Psychological Causes of ED — Is It All in Your Head?

When we think of erectile dysfunction, we usually think of it as an older man's game — something caused by things like cardiovascular conditions and other health issues.

But the reality is that ED affects younger men too. In fact, it can hit men of all ages and backgrounds, and even guys who would clear a physical as “healthy.”

A big reason why? Your brain. Believe it or not, your mental health may play as big a role as your mental health in your erection quality. Yes, really.

Below, we’ve explained how psychological factors play a role in the development of ED. We’ve also talked about what you can do to treat psychological ED and enjoy a fulfilling, satisfying sex life.

Common Causes of Psychological ED

Erectile dysfunction (ED) is a common sexual performance issue that occurs in men of all ages and backgrounds. If you’re prone to ED, you may find it difficult or impossible to get or maintain an erection that’s firm enough for sex. 

An estimated 30 million men in the United States are affected by ED, making it an extremely common issue. 

Statistics show that ED affects men of all ages, with some research suggesting that approximately 26 percent of new ED cases occur in men under the age of 40.

When erectile dysfunction is related to a psychological problem, it’s referred to as psychological ED, or psychological impotence. 

Like with physical ED, there’s no single psychological cause that can trigger erectile dysfunction in men. Instead, a variety of issues can all cause or contribute to psychological ED, such as:

• Performance anxiety

• General stress and anxiety

• Relationship problems

• Depression

• Guilt and low self-esteem

• Pornography use

Some medications used to treat psychological issues, such as antidepressants, can also play a role in the development of erectile dysfunction.

Many of these triggers are closely linked, and it’s entirely possible that you could be affected by more than one at a time. 

Let’s take a closer look at each potential cause to understand how it can play a role in the development of psychological ED.

Performance Anxiety

In many ways, performance anxiety becomes a self-fulfilling prophecy in the bedroom. You feel nervous about being able to satisfy your partner, so when you get into the bedroom, you panic and wind up not being able to perform. It's a lovely little doom-loop. 

​​In some cases, sexual performance anxiety is triggered by negative self-talk — like if you’ve convinced yourself that you won’t be able to achieve an erection, please your partner or avoid ejaculating too early.

If you’ve found it difficult to get an erection in the past, these experiences may also stick in your mind and affect your ability to relax in the bedroom. 

Stress and Anxiety 

Though stress and anxiety are two different things, they’re closely related when it comes to the issue of erectile dysfunction.

Stress is often an underlying factor in erectile dysfunction. But over time, stress can cause anxiety, which in turn triggers more stress, creating a vicious cycle that’s bad for both your mental health and your sex life. 

To give you some evidence of the link between anxiety, stress and ED, consider the results of a study published in 2015.

Researchers analyzed case records for 64 men with ED or premature ejaculation (PE), and found a significant link between ED and anxiety or depression. Of the 64 participants, eight had comorbid depressive disorders and 15 had anxiety disorders.

In the majority of the study participants, the mental health disorders predated the onset of sexual dysfunction, suggesting that they may have been a contributing factor. 

Relationship Problems

Any guy who’s ever been “in the doghouse” or on the couch for the night knows that if your partner’s unhappy, it’s going to affect things in the bedroom (like whether you’re allowed in there at all). 

It could also be the case that your erectile dysfunction is creating problems in the relationship —  another example of the cycle of ED that can affect many different aspects of your life.

Communication is the first step in resolving this particular cause of psychological ED, but it is also one of the most difficult steps to take. 

Couples counseling is a safe space for two people who love each other to get help learning to listen and find the magic again. 

Depression

Depression‘s most common symptoms can go beyond a persistent sad, empty mood — they can make it difficult to take pleasure in much of anything, let alone sex. And the worst part is that this depressive ED can hit us all equally. 

A 1998 study, for example, found that depression-related ED was independent of aging and demographics.

(Oh, and by the way, depression is far from the only mental health condition that can affect your dick — there’s also a close relationship between post-traumatic stress disorder and erectile dysfunction).

Guilt and Low Self-Esteem

Many men who suffer from erectile dysfunction feel guilty about not being able to satisfy their partner. If the problem persists, the guilt becomes more than just a minor issue — it can often contribute to the ongoing cycle of ED as well. 

Low self-esteem may also keep you down in more ways than one. If you don't feel confident about your sexual performance or worry that you’re not attractive enough for your partner, this can heighten your risk of sexual performance issues.

Like with many other aspects of psychological erectile dysfunction, low self-esteem and sexual performance issues often make each other worse.

In a study published in the BMJ, researchers found that erectile dysfunction can cause serious distress in men, and that this distress can have a real impact on self-esteem and the quality of relationships.

Pornography Use

While watching porn isn’t inherently bad or harmful, excessive use of pornography may contribute to both depression and sexual performance issues such as ED. 

It’s an important issue (regardless of what kind of porn you like), and our guide to pornography consumption and depression is worth reading if you’re unsure about your own relationship to porn at the moment. 

Research suggests that if you spend a lot of time watching — and masturbating to — pornography, you may develop unrealistic expectations about sex or about your sexual partners.

When this causes you to face difficulties mentally keeping a hard on, it’s referred to as porn-induced erectile dysfunction.

Although research is limited, watching and masturbating to porn may also reduce your level of sexual satisfaction through something called “death grip” syndrome — a lack of sensitivity that can be caused by masturbating with an overly firm grip.

This combination of porn-induced ED and death grip syndrome can affect your level of function and enjoyment from real-life sex.

How Do You Know if Your ED is Psychological?

If you’re physically healthy and feel worried that you may have psychological ED, the first step in making progress is to talk to your healthcare provider.

