Racial differences in hematologic profiles among men with erectile dysfunction: a cross-sectional analysis of NHANES 2001–2004

Introduction

Erectile dysfunction (ED) is characterized by the inability to achieve or sustain an erection adequate for satisfactory sexual performance. This condition is prevalent and has substantial negative impacts on both quality of life and overall health (1,2). Although not life-threatening, ED affects not only the individuals experiencing it but also their partners and the broader societal health landscape. A comprehensive longitudinal study conducted in Massachusetts reported an incidence rate of 26 cases per 1,000 person-years, highlighting its public health importance (3). The pathophysiology of ED is complex and multifactorial, involving vascular, hormonal, neurogenic, and anatomical factors (4). Vascular causes are particularly significant, as ED is closely linked with endothelial dysfunction, diabetes, atherosclerosis, inflammation, and smoking (5-8). Notably, ED is acknowledged as an early indicator of coronary artery disease (CAD) and can independently predict its onset (9,10). This association has led researchers to investigate the relationship between blood cell parameters and ED, aiming to uncover shared pathophysiological mechanisms such as inflammation and endothelial dysfunction.

Recent studies have linked specific blood parameters, such as elevated white blood cells (Wbc), neutrophil-to-lymphocyte ratio (NLR) and platelet (Plt), to increased risk and severity of ED (11,12). However, these studies often focus on homogeneous or ethnically restricted cohorts, neglecting racial diversity. This is a significant limitation, as interethnic variations in genetic predispositions, lifestyle factors, and disease susceptibility can influence ED progression and its hematological correlates (13-15). Despite interest in the relationship between hematological parameters and ED, research on racial differences remains limited, with small-scale studies lacking statistical power, thus affecting the representativeness and generalizability of the findings.

An important unresolved inquiry pertains to the existence of racial disparities in the relationship between blood cell parameters and the pathogenesis of ED, as well as the potential for these disparities to enhance early detection and inform personalized treatment strategies. Addressing this gap necessitates rigorous, large-scale, multi-ethnic cohort studies to validate preliminary findings and elucidate the biological or socio-cultural mechanisms underlying these disparities.

In particular, identifying race-specific hematologic markers associated with ED could offer new avenues for individualized risk assessment. Such markers may act as early indicators of systemic inflammation or vascular dysfunction in specific populations—especially in younger men—prior to the onset of overt cardiovascular symptoms. Incorporating these biomarkers into ED screening protocols could support stratified prevention strategies, helping clinicians detect high-risk patients earlier and tailor interventions accordingly. These efforts also hold implications for public health policy, where incorporating racial and ethnic considerations into sexual health initiatives may help reduce disparities and improve outcomes across diverse patient groups.

This study aims to explore racial differences in the association between blood cell parameters and ED utilizing cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), covering the period from 2001 to 2004. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-220/rc).

Methods

To examine racial differences in the correlation between hematologic parameters and ED, we conducted a cross-sectional study using data from the NHANES [2001–2004] https://wwwn.cdc.gov/nchs/nhanes/. We examined the relationship between racial groups (Black, White, and Mexican) and hematologic parameters including hemoglobin (Hb), neutrophils (Neu), Wbc and Plt. To account for potential confounders, we used linear regression models with multiple adjustment for sociodemographic variables and clinical covariates. In addition, we performed age-stratified analyses to evaluate potential effect modification in different age groups (≤40 vs. >40 years). The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Study population

The NHANES database originated from a series of surveys addressing various health issues, collectively known as the NHANES Program, which was initiated by the National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC) in the early 1960s (16). The NHANES Program is a cross-sectional survey that has been updated and released biennially since 1999, allowing for annual adjustments based on the previous cycle to refine the research project for the upcoming year and to make minor revisions to prior data (17). The NHANES Program comprises both an interview survey and a physical examination. The interview survey is conducted in the participant’s home, with trained personnel administering all questionnaires to ensure accurate data collection. This is followed by a standardized physical examination and laboratory tests (18).

