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The Impact of Disrupted Childhood Attachment on the Presentation of Psychogenic Erectile Dysfunction: An Exploratory Study
798
ORIGINAL RESEARCH—PSYCHOLOGY The Impact of Disrupted Childhood Attachment on the Presentation of Psychogenic Erectile Dysfunction: An Exploratory Study Ravi P. Rajkumar, MD Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India DOI: 10.1111/jsm.12815
ABSTRACT
Introduction. Erectile dysfunction (ED) is a common form of male sexual dysfunction. Psychological factors play an important role in the onset and persistence of ED. Disturbed childhood attachment is a biologically and psychologically plausible predisposing factor for psychogenic ED that has not been systematically studied to date. Aim. This study aims to assess the frequency and correlates of events associated with parental separation (actual or threatened) and loss in men with a diagnosis of psychogenic ED. Methods. The case records of 46 men who presented to a clinic for psychosexual disorders in the period 2012–2013, and were diagnosed with psychogenic ED using a semi-structured interview schedule, were reviewed. Results. Events causing actual or potential disturbed attachment (DA) in childhood were reported by 20 of 46 men with psychogenic ED (43.5%). This group of men (DA+) had an earlier age at onset of ED (median 25 vs. 29 years, P = 0.005), were more likely to be single (15/20 vs. 5/26 (χ2 = 14.307, P < 0.001), reported sexual performance anxiety more frequently (12/20 vs. 7/26, χ2 = 5.101, P = 0.024), and were more likely to develop ED in the absence of a proximate stressor (4/20 vs. 15/26, P = 0.015). They also showed a trend toward being more likely to report guilt over early sexual experiences as a contributory factor (5/20 vs. 1/26, P = 0.072). In a binary logistic regression analysis, the presence of performance anxiety (B = 2.01, P = 0.023) and marital status (B = −2.85, P = 0.001) were significantly associated with events causing DA. Conclusions. Disrupted childhood attachment was common in our sample of men with ED and is associated with significant differences in their clinical profile, particularly an earlier onset, a lower likelihood of being married, and higher rates of performance anxiety. This study highlights the need to consider early childhood experiences, particularly using an attachment theory framework, when examining the origins of psychogenic erectile dysfunction. Rajkumar RP. The impact of disrupted childhood attachment on the presentation of psychogenic erectile dysfunction: An exploratory study. J Sex Med 2015;12:798–803. Key Words. Erectile Dysfunction; Attachment Theory; Anxiety
Introduction
E
rectile dysfunction (ED), also known as erectile impotence, is a common form of male sexual dysfunction. ED affects up to 5% of men in community-based studies [1]. The International Society for Impotence Research has classified ED into organic and psychogenic types, with psychogenic ED being further divided into generalized
J Sex Med 2015;12:798–803
and situational subtypes [2]. Though the boundary between organic and psychogenic ED is disputed, and subject to revision in the light of emerging research [3], psychological factors certainly play an important role in the genesis or maintenance of ED [4]. Moreover, psychosocial therapies have robust efficacy in patients with ED, and combination therapy often outperforms monotherapy with agents such as sildenafil [5]. © 2015 International Society for Sexual Medicine
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Early formulations of the psychological origins of ED focused on psychodynamic theories, such as Oedipal conflict [4,6]. These were later replaced by behavioral models based on the work of Masters and Johnson [6]. It is now recognized that a wide variety of psychological factors can trigger or aggravate ED. These include anxiety [7], depression [8], interpersonal conflict [9], guilt related to sexuality, body image disturbances, stressful life events, and partner-related problems [4]. Another psychological factor of potential relevance is the impact of early childhood experience, especially the disruption of attachment bonds, on sexual functioning. Though psychodynamic models emphasized these factors, they are often passed over in behavioral or “psychosomatic” formulations that tend to emphasize recent events and current circumstances. In humans, sexual behavior may be shaped and influenced by the attachment system [10], and attachment behavior strongly influences adult romantic relationships and sexuality [11]. Disturbed attachment (DA+) can significantly affect neurochemical and neuroendocrine functioning [12,13], and this may be related to some of the “organic” changes seen in men with ED [3]. Furthermore, DA is one of the key psychological factors underlying both anxiety [14] and depression [13,15], both of which are risk factors for ED. For these reasons, we determined the frequency and correlates of disturbed childhood attachment in the case records of men presenting to our psychosexual disorders clinic with a primary complaint of ED.
prolonged parental separation followed by reconciliation, parental marital disharmony with threats of separation, parental suicide, parental alcoholism or substance abuse, and parental physical or mental illness during childhood. If a patient answered “yes” to a screening question on the above, further details were collected. The inclusion of parental alcoholism in the interview schedule was based on the high rates of childhood adversity experienced in such homes [16]. This study was conducted in accordance with the guidelines of the hospital’s Scientific Advisory Committee, which requires no informed consent for retrospective reviews of clinical data as long as patient confidentiality is maintained. After reviewing the patients’ case records, they were divided into two groups: patients with ED and a history of disturbed attachment (DA+) and those without such a history (DA–). The two groups were compared on demographic and clinical variables, including psychiatric comorbidity. Statistical analyses were carried out using the Statistical Package for Social Sciences (SPSS; SPSS Inc., Chicago, IL, USA) version 20 and the WinPEpi program (WinPEpi version 11.0, copyright J. H. Abramson, October 20, 2010, Hebrew University, Jerusalem, Israel). All tests were two tailed, and a significance level of P < 0.05 was considered significant. As this was an exploratory study, there was no a priori hypothesis.
