SEXUAL MEDICINE ORIGINAL RESEARCH PSYCHOLOGY Psychological Distress in Erectile Dysfunction: The Moderating Role of Attachment Francesc Maestre-Loren, MSc,1 Jose A. Castillo-Garayoa, PhD,2 Xavier L opez-i-Martín, PhD,2 Joaquim Sarquella-Geli, MD,3 Ana Andres, PhD, and Ignacio Cifre, PhD 2 2 ABSTRACT Introduction: In clinical consultations, men with erectile dysfunction do not always express personal, sexual, and interpersonal concerns. Aim: We explore whether the attenuated impact of erectile dysfunction may be explained by a regulation of nega- tive affect that causes activation of the attachment system. Methods: The study sample consisted of 69 men diagnosed with erectile dysfunction, mean (SD) age 56 (10.83) years. Participants completed self-reported questionnaires to assess erectile dysfunction severity, attachment style, sexual satisfaction, relationship satisfaction, and psychological symptoms. Main Outcome Measure: The moderating role of attachment between erectile dysfunction and sexual satisfac- tion, relationship satisfaction, and psychological distress was evaluated using multiple linear regression and moderation analysis. Results: All men in the sample had high attachment avoidance, distributed between the dismissive-avoidant (69.6%) and fearful-avoidant (30.4%) substyles, but low levels of psychological symptoms. Despite their erectile dysfunction, 27 patients (39.1%) rated their sexual life as satisfactory, and 46 (66.7%) rated their relationship with their partner as satisfactory. Men with fearful-avoidant attachment reported feeling more sexual desire and less sexual satisfaction than men with dismissive-avoidant attachment. Multiple linear regression analysis showed that sexual satisfaction variance was explained by erectile dysfunction severity, attachment anxiety, and relation- ship satisfaction scores. Moderation analysis showed that attachment anxiety, but not relationship satisfaction, moderated the impact of erectile dysfunction on sexual satisfaction. Conclusion: The avoidance dimension of attachment, which tends to be high in patients with erectile dysfunction, involves deactivation of the sexual system in an effort to minimize the emotional distress associated with erectile dysfunction, which damages sexual and relationship intimacy and delays the decision to obtain professional help. The presence of high attachment avoidance and the moderating value of attachment anxiety allow us to propose specific treatments for these men. Maestre-Loren F, Castillo-Garayoa JA, Lopez-i-Martín X, et al. Psychological Distress in Erectile Dysfunction: The Moderating Role of Attachment. Sex Med 2021;9:100436. Copyright © 2021, International Society of Sexual Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Key Words: Erectile Dysfunction; Attachment; Sexual Satisfaction; Relationship Satisfaction; Psychological Distress INTRODUCTION Received March 31, 2021. Accepted August 4, 2021. 1 According to the Diagnostic and Statistical Manual of Mental Clinical Psychology Department, Fundaci o Puigvert, Barcelona, Spain; 2 Disorders (DSM-5),1 erectile dysfunction (ED) is defined as a FPCEE Blanquerna, Universitat Ramon Llull, Barcelona, Spain; 3 marked difficulty in obtaining an erection during sexual activity, Andrology Service, Fundaci o Puigvert, Barcelona, Spain with symptoms persisting for around 6 months and causing clini- Copyright © 2021, International Society of Sexual Medicine. Published by cal discomfort in the patient. The ED should not be better Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). explained as a nonsexual mental disorder, be the outcome of https://doi.org/10.1016/j.esxm.2021.100436 severe relationship distress or other stressors, or be attributable to Sex Med 2021;9:100436 1 2 Maestre-Loren et al substance abuse or medication or a medical condition. Epidemi- care of the other. The avoidant attachment style (low anxiety ological studies of sexual problems show that a prevalence of and high avoidance) reflects an attitude of self-sufficiency and a 34.8%-41.6% is greatly reduced to 9.9%-15.1% if we only preference for maintaining emotional distance in relationships, include men who report distress.2,3 Clinical practice also con- leading to a suppression of attachment needs.16,20 Bartholomew firms that the expression and intensity of personal and relation- and Horowitz16 identified a fearful-avoidant subtype, character- ship distress in men with ED is lower than expected; a possible ized by high avoidance and also high anxiety (a subtype labelled explanation for this attenuated emotional impact of ED might dismissive-avoidant that was included with the other avoidant be the regulatory function