The Psychology of Erectile Dysfunction

For 25 percent of men with erectile dysfunction, medication can be ineffective—since their difficulties are largely psychological. To avoid performance anxiety, men and their partners should reframe their ideas of good sex.

One of the most common sexual complaints men present to their primary care physicians is trouble “getting hard” and “keeping it up.” For the last 20 years the treatment for erectile dysfunction (ED) has improved tremendously with the advent of medications such as Viagra, Cialis, and Levitra. Over 75 percent of men taking these medications are able to restore erections. However, for the remaining 25 percent of men, medical treatments are largely ineffective. In addition, a high percentage of men stop taking their medication. This can be explained in part by the fact that ED is both a physical and psychological problem.


Identifying and Changing Beliefs About Sexual Performance

For starters, a lot of men carry the belief that sexual performance and having a firm erection is one of the most defining and important characteristics of every sexual experience. As men try to make sense of their ED, many traditional (and implicit) male values about sexuality are triggered. For example, the inability to maintain erection often leads to feelings of shame because many men believe that “real” men should be able to satisfy their partner. And the only—or best—way to satisfy their partner requires an erection. Some partners will hold similar expectations of the need for the satisfying partner that can serve to worsen the situation.

ED is often strongly linked to performance anxiety. Performance anxiety is a widespread psychological phenomenon that affects many aspects of life, not just sex. It occurs when men become fearful of failure or embarrassed that they cannot achieve or maintain erections. Common thoughts that run through the man’s mind are, “Do I have an erection yet?” or “Am I going to have an orgasm this time?” A vicious circle of anxiety can develop where the anticipated fear of not having an erection results in recurring difficulties actually having one.

Here’s how the cycle starts: Men may hold some imagined fantasy of good sex, which leads to pressure to perform. When men do not achieve the result they were hoping for (i.e., a firm erection), this leads to troublesome feelings—sadness, disappointment, guilt and shame—and a return to negative thoughts that are now compounded by performance anxiety in the company of self-criticism.

The cycle can go on for a long time. For men to break the cycle, they first need to recognize that it exists. Only then can men start to change maladaptive ideas about sexuality that are not entirely helpful. First, men need to appreciate that setting the bar too high is a recipe for failure. Men need to reassure themselves that they do not have to be hard enough to drive nails every time they are intimate. Research has shown that many men with ED actually underrate their erectile response during sexual activity.

Secondly, men need to know that occasional sexual difficulties are normal and thus so are they. Research shows that most healthy men occasionally experience erectile dysfunction or failure. It does not mean you are necessarily impotent or that there is something inherently wrong with you. This can happen to anyone, and usually does at least occasionally.

Third, in western society we see a trend towards “instant gratification.” We want everything right away and instantaneously. This trend influences our relationships and sexual performance by creating a pressure to have an erection instantly and to be outstanding sexual performers. This trend of instant gratification does not take into account the fact that sexual performance is a learning process that takes time. Achieving mastery in sexual performance is no different than achieving mastery in sports or other activities: it takes practice. Sexual performance is a life-long learning process.

Reframing sexual performance as an evolving process that changes over time can lower the pressure that may be causing ED. For example, in the beginning of his career Michael Jordan was a prolific dunker who dominated games with his athletic ability. But as he got older, he relied more prominently on jump shots. The results were the same: He was still able to score—he just did it differently.


Changing the Ways Couples Think About Sexuality

In too many cases, a man’s inability to reach a firm and enduring erection leads to the end of all sexual activity. Here’s a provocative idea for couples: Good sex does not have to involve sexual intercourse. Couples can learn many different non-intercourse forms of sexual stimulation. For example, oral sex, cuddling, sensual touching, sexual massage, role-play, introducing sexual videos, or even food creates new and interesting ways to achieve sexual intimacy and orgasm.

Couples can collaboratively identify novel ways of being sexual together. It is not always easy to start these conversations, but once the subject is introduced and a rule is established about refraining from judgments, people can begin to risk sharing something new they may want to try.

