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Prevalence of Erectile Dysfunction
as Defined by the International Index
of Erectile Function (IIEF) and Self-
Reported Erectile Dysfunction in a
Sample of Brazilian Men Who Consider
Themselves Healthy
Margareth de Mello Ferreira dos Reis
a
& Carmita Helena Najjar Abdo
b
a
Experimental Physiopathology, Universidade de So Paulo, So
Paulo, Brazil
b
Department of Psychiatry, Universidade de So Paulo, So Paulo,
Brazil
Version of record first published: 06 Jan 2010.
To cite this article: Margareth de Mello Ferreira dos Reis & Carmita Helena Najjar Abdo (2010):
Prevalence of Erectile Dysfunction as Defined by the International Index of Erectile Function (IIEF)
and Self-Reported Erectile Dysfunction in a Sample of Brazilian Men Who Consider Themselves
Healthy, Journal of Sex & Marital Therapy, 36:1, 87-100
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Journal of Sex & Marital Therapy, 36:87100, 2010
Copyright Taylor & Francis Group, LLC
ISSN: 0092-623X print / 1521-0715 online
DOI: 10.1080/00926230903375719
Prevalence of Erectile Dysfunction as Dened
by the International Index of Erectile Function
(IIEF) and Self-Reported Erectile Dysfunction
in a Sample of Brazilian Men Who Consider
Themselves Healthy
MARGARETH de MELLO FERREIRA dos REIS
Experimental Physiopathology, Universidade de S ao Paulo, S ao Paulo, Brazil
CARMITA HELENA NAJJAR ABDO
Department of Psychiatry, Universidade de S ao Paulo, S ao Paulo, Brazil
A cross-sectional study was carried out with 288 male blood
donors, aged between 40 and 60 years old, with the aim of
comparing the prevalence of erectile dysfunction (ED) as dened
by the International Index of Erectile Function (IIEF) and that
resulting from the simple questioning of the presence of ED. Socio-
demographic, clinical, and behavioral factors that are associated
with the presence of ED were considered. Erectile dysfunction
prevalence in the IIEF was 31.9%, while self-reported ED prevalence
was 3.1%. The factors associated to ED, as reported by the IIEF
were: professional inactivity, suspected depression and/or anxiety,
reduced sexual desired, and self-reported ED.
Erectile dysfunction (ED), previously known as sexual impotence, is
the persistent inability to obtain and/or maintain a penile erection that is
hard enough for satisfactory sexual intercourse (NIH, 1993). Epidemiological
studies carried out in different countries point to a high prevalence of
ED, although consensus has not yet been reached on its exact magnitude
(Kubin, Wagner, & Fugl-Meyer, 2003). Erectile dysfunction studies carried
out in Brazil on volunteers or health service users have reported prevalences
around 40% (Moreira, Lisboa L obo, Villa, Nicolosi, & Glasser, 2002; Abdo,
Oliveira, Scanavino, & Martins, 2006). Nonetheless, different studies do agree
Address correspondence to Margareth de Mello Ferreira dos Reis, Rua Barata Ribeiro 237,
13

andar, S ao Paulo (SP), Brazil CEP 01308-000. E-mail: margarethreis@uol.com.br

87
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88 M. M. F. Reis and C. H. N. Abdo
that prevalence increases with age (Feldman, Goldstein, Hatzichristou, Krane,
& McKinlay, 1994; Schiavi & Rehmam, 1995, Aytac, McKinlay, & Krane,
1999; Moreira, Abdo, Torres, Lobo, & Fittipaldi, 2001; Moreira, Lisboa, Villa,
Nicolosi, & Glasser, 2002; Morillo et al., 2002; Laumann, Nicolosi, Glasser,
Paik, Gingell, Moreira, & Wang, 2005; Abdo, Oliveira, Scanavino, & Martins,
2006).
