Original Article

Relationships Between Erectile
Dysfunction, Depression, Anxiety, andQuality of Life in Young Japanese Men:
A Cross-Sectional Study

Journal of Psychosexual Health5(2) 77–83, 2023
© The Author(s) 2023
Article reuse guidelines:
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DOI: 10.1177/26318318231181687
journals.sagepub.com/home/ssh

Junichi Saito1 , Hiroaki Kumano1,2, Mohammad Ghazizadeh3, Chigusa Shimokawa3
and Hideki Tanemura3

Abstract
Background: It is generally assumed that erectile dysfunction (ED) under the age of 40 is primarily driven by psychosocial
factors.
Aims: This cross-sectional study evaluated ED, depression, anxiety, and quality of life among young Japanese men.
Materials and Methods: We used an online survey to gather data from a wide range of community samples. ED wasassessed by the IIEF-5 questionnaire, while depression, anxiety, and quality of life were assessed by the PHQ-9, GAD-7, and
LISAT-8 questionnaires, respectively. Categorical data were evaluated by chi-square test and numerical data were estimatedby one-way ANOVA. Post-hoc tests were conducted using the Holm method, which was used to control for type I errors.
Cohen’s d index was calculated as effect sizes.
Results: Valid responses from 329 individuals (age 33.93 ± 6.41 years) were obtained. According to IIEF-5 scores, the distribution of various severities of ED was as follows: non-ED, 37.39%; mild ED, 18.24%; mild to moderate ED, 27.36%; andmoderate and severe ED, 17.02%. There were no significant differences in depression and anxiety between non-ED and
ED men. In contrast, there were significant differences in quality of life between non-ED and ED men (P < .01).
Conclusions: We conclude that psychosocial factors may also be the cause of ED in young Japanese men besides depression and anxiety, and ED may reduce quality of life in various aspects. It is necessary to develop a Japanese version scale tomeasure ED-related psychosocial factors.
Keywords
Erectile dysfunction, psychological, depression, anxiety, quality of life, cross sectional study
Received 02 September 2022; accepted 04 May 2023

Introduction
Erectile dysfunction (ED) is a male sexual disorder characterized by the inability to obtain and/or maintain a penile erection sufficient for satisfactory sexual performance.1 ED has
been a common disease worldwide with high reported morbidity rate.2,3 ED patients were identified in an estimated34.5% of Japanese men.4
In Japan, Sugimori et al. surveyed relationships amongED, depression, and anxiety.5 In their study, the subjects were1,419 non-institutionalized Japanese men aged 40–64 years.
As a result, ED associated significantly with depression andanxiety status only in the late 40s to early 50s (45–55 years).

As ED prevalence varies across racial, cultural, religious,and socioeconomic backgrounds,6 psychological associations(depression and anxiety) with ED in Japanese men may bein a different situation from previous studies. For example,
the Massachusetts Male Aging Study7 demonstrated a strong
Comprehensive Research Organization, Waseda University, Tokyo, Japan
Faculty of Human Sciences, Waseda University, Tokorozawa, Japan
3
Logos Science Corp., Ltd. Minato, Tokyo, Japan
1
2

Corresponding author:
Junichi Saito, Comprehensive Research Organization, Waseda University,
Shinjuku-ku, Tokyo Prefecture 162-0041, Japan.
E-mail: tekuteke@aoni.waseda.jp

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons AttributionNonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-Commercial use, reproduction
and distribution of the work without further permission provided the original work is attributed as specified on the Sage and Open Access pages(https://us.sagepub.com/en-us/nam/open-access-at-sage).

