Psychology of Men & Masculinity

Meaning of Sexual Performance Among Men With and Without Erectile Dysfunction
Edward H. Thompson, Jr. and Kaitlyn Barnes Online First Publication, August 6, 2012. doi: 10.1037/a0029104

CITATION Thompson, E. H., Jr., & Barnes, K. (2012, August 6). Meaning of Sexual Performance Among Men With and Without Erectile Dysfunction. Psychology of Men & Masculinity. Advance online publication. doi: 10.1037/a0029104

Psychology of Men & Masculinity 2012, Vol. , No. , 000 000

2012 American Psychological Association 1524-9220/12/$12.00 DOI: 10.1037/a0029104

Meaning of Sexual Performance Among Men With and Without Erectile Dysfunction
Edward H. Thompson, Jr.
College of the Holy Cross

Kaitlyn Barnes
Case Western Reserve University

The purpose of this study was to explore the meaning of sexual performance expectations for adult men with and without erectile dysfunction (ED) and how masculinity ideology and age likely affect perceptions of sexual performance. A convenience sample of men age 50 and older (N 132) completed questionnaires addressing their physical and sexual health, traditional masculinity ideology, and attitudes about sexuality and aging. A Sexual Performance Beliefs Scale that addresses older men was developed. H1: Results indicate that middle-aged and older men disavowed the importance of sexual performance as a dening feature of masculinity, yet men with ED less strongly rejected the principle that ED undermines performative masculinity, and men with ED and using oral ED medication were even less likely to disagree with the maxim that ED equals troubled masculinity. H2: The hypothesized relationship between age and sexual performance beliefs was not supported. H3: Men endorsing a traditional masculinity ideology predictably endorsed the principle that sexual performance signies masculinity. These ndings are discussed in terms of adult mens sexuality and possible clinical implications. Keywords: sexual health, masculinity ideology, erectile dysfunction

It comes as little surprise that mens sexuality and sexual health have become a major interest among academic and medical researchers. It is estimated that nearly one quarter to one half of men report some degree of erectile dysfunction (ED; Cappelleri & Rosen, 2005; Chew, Bremner, Stuckey, Earle, & Jamrozik, 2009; Feldman et al., 2000; Harvard Mens Health Watch, 2006). The pervasiveness of the condition is associated with the general health of the nations aging male population. Erectile dysfunction is a cormorbidity of benign prostate enlargement, cardiovascular disease, diabetes, obesity, and prostate cancer, a side effect of

many medications used to manage chronic conditions, and a side effect of heavy alcohol and tobacco use (Bokhour, Clark, Inui, Sillman, & Talcott, 2001; Feldman et al., 2000; Goldstein, 2004; Lindau & Gavrilova, 2010). As much as the impact of sexual dysfunction on mens lives has captured the interests of many, no study has assessed how the sexual performance expectations associated with traditional masculinity are perceived among men with and without ED nor if these views are affected by mens masculinity ideology. Mens Sexuality It is important to recognize that mens sexuality is not simply the equivalent of erectile ability. Sexuality is a complex phenomenon tied to social and cultural contexts, partner availability, and embodied self-images (Marsiglio & Greer, 1994). However, even before the introduction of Viagra (sildenal citrate) in 1998, the medical model of mens sexuality almost exclusively prioritized erectile ability (Tiefer, 1986, 1994). Ever since the advent of pharmaceutical treatments for ED, many bodily changes that were once considered normal aspects of aging
1

Edward H. Thompson, Department of Sociology and Anthropology, College of the Holy Cross, Worcester, Massachusetts; and Kaitlyn Barnes, Department of Sociology, Case Western Reserve University, Cleveland, Ohio. The authors would like to acknowledge Jenna Constantino, Kaitlin Foley, James B. Broadhurst, MD, and Joseph H. Pleck for their assistance. Correspondence concerning this article should be addressed to Edward H. Thompson, Department of Sociology and Anthropology, College of the Holy Cross, 1 College Street, Worcester, MA 01610-2395. E-mail: ethompson@ holycross.edu

