males. However, these studies are limited to populations under 60 years of age.7,8 Cheung CKJ et al9 study on the elderly sex concentrated more on the psychosocial aspect and coping. There is no study of this nature on the elderly population. Therefore, it seems that there is little knowledge about sexual aspects of the local elderly population. This study aims to clarify the following issues:
Methodology Design A cross-sectional survey using a questionnaire as the instrument of measurement. Target population Eighteen Elderly Health Centres (EHC), one in each district, have been established in Hong Kong by the Department of Health since 1998. All citizens aged 65 or above are eligible for enrollment as clients of the EHCs for health assessment and health maintenance programme after payment of a small amount of fee.10 There is no programme related to sex health in the assessment. Sampling frame Five of the 18 EHCs were randomly selected from Hong Kong Island, Kowloon and the New Territories with one in Hong Kong Island, two in Kowloon and two in the New Territories. All Chinese male clients were invited to participate during their visits to the health centres. The study was carried out from October 2002 to February 2003. Clients who had cognitive impairment or significant hearing loss were excluded. Verbal consent was obtained from the client; confidentiality and anonymity would be assured. A pilot study was carried out to test the validity of questionnaire before proceeding with this study. The questionnaire covered participants' demographic data, the level of sexual desire and sexual activity (including sexual activity with various sex partners), pattern of condom usage, sexual dysfunction, use of medication or other love potions to boost sexual performance, their knowledge about contraindications on the use of Sildenafil (Viagra), previous sexually transmitted disease (STD)/HIV infection, their perceived risk of contracting STD/HIV infection and sex related health information needed. During the pilot study, illiterate elders were also excluded. The elders were asked to fill in the questionnaire by themselves in a room with privacy. However, there were quite a lot of missing data and double entry. Therefore the idea of self-administered questionnaire was dropped. Family physicians, after being briefed on the questionnaire, were asked to conduct face-to-face interview with the standardised questionnaire in a separate room where no other person was present. The interview was conducted after our routine health assessment and curative sessions, which was performed by a different family physician. Three male doctors and two female doctors who happened to work in these centres were chosen as interviewers. A trained research assistant performed data entry and checked for internal consistency of data. The project was approved by the Ethics Committee of the Department of Health. Statistical analysis Univariate analysis was performed for each potential factor for the risk taking behaviour in the risk-takers (those with multiple sex partners or had commercial sex in the past one year). Chi square test or Fisher's exact test were carried out for categorical factors. Independent sample t-test was performed for continuous variables. Those with a p-value >0.8 were included in the forward stepwise logistic regression to identify the risk-takers. The tool used for analysis of data was SPSS 11.0 software package (SPSS, Chicago, IL, USA). P<0.05 was regarded as statistically significant. Results A total of 708 attempts had been made to recruit the participants but 180 elders refused. The response rate was 74.6%. The age of the 528 Chinese male participants ranged from 65 to 95 years with a median age of 73. The socio-demographic characteristics of the participants were listed in Table 1. 83.1% (n=439) were married or cohabited. About half of them had only primary education level. 98.3% (n=519) ever had sex in their lifetime.
Attitude, knowledge and sexual behaviour of participants As shown in Table 2, 47.7% (n=252) considered sex is important to the elderly. 66.1% (n=349) reported having sexual desire in the past year. 52.5% (n=276) admitted that they were sexually active and 15% (n=79) had practiced masturbation in the past year. 27% (n=75) expressed difficulty in maintaining erection on more than half of the occasions during sexual intercourse and 6.8% (n=19) had complete erectile dysfunction. 6.06% (n=32) reported history of using Sildenafil. 5% (n=26) had used Chinese herbal medicine or other Western medicine to improve potency. It should be noted that 40.4% of the elderly males had sexual problems with their wives. 16.7% (n=88) of their wives considered sex was inappropriate and 23.7% (n=125) of their wives refused to have sex when their husband wanted.
Sexual activities with various sex partners Table 3 listed out the sexual activities with various sex partners for those who are sexually active in the past one year. A total of 276 sexually active elders were analysed. 13.8% (n=38) had more than one sex partners. Of those who had girl friends, about half of their girl friends were in Hong Kong and another half in Mainland China. Of those who had commercial sex, 60% were practiced solely in Hong Kong, 36% solely in Mainland China and 4% in both places. Majority (approximately 77%) of the sexually active subjects had sexual activity less than once per month. Table 4 gave findings on self-reported STD and self- perceived risk of STD and HIV for the entire cohort. Although only three persons had contracted STD in the past one year, it was interesting to note that three of them were in the category of age 75 to 84.
Risk-takers were defined as those who had sex with more than one partner or had visited commercial sex workers. Characteristics of risk-takers and non risk-takers were listed in Table 5. There were no differences in education level among the risk takers and non risk-takers. Significantly more risk-takers are inclined to consume Viagra then non risk-takers (P=0.002). There was also a significant difference in self-perceived risk of STD and HIV between risk-takers and non risk-takers (P<0.001). Risk-takers had significantly more sexual problems with their wives. Stepwise logistic regression analysis revealed four associated factors for risk takers. These included those never married (adjusted OR 14.55; 95% CI: 1.15-184.6); sexual drive at least once a week (adjusted OR: 5.39; 95% CI: 1.07-27.15); self-perceived as having risk of STD (adjusted OR 11.85; 95% CI: 4.822-29.13); wife refused sex when they had sex drive (adjusted OR: 3.18; 95% CI: 1.28-7.94).
