How Erectile Dysfunction Affects Men

Impact of erectile dysfunction and its subsequent treatment with sildenafil: qualitative study John Tomlinson, David Wright

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John Tomlinson and David Wright investigated the impact of erectile dysfunction on men and their partners, as well as investigating the effects of treatment with sildenafil.

 They conducted their study on 40 men who had erectile dysfunction and attended a clinic in the British National Health Service; they investigated the men's experience of erectile dysfunction and their expectations of sildenafil, and its impact on both them and their relationships. In the abstract of their paper they state, perhaps unsurprisingly, that erectile dysfunction caused marked distress in all the men who experienced it, and also had a profound effect on their self-esteem and their relationships.

Sildenafil seemed to cause a great improvement in the men's well-being when it worked, but if sildenafil did not work, men developed an even lower level of self-esteem, the treatment failure perhaps serving to confirm their lack of self-worth. This clearly means that professionals who prescribe sildenafil need to be conscious of the possible consequences of this course of treatment.

In the body of their article the authors go into more detail about these issues: they start by making the observation that despite a high prevalence, and plenty of awareness about the importance of emotional and psychological issues as cause of the ED, there has been little research into the impact of the condition and the effect of its treatment on either men who suffer from it or their partners.

For example, studies into the quality of life experienced by men with ED have often involved the use of questionnaires that have not always been sensitive to the impact of ED on a man's well-being; for example, one review of over 400 scientific studies on the frequency of impotence and ED simply dismissed the psychological impact of the condition by stating broadly that "Erectile dysfunction is a common condition... [and]... has a negative impact on the quality of life," but failed to elucidate what the impact might be.

Despite this unsatisfactory body of work, some studies have been more sympathetic to men suffering from the condition.

For example, the Sexual Dysfunction Association discovered that just over 60% of men who took part in an online survey agreed that ED reduced their self-esteem; just under 30% reported that their relationships had been adversely affected; and just over 20% claimed that their relationship had come to an end simply because of the erectile dysfunction.

(In our opinion it is actually much more likely that the relationships ended because of a man's inability to cope with the psychological consequences of the ED, which is not quite the same thing.) At the time of this review -- 2004 -- there was considerable social stigma around the condition, with impotence serving as a prolific source of jokes, the social stigma thereby inhibiting men even more from either confiding in others or obtaining treatment from healthcare professionals.

It's interesting to reflect that sildenafil has now been around for over 12 years, and in that period of time what's become very clear is that the initial assumptions made for the drug -- i.e. that it was a "cure-all" for erectile dysfunction -- were unrealistic; a large proportion of men who take the drug find that it does not work for them.

The focus of this study was on the men themselves rather than on their partners, but it does provide interesting insights into the effect of the condition.

As mentioned above, 40 men who had been prescribed sildenafil at a men's health clinic agreed to take part in an exploration of the psychological impact of ED and its treatment.

These men were selected from 302 referrals to the clinic in a 12 month period: these referrals were divided into two groups, one consisting of men for whom sildenafil had been successful, and the other consisting of men where the use of sildenafil had not produced a successful outcome.

It should be made clear at this point that whether or not treatment was successful was determined by the patient's interpretation of the criteria of success provided by the authors of the paper: success was defined as achieving successful vaginal intercourse, while failure was defined as an inability to complete the act of intercourse because of failure to generate an erection which was firm enough to penetrate the man's partner.

From the men in each of these groups, 20 were selected to take part in the study, making a total of 40 participants. The men ranged in age from 22 to 72 years, although the median was just under 52 years. All the men had been prescribed sildenafil at the men's clinic, with an introduction to the treatment method which ensured that their existing expectations were not altered by the consultation.

By using a system of semi structured interviews, the two authors of the paper were able to explore a whole range of issues around the men's experience of both ED and taking sildenafil. The men were interviewed by the same consultant who had prescribed medication for them, with the interviews being audiotaped, and conducted in line with a protocol which was flexible enough to allow the inclusion of new issues raised by any of the participants.

The data gathered were subjected to a thematic analysis, so that any themes which emerged during the course of the initial interviews could be explored in greater depth in subsequent interviews. It's hardly surprising that most men's first reaction to the experience of erectile dysfunction is a sense of being emasculated.

