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Erectile Dysfunction and Constructs of Masculinity and Quality of
Life in the Multinational Men’s Attitudes to Life Events and
Sexuality (MALES) Study

Michael S. Sand, PhD, MPH,* William Fisher, PhD,† Raymond Rosen, PhD,‡ Julia Heiman, PhD,§ andIan Eardley, MD¶ *Bayer Schering Pharma AG, Wuppertal, Germany; †University of Western Ontario, London, Ontario, Canada;‡New England Research Institutes, Watertown, MA, USA; §The Kinsey Institute, Indiana University, Bloomington, IN, USA;¶St James’s University Hospital, Leeds, UK A B S T R A C T
Introduction. The Men’s Attitudes to Life Events and Sexuality (MALES) study assessed the prevalence and
correlates of erectile dysfunction, and examined men’s attitudes and behavior in relation to this dysfunction.
Aim. To report on the attitudes of men, with and without self-reported erectile dysfunction, concerning masculine
identity and quality of life.
Methods. The MALES Phase I study included 27,839 randomly selected men (aged 20–75 years) from eight
countries (United States, United Kingdom, Germany, France, Italy, Spain, Mexico, and Brazil) who responded to a
standardized computer-assisted telephone interview.
Main Outcome Measure. Perceptions of masculinity and quality of life in men with and without erectile
Results. Men’s perceptions of masculinity differed substantially from stereotypes in the literature. Men reported that
being seen as honorable, self-reliant, and respected by friends were important determinants of self-perceived
masculinity. In contrast, factors stereotypically associated with masculinity, such as being physically attractive,
sexually active, and successful with women, were deemed to be less important to men’s sense of masculinity. These
findings appeared consistently across all nationalities and all age groups studied. For quality of life, factors that men
deemed of significant importance included good health, harmonious family life, and a good relationship with their
wife/partner. Such factors had significantly greater importance to quality of life than concerns such as having a good
job, having a nice home, living life to the full, or having a satisfying sex life. Of note, rankings of constructs of
masculinity and quality of life did not meaningfully differ in men with or without erectile dysfunction, and men with
erectile dysfunction who did or did not seek treatment for their sexual dysfunction.
Conclusions. The present findings highlight the significance of partnered relationships and interpersonal factors in
the management of erectile dysfunction, and empirically challenge a number of widely held stereotypes concerning
men, masculinity, sex, and quality of life. Sand MS, Fisher W, Rosen R, Heiman J, and Eardley I. Erectile
dysfunction and constructs of masculinity and quality of life in the multinational Men’s Attitudes to Life
Events and Sexuality (MALES) study. J Sex Med 2008;5:583–594.

Key Words. Erectile Dysfunction; Quality of Life; Masculinity; Gender Identity
of masculinity, and their subjective quality of life.
In addition, men’s help seeking and treatment A lthough the epidemiology, risk factors, utilization for erectile dysfunction have only pathophysiology, and treatment of erectile recently been investigated [9–11], and the poten- dysfunction have been rigorously investigated in tial for factors such as masculine identity and recent years [1–8], no large-scale studies have quality of life considerations to influence treat- investigated the association between men’s expe- ment seeking for erectile dysfunction remains to rience of erectile dysfunction, their perceptions 2008 International Society for Sexual Medicine Current discourse on help seeking and mascu- structs and attitudes toward help seeking rather linity has focused largely on differences between than help-seeking behavior per se [16,24,25].
the sexes. Available research has highlighted In the context of sexual dysfunction, it has been well-recognized sex differences such that men seek estimated that up to 70% of men with erectile professional help less frequently than women of dysfunction do not seek treatment [8]. Male comparable age, nationality, race, and ethnicity; gender role socialization theory suggests that men visit general practitioners and specialists less men with erectile dysfunction might avoid seeking frequently than women do; and—when they do treatment, because to do so would conflict with or consult with a physician—men ask fewer questions threaten masculine self-concepts, which hold that and play a more passive role in the physician– having an “active sex life” and “success with patient relationship than women do [12–16].