of negative affect in the attachment subtypes). People with fearful-avoidant attachment have a nega- system.4-7 tive representation of their partners, which makes empathy and The attachment system is an innate behavioural system that proximity difficult. A key characteristic of this kind of attach- aims to restore security and alleviate distress through proximity ment is that a fear of rejection makes it difficult for the person to to attachment figures.8 Attachment theory, therefore, helps us approach others, while their avoidance is ineffective in eliminat- understand the process of regulation of affect. The greater or ing distress, with the result that their psychological wellbeing is lesser availability and sensitivity of attachment figures, and the affected.12,21 degree to which they respond or not to a person’s needs, shapes a According to attachment theory, the sexual system is another history of relationships that is internalized in the form of mental innate behavioural system that governs sexual relations and indi- representations, expectations, emotions, and attitudes associated vidual differences in attitudes, behaviours, physiological aspects, with intimate relationships. Bowlby9 pointed out that such cog- motivations, emotions, and cognitive representations of sexual- nitive-affective representations, called internal working models, ity.4 While the sexual system is independent of the attachment reflect information about the self and about others, about the system, both are usually integrated within a relationship. In degree to which one is worthy or unworthy of receiving affection, adulthood, a partnership of 2 or more years of duration consti- and about whether or not others are reliable and available to offer tutes a link in which sexuality is present and in which attachment support and care. In securely attached people, internal working is activated when one of the partners experiences anxiety or fear; models also configure a facility to regulate emotions. Conversely, this attachment is reflected in proximity, sought to relieve emo- people with insecure attachment tend to hyperactivate or deacti- tional pain and regain a feeling of security.22-24 As with the vate emotions.10-12 attachment system, the primary strategy of the sexual system is Although attachment is established in the context of the rela- to seek proximity and seduce a partner who is attractive as a way tionship between a child and their caregiver, adults also seek of achieving a pleasurable sexual relationship that reinforces feel- closeness and support when they feel stressed or threatened.13,14 ings of self-efficacy and the experience of intimacy. However, if, In an adult context, the couple relationship promotes an intense as the primary strategy, the sexual experience is unsatisfactory, emotional bond and the expectation of being cared for and pro- and the search for proximity to the partner does not reduce the tected, or, on the contrary, a fear of rejection. Hazan and distress resulting from the threat to the self and the relationship, Shaver15 consequently argue that the couple relationship, includ- then secondary strategies to regulate affect will be mobilized, as ing sexual experience, is also an attachment relationship. Unlike follows:14,25 childhood attachment, where it is the child who seeks proximity with the adult caregiver, in adult relationships the couple acts a) Hyperactivation, involving excessive emphasis on sex, a hypervigi- reciprocally as each other’s attachment figure. lant attitude regarding the sexual needs of the partner and regarding signs of attraction or rejection, and a risk of coercive attitudes and The different attachment styles can be understood as combi- chronic activation of the sexual system, generating anxiety. nations of 2 main dimensions: attachment anxiety and attach- b) Deactivation, involving inhibited sexual desire, sexual excitement ment avoidance.16,17 Attachment anxiety is associated with the and orgasmic pleasure, erotophobia, avoidance of sex, and distanc- model of the self and with whether the person has mainly posi- ing from the partner when they express interest in sex, with the tive or negative perceptions of the self, which, in turn, results in result that the sexual experience is separated from tenderness and a greater or lesser fear of rejection and abandonment. Attachment intimacy, leading, in turn, to possible promiscuity with the aim of avoidance is related to the perception of others as unreliable or reinforcing self-image. rejecting, which, in turn, determines whether the person will feel better or worse in a relationship of dependency or intimacy.18,19 The characteristics of the