Materials and Methods
The case records of 46 men with psychogenic ED presenting to the Marital and Psychosexual (MAPS) clinic of a tertiary care hospital in South India between 2012 and 2013 were reviewed. Patients in the MAPS clinic are evaluated by psychiatry residents using a semi-structured interview schedule. All diagnoses of psychogenic ED were confirmed by the author using the World Health Organization’s International Classification of Diseases, 10th Edition (ICD-10) clinical descriptions and diagnostic guidelines, following referrals to other specialty departments, such as urology or endocrinology, to rule out the presence of “organic” causes. Questions on early life experiences were a part of the interview schedule and included screening questions on the following: parental loss in childhood (before the age of 10), parental divorce,
Results
A total of 46 case records of men with a diagnosis of psychogenic ED (ICD-10 code F52.2, failure of genital response) were reviewed. The mean age of the sample was 31.04 ± 6.03 years, with a range of 22–47 years. Twenty of these men were single, 24 were married, one was divorced, and one was a widower. Patients had a mean of 9.93 ± 4.18 years of education (range 0–18), and most were employed as laborers or farmers. Of the entire sample, 20 men (43.5%) had a history of one of more adverse events that led to a disruption of attachment during childhood. These included parental alcoholism (13/20), parental marital discord with threats of separation (10/20), parental separation followed by reconciliation (2/20), natural death of a parent before the age of 10 years (1/20), parental divorce and remarriage (1/20), and suicide of a parent (1/20). These 20 men (DA+) were compared with the remaining 26 men without a history of actual or J Sex Med 2015;12:798–803
800 Table 1
Rajkumar Comparison of men with psychogenic ED with and without disturbed attachment (DA)
Variable Age at presentation Years of education Marital status Married Single Age at onset Duration of ED (in months) Comorbid premature ejaculation (PE) Performance anxiety related to intercourse Guilt related to masturbation / premarital intercourse Stressors preceding ED Marital disharmony Semen loss anxiety Any psychiatric comorbidity Mood disorder Anxiety disorder Substance use disorder Suicidality
Men with psychogenic ED with disturbed attachment (DA+) (n = 20)
Men with psychogenic ED without disturbed attachment (DA–) (n = 26)
28.4 ± 5.1 9.6 ± 4.1
33.1 ± 6.0* 10.2 ± 4.3
5 (25%) 15 (75%) 25.0 28.6 ± 30.2 7 (35%) 12 (60%) 5 (25%) 4/20 (20%) 2/5 (40%) 2 (10%) 11 (55%) 1 (5%) 6 (30%) 6 (30%) 3 (15%)
21 (80.8%) 5 (19.2%)† 29.0‡ 34.5 ± 34.3 10 (38.5%) 7 (26.9%)§ 1 (3.9%)¶ 15/26 (57.7%)** 13/21 (61.9%) 1 (3.9%) 10 (38.5%) 3 (11.5%) 4 (15.4%) 10 (38.5%) 5 (19.2%)
*t = −2.86, P = 0.006 † 2 χ = 14.307, P < 0.001 ‡Values given as median due to non-normal distribution. P = 0.005, Mann–Whitney U-test §χ2 = 5.101, P = 0.024 ¶ P = 0.072, Fisher’s exact test **P = 0.016, Fisher’s exact test
threatened parental separation in childhood (DA–). The demographic and clinical characteristics of these two groups are summarized in Table 1. Men in the DA + group were significantly younger (mean age 28.4 ± 5.1 years as against 33.1 ± 6.0, t = −2.86, P = 0.006) and were more likely to be single (75% vs. 19.2%, χ2 = 14.307, P < 0.001). They also had a significantly earlier age of onset of ED (median 25.0 vs. 29.0; Mann–Whitney U1 = 386.5, U2 = 133.5, Z = 2.80; P = 0.005). A total of 12 men (60%) in the DA + group reported significant levels of performance anxiety during sexual intercourse, in contrast to seven (26.9%) in the DA− group. This difference was statistically significant (χ2 = 5.101, P < 0.05). Rates of comorbid premature ejaculation (PE) were comparable in the two groups. However, when examining the temporal relationship between PE and ED, PE predated ED in 4/7 (57.1%) of the DA+ group, whereas ED predated PE in all the men in the DA− group; this difference was statistically significant (P < 0.05, Fisher’s exact test). Semen-loss anxiety, a common condition in India, was infrequent in both the groups and occurred at comparable rates. However, there was a trend for men in the DA+ group to report guilt J Sex Med 2015;12:798–803
over previous sexual experiences, such as masturbation or premarital intercourse, as a contributory factor toward ED (5/20 in the DA+ group; 1/26 in the DA− group; P = 0.072, Fisher’s exact test.) Information on stressful events temporally correlated with the onset of ED, such as marital disharmony or infertility, was also collected. Such events were reported by more than half the men in the DA− group (15/26, 57.7%) as opposed to four men in the DA+ group (4/20, 20%). This difference was statistically significant (P < 0.05, Fisher’s exact test). In terms of clinical presentation, the two groups had comparable rates of comorbid psychiatric disorders, including mood and anxiety disorders, and substance use disorders. There was no difference in the frequency of suicidal ideation or attempts between the two groups. To confirm the strength of these associations, a binary logistic regression analysis using the backward Wald method was carried out to identify those factors which reliably distinguished between the DA+ and DA− groups. All variables that reached at least a trend level of significance in the univariate analysis were entered into the model. The final model, which correctly classified 75% of patients in the DA+ group and 80.8% in the DA− group found that performance anxiety (B = 2.01, Wald = 5.16,
