Treatment Motivation of Men With ED

Abstract and Introduction Abstract Although ED can impair sexual satisfaction as well as the quality of partnership and life, men affected often avoid seeking treatment. There is growing evidence that women have an influence on their partner's help-seeking behavior. This qualitative study examined men with ED and their female partners in order to detect motivational factors for men to seek treatment and motivational actions of the women to support their partners. Twelve couples took part in a semi-structured telephone interview, which was performed separately in men and women. Analysis was on the basis of the Grounded Theory. The identified motivational factors could be divided into extrinsic (for example, media, female partner) and intrinsic (for example, desire to clarify the cause of the ED, hope for improvement) factors. Women can support their partners in treatment-seeking through various motivational actions such as talking with each other, showing interest and dealing actively with the problem, appealing to the male self-esteem, supporting the doctor's visit, forcing the treatment, active cooperation and participation in the treatment or initiating sexual intercourse. On the basis of these findings, recommendations for women were developed to support their partners and increase the probability of help-seeking behavior. Introduction ED is highly prevalent (20% in all age groups and 40% in older populations) in the general population.[1–3] Studies have found a strong association between erectile function and quality of life and partnership.[4–9] An insufficient erection hardness usually leads to the couple's sexual dissatisfaction.[10–18] This discontent is often associated with increased relationship problems, especially communication problems, allegations and a decrease in tenderness and closeness.[19–22] However, different studies demonstrated a significant improvement in quality of life and relationship in men and their partners, following a medical treatment of ED.[16,23–25] Despite these facts, 70–80% of the patients are often hesitant to seek treatment.[26–29] The main reasons for this are feelings of shame and the concern that the physician won't take the sexual problem seriously. Owing to the improved sexuality after an adequate treatment and its positive influence on the quality of life and partnership, it is necessary to find ways to motivate men to seek professional help. Shabsigh et al. [30] investigated motivational factors in help-seeking behavior in a semi-quantitative study. They found that men's own sexual desire is often an important precondition or trigger for treatment-seeking behavior of men. However, men wish not only for an improvement of their own sexual satisfaction, but also of the satisfaction of the partner.[31] According to the data of Shabsigh et al.,[30] 57.8% of all included men were self-motivated, but ~40% reported that their female partner influenced them to seek help. Other studies found that the female partner is often the first contact to talk about sexual problems.[29,32] A German study performed in 443 men with ED revealed that talking to the partner led to a significant improvement of partnership quality as well as erectile function.[33,34] Beside the importance of the dialog with the partner, the female partner seems to have an important role in the process of treatment of the ED. Studies show that treatment compliance in men is markedly higher if spouses agree to the treatment procedure.[10,18,35] It was shown that the female partner has a key role in the process of motivation and treatment of men with ED. Conversations between the couple seem to be important. However, it has not yet been established or thoroughly examined how women can motivate their partners to seek treatment and what are the likely reasons for men with ED to seek help besides their own sexual desire and sexual satisfaction of the partner. To get some evidence about these questions from the subjective perspective of those who are affected, we chose an explorative way by using qualitative interviews. Aims This study examined • What motivates men to seek treatment in general and • How women motivate their partner in particular. On the basis of these findings, the aim of this study was the development of communication guidelines that provide recommendations for women on how to talk with their partners to increase the probability of help-seeking behavior. Participants We can help you achieve your nursing educational goals For more than 27 years, University of Phoenix® College of Nursing has been educating nurses. Learn how you can become a nurse leader in your community Information from Industry The study was performed between June 2010 and March 2011. Help-seeking men with ED, both with and without a current treatment, and their female partners were recruited by different ways, which are as follows: men who had contacted the German Information Center for Sexuality and Health (ISG e.V.), patients who visited the sexual counseling in the Department of Psychiatry and Psychotherapy, as well as patients who visited the Department