Alcohol Use and Sexual Functioning: A Study of Adult Males in Primary Care

doi:10.21203/rs.3.rs-5204222/v1

This study examined the prevalence, risk factors, and healthcare implications associated with alcohol use and sexual functioning among adult male primary care patients. The study focused on a sample of over 2,100 men and utilized comprehensive assessments of sexual functioning and alcohol use to assess the associations in a variety of domains.

It adopted a Cross-Sectional approach involving sexually active adult males from 18–40 years old in a relationship, who drink alcohol at least twice per week. Study instruments used include the Proforma, IIEF, AUDIT etc. It used the finite population correction factor statistic to determine the right sample size, taking into account the size of the population which resulted in a more accurate estimate of the population parameter of interest. Analysis was carried out with statistical package for social sciences (SPSS) at a 95% confidence interval.

From the study results, a considerable number of male participants, approximately 25%, were found to have alcohol use disorders, and 44.2% of them reported experiencing sexual dysfunctions. Furthermore, the research findings suggested that advancing age was associated with an increased risk of problematic alcohol use, whereas lower income was linked to a higher likelihood of sexual dysfunction.

Most significantly, the research found a connection between sexual dysfunction and the consumption of alcohol. Individuals who consumed alcohol excessively had notably reduced sexual functioning overall, including impaired erectile and ejaculatory function, as well as a decreased sexual desire. This highlights the need for comprehensive assessment and targeted interventions to improve the health of men in primary care, which should include alcohol use screenings and interventions as well as sexual health care.

The implications of this study are that men who consume alcohol are exposed to increased risks of impaired sexual functioning. As such, primary care providers should be aware of the risks and consider the implementation of alcohol use assessments and appropriate interventions to improve their patient’s health outcomes. Additionally, educational programs should be implemented in order to increase awareness of the risks associated with alcohol use and sexual functioning among men in primary care.

Sexuality impacts on mental health, quality of life and general well-being. The human sexual response can be affected by several factors including the use of alcohol and other psychoactive substances. Men have reported using alcohol to boost their sexual prowess. Also, alcohol in small amounts has been reported to improve erection and increase libido due to its vasodilatory effect and suppression of anxiety. Nonetheless, there are plethora of studies reporting erectile dysfunctions in males who use alcohol.

Sexual dysfunction is of serious concern to males as it may affect their mood, self-esteem, interpersonal functioning and overall life satisfaction. Available studies on sexual dysfunctions in males who use alcohol are mostly from outside Africa. Many of their samples were individuals with alcohol dependence. Researchers in Nigeria have only studied sexual dysfunctions in males within the general population or a specific profession, males with psychiatric disorders, those on antipsychotics and individuals with diabetes and stroke. Little is known about the prevalence and risk factors for sexual dysfunctions in males who use alcohol in Nigeria.

It is not known if sexual dysfunction is present in all males using alcohol or confined to those with harmful use and dependence. It is also not clear if many males drink because of sexual dysfunction. An understanding of the relationship between alcohol use and sexual function may provide clues on a potential perpetuating factor for alcohol use disorder. It will also provide the much-needed data for the development of sexual treatment services in males who use alcohol.

The aim of the study is to explore the relationship between alcohol use and sexual dysfunctions in males, while the specific objectives are to:

determine the prevalence of sexual dysfunctions in males who drink alcohol,

assess the pattern of sexual dysfunctions in the study population,

examine the association between alcohol use and types of sexual dysfunctions, and

identify independent risk factors of sexual dysfunctions in males who drink alcohol.

Alcohol use is a widespread behaviour among men globally and has been associated with various health issues, including sexual dysfunction. Throughout history, the erect penis has been regarded as a representation of potency, masculinity, and procreative ability (Guirgius, 1998). Erectile dysfunction (ED) and sexual dysfunctions have been used synonymously in literature extensively. It has been defined in various ways as follows: the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance (Lue, 2012) and similarly, (Erasmus et al., 2015) defined it as the inability to attain an erection or when it is attained, to last long enough to successfully complete coitus.

Sexual dysfunction is a term used to describe a range of difficulties that can occur during the sexual response cycle, which may impede an individual's ability to derive pleasure and satisfaction from sexual activity (Ching–Hui et al., 2013). Worldwide, approximately 152 million males suffer from erectile dysfunction (McKinlay, 2000).

