Motivations for Seeking Treatment for ED: the Woman’S Perspective

ORIGINAL ARTICLE Motivations for seeking treatment for ED: the woman’s perspective

MP McCabe1, H Conaglen2, J Conaglen3 and E O’Connor1

1School of Psychology Deakin University, Melbourne, VIC, Australia; 2Psychology Department, University of Waikato, Hamilton, New Zealand and 3Waikato Clinical School, University of Auckland, Hamilton, New Zealand

There is increasing evidence that partners have a major role in treatment-seeking behavior for men with ED. This study investigated the motivations of 100 females for seeking medical treatment for their partner’s ED. Semi-structured interviews focused on reasons for seeking treatment from the female’s perspective. The themes that emerged from the data centered on the importance of sex in the relationship, with closeness and intimacy frequently being seen as more important than sex. The second major theme related to hopes that females had in relation to the medication, particularly in relation to increasing their partner’s confidence and reducing his sexual frustration. Enhancement of the relationship as well as improving the female’s own feelings of self-doubt and sexual frustration were also mentioned. The results of this study show the multi-faceted nature of the motivations that females express in terms of seeking help for their partner’s ED. International Journal of Impotence Research (2010) 22, 152–158; doi:10.1038/ijir.2009.60; published online 17 December 2009

Keywords: erectile dysfunction; woman’s perspective; motivations for treatment

Introduction sexual dysfunction (FSD), if FSD led to male ED, or if there were other factors (for example relationship There is a growing body of literature that shows the problems) that led to both ED and FSD. However, importance of the partner and the relationship in the there is evidence that treatment of male ED has a treatment of ED in men.1–7 Although a wide range of positive effect on FSD.18,20–22 The use of a range literature shows that PDE5 inhibitors (PDE5i) are of PDE5i medications has been shown to be associ- very effective in restoring an erection in men with ated with improvements in the female partner’s ED,8 a large number of men do not continue with the sexual function/satisfaction, as well as relationship use of these treatments for their ED.9–11 functioning. There are likely to be a wide range of factors that are Cayan et al.18 reported that all aspects of sexual associated with this discontinuation of PDE5i medica- functioning (except sexual desire) among 38 females tion, or the failure to even use these medications whose partners experienced ED were lower than for despite their efficacy.11,12 One particular factor that 49 partners of men who did not experience ED. has been identified is the importance of the views of Further, after the treatment of ED, these females the partner.13–15 As sexual intercourse is a shared showed significant improvements in their sexual activity, it is not surprising that the views of the functioning. Chevret et al.19 also showed that ED partner are likely to impact both on initial use and had a negative impact on the sexuality of female continuation or otherwise of medical treatment for ED. partners. Female partners (n ¼ 376) of men with ED A substantial number of studies have now shown evidenced lower levels of sexual satisfaction and that ED is associated with both quality of life16 and sexual desire than female partners (n ¼ 345) of men sexual dysfunction in the man’s partner.17–20 It is not who did not have ED. Even life satisfaction was clear from these studies if the ED led to female lower among the females whose partners experienced ED. Similar findings were obtained by Hei- man et al.23 who found that postmenopausal Correspondence: Professor MP McCabe, School of Psy- females (n ¼ 85) whose partners were treated for chology, Deakin University, 221 Burwood Highway, Bur- wood, VIC 3125 Australia. ED (compared with 91 females whose partners E-mail: [email protected] received a placebo) showed improvements in their Received 15 July 2009; revised 10 November 2009; sexual function, sexual satisfaction, and treatment 22 accepted 19 November 2009; published online 17 Decem- satisfaction. Finally, Fisher et al. showed that the ber 2009 frequency of orgasm, sexual activity, and sexual Motivations for seeking treatment for ED: the woman’s perspective MP McCabe et al 153 satisfaction was lower among females whose male Materials partners experienced ED. Females whose partners In depth, semi-structured interviews explored mo- were using PDE5i medications showed a more tivations for entering a treatment program for ED, favorable sexual experience than those females such as the woman’s perspective on the importance whose partners experienced ED, and were not using of sex to the couple’s relationship, as well as a PDE5i medication. questions about hopes for beginning the use of One would expect from the above studies that PDE5i medication, and any fears about their part- females whose partners experience ED would be ners taking the medication. For example, females keen to seek treatment for this condition. Consistent were asked, ‘How important is obtaining treatment with this suggestion, Fisher et al.24 found that there for your partner’s ED, as far as you’re concerned, to were high levels of agreement between men and you, and to your relationship?’ their partners on their perceptions of ED and their communication about ED. In contrast, Mita et al.25 found that among adult females recruited through Procedure the internet, almost half of them expressed a negative attitude toward the use of drugs for ED. The study was approved by the regional ethics However, it is important to note that it is not known committee, and all participants provided informed consent to be involved in the study. The majority of if the partners of these females experienced ED, and females participated in face-to-face interviews, all respondents were drawn from Japan. It is possible that the response to the use of PDE5i which were digitally recorded to enable repeated review during the analytical process. Interviews medication may be quite different once one’s partner lasted B20 min. Interviews were transcribed from is diagnosed with ED, and beyond that, prescribed and/or treated with PDE5i for the condition. Further, the digital recordings, and then coded using NVivo software version 8.28 Coding and analysis were there may be different attitudes to the use of carried out using principles from interpretative medication to treat ED (or even any treatment of 29 ED) within Japanese society compared with US phenomenological analysis. Using this approach, transcripts were examined one by one, so that society. extracts could be grouped into relevant themes as Given the central role that females have in their 26,7 they emerged. As the iterative analysis continued, partners’ treatment-seeking behavior, it is important to obtain a better understanding of the reasons themes were constantly revised and extended until no further themes could be identified, and the why females seek treatment. This study examined resulting framework accounted for all relevant the motivation of females for seeking treatment with PDE5i therapy for their partner’s ED. The study used extracts found within the transcripts. A second coder, external to the initial analysis, coded 10% of a qualitative approach to explore women’s motiva- the interviews to ensure consistency of emerging tions. The results from this study are expected to provide data that will be useful in a large-scale themes. From the analysis, a number of main themes were identified. quantitative study.