of Urology (University Medical Center Freiburg), were informed about the study and asked to take part. Furthermore, information about this study was posted in three rehabilitation centers, in a journal of the University Medical Center Freiburg and in various internet forums. Finally, various self-help groups were informed about this study. Ultimately, 12 couples took part in this study, seven couples with and five couples without current ED treatment. The age of the participants ranged from 27 to 68 years, with an average age of 50 years. They had different socioeconomic backgrounds (for example, students, employees, self-employed, retirees). The duration of the present relationships ranged from 3 months to 43 years, with a mean duration of 16 years; six couples were married. Materials and Methods Figure 1 shows the procedure of the qualitative study. (Enlarge Image) Figure 1. Procedure. On the basis of a thorough review of the literature, a semi-structured questionnaire was developed to conduct the interviews by telephone. The questionnaire explored quality of relationship, experience and dealing with the ED, the impact of the ED on partnership and sexuality, attitude toward professional help and attitude toward erection hardness and duration, communication with the partner about the ED, the partner's handling of the problem and recommendations for other couples. Men and women were interviewed separately over the telephone by trained and experienced interviewers. Usually, the interviews were conducted by a female interviewer. Men could decide if they prefer talking with a woman or a man, whereby only two men preferred to be interviewed by a man. All participants provided an informed consent to participate in the study. The interviews lasted between 34 and 73 min (average 54 min), were digitally recorded and than completely transcribed on the basis of the conversation analytic transcription system.[36] The qualitative analysis was on the basis of the Grounded Theory methodology of Glaser and Strauss,[37,38] by using the method of Flick's thematic coding.[39,40] Grounded Theory method is a set of systematic methodological strategies for conducting research and analyzing inductive data. It consists 'of systematic, but flexible, guidelines for data gathering, coding, synthesizing, categorizing and integrating concepts for the explicit purpose of generating middle-range theory' (p.406).[41] The use of thematic coding allows differences to be found between groups (men vs women). In general, qualitative research enables a better understanding of human attitudes and behavior, which is relevant for the aims of this study. Results generated from this method can than be tested in quantitative studies. In the following, a short overview should be given about the methods. First, distinctive features (= quotation) in ten of all transcribed interviews were assigned to a specific description (= code), which were noted on the left margin of the transcript. This step is called 'open coding'. In further axial and selective analyses of the texts, these first codes were compared, connected to and differentiated from each other in order to facilitate the generation of potential relationships and links between them, such as similarities or differences. These relationships lead to find theoretical categories (concepts) and a so called 'thematic structure'. This structure includes for example categories like treatment, handling of the female partner or expectancies and is used to keep an overview of the amount of data. Figure 2 shows the bottom-up process. (Enlarge Image) Figure 2. Analyses steps. How do you find time to balance school with a busy nursing career? Our nursing alumni balanced school, work, and family. Find out how our accredited programs fit your schedule Information from Industry On the basis of this structure, a further 14 interviews were coded, while remaining open to new phenomena. Subsequently, analyses of individual cases, couples, groups and all interviews were performed to find core categories, in relation to the aims of the study. In this way, analyses resulted in the identification of motivational factors and actions. On the basis of the findings about helpful motivational actions and the additionally identified needs and expectancies of the interviewed women and men, some recommendations for women could be developed. The group analysis was conducted in order to find possible differences between women and men. Throughout the evaluation phase, all thoughts, links and questions of the evaluations were held in so-called memos that were included in the interpretative elaboration. Interpretative and abstract steps were always discussed in the research group and checked against the original items. The analysis was supported by and conducted with the computer program ATLAS.ti 5.0[42,43] and took about 15–20 h per interview. Results First, the motivational factors are reported (according to the question 'What motivates men to seek treatment?'). Following this, the motivational actions of the women (according to 'How do women motivate their partners?') are presented. Finally, important