Erectile Dysfunction Part One: Psychological Causes

We hear a lot about erectile dysfunction (ED) in the news, in commercials, in advertisements. The most talked-about new prescription drug in recent years is Viagra, the trade name for sildenafil, which treats erectile dysfunction. But what is erectile dysfunction, how common is it, and what does it really mean for a healthy sex life?

Erectile dysfunction is usually thought of as a man’s inability to achieve a full or partial erection even though he’s turned on. It was once called “impotence,” and recently renamed by the medical community in an attempt to lessen its stigma.

When a man becomes aroused, the arteries in the penis relax and open up, allowing more blood to flow into the penis. The veins that normally carry blood away from the penis compress, preventing that blood from flowing out of the penis. This makes the penis get hard. When a physical condition exists that prevents the nerves or blood vessels involved in this process from working properly, it may be more difficult for a man to achieve and maintain an erection.

This can be caused by a number of different physical problems — high blood pressure, high cholesterol levels, diabetes and heart disease can all contribute to a lack of response in filling the penile tissue with blood and limiting the flow of blood out of that tissue. Similarly, certain medicines, injuries, smoking, drug use or alcohol consumption can affect the ease with which an erection is achieved.

On the other hand, many psychological issues can interfere with a man achieving an erection even though he’s aroused. Depression, stress, emotional trauma and anxiety can contribute.

In part two of this series, I’ll talk about medications like Viagra and how they affect the functioning of the nerves and blood vessels that govern erection. Here, however, I’ll elaborate on the causes and prevalence of erectile dysfunction in all its forms — whether one-time or chronic.

The good news is the same as the bad news: almost every man at some point in his life has some trouble achieving an erection when he (or his partner) thinks he should. Similarly, he may be able to achieve an erection but lose it at some point before he’s ready to — or before he achieves orgasm. For some men, this becomes a common experience, and Pfizer (the company that markets Viagra) estimates that half of men between ages 40 and 70 experience some form of erectile dysfunction.

Whether a man’s experience of erectile dysfunction is one-time or chronic, the causes can be the same. Besides the physical and emotional factors noted above, a critical issue that’s rarely talked about in the medical literature is arousal.

A medication like Viagra may make it quite a bit easier for a man to achieve an erection if he’s aroused — but will not “create” desire or “horniness” where none exists. Far from being what people think about as an aphrodisiac, Viagra merely facilitates a physical response to arousal. However, for many men with erectile dysfunction, the problem starts before that point. There are any number of ways to help facilitate arousal — and the one thing they have in common is that your physician is very unlikely to tell you about them — unless you’re lucky enough to have a sex-positive physician (see the book Health Care Without Shame by Charles Moser, MD, PhD for more information on finding one).

In practical terms, for the man who experiences erectile dysfunction, there’s a qualitative difference between physical causes, like heart disease, diabetes or injury, and psychological causes. Psychological causes can interfere with the physical response that governs erection, but they have an even more profound effecton the psychological cause of erection — that is to say, arousal. While psychologically-caused erectile dysfunction is a real and concrete issue, it can also be a misnomer for a lack of interest in sex — something very commonly caused by stress, anxiety or depression.

If you have any suspicion that any erectile dysfunction has a physical cause, you should definitely talk to your doctor, and not just to improve your sex life. Erectile dysfunction can be an early indicator of one of the underlying problems mentioned above. But if you’re experiencing erectile problems and suspect that your frame of mind or underlying psychological issues are the root cause, there are a few places to start even before you see your doctor.

First, don’t hold yourself to unrealistic sexual expectations. If you’re in your 30s or older, keep in mind that your body is changing. Many men form their sexual self-image during their early “dating” years, when they find they’re physically able to achieve erection (sometimes repeatedly) with great ease. Most of us aren’t thrilled about getting older and losing some of our perceived physical prowess, but the fact of the matter is that a 20-year-old is profoundly different in hormonal makeup, musculature and mindframe than a 50-year-old. Recognize that just as you might have been able to sprint up four flights of stairs more easily when you were 20 than you can now, you may only be able to get an erection three times in a row rather than four times in a row — or, more commonly, only once. While erections are a glorious and celebratory tool for enjoying sex, they’re not the only one, and you may want to explore other forms of physical intimacy with your partner or by yourself.

Second, don’t be shy about telling your partner what turns you on. Many men (and, incidentally, many women) have a much easier time achieving erection and orgasm when they’re alone, because their erotic fantasies, their favorite pornography, or their favorite toys do exactly what they want, without the messy business of negotiation. However, many people are reluctant to share this fact with their partners, fearing that an attraction to erotica, sex toys or particular sexual kinks will imply a lack of attraction to one’s partner. Just because you find it easier to get aroused by your fantasies, by pornography or by sex toys doesn’t mean you don’t want to be with your partner. There are many things that make partner sex important and enjoyable, even if it’s not as quick and easy as masturbation or fantasy.

The more willing you are to tell your partner what really turns you on, the more likely you are to be able to share that with your partner. In many cases, a favorite kink can turn from a cherished fantasy to an anxiety-producing secret when it’s kept hidden. With time and care, you may be able to bring your partner into those fantasies, increasing the arousal you share and facilitating a greater frequency of sexual interaction.

Third, explore with yourself. If your problems with partner sex are caused by stressors in your outside life, are you taking time to masturbate? Some men who experience erectile dysfunction have just as much trouble achieving erection when they’re alone as when they’re with a partner, but many don’t. Having sex with a partner ups the emotional ante, and consequently stress levels may be higher. Furthermore, if lack of frequent erections is causing an issue between you and your partner, you may not feel entitled to masturbate — but “conserving” those erections is actually unlikely to help. Orgasm is a great stress-reliever, and may increase your sexual confidence when you’re with your partner.

In part two of this series, I’ll talk in greater detail about physical causes and treatments for erectile dysfunction. But if you’re experiencing ED, take some time to assess the causes and evaluate all the ways you can care for yourself. And again, make sure that if you have — or suspect you have — an underlying physical cause for your ED, talk to your docto


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