Attitudes of Men with Erectile Dysfunction: A Cross-National Survey

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1 Blackwell Science, LtdOxford, UKJSMJournal of Sexual Medicine Journal of Sexual Medicine Original ArticleAttitudes of Men with ED: A Cross-National SurveyPerelman et al. 397 Attitudes of Men with Erectile Dysfunction: A Cross-National Survey Michael Perelman, PhD,* Ridwan Shabsigh, MD, Allen Seftel, MD, Stanley Althof, PhD, and Dan Lockhart, PhD *Weill Medical College of Cornell University Psychiatry, Reproductive Medicine, & Urology; Department of Urology, Columbia University, New York, NY; Case Western Reserve University Department of Urology; Case Western Reserve University School of Medicine, Cleveland, OH; Eli Lilly and Company, Indianapolis, IN, USA Corresponding Author: Michael A. Perelman, PhD, Psychiatry, Reproductive Medicine and Urology, The New York Presbyterian Hospital, Weill Medical College of Cornell University, 70 East 77 th Street, Suite 1C, New York, NY 10021, USA. Tel: (212) ; Fax: (212) ; perelman@earthlink.net ABSTRACT Introduction. Erectile dysfunction (ED), the inability to achieve or maintain an erection sufficient for sexual performance, is a complex disorder involving multiple biopsychosocial factors. Aim. To better understand the psychological and behavioral aspects of ED and compare the attitudes of ED patients in different countries. Methods. The Cross-National Survey on Male Health Issues surveyed men aged years in six countries. Participants completed questionnaires on attitudes, behavior, doctor-related issues, and comorbidities. Main Outcome Measure. Men rated their attitudes using a scale of 1 (strongly disagree) to 5 (strongly agree). Responses of somewhat agree and strongly agree were combined and the percentage calculated for each country and overall. A mean score for all responses (1 5) was calculated for each country. Results. Attitudes held by men with ED overlap significantly when compared between countries. Men in all countries agreed that ED was a source of great sadness for themselves and their partners, and nearly all disagreed with the idea that they were too old for sex. Men in all countries agreed that it was important to know they had the capacity to perform sexually, and half of all men reported they would do nearly anything to cure their ED. Men in all countries also agreed that their doctor was the best source of information on sexual issues. Men in the United States and the United Kingdom were less willing to accept ED, more motivated to find a cure, and less likely to consider ED a result of psychological problems. Conclusions. Attitudes of men with ED overlap significantly when compared between countries, but interesting differences were seen. Additional research is needed to understand how attitudes and behaviors reported reflect actual experiences. This study highlights some of the barriers that exist between physician patient communication surrounding identification and treatment of ED. Key Words. Erectile Dysfunction; Sex Coaching; Male Attitudes; Cultural Differences Introduction A s defined by a National Institutes of Health consensus panel, erectile dysfunction (ED) is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance [1]. Estimates of the prevalence of ED vary widely, from 11% in a study in the Netherlands [2] to a range of 24.1% [3] to 52% [4] in the United States. This large variation in prevalence rates may

2 398 Perelman et al. reflect differences in study methodology, definitions and perceptions of ED, age of participants, and comorbid medical conditions. The Massachusetts Male Aging Study reported that ED is highly correlated with age, and independent of age, is also associated with heart disease, diabetes, and hypertension [4]. Other risk factors include lower urinary tract symptoms [5], some medications, obesity, alcohol use, and tobacco use [6]. With the advent of oral therapy for ED, public awareness of this condition has increased, and the social stigma has decreased [7]. However, only about 30% of men with ED seek professional help [8], and as few as 11% actually receive treatment [9]. The Cross-National Survey on Male Health Issues (Cross-National Survey) was undertaken to help physicians better understand the psychological and behavioral aspects of ED. Its objective was to describe and compare the attitudes and behaviors of men with ED in six countries. The study focused on men currently using the health care system. Earlier analysis of men in this cross-national survey found that most men with ED did not seek treatment. Furthermore, the data showed that a desire for sex was typically necessary before men sought treatment, and that younger men were least likely to seek treatment [10]. This report focuses on the Cross-National Survey s findings on the attitudes of men with ED, including how those attitudes affect their feelings about themselves, their partners, their treatment-seeking behaviors, and their treatment compliance. In the clinical setting, physicians must consider all potential physical factors and must also attend to relevant psychosocial factors [11,12]. A thorough understanding of patients attitudes can help the physician provide better treatment. Understanding these issues and how they are perceived can help the physician place the individual patient s concerns in perspective, and the physician is then able to provide appropriate support and reassurance. This support also requires that the physician demonstrate an appropriate sensitivity to issues that vary across different nationalities and cultures. Additionally, by putting the patient at ease, the physician will find it easier to uncover any patient comorbidities. Integrating