One way to open up a supportive and non-judgmental dialog is by having each person write privately something the couple used to do sexually but rarely does anymore, then share these together. Partners can share their beliefs around what constitutes sexual intimacy. They can voice their frustrations about what is not satisfying them, validate and reinforce the activities that they enjoy, and make suggestions for different types of sexual activity they want to engage in.

It is also important for men to discuss the anxieties, pressures, and negative feelings (shame, guilt, etc.) they face when it comes to sexual performance. Vocalizing these fears can help increase empathy, understanding, and awareness. It also gives both partners an opportunity to examine how each of them may contribute to the ideas that exacerbate ED.

If there are negative relationship patterns that are not helping one’s sex life or relationship, there are ways to change them. A great starting point is for the couple to make the commitment to read together John Gottman’s The Seven Principles for Making Marriage Work. Reflect together on the chapters as they pertain to your relationship and complete the exercises contained inside. These exercises can help strengthen the relationship and lay a firm foundation for increasing sexual intimacy.


Getting Help for Your Erectile Dysfunction

We always recommend contacting your primary care physician first for a thorough assessment in determining the extent to which a man’s ED is physical or psychological. Many of the psychological difficulties that maintain ED are self-induced. This means that men have the ability not only to exacerbate sexual problems; they also have the power to overcome them. The old adage that you must always have a firm erection quickly followed by sexual intercourse to qualify for having good sex is unrealistic and simply inaccurate. Challenging these unrealistic beliefs, tempering unreasonable expectations, embracing sexuality as a life-long process, and being open to different forms of sexual activity can help men achieve diverse kinds of intimate moments with their partners.


Maneet Bhatia is a doctoral candidate in counseling psychology at McGill University in Montreal, Canada. His specializations are in the areas of psychotherapy research, emotions, and male psychology. He is also a practicing psychotherapist and author of a psychology blog entitled Psych State of Mind.

Chris MacKinnon is a psychologist and doctoral candidate in counseling psychology at McGill University in Montreal, Canada. He is currently completing his pre-doctoral internship in the Psychosocial Oncology Program at the Montreal General Hospital. He has written and presented in the areas of male psychology, sexuality and intimacy, as well as bereavement.


More from Sex Week at the Good Men Project:

Benoit Denizet-Lewis: The Dan Savage Interview

Hugo Schwyzer: Male Self-Pleasure Myths

Amanda Marcotte: What Women Don’t Tell You

Ed Fell: 10 Secrets to Satisfying Sex

Andrew Ladd: A Billion Wicked Assumptions

Charles Allen: Why I Hate My Giant Dong

Emily Heist Moss: Does Size Matter?

John DeVore: Multiple Inches of Love

Joshua Matacotta: Do Gay Men Fear Intimacy?

Hugo Schwyzer: Mythbusting Bisexual Men

Wilson & Robinson: Can’t She See I Need It?

Robert Levithan: Sex at 60

—Photo iwona_kellie/Flickr

About the Editors

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  1. Perhaps several areas of ED should be added. Research shows that many males slow down sexually in their early 20s. (as compared to age 16-18: Kinsey). Penile blood flow/capacity lessens as shown by the angle of erection in the early to mid 20s. Refractory Period lengthens in the 20s as compared to 16-18 years of age. Nocturnal Emissions cease in the mid to late 20s. Blood flow to the penis and thus engorgement lessens in the late 20s / early 30s. The number of orgasms possible in a set period diminishes / is cut in half in the late 20 / early 30s. Testosterone levels diminish 1 – 2 % per year as of late 20s. (Mass Male Aging Study). By the 40s, 52% of males have some issue with ED. Sensitivty and orgasmic sensations are diminishing in the 30s. To discuss ED and ignore these truths / situations is denying Male Sexuality and Reality. This is what many males fear. Early and diminishing sexual ability and response. No one talks about of mentions this. Bhatia and Mackinnon should be aware and mention and research these concerns and not ignore these very real unmentioned fears.

  2. I’m 71 years old and had ed for around least 50 years, back in the 60s things were different. Also I’ve been married 47 years and really had no interest in any sex. Wife hated me and I her, so we really have lead separate lives all these years. I just told her s%t happens and that’s the way it is. I rather enjoy not talking or living with her.

