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The Sexual Beliefs of Turkish Men: Comparing the Beliefs of Men With and Without Erectile Dysfunction a
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Serap Ejder Apay , Elif Yagmur Özorhan , Sevban Arslan , Hava Özkan , Erdem Koc & Isa Özbey a
Atatürk University, Erzurum, Turkey Accepted author version posted online: 25 Sep 2014.
To cite this article: Serap Ejder Apay, Elif Yagmur Özorhan, Sevban Arslan, Hava Özkan, Erdem Koc & Isa Özbey (2014): The Sexual Beliefs of Turkish Men: Comparing the Beliefs of Men With and Without Erectile Dysfunction, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2014.966397 To link to this article: http://dx.doi.org/10.1080/0092623X.2014.966397
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ACCEPTED MANUSCRIPT The Sexual Beliefs of Turkish Men: Comparing the Beliefs of Men With and Without Erectile Dysfunction
Serap Ejder Apay Elif Yagmur Ӧzorhan
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Sevban Arslan Hava Ӧzkan
Erdem Koc Isa Ӧzbey
Atatürk University, Erzurum, Turkey
Address correspondence to Dr. Serap Ejder Apay. Email: [email protected]
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ACCEPTED MANUSCRIPT Abstract Sexual beliefs underlying male sexual dysfunction are known to emphasize excessively high sexual performance, among other inaccuracies. The purpose of this study was to determine the frequency of certain sexual beliefs among Turkish men with and without erectile dysfunction. In this comparative-descriptive study, demographic data and participant views regarding 50 common sexual beliefs were collected via questionnaire. The study was conducted at the
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Urology Clinic of a university hospital in Turkey, between May 2011 and August 2013. Eight hundred and fifteen (815) men were enrolled in this study: 304 men with erectile dysfunction and 511 men without erectile dysfunction. Men with erectile dysfunction endorsed eight beliefs about sexual activity more frequently than men without erectile dysfunction, These findings indicate the association of certain cognitions with erectile dysfunction. Most of these cognitions concerned high expectations of male sexual function.
Keywords: Sexual beliefs, Erectile dysfunction, Erectile function, Men.
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ACCEPTED MANUSCRIPT INTRODUCTION Erectile dysfunction (ED) is defined as insufficiency in reaching and maintaining an erect penis as required for sexual intercourse (Akkus et al., 2002; Wespes et al., 2006). ED is one of the most frequent sexual dysfunctions in men (Akkus et al., 2002; Aschka et al., 2001; Rosen, 2000). It is generally accepted that the majority of cases of erectiel dysfcuntion have both organic and psychologicloa components. (Metz, & Epstein, 2002; Ekmekçioğlu, & Demirtaş,
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2006; Ozbey, 2010). Among the organic factors that have a role in the etiology of ED, the most important factors are vascular (arterial and venous insufficiency), neurological, iatrogenic (drugs, surgical interventions), metabolic, and endocrinological (Ekmekçioğlu, & Demirtaş, 2006). The presence of a psychic disorder accompanied by an organic pathology (for example, vascular insufficiency) should be kept in mind. Performance anxiety, extramarital affairs with the accompanying guilt, sexual dysfunction of the individual’s partner, various sexual beliefs, exaggerated expectations, accidental failures, and marital problems may also cause ED with psychogenic characteristics (Metz, & Epstein, 2002). In studies conducted in Turkey, the ED incidence rate in men aged >40 years varied between 64–86%, and the majority were considered mild-to-moderate (Ekmekçioğlu, & Demirtaş, 2006; Ozbey, 2010; Uluocak, & Kadıoğlu, 1999; Gülpınar et al., 2012; Gonulalan et al., 2013). Some studies in the literature have revealed that factors such as age, education, marital status, and sexual beliefs are related to sexual dysfunction (Akkus et al., 2002; Kinsey, Pomeroy, & Martin, 1948; Feldman et al., 1994; Zilbergeld, 1999). Sexual beliefs might have adverse effects on the sexual, and consequently, the general health of individuals (Baker, & DeSilva, 1988). These misinformed beliefs and false
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ACCEPTED MANUSCRIPT expectations can affect the attitudes and behaviors of individuals regarding their sexuality (Nyanzi et al., 2005; Baker, & DeSilva, 1988; Nobre, Pinto-Gouveia, & Gomes, 2003). The exact effect of beliefs on sexual functioning is beginning to attract attention following some clinical studies. In terms of clinical data, Zilbergeld’s studies deserve special attention (Zilbergeld, 1999). Zilbergeld stated that men with erectile disorders present a set of beliefs about sexuality that work as a factor of vulnerability in the development of their difficulties, such
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as, “a man always wants and is ready to have sex”; “a real man is sexually functional”; “sex is centered in a rigid penis and what we can do with it”; and “sex equals intercourse.” (Zilbergeld, 1992; Zilbergeld, 1999). According to Zilbergeld, a man who presents with this set of beliefs about sexuality is more susceptible to the development of catastrophic ideas about the potential consequences of an eventual sexual failure (Zilbergeld, 1999). When confronted with these situations, men who hold strongly to beliefs such as those mentioned above usually develop a negative self image manifested in thoughts such as: “I’m less than a man”, “I’m a sexual failure”, or “I will never solve this problem.” These beliefs, and the subsequent negative self image, not only predispose these men to develop sexual difficulties, but also play a central role in perpetuating the problem. Wincze and Barlow identified a set of sexual beliefs underlying male sexual dysfunction by emphasizing excessively high sexual performance and other inaccuracies (Wincze, & Barlow, 1997). Hawton
presented a list of sexual beliefs conceptualized as
predisposing factors to the development of sexual dysfunction (Hawton, 1985). Other previous studies have assessed similar concepts (Wincze, & Barlow, 1997; Hawton, 1985; Baker, & DeSilva, 1988). Baker and De Silva showed that dysfunctional males have a higher rate of erroneous beliefs than functional males (Baker, & DeSilva, 1988). In another study, Ejder Apay
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ACCEPTED MANUSCRIPT et al. revealed that the ratio of Turkish students upholding such incorrect sexual beliefs as truths was very high (Ejder Apay et al., 2013; Ejder Apay, Balcı Akpınar, & Aslan, 2013). The purpose of this study was to determine the frequency of such inaccurate sexual beliefs among Turkish men with and without ED.
