Erectile Dysfunction and Sex Therapy

Erectile dysfunction or impotence affects 50% of men over 40 years of age which is an estimated 30 million people in the U.S and approximately 140 million men worldwide. This is likely to be underestimated as many men do not report erectile dysfunction symptoms to a Sex Therapist due to shame or embarrassment. Erectile Dysfunction can include libido issues, delayed or premature ejaculatory function and erectile function (inability to get or maintain an erection). This can mean not having an erection to fantasy alone or requiring excessive stimulation to get an erection or find that erections are semi-hard and may get softer easier. Erectile dysfunction is not failing to get an erection after excessive amounts of alcohol nor failing to get an erection after a period of extreme stress. ED that has a gradual, slow onset can be due blood flow or nerves while ED that comes on quickly can be due to a medication or psychological. In an initial sex therapy session, these can be explored further.

Causes of erectile dysfunction

In sex therapy and counselling, we can explore potential causes of erectile dysfunction. It may be that prior negative disappointing sexual experiences created a fear-based thought, which currently causes anxiety or relationship issues. There may be a psychological dependency on taking erectile enhancing drugs. In some circumstances it may be medical such as low testosterone, blood pressure, diabetes, prostate surgery or side effect of a medication. Even if there is a medical cause sex therapy and counselling are still incredibly useful to discuss sexual enhancement, communication and how to have a sexually fulfilling sex life with a partner.


Are erectile dysfunction drugs a solution to erectile dysfunction?

Medications are used to treat erectile dysfunction. It is effective but not all individuals can use it. Also, while it can help someone to temporarily maintain an erection, it is not a cure for erectile dysfunction. It has been shown to have a significant placebo effect. In sex therapy, this, as well as other solutions can be discussed

Psychological Dependence

Erectile dysfunction drugs does not work on emotions, a broken relationship, or create sexual desire that is not there. While medication solves the physical side of getting an erection, it may create other psychological issues such as dependence. Psychological dependence on medication may result in not being able to perform without it and result in increased anxiety and lack of self-esteem. Sex therapy can help you communicate with you partner about intimate issues. When taking these is a mutual decision, it can have a positive effect on the relationship and change lives for the better.

Erectile Dysfunction impact on relationship

Erectile dysfunction can strain a relationship as a partner may believe that he/she is no longer attractive, even if you assure him/her that this is not true. It can lead to a loss of self-esteem and avoidance of sex or sexual playfulness. Because there is a lack of sexual initiation, a partner may feel that they are not loved. It can affect a partners sense of self-esteem as well as a sense of security as they can question does he really like me or is it the pill talking?. It is much better to talk with a partner and make a decision as a couple and certainly not in secret.

It can make spontaneous sexual activity difficult. Sex Therapy Counselling can help identify alternatives to these and rule out any underlying causes.

Contra-indicated erectile dysfunction treatments

Erectile dysfunction medication can be contra indicated for individuals with low blood pressure, degenerative retinal disorders, kidney disease, liver impairment, cardiovascular risks. In some individuals, medication can cause loss of vision (particularly in people with diabetes, high cholesterol or heart disease). It can also cause headaches, indigestion, sensitivity to light and nasal congestion. It can be expensive and $30+ per tablet.

Premature Ejaculation and sex therapy

Premature ejaculation is one of the most frequent sexual dysfunctions affecting up to 40% of men. The International Society for Sexual Medicine defined Premature Ejaculation as 1) ejaculation always (or nearly always) occurring either prior to vaginal penetration or within 1 minute 2) inability to delay ejaculation in all (or nearly all) vaginal penetration and 3) negative personal consequences for the affected individual including distress, frustration, or avoidance of sexual intimacy.

Impact of Premature Ejaculation on relationship

Premature ejaculation can affect self-esteem quality of life, satisfaction with intercourse, result in low self-confidence and result in relationship issues and performance anxiety.

Indicators of Premature Ejaculation

Traditionally, clinical trials have only considered intromission time and not considered emotional distress and sexual dissatisfaction. Indicators of Premature Ejaculation may include:

  • Difficulty in delaying ejaculation
  • Ejaculation happening before it is desirable
  • Ejaculation occurring with very little stimulation
  • Feelings of frustration due to lack of control over ejaculation
  • Concerns that ejaculation leaves your partner unfulfilled

Delayed Ejaculation and Sex Therapy

Delayed ejaculation is the least studied and understood male sexual dysfunction occurring in an estimated 1-4% of men (Chen 2016). Delayed ejaculation is defined in DSM-5 as difficulty achieving orgasm despite adequate desire, arousal, and stimulation. It may be lifelong or it may be acquired. Although there is no time definition of what is “normal” vaginal-penile penetration, some studies have found that the average time from vaginal penetration is 5.4 minutes (Waldinger et al 2005) and other studies) found that 75% of individuals ejaculation within two minutes of penetration at least half the time (Kinsey (1948). Frequently men that present with delayed ejaculation are able to ejaculate while masturbating however unable to do so with a partner during intercourse. Other indicators of delayed ejaculation are distress or frustration at lack of sexual satisfaction, stopping because of sexual fatigue, physical irritation or a request from your partner to stop.