attachment system will therefore A secure attachment style is characterized by low anxiety and low influence the functioning of the sexual system and patterns of avoidance, by a feeling of security and comfort with proximity sexual behaviour (Figure 1).14-20 People with secure attachment and interdependence, and by confidence that the support of the easily and harmoniously integrate sex in their relationship. Peo- other can be counted on to cope with stress. A preoccupied ple with preoccupied attachment, on the other hand, tend to attachment style (high anxiety and low avoidance) is character- confuse sex and love in such a way that sexual relations become a ized by an imperative need for closeness and a simultaneous fear means to satisfy the need for proximity; this explains why these of rejection, leading to an insistent search for the attention and individuals mostly value the affective aspects of sexual experience Sex Med 2021;9:100436 Psychological Distress and Attachment in ED 3 Figure 1. Attachment styles, the sexual system, and emotional regulation strategies. and why satisfaction (dissatisfaction) with sexual relations is ED,34 suggesting that deactivation of affections predominates, equated with a better (poorer) affective relationship.7,26 People explaining why men with ED tend to underplay their level of with avoidant attachment tend to decouple sex from affectivity, discomfort.35 as they experience intimacy as distressful and use sex as a means Most studies on the relationship between attachment and sex to reduce stress, thereby repressing their sexual desire and their have been carried out with the general population.26,28 The receptivity to a partner’s sexual and affective needs.5,14 objective of this study was to evaluate that relationship in a clini- The interaction between attachment, sexuality, and relation- cal context by investigating associations between attachment, ship quality has broad empirical support.27 On the one hand, psychological distress, and sexual and relationship satisfaction in although insecure attachment is a risk factor for ED in men,28 a men with ED attending the Andrology Service of a Barcelona satisfactory sex life can buffer the negative impact on relationship public health hospital. Bearing in mind the studies reviewed quality29 by enhancing the security of the relationship bond. On above,26,28 we would expect to find a higher prevalence of avoi- the other hand, a person’s attachment type leads to sexuality dant attachment in men with ED. What has not been investi- being associated with different relational goals; therefore, if diffi- gated, to our knowledge, is the prevalence of the Bartholomew culties appear, a different type of emotional regulation is also and Horowitz16 avoidant attachment subtypes, namely, dismis- activated.20 Thus, for men with ED, if attachment is insecure, sive-avoidant attachment (high avoidance and low anxiety) and the attachment system is activated in the form of secondary regu- fearful-avoidant attachment (high avoidance and high anxiety). lation strategies consisting of hyperactivating or deactivating Given that ED limits sexual satisfaction and, consequently, inter- both the emotions and the sexual system;14 if attachment is fear- feres with the protective role of sex in a relationship, we would ful, hyperactivation of the sexual system reduces the feeling of expect to see negative repercussions for the relationships of the sexual inadequacy and mitigates the fear of abandonment, as sex- men in our sample. In this context, secondary emotional regula- ual relations become a way of achieving proximity with the part- tion strategies would be activated in such a way that distress ner; finally, if attachment is avoidant, the sexual system is would be moderated, not only by the attachment anxiety and typically deactivated, with sexual needs suppressed or minimized attachment avoidance dimensions, but also by the quality of the in order to avoid frustration.4 partnership.26,28,36 The differences between attachment styles and their corre- The aim of the present study was to answer the following sponding emotional regulation strategies can increase in stressful research questions: Is there a high incidence of insecure attach- circumstances30,31 and influence the intensity of the emotional ment (high anxiety and/or attachment avoidance) in men diag- reactions associated with sexual dysfunction.20,32,33 High attach- nosed with ED? Does anxiety and/or attachment avoidance ment avoidance is reported to be prevalent among men with moderate the relationship between ED and sexual distress, Sex Med 2021;9:100436 4 Maestre-Loren et al relationship distress, and psychological