A Typology of Men's Sexual Attitudes, Erectile Dysfunction Treatment

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 interviews, 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 of self- Principal component analysis of attitudes to love identified ED. and sexuality yielded eight factors with eigenvalues 41, explaining 52% of variance. Interpretation of factors, items with the highest factor loadings and Attitudes, perceptions, expectations and barriers explained variance, are shown in Table 1. Treatment Sexual attitudes concerning partnership and self- expectations and barriers was also reduced to eight esteem with 450% agreements in the total sample factors with eigenvalues 41, explaining 59% of are shown in Figure 1. The most important varia- variance (Table 1). tions across types are seen with regard to the Five statistically significant and meaningfully importance of sex, impact of sex on self-esteem interpretable association patterns were selected and issues of potency.

Table 1 Dimensions of attitudes to love and sexuality and of treatment expectations and barriers

Explained Interpretation Item with highest loading variance (%)

Attitudes to love and sexuality factor Sensation seeking/ 10.1 Desire for extensive and wild sexual life, ‘I prefer particularly wild and riotous sex.’ excitement meeting social expectations in potency Sensuousness/ 8.2 Love as basis for sexual life, focus on partner’s ‘A sensual and romantic ritual is necessary emotional closeness needs, sex as sensual experience for me to be able to completely enjoy sex.’ Egocentricity/control 7.5 Need for control, focus on own satisfaction, ‘It is important for me to have everything self-confidence based on potency, latent under control during sex.’ performance anxiety Anxiety/inferiority 7.4 Fear of not meeting social expectations, ‘I’m sometimes afraid, that I’m not able to feeling sexual dysfunction as personal fault fulfill my partners sexual expectations.’ Abstinence/disinterest 6.9 Leaving sex behind in later life, accepting ‘I do not mind at all to go without sex for a declining sexual life, shift of priorities longer period.’ Frankness/no taboos 5.2 Relaxed attitude towards sex, open ‘I´m one of those people who talk openly communication with partner about sexual weaknesses and problems.’ Spontaneity 3.6 Preference for sex without planning ‘I do not want to have to plan to have sex’. Destigmatization of ED 3.0 Desire for acceptance of sexual dysfunction ‘I wish, that erectile dysfunction would be perceived as something normal.’

Treatment expectations and barriers factor Quality of life/better 19.3 Emotional and social dimension of sex More joy and pleasure having sex sex/self-esteem Fears 11.5 Skepticism towards drug treatment; anxiety Fear of possible addiction towards unpredictable health risks; uncertainty and insecurity Hard reliable erections 7.0 Physical, mechanistic aspect of erectile Strong, hard erection function; wish of reliable and fast effect Naturalness/tolerability 5.8 Desire for good tolerability and naturalness Good tolerability Anonymity 5.8 Preference for anonymous and impersonal Opportunity to purchase the drug places for purchasing; easy and simple anonymously purchase fear of others finding out Medical aspects 4.1 ED drug as a real cure for the treatment of To avoid limitations in life existing diseases Lifestyle aspects 3.7 Desire for an attractive product with an Nice packaging for traveling appealing packaging (without medical connotation); long duration of action Refusal 2.9 Low expected benefit/no need; social barriers I do not need it and defense of problems

International Journal of Impotence Research Typology of men’s sexual attitudes, ED treatment expectations and barriers MM Berner et al 571 Table 2 Interpretation of types

Type Interpretation Mean age (standard Self-identified deviation) (years) ED (%)

1 The Sensation Central role of sexuality, desire for an intensive and excessive sex life. 45.5 (11.1) 42.7 seeker Disconnection of sexuality from emotional closeness to the partner. High self-confidence through virility, strong identification with an image of a potent man. Self-evident advantage of erection-enhancing drugs. Desire for reliable and fast effectiveness. Limited significance of risks.

2 The Sensuous Love and sexuality are inseparable. 48.8 (11.0) 47.4 Critical distance to the traditional man’s role. Desire for spontaneity, focus on individual needs. Intensification of sexual experience and closeness to the partner through the use of ED drugs. Anxiety about losing control. Diffused risk awareness.