After completing a physical exam and discussing your medical history, your healthcare provider will ask you some questions and run some tests to rule out medical causes for your ED. 

In order to rule out physical ED or ED related to medical conditions, your healthcare provider may perform tests such as the following: 

• Complete blood count (CBC)

• Fasting glucose or glycated hemoglobin (A1C)

• Comprehensive metabolic profile

• Thyroid-stimulating hormone

• Lipid profile

• Serum total testosterone

In addition to these laboratory tests, your healthcare provider may also ask you questions about your sexual desire (libido), your ability to get and maintain an erection, your ability to reach orgasm, your level of satisfaction from sexual intercourse and your general sexual satisfaction.

Based on your answers and the results of your lab tests, your healthcare provider may recommend a psychological evaluation to further explore the potential cause of your ED.

Whether you’ve talked to a healthcare professional or not, there are a few signs to look for that may suggest that your erectile dysfunction is psychological in nature:

• Are you interested in sex and attracted to your partner, but have trouble performing?

• Are you able to achieve an erection while masturbating?

• Do you experience morning erections?

• Are you under a lot of stress or experiencing an abnormal amount of anxiety?

• Do you get nervous about pleasing your partner?

Answering “yes” to any of these questions doesn’t always mean that your ED is psychological, but it’s a sign that one or several psychological factors may play a role in your symptoms.

It’s especially important to talk to a healthcare provider if you think that your ED symptoms may have something to do with a clinical mental health issue such as anxiety or major depression.

Treatment Options for Psychological ED

Just like erectile dysfunction caused by physical health issues, psychological ED is almost always treatable. The best way to treat psychological erectile dysfunction is to address the root of the problem, whether it’s a mental illness or simply feelings of guilt about sex. 

The many approaches can be categorized neatly into three groups:

• Medication

• Therapy

• Lifestyle changes

Let’s look at your options in more detail.

Medication

You should know that treating psychological ED isn’t always quite as simple as taking a tablet of sildenafil (the active ingredient in Viagra®) before sex. 

Although medications like Viagra®, tadalafil (Cialis®), vardenafil (Levitra®) and avanafil (Stendra®) are effective at treating ED for many men, they're not magical cures that create libido or sexual interest — they only work when you're actually in the mood, dude.

Most ED medications are PDE5 inhibitors that work by increasing blood flow to the soft tissue in your penis. 

These drugs are designed to help with the physiological causes of ED, such as poor blood flow or damage to your nerves. They may give you a little more confidence, but they’re not going to get rid of your anxiety or other psychological causes of ED.

Therapy

There are several types of therapy that can help you with performance problems. Both cognitive behavioral therapy and psychosexual therapy are approaches where a therapy professional can help you get hard (not like that), but they get you where you want to be in very different ways.

Cognitive-Behavioral Therapy

Cognitive behavioral therapy (CBT) is a common depression and anxiety treatment in which a therapy provider helps to identify and change your unhealthy patterns of thinking and behavior. Research also indicates that it’s useful as a form of treatment for men with ED. 

CBT operates under the understanding that your inability to achieve or maintain an erection isn’t the core problem — rather that you’re thinking about intimacy in a way that’s causing issues. 

When you better understand your thought patterns, you may be able to change them in a positive way to resolve your issues.

Psychosexual Therapy (Sex Therapy)

Another option is psychosexual therapy, or sex therapy. This is a specialized form of counseling that’s designed to help you (and, in many cases, your partner) overcome sexual issues such as erectile dysfunction.

Lifestyle Techniques and Therapies

If you aren’t quite ready to talk to a therapist about your psychological ED, there are numerous alternative therapies you can try at home. These include:

• Meditation. Although there’s no direct research on the effects of meditation on erectile dysfunction, studies have found that some forms of meditation may improve depression and anxiety.

• Relaxation techniques. Other techniques for promoting relaxation and reducing stress, such as rhythmic breathing and guided imagery, may help you to overcome psychogenic ED and improve your sexual function. 

If you suffer from psychological ED, you probably have a lot on your mind. As such, the thought of sharing your problems with your healthcare provider, let alone anyone else, might feel a little overwhelming. 

It is important to realize, however, that discussing ED with your healthcare provider and partner is an important part of the healing process. 

You may find that the simple act of acknowledging the issue and being honest with your partner takes some of the weight off your shoulders. 

Give your partner the opportunity to ask questions to help them understand. You might even be able to give them some tips on how to get you in the mood for sex or help you when you start to experience difficulties getting or maintaining your erection.

ED and Mental Health 

For years, men believed that ED was a normal part of growing older — and pretty exclusively related to physical causes — but hopefully your sexual health education has now been updated to include mental causes of erectile dysfunction.

What’s next? Well, If you’re having the kind of men’s health issue related to penile performance that we’ve been talking about, you still need to rule out other causes. 

Here’s your roadmap for dealing with ED:

• Don’t dismiss sexual problems just because you’re young and healthy. Young men experience relationship issues and sexual problems just like older men.

• Seek medical advice to rule out underlying causes like high blood pressure, heart disease, obesity, high cholesterol, low testosterone, problems with your nervous system and urology-related triggers for ED.

• If you think ED could be psychological in nature, talk to your healthcare provider. They will be able to help you pinpoint the cause, and suggest treatments such as medication, if necessary.

• A healthcare provider can also recommend things like psychotherapy or other mental health treatments — one of the easiest ways to get started with that today is Hims online therapy. 

We offer several FDA-approved ED medications online, which are available after a consultation with a licensed healthcare provider who will determine if a prescription is appropriate.

You can find out more about dealing with ED in our complete guide to the most common erectile dysfunction treatments and drugs.