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Table 2 Binary logistic regression analysis of variables that differentiate the DA+ and DA− groups of men with ED
The low rates of comorbid depression and anxiety in our DA+ group were an unexpected finding, as anxiety and depression are wellestablished sequelae of disturbed attachment. They may be explained by the small sample size or the nature of the study sample, which was recruited from a general hospital psychiatry unit largely based on referrals from surgeons or urologists. The role of childhood factors in the pathogenesis of ED is a relatively neglected area of study. Negative parental attitudes toward sexuality have been linked with ED in men during initial sexual experiences [17], but this study did not assess parent–child attachment. It has been suggested on theoretical grounds that “global impotence” in men is linked to a rigid father or later birth order [18]; in contrast, a population-based study found that being an only child was a risk factor for ED [19]. In a study of patients with “neurotic complaints,” maternal absence and paternal hostility were significantly associated with male sexual dysfunction [20], which is broadly consistent with our results. In contrast, a study of patients with panic disorder found no association between childhood adversity and male sexual dysfunction; however, the interpretation of these results is confounded by high rates of depression and a small number of men in the study sample [21]. Finally, a study of undergraduate students found that attachmentrelated anxiety significantly affected sexual interest and desire in initial relationships [22]; this is relevant to our study, in which the majority of the DA+ group were single men. Two further findings need to be highlighted. First, although the two groups had comparable rates of comorbid PE, men in the DA+ group were more likely to have initial PE, followed by ED. As PE is also associated with anxiety [23,24], and anxiety was more common in the DA+ group, this may have been the mediating variable, though the small numbers in each subgroup do not permit a meaningful comparison. Second, attribution of ED to guilt over past sexual experiences (masturbation and premarital sexual activity) was more common in the DA+ group, though this failed to reach statistical significance. As guilt is also a feature of insecure attachment [15,25], this finding needs to be studied in larger samples. In conclusion, disturbances in childhood attachment appear to be common in men with ED. Men who have experienced such adversities develop ED at an earlier age, are more likely to be single, and experience more performance anxiety in relation to sexual intercourse. They are more
Variable
B
SE
Wald
Exp df Significance (B)
Marital status −2.85 0.86 11 1 Performance anxiety 2.01 0.89 5.16 1 Constant 0.46 0.58 0.63 1
P = 0.001 P = 0.023 P = 0.428
0.06 7.48 1.58
df = degrees of freedom; SE = standard error Number of steps: 4 Variables excluded: age at onset of ED (step 2), sexual guilt (step 3), presence of other stressors (step 4) Nagelkerke R2 for the final model = 0.514
P = 0.023) and marital status (B = −2.85, Wald = 11, P = 0.001) were significantly associated with disturbed attachment (Table 2). Discussion
Events that led to threatened or actual separation from parents were common in our sample of men with psychogenic ED, affecting 45% of the sample. The majority of these events (17 out of 20) were related to temporary separations or recurrent threats of separation; in only three patients was there a permanent parental loss through death or divorce. The numbers of men in these two groups were too small to permit a meaningful comparison. The differences between men in the DA+ and DA− groups can be explained using the framework of attachment theory. For example, the higher number of single men in the DA+ group could be explained by the effect of disturbed attachment on adult romantic behavior [11], making it more difficult for these men to achieve satisfactory, longlasting intimate relationships. Similarly, the higher rates of anxiety in the DA+ group suggest that their early life experiences may have left them more prone to develop anxiety in interpersonal contexts. Anxiety is a fundamental initial response to separation [14], particularly when separation is temporary or threatened, and the majority of our DA+ group experienced events or circumstances of this sort. Though we did not use a structured instrument to assess the severity of ED and relied on patients’ self-reports, there was some evidence that men in the DA+ group had a more severe form of dysfunction, characterized by an earlier age at onset and a tendency to develop ED even in the absence of stressors. This suggests that childhood adversity in these patients may have sensitized them both neurobiologically [12,13] and psychologically [11], lowering their threshold to develop ED in adult life.
