The chain mediating role of social support and anxiety between intimacy and self-efficacy in patients with psychogenic erectile dysfunction

Introduction

Erectile dysfunction (ED) is defined as the persistent and recurrent inability to achieve or maintain an erection sufficient for satisfactory sexual intercourse (1). Traditionally considered a condition of older men, recent studies have reported a rising incidence of ED among men under the age of 40 years (2). Numerous epidemiological investigations have confirmed the high prevalence of ED, with projections indicating a potential worsening trend—particularly in developing countries (3,4). Among Asian men, the reported prevalence ranges from 9% to 73% (5). Moreover, as a global public health event, the coronavirus disease 2019 (COVID-19) pandemic not only affects overall individual health but may also exert adverse effects on male reproductive health and sexual function through multiple pathways, such as physiological damage and increased psychological stress (6). Psychogenic erectile dysfunction (pED), a subtype of ED, is primarily driven by psychological and interpersonal factors and is more commonly observed in younger men (7). Self-efficacy refers to an individual’s belief in their own capability to perform behaviors necessary to achieve specific goals when facing difficulties or challenges (8). Research has demonstrated that enhancing self-efficacy through psychological interventions can effectively improve erectile function and quality of life in patients with pED (9). The quality of intimate relationships has been shown to influence individuals’ level of self-efficacy (10), and research demonstrates that a good partner relationship is significantly associated with better sexual function (11). Greater levels of social support are associated with higher self-efficacy (12), whereas anxiety is negatively correlated with self-efficacy and has been found to diminish one’s confidence in managing health conditions (13). This study aimed to investigate the associations between self-efficacy and psychosocial factors, specifically social support and anxiety, in patients with pED. Furthermore, it sought to analyze the potential relationships between intimate relationships and self-efficacy, with the goal of providing a theoretical basis for the development of targeted psychological interventions. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-1-983/rc).

Methods

Study subjects

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study protocol was reviewed and approved by the Ethics Committee of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (approval No. 2022-737-03). All participants were informed about the objectives and procedures of the study, and written informed consent was obtained prior to participation. This study recruited pED patients who are were diagnosed by clinical physicians and treated at our hospital through convenience sampling by nurses. pED is primarily or entirely caused by psychological or interpersonal factors, including performance anxiety, generalized anxiety, interpersonal and social stressors, depression, guilt, and fear. Inclusion criteria: (I) males aged 18–55 years; (II) diagnosed with pED by a urologist based on the diagnostic criteria of the Chinese Society of Andrology Guidelines for the Diagnosis and Treatment of ED (14), with International Index of Erectile Function-5 (IIEF-5) scores <22; (III) in a stable sexual relationship with regular sexual activity; (IV) provided informed consent. Exclusion criteria included: (I) presence of severe physical illness or long-term medication use; (II) history of psychiatric disorders or current unstable mental state.

Survey tools

General information questionnaire

The questionnaire, developed by the research team to align with the objectives of the study, was designed to collect comprehensive information across multiple dimensions: patient’s age, education level, place of residence, occupation, income, marital status, marital satisfaction, and family sexual attitudes.

IIEF-5

The IIEF-5, developed by Rosen et al. (15), the scale consists of five items, each with six response options scored from 0 to 5, yielding a total score ranging from 5 to 25. A total score of <7 indicates severe ED, 8–11 indicates moderate ED, 12–21 indicates mild ED, and 22–25 is considered normal erectile function. In the present study, the Cronbach’s α coefficient of the scale was 0.902.

Quality of Relationship Inventory (QRI)

The QRI was developed by Patrick et al. (16), the scale assesses multiple dimensions of intimate relationships, including emotional experience, stability, and commitment. It consists of six items rated on a 7-point Likert scale ranging from “strongly disagree” to “strongly agree,” with scores from 1 to 7. The total score of the scale ranges from 6 to 42. Higher scores indicate greater satisfaction with the current intimate relationship. In the present study, the Cronbach’s α coefficient for the scale was 0.872.