Since the development of the International Index of Erectile Function
(IIEF) (Rosen et al., 1997), many studies have used this instrument in
randomized clinical trials to classify the frequency and seriousness of this
dysfunction (Rosen, Cappelleri, & Gendrano, 2002). Erectile dysfunction
prevalence, as reported in a study of Spanish men (Martin-Morales et al.,
2001), showed that 12.1% of men displayed some degree of ED when a
single question was asked about self-perceived erectile capacity, and the
prevalence of ED when the IIEF was applied was 18.9%. In another study
of Chinese men (Wu et al., 2007), the prevalence of self-reported ED was
13.1% compared to a prevalence of 26% when the IIEF-5 was applied (Rosen,
Cappelleri, Smith, Lipsky, & Pe na, 1999).
The objectives of this study were to estimate the prevalence of ED
according to both the IIFE and self-reported prevalence among men who
consider themselves healthy and to investigate the factors that are associated
with this condition. The tested hypothesis was that the prevalence of ED
would be different using two ways of assessment: the self-perception and a
specic inventory.
METHODS
Study Design and Reasoning
The research involved a cross-section study of blood donors at a private,
philanthropic hospital in Sao Paulo, Brazil, during the period of January 2006
and July 2007, with the hospitals Ethic Committee approval. All participants
signed informed consent forms.
To be eligible for the study, the blood donors had to be male, aged 40
to 60, and had to have completed at least 4 years of schooling. They also
needed to heterosexual and in a stable partnership for at least 6 months,
irrespective of their marital status (in order to guarantee a minimum length
of sexual interaction with their partner). All participants agreed to partake in
the research by signing Terms of Free Consent.
The criteria for exclusion were: to be unable to understand or to reply
to the questionnaire and to be using medication that may affect sexual
functioning, such as diuretics, anti-depressants; or hypertension therapy.
After excluding participants on this basis, the sample size was made up
of 300 subjects.
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Dysfunction is Less Common When Self-Reported 89
Research Tools
The subjects completed a number of self-applied questionnaires in a single
sitting and in the following order: identication form (to obtain socio-
demographic information), the (IIEF; Rosen et al., 1997; Ferraz & Ciconelli,
1998), which was transculturally adapted to Brazilian Portuguese, the Short
Form-36 Questionnaire on Quality of Life (SF-36; Ciconelli, Ferraz, Santos,
Mein ao, & Quaresma, 1997), and the Psychiatric Screening Questionnaire
(SRQ-20; Mari & Williams, 1986). The men also gave answers to questions
relating to their own perception of aspects of their personal lives. To assess
the self-perception of ED, men answered yes or no to the question: Do you
feel sexually potent? When men responded that they did not feel sexually
potent, they were asked: for how long, if they had sought treatment, and
the reasons why they had not or would not seek treatment. Data were also
compiled from the blood donation medical records of the subjects, including
weight, height, and blood pressure.
The IIEF (Rosen et al., 1997) assesses the different areas relating to
male sexual function, including: erectile function, orgasmic function, sexual
desire, satisfaction with the relationship, and general satisfaction. It involves
a questionnaire with 15 items, most of which relate to the frequency of sexual
activity in the previous 4 weeks. Generally, each item is given a score such
as: never (0), almost never/never (1), rarely (2), sometimes (3), most times
(4), and almost always/always (5).
For items relating to erectile function (15 and 15), the IIEF evaluates
the principle aspects of ED: the individuals ability to obtain or maintain a
sufcient erection for sexual intercourse, the level of satisfaction obtained,
the ability to obtain erections independently of sexual intercourse, and the
persons level of condence in obtaining and maintaining erections. The
replies relating to erectile function are then totalled to give a score as follows:
6 to 10 severe ED, 11 to 16 moderate ED, 17 to 25 mild ED, and 26 to 30 no
ED.
Statistical Analysis
The prevalence of ED according to the IIEF and self-reported ED prevalence
were estimated along with their respective condence intervals (condence
level 95%). Logistical regression models were used to evaluate which socio-
economic, demographic, physical, and emotional factors were associated
with the presence of ED. The dependent variable was the presence of ED
detected by the IIEF. The explanatory variables were the above factors.
