Through many years of clinical practice, we have found that men who come to our clinic after exhausting other options for the treatment of erectile dysfunction (ED) have similar types of thoughts about their sexuality, sexual performance, sexual functioning, or sexual body parts. 

Having negative thoughts — also referred to as negative cognitions clinically — is one of the factors that maintains non-medically caused ED in men.

Almost all men with erectile dysfunction have difficulty being present in the moment during partner sexual activity, while many men can have successful masturbation with an erection without negative cognitions interfering. Some men have difficulty maintaining an erection both in solo sex and in partner sex. Some common examples of negative cognitions that occur during masturbation or partner sexual activity can be:

• My penis is too small

• Masturbating is bad

• I won’t be worthy to my partner if I can’t stay hard

• I can’t tell my partner what I really want sexually

• My partner’s vagina isn’t tight enough or my partner’s vagina is too tight

• I have to have an orgasm and ejaculate to have good sex

• I am not satisfying my partner sexually

• I have to perform

• My partner will leave me if I can’t get an erection

Most men who have ED have generalized anxiety even outside of sexual situations, but more specifically have anxiety about sexual performance. Research has shown that men with ED tend to have cognitive states that are prone to worrying as a way to cope with a perceived problem such as inadequate arousal and erection. 

In other words, men worry and think about lack of sexual functioning and performance as a way to try and solve the problem. However, this worried mindset becomes a preoccupying deterrent from men being able to stay in the present and just feel their own natural physiological reactions to sexual arousal. 

Sexual arousal and response in men are negatively impacted by concern over getting an erection, mental distraction, fear of not performing, and having negative thoughts about sex in any form. In men who have experienced ED, it becomes a self-sustaining process as negative cognitions about perceived sexual failures continue to create more negative cognitions and less sexual self-efficacy.

In human psychology, a set of thoughts and beliefs are referred to as a schema. Research has also shown that men with ED have more negative sexual schemas when a sexual situation doesn’t go as expected or desired than men who do not have ED. 

So why do men who have ED have negative cognitions and negative sexual schemas? 

Both research and clinical practice indicate that men obtain negative thoughts about sex and/or sexual performance through the acquisition of negative sexual experiences during their sexual developmental history, specifically in childhood and adolescence. Some common contributing experiences to developing negative cognitions or negative sexual schemas include:

• Critical parents

• Lack of sex-positive education or no sex education at all

• Unrealistic expectations about performance due to early exposure to pornography

• Inappropriate sexual boundaries in the home

• Sexual abuse as a child

• Sex negative messages and shame about sex from religion

• Negative experiences with sex during first sexual experiences in adolescence

• Homosexual experiences at a young age that feel shameful as an adult 

• Lack of affection from caregivers or parents growing up

• Witnessing infidelity by parents growing up

• Bullied about weight or body growing up

• Lack of appropriate developmental sexual experiences

Identifying negative cognitions and understanding where they originated from is one of the first steps in moving towards the treatment and management of ED. Not being able to get an erection isn’t usually the problem with men who have ED due to non-organic causes — the negative thoughts about not getting an erection are the clinical issue to be treated. 

Fortunately, there are many successful treatments for correcting negative cognitions related to sexual performance and functioning that interfere with sexual arousal and erection. While the specific treatment plan within sex therapy and psychotherapy is customized for each man given the origins of the negative cognitions is specific to each man’s history, cognitive-behavioral therapy, mindfulness meditation practices, Eye-Movement Desensitization Reprocessing (EMDR), and Internal Family Systems (IFS) are all successful at correcting negative cognitions and helping men with symptoms of ED come back to their bodies to achieve the sexual arousal and response they desire.

If you or a loved one has struggled with ED, feel free to reach out to our office to schedule an appointment. Our team of sex therapists can help you enjoy sex again.