Social Support Rating Scale (SSRS)

The SSRS, developed by Xiao et al. in 1994 (17), is used to evaluate the level of social support among various patient populations. The scale consists of 10 items encompassing three dimensions. The total score of the scale ranges from 12 to 66. A score of ≤22 indicates a low level of social support, 23–44 indicates a moderate level, and 45–66 indicates a high level. Higher scores reflect stronger perceived social support. In the present study, the Cronbach’s α coefficient for the scale was 0.903.

Generalized Anxiety Disorder-7 scale (GAD-7)

The GAD-7, developed by Spitzer et al. (18), is a brief self-report measure for assessing symptoms of anxiety. The scale consists of seven items, each rated on a 4-point Likert scale from 0 to 3, with higher scores indicating greater severity of anxiety. The total score of the scale ranges from 0 to 21.A total score of 0–4 indicates minimal or no clinically significant anxiety; 5–9 indicates mild anxiety; 10–14 indicates moderate anxiety; and a score of 15 or higher suggests severe anxiety. In the present study, the Cronbach’s α coefficient for the GAD-7 was 0.919.

General Self-Efficacy Scale (GSES)

The GSES, originally developed by Zhang and Schwarzer [1995] (19), is a unidimensional instrument comprising 10 items. Each item is rated on a 4-point Likert scale ranging from 1 (“not at all true”) to 4 (“exactly true”), with higher scores indicating greater levels of perceived self-efficacy. The total score of the scale ranges from 10 to 40. In the present study, the Cronbach’s α coefficient for the GSES was 0.864.

Survey methods

Surveys were conducted using an electronic questionnaire platform after uniform training of data collectors. Patients were informed of the study’s purpose and procedure and provided electronic informed consent. Questionnaires were completed on-site and checked for completeness by trained research staff. Double data entry and verification procedures were performed to ensure accuracy. According to the literature, a minimum sample size of 100–200 participants is generally recommended for structural equation modeling (SEM). Based on the methodological reference and practical clinical considerations, a total sample of 210 participants was ultimately collected in this study (20).

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics 27.0. Categorical variables were expressed as frequencies and percentages, while continuous variables were presented as mean ± standard deviation (mean ± SD). Harman’s single-factor test was employed to assess potential common method bias. Pearson correlation analysis was utilized to examine the associations among intimate relationships, social support, anxiety, and self-efficacy. SEM was conducted using IBM SPSS AMOS 26.0 to test the hypothesized associations among the study variables. All variables were treated as continuous, and parameter estimation was performed using the maximum likelihood (ML) method. Latent variables were measured using subscale scores from validated scales as observed indicators, and composite scores were calculated using the mean value method. Model fit was evaluated using multiple indices, including the ratio of Chi-squared to degrees of freedom (χ²/df), Goodness-of-Fit Index (GFI), Normed Fit Index (NFI), Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Incremental Fit Index (IFI), and Root Mean Square Error of Approximation (RMSEA). In cases of suboptimal initial model fit, model modifications based on modification indices were performed only when theoretically justifiable, thereby avoiding purely data-driven adjustments. The bootstrapping method (with 5,000 resamples) was applied to test the statistical significance of the indirect effects (statistical mediation). A two-tailed P value <0.05 was considered statistically significant.

Results

General information of subjects

The general demographic characteristics of the 210 patients with pED are summarized in Table 1.

Common method bias

Harman’s single-factor test was conducted to assess common method bias. The results revealed that eight factors had eigenvalues greater than 1, with the first factor accounting for 30.998% of the total variance, which is below the critical threshold of 40%. These findings suggest that there was no significant common method bias in this study.

Scores of ED, intimacy, social support, anxiety, and self-efficacy

The mean scores of ED, intimacy, social support, anxiety, and self-efficacy among patients with pED were 9.18±6.45, 32.28±7.88, 34.73±6.28, 6.79±4.92, and 23.72±5.33 (Table 2).

Correlation analysis among intimacy, social support, anxiety, and self-efficacy

Among patients with pED intimacy was positively correlated with social support and self-efficacy, and negatively correlated with anxiety. All correlations were statistically significant (P<0.01) (Table 3).

