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A Typology of Men's Sexual Attitudes, Erectile Dysfunction Treatment International Journal of Impotence Research (2007) 19, 568–576 & 2007 Nature Publishing Group All rights reserved 0955-9930/07 $30.00 www.nature.com/ijir ORIGINAL ARTICLE A typology of men’s sexual attitudes, erectile dysfunction treatment expectations and barriers MM Berner1, W Plo¨ger2 and M Burkart3 1Department of Psychiatry and Psychotherapy, Freiburg University Medical Center, Freiburg, Germany; 2Sinus Sociovision GmbH, Heidelberg, Germany and 3Pfizer Pharma GmbH, Karlsruhe, Germany In total, 1122 men completed non-validated structured interviews on sexual attitudes and on erectile dysfunction treatment expectations and barriers. Dimensions of sexual attitudes and treatment expectations and barriers were extracted by factor analysis and subjects were grouped into types by cluster analysis. Five types emerged: the sensation seeker, the sensuous, the anxious, the confident and the abstinent. The majority of men agreed on the importance of sex for the partnership. For the majority of anxious, sensuous and sensation-seeking men, sex was important for self-esteem. Expecting quality of life, enjoyment, self-esteem and hard reliable erections from treatment with phosphodiesterase-5 inhibitors, anxieties for side effects and loss of control, sexual abstinence and desire for an intensive sex life had the strongest impact on the likelihood of use. Men’s sexual attitudes vary considerably and impact reactions to erection difficulties. A typology of five groups was developed, which will contribute to research on and understanding of men’s sexual and treatment-seeking behaviors. International Journal of Impotence Research (2007) 19, 568–576; doi:10.1038/sj.ijir.3901571; published online 23 August 2007 Keywords: impotence; attitudes; phosphodiesterase inhibitors Introduction campaigns and health-care interventions.12–17 With regard to motivation for behavioral changes in other Erectile dysfunction (ED) is frequent and bother- fields, brief interventions have been shown to be some but underreported and undertreated, despite useful that are based on a specific state or trait the availability and publicity of phosphodiesterase- markers of patients.15,17–20 5 (PDE-5) inhibitors, such as sildenafil (Viagra, Previous major studies on ED treatment-related Pfizer Inc., New York, NY, USA), tadalafil (Cialis, behaviors (for example, Global Study of Sexual Eli Lilly and Company Inc., Indianapolis, IN, USA) Attitudes and Behaviors (GSSAB),6 men’s attitudes and vardenafil (Levitra, Bayer GmbH, Leverkusen, to life events and sexuality (MALES),7,9 Cross- Germany).1–5 This discrepancy has stimulated ex- National Survey on Male Health Issues tensive research on adult males’ sexual attitudes, (CNSMHI)3,8) reported findings for total samples behaviors and treatment barriers.3,6–11 and did not break down results by variation in Studies of human sexuality have highlighted a sexual attitudes. Therefore, we aimed to analyze large variability in men’s sexual life and attitudes, associations between sexual attitudes, beliefs and and it can be expected that sexual behavior styles ED-related behaviors and to develop a typology and beliefs affect men’s reactions to erection based on such associations. Such a typology might difficulties. Grouping patients by behaviors and contribute to the understanding of men’s coping beliefs has been useful for designing educational mechanisms and treatment-seeking behaviors and facilitate future educational activities. Correspondence: Dr MM Berner, Department of Psychiatry and Psychotherapy, Freiburg University Medical Center, Materials Hauptstrasse 5, Freiburg, 70194, Germany. E-mail: [email protected] The study was carried out in accordance with the Received 1 December 2006; revised 19 April 2007; International Chamber of Commerce (ICC)/ESOMAR accepted 20 April 2007; published online 23 August 2007 International Code of Marketing and Social Research Typology of men’s sexual attitudes, ED treatment expectations and barriers MM Berner et al 569 Practice (www.esomar.org). Compliance with these household size, number of children, education, widely accepted standards secured the considera- occupation, income and community size. tion of relevant ethical principles. The research question was exploratory in nature, not hypothesis driven, and therefore we selected an exploratory, multistep approach. First, we aimed to Interview identify aspects and topics relevant for ED-related Participants completed 30 min face-to-face at-home behavior. After this step it was obvious that a large interviews on sexuality and erection problems number and variety of beliefs and attitudes modify conducted by professionally trained male inter- ED-related behavior. We then tried to condense this viewers. The structured interview covered general variability to underlying dimensions and to a questions on socio-demographic variables, conco- typology. Finally, we analyzed beliefs and behaviors mitant disorders and medication, sexual attitudes by type. and behaviors, erection problems and treatment. Self-identified ED was defined as answering ‘yes’ to the question ‘Do you suffer from erection problems/ ED?’