Psychological aspects of Impotence

Erectile Dysfunction has emotional dimensions

/ Author:  / Reviewed by: Robert Carlson, M.D

Why erectile dysfunction? Why now? One index of recent preoccupation with erectile dysfunction is the increased number of television and other ads by the pharmaceutical industry.

Changes in public attitudes allow for near-blanket advertising of remedies for this condition that in previous years would not be acceptable to media gatekeepers or good manners. Either there are indeed millions of men with this problem, or the drug companies are mistaken about how many men suffer from the problem.

It would be wrong to assume that the recent sweep of erectile dysfunction ads means there is some corresponding rapid increase in the disorder itself. However, our greater willingness to talk about it can have the benefit of bringing to light some of the less obvious causes for the condition.

An important idea to keep in mind about impotence is that there are primarily physiological causes for some men, but psychological explanations in other cases. A given patient may have a condition with both aspects, yet actually benefit more from a treatment plan by a psychiatrist than a urologist.

It's time we talked

The Mayo Clinic lists "depression, anxiety or other mental health conditions, stress, relationship problems due to stress, poor communication" as causes for erectile dysfunction. Patients may or may or may not be aware of the role such emotional issues may be playing. Even if they sense psychological problems are a factor, talking about it to a doctor can be awkward.

Figuring out whether the problem is more psychological and emotional rather than vascular or "mechanical" may require the consulting physician to ask very personal, intimate questions. Some men may be more comfortable thinking about their condition as a medical problem mostly involving blood pressure and stamina.

After reviewing the patient's medical history and basic physiological variables such as weight, heart rate and blood pressure, the consulting physician may suspect the fundamental problem is psychosexual or emotional. Getting some men to open up about this can be a tricky business, and the more diverse nature of 21st Century populations can require doctors to be sensitive to a whole range of issues.

Some men will have a background in cultures that do not encourage them to divulge intimate sexual information. However, a dispassionate, clinical chat that starts with more physiological rather than emotional themes should not be too embarrassing or stressful. The impotence issue can be explored gradually, perhaps after general physical and emotional health issues are explored.

Melnick and colleagues reviewed a series of studies about treating erectile dysfunction and concluded "there was evidence that group psychotherapy may improve erectile function." Men with this problem will want to explore whether talking about their problems in a group setting, possibly in conjunction with medication, will help.

When the real reasons for impotence are not easy to divulge or even know

The wise physician will keep in mind the role of men's physical health in erectile dysfunction, but will intuit when the real problems lay elsewhere. The reason for lack of getting or maintaining an erection, or for a lack of desire at all, could have everything to do with economic, family, relationship, parenting or self-esteem issues.

Men can have a sense of masculinity that is threatened by emotional, but not physiological or "medical" reasons they cannot have satisfying sexual experiences. They may explain erection difficulties as stemming from primarily physiological causes; for instance, recent weight gain, recovering from illness, lower back pain or other common health concerns.

Clinicians will over time develop intuition about the respective role that physiological causes have compared to "life issues" in their patient's situations. Oftentimes there is no easy separation. Complicating matters is the lack of knowledge men may possess about their own bodies,  emotions and sexuality. The complexity of these issues may not lend themselves to fast clinical interactions where the patient walks out with a prescription for the latest ED drug.

Doctors have to be shrewd in assessing whether financial pressures, conflicts with one's partner, or coping with the death of a loved one and other intimate "existential" issues are causing the problem. Men may giving short shrift to these sorts of explanations for a variety of reasons, not the least of which is shame, shyness, embarrassment, lack of comfort discussing sexuality and so forth.

Time pressures can work against exploring the emotional side of impotence

Real tact and skill are called for here. The all-too-brief availability of the modern physician may create time pressure to not explore deeper emotional problems and just prescribe drugs after a fifteen minute consult. Patients need to be their own advocates though, and this kind of short interaction might not allow for deeper issues to be raised.

Men may need time to trust a doctor enough to divulge a feeling that stress about money woes, drinking, body image, coping with the aftermath of losing a parent or other issues is part of the problem. This time is not easy to come by in the modern medical world, but not all health issues can be resolved through a fifteen minute consultation and a prescription for drugs.

For that matter, they may not be fully aware that such emotions and psychosexual issues are interfering with their sexual enjoyment and performance. Doctors routinely confront limits on patient's self-knowledge. It might turn out that a man is biased towards non-emotional explanations of why maintaining an erection is difficult, and instead cite recent health incidents, sleep issues, getting older, weight gain or lower back pain. Getting to the root of the problem is non-trivial indeed.

It can take a number of counseling sessions to create a safe enough zone for a man to explore the full range of factors involved. Men need to make getting enough access to physicians and other medical professionals a priority. Empowered patients will at first recognize the need for extended interactions and then make serious efforts to get doctors and others to cooperate.


Some men may find erectile dysfunction medications that are available nowadays good enough to manage their impotence. Others may really be needing to address emotional and psychosexual barriers to satisfying sex.

A sensitive and experienced physician can gently help a man seeking help to explore what is going on in their life that might be leading to erectile problems. Men may find this type of conversation difficult and may instead come up with other explanations for the problem. Men with psychological problems that prevent fulfilling sexuality may need to make getting conversation time with doctors a priority.

Review Date: 
June 19, 2012