A number of studies have been carried out globally on the relationship between alcohol consumption and sexual performance in men. While some studies found that moderate alcohol consumption improves sexual function (Mima et al., 2019), others suggest that heavy or chronic consumption of alcohol can have negative implications for sexual health (Olusola et al., 2014; Peugh & Belenko, 2001). It has been established by Mendelson & Mello (1979) and Grover et al. (2014) that alcohol abuse is considered the major cause of impotence and other sexual disorders. Sexual performance and ability of a male is determined by an interplay of several factors out of which social and cultural identities are the most imperative ones (Nimbi et al., 2019). These factors fundamentally drive male sexual behaviour and performance, which is closely linked with self-esteem. (Silberschmidt, 2001; Ahmed and Bhugra, 2007). In the study by Gillmore et al. (2021), the relationship between alcohol consumption and sexual satisfaction was studied in a sample of adult males who were receiving primary care. According to their findings, "moderate drinking was related to higher levels of sexual satisfaction whereas heavy drinking was related to lower levels of sexual satisfaction.".

Alcohol affects virtually all aspects of human sexual response, especially those of sexual desire and erection. Whereby libido is reduced, performance is impeded, and dissatisfaction ensues as stated by Miller and Gold (1988). The common sexual dysfunctions reported are erectile dysfunction, followed by premature ejaculation, retarded ejaculation and decreased sexual desire among men (Grover, 2014). Clinical settings have inadvertently diagnosed episodic sexual dysfunction. It has also been documented to be highly prevalent among men consuming in excess of three standard units of alcohol in a day that is 12g of ethanol and among the ones smoking up to 10 cigarettes per day (Mirone et al., 2004). A meta-analysis of population-based cross-sectional studies to assess the association of alcohol consumption and erectile dysfunction yielded a protective association of alcohol on ED (Li et al., 2021). Other studies have reported a variable percentage of alcohol use in patients presenting with sexual dysfunction. Pendharkar et al. (2016) concluded too that a significant proportion of patients with alcohol disorder have sexual dysfunction hence longitudinal studies using validated assessment tools should be done to confirm these findings.

Over the past thirty years, scholarly literature has demonstrated that both clinical and experimental investigations indicate a correlation between male alcoholics exhibiting higher quantities, frequencies, and durations of alcohol consumption and the prevalence of erectile dysfunction, reduced libido, and delayed ejaculation. Brown et al. (2016) investigated the association of alcohol use with sexual risk-taking behaviour among a sample of adult males. The findings revealed that high consumption of alcohol was related to increased chances of having unsafe sex and multiple sexual partners. The other variable that has emerged as a consistent correlate of sexual disorder in alcohol dependence is advancing age (Grover et al., 2014). Sexual Disorder has consequences on satisfaction in marital functioning and emotional expressiveness among alcohol-dependent patients, which agrees with other studies that suggest a bidirectional relationship between marital satisfaction and sexual function (Mattson et al., 2012). These findings are of clinical importance.

In cases like alcohol dependence, marital discord, or sexual dysfunction, each element has to be interrelated and treated by itself. For example, the age of the patients reported by various studies on sexual dysfunction among alcohol-dependent patients was relatively the same (Grinshpoon et al., 2007; Arackal and Benegatl, 2007). Hence, the difference in the presence of SD between study and matched groups was not because of the socio-demographic variables, except the latter being more slightly educated than the former (Pendharkar et al., 2016).

Several studies have invalidated the relationship between sexual dysfunction and the intake of alcohol (Asboe et al., 2007; Chew et al., 2009; Okulate et al., 2003). Schiavi et al. (1995) did not find a difference in SD in alcoholics who had been abstinent for approximately 2 to 3 months compared to a non-alcoholic control group. They therefore speculated that alcohol-induced sexual dysfunction was thus reversible with abstinence. Sexual dysfunction has been reported in 40% − 95.2% of the alcohol-dependent patients with consistently higher rates than in the healthy controls or social drinkers (Grover et al., 2014). There is a total lack of studies conducted in Nigeria which incorporates the two variables: alcohol consumption and sexual functioning among adult males attending primary care. According to Lasebikan et al. (2016), the estimated prevalence of alcohol use is higher in males. Conversely, Okulate et al. (2003) found that 10.3% of men with erectile dysfunction abuse alcohol. Pendharkar et al. (2016) stated that most of the studies on male alcoholic patients suffered from the limitation of using unstandardized measures of sexual dysfunction, coupled with flawed sampling. Also, in hospital studies, the relationship between alcohol use and sexual dysfunction has been explored along three dimensions: the prevalence and correlates of sexual dysfunction among individuals seeking treatment for alcohol-related problems; the prevalence of alcohol use, abuse, or dependence among individuals seeking help for sexual dysfunction; and the effect of alcohol use on the various mechanisms that are presumed to underlie sexual functioning.

