Erectile dysfunction can be about much more than getting or keeping an erection.
For some men, erectile dysfunction begins with a physical change. For others, it appears during a stressful period, after a difficult sexual experience, or seemingly out of nowhere. Sometimes the body responds differently from one sexual encounter to the next. As a sex therapist for erectile dysfunction in NYC I have heard hundreds, even thousands of stories about what this does to men and how it makes them feel. Initially, you worry about it and become acutely aware of your erection, and you wonder whether you will be able to stay hard. Sometimes that wondering turns into anxiety and even panic. And while all this is happening internally, you’re monitoring your body instead of experiencing pleasure. That is where male performance anxiety overtakes everything else in your life. This is an important distinction. Erectile dysfunction can have physical, psychological, relational, or medication-related causes—and sometimes several factors are operating at once. erectile dysfunction isn’t simply “in your head,” but anxiety about sexual performance can absolutely make erectile difficulties worse.
What is erectile dysfunction?
Erectile dysfunction (ED) is difficulty getting or maintaining an erection that is firm enough for sexual activity.
You might:
- Get an erection sometimes but not every time you want sex
- Get an erection but lose it during sex
- Find that your erection changes depending on the situation
- Have difficulty becoming erect even when you feel sexually interested
Occasional changes in erectile function are common. But if erectile difficulties keep happening or are causing distress, it’s worth getting them evaluated.
Erectile dysfunction is also not simply an inevitable part of getting older. It becomes more common with age, but ED can have many different causes, including cardiovascular and metabolic conditions, hormonal issues, medications, nerve problems, stress, anxiety, depression, and lifestyle factors.
This is why the first step in treatment is always a medical assessment to determine if this is physical in its origins.
Your erection does not tell the whole story
One of the most important things to understand about erectile dysfunction is that erection and desire are not the same thing. You can want sex and not have an erection and you can be attracted to someone and lose your erection or be highly aroused mentally while your body isn’t cooperating. And you can have an erection without actually wanting sexual contact. An erection is a physiological response involving blood flow, nerves, hormones, the brain, and psychological and emotional factors. It is not a reliable test of attraction, masculinity, sexual confidence, or how much you want your partner. That distinction can be enormously important when you’re dealing with ED.
How male performance anxiety can create a cycle
Imagine this: You are having sex and everything is going well. Then you notice your erection isn’t quite as firm. Instead of staying with the sensations in your body, your attention moves into your head.
- Is it going away?
- Can she/he/they tell?
- What if I can’t get it back?
- This happened last time.
- What is wrong with me?
Now you’re monitoring your erection rather than experiencing sex. That shift can increase anxiety and take you further away from arousal so you lose your erection. Then the experience becomes proof that your fear was justified so the next time you have sex, you’re already anticipating the problem. That is the performance anxiety cycle. The more you try to guarantee that you will stay hard, the more sex can start to feel like an examination you have to pass.
Sexual performance anxiety isn’t just about sex
Performance anxiety can start affecting your life outside the bedroom. A lot of men stop initiating sex, they avoid dating, they turn down sexual opportunities. they become dependent on particular ‘circumstances’ in which they feel more confident, they might worry about whether they’ll be able to “perform” before they’ve even kissed someone. And, the big one is many of them begin to define themselves by what their penis is doing.
This can be especially difficult because many men have absorbed the idea that sexual performance is part of masculinity That if you can’t maintain an erection, you may feel embarrassed, inadequate, or afraid that your partner will lose interest. But an erection is not a measure of your worth as a sexual partner, your capacity to be a good lover is, and you do not need a raging boner to be incredible in bed.
Erectile dysfunction and relationships
ED can affect both people in a relationship. The person experiencing erectile difficulties may feel shame or fear of disappointing their partner. The partner may wonder:
- “Are they still attracted to me?”
- “Am I doing something wrong?”
- “Do they actually want me?”
Neither interpretation may be true, but when nobody talks about what is happening, both people can start filling in the blanks. Sex can become increasingly cautious. Initiation can decrease. Affection can become loaded. And eventually the couple may be dealing with a relationship problem that began with a sexual one. This is one reason sex therapy for erectile dysfunction can include working with couples—not just the individual experiencing ED.
When erectile dysfunction has a physical cause
Psychological factors are only part of the picture. Erectile dysfunction can be associated with conditions affecting blood vessels, nerves, hormones, and overall health.
Diabetes, cardiovascular disease, high blood pressure, certain medications, and other medical conditions can contribute to ED. That means persistent erectile difficulties need an appropriate medical evaluation.
A doctor or urologist may look at your medical and sexual history, medications, physical health, and relevant laboratory or other tests to understand what might be contributing to the problem. Treatment can include addressing an underlying medical condition, changing a medication when medically appropriate, prescription ED medications, devices, and other medical interventions. Counseling may also be recommended when emotional or psychological factors are contributing to ED. Seeing a medical professional doesn’t mean the problem is “physical.” Seeing a sex therapist doesn’t mean the problem is “psychological.” Usually both sides of the equation need attention.
What does sexual performance anxiety treatment involve?
Sexual performance anxiety treatment isn’t about teaching you how to force an erection. It is about changing the relationship you have with sex, arousal, your body, and the expectations you’ve placed on yourself.
Sex therapy may involve exploring:
- Fear of losing your erection
- Anxiety before or during sex
- Shame around sexual performance
- Pressure to satisfy a partner
- Negative beliefs about masculinity
- Avoidance of sexual situations
- Relationship dynamics that increase pressure
- Difficulty staying present during sexual activity
- Changes in desire or arousal
- Previous sexual experiences that continue to affect confidence
A major part of the work can be learning to move your attention away from performance monitoring and back toward sensation, pleasure, connection, presence and curiosity, because the goal isn’t to become better at passing a sexual test, but to experience sex as joyful again.
Sex therapy for erectile dysfunction in NYC
If you’re looking for a sex therapist for erectile dysfunction in NYC, you may be looking for something different from a purely medical approach. Perhaps you’ve already talked to a doctor or you’ve tried medications which help physically but you’re still anxious about sex. Or perhaps you don’t understand why you can have an erection in some situations (solo) but struggle in others ( partnered). Sex therapy can provide a space to explore the psychological and relational dimensions of erectile dysfunction without reducing the problem to either “it’s all physical” or “it’s all in your head.” You can work on the anxiety, shame, expectations, relationship dynamics, and sexual patterns that may be keeping the cycle going. And you can learn to experience your body without constantly checking whether it is doing what you think it should.
You don’t have to make your erection the center of sex
Perhaps one of the most useful shifts is also one of the simplest: Your erection does not have to determine what happens next. An erection can change. It can come and go. You can slow down, change activities, ffocus on touch, experience pleasure without penetration, stay connected to your partner and you can have a sexual experience that is satisfying even when your body doesn’t behave exactly as you expected.
That isn’t giving up on erectile function but expanding your definition of it to include taking the pressure off it. And paradoxically, removing the demand to perform can create more room for arousal, pleasure, and connection.
Looking for help with erectile dysfunction or male performance anxiety in NYC?
If erectile dysfunction has started affecting your confidence, relationship, or enjoyment of sex, working with a sex therapist for erectile dysfunction can help you understand what is happening and develop a different relationship with sexual performance. Sex therapy can be particularly useful when ED is accompanied by male performance anxiety, sexual performance anxiety, shame, avoidance, relationship difficulties, or fear around sexual intimacy. Medical evaluation remains important for persistent erectile difficulties, while sex therapy can address the emotional, psychological, and relational dimensions of the experience. You don’t have to figure it out alone.
