Perceptions and opinions of men and women on a man s sexual confidence and its relationship to ED: results of the European Sexual Confidence Survey

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1 International Journal of Impotence Research (2012) All rights reserved /12 ORIGINAL ARTICLE Perceptions and opinions of men and women on a man s sexual confidence and its relationship to ED: results of the European Sexual Confidence Survey C San Martín 1, C Simonelli 2, J Sønksen 3, G Schnetzler 4 and S Patel 5 The European Sexual Confidence Survey examined the opinions of men and women on the link between a man s sexual confidence and functional (erectile and orgasmic) and emotional (satisfaction and self-confidence) aspects of sex and life in general. The online survey of sexually active adults ( years of age) was conducted in 12 European countries using multiple-choice questions and predefined statements on sexual confidence. Erectile function was assessed by erection hardness score (EHS). Of 8576 respondents (4246 men, 4330 women), 23.9% reported non-optimal erectile hardness (EHSp3) for themselves or their partners. 79.0% believed that an ability to sexually satisfy their partner is most closely linked to a man s sexual confidence. One in three linked a man s sexual confidence to erection hardness and ability to reach orgasm. The majority (B94.0%) believed that it is important for a man to be sexually confident for good sex and that being able to have good sex enables men to have greater satisfaction with life overall. Lack of sexual confidence due to insufficient erection rigidity was considered by most respondents (B65.0%) to reduce a man s confidence about the next sexual encounter and also his self-confidence and self-esteem overall. International Journal of Impotence Research advance online publication, 21 June 2012; doi: /ijir Keywords: erectile dysfunction; erection hardness; health surveys; quality of life; sexual confidence; sexual satisfaction INTRODUCTION Little data are available regarding the opinions of the general population on the link between a man s erectile function and his sexual confidence, and impact on quality of life (QoL). ED, the consistent inability to attain and maintain an erection sufficient for satisfactory sexual performance, 1 occurs to some degree in % of men aged 440 years ED negatively impacts QoL, self-esteem and the ability to maintain intimate relationships, which can be improved with phosphodiesterase 5 inhibitor treatment Effective treatment also has a positive impact on QoL in the female partners of men with ED To understand the relationship between ED and QoL, several validated patientreported outcomes questionnaires have been developed that capture the degree of erectile function, its psychosocial impact and response to treatment Erection hardness has been identified as a core parameter and determinant for erectile function, psychosocial measures and satisfaction with medical treatment. 17 Furthermore, there are strong correlations between erection hardness, measured by the erection hardness score (EHS), and other patient-reported outcomes questionnaires. 18 In the Global Better Sex Survey, involving more than participants, 95% of men and 88% of women reported that achieving and maintaining an erection was important for good sexual experiences. Furthermore, 90% of women and 91% of men believed that a man s sexual confidence is critical to having a good love relationship. This study also demonstrated an association between satisfaction with erection hardness and satisfaction with sex life, love and romance, and surprisingly, overall health. 19 The European Sexual Confidence Survey examined the factors that the general population associate with a man s sexual confidence. Survey questions were developed to investigate the perceptions and opinions of men and women on the influence that erectile function has on a man s sexual confidence, and the relationship between functional (erectile and orgasmic) and emotional (satisfaction and self-confidence) aspects of sex. The survey also evaluated the participants views on what was important for a good sexual experience, their perception of erectile function in general, and how a lack of sexual confidence, through insufficient erection hardness, may impact on a man s overall QoL. MATERIALS AND METHODS Study design The European Sexual Confidence Survey was a population-based observational study comprising an online survey of sexually active adults conducted between August and September 2009 in 12 European countries. Study participants Participants were recruited from existing online consumer opinion research panels by