3 The Anxious Anxiety and repression as a central motive. 52.5 (10.8) 74.7 Fear of failure because of the high social sexual standards. Perception of sexual disorders as a personal liability and self-failure. Desire for an easy and fast resolution to the ‘ED problem’. Fear of discovery.

4 The Confident Competent and comfortable handling of sexuality. 48.0 (11.4) 25.3 The personal self-perception, self-confidence is not formed by sexuality. Sexuality is neither overrated nor neglected. Hardly any thought about ED or ED drugs. Low expectation of use, because the necessity of taking the ED drug is not seen – but also no fundamental decline.

5 The Abstinent Parting from sexuality at older age. 53.5 (10.8) 44.6 Acceptance of decrease of sexuality for the own life – thereby no sense of sacrifice. Displacement of priorities onto other sphere. High barriers against ED drugs: no need for use, because ED cannot and should not be prevented, being that it is a natural symptom of aging. Fundamental skepticism against drugs.

Attitudes to sexuality

The Abstinent The Confident The Anxious The Sensuous The Sensation seeker

During sex I feel particularly close to my partner

Primarily, sex means love, tenderness and closeness

I expect good sex in my partnership

My partner's orgasm is the most important aspect

I speak frankly with my partner about sex

I need to have everything under control

ED means a personal defeat

Without erections I am half the men

My self-esteem does not depend on good sex

During sex I want to feel like a real men

I admire potent men

0% 20% 40% 60% 80% 100% Figure 1 Percentage of men ‘agreeing’ or ‘agreeing completely’ on predefined statements on sexual attitudes concerning partnership and self-esteem by type. From a list of given statements, only those are shown that 450% of the total sample agreed.

International Journal of Impotence Research Typology of men’s sexual attitudes, ED treatment expectations and barriers MM Berner et al 572 Two-third of men did not perceive ED pre- disturbance that does not deserve special dominantly as a medical condition: 28% attention. ED was first and foremost addressed regarded erection problems primarily as a natural as medical condition by 22%, whereas 12% consequence of aging, 26% as a phenomenon regarded it mainly as sequel of another disease that can easily be settled and 12% as transient (Figure 2).

Attribution of causes of ED

The Abstinent The Confident The Anxious The Sensuous The Sensation seeker

A natural consequence of aging

Easy treatable phenomenon (no disease)

A disease which has to be treated

A sequel of another disease

A transient disturbance which requires no action

0% 10% 20% 30% 40% 50% Figure 2 Percentage of men rating on most appropriate description of ED in a forced choice question.

ED treatment expectations

The Abstinent The Confident The Anxious The Sensuous The Sensation seeker

Tolerability

Reliable effect

Satisfying partner

Erection until orgasm

Cure of ED

Natural course of erection

Drug in the body only as long as needed

Quick solution of ED

Sexual fun and enjoyment

0% 20% 40% 60% 80% 100% Agreement on importance

Figure 3 Percentage of men rating predefined ED treatment expectations as ‘extremely important’ or ‘very important’ by type. From a list of 30 statements given, only those are shown that 475% of the total sample rated as extremely or very important.

International Journal of Impotence Research Typology of men’s sexual attitudes, ED treatment expectations and barriers MM Berner et al 573 Psychological stress (61.4%), organic disease The group of 524 men with self-identified ED (58.2%) and aging (55.6%) were the most frequently comprised 126 sensation seekers, 91 sensuous, 165 cited likely causes of ED without marked differences anxious, 56 confident and 86 abstinent. Reasons for between types. ED treatment expectations with not using ED treatments in this group with 450% 475% agreements in the total sample are shown agreements are shown in Figure 4. in Figure 3. In all, 54.6% of sensation seekers, 64.6% of sensuous and 57.0% of anxious rated the opportunity to purchase a treatment anonymously Treatment-seeking behavior as important, 65.8, 72.9 and 67.0% the availability Table 3 shows contact persons and information without prescription. For confident and abstinent, sources men would use in case affected by ED. On the agreement to these two statements was well average, approximately 10% more would talk to below 50%. their general practitioners than to their partners.