THOMPSON AND BARNES

have been redened as xable biological conditions (Conrad, 2007; Marshall, 2008; Tiefer, 2006). The advertising campaigns marketing erectile medication put forward the cultural model that masculinity is protected by medicine whenever men take control over their changing bodies and use drugs to assure reliable erectile quality (Wienke, 2005). Erectile medication is presented as a treatment for diminished, troubled, or incomplete masculinity. For example, advertising counsels men to be whole again (Loe, 2004), and as Marshall and Katz (2002) asserted, forever functional. The underlying implication within the medical model is that sexual intimacy depends on intercourse (MacDougall, 2006) and maintaining youthful masculine sexualities (Brooks & Levant, 2006; Mamo & Fishman, 2001; Vares & Braun, 2006). Equating mens sexual health with only erectile function parallels the meaning of sexuality within traditional masculinity. The work of many gender studies researchers has helped theorize that masculinity is a culturally based ideology scripting gender relations, attitudes, and beliefs (Thompson & Pleck, 1995, p. 130). The dominant model of masculinity encourages men to think and behave in ways that correspond with norms valuing self-reliance, emotional control, and toughness and devaluing behaviors that more closely resemble femininity, such as revealing vulnerabilities (Mahalik et al., 2003; ONeil, 2008). Sexuality and sexual performance have nearly always been integral to normative masculinity (Connell, 1995; Levant, 1997; Potts, 2000); the exception was possibly the historical period where monastic life and celibacy characterized ideal masculinity. Baglia (2005) argues that the prevailing sexual script for men strongly emphasizes erections as the sine qua non of manliness. In the same way, in his study of the cultural history of impotence, McLaren (2007) contends that sexual performance proves masculinity and that impotence signals failed masculinity. According to the normative masculinity script, the call is for men to value intercourse over other forms of sexual contact and to value performance over emotional connection (Zilbergeld, 1978, 1992). One effect is, as Brooks (2001, p. 52) proposed, the adolescent male becomes the exemplar of mens sexual health. The question begs to be asked, what standard of sexual performance do mature and older men

perceive as theirs? As Coles (2009) eloquently argued, masculinity is embodied in different ways by generation, context, and stage in the life course as much as by class and mens racial and ethnic heritage (Meadows & Davidson, 2006; Morgan, 2004). Recognizing that there is a predictable decline in erectile quality and function with the onset of many age-related health conditions (Araujo, Mohr, & McKinlay, 2004), do middle-age and older men continue to rely on traditional masculinity to dene their sexuality or do they modify their sexual expectations? The ndings from several studies suggest that mature men are not true believers of the cultural model that proposes erectile quality and sexual performance signify masculinity. Middle-age and older men have many other ways to perform masculinity, and they may well report less sexual enjoyment than they did 10 years earlier (Wiley & Bortz, 1996); however, markedly few men with ED actually seek treatment, perhaps no more than 20% (Lindau et al., 2007; Rosen et al., 2004). In one multinational study (N 2,829), a third (35%) of the 866 U.S. men in the study believed ED was something you must learn to accept, and more than half (58%) of the men reported that they were able to work around the erection problem (Perelman, Shabsigh, Seftel, Althof, & Lockhart, 2005, p. 399). When examining the sexual quality of life in a sample of older men (n 907; Mage 60.7) with varying levels of ED, Gralla et al. (2008) also observed that it was only younger men with an earlier onset of more severe ED who reported worries about their sexual performance and relationship functioning. Worry was operationalized as failed masculinity and measured using three items from the Berlin Male Study, including one that directly asked if the man had felt less of a man because of a weak erection during the past four weeks. In the only known study of its kind, Sand, Fisher, Rosen, Heiman, and Eardley (2008) examined perceptions of masculinity among men with and without ED from eight countries: United States, United Kingdom, Germany, France, Italy, Spain, Mexico, and Brazil (N 27,839; age range 20 75). Sand et al.s objective was to determine what dimensions of masculinity were most salient to the men, and they found that men in all age cohorts across all eight nations rated being seen as honorable, self-reliant, and respected as much more impor-

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tant than having an active sex life. There were no signicant differences between the groups of men with and without ED. These ndings reveal that mature mens lives are not as determined by erectile quality as stereotypes suggest, nor does ED strike at the very core of mens masculine self-concept (Sand et al., 2008, p. 591). Sand et al. argued that their ndings were contrary to stereotypes about masculinity, but, in fact, their study did not assess how men with and without ED evaluate the sexual performance expectations within normative masculinity. The current study was designed to assess the meaning of traditional sexual performance expectations among mature men with and without ED. Aging, Sexuality, and Masculinity Ideology Mens beliefs about sexual performance are likely associated with their age and masculinity ideology. Gerontologists report that although the salience of sexual activity slowly diminishes in its importance to relational intimacy as men age, diminish does not mean end. Sexual desire and activity continue to play a vital part in most mens sense of self throughout their middle and later years, whether gay or heterosexual (Kontula & Haavio-Mannila, 2009; Lindau & Gavrilova, 2010; Wierzalis, Barret, Pope, & Rankins, 2006). Among those men who maintain sexual interest, and most men do (cf., DeLamater & Sill, 2005; Lindau et al., 2007; Perelman et al., 2005), some men inevitably experience the sexual side effects of aging and/or prescription drugs and are obliged to reformulate their understanding of sexuality to bring it closer to what is physically possible (Fergus, Gray, & Finch, 2002; Gray, Fitch, Fergus, Mykhalovskly, & Church, 2002). And, among the men who remain sexually active, and most men are (cf., DeLamater & Moorman, 2007; Waite, Laumann, Das, & Schumm, 2009), the activity can eventually shift to entirely kissing, hugging, and sexual touching. The evolution of the meaning of sexuality as men age and the shift in sexual activity from always or usually including sexual intercourse to other forms of sexual intimacy will quite likely inuence middle-age and older mens attitudes toward the sexual performance standards that underlie masculinity. Although endorsing a traditional masculinity ideology is strongly associated with mens atti-

