Sexual Health of Men in Germany – The Third Men´s Health Report

By Doris Bardehle, PhD

Foundation of Men´s Health, Berlin, Germany


In a critical review of the First [1] and the Second Men's Health Report [2] published by the Men's Health Foundation Berlin, the Report of the Robert Koch-Institute "Health Status of Men in Germany” [3] and the Men's Health Report of the European Union: “The Men's State of Health” [4] has shown that the sexuality of men as a relevant topic was excluded.

In a Survey [5] conducted by Global Action on Men's Health (GAMH) and Sanofi in 2015, with 16,000 adult men and women in 8 countries (including Germany), the question of the relevance of sexuality for life quality was raised. The result was that sex is ranked first, at least in the younger age groups.

For this reason, it seemed to the Men´s health Foundation as the editor to take up the issue of sexuality of men for the Third German Men´s Health Report.

In order to cover the diverse facets of male sexuality despite poor "official" data, the German Men´s Health Foundation cooperated with the Institute for Applied Sexual Science at the University of Applied Sciences in Merseburg, Germany.

The interlinking of social sciences with the medical perspective in the field "Sexual health of men" was the key to the successful approach of the topic “sexual health of men” [6].

The report includes 31 articles written by 40 experts. Official data, which is a criterion for a health report, could only be used marginally. Figures result predominantly from scientific and literature research.

1. Sexuality of Men

Is the right to sexuality a fundamental right (of citizens) and how is it perceived? What achievements do we have in Germany and where do prejudices still exist? And in what field is catching up needed?
Can the right to sexuality also be abused and how can it be counteracted? These are questions of the social development of sexuality, to which are given valuable answers in this report.
Furthermore: How does sexuality develop in the 21st century? How do we avoid discrimination based on sexual orientation? How can sexual offences be further reduced? These topics are addressed specifically from a male perspective.

The Right to Health and the Right to Sexuality
WHO defined in 1946: "Health is a state of complete physical, mental and social well-being and not just the absence of disease or infirmity” [7]. It was only in 1975 that discussions began in the WHO on reproductive and sexual health [8].

The first definition of "sexual health" is from 2006 [9] and says:

Sexual health is a state of physical, mental and social well-being in relation to sexuality. It is not just the absence of illness, function disorders or infirmities. Sexual health requires a positive and respectful approach to sexuality and sexual relations, as well as the opportunity to experience pleasant and safe sexual experiences, free of coercion, discrimination and violence. In order to reach sexual health permanently, the sexual rights of all people must be respected, protected and preserved [6, p. 81/82].

The sexual health of a population is defined by the following 5 thematic topics [10]

Factors influencing sexual health (WHO, 2010)

1. Legislation, politics, human rights

2. Education

3 Society and culture

4 Economics

5 Health care

Sexual health is dependent on the realization of human rights and is relevant to the entire life span of a man, not only for the reproductive years, but also for boys and older men.

The men's health report clarifies the influencing factors on sexual health in Germany in the 21st century in a transparent way and shows opportunities, but also threats to our society and every male individual. The most important positive aspects of male sexuality in the digital age are: Sexual pleasure, interpersonal closeness, sexuality as a life and creative energy, intentional procreation of a child, generation and role as father, sexual competence and sexual satisfaction, good physical and mental health with satisfactory sexuality.

Among the negative aspects of male sexuality in the digital age is sexual violence of men as perpetrators and victims, sexually transmitted infections and diseases, unplanned paternity, sexual function disorders, discrimination of men on the basis of sexual orientations.

2. Medical burden (stress factors) for male sexuality and health care situation

Limitations of sexual function through erectile dysfunction and treatment needs [12]

Primary erectile dysfunction (ED) and ejaculatio praecox (premature ejaculation) are the most common male sexual disorders despite good research and therapy.

Definition: An erectile dysfunction occurs when a sufficient erection can´ t be achieved and maintained for a satisfactory sexual intercourse permanently (> 6 months) [12, p. 312] .

Erectile dysfunction shows an increase in age with a frequency of about 20% of the 30-70-year-old men, a further 20% of the ejaculatio praecox. The frequency / prevalence of erectile dysfunction is already rising to 9.5% in men aged 40-49, with 70-80-year-old men affected more than half of men (53%) (Figure 2).

Data on erectile dysfunction and sexual satisfaction are derived from the "Cologne Study" with 8,000 men interviewed in 2000. 56% of the responses (4,489 men) were evaluated [12, Klotz, p. 312].

Fig 1: Percentage of men who are dissatisfied with their sex life depending on age [12].

It was determined from interviews with men in Germany that, depending on the age, 32 to 44% of men are not satisfied with their sexual life (see Figure 1). Dissatisfaction with sexual life did not correlate clearly with erectile dysfunction, so other factors also play a role. An erection disorder does not mean that a high suffering pressure/distress leads all affected men to the doctor. Not every 20%, but only half (9%) of the men with ED estimate themselves to be in need of treatment.

Fig. 2: Prevalence of an erectile dysfunction as a function of age [12]

Erectile dysfunction is often an early symptom of an underlying disease (a primary disease), mainly a cardiovascular disease or diabetes. Therefore, there is a need for diagnostic clarification and treatment. Approximately 80% of men with erectile dysfunction can be treated (therapeutically) successfully.