78
positive association within a much wider age distribution(40–70 years). It was suggested that inconsistent results
in “late” adulthood with previous studies might be partly
explained by older Japanese men experiencing less difficultyadjusting to life with ED than younger Japanese men. From
this result, there might be three sub-types of ED assessed by
IIEF-5 in the Japanese general male population, comprised of
EDs in “early” (less than 45 years), “middle” (45–54 years),and “late” (55 years or more) adulthood.
By now, there are several review papers and clinicalguidelines available on ED, but many of these papers approach
the assessment and treatment of ED from a purely medical
perspective and pay only little attention to describing thepsychosocial factors of ED.8 Because the introduction of phosphodiesterase-5 inhibitors (PDE5Is) such as sildenafil, tadalafil, vardenafil, and avanafil has dramatically changed thetherapeutic approach to the ED, they have become the firstline treatment for most patients.9,10 However, pharmacologicaltreatment alone does not respond to all the concurrent factorsof ED, including anxiety, loss of self-esteem, depressed mood,a couple’s communication problems, relationship problems,or a partner’s sexual dysfunction.11 A systematic review of thepsychosocial outcomes associated with erectile dysfunction
suggested the importance of evaluating psychosocial factors
associated with ED and its treatment.12 In fact, ED has shown
an influence on psychosocial health with 63.1% of ED patientsdeveloping psychiatric symptoms.13 In particular, depression is
known to be associated with ED.14
It is widely assumed that ED in men under the age of 40
is primarily caused by psychosocial factors, whereas ED in
older men is more likely to be caused by biological factors.
Moore et al. showed a difference in symptom patterns among
ED patients according to age groups.15 They reported thatyounger men had comparatively greater depressive symptoms, accompanied by lower relationship satisfaction, morenegative reactions from partners, and lower job satisfaction.
However, the association of depression, anxiety, and qualityof life with ED of different severity ratings in young Japanese
men is unknown. Therefore, this cross-sectional study using
standardized self-administered assessments aimed to evaluate
depression, anxiety, and quality of life in the context of ED
severity using the International Index of Erectile Function(IIEF-5) questionnaire16 in young Japanese men.

Participants and Methods
Participants
To gather data from a wide range of community samples, weused an online survey conducted with the assistance of a marketing research service provider, Rakuten Insight, Inc., inJapan. Based on the IIEF-5 cutoff point, all severities wererecruited to include a certain percentage of patients. All
enrolled participants followed these criteria: (a) male;

Journal of Psychosexual Health 5(2)(b) 20–44 years old; and (c) married or living with a fixedsexual partner for more than 6 months. Besides, the exclusive
criteria were as follows: (a) sexual dysfunction caused by
Peyronie’s disease or other organic lesions of the external
genitalia; (b) organic diseases such as diabetes, chronic kidney disease, and cardiac disease; and (c) a history of sertraline
or other medicines that may influence their erection and psychological symptoms.
Participants first read an explanation that this survey
would be conducted anonymously, and that they would not
be forced to respond. Subsequently, only those who agreed toparticipate in this study responded to the questionnaires. Asa reward, respondents received points that they could redeem
for goods within the system of the survey company.

Measurements
International Index of Erectile Function-5
The Japanese version of IIEF-5 is a 5-item self-report questionnaire designed to measure erectile function.17 Items are
rated on a 5-point Likert-type scale, ranging from 1 to 5. The
total score can range from 5 to 25, with high scores meaninghigh erectile function. Based on the original validation studies, the total score can then be interpreted as suggesting “noED” (22–25); “mild ED” (17–21); “mild-to-moderate ED”(12–16); “moderate ED” (8–11); and “severe ED” (1–7).
Patient Health Questionnaire-9
The Japanese version of PHQ-9 is a 9-item self-report questionnaire designed to measure depression.18 This scale evaluates
each of the 9 DSM-IV (the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition) criteria for major depressive
disorder. Items are rated on a 4-point Likert-type scale, ranging
from 0 to 3. The total score can range from 0 to 27, with highscores meaning high depression. Based on the original validation
studies, the total score can then be interpreted as suggesting no
depression (0–4), mild depression (5–9), moderate depression(10–14), moderately severe depression (15–19), or severe(20–27). A cut-off score of 10 is suggested as indicating a possible diagnosis of depressive disorder.
Generalized Anxiety Disorder-7
The Japanese version of GAD-7 is a 7-item self-report questionnaire designed to measure generalized anxiety disorder.19
This scale evaluates each of the seven DSM-IV criteria forgeneralized anxiety disorder. Items are rated on a 4-point
Likert-type scale, ranging from 0 to 3. The total score canrange from 0 to 21, with high scores meaning high anxiety.
Based on the original validation studies, the total score canthen be interpreted as suggesting no anxiety (0–4), mild
(5–9), moderate (10–14), or severe (14–21). A cutoff score of
10 is suggested as indicating a possible diagnosis of generalized anxiety disorder.