the understanding of psychosocial issues with prescription of appropriate pharmaceuticals to treat ED is key to comprehensive treatment [11,13]. Methods Study Methodology and Demographics The Cross-National Survey on Male Health Issues recruited male participants in several regions of the United States, Germany, the United Kingdom, France, Italy, and Spain. The survey, conducted in 2000, was carried out in accordance with the codes of conduct of the Council of American Survey Research Organizations and the European Society of Opinion and Marketing Research. A detailed discussion of the methods and patient recruitment has been published [10]. A brief description is presented here. In stage 1, a screening questionnaire designed so that participants did not know that ED was the focus of the survey was given to men in their physicians offices. The ED status of the men was determined by the response to the item, Difficulty Getting or Keeping an Erection. The possible responses were (i) never had it; (ii) had it before, but not now; (iii) have it now sometimes; and (iv) have it now always. Those who chose response number 1 were not evaluated further. Those who chose response number 2 were classified as former ED sufferers, and those who chose response numbers 3 or 4 were classified as current ED sufferers. Follow-Up Questionnaire Responses In stage 2, former and current ED sufferers were asked to complete a follow-up questionnaire that focused on attitudes toward ED, behavior relating to the disorder, doctor-related issues, treatment seeking, and comorbidities. A total of 3,093 men who were current or former ED sufferers completed this follow-up questionnaire. The men ranged in age from 20 to 75 years (mean 57 years); 47% were employed at least part-time, 43% were retired, and the rest were either unemployed or students; 77% were either married or living with a partner, and 9% were single and never married; 34% had only a primary education, while the rest had secondary and postsecondary education. Detailed sample demographics are available elsewhere [10]. Of the original questionnaires that were completed, 2,829 questionnaires (91.5%) qualified for evaluation (more than 50% of questions answered): 866 from the United States, 417 from France, 394 from Germany, 381 from Italy, 380 from Spain, and 391 from the United Kingdom. The lower number of completed questionnaires seen in some countries reflected recruitment

3 Attitudes of Men with ED: A Cross-National Survey 399 Table 1 Overall attitudes and behaviors (% who somewhat or strongly agree) Category United States France Germany Italy Spain United Kingdom A. Attitudes about ED 1. The erection problem is a source of great sadness for me. 2. I m too old for sex Hardly a day goes by that I do not think about this problem B. Attitudes about treatment C. Attitudes about sexual activity and partner D. Speaking to doctor/ other 4. I think that the erection problem is more psychological than physical. 1. It s not so much that I want more sex, it s that I want to know that I could do it if I wanted. 2. I would give almost anything to be able to cure my erection problem. 3. When you have this sort of problem, you must learn to accept it. 4. I don t want to take drugs for this condition. 5. The erection problem is a source of great sadness for my partner. 1. If I had a different partner the problem might go away. 2. There are other ways to get sexual gratification that do not require a good erection. 3. My sex partner and I are able to work around the erection problem Weighted mean* 1. To speak face to face with someone about erections is impossible for me. 2. Embarrassed to talk about it * The weighted mean was calculated by averaging the country averages presented for each item, taking into account the number of responses received for each country. No significant differences were found between the weighted mean and the mean, calculated by averaging all of the somewhat agree and strongly agree responses, disregarding the country of origin. ED = erectile dysfunction. differences and issues. Questions are listed in Table 1. Respondents could choose responses ranging from (1) strongly disagree to (5) strongly agree. Analyses Men who visited doctors offices more often were more likely to be recruited into the study and therefore may be more likely to seek treatment for ED. To adjust for this potential selection bias, the survey results were weighted to take into account how often participants consulted physicians; each participant s data were weighted as the reciprocal of the number of visits to the doctor in the past year. However, this weighting did not significantly affect results. To assess responses to the overall attitude and behavior items (Table 1) and the doctor-related items (Table 2), the responses somewhat agree and strongly agree were combined, and the percentage of respondents who agreed with those statements was calculated for each country. An overall mean was also calculated for each question. For the analyses that compared attitudes across countries (Figures 1 5), scores for all answers were included (from strongly disagree to strongly agree ), and mean scores were calculated for each country. All analyses were conducted by using Statistical Package for the Social Sciences (SPSS) Results Overall Attitudes and Behaviors A summary of the participants attitudes and behaviors about ED is presented in Table 1. Responses were divided into four categories: attitudes about (a) ED, (b) treatment, (c) sexual activity and partner, and (d) speaking to a physician. The percentages listed under each country represent those who said they either somewhat agree or strongly agree with the statement (Table 1).