This study utilized 21,047 participants from the NHANES database between 2001 and 2004. Preferred exclusion of females (n=10,860). Further exclusion criteria include: (I) participants who have not completed the ED survey (n=6,071); (II) non-ED patients (n=2,117); (III) covariant data missing (n=256). After excluding these factors, the final study sample included 1,743 participants with erectile dysfunction (ED) (Figure 1).

Figure 1 Flowchart of the study design and participants. ED, erectile dysfunction; NHANES, National Health and Nutrition Examination Survey.

Determination of variables

We identified multiple potential confounders that could influence outcomes and included them in the analysis. These included demographic characteristics [age ≤40 and >40 years, race (Mexican, White, Black, and other), education level (less than high school, high school diploma, and more than high school), marital status (living alone and married or living with a partner)], socioeconomic status [household poverty-to-income ratios (PIRs) were categorized as ≤1.3, >1.3–<3.5, and ≥3.5], smoking was defined as smoking a lifetime more than 100 cigarettes; alcohol consumption defined as more than 12 lifetime drinks; vigorous activity defined as at least 10 minutes of activity resulting in heavy sweating or a significant increase in respiratory heart rate; moderate activity defined as at least 10 minutes of activity resulting in light sweating or a mild to moderate increase in respiratory heart rate; Hypertension defined as a mean systolic blood pressure of ≥130 mmHg and diastolic blood pressure of ≥80 mmHg, self-reported diagnosis, or use of antihypertensive medications; diabetes mellitus (DM) defined as fasting glucose (FPG) ≥7.0 mmol/L, 2-hour oral glucose tolerance test plasma glucose ≥11.1 mmol/L, glycosylated hemoglobin (HbA1c) ≥6.5%, use of hypoglycemic medications, or self-reported diabetes; impaired fasting glucose (IFG) defined as FPG ≥5.6 and <7.0 mmol/L; CVD defined as self-reported diagnosis by a healthcare provider, including congestive heart failure, coronary heart disease, angina, myocardial infarction, or stroke). BMI categorized as ≤24, >24–<30, and ≥30 kg/m²; and hematological parameters including Wbc, Lym, Neu, Hb and Plt.

Evaluation of ED

Participants in NHANES used a self-paced audio computer-assisted self-interview system in a private room, allowing them to listen to questions via earphones and read them on a computer screen concerning ED. To evaluate ED, men aged 20 and above were asked a question, which was proposed to be included in extensive ongoing national epidemiologic surveys to gather data on the prevalence of ED: ‘Many men encounter issues with sexual intercourse’. How would you describe your ability to get and keep an erection adequate for satisfactory intercourse? The following answers were provided: “Would you say that you are…always or almost always able, usually able, sometimes able, or never able?” In this study, positive ED was classified based on responses of ‘sometimes able’ or ‘never able’ to maintain an erection, while negative ED was identified from responses of ‘almost always able’ or ‘usually able’ to keep an erection (19).

Statistical analysis

In this study, all statistical analyses considered the complex multi-stage sampling design of NHANES, ensuring national representativeness estimation by incorporating appropriate sampling weights, stratified variables, and primary sampling units. Individuals with missing values in the covariates were excluded from the study to ensure the reliability of the study data. The baseline characteristics of participants are represented as continuous variables by weighted mean and standard error (SE), and categorical variables by weighted proportion. Evaluate the differences in baseline characteristics between different ethnic groups by using linear regression analysis based on sampling weights for continuous variables and chi square test analysis based on sampling weights for categorical variables.

To evaluate the association between race and hematological parameters, a linear regression model based on sampling weights was employed. Three models were constructed in the analysis: Model 1 was not adjusted; Model 2 adjusted for age BMI, Educational level, marital status, and PIR; Model 3 further adjusted smoking status, drinking status, hypertension and diabetes on the basis of model 2. Exploring potential effect modifications by stratifying participants by age groups (≤40 and >40 years). Bilateral P values <0.05 are considered statistically significant. All statistical analyses were conducted using R software (http://www.R-project.org; The R Foundation) has completed it.

