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 defining 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 signifies masculinity.
These findings 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 re-
searchers. 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 dis-
ease, 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 phenom-
enon tied to social and cultural contexts, partner availability, and
embodied self-images (Marsiglio & Greer, 1994). However, even
before the introduction of Viagra (sildenafil 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 have been redefined as
fixable biological conditions (Conrad, 2007; Marshall, 2008; Ti-
efer, 2006). The advertising campaigns marketing erectile medi-
cation 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 implica-
tion within the medical model is that sexual intimacy depends on
intercourse (MacDougall, 2006) and maintaining youthful mascu-
line sexualities (Brooks & Levant, 2006; Mamo & Fishman, 2001;
Vares & Braun, 2006).
Equating mens sexual health with only erectile function paral-
lels 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 rela-
tions, 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 perfor-
mance 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.
This article was published Online First August 6, 2012.
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
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Psychology of Men & Masculinity 2012 American Psychological Association
2013, Vol. 14, No. 3, 271280 1524-9220/13/$12.00 DOI: 10.1037/a0029104
271
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 mascu-
linity 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 per-
formance 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 perfor-
mance 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 pre-
dictable 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 define their sexuality or do they modify their sexual expectations?
The findings 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; M
age
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 mea-
sured 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 2075). 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 important than having an active sex
life. There were no significant differences between the groups of
men with and without ED. These findings 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 findings 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; Perel-
man 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 influence 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 attitudes toward nonrelational sex
(Kimmel, 2008; Levant & Fischer, 1998), little is known about
how masculinity ideology affects middle-age and older mens
attitudes toward relational-based 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 experi-
ence, 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) findings 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 asso-
ciated. 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, com-
pared to the men with ED who decided to not use medication.
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272
THOMPSON AND BARNES
Their decisions to use ED medication likely reveal their
beliefs about sexual performance affirming 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 affirmed 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 signifier 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 dimin-
ished 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) de-
scribedno sissy stuff (antifemininity), the sturdy oak (self-
reliance), the big wheel (acquiring respect and being accom-
plished), 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 signifier of masculinity. The theoretical
rationale is that despite how physiological aging affects mas-
culinity 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 office of an internist (n 21). All men aged 50 and older
working for the employer 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 partic-
ipation was voluntary and anonymous. The purpose was presented
as We are asking a number of men to fill 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 office. Consent was
affirmed when the participant chose to return the completed ques-
tionnaire, and anonymity was preserved by using a prepaid return
envelope. Although some participants could have returned the
questionnaire directly to the first author, none did.
The sample was largely comprised of white, heterosexual, mar-
ried men. The mean age was 59.8 (SD 8.21, range: 4583), 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 full-time, 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,
middle-class men largely targeted by the pharmaceutical advertis-
ing 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 significant correlations with mens reports
of high blood pressure, cardiovascular disorder, and diabetes as
comorbidities (r
s
.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 ques-
tion, 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 Ser-
vices) 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 difficulties was added. Others (e.g.,
ODonnell, Araujo, Goldstein, & McKinlay, 2004) have used a
single question. Our question identifies 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
five-item International Index of Erectile Function, IIEF-5 (kappa
coefficient .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 expe-
riencing 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 diffi-
culties 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 con-
structed, with heterosexuals coded 1 and the gay and bisexual
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273
MEANING OF SEXUAL PERFORMANCE
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 atti-
tude statements is hetero-normative and might be (mis)inter-
preted 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)
flagged the importance of marriage as a condition for being sex-
ually active. Sand et al.s (2008) cross-national study also revealed
that men with and without ED routinely defined 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 satisfied are you with your relationship with
your partner? and rated on a 7-point Likert scale ranging from
very unsatisfied to very satisfied (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 short-
ened, 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 coital-based expectations evident within both traditional mas-
culinity and the medicalized view of mens sexuality were deemed
a necessary component of adult mens performative masculinity.
The first 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 five items. Three items from the mea-
sure 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 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
disagree-agree 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 coefficients were greater than .30, and
77% were significant (two-tailed, p .05). However, nearly half
(45%) of the correlation coefficients smaller than .30 were ac-
counted for by two items, and both items item-total scale score
coefficients 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
Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy were
conducted to determine if factor analysis was appropriate. Bar-
tletts test for sphericity was significant, 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. Ex-
tracting 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 difficult 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 vari-
ance. The matrix was rotated obliquely to allow for the possi-
bility of correlated factors. The first factor included 7 items,
accounted for 39% of the variance, and emphasized erectile
ability and sexual performance as a requisite for affirming
masculinity ( .83). It seemed to measure embodying mas-
culinity. The second factor involved 3 items, accounted for 13%
of the variance, and addressed the continuing sexual perfor-
mance expectations in later life ( .57). It seemed to measure
how older men are not exempt from embodying sexual perfor-
mance 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 first 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 coefficients for the two factors were unequal
( .83 and .57, respectively), reflecting the small number of
items and lesser variance in the second factor; a second reason is
that the two factors are significantly correlated; and, finally, ag-
ing is explicitly referenced in two items within the first factor and
all three items of the second factor. Because the difference be-
tween 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
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THOMPSON AND BARNES
performance and the premise that older men are not exempt from
sexual performance expectations.
