Misconceptions of Erectile Dysfunction: A pill will fix it right?

Not getting erections when you want them, losing an erection before you want to, or not getting hard enough to engage with the kind of sex you want to are all common experiences for people of many ages. They are commonly labelled as erectile dysfunction (ED) by people going through this; however, these experiences do not always meet the diagnosable criteria for ED, and treatment should always be tailored to the specifics of the individual. For example, does this occur only with sexual partners, all the time, only sometimes? It’s important information. 

Unfortunately, most people are directed towards pharmaceutical treatment without a comprehensive assessment to determine if this would be the best course of action for the individual. Some clients see incredible results from taking PDE5 inhibitors like sildenafil or tadalafil (AKA viagra), while others see little results, or feel like it is only a bandaid solution. This is why seeing a specialist is so important. This is why this article is so important.

By the end of this article, you should have a deeper understanding of the impacts psychological, emotional, relational, physiological, and lifestyle factors can have on the development of ED symptoms and how an integrative and tailored approach is the best bet for long-lasting sexual confidence and fulfilment.

Before we begin, it is important to state that having a qualified medical practitioner check individuals with ED symptoms for any underlying biological causes is the first step when engaging with treatment. I refer all of my clients to a trusted specialist to make sure there is not an underlying medical concern.

Prevalence Rates

Did you know that a recent study conducted in the UK in 2022 involving over 12,000 men found that 29.3% of men aged 18-39 reported experiencing ED, which increased to 45.6% for men over the age of 40. It’s more common than you think. 

You can read more on the study here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9159135/. 

Overarching Psychological Factors

Let’s start with exploring some of the key reasons men with ED symptoms benefit from sex therapy. 

  Stress and anxiety are one of the leading causes ED. Performance anxiety in particular can create a vicious cycle where fear of not being able to achieve, or maintain, an erection leads to further stress and therefore exacerbating the problem. Slowing down and exiting out of self-critical thoughts to engage with compassionate exploration can lead to a deeper understanding of where the stress and anxiety stems from. Only then can results truly start to be seen.

Anxiety can stem from so many places. Societal pressures, personal expectations, and previous negative sexual experiences are all examples. Meanwhile, chronic stress can affect the body's ability to function, leading to hormonal imbalances and impaired blood flow, both of which are crucial for erectile function. Of course, this can also impact the desire to engage with sex at all.

Depression is another mental health condition that can significantly impact sexual health. Feeling a lack of energy, motivation, excitement and playfulness often leads to a decreased interest in any sexual activity, but especially partnered sex which can feel like ‘too much effort’, and can also impact the ability to achieve or maintain an erection. It’s as if the body is too exhausted to generate physiological arousal. Furthermore, this can be made worse when paired with medications commonly prescribed for depression, such as selective serotonin reuptake inhibitors (SSRIs) which lists ED as a side effect. 

Men experiencing depression may also struggle with low self-esteem and feelings of inadequacy. Which is a tricky thing to navigate during partnered sex, which can be quite vulnerable. Feeling inadequate is definitely not a turn on for the vast majority of people. Being able to work through these feelings is a key turning point for many men to be able to reintroduce playful, sensual, or enlivening sensations back into their sex lives, resulting in greater pleasure and increasing their sense of connection to both their partner and their own sexuality.  

While some men can see significant change in a few sex therapy sessions, men with trauma, especially related to sexual abuse or emotional neglect, can find that there is more to unpack. Trauma creates long-lasting impacts in individual’s interpersonal and sexual lives. It needs to be unpacked slowly and at an accessible pace. For example, for individuals with traumatic experiences, other people can still unconsciously regarded as threats in vulnerable situations, even if they are loved intimate partners. This results in the body raising defences and entering a fight/flight/freeze response during sexual activities. While this can be obvious in the case of a panic attack, it can also be subtle; such as the inability to maintain an erection. Trauma does not have to be sexual for it to manifest this way either. It can be any unresolved trauma.

Specific Psychological Factors

Two specific experiences that I have seen in the clinical space frequently are fear of intimacy and guilt and shame - their linking factor? Avoidance and withdrawal.

Fear of intimacy often develops from previous experiences of betrayal, abandonment, or rejection by a significant person or intimate partner. This can sometime be as complex as experiencing a messy divorce of parents as a child, or as self-explanatory as ED developing after being sexually criticised in a cruel way by a sexual partner. This fear exists as a protective mechanism to prevent further emotional harm, however can ultimately cause more distress which becomes a worsening cycle of avoidance and fear.