Reasons for not taking ED treatments in 524 men with self-identified ED ( > 50% agreement)

The Abstinent The Confident The Anxious The Sensuous The Sensation seeker

fear of side effects

fear of unnatural prolonged erection

limited understanding of mode of action

fear of loosing control

limited knowledge about exposure to drug

price

fear of dependency

fear of tolerance

low trust into drugs

does not take chemical drug

0% 20% 40% 60% 80% 100% Agreement on importance

Figure 4 Percentage of men rating predefined reasons for not taking ED treatments as ‘extremely important’ or ‘very important’ by type. From a list of given 12 statements, only those are shown that 450% of the 524 men with self-identified ED rated as extremely or very important.

Table 3 Contact persons and information sources men would use in case affected by ED

% agreement The Sensation seeker The Sensuous The Anxious The Confident The Abstinent

‘To whom would you talk to in case affected by ED?’ GP 62.0 59.4 61.1 61.1 57.0 Partner 48.5 54.7 46.6 53.4 43.5 Andrologist 46.8 54.7 46.6 53.4 43.5 Friends 19.3 17.7 16.3 19.9 14.5 Psychologist 11.2 8.3 9.0 10.4 6.2 Acquaintance 5.1 4.7 5.9 3.2 4.7 No one 4.1 2.6 5.9 1.8 6.2

‘What media would you consult for information on ED treatments?’ Written information from physician 56.3 62.0 62.0 66.5 67.9 Written information from pharmacist 33.6 43.8 47.1 47.1 38.9 Journals 38.3 39.6 46.4 31.2 33.7 Internet 43.7 40.6 26.2. 39.4 24.9 Books 21.7 27.1 14.5 20.4 22.8 Magazines 18.0 8.9 9.0 5.9 3.1 Telephone help-lines 6.1 5.2 4.1 1.8 3.1

