Michael J. Telch, PhD and Yasisca Pujols, MA
ONLINE: August 23, 2013 – The Journal of Sexual Medicine
A common condition, erectile dysfunction (ED) affects men psychologically and emotionally as well as physically. Research has shown that men with ED are not as happy in their romantic relationships when compared to men without ED. In addition, sexual dysfunction tends to be more prevalent among women whose partners have ED.
Potential physical causes of ED include smoking, medications, low testosterone, cardiovascular disease, diabetes, lower urinary tract infections, extensive bicycling, and medical procedures.
Psychosocial variables have also been investigated, including depression, anger, personality trait dominance, and relationship factors.
In the 1940s, it was believed that anxiety was the main cause of sexual dysfunction for both men and women.
However, in 1986, D.H. Barlow suggested that anxiety and cognitive interference work together to create sexual dysfunction. This combination can cause a man’s attention to shift from erotic cues to the possibility of erectile problems, resulting in ED.
Review of Related Measures
Several self-report instruments have been developed to assess ED:
• The International Index of Erectile Function (IIEF) is considered the gold standard. It includes 15 items that assess five domains: erectile function, intercourse satisfaction, orgasmic function, sexual desire, and overall satisfaction.
• The Self-Esteem and Relationship Questionnaire (SEAR) includes 14 items that address ED’s effects on sexual confidence, self-esteem, and relationship satisfaction.
• The Erectile Dysfunction Inventory of Treatment Satisfaction uses 11 items to evaluate how satisfied men are with their ED treatment.
• The Psychological Impact of Erectile Dysfunction (PIED) includes 16 items that assess disease-specific quality of life for men with ED. It includes two subscales: impact of ED on sexual experience and impact of ED on emotional life.
• The Structured Interview on Erectile Dysfunction is a recently validated tool that evaluates organic, relational, and psychopathologic contributors to ED.
Even though anxiety has been shown to influence erectile function, there are not many psychometrically validated tools to assess anxiety in this context. The Sex Anxiety Inventory and the Sexual Function Scale (SFS) do address anxiety in general, but do not include items specific to erectile performance anxiety (EPA).
Given that currently-available ED assessment tools do not directly assess EPA, this study discusses the development and preliminary psychometric evaluation of the Erectile Performance Anxiety Index (EPAI), a 10-item self-report scale.
The authors explained, “We conceptualize EPA as a state of apprehension and self-focused attention to the anticipation of difficulty to achieve or maintain an erection during sexual activity.”
The authors’ vision of EPA was informed by their clinical experience and extensive research. They developed instrument items with the following “hypothesized facets of EPA” (emphasis is the authors’):
• Anxiety and/or worry in anticipation of a sexual performance context
• Anxiety and hypervigilance while engaging in or attempting to engage in one or more sexual activities
• Avoidance and other safety behaviors in response to the anticipation of erectile failure
Colleagues in the field of sexual dysfunction reviewed a preliminary 13-item version of the EPAI for language, clarity, and face validity. A first wave of data collection allowed 165 study participants to make comments and suggestions. A second wave included 42 male university students who took a retest of the EPAI.
Both groups completed the entire battery of questionnaires as detailed below.
Two hundred seven men between the ages of 18 and 70 participated in the study. One hundred sixty-five “community participants” were recruited online. Their mean age was 33.9. Forty-two college students (mean age 19.6) were recruited through the website of the psychology department at the University of Texas at Austin.
Erectile Performance Anxiety Index
The EPAI is a 10-item assessment tool designed by the authors of the current study. Each item is rated on a five-point Likert-type response scale ranging from 1 (“not like me”) to 5 “very much like me.”
The final 10-item scale includes the following (emphasis by the authors):
1. When I ﬁnd myself in a situation where sex is a possibility, I often worry or become apprehensive that I will have trouble getting or keeping an erection.
2. I have frequent thoughts about not being able to get or keep an erection.
3. I ﬁnd myself getting nervous when my sexual partner talks about having sex.
4. I sometimes use excuses (e.g., feeling tired, headache) to avoid sex.
5. I sometimes feel the need to take erection dysfunction (ED) medications or supplements in order to get or keep an erection.
6. I often feel the need to drink alcohol or take other anti-anxiety medications to manage my anxiety about not being able to get or keep an erection.
7. When in a sexual situation, I often check to see whether I am becoming aroused.
8. I sometimes read books or articles on the Internet about ways to prevent erection problems.
9. In the middle of having sex, I often ﬁnd myself focusing on whether I will be able to maintain my erection.
10. I feel tense or nervous in sexual situations even when I know the person well.
Performance Anxiety Subscale of the SFS
This 10-item scale can be completed by both men and women and assesses the extent the respondent feels anxiety or pressure to engage in sexual activity. An example item is “Do you become irritated or annoyed about being too slow to become sexually aroused?” Respondents rate each item on a Likert scale ranging from 0 (never) to 4 (always). The sum of scores for all 10 items yields the entire score. Higher scores indicate greater performance anxiety. This instrument has high internal consistency and high test-retest reliability.