Limitations of sexual functions by chronic diseases [11]

The proportion of chronically ill men increases from about 20% in young people to over 50% in men up to 65 years and still further in the higher age. Cardiovascular diseases, diabetes, cancer, especially prostate cancer, musculoskeletal disorders, but also HIV and other sexually transmitted infections and mental illness affect the sexual functions of man [14]. The European Men´s Health Report points out that men´s risk management also has an adverse effect on their health situation [4].

There are hardly any reliable research results on the sexual behavior of chronically ill men. In scientific studies about half of the erectile dysfunction is attributed to cardiovascular disease and diabetes.
Fig. 3 shows the relationship between coitus frequency and health status. The worse the health condition, the lower the monthly coitus frequency. Another difference concerns men who live in partnership and singles, whose coitus frequency is much lower than that of men in partnership.

Fig. 3: Monthly coitus frequency according to health status [15]

Prostate cancer is currently the most common cancer of males with a share of 25%. For many men, the treatment of prostate cancer means severe restrictions on their quality of life, such as incontinence, osteoporosis, depression, diminished self-esteem, diminishing attractiveness and conflicts in the partnership [11].

Prostate carcinoma patients show up to 30 to 40% postoperative disorders of sexual function, especially erectile dysfunction. The decreasing possibility of an erection is considered by affected men as "withdrawal of their masculinity" or a drastic element with regard to their male identity.

Limitations of sexual function based on mental disorders [13]

Sexual disorders of (based on) mental illness are of extreme importance of the medical care for men [13] because of their high prevalence. Depressions have a significant impact on erectile function.
Mental disorders are complex disturbance images with many psychosocial stress factors that lead to disturbances in interpersonal relationships and in sexual life. Mental diseases always affect the whole human being. The man is changed in his feeling, thinking and acting, but also in his body reactions.

Against this background it is understandable that 50 to 90% of mentally ill people suffer from sexual problems [13]. Sexual problems occur in mood disorders, anxiety and obsessive-compulsive disorders, as well as in addiction disorders, psychosis and personality disorders.
The lifetime prevalence of mental disorders in the population is indicated at 30%, which means that about every third citizen in his / her CV has suffered at least one mental disorder.

Mental illness is a complex disorder with many psychosocial stress factors, which have a negative impact on interpersonal relationships and leading therefore to difficulties in sexual life.

Despite these high prevalence rates, sexual problems are barely included in psychiatric diagnostics and therapy. The connection between a mental disorder and sexuality can be of a different nature: either a mental illness leads to a sexual disorder or a primary dependency (addiction) cause a sexual disorder. Psychopharmaceuticals can have a negative impact on sexuality through side effects.

Limitations of sexual function through sexually transmitted infections [14]

Sexually transmitted infections are a central health issue because they occur frequently and have a profound impact on sexual and reproductive health.

Sexually transmitted infections include not only HIV but also chlamydia, gonorrhea, human papillovirus, viral hepatitis, syphilis and trichomoniasis. Since the 2000s, the number of infections has risen again, among other things due to progress in the treatment of HIV.

At present, 1/3 of the 83,000 HIV patients in Germany are older than 50 years. Comorbidity increases with age in men with HIV, and sexual dissatisfaction is growing due to the accompanying symptoms of drug intake and social stigmatization [11].

Men are more frequently affected by sexually transmitted infections than women. The infection process can be influenced by behavior and precaution. Promiscuous behavior and male homosexuality are the most important pathways, and they show where prevention has
to start.

3. Discussion and recommendations for the treatment of sexual disorders [12]

Many, especially older men, do not consult for a doctor for erectile dysfunction because they do not want any help, or because they are "ashamed". In the case of reported erectile dysfunction, an assessment of cardiovascular disease, diabetes and prostate disease should be done in any case because erectile dysfunction can be a "marker" for a chronic disease, especially cardiovascular disease or diabetes.

Patients with mental disorders often show negative effects on interpersonal relationships, which in turn have a negative impact on sexual life. Clinical practice has the task to clarify premorbid sexuality and its development. Treatment should aim at targeted changes in sexual life.

Sexual symptoms should to be asked because they are usually not spontaneously reported. The prescription of psychopharmaceuticals, e.g. antidepressants and their side effects are to be identified because they often have an impact on sexuality [13]. Relationship problems of the partners should also be the subject of diagnostics and therapy.

In the training of physicians and psychotherapists, sexual dysfunctions in mental disorders are to be considered more closely.

There is an insufficient medical care for erectile dysfunction, starting with the anamnesis done by the physician / treating physician / psychologist. The authors Ahmad and Langer [11] recommend to sensitize treating physicians for the complex interaction of sexuality and masculinity in the context of chronic diseases, in order to jointly discuss the possibilities of a successful treatment of sexual problems.

Klotz summed up the situation as follows [12, p.315]: "In the last few years, the media has ensured that erectile dysfunction and the possibilities for therapy are at least partially no longer taboo”.

Thus, patients with this primary symptom are increasingly prevalent among physicians, since the erectile function has a decisive influence on the male self-image. Erectile dysfunction builds up psychological strain / stress in men. But this refers to only a part of the affected men who are also willing to change their lifestyle.

Therefore intersectional health care is recommended for chronically and mentally ill hetero-, homo- and intersexual men, including sexual function.


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