Double Helix Inc. and invited by to participate in an anonymous survey exploring their opinion on sexual health aspects. Participants were years old and had experienced X1 sexual encounter with another person in the last year. Male and female participants were not partners. Respondents working in market research, 1 CIPSA Institute of Psychology & Sexology Sciences, Santander, Cantabria, Spain; 2 Faculty of Medicine and Psychology, Sapienza University, Rome, Italy; 3 Department of Urology, Herlev Hospital, Herlev, Denmark; 4 Prism Ideas Ltd, Basel, Switzerland and 5 Pfizer Ltd, Walton Oaks, UK. Correspondence: Dr C San Martín, CIPSA Institute Psychology & Sexology Sciences, C/de Emilio Pino, 6, Santander, Cantabria 39002, Spain. cipsa@cipsaonline.com Parts of the study have been presented at the 12th Congress of the European Society for Sexual Medicine, November 2009, Lyon, France (Abstract PO ). Received 14 September 2011; revised 24 February 2012; accepted 11 May 2012

2 Perception of sexual confidence: a European survey 2 advertising, or the healthcare industry were excluded from the survey. Participants completed a screening questionnaire and the main survey. Quotas on the number of participants of each gender, age group, incountry geographical distribution and socio-economic status group ensured that survey participants were representative of the general population in each country. The study closed when a target quota of 500 eligible subjects (1000 in the UK, France, Germany, Italy and Spain) per country with complete questionnaires was reached (incomplete questionnaires were not accepted by the online system). This survey followed the standards of the International Code on Market and Social Research 20 as well as local law and regulations. Participation was voluntary, data were anonymised and participants could refuse to answer questions. All subjects provided informed consent before participation and were offered a minimal monetary incentive upon completion. Questionnaire Questions addressed perceptions and opinions on the relationship between a man s sexual confidence and his erectile function. Based on the known link between erectile function and psychosocial parameters (including sexual confidence) in men with ED 5,6,18,21,22 and the impact on their partners, questions were developed to examine how men and their partners perceive sexual confidence. The questions also evaluated the number of men experiencing sub-optimal erections, their erection aspirations and the importance of a man s sexual confidence on their overall well-being. Questions were developed by the study sponsor in collaboration with an expert panel, including specialists in opinion-based population research. The main question explored possible associations between a man s sexual confidence and sexual satisfaction, erectile and orgasmic function and examples of self-confidence using lay person s terms. Four questions explored associations between good sexual experiences and sexual confidence, erectile function and impact on satisfaction with life, as well as the impact that a man s lack of sexual confidence due to insufficient erectile function might have on his life. One question explored the general population s understanding of the term erectile dysfunction and one question explored the male participants desire to improve erectile function or female participants opinion on their partners desire. Participants were asked to rate their agreement with statements using a four-point scale ( agree strongly, agree, disagree, disagree strongly ; three questions), select answers from a pre-determined list (multiple answers possible; three questions), or choose a yes/no answer (with the option of refusing to answer; one question). Erection hardness was assessed using the validated EHS. 23 Questions were presented in a fixed order in the respondent s native language. Demographic information, including education level and occupation, was also collected. Social grade was defined using education level and profession according to the National Readership Survey ABCDE-scheme. 