distress? We hypothesized consistency among the different domains is above a = 0.73 (over- that: all test a = 0.90). Attachment was measured using the Spanish version18 of 1. The incidence of insecure attachment (high anxiety and/or attach- the Experiences in Close Relationships (ECR) instrument,39 ment avoidance) is high in men diagnosed with ED. a self-administered scale of 36 items, 18 each evaluating the 2. Anxiety and/or attachment avoidance moderates the relationship anxiety and avoidance dimensions of attachment (distress between ED and sexual satisfaction, relationship satisfaction, and psychological distress. occasioned by fear of rejection and abandonment, and dis- tress generated by proximity and dependence on others, respectively). Satisfactory internal consistency has been dem- MATERIAL AND METHODS onstrated for this instrument for both the avoidance (a = 0.87) and anxiety (a = 0.85) dimensions. Dimensional Participants evaluation of the ECR, based on combining the 2 dimen- Our sample was composed of 69 men diagnosed with psy- sions of anxiety and avoidance, reflects 4 attachment styles: chogenic ED, consulting for the first time at the Andrology secure, preoccupied, dismissive-avoidant, and fearful-avoi- Department of a Barcelona public health hospital. Inclusion dant. criteria were as follows: (i) ED diagnosis according to DSM- Psychological distress was evaluated using Symptom Checklist 5;1 (ii) mild, moderate, or severe ED according to the Inter- 90 Revised (SCL-90-R),40 in its Spanish validated version.41 national Index of Erectile Function (IIEF); (iii) absence of This self-administered scale is composed of 90 items that evalu- any physical illness or psychiatric disorder that might cause ate 9 dimensions of distress: somatization, obsession-compulsion, ED; and (iv) men in a stable relationship with a partner (of interpersonal sensitivity, depression, anxiety, hostility, paranoid 2 or more years’ duration). As for exclusion criteria, these ideation, phobic anxiety, and psychoticism. To generate an over- were: (i) ED with no spontaneous erections according to the all measure of psychological distress, based on the number and nocturnal penile tumescence and rigidity test (NPTR); (ii) intensity of symptoms in the patient, we used the General Sever- men with a penile implant; and (iii) men who had under- ity Index (GSI) from the SCL-90-R (a = 0.97). gone a prostatectomy. Sexual satisfaction and relationship satisfaction were measured using the Spanish versions42 of the Global Measure of Sexual Sat- Procedure isfaction (GMSEX) and the Global Measure of Relationship Sat- Patients attended the Andrology Department for a semi-struc- isfaction (GMREL),35 respectively, both subscales of the tured interview and physical examination; when necessary, to Interpersonal Exchange Model of Sexual Satisfaction (IEMSS).43 exclude organic ED, the patient underwent an NPTR test, neu- The GMSEX (a = 0.92) and GMREL (a = 0.94) instruments rological examination, penile duplex doppler ultrasound, and are each composed of 5 Likert-scored (5−35) items, with higher hormonal assessment. To rule out other psychiatric disorders, an scores indicating greater satisfaction. experienced psychologist evaluated patients according to DSM- 51 criteria. The study sample was recruited before the COVID- 19 pandemic. Data Analysis Participants were informed about the objective of the study, Descriptive analyses were computed to describe sample char- signed the informed consent, and completed a set of psychomet- acteristics. Paired-sample Mann-Whitney U tests were used to ric evaluation instruments (described in detail below). The study examine mean differences between dismissive-avoidant and fear- was approved by the ethics committee of the hospital. ful-avoidant patient groups (those who scored lower and higher attachment anxiety scores, respectively). Pearson correlations were computed to test the pattern of associations between attach- Measures ment, psychological distress, sexual and relationship satisfaction, Sexual function was measured using the IEFF37 (validated sexual function, age, and ED duration. The impact of the mea- Spanish version38). This self-administered Likert-scored 15-item sured variables on sexual satisfaction were further evaluated using scale identifies problems in the sexual response domains of sexual multiple linear regression and moderation analysis. The regres- desire, erectile function, orgasmic function, intercourse satisfac- sion analysis was performed considering sexual satisfaction as the tion, and overall satisfaction, that is, satisfaction with sexual life dependent variable, and ED, attachment anxiety and