METHODS
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Study Type We conducted a comparative-descriptive study in the Urology Clinic of a university hospital located in northeastern Turkey. Eight hundred and fifteen (815) men were included in this study: 304 men with ED and 511 men without ED. Date of the Study The study was conducted between May 2011 and August 2013. Participants Between the dates of this study, all men who were sexually active, who admitted to the Urology Clinic, and who accepted the study conditions were included in the study. The International Index of Erectile Function (IIEF) was applied in all men included in the study. According to the IIEF, ED is evaluated as follows: 1-7: severe ED, 8-11: moderate ED, 12-16: mild-moderate
ED,
17-21:
mild
ED,
22-25:
(http://surgery.arizona.edu/sites/surgery.arizona.edu/files/pdf/SHIM%20score.pdf).
no
ED Sexually
active male patients who had been diagnosed with ED by a urologist, according to the IIEF scoring system, were included in the study. The mean IIEF score of the male patients with ED was determined as 17.15±16.03. Sexually active male patients who had been determined to not
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ACCEPTED MANUSCRIPT have ED by a urologist, according to the IIEF scoring system, and who applied to the clinic with varying complaints, such as urinary infection or renal problems, were also included in the study. The mean IIEF score of the male patients without ED was determined as 26.88±6.91. During the study, 476 men with ED applied to the clinic and 342 of them agreed to participate in the study. A questionnaire was given to 342 patients with ED, and 304 of them returned the form, for a return rate of 89%. Five hundred forty-two men without ED agreed to participate in the study,
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and 511 returned the questionnaire, for a return rate of 94%. All participants were informed about the study and questionnaire via a letter and the decision to participate was voluntary. They sent this information via a letter and returned the completed questionnaire in a sealed envelope. Data Collection Tool The data were collected via a questionnaire prepared by researchers based on the results of a literature review (Zilbergeld, 1999; Nyanzi et al., 2005; Baker, & Desilva, 1988; Nobre, Pinto- Gouveia, & Gomes, 2003; Zilbergeld, 1992; Wincze, & Barlow, 1997; Haeton, 1985; Ejder Apay, Balcı Akpınar, & Arslan, 2013; Ejder Apay et al., 2013; Torun, Dilek Torun, & Özaydın, 2011; Güleç et al., 2007; Bostancı et al., 2007; Motavallı et al., 1991; Yaşan, & Gürgen, 2004; Kukulu, Gürsoy, & Ak Sözer, 2009). Following a review of the related literature, the researchers determined that these statements are commonly accepted sexual beliefs. In consultation, the researchers decided which of these beliefs were to be used in the study. The questionnaire form was prepared in Turkish, and then the manuscript in its entirety and the sexual belief statements were translated into English. There were no challenges in translating the sexual belief statements, which have also been used by other authors in similar studies. The
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ACCEPTED MANUSCRIPT questionnaire form included two parts: the first, regarding data collection, included 12 questions regarding the participant’s age, educational level, place of residence, family type, and their sources of information regarding sexuality. The second part consisted of 50 sexual belief statements, which participants were asked to evaluate as either “true” or “false”. A response of “true” showed that the participant accepted the belief as factual. Participants with and without ED were compared with regard to their acceptance or not of each belief. An initial pilot study
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was conducted with 20 sexually active men without ED, aged 20 years and above. Based on this pilot study, the questionnaire form was revised; the data from the pilot study were not included in the current study. Two beliefs that remained unanswered (“Masturbation is not a proper activity for respectable people.”, and “Sexual activity must be initiated by a man.”) were removed from the questionnaire form. Data Analysis The Statistical Package for the Social Sciences (SPSS) ver. 16 was used for the statistical analysis. Percentages were used for examining the descriptive characteristics of groups, and chisquare was used to compare beliefs and the groups. Because of multiple statistical comparisons, a probability of less than >01 was required to be considered as statistically significant. Ethical Considerations Before commencing the study, ethical approval was received from the Ataturk University, Faculty of Health Sciences, Ethics Committee, as well as the written permission of the hospital in which the study would be conducted and the verbal consent of the participants. All participants were informed about the purpose of the study, that the collected information
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ACCEPTED MANUSCRIPT would be used solely for scientific purposes, and that such information would be kept confidential and not shared with others outside the researchers. RESULTS When the sociodemographic characteristics of men with and without ED were examined, it was determined that 71.1% of men with ED and 67.6% of men without ED were aged over 40 years; 44.1% of men with ED and 42.5% of men without ED were primary school graduates, and
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the majority of both groups resided in urban areas. Of men with ED, 88.9% had a middle income level, 89.8% were from a nuclear family, and 68.1% had received information about sexuality. Of men without ED, 86.9% had a middle income level, 90.0% were from a nuclear family, and 67.9% had received information about sexuality. Most of the study participants indicated that they had obtained information about sexuality from their friends. It was determined that the difference between groups was not statistically significant, and the groups had similar features in terms of variables (p>0.05). [Insert Table 1 Here] Eight sexual beliefs were held more commonly by men with ED as compared to men without ED. These beliefs1 were:
Good lovemaking connotes a constant sexual excitement and orgasm as a consequence.
Sexual intercourse is forbidden during pregnancy.
It is challenging to insert the penis into the vagina.
Strong men are able to make love a few times successively.
1
The 8 beliefs statistically significantly different at the 0.01 level of significance.Researchers who want to use these beliefs, can contact Serap EJDER APAY.
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Some men make love very well, while others are incapable of doing so, no matter the extent to which they may increase their sexual knowledge and skills.
Sexuality in men culminates during the adolescence period.
All physical intimacies should result in sexual intercourse.
The man who “fails” the first sexual intercourse is not a man.
This study revealed that most of the sexually active men included in the study held as true
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a number of sexual beliefs, but there were many differences in the beliefs between men with and without ED.
DISCUSSION We will discuss the false beliefs that men in the ED and non-ED groups reported as true, considering how these beliefs may increase men’s likelihood of developing ED and how these beliefs may change between men with ED and without ED. In the literature, men with ED have been shown to hold as true a number of false sexual beliefs (Zilbergeld, 1999). Responses to Belief 7 (Good lovemaking connotes a constant sexual excitement and orgasm as a consequence.) revealed a statistical difference between the groups with and without ED. Acceptance of this belief may be higher in men with ED when compared to those without. Penile erection required for sexual intercourse is not fully functional in men with ED. However, in studies conducted among men without ED, it has been reported that belief in this myth is quite high (Ejder Apay, Balcı Akpınar, & Arslan, 2013; Torun, Dilek, Torun, & Özaydın , 2011; Bostancı et al., 2007). A goal of orgasm during every act of intercourse may eliminate the sincerity between couples and expectations may create a basis for disappointment. Acceptance of
