We describe psychological determinants of erectile dysfunction (ED) among middle-aged men with no identifiable medical risk factors and compare them with a sample of young individuals. Two groups of young (⩽30 years, n=59) and middle-aged men (⩾40 years, n=63) who scored ⩽25 on the erectile functioning domain of the International Index of Erectile Functioning were enrolled. Patients were included if they had no metabolic diseases, prostate problems or external genitalia abnormalities. Patients were not included if they were smokers, excessive drinkers or took medications known to cause ED. To assess psychopathology, symptom check list 90-revised (SCL-90-R) was administered. Structural equation modeling was performed to assess the relationship between psychopathology and ED. One in five men had severe ED, and the proportion was not different between the two groups. Middle-aged men had lower scores on different SCL-90-R domains. In both age groups, somatization and interpersonal sensitivity contributed to ED. Among younger individuals, anxiety and psychosis-related domains were also associated with ED. Unique contributors to ED in middle-aged men were depression and additional questions. In conclusion, among middle-aged men, psychological factors significantly contribute to ED when no medical risk factors are present. The pattern and composition of distress depicts distinct features, not seen in young age.
Erectile dysfunction (ED) defined as the inability to achieve and/or maintain penile erection satisfactory for sexual performance is a disorder of sexual health that significantly lowers an individual’s quality of life, relationship and overall happiness.1 Over the past two decades, there has been a paradigm shift in how health-care professionals look at, classify and approach to ED. Although early viewpoints portrayed erectile problems as principally disorders of psychological origin,2 there has been an overwhelming predilection toward ‘medicalization’ of ED in the population of middle-aged men,3 primarily due to the following reasons. First, large cross-sectional and cohort studies of ED have ubiquitously showed that the prevalence of ED greatly increases with advancing age.1,4, 5, 6, 7, 8 This precipitous increase has been largely ascribed to morbid lifestyle habits and medical conditions including, but not limited to, cigarette smoking, excessive alcohol consumption, physical inactivity, diabetes, overweight and obesity, hypertension, dyslipidemia, cardiovascular and peripheral vascular diseases, diseases of the prostate and decreases in levels of the sex hormone, testosterone.4, 5, 6, 7,9, 10, 11, 12, 13, 14 It has been suggested that through the prevention and treatment of the aforementioned conditions, the trajectory of ED at middle age could be overturned. Second, the introduction of 5-phosphodiesterase inhibitor, Sildenafil, has also substantially lent credence to the standpoint that ED is a medical condition responding well to pharmacological interventions.15
Notwithstanding the germane role of medical and lifestyle factors in the etiopathogenesis of ED, the putative contribution of psychological factors should not be undermined.7,16, 17, 18 In a proportion of middle-aged men with no apparent medical cause for ED, psychological abnormalities seem to have a more prominent role.
Even when presumptive medical factors are present, psychological distress might still be the principal contributor, or at least be partly responsible for the condition.19 This probably explains why Sildenafil or other medications aimed at treating ED fail to help some patients achieve erection, or why a sizable minority of patients discontinue taking the medication despite the initial ‘quick fix’ they observe in their sex life.1,20 The European Male Ageing Study showed that testosterone deficiency is strongly associated with ED, and psychological symptoms do not correlate with the levels of testosterone.14 These findings indicate that psychological distress influences ED via independent mechanisms and are to be considered separately from medical causes.
For these considerations, we aimed to investigate the presence and characteristics of erectile problems in a group of middle-aged men presenting to a sex clinic with the chief complaint of ED, despite having no evident medical risk factors. We hypothesized by incorporating a comparative framework, a better understanding of the psychological determinants of ED among middle-aged men could be achieved. For this reason, a second group of young men under 30 years with a similar complaint were also enrolled, and the findings of the study are presented in a comparative manner.
