Erection problems and the mind: when the body is not the main culprit

“It’s nothing. I’m just tired.”

This is something a lot of men say when an erection fades or doesn’t come at all. They say it quickly, a little too quickly, then turn over and lie in the dark counting how many times it has happened now. The person lying next to him doesn’t know whether to ask something or pretend not to have noticed anything. And the next time an evening starts drifting in the same direction, both of them are already a little tense before anything has happened.

In Slovenia, erection problems are still talked about more in jokes than in earnest. But behind the jokes there is often a great deal of quiet worry: “Is something wrong with me?”, “Doesn’t he find me attractive any more?”, “Am I getting old?” In this post I want to write about how large a part of the story the mind can be: fear, watching yourself, and what happens between two partners. But I have to begin with something that is not psychological, and that order is no accident.

See a doctor first, and why this is not a formality

Before you put anything down to stress, see your GP, who can refer you to a urologist if needed. This is not the polite line everyone writing about mental health adds at the end. An erection is very much a matter of blood vessels: blood has to flow in and stay there. The arteries in the penis are smaller than the ones supplying the heart, so narrowing can show up there first, sometimes years before a person notices any problem with their heart.

An American study that followed several thousand men over a number of years found that those who developed erection problems later had a higher risk of cardiovascular events. This is why doctors today also see erectile dysfunction as a possible early sign of heart and blood vessel disease. The same goes for diabetes, high blood pressure, raised cholesterol, hormonal changes, some medications and smoking. If you take regular medication, tell your doctor about this too, because some medicines can affect sexual function, and never stop taking a medication on your own.

The doctor will ask about your health, perhaps take your blood pressure and order blood tests. None of this is humiliating. It can, however, be important, and if it turns out that your body is fine, you will be able to explore the rest of this post with a calmer mind. And if body and mind are intertwined, which is very common, you need both: a doctor and a space to talk.

One more thing: I am not a sexologist or a sex therapist. I am a therapist in training under supervision in marriage and family therapy, and in couples therapy intimacy can be one of the themes we talk about. For a sexual dysfunction itself, though, the right path is a doctor or a specialist in sexual medicine.

How common this is

One of the best-known studies on the subject is the Massachusetts Male Aging Study from the 1990s. In it, roughly half of men aged 40 to 70 (52 per cent) reported at least occasional erection problems, ranging from mild to complete. The proportion rose with age, with cardiovascular disease and with medication, and it was also linked to low mood and to anger a person kept bottled up.

This figure does not mean that half of all men are “ill”. It means something else: that an erection that once fails to come or fades is an ordinary human event, not a verdict on someone’s masculinity. Tiredness, alcohol, worry, an argument the day before, a new partner, a child waking up in the next room: all of this can affect a body that is not a machine.

The problem often doesn’t begin on the first such evening. It begins with what we tell ourselves about it.

How the mind stops the body

An erection is a response you cannot command. You can only allow it to happen. It is regulated by the part of the nervous system that works when we feel relaxed and safe, the part responsible for rest, digestion and closeness. When the alarm goes off (fear, pressure, the feeling of being judged), the body switches into a different mode. Blood goes where it is needed for fight or flight, not where it is needed for pleasure.

That is why it is such a cruel paradox that the more a man wants an erection and the harder he tries, the less likely it is to come. Effort and worry are danger signals to the body. In the 1980s the psychologist David Barlow showed something in the laboratory that was surprising at the time: in men without difficulties, pressure to respond actually increased arousal, while in men with erection problems it reduced it. The difference was not in their bodies but in where their attention went. Under pressure, the men with difficulties turned towards worry and towards whether “it would work”, instead of towards what was actually happening.

This shift of attention is at the heart of what is often called performance anxiety. The post Sexual anxiety: the fear of failing and how to break the loop looks more broadly at how the fear of failing takes root in sexuality. Here I want to pause on one particularly insidious part of it.

The observer by the bed

William Masters and Virginia Johnson, who laid the foundations of modern sex therapy in the 1960s and 1970s, described a phenomenon they called spectatoring: watching yourself. A man who has “failed” once or twice is no longer fully present during intimacy. Part of him steps to the side and watches: “Is it enough? Is it still holding? Is it going to fade now?”

This inner observer believes it is helping. In fact it does two things. First, it pulls attention away from touch, scent and closeness, from everything that feeds arousal. Second, it keeps telling the body that something is wrong and that it needs to stay on guard. The body does not respond to being on guard with arousal.

And so a self-sustaining loop forms. The memory of the previous evening brings expectation, expectation brings self-watching, self-watching reduces arousal, and reduced arousal confirms the fear. And next time the memory is even stronger.

It is important to say that this loop is not a sign of weakness. It is a sign that someone cares a great deal: about their partner, about the relationship, about how the other person sees them. In the bedroom, though, that very care turns against him.

What happens between the two of you

Erection problems don’t happen to one person alone. They happen in a relationship. And a partner’s response can calm the loop or, quite unintentionally, strengthen it.

I often see two extremes. One is too much concern: after every evening the partner comforts, asks questions, suggests solutions, searches online. The intention is good, but a man may experience it as added scrutiny: now two people are watching him. The other extreme is silence: nobody talks about it, it becomes the elephant in the room, and closeness starts to shrink because both are a little afraid of it.

Many partners quietly carry their own question: “Doesn’t he find me attractive any more?” Out of shame, a man often doesn’t say what is going on inside him and withdraws instead, even from tenderness, hugs and kisses that might lead “too far”. And so a problem that was small and physical at the start becomes wrapped in a layer of misunderstanding bigger than the problem itself. I wrote about how shame silences people in Shame: the emotion that whispers “something is wrong with me”.