women” are central to their core sense of mascu- Research has also found that men seek psychiatric linity [26–28]. Following this, it may be hypoth- and counseling services less often than women esized that men with erectile dysfunction who seek with comparable emotional problems [17,18], treatment for their sexual dysfunction would differ and demonstrate lower rates of help seeking for from men with erectile dysfunction who have not such diverse conditions as cancer and depression sought treatment in their endorsement of the [19,20]. The male disinclination to seek medical importance of these constructs to their masculine help is not indicative of better health: on average and across most nationalities, men suffer higher The Men’s Attitudes to Life Events and Sexu- mortality from heart disease, higher rates of ality (MALES) study was a large, multinational suicide and trauma, and higher rates of alcohol and two-phase investigation that was conducted in part substance abuse [21]. Investigators have proposed to assess erectile dysfunction-related variations in a number of mechanisms to account for these perceptions of masculinity and quality of life, and differences. One such proposition uses a social to examine the relationship of erectile dysfunction constructionist/feminist perspective to suggest treatment-seeking practices with these factors.
that health-related beliefs and behaviors are a The initial MALES research report documented means of demonstrating masculinity. Men adhere the prevalence of erectile dysfunction and its asso- to cultural definitions of masculinity and actively ciation with other common comorbid diseases reject what is feminine: in practice, they adopt of men [29]. Further studies have established that riskier behaviors (than women) and are less perceived erectile dysfunction severity, beliefs inclined to seek help when health problems are about erectile dysfunction medication, and refer- encountered [22]. However, we remain largely ent influences are strongly correlated with erectile uninformed about male-specific within-group dysfunction treatment-seeking behavior [11,30].
variations in psychological and cultural factors thatmay influence men’s patterns of help-seeking behavior, and we have little understanding of whysome men seek treatment for a given condition The current research assessed constructs of mas- culinity and quality of life in the large, multina- Models of gender role socialization suggest tional MALES sample in an effort to understand that men (and women) learn gendered attitudes how these constructs may differ between men with and behaviors from prevailing societal values and and without erectile dysfunction, and to define the norms—strongly represented and reinforced in relationship between men’s help-seeking behavior popular media—about what it means to be a man for erectile dysfunction and their construction of or a woman (for a review of psychological concepts and measures of masculinity, see Smiler [23]). Assuggested by Addis and Mahalik [16], many of the tasks associated with help seeking—e.g., admissionof the need for help and reliance on others—are in The MALES Phase I study sample consisted of conflict with men’s socialization concerning the 27,839 adult men, aged 20–75 years, from eight importance of self-reliance and emotional control.
countries (United States, United Kingdom, Much research in the area of gender and help Germany, France, Italy, Spain, Mexico, and Brazil) seeking has been conducted in convenience who participated from February 2001 to April samples, often college undergraduates, and has 2001. Men were recruited via random digit dialing focused on the association between masculine con- (80% of the sample) or via e-mail following a Constructs of Masculinity and Quality of Life random selection of names from a list of men who men who self-reported having or not having erec- had previously agreed to participate in a study of tion difficulties, as compared with a wide variety of men’s health issues (20%). Reported findings were other common male health-related concerns. Full weighted to represent the general male population details of the self-report instrument used to assess by age within each national sample. Weighted N erectile dysfunction in the study have been previ- values for each country were as follows: United States, 9,284; United Kingdom, 2,053; Germany, In the context of the MALES telephone inter- 3,040; France, 2,053; Italy, 2,130; Spain, 1,453; view, men were also asked for their views of the importance of a number of potential constituents A standardized questionnaire was administered of male identity. Men were asked to rate the in the course of the computer-assisted telephone importance of each of the following survey items interviews, which lasted for approximately 15 in regard to male identity: having a good job, minutes. Interviews were conducted by both having financial stability, being seen as a man of female and male interviewers. The questions honor, having success with women, coping with assessed general demographic information (age, problems on your own, having an active sex life, marital/relationship and economic status, size of being in control of your own life, being physically household) and overall health ratings. The survey attractive, and having the respect of friends. Par- also assessed the prevalence of selected diseases ticipants were asked to rate each item on a 7-point and conditions; current use of medication for Likert scale (from 1, not at all important to the selected diseases and conditions, and for erectile male identity, to 7, very important to the male dysfunction per se; attitudes to medical consulta- identity) from a personal perspective; they were tion and medical treatment; awareness, trial, and also asked how they thought the general public continuing use of several prescription drugs; and would similarly evaluate each construct. Res- attitudes toward male identity and quality of life.
pondents were then asked to cite which of the Questions on sexual orientation were not asked.
characteristics of male identity listed was the The survey gathered self-report information only most important. Only men’s personal ratings were and no attempt was made to validate responses reported here; their ratings for what they believed with medical records, physician or partner reports.
the general public perceives were not reported.
