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BackTable / Urology / Article
Psychogenic Aspects of Erectile Dysfunction & Sexual Performance Conditions
Javier Prieto III • Apr 10, 2024 • 35 hits
Erectile dysfunction (ED), characterized by the inability to achieve or maintain an erection sufficient for satisfactory sexual performance, is one of the most common forms of sexual dysfunction. However, its impact frequently extends beyond the confines of ED alone, intertwining with other conditions such as performance anxiety, premature ejaculation, overexcitation, and anorgasmia, which collectively present complex challenges in both assessment and treatment.
Sex therapist Mark Goldberg and urologist Dr. Jose Silva explore strategies to manage the intricate interplay between psychological and physiological factors impacting sexual function and performance. Recognizing the complex psychogenic roots of sexual dysfunction, they advocate for a treatment approach that integrates mental health professionals like sex therapists to enhance overall sexual satisfaction for patients.
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
• Erectile dysfunction often triggers performance anxiety, which can affect individuals regardless of ED presence. This anxiety, marked by self-consciousness and fear of judgment, complicates sexual satisfaction. Treatment, involving therapy and medical intervention, aims to address both psychological and physiological aspects for a comprehensive approach to sexual dysfunction.
• Premature ejaculation, often concurrent with erectile dysfunction, poses challenges for assessment and treatment. Cognitive behavioral therapy offers a promising approach by targeting neurological and psychological aspects, aiding patients in developing ejaculatory control and enhancing sexual function.
• Techniques for ejaculatory control utilized for premature ejaculation extend to managing overexcitation in sex therapy. Patients learn to identify triggers and implement behavioral interventions, with therapists guiding personalized strategies for improved sexual function and communication within relationships.
• Anorgasmia, a complex issue often linked with erectile dysfunction, poses challenges in identifying its physiological or psychological origins. While treatment options for anorgasmia are limited, therapists emphasize how these challenges can lead to deeper intimacy and improved communication between partners when treatment is not feasible.
Table of Contents
(1) The Interplay Between Erectile Dysfunction & Performance Anxiety
(2) Addressing Premature Ejaculation in Erectile Dysfunction
(3) Managing Overexcitation & Utilizing Ejaculatory Control Strategies for Sexual Satisfaction
(4) Anorgasmia Challenges & Therapeutic Approaches
The Interplay Between Erectile Dysfunction & Performance Anxiety
Erectile dysfunction (ED) can often lead to other sexual dysfunctions, such as performance anxiety. Performance anxiety is a complex issue for patients, as it can occur with or without ED and manifest in various ways. Many individuals with performance anxiety experience self-consciousness during sexual activity, leading to dissatisfaction with their performance, even if their partners are satisfied. Fear of criticism and judgment further compounds this issue.
Since performance anxiety is multifaceted, there's no fixed timeline for patients to overcome it. Younger patients may recover more quickly due to their adaptable mindset, but progress varies depending on the individual and the severity of their anxiety. Typically, significant improvement can be seen within four to six therapy sessions, though this isn't guaranteed.
Patients are advised to seek treatment from both a sex therapist and a primary care physician or urologist for ED and related conditions. While psychogenic factors play a role in these conditions, they are still medical conditions requiring proper treatment. Sometimes, underlying medical issues like venous leaks may necessitate medical intervention alongside therapy. Collaborating with both types of medical professionals allows for a more comprehensive approach, increasing the chances of identifying and addressing any underlying factors contributing to sexual dysfunction.
[Dr. Jose Silva]
I want to talk about specific conditions. For example, performance anxiety. What do you tell the patient that say, hey, everything is good, I'm having good erections, but then when I'm about to penetrate, the penis becomes flaccid? What do you tell the patient?
[Mark Goldberg]
Performance anxiety is a very complex experience, and it's hard to simplify it down into some advice. That's where it goes back to when performance anxiety is present, it really needs to be assessed because performance anxiety can present in different ways for different people. For some people, performance anxiety is stemming from fear of perceived or real criticism from a partner, and they really want to avoid that.