24 The survey was expected to take o10 min to complete. A copy of the survey is available in the Supplementary information. Analyses Only complete questionnaires were analysed. Descriptive statistics and 95% confidence intervals (CI) were calculated using SAS software (version 8). Differences between groups were analysed using chi-squared tests; a P- value o0.05 was considered statistically significant. As an exploratory analysis, a logistic regression model identified predictive factors and potential confounders for a positive answer to the statement, sexual confidence is most closely related to a strong or hard erection, using all other questions and basic demographics as covariates (except for questions on ED knowledge). A second model was built for a positive answer to the statement, a man s lack of sexual confidence, as a result of insufficient hard erections, would reduce his overall self-confidence and self-esteem. RESULTS A total of panellists were invited to participate; volunteered before the target quotas of eligible participants were reached (Figure 1). The demographics of the 8576 subjects Figure 1. Flow of panellists, respondents and study participants though the study. *Respondents who worked in market research, advertising or the healthcare industry (for example, employees of pharmaceutical companies, pharmacists, doctors or nurses), were excluded from the survey. included in the analysis (mean age 42.7 years, 95% CI: ) are described in Table 1. Overall, 25.1% participants reported non-optimal erection hardness (EHS of p3) for themselves or for their partners. An EHS of 4 was reported by 69.9% (95% CI: ) of men and 69.8% (95% CI: ) of women for their partners. EHSs reported in the year age group were consistently higher than those reported in other age groups (Figure 2). Only 49.7% (95% CI: ) of subjects reported an EHS of 4 in the oldest age group ( years). Factors associated with a man s sexual confidence The response most frequently selected as being, most closely associated with a man s sexual confidence, was the ability to sexually satisfy their partner (79.0%; 95% CI: ; Figure 3a). One in three people believed that a man s sexual confidence is associated with achievement and maintenance of a strong or hard erection (33.5%; 95% CI: ) and reaching an orgasm at each sexual encounter (33.8%; 95% CI: ); three in ten respondents linked a man s sexual confidence to his ability to attract sexual partners (28.4%; 95% CI: ). Men were significantly more likely than women to associate a man s sexual confidence with the ability to: (a) satisfy their partner sexually (83.5 vs 74.5%; Po0.0001), (b) achieve a strong and hard erection (35.9 vs 31.1%; Po0.0001) and (c) attract their partner sexually (31.9 vs 25.0%; Po0.0001). Female respondents were significantly more likely than male respondents to link a man s sexual confidence with his ability to achieve an orgasm during each sexual encounter (35.8 vs 31.6%; Po0.0001). Perceived impact that a man s lack of sexual confidence may have on his QoL Figure 3b shows the opinions of study participants regarding the impact that a lack of sexual confidence, as a result of insufficiently hard erections, would have on a man s life (multiple answers were possible). Most participants believed this would reduce a man s overall self-confidence and self-esteem (65.1%; 95% CI: ), and make him feel less confident about his next sexual encounter (64.2%; 95% CI: ). Almost half of all respondents believed that a lack of sexual confidence would impact a man s life beyond the immediate sexual activity, by negatively affecting his ability to maintain a successful relationship (44.7%; 95% CI: ) or make him less confident about his life overall (47.7%; 95% CI:

3 Table 1. Baseline and demographic characteristics of the study participants n (%) Total number of eligible participants 8576 (100.0) Male/female (%) a 4246 (49.5)/4330 (50.5) Country of origin UK 1010 (11.8) France 1003 (11.7) Italy 1003 (11.7) Germany 1005 (11.7) Spain 1000 (11.7) Sweden 507 (5.9) Denmark b 513 (6.0) Belgium 502 (5.9) The Netherlands 524 (6.1) Finland 503 (5.9) Romania 502 (5.9) Turkey 504 (5.9) Age (years) a (26.9) (28.9) (24.6) (19.6) Marital status Married/have partner 6493 (75.7) Single 1309 (15.3) Divorced/separated 734 (8.6) Refused to answer 40 (0.5) Working status Working---full time 4627 (54.0) Working---part time 1137 (13.3) Unemployed 838 (9.8) Housewife 915 (10.7) Retired 781 (9.1) Student 218 (2.5) Refused to answer 60 (0.7) Social grade a ABC 1 (high) 3551 (41.4) C 2 DE (low) 4968 (57.9) Refused to answer 57 (0.7) a Quotas were placed on age, gender and social group to ensure a representative spread of responses. b For Denmark, quotas were placed using the highest education level of participants instead of social grade ). Significantly more women than men believed that a lack of sexual confidence due to insufficient erectile rigidity would reduce a man s overall self-confidence and self-esteem (70.0 vs 60.2%; Po0.0001) and make him feel less confident about his life overall (51.2 vs 44.1%; Po0.0001). Notably, only 10.0% (95% CI: ) of the study population believed a lack of sexual confidence due to insufficient erection hardness would not impact a man s life