Another thing that can evolve from negative sexual experiences is guilt and shame. But it can also originate from cultural, familial, or religious beliefs, even infertility. Sometimes shame is something that evolves after engaging in behaviour that is at odds with personal values, and sometimes it evolves from external judgements around what sex should be that have been internalised unconsciously. These feelings can often be strong and elusive, operating insidiously in the background to influence avoidance behaviours, physiological stress, and contributing heavily to the development of negative self-esteem and ruining sexual confidence.

Addressing the complexity of emotions that may be underpinning the development and continuation of ED is admittedly far less straight forward than being prescribed a medical intervention. It can be daunting going to therapy. It requires courage to face the things that are currently being avoided. Every client of mine is brave and I admire their courage daily. I get to hear their ‘why’. Why do they value this? What do they hope to gain from it? How do they stay motivated? The reason is often some variation of connection. They want to connect to their bodies again, to pleasure, and to their partners.

Relational Factors

Relational concerns are another key feature of sex therapy for ED if a client has a committed sexual relationship. Sex in relationship is not just about one person and difficulties soon begin to become shared experiences. Thus, they need to be treated as such. There are so many unique difficulties people can experience, however some overacting categories do pop up more frequently than others. Primarily they are communication, attraction, and mismatched desires.

Open and honest communication is fundamental to a healthy sexual relationship. When partners cannot discuss their sexual needs, desires, and concerns, misunderstandings and dissatisfaction can easily arise, contributing to ED because men feel confused, uncertain and hesitant. Working with couples to talk openly about their sexual experiences in a supportive and non-judgemental environment can help alleviate the pressure and improve erectile function simply because confidence and connection improves with both individuals and the relationship as a whole.

  Changes to attraction and the desirability of sex can be slightly more difficult to support positive change without the help of a sex therapist. Society loves to tell long-term couples that sex should be something that ‘just happens’ and continues to happen. Sure, there might be some conversations about novelty seeking, and “relighting the spark” but what does that actually mean? How do couples support the continued nurturing of attraction, intimacy, and desire? It takes work. For couple who experience this, I love to give them more resources and work together with them to find out their sexual blueprint. What state do they need to be in to invite in the erotic? A great book I recommend is the recent publication: Come Together: The Science (and Art!) of Creating Lasting Sexual Connections by Emily Nagoski. 

Lastly, mismatched desire. Whether it be a mismatch of the amount of sex desired, or a mismatch of the type of sex wanted. It can be a lot of pressure to engage with sex that is undesired, even if the motivation to please your partner is a strong one! People pleasing is not often an arousing motivation for sex. It does not excite the body or the mind. Men in both heterosexual and gay relationships can find themselves with a lower libido than their partner. For heterosexual men this can be a strange experience that seems at odd with societal messaging. In truth, gender is not a strong factor in who has the higher libido, but preconceived notions result in embarrassment, a break down of communication, and men feeling shame that results in the loss of erections. Another common reason is for individuals with sexual interests that are not shared with a partner. It may be a kink or fetish, or something more vanilla, but if one person’s interests are being entirely prioritised then this creates an undesirable imbalance. When relationship factors become a concern, it can be beneficial to have a client’s partner come in for some couples sessions to support the therapeutic journey.

Sex Therapy

Sex therapy can look like a lot of things. I often speak to clients during their discovery call who ask me how long it will take and what it will involve. I have to respond honestly and say that it depends on where the journey takes them. Struggling to gain and maintain erections is often a symptom of a bigger concern. The first step is to therefore figure out what that broader concern is before we can start to treat it. From there we can tailor a plan that concentrates on addressing the core problem with emphasis on their goals. I will often use emotion-focused therapy for clients with a strong emotional concern such as fear, shame, and trauma, whereas I would use more educational and behavioural interventions for clients who are struggling with finding the specific type of sex that excites them. Medical approaches may be an option to explore. Mindfulness-based interventions are great for being able to access greater forms of felt pleasure and present-moment awareness, and couples therapy is essential if the ED is primarily relational! There is no one-size fits all. 

If this is something you a struggling with then I encourage you to be brave and to reach out to book in a 15 minute discovery call today.