Patients and methods
Between June 2007 and September 2009, two groups of men who visited a university-affiliated sex clinic in Tehran with the chief complaint of ED were enrolled. The first group comprised men in intact first marriages who were 30 years old or below. The second group consisted of men in intact first marriages who were at least 40 years old. Individuals were enrolled if they had a score of 25 or below on the erectile function domain of the International Index of Erectile Functioning (see below), but upon evaluation had no identifiable medical or lifestyle factor for ED to be ascribed to. The initial assessment, performed by a general practitioner or a urologist consisted of obtaining a detailed medical history and conduct of a thorough physical examination. Wherever indicated, patients were also referred for a blood draw and laboratory assessment. On the basis of the initial evaluations, individuals were not enrolled if they had (1) diabetes mellitus (type 1 or 2) or impaired fasting glucose; (2) high blood pressure; (3) body mass index above 30 kg m−2; (4) known cardiovascular disease or medical history suggestive of coronary artery disease, cerebrovascular disease or peripheral vascular disease; (5) known chronic liver or kidney disease; (6) known neurological or cognitive disorders or neurological impairments on examination; (7) taken medications linked to ED (that is, anti-hypertensive medications including, but not limited to beta blockers, diuretics and calcium channel blockers, all classes of anti-depressants and anxiolytics, antihistamines, antiarrhythmics, gonadotropin-releasing hormone agonists and testosterone antagonists) in the past 6 months; (8) abnormal findings after external genitalia examination (Peyronie’s disease, chordee, hypospadias, epispadias, previous penile fracture, ambiguous genitalia and lack of development of secondary sex characteristics); (9) benign prostatic hyperplasia, prostate malignancies or abnormalities detected upon digital rectal examination. Individuals were also excluded if, in the past year, they had (10) smoked cigarettes; (11) consumed >21 units of alcohol per week; (11) taken psychoactive drugs and substances. Of >400 consecutive individuals with ED initially interviewed, 128 (young group=63, middle-aged group=65) met the inclusion and exclusion criteria and were recruited. For the included subjects, the symptom checklist-90-revised edition (SCL-90-R) was administered (see below).
Written informed consent was obtained from all participating individuals. All procedures were conducted in accordance with the guidelines laid down in the Helsinki declaration. Ethics committee of the university also approved the study protocol.
International Index of Erectile Functioning: It is a 15-item likert-type self-administered instrument developed by Rosen et al.8 to evaluate different domains of male erectile and sexual functioning. For the purpose of this study, the first domain ‘erectile function’ was employed, which comprises questions 1–5 and also question 15. Each question is rated on a likert-type and a composite score ranging between a minimum of 6 and maximum of 30 is then derived by adding the individual scores. According to a study by Cappelleri et al.,21 and based on classification and regression trees analysis, 25 has been set as the optimal cutoff point for diagnosis of ED, yielding a sensitivity and specificity of 97% and 88%, respectively. Therefore, individuals with scores 26 and above have no ED. Scores 25 and lower are further categorized to delineate the severity of the problem. According to Cappelleri’s recommendations, the four categories of ED severity are as follows: mild (score 22–25), mild-to-moderate (score 17–21), moderate (score 11–16) and severe (score 6–10).21 In the present study, a translated (Farsi) version of the instrument developed by Mehraban et al.22 was used.
SCL-90-R: developed originally by Derogatis et al. in 1973 and revised in 1976, is a multidimensional, 90-item, self-administered, likert-type instrument that aims to assess a broad range of psychological problems categorized in nine principal symptom groups.23,24 The 10 distinct domains of the SCL-90-R include somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism and additional questions. Each item of the questionnaire is rated on a 5-point likert-type scale of 0 (not at all) to 4 (extremely). The scores on individual items within each domain are then added and divided by the number of items in that specific domain to calculate a raw score. Apart from 10 domain-specific scores, a set of three summary scores namely global severity index (GSI), positive symptom total and positive symptom distress index (PSDI) are also calculated. GSI provides a summary score for the number and intensity of psychological distress, and is determined by adding raw scores from all dimensions divided by the total number of items (90). Positive symptom total is concerned with the number of symptoms and is calculated by counting the total number of items with non-zero answers. Finally, the PSDI, a measure of pure intensity, is calculated by adding the raw scores from individual domains and then dividing it by the positive symptom total.
In this study, a translated (Farsi) version of this inventory was used.
Univariate analyses were conducted using the IBM SPSS Statistics for Windows, version 20 (IBM, Armonk, NY, USA). For structural equation modeling, Amos version 7.0 (SPSS, Chicago, IL, USA) was used. Before conducting structural equation modeling, SCL-90-R domains underwent reliability testing using Cronbach’s alpha. An alpha of ⩾0.9 presents excellent reliability; 0.8⩽α<0.9 indicates good reliability, 0.7⩽α<0.8 represents acceptable consistency and in cases of α⩽0.7 the internal consistency between individual elements is poor. Continuous variables were expressed as mean±s.d. and categorical ones as proportions. To compare continuous variables across the two groups, independent t-test was used. Proportions across groups were compared using the χ2-test. To assess the correlation between individual domains of SCL-90-R and ED score, partial correlation coefficient was calculated and the confounding effect of age within each group was accounted for.
