Counseling for Erectile Dysfunction (ED)
Treating Erectile Dysfunction in Counseling
There are many causes of erection problems. Although the term “erectile dysfunction” (ED) officially refers to an issue caused by a medical problem or illness, many people use the term to describe all problems with getting or maintaining an erection regardless of their origin. For the purpose of brevity and clarity, we will refer to all erection problems as ED regardless of their origin - medical, psychological, or social.
We get hundreds of calls a year from men struggling with ED, and we have helped many of them better understand and address the problems they are facing. And we have learned a few things along the way that we want to share with you before you commit to counseling.
What are the causes of ED?
There are many causes of erection problems. Although the term “erectile dysfunction” (ED) officially refers to an issue caused by a medical problem or illness, many people use the term to describe all problems with getting or maintaining an erection regardless of their origin. For the purpose of brevity and clarity, we will refer to all erection problems as ED regardless of their origin - medical, psychological, or social.
We get hundreds of calls a year from men struggling with ED, and we have helped many of them better understand and address the problems they are facing. And we have learned a few things along the way that we want to share with you before you commit to counseling.
What are the causes of ED?
Biological
There are several medical problems that can lead to ED. The most common issues are normal aging, heart disease/problems, and prostate problems. The majority of the medical causes are serious and have several other noticeable effects on the body. For most men experiencing medical ED, they will also be experiencing other symptoms related to the underlying problem.
Many of our clients reference low testosterone as a concern and possible cause for ED. We are not convinced that testosterone supplementation has any significant effect on non-medical ED. Most who have asked their doctors about testosterone receive some skepticism and push-back from their providers. Most doctors are reluctant to prescribe testosterone without a significant medical diagnosis and treatment plan that calls for it. Medical scientists also remain unconvinced of the role testosterone plays in ED treatment, particularly those that are not caused by a significant medical illness like heart disease[1].
Although the medical causes of ED are common and severe, many men, particularly younger men, encounter erection problems with no detectable medical cause and thus are left with no clear or standard medical intervention to help them.
Psychological
The traditional model of ED treatment addresses ED as a psychological issue inherent to and influenced by the individual. For example, the typical psychological diagnoses that accompany erection problems are anxiety, obsessive compulsive disorder, and/or depression.
We believe that these diagnoses can be useful and can help to explain ED problems. If applicable, they are highly treatable, and therapy plus medication can eliminate the ED portion of the issue relatively easily. However, we encounter many men whose problems with ED seem to extend far beyond a simple diagnostic explanation and general treatment plan.
Social
Recently, in sex therapy circles, we have begun addressing the social contexts of people’s sexual lives, specifically their relationships and the agreements and disagreements, comforts and discomforts of their sex[3].
Many of our clients report how their partners respond when they lose or are unable to obtain an erection. Some clients describe being shamed, ridiculed, rejected, verbally castigated, and humiliated. Many other clients describe a partner who experiences their own crisis of shame and self doubt as they question if they are attractive enough, desired enough, good enough. Regardless of the reason or nature of the response, the partner’s response can have major consequences to how the ED unfolds, helping or hurting the problem.
Although the social contexts of the problem are important, they can be difficult to address in individual therapy causing many men to feel helpless and alone, unable to fix what is wrong.
As with all issues addressed in therapy, we believe the biopsychosocial model of ED is helpful to understand. But it is often far too vague to be useful. Most men need to understand their own problem in its unique context.
[1] https://pubmed.ncbi.nlm.nih.gov/34997198/
[2] https://www.goodreads.com/book/show/54744301-come-as-you-are
[3] https://www.goodreads.com/book/show/54744301-come-as-you-are
Schedule a free, 15-minute, phone consultation to see if we’re the right fit for you.
How does therapy help ED?
Every penis has a story. It’s funny to think about at first; some even consider it ridiculous to consider. But every penis exists in a world, in a family, in a relationship, in a friendship, in a job, in a context, in a story that is unique, complex, and imperfect.
For some penis owners, their erection becomes a sort of bellwether, a measure of how they are doing, how the day will go, where they are in their relationships. It can measure almost anything and everything, a useful if annoyingly uncontrollable barometer.
