Erectile Dysfunction (Part 2): When the Problem Isn’t Just Physical
When men experience erectile dysfunction (ED), the first assumption is often that something is physically wrong.
Maybe it's low testosterone. Maybe it's blood flow. Maybe it's age. Maybe something isn't working the way it should.
And sometimes there is a medical contributor. That's why a medical assessment is an important part of evaluating erectile dysfunction.
But erections don't happen in isolation from the rest of you.
Your nervous system, stress levels, relationships, beliefs about sex, past experiences, expectations, attention, and ability to relax can all influence erectile function.
In Part 1 of this series, I spoke with urologist Dr. Chris Bitcon about the medical considerations associated with erectile dysfunction.
For Part 2, I sat down with Justin Paulson, a registered clinical counsellor, couples counsellor, and clinical sexologist who works extensively with sexual concerns, including erectile dysfunction and performance anxiety.
And one of the biggest messages from our conversation was surprisingly simple:
Sometimes getting an erection requires doing less—not trying harder.
Erections Require Relaxation
An erection isn't something you consciously do.
Your nervous system has to allow it to happen.
Justin describes two important ingredients for erectile function:
Relaxation
Stimulation
The first is particularly important.
Your body needs to feel safe enough to prioritize sexual function.
Imagine you're walking through the woods and suddenly encounter a bear. Your nervous system immediately shifts into survival mode. Your heart rate increases, muscles tense, attention narrows, and blood flow is prioritized toward the systems needed to protect you.
An erection isn't particularly useful in that situation.
Of course, most of us aren't encountering bears during sex.
But our nervous system can respond to many other things as threats:
Stress
Performance anxiety
Relationship tension
Fear of losing an erection
Body image concerns
Pain
Fatigue
Previous negative sexual experiences
Worry about satisfying a partner
Major life changes
If your brain interprets something about the situation as threatening, your body may have difficulty shifting into the relaxed state that supports an erection.
And sometimes simply understanding this can be incredibly reassuring.
Your body may not be failing you.
It may be responding to the environment it's experiencing.
The Performance Anxiety Cycle
For some people, erectile difficulties begin with one experience.
Maybe you're exhausted.
Maybe you've had too much to drink.
Maybe you're distracted.
Maybe life is particularly stressful.
And one night, you don't get the erection you expected.
That alone isn't necessarily unusual.
The problem is what can happen next.
You start wondering:
What if it happens again?
The next sexual experience becomes a test.
Am I getting hard?
Am I hard enough?
Will I stay hard?
Is my partner noticing?
What's wrong with me?
Suddenly your attention is no longer on the person you're with or the sensations you're experiencing. You're monitoring your erection.
That creates anxiety.
Anxiety increases nervous system arousal.
And increased nervous system arousal can make an erection more difficult.
The fear of losing an erection can therefore become one of the very things contributing to losing it.
Are You Actually Paying Attention to What Feels Good?
This brings us to Justin's second ingredient: stimulation.
Imagine you're with someone you're incredibly attracted to.
But instead of noticing their body, their touch, your sensations, or what feels pleasurable, you're thinking:
Please get an erection.
That's not a particularly erotic thought.
Your brain needs sexual information too.
When attention becomes consumed by monitoring performance, there may be much less attention available for pleasure and arousal.
One goal of treatment can therefore be helping someone move away from performance and back toward sensation, curiosity, and pleasure.
The Pressure to "Perform"
There are also powerful expectations around what someone with a penis is "supposed" to do during sex.
You should get an erection.
You should maintain it.
You should know what your partner wants.
You should satisfy your partner.
You should orgasm.
Your partner should orgasm.
And somehow, you're supposed to make all of this happen without much communication.
That's a lot of pressure to bring into a sexual experience.
Justin often helps clients examine these expectations and ask:
Where did I learn what sex is supposed to look like?
And perhaps more importantly:
Are those expectations actually helping me?
Sex doesn't need to follow a predetermined script.