Statistical Analysis
An analysis of covariance (ANCOVA) was used to determine
the extent to which self-reported ED and/or use of oral ED med-
ication affects mens attitudes about the meaning of sexual per-
formance. The 2 2 ANCOVA introduces both dichotomous
variables as fixed factors and then adds their interaction. The
covariates included the mens age, health status, sexual orientation,
relationship satisfaction, and masculinity ideology. A general lin-
ear 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 coefficients.
Results
Generally speaking, the men in this study disagreed with the
precept that erectile ability and sexual performance are integral to
masculinity (M 3.40, SD 0.82, range 1.507.00). Correla-
tional analyses were computed to examine the relationship be-
tween the SPBS and demographic variables. The SPBS was in-
versely 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-
defined their health as poorer (see Table 1). As would be expected,
the men with and without self-reported ED differed significantly
on IIEF-5 scores (M 14.52 and 8.53, SD 5.08 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 medi-
cation 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 with-
out 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 significant, F(8, 114) 9.45,
p .001,
p
2
.399. The partial eta squared indicates that 39.9%
of the variance in sexual performance beliefs was explained. There
was a marginally significant main effect for ED, F(1, 114) 3.14,
p .079,
p
2
.027, but not for the use of ED medication. In
addition, there was a significant interaction between ED and use of
ED medication, F(1, 114) 7.53, p .007,
p
2
.062. The
Table 1
Differences Between Men With and Without Erectile Dysfunction
Without Erectile
Dysfunction
(n 89)
With Erectile
Dysfunction
(n 43)
Chi-square
or t-value df p
Race/ethnicity
White 95.5% 95.3% 0.00 1 .968
African-American or Latino 4.5 4.7
Sexual orientation
Heterosexual 89.9% 95.3% 1.13 1 .473
Bisexual or gay 10.1 4.7
Marital status
Married 79.8% 83.7% 0.29 1 .588
Not married 20.2 16.3
Age (M, SD) 58.3 (8.08) 62.8 (7.71) 3.01 128 .003
Education (range 16; 1 less than high school,
4 college graduate 6 professional
degree)
4.40 (1.43) 4.23 (1.32) 0.66 129 .513
Masculinity Ideology (Male Role Norms Scale) 3.67 (0.80) 3.72 (0.73) 0.20 128 .984
Comorbidity: Number of illness 1.37 (1.45) 4.52 (2.65) 8.81 130 .001
Subjective health (range 010) 8.32 (1.51) 7.33 (2.11) 3.03 129 .003
Health status (functional limitations)
Not at all 70.1% 46.5% 7.87 2 .020
A little 26.4 41.9
A great deal 3.4 11.6
IIEF-5 14.52 (5.08) 8.53 (3.89) 7.47 129 .001
Used ED medication
No 92.0% 47.6% 31.95 1 .001
Yes 8.0 52.4
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MEANING OF SEXUAL PERFORMANCE
magnitude 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 (M
age
67.4, SD 5.87)
tended to endorse the SPBS more than the younger men in the
sample (M
age
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 signifies
masculinity, F(1, 114) 1.58, p .212,
p
2
.014. With the
paucity of the observed power coefficient (.238) and a trivial effect
size, we conclude that Hypothesis 2 was not supported. By con-
trast, endorsing a traditional masculinity ideology was substan-
tively predictive of mens attitudes toward the meaning of
sexual performance, F(1, 114) 57.32, p .000,
p
2
.335.
The effect size of the MRNS was unsurprisingly large. Un-
equivocally, 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 defines masculin-
ity, 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 tradi-
tional masculinity ideology.
This study illustrates some of the incongruous connections
between masculinities and adult mens sexuality. One of the dom-
inant 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) find that most adult men accept this
premise. Many researchers also have presented empirical evidence
confirming that the onset of erectile problems can have a pro-
foundly 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 perfor-
mance 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 rethink-
ing 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 affirming masculinity. As theorized earlier, because
the meaning of masculinity 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 fields,
whether retired or living with ED. Erectile ability is less central to
and does not necessarily define 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 conflict 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
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.
