From International Journal of Impotence Research
Motivations for Seeking Treatment for ED: The Woman’s Perspective
M P McCabe; H Conaglen; J Conaglen; E O’Connor
Posted: 03/29/2010; Int J Impot Res. 2010;22(2):152-158. © 2010 Nature Publishing Group
Abstract and Introduction
There is increasing evidence that partners have a major role in treatment-seeking behavior for men with ED. This study investigated the motivations of 100 females for seeking medical treatment for their partner’s ED. Semi-structured interviews focused on reasons for seeking treatment from the female’s perspective. The themes that emerged from the data centered on the importance of sex in the relationship, with closeness and intimacy frequently being seen as more important than sex. The second major theme related to hopes that females had in relation to the medication, particularly in relation to increasing their partner’s confidence and reducing his sexual frustration. Enhancement of the relationship as well as improving the female’s own feelings of self-doubt and sexual frustration were also mentioned. The results of this study show the multi-faceted nature of the motivations that females express in terms of seeking help for their partner’s ED.
There is a growing body of literature that shows the importance of the partner and the relationship in the treatment of ED in men.[1–7] Although a wide range of literature shows that PDE5 inhibitors (PDE5i) are very effective in restoring an erection in men with ED, a large number of men do not continue with the use of these treatments for their ED.[9–11]
There are likely to be a wide range of factors that are associated with this discontinuation of PDE5i medication, or the failure to even use these medications despite their efficacy.[11,12] One particular factor that has been identified is the importance of the views of the partner.[13–15] As sexual intercourse is a shared activity, it is not surprising that the views of the partner are likely to impact both on initial use and continuation or otherwise of medical treatment for ED.
A substantial number of studies have now shown that ED is associated with both quality of life and sexual dysfunction in the man’s partner.[17–20] It is not clear from these studies if the ED led to female sexual dysfunction (FSD), if FSD led to male ED, or if there were other factors (for example relationship problems) that led to both ED and FSD. However, there is evidence that treatment of male ED has a positive effect on FSD.[18,20–22] The use of a range of PDE5i medications has been shown to be associated with improvements in the female partner’s sexual function/satisfaction, as well as relationship functioning.
Cayan et al.  reported that all aspects of sexual functioning (except sexual desire) among 38 females whose partners experienced ED were lower than for 49 partners of men who did not experience ED. Further, after the treatment of ED, these females showed significant improvements in their sexual functioning. Chevret et al.  also showed that ED had a negative impact on the sexuality of female partners. Female partners (n=376) of men with ED evidenced lower levels of sexual satisfaction and sexual desire than female partners (n=345) of men who did not have ED. Even life satisfaction was lower among the females whose partners experienced ED. Similar findings were obtained by Heiman et al.  who found that postmenopausal females (n=85) whose partners were treated for ED (compared with 91 females whose partners received a placebo) showed improvements in their sexual function, sexual satisfaction, and treatment satisfaction. Finally, Fisher et al.  showed that the frequency of orgasm, sexual activity, and sexual satisfaction was lower among females whose male partners experienced ED. Females whose partners were using PDE5i medications showed a more favorable sexual experience than those females whose partners experienced ED, and were not using a PDE5i medication.
One would expect from the above studies that females whose partners experience ED would be keen to seek treatment for this condition. Consistent with this suggestion, Fisher et al.  found that there were high levels of agreement between men and their partners on their perceptions of ED and their communication about ED. In contrast, Mita et al.  found that among adult females recruited through the internet, almost half of them expressed a negative attitude toward the use of drugs for ED. However, it is important to note that it is not known if the partners of these females experienced ED, and all respondents were drawn from Japan. It is possible that the response to the use of PDE5i medication may be quite different once one’s partner is diagnosed with ED, and beyond that, prescribed and/or treated with PDE5i for the condition. Further, there may be different attitudes to the use of medication to treat ED (or even any treatment of ED) within Japanese society compared with US society.
Given the central role that females have in their partners’ treatment-seeking behavior,[26,7] it is important to obtain a better understanding of the reasons why females seek treatment. This study examined the motivation of females for seeking treatment with PDE5i therapy for their partner’s ED. The study used a qualitative approach to explore women’s motivations. The results from this study are expected to provide data that will be useful in a large-scale quantitative study.
Materials and Methods
The data for this study were drawn from a sample of 100 females from New Zealand, whose partners were experiencing ED, determined by an Erectile Function subscale score ≤20, from the International Index of Erectile Dysfunction. Participants were obtained through convenience sampling through advertisements for volunteers placed in a local newspaper. Potential participants were informed that they would be taking part in a trial to determine their satisfaction with two different PDE5 inhibitors. Participants ranged from 30 to 75 years of age, with a mean age of 53 years (s.d.=8.89), and the majority were Caucasian (83%). Eighty-two percent of the females were married to their partners and had been in the present relationship from 3 months to 52 years, with a mean duration of 23 years (s.d.=14.95).
