Main findings
Most of the men (70.9%) reporting ED was categorized as having bothersome ED and the majority of those (62.4%) did not contact the GP. Among those bothered by ED and not contacting their GP, 60.6% reported barriers for GP contact. The most common barrier was ‘being too embarrassed’ (29.7%).
In general, respondents in the older age groups were less likely to report embarrassment, business and worrying what the GP might find as a barrier. Respondents with highest attained educational level were less likely to have embarrassment and worrying as barriers for not contacting the GP, but more often indicated other considerations. The respondents who were out of work force were more likely to be worried about what the doctor might find.
Strengths and weaknesses of the study
This study included a large number of randomly selected individuals’ representative of the Danish adult population. The overall response rate among men was 49.8%. The respondents were slightly older compared to the non-respondents (Fig. 1).
A total of 1042 men either missed or did not wish to answer the question concerning ED resulting in a response rate of 47.6% for the ED question, which is comparable to similar studies covering self-reported ED [18,19,20]. Individuals with missing information or not wishing to answer the ED question were generally older (Fig. 1). Some individuals might consider ED as a topic too intimate to report. Not wishing to answer a question regarding ED could hypothetically be associated to barriers for contacting the GP, leading to an underestimation of the proportion of men not consulting the GP and hence also underreporting of some of the five barriers.
Our design using a web-based questionnaire is an advantage as it provides anonymity. Participants completing the questionnaire by telephone interview might find the topic too delicate and tend to dismiss their ED compared to those completing the web-based questionnaire. However, only 1.9% of the respondents completed the question regarding ED by telephone interview (Fig. 1) and a possible difference is therefore presumed to minimally influence the results.
The understanding and interpretation of the question regarding ED might depend on age, cohabitation status, sexual activity etc. However, the field and pilot testing did not reveal problems in relation to this. Participants were asked to recall symptom experience during the preceding four weeks. The short recall period reduces risk of recall error. As we addressed bothersome ED i.e. which either worried or influenced daily activities, it seems reasonable to assume a correct recall within this time frame.
The definition of bothersome ED was constructed by two questions regarding worrying about having ED and the degree of influence on daily activity. It is possible that some respondents have answered negatively on these two questions but still feeling bothered by their ED.
The questionnaire did not contain information on for how long the respondents had been bothered by ED. It only states whether they had experienced ED within the past four weeks. Therefore, it might seem reasonable not to contact the GP if they had only experienced ED once.
In addition to the predefined barriers the questionnaire also comprised an open-ended category with the possibility to express other barriers. These statements are gathered in an ‘other’ category in the present study. Qualitatively exploring the statements in the ‘other’ category is beyond the scope of this study.
Comparison with existing literature
In a survey of male health issues from 2000 conducted in six western countries (US and Europe) Shabsigh et al found that 53.0% of men aged 20–75 years experiencing ED had not sought treatment [10], which is slightly lower than our findings. This difference could be due to this study including men > 75 years as well or by the fact that Shabsigh et al recruited respondents visiting their physician, i.e. their respondents might have a higher tendency to contact their GP in general and therefore be more likely to seek medical attention when experiencing ED as well.
Further, Shabsigh et al found that younger men were less likely to contact the GP regarding ED, which is comparable to our findings. They found that reasons for not seeking medical attention differed between age groups as the younger men believed that their ED would resolve spontaneously, whereas older men thought that ED was a natural part of ageing. We did not measure such considerations in our study but that may explain the low proportion of health seeking among the youngest and oldest respondents in our study and may be the reasons for the frequent choosing of the barrier ‘other’.
In a Turkish survey of men with ED Gulpinar et al [12] found that embarrassment was the most frequent reason for delayed consultation underlining our result of embarrassment being an important barrier for GP contact. The ability to perform sexually is linked to the male masculine role and societal expectations, hence problems relating to this is, although very common, still a taboo.
To our knowledge no studies have previously studied ‘being too busy’ and ‘worrying what the doctor might find’ as barriers for healthcare-seeking with ED. Odds of reporting these barriers were lower in the older age groups. As it becomes more likely that ED often is due to a structural disease with increasing age, it is a reassuring finding that worrying what the doctor might find, is not considered as a barrier for older men. It is expectable that increasing age is not associated with being too busy as older men are not as often congested by e.g. work.
Implications
The fact that most respondents bothered by ED did not contact their GP and reported embarrassment as a frequent barrier highlights the importance of the GP taking a proactive approach to identifying patients bothered by ED and breaking down the taboo of ED. However, several other barriers exist for dealing sufficiently with sexual health issues in general practice such as constraints of time and expertise [21]. It has been shown that patients are more likely to seek help regarding sexual health if their doctor had asked about sexual function during a routine visit sometime during the previous years [22] so it might not be unrealistically time-consuming to reduce the patients’ hesitation to consult when being bothered by ED. Therefore, it could be an idea to implement it as a standard subject in routine consultations for hypertension etc.