. Participants were asked about actual and prior Interview development PDE-5 inhibitor usage and the likelihood of using A professional research company started with a such drugs in case they were affected by ED qualitative research conducted as face-to-face in- (1 ¼ very likely, 2 ¼ likely, 3 ¼ unlikely, 4 ¼ very depth semi-structured interviews with 75 ED suf- unlikely). In addition, the two batteries about ferers and three 4-h group discussions with ED attitudes to love and sexuality, and treatment sufferers, partners and treating physicians, respec- expectations and barriers were applied. tively, all recruited by advertising, to identify themes and topics important for ED perception and treatment. In view of transcripts from these inter- views, a list of items covering all relevant aspects of Statistical analysis sexual life, perception and treatment of ED were To extract dimensions of attitudes as well as constructed and grouped by topics. This list was expectations and barriers, both 42-item sets were reviewed for redundancy and content validity by subjected to principal component analysis with psychologists experienced in questionnaire devel- orthogonal VARIMAX rotation. Factors with eigen- opment and condensed to two sets of 42 items values 41 were selected. Extracted attitudes factors covering attitudes to love and sexuality and treat- were correlated with expectations and barriers ment expectations and barriers, and transformed factors. Statistically significant (Po0.01) associa- into a forced-decision four item Likert format tions that allowed meaningful interpretation based (‘completely agree’ ‘agree’ ‘do not agree’ ‘do not on the previous qualitative research from the inter- agree at all’ or ‘extremely important’ ‘important’ views conducted for the development of the struc- ‘less important’ ‘not important at all’). tured interview were selected to define types. Selected associations were seeded into procrustes cluster analysis to assign each participant to a specific type based on his individual factor value Pretest pattern. Five experts in social and medical sciences per- Thereafter, answers to questions on attitudes, formed a semantic analysis of both lists of items, expectations and barriers, ED perception and treat- including assessment of association patterns. In ment were analyzed descriptively by type. view of this analysis, wording of individual items Multiple linear regression was used to analyze the was revised. Apart from this semantic examination, relationship between likelihood of using PDE-5 no further analyses to assess the psychometric inhibitors (dependent variable) and both sets of quality of the structured interview were performed. factor values (attitudes as well as expectations and barriers). Sample A market research company recruited a nationwide Results sample of men aged 30–70 years. Sampling was stratified to include about 25% of men from each age Exploratory individual interviews and group dis- decade (30–39, 40–49, 50–59, 60–70), 50% with self- cussion identified the following relevant topics: identified ED and about one-third of them having socio-demography, health status, health-related be- used a PDE-5 inhibitor. Participants were selected to havior, sexual attitudes and behaviors, ED percep- be representative for the German general male tion, ED-related interactions with health-care population concerning geographic and other socio- professionals, perception of and experience with demographic variables, including marital status, ED treatments and communication on ED. International Journal of Impotence Research Typology of men’s sexual attitudes, ED treatment expectations and barriers MM Berner et al 570 In total, 1122 structured interviews were com- among correlations between attitudes factors and pleted in September 2004. Among whom, 524 expectations and barriers factors. Interpretation of participants (46.7%) had erection problems of these associations as types is shown in Table 2. In whom 185 (35.3%) had taken PDE-5 inhibitors view of individuals’ factor values, every subject was (152 sildenafil, 30 tadalafil and 18 vardenafil). grouped to one of the types resulting in following distribution of types (% of sample): the sensation seeker 27%, the sensuous 17%, the anxious 20%, the confident 20% and the abstinent 17%. The types Factor structures and typology differed by age group and prevalence
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