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Saito et al.
Life Satisfaction Checklist-8
The Japanese version of Life-11 is an 11-item self-reportquestionnaire (LISAT-11) designed to measure life satisfaction.20 In this study, we used an 8-item version based on theoriginal version.21 This scale evaluates satisfaction with eight
different aspects of the patient’s life; life in general, sexual
life, relationship with a partner, family life, relationship withfriends, leisure, professional, and financial situation. Items
are rated on a 6-point Likert-type scale, ranging from 1 to 6.
The total score can range from 8 to 48, with high scores
meaning high satisfaction. All items can be grouped in three
dimensions: satisfaction with social life (items 1 and 4–6),
satisfaction with affective life (items 2 and 3), and satisfaction with financial life (items 7 and 8).

Statistical Analysis
We used mean ± standard deviation (SD) to describe numerical data and used counts and percentages to describe categorical data. Categorical data were evaluated by the chi-square
test and numerical data were estimated by a one-way ANOVA.
Post-hoc tests were conducted using the Holm method, which
was used to control for type I errors. Cohen’s d index was
calculated as effect sizes, serving as standardized indicators
unaffected by sample sizes. All tests were two-tailed, and astatistical difference was assumed when the p-value was<0.05. All statistical analyses were carried out through IBM
SPSS Statistics 25.0.

Results
Demographic Characteristics
We obtained valid responses from 329 individuals (aged33.93 ± 6.41 years). According to IIEF-5 scores, the distribution of severities of ED in men was as follows: non-ED,
37.39% (123/329); mild ED, 18.24% (60/329); mild to moderate ED, 27.36% (90/329); and moderate and severe ED,
17.02% (56/329). Table 1 shows the demographic characteristics of participants by erectile function groups. No statisticaldifference was found between non-ED and ED men in age,marriage years, or lifestyles.

IIEF-5, PHQ-9, and GAD-7 Results
Table 2 shows the prevalence of depression using PHQ-9 ³
10 cut-off score among non-ED men was 35.77% (44/123) andamong ED men was 36.90% (76/206). Also, the prevalence ofanxiety using GAD-7 ³ 10 cut-off score among non-ED men
was 41.46% (51/123) and among ED men was 40.77%(84/206). There was no difference in the prevalence of depression and anxiety between non-ED and ED men (p = n.s.).

Table 1. Demographic Characteristics of Non-ED and ED Men.

Age
Marriage years
Smoking smoker [n (%)]
former smoker, non-smoker [n (%)]
Drinking 7/week [n (%)]
non-drinker to <6/week [n (%)]
Sleeping 7–9 h [n (%)]
<7 h, 9 h > [n (%)]
Exercise ≧ 1/week [n (%)]
do not exercise, sometime [n (%)]

Non-ED(n = 123)

Mild ED(n = 60)

Mild-toModerate andModerate ED Severe ED(n = 90)(n = 56)

33.42 ± 6.80
6.79 ± 6.25
32 (26.02)
91 (73.98)
21 (17.07)
102 (82.93)
51 (41.46)
72(58.54)
77 (62.60)
46 (37.40)

35.40 ± 6.33
7.48 ± 6.63
13 (21.67)
47 (78.33)
15 (25.00)
45 (75.00)
32 (53.33)
28 (46.67)
34 (56.67)
26 (43.33)

34.11 ± 5.70
7.03 ± 6.22
26 (28.89)
64 (71.11)
18 (20.00)
72 (80.00)
41 (45.56)
49 (54.44)
58 (64.44)
32 (35.56)

33.20 ± 6.57
6.86 ± 6.34
15 (26.79)
41 (73.21)
12 (21.43)
44 (78.57)
31 (55.36)
25 (44.64)
36 (64.30)
20 (35.70)|2/F

p-value

1.59
0.15
0.99

.19
.93
.84

1.66

.65

4.12

.25

1.09

.78

Note: ED, Erectile dysfunction.

Table 2. Prevalence of Depression and Anxiety Among Non-ED and ED Men.

