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.
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