Results Materials and methods Three major themes emerged in female’s discussions Participants of their motivation for their partner seeking ED The data for this study were drawn from a sample of medication. These included the importance of sex to 100 females from New Zealand, whose partners the relationship, hopes for the medication, and were experiencing ED, determined by an Erectile worries about the medication. These themes are Function subscale score p20, from the International considered in more detail below. Index of Erectile Dysfunction.27 Participants were obtained through convenience sampling through advertisements for volunteers placed in a local Importance of sex newspaper. Potential participants were informed Table 1 outlines the main themes in relation to the that they would be taking part in a trial to determine importance of sex in the relationship. A common their satisfaction with two different PDE5 inhibitors. response was that sex was not the most important Participants ranged from 30 to 75 years of age, with aspect of the relationship. Closeness and intimacy a mean age of 53 years (s.d. ¼ 8.89), and the were often discussed as being more important than majority were Caucasian (83%). Eighty-two percent sex: of the females were married to their partners and had been in the present relationship from 3 months ‘We do a lot of kissing and cuddling and stuff to 52 years, with a mean duration of 23 years like that, I mean we are really close. We’ve (s.d. ¼ 14.95). been married for 35 years and we can still sit

International Journal of Impotence Research Motivations for seeking treatment for ED: the woman’s perspective MP McCabe et al 154 Table 1 Frequencies for important of sex Table 2 Frequencies of hopes for the medication

