ORIGINAL RESEARCH

Prevalence and Predictors of Sexual Problems Among Midlife

Canadian Adults: Results from a National Survey
Christopher Quinn-Nilas, MA,1 Robin R. Milhausen, PhD,1 Alexander McKay, PhD,2 and Stephen Holzapfel, MD3,4

ABSTRACT

Background: Sexual problems are common among midlife men and women, and studies have identified a range of
demographic, health, and relational correlates. Research on prevalence of these sexual problems within Canada is sparse
and is warranted given the unique context related to provision of health care services in contrast to other countries.
Aim: We investigated sexual problems (women’s low desire, orgasm difficulties, and vaginal pain, as well as men’s
low desire, erection difficulties, and ejaculation difficulties) and their correlates among a large sample of Canadian
men and women aged 40e59 years.
Methods: A national sample of Canadians was recruited (N ¼ 2,400). Prevalence statistics for the sexual
problems, and odds ratios for correlates were computed using logistic regression to identify demographic, health,
and behavioral correlates of men’ and women’s sexual problems.
Outcomes: Self-reported experiences in the last 6-months of low desire, vaginal dryness, vaginal pain, and
orgasm difficulties for women, and low desire, erectile difficulties, and ejaculation problems for men.
Results: Sexual problems were relatively common; low desire was the most common sexual problem, particularly
for women, with 40% reporting low sexual desire in the last 6 months. Women who were post-menopausal were
much more likely to report low desire, vaginal pain, and vaginal dryness. Low desire and erectile difficulties for men,
and low desire and orgasm difficulties for women were significant predictors of overall happiness with sexual life.
Clinical Translation: Given the prevalence and impact of sexual problems indicated in our study, physicians are
encouraged to routinely assess for and treat these concerns.
Conclusions: Strengths include a national sample of an understudied demographic category, midlife adults, and
items consistent with other national studies of sexual problems. Causal or directional associations cannot be
determined with these cross-sectional data. Results are largely consistent with previous national samples in the
United States and the United Kingdom. Sexual problems are common among Canadian men and women, with
many being associated with self-reported sexual happiness. Quinn-Nilas C, Milhausen RR, McKay A, et al.
Prevalence and Predictors of Sexual Problems Among Midlife Canadian Adults: Results from a National
Survey. J Sex Med 2018;XX:XXXeXXX.
Copyright
2018, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Sexual Problems; Midlife; Canadians

INTRODUCTION potential health and psychosocial correlates and has found, for
Sexual problems are common among midlife men and wom- example, that women who are post-menopausal are more likely to
en.1e3 Research on sexual problems has typically aimed to identify report low desire, and that diabetes and hypertension are correlates
of men’s erectile problems.4e6 Large-scale studies of midlife Cana-
Received December 19, 2017. Accepted March 30, 2018. dians are sparse, but U.S. research indicates that women’s low desire,
1
Department of Family Relations and Applied Nutrition, University of Guelph, inability to achieve orgasm, vaginal dryness, and vaginal pain, as well
Guelph, Ontario, Canada; as men’s low desire, erectile difficulties, and pre-mature ejaculation
2
Sex Information and Education Council of Canada, Toronto, Ontario, Canada; are common sexual problems among individuals of this age
3
Sexual Medicine Counseling Unit, Women’s College Hospital, Toronto, group.1,2,6e8 In a telephone survey of Canadians aged 40e80 years,
Ontario, Canada;
4
conducted between 2001e2002, 15% of Canadian men reported
Department of Family and Community Medicine, University of Toronto,
lack of interest in sex, 23% rapid ejaculation, and 16% erectile
Toronto, Ontario, Canada
difficulties.9 In this same study, 30% of women experienced lack of
Copyright ª 2018, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved. sexual interest, 22% inability to reach orgasm, 24% lubrication
https://doi.org/10.1016/j.jsxm.2018.03.086 difficulties, and 16% pain during intercourse. In a study of sexual