tudes toward nonrelational sex (Kimmel, 2008; Levant & Fischer, 1998), little is known about how masculinity ideology affects middle-age and older mens attitudes toward relationalbased sexual performance. Several studies raise doubt about the importance of the norms underlying nonrelational sexuality (Levant, 1997) for middle-age and older men who are in partnered relationships. Potts, Grace, Vares, and Gavey (2006), for example, found that the older men with ED were sexually active but not necessarily in the penetrative sex of their adolescence. Sexual relations had evolved with age and experience, and these men put less emphasis on erectile quality and coital-performance that was a staple when they were young. The Present Study In summary, currently little research has examined the meaning of sexuality among adult men, or whether mens masculinity ideology and ED status would affect their beliefs about sexual performance. The following hypotheses were examined. Hypothesis 1: Although Sand et al.s (2008) ndings might support a null hypothesis for how sexual health status affects sexual performance beliefs, it can be hypothesized that mens ED status and sexual performance beliefs are directly associated. Experiencing ED may well make men sensitive to sexual performance expectations (cf., Cushman, Phillips, & Wassersug, 2010; Oliffe, 2005), and the sensitizing effect of ED would seem to be particularly evident among the men who initiated use of medication to correct their ED, compared to the men with ED who decided to not use medication. Their decisions to use ED medication likely reveal their beliefs about sexual performance afrming their masculinity (cf., Fracher & Kimmel, 1998). Alternatively, it may be the case that sexual health status is negatively related to sexual performance beliefs because men bring their beliefs in line with their behavioral capabilities. That is, men with ED, and particularly those men not using medication, may be less concerned about erectile performance because they recognize that their masculinity can be af-

THOMPSON AND BARNES

rmed in other ways. As Gerschick and Miller (1995) and Oliffe (2005) observed, men with less-normative bodies are sensitized and more likely to emphasize how else they accomplish masculinity. Hypothesis 2: Older men will be less likely to endorse the principle that erectile ability is a signier of masculinity. As men age, the risk for ED comorbidities increases (Laumann et al., 2007; Lindau & Gavrilova, 2010) and mens identities adjust to the changes in their health. OBrien, Hart, and Hunt (2007) found that older men with prostate cancer and diminished sexual lives comfortably reported that they had other ways to perceive themselves as masculine. Middle-age and older mens gender touchstones may well continue to be the four normative masculinity standards Brannon (1976) describedno sissy stuff (antifemininity), the sturdy oak (selfreliance), the big wheel (acquiring respect and being accomplished), and give em hell (emotional and physical toughness). However, the behaviors the men do to signify accomplished masculinity are unlikely to be the same as young, unmarried men (Bennett, 2007; Spector-Mersel, 2006; Thompson, 1994). Hypothesis 3: Men who more strongly endorse the traditional masculinity norms will be more likely to endorse sexual performance as a signier of masculinity. The theoretical rationale is that despite how physiological aging affects masculinity performance, men who believe more strongly in the principles of a traditional masculinity ideology are also more likely to perceive sexual performance as an expectation they and other men should live by (Connell, 1995). Method Participants This study draws on a convenience sample of 132 men from the New England area. Participants were recruited from one large employer (n 78), an over 50 softball league (n 33), and from the ofce of an internist (n 21). All men aged 50 and older working for the em-

ployer or participating in the softball league were mailed a questionnaire packet that included a cover letter explaining the purpose of the study and advised that their participation was voluntary and anonymous. The purpose was presented as We are asking a number of men to ll out the attached questionnaire. In doing so, you are helping to provide information on mens health and attitudes about sexuality in later life. The same cover letter was attached to the questionnaires presented to patients by the receptionist at the internists ofce. Consent was afrmed when the participant chose to return the completed questionnaire, and anonymity was preserved by using a prepaid return envelope. Although some participants could have returned the questionnaire directly to the rst author, none did. The sample was largely comprised of white, heterosexual, married men. The mean age was 59.8 (SD 8.21, range: 45 83), and typical of New England, the vast majority of the men were white (96.9%). Heterosexuals (93.1%) far outnumbered the few bisexual men (3.1%) and exclusively gay men (3.8%) who completed the questionnaire. Most were married (82.3%), and there were nearly as many not married but living as married (5.4%) as separated/divorced (6.1%). More than two thirds of the men (69.2%) were employed fulltime, though nearly a quarter were retired (23.1%). The men were more educated than the general population in New Englandnearly one quarter of the sample had graduated college, and nearly half the sample had earned a graduate degree (e.g., M.B.A., J.D.). However, they were representative of the white, middleclass men largely targeted by the pharmaceutical advertising for ED (Calasanti & King, 2007). Measures Health status and erectile dysfunction. Sexual ability is known to be associated with health status, particularly chronic health conditions such as hypertension, heart disease, diabetes, and obesity. Health status was measured with a single question, How much does your health stand in the way of you doing the things you want to doa great deal, a little, or not at all? The measures construct validity is its signicant correlations with mens reports of

