Sexuality plays a major role in individual quality of life and differences in sexual prioritization have a strong impact on overall relationship satisfaction [1]. In recent years, sexuality has become less of a taboo and women have become more self-confident regarding sexuality [2]. Partners are challenged to integrate individual and gender-related sexual differences to develop a satisfactory sexual relationship [3].

Recent studies have risen doubt on what has long been commonly believed to be true: do attitudes towards sexuality really differ between men and women? [4,5]. Various findings support gender differences: Men seem to appreciate especially the physical pleasure of sexuality [6], whilst for many women sexuality seems to be strongly linked to trust [7]. Intimacy is reported to be an important goal of sexual activity for women [8]. Commonly, men think more about sexuality in their daily life, rate regular sexual activities as more important than women and tend to overestimate their frequency of sexual intercourse [9,10]. They seem to have a higher motivational approach toward more than a dozen of different sexual activities, i.e., thinking about sex, engaging in sexual activities, wishing for a high number of intercourse partners, etc., than women [9]. Evaluation of same sex relationships supports differences of the sex drive between genders: Homosexual women report lower and homosexual men higher frequencies of sexual activities and numbers of sexual partners than heterosexual men and women [11,10].

However, men do not only think more about sexuality but also about other drives, for example about food and about relaxing [4]. In men and women sexuality is experienced highly individually and is influenced by general health, cultural background, one’s general and sexual past and situational factors associated with the quality of sexual activities, such as pleasure and intimacy [11,7]. Sexuality-related gender differences have also been hypothesized to be exaggerated by pressure to conform to gender norms [5]. Men are socialized to hold more open attitudes towards sexuality, whereas sexually expressive women often suffer social aversion. Such stereotypes may affect sexual values and support gender differences independent from biological differences [12].

Study results from romantic couples show a strong interaction between female and male sexuality: For both genders sexual satisfaction depends on the sexual desire of the romantic partner [13] and is highly variable [11,14]. Partners of women with female hypoactive sexual interest disorder more often experience erectile dysfunction and report lower levels of sexual satisfaction than those of women without sexual problems [13]. Disagreement between partners’ sexual preferences has a negative impact on sexual satisfaction [15,16] and discrepancies in sexual desire are one of the main conflicts between romantic partners [13]. The actual intercourse frequency in heterosexual couples is usually a compromise between the higher desired frequency of the male and the lower desired frequency of the female partner [8] and a frequent cause for conflicts in the relationship [6].

Differences in sexual perceptions may have a strong impact on overall relationship satisfaction the resulting quality of life. They also represent a valuable resource in sexual counselling. While there is growing literature on general differences between male and female sexuality, very few research projects have addressed how these differences are experienced in specific couples, i.e. how the general differences are translated to the individual level and potential discrepancies may interfere with a satisfying sexual relationship.

Therefore, it was the aim of the present study to better understand a couples’ perception of sexuality by evaluating and comparing the experience of partnership sexuality in both partners in a large study group of heterosexual couples. We (i) evaluated qualitative and quantitative aspects of sexuality on an individual level, then (ii) compared findings on a group and on a partner level and (iii) investigated each factor for its association with sexual satisfaction.

Study Design

The present evaluation is an analysis of data from women and their partners collected within a large multicenter study investigating quality of life in couples with and without a pain-related gynecological disease [17]. To get an insight on sexuality without the confounding influence of a pelvic pain disorder only couples without a diagnosis of the disease in the female partner were included in the present analysis.

Recruitment

All female participants were recruited during regular annual gynecological consultations or within stationary hospital stays for minor surgery at different university and district hospitals as well as private practices in Switzerland, Germany and Austria. Study participants were required to be at least 18 years old. Participants with severe diseases and diseases influencing sexual activity (i.e. endometriosis, malignant tumors, angina pectoris, history of stroke, inflammatory arthropathy, osteoporosis, HIV infection, or mental diseases) were excluded. Further exclusion criteria were a current pregnancy or linguistic limitations that might impair understanding the survey.

Participants were given all documents, including a separate return envelope for both partners. One questionnaire was handed to the partner to be completed individually. To maximize the return rate, they were reminded of completing and returning the questionnaire after one and three months. The return rate of female participants was 43.5% (614/1411) of which 302 (49.2%) questionnaires included answered questions by a male partner. Only couples with less than 10% of the answers on our outcome measures missing in both partners were included which resulted in 260 questionnaires from both partners for the present evaluation.