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802 likely to develop ED even in the absence of a proximate stressor. Those with comorbid ED and PE are more likely to develop PE first, followed by ED. They are also somehwat more likely to experience guilt over early sexual experiences and to attribute their problems to such acts. These results are subject to certain limitations inherent in the study design. First, data were collected in a retrospective manner from medical records and could not be cross-checked with patients or their families, meaning that the information obtained could be incomplete or biased. Second, information on childhood adversity was collected using simple yes/no questions, whereas a more qualitative approach—or a structured measure of parent–child attachment—may have yielded more valuable information. Third, performance anxiety was assessed using a qualitative, history-based approach; a rating of anxiety severity with a standard scale would have permitted a more meaningful comparison of anxiety levels in the two groups. Fourth, diagnoses of psychiatric disorder were based on clinical interviews; a structured assessment may have provided a clearer picture of patterns of comorbidity. Fifth, ED was diagnosed clinically; no structured instrument was used to assess sexual function. Though this could lead to concerns regarding interrater reliability, all final diagnoses were confirmed by an experienced clinician (the author), which minimized this problem to some extent. Sixth, other psychosocial factors that may have interacted with childhood adversity— such as quality of the marital relationship [26], subsyndromal anxiety or depression [27], and substance use [28,29]—were not assessed in depth. Finally, the events grouped together as causing disturbed attachment are heterogeneous and may not have all affected patients to the same extent; the role of potential protective factors could not be examined. Despite the above limitations, we believe that these findings point to the potential importance of disturbed childhood attachment as a risk factor not only for depression and anxiety, but for psychogenic ED, as has been already recognized by sex therapists [30]. There is already evidence to suggest that combined psychological and pharmacological intervention may be more beneficial than monotherapy in some men with ED [31,32]. Psychological interventions aimed at addressing the impact of such separations and losses may be particularly beneficial in the subgroup of men described in this article. Further research—in larger, prospective samples, using structured J Sex Med 2015;12:798–803
Rajkumar instruments—should aim to clarify the role of different events affecting the parent–child bond, as well as different forms of insecure attachment, in the pathogenesis of male sexual dysfunction. This would lead to a better understanding of the manner in which the attachment and sexual behavioral systems interact in humans. Corresponding Author: Ravi P. Rajkumar, MD, Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Pondicherry 605 006, India. Tel: 0091-9884713673; Fax: +91413-2272067; E-mail: [email protected] Conflict of Interest: The author(s) report no conflicts of interest. Statement of Authorship
Category 1 (a) Conception and Design Ravi Philip Rajkumar (b) Acquisition of Data Ravi Philip Rajkumar (c) Analysis and Interpretation of Data Ravi Philip Rajkumar
Category 2 (a) Drafting the Article Ravi Philip Rajkumar (b) Revising It for Intellectual Content Ravi Philip Rajkumar
Category 3 (a) Final Approval of the Completed Article Ravi Philip Rajkumar References 1 Simons J, Carey MP. Prevalence of sexual dysfunctions: Results from a decade of research. Arch Sex Behav 2001;30:177–219. 2 Lizza EF, Rosen RC. Definition and classification of erectile dysfunction: Report of the Nomenclature Committee of the International Society for Impotence Research. Int J Impot Res 1999;11:141–3. 3 Sachs BD. The false organic-psychogenic distinction and related problems in the classification of erectile dysfunction. Int J Impot Res 2003;15:72–8. 4 Beutel M. Psychosomatic aspects in the diagnosis and management of erectile dysfunction. Andrologia 1999;31(S1):37–44. 5 Melnik T, Soares B, Nasello AG. Psychosocial interventions for erectile dysfunction. Cochrane Database Syst Rev 2007;(3): CD004825. 6 Turnbull JM, Weinberg PC. Psychological factors involved in impotence: A review of the literature. J Androl 1983;4:59–66. 7 Hedon F. Anxiety and erectile dysfunction: A global approach to ED enhances results and quality of life. Int J Impot Res 2003;15(S2):S16–9.
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8 Seidman SN, Roose SP. The relationship between depression and erectile dysfunction. Curr Psychiatr Rep 2000;2:201–5. 9 McCabe M, Althof SE, Assalian P, Chevret-Measson M, Leiblum SR, Simonelli C, Wylie K. Psychological and interpersonal dimensions of sexual function and dysfunction. J Sex Med 2010;7:327–36. 10 Birnbaum GE, Mikulincer M, Szepsenwol O, Shaver PR, Mizrahi M. When sex goes wrong: A behavioral systems perspective on individual differences in sexual attitudes, motives, feelings and behaviors. J Pers Soc Psychol 2014;106:822– 42. 11 Birnbaum GE. Bound to interact: The divergent goals and complex interplay of attachment and sex within romantic relationships. JSPR 2010;27:245–52. 12 Bloch M, Peleg I, Koren D, Aner H, Klein E. Long-term effects of early parental loss due to divorce on the HPA axis. Horm Behav 2007;51:516–23. 13 Heim C, Plotsky PM, Nemeroff CB. Importance of studying the contributions of early adverse experience to neurobiological findings in depression. Neuropsychopharmacol 2004;29: 641–8. 14 Bowlby J. Attachment and loss. Volume 2: Separation. London: Pimlico, Random House; 1998. 15 Bowlby J. Attachment and loss. Volume 3: Loss. London: Pimlico, Random House; 1998. 16 Dube SR, Anda RF, Felitti VJ, Croft JB, Edwards VJ, Giles WH. Growing up with parental alcohol abuse: Exposure to childhood abuse, neglect and household dysfunction. Child Abuse Neglect 2001;25:1627–40. 17 Santtila P, Sandnabba NK, Jern P. Prevalence and determinants of male sexual dysfunctions during first intercourse. J Sex Marital Ther 2009;35:86–105. 18 Rucquoy G. Sexual impotence: Clinical and existential context. Acta Psychiatr Belg 1975;75:74–92. 19 Lidberg L. Family constellation and psychosexual disturbances. Acta Psychiatr Scand 1976;54:125–30. 20 Sobanski JA, Klasa K, Rutkowski K, Dembinska E, Muldner-Nieckowski L, Cyranka K. Parental attitudes recollected by patients and neurotic disorders picture. Sexuality-related and sexuality-unrelated symptoms. Psychiatr Pol 2013;47:827–51.