The conversation that opens the loop often begins very simply. It might sound like this (a composite, not a real person):

“The other night you just turned over and went to sleep. I thought you were angry with me.”
“I wasn’t angry. I was ashamed.”
“Of what?”
“That it didn’t work again. That you’d think I don’t want you.”
“I thought you didn’t want me precisely because you turned away.”
Silence. “So we were both lying there thinking the same thing.”

That moment, when both realise they were afraid of the same thing, often does more than any technique. Because suddenly the problem is no longer his secret and her doubt, but something that is happening to the two of them.

Body or mind? Clues, not a diagnosis

People often want to know whether the problem is “all in the head”. The answer is almost always: the two are intertwined. Even when the cause is physical, fear soon joins in and makes things worse. And even when the start is psychological, the body can still play its part.

There are, however, clues that doctors and therapists take into account. The graphic below sums them up, but please read it as an aid for your conversation with a doctor, not as a self-diagnosis.

If you recognise yourself in the right-hand column, that is not proof that your body is healthy. But it is a good reason, alongside the medical check-up, to ask yourself what is going on in your life and in your relationship.

What helps

For physical causes, a doctor has various treatment options, which you decide on together; I won’t write about them, as this is not my field. I would, however, like to describe what helps with the part carried by the mind and the relationship.

Take away the goal. Masters and Johnson developed an approach we now know as sensate focus. For a while, the couple agrees that there will be no intercourse and turns instead to touch without a goal, paying attention to how the touch feels rather than to where it leads. Because there is no task to be accomplished, the inner observer has nothing to judge. And the body gets room to remember what it is like to feel safe in closeness. This approach is best carried out with a sex therapy specialist who adapts it to the couple.

Change the question. Instead of “Will it work?”, the question “What am I feeling now?” This is not a mental trick but a shift of attention from the future to the present. Practising mindfulness, the ability to notice what is happening without immediately judging it, helps with this.

Don’t avoid closeness. It is understandable that after a few bad experiences a person starts to withdraw. But avoidance only increases fear in the long run; there is more on this in Anxiety and avoidance: why avoiding helps you today and hurts you tomorrow. A hug that doesn’t lead anywhere is worth more than you think.

Talk about it outside the bedroom. Not straight after a difficult evening, when shame is at its strongest, but on a walk or over coffee, when you are both calm.

Look at what the relationship is carrying. Sometimes an erection fades where something has long gone unsaid in the relationship: resentment, tiredness of your roles, the sense that in this couple you are more a parent or a colleague than a lover. In couples therapy we then talk not about technique but about what happens between the partners when they are not in bed. If you are trying to decide whether a doctor, a sexologist or couples therapy is the right path for you, the post When to see a doctor, when a sex therapist, and when couples therapy is enough may help. And if a disagreement has built up between you about how often you even want sex, read When sexual desire is mismatched: sex in a long relationship as well.

Exercise: from judging to sensing

This exercise is not sexual. You can do it on your own, today, and it takes no more than ten minutes. Its purpose is to get to know your inner observer before you meet it in the bedroom.

1. Write down the observer’s sentences. What do you tell yourself before or during intimacy? “It’s going to fade again.” “I’ll disappoint her.” Write them down word for word, even if they seem silly.
2. Next to each sentence, write what it promises you. The observer almost always believes it is protecting you: “If I pay attention, I won’t be caught off guard.” Recognise that intention.
3. Try redirecting your attention in a non-sexual situation. When you catch yourself worrying in the shower or on a walk, shift your attention for one minute to what you can feel: the temperature of the water, your feet on the ground, your breath. Don’t judge, just describe.
4. Write a new sentence to have ready when the observer speaks up, for example: “I’m here. There’s no task. I’m just feeling.” Keep it short and make it yours.
5. Think about what you would say to your partner: one sentence, not an explanation. “Sometimes I’m gripped by the fear that it won’t work, and then I pull away.” You don’t have to say it today. It’s enough to know what you would say.

If during this exercise you notice a wave of strong shame or despair, that is information, not failure. It is a good moment to talk to someone about it: a doctor, a therapist or your partner.

Where this explanation does not apply

I want to be clear, because a psychological explanation can be misused, even with good intentions.

“It’s all in your head” is not a diagnosis. If you avoid a medical check-up because it is easier to believe it’s stress, you may miss something important. That is exactly why I began this post with the doctor.

Not every problem is about the relationship. Sometimes a couple is close, loves each other, talks, and the erection still fades because of a medication, an injury or an illness. Looking for a “deeper meaning” then is not only unnecessary but can add guilt that nobody needs.

Not everything depends on the man. If a partner uses the problem to humiliate or mock him, that is not a “lack of confidence” for the man to fix. It is a relationship that needs attention and, where there is abuse, also protection.

Sex is not only penetration. A good deal of distress comes from the belief that intimacy without an erection doesn’t count. Many couples discover that closeness widens once an erection is no longer the only measure.

What to remember

• With erection problems, see a doctor first: they can be an early sign of heart disease, vascular disease or diabetes.
• An occasional erection problem is common and in itself says nothing about masculinity or about how attractive your partner is.
• Watching yourself (spectatoring) pulls attention away from closeness and signals alarm to the body instead of safety.
• Your partner’s response matters: silence and too much concern often strengthen the loop, while a calm conversation outside the bedroom eases it.
• For sexual dysfunction, the right path is a doctor or a specialist in sexual medicine; couples therapy helps with what happens between the two of you around it.