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Management of Erectile Dysfunction: The Role of Stress & Mental Health

Author Javier Prieto III covers Management of Erectile Dysfunction: The Role of Stress & Mental Health on BackTable Urology

Javier Prieto III • Apr 10, 2024 • 34 hits

Effective management of erectile dysfunction (ED) often goes beyond the treatment of simple physiological factors. Sex therapist Mark Goldberg and urologist Dr. Jose Silva discuss how various stressors in life can impact a patient's sexual performance. They outline the protocol for evaluating first-time ED patients and emphasize the importance of conducting thorough assessments to understand the broader context of the patient's life and its influence on their sexual health.

This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable Urology Brief

• The initial assessment of an ED patient should prioritize establishing rapport and normalizing sexual health challenges to create a safe discussion. Comprehensive sexual health and psychological assessments follow to understand the patient's identity and the details of their condition, including triggers and correlations, while also addressing general mental health for a holistic approach to treatment.

• Healthcare providers, including primary care physicians and urologists, may attribute patients' erectile dysfunction to psychological causes during appointments, highlighting the importance of language sensitivity to avoid suggesting a mental illness diagnosis. Clarifying that mental well-being is vital for healthy sexual function promotes a holistic approach to addressing ED.

• Fluctuations in (ED) and sexual performance are often linked to the patient's life and work stressors, with improvements observed during less stressful periods. However, long-term improvement requires acknowledging that sexual performance is influenced by multiple factors, including stress, although rarely is there a single factor responsible for ED.

• Integrating the patient's partner in the ED conversation is a typical practice as it helps establish feelings of normalcy, addresses worries about intimacy and relationship stability amidst ED difficulties, and alleviates patient concerns during this sensitive phase.

Management of Erectile Dysfunction: The Role of Stress & Mental Health

Table of Contents

(1) Initiating Sex Therapy: The First Visit

(2) Clarifying the Relationship Between Erectile Dysfunction & Mental Health

(3) Stress & Erectile Dysfunction

(4) Guiding Couple’s Therapy for Sexual Dysfunction

Initiating Sex Therapy: The First Visit

During the initial visit with a patient experiencing erectile dysfunction, the primary objective is to establish a strong rapport. An effective workup requires the patient to be vulnerable and trusting. Therefore, it's crucial to normalize the challenges of ED and create a safe environment for open dialogue. Following the establishment of trust, a thorough assessment of sexual health and function is conducted. Collaboration with primary care physicians and urologists is essential to address any physiological aspects of the condition and ensure patients receive appropriate treatment.

Subsequently, a psychological evaluation delves into understanding the patient's identity and the specific details of their erectile dysfunction, including onset and dynamics with sexual partners. Identification of triggers and correlations related to the condition is emphasized, alongside inquiries into general mental health to identify any potential confounding factors influencing sexual function.

[Dr. Jose Silva]
I want to talk about the couples aspect at some point later in the episode but let's start with that individual person. That is usually the ones that we see in the office. What do you talk about on your first visit?

[Mark Goldberg]
On the first visit, it's usually a lot of assessment questions. The starting point of any therapy process is, really, establishing rapport. When a patient comes in or when a- I call them clients. -when a client comes in, and they're coming, really, under the context of a sexual dysfunction, it's really important that we normalize the challenges that they're going through, that we establish a comfortable environment, that we ask questions, we make sure that we're asking permission about getting involved in different aspects of their life, because we're doing this very quickly.

Oftentimes, unfolds in the first 10 to 15 minutes, we're already talking about sexual function challenges. Generally speaking, in my practice, it's rare that somebody is seeing us without having been to at least a primary care physician, if not a urologist, before coming in. It does happen from time to time, but we do our utmost that we can to ensure that somebody has been medically cleared.

To that end, we generally are just doing a basic check-in on the medical front in terms of what has been done, who they've spoken with, if there was any testing done, any medication. We're asking about that, but we don't consider ourselves to be the first line for medical assessment or what not. We just want to make sure that, however they got to us, they've had proper medical checkings. That usually is the first piece of the assessment.

We then will go through a much more broad-- We call a psychosocial assessment. We want to understand who this person is, what their backdrop is, relationship status, how long the problem's been going on. We also want to assess just where the problem is taking place. How often? Is it just with a partner? Is it happening when they're on their own? Times of day, specific triggers.

We try to be as quick and as thorough as we can to try to see what are the specific conditions where erectile dysfunction seems to be present or seems to be more exacerbated or whatnot. We will also ask questions about general mental health, and we may, if it's relevant, get into topics pertaining to family of origin as well.