J Sex Med 2018;-:1e7 1

2 Quinn-Nilas et al

Table 1. Prevalence of sexual problems adult Canadians. Data were collected between September 17,
Variable Prevalence No. (%) 2015, and October 12, 2015, by Leger (Toronto, Ontario,
Canada), a professional marketing company. Participants were
Men LegerWeb research panelists. The Leger panel was created using a
Low desire (N ¼ 1,168) 355 (29.6) random telephone recruiting method and is composed of
Erection problems (N ¼ 1,162) 286 (23.8)
approximately 460,000 people from the Canadian population.
Ejaculation problems (N ¼ 1,158) 296 (24.7)
No problems reported (N ¼ 1,156) 550 (45.8) Eligible panelists were invited to participate via an e-mail from
1 Problem reported (N ¼ 1,156) 346 (29.9) Leger and a single e-mail reminder was sent to those who did not
2 Problems reported (N ¼ 1,156) 199 (17.2) respond to the initial message. The participant clicked on a link
3 Problems reported (N ¼ 1,156) 61 (5.3) that led to the study portal in order to complete the survey.
Women Survey responses were transmitted over a secure, encrypted SSL
Low desire (N ¼ 1,119) 475 (39.6) connection and stored on a secure server. Participants received $1
Vaginal dryness (N ¼ 1,107) 319 (28.8) for completing the questionnaire, and the opportunity to enter
Orgasm difficulties (N ¼ 1,093) 159 (14.5) into a drawing for one $100 prize; or for one of two $1,000
Vaginal pain (N ¼ 1,103) 205 (17.1) prizes of either one 1,000 air miles reward or one tablet com-
No problems reported (N ¼ 1,076) 466 (43.3) puter. The survey was terminated once 2,400 completed ques-
1 Problem reported (N ¼ 1,076) 298 (27.7) tionnaires were obtained.
2 Problems reported (N ¼ 1,076) 170 (15.8)
3 Problems reported (N ¼ 1,076) 94 (8.7) The aim was to recruit 2,400 participants (approximately half
4 Problems reported (N ¼ 1,076) 48 (4.5) men and half women) between the ages of 40 and 59 years with
representation from all provinces and territories. A total of
32,354 e-mail invitations were sent to panelists between the ages
problems and their respective help-seeking behaviors in Canada,
of 40 and 59 years. Of these, 5,615 respondents clicked on the
very few midlife Canadians reported being asked by their doctor
survey link that led to the study portal. 141 Were disqualified
about sexual problems during their routine visits (over the last 3
because they did not fit the age range, and 2 indicated they
years), despite most believing that sexual functioning is a normal
would not respond to the survey truthfully. A further 2,642 were
part of health care, and that they should be asked.9 Given the high
disqualified because quotas for gender, province of residence, and
and rising number of midlife adults in Canada, the potential impact
age had been met. The overall sample comprised 2,400 mid-life
of sexual problems on overall health and well-being, and with
Canadians between the ages of 40 and 59 years who met all
treatments available or pending in Canada, national Canadian data
eligibility criteria and provided complete data. Ethics approval
are needed to identify potential sexual health care needs for both
for this study and informed consent was received from the
health care professionals and policy makers.2,10e12
University of Guelph Research Ethics Board.
Aims of this study were 3-fold. First, we sought to report the
prevalence of sexual problems (women’s low desire, orgasm dif-
ficulties, vaginal dryness, and vaginal pain, as well as men’s low Study Sample
desire, erection difficulties, and ejaculation difficulties) using a We included all cases in the analyses that had valid data for
large, national sample of Canadian men and women aged 40e59 each of the sexual problems (Table 1 for group sizes). We present
years, and the study was intended a partial replication of other sample size separately for each logistic regression analyses—
large-scale work to facilitate cross-study comparisons. Second, we samples composed of all cases with valid data for each of the
aimed to estimate odds ratios (OR) predicting sexual problems independent variables and the dependent variable using listwise
based on demographic, attitudinal, behavioral, health-related, exclusion of missing data.
and relationship predictors. Finally, we investigated the rela-
tionship between experience of sexual problems and self-reported
Measures
happiness with sexual life, calculating estimated OR using lo-
gistic regression analyses. Demographic, Health, and Relationship Variables
Demographic variables, including marital status, gender, sex-
ual orientation, and age were assessed. Participants were able to
METHODS
identify as a man, woman, transgender male to female, and
Study Population and Sampling transgender female to male; participants were analyzed in
The current investigation is based on data collected as part of a accordance with their identified gender identity. The survey also
larger study on the sexual health and well-being of mid-life collected data on participant marital status, subjective overall
Canadians. The overarching study and study questionnaire health [“For the purposes of this survey, health refers to physical,
were designed by the second and third authors in consultation emotional, and mental well-being, Overall, would you say your
with the Trojan Sexual Health Division of Church and Dwight health is .?”; response options ranged from poor (1) to excellent
Canada to better understand the sexual health needs of mid-life (5)], self-reported diagnosis of common medical conditions