avoidance, in general and with sexual relations with a partner. The overall relationship satisfaction, and psychological distress as predictors. test score ranges from 5 to 75, with lower scores indicating The moderation analysis was performed to assess the roles played greater dysfunction and greater dissatisfaction. In the erection by anxiety and relationship satisfaction in the link between ED domain, scores range from 1 to 30, with ED severity cut-off and sexual satisfaction (as the outcome). Analyses were con- points for the Spanish population of 6−10 (severe), 11−16 ducted using the Statistical Package for the Social Sciences (moderate), 17−25 (mild), and 26−30 (none). Internal (SPSS) Version 25 (IBM Corporation, Armonk, NY, USA). Sex Med 2021;9:100436 Psychological Distress and Attachment in ED 5 Table 1. Patient sociodemographic characteristics (n = 69) Of the 69 men in the sample, over half (n = 38; 55.07%) Characteristics Men experienced severe ED, while 16 (23.19%) and 15 (21.74%) had moderate and mild ED, respectively. Regarding the Age (y) GMSEX, 27 patients (39.1%) rated their sexual life as satisfac- Mean (SD) 56.07 (10.83) tory, while according to the GMREL, 46 (66.7%) rated their Median (range) 57.50 (30-76) relationship as satisfactory. According to the GSI, 41 patients ED duration (y) (59.42%) presented higher overall scores for psychological dis- Mean (SD) 4.9 (6.5) tress than the general population, although only 3 patients Median (range) 2 (0.3-30) (4.4%) achieved a higher score than the average for the psychiat- Education, n (%) ric population. Primary 17 (24.6) Secondary 33 (47.8) Tertiary 18 (26.1) The Role of Attachment Occupational status, n (%) The mean (SD) values for attachment anxiety and for attach- Employed 39 (56.5) ment avoidance were 3.54 and 3.95, respectively. All the patients Unemployed 7 (10.1) had a higher than normal avoidance score, while 48 patients Retired 17 (24.6) (69.6%) had a lower than normal anxiety score. From the point Relationship status, n (%) of view of attachment typologies (Figure 1), 69.6% of the sample Single 0 (0) tended towards dismissive-avoidant attachment (high avoidance Partnered 69 (100) and low anxiety), and the remaining 30.4% tended towards fear- Children, n (%) ful-avoidant attachment (high avoidance and high anxiety). Yes 53 (76.8) No 14 (20.3) Table 2, which compares dismissive-avoidant and fearful- Toxic habits, n (%) avoidant (lower and higher scores for attachment anxiety, respec- Alcohol 20 (29) tively) patient groups, shows that the latter presented with greater Smoking 17 (24.6) attachment avoidance and greater sexual desire. However, rela- Main health problems, n (%) tionship satisfaction (according to the GMREL) was higher in Hypertension 28 (40.6) patients with dismissive-avoidant attachment than in patients Hyperlipidaemia 29 (42.0) with fearful-avoidant attachment. Psychological distress 20 (29.0) Diabetes 14 (20.3) Joint disorders 17 (24.6) Attachment, Psychological Distress, and Sexual and Main medications, n (%) Relationship Satisfaction Antihypertensives 23 (33.3) The age of the patients negatively correlated with the overall Statins 24 (34.8) IIEF score and the erectile function and orgasmic function scores (Table 3). Sexual satisfaction (GMSEX) correlated positively with relationship satisfaction (GMREL), and correlated nega- tively with the anxiety dimension of attachment; it correlated positively with the IIEF overall score, and, except for the sexual RESULTS desire subscale, with the erectile function, orgasmic function, and intercourse satisfaction subscale scores. All GMSEX correla- Sample Characteristics tion values were moderate (between −.280 and.606). The As can be seen in Table 1, the mean (SD) age of the patients attachment avoidance and anxiety dimensions correlated posi- was 56.07 (10.83) years, and mean (SD) duration of ED before tively and moderately with each other, while correlation with consultation was 4.9 (6.5) years. All patients were in stable het- psychological distress (GSI) was low. erosexual relationships. Men who were employed (56.5%) or who were retired (24.6%) predominated, and most had second- ary (47.8%) or primary (24.6%) studies. Regarding toxic habits, Sexual Satisfaction Regression 29% of the men regularly consumed alcohol and 24.6% were A multiple linear regression analysis was performed consider- smokers. Most patients (88.4%) had health issues, and 68.1% ing sexual satisfaction as the dependent variable (R2 = 0.484, were on medication, mostly antihypertensives (33.3%) and sta- Adj-R2 = 0.434; F(5.52) = 9.739; P < .001). Results showed tins as treatment for cholesterol (34.8%). Examination con- that