Results

Clinical characteristics of ED patients of different races

Among the 1,743 ED patients included in our study, 292 (17%) were Black, 376 (22%) were Mexican, 976 (56%) were White, and the proportion of other races was 5.7%. The median age of White patients is the highest (68 years old), while that of other ethnic patients is the lowest (53 years old). Black people have the lowest Wbc count [5.90 (4.70, 7.43) ×10³ cells/µL], while White people have the lowest Lym count [1.70 (1.40, 2.20) ×10³ cells/µL]. In terms of central granulocytes, Black people have the lowest count [3.10 (2.20, 4.33) ×10³ cells/µL], while White and other races have higher counts (both around 4.00). In terms of Hb, Black people have the lowest [14.30 (13.60, 15.13) g/dL], while Mexican and other ethnic groups have higher (both around 15.40). In terms of Plt count, the Black population is significantly higher than the White population [231.50 (199.00, 274.00) ×10³ cells/µL]. Other characteristics, such as PIR, education level, smoking, alcohol consumption, marital status, and other variables, show significant differences among different populations. There were no statistically significant differences between races in BMI, smoking status, and intense activity (Table 1).

Age stratified linear regression analysis of blood cell parameters in ED patients of different ethnicities

We explored the changes in the relationship between ED patients of different ethnicities and blood cell parameters by stratifying them by age. In all age groups of different ethnicities, the Hb levels of Black patients were significantly lower than those of White patients (≤40 years: 14.82 vs. 15.78 g/dL; >40 years old: 14.30 vs. 15.15 g/dL), this difference is observed in Wbc count (×10³ cells/µL) (≤40 years old: 6.70 vs. 7.23; >40 years old: 6.28 vs. 7.26) and Neu count (×10³ cells/µL) (≤40 years old: 3.86 vs. 4.31; >40 years old: 3.39 vs. 4.39) still exists. In the age group of ≤40 years of different races, White people have the lowest lymphocyte (Lym) count (2.07×10³ cells/µL) and Plt count (251.36×10³ cells/µL). In the age group of over 40 years old of different ethnicities, the differences in Lym and Plt counts between individuals are relatively small, but in terms of Lym, Black people are slightly higher than White people (2.13×10³ cells/µL vs. 2.00×10³ cells/µL) (Table 2). In addition, we plotted a combination box plot and scatter plot to present data features more clearly (Figure 2).

Figure 2 Racial differences in blood cell parameters among ED patients. (A) Box plot showing the distribution of Wbc counts across racial groups. (B) Box plot illustrating Neu counts among different racial groups. (C) Box plot displaying Lym counts stratified by race. (D) Box plot of Hb levels across racial groups. (E) Box plot of Plt counts among racial groups. ED, erectile dysfunction; Hb, hemoglobin; Lym, lymphocyte; Neu, neutrophil; Plt, platelet; Wbc, white blood cell.

Multivariate linear regression analysis of blood cell parameters in White and Black ED patients

Through linear regression analysis, we found that the differences in various blood cell parameters mainly exist between Caucasian and Black populations. We further conducted a multivariate linear regression analysis between Black and White individuals, and then gradually adjusted for confounding factors based on this to reduce the influence between variables. In Model 1 (unadjusted for covariates), the levels of Hb, Neu, and Wbc in Black patients were significantly lower than those in White patients (Hb: −0.72; Neu: −1.02; Wbc: −1.01, all P<0.01). The Plt level of Black patients was significantly higher than that of White patients (12.24, P<0.01). In Model 2 (adjusted for sociodemographic variables: age, BMI, education, marital status, PIR), the levels of Hb, Neu, and Wbc in Black patients were still significantly lower than those in White patients (Hb: −0.98; Neu: −1.10; Wbc: −1.16, P<0.01). However, the difference in Plt levels decreased and was not significant (5.6, P=0.21). In Model 3 (further adjusting all covariates: smoking, drinking, hypertension, diabetes), the levels of Hb, Neu, and Wbc in Black patients were still significantly lower than those in White people (Hb: −0.95; Neu: −1.14; Wbc: −1.18, all P<0.01). The difference in Plt levels further decreased and was not significant (5.22, P=0.25). There was still no significant difference in Lym levels (0.09, P=0.45) (Table 3).

