The SMSNA periodically receives and publishes ‘guest editorials’ by sexual medicine specialists. The current article was submitted by Mark Goldberg, LCMFT, CST, a certified sex therapist and SMSNA member who specializes in sexual medicine in Maryland and hosts the Erectile Dysfunction Radio Podcast. The content has been reviewed by the SMSNA Website Committee for accuracy.
Erectile dysfunction (ED) is a complex medical condition which includes both physical and mental components. The paradigm of what causes ED and how it is treated has shifted over the past 50 years from a mental focus to a physical one.
This has been driven in part by the advent of non-invasive, oral medications and a more comprehensive understanding of the physical components of ED. However, the mental components of erections and ED continue to play a significant, yet often underappreciated, role, and many men can resolve ED by addressing these factors.
While some erections seem to just ‘happen,’ many require the mind to be activated, engaged, or interested in sexual activity. For some men this remains a subconscious process, meaning that a man does not need to actively think about sex, rather, his mind is open and receptive to stimuli or subconscious thoughts. It is for this reason that many men overlook the role of the mind in the erection process until ED occurs.
Psychogenic ED
Erectile dysfunction is different than many other medical conditions. Some physical ailments may be attributed to psychosomatic causes. In other words, the physical illness itself can actually be caused by a person’s mind. This concept is often erroneously applied to ED, causing confusion and creating barriers to proper treatment. While some men will experience ED as a manifestation of underlying mental health conditions such as stress, the role of the mind in erections is more expansive.
Erections are facilitated by what the mind thinks and how it processes the external environment. Without proper stimulation and desire, erections will be difficult, if not impossible, to achieve. Even when external stimulation is provided, the mind needs to process this in a way that signals to the body that an erection is needed for sexual engagement. When this does not happen, ED may result: not because the mind is blocking an otherwise natural process, but because an important component of erections (i.e. engaging the mind) is missing.
Mental Causes of Erectile Dysfunction
There are a number of mental health conditions that can contribute to challenges with erections including stress, depression, performance anxiety, and relationship problems. These are normal experiences that most people will encounter, if not on a regular basis, then at some point. More importantly, an understanding of how these normal human experiences impact erections is needed.
Distraction. A man needs to be interested and engaged in a path toward sexual activity in order to reliably gain and maintain an erection. If he is thinking about other things, or if his mind is preoccupied with stress or worry, it can be more challenging. Otherwise, direct sexual stimulation can be less impactful if the mind is not receptive and engaged.
Detraction. A man needs to be open and receptive to pleasure. However, the mind also needs to process and interpret what happens, whether mental or physical, as sexual stimulation. A number of mental health challenges can lead to anhedonia, which is the loss of pleasure in previously pleasurable activities. Even without distraction or stress, previously stimulating thoughts, sounds, visuals, and activities can lose their efficacy as facilitators of sexual arousal through habituation, anhedonia, and other mental factors.
Beliefs. What a man thinks about himself, his partner, and sex can impact both distraction and detraction as well as sexual desire and motivation. Issues may arise when men feel like they are underserving, or if they have low self-worth, poor self-esteem, or experience body image issues or relationship insecurities. Each of these can be deep seated and interfere with erections in both individual and partnered sexual activity.
Unrealistic expectations. Many people develop unrealistic expectations with regards to sex. Expectations for men are often about performance and partner responsiveness. When experiences do not live up to expectations, performance and relationship-based anxiety can ensue. For some men, a basic reset of expectations can be helpful, while others will benefit from more in-depth cognitive restructuring.
The Bottom Line
Many men experiencing ED are uncomfortable with the notion that their mind is a part of, if not the primary driver for, not achieving an erection. Often times, psychogenic ED can occur even in the absence of any current mental health concerns or distress, which may make it more difficult to grasp and accept.
These men may be quick to dismiss the possibility of psychogenic ED and ultimately ignore an important component of healthy erections. However, when men who experience ED can recognize that their minds are always involved in erections, reaching out for help becomes easier, and treatments for ED may ultimately yield better outcomes.