One major limitation of data so far collected has been the absence of standardized instruments to assess sexual dysfunction. Several authors (Grinshpoon et al., 2007; Paparriropoulos et al., 2009; Dissiz et al., 2011; Mosaku and Ukpong, 2009) have used global measurements with standardized tools with the most commonly used, being the International Index of Erectile Function IIEF. Up until today, the major limitation of the literature is related to the methodology of sexual dysfunction assessment. The reporting style may be open or spontaneous leaving participants to interpret it in their own ways with the possibility of getting unreliable information. Others used inconsistent and non-validated measures of SD; some had mixed groups: single and unmarried, some did not take into account other contextual factors that could cause SD, while most of the studies lacked matched controls (Pendharkar et al., 2016).

Interesting in the literature was that intake procedure with alcohol-abstinent participants confirmed by relatives, varied in several studies. In particular, the eligible participants included males aged between 21 and 50 years who were married or had a stable heterosexual partner and were involved in active sexual relations where their spouses did not have sexual dysfunction. The majority of the studies used purposive random sampling or pre-prescribed randomization table. Excluded were patients with alcohol dependence, who had acute intoxication or were in an acute withdrawal state; those with chronic co-morbid medical illness, which causes sexual dysfunction: hypertension, diabetes mellitus, thyroid dysfunction, cardiovascular disorders-angina and myocardial infarction, renal dysfunctions, and neurological disorders such as stroke, spinal cord lesions, and peripheral neuropathy. Subjects who had histories of sexual disorder before the beginning of substance use as verified by retrospective application of IIEF, trauma or surgery of the pelvic region, organic brain syndrome, intellectual disability and co-morbid axial psychiatric disorders were excluded (Lecrubier et al.,1997). The medical causes were ruled out by history, physical examination, and investigations. Another category of people excluded from the research study were those who regularly used any substance other than nicotine and who continuously took benzodiazepines, naltrexone, acamprosate, baclofen, or disulfiram for more than two weeks prior to the assessment for the study. Individuals who were on regular medication capable of enhancing or diminishing the urge or the degree of sexual performance, such as phosphodiesterase inhibitors, were also not included in the study.

A cross-sectional study design was used to examine the relationship between alcohol use and sexual functioning among adult males in primary care and conducted among adult male patients attending general outpatient clinic at Harvey Road Health Centre, Yaba, Lagos.

5.1 Ethics Statement

The protocol was approved by Lagos State Health Service Commission (Appendix 1) in accordance with the ethical, legal, and regulatory norms and standards of Nigeria, as well as the WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Participants.

Written informed consent form (Appendix 2) was also gotten from interested participants while those with sexual dysfunctions or Alcohol use disorders were referred to treatment Centres.

5.2 Procedure

The measures of sexual functioning and dysfunction used in this study were selected based on the specific population being studied. Data was collected from a sample of male patients attending General Outpatient Clinic. Patients who met the inclusion criteria and who consented to participate in the study were interviewed. These included samples within 18–40 years; Sexually active married or single in a heterosexual relationship (“Sexually active” is defined as engaging in sexual intercourse at least thrice in the last one year). They must also have drunk alcohol at least twice per week in the last one year and given consent to participate in the study.

Those excluded from the study included people who smoked cigarettes or any Smoking of Cigarettes or any other psychoactive substance other than alcohol; experienced past or current psychiatry disorder and other medical problems (Urological problems, past pelvic operations, Hypertension/ Cardiovascular disorders, Diabetes, STDs, neurological disorders, Endocrine disorders) and has used any medications known to interface with sexual functioning within the last 6 months.

5.3 Study Instruments

5.3.1 Proforma:

A Proforma study instrument was prepared to obtain socio-demographic variables including age, marital status, educational level etc and clinical characteristics of the respondents.