Listen to the Full Podcast

Exploring Psychogenic Aspects of Erectile Dysfunction with Mark Goldberg, LCMFT, CST on the BackTable Urology Podcast)
Ep 130 Exploring Psychogenic Aspects of Erectile Dysfunction with Mark Goldberg, LCMFT, CST
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Clarifying the Relationship Between Erectile Dysfunction & Mental Health

Both primary care physicians and urologists may suggest that the erectile dysfunction experienced by patients during initial or subsequent appointments could have psychological origins. It's crucial for healthcare providers to use careful language to avoid giving patients the impression of diagnosing a mental illness. Sex therapist Mark Goldberg stresses the importance of distinguishing between mental illness and mental health when interacting with patients. Erectile dysfunction is often linked more to mental health than mental illness, as it is influenced by factors like anxiety that are part of everyone's mental health profile. This clarification helps patients understand that their mental well-being plays a role in sexual function and encourages a holistic approach to addressing potential lifestyle factors affecting sexual health.

[Dr. Jose Silva]
Sometimes when you mention that 27-year-old guy, and we as urologists maybe say, "Hey, maybe it's mental." When you use that word, they're assuming that you're telling that he's crazy or extreme things like that. I say, "Hey, it might be just stress or something else." Sometimes they say, "Hey, I don't feel stressed." How do you divide that patient into different categories or if there are different categories?

[Mark Goldberg]
That's a fantastic question. What I divide this between is that there's something called mental illness, and there's something called mental health, and every human being has a mental health profile. A lot of times what we're talking about, even with psychogenic ED, has a lot more to do with mental health than it does with mental illness. People of all walks of life are going to experience elements of depression, elements of anxiety, performance anxiety, and none of that necessarily warrants a bona fide mental health diagnosis or a mental illness diagnosis, but it's part of the mental health profile that we all walk around with.

I know that, for myself, I have some days where it's just a tougher day, or I'm feeling anxious. That's part of my mental health profile. It doesn't necessarily mean I have a diagnosis. I think explaining to patients and to clients the difference between mental illness and mental health is really helpful for them to understand that our mental health has to be in a pretty decent place for us to be getting reliable erections.

Stress & Erectile Dysfunction

Fluctuations in ED and sexual performance are often tied to the patient's life and work schedule. Some individuals notice improvements in their sex lives and experience more spontaneous erections during periods of lower stress, such as vacations. However, when aiming for long-term improvement, it's crucial to emphasize to patients that sexual performance is influenced by various factors, with stress playing a significant role in causing ED. While stress can be a contributing factor, there is rarely one sole cause of ED, as it often accumulates alongside other life stressors. A demanding lifestyle characterized by long work hours and limited time for relaxation can impact both mental clarity and enjoyment of sexual activity.

[Dr. Jose Silva]
Yes, like you mentioned, I have patients, I'm sure them as well, that they say, "Hey, during the week, I'm working, having good erections. Then I go on vacation, I start having spontaneous erections, good sex with my wife or my partner," whatever. How do you explain to the patient, hey, you need time to recharge?

[Mark Goldberg]
It really depends on the patient. For some patients, they really want a solution, or like being able to have better erections during the week, or they want to be able to do this when they're not on vacation. For other patients, they just feel relief understanding what is going on, understanding that the stress is actually having an impact. For some of them, they're actually okay, their relationships are okay to have sex on the weekends or when there's an opportunity.

It's just a matter of helping them just come to an understanding or come to terms with the reality that if you have a very stressful work life or what not, that can have an impact on erection, so it really depends, also, on what each client's goals or what each patient's goals are.

[Dr. Jose Silva]
You mentioned that patient that wants immediate relief. Do you offer some immediate relief, or do you go to a urologist and get some pills? What do you tell that patient?

[Mark Goldberg]
If a patient is insistent on immediate release, I let them know that there are medical interventions that probably can provide more immediate relief. I do think that, sometimes, even the mental stress of not having that immediate relief sometimes warrants a medical intervention just to help this person be able to be in a much more calm and healthy state of mind.

I do not offer immediate relief because the mind is very tricky, very complex in many ways, and I think there's enough snake oil out there in the erectile dysfunction space and, generally, in the sexual function space that I don't think it's doing patients a service to offer them some kind of immediate, "We'll have you fixed within the hour." That being said, younger patients do tend to see results pretty quickly, even from the psychogenic process. I think that has to do with just their physically more fit bodies are just better positioned to be able to make those kinds of changes, but no, we don't offer anything immediate.

[Dr. Jose Silva]
That patient that says, okay, I'm going to work with you, let's start a process, what are your recommendations for that patient? Let's say most patients that I see that might be psychogenic is usually overwork, working two jobs, or working shifts at night, during the day they sleep. How do you tell them, hey, you need to change the way you function on a daily basis?

[Mark Goldberg]
That's a great question. I think with the patient base that I see that tends to be, let's say, a more rare presentation that it is a single factor event that's driving it. It tends to be more complex where there also is-- There's work stress, but it's also spilling over into the relationship. It tends to actually be a bit of a more complex picture. Sometimes it's as easy as saying, "Well, you need to cut back on work," and the response to that is, "That's just not possible."