Discussion

ED is a prevalent sexual dysfunction disorder in men over 40 years, significantly impacting their physical, mental, and social well-being (5). While a connection between blood cell parameters and ED is recognized, there is limited research on how this association varies across different races. In this study, we evaluated racial differences in the relationship between blood cell parameters and ED using the NHANES dataset. We found that Black ED patients had lower levels of Hb, Neu, and Wbc compared to White ED patients, and this difference persisted even after adjusting for sociodemographic variables and other covariates. Similar findings were also observed when stratified by age. In summary, these results indicate that racial factors are of great significance in exploring the association between ED patients and blood cell parameters.

Research indicates that certain blood parameters used to assess CAD also hold clinical importance for ED, due to the link between ED and CAD or other vascular conditions. Age, obesity, and smoking are among the many risk factors associated with ED (20,21). Vascular ED is the most prevalent and significant form of ED, associated with various factors linked to vascular conditions, including endothelial dysfunction, atherosclerosis, and inflammation. An early independent predictor of myocardial infarction or death in patients with CAD or those at high risk is the Wbc count (22). Wbc counts might be an independent risk factor for CAD, even in young patients with normal levels (23). Certain researchers have suggested potential mechanisms: Wbc are roughly equivalent to 700 red blood cells, and because of their large size and high viscosity, they frequently obstruct capillary pathways (24). Furthermore, a cohort study indicated that blood viscosity is a strong predictor of cardiovascular events (25). Moreover, the rheological properties of white blood cells greatly influence their roles, including their interactions with endothelial cells and their movement through capillaries, which is a crucial pathophysiological process in vascular diseases (26,27). Recently, it has been observed that heightened Plt activity affects vascular ED (28). MPV indicates Plt function, condition, and size, indirectly showing Plt activity, and can specifically represent adhesion molecule expression, Plt aggregation, thromboxane production, and procoagulant activity (28). The combination of current blood cell parameters serves as an effective indicator for cardiovascular disease. Studies indicate that PLR and NLR serve as predictive markers and indicators for negative outcomes in cardiovascular and other vascular conditions, and they can help forecast the prognosis of these diseases (29,30).

With the continuous deepening of research, the influence of racial factors on diseases has received increasing attention. Research has found that ethnic groups in Asia and the Pacific have higher urinary albumin to creatinine ratios (ACRs) and elevated levels of urinary albumin, resulting in a higher risk of kidney damage (31). In another study on predictors of weight gain and cardiovascular risk in a cohort of kidney transplant recipients of different races, African American recipients had the lowest graft survival and highest mortality rates (32). Prostate specific antigen is a specific biomarker for diagnosing prostate cancer. Recent study have shown that for prostate cancer patients in the same age group, Black men have a greater risk of developing prostate cancer than White men at the same PSA level (33). So racial factors have a huge impact on the occurrence and development of diseases, but this important factor has not yet been studied in the ED population.

Our findings hold substantial clinical implications for understanding the mechanistic basis of racial disparities in blood cell parameters among ED patients. The observed reduction in Hb levels among Black ED patients may signal an elevated anemia risk, a condition closely linked to cardiovascular disease, fatigue, and sexual dysfunction. This phenomenon could reflect race-specific variations in erythropoietic efficiency or oxygen transport mechanisms. For instance, genetic polymorphisms affecting iron metabolism or red blood cell synthesis—more prevalent in Black populations—might contribute to these hematological differences. Chronic tissue hypoxia secondary to low Hb levels could exacerbate endothelial dysfunction, a key driver of ED pathogenesis. Consequently, clinicians should prioritize regular hematological monitoring in Black ED patients to enable early detection and intervention for anemia.

Similarly, the diminished Neu and Wbc counts in Black ED patients may indicate race-specific divergence in immune regulation or inflammatory responses. Reduced leukocyte counts could reflect underlying chronic inflammation or immunosuppression, both recognized contributors to ED pathophysiology. Further investigations are warranted to elucidate whether these differences stem from dysregulated inflammatory pathways or immune dysfunction unique to Black populations.

