Performance Anxiety Related Erectile Dysfunction: Tips from a Portland Sex Therapist
By far the most common cause of erectile dysfunction in penis owners is performance anxiety. It can lead to strife and disconnect in intimate relationships and harm our sense of security in ourselves. When it becomes a recurring issue, it can even cause people to isolate or avoid sexual encounters altogether!
You may be relieved to know is that Erectile Dysfunction is incredibly common. Approximately 50% of all men ages 40-70 experience erectile dysfunction to some degree (1). For those in their 30's, that number drops to 11% and for those in their 20's, it's 8%, but recent data suggests that the prevalence of ED is actually increasing in recent years (2).
If you're experiencing erectile dysfunction and considering therapy - WAIT! Before you do anything else, chat with your doctor. If there is an organic cause such as low blood pressure or other cardiac issues, erectile dysfunction could be an early warning sign and you'll want to address that prior to or in tandem with a psychological approach like therapy.
Often, however, my clients are healthy and are only experiencing erectile difficulties during partnered encounters. A great question to ask yourself is: Am I having problems experiencing the erections I want when I'm masturbating? If the answer is no, then it's very likely your issue is a psychological one and sex therapy could make a big impact and help you get back to having the sex you want to have.
Performance Anxiety & Fight or Flight
I’ll start with a story. Michael is a 30 year old male who came to therapy feeling lost, discouraged and ashamed. He says that he’s not able to keep his erection during sex with his new partner and he’s terrified that if he can’t fix the issue soon, they’ll reject him out of hand. Michael says he’s deeply attracted to his new partner, physically and emotionally and can’t understand why this would be happening. When he masturbates, he never has any issues getting firm erections and reaching orgasm when he wants. He goes on to say that he often has erections with his partner, they just go away when it comes time for penetrative sex.
Michael is not a real person, but I hear this story so often that he might as well be.
The first question I always ask is “what is going through your head when it comes time for sex?” Here are some of the most common answers I get:
“Stay hard! Stay hard, stay hard, STAY HARD!”
“What’s my penis doing? Does it feel hard still? Will it stay hard? What if it doesn’t stay hard? What if I never get hard again? Will my partner leave me?”
“Ok, this is the moment. Don’t screw it up this time!”
“What must they think of my body? Are they looking at the thing I don’t like? Are they judging it like I do?”
“No turning back now…you’ve initiated sex and now you are officially obligated to get an erection!”
“I can’t lose my erection again. My partner would be so disappointed in me. I’ll hate myself.”
“Why am I thinking like this? Why can’t I just enjoy the moment? What’s wrong with me?”
So, there’s a lot to unpack in any of these statements, but there is a common denominator: my clients find themselves deep in anxiety and shame spirals at a moment when what they need most is sensation and pleasure. Their bodies are entering some degree of a state commonly referred to as “fight or flight” and suddenly all the wonderful sensory input that lends itself to arousal (erection) becomes secondary to survival.
My clients go from a state of groundedness and presence – a state that folks often describe as “being in their body” – to a state of panic and dissociation (being outside of one’s body). Rather than being the one who experiences, they become the monitor of their experience – judging it, managing it and ultimately impeding it entirely.
As frustrating as this is, it actually makes a lot of sense from an evolutionary perspective. Our earliest genetic ancestors faced very real and daily threats to their survival. This might have been anything from a lion chasing them across the savannah to their tribe rejecting them and withholding life-saving resources such as food, shelter or protection. Our minds and bodies are purpose-built for detecting and reacting to threats to our survival. When one of those threats is present, our minds and bodies will tend to align around one of the following physiological responses:
Fight – defeat, neutralize, kill or otherwise stop the threat.
Flight – avoid the threat entirely. Hide from it, run from it, just stay far enough away so it can’t hurt you.
Freeze – a state of immobility when fight or flight is not available. A sort of built in “play dead” function.
In any of these responses, your body does a few things: Your amygdala has detected a threat and sent a message that is picked up by the hypothalamus. Your hypothalamus then activates your sympathetic nervous system which (and here’s the important part) triggers the release of epinephrine, AKA adrenaline.
Adrenaline causes a few immediate physiological in your body. Most importantly, your heart rate and blood pressure increase and blood is directed to your vital organs. Biologically speaking, your penis is not vital, so erections become harder if adrenaline is in your system. Over time, with repeated “failures” the very thought of a sexual encounter can trigger a release of adrenaline, thereby reinforcing and compounding the issue and making it more and more difficult to have the sexual experience you want.
Why does any of this matter in the context of sex? Your partner is probably not trying to eat you or leave you to die in the cold. If they’re hopping into bed with you, they’re probably there to feel good with you, right!? So why would we be experiencing a threat to our survival in the middle of a sexual encounter?
A little history…
We modern day Homo Sapiens traded in cave walls for books, forests for cities and torches for iPhones, our bodies and our minds remain essentially the same as they were 10,000 years ago. Those early homo sapiens looked like you, laughed the way you laugh and felt the things you feel.