21 Bakim B, Karamustafalioglu O, Akpinar A, Tankaya O, Ozcelik B, Ceylan YC, Yavuz BG, Bozkurt S, Alpak G, Gonenli S. The effects of childhood trauma on sexual function in panic disorder patients. J Psychiatr Neurol Sci 2011;24:182–8. 22 Birnbaum GE, Reis HT. When does responsiveness pique sexual interest? Attachment and sexual desire in initial acquaintanceships. Pers Soc Psychol Bull 2012;38:946–58. 23 Strassberg DS, Mahoney JM, Schaugaard M, Hale VE. The role of anxiety in premature ejaculation: A psychophysiological model. Arch Sex Behav 1990;19:251–7. 24 Rajkumar RP, Kumaran AK. The association of anxiety with the subtypes of premature ejaculation. Prim Care Companion CNS Disord 2014; doi: 10.4088/PCC.14m01630. 25 Bowlby J. A secure base: Parent-child attachment and healthy human development. New York: Basic Books; 1988. 26 Yeoh SH, Razali R, Sidi H, Razi ZR, Midin M, Nik Jaafar NR, Das S. The relationship between sexual functioning among couples undergoing infertility treatment: A pair of perfect gloves. Compr Psychiatry 2014;55:S1–6. 27 Fadzil MA, Sidi H, Ismail Z, Hassan MRC, Thuzar K, Midin M, Nik Jaafar NR, Das S. Socio-demographic and psychosocial correlates of erectile dysfunction among hypertensive patients. Compr Psychiatry 2014;55:S23–8. 28 Nik Jaafar NR, Mislan N, Abdul Aziz S, Baharudin A, Ibrahim N, Midim M, Das S, Sidi H. Risk factors of erectile dysfunction in patients receiving methadone maintenance therapy. J Sex Med 2013;10:2069–76. 29 Nik Jaafar NR, Noormazita M, Azlin B, Normala I, Hazli Z, Abdul Aziz S, Sidi H. Clinical correlates of erectile dysfunction among male patients on methadone maintenance therapy (MMT) in Kuala Lumpur. Mal J Medicine Health Sci 2012; 8:27–35. 30 Leiblum SR, Rosen RC. Couples therapy for erectile disorders: Conceptual and clinical considerations. J Sex Marital Ther 1991;17:147–59. 31 Banner LL, Anderson RU. Integrated sildenafil and cognitivebehavior sex therapy for psychogenic erectile dysfunction: A pilot study. J Sex Med 2007;4:1117–25. 32 Abdo CH, Afif-Abdo J, Otani F, Machado AC. Sexual satisfaction among patients with erectile dysfunction treated with counseling, sildenafil, or both. J Sex Med 2008;5:1720–6.
J Sex Med 2015;12:798–803
ORIGINAL RESEARCH—PSYCHOLOGY The Impact of Disrupted Childhood Attachment on the Presentation of Psychogenic Erectile Dysfunction: An Exploratory Study Ravi P. Rajkumar, MD Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India DOI: 10.1111/jsm.12815
ABSTRACT
Introduction. Erectile dysfunction (ED) is a common form of male sexual dysfunction. Psychological factors play an important role in the onset and persistence of ED. Disturbed childhood attachment is a biologically and psychologically plausible predisposing factor for psychogenic ED that has not been systematically studied to date. Aim. This study aims to assess the frequency and correlates of events associated with parental separation (actual or threatened) and loss in men with a diagnosis of psychogenic ED. Methods. The case records of 46 men who presented to a clinic for psychosexual disorders in the period 2012–2013, and were diagnosed with psychogenic ED using a semi-structured interview schedule, were reviewed. Results. Events causing actual or potential disturbed attachment (DA) in childhood were reported by 20 of 46 men with psychogenic ED (43.5%). This group of men (DA+) had an earlier age at onset of ED (median 25 vs. 29 years, P = 0.005), were more likely to be single (15/20 vs. 5/26 (χ2 = 14.307, P < 0.001), reported sexual performance anxiety more frequently (12/20 vs. 7/26, χ2 = 5.101, P = 0.024), and were more likely to develop ED in the absence of a proximate stressor (4/20 vs. 15/26, P = 0.015). They also showed a trend toward being more likely to report guilt over early sexual experiences as a contributory factor (5/20 vs. 1/26, P = 0.072). In a binary logistic regression analysis, the presence of performance anxiety (B = 2.01, P = 0.023) and marital status (B = −2.85, P = 0.001) were significantly associated with events causing DA. Conclusions. Disrupted childhood attachment was common in our sample of men with ED and is associated with significant differences in their clinical profile, particularly an earlier onset, a lower likelihood of being married, and higher rates of performance anxiety. This study highlights the need to consider early childhood experiences, particularly using an attachment theory framework, when examining the origins of psychogenic erectile dysfunction. Rajkumar RP. The impact of disrupted childhood attachment on the presentation of psychogenic erectile dysfunction: An exploratory study. J Sex Med 2015;12:798–803. Key Words. Erectile Dysfunction; Attachment Theory; Anxiety
Introduction
E
rectile dysfunction (ED), also known as erectile impotence, is a common form of male sexual dysfunction. ED affects up to 5% of men in community-based studies [1]. The International Society for Impotence Research has classified ED into organic and psychogenic types, with psychogenic ED being further divided into generalized
J Sex Med 2015;12:798–803
and situational subtypes [2]. Though the boundary between organic and psychogenic ED is disputed, and subject to revision in the light of emerging research [3], psychological factors certainly play an important role in the genesis or maintenance of ED [4]. Moreover, psychosocial therapies have robust efficacy in patients with ED, and combination therapy often outperforms monotherapy with agents such as sildenafil [5]. © 2015 International Society for Sexual Medicine