sexual satisfaction variance was a function of the overall firmed that none of the physical health problems were causes of IIEF (bstd = 0.469; P < .001), attachment anxiety the ED. Around a third (29.0%) of the men reported having (bstd = −0.300; P = .018), and relationship satisfaction experienced psychological distress, although in no case did this (bstd = 0.364; P = .002) scores. In other words, greater sexual sat- imply their having a psychological disorder. isfaction was a function of less severe ED (higher IIEF scores), Sex Med 2021;9:100436 6 Maestre-Loren et al Table 2. Comparison between fearful-avoidant attachment and dismissive-avoidant attachment groups Dismissive-avoidant (n = 48) Fearful-avoidant (n = 21) Measure Mean SD Mean SD U P Age 55.60 10.89 57.14 10.90 436.0 .445 ED duration 4.82 6.53 5.00 6.70 345.0 .497 Attachment avoidance 3.78 0.44 4.31 0.58 220.0 <.001y GSI 0.60 0.45 0.72 0.40 405.0 .197 GMSEX 21.14 10.42 16.32 8.90 286.5 .079 GMREL 29.60 6.24 24.65 8.92 248.5 .017* IIEF 31.27 17.28 33.76 16.43 451.0 .489 - Erectile function 10.50 7.66 11.71 7.18 444.5 .436 - Orgasmic function 5.42 3.70 5.00 3.73 472.5 .678 - Intercourse satisfaction 5.25 3.91 5.48 3.84 485.5 .807 - Sexual desire 5.23 2.10 6.90 2.10 291.5 .005* - Overall satisfaction 4.87 2.57 4.67 2.13 500.5 .963 * P < .05, y P < .01.U refers to the Mann-Whitney U test. ED = erectile dysfunction; GMREL = Global Measure of Relationship Satisfaction; GMSEX = Global Measure of Sexual Satisfaction; GSI = General Severity Index (from the Symptom Checklist 90 Revised); IIEF = International Index of Erectile Function. lower attachment anxiety, and greater satisfaction with the part- IIEF*attachment anxiety (P = .032) but not for IIEF*relationship ner relationship (Figure 2). Excluded from the model were the satisfaction (P = .270) (see Table 4 and Figure 3). attachment avoidance variable and the GSI (both P > .05). DISCUSSION Sexual Satisfaction Moderators The objective of this study was to evaluate the moderating To further assess whether the association between sexual satis- role of attachment on the distress associated with ED. The results faction and ED severity was moderated by anxiety or relationship obtained for our sample of 69 men − over half with severe ED, satisfaction, a moderation analysis was performed using the sex- of longstanding duration (around 5 years) − reveal that they all ual satisfaction score as the outcome, the overall IIEF score as the had insecure attachment (confirming our first hypothesis) and predictor, and, as moderators, anxiety and relationship satisfac- that their psychological wellbeing, sexual satisfaction, and rela- tion dichotomized according to ECR18 and GMREL42 mean tionship satisfaction was maintained. Around a third of the scores. The model results (R2 = 0.445, Adj-R2= 0.392; F patients considered their sexual life to be satisfactory, while more (5.52) = 8.337; P < .001) pointed to significant interaction for than half reported also being satisfied with their relationship with Table 3. Means, SDs and correlations between the variables of interest Measure Mean (SD) 1 2 3 4 5 6 7 8 9 10 11 12 1. Age 56.07 (10.83) 2. ED duration 4.87 (6.53) .16 3. Avoidance 3.95 (0.54) .10 .09 4. Anxiety 3.54 (0.99) .14 .02 .56y 5. GSI 0.63 (0.44) -.01 -.09 .19 ,30* 6. GMSEX 4.10 (1.93) -,11 -.03 -.22 -.28* -.14 7. GMREL 5.73 (1.34) -.06 -.01 -.09 -.19 -.09 .37y 8. IIEF 32.03 (16.95) -.18 .06 -.11 -.02 -.03 .47y -.04 9. Erectile function 10.87 (7.49) -.23 .02 -.12 .04 -.08 .36y -.05 .93y 10. Orgasmic function 5.29 (3.68) -.19 .20 -.12 -.11 .00 .41y -.05 .88y .73y 11. Intercourse satisfaction 5.32 (3.86) -.11 .05 -.16 -.03 -.04 .51y .02 .93y .83y .79y 12. Sexual desire 5.74 (2.22) -.04 -.08 .21 .37y .07 .14 -.17 .51y .38y .38y .37y 13. Overall satisfaction 4.81 (2.43) -.07 .03 -.13 -.09 .01 .61y .10 .82y .66y .74y .82y .34y * P < .05, y P < .01.ED = erectile dysfunction; GMREL = Global Measure of Relationship Satisfaction; GMSEX = Global Measure of Sexual Satisfaction; GSI = General Severity Index (from the Symptom Checklist 90 Revised); IIEF = International Index of Erectile Function. Sex Med 2021;9:100436 Psychological Distress and Attachment in ED 7 Figure 2. Regression analysis results showing that greater sexual satisfaction is a function of less severe ED, lower attachment anxiety, and greater relationship satisfaction. their partner. Although a relationship was observed between sex- system;12 a high level of attachment avoidance would reflect the ual satisfaction and relationship satisfaction, also reflected in attempt to deny emotional pain and dissociation from sexual other studies,44-46 the latter was not associated with