Before the agricultural revolution, Homo Sapiens were largely nomadic hunter / gatherers who traveled around in groups of 150 at most, trading and sharing resources, forming friendships and social hierarchies, learning from one another and protecting each other from harm (3).
For early homo sapiens, the stakes were simply higher. Upsetting the wrong person meant you might not get to sleep close to the fire. You might not receive enough food. You might not be protected by others in a lethal physical conflict.
Sure, they never had the experience of waiting anxiously for their Tinder match to message back, but they did have the experience of being hyper aware of any hint of rejection or abandonment because for them, it was question of life or death. Our biological neural wiring is the very same as theirs. Evolution has not kept up with the pace of change in our environments and our threat systems are not sensitive enough to capture the nuance (and relative safety) of our modern lives.
As a human living in the 21st century, your odds of survival are the same whether or not your Tinder match messages you back, you pass that quiz, you’re late for the meeting or your partner leaves you, but your amygdala doesn’t know that! All it knows is that there is a threat and that means death could be at your doorstep, so it’s time to tell your sympathetic nervous system to pump out adrenaline to get ready to deal with that threat and maximize your chances of survival and ultimately passing on your DNA to some lucky homo sapien female.
Now, let’s return to Michael – when he shows up to a sexual encounter, he’s worried about one thing: abandonment. As we’ve discussed, rejection leading to abandonment is not a threat to his survival, but 10,000 years ago it would have been…and his wiring is at least that old! Abandonment, as you know by now, is a threat to survival, and when our body feels a threat, it releases adrenaline. When adrenaline floods our system it not only makes it physically more difficult for our bodies to produce an erection, it sends our brains into a hypervigilant, anxious, panicky tailspin.
To make matters worse, oftentimes our partners don’t know how to respond in a helpful way. Instead of offering support by redirecting or opening lines of communication, our partners will often communicate their own distress. Verbally, this might sound like:
“What’s wrong?”
“Did I do something?”
I’ve even heard more hostile examples like:
“I’m waiting…”
“What’s wrong with you?”
“You need to fix this / fix yourself”
“Again? Really?”
Nonverbal examples might be things like:
Heavy sighs
Eye rolling
Shutting down and silence
Physical disengagement
This is often why erectile dysfunction is viewed as a relational problem. When the loss of an erection sends a couple into an unhealthy pattern of conflict it raises the stakes and makes it even harder to experience the desire and sensations we need to produce an erection by shifting our attention away from pleasure and towards threat mitigation.
So what can you do?
A quick Google search will reveal things like the grip method (4) or the start stop method (5), which most people try on their own with limited success. If you're taking the pharmaceutical route, it's incredibly easy to procure sildenafil in forms like Viagra or Cialis (you should talk to your doctor if you are considering using these). You might also try toys like cock rings or cock pumps which can be effective and fun for some and unpleasant or even painful for others.
But lots of folks just want to figure out how to get out of their heads and start enjoying sex again, and that's where talk therapy can make a huge impact. Here are some of the ways:
Talk therapy can give you the tools you need to address and confront anxiety in the moment and drop back into the sensations your body needs to experience in order to cultivate arousal and produce a lasting erection.
Talk therapy can help you to address the relational issues (often stemming from relational trauma experience by one or both partners in previous relationships) that are eroding communication, escalating conflict and preventing connection.
Talk therapy can help normalize the experiences you are having and give you permission to be the sexual being you are. Your therapist will help you explore your desires and teach you how to ask for what you want, hopefully undoing some shame along the way.
Asking for help is one of the bravest things we can do. Starting therapy can feel scary and huge because it confronts us with things we may have avoided and uncover things we might not even know are there. But, armed with more information about yourself and how to navigate sexual relationships in healthier ways, you will be prepared to cultivate more satisfying relationships and have better sex.
About the Author
Patrick Bluett is a Licensed Professional Counselor in the State of Oregon and an AASECT Certified Sex Therapist. He specializes in working with relationship and sexual issues and sees individuals and couples in person and virtually from his Portland office. You can read more about Patrick and his approach and book appointments with him at his website https://bluettcounseling.com
(1) NHS inform. (2023b, December 12). Erectile dysfunction - Illnesses & conditions | NHS inform. NHS Inform. https://www.nhsinform.scot/illnesses-and-conditions/sexual-and-reproductive/erectile-dysfunction-impotence
(2) Fletcher, J. (2023, April 28). How does age affect erectile dysfunction? https://www.medicalnewstoday.com/articles/316215#
(3) Harari, Y. N. (2015). Sapiens: a brief history of humankind. Choice Reviews Online, 52(11), 52–5967. https://doi.org/10.5860/choice.190494
(4) Valeo, T. (2007, August 28). Overcoming ejaculation problems. WebMD. https://www.webmd.com/men/features/overcoming-ejaculation-problems
(5) Institute for Quality and Efficiency in Health Care (IQWiG). (2019, September 12). Premature ejaculation: What can I do on my own? InformedHealth.org - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK547551