Erectile Disorder and Sex Therapy
Many people do not realize that Erectile Disorder (ED), the inability to achieve or sustain an erection sufficient for intercourse, is extremely common. Today, 1 in every 10 men in the United States experiences ED, and by the year 2025 the prevalence of ED is expected to increase ultimately affecting an estimated 322 million men. ED affects every aspect of a man’s life–their physical health, mental health, and relational health. It affects not only the person with the condition, but their partners.
When men come in for individual sex therapy with the goal of improving their sexual functioning, I ask those currently in committed relationships if they would be open to inviting their partners, wives, or husbands to couples sex therapy. Why? Because when you are unable to get or keep your erection, a partner may not know how to react, how to be helpful, and may feel like they are doing something wrong. It can impact that person’s sexual self identity if they perceive the inability to sexually connect to be a reflection of their desirability. Why, they think, are they no longer into me?
Erectile Disorder
People with ED may be unable to get an erection sometimes, be able to get an erection but not keep it long enough for satisfactory sexual intercourse, or never be able to get an erection. To satisfy the diagnosis of Erectile Disorder in the DSM 5, one must have been having these challenges for at least six months and during at least 75 percent of their past sexual scenarios. ED can be diagnosed in conversation with a sex therapist or your medical provider who will ask about your health history and those experiences where you lost or couldn’t attain an erection.
While a less frequent occurrence in younger men, a study in The Journal of Sexual Medicine found that ED affects about 26 percent of men under the age of 40. Another study highlighting ED in young men found that 8 percent of men between the ages of 20 and 29, and 11 percent of males ages 30 to 39 have some form of ED.
The increasing prevalence of ED in young men is an important phenomenon. Particularly because the psychological burden of Erectile Disorder in young men can sometimes be greater as they are in a time in their lives when society expects them to be more sexually virile and, in many cultures, more active. ED has drastically impacted the dating lives of the younger men I see in my clinical practice. They often have avoided dating apps for fear they will be expected to initiate sexual activity after several dates with the same person and unable to perform. Some young men are turned on by texting with a potential partner for casual sex or hookup, but end up self-pleasuring with sexually explicit media or porn rather then asking the person to meet up and risking the embarrassment and misunderstanding that can follow an episode of ED.
Causes of Erectile Disorder
The most common cause of ED is vascular disease. 64 percent of difficulty getting and maintaining an erection are associated with heart attack and 57 percent with bypass surgery. Up to 75 percent of men with diabetes, 40 percent of men with renal failure, and 30 percent of men with COPD have some experience with Erectile Disorder. Psychological causes of ED are wide ranging. They include stress, depression, anxiety, feelings of guilt, low body image, issues in a man’s relationship, or sleep disorders.
As more young people are affected by Erectile Disorder, there is an increased risk that their doctor assumes that their ED is the result of a psychogenic cause without conducting a proper examination. Their doctor may offer the young man a prescription of a PDE5 inhibitor like Tadalafil (generic for Cialis) or Sildenafil (generic Viagra), or refer them to a sex therapist. However, similar to ED in middle-aged or older men, ED in young men can be the consequence of the combination of organic, psychological, and relational factors–all of which must be addressed in appropriate clinical treatment.
In particular, Erectile Disorder in young men–even more than in older men–is considered a harbinger of Cardiovascular Disease (CVD). As a sex therapist, I go through a complete biopsychosocial sexual history to help my clients figure out if their ED is an early warning signal of CVD so that they might work with their medical doctors and find critical preventative interventions if necessary.
Co-occurring Sexual Disorders
Most people don’t realize that there are a number of sexual disorders that co-occur in men who experience ED (most commonly different forms of ejaculatory dysfunction). One co-occurring sexual disorder is premature ejaculation, or what we sex therapists call uncontrolled ejaculation. A recent study found that 76.3 percent of its participants who report premature ejaculation also had an Erectile Disorder diagnosis. Premature ejaculation is relatively common, experienced by about 30 percent of men. Premature ejaculation can cause men shame and anxiety that their erections subside. Anxiety is one of the psychological experiences that causes loss of blood flow, and if there’s one thing a penis needs to keep erect, it is blood flow. Some of my male clients who come in because of their ED have never spoken about their premature ejaculation issue due to the embarrassment of not being able to control how long they last.