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ACCEPTED MANUSCRIPT this belief may have been found at a higher rate among men with than without ED because penile erection during lovemaking, which is necessary for sexual intercourse, is not always achieved in men with ED. Belief 15 (Sexual intercourse is forbidden during pregnancy.) was accepted at a higher rate among men without ED compared to those with ED. This may be attributed to the fact that the frequency of sexual intercourse among men without ED may be greater than among men
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with ED. The rate of those accepting this belief as true was 38.5% in Ejder Apay et al.’s study (Ejder Apay, Balcı Akpınar, & Arslan, 2013). In another study conducted by Ejder Apay et al. , the acceptance rate was 37.0% among Turkish participants and 13.8% among Polish participants ( Ejder Apay et al., 2013). This result was explained as follows: “As a pregnant woman is viewed in our society as being in the process of attaining the sacred role of motherhood and it is believed that intercourse could harm the baby, the couple does not engage in an active sex life during pregnancy, and this absence of intercourse during pregnancy is accepted as a belief”. Belief 20 (It is challenging to insert the penis into the vagina.) showed a statistically significant difference in responses. This belief was higher in men with ED when compared to men without ED. Men with ED may have difficulty penetrating the vagina since they lack the penile erection required for sexual intercourse, and this may explain the difference in responses between the groups. Belief 22 (Strong men are able to make love a few times successively.) showed greater acceptance by men with ED. In the literature, Ejder et al. (2013) reported the same results for men without ED, which was similarly reported by Ejder Apay et al. (Ejder Apay, Balcı Akpınar, & Arslan, 2013). Experiencing a sexual function disorder such as ED may cause men to feel
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ACCEPTED MANUSCRIPT light-headed, weak and incapable. The belief “How often a man can make love successfully shows his potency (Belief 39)” was also supported. Belief 23 (Some men make love very well, while others are incapable of doing so, no matter the extent to which they may increase their sexual knowledge and skills.) showed a great difference between groups. This may be because men with ED consider this problem untreatable, regardless of how much therapy they receive, and they cannot compare themselves with healthy
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men. However, results of other studies were not in line with ours (Ejder Apay et al., 2013; Torun , Dilek, Torun, & Özaydın, 2011; Güleç, Kılıç, & Bilgiç, 2007; Bostancı et al., 2007; Motavallı, 1991; Yaşan, & Gürgen, 2004). The reason for the differences between these studies may be that in the latter studies, no sexual dysfunction was determined in the sampling groups. Ejder Apay et al. determined this rate as 29.5%, and no statistically significant difference was found between students (Ejder Apay, Balcı Akpınar, & Arslan, 2013). The belief “Sexuality is instinctive and unteachable.” used in the study conducted by Yaşan and Gürgen also supported the results of this study, since sexuality is instinctive (Yaşan, & Gürgen, 2004). Belief 31 (Sexuality in men culminates during the adolescence period.) received the highest positive response rate in the group without ED. This may be explained by the fact that men without ED had a greater number of experiences/opportunities during their adolescence to explore their sexuality. This result is supported by findings of other studies (Ejder Apay, Balcı Akpınar, & Arslan, 2013; Ejder Apay et al., 2013). The perspective regarding sexuality prevalent in the society in which the individual lives is the most important factor affecting an individual’s sexual beliefs (Sungur, 1999). Even though the society in which the individual lives ignores the necessity of an individual being properly informed about sexuality, natural impulses force every
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ACCEPTED MANUSCRIPT individual to learn about their sexuality, beginning from childhood and continuing through adolescence. An individual’s sexual curiosity starts in childhood, while knowledge about sexual matters is obtained mostly in adolescence. Insufficient or inaccurate sexual knowledge obtained during the psychosexual development period of childhood and adolescence and inaccurate and exaggerated expectations regarding sexuality are reflected in the sexual beliefs and behaviors of the individual in adulthood, thus contributing to sexual problems later in life (Miller, 1992).
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Belief 45 (All moments of physical intimacy should result in sexual intercourse.) was found to be accepted as true at a higher rate among men with ED compared to those without ED; however, many studies have reported contradictory results (Ejder Apay et al., 2013; Güleç, Kılıç, & Bilgiç, 2007; Bostancı et al., 2007; Kora, & Kayır, 1996). This difference may have been caused by the sample group in these studies including healthy persons without ED, since sexual intercourse fails due to the lack of penile erection in ED. In this case, the focus of the men diagnosed with ED was the whole sexual relationship, that is, they believe focus should be not only on sexual intercourse but also on physical intimacy. Belief 46 (The man who “fails” the first sexual intercourse is not a man.) was accepted as true by 6.6% in the group with ED and by 12.5% in group without ED and focused on the sexual performance of a healthy and capable man, not failing in any circumstance. In Güleç et al.’s study, this belief was found to be statistically significant among male students and supportive of our result (Güleç, Kılıç, & Bilgiç, 2007). As stated previously, one study was not compatible with the results of this study (Ejder Apay et al., 2013). Men without ED usually experience no problems during sexual intercourse and see themselves as strong and "male", which may explain this difference. Success in one’s first sexual encounter is accepted in our
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ACCEPTED MANUSCRIPT society as an indicator of success throughout one’s subsequent sexual life; this success is perceived as a symbol of power, and this power is attributed to men. On the other hand, if a man fails in his first sexual intercourse experience, it is believed that he will not be successful throughout his life and he is considered weak and not a man, as this is contrary to the nature of manhood. CONCLUSION
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This study revealed that participants believed in and approved a similar number of sexual beliefs. However, with respect to three sexual beliefs related with sexual intercourse and orgasm (Beliefs 7, 8, 23), men with ED accept these to be true at a greater rate when compared to men without ED. These findings are important because these results will serve as the basis for studies among different cultures and groups. Sexuality, which concerns every individual, has considerable effects on a person’s physical and mental health, can cause social problems that are difficult to resolve, and is a delicate health issue. It is an undeniable fact that being informed about sexuality from accurate sources is an important factor towards experiencing sexuality in a healthy way. Psychoeducation should be offered for those who hold these sexual beliefs, as it can strengthen the capabilities, resources and coping skills of men with ED and can contribute to their health and well-being on a long-term basis. Analytic studies can be conducted in order to determine whether or not sexual beliefs are associated with psychological causes of ED. We suggest that clinicians and researchers undertake studies to compare patient groups with different types of sexual dysfunction. Findings of studies on sexual beliefs need to be taken into consideration when preparing the content of sex education programs. Training for qualified
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ACCEPTED MANUSCRIPT health educators (psychologists, physicians, nurses, midwives) regarding the beliefs that are commonly upheld in society should be provided.
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Disclosures: The authors declare no conflicts of interest.
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ACCEPTED MANUSCRIPT REFERENCES Akkus, E., Kadıoğlu, A., Esen, A., Doran, S., Ergen, A., Anafarta, K., Hattat, H. (2002). Turkish Erectile Dysfunction Prevalence Study Group. Prevalence and correlates of erectile dysfunction in Turkey: a population-based study. Eur Urol, 41, 125-133. Aschka, C., Himmel, W., Ittner, E., et al. (2001). Sexual problems of male patients in family practice. J Fam Pract, 50(9),773-778.