PHQ-9
Non-depression or mild depression (PHQ-9 < 10) [n (%)]
Prevalence of depression (PHQ-9 ≧10) [n (%)]
GAD-7
Non-anxiety or mild anxiety (GAD-7 < 10) [n (%)]
Prevalence of anxiety (GAD-7 ≧10) [n (%)]

Non-ED (n = 123)

ED (n = 206)

79 (64.23)
44 (35.77)

130 (63.53)
76 (36.89)

72 (58.54)
51 (41.46)

122 (59.97)
84 (40.78)

Note: ED, Erectile dysfunction; GAD-7, Generalized Anxiety Disorder-7; PHQ-9, Patient Health Questionnaire-9.

|2

p-Value

0.04

.84

0.02

.90

80

Journal of Psychosexual Health 5(2)Table 3. Severity of Depression and Anxiety Among Non-ED and ED Men.

PHQ-9
Non-depression [n (%)]
Mild depression [n (%)]
Moderate depression [n (%)]
Moderate-to-severe depression [n (%)]
Severe depression [n (%)]
Total PHQ-9 scores [mean (SD)]GAD-7
Non-anxiety [n (%)]
Mild anxiety [n (%)]
Moderate anxiety [n (%)]
Severe anxiety [n (%)]
Total GAD-7 scores [mean (SD)]

Mild-toModerate andModerate ED
Severe ED(n = 90)(n = 56)

Non-ED(n = 123)

Mild ED(n = 60)

40 (32.52)
39 (31.70)
26 (21.14)
16 (13.01)
2 (1.63)
7.75 ± 5.74

23 (38.33)
15 (25.00)
12 (20.00)
7 (11.67)
3 (5.00)
7.93 ± 6.08

34 (37.78)
23 (25.56)
24 (26.67)
7 (7.78)
2 (2.22)7.76 ± 5.67

7 (12.50)
28 (50.00)
14 (25.00)
4 (7.14)3 (5.36)
8.77 ± 4.78

33 (26.83)
39 (31.71)
39 (31.71)
12 (9.76)
8.63 ± 4.66

15 (25.00)
23 (38.33)
14 (23.33)
8 (13.33)
8.48 ± 4.73

19 (21.11)
33 (36.67)
27 (30.00)
11 (12.22)
8.64 ± 4.57

9 (16.07)
23 (41.07)
16 (28.57)
8 (14.29)
9.09 ± 4.54

|2/F

p-Value

22.09

0.48
5.18

0.19

<.05
<.05
n.s.
n.s.
n.s.
.70
n.s.
n.s.
n.s.
n.s.
0.90

Note: ED, Erectile dysfunction; GAD-7, Generalized Anxiety Disorder-7; PHQ-9, Patient Health Questionnaire-9.

The mean scores of PHQ-9 by ED severity were as
follows (Table 3): non-ED, 7.75 ± 5.74; mild ED, 7.93 ±
6.08; mild to moderate ED, 7.76 ± 5.67; and moderate andsevere ED, 8.77 ± 4.78. Also, the mean scores of GAD-7 by
ED severity were as follows: non-ED, 8.63 ± 4.66; mild ED,
8.48 ± 4.73; mild to moderate ED, 8.64 ± 4.57; and moderateand severe ED, 9.09 ± 4.54. There was no difference in meanscores of PHQ-9 and GAD-7 between non-ED and ED men(p = n.s.).

IIEF-5 and LISAT-8 Results
The mean total scores of LISAT-8 by ED severity were as follows: non-ED, 32.40 ± 6.79; mild ED, 29.18 ± 5.77; mild tomoderate ED, 28.55 ± 6.75; and moderate and severe ED,
27.58 ± 4.97 (Table 4). ED men showed significantly lower
total mean scores in LISAT-8 than non-ED men (p < .01). Also,
ED men showed significantly less mean score of social life
(items 1, 4–6), affective life (items 2 and 3), and satisfaction
with financial life (items 7 and 8) than non-ED men, respectively (p < .01). However, there was no difference in the meanscore of satisfaction with financial life (items 7 and 8) between
non-ED and mild ED men (p = n.s., d = 0.28).