Another co-occurring sexual disorder, though uncommon, is delayed ejaculation–or difficulty achieving orgasm despite adequate sexual stimulation. These are the men who can have penetrative sex for 30 minutes to an hour without climaxing. While American late night comics might make jokes about how fulfilled these men (and their partners) must be, the opposite is usually the case. Couples who come in with this problem often express disappointment that they can’t get pregnant the “normal” way. A delayed ejaculation client’s partner might feel they’re not truly loved or desired by a partner who can’t seem to ejaculate inside them. A female partner may avoid penetration because of the pain that long sessions of thrusting cause her vaginal opening. Over time, a man might begin to lose his erection in anticipation of the disappointment he and his partner will feel when he cannot climax.
These co-occurring conditions are often missed by general therapists. Their diagnosis requires a thorough assessment process including a deep dive sexual history interview and referral to a sexual health doctor, both of which are important in addressing a man’s overall sexual health.
Psychological Contributors to Erectile Disorder
Psychological impotence, or erectile disorder caused by psychological symptoms, is even more common than other forms of ED. It is estimated that up to 20 percent of men in the United States have experienced ED as the result of a negative mental health state. A survey of men living in the UK found that more than 50 percent of men in their 30s experience ED. About half of those who struggle with ED cite stress as the reason they cannot get or keep an erection.
One of the most common negative emotions that causes ED is performance anxiety, and rates of performance anxiety seem to be rising among young men. Up to 25 percent of men experience sexual performance anxiety. Sexual performance anxiety can be caused by a number of things including body image issues, low self-esteem, mental health issues like depression and anxiety, stress, previous sexual trauma, and feeling emotionally disconnected from your partner. The shame my clients feel around their sexual dysfunction worsen their performance anxiety and prevent them from talking about and addressing the issue.
Men may wait many months before seeking out sex therapy because they feel like they should be able to take care of this problem on their own. Men who are survivors of trauma, whether it’s sexual trauma or some other kind of trauma, may not connect their current ED problem with their past trauma on their own. I let clients know it takes tremendous courage to reach out for help and begin the healing journey of reclaiming their sexual pleasure and functioning.
Increased recreational use of erectile dysfunction medication
Phosphodiesterase type 5 (PDE5) inhibitors like sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra or Staxyn), and other oral erectile dysfunction medications, have become a popular sexual enhancement aid among some men without ED. A study in the Journal of Sex Medicine found that, among a sample of 167 male medical students reporting no issues with erectile function, 9 percent of these med students reported the use of PDE5 inhibitors. Of those who had used PDE5 inhibitors in the past, 46 percent reported using the drugs more than three times, and 71 percent used them with alcohol. Why is this happening?
With so much sexual prowess depicted in sexually explicit media like online porn, streaming series, social media, and campaign ads featuring buffed men with 6-packs and gleaming hairless chests, many young men feel they don’t live up to the standard. Clients who are more romantic types and need emotional triggers of closeness may lose their erection when with a partner they don’t know well enough yet. While these clients feel pressured to “make the first move” to show interest, they are not ready. Their mind and body are not in alignment and their penis sends the message. The pressure men feel may push them to use PDE5 inhibitors.
Men are surprised in therapy sessions to learn that the recreational use of Erectile Dysfunction medications (EDM) may have unintended negative effects. One 2011 study found that Recreational EDM college-aged users reported 2.5 times the rate of erectile difficulties compared to nonusers. In another study, recreational use of EDM has been found to decrease healthy young men’s confidence in their ability to get and maintain an erection on their own.
Men who come into sex therapy who tell me they’re using PDE5 inhibitors, despite having healthy erections when they masturbate, express anxiety that they won’t be able to “crush it” in the bedroom. Much of the work with men with ED is teaching them what a realistic sexual response cycle should look like, how they can identify their needed erotic triggers and skills to communicate them to partners. There is a lot of myth busting around what authentic masculinity actually is that is part of sex therapy.
Treatment for Erectile Disorder
As a result of the biopsychosocial elements inherent in possible caused of ED, it’s extremely important to get a thorough sexual assessment by a sex therapist and urologist. When seeing a urologist for ED, the assessment might include a physical exam, blood and urine tests, penile duplex ultrasonography (a test to analyze blood flow in the penis), a penile angiography (x-ray with injected dye to view blood circulation), and a combined intra-cavernous injection and stimulation to assess the quality of an erection.
When seeing a sex therapist, a client should expect the therapist to take the time to review one’s sexual history to find out possible medical reasons or injuries that occurred in one’s childhood, puberty and college years. The therapist can review the prescriptions and over the counter medications someone has taken in the past and/or currently, screen for alcohol and substance use and find out about psychiatric precursors that impact erectile problems.
A sex therapist will frequently refer the client to a doctor for more tests to ensure there aren’t any underlying or comorbid conditions contributing to their Erectile Disorder. And if he’s currently part of a couple, it’s important that the man’s partner/spouse be invited in to be part of the sex therapy treatment.