An erection can change during sex. Bodies respond differently from day to day. Partners can communicate. Pleasure can exist without penetration. And an orgasm doesn't have to be the measurement of whether sex was "successful."
Pornography Isn't Automatically the Problem
Pornography often comes up in conversations about erectile dysfunction, but this discussion deserves nuance.
Justin was very clear that pornography itself isn't automatically problematic.
Many people use pornography and have healthy sexual relationships.
Instead, it can be helpful to look at how pornography and masturbation are being used.
For example, if masturbation routinely happens:
In a very specific environment
With a very specific type of pornography
With particular stimulation
Quickly
As a way of relieving stress
…the body may become very familiar with responding under those particular circumstances.
Partnered sex may look completely different.
For some people, therapy may involve experimenting with masturbation differently—slowing things down, changing stimulation, reducing reliance on a particular type of pornography, noticing sensations, or making solo sexual experiences look a little more like partnered ones.
The goal isn't necessarily to eliminate pornography.
It's to become curious about what your body has learned to associate with sexual arousal.
Life Changes Can Affect Your Sex Life
Sometimes people search for one specific cause of erectile dysfunction when the bigger question might be:
What was happening in your life when things changed?
Think about major transitions such as:
Having children
Moving in with a partner
Getting married
Divorce
Starting a new relationship
Surgery
Cancer treatment
Injury
Work stress
Caregiving
Grief
Changes in body image
Relationship conflict
We don't leave these experiences outside the bedroom.
You are one person taking your nervous system, experiences, relationships, beliefs, and current life circumstances with you.
Sexual function is part of that whole system.
What Does the Pelvic Floor Have to Do With It?
Quite a bit.
The pelvic floor muscles contribute to erectile function, and like other muscles in the body, they need to be able to both contract and relax.
When someone is anxious or bracing, the pelvic floor may also become tense.
This is one reason I don't automatically teach Kegels to everyone experiencing erectile dysfunction.
For some people, strengthening may be appropriate.
For others, learning how to recognize and release pelvic floor tension may be much more important.
Pelvic floor physiotherapy might include:
Education about pelvic anatomy and erectile function
Learning to identify pelvic floor tension
Breathing and relaxation strategies
Pelvic floor coordination
Addressing pain
Looking at tissue or fascial restrictions
Addressing changes after injury or surgery
Improving awareness of what the pelvic floor is doing during sexual activity
And importantly, an internal examination is not automatically required.
There are many ways to begin pelvic floor physiotherapy using education, visuals, movement, breathing, external assessment, and body awareness.
Treatment should be individualized to the person in front of us, and you always have a choice in what assessment or treatment you consent to.
Sex Therapy Can Help Too
Just as pelvic floor physiotherapy isn't simply about doing exercises, sex therapy isn't simply sitting in a room talking about sex.
Treatment depends on what's contributing to the problem.
Justin described several approaches he may use with clients.
Sometimes this means exploring a person's sexual development and the messages they've absorbed about sex, masculinity, relationships, pleasure, or their body.
Sometimes it means examining all of the "shoulds" surrounding sex.
Sometimes it involves exercises focused on self-pleasure, body awareness, communication, curiosity, or learning to experience pleasurable touch without making an erection or orgasm the goal.
The aim isn't to try harder to achieve an erection.
In many cases, it's almost the opposite.
It's creating the conditions where the body doesn't have to try so hard.
Pleasure-Focused Sex Versus Goal-Focused Sex
One of my favourite ideas from this conversation was the distinction between pleasure-focused sex and orgasm-focused sex.
We're used to getting things quickly.
Food arrives at our door.
Information appears instantly on our phones.
Entertainment is available on demand.
And sometimes that same expectation shows up in sex.
We want the erection.
Then penetration.
Then orgasm.
But when we're constantly focused on the destination, we can miss everything happening along the way.
Touch.
Kissing.
Connection.
Arousal.
Anticipation.
Pleasure.
Curiosity.
Sometimes the goal isn't to force the body toward the next stage.
It's to give the body enough time and safety to get there on its own.
When Should You See a Doctor?