Discussion
This cross-sectional study aimed to evaluate depression, anxiety, and quality of life among young Japanese men. No statistical difference was found between non-ED and ED men withrespect to demographic characteristics. Since organic diseases
were excluded and the average age of the participants was
33.93 years, the population was assumed to have psychogenic
ED. Contrary to expectations, however, there were no significant differences in depression and anxiety between non-ED

and ED men. The mean PHQ-9 and GAD-7 scores among
both non-ED and ED men were below the cut-off limitof ≧ 10, corresponding to mild depression and mild anxiety),
respectively. However, a significant difference was observed in
LISAT-8 scores for life satisfaction between non-ED and ED
men. Furthermore, significant differences were found not only
in affective life but also in social life and financial life.
In a previous study, Yang et al. showed that in Chinese
young men, the PHQ-9 and GAD-7 scores among non-ED
men indicated no depression and no anxiety, respectively,
while in the mild and mild-to-moderate ED subjects, thePHQ-9 and GAD-7 scores corresponded to mild depression
and mild anxiety, respectively.22 In addition, in moderate andsevere ED subjects, the PHQ-9 and GAD-7 scores indicatedmoderate depression and moderate anxiety, respectively. The
results of our study were not consistent with the previous
study, which had found that depression and anxiety roseaccording to the severity of ED. This discrepancy, however,may be due to the online survey feature and self-assessmentof symptoms employed in our study. Interestingly, while there
was no difference in PHQ-9 and GAD-7 scores, there wasa significant difference in LISAT-8 scores between non-ED
and ED men. This included significant differences not only
in affective life, but also in social life and financial life. A
previous study had also found similar results.21 We found no
significant differences by severity of ED, although there wasa tendency toward higher mean PHQ-9 score for depression
in moderate and severe ED among the young Japanese men.
This suggests that ED reduces the quality of life in various
aspects.
Taken together, these results demonstrate that in addition
to depression, it is necessary to focus on other psychosocial
factors as well. For example, MaCabe suggest that treatment
of sexual dysfunction should take into account the attitudes towards sex, their extent of performance anxiety, and81

Saito et al.
Table 4. Quality of Life Among Non-ED and ED Men.

LIST-8 Total [mean(SE)] Affective life
[mean (SE)] Social life [mean(SE)] Financial life
[mean (SE)]Non-ED(n = 123)

Mild ED(n = 60)

32.40 (0.57)

29.18 (0.81)

8.50 (0.18)

16.67 (0.30)

7.24 (0.19)

7.35 (0.25)

15.18 (0.44)

6.65 (0.27)

Mild-toModerate andModerate ED Severe ED(n = 90)(n = 56)
28.55 (0.66)

7.18 (0.21)

14.94 (0.36)

6.43 (0.22)

27.58 (0.84)

6.86 (0.26)

14.57 (0.45)

6.16 (0.28)

F
10.54

12.95

7.25

4.38

Holm/
p-Value Post-hoc tests
<.00

< .00

< .00

< .00

Cohen’dNon-ED - Mild ED

0.51

Non ED - Mild-toModerate ED
Non-ED Moderate andsevere ED
Non-ED Mild ED
Non ED - Mild-toModerate ED
Non-ED Moderate andsevere ED
Non-ED Mild ED
Non ED - Mild-toModerate ED
Non-ED Moderate andsevere ED
Non-ED Mild ED
Non ED - Mild-toModerate ED
Non-ED Moderate andsevere ED

0.61
0.76
0.58
0.67
0.83
0.44
0.51
0.62
0.28
0.38
0.51

Note: ED, Erectile dysfunction; LISAT-8, life satisfaction checklist-8

the dynamics inherent in their personal relationships.23 Men
who experience erectile difficulties enter a sexual situation
with high negative affect and low positive affect, along withnegative expectations about their sexual performance.24,25
This mindset induces an attentional shift towards cues thatsignal failure and a strong evaluative focus on their own
bodily signals, which distracts them from erotic cues. They
react with spectating, self-monitoring, performance demands,
and failure anxiety, which are frequently associated with anincrease in sympathetic nervous system activity, leading togenital arousal inhibition. Eventually, some men will avoid
sexual activity, thereby maintaining or worsening the initial
negative affect associated with sex. Avoiding sexual activity
exacerbates ED, and ED may have an obvious impact on thequality of life of the ED patient and his sex mate.26 McCabe
recommends the use of validated multidimensional measuresthat are designed specifically for men with ED (e.g., the SEAR
questionnaire) when assessing psychosocial outcomes.11
The SEAR questionnaire possesses strong psychometricproperties that support its validity and reliability for measuring sexual relationship, confidence, and, particularly, selfesteem.27 Various scales have been developed to measure