Questionnaire

Socio-epidemiologic data as well as 9 adapted questions from the Brief Index of Sexual Functioning and from the Global Sexual Functioning questionnaire were selected (see appendix). The BISF was developed to investigate sexual functioning and satisfaction in women, while the SHF is a tool to evaluate female and male sexual functioning [18]. Questions addressed different quantitative as well as qualitative aspects of sexuality in both partners and response options were designed as single choice Likert scales; other questions asked for absolute or relative frequencies as well as for the actual value of the variable. The male partner questionnaire included selected questions on socio-epidemiologic factors (see table 1), and the same questions on partnership and sexuality as answered by their female partner, resulting in a total of 33 questions.

Ethics

The study was performed in accordance with the principles stated in the Declaration of Helsinki and approved by the cantonal ethics commission in Zurich (KEK_StV-Nr. 05/2008), Switzerland and by the ethic boards of participating hospitals. All women and participating partners provided signed informed consent for study participation. The STROBE (Strengthening the reporting of observational studies in epidemiology) criteria were used to draft the manuscript [19].

Statistics

Mann Whitney test was used to compare multiple-choice answers. Students t test was used for interval-scaled answers. A p-value ≤ 0.05 was considered as statistically significant. All tests were two-sided. Statistical analysis was performed by using SPSS (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY).

Sociodemographic characteristics of the study group are presented in Table 1.

Figure 1 summarizes estimation of the own and the partners’ sexual satisfaction. Sexual satisfaction of male and female study participants was similar (p=0.051). Both men and women estimated their partner’s satisfaction significantly lower than him- or herself.

Table 2 shows responses of both partners regarding various quantitative and qualitative aspects of sexuality and the statistical comparison of both groups as a total.

Figure 2 gives an overview on differences between answers within individual couples. More than 50% of male and female partners rated their sexual satisfaction equally high, in another 37% ratings were only one category apart from each other. The importance of sex in general was higher for men (p<0.001), however, over 90% of couples gave almost the same answer (max. one answering category apart). Only 20% of couples experienced an equal level of sexual desire.

No statistical differences were found regarding the reported length of foreplay (p=0.878) and intercourse, defined as time from first penile penetration of the vagina until male orgasm (p=0.813).

Most men and women reported foreplay to last either 2-10 minutes (43.4% of men vs 45.1% of women) or 11 – 20 minutes (39.1% of men vs 41.2% of women). Only 2.3% of men and 1.2% of women reported it to last longer than 30 minutes. Regarding sexual intercourse a majority reported it to last 5-10 minutes (49.2% of men vs 50.8% of women). A total of 22.5% of both genders reported it to last 1 – 4 minutes and 11.7% of men vs 8.8% of women 11 - 15 minutes. A minority reported it to last longer or shorter.

Note: Given are all answer possibilities with percentage. P-value corresponds to differences in answers between women and men and is the result of Mann Whitney test, bold answers represent the median.

In our sample overall sexual satisfaction was high, also in comparison with literature [20-22]. More than two third of both men and women reported to be sexually (very) satisfied. Our recruitment in countries with a high level of sexual self-determination of women will likely have improved female sexual satisfaction. Also, men and women agreeing to support a study as a couple have a higher probability for a well-functioning relationship, which will probably show an association with the quality of the sexual relationship. As discrepancies tend to be stronger in couples facing sexual difficulties, it is particularly interesting to learn about discrepancies in the perception of partnership sexuality in this low-risk group.

The perception of objective facts such as intercourse and foreplay length was similar in men and women and congruent with literature [23]. This contradicts findings that men generally overestimate the length of sexual intercourse or exaggerate their sexual performance [10].

Our data confirms a variety of sexual differences between men and women: Only few of the investigated couples (20%) reported identical levels of sexual desire. General sexual desire was higher in the male group, which is in accordance with literature [9]. However, reported and experienced levels of sexual desire may differ in men, as sexual drive is perceived as a feature of masculinity[14,24]. Furthermore, more than 90% of couples gave almost identical values regarding sexual desire. Therefore, the statistical significance results from few couples with stronger differences (Figure 2).

In our study men were less satisfied with the quantity of sexual activities and significantly more men desired a higher frequency of sexual activities (Table 2). Generally, conditions for sexual desire and quality of sexual contacts in women are complex [25,9]. Sexual cues inducing desire are reported to be less direct and more trust-dependent in women [25,8] and may eventually not be provided by male partners. While most women appreciate situational stimulants to change from a neutral position to sexual desire, sexual desire in men more often occurs spontaneously [25,9]. Visual cues, which represent one of the most important triggers for sexual desire in men [25], do classically have a weaker effect in women. Nevertheless, overall sexual satisfaction was very similar in both genders (Figure 1, 2) and more than 90% of couples reported almost the same answer regarding the general importance of sexuality. Therefore, motivation to aim for a fulfilling sexual relationship is high and most romantic couples seem to find successful strategies to overcome gender differences.