Table 2
Unadjusted Means and Standard Deviations on SPBS for Men
With and Without ED and Use of Oral ED Medication
ED
Use of ED
medication
SPBS
Mean SD n
No No 3.36 0.74 76
Yes 2.90 0.71 7
Yes No 3.30 0.79 18
Yes 3.78 1.10 22
Total 3.40 0.84 123
Table 3
Summary of the ANCOVA
F p
p
2

z
() B (SE)
Sexual performance beliefs 9.45 .001 .399
Age 1.58 .212 .014 .238 .010 (.008)
Heterosexual 2.76 .099 .024 .377 .438 (.264)
Health status 5.54 .020 .046 .646 .247 (.105)
Masculinity ideology (MRNS) 56.47 .001 .335 1.000 .653 (.086)
Relationship satisfaction 0.68 .411 .006 .128 .032 (.039)
ED 4.14 .044 .027 .420 .788 (.294)
Oral ED medication (RxED) 0.89 .384 .008 .155 .634 (.217)
ED RxED 7.53 .007 .062 .777 .945 (.344)
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276
THOMPSON AND BARNES
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 con-
fronted 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-
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 mascu-
linity. 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 per-
ceive an erection and penetrative sex as essential to their mascu-
linity was not wholly rejected by all men. Having ED and using
ED medication may well make men sensitive to sexual perfor-
mance 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 signified masculinity.
These men likely understand that middle-aged and older mens
masculinity can be affirmed in other ways.
It was unexpected to find 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 finding may
reflect 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 per-
ceive sexual performance as a valid signifier of masculinity.
The relationship between mens attitudes toward sexual perfor-
mance and masculinity ideology was, as expected, clear-cut. The
middle-age and older men who supported the traditional mascu-
linity norms were much more inclined to also believe that mascu-
linity 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 definitions of masculinity. Thus, it was not sur-
prising to find a strong relationship between their level of endorse-
ment 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 psy-
chologists 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
finding 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 interwo-
ven (Fergus et al., 2002; Oliffe, 2005). However, findings 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 mas-
culinity 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 func-
tional. They very likely regard their ED as age- and 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 first line of care is fixing the man or
adding to a couples sexual activity (cf., Brooks & Levant, 2006).
Clinicians working with men with erectile problems may also find
it invaluable to counsel the men seeking ED medication to con-
sider experimenting and expanding their practices outside of sex-
ual intercourse for mutual enjoyment. For example, OBrien, Hunt,
and Hart (2005) found that older men weighed their partners
preference for sexual practices that involved more frequent non-
penetrative sex against their interest in penile rigidity.
With divorce being prevalent and more mid-to-late life men
again dating, unpartnered men might desire the safety of pre-
senting 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 define 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, Gold-
man, 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 perfor-
mance. 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 per-
formance as emblematic of masculinity. They did not.
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MEANING OF SEXUAL PERFORMANCE
Study Limitations
These important findings 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 findings. The findings 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. Researchers 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 defines masculinity.
Third, our analysis urges reconsideration of the meaning of
sexual interest and activity among men in mid-to-late life; how-
ever, the findings 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 com-
fort 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.
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Appendix A
SPBS Items, Factors, Means, SDs
SPBS Items M (SD)
Oblimin rotation
factor loadings
Factor 1 Factor 2
Sexual Performance Beliefs Scale ( .82) 3.40 (0.82)
In sex, its a mans performance that counts. 3.00 (1.23) .608 .095
The troubles that men face with their sexuality as they grow older challenge
their manhood.
3.66 (1.32) .610 .032
Without an erection a man is sexually lost. 3.32 (1.53) .737 .020
Older men who have trouble maintaining sexual excitement are less masculine
than they used to be.
2.70 (1.38) .784 .066
Men who become unable to sexually satisfy their partner become less manly. 3.10 (1.35) .828 .063
Frankly, a man should always be ready for sex. 3.17 (1.29) .581 .209
A mans ability to have an erection is good evidence that his masculinity is
okay.
3.06 (1.34) .734 .001
Despite his aging, it is important for a man to be good in bed. 3.99 (1.27) .220 .599
Regardless mens age, most men believe that sex is a performance. 4.16 (1.15) .141 .800
From an older mans perspective, sex remains a pressure-filled activity. 3.91 (1.31) .053 .734
Received September 28, 2010
Revision received May 11, 2012
Accepted May 16, 2012
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