Men were considered to have a certain medical Respondents were subsequently queried about condition if they reported being diagnosed and/or constructs central to their perception of quality of receiving treatment for the condition.
life. Using a 7-point Likert scale (from 1, not at all As sexual dysfunction is a sensitive topic important, to 7, very important), the following deemed potentially susceptible to selection factors, aspects of quality of life were rated: harmonious an indirect measurement approach was employed family life, satisfying work life or career, good rela- in an effort to minimize subject self-selection. Spe- tionship with partner/wife, having a nice home, cifically, men were invited to participate in a survey having a satisfying sex life, being in good health, of men’s health concerns—not of erectile dysfunc- and enjoying life to the fullest. Respondents were tion per se—and the survey protocol covered a then asked to cite which of these constructs of number of men’s health content areas prior to the quality of life was the most important. Using a specific question about erectile dysfunction. The similar scale (from 1, not satisfied at all, to 7, com- questionnaire included the following item among pletely satisfied), men were then asked how satis- others: “The health conditions I have just men- fied they were with each aspect of quality of life.
tioned are all very common in men, but some men The Appendix contains the exact phrasing of the do something to treat or improve them while questions posed to assess constructs of masculinity others do not. I will read out each of the conditions again. For each one, please tell me if you have: (A)Seen a doctor, pharmacist or therapist about it; (B) Main Outcome Measures
Tried any kind of remedy, with or without pre-scription; (C) Not done anything about it; or (D) Perceptions of masculinity and quality of life in Never had it.” Men were asked this question for men with and without erectile dysfunction were occasional headache, weight problems, rapid hair determined. For purposes of this analysis, we loss, feeling overstressed, erection difficulties, grouped men who self-reported erectile dysfunc- hemorrhoids, and feelings of anxiety or depres- tion into two categories on the basis of physician sion. Thus, our study assessed the proportion of visits and treatment-seeking behavior: treatment seekers (men who responded “yes” to having population have been published previously [29].
erectile dysfunction and who sought professional The prevalence of self-reported erectile dysfunc- help by either seeing a physician or counselor, or tion increased with increasing age as follows: actively sought treatment with either prescription 20–29 (8%), 30–39 (11%), 40–49 (15%), 50–59 or nonprescription drugs; N = 2,207) and treat- (22%), 60–69 (30%), and 70–75 years (37%).
ment non-seekers (men who reported having erec- These data are consistent with other community- tile dysfunction and who did not seek any form of based studies that report increased erectile dys- professional help or treatment; N = 2,215).
function prevalence with increasing age [1,31–33].
Constructs of Masculinity as a Function Constructs of masculinity deemed most important varied substantially across countries in the over- A total of 27,839 men were recruited for Phase I of all sample (Table 2), although mean importance the MALES study. The age distribution of the scores were considerably more homogeneous study population in each country was generally (Table 2). “Being seen as a man of honor” was cited representative of the male population; the propor- as the most important attribute of masculine iden- tion of men recruited in each age group corre- tity in Spain, Brazil, Mexico, United States, and sponded with the census-based age breakdown of France, while “being in control of your own life” that country. The demographic data are summa- was the most important in Germany, the United Kingdom, and Italy. Contrary to popular stereo-types of masculinity and across all countries Prevalence of Erectile Dysfunction sampled, attributes involving social respect, e.g., The overall prevalence of self-reported erectile “being seen as a man of honor” and “having the respect of friends,” were overwhelmingly more Phase I study population, and was highest in men often cited as the most important constructs of from the United States (22%) and lowest in Spain masculinity than were attributes focused solely on (10%). Full data for erectile dysfunction preva- sexuality, e.g., “having success with women,” lence by country in the MALES Phase I study “having an active sex life,” and “being physicallyattractive,” Although sexuality-focused attributeswere not often cited as the most important con-structs of masculinity, mean importance scores Baseline demographic data of study population expressed on the 7-point Likert scale showed that men still considered them important.