4 400 Perelman et al. Table 2 Doctor issues (% who somewhat or strongly agree) United States France Germany Italy Spain My most useful source of information is conversation with doctor My doctor knows what is best for me I feel comfortable disagreeing with my doctor about treatment and medications he or she suggests for me. I don t feel comfortable talking to my doctor about my erection problem I think my doctor is uncomfortable talking about problems with erections United Kingdom Figure 1 Mean values indicate that men agreed that the erection problem is a great source of sadness in their lives. (See Methods for details.) Figure 2 Mean values indicate that when asked if they were too old for sex, men showed a general disagreement. (See Methods for details.)

5 Attitudes of Men with ED: A Cross-National Survey 401 Figure 3 Mean values indicate that men agreed they would like to know that they have the capacity for sexual performance, regardless if they have sex more frequently. (See Methods for details.) Summary of Attitudes Category A. Attitudes about ED Overall, almost 55% of men agreed with the statement, The erection problem is a source of great sadness for me. A comparison of the averaged responses among countries showed that men in the United Kingdom had the highest level of agreement with this statement, while men in Germany were neutral about whether ED caused them sadness (Figure 1). Only 9% of men agreed they were too old for sex, ranging from 5% in Spain to 15% in France (Table 1). On average, men in all countries somewhat to strongly disagreed with the notion that they were too old for sex (Figure 2). Despite the general agreement across countries on the two previous responses regarding ED as a source of sadness and being too old for sex, men in France, Italy, and Spain were about twice as likely as men in the United States or the United Kingdom to agree that the erection problem is more psychological than physical (Table 1). The number of men who thought about their ED on a daily basis also differed from country to country, with German men being least likely to think about it (Table 1). Category B. Attitudes about Treatment About half (49.3%) of the men surveyed agreed they would give almost anything to cure their Figure 4 Mean values indicate that men believed that the erection problem is a source of great concern and sadness for their sex partners. (See Methods for details.)

6 402 Perelman et al. Figure 5 Mean values show that men disagreed with the assumption that the erection problem would disappear if they were to have sex with a different partner. (See Methods for details.) ED, while about the same number (47.2%) agreed they must learn to accept it (Table 1). Among men who did not seek treatment for ED, about one-quarter (26.3%) said one reason they did not seek treatment was that they did not want to take drugs for ED. Nearly three-quarters of all men (71.8%) agreed that they didn t necessarily want to have more sex, but they did want to know that they could do so if they wanted. On average, men in all countries agreed it was important for them to know they had the capacity to perform sexually (Figure 3); men in Spain agreed with this statement more often than in all other countries. Men across countries disagreed about how important it was to find a cure for ED or whether they should just accept the condition. Men in the United Kingdom, the United States, and Spain felt more strongly about curing their ED (average score = 3.5) than did men in Italy, France, and Germany (2.9). Men in the United States and the United Kingdom were also less likely to be accepting of ED (2.7 score for you must learn to accept it ) compared with men in other countries (3.3). In addition, men in the United States and the United Kingdom were more likely to accept taking a pill to cure ED, while men in France were the least likely to do so (Table 1). Category C. Attitudes about Sexual Activity and Partner More than half (52.8%) of all men surveyed believed that ED is a source of great sadness (average score = 3.3) for their partners (Figure 4). In all countries, fewer than half (41.7%) of the participants agreed that they were aware of other ways to get sexual gratification that do not require a good erection, and only half reported that they were able to work around the erection problem with their partners (Table 1). Only a small percentage of men (21.7%) felt that their partner was somehow associated with their ED and that it might not occur with a different partner. However, men in Germany and Spain were neutral on this subject. On average, most men disagreed with the idea that their ED would go away if they had a different sex partner (Figure 5). But men in Italy and Spain were more likely to blame their partner than were men in other countries (Table 1). In Italy, 32% of men with ED and 30% of those in Spain agreed that their ED would not be a problem if they had a different partner. Category D. Speaking to Doctor/Other Overall, one-third of all men agreed that speaking to someone face to face about erections was impossible (Table 1). Responses to this item ranged from 23% agreement in the United States to 47% in France. Such embarrassment in talking about erections was identified by 30% of the men who had not sought treatment as one of their reasons for not doing so [10]. The majority of men in all countries agreed that a conversation with their doctor was the most useful source of information on erection problems