International Journal of Impotence Research Typology of men’s sexual attitudes, ED treatment expectations and barriers MM Berner et al 574 In all, 16.5% of the sample had already used a The reason for not choosing the classical cluster PDE-5 inhibitor, 5.8% were current users, 21.9% analysis techniques was that they tend to be classified it as very likely to take such a compound susceptible to response sets, complicating textual in case affected by ED and 32.5% as likely. Among interpretation of the resulting types. men with self-identified ED, 29.0% had already Third, based on the low percentage of men taken sildenafil (46.8% of sensation seekers, 26.4% actually treated for ED in Germany, we selected an of sensuous, 29.7% of anxious, 16.1% of confident age-stratified sample with oversampling of treated and 12.8% of abstinent). For tadalafil, the percen- and untreated ED sufferers. This was to allow an in- tages are 5.7% (7.1, 7.7, 7.9, 0 and 1.2%), and for depth analysis of barriers and drivers for ED vardenafil 3.4% (4.0, 4.4, 3.6, 3.6 and 1.2%). treatment-seeking behavior. Therefore, absolute per- Expecting quality of life, enjoyment and self- centages are not inferable to the general population. esteem from treatment (standardized regression However, this oversampling enabled us to detect coefficient 0.27), fear of side effects and loss of associations and differences between types that are control (À0.25), sexual abstinence and disinterest useful for individual patient counseling and the (À0.23), expecting hard reliable erections from design of educational activities. treatment (0.19) and desire for an intensive Furthermore, all findings reported here are based and excessive sex life (0.17) had the strongest on a survey of German men. Results should be impact on the likelihood to use PDE-5 inhibitors generalized to other nationalities only with caution, (all Po0.0001). owing to the probably high potentially language and culture sensitivity of the discussed issue of sexuality. Despite these premises our data add to the Discussion existing literature of treatment-seeking behavior: First, following our typology approach, we saw We developed a typology based on sexual attitudes, differences in the types not only with regard to their ED treatment expectations and barriers that aimed to attitudes the types were based on, but also in the facilitate understanding of ED-related behavior and perception of ED and in PDE-5 inhibitor usage. This approaching sufferers. We saw relevant differences observation not only supports the validity of the between types not only in the attitudes the types typology itself but also its likely usefulness for were based on but also in the perception of ED and understanding ED-related behavior. It also warrants in PDE-5 inhibitor usage. There are some limitations future research to explore whether these types to our study results, which require special attention. respond differentially to educational approaches. It First, owing to the explorative and qualitative might be important for the practitioner to have nature of our research questions and study goals, specific brief interventions by type to help to which were neither inferential, confirmative nor motivate patients to initiate or continue with quantitative, we choose an iterative, exploratory treatment. study design with the focus on variety of topics and Second, according to our data the most important associations covered, not on accuracy of metrics. In aspect of sexuality is its role for the partnership. line with this principles of qualitative research, the More than 80% of men agreed on statements on the sample was not fully representative for the general partnership-enhancing function of sex. This finding male population in certain variables, the structured is in agreement with previous studies.24,25 The interview was not subjected to a validating proce- strong interrelation of partnership and sexuality dure (for example, establishing test–retest and inter- was also shown in a recent study by Corona et al.,26 rater reliability, internal and external validity), and who reported that characteristics of the relation and only meaningful interpretable association were used the partner are associated with sexual dysfunction. for cluster analysis. As a consequence, results Accordingly, sexual dysfunction must always be should be interpreted qualitatively, not quantita- seen from a partnership perspective and the likely tively. This is fully in accordance with comparable effect of interventions on the partnership should research settings that have yielded important in- receive adequate attention. Successful treatment of sights into perceptual and motivational aspects of ED with the PDE-5 inhibitors has been shown to ED treatment.3,6–9,21–23 improve the partners’ quality of sexual life and the Second, our procedure to define types was quality of partnership.27–31 Following the typology, empirically and heuristically based. In contrast to a satisfying sex life was a significantly more classical cluster analysis techniques, we a priori important constituent of a partnership for sensation defined types as prototypical patterns of attitudes seekers and sensuous than for the other types in our based on empirically established correlations be- sample. tween the two sets of attitudinal factors, and then Third, erectile function in general has been linked performed cluster analysis. The main advantage of to self-esteem in many studies.21,32–34 We saw choosing this procedure is that it allows grouping this association for sensation seekers, sensuous subjects according to a specific research question. and anxious, whereas confident and abstinent

International Journal of Impotence Research Typology of men’s sexual attitudes, ED treatment expectations and barriers MM Berner et al 575 apparently had disconnected self-confidence from resolution of his problem. The confident and the potency issues. Therefore, it would be interesting to abstinent appear to be more difficult or even analyze the reported beneficial effects of ED treat- resistant to be motivated. ment on self-esteem34 by type. Fourth, expecting quality of life, better sex and self-esteem, and hard reliable erections from ED treatment were the most important predictors Acknowledgments increasing likelihood of PDE-5 inhibitor usage. Recent trials have highlighted that sildenafil po- The study was initiated and funded by Pfizer tentiates pudendal artery blood flow and penile Pharma GmbH, Karlsruhe, Germany. Michael Berner oxygenation, thereby helping men with ED achiev- has received honoraria and research funds from ing completely hard (grade 4) erections. Erection Bundesministerium fu¨ r Bildung und Forschung, hardness was correlated with sexual satisfaction and Bayer, Bo¨hringer Ingelheim, Lilly, Pfizer and Will- improvement of self-esteem.35–37 Addressing this mar Schwabe. Sinus sociovision GmbH, Heidelberg, aspect, which might be new to most physician– Germany, conducted the study. Martin Burkart is an patient communication, could therefore encourage employee of Pfizer Pharma GmbH, Karlsruhe, sufferers to seek or continue medical care. Germany. Fifth, perceived risks of ED treatment, mostly baseless from an evidence-based point of view, were found to be among the most important barriers discouraging sufferers from seeking ED treatment in References 9,38 our study as well as in previous surveys. 1 Braun M, Wassmer G, Klotz T, Reifenrath B, Mathers M, Apparently, the publicity of PDE-5 inhibitors and Engelmann U. 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