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The Psychology of Erectile Disorder

A recent review explores the psychological predictors, and consequences, of ED.

Key points

  • ED is a common and consequential disorder, affecting both individuals and relationships.
  • Personality factors may play a role in the development of ED.
  • ED is associated with anxiety, depression, and lower life satisfaction.
  • Multimodal treatments combining medication and psychotherapy may work better than each of them alone.

The DSM-5, psychology’s diagnostic manual, defines erectile disorder as a sexual dysfunction marked by a recurrent inability to achieve or maintain an adequate erection during partnered sexual activities. For a diagnosis, at least one of three specific symptoms should be reported as appearing at least 75 percent of the time during sexual activity:

  1. Marked difficulty in obtaining an erection during sexual activity.
  2. Marked difficulty in maintaining an erection until the completion of sexual activity.
  3. Marked decrease in erectile rigidity.

To be diagnosed, the symptoms must persist for at least six months, and be accompanied by the experience of marked emotional distress. ED is further classified as either generalized (appearing consistently across the board) or situational (appearing only in select situations or with certain partners), acquired or lifelong, and by severity level (mild, moderate, or severe).

Source: aslysun/Shutterstock
Source: aslysun/Shutterstock

Occasional problems with achieving and maintaining erection are extremely common and are not included in this definition. In addition, a diagnosis of ED should first rule out other disorders such as substance abuse that may better explain the problem.

Erectile dysfunction affects hundreds of millions of people worldwide, and the risk increases steadily with age. While affecting a minority of men before age 30, prevalence increases to 60 percent by age 60, 80 percent by age 70, and 90 percent in people over 70 years old.

Psychological Predictors of Erectile Dysfunction

Erectile dysfunction most often reflects a combination of both biological and psychological factors, yet the psychological experience of ED has been under-explored. A recent (2023) review by British psychologist Mark Allen and colleagues provides “a concise overview of research on the psychological experience of erectile dysfunction.”

The authors discuss several psychological predictors of ED:

  • Personality: The authors conclude that “there is evidence that people who score higher on neuroticism and lower on extraversion are at greater risk of erectile dysfunction.” The effects of personality are probably disseminated via several paths of influence. For one, people with different personalities tend to have different lifestyles and habits. Specifically, people who score high on measures of neuroticism and low on extraversion are more likely to smoke and less likely to exercise. Smoking and lack of physical fitness are known contributors to erectile dysfunction. Personality also informs people’s attitudes, worldviews, and risk of psychological disorders. Heightened anxiety, as well as high levels of stress and depression, have been shown to predict ED.
  • Worry and anxiety: Research has shown that in-the-moment worry (performance anxiety) and interfering negatively evaluative thoughts (“I’m a complete failure because my erection was not 100 percent” or “I’m sure it won’t work tonight”), “can distract from sexual stimuli that trigger signals from the brain to the penis to initiate and maintain erection.” Such cognitive-processing factors have been shown to contribute heavily to sexual dysfunction in both women and men
  • Change in attentional focus: Research has shown that shifts in attentional focus during sex are central to the emergence of ED, as men’s thoughts turn from external focus on the arousing touch sensation to an internal focus on their own worries, resulting in a loss of arousal and disengagement from the moment.
  • Cognitive attributions: In general, those who tend toward internal attributions of failure (e.g., biological causes) are more likely to develop consistent erectile problems than those making external attributions (e.g., tiredness, stress)

The problem of ED warrants attention in part because its consequences for the lives of men and their partners are considerable. These include a sense of emasculation, feelings of humiliation and shame, and relationship worries ("my partner might leave me").

Decreases in self-confidence and feelings of self-worth are often reported, as well as “feelings of isolation and loneliness, rumination and catastrophizing, and a more negative body image.” Within the human psychic architecture, negative cognitions and expectations often act as a self-fulfilling prophecy, as concerns over performance lead to further performance problems and in time, withdrawal and avoidance, which end up undermining the relationship.

Research has also documented more long-term effects of ED, finding that “people who suffer from erectile dysfunction show a greater deterioration in psychological, social, and physical well-being compared with those without erectile dysfunction.” These results concur with the findings of an earlier review by Canadian psychologist Dean Elterman and colleagues (2021), who found that “ED imposes a substantial quality of life burden on men and their female partners as well as a significant economic burden on their employers.”

Depression has also been linked to ED, and the relationship is reciprocal. Depression contributes to an increased risk of erectile dysfunction, and a diagnosis of ED is associated with a significant increase in subsequent depression risk.

ED tends to affect individual men negatively. In addition, it also tends to undermine the quality of their intimate relationships. ED, after all, is not typically a problem one can hide from an intimate partner.

Partners of individuals dealing with ED often report feelings of being unattractive, feelings of rejection, feeling unloved, and frustration. The withdrawal of intimacy, which often happens when men are overtaken by performance worries, may confuse and alarm intimate partners, causing them to worry about whether the man is losing interest, or is having an affair. Such anxious thoughts can negatively impact self-esteem and feelings of attractiveness, as well as decrease the partner’s ability to enjoy sex, and ultimately lead to a lower quality of life and decreased life satisfaction.

What Can Be Done About ED?

Importantly, effective solutions are available for those who are dealing with ED.

The first step is to establish open communication within the couple about the issue. Support and positivity from one’s partner are strong predictors of ultimate success in overcoming the problem. “The attitude, behavior, and understanding of the sexual partner are important influential factors in managing erectile dysfunction, and interventions that focus on couples, rather than just the affected individual, are thought to be a better approach to improving erectile function.”

In addition, lifestyle changes, such as limiting or avoiding the use of tobacco and/or alcohol, may prove beneficial. A thorough assessment may help pinpoint the underlying causes. When biological causes are identified, medication treatment may prove highly effective.

Since its advent in the late 90s, the class of agents known as type-5 phosphodiesterase (PDE-5) inhibitors has revolutionized the management of ED. It has become (along with testosterone treatment) the first-line therapy for ED, as recommended by the American Urological Association (AUA). If PDE-5 inhibitors fail to fully resolve the problem, other interventions are available, including vacuum constriction devices, vasoactive gels, intracavernosal injections, and, as a last resort, penile implants.

If the problem is diagnosed as psychogenic (centered around psychological concerns), then psychotherapy may be recommended. Yet, the record of psychotherapy alone in treating ED has been spotty and inconsistent, To wit, a 2019 review of 98 meta-analyses by Mark Allen and Emma Walter observed that psychological interventions were considerably more inconsistent in their effectiveness than medication

A more promising route is the multimodal approach, combining medication and therapy. Research exploring how psychological interventions combined with PDE5 inhibitors compared with PDE5 inhibitors alone has found that combination treatment was superior to PDE5 inhibitors alone. In a recent (2021) review of 13 studies, the psychosexologist Sandrine Atallah (American University Beirut, Lebanon) and colleagues found that the combination of psychological interventions (PI) and PDE-5 was more effective than either PI or PDE-5 alone, on both erectile function and long-term sexual satisfaction in men with psychogenic ED.

In sum, Allen and colleagues note: “It is clear that psychological factors have an important role in the experience of erectile dysfunction. However, this topic is still in its infancy, and more research is needed to help understand how psychological factors contribute to and might be implicated in the treatment of erectile dysfunction.”

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