For other people, performance anxiety is stemming from how they're assessing themselves, and they're totally not willing to hear anything that their partner is saying. Even if their partner is perfectly okay with it, the partner's not feeling like there's any negative impact, they're really very much assessing their own performance. It's really key to understand that performance anxiety is not a one-size-fits-all experience, and it really needs to be looked at as the unique thoughts and feelings that come with different manifestations of performance anxiety that will be contextually relevant to each patient.
[Dr. Jose Silva]
That's a good point that you're making, and that will lead to my other question in terms of premature ejaculation. For example, like you mentioned, the expectations. Some patients come to the office and they stay like half an hour. For them, it's premature ejaculation, so stand up and get out of the office. When that patient goes to your office, in terms of going back to the expectations, do you know, more or less, how many sessions it's going to take for somebody to get better, or it's just you go session by session?
[Mark Goldberg]
I've probably answered this question three times today on various phone calls from prospective patients. The way I approach this is I tell patients that it's very difficult to know. Generally speaking, again, the younger a patient is, certainly when it comes to erectile dysfunction as an example, the younger the patient is, the quicker the expectation is that we will see movement.
Now, again, that's a blanket statement, and I realize that cannot apply to everybody, but as people age, the physical body becomes, I think, a lot more relevant and the mind, I think, has become a lot more concrete, so the work tends to be a lot longer. What I aim for, and I tell people it's just an aim, what I aim for is that we should see some directional indicators within about four to six sessions. I know it sounds like a lot relative to appointments or visits with a urologist, in the therapy world, that certainly is not a very high number. Again, what we're looking for is to have a sense of what is going on and to be able to see some indicator that we're in the right direction.
[Dr. Jose Silva]
Most of the patients that you see, are-- You've been seeing them alone or do them in combination with a urologist?
[Mark Goldberg]
Almost exclusively in combination with at least a medical professional, preferably a urologist, but each person is in a bit of a different circumstance.
[Dr. Jose Silva]
Do you sometimes see patients that you need to tell, "Hey, you need to see a urologist because this is not just psychogenic"?
[Mark Goldberg]
All the time. What I remind my listeners on my podcast and all my patients is that erectile dysfunction and sexual dysfunction in general is a medical condition. It's impacted by psychology, but it is a medical condition. Even when I am fairly confident that it is psychogenic, I'm very much aware that there can be some more rare conditions that need to be assessed and need to be under medical care, so I look at erectile dysfunction as a medical condition that can be caused by and heavily impacted by psychogenic factors.
Everybody sees a medical professional, preferably before they come to see me, but secondarily, if they haven't, they're given a referral to do that in conjunction with the therapy. The other interesting thing, I think, towards this question is that a lot of times I will be working with somebody who's been medically cleared but something will emerge in the conversations that they didn't necessarily disclose to a urologist because there wasn't enough time, or they didn't think it was relevant, that may indicate something, maybe along the lines of say, of a venous leak, but they weren't really clear with the doctor in the first go-round, so I may send them back to the urologist and coordinate based on what comes out in the sessions.
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Addressing Premature Ejaculation in Erectile Dysfunction
Premature ejaculation frequently coexists with erectile dysfunction and affects numerous patients. When assessing affected individuals, it's crucial to determine if the premature ejaculation has been lifelong or acquired and whether it occurs situationally or universally. Sex therapy professionals often do not recommend psychotherapy for these cases, particularly in instances of lifelong premature ejaculation, as the issue is likely not solely psychological. Instead, for situational cases, the focus is typically on addressing overexcitation and performance anxiety.
The overlapping neurological and psychological aspects between the sexual arousal centers of the brain and thought patterns contribute to the interconnected nature of these conditions despite their seemingly contradictory characteristics. Cognitive behavioral therapy (CBT) is a viable treatment option for premature ejaculation. It can serve as a valuable tool for patients to transition to learning techniques for ejaculatory control and facilitate their growth toward improved sexual function.