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Early formulations of the psychological origins of ED focused on psychodynamic theories, such as Oedipal conflict [4,6]. These were later replaced by behavioral models based on the work of Masters and Johnson [6]. It is now recognized that a wide variety of psychological factors can trigger or aggravate ED. These include anxiety [7], depression [8], interpersonal conflict [9], guilt related to sexuality, body image disturbances, stressful life events, and partner-related problems [4]. Another psychological factor of potential relevance is the impact of early childhood experience, especially the disruption of attachment bonds, on sexual functioning. Though psychodynamic models emphasized these factors, they are often passed over in behavioral or “psychosomatic” formulations that tend to emphasize recent events and current circumstances. In humans, sexual behavior may be shaped and influenced by the attachment system [10], and attachment behavior strongly influences adult romantic relationships and sexuality [11]. Disturbed attachment (DA+) can significantly affect neurochemical and neuroendocrine functioning [12,13], and this may be related to some of the “organic” changes seen in men with ED [3]. Furthermore, DA is one of the key psychological factors underlying both anxiety [14] and depression [13,15], both of which are risk factors for ED. For these reasons, we determined the frequency and correlates of disturbed childhood attachment in the case records of men presenting to our psychosexual disorders clinic with a primary complaint of ED.
prolonged parental separation followed by reconciliation, parental marital disharmony with threats of separation, parental suicide, parental alcoholism or substance abuse, and parental physical or mental illness during childhood. If a patient answered “yes” to a screening question on the above, further details were collected. The inclusion of parental alcoholism in the interview schedule was based on the high rates of childhood adversity experienced in such homes [16]. This study was conducted in accordance with the guidelines of the hospital’s Scientific Advisory Committee, which requires no informed consent for retrospective reviews of clinical data as long as patient confidentiality is maintained. After reviewing the patients’ case records, they were divided into two groups: patients with ED and a history of disturbed attachment (DA+) and those without such a history (DA–). The two groups were compared on demographic and clinical variables, including psychiatric comorbidity. Statistical analyses were carried out using the Statistical Package for Social Sciences (SPSS; SPSS Inc., Chicago, IL, USA) version 20 and the WinPEpi program (WinPEpi version 11.0, copyright J. H. Abramson, October 20, 2010, Hebrew University, Jerusalem, Israel). All tests were two tailed, and a significance level of P < 0.05 was considered significant. As this was an exploratory study, there was no a priori hypothesis.
Materials and Methods
The case records of 46 men with psychogenic ED presenting to the Marital and Psychosexual (MAPS) clinic of a tertiary care hospital in South India between 2012 and 2013 were reviewed. Patients in the MAPS clinic are evaluated by psychiatry residents using a semi-structured interview schedule. All diagnoses of psychogenic ED were confirmed by the author using the World Health Organization’s International Classification of Diseases, 10th Edition (ICD-10) clinical descriptions and diagnostic guidelines, following referrals to other specialty departments, such as urology or endocrinology, to rule out the presence of “organic” causes. Questions on early life experiences were a part of the interview schedule and included screening questions on the following: parental loss in childhood (before the age of 10), parental divorce,
Results
A total of 46 case records of men with a diagnosis of psychogenic ED (ICD-10 code F52.2, failure of genital response) were reviewed. The mean age of the sample was 31.04 ± 6.03 years, with a range of 22–47 years. Twenty of these men were single, 24 were married, one was divorced, and one was a widower. Patients had a mean of 9.93 ± 4.18 years of education (range 0–18), and most were employed as laborers or farmers. Of the entire sample, 20 men (43.5%) had a history of one of more adverse events that led to a disruption of attachment during childhood. These included parental alcoholism (13/20), parental marital discord with threats of separation (10/20), parental separation followed by reconciliation (2/20), natural death of a parent before the age of 10 years (1/20), parental divorce and remarriage (1/20), and suicide of a parent (1/20). These 20 men (DA+) were compared with the remaining 26 men without a history of actual or J Sex Med 2015;12:798–803
800 Table 1
Rajkumar Comparison of men with psychogenic ED with and without disturbed attachment (DA)
Variable Age at presentation Years of education Marital status Married Single Age at onset Duration of ED (in months) Comorbid premature ejaculation (PE) Performance anxiety related to intercourse Guilt related to masturbation / premarital intercourse Stressors preceding ED Marital disharmony Semen loss anxiety Any psychiatric comorbidity Mood disorder Anxiety disorder Substance use disorder Suicidality
Men with psychogenic ED with disturbed attachment (DA+) (n = 20)
Men with psychogenic ED without disturbed attachment (DA–) (n = 26)
28.4 ± 5.1 9.6 ± 4.1
33.1 ± 6.0* 10.2 ± 4.3
5 (25%) 15 (75%) 25.0 28.6 ± 30.2 7 (35%) 12 (60%) 5 (25%) 4/20 (20%) 2/5 (40%) 2 (10%) 11 (55%) 1 (5%) 6 (30%) 6 (30%) 3 (15%)
21 (80.8%) 5 (19.2%)† 29.0‡ 34.5 ± 34.3 10 (38.5%) 7 (26.9%)§ 1 (3.9%)¶ 15/26 (57.7%)** 13/21 (61.9%) 1 (3.9%) 10 (38.5%) 3 (11.5%) 4 (15.4%) 10 (38.5%) 5 (19.2%)