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high blood pressure, cardiovascular disorder, and diabetes as comorbidities (rs .28, .23, .32, p .01, respectively), and subjective health (r .43, p .001), which was assessed on a 11-point scale ranging from very poor to excellent with the question, On a scale from zero to 10, how would you rate your health today? ED also was assessed with a single item. Placed early in the questionnaire, the OARS (Older Americans Resources and Services) measures health status by asking the respondents to identify in a yes/no format whether or not they have any of a list of 23 illness conditions and then to what extent each illness interferes with daily activities. Two-thirds of the way through the OARS list of illness conditions, erectile difculties was added. Others (e.g., ODonnell, Araujo, Goldstein, & McKinlay, 2004) have used a single question. Our question identies men with self-reported erectile problems. To assess the construct validity of the question, the severity of the mens ED was assessed by the widely used ve-item International Index of Erectile Function, IIEF-5 (kappa coefcient .85; Rosen, Cappelleri, Smith, Lipsky, & Pena, 1999; the scale is sometimes referred to as the Sexual Health Inventory for Men, SHIM, Cappelleri & Rosen, 2005). The key issue was whether or not the men admitted that they were experiencing ED. Mens use of oral ED medication was similarly measured with a yes/no self-report. The OARS includes a list of medications adults might use to manage their health status (e.g., diuretics, cholesterol drugs, high blood pressure medication). Inserted two thirds of the way through the list, medication for erectile difculties was added. Respondents were asked to only report what medications they had used within the past two months. Sexual orientation. A sexual orientation variable was constructed, with heterosexuals coded 1 and the gay and bisexual men coded 0. Though attitudes toward erectile ability (and/or sexual performance) are not necessarily statements about sexual orientation, an underlying implication in the wording of the attitude statements is hetero-normative and might be (mis)interpreted as only heterosexuals interest in (vaginal) penetration. We elected to statistically control for mens sexual orientation. Relationship satisfaction. Waite et al. (2009) and Loe (2004) agged the importance

of marriage as a condition for being sexually active. Sand et al.s (2008) cross-national study also revealed that men with and without ED routinely dened good relationships with their wife or partner as more important to their quality of life than their sexual health. Because the quality of mens primary intimate relationship may well affect their attitudes toward sexual performance, relationship satisfaction was assessed with a single item, How overall satised are you with your relationship with your partner? and rated on a 7-point Likert scale ranging from very unsatised to very satised (M 5.13; SD 1.67). Masculinity ideology. Masculinity ideology was assessed with a condensed version of the Male Role Norm Scale (MRNS, Thompson & Pleck, 1986). Using the four items with the strongest factor loadings from each of the three original subscales, a shortened, 12-item index of mens traditional masculinity was assessed using a 7-point disagree-agree Likert format ( .76). Statements were scored to reveal the extent to which traditional masculinity ideology was rejected/supported, and mean scores were calculated (M 3.72; SD .76). Although this shortened version of the MRNS has not been previously used, the means and measures internal consistency in this sample are very consistent with the full version of the measure (see Thompson & Pleck, 1986, 1995). Sexual Performance Beliefs Scale (SPBS). A self-report measure of sexual performance beliefs was developed to assess if the coitalbased expectations evident within both traditional masculinity and the medicalized view of mens sexuality were deemed a necessary component of adult mens performative masculinity. The rst step in constructing a sexual performance beliefs measure was to generate items that assessed the traditional masculinity precept that sex equals performance even for older men. Earlier, Snell, Belk, and Hawkins (1986) developed 10 six-item scales to represent stereotypes about male sexuality, and several contained items partially relevant to assess adult mens beliefs about sexual performance. We selected ve items. Three items from the measure of sex equals performance, one from the measure that men must be always ready for sex and one from the measure of sex requires [an] erection were reworded to make the items applicable to men and aging. Nine original items