[Dr. Jose Silva]
I wanted to ask you about premature ejaculation. Do you see patients, a lot of patients, like this?
[Mark Goldberg]
A fair amount, yes.
[Dr. Jose Silva]
Again, I guess, also, frustration can continue if the patient just overthinks it and it will continue to happen. Can you walk us through one of your sessions with this patient, with that patient like that?
[Mark Goldberg]
Premature ejaculation, there's different ways to categorize it, but again, a lot of this really depends on what the circumstances are. The big differentiators that we're looking for are if it's lifelong or if it's an acquired PE. We also want to know if it is situational or if it's across the board. When it's lifelong and it's across the board, I'm more hesitant these days to approach that as a psychosexual therapy to try to treat the underlying condition.
That's where therapy much more is supportive. It's helping to find alternative ways to engage in sexual activity that can be satisfying, but I think it's a lot more difficult to treat lifelong non-situational PE. When somebody comes in and it's much more situational, let's say it's only happening with a partner, so again, the two general areas that we're looking at are over-excitation with premature ejaculation as well as an anxiety, like a performance anxiety.
While these seem to work in opposite directions where anxiety does not sound like it's very exciting and over-excitation sounds like it's very hard to contain oneself, there is, certainly, an overlap both from a neurological and a psychological perspective between the excitation and the anxiety areas of the brain and those thought patterns, and we see a similar type of thing going on. That would be one of the areas that we're looking to understand for the patient.
Generally speaking, PE, like other forms of sexual dysfunction, is addressed with both-- Again, I'm a CBT therapist, so I look at it both from a cognitive but also from a behavioral standpoint, so the way I like to work is, as we are getting into the cognitive work, we also want to assign certain behavioral interventions so we can assess how progress is going. Also, helping men to learn ejaculatory control.\
Managing Overexcitation & Utilizing Ejaculatory Control Strategies for Sexual Satisfaction
Techniques for ejaculatory control, commonly used to assist individuals with premature ejaculation, can also benefit those struggling with overexcitation during sexual activity. Overexcitation, which involves both physical and psychological aspects, is often addressed in sex therapy with a focus on psychological factors. However, from a medical perspective, there are medications available that can reduce sensitivity and delay ejaculation.
The most effective approach to managing overexcitation typically involves psychological strategies aimed at identifying and addressing the underlying factors contributing to it. This often requires open communication and adjustments between the patient and their partner. Sex therapists typically do not recommend limiting sexual pleasure, so finding solutions may involve strategic experimentation with different approaches. Another helpful approach is desensitization, where patients are gradually exposed to the stimulating factors that trigger overexcitation.
Overexcitation can also lead to premature ejaculation, prompting discussions about ejaculatory control. Patients are encouraged to learn to recognize the sensations associated with impending ejaculation and develop techniques to manage them. However, practicing ejaculatory control can be easier for patients when alone compared to when with their partner, as they may feel less control over the pace and actions of the sexual encounter. Behavioral interventions such as the stop-start method or squeeze method are often recommended for these cases. Sex therapists conduct thorough assessments to determine which exercises are suitable for each patient and monitor their progress over time.
[Dr. Jose Silva]
Let's talk about the overexcitation. What does a patient can do about that?
[Mark Goldberg]
That's a great question. Overexcitation can have both a physical and, also, a psychological manifestation. On the physical side, there is very little that we can do on the psychological end. As I'm sure you're aware, and anybody listening to this podcast are aware, there are delay sprays, there's also some off-label use of medications that could help to decrease sensitivity or decrease the ejaculatory side of things.
From a psychological standpoint, there are a number of things that can be done. What I have found is what seems to be most effective is to be aware of what are the factors that lead to excitation and working with oneself or one's partner to try to -- Again, I don't like the idea of limiting pleasure or trying to cap sexual pleasure for the sake of extending performance, but I think working with a partner to be, maybe, a little bit more strategic about that when they bring in those more stimulating elements to the sexual experience.