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Baker, C., DeSilva, P. (1988). The relationship between male sexual dysfunction and belief in Zilbergeld’s myths: an empirical investigation. Sex Marital Ther, 3(2), 229–238. Bostancı, N., Buzlu, S., Tufek, F., Kalaycıoğlu, D., Yıldırım, N., Yılmaz, S. (2007). Evaluation of university students by gender in sexual myths: preliminary results. Andrology Bull, 31, 362-364. Ejder Apay, S., Balcı Akpınar, R., Arslan, S. (2013). Investigation of students' sexual myths. J Anatolia Nurs Health Sci, 16(2), 96-102. Ejder Apay, S., Nagorska, M., Balcı Akpınar, R., Sis Çelik, A., Binkowska-Bury, M. (2013). Student comparison
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myths:
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ACCEPTED MANUSCRIPT Gonulalan, U., Hayırlı, A., Kosan, M., Ozkan, O., Yılmaz, H. (2013). Erectile dysfunction and depression in patients with chronic lead poisoning. Andrologia, 45(6), 397-401. Güleç, G., Kılıç, Y., Bilgiç, S. (2007). The sexual myths comparison between first and sixth class students of the medical faculty of ESOGU. J. Fac. Med. Osmangazi, 29(3), 136–145. Gülpinar, O., Haliloğlu, A. H., Abdulmajed, M. I., Bogga, M. S., Yaman, O. (2012). Helpseeking interval in erectile dysfunction: analysis of attitudes, beliefs, and factors affecting
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from: 27.05.2014. Kinsey, A. C., Pomeroy, W. B., Martin, C. E. (1948). Age and sexual outlet. In: Kinsey, Editor. Sexual behavior in the human male. (pp 213-262). WB Saunders: Philadelphia. Kora, K., Kayır, A. (1996). Sex roles and sexual myths. J Psychiatry Neurological Sci, 9(2), 5558. Kukulu, K., Gürsoy, E., Ak Sözer, G. (2009). Turkish University Students’ Beliefs in Sexual Myths. Sex Disabil, 27, 49–59. Metz, M. E., Epstein, N. (2002). Assessing the role of relationship conflict in sexual dysfunction. J Sex Marital Ther, 28, 139-164. Miller, P. H. (1992).Theories of developmental psychology. Freeman and Company: New York. Motavallı, M., Yücel, B., Kayır, A., Üçok, A. (1991).Three groups of married women's sexual beliefs and life evaluation. Neuropsychiatry Arch, 28, 94-97.
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ACCEPTED MANUSCRIPT Nobre, P.J., Pinto-Gouveia, J., Gomes, F.A. (2003). Sexual dysfunctional beliefs questionnaire: an instrument to assess sexual dysfunctional beliefs as vulnerability factors to sexual problems. Sex Relation Ther, 18(2), 171–204. Nyanzi, S., Nyanzi, B., Kalina, B. (2005). Contemporary myths, sexuality misconceptions, information sources, and risk perceptions of bodabodamen in southwest Uganda. Sex Roles, 52(1), 111–119.
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Ozbey I. (2010). The role of androgen replacement therapy in erectile dysfunction. Turk Urol Sem, 1, 112-118. Rosen, R. C. (2000). Prevalence and risk factors of sexual dysfunction in men and women. Curr Psychiatry Rep, 2(3), 189-195. Sungur, M. Z. (1999). Cultural factors in sex therapy: the Turkish experience. Sex Marital Ther, 14, 165–171. Torun, F., Dilek Torun, S., Özaydın, N. (2011). Men’s belief in sexual myths and factors affecting these myths. J Psychiatry Neurological Sci, 24, 24-31. Uluocak, N., Kadıoğlu, A. (1999). The epidemiology of erectile dysfunction. In Yetkin N, İncesu C (Eds.), Sexual dysfunction in men (pp: 3-6). Sexual Dysfunction Monograph Series: Istanbul. Wespes, E., Amar, E., Hatzichristou, D., Hatzimouratidis, K., Montorsi, F., Pryor, J., Vardi, Y. (2006). EAU guidelines on erectile dysfunction: an update. Eur Urol, 49, 806-815. Wincze, J. P, Barlow, D. H. (1997). Enhancing sexuality: a problem solving approach. Client Work-book. (pp: 60-66). Graywind Publications: San Antonio, TX.
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ACCEPTED MANUSCRIPT Yaşan, A., Gürgen, F. (2004). Comparison of prevalence of sexual myths and methods of acquiring sexual information in a group of nurses with and without sexual partners. New Symposium, 42(2), 72-76. Zilbergeld, B. (1992). The man behind the broken penis: social and psychological determinants of erectile failure. In: Rosen RC, Leiblum SR, (eds.) Erectile disorders: Assessment and treatment.( pp 27-55). 1st Edition. The Guilford Press: New York.
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Zilbergeld, B. (1999). The New Male Sexuality. (pp 1-432). Revised Edition. Bantam Books: New York.
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ACCEPTED MANUSCRIPT Table 1. Distribution and comparison of sexual belief between the groups
No.
1 2
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3 4 5 6 7 8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
24 25 26 27
ED (n=304)
Belief
As long as the partners love each other, they will know how to find pleasure in making love. Couples know what they think and want during sexual intercourse. Men desire and are ready for sexual intercourse all the time. Every man should know how to give pleasure to every woman. Erection is always a sign of sexual desire and stimulation. Sexuality is instinctive and cannot be learned. Good lovemaking connotes a constant sexual excitement and orgasm as a consequence.b Regarding sexual intercourse, men prioritize the sexual act and orgasm; on the other hand, women prioritize sentimentality. The first sexual intercourse is very dangerous for women. Masturbation during sexual intercourse is wrong. A good lover should be able to help her/his partner achieve orgasm in every act of intercourse. Taking testosterone definitely increases sexual potency. Simultaneous orgasm should be the most important goal for a couple. The size of male genitalia is important sexually. Sexual intercourse is forbidden during pregnancy. b An erect penis is the key for good intercourse. Women should obviously have vaginal orgasm. The most natural position for sexual intercourse is man-ontop/missionary position. Masturbation is harmful. It is challenging to insert the penis into the vagina. b Men who have suffered a heart attack or paralysis are no longer sexually active. Strong men are able to make love a few times successively. b Some men make love very well, while others are incapable of doing so, no matter the extent to which they may increase their sexual knowledge and skills. b Sexual performance of a man cannot be spoiled under any condition. Women have less sexual desire. Making love requires erection of the sexual organ. If difficulty in erection is experienced at the beginning of 19
Without ED Test and (n=511) p valuea
n % n % 221 72.7 361 70.6 p>0.05 206 67.8 336 65.8 p>0.05 198 65.1 337 65.9 p>0.05 202 66.4 303 59.3 p0.05 171 56.3 299 58.5 p>0.05 164 53.9 197 38.6 p0.05 41.4 40.1 126 205 p>0.05 115 37.8 208 40.7 p>0.05 137 45.1 175 34.2 p0.05 29.9 111 21.7 p0.05
93
223 273 184 181 144
43.6 53.4 36.0 35.4 28.2
p0.05 p>0.05
96 31.6 72 14.1 p0.05
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34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
sexual intercourse, it will probably result in impotence. Menopause completely removes sexual desire. The hymen could be ruptured by dry humping. Neither the man nor woman can refuse sexual intercourse. Sexuality in men culminates during the adolescence period. b If no bleeding occurs during the first sexual intercourse, this means the woman is not a virgin. Sexual action should always be started and sustained by the man. Aging completely destroys sexual desire. Adult men lose their interest in fantasy and masturbation. Having sexual fantasies is an immoral and unfaithful behavior. Making love has some certain and explicit rules. The success in the first sexual intercourse is an indicator for success throughout one’s sexual life thereafter. How often and how many times successively a man can make love shows his potency. Women should not show their emotions. Loss of penile erection means that he does not find his partner attractive. If a sexual problem is experienced once, this means that it will repeat. A woman who starts sexual intercourse is vicious. Men should not show their emotions. All physical intimacies should result in sexual intercourse. b The man who “fails” the first sexual intercourse is not a man. b Pre-ejaculation in men is an indicator of manhood. It is only the woman’s responsibility to prevent unintended pregnancies. Women can get pregnant through intimate acts such as kissing, touching. Sexual life and sexual pleasure are only for men. a
Chi-square test was used.
b
p level was 0.01.