THOMPSON AND BARNES

were also constructed. These belief statements were placed near the end of the questionnaire. In deciding what wording to retain from the pool of items, we took into account input from several difference sources: outside expert reviews by a urologist and a clinical psychologist who work with men, the research team input, and relevant mens studies and gerontology literature. The goal was to be more inclusive than exclusive with item development and to depend on psychometric analyses to eliminate items. Beliefs were assessed using a 7-point disagreeagree Likert format, and a score of 1 represented very strongly disagree. We began by examining the correlation matrix among the items and then used an iterative process that involved an exploratory factor analysis of the items to determine the factor structure that underlies the responses to individual items (DeVellis, 1991). When the correlation matrix among the initial 12 items was examined, 53% of the intercorrelation coefcients were greater than .30, and 77% were signicant (two-tailed, p .05). However, nearly half (45%) of the correlation coefcients smaller than .30 were accounted for by two items, and both items item-total scale score coefcients were also smaller than .30. The two items were dropped. Use of factor analysis with a sample size of 132 is never ideal, even for 10 items; therefore, Bartletts test of sphericity and the KaiserMeyer-Olkin (KMO) measure of sampling adequacy were conducted to determine if factor analysis was appropriate. Bartletts test for sphericity was signicant, demonstrating that the matrix was not an identity matrix; as well, the KMO value was greater than .60 (KMO .796). It was anticipated that the 10 items would cluster into a single factor, but it was possible that multiple factors would be revealed within the variance of responses. The initial analysis yielded three factors with eigenvalues greater than 1 and accounted for 63.4% of the variance. Extracting factors based on only eigenvalues can yield more factors than can be interpreted theoretically, often because some factors can be principally determined by a single item and other times items load nearly equally on more than one factor. The 3-factor solution was difcult to interpret for both of these reasons. Therefore, we examined the scree plot and concluded a

2-factor solution would be a better approximation of the SPBS structure. The 2-factor solution accounted for 52% of the variance. The matrix was rotated obliquely to allow for the possibility of correlated factors. The rst factor included 7 items, accounted for 39% of the variance, and emphasized erectile ability and sexual performance as a requisite for afrming masculinity ( .83). It seemed to measure embodying masculinity. The second factor involved 3 items, accounted for 13% of the variance, and addressed the continuing sexual performance expectations in later life ( .57). It seemed to measure how older men are not exempt from embodying sexual performance expectations. The items, factors, factor loadings, and measures of central tendency are presented in Appendix A. Items were rated on a very strongly disagree to very strongly agree Likert-format. The correlations for the two factors within the SPBS to one another and to the SPBS as a whole were reviewed. The SPBS and its rst factor were highly correlated (r .95, p .001); whereas the second factor and the SPBS were not as highly correlated (r .66, p .001). The two factors were moderately correlated with one another (r .41, p .001). Although the factor solution showed two distinct factors, there is good reason for merging the two factors into one overall scale, the SPBS. One reason is that the internal consistency coefcients for the two factors were unequal ( .83 and .57, respectively), reecting the small number of items and lesser variance in the second factor; a second reason is that the two factors are signicantly correlated; and, nally, aging is explicitly referenced in two items within the rst factor and all three items of the second factor. Because the difference between the two factors is not readily interpretable, further analyses were conducted on the 10-item SPBS as a whole. A lower SPBS score indicates that the respondents disagree with the premise that sexual performance is at the core of masculinity. The SPBS has good internal consistency ( .82), and it appears that the SPBS incorporates the traditional masculinity precept that sex equals performance and the premise that older men are not exempt from sexual performance expectations.

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Statistical Analysis An analysis of covariance (ANCOVA) was used to determine the extent to which selfreported ED and/or use of oral ED medication affects mens attitudes about the meaning of sexual performance. The 2 2 ANCOVA introduces both dichotomous variables as xed factors and then adds their interaction. The covariates included the mens age, health status, sexual orientation, relationship satisfaction, and masculinity ideology. A general linear model ANCOVA is equivalent to a regression analysis. We used SPSS, Version 19.0, which directly constructs the interaction term between factors, plots the interaction effect, and calculates effect size estimates as well as observed power coefcients. Results Generally speaking, the men in this study disagreed with the precept that erectile ability and sexual performance are integral to mascu-

linity (M 3.40, SD 0.82, range 1.50 7.00). Correlational analyses were computed to examine the relationship between the SPBS and demographic variables. The SPBS was inversely correlated with the mens education (r .213, p .015) but was not associated with respondents health status or being retired, married, heterosexual, and white. Finally, though not a true indicator of the convergent validity of the scale, the SPBS was highly correlated (r .518, p .001) with masculinity ideology, as measured by the condensed 12-item version of the MRNS. Comparing men with and without ED revealed that the men self-reporting ED were older and more often retired than men not reporting ED, and they lived with more health problems, perceived their health status impairing their functional abilities, and self-dened their health as poorer (see Table 1). As would be expected, the men with and without selfreported ED differed signicantly on IIEF-5 scores (M 14.52 and 8.53, SD 5.08

Table 1 Differences Between Men With and Without Erectile Dysfunction

Without Erectile Dysfunction (n 89) Race/ethnicity White African-American or Latino Sexual orientation Heterosexual Bisexual or gay Marital status Married Not married Age (M, SD) Education (range 16; 1 less than high school, 4 college graduate 6 professional degree) Masculinity Ideology (Male Role Norms Scale) Comorbidity: Number of illness Subjective health (range 010) Health status (functional limitations) Not at all A little A great deal IIEF-5 Used ED medication No Yes 95.5% 4.5 89.9% 10.1 79.8% 20.2 58.3 (8.08) With Erectile Dysfunction (n 43) 95.3% 4.7 95.3% 4.7 83.7% 16.3 62.8 (7.71) Chi-square or t-value 0.00

df 1

p .968

1.13

.473

0.29 3.01

1 128

.588 .003

4.40 (1.43) 3.67 (0.80) 1.37 (1.45) 8.32 (1.51) 70.1% 26.4 3.4 14.52 (5.08) 92.0% 8.0