outside of sex. Agreement with statements on a man s sexual confidence The proportions of male and female respondents agreeing with statements on sexual confidence are summarised in Figure 4. The majority of respondents (94.7%; 95% CI: ) agreed that, it is important for a man to be sexually confident to ensure good sex ; significantly more men than women agreed strongly (49.6 vs 46.0%; P ¼ ). Although the majority of participants (87.5%; 95% CI: ) agreed that, being able to achieve and maintain a hard and firm erection enables men to have good sex, Perception of sexual confidence: a European survey this was more frequently supported by male respondents overall (Po0.0001) and in terms of those who agreed strongly (Po0.0001). The majority of participants (94.0%; 95% CI: ) agreed that, being able to have good sex enables men to have greater satisfaction with their life overall ; but strong agreement was significantly more frequent with female than male respondents (50.6 vs 46.2%; Po0.0001). Erectile dysfunction A third of respondents were not fully aware of the correct definition of ED (Table 2). Significantly more female respondents had a correct understanding of ED, whereas significantly more men believed common myths surrounding ED. Only a minority of men (4.3%) and women (2.8%) believed that ED was a reflection of an individual s manhood, or that ED was caused by low libido (14.3% of men and 9.3% of women). Finally, 59.7% (95% CI: ) of men reported they would like to consistently experience firmer or harder erections to improve their sex life, and 38.7% (95% CI: ) of women believed that their partner would like to consistently experience firmer or harder erections to improve their sex life. Exploratory analysis Table 3a shows multivariate regression analysis for a positive answer to the statement, sexual confidence is most closely related to a strong or hard erection. Generally, younger subjects were more likely to agree with this statement. The odds of a man with an EHS of p3 or women reporting an EHS of p3 for their partner agreeing with this statement was 1.6 times higher than for those with an EHS of 4. Several factors predicting a positive answer for the statement a man s lack of sexual confidence, as a result of insufficient hard erections, would reduce his overall self-confidence and self-esteem were identified (Table 3b). Younger subjects and women were more likely to agree with this statement. In both models, social grade was not a predictive factor. DISCUSSION In the general population, the ability of a man to satisfy his partner sexually was identified as the most important determinant of sexual confidence, particularly for men. Although respondents were not provided with specific definitions for the terms used, the results appear to align with the US National Institute of Health s statement that sexual satisfaction is the ultimate goal of a sexual encounter. 1 The finding that 95.3% of men and 94.0% of women believe a man must be sexually confident to ensure good sex supports earlier findings of the Global Better Sex Survey. 19 Approximately 30% of participants associated physiological aspects of the sexual encounter, such as erection hardness (predominantly men) and the ability to reach an orgasm (predominantly female participants), with a man s sexual confidence. This suggests that other aspects of sexual activity, which were not addressed in this survey, also have a decisive influence on sexual confidence. In contrast, in the Global Better Sex Survey study, men rated both the orgasmic and erectile aspects as very important for good sexual experience more frequently than women. 19 Furthermore, 58% of male and 53% of female respondents rated confidence in a man s sexual ability as very critical. This difference among the two surveys could be due to participants distinction between sexual confidence and sexual experience, which can not be assessed with the available information. The survey explored the general population s perception regarding lack of sexual confidence due to insufficient erection rigidity. Respondents felt this would reduce a man s confidence about the next sexual encounter, a finding supported by data demonstrating that treatment for ED reduces anxiety about the next intercourse attempt, 25 probably through the effect of improved erectile function on sexual confidence. 26 3

