The Psychology of Erectile Dysfunction

Except for premature ejaculation, men suffer from erectile dysfunction (ED) more than any other sexual dysfunction. ED is not a disease specifically caused by aging, nor is it an “old man’s disease.” It affects about 10 percent of men per decade of life; that is, 20 percent of men in their 20s, 40 percent of men in their 40s, 70 percent of men in their 70s, etc. And recent demography studies are reporting greater numbers of younger men having ED. For example, a 2018 poll of 2,000 men found the largest affected age group were those in their 30s, with 50% of them reporting the primary symptoms of ED: difficulties getting or maintaining an erection; in comparison, 42% of those polled in their 40s and 41% in their 50s reported difficulties with their erections. Sometimes brought on by medication (like antidepressants) or chronic disease (like diabetes), ED is typically caused by inadequate blood flow, damage to blood vessels, or stress.

The Good News About Treating ED

The good news is most causes of ED can be addressed and are readily treatable. Treatments range from something as simple as introducing exercise or medication into one’s life to things more complex such as surgery or psychological counseling. ED’s treatments include:

Alprostadil Self-Injection

Alprostadil Urethral Suppository

Alternative Medicines

Exercise

Oral Medications

Penile Implants

Penis Pumps

Psychological Counseling

Psychosexual Education

Testosterone Replacement

The Bad News About Treating ED

The bad news is most men do not seek treatments for ED. Recent studies report only about 25% of men do so. Merryn Gott and Sharron Hinch-liff of the University of Sheffield reported on some of the most likely barriers standing in the way of men seeking treatment for their sexual dysfunctions. They include:

The fear of being judged by their general practitioner.

Assuming sexual problems are due to the normal aging process.

A lack of knowledge about potential treatments.

Perceiving sexual problems as not being serious.

And shame, embarrassment, and fear about sex and sexuality in-general.

The Very Bad News About Treating ED

The very bad news is the most frequently used treatments for ED do not address the psychological or sociocultural roots of ED, but instead focus exclusively on its biological roots. For example, Drogo Montague and his colleagues at the American Urological Association make this point perfectly clear, when stating the American Urological Association’s treatment options for erectile dysfunction:

“The currently available therapies that should be considered for the treatment of erectile dysfunction include the following: oral phosphodiesterase type 5 [PDE5] inhibitors, intra-urethral alprostadil, intracavernous vasoactive drug injection, vacuum constriction devices, and penile prosthesis implantation. These appropriate treatment options should be applied in a stepwise fashion with increasing invasiveness and risk balanced against the likelihood of efficacy.”

You will note, the American Urological Association does NOT make a single recommendation for counseling or psychosexual education within any of their recommended therapies for erectile dysfunction.

Although ED can be successfully treated, one should be wary of treatments that solely focus on eradicating symptoms with biological fixes because these fixes neglect the often-fundamental issues of sexual dysfunctions which are grounded in psychological, relational, and social contexts. For example, imagine a young man seeking treatment for ED. He is most likely prescribed an oral medication (a PDE5 inhibitor like Viagra) by his general practitioner to alleviate his symptoms. And the next time the young man is sexually intimate with his partner, the medication solves his ED. However, the fact that the young man does not desire his partner due to his Internet porn compulsion is completely overlooked. Treating ED in this case enables a young man to be having physical sex with a person he wants to but cannot desire.

Although general practitioners and urologists have a variety of tests to determine the cause of a patient’s ED, most physicians use only a patient’s self-reported sexual history which inevitably leads to medication as being the treatment of choice.

However, if physicians routinely used an additional test to determine the causes of a patient’s ED, then they could easily determine if a patient’s ED is due to physical or psychological problems. This additional test is called a nighttime erection test.

Every time a healthy man goes into Rapid Eye Movement (REM) sleep, he will get an erection. For every eight hours of sleep, a man typically has about five REM-stages of sleep and therefore five erections (see Figure 1).

Fun Fact: “Morning Wood” results from waking up out of a REM-stage of sleep.

If a man’s ED is due to physical problems (e.g., high blood pressure, diabetes, obesity), then he will not have erections when he is sleeping or awake. However, if his ED is due to psychological problems (e.g., anxiety, relational issues, pornography addiction), then he will have erections when he is sleeping, but not when he is awake. Thus, men passing the nighttime erection test should be treated with psychosexual education or counseling and not be treated with medication because their ED is due to psychological problems and not due to physical problems.

