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 (25–64 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 (EHS⩽3) 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 (∼94.0%) 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 (∼65.0%) to reduce a man's confidence about the next sexual encounter and also his self-confidence and self-esteem overall.
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 10–50% of men aged >40 years.2, 3, 4 ED negatively impacts QoL, self-esteem and the ability to maintain intimate relationships, which can be improved with phosphodiesterase 5 inhibitor treatment.5, 6, 7, 8, 9 Effective treatment also has a positive impact on QoL in the female partners of men with ED.10, 11, 12, 13, 14 To understand the relationship between ED and QoL, several validated patient-reported outcomes questionnaires have been developed that capture the degree of erectile function, its psychosocial impact and response to treatment.15, 16, 17 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 12 500 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
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.
Participants were recruited from existing online consumer opinion research panels by Double Helix Inc. and invited by e-mail to participate in an anonymous survey exploring their opinion on sexual health aspects. Participants were 25–64 years old and had experienced ⩾1 sexual encounter with another person in the last year. Male and female participants were not partners. Respondents working in market research, 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, in-country 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 Research20 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.
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 ED5, 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 <10 min to complete. A copy of the survey is available in the Supplementary information.
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 <0.05 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’.
A total of 143 419 panellists were invited to participate; 13 255 volunteered before the target quotas of eligible participants were reached (Figure 1). The demographics of the 8576 subjects included in the analysis (mean age 42.7 years, 95% CI: 42.5–43.0) are described in Table 1.
Overall, 25.1% participants reported non-optimal erection hardness (EHS of ⩽3) for themselves or for their partners. An EHS of 4 was reported by 69.9% (95% CI: 68.4–71.2) of men and 69.8% (95% CI: 68.4–71.2) of women for their partners. EHSs reported in the 25–34 year age group were consistently higher than those reported in other age groups (Figure 2). Only 49.7% (95% CI: 47.2–52.2) of subjects reported an EHS of 4 in the oldest age group (55–64 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: 78.1–79.8; 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: 32.5–34.5) and reaching an orgasm at each sexual encounter (33.8%; 95% CI: 32.8–34.8); three in ten respondents linked a man's sexual confidence to his ability to attract sexual partners (28.4%; 95% CI: 27.5–29.4).
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%; P<0.0001), (b) achieve a strong and hard erection (35.9 vs 31.1%; P<0.0001) and (c) attract their partner sexually (31.9 vs 25.0%; P<0.0001). 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%; P<0.0001).
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: 64.1–66.1), and make him feel less confident about his next sexual encounter (64.2%; 95% CI: 63.2–65.2). 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: 43.6–45.7) or make him less confident about his life overall (47.7%; 95% CI: 46.6–48.7). 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%; P<0.0001) and make him feel less confident about his life overall (51.2 vs 44.1%; P<0.0001). Notably, only 10.0% (95% CI: 9.4–10.6) 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: 94.2–95.1) 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=0.0009). Although the majority of participants (87.5%; 95% CI: 86.8–88.2) agreed that, ‘being able to achieve and maintain a hard and firm erection enables men to have good sex’, this was more frequently supported by male respondents overall (P<0.0001) and in terms of those who agreed strongly (P<0.0001). The majority of participants (94.0%; 95% CI: 93.5–94.5) 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%; P<0.0001).
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: 56.5–59.4) of men reported they would like to consistently experience firmer or harder erections to improve their sex life, and 38.7% (95% CI: 30.9–33.7) of women believed that their partner would like to consistently experience firmer or harder erections to improve their sex life.
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 ⩽3 or women reporting an EHS of ⩽3 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.
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
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 consistently experience harder erections, whereas ∼70% 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 ⩽3) 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 self-esteem’. 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:
Only people with Internet access could participate, however, quotas ensured the study population was representative of the general population.
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.
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.
Other aspects of sexual activity known to influence sexual confidence, such as premature ejaculation, were not addressed in this survey.
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.
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 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.
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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.
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.
Parts of the study have been presented at the 12th Congress of the European Society for Sexual Medicine, 15–18 November 2009, Lyon, France (Abstract PO-03-030).
Supplementary Information accompanies the paper on International Journal of Impotence Research website
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San Martín, C., Simonelli, C., Sønksen, J. et al. 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. Int J Impot Res 24, 234–241 (2012). https://doi.org/10.1038/ijir.2012.23
- erectile dysfunction
- erection hardness
- health surveys
- quality of life
- sexual confidence
- sexual satisfaction
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