The relationship between anxiety, depression and religious coping strategies and erectile dysfunction in iranian patients with spinal cord injury

ABSTRACT OBJECTIVES: To assess the role of anxiety, depressive mood and religious coping in erectile function among Iranian patients with spinal cord injury (SCI). SETTING: Brain and Spinal

Cord Injury Repair Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. METHODS: A sample of _N_=93 men with SCI participated in this cross-sectional

study. Levels of anxiety and depressive mood were assessed using the Hospital Anxiety and Depression Scale. Religious coping strategies were measured using the 14-items Brief Coping

Questionnaire. Erectile function was assessed using the International Index of Erectile Function. The joint effect of anxiety, depressive mood and religious coping strategies on erectile

function was assessed by performing stepwise multiple linear regression analyses. RESULTS: The mean age of the SCI patients was 37.8 years with a mean post-injury time of 4.6 years.

Multivariate regression analyses indicated that age (_B_=−0.27, 95% CI=−0.47 to −0.07), education (_B_ for higher education=0.63, 95% CI=0.24 to 1.02), the American Spinal Injury Association

impairment scale (_B_ for complete impairment=−3.36, 95% CI=−3.82 to −2.89), anxiety (_B_=−3.56, 95% CI=−5.76 to −1.42), positive religious coping (_B_=0.30, 95% CI=0.03 to 0.57), negative

religious coping (_B_=−0.56, 95% CI=−0.82 to −0.29) and the duration of injury (_B_=−0.25, 95% CI=−0.22 to −0.29) were all independent factors influencing erectile function in SCI patients.

CONCLUSION: Overall, the results indicated that SCI patients who use positive religious coping strategies had better erectile function compared with individuals who applied negative

religious coping strategies. Furthermore, higher levels of anxiety, greater impairment and longer duration of injury turned out to be risk factors for erectile dysfunction. SIMILAR CONTENT

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EXAMINING THE RELATIONSHIPS BETWEEN BOWEL DYSFUNCTION AND QUALITY OF LIFE AFTER SPINAL CORD INJURY Article Open access 16 July 2024 INTRODUCTION Spinal cord injuries (SCIs) can have

detrimental effects on various aspects of life for affected individuals.1, 2 Apart from severely impacting on overall quality of life, SCI also impacts on sexual quality of life by reducing

sexual function and the sensation of the genital organs.3, 4 SCI predominantly affects males aged between 18 and 45 years.5 Previous studies have shown that male sexual dysfunctions are very

common among SCI patients, with erectile dysfunction (ED) being the most prevalent complaint.6, 7, 8 ED is an important public health problem defined as the persistent inability to achieve

and maintain an erection sufficient for satisfactory sexual activity.9 A vast amount of literature has identified ED as a frequent consequence of SCI.10, 11 It has been recognized that SCI,

its level and lesion severity can significantly affect both types of erection—the reflexogenic and the psychogenic erection—and consequently alter a patient’s overall erectile ability.12

Therefore, improvement of sexual functioning in patients suffering from SCI is considered a central issue during the post-SCI rehabilitation process, eventually leading to an overall

improvement of their quality of life.13 Identification of risk factors of ED in this specific patient cohort is an important step for the development of appropriate and holistic prevention

and treatment programs. Previous studies have shown that—among others—higher levels of anxiety and depressive mood are considered risk factors for male sexual dysfunction in patients with

SCI.14, 15 This particularly seems to be the case in SCI patients also reporting significant medical comorbidities, which can lead to increased pain expectation, discomfort, anticipation of

sexual distress, anxiety related to genital function or an altered body image.16 Moreover, depressed SCI patients frequently suffer from loss of energy and loss of overall and sexual

interest and decreased self-esteem, which can lead to various types of male sexual dysfunction, although loss of sexual desire has been the most frequent complaint reported.8, 10 Patients

with SCI have to deal with multiple challenges. To adapt and cope with the distressing situation or event, they apply a variety of coping strategies,1, 2, 17 some of which have shown to be

beneficial, whereas others tend to act dysfunctionally.18 Religious coping is one such beneficial strategy and is considered an active coping mechanism frequently used in individuals

suffering from all sorts of bodily disabilities1, 19 and often leading to a higher quality of life. The use of such positive religious coping strategies might be similarly helpful in

patients with SCI when being confronted with injury-related sexual impairment. Two broad religious coping patterns have been suggested in the literature: positive (adaptive) and negative