Analysis of the mediating roles of social support and anxiety in the association between intimacy and self-efficacy

SEM was employed to analyze the data, with intimate relationships specified as the independent variable, self-efficacy as the dependent variable, and social support and anxiety as potential mediators. Data analysis was conducted using AMOS 26.0. Given the significant correlation between social support and anxiety (r=−0.249, P<0.01), a serial mediation structure was constructed. The model fit indices indicated a good fit: χ²/df =1.245, GFI =0.917, NFI =0.915, CFI =0.982, TLI =0.979, IFI =0.982, and RMSEA =0.034 (see Figure 1).

Figure 1 Structural association model illustrating the sequential mediating associations of social support and anxiety between intimacy and self-efficacy. Major nodes (intimacy, social support, anxiety, and self-efficacy) represent questionnaires, and smaller nodes represent questionnaire dimensions. Numbers between major and small nodes indicate factor loadings, and numbers between major nodes indicate standardized path coefficients. AX, anxiety; IR, intimacy; SE, self-efficacy.

We used 5,000 bootstrap resamples to estimate the 95% confidence intervals (CIs) for the indirect associations. The results showed that intimate relationships were significantly and positively associated with self-efficacy (β=0.30, P<0.01). Social support was also positively associated with self-efficacy (β=0.39, P<0.01) and demonstrated a significant indirect association between intimate relationships and self-efficacy (coefficient =0.153), accounting for 24.56% of the total association. Anxiety was negatively associated with self-efficacy (β=−0.39, P<0.01) and similarly showed a significant indirect association (coefficient =0.114), accounting for 18.30% of the total association. Furthermore, a sequential association pattern involving social support and anxiety was observed (coefficient =0.053), accounting for 8.51% of the total association. The 95% CIs for all indirect paths did not include zero, indicating that these indirect associations were statistically significant (see Table 4).

Discussion

Modern diagnostic frameworks, particularly the ICD-11 published by the World Health Organization, have increasingly moved away from the simplistic binary classification of erectile dysfunction as solely “psychogenic” or “organic”, instead emphasizing a comprehensive biopsychosocial interaction mechanism (21). Against this backdrop, and after objectively excluding organic etiologies, this study systematically investigated the associations among intimate relationships, social support, anxiety, and self-efficacy in patients with pED. The aim was to elucidate the potential psychosocial mechanisms underlying their psychological adaptation.

The overall results indicated that patients generally exhibited lower levels of intimate relationships and self-efficacy, concurrent with elevated anxiety. This suggests a potential vulnerability regarding their interpersonal support resources and emotional regulation capabilities. SEM further revealed that intimate relationships were not only directly associated with self-efficacy but also demonstrated indirect links via social support and anxiety. Specifically, social support and anxiety functioned as partial mediators, presenting a serial mediation pattern. These findings suggest that relationship quality, social support resources, and emotional states may collaboratively contribute to the variance in self-efficacy and are closely related to erectile function status.

This finding aligns with Albert Bandura’s self-efficacy theory, which emphasizes that social situational factors, such as “vicarious experiences” and “verbal persuasion”, are critical sources of self-efficacy (22). Previous research indicates that multiple dimensions of relationship quality, such as affectional expression, dyadic cohesion, and dyadic consensus, are significantly associated with erectile dysfunction (23). Furthermore, extending beyond direct sexual outcomes, relationship quality correlates closely with individual psychosocial resources. For example, support utilization serves as a mediator between intimacy and psychological adaptation (24). Collectively, these findings imply that the impact of relational factors on sexual health may operate, in part, through psychosocial mechanisms. When individuals perceive understanding and support from partners, family, or friends, they are more likely to adopt a positive attitude toward the disease, thereby demonstrating higher levels of self-efficacy (25). Furthermore, epidemiological study have noted that relationship discord is significantly correlated with higher levels of stress and depression, and psychological stress may be linked to erectile function and sexual quality of life (26). Relationship strain or insufficient support may exacerbate expectations of failure and catastrophic thinking, potentially coinciding with increased anxiety levels and weakened confidence in recovery. Related study has further found that family function shares a sequential association with social support and anxiety, highlighting the pivotal role of social support in mental health (27). Therefore, the serial mediation path involving social support and anxiety observed in this study likely reflects a continuous psychological process encompassing relational resources, emotion regulation, and self-belief.