20
71 72 69 59 49
23.4 23.7 22.7 19.4 16.1
50
16.4 88
52 49 46
17.1 96 18.8 p>0.05 16.1 106 20.7 p>0.05 15.1 15.9 81 p>0.05
48 41
15.8 55 13.5 77
10.8 p0.05
36
11.8 57
11.2
37 33
12.2 95 10.9 71
18.6 p0.05
39
12.8 48
9.4
26 30 28
8.6 9.9 9.2 6.6
66 26 17
12.9 p>0.05 5.1 p0.05 p>0.05 p>0.05 p0.05
p>0.05
p>0.05 p>0.05
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Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
The Sexual Beliefs of Turkish Men: Comparing the Beliefs of Men With and Without Erectile Dysfunction a
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Serap Ejder Apay , Elif Yagmur Özorhan , Sevban Arslan , Hava Özkan , Erdem Koc & Isa Özbey a
Atatürk University, Erzurum, Turkey Accepted author version posted online: 25 Sep 2014.
To cite this article: Serap Ejder Apay, Elif Yagmur Özorhan, Sevban Arslan, Hava Özkan, Erdem Koc & Isa Özbey (2014): The Sexual Beliefs of Turkish Men: Comparing the Beliefs of Men With and Without Erectile Dysfunction, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2014.966397 To link to this article: http://dx.doi.org/10.1080/0092623X.2014.966397
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ACCEPTED MANUSCRIPT The Sexual Beliefs of Turkish Men: Comparing the Beliefs of Men With and Without Erectile Dysfunction
Serap Ejder Apay Elif Yagmur Ӧzorhan
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Sevban Arslan Hava Ӧzkan
Erdem Koc Isa Ӧzbey
Atatürk University, Erzurum, Turkey
Address correspondence to Dr. Serap Ejder Apay. Email: [email protected]
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ACCEPTED MANUSCRIPT Abstract Sexual beliefs underlying male sexual dysfunction are known to emphasize excessively high sexual performance, among other inaccuracies. The purpose of this study was to determine the frequency of certain sexual beliefs among Turkish men with and without erectile dysfunction. In this comparative-descriptive study, demographic data and participant views regarding 50 common sexual beliefs were collected via questionnaire. The study was conducted at the
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Urology Clinic of a university hospital in Turkey, between May 2011 and August 2013. Eight hundred and fifteen (815) men were enrolled in this study: 304 men with erectile dysfunction and 511 men without erectile dysfunction. Men with erectile dysfunction endorsed eight beliefs about sexual activity more frequently than men without erectile dysfunction, These findings indicate the association of certain cognitions with erectile dysfunction. Most of these cognitions concerned high expectations of male sexual function.
Keywords: Sexual beliefs, Erectile dysfunction, Erectile function, Men.
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ACCEPTED MANUSCRIPT INTRODUCTION Erectile dysfunction (ED) is defined as insufficiency in reaching and maintaining an erect penis as required for sexual intercourse (Akkus et al., 2002; Wespes et al., 2006). ED is one of the most frequent sexual dysfunctions in men (Akkus et al., 2002; Aschka et al., 2001; Rosen, 2000). It is generally accepted that the majority of cases of erectiel dysfcuntion have both organic and psychologicloa components. (Metz, & Epstein, 2002; Ekmekçioğlu, & Demirtaş,
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2006; Ozbey, 2010). Among the organic factors that have a role in the etiology of ED, the most important factors are vascular (arterial and venous insufficiency), neurological, iatrogenic (drugs, surgical interventions), metabolic, and endocrinological (Ekmekçioğlu, & Demirtaş, 2006). The presence of a psychic disorder accompanied by an organic pathology (for example, vascular insufficiency) should be kept in mind. Performance anxiety, extramarital affairs with the accompanying guilt, sexual dysfunction of the individual’s partner, various sexual beliefs, exaggerated expectations, accidental failures, and marital problems may also cause ED with psychogenic characteristics (Metz, & Epstein, 2002). In studies conducted in Turkey, the ED incidence rate in men aged >40 years varied between 64–86%, and the majority were considered mild-to-moderate (Ekmekçioğlu, & Demirtaş, 2006; Ozbey, 2010; Uluocak, & Kadıoğlu, 1999; Gülpınar et al., 2012; Gonulalan et al., 2013). Some studies in the literature have revealed that factors such as age, education, marital status, and sexual beliefs are related to sexual dysfunction (Akkus et al., 2002; Kinsey, Pomeroy, & Martin, 1948; Feldman et al., 1994; Zilbergeld, 1999). Sexual beliefs might have adverse effects on the sexual, and consequently, the general health of individuals (Baker, & DeSilva, 1988). These misinformed beliefs and false
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ACCEPTED MANUSCRIPT expectations can affect the attitudes and behaviors of individuals regarding their sexuality (Nyanzi et al., 2005; Baker, & DeSilva, 1988; Nobre, Pinto-Gouveia, & Gomes, 2003). The exact effect of beliefs on sexual functioning is beginning to attract attention following some clinical studies. In terms of clinical data, Zilbergeld’s studies deserve special attention (Zilbergeld, 1999). Zilbergeld stated that men with erectile disorders present a set of beliefs about sexuality that work as a factor of vulnerability in the development of their difficulties, such
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as, “a man always wants and is ready to have sex”; “a real man is sexually functional”; “sex is centered in a rigid penis and what we can do with it”; and “sex equals intercourse.” (Zilbergeld, 1992; Zilbergeld, 1999). According to Zilbergeld, a man who presents with this set of beliefs about sexuality is more susceptible to the development of catastrophic ideas about the potential consequences of an eventual sexual failure (Zilbergeld, 1999). When confronted with these situations, men who hold strongly to beliefs such as those mentioned above usually develop a negative self image manifested in thoughts such as: “I’m less than a man”, “I’m a sexual failure”, or “I will never solve this problem.” These beliefs, and the subsequent negative self image, not only predispose these men to develop sexual difficulties, but also play a central role in perpetuating the problem. Wincze and Barlow identified a set of sexual beliefs underlying male sexual dysfunction by emphasizing excessively high sexual performance and other inaccuracies (Wincze, & Barlow, 1997). Hawton
presented a list of sexual beliefs conceptualized as
predisposing factors to the development of sexual dysfunction (Hawton, 1985). Other previous studies have assessed similar concepts (Wincze, & Barlow, 1997; Hawton, 1985; Baker, & DeSilva, 1988). Baker and De Silva showed that dysfunctional males have a higher rate of erroneous beliefs than functional males (Baker, & DeSilva, 1988). In another study, Ejder Apay
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ACCEPTED MANUSCRIPT et al. revealed that the ratio of Turkish students upholding such incorrect sexual beliefs as truths was very high (Ejder Apay et al., 2013; Ejder Apay, Balcı Akpınar, & Aslan, 2013). The purpose of this study was to determine the frequency of such inaccurate sexual beliefs among Turkish men with and without ED.
