Many people do not realize that erectile disorder (ED), the inability to achieve or sustain an effect sufficient for intercourse, is extremely common. Today, 1 in every 10 men in the United States experiences ED.
Men with ED may be unable to get an erection sometimes, be able to get an erection but not keep it long enough for satisfactory sexual intercourse, or never be able to get an erection. To satisfy the diagnosis of erectile disorder in the DSM-5, one must have been having these challenges for at least six months and during at least 75 percent of their past sexual scenarios.
Erectile disorder can affect every aspect of a man’s life—his physical health, his mental health, and his relational health. It affects not only the person with the condition, but their partners too.
Erectile Disorder and Younger Men
While ED occurs less frequently in younger men, a study in The Journal of Sexual Medicine found that ED affects about 26 percent of men under the age of 40. Another study highlighting ED in young men found that 8 percent of men between the ages of 20 and 29, and 11 percent of males ages 30 to 39, have some form of ED.
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The increasing prevalence of ED in young men is an important phenomenon—particularly because the psychological burden of erectile disorder in young men can sometimes be greater as they are in a time in their lives when society expects them to be more sexually virile and, in many cultures, more active. ED has drastically impacted the dating lives of many younger men, many of whom are meeting prospective dates through apps. They may avoid getting started with a new person for fear they will be expected to initiate sexual activity after several dates and then be unable to “perform.” Some young men are erotically turned on by beginning to text with a potential partner, but end up self-pleasuring with sexually explicit media or porn rather then asking the person to meet up and risking the embarrassment and misunderstanding that can follow an episode of ED.
Causes of Erectile Disorder
The most common cause of ED is vascular disease. Sixty-four percent of difficulty getting and maintaining an erection are associated with heart attack and 57 percent with bypass surgery. Up to 75 percent of men with diabetes, 40 percent of men with renal failure, and 30 percent of men with COPD have some experience with erectile disorder. Psychological causes of ED include stress, depression, anxiety, feelings of guilt, low body image, issues in a man’s relationship, or sleep disorders.
As more young men are affected by erectile disorder, there is an increased risk that a medical doctor may quickly prescribe a PDE5 inhibitor like tadalafil (generic Cialis) or sildenafil (generic Viagra), or refer them to a sex therapist. However, ED in young men can be the consequence of the combination of organic, psychological, and relational factors—all of which must be addressed in appropriate clinical treatment. In particular, erectile disorder in young men—even more than in older men—is considered a harbinger of cardiovascular disease (CVD).
Co-Occurring Sexual Disorders with ED
Most people also don’t realize that there are a number of sexual disorders that co-occur in men who experience ED. One co-occurring sexual disorder is premature ejaculation (PE). A recent study found that 76.3 percent of its participants who report PE also had an erectile disorder diagnosis. Premature or uncontrolled ejaculation is experienced by about 30 percent of men. The anticipation of premature ejaculation can cause a man anxiety which then leads to a loss of erection. Some men who come into sex therapy because of ED have never spoken about their premature ejaculation issue due to embarrassment and shame.
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Another co-occurring sexual disorder, though uncommon, is delayed ejaculation (DE)—or difficulty achieving orgasm despite adequate sexual stimulation. These are the men who can have penetrative sex for 30 minutes to an hour without climaxing. Couples who come in with this problem often express disappointment that they can’t get pregnant the “normal” way, or the partner feels unwanted, or there is too much pain from lengthy penetrative sessions. Over time, a man might begin to lose his erection in anticipation of the disappointment he and his partner will both feel when he cannot climax.
Psychological Contributors to Erectile Disorder
Psychological impotence is even more common than other forms of ED. It is estimated that up to 20 percent of men in the United States have experienced ED as the result of a negative mental health state. A survey of men living in the UK found that more than 50 percent of men in their 30s experience ED. About half of those who struggle with ED cite stress as the reason they cannot get or keep an erection.
A common precursor to ED is sexual performance anxiety, which affects up to 25 percent of men. Sexual performance anxiety can be caused by a number of things including body image issues, low self-esteem, depression, generalized anxiety, stress, previous sexual/emotional/physical trauma, and feeling emotionally disconnected from one’s partner.
Men may wait many months before seeking out sex therapy because they feel like they should be able to take care of this problem on their own. Reaching out for help is actually taking a courageous step of action in reclaiming one’s sex esteem.
Increased Recreational Use of Erectile Dysfunction Medication (EDM)
Phosphodiesterase type 5 (PDE5) inhibitors like sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra or Staxyn), and other oral erectile dysfunction medications, have become a popular sexual enhancement aid among some men without ED. A study in the Journal of Sex Medicine found that, among a sample of 167 male medical students reporting no issues with erectile function, 9 percent of these med students reported the use of EDM. Of those who had used PDE5 inhibitors in the past, 46 percent reported using the drugs more than three times, and 71 percent used them with alcohol. Why is this happening?
With so much sexual prowess depicted in sexually explicit media like online porn, streaming series, social media, and campaign ads featuring buffed men with six-packs and gleaming hairless chests, many young men feel they don’t live up to the standard. Clients who are more romantic types and need emotional triggers of closeness may lose their erection when with a partner they don’t know well enough yet. While these clients feel pressured to “make the first move” to show interest, they are not ready. Their mind and body are not in alignment and their penis sends the message. The pressure men feel may push them to use erectile dysfunction medications (EDM).
Men are surprised in therapy sessions to learn that the recreational use of EDMs may have unintended negative effects. One 2011 study found that recreational EDM college-aged users reported 2.5 times the rate of erectile difficulties compared to nonusers. In another study, recreational use of EDM has been found to decrease healthy young men’s confidence in their ability to get and maintain an erection on their own.
Men who come into sex therapy who tell me they’re using PDE5 inhibitors, despite having healthy erections when they masturbate, express anxiety that they won’t be able to “crush it” in the bedroom. Much of the work with men with ED is teaching them what a realistic sexual response cycle should look like, how they can identify their needed erotic triggers and skills to communicate them to partners. There is a lot of myth-busting around what authentic masculinity actually is that is part of sex therapy.
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Treatment for Erectile Disorder
As a result of the bio-psychosocial elements inherent in possible causes of ED, it’s extremely important to get a thorough sexual assessment by a sex therapist and urologist. When seeing a urologist for ED, the assessment might include a physical exam, blood and urine tests, penile duplex ultrasonography (a test to analyze blood flow in the penis), a penile angiography (x-ray with injected dye to view blood circulation) , and a combined intra-cavernous injection and stimulation to assess the quality of an erection.
When seeing a sex therapist, a client should expect the therapist to take the time to review their sexual history to find out possible medical reasons or injuries that occurred in childhood, puberty, and college years. The therapist can create a list of the prescriptions and OTC medications someone has or is currently taking to review with his medical provider, screen for alcohol and substance use and find out about psychiatric precursors that impact erectile problems.
If he hasn’t already been seen by a medical provider, a sex therapist will frequently refer the client to a urologist for tests to ensure there aren’t any co-morbid conditions contributing to the erectile disorder. And if he’s currently part of a couple, it’s recommended that the man’s partner/spouse is invited to be part of the sex therapy treatment.