recommendations for women are highlighted. Differences in the answers between women and men were only marginal and are reported in the text. Here, we present the factors and exemplary key statements. Motivational Factors The identified motivational factors can be divided into extrinsic and intrinsic factors. The results are summarized in Table 1 . Extrinsic Motivational Factors Information Via Media Information from newspapers, advertisement or internet motivated men to seek treatment. Dissatisfaction and Request of the Significant Partner It seems that men like to reduce feelings of irritation, frustration, disappointment, sadness and dissatisfaction of the female partner: '…I've noticed that my wife is not just satisfied, that she is just unhappy that there is not enough sexual intercourse' (#223A, male, aged 39 years, in treatment). Desire to Maintain and Improve the Relationship Some men reported a fear that their women could have affairs or break up with them: 'What would happen if you did not seek treatment?' 'Well, probably bad. I think that was not a question. I think that would be the end of the relationship, someday.' (# 222A, male, aged 50 years, in treatment). The hope to improve the relationship, perhaps through having the possibility of more frequent sexual intercourse, and reducing the burden of the woman, the bad atmosphere and the problems in the relationship can also be motivating. Intrinsic Motivational Factors Desire to Clarify the Cause of the ED 'He was just scared and wanted to know what it's all about.' (#222B, female, aged 51 years, in treatment). Threatened male self-esteem 'I mean it is also true that it impairs the masculinity.' (#211A, male, aged 55 years, in treatment). Experiencing the ED as a problem that can't be hidden and solved alone 'I do a 360, somehow I can't get out of this mess.' (#218A, male, aged 55, in treatment). Hope for Improvement by Treatment Including • elimination of the problem • reduction of unpleasant and stressful feelings such as blame, shame, failure, irritability, confusion, disappointment, sadness, resignation, tensions, frustration, fear and inhibition, which were reported very often. • an improved management of the issue • getting relief through professional conversation • fear of worsening ED and avoiding long-term ED Importance of Sex, Wish for Successful Sexuality Including a Longer Duration and More Hardness of Erection 'She isn't satisfied with the duration of erection and that is very important to have intercourse. That is the most important thing.' (#222A, male, aged 50 years, in treatment). The wish to demonstrate that erection is functional can also be motivational for men. Feeling Responsible for Sexuality 'I thought for many years that I am responsible for sexuality. And now, I can't assume responsibility and so it goes wrong.' (#209B, male, aged 57 years, in treatment). Motivational Actions There are different actions that women could undertake to motivate their men to seek treatment: Talking to Each Other Common dialog is referred to as a central aspect of motivation. 'I think the consequence of the conversation was the decision to go to the doctor.' (#222A, male, aged 50 years, in treatment). It might feel 'unusual' to talk about such a topic, but it appears to be very helpful when the woman initiates the conversation and encourages her partner. It could also be helpful to communicate one's own feelings and perspective in order to disburden the partner. It can make things easier and create a basis of trust, openness and allow treatment to be started without any secrets. Furthermore, in a dialog, the couples can decide together which alternatives to sexual intercourse they could perform and tell each other their sexual wishes. Men mentioned that conversation reduces frustration and barriers, and women stated that a dialog could reduce feelings of guilt. However, there seem to be some preconditions to conducting a conversation: the willingness to talk, the right mood, having enough time and privacy (without children), being open for a dialog and avoiding of reproaches. Highlighting That the Problem is Shared 'I think he likes the fact that I perceive it as our common problem and not only as his problem. And this empowers him.' (#210B, female, aged 50 years, without current treatment). Showing Interest and Dealing Actively With the Problem Men and women stated that specific treatment proposals of the woman could be motivating. Women thought that asking the partner about the causes or giving them information about causes and treatment possibilities could motivate their men to seek treatment: 'My female partner supported me by giving some advice about getting help' (#220B, male, aged 62 years, without current treatment). Furthermore, women stated that reminding the partner to get a new prescription for a medication might be motivating to continue treatment. Supporting the Doctor's Visit 'Well, I think that she supported me. She didn't request it directly, but when I told her about it, I think she found it good and verified it.' (#207B, male, aged 50 years, without a current treatment). Forcing