Constructs of Masculinity as a Function of Age and Stratifying the data regarding the most important constructs of masculinity according to age did not substantially alter the overall pattern of findings (Table 3). The effect of being in a partnered rela- tionship was also negligible, although “being seen as a man of honor” was considered the most important by married men or men with partners, while single men considered “being in control of your own life” the most important construct of Constructs of Masculinity as a Function of Erectile In contrast to expectations, constructs of mascu- linity did not vary significantly between men witherectile dysfunction and men without erectile *Weighted to represent the general male population by age within eachsample selected.
dysfunction (Table 4). In addition, constructs of Constructs of Masculinity and Quality of Life Constructs of masculinity as a function of erectile dysfunction and treatment seeking Data shown are the percentage of men citing each attribute as the “most important.” Data for the construct cited as the most important within each group arehighlighted in bold.
masculinity were similar between men with erec- the percentage of men citing this construct in- tile dysfunction who were treatment seekers and creased consistently with increasing age (Table 6).
men with erectile dysfunction who did not seek No other factor showed a similar trend. “Being in good health” was also cited as the most importantin single men, although subjects who were Constructs of Quality of Life as a Function married/living with partner cited “harmonious family life” and “good relationship with a partner/ Across the nationalities sampled, the most impor- tant construct of quality of life showed significantvariation; mean importance scores, however, were Constructs of Quality of Life as a Function of Erectile similar across national samples (Table 5). “Having a good relationship with a partner/wife” was cited As was the case for constructs of masculinity, com- as the most important by men in the United States paring the cohorts of men with and without erec- (35%) and the United Kingdom (33%), but was tile dysfunction, men with erectile dysfunction ranked third by men in Germany (23%), France who actively sought treatment, and men with (20%), Spain (19%), Mexico (15%), Italy (13%), erectile dysfunction who do not seek treatment and Brazil (10%). In contrast, “being in good revealed no meaningful differences in constructs of health” was cited as the most important by men in quality of life (Table 7). However, when men were Brazil (43%), Italy (39%), Germany (33%), Spain asked to rate their current levels of satisfaction (33%), and France (32%); this contrasted with the with these elements of quality of life, a consistent United States, where it ranked third (19%). Inter- pattern emerged; men with erectile dysfunction estingly, a “harmonious family life” was cited as the described lower rates of personal satisfaction on second most important attribute in all countries all quality of life attributes compared with men except Mexico, where men narrowly rated it as the without erectile dysfunction, particularly regard- most important attribute (30%). In addition, the ing satisfaction with their sex life and overall overall study population least often cited “satisfy- ing sex life” (2%) and “having a nice home” (2%)as the most important constructs of quality of life.
Although men variously considered factors such as Discussion
good health, a harmonious family life, and a goodrelationship with their wife/partner as the most The MALES study provides the first large, age- important determinants, mean importance scores representative, multinational assessment of men’s for all constructs of quality of life—including constructs of masculinity and quality of life, and “satisfying sex life”—were Ն5.3 across all nation- the first examination in this broad population of alities, indicating that all measured constructs the relationship between erectile dysfunction, were deemed important to quality of life.
erectile dysfunction treatment seeking, and con-structs of masculinity and quality of life. A Constructs of Quality of Life as a Function of Age number of important findings in this regard were The most important construct of quality of life As is often the case, systematic data collection among all age groups was “being in good health”; and analysis is inconsistent with widely held but Constructs of Masculinity and Quality of Life Constructs of quality of life as a function of erectile dysfunction and treatment seeking Data shown are the percentage of men citing each attribute as the “most important.” Data for the construct cited as the most important within each group arehighlighted in bold.
empirically unexamined stereotypes. Although all masculinity. Despite the fact that it could be constructs of masculinity were considered impor- contended that different nationalities perceive tant (as evidenced by mean importance scores), “honor” in different ways, placing divergent men of all nationalities in this sample and across all emphases on component aspects such as honesty, age ranges identified being seen as honorable, self- respect (of peers or family), and integrity or fair- reliant, and respected as more important to their ness, it remains true that across national samples, perception of masculinity than being seen as physi- perceptions of masculinity most often centered on cally attractive, sexually active, and successful with the less sexual aspects of the masculine construct.