Importantly, the integration of race-specific hematologic biomarkers into ED assessment protocols offers valuable opportunities for personalized risk stratification. For example, routinely assessing Hb and Wbc levels in younger Black patients may help identify individuals at increased risk for endothelial dysfunction, systemic inflammation, or future cardiovascular disease—even before the manifestation of overt symptoms. By leveraging such markers as early warning signals, healthcare providers may implement timely interventions and targeted preventive measures. These findings also carry implications for public health planning in sexual medicine, supporting the design of race-conscious screening and management strategies that address both biological and social determinants of health.

Notably, while unadjusted models revealed higher Plt counts in Black patients, this disparity diminished after controlling for sociodemographic confounders (age, BMI, smoking). This attenuation suggests that lifestyle and sociodemographic factors may partially explain the observed variability in Plt levels, although the cross-sectional design limits definitive conclusions. Further research is needed to determine whether such associations are causal or reflective of underlying unmeasured biological factors. Nevertheless, Plt count remains a critical biomarker for thrombosis risk assessment in ED patients, given its established association with cardiovascular complications. Clinicians should integrate Plt metrics into comprehensive cardiovascular risk stratification, irrespective of racial categorization.

Research on age stratification has revealed that age exerts a significant regulatory influence on racial disparities in blood cell parameters. This finding suggests that as individuals age, race-related physiological differences may become increasingly obscured by other factors, such as chronic diseases and lifestyle choices. This discovery carries important implications for clinical practice, particularly in the evaluation and management ofED patients. Specifically, healthcare providers are encouraged to adopt a personalized approach when developing diagnosis and treatment plans, taking into account both the patient’s age and ethnic background. For instance, younger Black patients may benefit from earlier interventions, while older patients might require more comprehensive assessments involving multiple bodily systems.

The observed ethnic differences in blood cell parameters may also serve as a marker for underlying disparities in the risk of chronic diseases, such as cardiovascular disease and diabetes, across different racial groups. Regular monitoring of these parameters could facilitate early identification of high-risk patients, enabling the implementation of targeted preventive measures. However, it is important to note that sociodemographic factors only partially account for these racial differences, suggesting that race-related genetic predispositions or environmental exposures may play a more substantial role in regulating blood cell parameters. Consequently, clinicians evaluating ED patients should consider not only the patient’s socioeconomic status but also their ethnic background to achieve a more holistic understanding of their overall health status.

There are certain limitations in this study. Firstly, this is a cross-sectional study, we could not prove causal relationships. Secondly, due to limitations in the NHANES database, the diagnosis of ED was based on a simple question, which was not a completely reliable method for studying erectile function. Some sexual function assessment scales should be used to investigate the erectile function of the subjects. Thirdly, due to limitations in the NHANES database, there is a lack of data for other races, such as Asians. Therefore, it is necessary to conduct more carefully designed prospective studies and multicenter research to explore the potential biological mechanisms of racial differences in blood cell parameters, such as genetic background, metabolic function, or inflammatory response racial specific differences. It is necessary to evaluate the relationship between changes in blood cell parameters and the progression or therapeutic effect of ED through longitudinal studies, and further clarify its clinical significance.

Conclusions

This study reveals significant racial differences in hematological parameters among men with ED, particularly between Black and White individuals. Black patients consistently exhibited lower Hb, Neu, and Wbc counts, alongside higher Plt counts, even after adjusting for confounding factors. These findings underscore the need to incorporate racial factors into ED management, including tailored hematological monitoring to detect anemia or chronic inflammation early. Early interventions may be particularly beneficial for younger Black patients, while older patients may require comprehensive assessments for coexisting chronic conditions. Future research should prioritize multi-ethnic, longitudinal studies to validate these findings and investigate the genetic, inflammatory, and socioeconomic factors underlying these disparities, advancing personalized ED care and reducing health inequities.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-220/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-220/prf

Funding: This study was supported by the National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University (grant No. 2023LNJJ10), and the Natural Science Foundation of Hunan Province (grant No. 2023JJ30960).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-220/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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