4 Perception of sexual confidence: a European survey Refused to answer question Proportion of participants (%) a Overall population Males Females yrs yrs yrs yrs Overall population by age group Which of the following are most closely associated with a man s sexual confidence? Proportion of participants (%, 95% CI) EHS 4 (The penis is completely hard and fully rigid) EHS 3 (The penis is hard enough for penetration but not completely hard) EHS 2 (The penis is hard but not hard enough for penetration) EHS 1 (The penis does not increase in size or hardness/the penis is large but not hard) Figure 2. Erection Hardness Score (EHS) of male participants and male partners of female participants per age category. EHS scores of 0 and 1 were combined, as both represent severe ED Being able to satisfy his partner sexually Being able to reach orgasm during every sexual encounter A strong or hard erection Being able to attract sexual partners Feeling able to accomplish any goal or overcome any challenge Other Overall Males Females b How could a man s lack of sexual confidence as a result of insufficiently hard erections, impact his life? Proportion of participants (%, 95% CI) Reduce his overall self-confidence and self-esteem Make him feel less confident for/about his next sexual encounter Make him feel less confident about his life overall Reduce his enjoyment of sex Negatively affect his ability to maintain a successful relationship Cause him to avoid situations which may lead to sex Does not have an impact on his life outside of sex Other Overall Males Females Figure 3. (a) Responses selected by male and female participants as being, most closely associated with a man s sexual confidence. (b) Opinions of study participants regarding the impact a lack of sexual confidence, as a result of insufficiently hard erections, would have on a man s life (multiple answers were possible). *Po for difference between males and females.

5 Perception of sexual confidence: a European survey 5 Figure 4. Proportion of male and female respondents agreeing with statements on sexual confidence, that is, (a) it is important for a man to be sexually confident in order to ensure good sex, (b) being able to achieve and sustain a firm or hard erection enables men to have good sex, (c) being able to have good sex enables men to have greater satisfaction with their life overall. # P ¼ and *Po for difference between males and females. Table 2. Proportion of participants in agreement with the common myths/beliefs associated with ED (multiple answers were possible) Response Percentage of responders in agreement Male Female P-value for difference ED means complete impotence ED is only psychological ED is the inability to achieve and sustain a penile erection sufficient for satisfactory sexual performance ED is hereditary ED does not affect men below age 60 years ED is closely associated with depression, loss of self-image and self-confidence ED affects one in two men between the ages of 40 and 70 years ED is a reflection of an individual s manhood o ED is due to low libido o ED only affects a small number of men Treatment for ED enables men with ED to live a normal life I am not aware of this term or the causes or effects of ED Abbreviation: ED, erectile dysfunction. Almost half of respondents believed a lack of sexual confidence would affect a man s self-confidence and self-esteem overall, although only 10% agreed that this would not impact a man s life outside of sex. This discrepancy could reflect the way the double negation of the second statement was understood by the participants. However, an interesting gender effect was seen in this survey: when assessing the impact of a man s sexual confidence on self-confidence and general life aspects, male respondents consistently considered these aspects to be impacted less frequently than did women. This could support findings that men cite sexuality-focused attributes less often when assessing their constructs of masculinity. 27 Only a minority of men and women believed that ED was a reflection of an individual s manhood, or that ED was caused by low libido, compared with a higher percentage who believed that ED would affect a man s self confidence. This suggests that the general public can discriminate between the causes of, and the effects of, ED. While sexual self confidence may affect an individual s concept of manhood, this finding suggests that other factors also influence a man s idea of manhood. Sand et al. 27 reported that factors such as being seen as honourable, self-reliant and respected by friends were more important constructs of masculinity than stereotypical factors, including being sexually active and successful with women, and that constructs of masculinity did not significantly differ in men with or without ED. However, no further measures on manhood/ masculinity or gender roles were part of this survey. Women seemed to have better factual understanding of ED than men, a finding that suggests that ED is a shared sexual concern of couples. 14,28,29 However, fewer female respondents assumed their partner would wish to consistently experience firmer erections compared with male respondents. This difference may be explained by the non-relationship between female and male participants compared with studies performed in couples. Notably, the study showed that the majority of men wanted to