In depth, semi-structured interviews explored motivations for entering a treatment program for ED, such as the woman’s perspective on the importance of sex to the couple’s relationship, as well as questions about hopes for beginning the use of PDE5i medication, and any fears about their partners taking the medication. For example, females were asked, ‘How important is obtaining treatment for your partner’s ED, as far as you’re concerned, to you, and to your relationship?’
The study was approved by the regional ethics committee, and all participants provided informed consent to be involved in the study. The majority of females participated in face-to-face interviews, which were digitally recorded to enable repeated review during the analytical process. Interviews lasted ~20 min. Interviews were transcribed from the digital recordings, and then coded using NVivo software version 8. Coding and analysis were carried out using principles from interpretative phenomenological analysis. Using this approach, transcripts were examined one by one, so that extracts could be grouped into relevant themes as they emerged. As the iterative analysis continued, themes were constantly revised and extended until no further themes could be identified, and the resulting framework accounted for all relevant extracts found within the transcripts. A second coder, external to the initial analysis, coded 10% of the interviews to ensure consistency of emerging themes. From the analysis, a number of main themes were identified.
Three major themes emerged in female’s discussions of their motivation for their partner seeking ED medication. These included the importance of sex to the relationship, hopes for the medication, and worries about the medication. These themes are considered in more detail below.
Importance of Sex
Table 1 outlines the main themes in relation to the importance of sex in the relationship. A common response was that sex was not the most important aspect of the relationship. Closeness and intimacy were often discussed as being more important than sex:
Table 1. Frequencies for important of sex
Closeness and intimacy more important 31
Is part of a normal relationship 22
More important to partner than self 22
Increases intimacy and closeness 14
Part of aging 11
Nice benefit of a relationship 8
‘We do a lot of kissing and cuddling and stuff like that, I mean we are really close. We’ve been married for 35 years and we can still sit on the sofa and hold hands. Because we have such a good relationship, I think it’s what has enabled us to cope with this. I’ve been able to cope with it, and as long as I have my kisses and cuddles, I’m quite happy.’ (#83, aged 54 years, duration of relationship 35 years)
However, many females were also of the view that sex was part of a normal relationship:
‘It’s important, it’s part of who you are as a couple. It’s another way of expressing the love, the care, the enjoyment that you’ve got with that person.’ (#89, aged 54 years, duration of relationship 15 years)
Females were generally of the view that sex was more important to the male partner than the woman herself:
‘I would probably say it’s not wildly important to me—it’s very important to my partner so it’s important to me because it’s important to him. I enjoy sex when we have it and sometimes I want to really participate and sometimes I don’t—I’m not that bothered. I think at various times of the month—either side of my period—I’m usually quite wanting sex and then for the rest of the month I couldn’t give a toss but he certainly does.’ (#31, aged 51 years, duration of relationship 15 years)
A number of females indicated that they thought that sex increased their levels of intimacy and closeness with their partner:
‘I feel, I like the intimacy, to me it’s hand-in-hand with marriage, like, it makes me feel loved. I just really love the intimacy and the time, I mean, especially when you’re so busy all the time, to me, that’s our time out, together.’ (#03, aged 45 years, duration of relationship 19 years)
A number of females also noted that sex was not the most important aspect of their relationship because they believed that a decrease in sexual activity was a normal part of aging:
‘I just put it down to getting older. I mean, I don’t feel like sex as often as I used to and because we’re busy and we’re both getting older and I really just thought it was a part of aging and getting older. I mean, sex drive, my understanding of it anyway, is that it should wane as you get older or maybe it doesn’t, I don’t know. My experience is that it does for us or for me and perhaps for my partner too.’ (#32, aged 49 years, duration of relationship 30 years)
Finally, some females saw sex as being a nice benefit to their relationship:
‘I think, you know, I mean I’m not going to leave my partner because of it—because you know we’ve got a deeper situation than that. I mean that’s not why we’re together for the long term but I mean it is a nice benefit to have on tops of it isn’t it? So it is a nice plus.’ (#35, aged 51 years, duration of relationship 29 years)
Hopes for Medication
The main themes related to what the females hoped would occur as a result of using the PDE5i medication is summarized in Table 2. The themes from the female’s responses centered on how the medication would help the females themselves, their partner, and their relationship. There were a number of themes surrounding hopes for the medication that were focused on the impact of the woman herself. Examples of these three main themes of how the use of the PDE5i medication was expected to assist the females are outlined below.