psychosocial factors related to ED, but few are available inJapan. In the future, it will be necessary to develop a Japaneseversion of the scale to measure psychosocial factors related
to ED.
The limitations of this study are as follows. As thisstudy used a cross-sectional design, it has shown only
“associations” and not “causality” between the quality oflife and the ED. However, more experimentally controlled
and prospective studies are needed to better understand how
psychosocial factors are implicated in ED. Furthermore,factors such as the online survey nature of the study, selfreport of ED symptoms, purposive sampling, the lack of adiagnostic interview, and sample size calculation may haveaffected the findings. Finally, the racial/ethnic and socioeconomic particularities of the subjects could limit the generalizability of the results. The study was also conducted during
the COVID-19 epidemic, which may have influenced theresults. In comparison to the previous studies, the present
study showed higher levels of depression and anxiety
among the non-ED men. Psychological distress indices havebeen significantly correlated with several measures relating
to COVID-19 in Japan.28

82

Journal of Psychosexual Health 5(2)Conclusions
This cross-sectional study aimed to evaluate depression, anxiety, and quality of life among the young Japanese men. There
were no significant differences in depression and anxiety
between non-ED and ED men. On the other hand, there weresignificant differences in quality of life between non-ED and
ED men. These results suggest that psychosocial factors otherthan depression and anxiety may also be the cause of ED inyoung Japanese men and that ED may reduce quality of life invarious aspects. Partner relationships and performance anxiety are considered as important psychosocial factors. It isnecessary to develop a Japanese version of the scale to measure psychosocial factors related to ED.
Declaration of Conflicting Interests

7. Araujo AB, Durante R, Feldman HA, Goldstein I, McKinlay JB.
The relationship between depressive symptoms and male erectile dysfunction: cross-sectional results from the MassachusettsMale Aging Study. Psychosom Med. 1998;60(4):458–465.
8. Dewitte M, Bettocchi C, Carvalho J, et al. A Psychosocial
Approach to Erectile Dysfunction: Position Statements fromthe European Society of Sexual Medicine (ESSM). Sex Med.
2021;9(6):100434.
9. Corona G, Mondaini N, Ungar A, Razzoli E, Rossi A, Fusco
F. Phosphodiesterase type 5 (PDE5) inhibitors in erectile
dysfunction: the proper drug for the proper patient. J Sex Med
2011;8(12):3418–3432.
10. Wang H, Yuan J, Hu X, Tao K, Liu J, Hu D. The effectiveness andsafety of avanafil for erectile dysfunction: a systematic review
and meta-analysis. Curr Med Res Opin 2014;30(8):1565–1571.

Ethical Approval

11. McCabe MP, Althof SE. A systematic review of the psychosocial outcomes associated with erectile dysfunction: does theimpact of erectile dysfunction extend beyond a man’s inability
to have sex?. J Sex Med. 2014;11(2):347–363.

This study was approved by the Waseda University Academic Research Ethical Review Committee (2019-363). The study protocol
followed the guidelines for epidemiological studies in accordancewith the Declaration of Helsinki.

12. Boddi V, Castellini G, Casale H, et al. An integrated approachwith vardenafil orodispersible tablet and cognitive behavioral
sex therapy for treatment of erectile dysfunction: a randomized
controlled pilot study. Andrology, 2015;3(5):909–918.

MG, CS, and HT are members of Logos Science Corp., Ltd.

Funding
This research was funded by Logos Science Corp., Ltd, Tokyo, Japan.

Informed Consent
The participant has consented to the submission of the article to thejournal.

ORCID iD
Junichi Saito

https://orcid.org/0000-0002-8386-4650

References
1. NIH Consensus Conference. Impotence. NIH consensus development panel on impotence. JAMA. 1993;270:83–90.
2. Melman A, Gingell JC. The epidemiology and pathophysiology of erectile dysfunction. J Urol. 1999;161(1):5–11.
3. Najari BB, Kashanian JA. Erectile dysfunction. JAMA.
2016;316(17):1838.
4. Nicolosi A, Moreira ED Jr, Shirai M, Bin Mohd Tambi MI,
Glasser DB. Epidemiology of erectile dysfunction in four
countries: cross-national study of the prevalence and correlatesof erectile dysfunction. Urology. 2003;61(1):201–206.
5. Sugimori H, Yoshida K, Tanaka T, et al. Relationships between
erectile dysfunction, depression, and anxiety in Japanese
subjects. J Sex Med. 2005;2(3):390–396.
6. Shaeer KZ, Osegbe DN, Siddiqui SH, Razzaque A, Glasser
DB, Jaguste V. Prevalence of erectile dysfunction and its
correlates among men attending primary care clinics in three
countries: Pakistan, Egypt, and Nigeria. Int J Impot Res.
2003;15(suppl 1):8–14.