the overall problems.. ED is experienced as something foreign to both the IIEF score or with any of its subscale scores. While psychological individual’s personality and their relationship with a partner. distress was present, in very few of the evaluated men did it Men with ED therefore strive to play down both their sexual achieve clinically significant levels. problems and the possible impact on themselves and their rela- Our findings may be explained by the role played by attach- tionship, which, in turn, may explain why men allow around ment in regulating emotional distress.12 ED may lead to a feeling 2 years to elapse before seeking professional help for their ED. of insecurity in relation to sexual intimacy, and to activation of Dissociation may initially attenuate the sexual distress and safe- the attachment system, whereby each man makes an assessment guard satisfaction with the partner relationship, but it may also regarding his partner’s availability to help deal with that insecu- aggravate the loss of sexual potency associated with ED and lead rity. The attachment avoidance dimension reflects the degree of to delayed consultation.34,48 mistrust regarding a partner and the need to resort to deactiva- In our study, the attachment anxiety dimension correlated tion as a secondary strategy to regulate affect, while the attach- negatively with sexual satisfaction and positively with sexual ment anxiety dimension reflects the degree of concern about the desire and psychological distress. The greater the fear of rejection partner’s availability and the need for greater proximity as a strat- and abandonment, therefore, the more sexual relations with the egy to regulate affect. partner are sought, yet the difficulties generated by ED result in In the 69 patients evaluated in our study, attachment avoid- greater frustration and emotional pain.27,49 ance in particular was high, corroborating other studies that Considering both dimensions of attachment together (accord- report that attachment avoidance is frequent in men with ing to the Bartholomew and Horowitz16 model), just over 2 ED;34,47 in contrast, women with sexual problems typically expe- thirds of our patients with ED had characteristics of a dismissive- rience high anxiety.35 Men with ED tend to regulate sexual, rela- avoidant attachment style (high avoidance and low anxiety), tionship, and psychological distress by deactivating the sexual while the remaining third experienced a fearful-avoidant Table 4. Moderation model scores 95% CI b SE bstd t P Lower Upper (Intercept) 8.797 11.98 0.734 .466 -15.25 32.85 IIEF 0.221 0.344 0.380 0.643 .523 -0.469 0.911 Attachment anxiety -15.89 4.972 -0.766 -3.198 .002y -25.87 -5.923 Relationship satisfaction 12.60 5.667 0.567 2.224 .030* 1.234 23.97 IIEF*attachment anxiety 0.294 0.133 0.885 2.206 .032* 0.027 0.561 IIEF*relation. satisfaction -0.173 0.155 -.567 -0.597 .270 -0.485 0.139 P < .05, * y P < .01.IIEF = International Index of Erectile Function. Sex Med 2021;9:100436 8 Maestre-Loren et al activity in relationships is diverse: while for some couples it is crucial, for others it may be secondary.6 We suggest that the results of our study have important clini- cal implications. Our findings underline the importance of evalu- ating the role played by sexual activity in the partnerships of men who consult for ED. Affective needs associated with sexual inter- course should also be considered, along with the deactivation strategies by which the distress that may be caused by ED is regu- lated. In a stable partnership, sexual intercourse meets needs that are not strictly sexual,4 so the general objective of interventions should be to reduce the perception that ED poses a serious threat to both the self and the relationship with a partner. To re-estab- lish intimacy in a relationship, clinical work should therefore focus on clarifying 2 issues: how the man assesses the availability of his partner, and the strategy the man uses to regulate the nega- tive affect activated by ED. It is also important to understand Figure 3. Sexual satisfaction and erectile function (International what triggered the request for professional help, as well as the Index of Erectile Function, IIEF). Linear fits for high-anxiety patient’s awareness of ED and their underlying unexpressed emo- (bstd = 0.876) and low-anxiety (bstd = 0.306) men. tional pain. Treatment strategies need to be considered from a biopsycho- social perspective. For patients with a dismissive-avoidant attach- attachment style (high avoidance and high anxiety). We consider ment style, the psychotherapeutic focus needs to be on the this finding to be one of the contributions of our