Based on these results, clinical interventions should not be limited to individual symptom management but should integrate the relationship and social support environment. In practice, intimate interactions could be strengthened through partner-involved communication training or couple-based therapy; social resource utilization could be enhanced via peer support groups; and emotional regulation capabilities could be improved through anxiety screening combined with cognitive-behavioral interventions. Such a multi-level comprehensive intervention model may facilitate the synergistic enhancement of patients’ self-efficacy and disease adaptability across relational, emotional, and cognitive dimensions.

Although this study employed SEM to comprehensively analyze the complex relationships among variables, several limitations should be acknowledged. First, regarding the study design, the cross-sectional nature of the data precludes the inference of causal relationships between variables. While our model specifies directional paths based on theoretical assumptions, longitudinal or prospective designs are required in future research to confirm the temporal sequence of these associations. Second, concerning sampling and generalizability, participants were recruited via convenience sampling from a single hospital outpatient clinic. This sampling strategy, although practical, may introduce selection bias and limit the representativeness of the findings. Specifically, recruiting solely from clinical settings may result in healthcare-seeking behavior bias, as these individuals often demonstrate higher treatment motivation or health literacy compared to those who do not seek medical care. Consequently, the generalizability of our findings to males with psychogenic ED who do not seek treatment or tend to internalize their distress should be interpreted with caution. Third, from an analytical perspective, ED severity may simultaneously relate to anxiety levels, self-efficacy, and the quality of intimate relationships. As a potential confounding factor, it could introduce bias into the estimation of path coefficients. Although we attempted to account for relevant psychosocial variables through model specification, residual confounding cannot be completely ruled out. Future studies incorporating clinical severity indicators as covariates or employing stratified or longitudinal analyses may help provide more precise estimates. Finally, in terms of measurement, the reliance on self-reported instruments poses a risk of recall bias and social desirability effects. Given the sensitive nature of sexual health topics, participants may have underreported negative experiences or overreported positive adaptation, potentially influencing the accuracy of the findings. Sexual dysfunction significantly impacts couple relationships, and dyadic coping strategies are beneficial in providing emotional support and improving treatment outcomes. Therefore, future research should place greater emphasis on examining interpersonal dynamics between partners and exploring how joint interventions can enhance coping mechanisms and reduce psychological distress.

Conclusions

This study identified a chain mediation pattern suggesting that intimacy was associated with self-efficacy in patients with pED both directly and indirectly through social support and anxiety. The findings highlight the potential importance of intimate relationships in relation to psychological resilience and treatment engagement among this population. Specifically, higher levels of intimacy were linked to greater social support, lower anxiety, and higher self-efficacy. These results suggest that interventions focusing on strengthening intimate partner relationships and enhancing social support may help support patients’ self-efficacy and treatment adherence. Future research using longitudinal or experimental designs is warranted to further clarify these psychosocial associations and inform the development of targeted psychological interventions.

Acknowledgments

We extend our heartfelt gratitude to all the participants of this study, as well as to the nursing and medical staff of Nanjing Drum Tower Hospital for their invaluable support and collaboration throughout the research process.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-1-983/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-1-983/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-1-983/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-1-983/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. The study protocol was reviewed and approved by the Ethics Committee of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (approval No. 2022-737-03). All participants were informed about the objectives and procedures of the study, and written informed consent was obtained prior to participation.

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/.