There are ways to, I guess, gain more control over that psychological stimulation. That's one of the approaches. The other approach is to help desensitize a person to those stimulating factors both from a cognitive and, also, from an exposure standpoint.
[Dr. Jose Silva]
Is that like thinking of something else?
[Mark Goldberg]
That's more of a distraction type of thing. I know that some people use those. I'm not, as a therapist, I'm just not a big fan of distraction. I think being present in a sexual experience is something that I value both as a therapist and as a person, so I want to try to work within those confines so that a person is really there with themselves and with their partner.
[Dr. Jose Silva]
You mentioned distraction. What's the difference between distraction and detraction?
[Mark Goldberg]
In the erection space, what it probably means is like detraction from stimulation.
[Dr. Jose Silva]
Okay.
[Mark Goldberg]
If you wanted like a difference, there may be-- Distraction may be like I'm not paying attention to the experience, or I'm thinking about other things. Detraction may be that I find certain things stimulating and when other things are brought into the experience or are not brought into the experience, it detracts or it erodes the kind of stimulation that I would need to maintain my erection.
[Dr. Jose Silva]
I see that pa-- Sometimes it can be a change of position. The male partner that is the one that I see in the office sometimes feels different and, maybe, the change of position, they can have a decrease in the erection or there is some flaccidity. You mentioned, also, the con-- The ejaculatory control. How do you tell the patients to control that?
[Mark Goldberg]
If I could tell them to control it that would make my job a lot easier. [laughs]
[Dr. Jose Silva]
Okay. [chuckles]
[Mark Goldberg]
Ejaculatory control, I think, again, goes back to both the cognitive and behavioral components. Generally speaking, when I'm working with somebody with premature ejaculation, we want to help that person learn ejaculatory control on their own. Part of that is recognizing when they're approaching or reaching ejaculatory inevitability and being able to really become familiar with that sensation, understanding what brings them towards ejaculatory inevitability, and being able to back off of that sensation.
Where it gets a little bit more complicated is partner sexual activity. Again, this ties back into the performance component. Not even performance anxiety, but the performance elements of sexual activity. A lot of men are able to gain ejaculatory control when they're on their own because they can slow down the tempo, they can slow down the friction, they can control certain aspects.
Even when their partners are okay with them doing that in a partnered setting, a lot of men don't feel comfortable to actually slow down or detract from the experience that they believe they should be having or delivering to a partner, so gaining ejaculatory control with a partner tends to be a little bit more challenging.
[Dr. Jose Silva]
Are there any exercises that the patient can do for-- To be able to get some control?
[Mark Goldberg]
There are a number of behavioral interventions. There's the stop-start method, there's the squeeze method. There's various methods out there that do work to varying degrees. What I do try to encourage, though, is that people should go through a proper assessment to determine if these exercises are going to be applicable, if it really makes sense. There's a lot of people who will find this, it's published information on the internet, and without a proper assessment, will go ahead and try to engage in these exercises not understanding the backdrop, not understanding their own psychology, and a lot of times, it just ends up not working.
Anorgasmia Challenges & Therapeutic Approaches
Anorgasmia presents a significant challenge in the realm of sexual dysfunction, often intertwining with erectile dysfunction. These cases pose difficulty in ascertaining whether the root cause is physiological or psychological. Typically, the initial step in patient evaluation involves determining if the individual can achieve orgasm through masturbation and comparing this experience with penetrative sex. Various psychological factors can contribute to anorgasmia, including concerns about pregnancy or engaging in sexual activity with multiple partners. Treatment options for anorgasmia remain limited, with ongoing developments in the field.
When cases of untreatable anorgasmia emerge, whether stemming from psychological or physical causes, sexual therapists often highlight how this can pave the way for deeper intimacy. Such challenges may bring previously overlooked issues to light, fostering improved communication and connection between partners.