Causes Delayed or Retarded Ejaculation

Psychological causes can include depression, anxiety, relationship problems, performance anxiety, poor body image, cultural or religious stigma and differences between the reality of sex with a partner and sexual fantasies. The later can occur due to unusual masturbation techniques from pornography use which can cause genital desensitisation (Bronner 2014). Medications such as antidepressants, antipsychotics, medication for high blood pressure, substance abuse, chronic health conditions, surgeries can cause delayed ejaculation. Whatever the cause, sex therapy and counselling can help identify the underlying cause and provide a treatment plan.

Retrograde Ejaculation and Sex Therapy

Retrograde ejaculation occurs when the ejaculatory fluid travels backward into the bladder rather than through the urethra. Anejaculation is the total failure of seminal emission into the posterior urethra. Common symptoms include dry orgasm, infertility and cloudy urine. Causes of retrograde ejaculation include diabetic nerve damage, prostate or bladder surgery and radiation therapy to treat cancer. Treatment includes managing blood sugar levels if you are a diabetic and starting or changing medication. Sex Therapy and relationship counselling can help manage concerns and assist maintaining or rebuilding a great relationship with a partner. 

Painful Sexual Dysfunction and Sex Therapy

There is surprisingly little academic research done on painful sex in men, despite alot of studies on cis female individuals. One such cause is Peyronie’s disease is the development of scar tissue that can result in curved and painful erections. Enlarged prostate, yeast infections, psoriasis, dermatitis, allergies to chemicals or latex condoms, herpes or any situation where the foreskin is too tight. When pain has been present in the past, a fear-tension-pain cycle can result. This means that a fear that sex will be unpleased can create anxiety which results in tension and result in an inevitable dissatisfying sexual experience or low desire to engage in sex.

Treatment of Erectile Dysfunction in Sex Therapy

Because the brain can be the biggest sex organ erections and great sex begin there. Treatment for sexual dysfunction starts by doing a thorough assessment which is crucial to determining a treatment plan. A professional Sex Therapist can help you with techniques such as CBT,  Mindfulness, Sensate Focus, communication exercises and psychoeducation.  Therapy may help navigate any negative sexual experience, poor body image, anxiety, depression, shame, and guilt and help manage stressors that have nothing at all to do with sex and help you focus on sexual pleasure. Two common psychological causes for erectile dysfunction can be anxiety and/or past negative experiences. One particular therapy that is gaining popularity and increased scientific evidence is hypnotherapy. Sometimes, Sex Therapy may mean redefining what great sex  really is and exploring alternatives to intercourse. In other instances, it may be useful to do relationship counselling with your partner prior or in addition to Sex Therapy. Counsellors trained in both Sex Therapy and Relationship Counselling can help individuals identify innate resources and feel comfortable communicating about sexual difficulties and desires.

Research on Male Sexual Dysfunction


Up to 40% of men have experienced Premature Ejaculation, making it the most common sexual dysfunction. Premature Ejaculation results in personal distress and relationship issues, low quality of life and slow sexual confidence.


Vukina, J., Mcbride, J. A., Carson, C. C., & Coward, R. M. (2018). Premature ejaculation. Evidence-Based Urology,569-578. doi:10.1002/9781119129875.ch51


Premature Ejaculation is the most common sexual dysfunction and it is underdiagnosed as doctors do not inquire about it, making it difficult to treat. Premature Ejaculation can often have psycho-sexological components in addition to medical aspects.


Porto, R., & Giuliano, F. (2013). L’éjaculation prématurée. Progrès En Urologie,23(9), 647-656. doi:10.1016/j.purol.2013.01.005


Delayed ejaculation is a complex event that is poorly understood sexual dysfunction. A study of 100 couples found that 17% of men experienced inhibited ejaculation. Another study found that 2.5% of men were unable to have an ejaculation.


Butcher, M. J., & Serefoglu, E. C. (2017). Treatment of Delayed Ejaculation. The Textbook of Clinical Sexual Medicine,255-269. doi:10.1007/978-3-319-52539-6_17


Sexual dysfunction can have a correlation with unusual masturbatory practices. Learning new practices can have a positive effect on sexual function, unlearning old ways. It is important for clinicians to ask questions about masturatory practices when assessing sexual dysfunction.


W.B. Saunders Co.Bronner, G., & Ben‐Zion, I. Z. (2014). Unusual Masturbatory Practice as an Etiological Factor in the Diagnosis and Treatment of Sexual Dysfunction in Young Men. The Journal of Sexual Medicine,11(7), 1798-1806. doi:10.1111/jsm.12501


This study examines 88 patients with retrograde ejaculation and 136 studies of anejaculation. Medical treatment can include electroejaculation, electrovibration stimulation. Sperm quality can be impaired however there are techniques available to help with this.


Kamischke, A. (1999). Mini symposium: Non-surgical sperm recovery: Part II. Treatment of retrograde ejaculation and anejaculation. Human Reproduction Update,5(5), 448-474. doi:10.1093/humupd/5.5.448


Untreated impotence can become progressively worse as a fear of failure can eventually result in total sexual incapacity. Hypnosis has had positive result in improving impotence.


Nuland, W. (1978). The Use of Hypnosis in the Treatment of Impotence. Hypnosis at Its Bicentennial,221-227. doi:10.1007/978-1-4613-2859-9_21