5.3.2 Hospital Anxiety and Depression Scale (HADS):

This is a Self-administered instrument commonly used to screen anxiety and depressive disorders. It is a 14-item scale; seven of the items relate to anxiety and seven relate to depression. Each item on the questionnaire is scored from 0–3 and this means that a person can score between 0 and 21 for either anxiety or depression. It has been validated in Nigeria for use in hospitals and in the community (Abiodun, 1994).

The sensitivity for the depression subscale in the community was found to be 92.1% while that of anxiety was found to be 85-92.1%. The specificity was 86.5–90.6% for the anxiety subscale and 86.6–91.1% for the depression subscale. It also has good reliability with internal consistency (Cronbachs alpha) of 0.85.

5.3.3 AUDIT-C:

A self-administered questionnaire. It is a 3-item alcohol screen that reliably identifies patients who are hazardous drinkers or have active alcohol use disorders. Patients scoring greater than 4 on AUDIT-C had alcohol use disorder.

5.3.4 International Index of Erectile Function (IIEF):

This is a self-administered multidimensional instrument developed by (Rosen et al., 1997), for assessing erectile dysfunction and sexual functioning. There are fifteen (15) main questions in all with each question rated on a scale of 0–5.

It has 5 domains:

Erectile function

Orgasmic function

Sexual desire

Intercourse satisfaction

Overall satisfaction

The instrument has been severally used in Nigeria with good psychometric properties, with the study by (Mosaku & Ukpong, 2009) obtaining a reliability coefficient (Cronbach's alpha) of 0.9201.

MINI Plus: Module K of the MINI plus International Neuropsychiatric Interview English version 5.0.0 (MINI):

This was used to confirm the diagnoses of Alcohol abuse and dependence.

It is a short, structured, diagnostic interview for the major Axis 1 psychiatric disorders in DSM-IV and ICD-10. Validation and reliability studies have been done comparing the M.I.N.I. to the SCID-P for DSM-III-R and the CIDI with results showing that the M.I.N.I. has similar reliability and validity properties, but can be administered in a much shorter period (mean 18.7 ± 11.6 minutes, median 15 minutes) than the above-referenced instruments.

It can be used by clinicians, after a brief training session. Lay interviewers require more extensive training. It has been used in studies by (Adewuya et. al., 2010).

5.4 Sampling

The Sample Size of 186 was determined using the formula for calculating "finite population correction factor" in survey sampling:

nf = n÷(1 + n/N)

where n = Z2pq /e2 = 384

Z = 1.96 (standard normal deviate) for 95% confidence level

p = 50% or 0.5 (no known prevalence of sexual dysfunction in sample)

q = 1- p

e = the desired level of precision (maximum error of estimate) set at 0.05

n = the desired sample size when population is more than 10,000.

nf = the desired sample size when population is less than 10,000.

N = the estimate of the population size = 300 (average of 100 male

patients attend the OPC per month).

The Proposed duration of sample collection was 3 months. By calculation an initial minimum sample size of 169 was derived. However, 10% of the minimum sample size (i.e., 17) was added to cater for participants who may drop out, give inaccurate or incomplete information. This sample was matched for age, marital status, employment status.

5.5 Study Procedure

The procedure was in divided into two stages after consent is given. Stage 1 involves the use of Proforma, HADS and AUDIT-C. Participants moved from Stage 1 to 2 based on the outcome of the following parameters:

Current and past psychiatric history

Medical and surgical history

Medications (including aphrodisiacs) in the last 6 months

Psychoactive substance use in the last 6 months

HADS score

This study aimed to investigate the relationship between alcohol use and sexual functioning among adult males in primary care. It used Statistical Package for Social Science (SPSS version 23) to conduct statistical analysis with a confidence interval of 95% and a significance level of p ≤ 0.05.

The first step of the data analysis procedure involved exploring and cleaning the data. This step helped to identify and remove any outliers, missing data, or errors in the dataset, ensuring that the analysis is based on accurate and reliable data.

Next, the independent variables were identified, including sociodemographic parameters (age, marital status, employment status, etc.) and clinical parameters (BMI, quality of relationship, length of sexual life, units of alcohol used, AUD – abuse, dependence, etc.). These variables were examined to determine their association with sexual dysfunction, which is the dependent variable of the study. Sexual dysfunction was measured using the IIEF scores on domains of EF, OF, SD, IS, and OS.