Table 2. Frequencies of hopes for the medication
Theme Frequency Focus
Reduce cognitive preoccupation, increase confidence 29 Male
Reduction in partner’s sexual frustration 26 Male
Increased intimacy and closeness 23 Couple
Reduce own feelings of self-doubt 22 Female
Partner to feel more masculine 19 Male
Reduction in own sexual frustration 18 Female
To enhance the relationship 16 Couple
Reduce hesitation about becoming involved in sex 16 Female
Return to normal life 9 Couple
Determine how the medication works 8 Couple
Reduce Own Feelings of Self-doubt
‘It’s impacted I would say quite a lot, we are at the stage now where we are able to talk about it, and we’re much more open, … I sort of think, it’s me, I’m old, and you know, typical, he doesn’t fancy me any more, I’m unattractive to him, and I went through all those self-doubt things, and that was impacting very badly. We were starting to grow apart, and as I say, we decided to talk about it, and open up, and he said look, it’s got to keep reinforcing that it’s not me, it’s just a thing that’s happening, and we must work together.’ (#53, aged 52 years, duration of relationship 27 years)
Reduction in Own Sexual Frustration
‘It is very frustrating and I ended up saying ‘we have to do something, because I’m 33 years old and I can’t go on like this for the rest of my life’. And that was the trigger for him to say ‘I’ll go and do something’. He was quite nervous I guess, and I can understand that it must be difficult for a guy to suddenly go in to the doctor and say ‘I’m having problems’. Of course once the drug worked it was great and it seemed to restore some confidence, but the other thing we found was that when he could have an erection he would ejaculate very quickly, so it was all over within like 20 seconds. So again, that is very frustrating.’ (#75, aged 33 years, duration of relationship 12 years)
Reduce Hesitation about Becoming Involved in Sex
‘It was a two way thing I think, I know personally it was just that attitude, oh look, don’t even start. Because I’m not even going to try to be aroused, I got to the point where I wouldn’t allow myself to get aroused because I thought, oh damn, I don’t want to get like that, and then get so aroused, where you can’t complete the job, and I’d just be left frustrated.’ (#17, aged 49 years, duration of relationship 28 years)
There were also three main themes surrounding hopes for how the medication would help the male partner.
Partner to Feel More Masculine
‘I feel deeply for my husband because he feels a failure as a man; if there was some form of treatment that would give him his erection function back again I would be only too happy; as much as anything just for his peace of mind.’ (#27, aged 65 years, duration of relationship 47 years)
Reduce Cognitive Preoccupation, Increase Confidence
‘But of course, what happens is, being a male, even though there’s an underlying physical cause, psychologically it has a huge impact which probably compounds the whole situation even more. I think certainly from (partner)’s perspective, if by using some medication then it’s easier for him to become erect it’s certainly going to do his self-esteem and him a world of good, and hopefully he’ll be feeling less sexually frustrated, and that’s got to have positive spin-offs in the rest of our relationship.’ (#43, aged 46 years, duration of relationship 26 years)
Reduction in Partner Sexual Frustration
‘Just… he’s happier, I’m happier. He just gets so frustrated with the whole thing when it doesn’t work like he wants it to.’ (#29, aged 54 years, duration of relationship 27 years)
Finally, there were four themes that were focused more directly on the dyadic relationship and hopes for how the medication might help the couple.
Increase Intimacy and Closeness
‘Of course, the desire and the arousal depend so much on the situation, and a lot of different things come into it. And I can, in the past, I can remember being so aroused, and so full of wanting to get going, but when you kind of get into a relationship, and you’ve been together for quite a long time, things change. So I don’t feel a lot of desire now, but what I’m wanting is the closeness, and I’m wanting it for (partner), so that he can, you know, experience that again.’ (#14, aged 66 years, duration of relationship 18 years)
Return to Normal Life
‘Strangely we’re still getting on fine and we thought ‘well this is how it will be till the end of our days’, but it would be nice if it could be like it was.’ (#79, aged 66 years, duration of relationship 48 years)
Determine How the Medication Works
‘To find a product, obviously, because we’re going to have to use a product, we know that now. To find a product that’s going to suit both of us and for the side effects not to be too damaging.’ (#92, aged 49 years, duration of relationship 25 years)
Enhance the Relationship
‘I think that probably, if the sex in the relationship was right, everything else would balance out.’ (#90, aged 35 years, duration of relationship 6 years)
Table 3 summarizes the frequencies of the main worries that the females expressed in relation to their partner’s use of the PDE5i medication. There were five major themes that arose regarding these worries.