So, what does this all mean? This means ED is one of the most frequent sexual dysfunctions men of all ages suffer from, yet few men seek treatment for it, even though there are a variety of worthy treatments for it. And for those men seeking treatments, they are most often prescribed medications without considering the underlying causes of their ED. When psychological factors are not addressed, the healthcare system is systematically misdiagnosing, over medicating, and maltreating millions of men suffering from ED.

References

de Alarcón, R., de la Iglesia, J. I., Casado, N. M., & Montejo, A. L. (2019). Online porn addiction: What we know and what we Don’t-A systematic review. Journal of Clinical Medicine, 8, 91. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352245/pdf/jcm-08-00091.pdf

Bagot, M. (2018). Men in their 30s hit by impotence epidemic as half suffer from erectile dysfunction. https://www.mirror.co.uk/lifestyle/health/men-30s-hit-impotence-epidemic-12541561

Capogrosso, P., Colicchia, M., Ventimiglia, E., Castagna, G., Clementi, M. C., Suardi, N., Castiglione, F., Briganti, A., Cantiello, F., Damiano, R., Montorsi, F., & Salonia, A. (2013). One patient out of four with newly diagnosed erectile dysfunction is a young man — worrisome picture from the everyday clinical practice. Journal of Sexual Medicine, 10, 1833–1841.

Frederick, L. R., Cakir, O. O., Arora, H., Helfand, B. T, & McVary, K. T. (2014). Undertreatment of erectile dysfunction: Claims analysis of 6.2 million patients. Journal of Sexual Medicine, 11, 2546–2553.

Gott, M., & Hinchliff, S. (2003). Barriers to seeking treatment for sexual problems in primary care: A qualitative study with older people, Family Practice, 20, 690–695.

Johannes, C. B., Araujo, A. B., Feldman, H. A., Derby, C. A., Kleinman, K. P., & McKinlay, J. B. (2000). Incidence of erectile dysfunction in men 40 to 69 years old: Longitudinal results from the Massachusetts male aging study. Journal of Urology, 163, 460–463.

Lowe, G., & Costabile, R. A. (2012). 10-Year analysis of adverse event reports to the Food and Drug Administration for phosphodiesterase type-5 inhibitors. Journal of Sexual Medicine, 9, 265–270.

Meerkerk, G.-J., van den Eijnden, R. J. J. M., & Garretsen, H. F. L. (2006). Predicting compulsive Internet use: It’s all about sex! CyberPsychology & Behavior, 9, 95–103.

Montague, D. K., Jarow, J. P., Broderick, G. A., et al. (2005). The management of erectile dysfunction: An AUA update. Journal of Urology, 174, 230–239.

Park, B. Y., Wilson, G., Berger, J., Christman, M., Reina, B., Bishop, F., Klam, W. P., & Doan, A. P. (2016). Is Internet pornography causing sexual dysfunctions? A review with clinical reports. Behavioral Sciences, 5, 17. https://pdfs.semanticscholar.org/6c41/626318c1aaa2a3254a12f91db6983068f1de.pdf

Rajkumar, R. P., & Kumaran, A. K. (2015). Depression and anxiety in men with sexual dysfunction: A retrospective study. Comprehensive Psychiatry, 60, 114–118.

Rastrelli, G., & Maggi, M. (2017). Erectile dysfunction in fit and healthy young men: psychological or pathological? Translational Andrology and Urology, 6, 79–90. https://doi.org/10.21037/tau.2016.09.06

Dr. Don Lucas, Ph.D. is a Professor of Psychology and head of the Psychology Department at Northwest Vista College in San Antonio Texas. He loves psychology, teaching, and research.

If you like this story, then check out Don’s videos on his YouTube channel, 5MIweekly: https://www.youtube.com/channel/UCQFQ0vPPNPS-LYhlbKOzpFw/featured, follow him on Instagram @5MIweekly, like him on Facebook: http://fb.me/5MIWeekly, and check out his website: http://5Miweekly.com

I am a Professor of Psychology at Northwest Vista College in San Antonio Texas. My research focus is human sexuality. I also host a YouTube channel, 5MIweekly.

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