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The Sensible Psychology Dictionary Psychiatric Diagnoses in Plain English

Male erectile disorder (impotence)

DSM Classification

(The psychiatry bible)

Male Erectile Disorder

Diagnostic criteria

A. Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection.

B. The disturbance causes marked distress or interpersonal difficulty.

C. The erectile dysfunction is not better accounted for by another Axis I disorder (other than a Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Sensible Psychology Definition


Inability to have or maintain an erection.

Can cause great psychological distress if prolonged.

Impotence – hard evidence of the mind-body connection

Impotence, although often treated as a joke, can be devastating for the man who experiences it more than very occasionally. All men will experience some occasions when they expect and want to get an erection, but find that it simply does not happen. Such isolated incidents are not usually a matter for concern, although they may be embarrassing or disappointing at the time. But if a man finds that impotence has become the norm rather than the exception, he is right to question what is going on.

Impotence is a phenomenon that clearly demonstrates how closely mind and body are linked. Impotence can arise (and persist) as a result of what is going on in your mind and/or what is going on in your body, and the two aspects directly influence each other.

For example, low testosterone levels can reduce sex drive and sexual response (in both men and women). This is clearly a physical factor, but it can be influenced by emotional factors. If you are made redundant, the emotional stress of this change in status can measurably reduce your testosterone levels.

It is important to establish, if possible, whether the original cause is mainly physical or mainly psychological.

Erectile dysfunction: not all in the mind

Physical causes (such as low testosterone levels, type two diabetes, hypertension (high blood pressure) and other diseases should be ruled out before concluding that impotence must be either stress related or a self-fulfilling prophecy (“I expect this not to work, so it doesn’t”).

Anyone experiencing impotence, especially if there is no clear emotional or stress-related change going on, should get medically checked out.

One way to ‘test’ whether impotence has a physical rather than a psychological cause is to notice whether spontaneous erections occur outside of sexual situations, such as when you wake up in the morning (‘morning glory’).

Lifestyle factors such as smoking (which damages arteries running into the penis) and drinking excessive amounts of alcohol (which diminishes the sex hormone testosterone) can also result in impotence. This may then become part of an ‘anxious habitual cycle’.

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Stress and sex

Not getting an erection is not always a sign that something is wrong. On the contrary. Our bodies have evolved to ‘switch off’ sexual response in certain circumstances, especially when we are (or think we are) under threat.

In such situations, the human stress response (the ‘fight or flight’ mechanism) kicks in automatically to prepare your body for the immediate physical demands of fighting off the threat or running away as fast as you can.

When we feel threatened, blood is pumped away from the stomach (we don’t need to be digesting when fending off a vicious bear) and also away from the penis (we don’t need an erection when fleeing a predator).

If you’re sprinting flat out at the end of a half marathon you’d be most surprised if you found you had developed a spontaneous erection. The point here is that not getting or keeping an erection is adaptive under the right circumstances.

It is only seen as a ‘disorder’ (and that is a scary word) when we get into the habit of feeling threatened during intimacy.

Fortunately, just as men can (quite inadvertently) learn to worry about whether they will or won’t get and keep an erection, so too can they learn to relax and re-associate sex with the right kind of focus of mind – which helps it feel non-threatening and enjoyable again.

Impotence and performance anxiety

Shame, embarrassment, and a gnawing feeling of being less ‘manly’ can all result from a failure to achieve erection, but the anticipation of such feelings can also interfere with the process of getting hard.

We all know the power of expectation. Performance anxiety – that is, focusing more on your own sexual response rather than that of your partner – can produce the very result you don’t want.

Paradoxically, not being focussed on sexual performance but just being in flow ‘in the moment’ helps a man ‘perform’ better. Caring too much about the result, as with many things in life, can release so much stress hormone into the bloodstream that your body wrongly identifies the situation as ‘threatening’ – and so the chemical and blood flow changes that need to happen for erection to occur don’t happen.