We believe that psychotherapy is helpful in addressing ED, because it can help the person experiencing it understand how to better measure and address their mental and emotional wellbeing. It can help them learn to read a compass, use a map, measure which way the wind blows in new and more meaningful ways that actually help them navigate their body and their sexual contexts more successfully.
Psychotherapy, specifically sex therapy, can also help men feel better equipped in sex, to understand their sexuality more intimately and to learn more about their sexual needs and desires and how to fulfill them.
Although every man is different (that’s why psychotherapy is useful to better understand how each man is different), we have learned a few things over the years about how modern men are struggling in and outside the bedroom.
So what are some specific stories of ED in physically healthy men?
Overuse/Misuse
Tiktok is awash with influencers encouraging men to “retain” their semen and protect their brains from too much porn and masturbation induced endorphins and dopamine. These claims are not scientifically validated, but they are rooted in a sort of common sense. If you use a muscle too much, you wear it out and it stops growing. Most of these influencers miss or intentionally misrepresent the converse idea - if you don’t use a muscle enough, it atrophies.
Scientists have found some, inconclusive evidence that too much porn and masturbation can affect ED[1]. Others have found that not enough sexual stimulation (porn and/or masturbation) can also influence perceived sexual dysfunction[2][3]. We believe these seemingly contradictory findings are not actually contradictory but evidence of the common wisdom. Use the muscle too much, wear it out. Don’t use it enough, lose mass. Use it or lose it but not too much.
“Too much” is different for everyone. Finding a sweet spot can be a focus of sex therapy with men struggling with ED. For some, looking at any porn and masturbating is indeed a bad behavior that should be extinguished. For others, striking a balance with masturbation and partnered sex is preferred and healthy. Every man must understand what he needs for himself and stick to it.
Performance Anxiety
For many, the first event of ED was not a big deal. They were informed enough to know that sometimes guys don’t get erections, so they blew it off as a fluke. Oftentimes the second instance is the same, “I am just having a hard time right now.” But by the fifth and sixth time, panic starts to set in.
The panic takes on a life of its own, like a snowball rolling down an infinite, snowy mountain, it grows bigger with each instance of ED. Then it becomes a syndrome where the person reacts anxiously to even the idea of sex, with heart palpitations, headaches, and even full on panic attacks when sex and their erection are expected.
Most of our ED clients experience some kind of performance anxiety especially after struggling with the issue over longer periods of time. The performance anxiety is often a secondary, immersion of an underlying problem. But, without addressing the cascade of anxiety that exacerbates any event, deeper problem solving is impossible.
Whiskey Dick
Where Dr. Kinsey comes from (Texas), whiskey is important, not just as a powerful intoxicant but as a symbol of masculine good taste. The better the bourbon, the better the man. Dr. Kinsey loves bourbon; that’s why he doesn’t drink anymore.
Many men we talk to experience whiskey dick in college. After some ill-advised binge drinking, the body kicks into triage mode, affecting the blood supply in all sorts of ways leaving one’s penis wanting. Most of the men we talk to understand and accept this inevitable outcome. A small, temporary price for the occasional, good whiskey pour (or five).
But this story, particularly as it becomes a pattern, conceals a more complex picture. It’s often the story of a man who doesn’t understand how his body works, who expects his choices, regardless of their recklessness, to not impact him meaningfully let alone in such an unexpectedly vulnerable way - by paralyzing his sexual system.
In therapy, these men often learn to understand their drinking - why they do it, what it does to them, and how to stop or reduce it. They also can attempt to better address feelings of vulnerability, to admit they need help, to reach out to others when they are suffering instead of reaching for that treacherous whiskey.
Intimacy Needs Rejection (Shame)
Men are often taught that their intimacy needs are simple and few; frequently they are reduced to the singular penetrative act of sexual intercourse. We reject this mythology about male needs. Men are far from simple, and their intimacy needs are as robust, profound, and “needy” as any other gender.
In our experience, men often not only deny their intimacy needs, they also reject them, casting them aside without much care or thought. They bury them in work. They sacrifice them to the gods of productivity, creation, and purpose. Providence and purpose are important things that our intimacy needs can support, but men are often taught that their emotions are impediments to be overcome, adversaries to be conquered, wild rebellious impulses to be controlled.
Many sometimes see sex as a reward for their productivity, something the hard work they’ve already completed earned them. But sex with a romantic, long term partner is often the result of a different kind of work, a loving, tender, intentional work toward meeting the emotional and psychological parts of intimacy needs.