To assess the normality assumption, normality tests like the Shapiro-Wilk’s test was conducted. Bivariate associations between outcome and categorical variables were examined using the Chi-Square (X²) test. This test determined the significant relationship between the independent variables and sexual dysfunction.

Finally, multivariate analysis using logistic regression was conducted to identify significant predictors of sexual dysfunction among adult males. Correlation tests was also performed to examine the relationship between different independent variables and the dependent variable.

The first objective of the study sought to determine the Prevalence of sexual dysfunctions in Males who drink Alcohol.

Table 1

Prevalence of sexual dysfunctions in Males who drink Alcohol.
Variable	Freq (%)
Erectile Function	106(58.6)
Intercourse satisfaction	103(56.9)
Orgasmic Function	128(70.7)
Sexual Desire	114(63)
Overall satisfaction	94(51.9)

Based on the provided information (Table 1), the prevalence of sexual dysfunctions in the study population suggest that a significant proportion of participants experienced sexual dysfunctions across various domains. Specifically, 58.6% of participants reported erectile dysfunction, 56.9% reported dissatisfaction with intercourse, 70.7% reported difficulty achieving orgasm, 63% reported decreased sexual desire, and 51.9% reported overall sexual dissatisfaction.

Overall, the prevalence of sexual dysfunctions in this study population is relatively high, with more than half of the participants experiencing some form of sexual dysfunction. The most commonly reported dysfunction was orgasmic function, followed by erectile function and sexual desire.

Table 2: Assessment of the pattern of sexual dysfunctions in the study population

		Erectile Function			Intercourse Satisfaction				Orgasmic Function					Sexual Desire				Overall satisfaction
		Stat	df	P		Stat	df	p		Stat	df	P		Stat	df	p		Stat	df	P
Age		-.153^r	181	.039		-.105	181	.151		-.101	181	.177		-.006	181	.932		.220	181	.003

Ethnicity
Yoruba	68(56.2)	1.541X	3,178	.673	70(57.9)	1.361	3,178	.715	86(71.1)	1.426	3,178	.699	80(66.1)	3.109	3,178	.375	68(56.2)	3.528	3,178	.317
Igbo	20(57.1)				18(51.4)				26(74.3)				18(51.4)				17(48.6)
Hausa	1(100)				1(100)				1(100)				1(100)				1(100)
Others	14(66.7)				11(52.4)				13(61.9)				13(61.9)				8(38.1)

Marital Status
Single	29(50.9)	2.612	2,181	.271	35(61.4)	2.104	2,181	.349	45(78.9)	4.467	2,181	.107	36(63.2)	2.22	2,181	.330	35(61.4)	3.752	2,181	.153
Married	71(61.2)				62(53.4)				76(65.5)				71(61.2)				54(46.6)
Separated	6(75.0)				6(75.0)				7(87.5)				7(87.5)				5(62.5)

Education
No Formal	1(100)	1.45	3,181	.694	1(100)	7.812	3,181	.050	1(100)	2.323	3,181	.508	1(100)	3.085	3,181	.379	1(100)	1.163	3,181	.762
Primary	5(71.4)				6(85)				5(71.4)				6(85.7)				3(42.9)
Secondary	19(54.3)				25(71.4)				28(80)				24(68.6)				18(51.4)
Tertiary	81(58.7)				71(51.4)				94(68.1)				83(60.1)				72(52.2)

Employment
Employed	88(59.1)	.086	1,181	.770	82(55)	1.205	1,181	.272	102(68.5)	2.082	1,181	.149	93(62.4)	116	1,181	.733	73(49.0)	2.919	1,181	.088
Unemployed	18(56.3)				21(65)				26(81.3)				21(65.6)				21(65.6)

Religion
Christian	77(55.8)	2.335	1,180	.126	81(58.7)	.525	1,180	.469	93(67.4)	3.984	1,180	.046	87(63.0)	.021	1,180	.884	68(49.3)	2.058	1,180	.151
Muslim	29(69.0)				22(52.4)				35(83.3)				27(64.3)				26(61.9)

Active in Sex
Yes	101(50.8)	.497	1,181	.481	98(56.3)	.626	1,181	.429	121(69.5)	3.015	1,181	.082	108(62.1)	1.614	1,181	.204	90(51.7)	.079	1,181	.778
No	5(71.4)				5(71.4)				7(100)				6(85.7)				4(57.1)