13. Mallis D, Moysidis K, Nakopoulou E, Papaharitou S,
Hatzimouratidis K, Hatzichristou D. Psychiatric morbidity isfrequently undetected in patients with erectile dysfunction. J
Urol. 2005;174(5):1913–1916.
14. Liu Q, Zhang Y, Wang J, et al. Erectile dysfunction and depression: a systematic review and meta-analysis. J Sex Med.
2018;15(8):1073–1082.
15. Moore TM, Strauss JL, Herman S, Donatucci CF. Erectile
dysfunction in early, middle, and late adulthood: symptom
patterns and psychosocial correlates. J Sex Marital Ther.
2003;29(5):381–399.
16. Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Peña BM.
Development and evaluation of an abridged, 5-item versionof the International Index of Erectile Function (IIEF-5) asa diagnostic tool for erectile dysfunction. Int J Impot Res.
1999;11(6):319–326.
17. Kimoto Y, Ikeda S, Nagao K, et al. The New Japanese versionsof International Index of Erectile Function (IIEF) and IIEF5.
Jpn J Impot Res. 2009;24:295–308.
18. Muramatsu K, Miyaoka H, Kamijima K, et al. The patient
health questionnaire, Japanese version: validity according to
the mini-international neuropsychiatric interview-plus. Psychol
Rep. 2007;101(3 Pt 1):952–960.
19. Muramatsu K, Muramatsu Y, Miyaoka H, et al. Validation
and utility of a Japanese version of the GAD-7. Panminerva
Medica 20th World Congress on Psychosomatic Medicine.
Abstract Book. 2009;51:79.
20. Kajiwara S, Nishigami T, Mibu A. Development of a Japaneseversion of the life satisfaction checklist(LiSat-11): Translationand linguistic validation. Jpn Journal of Musculoskeletal Pain
Research. 2015;7:139–144.

Saito et al.
21. Moncada I, Micheltorena CF, Martínez-Sánchez EM, Gutiérrez
JR. Evaluation of the psychometric properties of the life satisfaction checklist as a screening tool for erectile dysfunction. J
Sex Med. 2008;5(1):83–91.
22. Yang Y, Song Y, Lu Y, Xu Y, Liu L, Liu X. Associations between
erectile dysfunction and psychological disorders (depression
and anxiety): A cross-sectional study in a Chinese population.
Andrologia. 2019;51(10):e13395.
23. McCabe, M. P. The role of performance anxiety in the development and maintenance of sexual dysfunction in men andwomen. Int. J. Stress Manag. 2005;12(4):379–388.
24. Barlow DH. Causes of sexual dysfunction: the role ofanxiety and cognitive interference. J Consult Clin Psychol.
1986;54(2):140–148.
25. Sarin S, Amsel R, Binik YM. How hot is he? A psychophysiological and psychosocial examination of the arousal patterns

83
of sexually functional and dysfunctional men. J Sex Med.
2014;11(7):1725–1740.
26. Salonia A, Castagna G, Saccà A, et al. Is erectile dysfunction
a reliable proxy of general male health status? The case for
the International Index of Erectile Function-Erectile Function
domain. J Sex Med. 2012;9(10):2708–2715.
27. Cappelleri JC, Althof SE, Siegel RL, Shpilsky A, Bell SS,
Duttagupta S. Development and validation of the Self-Esteem
And Relationship (SEAR) questionnaire in erectile dysfunction. Int J Impot Res. 2004;16(1):30–38.
28. Sugaya N, Yamamoto T, Suzuki N, Uchiumi C. A realtime survey on the psychological impact of mild lockdown
for COVID-19 in the Japanese population. Sci Data.
2020;7(1):372.