In this study we determined that a several variables known to be associated with increased prevalence of sexual problems in heterosexual men (age, voiding concerns, absence of a stable relationship) were also associated with sexual problems in MSM. An association of sexual problems with age in MSM has been previously reported.14, 22
The quality of intimate relationships and social support have also been associated with lower risk of sexual problems in MSM. 11–13, 23
Our findings corroborate these prior reports; while not surprising nor entirely novel, these data support the contention there are important similarities in sexual function between MSM and non-MSM males. Additionally, we report new findings on the association between LUTS and sexual problems in MSM. LUTS have been linked to erectile dysfunction in heterosexual men but until now this has not been clearly evidenced in MSM.24
Interestingly, our multivariate model suggested that odds of PE were slightly greater in younger MSM, dissimilar to what has been reported in prior studies of non-MSM males. 25–26
Vascular diseases are known to be associated with greater odds of ED in heterosexual men but were not independently associated with ED in this population.27
It seems unlikely that vascular disease exerts a different effect on erectile function in MSM; it is more likely that because our population was generally younger medical conditions were either not yet present or had not progressed to the point of causing end-organ damage. Furthermore, severity of co-morbid conditions was not assessed; this necessitates caution in interpreting these findings.
A recent study similar in concept to our own was reported by Hirshfeld et al. This internet survey enrolled 7,001 MSM; a relatively high fraction (79%) of the respondent pool endorsed at least one sexual concern in response to single item questions on a variety of sexual issues. Low sexual desire was the most prevalent complaint at 57%, with erectile problems, non-pleasurable sex, difficulty with orgasm, and sexual pain reported .by 45%, 37%, 36%, and 14% of men, respectively.11
Age less than 30, use of club drug or medications for ED, single status, a history of sexually transmitted infection, and poorer self-reported mental/physical health were also risk factors for sexual problems in this study.11
These authors did report that while sexual problems in general were more prevalent in men less than 30 years, erectile dysfunction as a specific problem was associated with age greater than 50 years. The nature of data acquisition in this study differs substantially (single item questionnaire in the prior work compared to a validated scale in our study); furthermore, our study builds upon health related variables not assessed in the publication by Hirshfeld.
We did not find an association between condom usage and ED. In a cross-sectional questionnaire study of 78 HIV+ MSM seen in a specialty clinic, Cove and Petrak reported that condom-associated ED led to substantial declines in condom usage during anal insertive intercourse.28
Adam et al reported similar findings in a qualitative study of 102 gay and bisexual men recruited from a non-clinic population.29
This difference in outcomes may be related to substantial differences in study design and/or study cohort. Our investigation of the relationship between condom usage and PE in MSM is to our knowledge novel; while not statistically significant, men with lower adherence to condom usage during insertive anal sex had greater odds of PE. Cause and effect cannot be gleaned from these data although it seems logical to speculate that the decreased sensitivity afforded by condoms may help to prolong ejaculation latency in MSM who are concerned with PE; this may represent an attractive adjunctive incentive for condom use in select MSM.
Our study population consists of English-speaking, internet-using MSM willing to respond to a series of sexuality questions posted on an internet-website; results may thus not necessarily be generalizable to all MSM. Older MSM are under-represented in this study so our conclusions in this population must be interpreted cautiously; the relative dearth of older men (in whom a higher burden of disease would be expected) may account for the absence of a statistically significant relationship between vascular health variables and ED in this study. Our younger population also had a relatively high prevalence of HIV infection and drug use; this may partially limit the generalizabiity of our results. In the absence of any form of compensation for participation there is no clear reason for misrepresentation in a survey such as this; however we must entertain the possibility of false reporting due to recall bias or deliberate attempts (malicious or otherwise) to skew these data on sexuality in a sexual minority group.30
Occult co-morbid conditions may also be present in this population, although we maintain that we accounted for the vast majority of known causes of sexual dysfunction in the male population.
This study was designed as an exploratory, hypothesis generating investigation and causality cannot be inferred based on the cross-sectional design. Despite its’ limitations, our data are a novel contribution to the biomedical literature on sexuality in MSM. Additional investigation of how health care providers can best tend to the sexual health needs of their MSM patients are warranted. Formal development of cut-off scores for ED severity using the IIEF-MSM-EF would be of interest. Furthermore, more information is required on how MSM adapt to changes in their erectile capacity rigidity with age/medical co-morbidity, the efficacy of PDE5I in management of ED in MSM, and the definition of clinically relevant PE in male same-sex encounters. This last question is of great interest as the current International Society for Sexual Medicine definition of premature ejaculation explicitly includes language that presupposes vaginal penetration, creating something of a quandary for diagnosis of PE in MSM.31
For the time being, it is important that sexual medicine providers inquire about the sexual orientation and practices of their patient. A small but important minority of male sexual medicine patients engage in same sex activity; their specific healthcare needs may differ from those of men who have sex exclusively with women.