[Dr. Jose Silva]
What about the opposite? That patient that is having anorgasmia?
[Mark Goldberg]
Anorgasmia or not just like delayed ejaculation, but not ejaculating at all?
[Dr. Jose Silva]
Yes, or they get tired at some point because they haven't ejaculated yet, or their partner says, "Hey, get off."
[Mark Goldberg]
Yes. This, I think, is one of the harder or more challenging sexual dysfunction conditions to treat both from a psychological, but also, from what I understand, from a medical standpoint. I find it a little bit challenging because it's very difficult to assess if it's a physical stimulation or a psychological issue. There are certain factors that I think sometimes can be enlightening where I've seen very interesting presentations of delayed ejaculation or an ejaculation have been around a unwanted pregnancy or a fear of an unwanted pregnancy. It's like a telltale sign of there being like a psychogenic or a real psychological factor.
Generally speaking, we try to assess if a man can ejaculate, obviously, on their own, but there is a difference between masturbation and like a penetrative sex experience that, again, it's very difficult sometimes to assess if it is a physical stimulation issue or if it is psychological. There are historical theories about men wanting to withhold from their partners and whatnot. I think those have limited applications, certainly based on how we are structured in our relationships in 2023, but it's important to be aware that there definitely are other ways to think about this from a psychological perspective.
[Dr. Jose Silva]
Exactly. Mark, another question that I have, patients that, for example, let's say a patient is a diabetes patient, for some reason, that patient is not a candidate for IPPs or any other intervention that, unfortunately, he's going to have to leave without being able to have erections. Let's say that a patient that, for some reason, is-- I saw a patient like that today. Multiple cardiac conditions that, unfortunately, they're poor candidate for sex.
Definitely, I can give, even if I put an IPP or an inflatable device on the patient, definitely, that patient is not going to be able to have sex because of the cardiac conditions. That patient was his partner so he was asking, "What are my options?" The guy clearly, while he was talking to me, was gasping. A guy that, just by walking, gets very fatigued or has multiple conditions, how do you approach this guy?
[Mark Goldberg]
It's a great question. I like the case that you're describing because he himself sounds like he's very limited. His options are going to be very limited. Why I think the role of a therapist, and certainly, a sex therapist, is to help this couple adjust to a new reality. Sex is a conduit for intimacy and for connection for a lot of these people and when that gets lost, unfortunately--
This can really apply to any type of person who experiences a sexual function challenge. That intimate connection starts to dwindle because the couple does not know how to adjust and does not know how to continue to engage with one another. In this case where this sounds like this gentleman is winded, like he really-- Like he's got to be careful about even exerting himself in any significant way.
Even like the incorporation of a device or a toy to be able to provide stimulation without having to overly exert and learning how to incorporate that and building some sort of intimacy around that is where a therapist would be able to be helpful. Obviously, we cannot psychologically treat the respiratory issues that are going on or the cardiac issues that are going on, but medical issues does not mean that a person does not crave and want that intimate connection, and a lot of times, there are ways to facilitate that.
[Dr. Jose Silva]
Yes, we always talk about the patient that we help or we can help, but what about the patient that sometimes there's nothing that we can do or offer to that patient? I'm glad that you mentioned that there are things that you as a therapist can talk about toys, other things, so at least that emotional and mental health is still there at least somehow.
[Mark Goldberg]
I would just also add to that there are many instances that I've heard of in my office where a sexual function challenge actually opens the door to deeper intimacy because a couple's forced to communicate about things that they never really spoke about. It was just almost automated. They had their routine and they went through that, and it forces them to really talk about their intimate life.
Certainly, for men with female partners, a lot of times when an erection is inhibited, it actually brings more into focus some of the other areas of their sexual life and sexual encounters that can actually be much more to the benefit of the female partner. A lot of times that only really comes to light in the face of erectile dysfunction.
Podcast Contributors
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
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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