METHODS
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Study Type We conducted a comparative-descriptive study in the Urology Clinic of a university hospital located in northeastern Turkey. Eight hundred and fifteen (815) men were included in this study: 304 men with ED and 511 men without ED. Date of the Study The study was conducted between May 2011 and August 2013. Participants Between the dates of this study, all men who were sexually active, who admitted to the Urology Clinic, and who accepted the study conditions were included in the study. The International Index of Erectile Function (IIEF) was applied in all men included in the study. According to the IIEF, ED is evaluated as follows: 1-7: severe ED, 8-11: moderate ED, 12-16: mild-moderate
ED,
17-21:
mild
ED,
22-25:
(http://surgery.arizona.edu/sites/surgery.arizona.edu/files/pdf/SHIM%20score.pdf).
no
ED Sexually
active male patients who had been diagnosed with ED by a urologist, according to the IIEF scoring system, were included in the study. The mean IIEF score of the male patients with ED was determined as 17.15±16.03. Sexually active male patients who had been determined to not
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ACCEPTED MANUSCRIPT have ED by a urologist, according to the IIEF scoring system, and who applied to the clinic with varying complaints, such as urinary infection or renal problems, were also included in the study. The mean IIEF score of the male patients without ED was determined as 26.88±6.91. During the study, 476 men with ED applied to the clinic and 342 of them agreed to participate in the study. A questionnaire was given to 342 patients with ED, and 304 of them returned the form, for a return rate of 89%. Five hundred forty-two men without ED agreed to participate in the study,
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and 511 returned the questionnaire, for a return rate of 94%. All participants were informed about the study and questionnaire via a letter and the decision to participate was voluntary. They sent this information via a letter and returned the completed questionnaire in a sealed envelope. Data Collection Tool The data were collected via a questionnaire prepared by researchers based on the results of a literature review (Zilbergeld, 1999; Nyanzi et al., 2005; Baker, & Desilva, 1988; Nobre, Pinto- Gouveia, & Gomes, 2003; Zilbergeld, 1992; Wincze, & Barlow, 1997; Haeton, 1985; Ejder Apay, Balcı Akpınar, & Arslan, 2013; Ejder Apay et al., 2013; Torun, Dilek Torun, & Özaydın, 2011; Güleç et al., 2007; Bostancı et al., 2007; Motavallı et al., 1991; Yaşan, & Gürgen, 2004; Kukulu, Gürsoy, & Ak Sözer, 2009). Following a review of the related literature, the researchers determined that these statements are commonly accepted sexual beliefs. In consultation, the researchers decided which of these beliefs were to be used in the study. The questionnaire form was prepared in Turkish, and then the manuscript in its entirety and the sexual belief statements were translated into English. There were no challenges in translating the sexual belief statements, which have also been used by other authors in similar studies. The
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ACCEPTED MANUSCRIPT questionnaire form included two parts: the first, regarding data collection, included 12 questions regarding the participant’s age, educational level, place of residence, family type, and their sources of information regarding sexuality. The second part consisted of 50 sexual belief statements, which participants were asked to evaluate as either “true” or “false”. A response of “true” showed that the participant accepted the belief as factual. Participants with and without ED were compared with regard to their acceptance or not of each belief. An initial pilot study
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was conducted with 20 sexually active men without ED, aged 20 years and above. Based on this pilot study, the questionnaire form was revised; the data from the pilot study were not included in the current study. Two beliefs that remained unanswered (“Masturbation is not a proper activity for respectable people.”, and “Sexual activity must be initiated by a man.”) were removed from the questionnaire form. Data Analysis The Statistical Package for the Social Sciences (SPSS) ver. 16 was used for the statistical analysis. Percentages were used for examining the descriptive characteristics of groups, and chisquare was used to compare beliefs and the groups. Because of multiple statistical comparisons, a probability of less than >01 was required to be considered as statistically significant. Ethical Considerations Before commencing the study, ethical approval was received from the Ataturk University, Faculty of Health Sciences, Ethics Committee, as well as the written permission of the hospital in which the study would be conducted and the verbal consent of the participants. All participants were informed about the purpose of the study, that the collected information
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ACCEPTED MANUSCRIPT would be used solely for scientific purposes, and that such information would be kept confidential and not shared with others outside the researchers. RESULTS When the sociodemographic characteristics of men with and without ED were examined, it was determined that 71.1% of men with ED and 67.6% of men without ED were aged over 40 years; 44.1% of men with ED and 42.5% of men without ED were primary school graduates, and
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the majority of both groups resided in urban areas. Of men with ED, 88.9% had a middle income level, 89.8% were from a nuclear family, and 68.1% had received information about sexuality. Of men without ED, 86.9% had a middle income level, 90.0% were from a nuclear family, and 67.9% had received information about sexuality. Most of the study participants indicated that they had obtained information about sexuality from their friends. It was determined that the difference between groups was not statistically significant, and the groups had similar features in terms of variables (p>0.05). [Insert Table 1 Here] Eight sexual beliefs were held more commonly by men with ED as compared to men without ED. These beliefs1 were:
Good lovemaking connotes a constant sexual excitement and orgasm as a consequence.
Sexual intercourse is forbidden during pregnancy.
It is challenging to insert the penis into the vagina.
Strong men are able to make love a few times successively.
1
The 8 beliefs statistically significantly different at the 0.01 level of significance.Researchers who want to use these beliefs, can contact Serap EJDER APAY.
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Some men make love very well, while others are incapable of doing so, no matter the extent to which they may increase their sexual knowledge and skills.
Sexuality in men culminates during the adolescence period.
All physical intimacies should result in sexual intercourse.
The man who “fails” the first sexual intercourse is not a man.
This study revealed that most of the sexually active men included in the study held as true
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a number of sexual beliefs, but there were many differences in the beliefs between men with and without ED.