the Treatment It could be helpful to call on the man to go to the doctor to force the treatment: '… my female partner has sent me [to the doctor]' (# 208B, male, aged 56 years, without current treatment). Some men seem to need the pressure of their partners to change motivation into volition and to initiate a treatment: 'Yes, I've exerted pressure on him' (# 211 B, female, aged 55 years, in treatment). Active Cooperation and Participation in the Treatment Including • Accompanying the partner to the treatment, information events or even showing willingness to accompany him to the doctor. • Showing willingness to participate in treatment, for example, couple or sexual therapy • Performing therapeutic exercises with the partner • Supporting the partner in everyday life, for example, by reducing his weight to improve erectile function Appeal to His Male Self-esteem '… she always says, if it was functional (to have sexual intercourse), you would be confirmed as a man and you would surely feel much better as a man, and I think she is right.' (#208B, male, aged 56 years, without current treatment). Exert no Pressure One man wished not to be pushed by his partner. Another referred to reassurance as helpful. Be a Model for Learning One woman told her partner about her own therapeutic experiences, so that he could learn from her: At the University of Phoenix® College of Nursing, we have the cure for the common curriculum Our coursework focuses on key critical thinking and leadership skills. Learn how we are putting nurses to work Information from Industry 'He got bitten by me, because I go to a therapist and told him about my good experiences … and then firstly, he started treatment by a sex therapist.' (218B, female, aged 38 years, in treatment). Initiate Sexual Intercourse 'Often I take the initiative and my partner says that it is great that I started with sexual activity.' (#207A, female, aged 43 years, without current treatment) Furthermore, the purchase of sex toys and the feedback from the female partner when the sex was satisfying were named. Recommendations for Women On the basis of analysis of the interviews, some communication guidelines for women could be developed, which might be helpful in motivating men to seek professional treatment. However, it is important to note that these are general recommendations and each woman has to choose her own way to support her partner. The recommendations are summarized in Info Box 1 . Discussion This study investigated motivational factors and actions to motivate men with ED to seek treatment. In this regard, the specific role of the female partner was examined. In general, women seem to contribute significantly to their partner's help-seeking behavior, as found, for instance, by Norcross et al. [44] Women are referred to as 'brokers or arrangers of health care', and Umberson[45] showed that they have an eye on the health of others. The results of our own study, which are discussed in the following, support these previous findings and yield some further important information about the key role of the female partner and additional motivational factors. By analyzing the interviews, we identified various factors that motivate men to seek professional help und which can be divided into extrinsic factors (information in the media, the female partner) and intrinsic factors (for example, desire to clarify the cause of the ED or the wish for successful sexuality). These factors probably influence each other and the knowledge of the intrinsic factors could be used to increase the motivation through exterior actions. For example, the intrinsic motivational factor 'desire to clarify the causes' should be addressed by the extrinsic factor 'information in the media', so that this desire is supplied by information. Furthermore, information campaigns could pick up on other intrinsic factors such as 'threatened self-esteem of the man', 'experiencing the ED as a problem that can't be hidden and solved alone' or 'hope for improvement'. Besides the information in the media, the female partner is mentioned as a further extrinsic factor that also seems to be connected to intrinsic factors like 'threatened self-esteem of the man' or 'desire for successful sexuality'. Both the desire for sexuality and the female partner as 'drivers' to seek treatment were also found in the study by Shabsigh et al. [46] The female partner herself seems to have a key role within the motivational process. Women have a direct influence through different motivational actions, as well as an indirect influence due to their importance as a partner. The finding of Fisher et al. [47] that sexual satisfaction of the women is a reason to seek treatment for the man could be confirmed in this study. Moreover, the identified motivational 'desire to maintain and improve the relationship' is comprehensible in view of the fact that ED can lead to relationship problems.