Similarly, men of all ages and across nationalities Overall, being seen as honorable was con- far more frequently ranked good health, harmoni- sidered to be the most important construct of ous family life, and good relationship with their Figure 1 Personal satisfaction with
constructs of quality of life in men
without erectile dysfunction and men
with erectile dysfunction. Data shown
represent the percentage of men pro-
viding a score of 6 or 7 when asked to
rate their degree of satisfaction on a
7-point Likert scale (where 1 equals
“I am not at all satisfied” and 7 equals
Constructs of Masculinity and Quality of Life wife/partner as the most important to their quality included. As the proportion of gay/bisexual men is of life compared with material (e.g., “satisfying unknown (and likely varied across countries and work life or career,” “having a nice home”), self- age brackets) and may have influenced survey find- fulfilling (e.g., “enjoying life to the full”), or purely ings, results have to be taken in the context of sexual (e.g., “satisfying sex life”) concerns.
this limitation. Similarly, masculine constructs and help-seeking behavior are heavily influenced by contributions to our understanding of masculinity, occupational and socioeconomic status; indeed, a quality of life, and erectile dysfunction. Specifi- number of reports suggest that occupational status cally, we found that men with and without erectile is a greater predictor of help-seeking behavior dysfunction, men with erectile dysfunction who than gender alone [14,38,39]. Therefore, future actively sought treatment, and men with erectile analyses of constructs of masculinity, erectile dysfunction who do not seek treatment reported dysfunction, and help-seeking behavior should identical rankings of the importance of sexual and include parameters designed to assess the impact nonsexual elements of quality of life. We also of sexual orientation and socioeconomic status.
noted that the experience of erectile dysfunction Further avenues of research might also include neither increased nor decreased the importance how body image and the degree of alexithymia men placed on “having an active sex life” or (the extent to which individuals have deficiencies “having success with women,” compared with in understanding, processing, or describing emo- the cohort of men without erectile dysfunction, tions) exhibited by participants influence their per- although understandably, men with erectile dys- ception of masculinity, the importance attached to function reported less satisfaction with their sex various aspects of quality of life, and help-seeking life than did men without erectile dysfunction.
These findings question the very widely held view Many critics in the current discourse about that erectile dysfunction strikes at the very core of male sexuality, particularly erectile dysfunction men’s masculine self-concept. Similarly, these therapy, have legitimately argued that too little findings do not support the view that men’s attention is paid to the context in which men and unwillingness to confront a threat to their mascu- their partners experience sexual concerns. The line identity accounts for avoidance of treatment.
current findings emphasize that men across cul- These results question the opinion that erectile tures and ages value couple relationships over dysfunction therapies appeal to men with a phal- purely sexual pleasure, and indicate that men are locentric concern for their own pleasure and/or particularly concerned about their partnered rela- tionships, whether or not they report erectile dys- Along with the strengths of this research come function. These findings converge with a body of certain limitations that are shared with most large- previously reported research that has indicated the scale surveys. In particular, the current analysis was importance of the partner in defining sexual activ- based on self-reported identification of erectile ity functioning and satisfaction [40–42]. Such work dysfunction, and while there is extensive evidence has demonstrated that men’s experience of erectile of the validity of self-reports in sexuality research dysfunction is associated with the deterioration of [34–36], direct measurements of erectile function female’s sexual desire, arousal, orgasm, and satis- were not undertaken in this study. A number of faction [40]; and that treatment of men’s erectile other factors that may affect how masculinity is dysfunction results in the restoration of these erec- constructed were not examined in this survey.
tile dysfunction-induced impairments of female Notably, participants were not questioned as to their sexual orientation, and the language used in The current findings have a number of impli- the survey was implicitly heterosexually oriented.
cations for clinical practice. Given that erectile Consistent with a social constructionist theory of dysfunction is prevalent, inconsistently treated, men’s health, it has been demonstrated that gay and has a detrimental impact on sexual quality of and bisexual men hold more traditional beliefs life, this and related research underscore the need about masculinity than young men who describe to develop strategies to encourage men to seek themselves as exclusively heterosexual [22,37].