Okay, so now we're on to those next steps where we have to work within the confines of this person's reality. A lot of times, there's enough factors that, I think, can be addressed both in terms of a person's relationship, their own internal psychology, that they can both maintain a challenging lifestyle and still be able to carve out space to decompress and have enough mental bandwidth to be able to have the kind of sexual function that they want.

Guiding Couple’s Therapy for Sexual Dysfunction

Building a strong connection, addressing mental well-being, and identifying stressors is essential for enhancing outcomes in treating erectile dysfunction (ED). However, the process can become more intricate when involving a patient's partner. An individual assessment is conducted before including the partner in discussions to respect the patient's comfort and ensure they can share their story fully. While most male patients eventually involve their partners, they are integrated as part of the solution rather than solely focusing on the problem. Creating a sense of normalcy within the couple is essential for addressing ED effectively, as it removes any concerns that may arise about the stability of the relationship or mutual attraction. Recognizing the high prevalence of ED among partners can ease the worries that patients may experience during this vulnerable period.

[Dr. Jose Silva]
Mark, when do you tell a client, hey, bring your partner into the therapy? When does that happen?

[Mark Goldberg]
That's a great question. I want to be careful with how I answer this because it's an evolving approach for me. Initially, because I was trained as a couple's therapist, I would treat people experiencing sexual dysfunction in a couples context. I think what I have found over the years of doing this work and what works best for me is to default to an individual assessment and an individual approach because, a lot of times, I think what's going on is very much paradigmatic.

In other words, it's very much up inside of a man's head. It doesn't mean the relationship isn't having an impact, but a lot of times, because there's a lot of shame, there's a lot of things that people don't want to say in front of their partner, proper assessment and a proper approach are sometimes hard to develop when the partner is present. I like to make sure that part is done individually and, once we've made that assessment and if it really seems there's something specific to the relationship, we would then look to bring a partner in.

I would say I'm doing that less and less as part of the treatment over the years that I've been doing that work. Most men will bring their partner in at some point. I want to be clear about that. It's not like we're not including the partners in the treatment, but they're there to be much more part of the solution as opposed to viewing the dysfunction as stemming from something problematic in the relationship.

[Dr. Jose Silva]
In your practice, do you see, usually, more females, more women than men?

[Mark Goldberg]
As my practice has expanded, I think we're getting closer to a 50-50. I, as a clinician, I see more individual men than women. It's just because my area of expertise is a lot more around male sexual dysfunction. I also see a lot of couples as well, so I interact with plenty of women in the therapy setting, but on the dysfunction side, I primarily see men.

[Dr. Jose Silva]
On the dysfunction side, mainly men.

[Mark Goldberg]
Yes. In my practice, we treat both, and there's a number of clinicians that are specifically focused on female sexuality and female sexual function.

[Dr. Jose Silva]
Just out of curiosity, at least in your practice, are the expectations the same between men and women or what are the expectations? Do you see more false expectations from men compared to women?

[Mark Goldberg]
That is a fascinating question. I see it more in men, but it's probably because I'm seeing more men. I think men have higher expectations of themselves. I think it'd be fair to say I think women oftentimes feel like they are not living up to the bar a lot more. I know that's a subtle difference, but I think I see a lot more of that with women.

[Dr. Jose Silva]
In men, most of-- They always say, maybe at least these 60, 70-year-old guys, that when they were younger they had a 13-inch-- Everybody had a 12-inch, 13-inch penis. Now it's less than half. I say, "Okay, sure you did." I don't treat women in the office for sexual dysfunction, so I just wanted to see what you had to say about that. Anything else you want to add?

[Mark Goldberg]
The one thing I would add is, for any urologists who are out there, understand that I really respect how limited the time is in the office. In many practices, I know that sometimes it's just 10 or 15 minutes, but I think being able to just have that conversation, certainly, when it seems like there is a real relationship issue or a psychological issue going on, I think to be able just to have that even a minute conversation to normalize this, to let the patient know that it's not a mental illness, it's not something where it's all up in your head, it's not because your psychology is off or there's something fundamentally wrong.

We all have mental health, and sometimes our mental health is not as balanced as we want it to be, or we are pretty mentally healthy, and we get performance anxiety, and this is a normal part of being human. I think being able to have that conversation, I think, will help these patients get from the urologist's office to be able to talk to somebody. I just want to make sure that we emphasize that point.

Podcast Contributors

Mark Goldberg, LCMFT, CST discusses Exploring Psychogenic Aspects of Erectile Dysfunction on the BackTable 130 Podcast

Mark Goldberg, LCMFT, CST

Mark Goldberg is a couples and sex therapist at the Center for Intimacy, Connection and Change in Washington, D.C.

Dr. Jose Silva discusses Exploring Psychogenic Aspects of Erectile Dysfunction on the BackTable 130 Podcast

Dr. Jose Silva

Dr. Jose Silva is a board certified urologist practicing in Central Florida.

Cite This Podcast

BackTable, LLC (Producer). (2023, October 23). Ep. 130 – Exploring Psychogenic Aspects of Erectile Dysfunction [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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