6 6 Table 3a. Perception of sexual confidence: a European survey Factors predictive for a positive answer to the statement: sexual confidence is most closely related to a strong or hard erection Factor OR estimate 95% CI Chi-squared P-value Gender (men vs women) Age (years) ( vs ) ( vs ) ( vs ) Social grade (low vs high) a Respondents who believed sexual confidence was most closely related to Being able to attract sexual partners (yes vs no) o Being able to satisfy his partner sexually (yes vs no) Being able to reach orgasm during every sexual encounter (yes vs no) o Feeling able to accomplish any goal or overcome any challenge (yes vs no) Other (yes vs no) Strongly agree that It is important for a man to be sexually confident in order to ensure good sex Strongly agree that Achieving and sustaining a firm or hard erection enables men to o have good sex Strongly agree that Good sex leads to greater overall satisfaction with life Respondents who believed a lack of self-confidence due to insufficiently hard erections would Make him feel less confident for/about his next sexual encounter (yes vs no) o Cause him to avoid situations which may lead to sex (yes vs no) o Reduce his enjoyment of sex (yes vs no) o Reduce his overall self-confidence and self-esteem (yes vs no) o Negatively affect his ability to maintain a successful relationship (yes vs no) Make him feel less confident about his life overall (yes vs no) Does not have an impact on his life outside of sex (yes vs no) Other (yes vs no) EHS score (EHS of p3 vs EHS of 4) o Respondents who would like to experience harder erections o Abbreviations: CI, confidence interval; EHS, erection hardness score; OR, odds ratio. n ¼ 2872 respondents believed that a strong or hard erection was most closely associated with a man s sexual confidence. a Level of education was recorded instead of social grade in Denmark. consistently experience harder erections, whereas B70% of men reported the highest EHS score. Responses could be biased by aspirational thinking and social desirability as seen in surveys with sensitive questions. 30 However, both non-optimal erection hardness (EHS of p3) and the wish to consistently experience harder erections were predictive factors for a positive answer to the statement that, a strong or hard erection was most closely associated with a man s sexual confidence. Interestingly, these factors were not predictive for a positive answer to the statement that, a man s lack of sexual confidence, as a result of insufficiently hard erections, would reduce his overall self-confidence and selfesteem. Most other findings of this multivariate analysis support the expected relationship, although the analysis was exploratory and should be interpreted with caution. This study has several limitations: (1) Only people with Internet access could participate, however, quotas ensured the study population was representative of the general population. (2) Only sexually active subjects were included; subjects whose lack of sexual confidence had prevented them from being sexually active within the last year were excluded. Although sexual confidence could relate to the amount of sexual experience, the frequency of sexual encounters was not assessed. The absence of sexual frequency data also compromises assessment of the actual dimension of sexual confidence associated with ED, as the presence of untreated ED may lead to a lower sexual frequency. (3) The approximately 8500 subjects included in the analysis represent only 6% of the invited panellists, as inclusion criteria and stratification factors were applied. As recruitment was stopped once target quotas were achieved (in most countries within 2 weeks), this may have potentially skewed the surveyed population to one being more confident in responding to questions on sexual health. (4) Other aspects of sexual activity known to influence sexual confidence, such as premature ejaculation, were not addressed in this survey. (5) The questionnaire was provided in a fixed order and did not allow respondents to clarify questions. Some questions linked sexual confidence directly with insufficient erectile function without exploring other factors contributing to a lack of sexual confidence. This may have influenced