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  4. Healthy lifestyle can have a very good effect in your sexual performance. Make sure to make it a point to have balanced routine.

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  6. Good Post. I really like your way of expressing the opinions and sharing the information.ED can be treatable at any age. Exercising everyday and right amount of sleep could be good for health and stay fit. If you are suffering from ED you should quickly concern a doctor and resolve this issue. Kamagra impotence drug are the most effective pills in medications of ED. They causes very less side effects.

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  8. Change the Metaphor—

    How tragic that so many men treat their own precious sexuality like it were a sport, something to be documented on the front page of the Sports section of their favorite newspaper. To wit: keeping score, always wanting something better, statistics, turbo-charging it with porn, taking Viagra as if it were a chemical cast for a sprained member (or perhaps, a fix for a flat tire), etc., all competitive, linear, sports metaphors for one of the greatest mysteries of life.

    Therein lies the problem. Men are applying a one-dimensional metaphor (sports statistics) to their sexuality. Genuine sexuality cannot be captured, bought, sold, possessed, understood, measured, quantified, dominated, enhanced or diminished—none of those things at all. Poets allude to sexuality, great music dances with it, literature and art express our yearnings, our joys and frustrations, but these thisngs are the closest we human are allowed to “document” sexuality. The metaphor for sexuality is Mystery itself.

    Genuine sexuality requires full-on, fully-developed masculinity. That means a fully-developed man—including his heart. His mind and penis are invited to participate BY his own heart and his partners’ heart. Taking Viagra is a complete msiunderstanding of where and what the dysfunction really is. Given that many men do not bring their hearts to their sexual experiences, it is especially poignant that Viagra is dangerous to the heart. These men continue having “experiences” and try to make quantity the cover for the vague emptiness they feel somewhere in the vicinity of their chests.

    Change the metpahor for sexuality, guys. Forgo the Viagra and read Robert A. Johnson’s “We,” (and everything else that man ever wrote). Read Robert A. Master’s work. Make Mystery your sexual metaphor and the Viagra will be exposed as the marketing ploy to keep you men one-dimensional ad infinatum that it really is.

    • Please excuse the typos, I sent that from my cell phone. 🙂

    • Henry Vandenburgh says:

      I don’t use sports statistics. I’m a dedicated and sensuous lover of my wife, and, in the past, a number of other women. There is zero difference between my pre-Viagra lovemaking and my post -Viagra lovemaking. None. I don’t know if my ED is due to my high blood pressure meds or my age. I don’t care.

      Years ago, I picked up a psychiatric nursing degree, although I’m now a medical sociologist. You are completely wrong about Viagra and the heart. If anything, it would de-stress the heart because of lowered blood pressure. It was developed as a high blood pressure medication.

  9. Viagra seems to be given more power than it should have in setting the stage for the sexual exploitation of older women. As I have seen Virectin Side Effects pills it is also the best to enhance sexual life .

  10. Great information here…wish it included a common culprit, Internet Porn viewing which often becomes insidiously compulsive. At our website, we get contacted by many men just dumbfounded at how they initially sought out online porn in an effort to BOOST their libidos, and Presto, their ED seems to have vanished while surfing porn as their tumescence reaches unparalleled levels in front of their computers. But then after repeated usage and time, their attempts to transfer their new sexual ‘prowess’ to a real-life partner often leaves them even LESS able to achieve erection.. Neuroscience fully supports the data for why/how this happens….check out our resources online, all of them free at Partners of Sex Addicts Resource Center dot com….but especially useful is a chapter in Dr. Norman Doidge’s book, The Brain That Changes Itself, (chapter on Acquiring Tastes and Loves)….it’s all right there in plain science.

    Tragic that what starts out as a “solution” to low desire can end up crashing the man altogether, sexually. And Mr. MacKinnon and Mr. Bhatie are right; ED is only partly a physical problem. With porn, what easily creeps into one’s psychology are also unrealistic expectations superimposed onto our real-life partners, comparisons we can’t really parse away…and often leaves us with the unwanted feeling that we’re not “getting it all” or enjoying as much of the sexual smorgasbord as others are….
    What a high cost to pay for such a supposedly “harmless” past-time.