*t = −2.86, P = 0.006 † 2 χ = 14.307, P < 0.001 ‡Values given as median due to non-normal distribution. P = 0.005, Mann–Whitney U-test §χ2 = 5.101, P = 0.024 ¶ P = 0.072, Fisher’s exact test **P = 0.016, Fisher’s exact test
threatened parental separation in childhood (DA–). The demographic and clinical characteristics of these two groups are summarized in Table 1. Men in the DA + group were significantly younger (mean age 28.4 ± 5.1 years as against 33.1 ± 6.0, t = −2.86, P = 0.006) and were more likely to be single (75% vs. 19.2%, χ2 = 14.307, P < 0.001). They also had a significantly earlier age of onset of ED (median 25.0 vs. 29.0; Mann–Whitney U1 = 386.5, U2 = 133.5, Z = 2.80; P = 0.005). A total of 12 men (60%) in the DA + group reported significant levels of performance anxiety during sexual intercourse, in contrast to seven (26.9%) in the DA− group. This difference was statistically significant (χ2 = 5.101, P < 0.05). Rates of comorbid premature ejaculation (PE) were comparable in the two groups. However, when examining the temporal relationship between PE and ED, PE predated ED in 4/7 (57.1%) of the DA+ group, whereas ED predated PE in all the men in the DA− group; this difference was statistically significant (P < 0.05, Fisher’s exact test). Semen-loss anxiety, a common condition in India, was infrequent in both the groups and occurred at comparable rates. However, there was a trend for men in the DA+ group to report guilt J Sex Med 2015;12:798–803
over previous sexual experiences, such as masturbation or premarital intercourse, as a contributory factor toward ED (5/20 in the DA+ group; 1/26 in the DA− group; P = 0.072, Fisher’s exact test.) Information on stressful events temporally correlated with the onset of ED, such as marital disharmony or infertility, was also collected. Such events were reported by more than half the men in the DA− group (15/26, 57.7%) as opposed to four men in the DA+ group (4/20, 20%). This difference was statistically significant (P < 0.05, Fisher’s exact test). In terms of clinical presentation, the two groups had comparable rates of comorbid psychiatric disorders, including mood and anxiety disorders, and substance use disorders. There was no difference in the frequency of suicidal ideation or attempts between the two groups. To confirm the strength of these associations, a binary logistic regression analysis using the backward Wald method was carried out to identify those factors which reliably distinguished between the DA+ and DA− groups. All variables that reached at least a trend level of significance in the univariate analysis were entered into the model. The final model, which correctly classified 75% of patients in the DA+ group and 80.8% in the DA− group found that performance anxiety (B = 2.01, Wald = 5.16,
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Table 2 Binary logistic regression analysis of variables that differentiate the DA+ and DA− groups of men with ED
The low rates of comorbid depression and anxiety in our DA+ group were an unexpected finding, as anxiety and depression are wellestablished sequelae of disturbed attachment. They may be explained by the small sample size or the nature of the study sample, which was recruited from a general hospital psychiatry unit largely based on referrals from surgeons or urologists. The role of childhood factors in the pathogenesis of ED is a relatively neglected area of study. Negative parental attitudes toward sexuality have been linked with ED in men during initial sexual experiences [17], but this study did not assess parent–child attachment. It has been suggested on theoretical grounds that “global impotence” in men is linked to a rigid father or later birth order [18]; in contrast, a population-based study found that being an only child was a risk factor for ED [19]. In a study of patients with “neurotic complaints,” maternal absence and paternal hostility were significantly associated with male sexual dysfunction [20], which is broadly consistent with our results. In contrast, a study of patients with panic disorder found no association between childhood adversity and male sexual dysfunction; however, the interpretation of these results is confounded by high rates of depression and a small number of men in the study sample [21]. Finally, a study of undergraduate students found that attachmentrelated anxiety significantly affected sexual interest and desire in initial relationships [22]; this is relevant to our study, in which the majority of the DA+ group were single men. Two further findings need to be highlighted. First, although the two groups had comparable rates of comorbid PE, men in the DA+ group were more likely to have initial PE, followed by ED. As PE is also associated with anxiety [23,24], and anxiety was more common in the DA+ group, this may have been the mediating variable, though the small numbers in each subgroup do not permit a meaningful comparison. Second, attribution of ED to guilt over past sexual experiences (masturbation and premarital sexual activity) was more common in the DA+ group, though this failed to reach statistical significance. As guilt is also a feature of insecure attachment [15,25], this finding needs to be studied in larger samples. In conclusion, disturbances in childhood attachment appear to be common in men with ED. Men who have experienced such adversities develop ED at an earlier age, are more likely to be single, and experience more performance anxiety in relation to sexual intercourse. They are more
Variable
B
SE
Wald
Exp df Significance (B)
Marital status −2.85 0.86 11 1 Performance anxiety 2.01 0.89 5.16 1 Constant 0.46 0.58 0.63 1