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Sexual Problems Among Midlife Canadians 3

Table 2. Summary of odds ratios and CI for logistic regression analyses for women’s sexual problems
OR (95% CI)

Low desire, Vaginal dryness, Orgasm difficulties, Vaginal pain,

Variable N ¼ 711 N ¼ 712 N ¼ 702 N ¼ 709

Age 1.002 (.973e1.031) 1.072 (1.040e1.105)* 1.004 (.967e1.043) 1.029 (.994e1.064)

Marital status
Married/cohabitating Referent Referent Referent Referent
Single, never married .398 (.257e.618)* .905 (.583e1.405) 1.031 (.585e1.815) .605 (.353e1.038)
Widowed, separated, divorced .408 (.269e.621)* .690 (.450e1.058) 1.321 (.796e2.191) .673 (.410e1.102)
Health problem
Hypertension or cardiovascular disease .985 (.631e1.538) .737 (.468e1.159) .843 (.470e1.513) .589 (.338e1.025)
Rheumatoid or osteoarthritis 1.646 (1.054e2.570)† 1.141 (.735e1.772) 1.485 (.876e2.519) 1.404 (.861e2.292)
Diabetes .843 (.412e1.727) 1.266 (.624e2.570) .561 (.190e1.659) 1.730 (.804e3.724)
Sexual frequency in past year .793 (.717e.878)* .881 (.797e.975)† .860 (.755e.980)† .815 (.724e.918)‡
‡
Very interested in trying new sexual things .541 (.376e.778) .833 (.572e1.213) 1.263 (.755e1.998) .896 (.578e1.387)
Rating of overall health .922 (.605e1.405) .415 (.256e.671)* .605 (.323e1.133) .962 (.579e1.596)
OR ¼ odds ratio.
*P < .001.
†
P < .05.
‡
P < .01.