(maladaptive) religious coping strategies. Positive religious coping is related to a secure relationship with a supportive God, whereas negative religious coping describes a less secure

relationship with God who presents itself distant and punishing.20 Given the beneficial role of religious coping in other patient groups having to deal with bodily disabilities, we

hypothesized that there would be a relationship between depressive mood, anxiety and religious coping with erectile dysfunction in patients with SCI. Therefore, the aim of the present study

was to investigate the influence of comorbid anxiety and depressive mood in patients suffering from SCI on their erectile function by considering the usefulness of positive religious coping

in dealing with the injury. For this, the effects of religious coping on erectile functioning and sexual quality were explored. MATERIALS AND METHODS PATIENTS AND SETTINGS Male patients with

SCI participated in this cross-sectional study conducted in Tehran, Iran. Participants were recruited consecutively from the Brain and Spinal Cord Research Center—an academic referral

center. Individuals were included if they were male and at least 18 years of age at the time of study. To avoid potential biases resulting from the influence of certain medical comorbidities

known to cause male sexual dysfunction, patients suffering from diabetes mellitus, cardiovascular diseases, hypertension, rheumatic diseases and kidney disease were excluded from this

study.21 A total of 100 patients with SCI were approached. Seven patients declined to participate in the study for personal reasons, resulting in a final sample of _N_=93 individuals with

SCI meeting the inclusion criteria. Demographic and injury-related characteristics were obtained through interviews (self-report), neurologic examinations and hospital records. The study was

approved by the Institutional Review Board of the Brain and Spinal Cord Injury Research Center in Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. All the

patients provided written informed consent before entering the study. MEASURES Demographic and injury-related characteristics of the men participating in the study were collected using

study-specific questionnaires. SCI severity was classified according to the American Spinal Injury Association (ASIA) assessment protocol into complete (ASIA grade A) vs incomplete (ASIA

grades B and E) SCI.22 All the patients were rated by a neurosurgeon who was blinded to the study aims. To assess religious coping strategies, the 14-item self-report Brief Religious Coping

Questionnaire was used.23 The questionnaire consists of two subscales including positive and negative religious coping. Items are rated on a four-point Likert-type scale ranging from 1

(strongly disagree) to 4 (strongly agree), resulting in a total score ranging from 7 to 28 for each subscale.23 The inventory has been validated in an Iranian population sample and has

demonstrated excellent psychometric properties.24 ED was assessed using the short version of the International Index of Erectile Function—the IIEF-5.25 The IIEF-5 contains five items

assessing the presence and severity of ED over the past 6 months. Each item is scored on a five-point Likert-type scale ranging from 1 to 5, with higher scores indicating better erectile

functioning. IIEF-5 scores range from 5 to 25. The presence and severity of ED was classified based on the IIEF-5 total score into absent (>21), mild (17–21), mild/moderate (12–16),

moderate (8–11) and severe (<8). The psychometric properties of the Iranian version of the IIEF-5 have been previously demonstrated.26 Anxiety and depressive mood were assessed using the

Hospital Anxiety and Depression Scale.27 The questionnaire consists of 14 items, each rated on a four-point Likert-type scale ranging from 0 (absence of symptoms) to 3 (severe symptoms),

resulting in a maximum score of 21. An Iranian version of Hospital Anxiety and Depression Scale exists and has shown to have adequate psychometric properties.27 STATISTICAL ANALYSIS The

total IIEF-5 score was considered as the main erectile functioning outcome variable. The level of significance was set at 5%. The _B_ coefficient and 95% confidence intervals were reported

as indicators of any association between the dependent and the independent variables. Negative values indicated a negative relationship, whereas positive values indicated a positive

relationship between the variables. Normality of the variables was tested using the Kolmogorov–Smirnov test. Logarithmic transformation was used to convert non-normally distributed

variables. Stepwise multivariate linear regression analyses were performed to assess the magnitude and significance of the associations between anxiety, depressive mood, religious coping and

erectile functioning. To identify the factors affecting erectile functioning, univariate analyses (that is, Pearson’s product moment correlations) were performed before running the

multivariate linear regressions. Pearson’s product moment correlations were used to identify the factors (using _P_-value <0.15) to be included in the multivariate model. A _P_-value