Impotence and relationships

Although it’s often jokingly said that the quickest way to overcome a sexual problem within a relationship is to change the relationship, it’s actually not true that men always separate (or ‘compartmentalize’) the state of their relationship from their sexual experience.

Impotence can damage relationships as it diminishes sexual satisfaction for both partners. But, in turn, it can be caused by an unsatisfactory relationship. If a man feels undermined, disliked or disrespected by his partner, it would be somewhat strange if he had no problems with his sexual response.

Sexual responsiveness shouldn’t be seen in isolation from the state of a relationship. It may be symptomatic of wider relationship problems.

Treatment for impotence

It can take a lot of courage for a man to admit, even to himself, that there’s something wrong.

Treatment may be through the use of a physical aid, or with medication. Common psychological treatments include ‘paradoxical’ behavioural therapy, which may include setting a ‘task’ to have partners sleep together but not have sex. In this way the man is freed from pressure to perform and can begin to re-associate naked intimacy with feeling non-threatened again. Often, sooner or later, erections will return.

Common treatments

Vacuum pump


A plastic cylinder is placed over the penis and the air is sucked out. This creates pressure and rapidly forces blood into the penis. A ring is then applied around the base of the penis to keep the blood in place to sustain the erection.

Can be very effective.

Possible side effects

  • bruising
  • inability to ejaculate
  • pain
  • priapism (prolonged painful erection requiring medical treatment)
  • lack of spontaneity

Penile drug injection

A dilatory drugs (such as Papaverine) is injected directly into the penis about 15 minutes before sexual intercourse.

  • headaches
  • dizziness
  • priapism

Viagra (Sildenafil citrate)

Induces vasodilation and increased inflow of blood into the penis, resulting in an erection.

Widely available in tablet form.

  • headaches
  • flushing
  • indigestion
  • impaired vision
  • nasal congestion
  • priapism
  • hypotension (abnormally low blood pressure)
  • heart attack
  • sudden hearing loss
  • stroke

A number of other drug and hormone treatments are available. Troublesome side effects are not, of course, experienced by everyone.

The sensible psychology approach

It helps to avoid words like ‘problem’ and ‘disorder’ when dealing with impotence and instead speak of ‘desirable’ and ‘undesirable’ responses. A ‘sexual dysfunction’ label is damaging to self-esteem and can aggravate the difficulties being encountered. After all, experiencing impotence isn’t so unusual – just about every man at some time in his life will experience it.

The first task is to reassure any man experiencing impotence that it is certainly not his fault. He doesn’t decide not to get an erection any more than people decide to blush or decide to have a certain dream at night.

If clear medical problems that need treatment have not been identified, it is important to try a psychological approach before resorting to physical treatments. This will

  1. prevent development of dependence on a drug or a device (leading to the erroneous belief that sex is not possible without these aids)
  2. avoid any risk of side effects.

Sexual response is an unconscious function, controlled by the unconscious mind. This is why hypnosis is an ideal way to help the unconscious part of the mind disconnect the association that has come about between sex and stressful feelings, and re-associate times of intimacy with feeling safe and relaxed and therefore free to enjoy sexual arousal.

Effective psychological therapy for impotence will

  1. examine lifestyle and habits to see if background stress levels, chronic smoking, drinking or other addictions might be having a negative impact on sexual function
  2. find out whether attitudes to sex are a factor – e.g. seeing sex as a ‘performance’ where you have to ‘measure up’, being hindered by sexual guilt, experiencing other fears about sex – and work to develop healthier attitudes and remove unnecessary fears
  3. discover what is going on in the relationship and explore ways to improve it (if appropriate)
  4. use hypnosis to build a new, more positive and calm ‘pressure off’ association with sex in future.

Hundreds of millions of men suffer impotence at some time or another – and millions learn to leave it behind naturally and easily.

Related: Treating Psychological Impotence (article)

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Mark Tyrrell

About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

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