We explore these ideas with men. What are your intimacy needs, and how does sex fit into them?
[3] https://pubmed.ncbi.nlm.nih.gov/35840678/
[4] https://pubmed.ncbi.nlm.nih.gov/33724108/
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6679165/
Lack of Freedom of Expression
When sexual problems arise or even when things just get stale couples often stop expressing themselves loudly and vigorously in sex. Good sex is often expressive. It doesn’t have to be loud or even vigorous, but it is rare for good sex to be silent or unemotive.
There are many factors that may encourage lovers to withdraw from sexual expression. Couples most often cite exhaustion from life’s responsibilities and/or tension between them that leads to withdrawal in sex. They force themselves into the act of sex, knowing it will help them feel better and more connected, but they are still feeling uncertain, anxious, shy, or tired.
Fantastic sex masters the practices that drive instinctual, pleasurable reactions to sex - think groans, moans, grunts, smells, tastes, and breath. Out of context, many lovers would laugh hysterically at each other because of how ridiculous they look and sound. But in sex, their minds and bodies are alight with fire because they are doing the “silly” things that set them ablaze. Conflict, self consciousness, body dysmorphia, body rejection, even shyness can all play a role in asking men to make less sound, sweat less, smell less, ask for less.
In our experience, lack of freedom to seek increased stimulation is a major cause of non-medical ED.
Repression and/or Concealment
Men are often shamed for their sexual interests. If their desires go beyond penetration and light foreplay, they may encounter resistance to exploring other experiences especially early in their sexual development. Men often tell us that this resistance encouraged them to repress or hide any interest that might deviate from the typical sexual script.This repression and concealment often leads these men to feelings of isolation and grief of never having truly experienced and expressed their desires.
We work with these men to better understand and integrate their desires. If they are not reaching for what turns them on the most in sex, they may experience the barriers to stimulation and erection more acutely than those who have their desired stimulations present. We also believe that shame is an impediment to good sex and the intimacy it brings.
Relationship Realities
The sexual relationship is not separate from the other relationships partners share. That relationship may be one of strangers who just met, but that context matters and has impacts on the sex they share. The health and wellness of the larger relationship can and will impact the health and wellness of the sexual relationship in ways that are often difficult to predict.
Relationships that are otherwise healthy and safe often struggle in the bedroom. Maybe it’s from lack of excitement, from lack of novelty. Maybe it’s from emotional fusion and codependence. Relationships that are unhealthy and turbulent may suffer from complete erotic death, but sometimes they are as rocky and turbulent in the bedroom as outside of it with lots of highs and lots of lows.
Many men who are struggling with ED are also struggling to acknowledge and address the larger relational dynamics that might be impacting them. Sex therapy for ED often turns into a therapy for a relationship, and we help men navigate those dynamics.
Counseling for erectile dysfunction can help but try these steps first
We believe that seeking counseling for ED is a good step, but we recommend a few steps before you commit.
Talk to your partner about what you are experiencing. If you have the privilege of being in a relationship with a supportive partner, talking to them will almost certainly help. Although this can be a difficult step, we encourage you to try and resolve the problem with your partner before committing to therapy. Maybe they will have a perspective that helps you. Maybe they will be able to offer some solutions. Maybe you will just stop feeling so alone and ashamed, enough to get you unstuck.
Talk to your doctor. In our experience, most physicians are ill equipped to handle ED. They will often say, “It’s in your head. Go to therapy.” Or they will say, “Here’s 5 pills of viagra. Should be enough to get you over the hump.” Although uncomfortable, a good, 7-minute conversation with your physician will give you the confidence you need to take next steps. We encourage you to ask:
Is there something wrong with my heart?
What are my cholesterol levels?
What are my blood pressure levels?
Are they normal for my age and weight?
What changes or medications (besides Viagra or Cialis) might strengthen my erections?
Is there something wrong with my prostate?
What are my PSA levels?
Have them perform a physical exam. It is uncomfortable, but it is the easiest way to diagnose an enlarged prostate and prostate cancer.
Could I be experiencing a hidden bladder or prostate infection (prostatitis)?
Discuss the details. Tell them:
How frequently you do not get an erection.