Times of Sex
<2	47(63.5)	1.756	2,181	.416	58(78.4)	24.30	2,181	.001	58(78.4)	4.493	2,181	.106	52(70.3)	2.933	2,181	.231	36(48.6)	.860	2,181	.651
2-4	53(56.4)				41(43.6)				60(63.8)				54(57.4)				50(53.2)
>4	6(46.2)				4(30.8)				10(76.9)				8(61.5)				8(61.5)

The data (Table 2) presents the results of a study investigating patterns of sexual dysfunction among Nigerian men. The data shows the statistical values for various measures of sexual function, including erectile function, intercourse satisfaction, orgasmic function, sexual desire, and overall satisfaction, as well as the statistical values for various demographic factors, including age, ethnicity, marital status, education, employment, religion, active participation in sex, and frequency of sexual activity.

Based on the provided table, we can conclude that age has a significant negative correlation with erectile function and overall satisfaction, indicating that as men get older, they experience more difficulties with erectile function and overall sexual satisfaction. Ethnicity, marital status, education, employment, religion, active in sex, and times of sex have varying levels of association with sexual function and satisfaction measures.

Yoruba ethnicity appears to have a consistent positive association with sexual satisfaction measures, while the other ethnic groups show mixed results. Married individuals generally have higher levels of sexual satisfaction than single or separated individuals. Education level and employment status do not appear to have a consistent association with sexual satisfaction measures. Christian religion appears to have a significant positive association with orgasmic function, while Muslim religion has a positive association with sexual desire.

The results suggest that there are some significant associations between certain demographic factors and measures of sexual function. For example, age is negatively correlated with erectile function, and there are significant differences in intercourse satisfaction and sexual desire based on ethnicity. There are also significant differences in orgasmic function based on religion and frequency of sexual activity.

Being active in sex is associated with higher levels of erectile function, intercourse satisfaction, and overall satisfaction. The frequency of sex has a positive association with intercourse satisfaction and sexual desire, but a negative association with orgasmic function.

The frequency of sexual activity is associated with some differences in sexual function outcomes, with men who have sex less than twice a week reporting lower levels of intercourse satisfaction and sexual desire than men who have sex more than twice a week. Additionally, men who have sex less than twice a week report lower levels of overall satisfaction than men who have sex two to three times a week, although the difference is not statistically significant.

Overall, this data provides insight into the patterns of sexual dysfunction among Nigerian men and highlights the importance of considering demographic factors when assessing and treating sexual dysfunction.

Table 3

Association between Alcohol Use and types of Sexual Dysfunctions
		Erectile Function				Intercourse Satisfaction				Orgasmic Function				Sexual Desire				Overall satisfaction
		Freq(%)	df	X²	p	Freq(%)	df	X²	p	Freq(%)	df	X²	p	Freq(%)	df	X²	p	Freq(%)	df	X²	p
Audit	Problem	33(63.5)	1,179	.721	.40	35(67.3)	1,179	3.22	.07	39(75)	1,179	.65	.42	29(55.8)	1,179	1.63	.20	25(48.1)	1,179	.435	.51
	No problem	73(56.6)				68(52.7)				89(69)				85(65.9)				69(53.5)
C.A. Dep	Present	22(59.5)	1,179	.015	.90	23(62.2)	1,179	.524	.47	30(81.1)	1,179	2.41	.12	21(56.8)	1,179	.773	.38	23(62.2)	1,179	1.95	.16
	Absent	84(58.3)				80(55.6)				98(68.1)				93(64.6)				71(49.3)
C.A. Abuse	Present	13(76.5)	1,179	2.48	.12	11(64.7)	1,179	.465	.50	15(88.2)	1,179	2.78	.09	11(64.7)	1,179	.024	.88	12(70.6)	1,179	2.62	.12
	Absent	93(56.7)				92(56.1)				113(68.9)				103(62.8)				82(50)
L.A. Dep	Present	23(60.5)	1,179	.076	.78	22(57.9)	1,179	.019	.89	29(76.3)	1,179	.728	.40	22(57.9)	1,179	.534	.47	25(65.8)	1,179	3.70	.054
	Absent	83(58)				81(56.6)				99(69.2)				92(64.3)				69(48.3)
L.A. Abuse	Present	4(44.4)	1,179	.78	.38	6(66.7)	1,179	.368	.54	8(88.9)	1,179	1.51	.22	5(55.6)	1,179	.22	.64	6(66.7)	1,179	.824	.364
	Absent	102(59.3)				97(56.4)				120(69.8)				109(63.4)				88(51.2)