[“Have you ever been diagnosed by a health professional as sex) is lower than I would like it to be; (2) I have trouble getting
having any of the following medical conditions? (Check all that and maintaining an erection; and (3) I ejaculate more quickly
apply)”; cardiovascular disease, hypertension, rheumatoid than I would like. Women were given the same response op-
arthritis, osteoarthritis, diabetes], and women were asked to tions for questions related to low desire, inability to orgasm,
report whether they were pre-menopausal, peri-menopausal, or vaginal pain, and vaginal dryness: (1) my level of sexual desire
post-menopausal (dichotomized for the purposes of analysis into (interest in having sex) is lower than I would like it to be; (2) I
pre-menopausal and post-menopausal). am not able to have an orgasm; (3) I experience pain in the
The survey also asked questions about participant’s sexual vaginal area during sex; and (4) I experience vaginal dryness
experiences including: sexual frequency in the past year [“On during sex.
average, in the past year, how often have you engaged in penis-
vagina intercourse?”; response options were: I did not engage in Statistical Analysis
penis-vagina intercourse in the last year, a few times in the last Prevalence of sexual problems was calculated and percentages
year (ie, less than once a month), once per month, 2e3 times per are reported by gender. We conducted 7 logistic regression
month, once per week, 2e3 times per week, or 4 or more times analyses to estimate ORs and their 95% CI for each sexual
per week], their interest in new sexual experiences compared to a problem separately for women (Table 2) and men (Table 3) after
decade ago [“How strongly do you agree or disagree with the controlling for age and marital status. ORs provided were
following statement? Compared to a decade ago, I am more adjusted for other predictor variables in the model. Separate
interested now in trying new things to enhance sexual pleasure”; logistic regressions were conducted with menopause status pre-
response options ranged from strongly disagree (1) to strongly dicting each sexual problem. Two logistic regression analyses
agree (4)], and their sexual happiness within their relationship were computed to estimate ORs and their 95% CI for subjective
[“Even if you are not sexually active, how happy would you say ratings of sexual happiness separately for men (Table 4) and
you are overall with the sexual part of your life?”; response women (Table 5). ORs for multinomial independent variables
options ranged from not happy at all (1) to very happy (4)]. are presented in relation to the referent (using indicator variable
coding). Two ordinal variables were dichotomized, including
Experiences of Sexual Problems overall health [dichotomized as excellent (1) compared to poor,
Experiences of sexual problem were assessed with a series of fair, good, and very good (0)], and interest in trying new sexual
questions with the following item stem and a dichotomous (yes things [strongly agree (1) compared with strongly disagree,
or no) response option: “Thinking back over the past 6 months, somewhat disagree, and somewhat agree (0)]. Age (measured as
have you experienced any of the following sexual problems on a exact numerical age) and sexual frequency retained their original
regular basis?” Men were prompted to respond with yes or no to metrics. P < .05 was considered statistically significant, and
questions related to low desire, erectile difficulties, and ejacu- analyses were performed using software (SPSS, Version 25; IBM
lation difficulties: (1) my level of sexual desire (interest in having Corp, Armonk, NY).

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4 Quinn-Nilas et al

Table 3. Summary of odds ratios and CI for logistic regression analyses for men’s sexual problems
OR (95% CI)

Low desire, Erection difficulties, Ejaculation problems,

Variable N ¼ 804 N ¼ 805 N ¼ 806

Age .990 (.962e1.018) 1.020 (.989e1.051) .993 (.965e1.021)

Marital status
Married/cohabitating Referent Referent Referent
Single, never married .557 (.370e.837)* .903 (.587e1.389) .374 (.243e.576)†
Widowed, separated, divorced .564 (.351e.909)* 1.351 (.857e2.129) .361 (.221e.592)†
Health problem
Hypertension or cardiovascular disease 1.123 (.766e1.646) 1.316 (.888e1.951) 1.339 (.914e1.961)
Rheumatoid or osteoarthritis .821 (.495e1.361) 1.513 (.926e2.473) .690 (.412e1.158)
Diabetes 1.464 (.847e2.529) 1.626 (.943e2.803) 1.015 (.572e1.801)
Sexual frequency in past year .850 (.768e.942)* .858 (.770e.955)* .959 (.867e1.061)
Very interested in trying new sexual things .780 (.543e1.119) 1.370 (.947e1.981) 1.261 (.891e1.783)
Rating of overall health .581 (.365e.923)‡ .346 (.192e.624)† .779 (.506e1.199)
OR ¼ odds ratio.
*P < .01.
†
P < .001.
‡
P < .05.