7 Attitudes of Men with ED: A Cross-National Survey 403 (Table 2). Men in France were most likely to agree. Men in France and Spain were also much more likely to agree with the statement, My doctor knows what is best for me. Men in the United Kingdom reported being much less comfortable than other men in disagreeing with their doctor about treatments and medications. In all countries, men were willing to talk with their doctors about ED; fewer than 43% of all men agreed that they do not feel comfortable talking with their doctors about ED, and only 9 35% said they think their doctors are uncomfortable talking about erection problems. Interestingly, men in Spain were more than twice as likely (35%) as men in all other countries to think that their doctor might be uncomfortable discussing sexual issues. Men in the United States (2.4) and Spain (2.5) appeared less embarrassed about the prospect of discussing their ED problem face to face with someone, while men in France were most likely to agree that to speak face to face with someone about erections is impossible for me (3.1). Discussion Attitudes held by men with ED overlap significantly when compared between countries. Men in all countries agreed that ED was a source of great sadness for themselves and their partners, and nearly all disagreed with the idea that they were too old for sex. Men in all countries agreed that it was important to know they had the capacity to perform sexually, and half of all men reported they would do nearly anything to cure their ED. Men in all countries also agreed that their doctor was the best source of information on sexual issues. Similarities and Differences among Countries In this study, men in the United Kingdom and France agreed more often than others that ED was a source of great sadness for themselves and their partners. Those in the United States and the United Kingdom seemed to be less willing to accept their ED, more motivated to find a cure, and less likely to consider ED a psychological problem, rather than a physical one. Subjects in the United States and Spain were the least embarrassed to discuss ED face to face. Compared with others, German men tended to not think about ED daily. Participants in the United States and the United Kingdom were more likely than others to accept taking a pill for ED. Those in France and Spain were two to three times more likely to agree that they didn t want to take drugs for ED as those in the United States and the United Kingdom. Moreover, French and Spanish men were more likely to believe they had to just accept ED. Similarly to our results, Giuliano et al. s study of 1,004 French men with ED aged 40 years noted that 44% of the men said they do not wish to consult a doctor for treatment, and tended to be resigned to their condition [14]. Fisher et al. s multinational study of 2,912 men with ED reported that men were unlikely to seek treatment for their ED if they believed that ED medications were dangerous. In addition, these men were unlikely to seek treatment for ED if they believed that their ED was simply due to stress or the need for a healthier lifestyle [15]. Low et al. s study on ED found that Malaysian and Chinese men tended to hold their wives responsible for their ED and were also concerned that their ED might lead to their spouses having extra-marital affairs. In addition, Indian men considered their ED to be fated. All three groups preferred discussions on sexual issues to be initiated by their physicians [16]. Clearly, a number of diverse cross-national and cultural studies reflect some common similar and different variations in attitudes toward illness and treatment in general. Some attitudinal differences may be secondary to differences among sample groups. For example, men in the United States who participated in our survey were more educated and had higher incomes than men from other countries. The United States is also the only country that allows direct advertising of pharmaceutical drugs to consumers, resulting in the potential frequent exposure of some U.S. study participants to advertising of ED drugs, which could certainly impact an individual s willingness to try a treatment. Additionally, exposure to advertising probably reduces the stigma associated with ED, increasing desire to seek a cure, and reducing embarrassment in discussing ED. Although attitudes and behaviors identified through surveys may not exactly reflect actual attitudes and behaviors, physicians still need to consider how these issues might be manifested in their patients. Noncoital Gratification As our study results indicate, most men typically have little or no interest in alternative ways to get sexual gratification. Only 41% of the men in our survey agreed that there are ways to get satisfaction that do not require a good erection, and only