In the univariate analysis, the estimates were calculated using a simple
logistic regression model (the odds ratio, p value, and the order of
importance of the variable were determined using the value 2log), with
the dependent variable being the presence of dysfunction. Given the large
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90 M. M. F. Reis and C. H. N. Abdo
number of explanatory variables, it was decided to use the stepwise forward
method (Hosmer & Lemeshow, 1989) for the multivariate analysis. In this
way, the explanatory variables were introduced to the model one by one,
starting with the most important and ending with the least. The order of
importance of the variables was dened according to the logarithm of
verisimilitude of the univariate model (the lower the value of 2 the
logarithm of likelihood, the more important the variable in question). For
the collinear variables, different models were also tested to see which one
was the most stable (age and length of relationship, for example).
The criterion that was used to determine if a particular variable should
be included or not in the model was whether its coefcient was signicant
or marginally signicant (the descriptive level of Walds test 0.10). To
evaluate the agreement between the presence of ED as detected by the IIEF
and the presence of self-reported ED, the coefcient of kappas agreement
was used (Nascimento & Menezes, 2000). The analyses were carried out
with the help of the R for Windows software (Version 2.7.0, University of
Wisconsin-Madison, Madison, WI).
RESULTS
After an initial evaluation of the answers to the questionnaires, 12 individuals
(4% of the sample) were excluded from the study because they had used or
were currently using medication to specically obtain an erection. Of these,
six individuals reported using such medication on the advice of a doctor,
while the remainder had chosen to do so independently of any medical
advice.
Of the 288 subjects included, 92 were classied according to the IIFE as
having some degree of erectile dysfunction, which represents a prevalence
of 31.9% (condence interval of 95%, CI95%: 26.6% to 37.7%). According to
IIFE, 87 (30.2%; CI95%: 25.0% to 35.9%) individuals showed mild degrees
of dysfunction, 4 (1.4%; CI95%: 0.4% to 3.5%) moderate dysfunction and
1(0.3%; CI95%: 0.01% a 1.9%), severe dysfunction.
However, only 9 (3.1%; CI95%: 1.4% to 5.8%) individuals reported that
they did feel themselves as presenting ED (as an answer to the specic
questioning), and of these only two sought treatment. Table 1 shows the
distribution of individuals who participated in the research, by dysfunction
detected by the IIFE and by reported dysfunction. Since the number of
respondents with moderate or severe ED was small, it was necessary to
group the individuals in just two categorieswith dysfunction and without
dysfunctionin order to facilitate the statistical analysis and interpretation
of the data.
Only 8 of the 92 subjects who were classied as having at least some
degree of ED reported that they had ED. Thus, the agreement between ED
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Dysfunction is Less Common When Self-Reported 91
TABLE 1. Distribution of Study Participants by Erectile Dysfunction (ED), as Detected by
the International Index of Erectile Function (IIEF) and Self-Reported
ED Reported
No Yes Total
ED (IIEF) absent 195 67.7% 1 0.3% 196 68.1%
IIEF
Mild 81 28.1% 6 2.2% 87 30.2%
Moderate 3 1.0% 1 0.3% 4 1.4%
Severe 0 0.0% 1 0.3% 1 0.3%
Total 279 96.9% 9 3.1% 288 100.0%
detected by the IIEF and self-perceived ED was low (kappa = 0.11; p <
.001).
Table 2 shows the distribution of the cases of ED detected by the IIEF,
according to the categories of each explanatory variable.
Using the results of the univariate analysis (simple logistical regression),
the following risk factors for ED detected by the IIEF were considered, in
order of importance: sexual desire currently reduced ( p < .01), to not feel
sexually potent ( p = .01), to have indices of depressive or anxiety disorders
( p = .01), a score of 88 or less in the score for social aspects of SP-36 ( p <
.01), to not have a high level of satisfaction in their relationship ( p = .02),
to be professionally inactive ( p = .02), to be in a relationship for 22 years
or more ( p = .05), to be stressed ( p = .04), and to score 67 or less in the
emotional aspects of the SF-36 ( p = .05).