Health information on sex As seen from Table 6, most elderly obtained health information on sex from newspapers and magazines (56%). Less than 5% got information from doctors. The most wanted information was treatment for sexual dysfunction (39.8%), common physiological changes on sex in the elderly (38.6%) and ways of handling commonly encountered sexual problems in elderly (28.3%).
Discussion Sexual activity is a component of the well-being of an individual. It has been shown to be associated with positive physical and psychological benefits. Sex interest is still preserved in older persons.11 66.1% of the study participants volunteered that they had sexual drive and 15% had history of masturbation in the past year. About 52.3% admitted to have some form of sex in the past one year, either with wives, girl friends or commercial sex partners. This is compatible with a study in Germany where 51% are sexually active among those between age 61-92.12 This is in contrast to a similar study conducted in U.K. which reported 81.5% of their study participants were sexually active.13 In fact Masters14 reported that 75% of men in their 70s had sex at least monthly, and approximately 30% of men between 61 and 70 years had sex weekly. In fact, in our study, 47.7% thought that sex was important for the elders and 63.8% agreed that elders might have interest in sex. As to risk-taking sexual activities, i.e. having sex with 2 or more female in the past year or having sex with commercial sex workers (CSWs), there are 38 out of 276 (13.8%) sexually active elders. Overseas figure revealed <7% of people age greater than 50 engaged in risk-taking behaviour.13 In our study, there is no statistical difference in education level between the risk- takers and non risk-takers. More risk-takers use Viagra (P=0.002) and have sexual problems with wives. Their wives either refuse sex with them when they so desire (P=0.009) or their wives consider sex is not appropriate (P=0.008). Logistic regression analysis also shows that risk-takers are closely related with the negative attitudes of their wives on sex who refuse to have sex with them when they have sexual desire. More sex education for the wives or their regular sex partners is necessary to correct the myths and misconception about sex in elderly. It is important to note that engaging in commercial sex is not uncommon in these elders. Of the 25 elderly who had sex with CSWs in the past year, 9 of them (36%) did not use condoms consistently. The elderly engaged in commercial sex more often in Hong Kong than in Mainland China. This differs from a local study on younger population.8 In another local study on sexually-related risk behaviour of the Chinese male general populations age 18 to 60, 27% did not always use condom when having sex with CSWs.8 Although our sample is much smaller, it is obvious that the elderly male population is not without risk of contacting sexually transmitted disease (STD), and it is worth noting that 70.5% of our sexually active elders do not use condoms when having sex with their girlfriends. In our study, 5 elders reported STD in the past year with three among them aged The sexual response change as the male becomes older and sexual dysfunction(ED) is not uncommon in the elderly. In this study, only 42.3% could maintain erection most of the time; 27% expressed difficulty in maintaining erection for half of the occasions during sexual intercourse and 6.8% had total ED. An Italian study quoted the age specific prevalence of moderate to complete ED as 38% for 60 to 64 years and 54% for 65 to 70 years. About 5% of our study population resorted to using Chinese herbal medicine or Western medicine other than Viagra and 6.4% had used Viagra before. Just less than half of them obtained prescription from doctors and another half of them got the drug through improper channel. This can be dangerous because 9.1% of our elderly in this cohort have coronary heart disease. More health education and counselling is necessary on the management of erectile dysfunction. Our elderly subjects receive sexual knowledge mostly from health education leaflets, books, newspaper and magazine, internet and radio. The common topics they want to learn is treatment for sexual dysfunction, common physiological changes of sex in the elderly, ways of handling commonly encountered sex problem, proper use of Viagra, with treatment of sexual dysfunction being the most favoured topics. These data are useful for the planning of sex education and health promotion among elderly males. It is worth noting that only 0.9% had received sex knowledge from doctors. Family physicians should be more ready and proactive to discuss sexual problems with their elderly patients. A note of caution must be taken not to generalise the findings to the population as a whole because our study is not population based. Compared with the general elderly population, our clients are slightly younger. The proportion living in public and aided housing is lower than that of the general elderly population although the education levels are comparable.10 Initially, a pilot study with a self-administered questionnaire had been used, but the result was rather unsatisfactory with a lot of missing data, probably related to our aged population and their relatively low education level. In the end, this survey was conducted by face-to-face interview with a family physician. It is hoped that the participants can discuss more frankly and give more genuine facts to the attending physicians on this sensitive topic. However, the validity of the questionnaire has not been tested because of the sensitivity of the topics and the need for anonymity. In addition, this study is limited to the male population. Further study on attitude and knowledge of sex in the female population may be worthwhile. Conclusion Although this survey is not a population based study, it is the first comprehensive study on sex behaviour, knowledge, attitude and education need for the local Chinese elderly male population. It shows that sex is considered important by the elders and many of them are still sexually active. Some of these elders even engage in risk taking behaviour and many use drugs to boost up their sexual potency despite their lack of knowledge on the use of these drugs. It dispels the myth that older persons are usually "sexless". A more focused education and health promotion on sex for the elderly should be implemented. Family physicians should include sex counselling in their health maintenance programme for the elderly. Acknowledgement We are indebted to Dr Teresa M P Li for her comment on this project and Ms Shelley Chan for her input on statistical analysis. Key messages
C C N Chan, MBChB(CUHK), MMed(OM)(Singapore)
K S Ho, MBBS(HK), FHKAM(Medicine), FHKAM(Family Medicine) L C L Heung, MBChB(CUHK), MRCP(UK)
W M Chan, MBBS(HK), FHKAM(Community Medicine) Correspondence to : Dr K S Ho, Consultant (Family Medicine), Elderly Health Service, Department of Health, Room 3502, 35/F Hopewell Centre, Wanchai, Hong Kong. References
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85 (N=23)
1 per month