8 404 Perelman et al. 50% of the men reported that they and their partners are able to work around the problem. Behaviorally and physiologically, men can satisfy their partners in different ways (such as manually or orally) as a viable sexual alternative. Yet it seems that many choose to ignore this avenue. A recent study by the American Association of Retired Persons found that men are about eight times more likely than women to engage in selfstimulation, and only about 5 6% of both men and women routinely engage in oral sex as an alternative form of sexual release [17]. Historically, men have reported higher rates of masturbation than women across age groups [18]. The avoidance of partnered noncoital activity may be an attempt to avoid a repetitive explicit acknowledgment of the ED and the limitations it may impose on sexual expression, an issue that has its roots in shame and embarrassment. Patient Embarrassment Embarrassment is an issue of concern for many patients. A 1999 poll of U.S. adults [19] found that 68% were somewhat or very concerned that their doctors would be embarrassed to talk about sexual problems, and 71% feared the doctor would dismiss their concerns. In contrast, only 9 35% of the men in our survey believe their doctor might be uncomfortable talking about erection problems, and only 25 42% said they are not comfortable talking with their doctors about sexual issues. These differences might be partly a result of the men in the Cross-National Survey being recruited primarily from doctors waiting rooms. These men are already using the health care system, may be more comfortable interacting with their physicians, and have more contact with them, compared with a community sample [19]. Taken together, however, the 1999 poll and the Cross-National Survey do illustrate that a significant number of patients remain embarrassed to talk with their doctors about sexual problems, and that many also believe their doctors are embarrassed to do so. However, both studies also illustrate that patients see their physicians as a good source of information on sexual issues. To ensure the best possible care, it is the doctor s responsibility to help patients overcome embarrassment; this means that the doctor must try to raise the subject in a sensitive manner. Sex Coaching and Combination Treatment The results from this Cross-National Survey illustrate how important it is for the physician to evaluate not just the physical aspects of ED, but also the psychosocial and contextual aspects. The physician who makes the effort to help the patient overcome embarrassment and who understands the roles of psychological, behavioral, and partner issues will provide better treatment. This may be difficult to accomplish for patients with numerous comorbidities (diabetes, etc.), i.e., situations in which a physician must prioritize and manage within the time constraints of a particular type of practice. Raising these issues with the patient and discussing them in an open, nonjudgmental manner is the first step, in combination treatment, in which sex therapy techniques and other psychosocial educational processes are folded into the treatment plan. The authors believe that a combination treatment integrating pharmaceuticals and sex coaching to treat ED will result in better patient compliance and more effective treatment [11,12,20]. One option for opening discussion is the ALLOW algorithm [21], which may help primary care clinicians deal with sexual problems. The ALLOW steps are as follows: (i) Ask the patient about his or her sexual function; (ii) Legitimize any issues the patient raises and reassure the patient that sexual issues are a valid clinical concern; (iii) recognize your own Limitations, such as personal discomfort or lack of resources; (iv) Open up the issue for discussion, with the option of referral to another health professional; and (v) Work with the patient to develop a treatment plan. The physician can use a sex status exam [11] to focus history taking with a simple request, Tell me about your last sexual experience. This often leads the patient to reveal immediate causes of ED, such as insufficient stimulation or partner issues. If discussion indicates that deeper psychological issues, such as sexual trauma or abuse, seem to be a cause of a patient s ED, the physician may then refer the patient to a mental health professional for collateral treatment. Sex coaching is most effective for men who desire treatment for their ED but who have unforeseen psychosocial barriers; additionally, some men s reluctance to take a pill for ED (as shown by this survey), may also benefit from combination treatment. Effective sex coaching can help the physician and the patient to identify the psychosocial issues that might be affecting the patient s ability to obtain or maintain an erection. If the patient is resistant to taking a drug to treat his ED, he may be assured that as these psychoso-