Table 3. Frequencies of worries for the medication
Side effects and health issues 29
The cost of medication 15
Not natural 10
Puts pressure on woman to perform 9
That it will take away the spontaneity 8
Side Effects and Health Issues
‘Oh only what you hear, you know, I’d hate him to drop dead of a heart attack or anything! But he’s been fairly extensively tested for his health and he’s a real physical health nut person so I don’t imagine he puts himself under any more stress than when he’s working out at the gym or walking up mountains or things like that.’ (#31, aged 51 years, duration of relationship 15 years)
Cost of Medication
‘I was going to say to you, we’re not that financial and it’s just horrendous, the cost, you know, one hundred dollars for four tablets, that’s, you know, there’s times that we just can’t get them, and we can go on for weeks or months and then I get really frustrated too, and I know (husband) does too. Because, you know, we’ve got a family, and we’ve got bills to pay, so it’s like, but then I think to myself, gosh, this is part of our life now, and you know, we need something for us as well, and I think sometimes that, I think it is important that we put money aside to try and get them, but it’s not always possible.’ (#03, aged 41 years, duration of relationship 19 years)
‘It doesn’t light my fire, but if it’s going to help (partner) then that’s fine with me. Because you know we had a little sample tablet and we had one and it was just, we couldn’t get over how it works. To me, I feel it’s a bit out of nature, but, one minute you can’t do it and the next minute suddenly wow! And you can do it about 1000 darn times, you know? And to me that’s just not a natural process. But if it’s going to give (partner) some satisfaction well that’s fine with me.’ (#19, aged 50 years, duration of relationship 31 years)
Puts Pressure on Woman to Perform
‘I think, if you have a pretty full-on day, really all you want is a cup of tea. ‘Oh, I’ve taken a pill’; well, it doesn’t always work that way I don’t think. Because, I think it’s going to be easier for him, having the pill, to be into it, than for me who doesn’t have a pill. I mean, he’s going to be able to perform, whereas a woman can’t always perform at that time.’ (#16, aged 55 years, duration of relationship 33 years)
That it will Take Away the Spontaneity
‘But I find with me, if he tells me he’s taken a tablet, then I don’t want it. You know, I don’t want sex. Because to me sex is something you do just out of the blue, you know? That’s where the excitement and all that comes into it. And when you think oh hell, I’ve got to do that.’ (#91, aged 48 years, duration of relationship 28 years)
This analysis of female’s motivation for treatment revealed that a large number of the themes related to their partner’s sexual and psychological functioning. Female partners wanted the partner to feel better about himself (more confident and masculine), and through addressing his needs, they expected that there would be a flow-on effect to their own sexual and interpersonal relationship. Many of the females indicated that sexual performance was more important to their partner than to them. In fact, they were of the view that closeness and intimacy was more important to them than sexual interactions. Interestingly, many females viewed sex as being part of a normal relationship, and a number of them experienced sexual frustration if they could not have sex with their partner. As suggested by Chevret-Méasson et al., females’ satisfaction with their sex lives were improved with the use of PDE5i medication and this is a central motive for females to seek treatment for their partner’s ED. Females expressed a number of concerns about using medication for their partner’s ED. These primarily focused on the cost of the medication, the side effects, pressure on them to perform as well as the lack of spontaneity that may result from the use of the medication.
These results are useful for identifying what motivates females seeking treatment for their male partner’s ED. Earlier research has shown that treatment of male ED has a positive impact on FSD, as well as on their levels of sexual satisfaction.[18,13,22,23] This study shows that the main motives for females seeking treatment for their partner’s ED primarily center on their partner’s needs rather than their own level of s.d. The other major motive was to improve the level of intimacy and communication in their relationship. These results would suggest that the females in the study were supportive of their partner seeking help for his ED, and were likely to have a role in his treatment-seeking behavior.
The themes emerging from the data also centered on the male’s sense of masculinity and confidence. Rosen et al.  found that treatment of ED using PDE5i medication led to an improvement in the quality of life of treated males, and that this relationship was mediated by mood and their relationship with their partner. Overall, these results show the broader impact of treatment on the lives of males with ED, and that female partners are aware of these change. Further, females seek treatment for their partner’s ED in an attempt to achieve positive changes in their partner’s lives, as well as broader aspects of their own life.
It is important to note that the couples in this study may not be representative of the general population, in that they were all motivated to be in the study, and hence, to seek treatment. Also many of them had been in their current relationship for a long period of time. Future studies need to further explore the role that female partners have in men with ED seeking treatment for this condition. Given that so many men do not continue with PDE5i medication despite its effectiveness in treating their ED, it is important to understand the role that their partner has in initiating and continuing this treatment regime. In this way, treating physicians will have the information to enlist the assistance of partners to ensure that men seek and continue treatment for ED. Such a process is likely to improve both male and female s.d., enhance their quality of life, and improve the level of intimacy and communication in their relationship.