Theme Frequency Theme Frequency Focus

Closeness and intimacy more important 31 Reduce cognitive preoccupation, 29 Male Is part of a normal relationship 22 increase confidence More important to partner than self 22 Reduction in partner’s sexual 26 Male Increases intimacy and closeness 14 frustration Part of aging 11 Increased intimacy and closeness 23 Couple Nice benefit of a relationship 8 Reduce own feelings of self-doubt 22 Female Partner to feel more masculine 19 Male Reduction in own sexual frustration 18 Female To enhance the relationship 16 Couple Reduce hesitation about becoming 16 Female on the sofa and hold hands. Because we have involved in sex such a good relationship, I think it’s what has Return to normal life 9 Couple enabled us to cope with this. I’ve been able to Determine how the medication works 8 Couple cope with it, and as long as I have my kisses and cuddles, I’m quite happy.’ (#83, aged 54 years, duration of relationship 35 years) olderandIreallyjustthoughtitwasapartof However, many females were also of the view aging and getting older. I mean, sex drive, my that sex was part of a normal relationship: understanding of it anyway, is that it should wane as you get older or maybe it doesn’t, I don’t ‘It’s important, it’s part of who you are as a know. My experience is that it does for us or for couple. It’s another way of expressing the love, me and perhaps for my partner too.’ (#32, aged the care, the enjoyment that you’ve got with 49 years, duration of relationship 30 years) that person.’ (#89, aged 54 years, duration of relationship 15 years) Finally, some females saw sex as being a nice benefit to their relationship: Females were generally of the view that sex was more important to the male partner than the woman ‘I think, you know, I mean I’m not going to herself: leave my partner because of it—because you know we’ve got a deeper situation than that. I ‘I would probably say it’s not wildly important mean that’s not why we’re together for the long to me—it’s very important to my partner so it’s term but I mean it is a nice benefit to have on important to me because it’s important to him. tops of it isn’t it? So it is a nice plus.’ (#35, aged I enjoy sex when we have it and sometimes I 51 years, duration of relationship 29 years) want to really participate and sometimes I don’t—I’m not that bothered. I think at various times of the month—either side of my Hopes for medication period—I’m usually quite wanting sex and The main themes related to what the females hoped then for the rest of the month I couldn’t give would occur as a result of using the PDE5i a toss but he certainly does.’ (#31, aged 51 medication is summarized in Table 2. The themes years, duration of relationship 15 years) from the female’s responses centered on how the A number of females indicated that they thought medication would help the females themselves, that sex increased their levels of intimacy and their partner, and their relationship. There were a closeness with their partner: number of themes surrounding hopes for the medication that were focused on the impact of the ‘I feel, I like the intimacy, to me it’s hand-in- woman herself. Examples of these three main hand with marriage, like, it makes me feel themes of how the use of the PDE5i medication loved. I just really love the intimacy and the was expected to assist the females are outlined time, I mean, especially when you’re so busy below. all the time, to me, that’s our time out, together.’ (#03, aged 45 years, duration of relationship 19 years) Reduce own feelings of self-doubt A number of females also noted that sex was not the most important aspect of their relationship ‘It’s impacted I would say quite a lot, we are at because they believed that a decrease in sexual the stage now where we are able to talk about y activity was a normal part of aging: it, and we’re much more open, I sort of think, it’s me, I’m old, and you know, typical, ‘I just put it down to getting older. I mean, I he doesn’t fancy me any more, I’m unattractive don’t feel like sex as often as I used to and to him, and I went through all those self-doubt because we’re busy and we’re both getting things, and that was impacting very badly. We

International Journal of Impotence Research Motivations for seeking treatment for ED: the woman’s perspective MP McCabe et al 155 were starting to grow apart, and as I say, we which probably compounds the whole situa- decided to talk about it, and open up, and he tion even more. I think certainly from (part- said look, it’s got to keep reinforcing that it’s ner)’s perspective, if by using some medication not me, it’s just a thing that’s happening, and then it’s easier for him to become erect it’s we must work together.’ (#53, aged 52 years, certainly going to do his self-esteem and him a duration of relationship 27 years) world of good, and hopefully he’ll be feeling less sexually frustrated, and that’s got to have positive spin-offs in the rest of our relation- Reduction in own sexual frustration ship.’ (#43, aged 46 years, duration of relationship 26 years) ‘It is very frustrating and I ended up saying ‘we have to do something, because I’m 33 years old and I can’t go on like this for the rest of my life’. Reduction in partner sexual frustration And that was the trigger for him to say ‘I’ll go ‘Justy he’s happier, I’m happier. He just gets and do something’. He was quite nervous I so frustrated with the whole thing when it guess, and I can understand that it must be doesn’t work like he wants it to.’ (#29, aged 54 difficult for a guy to suddenly go in to the doctor years, duration of relationship 27 years) and say ‘I’m having problems’. Of course once the drug worked it was great and it seemed to Finally, there were four themes that were focused restore some confidence, but the other thing we more directly on the dyadic relationship and hopes found was that when he could have an erection for how the medication might help the couple. he would ejaculate very quickly, so it was all over within like 20 seconds. So again, that is Increase intimacy and closeness very frustrating.’ (#75, aged 33 years, duration of relationship 12 years) ‘Of course, the desire and the arousal depend so much on the situation, and a lot of different things come into it. And I can, in the past, I can remember being so aroused, and so full of Reduce hesitation about becoming involved in sex wanting to get going, but when you kind of get ‘It was a two way thing I think, I know personally into a relationship, and you’ve been together it was just that attitude, oh look, don’t even start. for quite a long time, things change. So I don’t Because I’m not even going to try to be aroused, I feel a lot of desire now, but what I’m wanting is got to the point where I wouldn’t allow myself to the closeness, and I’m wanting it for (partner), get aroused because I thought, oh damn, I don’t so that he can, you know, experience that want to get like that, and then get so aroused, again.’ (#14, aged 66 years, duration of relation- where you can’t complete the job, and I’d just be ship 18 years) left frustrated.’ (#17, aged 49 years, duration of relationship 28 years) There were also three main themes surrounding Return to normal life hopes for how the medication would help the male ‘Strangely we’re still getting on fine and we partner. thought ‘well this is how it will be till the end of our days’, but it would be nice if it could be like it was.’ (#79, aged 66 years, duration of Partner to feel more masculine relationship 48 years) ‘I feel deeply for my husband because he feels a failure as a man; if there was some form of treatment that would give him his erection Determine how the medication works function back again I would be only too happy; ‘To find a product, obviously, because we’re as much as anything just for his peace of mind.’ going to have to use a product, we know that (#27, aged 65 years, duration of relationship 47 now. To find a product that’s going to suit both years) of us and for the side effects not to be too damaging.’ (#92, aged 49 years, duration of relationship 25 years) Reduce cognitive preoccupation, increase confidence Enhance the relationship ‘But of course, what happens is, being a male, even though there’s an underlying physical ‘I think that probably, if the sex in the relation- cause, psychologically it has a huge impact ship was right, everything else would balance