9 Attitudes of Men with ED: A Cross-National Survey 405 cial issues are resolved, he might require less medication and eventually the drug may be tapered off completely. This approach may help reduce the patient s reluctance to take medication and has the added benefit of allowing the doctor to demonstrate sensitivity to the patient s cultural or personal preferences, thereby enhancing rapport with the patient. Having a better understanding of the attitudes of men with ED will help the physician put each patient s attitude into proper context, allowing the physician to recognize when a sex coaching approach may work or when a referral is required. Recognizing attitudes that might impede treatment seeking or compliance will help the physician accommodate a patient s personal preference and is likely to improve patient satisfaction and quality of life (QOL). The importance of QOL considerations to patients and their partners being treated for ED is well documented [22 24]. Additional Research and Education Additional research is needed to explore to what degree the attitudes and behaviors reported by men with ED reflect their actual experiences. In particular, studies need to focus on how attitudes affect men s level of ED-related distress. Qualitative research on such issues could facilitate a progressively deeper understanding of these belief systems and attitudes, leading to more focused educational efforts and better intervention. Conclusion The Cross-National Survey demonstrates that while differences exist among men from various countries, there is a significant overlap in concerns about sexual health. ED is a great source of sadness to both the patient and his partner, and most men do look to their physicians for help in this area. To provide optimal care, physicians need to understand the psychological issues that can affect men with ED and use that knowledge to work with patients in a direct, yet compassionate, manner. Physicians should help men understand that sexual issues are a valid clinical concern, and should be empowered to realize their own capacity for restoring their patients health. References 1 National Institutes of Health. Impotence: NIH Consensus Statement. 1992;10:1 31. Available at: pdf. Accessed October 3, Blanker MH, Bohnen AM, Frans PMS, Groeneveld FP, Bernsen RM, Prins A, Thomas S, Bosch JL. Correlates for erectile and ejaculatory dysfunction in older Dutch men: A community-based study. J Am Geriatr Soc 2001;49: Bacon CG, Hu FB, Giovannucci E, Glasser DB, Mittleman MA, Rimm EB. Association of type and duration of diabetes with erectile dysfunction in a large cohort of men. Diabetes Care 2002;25: Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: Results of the Massachusetts Male Aging Study. J Urol 1994;151: Rosen R, Altwein J, Boyle P, Kirby RS, Lukacs B, Meuleman E, O Leary MP, Puppo P, Robertson C, Giuliano F. Lower urinary tract symptoms and male sexual dysfunction: The Multinational Survey of the Aging Male (MSAM-7). Eur Urol 2003;44: Nusbaum MRH. Erectile dysfunction: Prevalence, etiology, and major risk factors. J Am Osteopath Assoc 2002;102(4 suppl):s Tiefer L, Schuetz-Mueller D. Psychological issues in diagnosis and treatment of erectile disorders. Impotence 1995;22: Kubin M, Wagner G, Fugl-Meyer AR. Epidemiology of erectile dysfunction. Int J Impot Res 2003;15: Chew KK, Earle CM, Stuckey BGA, Jamrozik K, Keogh EJ. Erectile dysfunction in general medicine practice: Prevalence and clinical correlates. Int J Impot Res 2000;12: Shabsigh R, Perelman MA, Laumann EO, Lockhart DC. Drivers and barriers to seeking treatment for erectile dysfunction: A comparison of six countries. BJU Int 2004;94: Perelman MA. Sex coaching for physicians: Combination treatment for patient and partner. Int J Impot Res 2003;15(5 suppl):s Althof SE. Therapeutic weaving: The integration of treatment techniques. In: Levine SB, editor. Handbook of clinical sexuality. New York, NY: Brunner- Routledge; 2003: Althof SE. When an erection alone is not enough: Biopsychosocial obstacles to lovemaking. Int J Impot Res 2002;114(1 suppl):s Giuliano F, Chevret-Measson M, Tsatsaris A, Reitz C, Murino M, Thonneau P. Prevalence of erectile dysfunction in France: Results of an epidemiological survey of a representative sample of 1,004 men. Eur Urol 2002;42: Fisher WA, Rosen RC, Eardley I, Niederberger C, Nadel A, Kaufman J, Sand M. The Multinational Men s attitudes to Life Events and Sexuality (MALES) Study phase II: Understanding PDE5 inhibitor treatment seeking patterns, among men

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