[19,21,22,48] Besides this indirect influence, firstly, our study identified various motivational actions, which women can perform to foster treatment-seeking behavior. In particular, talking about the erection problem seems to be an important motivational action, which was also shown by our own previous work of Günzler et al. [33] Our study is indeed the first to specify not only that women should talk to their partner to increase the probability of help-seeking behavior, but also how they should do so, and provides corresponding recommendations, such as initiating the conversation, talking about their own feelings or highlighting that the problem is shared. Furthermore, it might be helpful to ask the partner whether he wants to talk about this topic, because the willingness to speak, the right mood and openness are preconditions to conducting a helpful conversation. These findings were incorporated into the presented recommendations. However, to use these recommendations adequately, it is necessary to consider that in different couples, different motivational strategies might be helpful. Interestingly, we were able to ascertain that for some male participants of our study, it was helpful when their partners forced the treatment, while others preferred to receive no pressure from their women. Personality factors and characteristics of partnership will influence whether men prefer pressure to seek treatment or patience and understanding of their female partner. Future studies might investigate, which personal and relationship factors are related to the motivational action 'forcing the treatment' and develop specific strategies for different male subgroups. In the interviews, it was also shown that some women need more support to help their men than others; for example, some women had already talked to their men, whereas others had not yet done so. We tried to consider these differences in our recommendations, which include suggestions for a dialog and initial support as a first step as well as treatment-specific recommendations as a second step, depending on the needs of the women. In further studies, the evaluation of the efficacy of the developed recommendations with regard to help-seeking behavior of men and ultimately to the quality of sexuality, partnership and life would be desirable. Therefore in the next step, we will post the recommendations on the internet website of the German Information Center for Sexuality and Health (www.isg-info.de). Women who visit the website because of an erection problem of their partner and read the recommendations are asked to participate in a short anonymous questionnaire about their usefulness and helpfulness. Therefore, this survey allows to evaluate the feasibility and efficacy of the provided recommendations. Beyond that, in future, the recommendations might be implemented in training interventions for women. Furthermore, owing to their important supportive role, women should be integrated more into the therapeutic process itself. In line with Riley,[35] our study pointed out that 'active cooperation and participation in the treatment' is an important motivational female action to show the men concerned that they are not alone with the sexual problem. Dean et al. [18] developed a practical treatment guidance for physicians of men with ED that required the inclusion of the female partner in the treatment. The acceptance of and adherence to these guidelines for physicians might be evaluated in future studies. Finally, there are some limitations to this qualitative study, which should be reported. At the University of Phoenix® College of Nursing, we have the cure for the common curriculum Our coursework focuses on key critical thinking and leadership skills. Learn how we are putting nurses to work Information from Industry Owing to the intimate nature of the topic, problems like social desirability and shame are possible. We tried to reduce these issues through the voluntary study participation and the interview by telephone instead of face-to-face interviews. Furthermore, we only interviewed twelve couples, who cannot be representative for the general population, whereby, generalization is not an objective of qualitative research. Therefore, our results should be verified by quantitative studies. In general, in Grounded Theory studies, the sample size varies between a minimum of 6 and a maximum of ~50 cases.[49–52] Nevertheless, because of the variability of the sample (for example, age, socioeconomic background, profession), the 24 interviews in our study are a sufficient sample size, and in view of this sample, the horizontal comparative analysis and the correspondence with other study results, the study does have substantial value. In addition to that, the in-depth analysis of the participants' experiences and opinions might suggest that the analyzed results could be occurring in similar groups of concerned men and women. The adherence to the specific criteria of qualitative research[53,54] ensured the quality of this study. In summary, the use of the qualitative design enabled us to develop recommendations for women, which are based on their subjective perceptions and experiences as a solid evidence base. These might help women in their important role to motivate men with ED to begin treatment. http://www.medscape.com/viewarticle/781328_4