Men enjoyed sexual activities significantly more often than their partner, which also explains why sexual desire might be lower in women. Consequently, increasing sexual pleasure in women represents a valuable resource to improve sexuality for both partners. Interestingly, the reaction to sexuality-related diseases also supports that male sexual pleasure is more robust than that of women: Erectile dysfunction is associated with a decrease of the female partner’s sexual desire [26] whereas endometriosis - a chronic gynaecological disease causing dyspareunia - shows no association with a decrease in sexual desire of the male partner [17].

Estimation of Sexual Satisfaction of Partner

Interestingly, both men and women strongly underestimated the real sexual satisfaction of their partner (Figure 1). This might be explained by an unrealistic image of sexual activity in society, false expectations regarding sexual activities and fear to sexually disappoint a partner: Media, erotic literature and pornographic films present intercourse lengths (time from first penile penetration to ejaculation) far beyond 7 minutes [27,28]. However, in our study more than half of the participants of both genders reported intercourse to last less than 7 minutes. Although sex therapists consider an intercourse length of 7 minutes as less than desirable, it seems to be a typical duration of intercourse [23]. Presentations or descriptions of unrealistic body images, impressive physical performance and creative variations of sexual activity likely add to false assumptions and psychosexual burden when it comes to everyday partner sexuality [27,28]. False assumptions likely have a greater impact on estimating the partner’s satisfaction on one’s own sexual satisfaction, as they are more amenable to correction here. Most couples in our study report very similar estimations of sexual satisfaction and importance of sexuality. However, literature usually focuses more on differences than similarities [5]. Anticipated gender roles such as men being more centred on intercourse, women giving a higher importance to foreplay, etc [29]. Might reflect another reason for the misjudgement. Our data confirms gender differences regarding sexuality, but they were not associated with reduced sexual satisfaction. According to Miller and Byers [30], women underestimate their partner’s desired duration of foreplay and both genders wish foreplay to last longer, which is in contrast to male sexuality being focussed on “intercourse only”. In agreement with our findings, several studies underline the importance of qualitative aspects of sexuality [31], which so far only showed limited effects [29]. So, gender differences might be over-exaggerated and lead to false assumptions, which hamper fulfilling sexual relationships. Our findings clearly support the previously reported importance of quantitative aspects of sexuality for men [6], however, do not object to a high relevance of qualitative aspects at the same time. Underestimation of the partner’s sexual satisfaction and false assumptions could easily be corrected by enhancing the communicative abilities in the couple, a classical element in sexual counselling, which is well-known for its relevance in sexual disorders [21].

Strengths and Limitations

The present evaluation is one of very few research projects comparing data on a general and on an individual level of partners of a couple in a large study group coming from a broad educational background [10]. To the best of our knowledge, this is the only study in which couples rated their own sexual satisfaction as well as the anticipated sexual satisfaction of the partner. The main reason for exclusion from study participation were incomplete answers on sexuality, with discomfort with the intimate nature of the questions being given as the main reason, which might have caused selection bias. Our study sample consisted mostly of German speaking people, i.e. did not include ethnic minorities. As attitudes towards sexuality and sexual behaviour strongly depend on cultural background, the generalizability of our results is consequently limited, also as study participants were recruited in countries with a high level of female sexual self-determination. Our evaluation focused on heterosexual couples and can therefore not be extrapolated to same sex couples.

Gender differences, especially regarding sexual desire, the frequency of desired sexual contacts and enjoyment of sexual contacts were confirmed by our study. However, on the background that sexual activity was equally important for men and women, individual couples dealt successfully with such differences so that sexual satisfaction was equally high in both partners. An orientation towards misconceptions of gender differences and unrealistic sexual scripts could be responsible for underestimation of one’s partner’s sexual satisfaction. Knowledge of the underestimation of the partner’s sexual satisfaction represents a valuable resource to reduce sexual stress, which is easily accessible by communicating on sexual needs either in private or supported by a sexual counsellor. Improving sexual pleasure in women will likely help to increase their sexual desire and interest in a higher frequency of sexual contacts.

Acknowledgements: We thank all study participants for supporting our research.

Funding: We did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of interest statement: The authors report there are no competing interests to declare.

Data availability statement: Data are available from the authors on reasonable request.

Authors’ contributions: The first and the last author contributed to the study conception and design. Material preparateion, data collection, data entry and analysis were performed by SH, AN, and BL. The first draft of the manuscript was written by SH and all authors participated in finalization of the manuscript.