<0.05 was considered statistically significant unless stated otherwise. All statistical analyses were performed using SAS version 9.1.3 (SAS Institute Inc., Cary, NC, USA). RESULTS Sample

characteristics are shown in Table 1. The mean age of the participants was 37.76 years (s.d.=9.2, ranging from 19 to 63 years). Overall, SCI patients reported more positive religious coping

than negative religious coping (mean of 24.3, s.d.=3.5 vs 14.90, s.d.=3.7). In addition, the participants reported slightly higher levels of anxiety than depressive mood (mean=7.79,

s.d.=4.0 vs 7.41, s.d.=3.2). Eighteen (19.4%) patients reported having completed a higher education and 11 (11.8%) patients were employed. Almost half of the patients (51.6%) suffered from a

complete SCI according to the AIS (ASIA Impairment Scale) A (Table 1). On the basis of the IIEF-5 classification for ED, only 29% (_n_=27) of the patients did not suffer from ED, whereas

mild, mild/moderate, moderate and severe ED was reported by 14% (_n_=13), 7.7% (_n_=7), 8.7% (_n_=8) and 41% (_n_=38), respectively. Pearson's product correlations revealed significant

correlations between erectile functioning and depression (_r_=−0.30, _P_=0.003), anxiety (_r_=−0.38, _P_=0.003), positive religious coping (_r_=0.25, _P_=0.031), negative religious coping

(_r_=−0.215, _P_=0.038), AIS (_r_=−0.22, _P_=0.032), age (_r_=−0.25, _P_=0.016), injury duration (_r_=0.20, _P_=0.05) and education (_r_=0.30, _P_=0.004; data not shown). Similarly, when

entered into the multivariate regression model, significant independent effects of age (_B_=−0.27, 95% CI=−0.47 to −0.07), education (_B_ for higher education=0.63, 95% CI=0.24 to 1.02),

ASIA (_B_ for complete impairment=−1.76, 95% CI=−2.24 to −1.28), anxiety (_B_=−3.59, 95% CI=−5.75 to −1.42), positive religious coping (_B_=0.30, 95% CI=0.03 to 0.57), negative religious

coping (B=−0.56, 95% CI=−0.82 to −0.30) and depression (_B_=−0.75, 95% CI=−1.30 to −0.20) on erectile function could be detected (Table 2). DISCUSSION Studies investigating the risk factors

for ED in men with SCI are scarce, and the majority of the existing studies have focused on demographic variables and injury-related factors such as injury level, severity, distress and so

on.2, 14, 16 The aim of the present study was to explore how psychological comorbidities (that is, anxiety and depressive mood), as well as religious coping, influence SCI patients’ erectile

functioning. Previous research has shown that religiousness as an individual coping strategy can have a significant influence on the rehabilitation process and the re-establishment of

overall quality of life in patients with SCI.28, 29 This may also be true for their sexual quality of life and erectile function, although this specific aspect has received little attention

in previous research. RELIGIOUS COPING According to our findings, positive religious coping was associated with less erectile dysfunction, with men reporting being more religious, also

reporting less erectile impairment and dysfunction—independent of the injury level and severity, as well as psychological comorbidities. SCI patients may use spiritual coping to deal with

their disability and its effects on erectile dysfunction. However, the strength of the association was small, and therefore the results have to be interpreted with caution and replicated in

larger samples as it could reflect unmeasured confounding and/or measurement error. Nevertheless, our results are somewhat in accordance with findings from a previous study reporting a

positive association between spirituality, life satisfaction and overall quality of life in people with spinal cord injury, and our findings are justifiable.28 Associations between sexual

problems and more general sexual behaviors with religiosity have also been investigated in several other studies. Gudorf,30 for example, reported people with sexual dismorphism to be more

engaged in religious beliefs and behaviors compared with people with a ‘normal’ sexual appearance. Less engagement in risky sexual behaviors among religious people compared with

non-religious people may also explain the important implications of religiosity in coping with sexual dysfunctions.31, 32 ANXIETY AND DEPRESSIVE MOOD Apart from religious coping, we were

also able to observe a significant association between anxiety and depressive mood and erectile function in men with SCI. It has been repeatedly shown that depressive mood and anxiety levels

are high in patients with SCI.2, 16 Equally, both have been shown to act as important factors influencing men’s sexual function.33, 34 It has been argued that psychological factors are more

important for a satisfying sex life and the quality of the relationship in patients with spinal paraplegia.35 Molina-Leyva _et al._,36 for example, suggest that when secondary psychological

problems in individuals suffering from chronic physiologic conditions are present, very often this may also negatively affect sexual functioning. In other words, in people with psychosis or

other psychological disorders, sexual activity may be decreased because of their impaired mental health. In addition, physically handicapped individuals reporting sexual impairment often

tend to become sexually isolated—therefore further aggravating and extending the problem.37 In people with SCI, the limited mobility and inappropriate coping with the situation can cause

anxiety/depressive mood, which may be further enhanced by additional disease-related impairments such as sexual problems. Another mechanism that may underlie the link between sexual

disability and anxiety/depressive mood might be attributable to social relations—especially romantic relationships—in people suffering from SCI. Several studies have shown that people with

sexual problems receive lower degree of social support from their friends or social networks than healthy people.38, 39 The mediating role of religious coping on depressive mood and anxiety

in such people has also been confirmed in previous studies.29, 40 AGE, EDUCATION AND AIS LEVELS In this study, we were also able to observe an association between erectile function and age.