Estimates of the nal model are presented in Table 3. The variables that
remained independently associated to the presence of ED detected by the
IIEF were: reduced sexual desire, reported ED, depressive and/or anxiety
disorders, and professional inactivity.
DISCUSSION
Interpretation of Results
The prevalence of some degree of ED, using the IIEF was 31.9% (CI 95%:
26.6% to 37.7%), while the degree of self-reported ED was 3.1% (CI 95%:
1.4% to 5.8%). This nding supports our hypothesis that ED can be found
in men who consider themselves healthy. The estimate for ED prevalence
based on the IIEF was similar to that found in a household survey carried
out by Moreira et al. (2002; 39.5%) and lower than Brazilian studies using
other strategies for including subjects (Moreira et al., 2001; Moreira, Santos,
Abdo, Wroclawski, & Fittipaldi, 2004). The self-reported degree of ED in our
study of 3.1% (CI 95%: 1.4% to 5.8%), was greater than that found in another
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96 M. M. F. Reis and C. H. N. Abdo
TABLE 3. Estimates of the Final Multiple Logistical Regression Model Obtained by a
Stepwise Forward Procedure, With the Dependent Variable Being the Presence of Erectile
Dysfunction (ED) Detected by the IIEF
Explanatory Variables OR CI (OR. 95%) p
Current sexual desire
Excellent 1
Good 2.5 0.9 to 7.0 .082
Low/moderate 5.5 1.2 to 25.1 .027
Reported ED
No 1
Yes 7.5 0.8 to 71.7 .080
Depressive and/or anxiety disorder
No 1
Yes 2.6 1.1 to 6.3 .033
Employment status
Active 1
Inactive 3.3 1.4 to 7.8 .005
Goodness-of-t test (Hosmer-Lemeshow): p = .83.
OR = odds ratio; CI = condence interval.
Brazilian study (1.7%; Lopes, 2000). In this latter study, all those men who
reported ED had clinical illnesses, particularly diabetes mellitus and systemic
arterial hypertension.
The agreement between ED detected by the IIEF and self-reported ED
was low (kappa = 0.11; p < .001). Other studies that sought to evaluate
ED using questions relating to the self-perception of subjects and the IIEF
found there to be important differences in the results obtained from the two
methods of evaluation: in China (Wu et al., 2007) and Spain (Martin-Morales
et al., 2001). The prevalences of self-reported degrees of ED however, were
higher than those found in the present study (12.1% and 13.1%, respectively)
and the prevalence of ED identied in the use of the IIEF were lower (18.9%
and 26.0%, respectively). The methodological differences in the studies and
cultural characteristics may explain these variations.
It is important to note that most subjects whose ED was detected by the
IIEF were classied as having mild ED: 87 of the 299 subjects, or 30.2% (CI
95%: 25.0% to 35.9%). This may be due to the different elements evaluated:
while an individuals answer to the question do you feel sexually potent
may be affected by their level of knowledge about sexual potency, their
self-esteem, how they feel and their level of satisfaction in their sexual and
emotional relationships, the IIEF evaluated erectile function from a more
functional perspective (difculty in obtaining or maintaining an erection,
for example). If on the one hand, only asking whether the man feels sexually
potent may lead to imprecise data and possibly to a subestimation. On the
other hand, investigating the presence of ED using only the IIEF may lead
to valuing the functional or mechanical aspects of erectile function, and will
fail to sufciently acknowledge the relational and behavioral aspects.
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Dysfunction is Less Common When Self-Reported 97
The decision was made to exclude the 12 subjects who had used or
were using erectile stimulation medication since the objective of the study
was to estimate the prevalence of self-perceived ED, and the use of such
medication could alter the subjects sexual performance, as well as their
perception of their erectile function (NIH, 1993; Moreira, Glasser, Santos, &
Gingell, 2005).
