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By Miranda Christophers
E.D. (Erectile Dysfunction) is the most common sexual concern for men affecting up to 1 in 2 men during their lifetime. A 2013 study suggests it affects up to 26% of men under the age of 40, while other studies suggest that as many as 40% of men may be affected around the age of 40, and up to 70% by the time they are 70 (Feldman et al, 1994). It affects men of all ages for a number of different reasons. It can be extremely distressing and affects the self-esteem of men suffering with it, often impacting their relationship and other areas of their life.
1. Understanding the Physiology of Erections
Sexual arousal involves the mind, body and emotions positively connecting in what we can understand as an arousal circuit
Sexual arousal starts in the brain as a result of something you see, think, feel, smell or hear.
The brain sends a message to the nerve endings in the penis to relax muscles in the spongy tissue that appear along the length of the penis.
The heart pumps more blood to the penis, where the arteries open to allow the blood in, filling the membranes in this spongy tissue, while the veins close-up, and pressure traps the blood, thus creating the erection.
When the incoming blood flow stops and the veins reopen the penis becomes soft again.
Understanding how the Sexual Arousal Circuit maintains erections
Sexual arousal involves the mind, body and emotions positively connecting in what we can understand as an arousal circuit (like an electrical circuit). These three parts are key to achieving and maintaining arousal and thus erections. Each of these 3 components has break points whereby they can create a break in the flow of the circuit. This concept can help to understand where the issue lies and to work to eradicate the break.
While arousal can be maintained without physical stimulation, the body facilitates the physical feeling of pleasure. When it comes to touch and feeling the physical body requires appropriate stimulation. There may be certain areas which trigger or intensify arousal (in addition to the genitals) and there may be preferences in stimulation/sensation. In order to maintain arousal, the feeling has to feel arousing so if something does not feel pleasure inducing then it is likely to cause an interference/break in the arousal circuit. It is important to note that the penis may change in sensitivity as a male gets older so it’s worth varying the stimulation if you notice changes.
We can understand that a break in the arousal circuit relating to the body may be as a result of not having the right or enough stimulation or experiencing discomfort or pain. If you experience cramp in your leg mid-arousal it’s likely to interfere with it. Similarly, not being stimulated in a way that feels pleasurable – too fast, off point etc.
The mind is significant as it does all the processing and regulating, in addition to controlling focus. Therefore, the mind needs to be positively connected – present and processing the pleasurable sensations and feelings of arousal. It can be positively connected with the feeling of physical sensations while being stimulated by other senses that heighten arousal such as visual, fantasies, scents, sound etc. It is helpful to consciously remove distractions and bring your mind back to the feelings and arousing thoughts if you notice your mind is not fully connected.
Anything that takes the mind away from engaging with the physical sensation is likely to cause a break. This can include being distracted with other things: work; focusing on pleasing a partner to the extent you are wondering if they are enjoying it, or thinking what to do next; if the doorbell rings or you can hear someone in another room etc. ‘Spectatoring’ is a term used in sex therapy which describes focusing on the performance such as being preoccupied with how hard it is. It is helpful to consciously remove distractions and bring your mind back to the feelings and arousing thoughts if you notice your mind is not fully connected.
Emotions are powerful in the arousal circuit as they affect how we feel. If you are feeling relaxed, happy or excited you are likely to feel a positive connection with arousal. Conversely, if you are feeling upset, stressed, anxious or even if you are just tired it is likely to have some impact on it.
Feeling upset, anxious, stressed, angry. Other common causes may include: performance anxiety; feeling unsafe/not able to trust/relax with a partner; fear of being caught/seen/overheard.
For those suffering with performance anxiety, it’s important to be aware of how it may affect arousal. Think about relaxing prior to sex if you are stressed or anxious – perhaps use mindfulness techniques and try to notice the physical sensations and clear your mind. Always remember that sex is about pleasure not the performance.
"Hence, if there is an interruption of the physiological process or arousal circuit then it will affect a man’s erection – be it obtaining or maintaining one"
2. Medical Causes
There are a number of medical causes of ED including but not limited to:
(a) The Use of Certain Types of Medication
Use of medications such as:
- High blood pressure medication
- Calcium channel blockers
- Hormone therapy such as DHT blockers
If you feel medication may be causing your ED it is advisable to talk to your doctor to see if alternative options are available.
(b) Underlying Medical Conditions
Medical Conditions can be an underlying cause of E.D., such as:
- Heart Disease
- High blood pressure
- High cholesterol
- Low Testosterone
- Enlarged Prostate
- Parkinsons Disease
- Multiple Sclerosis
It is always important to rule out medical conditions if repeatedly experiencing difficulty – see a doctor for advice. They are able to test testosterone levels, check for nerve damage in the case of diabetes, as well as testing to ensure there is no interference with blood flow as a result of heart disease or as a result of artery blockages.
(c) Lifestyle Factors
Other common causes include:
- Excessive alcohol
- Use of recreational drugs
- Excessive porn use
3. Psychological Causes
There are numerous psychological causes of E.D. but here are a few common ones:
Performance Anxiety is one of the most commonly seen causes of ED. Both the mind and the emotions are powerful in having the ability to interrupt the arousal circuit. If a man worries about maintaining an erection whilst actually in the intimate situation, it is very likely that this will have an effect on the quality of his erection. This similarly goes for men worrying about premature ejaculation or those who struggle to orgasm – the more they think about it, the more problematic it becomes as the anxiety negatively impacts arousal. It’s important to relax and allow yourself to be totally immersed in the feelings and sensations of pleasure. The only thoughts in the mind should be positive, enjoyable ones that connect to sexual pleasure.