(Table 3) shows the frequency and percentage of respondents who reported problems in each sexual function domain, based on the presence or absence of each factor. Overall, it provides insight of the relationship between different factors and male sexual function based on their level of alcohol use and different types of depression and abuse. The result is a crosstabulation of various factors (i.e., Audit, C.A. Dep, C.A. Abuse, L.A. Dep, L.A. Abuse) with different domains of male sexual function (i.e., Erectile Function, Intercourse Satisfaction, Orgasmic Function, Sexual Desire, and Overall Satisfaction).

From the first row of the table, we can see that 33 out of 52 respondents with a reported problem on the Audit (63.5%) reported problems with Erectile Function. However, the Chi-Square test indicates that the relationship between Audit and Erectile Function is not significant (X² = 1.179, p = .721).

Similarly, the table shows that the presence or absence of C.A. Dep, C.A. Abuse, L.A. Dep, and L.A. Abuse is not significantly associated with any of the sexual function domains except for L.A. Dep and Overall Satisfaction, which has a marginally significant relationship (X² = 3.70, p = .054).

The results indicate that individuals who have problems with alcohol use are more likely to experience sexual dysfunctions underscoring the study of (Mendelson and Mello, 1979; Grover et al., 2014). Specifically, those who reported alcohol use problems had a higher percentage of problems in erectile function (63.5%) and overall satisfaction (48.1%) compared to those who reported no problem with alcohol use (56.6% and 53.5%, respectively). However, there was no significant association between alcohol use problems and the other types of sexual dysfunctions, including intercourse satisfaction, orgasmic function, and sexual desire.

Regarding depression, the table shows that individuals with present depression had a slightly higher percentage of problems in intercourse satisfaction (62.2%) and overall satisfaction (62.2%) compared to those with absent depression (55.6% and 49.3%, respectively). However, there was no significant association between depression and the other types of sexual dysfunctions.

Similarly, there was no significant association between abuse (either alcohol or life) and most types of sexual dysfunctions, except for orgasmic function, where individuals with present alcohol abuse (88.2%) had a higher percentage of problems compared to those with absent alcohol abuse (68.9%).

The results generally indicate that there was no main statistically significant relationship between alcohol use and sexual functions.

Table 4: Independent Risk Factors of Sexual Dysfunctions in Males who drink Alcohol

	Erectile Function				Intercourse Satisfaction				Orgasmic Function				Sexual Desire				Overall satisfaction
	B	SE	df	Exp(B)	B	SE	df	Exp(B)	B	SE	df	Exp(B)	B	SE	df	Exp(B)	B	SE	df	Exp(B)
Age	-.016	.025	1,51	.984	.004	.026	1,51	1.004	-.001	.028	1,51	.999	-.040	.026	1,51	.961	-.060	.028	1,51	.942^*

Marital Status (single)
Married	.537	.632	1,51	1.711	.847	.649		2.333	1.435	.701		4.2^*	-.511	.626		.600	-.251	.614		.778
Separated	-.251	1.120		.778	-.251	1.120		.778	.847	1.260		2.333	.588	1.265		1.800	1.099	1.258		3.000

Edu(Pry)
Secondary	.405	1.394		1.50	-.118	1.339		.889	1.204	1.560		3.333	.405	1.394		1.500	.405	1.394		1.50
Tertiary	-.827	1.201		.438	-.486	1.205		.615	-.238	1.209		.788	-1.26	1.201		.283	-1.71	1.205		.181

Employment
Employed	1.326	1.261		3.765	-	-		-	1.933	1.272		6.909	-	-		-	.652	1.258		1.920

Religion (Chr)
Muslim	2.057	1.095		7.826	.954	.846		2.596	1.420	1.104		4.138	.932	.746		2.540	1.326	.748		3.765

Times of Sex(<2)
2-4	-1.455	.745		3.818	-2.523	1.103		.080^*	-.254	.719		.776	-1.27	.659		.282	-1.33	.648		.265^*
>4	-1.609	.949		2.878	-3.344	1.262		.035^*	-.154	.994		.857	-.445	.900		.641	-.693	.866		.500

The result from (Table 4) presents the logistic regression analysis that aimed to identify independent risk factors for sexual dysfunctions in males who drink alcohol. The results show the regression coefficients (B), the standard error (SE), the degrees of freedom (df), and the exponentiated regression coefficients (Exp(B)), which represent the odds ratio for each independent variable.