4.23 (1.32) 3.72 (0.73) 4.52 (2.65) 7.33 (2.11) 46.5% 41.9 11.6 8.53 (3.89) 47.6% 52.4

0.66 0.20 8.81 3.03 7.87

129 128 130 129 2

.513 .984 .001 .003 .020

7.47 31.95

129 1

.001 .001

THOMPSON AND BARNES

and 3.89, respectively; t(129) 7.47, p .001), and 65.8% who self-reported ED also scored in the ED range on the IIEF-5, 2 (1) 21.86, p .001. Many more men with ED reported using medication for ED within the past two months than men without ED, 2 (1) 31.95, p .001. However, neither self-reported ED (r .131, p .136), use of ED medication (r .109, p .220), or the IIEF-5 score (r .004, p .966) correlated with the SPBS. Hypothesis 1 The between-groups differences among the men with and without ED and using or not using ED medication were assessed with ANCOVA. The unadjusted means and standard deviations for the two conditions ED and use of ED medication-are reported in Table 2, and Table 3 summarizes the results of the analysis. The sample size is a bit smaller (N 123) as a result of missing data. The overall model ANCOVA was signicant, F(8, 114) 9.45, p .001, 2 .399. The p partial eta squared indicates that 39.9% of the variance in sexual performance beliefs was explained. There was a marginally signicant main effect for ED, F(1, 114) 3.14, p .079, 2 .027, but not for the use of ED medication. p In addition, there was a signicant interaction between ED and use of ED medication, F(1, 114) 7.53, p .007, 2 .062. The magnip tude of the overall effects for ED status and the interaction term were small and medium, respectively (Cohen, 1988). As noted in Figure 1, the men with ED and using ED medication disagree less with the SPBS.

Hypotheses 2 and 3 We observed that men over age 60 (Mage 67.4, SD 5.87) tended to endorse the SPBS more than the younger men in the sample (Mage 53.8, SD 3.33), M 3.26 and 3.51, SD 1.03 and 0.58, respectively; t(128) 1.76, p .08. However, as a continuous variable within the ANCOVA, age was not predictive of mens endorsement of the precept that erectile ability signies masculinity, F(1, 114) 1.58, p .212, 2 .014. With the p paucity of the observed power coefcient (.238) and a trivial effect size, we conclude that Hypothesis 2 was not supported. By contrast, endorsing a traditional masculinity ideology was substantively predictive of mens attitudes toward the meaning of sexual performance, F(1, 114) 57.32, p .000, 2 p .335. The effect size of the MRNS was unsurprisingly large. Unequivocally, men who believed more strongly in the principles of a traditional masculinity ideology were more likely to agree with the principle that erectile ability and sexual performance also symbolize masculinity. Discussion The middle-aged and older men in this study did not endorse the criterion that erectile ability is vital to masculine identity. In fact, they rejected the logic that sexual performance denes masculinity, and it was only the men who lived with ED and used ED medication who showed any inclination to link masculinity with sexual performance. What best predicted mens attitudes toward erectile ability signifying masculinity was their support of a traditional masculinity ideology. This study illustrates some of the incongruous connections between masculinities and adult mens sexuality. One of the dominant cultural narratives is how masculinity is embodied through (hetero)sexuality. The cultural maxim suggests that so long as the man sexually performs, his manhood is unquestioned. But should he fail to get and sustain an erection, his sexual health is not in question; his masculinity is. Evidence from studies of men with chronic illness and erectile problems (e.g., Burns & Mahalik, 2007; Loe, 2004; Oliffe, 2005) nd that most adult men accept this premise. Many re-

Table 2 Unadjusted Means and Standard Deviations on SPBS for Men With and Without ED and Use of Oral ED Medication
Use of ED medication No Yes No Yes Total SPBS Mean 3.36 2.90 3.30 3.78 3.40 SD 0.74 0.71 0.79 1.10 0.84 n 76 7 18 22 123

ED No Yes

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Table 3 Summary of the ANCOVA

F Sexual performance beliefs Age Heterosexual Health status Masculinity ideology (MRNS) Relationship satisfaction ED Oral ED medication (RxED) ED RxED 9.45 1.58 2.76 5.54 56.47 0.68 4.14 0.89 7.53 p .001 .212 .099 .020 .001 .411 .044 .384 .007
2 p z

( )

B (SE) .010 (.008) .438 (.264) .247 (.105) .653 (.086) .032 (.039) .788 (.294) .634 (.217) .945 (.344)