RESULTS desire in the last 6 months. Single (never married) men and men
who were widowed, separated, or divorced were less likely to report
Demographic information is presented next for participants with
low desire than married men. Age was a significant predictor of
valid data on the applicable sexual problems items (N ¼ 2,239). The
vaginal dryness—as age increases, the probability of women
mean age of this analytic sample was 49.46 (SD ¼ 5.73) and was
reporting vaginal dryness in the last 6 months also increases.
split almost evenly by gender, with 51.8% (n ¼ 1,160) identifying
as men and 48.2% (n ¼ 1,079) identifying as women. Most
participants were married (50.2%; n ¼ 1,123), with sizable Health-Related Predictors
proportions single, having never been married (28%; n ¼ 628) and Women who reported being diagnosed with rheumatoid or
either widowed, separated, or divorced (21.8%; n ¼ 488). Most of osteoarthritis were more likely to report low desire in the last 6
the sample was heterosexual (90%; n ¼ 2,014), with smaller months than women who did not report being diagnosed with
numbers of gay (5.1%; n ¼ 114), lesbian (.8%; n ¼ 18), bisexual these conditions. In addition, women’s ratings of overall health
(2%; n ¼ 44), other (.7%; n ¼ 16), and prefer not to answer (1.5%; were a significant predictor of vaginal dryness. For men, their
n ¼ 33) responses. ratings of their overall health significantly predicted their reports
of low desire, and erection difficulties.
We present prevalence statistics in Table 1. Approximately a
third of men (29.6%) and women (39.6%) reported their sexual
Attitudinal Predictors
desire was lower than they would have liked over the past 6
Women who reported being more interested in trying new
months. Rates of women’s orgasm difficulty, vaginal pain, and
sexual things currently compared to 10 years ago were less likely
vaginal dryness were 14.5%, 17.1%, and 28.8%, respectively.
Approximately one quarter of men reported erection problems
(23.8%) and ejaculation problems (24.7%). Almost one half of Table 4. Summary of odds ratios and CI for logistic regression
men (46%) and women (43%) reported none of the sexual predicting men’s sexual happiness (N ¼ 1,143)
problems assessed. Variable OR (95% CI)
Tables 2 and 3 present the results of logistic regression analyses Age .977 (.950e1.005)
for women’s and men’s sexual problems; age and marital status Marital status
were entered in the initial block, and all other variables were Married/cohabitating Referent
entered simultaneously in the subsequent block. Single, never married .700 (.478e1.026)
Widowed, separated, divorced 1.208 (.796e1.826)
Low desire .479 (.313e.733)*
Predictors of Sexual Problems Erectile difficulties .494 (.309e.792)*
Demographic Predictors Ejaculation difficulties .823 (.555e1.221)
Single (never married) women and widowed, separated, or OR ¼ odds ratio.
divorced women were less likely than married women to report low *P < .01.

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Sexual Problems Among Midlife Canadians 5

