Erectile Dysfunction: Is It All in My Head?

March 26, 2023

Elizabeth Perri

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I'm a licensed clinical psychologist and certified sex therapist based in Chicago. I specialize in anxiety, relationship concerns, and sexual dysfunction. Click here to learn more about me and my private practice.

Hi, I'm liz

Professionals have long debated the physical versus psychological causes of erectile dysfunction. Some believe that most cases of ED are psychological in nature, and some insist most cases are physical in origin. Modern sexual health professionals, such as certified sex therapists and educators, take a comprehensive approach to understanding the causes of erectile dysfunction. Any sexual dysfunction, including ED, can have multiple dimensions that are physical, behavioral, emotional and/or relational. Addressing all of these variables in the assessment and treatment of ED improves a patient’s chances for success.

When is erectile dysfunction potentially a physical problem?

The physiological variables that contribute to ED include unhealthy lifestyle habits such as smoking, alcohol and drug abuse, lack of exercise, and poor sleep habits. Untreated vascular, hormonal, or neurological conditions can impact erectile health. The use of certain medications, especially those used to treat depression and high blood pressure may also have an impact. Sometimes, ED can be the first sign of an undiagnosed medical problem. When in doubt, it’s always best to ask your medical provider.

Perhaps you’ve already met with your doctor, they reviewed your medical history, and they ran some tests, such as checking your testosterone levels. They ruled out potential medical concerns, and you practice fairly healthy lifestyle habits. So now what?

5 Reasons For Erectile Dysfunction That Have Nothing To Do With A Medical Problem

1. Psychological Factors

Psychological distress can impact both sexual desire and performance. For instance, anxiety, depression, and stress can decrease sexual desire and arousal, making erections more elusive. However, as is the case with many of the ED patients I’ve seen in my practice, it’s less about decreased sexual desire and more about how anxiety and negative thinking are getting in the way of erectile function.

When it comes to sex, the mind-body connection is often underestimated. If you’re anxious about sexual performance (i.e., preoccupied with obtaining and maintaining erections), you’ll be less likely to perform the way you’d like. Anticipatory anxiety resulting from previous, failed attempts can make it challenging to be present and relaxed. If you’re too tense, this can inhibit the blood flow necessary for erection quality. Anxiety and tension can lead to repeated ED symptoms, embarrassment, and even avoidance of sexual activity.  

2. Situational Factors

Situational problems that can get in the way of being relaxed and present during sexual activity include: issues with privacy, poor timing, and other distractions. For example, some couples struggle to be intentional about prioritizing sex at a time when they’re not overtired at the end of a long day. Other couples worry about children barging in or overhearing them. We need to minimize distractions and feel safe and secure in order to tap into sexual responsivity. Taking steps such as locking the bedroom door or using a white noise machine may help to alleviate these concerns.

3. Relationship Stress and Conflict

The medical approach to ED puts all the emphasis on the ED patient. It’s assumed he’s the one with the problem and is seldom asked about his partner, relationship, or surrounding circumstances.

Sex is an interpersonal, relational experience. Relationship problems – including conflict, emotional disconnection, distrust, criticism, disappointment with your partner or marriage – can all put a damper on sexual desire, arousal, and performance.

4. Your Partner’s Response to Erection Problems During Sex

I could write a separate article about the partner’s response to this issue (stay tuned!). The partner’s response when ED symptoms occur is crucial. If a partner reacts by becoming derogatory, critical, angry or demanding, the ED symptoms are much more likely to persist or even be exacerbated.

Sometimes, the partner or even the ED patient will have such firmly-held beliefs that “a man should just be able to perform” that I’ll get pushback about the importance of the partner’s role in treating ED. In other words, they do not believe that a partner’s response, the relationship, or any other situational factors are relevant. That couldn’t be further from the truth. It’s the responsibility of both partners to work together to create an emotionally safe and supportive environment that facilitates desire and arousal.

5. Limited Sexual Repertoire

Broadening your sexual repertoire becomes increasingly important with age. The expectation is that erections should always be spontaneous with little to no foreplay. However, after the age of 30, and certainly into a man’s 40s and 50s, spontaneous erections become unrealistic for many men.

Long-term sexual relationships that are hyper-focused on intercourse can become problematic. There are many ways of being sexual with your partner. Engaging in more foreplay, manual stimulation, or oral sex can take the pressure off of needing to maintain an erection for intercourse. Intercourse doesn’t need to be the main event every single time. Switch it up!

Medication for Erectile Dysfunction

Medications such as Viagra and Cialis can be effective in treating ED caused by physical and/or psychological factors. While some men may experience negative side effects, in general, ED medication can be a tremendously beneficial resource in gaining confidence with erections. However, if there are complex psychological, situational, and relationship variables, ED medication alone can be insufficient. Significant anxiety, stress, or toxic relationship dynamics can actually override the efficacy of the medication. In this case, medication alone will not suffice.

If you’ve ruled out potential medical or physical causes of ED and have tried ED medications with less-than-ideal results, addressing the psychosocial factors listed above would be a logical next step.


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