P = 0.001 P = 0.023 P = 0.428
0.06 7.48 1.58
df = degrees of freedom; SE = standard error Number of steps: 4 Variables excluded: age at onset of ED (step 2), sexual guilt (step 3), presence of other stressors (step 4) Nagelkerke R2 for the final model = 0.514
P = 0.023) and marital status (B = −2.85, Wald = 11, P = 0.001) were significantly associated with disturbed attachment (Table 2). Discussion
Events that led to threatened or actual separation from parents were common in our sample of men with psychogenic ED, affecting 45% of the sample. The majority of these events (17 out of 20) were related to temporary separations or recurrent threats of separation; in only three patients was there a permanent parental loss through death or divorce. The numbers of men in these two groups were too small to permit a meaningful comparison. The differences between men in the DA+ and DA− groups can be explained using the framework of attachment theory. For example, the higher number of single men in the DA+ group could be explained by the effect of disturbed attachment on adult romantic behavior [11], making it more difficult for these men to achieve satisfactory, longlasting intimate relationships. Similarly, the higher rates of anxiety in the DA+ group suggest that their early life experiences may have left them more prone to develop anxiety in interpersonal contexts. Anxiety is a fundamental initial response to separation [14], particularly when separation is temporary or threatened, and the majority of our DA+ group experienced events or circumstances of this sort. Though we did not use a structured instrument to assess the severity of ED and relied on patients’ self-reports, there was some evidence that men in the DA+ group had a more severe form of dysfunction, characterized by an earlier age at onset and a tendency to develop ED even in the absence of stressors. This suggests that childhood adversity in these patients may have sensitized them both neurobiologically [12,13] and psychologically [11], lowering their threshold to develop ED in adult life.
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802 likely to develop ED even in the absence of a proximate stressor. Those with comorbid ED and PE are more likely to develop PE first, followed by ED. They are also somehwat more likely to experience guilt over early sexual experiences and to attribute their problems to such acts. These results are subject to certain limitations inherent in the study design. First, data were collected in a retrospective manner from medical records and could not be cross-checked with patients or their families, meaning that the information obtained could be incomplete or biased. Second, information on childhood adversity was collected using simple yes/no questions, whereas a more qualitative approach—or a structured measure of parent–child attachment—may have yielded more valuable information. Third, performance anxiety was assessed using a qualitative, history-based approach; a rating of anxiety severity with a standard scale would have permitted a more meaningful comparison of anxiety levels in the two groups. Fourth, diagnoses of psychiatric disorder were based on clinical interviews; a structured assessment may have provided a clearer picture of patterns of comorbidity. Fifth, ED was diagnosed clinically; no structured instrument was used to assess sexual function. Though this could lead to concerns regarding interrater reliability, all final diagnoses were confirmed by an experienced clinician (the author), which minimized this problem to some extent. Sixth, other psychosocial factors that may have interacted with childhood adversity— such as quality of the marital relationship [26], subsyndromal anxiety or depression [27], and substance use [28,29]—were not assessed in depth. Finally, the events grouped together as causing disturbed attachment are heterogeneous and may not have all affected patients to the same extent; the role of potential protective factors could not be examined. Despite the above limitations, we believe that these findings point to the potential importance of disturbed childhood attachment as a risk factor not only for depression and anxiety, but for psychogenic ED, as has been already recognized by sex therapists [30]. There is already evidence to suggest that combined psychological and pharmacological intervention may be more beneficial than monotherapy in some men with ED [31,32]. Psychological interventions aimed at addressing the impact of such separations and losses may be particularly beneficial in the subgroup of men described in this article. Further research—in larger, prospective samples, using structured J Sex Med 2015;12:798–803
Rajkumar instruments—should aim to clarify the role of different events affecting the parent–child bond, as well as different forms of insecure attachment, in the pathogenesis of male sexual dysfunction. This would lead to a better understanding of the manner in which the attachment and sexual behavioral systems interact in humans. Corresponding Author: Ravi P. Rajkumar, MD, Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Pondicherry 605 006, India. Tel: 0091-9884713673; Fax: +91413-2272067; E-mail: [email protected] Conflict of Interest: The author(s) report no conflicts of interest. Statement of Authorship
Category 1 (a) Conception and Design Ravi Philip Rajkumar (b) Acquisition of Data Ravi Philip Rajkumar (c) Analysis and Interpretation of Data Ravi Philip Rajkumar
Category 2 (a) Drafting the Article Ravi Philip Rajkumar (b) Revising It for Intellectual Content Ravi Philip Rajkumar
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