    • Henry Vandenburgh says:

      I agree with Lili in essence. A dimension that’s missing, though, is the way in which couples and women use porn as an adjunct to develop the woman’s desire. As a sociologist, I’ve heard multiple accounts of this. Given the overarching sex-negative culture, it’s likely that women get a “permission giving” from this. Also, women respond physiologically to porn, lubricating and so forth when watching it, even if their response isn’t a conscious one. During actual sex while using porn, it’s likely that this activity becomes conscious, and supercharges the woman’s response. Even if this activity is initiated by the male partner (it usually is), women do experience, and frequently respond to, porn used in this way. I’d fault, again, the amazingly (and subtlely) repressive culture we have.

      • Sorry, Henry, I think I might have been unclear….when I wrote, ‘…we are not “getting it all” and enjoying as much of the sexual smorgasbord as others are….” I did not mean WE as women. I meant the collective we.
        On our website, we deal with the effects of sexual compulsivity on the partners of the compulsives/ addicts, which can be either gender.
        Once compulsion enters the picture, all bets are off…..and Internet porn creates such a potent neurochemical experience, in the user it leaves the partner of the compulsive completely out of the picture unless they don’t mind being masturbated inside of, since most compulsives begin superimposing their favorite acts and performers onto their real-life partners. So….I need to be very clear in that. That there are many women who get excited by watching porn is certainly true, but again, I was speaking about once using it becomes compulsive….and that’s often when ED can happen or if it already exists, it can be greatly exacerbated when porn is consumed. That’s the context for this comment, after all. (see Marnia’s comment as well)
        And yes, I agree with you…we have an amazingly repressive culture and that’s why we are all out here discussing this! Thanks for your participation……Lili

  11. This article does a good job discussing “performance anxiety.” I would also mention that David Schnarch, in his books (including the pioneering “Passionate Marriage”), discusses how anxiety over intimacy is also a barrier to arousal. He characterizes this problem as a man having a “high threshold for pain, but a low threshold for anxiety.” Anxiety itself is often a defense to feeling an emotion (the primary four being: mad, sad, glad and scared). So, the more we become emotionally available, the less pain we have to feel, the less anxiety we have to feel and the more we can have good sex – at any age.

    For those who care about women and like having sex with them, I would also mention that, as a woman, I don’t really want sex to be a performance anyway. As Schnarch discusses, when you are relaxed around your partner, sex, including arousal and orgasms, are much easier and more fulfilling (and not just for the man but also for the woman, for those who are concerned about our experience).

  12. Although ED can be anxiety producing, it is not always a product of anxiety. We listen to the woes of many young men with ED/delayed ejaculation issues. I’m happy to report that they consistently overcome their ED when they stop masturbating to hyperstimulating Internet porn/chat for 4-12 weeks. This 28-year old’s story is becoming typical: (More recovery self-reports are available at I hope experts will counsel their clients about this approach. It requires no risky sexual enhancement drugs, and guys notice additional benefits from their change in behavior as well.

  13. Henry Vandenburgh says:

    I don’t disagree with any of the above, and I do appreciate the lack of the usual anti-Viagra hysteria that this site sometimes promotes.

    • Henry P. Belanger says:

      I think if you read the articles that we’ve run that have mentioned / are about Viagra, you’ll see a fairly consistent message (esp. given that we don’t actually have an editorial position on Viagra, let alone promoting anti-Viagra hysteria): It’d great for men who need it, and it can be great for men who don’t really need it. But 1) it shouldn’t stand in for being a great lover (ie, being rock-hard all the time isn’t a necessary or sufficient condition for having great sex), and 2) It shouldn’t stand in for good physical or psychological health. i.e., If you’re an overweight, inactive smoker with poor blood flow and performance anxiety, Viagra will probably do the job—but in addition to taking Viagra you should probably quit smoking, take a walk now and then, and maybe talk to a therapist.

      You may argue with that message, but to say that we promote “anti-viagra hysteria” isn’t even just hyperbole; it’s not true.