DISCUSSION We will discuss the false beliefs that men in the ED and non-ED groups reported as true, considering how these beliefs may increase men’s likelihood of developing ED and how these beliefs may change between men with ED and without ED. In the literature, men with ED have been shown to hold as true a number of false sexual beliefs (Zilbergeld, 1999). Responses to Belief 7 (Good lovemaking connotes a constant sexual excitement and orgasm as a consequence.) revealed a statistical difference between the groups with and without ED. Acceptance of this belief may be higher in men with ED when compared to those without. Penile erection required for sexual intercourse is not fully functional in men with ED. However, in studies conducted among men without ED, it has been reported that belief in this myth is quite high (Ejder Apay, Balcı Akpınar, & Arslan, 2013; Torun, Dilek, Torun, & Özaydın , 2011; Bostancı et al., 2007). A goal of orgasm during every act of intercourse may eliminate the sincerity between couples and expectations may create a basis for disappointment. Acceptance of
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ACCEPTED MANUSCRIPT this belief may have been found at a higher rate among men with than without ED because penile erection during lovemaking, which is necessary for sexual intercourse, is not always achieved in men with ED. Belief 15 (Sexual intercourse is forbidden during pregnancy.) was accepted at a higher rate among men without ED compared to those with ED. This may be attributed to the fact that the frequency of sexual intercourse among men without ED may be greater than among men
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with ED. The rate of those accepting this belief as true was 38.5% in Ejder Apay et al.’s study (Ejder Apay, Balcı Akpınar, & Arslan, 2013). In another study conducted by Ejder Apay et al. , the acceptance rate was 37.0% among Turkish participants and 13.8% among Polish participants ( Ejder Apay et al., 2013). This result was explained as follows: “As a pregnant woman is viewed in our society as being in the process of attaining the sacred role of motherhood and it is believed that intercourse could harm the baby, the couple does not engage in an active sex life during pregnancy, and this absence of intercourse during pregnancy is accepted as a belief”. Belief 20 (It is challenging to insert the penis into the vagina.) showed a statistically significant difference in responses. This belief was higher in men with ED when compared to men without ED. Men with ED may have difficulty penetrating the vagina since they lack the penile erection required for sexual intercourse, and this may explain the difference in responses between the groups. Belief 22 (Strong men are able to make love a few times successively.) showed greater acceptance by men with ED. In the literature, Ejder et al. (2013) reported the same results for men without ED, which was similarly reported by Ejder Apay et al. (Ejder Apay, Balcı Akpınar, & Arslan, 2013). Experiencing a sexual function disorder such as ED may cause men to feel
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ACCEPTED MANUSCRIPT light-headed, weak and incapable. The belief “How often a man can make love successfully shows his potency (Belief 39)” was also supported. Belief 23 (Some men make love very well, while others are incapable of doing so, no matter the extent to which they may increase their sexual knowledge and skills.) showed a great difference between groups. This may be because men with ED consider this problem untreatable, regardless of how much therapy they receive, and they cannot compare themselves with healthy
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men. However, results of other studies were not in line with ours (Ejder Apay et al., 2013; Torun , Dilek, Torun, & Özaydın, 2011; Güleç, Kılıç, & Bilgiç, 2007; Bostancı et al., 2007; Motavallı, 1991; Yaşan, & Gürgen, 2004). The reason for the differences between these studies may be that in the latter studies, no sexual dysfunction was determined in the sampling groups. Ejder Apay et al. determined this rate as 29.5%, and no statistically significant difference was found between students (Ejder Apay, Balcı Akpınar, & Arslan, 2013). The belief “Sexuality is instinctive and unteachable.” used in the study conducted by Yaşan and Gürgen also supported the results of this study, since sexuality is instinctive (Yaşan, & Gürgen, 2004). Belief 31 (Sexuality in men culminates during the adolescence period.) received the highest positive response rate in the group without ED. This may be explained by the fact that men without ED had a greater number of experiences/opportunities during their adolescence to explore their sexuality. This result is supported by findings of other studies (Ejder Apay, Balcı Akpınar, & Arslan, 2013; Ejder Apay et al., 2013). The perspective regarding sexuality prevalent in the society in which the individual lives is the most important factor affecting an individual’s sexual beliefs (Sungur, 1999). Even though the society in which the individual lives ignores the necessity of an individual being properly informed about sexuality, natural impulses force every
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ACCEPTED MANUSCRIPT individual to learn about their sexuality, beginning from childhood and continuing through adolescence. An individual’s sexual curiosity starts in childhood, while knowledge about sexual matters is obtained mostly in adolescence. Insufficient or inaccurate sexual knowledge obtained during the psychosexual development period of childhood and adolescence and inaccurate and exaggerated expectations regarding sexuality are reflected in the sexual beliefs and behaviors of the individual in adulthood, thus contributing to sexual problems later in life (Miller, 1992).
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Belief 45 (All moments of physical intimacy should result in sexual intercourse.) was found to be accepted as true at a higher rate among men with ED compared to those without ED; however, many studies have reported contradictory results (Ejder Apay et al., 2013; Güleç, Kılıç, & Bilgiç, 2007; Bostancı et al., 2007; Kora, & Kayır, 1996). This difference may have been caused by the sample group in these studies including healthy persons without ED, since sexual intercourse fails due to the lack of penile erection in ED. In this case, the focus of the men diagnosed with ED was the whole sexual relationship, that is, they believe focus should be not only on sexual intercourse but also on physical intimacy. Belief 46 (The man who “fails” the first sexual intercourse is not a man.) was accepted as true by 6.6% in the group with ED and by 12.5% in group without ED and focused on the sexual performance of a healthy and capable man, not failing in any circumstance. In Güleç et al.’s study, this belief was found to be statistically significant among male students and supportive of our result (Güleç, Kılıç, & Bilgiç, 2007). As stated previously, one study was not compatible with the results of this study (Ejder Apay et al., 2013). Men without ED usually experience no problems during sexual intercourse and see themselves as strong and "male", which may explain this difference. Success in one’s first sexual encounter is accepted in our
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ACCEPTED MANUSCRIPT society as an indicator of success throughout one’s subsequent sexual life; this success is perceived as a symbol of power, and this power is attributed to men. On the other hand, if a man fails in his first sexual intercourse experience, it is believed that he will not be successful throughout his life and he is considered weak and not a man, as this is contrary to the nature of manhood. CONCLUSION
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This study revealed that participants believed in and approved a similar number of sexual beliefs. However, with respect to three sexual beliefs related with sexual intercourse and orgasm (Beliefs 7, 8, 23), men with ED accept these to be true at a greater rate when compared to men without ED. These findings are important because these results will serve as the basis for studies among different cultures and groups. Sexuality, which concerns every individual, has considerable effects on a person’s physical and mental health, can cause social problems that are difficult to resolve, and is a delicate health issue. It is an undeniable fact that being informed about sexuality from accurate sources is an important factor towards experiencing sexuality in a healthy way. Psychoeducation should be offered for those who hold these sexual beliefs, as it can strengthen the capabilities, resources and coping skills of men with ED and can contribute to their health and well-being on a long-term basis. Analytic studies can be conducted in order to determine whether or not sexual beliefs are associated with psychological causes of ED. We suggest that clinicians and researchers undertake studies to compare patient groups with different types of sexual dysfunction. Findings of studies on sexual beliefs need to be taken into consideration when preparing the content of sex education programs. Training for qualified
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ACCEPTED MANUSCRIPT health educators (psychologists, physicians, nurses, midwives) regarding the beliefs that are commonly upheld in society should be provided.
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Disclosures: The authors declare no conflicts of interest.
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ACCEPTED MANUSCRIPT REFERENCES Akkus, E., Kadıoğlu, A., Esen, A., Doran, S., Ergen, A., Anafarta, K., Hattat, H. (2002). Turkish Erectile Dysfunction Prevalence Study Group. Prevalence and correlates of erectile dysfunction in Turkey: a population-based study. Eur Urol, 41, 125-133. Aschka, C., Himmel, W., Ittner, E., et al. (2001). Sexual problems of male patients in family practice. J Fam Pract, 50(9),773-778.