How frequently you get an erection but then lose it.
If you lose the erection, tell them exactly when. (Sometimes loss of erection during vigorous points in sex are a sign of heart problems.)
If you are able to get and maintain an erection during other forms of sexual stimulation like masturbation.
If you wake up in the morning with erections and how often.
How frequently you urinate and the quality of the stream, if you experience starting and stopping during urination, etc.
The quality, consistency, color, smell, and possibly taste of your ejaculate. Discolored or odd smelling ejaculate can be a sign of infection.
Try self-help. We have found that most self-help resources on this issue are a waste of time and money. But some of our clients have responded to the simple information and guidance of two books:
The Penis Book, by Aaron Spitz, MD - This book is particularly helpful for those who are concerned they may have a medical issue and want to better understand the biology and anatomy of their penis. It is a great companion and guide for advocacy with medical professionals when seeking medical care.
Coping with Erectile Dysfunction, by Barry McCarthy, PhD and Michael Metz, PhD - This book is helpful for those who know that their issue is more psychological in nature and want to try some basic problem solving. The authors explain the common, psychological causes of ED as well as their accompanying, research supported interventions. We recommend this book to everyone before they try therapy, but it can also be used as a helpful addendum to therapy.
Our Approach
So when should I seek out sex therapy for erectile dysfunction?
We encourage men to seek out sex therapy for ED after exhausting the steps above. If you and your partner are both at a loss for how to help, if you and your doctor are both convinced there is no medically treatable cause, if you have done some basic self-help and problem solving and the issue persists, then sex therapy is a good next step.
What if the problem is medical in nature?
If the problem is primarily medical, we work in partnership with your medical professional to understand and treat the ED through therapy. We do not provide medical treatment for the cause of the ED, but we can provide sex education and therapy expertise to help either increase the chances of an erection or create a workaround.
Due to the medical issue, some men may never regain full erection functioning. Unfortunately, in that case, sex therapy will not be able to fix what modern medicine cannot. But that does not mean that these clients cannot create fulfilling, erotic, and exciting sex. Sex therapy can help clients grieve the loss of function enough to create alternative pathways toward a new (often better) functioning.
What should I expect from sex therapy for erectile dysfunction?
Men often come to counseling for ED not fully understanding that they are asking for psychotherapy. It is also not uncommon for other medical and mentalh health professionals to misunderstand how sex therapy works, leading some men to expect something from sex therapy that no therapy can provide - a simple cure.
Sex therapy is not a problem solving, medical intervention. Sex therapy is psychotherapy with an extra focus on sex facilitated by a credentialed psychotherapist with extra expertise in sex and sexuality. Here are some basic facts about what to expect in sex therapy for erectile dysfunction:
● Three months at least - Sex therapy, like all psychotherapy, is not a short term treatment or a quick fix. All clients should expect at least three months of regular, weekly sessions. Most clients should expect upwards of six months of work. We will do our best to be efficient and effective, but we cannot offer our services without this kind of time investment.
● Discussions about your overall life and mental health - Although sex therapy is focused on your sexuality, it never ignores the rest of you. We will talk about your feelings as well as your erections. And we will attempt to treat mental health problems, with your consent, if we agree that they are related to the sex issue.
● ED medications - We are not medical doctors, so we cannot prescribe ED medications. We also recommend that most people do not take ED medications during the course of sex therapy treatment. There are many exceptions to this recommendation including if the problem is medical in nature.
● Stellar psychotherapy - Although we will help you with the ED issue, we will do so by offering you top shelf psychotherapy. We believe that the focus of sex helps create an intimacy and honesty that enhances the therapeutic process, providing a great opportunity for excellent therapy.
● Personal growth - Even though the therapy is focused on the ED, clients often tell us that they benefitted as a person from the process. It is often the case that to overcome the ED one must learn to accept themselves, with the mixed bag of pros and cons, strengths and weaknesses, warts and all.
Conclusion
We believe that erectile dysfunction is a great reason for clients to enter into a therapy that helps them address all of their therapy goals, not just ED. We also believe that ED is highly treatable, responding well to therapeutic intervention within a few months. We also know that the focus on sex in therapy can deepen and enhance the therapeutic experience for our clients leading them toward personal growth, better sex, and more joyful and purposeful lives.