For path analysis, structural equation modeling was used. In the initial model, all SCL-90-R domains were vectored toward ED. Residual variances for variables in the model were assumed and interrelatedness between residual terms of the SCL-90-R components was allowed. For each model, fit indices including χ2, P-value for χ2, degrees of freedom, comparative fit index and root mean square error of approximation (RMSEA) along with its 90% confidence interval were determined. For drawn paths, standardized regression coefficients were calculated and a t-test for statistical significance of the path was performed. To revise the baseline model, preliminary paths not reaching statistical significance were removed in a stepwise manner, and the procedure was continued until all remaining paths were statistically significant and fit indices were acceptable and/or excellent. On the basis of Kline’s recommendations, comparative fit index>0.90 and RMSEA⩽0.08 suggest an acceptable fit for the specified model. In the group of middle-aged men, paths with significant associations were placed in binary logistic regression models to test the hypothesis whether individual domains predict severe ED. In all tests, a P-value <0.05 was considered as the threshold to reject the null hypothesis.
Completed assessments were available for 59 and 63 individuals in the young and middle-aged groups, respectively. The minimum and maximum age for the middle-aged group were 40 and 57 years, respectively (mean±s.d.: 45.7±3.7). For the young age group, the minimum and maximum age were 24 and 30 years, respectively (mean±s.d.: 27.4±1.6). The mean±s.d. of ED scores for young and middle-aged men were 15.9±5.1 and 14.4±5.5 in order, and were not significantly different between the two groups (P=0.125). The proportion of men with mild, mild-to-moderate, moderate and severe ED is delineated in Figure 1. Despite the observed discrepancies in the distribution of mild and mild-to-moderate ED, the proportion of individuals with severe ED was nearly identical in young and middle-aged men.
Cronbach’s alpha for different domains of SCL-90-R showed an acceptable-to-excellent level of internal reliability (ranging between 0.734 and 0.875 for individual domains). Mean scores for the 10 distinct domains of SCL-90-R questionnaire along with composite GSI and PSDI scores are presented in Figure 2. In all domains examined, middle-aged men scored lower than young men did, and except for interpersonal sensitivity (P=0.662) and paranoid ideation (P=0.364) the between-group difference was statistically significant. Middle-aged men also scored significantly lower on GSI, but not PSDI (P=0.001 and 0.530, respectively).
The results of partial correlation analysis between ED score and SCL-90-R domains and also composite scores are presented in Table 1. Among young men, the largest correlation coefficient belonged to the interpersonal sensitivity domain (r=−0.639, P<0.001). Summary scores GSI and PSDI also negatively correlated with ED (Table 1). With regard to middle-aged men, a significant but negative correlation between ED and the following individual domains was identified: somatization, depression, paranoid ideation and psychoticism. The strongest correlation coefficient for middle-aged men belonged to somatization (r=−0.639, P<0.001). Summary scores GSI and positive symptom total, but not PSDI, also negatively correlated with ED. Collectively, whereas for young men 8 out of 10 individual domains significantly correlated with the ED score, among men aged 40 years and above, only four significant relationships were noted.
The findings from path analysis are demonstrated in Figure 3. Fit indices for the final model in each group are summarized in Table 2. In both young and middle-aged groups, somatization and interpersonal sensitivity contributed to ED. Among younger individuals, anxiety and psychosis-related domains (obsessive compulsive, anxiety, paranoid ideation and psychoticism) were also associated with ED. Among middle-aged men, unique associations from depression and additional questions to ED were observed. Among middle-aged men, the largest standardized regression coefficient was observed for the path connecting somatization to ED (Figure 3b).
In binary logistic regression models, as delineated in Table 3, somatization, depression, additional questions, but not interpersonal sensitivity, were all significant predictors of severe ED among middle-aged men. The largest odds ratio was calculated for somatization; each unit increase in the somatization score was associated with a sixfold increment in risk of being diagnosed with severe ED.
In the present study, we aimed to characterize a select cohort of middle-aged men with ED in whom ED could not simply be attributed to the coexisting lifestyle, habitual and medical risk factors. On the basis of our findings, middle-aged men are more likely to have mild-to-moderate ED, yet the frequency of severe ED is almost identical between middle-aged and young men.
We observed here that among middle-aged men, similar to their younger counterparts, there is a strong link between psychological distress and ED. Middle-aged men tended to score lower on various dimensions of SCL-90-R; multiple strong correlations were identifiable, nonetheless.
In the multivariate analysis, significant paths from psychological domains to ED score were noted, further highlighting the possibility of presence of a link between psychological problems and ED. Given the comparative framework of the study, we were able to identify some similarities and some discrepancies between young and middle-aged men. Somatization and interpersonal sensitivity appeared to be significant contributors in both age groups. However, although anxiety, obsessive compulsive, paranoid ideation and psychoticism seemed to be of importance among young men, they did not stand out in the final model for middle-aged men. Instead, lower ED scores were linked to higher scores on depression and additional question domains, highlighting the unique psychological profile of ED in middle-aged men. Another unique observation made herein was that except for interpersonal sensitivity, other domains were associated with ED severity.