research, since dissociated and avoided emotions. Efforts should therefore focus it identifies a subgroup of patients with ED who experience both on awareness and improved management of emotions, so as to high avoidance and high anxiety. In this fearful-avoidant attach- reduce distancing and increase sexual and relationship intimacy. ment subgroup, the secondary deactivation strategy hinders For patients with a fearful-avoidant attachment style, the focus expression and fails to significantly reduce distress, resulting in needs to be on representations of the self and others, on negative ongoing latent suffering. This characteristic in men with ED and self-perceptions, and on fears of rejection. fearful-avoidant attachment has important implications for clini- Whenever possible, type-5 phosphodiesterase (PDE5) inhibi- cal interventions, as indicated below. tors can be used to alleviate sexual symptoms and facilitate a The multiple linear regression analysis confirmed the sexual recovery of confidence in sexual capacity. Including the partner satisfaction association with attachment style, relationship satis- in treatment can also help modify certain beliefs about what is faction, and ED severity. Specifically, greater sexual satisfaction sexually expected of the patient, which, in turn, will alleviate the is linked to less severe ED, lower attachment anxiety, and greater fear that sexual difficulties will damage the relationship and lead relationship satisfaction. Moderation analysis further highlighted to abandonment. In general, what is observed in clinical care is this association, showing that anxiety plays a significant role in that sexual problems are ultimately an expression of intrapersonal the link between ED and sexual satisfaction (thereby confirming and/or interpersonal conflicts. our second hypothesis). A greater fearful-avoidant attachment One of the limitations of our study is its transversal nature, score was associated with both poorer sexual satisfaction and which prevents us from understanding how ED in our patients poorer relationship satisfaction. Sexual satisfaction was better evolves over time and what the possible causal implications of preserved in men with dismissive-avoidant attachment, while our results could be. The size of our sample weakens the statisti- their relationship satisfaction was comparable to that of the gen- cal power of the study, not to mention limiting the statistical eral population. procedures that could be applied. These issues may affect the sta- Although the results discussed so far suggest that attachment bility of our results, the variables that interact with each other, avoidance played an important role in our patients with ED and the kind of interactions between variables; for instance, the (recall that all patients in our sample had high avoidance levels), fact that attachment avoidance is not significant in our models attachment avoidance was not a significant variable in the regres- may be due to this limitation. Likewise, in our study we have sion analysis. This is explained, not only by the high avoidance proposed that attachment moderates the relationship between levels, but also by the fact that there was not enough variability ED and sexual satisfaction, although other models of interaction in relation to this dimension in our sample to be able to detect between the variables could be formulated; for instance, lower statistically significant results in the regression analysis. Also mer- sexual and/or relationship satisfaction might increase the likeli- iting consideration is the fact that the role played by sexual hood of ED in men with a certain type of attachment. Sex Med 2021;9:100436 Psychological Distress and Attachment in ED 9 Our findings, furthermore, may be distorted by sample STATEMENT OF AUTHORSHIP recruitment from a single health centre, the wide age range of the Conceptualization, F.M.L. and J.C.G.; Methodology, J.C.G., patients, the time elapsed between ED onset and the first consul- A.A., and I.C.; Investigation, F.M.L. and J.S.; Formal Analysis, tation, and the fact that self-reporting typically involves biases I.C. and X.L.M.; Writing − Original Draft, F.M.L. and J.C.G; and also prevents understanding of the personal significance of a Writing − Review & Editing, F.M.L., J.C.G., X.L.M., J.S., and response. Finally, while all the men in the sample had been in a I.C.; Visualization, X.L.M., A.A., and I.C.; Supervision, F.M.L. relationship for more than 2 years, the precise duration of their and J.C.G. relationships was not determined, so this could be an important issue to consider in future studies. 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