It's well known both to sex therapists and the layman alike that being able to maintain an erection and being able to adequately one's female partner is regarded by most men as a fundamental cornerstone and indicator of both virility and masculinity. This is expressed by the men's clear association between being able to obtain an erection and being a man. As we have said, it isn't only the penis that's a fundamental sign of masculinity; the ability of that penis to become erect is just as important, if not more so.

In many cases a man who cannot get an erection will experience depression. If he is not already in a relationship, a man may find his ability to form new relationships appears to be severely diminished: the logic seems to go something like this; "If a man can't get an erection, he's not a man, therefore no woman would have any respect for him; in any case it would be pointless trying to chat her up because if he were able to get her into bed he couldn't do anything about it."

This is representative of a clear decline in the men's sexual self-confidence, which interestingly enough not only impacted on their sexual relationships, but on their day-to-day relationships with other significant people, including work colleagues and friends.

Often this loss of confidence would be disguised externally, while the man felt internally that he wasn't as good as the men around him. Unsurprisingly, this led to a common sense of isolation and despondency; a feeling which was made worse by the prevalent belief that erectile dysfunction is a condition which only affects men over a certain age, thereby leading younger men with ED to infer that they were "old before their time".

It's equally unsurprising that erectile dysfunction caused these men to feel very concerned about the impact of the condition on their relationships. It is a common characteristic of men to believe that they have a duty to satisfy their partner sexually, so it's no surprise to hear that about a quarter of the men in the study thought that they were letting down their partners by their inability to engage in sexual intercourse.

 Indeed, 15% of them were so concerned about the possible impact of erectile dysfunction that they began to think their partners would desert them: the association here was that if a man couldn't keep an erection he wouldn't be able to keep a woman.

To make this worse, around 40% of the men felt unable to discuss the condition with their partners, probably because they found it easier to avoid the issue or because they felt demeaned by their inability to obtain an erection.

It's interesting that many of the men in the study believe that the administration of sildenafil would cause them to gain an instant erection without any difficulty immediately before sexual intercourse started; in general the expectations were too high, including for example the belief that sildenafil would produce a full or uncontrollable erection, or that it would have a 100% success rate. Like the media reporting of the drug's possible impact on ED, the expectations of the men before treatment appeared to be unrealistic.

Those men for whom it actually worked felt pleased and even elated at their ability to achieve an erection -- this is the real impact of what these men termed "a return to manhood": a sense of well-being and confidence; a sense being able to satisfy whatever sexual needs his partner expressed; a recapturing of a sense of manhood and masculinity.

It is therefore no surprise that when treatment with sildenafil was unsuccessful, the men's perception of the failure was massively impacted by their previous expectations. If, for example, they had believed that all that was necessary to achieve a firm erection was to take one pill, their hopes would fall, and then if a second failure ensued, they would report feelings like bereavement, grief for the loss of their masculinity, or even a sense that they would never be able to have sex again.

The researchers report that "considerable disappointment" was a common reaction to the failure of treatment, and some men in the study for whom sildenafil was ineffective felt devastated; others regarded the treatment as a failure because they hadn't understood there needs to be a certain element of planning in taking sildenafil, and they felt that sex had become unspontaneous, planned, or clinical.

All in all, the study revealed that most men with ED are more deeply shocked than most health care practitioners have previously understood, with their sense of self-esteem and their sense of masculinity being particularly devastated. It doesn't matter what the cause of ED might be, its impact is more or less the same in every case -- a severely damaged sense of masculinity, a profound reduction in a man's feeling of self-worth, and a reduction in his sense of value to his partner, as well as a profound loss of self-esteem about his place in wider society.

The researchers conclude from this that it is not adequate to treat a man in isolation; details of his sexual relationship should be obtained, and perhaps as later researchers have demonstrated, the partner should be involved in decisions around treatment and explanations of what may be expected.

The men for whom sildenafil did not work at this time probably didn't receive advice and counseling which would have given them a higher chance of success, because subsequent work has demonstrated that it can take up to 8 doses for sildenafil to have its full effect, and that persistence is often necessary for treatment to become effective. At this time, men who didn't have this information might experience one or two failures of treatment, which would have the undesirable effect of reinforcing their sense of worthlessness.