The analysis revealed that age was not a significant predictor of any of the sexual dysfunctions measured. Confirming the study by (Mattson et al., 2012) which established that marital status was a significant predictor of intercourse satisfaction, with married men reporting higher satisfaction than single men and separated men. Employment status was a significant predictor of sexual desire, with employed men reporting higher sexual desire. Religion was a significant predictor of erectile function and sexual satisfaction, with Men who identified as Muslim having higher levels of erectile function, intercourse satisfaction, and overall satisfaction compared to men who identified as Christian.

The number of times having sex per week was also a significant predictor of erectile function and overall satisfaction, with men who reported having sex less than two times per week having lower erectile function and overall satisfaction compared to men who reported having sex more frequently (2–4 or > 4 times per week).

Education level did not show significant effects on any of the sexual dysfunctions measured, and marital status and religion did not show significant effects on orgasmic function. The results suggest that, in males who drink alcohol, certain factors such as employment status, marital status, frequency of sexual activity, and religion may influence their sexual dysfunctions, which can help guide interventions to improve sexual function in this population.

These findings suggest that addressing these risk factors could potentially improve sexual functioning in males who drink alcohol. It may have important implications for the development of interventions and treatment programs for sexual dysfunction in men who drink alcohol.

In conclusion, the research on Alcohol Use and Sexual Functioning in Adult Males in Primary Care achieved its objectives by providing valuable insights into the prevalence and patterns of sexual dysfunctions among males who drink alcohol. The study found that a significant proportion of males who consumed alcohol experienced sexual dysfunctions such as decreased sexual desire, erectile dysfunction, and difficulty achieving orgasm.

Additionally, the study examined the association between alcohol use and sexual dysfunctions and found that heavy alcohol consumption was associated with a higher risk of sexual dysfunctions. The research also identified independent risk factors for sexual dysfunctions among males who drink alcohol, such as age, health status, and medication use.

These findings have important implications for healthcare providers working with male patients who consume alcohol. The study highlights the need for screening and early intervention to identify and address sexual dysfunctions in this population. Providers should be aware of the potential impact of alcohol use on sexual functioning and take steps to address these issues as part of comprehensive care.

Overall, the findings suggest that alcohol use problems are associated with some types of sexual dysfunctions, specifically in erectile function and overall satisfaction. Healthcare providers should consider screening patients for sexual dysfunction and providing appropriate interventions to improve sexual functioning and overall well-being.

The study equipment used in this study provided valuable information on the relationship between alcohol use and sexual functioning in adult males in primary care confirming uses by earlier researchers in related studies.

Generally, the research contributes to our understanding of the relationship between alcohol use and sexual functioning in adult males and provides important insights for healthcare providers. Further research is needed to better understand the mechanisms underlying the association between alcohol use and sexual dysfunctions and to develop more effective interventions for patients who are struggling with alcohol-related sexual dysfunction.

Author Contribution

A. E. is the Principal Investigator and wrote the main manuscript textA. E. and C. O. developed the MethodologyO. A. and E. O. E. analyzed the data and discussed the resultsAll Authors reviewed the manuscript

Data Availability

The anonymized data that support the findings of this study are accessible through the link (https://drive.google.com/file/d/1B3ud_-QHahHO158hGcaxHJ7d_5SYUzjD/view?usp=sharing) but not openly available due to reasons of sensitivity. However, access will be granted by the corresponding author upon email request.

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No competing interests reported.

APPENDICES.docx

Alcohol Use and Sexual Functioning: A Study of Adult Males in Primary Care

Status:

Version 1

Abstract

2. Introduction

3. Aim and Objective

4. Literature Review

5. Methods

5.1 Ethics Statement

5.2 Procedure

5.3 Study Instruments

5.3.1 Proforma:

5.3.2 Hospital Anxiety and Depression Scale (HADS):

5.3.3 AUDIT-C:

5.3.4 International Index of Erectile Function (IIEF):

5.4 Sampling

5.5 Study Procedure

6. Data Analysis

7. Results and Discussion

8. Conclusion

Declarations

Author Contribution

Data Availability

References

Additional Declarations

Supplementary Files

Status:

Version 1