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Baker, C., DeSilva, P. (1988). The relationship between male sexual dysfunction and belief in Zilbergeld’s myths: an empirical investigation. Sex Marital Ther, 3(2), 229–238. Bostancı, N., Buzlu, S., Tufek, F., Kalaycıoğlu, D., Yıldırım, N., Yılmaz, S. (2007). Evaluation of university students by gender in sexual myths: preliminary results. Andrology Bull, 31, 362-364. Ejder Apay, S., Balcı Akpınar, R., Arslan, S. (2013). Investigation of students' sexual myths. J Anatolia Nurs Health Sci, 16(2), 96-102. Ejder Apay, S., Nagorska, M., Balcı Akpınar, R., Sis Çelik, A., Binkowska-Bury, M. (2013). Student comparison
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ACCEPTED MANUSCRIPT Nobre, P.J., Pinto-Gouveia, J., Gomes, F.A. (2003). Sexual dysfunctional beliefs questionnaire: an instrument to assess sexual dysfunctional beliefs as vulnerability factors to sexual problems. Sex Relation Ther, 18(2), 171–204. Nyanzi, S., Nyanzi, B., Kalina, B. (2005). Contemporary myths, sexuality misconceptions, information sources, and risk perceptions of bodabodamen in southwest Uganda. Sex Roles, 52(1), 111–119.
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Ozbey I. (2010). The role of androgen replacement therapy in erectile dysfunction. Turk Urol Sem, 1, 112-118. Rosen, R. C. (2000). Prevalence and risk factors of sexual dysfunction in men and women. Curr Psychiatry Rep, 2(3), 189-195. Sungur, M. Z. (1999). Cultural factors in sex therapy: the Turkish experience. Sex Marital Ther, 14, 165–171. Torun, F., Dilek Torun, S., Özaydın, N. (2011). Men’s belief in sexual myths and factors affecting these myths. J Psychiatry Neurological Sci, 24, 24-31. Uluocak, N., Kadıoğlu, A. (1999). The epidemiology of erectile dysfunction. In Yetkin N, İncesu C (Eds.), Sexual dysfunction in men (pp: 3-6). Sexual Dysfunction Monograph Series: Istanbul. Wespes, E., Amar, E., Hatzichristou, D., Hatzimouratidis, K., Montorsi, F., Pryor, J., Vardi, Y. (2006). EAU guidelines on erectile dysfunction: an update. Eur Urol, 49, 806-815. Wincze, J. P, Barlow, D. H. (1997). Enhancing sexuality: a problem solving approach. Client Work-book. (pp: 60-66). Graywind Publications: San Antonio, TX.
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ACCEPTED MANUSCRIPT Yaşan, A., Gürgen, F. (2004). Comparison of prevalence of sexual myths and methods of acquiring sexual information in a group of nurses with and without sexual partners. New Symposium, 42(2), 72-76. Zilbergeld, B. (1992). The man behind the broken penis: social and psychological determinants of erectile failure. In: Rosen RC, Leiblum SR, (eds.) Erectile disorders: Assessment and treatment.( pp 27-55). 1st Edition. The Guilford Press: New York.
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Zilbergeld, B. (1999). The New Male Sexuality. (pp 1-432). Revised Edition. Bantam Books: New York.
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ACCEPTED MANUSCRIPT Table 1. Distribution and comparison of sexual belief between the groups
No.
1 2
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3 4 5 6 7 8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
24 25 26 27
ED (n=304)
Belief
As long as the partners love each other, they will know how to find pleasure in making love. Couples know what they think and want during sexual intercourse. Men desire and are ready for sexual intercourse all the time. Every man should know how to give pleasure to every woman. Erection is always a sign of sexual desire and stimulation. Sexuality is instinctive and cannot be learned. Good lovemaking connotes a constant sexual excitement and orgasm as a consequence.b Regarding sexual intercourse, men prioritize the sexual act and orgasm; on the other hand, women prioritize sentimentality. The first sexual intercourse is very dangerous for women. Masturbation during sexual intercourse is wrong. A good lover should be able to help her/his partner achieve orgasm in every act of intercourse. Taking testosterone definitely increases sexual potency. Simultaneous orgasm should be the most important goal for a couple. The size of male genitalia is important sexually. Sexual intercourse is forbidden during pregnancy. b An erect penis is the key for good intercourse. Women should obviously have vaginal orgasm. The most natural position for sexual intercourse is man-ontop/missionary position. Masturbation is harmful. It is challenging to insert the penis into the vagina. b Men who have suffered a heart attack or paralysis are no longer sexually active. Strong men are able to make love a few times successively. b Some men make love very well, while others are incapable of doing so, no matter the extent to which they may increase their sexual knowledge and skills. b Sexual performance of a man cannot be spoiled under any condition. Women have less sexual desire. Making love requires erection of the sexual organ. If difficulty in erection is experienced at the beginning of 19
Without ED Test and (n=511) p valuea
n % n % 221 72.7 361 70.6 p>0.05 206 67.8 336 65.8 p>0.05 198 65.1 337 65.9 p>0.05 202 66.4 303 59.3 p0.05 171 56.3 299 58.5 p>0.05 164 53.9 197 38.6 p0.05 41.4 40.1 126 205 p>0.05 115 37.8 208 40.7 p>0.05 137 45.1 175 34.2 p0.05 29.9 111 21.7 p0.05
93
223 273 184 181 144
43.6 53.4 36.0 35.4 28.2
p0.05 p>0.05
96 31.6 72 14.1 p0.05
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ACCEPTED MANUSCRIPT 28 29 30 31 32 33
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34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
sexual intercourse, it will probably result in impotence. Menopause completely removes sexual desire. The hymen could be ruptured by dry humping. Neither the man nor woman can refuse sexual intercourse. Sexuality in men culminates during the adolescence period. b If no bleeding occurs during the first sexual intercourse, this means the woman is not a virgin. Sexual action should always be started and sustained by the man. Aging completely destroys sexual desire. Adult men lose their interest in fantasy and masturbation. Having sexual fantasies is an immoral and unfaithful behavior. Making love has some certain and explicit rules. The success in the first sexual intercourse is an indicator for success throughout one’s sexual life thereafter. How often and how many times successively a man can make love shows his potency. Women should not show their emotions. Loss of penile erection means that he does not find his partner attractive. If a sexual problem is experienced once, this means that it will repeat. A woman who starts sexual intercourse is vicious. Men should not show their emotions. All physical intimacies should result in sexual intercourse. b The man who “fails” the first sexual intercourse is not a man. b Pre-ejaculation in men is an indicator of manhood. It is only the woman’s responsibility to prevent unintended pregnancies. Women can get pregnant through intimate acts such as kissing, touching. Sexual life and sexual pleasure are only for men. a
Chi-square test was used.
b
p level was 0.01.
20
71 72 69 59 49
23.4 23.7 22.7 19.4 16.1
50
16.4 88
52 49 46
17.1 96 18.8 p>0.05 16.1 106 20.7 p>0.05 15.1 15.9 81 p>0.05
48 41
15.8 55 13.5 77
10.8 p0.05
36
11.8 57
11.2
37 33
12.2 95 10.9 71
18.6 p0.05
39
12.8 48
9.4
26 30 28
8.6 9.9 9.2 6.6
66 26 17
12.9 p>0.05 5.1 p0.05 p>0.05 p>0.05 p0.05
p>0.05
p>0.05 p>0.05
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