References

1. McCabe MP, Sharlip ID, Atalla E, et al. Definitions of Sexual Dysfunctions in Women and Men: A Consensus Statement From the Fourth International Consultation on Sexual Medicine 2015. J Sex Med 2016;13:135-43. [Crossref] [PubMed]
2. Nguyen HMT, Gabrielson AT, Hellstrom WJG. Erectile Dysfunction in Young Men-A Review of the Prevalence and Risk Factors. Sex Med Rev 2017;5:508-20. [Crossref] [PubMed]
3. Corona G, Lee DM, Forti G, et al. Age-related changes in general and sexual health in middle-aged and older men: results from the European Male Ageing Study (EMAS). J Sex Med 2010;7:1362-80. [Crossref] [PubMed]
4. Ayta IA, McKinlay JB, Krane RJ. The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences. BJU Int 1999;84:50-6. [Crossref] [PubMed]
5. Ho CC, Singam P, Hong GE, et al. Male sexual dysfunction in Asia. Asian J Androl 2011;13:537-42. [Crossref] [PubMed]
6. Leitner M, Pötz G, Berger M, et al. Characteristics and burden of acute COVID-19 and long-COVID: Demographic, physical, mental health, and economic perspectives. PLoS One 2024;19:e0297207. [Crossref] [PubMed]
7. Rosen RC. Psychogenic erectile dysfunction. Classification and management. Urol Clin North Am 2001;28:269-78. [Crossref] [PubMed]
8. Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety 2003;18:76-82. [Crossref] [PubMed]
9. Xue MY, Wu HC, Li YL, et al. Effect of Naikan cognitive therapy combined with motivational empowerment education on negative emotions and treatment coordination in male patients with psychogenic erectile dysfunction. Chinese Journal of Human Sexuality 2022;31:1-4.
10. Lai XL, Liu XL, Li L. Self-expansion in intimate relationships. Advances in Psychological Science 2018;26:2170-9. [Crossref]
11. Lyu B, Yan Z, Yu W, et al. Long-term and multiwavelength evolution of a changing-look AGN Mrk 1018. Monthly Notices of the Royal Astronomical Society 2021;506:4188-98. [Crossref]
12. Hu SH, Yu Y, Chang W, et al. Social support and factors associated with self-efficacy among acute-care nurse practitioners. Journal of Clinical Nursing 2018;27:876-82. [Crossref] [PubMed]
13. Croy G, Garvey L, Willetts G, et al. Anxiety, flipped approach and self-efficacy: Exploring nursing student outcomes. Nurse Educ Today 2020;93:104534. [Crossref] [PubMed]
14. Chinese Society of Andrology. Guidelines for the diagnosis and treatment of erectile dysfunction. Chinese Journal of Andrology 2022;28:722-55.
15. Rosen RC, Cappelleri JC, Smith MD, et al. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res 1999;11:319-26. [Crossref] [PubMed]
16. Patrick H, Knee CR, Canevello A, et al. The role of need fulfillment in relationship functioning and well-being: a self-determination theory perspective. J Pers Soc Psychol 2007;92:434-57. [Crossref] [PubMed]
17. Xiao SY. The Theoretical Basis and Research Application of Social Support Rating Scale. Journal of Clinical Psychiatry 1994;4:98-100.
18. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-7. [Crossref] [PubMed]
19. Schwarzer R, Bäßler J, Kwiatek P, et al. The assessment of optimistic self-beliefs: Comparison of the German, Spanish, and Chinese versions of the General Self-efficacy Scale. Applied Psychology: An International Review 1997;46:69-88.
20. Hair JF Jr, Black WC, Babin BJ, et al. Multivariate Data Analysis. Boston: CENGAGE; 2018.
21. Başar K. The Changes in ICD-11 Related to Sexual Health and Dysfunction and Their Implication for Clinical Practice. Turk Psikiyatri Derg 2025;36:31. [PubMed]
22. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977;84:191-215. [Crossref] [PubMed]
23. Trifu DM, Leucuța DC, Pintea-Trifu ML, et al. The Relationship Between Erectile Dysfunction and Dyadic Adjustment, Couple Relationship Quality, and Intimacy: A Cross-Sectional Study. Medicina (Kaunas) 2025;61:1590. [Crossref] [PubMed]
24. Chen J, Ge Y, Jin X, et al. The mediating effect of social support on the relationship between intimacy and perceived partner responsiveness in endometriosis women of childbearing age. Front Psychol 2024;15:1437335. [Crossref] [PubMed]
25. İyiaydın AA, Sümer ZH. The mediational role of intimate partner acceptance and psychological adjustment in the relationship between intimate partner control and marital adjustment. Current Psychology 2023;42:1598-608. [Crossref]
26. Alzahrani MA, Alkhamees M, Almutairi S, et al. Effect of COVID-19-Induced Stress among Males on the Partner Relationship and Sexual Activity during COVID-19 Pandemic: A Cross-Sectional Study. Healthcare (Basel) 2022;10:1663. [Crossref] [PubMed]
27. Hu P, Qin X, Zhu Y, et al. The chain mediating effects of self-efficacy and social support on family function and anxiety in male infertility patients. Transl Androl Urol 2024;13:1859-67. [Crossref] [PubMed]