help for this condition. The quality of life aspects Although it may be assumed that the majority of of our findings suggest that within the context of survey participants were heterosexual, the very treating erectile dysfunction, greater prominence nature of the survey may have meant that a dispro- should be placed on the couple’s relationship, and portional number of nonheterosexual men were that involvement of partners should be encouraged throughout the process, from initially seeking Statement of Authorship
professional help to participation in physician con- sultations. The findings that men value their (a) Conception and Design
health above other aspects of quality of life, and Michael S. Sand; Raymond Rosen; William Fisher; that being considered honorable, self-reliant, and respected are central to male perceptions of mas- (b) Acquisition of Data
culinity, could also be harnessed to encourage men Michael S. Sand; Raymond Rosen; William Fisher; to seek medical help with respect to erectile dys- function. The prevailing paradigm needs to be (c) Analysis and Interpretation of Data
challenged such that seeking medical help is per- Michael S. Sand; Raymond Rosen; William Fisher; ceived to be a responsible act undertaken by respected, honorable men who feel empowered totake their health into their own hands for the sake of their families and their relationships with their (a) Drafting the Article
partners. Once professional help is sought, of Michael S. Sand; Raymond Rosen; William Fisher; course, a formal medical and sexual history should be taken to identify the primary cause of erectile (b) Revising It for Intellectual Content
dysfunction. As being of good health is considered Michael S. Sand; Raymond Rosen; William Fisher; to be of central importance, a medical history should not be seen as a catalogue of health “fail-ures” but a means of improving that aspect of life that is held in such esteem. Whether lifestyle (a) Final Approval of the Completed Article
changes are advocated, counseling endorsed, or Michael S. Sand; Raymond Rosen; William Fisher; treatment prescribed for the treatment of erectile dysfunction, the support and involvement of thepartner is crucial. Finally, and perhaps mostimportantly, the current findings strongly suggest References
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Respondents were then asked to cite which of the 41 Fisher WA, Rosen RC, Mollen M, Brock G, Karlin characteristics of male identity listed they consid- G, Pommerville P, Goldstein I, Bangerter K, BandelTJ, Derogatis LR, Sand M. Improving the sexual quality of life of couples affected by erectile dysfunc- “People place different degrees of importance on different areas of their personal and professional controlled trial of vardenafil. J Sex Med 2005;2: life. Now I would like to ask your views on various aspects of your quality of life. On a scale 42 Goldstein I, Fisher WA, Sand M, Rosen RC, Mollen M, Brock G, Karlin G, Pommerville P, Bangerter K, of 1 (not at all important) to 7 (very important), Bandel TJ, Derogatis LR. Women’s sexual function how important are the following to your quality improves when partners are administered vardenafil for erectile dysfunction: A prospective, randomized, double-blind, placebo-controlled trial. J Sex Med 43 Edwards D, Hackett G, Collins O, Curram J. Vard- • Good relationship with a partner/wife.
enafil improves sexual function and treatment satis- faction in couples affected by erectile dysfunction controlled trial in PDE5 inhibitor-naive men with ED and their partners. J Sex Med 2006;3:1028–36.
Respondents were then asked to cite which ofthese constructs of quality of life was the mostimportant.
“On a scale of 1 (not satisfied at all) to 7 (com-pletely satisfied), how satisfied are you with the Extracts from the MALES survey, previously “We are going to talk about the stereotypes people have about the male identity, or, in other words what makes a ‘real man’. I will read a list of items, which some people think are important to the male identity. For each one, I’ll first ask you about what you feel personally, and then what you believe the general public thinks. From a scale of 1 • Your overall contentment or happiness.”



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R. Mennes, voorzitter (burgemeester) G. Rottiers, N. Moortgat, K. Van Hoofstat, schepenen A. Ams, G. Van Frausem, L. Haucourt, D. Backeljauw, V. Goris, J. Van Wijnsberghe, R. Jacobs, R. Wilms, P. Van Bellingen, S. Billiau, F. Sleeubus, R. De Clerck, raadsleden K. Moulaert, secretaris A. Boen, schepen van rechtswege I. Barbier, D. Bollé, L. Van der Auwera, raadsleden OpeGelet op artikels 117, 11

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