      • Henry Vandenburgh says:

        A couple of your articles (different authors) have strongly implied that there a dichotomy between sensitivity and Viagra use. The first one seemed to say that Viagra likely caused sexual compulsiveness in terms of forcing unwanted duration on a partner (based on an anecdote the author heard.) Another tossed off the line (something like) “get off the Viagra and exercise.” I’ve seen Viagra used in this counterpunctual way at least one other time, and certain commentators seem to believe that Viagra is the “anti-sensuality.”

        I agree with 99 percent of your first paragraph.

      • Mr. Belanger. On behalf women who have been harmed in having sex or other relationships with “Viagra men,” thank you.

        • Henry Vandenburgh says:

          Emily, I ordinarily appreciate your posts. I’d sincerely like to know more about the idea of “Viagra Men Harming People.” Can you say more about this?

          • Henry Vandenburgh says:

            I guess I need to take the bull by the horns here. In several pages of google search, I only found two creditable critiques of Viagra use. One, by Resh, an OB-Gyn, cites the idea that men who use Viagra in their old age my not be paying attention to the fact that older women may have lost ability to lubricate and vaginal elasticity. So they may be physically less able to have comfortable intercourse. This IS probably a factor. I’ve taught aging, and know that this is true. To some extent, sex with the elderly is a “use it or lose it” proposition. Still, Viagra can be a comfortable adjunct to continuing intercourse for couples who are interested. There’s nothing about Viagra that operates like an aphrodesiac, so the couple’s use of sexuality still depends and should depend on mutual comfort and consent. The physical truth about elder sex is that lubricants must frequently be used and that an unused vagina will contract.

            There’s also an interview with Mika Loe, a sociologist (this happens to be my discipline as well) where Viagra seems to be given more power than it should have in setting the stage for the sexual exploitation of older women. I’ve no doubt that Loe has identified some issues about communication and elder-sex, but she seems to take a procrustian a priori stance that the Viagra is the driver. Inserted in the interview somewhat oddly is an incident where an elderly rapist also used Viagra, and reference to a pharmaceutical article where Viagra was said to “play a role” in 27 incedents of sexual misbehavior.

            Again, Viagra isn’t an aphrodesiac, and, even if used to get an erection, is not a driver of this behavior.

            • Henry Vandenburgh says:

              It turned our that I had a Loe article here at home. The article is much more extreme (and flawed) than the interview. Loe announces that she is a postmodernist by citing “phallogocentrism” at the beginning. This sets the stage for an extremely theoretically and methodologically flawed piece where she just assumes such troubled (and in my mind discredited) concepts as progressive “medicalization” as bad things. Medicines that may give relief from credible medical conditions are reframed as reengineering the male body in a bad way. I don’t want to hit this too hard, but this may be analogous to saying that Digoxin (a heart med) may be reengineering bodies toward prolonged survival. Okay by me.

              The set of interviews are framed as male self-critiques of Viagra use. They are an opportunity sample in which there is much confabulation to please the interviewer– at least this seems to be the case. One interviewee says that on Viagra “all you can think about is sex.” This is absolutely not true. There is no direct psychological effect. As a satisfied Viagra user, I find the interviews extreme. Because of the drug’s popularity, I believe that most users do not react this way. My own experience, too, is that female partners don’t mind if the male uses Viagra. Quite the opposite in fact.

              Clearly if a new Viagra user is forcing sex on a partner who doesn’t want it, he should stop. But I do find a suspicious sex-negativity in Loe’s article, and sex-negativity also directed against seniors (which is an old story – it always shocks younger people when they find out that we seniors have active sex lives – agism at least.) Loe makes facile assumptions (probably from postmodernism’s too untroubled assumptions about power-without-details) that reengineered men are forcing sex on people…

            • The only negative about Viagra that I’ve read about is the idea that men think it will solve the problems in their sex lives, only to discover that their female partners find it unsexy or a reflection of their own lack of desirability (“he used to be aroused by me, now he’s aroused by a pill”). But obviously that is a problem in communication, not a problem with Viagra per se.

  14. What a great contribution you guys! I recently attended a workshop with a sex therapist. I think it is important that men know that sexual therapy can be very helpful for these issues, if it does turn out to be a psychological and not physical issue.


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