Erectile dysfunction was found to be an age-dependent problem with prevalences increasing as function of age.41, 42 Interestingly, the more time had passed since the injury, the less

erectile problems were reported. This is in accordance with the findings from another study reporting a positive association between time since injury and sexual satisfaction.43 This can be

explained by the fact that patients with SCI may take some time to adapt to the situation and to learn more problem-focused strategies to deal with their condition and related sexual

problems. We also found an association between AIS level and erectile function. Again, this result is consistent with previous studies showing significant relationships between the degree of

the injury and the location and sexual functioning.44, 45 In addition, it has been reported that AIS level affects other dimensions of sexual function in men with SCI. Therefore, it was

determined that men with incomplete SCI were more likely to experience orgasm compared with men with complete SCI.46 Our results also showed that the level of education was a significant

contributing factor to sexual functioning in men with SCI. Again, results from a previous study showed that patients with greater improvement in sexual function after time also report higher

levels of education.47 This could be explained by the fact that as the level of education is one of the personality-related predisposing factors for help-seeking behaviors and a healthier

lifestyle, the well-educated patients are more likely to have help-seeking behavior for sexual function. LIMITATIONS The results have to be considered in light of a number of limitations.

First, we used a consecutive sample, and therefore our findings may not be generalizable to all people with SCI. Using a randomized, multicenter study with larger samples may overcome this

limitation in future studies. Second, we designed a cross-sectional study, which is inherently limited for detecting causal relationships. Thus, future research should consider using

longitudinal studies to better understand the direction and nature of these associations. Finally, we used self-report measures to investigate sexual function and other variables such as

anxiety, depressive mood and religious coping. Recall or information bias, as well as social desirability, may have confounded our results; however, for socially sensitive topics such as

sexual behavior, using these scales is inevitable. CONCLUSION Significant associations between religious coping, anxiety and depressive mood and erectile functioning in men with SCI could be

observed. This is the first study to demonstrate the importance of religiosity in coping with sexual disabilities resulting from SCI. Further research is needed to understand how religious

coping may influence the adjustment to chronic conditions, especially in those with physical disabilities related to spinal cord damage. DATA ARCHIVING There were no data to deposit.

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29: 17–25. Article  Google Scholar  Download references ACKNOWLEDGEMENTS We thank all patients who participated in the study. AB reports an Ambizione personal career fellowship from the

Swiss National Science Foundation. AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Social Determinants of Health Research Center, Qazvin University of Medical Sciences, Qazvin, Iran A H

Pakpour * Iran Department of Midwifery, Shahed University, Tehran, Iran P Rahnama * Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical

Sciences, Tehran, Iran H Saberi * Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran M Saffari & M Hajiaghababaei * Sina Trauma and Surgery Research

Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran V Rahimi-movaghar * Department of Psychology, University of Zurich, Zurich, Switzerland A Burri Authors * A H

Pakpour View author publications You can also search for this author inPubMed Google Scholar * P Rahnama View author publications You can also search for this author inPubMed Google Scholar

* H Saberi View author publications You can also search for this author inPubMed Google Scholar * M Saffari View author publications You can also search for this author inPubMed Google

Scholar * V Rahimi-movaghar View author publications You can also search for this author inPubMed Google Scholar * A Burri View author publications You can also search for this author

inPubMed Google Scholar * M Hajiaghababaei View author publications You can also search for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to M Hajiaghababaei.

ETHICS DECLARATIONS COMPETING INTERESTS The authors declare no conflict of interest. RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Pakpour, A.,

Rahnama, P., Saberi, H. _et al._ The relationship between anxiety, depression and religious coping strategies and erectile dysfunction in Iranian patients with spinal cord injury. _Spinal

Cord_ 54, 1053–1057 (2016). https://doi.org/10.1038/sc.2016.7 Download citation * Received: 29 June 2015 * Revised: 16 December 2015 * Accepted: 05 January 2016 * Published: 16 February 2016

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