.399 .014 .024 .046 .335 .006 .027 .008 .062

.238 .377 .646 1.000 .128 .420 .155 .777

searchers also have presented empirical evidence conrming that the onset of erectile problems can have a profoundly adverse effect on mens psychological well-being and quality of life (cf., Bokhour et al., 2001; Cappelleri et al., 2004; Tomlinson & Wright, 2004). Thus, why did the vast majority of the men in the study fundamentally disagree that sexual performance is a basis of performative masculinity? As is often the case, reliable data are inconsistent with widely held but empirically unexamined constructs and require a rethinking of the accepted wisdoms. We suspect that two theoretically important explanations account for why the middle-age and older men in the study renounced the precept that erectile ability is essential to afrming masculinity. As theorized earlier, because the meaning of masculinity

Erectile Difficulties

Figure 1. Interaction effect of ED and use of ED medication on sexual performance beliefs. Men reporting ED and use of oral ED medication within the past two months reveal less disagreement with the SPBS.

shifts as men age (cf., Coles, 2009; Thompson, 1994), being a man can continue to be accomplished successfully by middle-aged and older men in many elds, whether retired or living with ED. Erectile ability is less central to and does not necessarily dene adult mens masculine self-concept (cf., Sand et al., 2008), which is consistent with Tannenbaum and Franks (2011) and OBrien et al.s (2007) observation that, with age, men incorporate health changes into their daily lives in ways that do not conict with their masculine identity. In addition, we suspect that the sexual performance maxim was rejected because most of the men in the sample were sexually healthy, partnered men. Sexual intimacy for men in partnered relationships includes an emphasis on relaxing and gentle sex, mutual enjoyment, and pleasuring ones partner, all of which is done without the necessity of a full erection. For men in long-term partnered relationships, sexuality is about intimacy; sex also can be recreational and about fun. Nearly 80% of the men in the current study were sexually active with their partner, and two thirds did not report an erectile problem. [Nationally, 90% of men in their middle years engage in vaginal (or penetrative) intercourse, and at least 75% of men age 6574 report that vaginal sex is usually or always part of sexual activity (Waite et al., 2009).] Their sexual health was not (yet) at issue. As Gross & Blundo (2005, p. 90) recognized, men see their sexuality as a taken-for-granted asset, like a heartbeat, until confronted by its failure. It is very likely that when men are partnered, sexually healthy, and sexually active, sexual intercourse remains a routine dimension of a relationship rather than means of assess-

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ment of their masculinity. Being partnered and remaining bodily unchallenged, the men without ED seem to be impervious to the suggestion in advertising that failed sexuality is toxic to masculinity. They likely regard their sexuality as a dimension of a relationship, something managed by theirs and their partners sexual interest. However, the premise that (partnered, adult) men would perceive an erection and penetrative sex as essential to their masculinity was not wholly rejected by all men. Having ED and using ED medication may well make men sensitive to sexual performance expectations. As hypothesized, the sensitizing effect of ED to sexual performance beliefs was somewhat evident among the men who used ED medication. Also consistent with the alternative hypothesis, the men with ED but not using ED medication did not agree with the premise that erectile ability signied masculinity. These men likely understand that middle-aged and older mens masculinity can be afrmed in other ways. It was unexpected to nd that the age of the participants failed to predict sexual performance expectations. Despite the initial observation of a between-groups difference for the older and younger men, once other covariants (such as health status) of age and sexual performance beliefs were statistically controlled, age was not predictive. Given the limited sample size, this nding may reect inadequate statistical power and the age homogeneity of the participants in the sample. Yet it may also be the case that the expected relationship between the two constructs does not emerge simply because adult men in partnered relationships do not perceive sexual performance as a valid signier of masculinity. The relationship between mens attitudes toward sexual performance and masculinity ideology was, as expected, clear-cut. The middleage and older men who supported the traditional masculinity norms were much more inclined to also believe that masculinity is embodied in sexual performance. Because the men in the sample are from similar age cohorts (with their boyhood embedded in the cultures of 1950s through 1960s), they probably adopted similar cultural denitions of masculinity. Thus, it was not surprising to nd a strong relationship between their level of endorsement of a traditional

