The specific psychosocial therapy needed for erectile dysfunction (ED) is dependent on understanding all medical and non-medical contributions.

A thorough psychosexual evaluation is needed to determine the underlying psychological, relational, environmental and medical contributions. It is important to understanding:

• How the symptoms evolved over time.

• How the factors that predisposed the individual precipitated and maintain the symptoms.

A Man’s Relationship To Himself

There are a number of factors that can contribute to erectile dysfunction from an individual psychological perspective.

Performance anxiety is the most common psychosocial factor and can manifest as performance demand or cognitive distraction. Many men with ED focus on performance rather than pleasure. This is relatively easy to assess by determining if erections happen during sleep, early in the morning or while masturbating.

Typically, men with performance anxiety-related ED do not have difficulty achieving and maintaining erections during these activities. There are a number of comorbid disorders that occur with ED, including:

• Generalized anxiety disorder

• Obsessive-compulsive disorder

• Posttraumatic stress disorder

• Substance abuse

These disorders may contribute to the ED and impede treatment if they are not addressed.

Many men with ED also report a history with sex-negative messages given by their family, culture or religion. These messages can create negative thoughts and beliefs about sex that interfere with the man being fully present in his body during sexual arousal and response.

During a psychosexual assessment, a history of sexual or nonsexual trauma is obtained given that abuse can cause low sexual desire or sexual performance issues. Gender identity, sexual orientation, and paraphilia orientations are also assessed.

Men may be in sexual relationships due to family expectations or social pressures that are not congruent with their sexuality, thus limiting sexual arousal and response.

In addition, men can have partners who are not compatible with their specific sexual preferences. For example, men with a particular fetish whose partner does not wish to participate in it may not be able to become adequately aroused during partner activities.

A thorough assessment may also reveal that a man has misinformation about sex and a lack of sexual skills required to achieve arousal and maintain an erection. For example, men who are focused on penis-in-vagina intercourse and do not spend adequate time on foreplay may not be sufficiently aroused.

A Man’s Relationship To His Partner

The presenting symptom in ED is a “man’s erectile dysfunction”, but what may appear as “his problem” is actually due to relationship factors.

• Couple issues can play a major role in many cases of ED, and may cause or exacerbate the symptoms of ED.

• It has been found that couples who have good communication overall have more success with sex therapy interventions, although there is not currently a standardized or researched couples therapy approach to treating ED.

• Erectile dysfunction may be related to lack of sexual attraction to the partner or a history of conflict that may have changed a man’s perception of his partner.

• A man’s ED can also be a secondary symptom to a partner’s sexual dysfunction or other mental health problems. For example, men whose partners experience pain with intercourse can lead men to lack arousal or be fearful of hurting their partner, which can create symptoms of ED.

• In addition to stress within the relationship contributing to ED, couple stress unrelated to conflict may cause ED.

A Man’s Relationship To His Environment

Many healthcare providers do not assess environmental contributions. Comfort, privacy and time that is relaxed usually produce the best outcomes for sexual arousal and response.

Lack of comfort psychologically or physically can create or contribute to ED. Worries about children or in-laws in the same house or architectural issues such as lack of sound privacy can create psychological distractions that impact focusing on sexual sensations and pleasure.

Psychological Treatment & Sex Therapy For Erectile Dysfunction

Men who are single or in a relationship can seek sex therapy and treatment for erectile dysfunction.

Men with partners can have partners who are unsupportive and unwilling to attend sessions, which can impact restoring erectile function within the relationship context, but sex therapy is still encouraged. Men who are in supportive relationships are encouraged to attend sex therapy with their partner at some stage in the process.

After men have ruled out organic causes for symptoms of ED, they undergo a complete psychosexual evaluation and a treatment plan is written specifically to target the origins of their symptoms.

While there are several psychometric measures or psychological tests that can be completed, a thorough psychosexual assessment allows both the clinician and the man to understand the complete development and current manifestation of the symptoms in context, thus allowing a targeted treatment plan to be developed and implemented.

Given the unique history of each man, there is no direct pathway for treatment, but some common interventions used include:

• Cognitive-behavioral therapy (CBT)

• Sex-positive education

• Sexual stimulation techniques

• Mindfulness training

• Sensate focus for couples exercises.

Cognitive-behavioral interventions use bibliotherapy (reading) and cognitive restructuring to provide positive sex education and challenge unrealistic expectations.  It is important to educate men and their partners on the basic mechanisms and processes of erectile function and the causes of dysfunction.

Masturbation skills training can be provided and men can be taught fantasy skills development to be able to stay focused on desirable images and scenes that enhance stimulation and pleasure.

Sensate focus is a technique developed by Masters & Johnson in 1970 that encourages a couple to have sexual relations without intercourse regardless of whether a man has an erection. It focuses on the experience of pleasure without necessarily having intercourse or orgasm, thus broadening what it means to be sexual. The focus is taken off the erection and encourages both partners to be in the moment experiencing pleasure and sensations rather than a focus on performance and outcome.

If your therapist gives you these exercises, each step is thoroughly explained, readings are given and guided videos will be provided that demonstrate the techniques. This is just one of many possible sex therapy interventions that are available. Sex therapists can help men to reframe the symptoms of ED as a specific type of physical communication.

ED symptoms can be used to help men understand themselves, their emotions, their needs, and their relationships. Once physical causes have been ruled out, ED symptoms typically signal to a man something that isn’t working in their thoughts, emotions or relationship that needs attention. Men are encouraged to examine themselves and their symptoms in a positive light and in developing a new understanding of the body and address issues that need attention.

With these discoveries, erectile functioning can be restored.