The association between psychological distress and ED is well recognized.17,18,25, 26, 27 Derogatis et al.28 demonstrated that a psychiatric diagnosis can be made in as many as 37% of the male patients with ED who sought treatment at a sex clinic. The sample was also characterized by a high GSI score, indicating a significant level of psychological distress in the average patient with ED, even in the absence of a clear-cut psychiatric diagnosis.28 In another effort, Mallis et al.26 showed that in a series of patients diagnosed with mostly moderate-to-severe ED, a psychiatric diagnosis can be traced in about two-thirds of them; major diagnostic classes were depressive disorders, anxiety disorders, depression-anxiety comorbidity and also personality disorders.
In comparison with young men, middle-aged men with ED, on average, scored lower on individual, as well as global constructs of psychological distress. This finding falls well within the currently accepted narrative that psychological problems gradually decline with advancing age.29, 30, 31, 32 The lower prevalence of psychological distress in middle age and older age has been ascribed to the development of better coping mechanisms, improved handling of emotional stressors and waning of emotional responsiveness.29 Apart from this declining trend, we observed herein that the composition of domains associated with ED differs between the two age groups. Although anxiety and psychosis-related domains prevailed among the young, depression and additional questions were of more importance among the middle-aged men. Collectively, it can be stated that in middle-aged men, a transformation in both composition and severity of the psychological domains associated with ED is observed. The reason behind this transformation toward lesser, and different constructs remains speculative at best, but might be a part of general psychological changes that a man goes through with advancing age.
Somatization was associated with ED in both young and middle-aged men; the regression coefficient was in fact larger among the middle-aged men. In line with our findings, Corona et al.25 in a sample of 1388 men of whom the majority were middle-aged (average age: 51 years) concluded that among different psychiatric symptoms, men with somatization symptoms exhibited the worst levels of erectile functioning. On the basis of their account, a heightened attention toward ones’ body and physical malfunctions could intensify and worsen the already present ED, thus forming a vicious cycle of negative feedback and feedforward.25
A number of limitations in our study deserve mention. First, the cross-sectional nature of our study precludes any inferences of causality or directionality to be drawn. Although available evidence suggest that psychological distress is likely to be the cause of ED and not its consequence,33 yet the vector of this relationship could well be inverse or bilateral.25,34 A third possibility is that both constructs might be the consequences of a yet an independent underlying attribute such as personality type, marital discord and so on. Second, ED is a perplexing phenomenon of multifactorial etiology; accordingly, a comprehensive assessment of the problem should not only include evaluating medical, lifestyle and psychological factors, but should also take social, cultural and above all relationship/marital factors into account.35 Marital conflict and dissatisfaction may well be a source of sexual problems or at least be mediated or moderated by them.18 In the present study, for both groups, married men in intact first marriages were enrolled. Future studies that include marital quality and/or discord into their model of ED are needed. Third, in the current sample, we only included young and middle-aged men with ED and no apparent medical comorbidity. Ideally, this study should have been expanded to include a matched group of middle-aged men with no ED. In such a scenario, the levels of psychological problems could have been compared between the two groups of middle-aged men, and more factual inferences about the possible etiology of ED in middle age could be drawn. Fourth, structural equation modeling is an analysis of large sample sizes, and available literature suggests that the larger the sample size, the more powerful the analysis to detect significant paths between variables. Our included sample size was relatively small and this might have resulted in inadequate power to detect some significant paths between psychological domains and ED. Future studies with larger sample sizes are paramount in this regard to overcome this shortcoming.
Despite these limitations, our findings have important implications for practitioners in the field of sex therapy. A sound and thorough initial work-up of the middle-aged man presenting with ED should include acquisition of a detailed medical history, performance of a complete physical examination, along with ordering relevant laboratory assessments. Moreover, a comprehensive psychosocial survey should be conducted, and in the presence of significant abnormalities, apropos referral to a psychologist expert in the field of relationship counseling and sex therapy should be made. Even in the face of clear medical causes, caution should be made not to neglect the possible underlying psychological distress and these considerations should also be taken into account before choosing the treatment strategy, which would likely include a combination of psychological as well medical interventions.
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The authors declare no conflict of interest.
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Aghighi, A., Grigoryan, V. & Delavar, A. Psychological determinants of erectile dysfunction among middle-aged men. Int J Impot Res 27, 63–68 (2015). https://doi.org/10.1038/ijir.2014.34
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