Appraisal of Social Concerns (ASC)
This 20-item self-report scale assesses “the level of concern with potentially negative outcomes arising in social situations.” It contains three subscales: negative evaluation, observable symptoms, and social helplessness. Respondents rate items on a scale of 0 to 100, marked in intervals of 10. The total scale score equals the average item rating. This scale has “excellent” internal consistency and convergent validity with other social anxiety measures and sensitivity to treatment.
State-Trait Anxiety Inventory, State Anxiety Scale (STAI-S) – Short Form
This scale includes six items rated on a 4-point Likert scale ranging from 1 (not at all) to 4 (very much). The score is the sum of all 6 items. This tool has high internal consistency and high test-retest reliability.
Center for Epidemiologic Studies Depression Scale, Short Form (CES-D-10)
This scale contains 10 items that evaluate primarily affective depressive symptoms in the past week. An example of one item is “I felt that everything I did was an effort.” Each item is rated on a 4-point Likert scale ranging from 0 (rarely or none of the time) to 3 (all of the time). The total score is the sum of all 10 responses. This scale has high internal consistency and high test-retest reliability.
International Index of Erectile Function
The IIEF includes 15 items that cover five domains of male sexual function: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction. Higher scores indicate higher levels of sexual function and satisfaction. This instrument has shown high temporal stability and “excellent” internal consistency. It has also been shown to be “a sensitive outcome measure for detecting treatment-related change in sexual functioning.”
After providing informed consent, the community participants and college students took the entire battery online. The battery included demographic questions and the six measures described above.
Three items from the original 13-item EPAI scale were dropped because of low item-total correlations.
Total scores were analyzed as a function of source of sample (community vs. university) and age of sample (younger than 25 years vs. 25 years and older). The older group scored significantly higher than the younger group. After controlling for age, the community sample did not differ from the university sample.
An exploratory factor analysis was conducted. A maximum likelihood analysis with oblique rotation (oblimin) was conducted on the final 10 items. It was suggested that the sample size of 207 was adequate for the analysis.
Reliability of the EPAI
The internal consistency of the 10-item EPAI was analyzed, resulting in a Cronbach’s alpha of 0.94. Temporal stability was assessed by calculating the correlation between two administrations of the EPAI spaced an average of 3.5 weeks apart on a subsample of 42 participants. The results suggested a highly stable scale across this time period.
Convergent and Discriminant Validity
Convergent validity was tested by examining the association of the EPAI with measures of other constructs related to EPA: the performance subscale of the SFS, the IIEF, and the ASC.
The EPAI was moderately correlated with the performance anxiety subscale of the SFS across two age groups (younger than 25 years and 25 years and older).
The EPAI had a moderate inverse relationship with the IIEF among older men, but only a modest negative association in younger men.
The EPAI was moderately correlated with the ASC for older men, but less so for younger men.
Discriminant validity was tested by analyzing the association of the EPAI with measures of construct less related to EPA: the STAI-S and the CES-D-10. There was no significant association between the EPAI and the STAI-S for either the younger or older samples. However, there was a modest but significant positive association with the CED-D-10.
It was determined that the EPAI was more strongly related to each of the three convergent measures than it was to the STAI-S.
The EPAI is designed specifically for men and focuses only on EPA.
Summary of Findings
The authors noted that the “results of our exploratory factor analysis indicate that the EPAI appears to measure a single superordinate factor that accounted for over 63% of the variance.”
They explained that the EPAI “possesses outstanding internal consistency and excellent temporal stability over a 3-week period.” These results “provide encouraging preliminary support for the EPAI’s reliability.”
Support for the convergent validity of the EPAI was “unequivocal.” However, the evidence for discriminant validity was not as strong, especially for men under age 25.
Potential Uses of the EPAI
The authors suggested the following clinical uses for the EPAI:
• a screening tool in urology clinics to identify men who might need psychoeducational interventions for EPA
• a means to assess how ED medication may affect EPA
• a way for mental health providers to identify men who need psychosocial interventions
• a tracking tool to evaluate patients’ improvement over time
The EPAI could also provide the following benefits for researchers:
• information on the prevalence of EPA and its role as a risk factor for ED
• a secondary outcome measure in studies that assess whether ED treatments improve men’s EPA
• information on whether a man’s EPA may predict his response to ED treatment
• a test to see how treatment-related changes in EPA might relate to erectile performance (and vice versa)
The authors noted the following study limitations:
• The sample size was small and included relatively healthy men.
• The findings on discriminant validity were mixed. There was “rather weak evidence of discriminant validity” in relation to the EPAI’s association with depression, especially for the younger subgroup.
• There is no data on whether the EPAI can detect changes in EPA before and after ED treatment.
The authors stated that “the EPAI is a promising, cost-effective, psychometrically sound index of anxiety specific to erectile performance concerns that fills an important gap in the assessment of ED in both clinical and research settings.”