masculinity ideology and belief that sexual performance is an indicator of masculinity. The association between mens sexual health status and their sexual performance attitudes has fascinating implications for psychologists engaged in clinical practice with men and couples facing erectile problems. It was men in good sexual health and men not using ED medication who most severely spurned the premise that sexual performance equals masculinity, likely because they were unconcerned about performance. By comparison, the men with ED and taking ED medication were reluctant to reject the axiom that sexual performance is central to masculinity. This nding may seem counterintuitive, especially since researchers examining men who experience prostate cancer or have undergone a prostatectomy and faced the side effect of erectile problems conclude that mens sexuality and masculinity are highly interwoven (Fergus et al., 2002; Oliffe, 2005). However, ndings from studies of clinical populations ought not be generalized to all adult men. The evidence from our sample of community-based men is that, in general, middle-age and older men do not perceive masculinity to be anchored to sexual performance. Even the men living with challenged sexual health and using ED medication seemed wary to endorse the association between sexual performance and diminished masculinity. Clinicians must not assume as credible the stereotype that men with erectile problems are troubled men. Should men with ED consult, their troubles are more likely functional. They very likely regard their ED as ageand health-related, and not as emblematic of failed masculinity. It is also likely that the mid-to-late life men facing erectile problems use ED medication to reintroduce sexual intercourse back into their relationship and reclaim what is pleasurable rather than to reclaim sexual intercourse as a sign of their manhood. Psychologists and physicians engaged in counseling men would be advised to determine if the rst line of care is xing the man or adding to a couples sexual activity (cf., Brooks & Levant, 2006). Clinicians working with men with erectile problems may also nd it invaluable to counsel the men seeking ED medication to consider experimenting and expanding their practices outside of sexual intercourse for mutual enjoyment. For example, OBrien, Hunt, and Hart (2005) found

MEANING OF SEXUAL PERFORMANCE

11

that older men weighed their partners preference for sexual practices that involved more frequent nonpenetrative sex against their interest in penile rigidity. With divorce being prevalent and more midto-late life men again dating, unpartnered men might desire the safety of presenting themselves as sexually unencumbered by their age and/or health. Returning to the dating marketplace may trigger mens youthful anxieties about sexual performance playing a large part in how the men form intimate relationships and dene manliness. Physicians and psychologists working with either older gay men or divorced or widowed heterosexual men who are dating may seek to explore their clients perceptions of sexuality and safe sexual practice and how their worries might create a pharmaceutical dependency as well as add risk to their sexual health. Jena, Goldman, Kamdar, Lakdawalla, and Lu (2010) reported that middle-age and older men who use ED drugs are at a higher risk of sexually transmitted diseases. The present study provides support for the expected association between masculinity ideology and sexual performance beliefs. But it raises doubt about middle-aged and older mens acceptance of the gender norms that equate being a man with sexual performance. Because hegemonic masculinity in the United States is currently embodied in younger, heterosexual, highly educated, white American men with upper-middle class status (Connell, 1995) and extended to middle-age men who willingly use oral ED medication (Loe, 2004), we expected men to endorse sexual performance as emblematic of masculinity. They did not. Study Limitations These important ndings must be considered in light of the studys limitations. To begin with, the study was exploratory in nature and based on self-report data from a small sample. The men in the sample completed more education than would be found in a nationally representative sample, which limits the generalizability of the ndings. The ndings need replication. Second, even though we developed a reliable measure of mens sexual performance beliefs, the SPBS only measured one aspect of the way masculinity can be embodied. Adult mens embodied masculinity needs more attention. Re-

searchers could explore the construction of a force-choice format measure of mature and older mens experiences with sexuality and/or their other attitudes about the meaning of sexual performance, similar in style to the Masculine Gender Role Stress scale (Eisler & Skidmore, 1987). This assessment strategy might provide an image of the extent to which men with and without ED are experiencing gender trouble even while rejecting the maxim the sexual performance denes masculinity. Third, our analysis urges reconsideration of the meaning of sexual interest and activity among men in mid-to-late life; however, the ndings are based on a sample of mostly partnered white men, mean age 60. There are other factors that also merit attention beyond age, sexual orientation, and health status, including comfort with forms of sexual intimacy that do not involve sexual intercourse and the health of ones partner. Future studies using larger, more diverse samples could better address the sensitivity of the measures of mens attitudes toward sexual performance among men who are at different stages in their experience with erectile problems. References
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(Appendix follows)

MEANING OF SEXUAL PERFORMANCE

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Appendix A SPBS Items, Factors, Means, SDs

Oblimin rotation factor loadings SPBS Items Sexual Performance Beliefs Scale ( .82) In sex, its a mans performance that counts. The troubles that men face with their sexuality as they grow older challenge their manhood. Without an erection a man is sexually lost. Older men who have trouble maintaining sexual excitement are less masculine than they used to be. Men who become unable to sexually satisfy their partner become less manly. Frankly, a man should always be ready for sex. A mans ability to have an erection is good evidence that his masculinity is okay. Despite his aging, it is important for a man to be good in bed. Regardless mens age, most men believe that sex is a performance. From an older mans perspective, sex remains a pressure-lled activity. M (SD) 3.40 (0.82) 3.00 (1.23) 3.66 (1.32) 3.32 (1.53) 2.70 (1.38) 3.10 (1.35) 3.17 (1.29) 3.06 (1.34) 3.99 (1.27) 4.16 (1.15) 3.91 (1.31) Factor 1 .608 .610 .737 .784 .828 .581 .734 .220 .141 .053 Factor 2 .095 .032 .020 .066 .063 .209 .001 .599 .800 .734

Received September 28, 2010 Revision received May 11, 2012 Accepted May 16, 2012