Even when erectile dysfunction seems strongly connected to stress or performance anxiety, it's still important to consider the medical side.
Justin encourages clients to speak with their healthcare provider because physical contributors can often be investigated more easily than psychological ones.
Some useful questions include:
Are you still having morning or nighttime erections?
Can you get an erection during masturbation?
Does the difficulty occur in every sexual situation or only certain ones?
Is there pain with erections?
Has something physically changed?
Are there other health symptoms occurring?
If you're consistently unable to achieve erections in any context, no longer experiencing nighttime or morning erections, or experiencing pain or other physical changes, medical assessment becomes particularly important.
This is also why ED care can work best as a team approach.
Depending on what's happening, that team might include a physician or urologist, pelvic floor physiotherapist, counsellor, sex therapist, or other healthcare professional.
Trauma Can Be Part of the Picture
For some people, difficulty relaxing goes deeper than everyday stress or performance anxiety.
Trauma can affect the nervous system's ability to experience safety.
And trauma doesn't necessarily mean one catastrophic event. It may involve one significant experience, or it may be the accumulation of many smaller experiences over time.
If someone's nervous system doesn't feel safe enough to "let go," simply adding more exercises or trying harder may not solve the problem.
Trauma-informed therapy may need to become part of the treatment plan.
Because sexual function, bowel function, and bladder function all have something important in common:
At some point, the body needs to be able to let go.
If You're Not Ready to Ask for Help Yet
Talking about erectile dysfunction can feel incredibly vulnerable.
You may not be ready to walk into a doctor's office, pelvic floor physiotherapy clinic, or therapist's office and start talking about your sex life.
That's okay.
Justin suggested starting by simply becoming more curious about your body.
Try noticing:
Where do I hold tension?
Can I tell when my body feels relaxed?
What happens in my pelvic floor when I'm stressed?
You might also write down some of your beliefs about sex.
What do you think you're supposed to do during sex?
What is your partner supposed to do?
What does "good sex" mean to you?
What makes a sexual experience successful?
What do you believe an erection says about you?
You don't necessarily need to change any of these thoughts yet.
Start by noticing them.
One of the Most Important Takeaways
Erectile dysfunction doesn't always mean that your body has lost the ability to have an erection.
Sometimes the fact that erections occur in certain situations but not others provides valuable information.
Your body may be capable of the physical process—but something about stress, attention, expectations, relationships, previous experiences, or the sexual environment is influencing how that system responds.
And that's hopeful.
Because instead of asking:
"How do I make myself get an erection?"
A more useful question might sometimes be:
"What does my body need in order to feel safe, relaxed, stimulated, and present enough to allow an erection to happen?"
That's a very different place to start.
Final Thoughts
Erectile dysfunction is rarely as simple as "something isn't working."
Erections sit at the intersection of the brain, nervous system, blood flow, pelvic floor, relationships, beliefs, experiences, health, and emotional wellbeing.
That's why treating ED sometimes requires more than medication.
For one person, the missing piece may be medical treatment.
For another, pelvic floor physiotherapy.
For another, sex therapy.
And for many people, it may be a combination.
If you're experiencing erectile dysfunction, you don't need to figure out which category you fit into before asking for help.
Start the conversation.
Find healthcare providers who are willing to look at the whole picture.
And remember: sexual function isn't something you necessarily achieve by trying harder.
Sometimes the work is learning how to create the conditions that allow your body to respond.
Listen to the full podcast episode:
Erectile Dysfunction Part 2: Non-Medical Considerations with Justin Paulson
And if you haven't listened yet, start with Part 1:
Erectile Dysfunction Part 1: Medical Considerations with Dr. Chris Bitcon
This blog is intended for educational purposes only and does not replace individualized medical advice.
About Justin Paulsen
Justin Paulsen (he/him) is a virtual Psychotherapist, Couples Counsellor and Clinical Sexologist based in Vancouver. He works with individuals and couples on mental health concerns, relationship and communication concerns, and sexual concerns. His research background is in penis complications such as erectile dysfunction and premature or delayed ejaculation.