Table 5. Summary of odds ratios and CI for logistic regression predictability and familiarity with the sexual relationship
predicting women’s sexual happiness (N ¼ 1,066) contribute to low sexual desire among partnered individuals, and
Variable OR (95% CI) with empirical results indicating women who are married report
lower sexual desire.4,13,14 Age was not associated with increased
Age 1.003 (.976e1.031) likelihood of reporting sexual problems among men or women,
Marital status
which may be due to our sample being a relatively healthy
Married/cohabitating Referent
community sample, and not a clinical one.
Single, never married .550 (.370e.818)*
Widowed, separated, divorced .677 (.463e.989)† Among men, self-reported overall health status was associated
Low desire .260 (.176e.383)‡ with men’s erectile difficulties and low desire. However, the
Orgasm difficulties .203 (.087e.474)‡ specific medical conditions examined in this study (hyperten-
Vaginal pain .763 (.445e1.309) sion/cardiovascular disease, arthritis [osteo and/or rheumatoid],
Vaginal dryness .755 (.496e1.148) and diabetes) did not correlate with sexual dysfunctions, specif-
OR ¼ odds ratio. ically with erectile dysfunction, in contrast to some previous
*P < .01. research.5,6 This may be due to the lack of severity measures used
†
P < .05. for these illnesses. Given that this was a general population
‡
P < .001. sample, the expected severity would be less than a sample from
focused medical clinics dealing with these conditions, though in
to report low desire, but this relationship was not present for any the current study, the length of time and degree of severity of
other sexual problem nor for men. health concern was not assessed. Variations in these factors may
account for the lack of relationships found in our data. Mild
hypertension and diet-controlled diabetes would, for example, be
Menopause
less likely to cause erectile dysfunction than symptomatic coro-
Because menopausal status was confounded with age, meno-
nary artery disease or insulin-dependent diabetes.3,15 The rating
pause was entered alone as a predictor of each sexual problem (not
of overall health likely better represents the effect of a broad
displayed in tables). Menopause was a significant predictor of
range of illnesses on sexual function including desire and erectile
women’s low desire (OR ¼ 1.64; 95% CI, 1.29e2.09; P < .001),
dysfunction for men and vaginal dryness for women.
vaginal pain (OR ¼ 1.94; 95% CI, 1.46e2.70; P < .001), and
vaginal dryness (OR ¼ 2.20; 95% CI, 1.69e2.87; P < .001), but Among women, rheumatoid or osteoarthritis was associated
not orgasm difficulties (OR ¼ 1.33; 95% CI, .95e1.87; P ¼ .10). with low desire, perhaps because of pain or discomfort, which may
accompany those conditions. Women who were post-menopausal
were more likely to report low desire and vaginal pain. For post-
Sexual Problems as Predictors of Sexual Happiness menopausal women, vaginal atrophy is a significant concern and
Men who reported low desire and erectile difficulties were less
is associated with sexual dysfunction.16 Thinning of the vaginal
likely to report being very happy compared to those who did not
walls and reduced lubrication post-menopause may account for
report those sexual problems. In addition, women who experi-
increased pain.17 Other research also indicates non-surgically
enced low desire and orgasm difficulties were less likely to report
menopausal women may experience lower desire.4
being very happy with their sexual lives.
Relational factors have consistently been among the most
important factors related to sexual problems.1,18 Engaging in
DISCUSSION novel sexual activities can break up routine and enhance
Data from the current national study of Canadians indicated desire.14,19 In the current study, low interest in trying new sexual
sexual problems are common, and at rates similar to those activities was associated with women’s low desire. Notably, fre-
demonstrated by other national studies.2,6,7,9 Low desire was the quency of sex was associated with all of women’s sexual prob-
most common sexual problem for both genders; approximately lems, as well as low desire and erection difficulties for men;
30% of men and 40% of women reported experiencing desire consistent with other national samples.2
lower than they would have liked over the past 6 months. Our Causal or directional associations cannot be concluded based
results are also comparable to the limited available Canadian on these cross-sectional data (eg, low frequency of sex might
data, which demonstrated similar rates of rapid ejaculation precede or be subsequent to the experience of sexual problems).
(23%) and erectile difficulties for men (16%).9 Higher rates of Sexual problems were assessed via self-report, and not medical
low sexual interest among women (30%) were reported in the diagnosis. Although the advertisement for the survey did not
current sample than in Brock et al.9 indicate that participants would be asked about sexual problems,
Being married or cohabitating was associated with desire this study is vulnerable to selection bias because the survey may
problems among men and women and ejaculation difficulties have attracted individuals who were comfortable discussing sex-
among men. Findings are consistent with theories suggesting that ual topics. There has been debate about the recall period when

J Sex Med 2018;-:1e7

6 Quinn-Nilas et al

measuring sexual problems, particularly concerning the differ- (c) Analysis and Interpretation of Data
entiation between episodic problems and chronic problems.20,21 Christopher Quinn-Nilas; Robin R. Milhausen; Alexander McKay;
The time frame used in this study is between the longer time Stephen Holzapfel
frame of 1 year and shorter time frame of 1 month that other Category 2
national studies have used, but may be limited in its sensitivity to (a) Drafting the Article
these episodic or longer-term problems.2,22 As well, this time Christopher Quinn-Nilas; Robin R. Milhausen; Alexander McKay
frame limits the validity of cross-study comparisons between (b) Revising It for Intellectual Content
several large studies.2,22 In addition, although we utilized mea- Christopher Quinn-Nilas; Robin R. Milhausen; Alexander McKay;
sures similar to those in previous studies, we assessed sexual Stephen Holzapfel
problems with unvalidated, single-item measures that did not Category 3
take into account diagnostic criteria, ie, from the Diagnostic and
(a) Final Approval of the Completed Article
Statistical Manual of Mental Disorders, Fourth Edition, Text Christopher Quinn-Nilas; Robin R. Milhausen; Alexander McKay;
Revision.23 This study is also limited because we did not collect Stephen Holzapfel
information about any disease severity or duration, or medica-
tions currently used by participants, nor was the list of health
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