participant s answers and leaves the possibility that questions may have become circular arguments, rather than true response patterns. (6) The use of lay person s terms could limit the interpretation of these findings, as it is unclear what respondents understood by good sex, satisfying one s partner or successful relationship. The importance of undertaking large surveys of the general population was recently highlighted in a study investigating masculinity, 27 as the findings challenged widely believed stereotypes. As the majority of survey participants linked sexual confidence with a man s ability to satisfy his partner sexually, it might be interesting to further explore determinants of sexual satisfaction as perceived by the general population. In conclusion, the European Sexual Confidence Survey suggests that in the general population a man s sexual confidence is mainly associated with sexual satisfaction of his partner and with aspects of erectile and orgasmic function. Both men and women believe

7 Perception of sexual confidence: a European survey Table 3b. Factors predictive for a positive answer to the statement: a man s lack of sexual confidence, as a result of insufficiently hard erections, would reduce his overall self-confidence and self-esteem 7 Factor OR estimate 95% CI Chi-squared P-value Gender (men vs women) o Age (years) ( vs ) ( vs ) ( vs ) Social grade (low vs high) a Respondents who believed sexual confidence was most closely related to A strong or hard erection (yes vs no) o Being able to attract sexual partners (yes vs no) Being able to satisfy his partner sexually (yes vs no) o Being able to reach orgasm during every sexual encounter (yes vs no) Feeling able to accomplish any goal or overcome any challenge (yes vs no) Other (yes vs no) Strongly agree that It is important for a man to be sexually confident in order to ensure good sex Strongly agree that Achieving and sustaining a firm or hard erection enables men to have good sex Strongly agree that Good sex leads to greater overall satisfaction with life o Respondents who believed a lack of self-confidence due to insufficiently hard erections would Make him feel less confident for/about his next sexual encounter (yes vs no) o Cause him to avoid situations which may lead to sex (yes vs no) o Reduce his enjoyment of sex (yes vs no) o Negatively affect his ability to maintain a successful relationship (yes vs no) o Make him feel less confident about his life overall (yes vs no) o Does not have an impact on his life outside of sex (yes vs no) o Other (yes vs no) o EHS score (EHS of p3 vs EHS of 4) Respondents who would like to experience harder erections Abbreviations: CI, confidence interval; EHS, erection hardness score; OR, odds ratio. n ¼ 5585 respondents believed that a man s lack of sexual confidence, as a result of insufficiently hard erections, would reduce his overall self-confidence and self-esteem. a Level of education was recorded instead of social grade in Denmark. that a man s sexual confidence may impact his life in general. The factual understanding of ED demonstrated in this general population (particularly in men) suggests that an educational programme may be of value. CONFLICT OF INTEREST Carlos San Martín has acted as a consultant or speaker for Lilly, Bayer and Pfizer. Chiara Simonelli has acted as a consultant for Boehringher Ingelheim and as a consultant or speaker for Lilly, Bayer, Takeda, Abbott and Pfizer. Jens Sønksen has acted as a consultant or speaker for Lilly and Pfizer. Gabriel Schnetzler has acted as a consultant for Pfizer and was previously an employee of Pfizer. Seema Patel is an employee of Pfizer. ACKNOWLEDGEMENTS The authors would like to thank Brian Larkin and Mandira Ray of Double Helix Ltd London, UK for assistance in conducting the study, Sarah Bowen, a contractor employed by Pfizer Global Research and Development Ltd, Sandwich, UK for performing analysis of the data, and Jamie Ashman, PhD of Prism Ideas CH GmbH, Basel, Switzerland for providing editorial support in the preparation of the manuscript. This study and editorial support for the preparation of the manuscript were funded by Pfizer. REFERENCES 1 NIH Consensus Development Panel on Impotence. Impotence---NIH Consensus Conference. JAMA 1993; 270: Nicolosi A, Laumann EO, Glasser DB, Moreira Jr ED, Paik A, Gingell C. Sexual behavior and sexual dysfunctions after age 40: the global study of sexual attitudes and behaviors. Urology 2004; 64: Rosen RC, Fisher WA, Eardley I, Niederberger C, Nadel A, Sand M. The multinational Men s Attitudes to Life Events and Sexuality (MALES) study: I. 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