Dissipating Performance Anxiety

Gambescia and Weeks (2020) have described the significant role that performance anxiety plays in ED. The formula is quite simple and should be described to the couple. Anxiety and fear about performance (getting and keeping an erection) significantly decreases the ability to acquire and maintain an erection. Men get caught in a vicious cycle of performance anxiety: the loss of an erection produces anxiety, which in turn makes getting an erection more difficult, which increases anxiety. Two techniques are useful in reducing performance anxiety after the man knows about the detrimental role anxiety plays. First, the therapist never actually prescribes that the client should achieve an erection.

The wording of the exercises in treating ED should include “if” an erection happens not that it will happen. Second, we ask men to place themselves in a mental loop of focusing on the present. They are instructed to keep saying to themselves, “What is feeling good right now, and what would I like in order to continue feeling pleasurable sensation?” We explain that any time they start to think about the next moment or past experiences, they are inviting the anxiety back. For example, if they start thinking ahead, they will inevitability think about whether the erection will persist or be firm. This thought engenders anxiety that diminishes erectile ability.

Conducting Cognitive Work

Men with ED often have several negative thoughts about their erectile ability that generate fear and anxiety. They must be helped to identify and neutralize their negative thoughts, stop them, and substitute positive cognitions. Men can become cognitively distracted with a myriad of catastrophic thoughts that interfere with keeping an erection: “It never works,” “I do not want to fail again,” and “I just know it isn’t going to work so why try.” Men with performance anxiety monitor their erections constantly while thinking negative thoughts. The man’s preoccupation with his erection increases his performance anxiety. Getting and keeping the erection may become the only focus of the sexual interaction. When both partners get caught up in his erection or lack thereof, sex becomes a task, chore, or performance. The interaction is no longer about being emotionally and physically connected and sharing a pleasurable experience. Overall, the couple loses sight of any other sexual activity. Their repertoire of sexual activities begins to shrink due to the exclusive focus on the erection or lack thereof. Rather than take advantage of other pleasurable activities and see those as a successful sexual experience, sexual success is measured in terms of erectile ability. The entire meaning of sex involves successful penetration. The meaning of sex needs to be broadly defined as any pleasurable physical interaction leading to emotional and physical satisfaction.

Since the immediate or most obvious cause of ED is usually the result of performance anxiety, reducing this anxiety may produce significant improvement or complete recovery of erectile ability. Additionally, the therapist must also listen for hidden, remote, or underlying causes of ED, such as lack of desire for partner, individual psychopathology, fear of pregnancy, resentment of the partner, denial of self-pleasure, attraction to an affair partner, addiction to pornography, and a host of other reasons mentioned previously in this chapter.

Understanding Medical Treatments

Often, and particularly as the man ages, the probability of ED increases due to the influence of organic disease states such as cardiovascular disease or diabetes. Thus, many cases of ED have mixed organic and psychogenic etiologies. Most of these men can be helped by oral medications such as Viagra, Levitra, or Cialis. These medications are mild vasodilators, and each has a slightly different mode of action and duration of efficacy. Sometimes a man may not respond to the oral medications due to more severe neurological involvement, for instance. In these cases, an injectable treatment, where the vasodilator is directly injected into the spongy tissue of the penis, can be used. Several other options such as the penile vacuum pump and/or a tourniquet can be employed. Read more about these and other treatments as reviewed by Gambescia and Weeks (2020). In addition to augmenting the blood supply to the penis, medical treatments for ED can give the man confidence and better erectile ability when used in conjunction with psychotherapeutic exercises.

Although there are currently many effective medical treatments for ED, a surprising finding is that compliance to treatment is relatively poor regardless of the modality used (Gambescia & Weeks, 2020). It is understandable that the man and his partner will complain about the awkwardness while using a penile pump, physical discomfort related to the injection, or the surgical implications of the penile prosthesis. The most common medical treatment for ED is an oral medication called PDE-5 (phosphodiesterase type 5) inhibitors, which are reasonably safe, effective and easy to use; nonetheless, the discontinuation rate is roughly 50% (Carvalheira, Pereira, Maroco, & Forjaz, 2012). There are several reasons why men ceased using a drug that was working. Most of these involve unrealistic fears about the safety of the drugs, complaints about side effects such as flushing, embarrassment, and relationship factors. All these factors can be addressed in couple/sex therapy. For example, when a man is taking the oral medication, we often observe that he is still experiencing significant performance anxiety, self-monitoring, and worry about his partner’s response. Further, the man may question why he must rely on a drug to obtain an erection and his partner may have concerns that an “artificial erection” is an insult to her sexual attractiveness. These issues may still reduce the effectiveness of the medication for the ED and the quality of the sexual experience for the couple. In short, men who use oral medications for ED can greatly benefit from sex therapy. When using a medication to facilitate an erection, there is often a battle between the level of anxiety and the erection-promoting drug. In fact, the greatest benefit for those using an ED medication is learning how to incorporate a medication into their sexual lives, removing any obstacles to having sex, and learning there are many ways to achieve sexual satisfaction without an erection.

In our experience, men with ED have usually had the problem for an extended length of time, especially if the man is older. The couple may have adapted or resigned themselves to not being sexual; alternatively, it might actually be a relief to a partner who is not interested. The restoration of the man’s sexual ability may not be a welcome event for the partner—or for the man himself. Frequently, there is a long-standing pattern of sexual avoidance, which tends to be self-perpetuating. Men who are prescribed ED medications or treatment by their physicians also need psychological help incorporating a medically enhanced erection into their sexual relationship. Medical therapies used in conjunction with sex therapy is more successful in promoting sexual satisfaction and compliance than the use of either psychotherapy or medical treatments alone (Mobley, Khera, Si Baum, 2017).