After the multivariate analysis, the factors associated with the presence of
ED detected by the IIEF were: professional inactivity suspected depressive
and/or anxiety disorder, good (not excellent) sexual desire, sexual desire
low/moderate, and reported ED. The association between ED and symptoms
of depression and anxiety have already been reported in the literature
by Feldman et al. (1994) and Araujo, Durante, Feldman, Goldstein, and
McKinlay (1998), among others. However, as Moreira et al. (2005) point
out, it is not possible to establish a cause and effect relationship between
these characteristics and the presence of ED in studies that evaluate these
conditions simultaneously. Erectile dysfunction may form part of a wider
context of depressive and/or anxiety disorders which themselves may be
responsible for signicant changes in desire and sexual performance. In such
a context, ED may be understood as a symptom of psychological suffering,
rather than as a disorder in and of itself. Thus, when treating a patient with
ED, it is important that the health professional investigates whether or not
there are associated mental symptoms.
The association between professional inactivity and the presence of ED
can be understood in a number of ways: on the one hand, professional
inactivity may form part of the context of a moment of mental suffering,
either as a cause (in situations involving unemployment, for example),
or a consequence (in cases where the patient has stopped working as a
result of symptoms of depression); on the other hand, there are cultural
expectations for men to work and to be providers. While age is a variable
that is traditionally associated with ED (Feldman et al., 1994; Aytac et al.,
1999; Moreira et al., 2001, 2002; Morillo et al., 2002; Laumann et al., 2005),
the present study did not nd there to be any association. It is worth pointing
out that the participants of this study were considered healthy (as part of a
medical evaluation for donating blood) and are relatively young compared
to the populations of other studies (Feldman et al., 1994; Moreira et al., 2002;
Martin-Morales et al., 2001; Morillo et al., 2002; Wu et al., 2007).
Study Limitations
This research was developed in the form of a cross-sectional (or prevalence)
study, which does not allow for causal inferences between the outcomes
studied (ED according to the IIFE) and the characteristics of the subjects
in the study (for example, if the ED preceded depressive and/or anxiety
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98 M. M. F. Reis and C. H. N. Abdo
disorders or developed subsequent to symptoms of depression and/or
anxiety). However, it does point to the existence of important associations
that could be investigated using other research strategies.
The use of blood donors as the subjects for the research was considered
as an alternative to using health service users and volunteers, who may be
more prone to suffering from ED than the general population (selection
biases resulting from their interest in seeking treatment). It is important to
point out, however, that the prevalence of blood donors may be lower than
that of the general population, since it involves quite a selective group that
possibly may display better general health conditions.
The choice of self-application of the research instruments may have led
to imprecision in the data that was collected, since some of the questions
contained in the research instruments use technical terms or contain the
word no, which could lead to difculties in understanding on the part
of the research subjects. On the other hand, given the intimate nature of
some of the questions, it is possible that the subjects feel more comfortable
providing answers on their own rather than directly to a researcher.
The strength of the associations between the subjects characteristics
and the presence of ED detected by the index expressed in the form of an
odds ratio (OR) is overestimated, since the prevalence of ED was high. The
associations that were found do exist but may not have been as acute as
presented.
It was not possible to investigate the association between the character-
istics of the subjects and the presence of reported ED which were obtained
from the univariate analysis by constructing a multiple logistical regression
model, on account of the small number of participants that reported this
condition. Future studies, with larger samples should allow for a more
in-depth investigation into the prevalence of self-reported ED.
CONCLUSIONS: IMPLICATIONS FOR RESEARCH AND FOR THE
ORGANIZATION OF HEALTH SERVICES
While the ndings of this current study have shown evidence of lower ED
prevalence than do other Brazilian studies that use different kinds of samples,
it still presents a prevalence of the condition that is high: 3 in every 10 men
aged 40 to 60 show some degree of ED. Conversely, the seeking of treatment
remains erratic, since individuals that report ED do not seek treatment while
others use medication without any medical guidance. It is important that
health professionals are aware of mens sexual performance, particularly
after the age of 40, and of the possible conditions that can accompany ED.
The development of studies regarding the relationship between ED
and socio-demographic, cultural, and clinical factors, as well as those
relating to relationships and emotions, requires investigations into the causal
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Dysfunction is Less Common When Self-Reported 99
associations between these factors (cohort studies, for example) and their
signicance for men (by means of qualitative studies).
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