International Journal of Impotence Research Motivations for seeking treatment for ED: the woman’s perspective MP McCabe et al 156 Table 3 Frequencies of worries for the medication suddenly wow! And you can do it about 1000 darn times, you know? And to me that’s just Theme Frequency not a natural process. But if it’s going to give (partner) some satisfaction well that’s fine with Side effects and health issues 29 me.’ (#19, aged 50 years, duration of relation- The cost of medication 15 Not natural 10 ship 31 years) Puts pressure on woman to perform 9 That it will take away the spontaneity 8 Puts pressure on woman to perform out.’ (#90, aged 35 years, duration of relation- ‘I think, if you have a pretty full-on day, really ship 6 years) all you want is a cup of tea. ‘Oh, I’ve taken a pill’; well, it doesn’t always work that way I don’t think. Because, I think it’s going to be easier for him, having the pill, to be into it, than Worries for me who doesn’t have a pill. I mean, he’s Table 3 summarizes the frequencies of the main goingtobeabletoperform,whereasawoman worries that the females expressed in relation to their can’t always perform at that time.’ (#16, aged 55 partner’s use of the PDE5i medication. There were years, duration of relationship 33 years) five major themes that arose regarding these worries.

That it will take away the spontaneity Side effects and health issues ‘But I find with me, if he tells me he’s taken a ‘Oh only what you hear, you know, I’d hate him tablet, then I don’t want it. You know, I don’t to drop dead of a heart attack or anything! But want sex. Because to me sex is something you do he’s been fairly extensively tested for his health just out of the blue, you know? That’s where the and he’s a real physical health nut person so I excitement and all that comes into it. And when don’t imagine he puts himself under any more you think oh hell, I’ve got to do that.’ (#91, aged stress than when he’s working out at the gym or 48 years, duration of relationship 28 years) walking up mountains or things like that.’ (#31, aged 51 years, duration of relationship 15 years) Discussion

Cost of medication This analysis of female’s motivation for treatment ‘I was going to say to you, we’re not that revealed that a large number of the themes related to financial and it’s just horrendous, the cost, you their partner’s sexual and psychological function- know, one hundred dollars for four tablets, ing. Female partners wanted the partner to feel that’s, you know, there’s times that we just better about himself (more confident and mascu- can’t get them, and we can go on for weeks or line), and through addressing his needs, they months and then I get really frustrated too, and expected that there would be a flow-on effect to I know (husband) does too. Because, you know, their own sexual and interpersonal relationship. we’ve got a family, and we’ve got bills to pay, Many of the females indicated that sexual perfor- so it’s like, but then I think to myself, gosh, this mance was more important to their partner than to is part of our life now, and you know, we need them. In fact, they were of the view that closeness something for us as well, and I think some- and intimacy was more important to them than times that, I think it is important that we put sexual interactions. Interestingly, many females money aside to try and get them, but it’s not viewed sex as being part of a normal relationship, always possible.’ (#03, aged 41 years, duration and a number of them experienced sexual frustra- of relationship 19 years) tion if they could not have sex with their partner. As suggested by Chevret-Me´asson et al.,30 females’ satisfaction with their sex lives were improved with the use of PDE5i medication and this is a central Not natural motive for females to seek treatment for their ‘It doesn’t light my fire, but if it’s going to help partner’s ED. Females expressed a number of (partner) then that’s fine with me. Because you concerns about using medication for their partner’s know we had a little sample tablet and we had ED. These primarily focused on the cost of the one and it was just, we couldn’t get over how it medication, the side effects, pressure on them to works. To me, I feel it’s a bit out of nature, but, perform as well as the lack of spontaneity that may one minute you can’t do it and the next minute result from the use of the medication.

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