A variety of emotional factors may cause E.D. From stress and low mood to relationship issues, bereavement to poor self-confidence and low self-esteem. We can understand that how you feel generally can significantly impact both sexual desire and arousal so it’s worth considering if these may be factors and seek to address the root cause while also using body-mindfulness based techniques to help you engage the arousal circuit.
E.D. can occur when a man feels under pressure. That can be pressure from himself or a partner. If he’s having sex because he feels he should rather than because he wants to it can understandably affect his ability to get or maintain an erection. Men often report changes in their erections when they are trying to conceive – if there is a focus on sex for conception this can put a lot of pressure on. If trying to conceive naturally then it is helpful to remember that it is pleasure than drives arousal, erections and ejaculation – conception is a by-product.
Porn-related ED can be experienced when a man finds that he struggles to maintain an erection for sex with partners, as a result of excessive porn use. This can be as a result of becoming desensitised as a result of the porn – it can feel difficult to recreate the effect that jumping between porn-clips gives, thus impacting arousal and erections. Many men will also find they get used to solo sex experiences and a hand grip as opposed to the feeling of a vagina.
4. Treatment Options
Before deciding how to treat E.D. it’s important to make sense of what is causing it. It’s always worth considering the psychological causes and it’s always important to rule out medical causes if you suspect it is health related.
- Understanding the causes and taking an approach of mindfully focussing on pleasure can really make all the difference.
- Take a logical approach and recognise that if we address the cause we can change the effect.
- You can use mindfulness based techniques such as focussing on sensations, or the concept of immersing yourself into the feeling of pleasure – they key to such techniques is acknowledging and removing distracting thoughts.
Understanding the arousal circuit and consciously engaging with the mind, body and emotions as described above and focussing on being present in your body rather than up in your head is important to help overcome the difficulties.
Work on challenging negative thought patterns – these are often what maintain the issue for people – practical and logical reminders can also help.
If you know that things such as alcohol, tiredness or having someone awake in the next room are affecting you then address them.
If a man is concerned that he loses the erection when trying to penetrate, or that he has become accustomed to a certain hand grip then he may find trying a ‘fleshlight’, which mimics the feeling of the vagina, helpful.
There are apps available that can help men struggling with psychological causes of E.D. Apps such as Mojo Men provide a number of tools and advice, and support to help overcome the difficulty. The Kama app can also be very helpful as it focuses on techniques that get you out of your head and into your body such as focussed breathing.
If you find you are struggling with ED and medical causes have been ruled out, it’s worth seeing a psychosexual (sex) therapist who can work through understanding the cause and help you to overcome it in with tools and techniques. In almost all cases, it’s worth taking advice from an expert, whether a doctor or a therapist, as their knowledge will help you overcome the difficulty if you are struggling with a persistent problem.
Medications such as Viagra & Cialis
Viagra and Cialis are the most well known oral medications for E.D. The drugs work by relaxing the blood vessel walls. This makes it easier for blood to flood into the penis tissues and thereby giving you an erection. One important factor is that unlike injections these E.D. medicines will only work if you are already aroused.
E.D. tablets are taken shortly before having sex (30 mins before for Cialis and at least 1 hour before for Viagra). However, the big difference between Viagra and Cialis is that whilst Viagra remains effective for between 4-6 hours, Cialis is still effective up to 36 hours after taking the tablet. Don’t worry though that doesn’t mean you will have an erection for all that time as they should only come into effect when you are sexually stimulated.
It is worth noting that a lot of people take these who probably don’t need to, and some people take them to a point they feel dependent on them for sexual confidence. Treating the psychological issues is always preferable to medicating. Consulting a doctor or pharmacist is always advised.
Penis pumps and vacuum devices are now widely used by men for tackling erectile dysfunction and building confidence. The idea is that you use the penis pump before having sex, to facilitate a powerful and long erection. A penis pump consists of a plastic tube that fits over the penis, a hand or battery-powered pump attached to the tube, and a band that fits around the base of the penis once it is erect (constriction ring). Some pump’s use water instead of air and can give quicker and more controlled results.
Generally, speaking, any man can use a vacuum pump comfortably. However, we recommend you should exercise caution or consult a specialist if you suffer with cardiovascular problems or are taking anticoagulant drugs
Whilst it might sound unappealing the use of an injection based drug for the treatment of E.D. can be highly effective. Injections are typically used for more severe cases of E.D. or where a person cannot take oral E.D. medications. It is a relatively shallow and painless injection (you might feel a slight pinch or sting) that creates an erection within 5 to 20 minutes and that will last for between 30 – 60 minutes. Injectable ED treatments work by relaxing the smooth blood vessel walls causing them to dilate and fill the penis with blood, meaning that they are effective without the need for sexual stimulation.
5. Don't struggle alone, seek help
It can’t be stressed enough, that if you are struggling, seek help. E.D. is extremely common, and in the vast majority of cases, treatable so you really don’t need to suffer alone.
Miranda Christophers: Sex & Relationship Therapist / Contributing Editor
Miranda is a COSRT Accredited Sex and Relationship Therapist and a regular media contributor who promotes a sex positive attitude with a philosophy that sex is the most natural source of pleasure which should be enjoyed healthily by all no matter gender, age, ethnicity or relationship status. Her views are embedded in social and sexual equality and the liberation of people to have choice.