The Fundamentals of Sex

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Erectile disorder has a specific clinical definition that men with erection difficulty do always not meet.

Variability in erections is normal and not necessarily a dysfunction.

Excessive worry about erections is a common way men inadvertantly contribute to erectile issues.

Erectile dysfunction (ED) is a real problem, affecting millions of men worldwide. It is also one of the most over-applied terms in men's health. This is especially the case when we self-diagnose.

If you're experiencing difficulty with erections for the first time, you might wonder: Do I have ED?

Probably not. Understanding the difference between dysfunction and normal variability matters more than you might think.

Please note that the following case is a composite with client details anonymized to protect privacy.

Mark was 28 years old and relatively fresh out of his first and only relationship—a high school romance. He had never experienced erectile problems during the relationship, but the couple had also stopped having any kind of intimacy over the past few years. He denied anxiety about being single and was actively looking forward to dating again. However, several of his first new sexual encounters ended with an unexpected outcome—difficulty maintaining his erections.

He entered therapy talking about his problems with “erectile dysfunction.” But was this term accurate?

The Clinical Definition

Erectile dysfunction requires meeting a specific clinical threshold. According to the DSM-5, an erectile disorder is when you experience difficulty getting or maintaining an erection (or have a noticeable change in rigidity) during at least 75 percent of sexual activity for at least six months.

That's a high bar. And it's intentional. When any erection difficulty gets labeled as ED, it’s not clinically accurate and creates unnecessary stigma.

Mark was worried that his erection problems were part of a larger issue—that this was the start of a downhill slide and the rest of his sexual life would be plagued with trouble. At the same time, he acknowledged he had no issues when masturbating on his own. Even during partnered sex, his erections were not completely unreliable. Sometimes, he had no trouble. Other times, his erections would return during an encounter. He did not meet the “75 percent of sexual activity” criteria.

Losing an erection after a night of drinking is not ED. Going soft while in conflict with a partner is not ED. Having difficulty shortly after orgasm is not ED.

Erections naturally fluctuate. This is true at any age and becomes more noticeable as we get older. Many physical and psychological factors can contribute to erection variability: alcohol, poor sleep, stress, dehydration, anxiety, relationship tension, and refractory periods. These are all normal.

These types of difficulty do not require ED treatment. They require context. When situational factors can be identified and addressed, it helps switch the focus away from thinking of yourself as “broken.”

In fact, one of the most common ways men develop genuine erectile dysfunction is by excessively worrying. When a man begins monitoring his erections, anxiety builds, causing disconnection during sex, and reinforcing the belief that sex is difficult. This then leads to an avoidance of intimacy, making any future encounters more intimidating. This is performance pressure feeding upon itself.

When the cause of his erection issues was uncertain, Mark blamed himself. He focused on his faults and, during sexual encounters, looked for signs that he was “failing.” This distracted him from what was pleasurable in those moments.

Through therapy, Mark was able to identify an important commonality in the times he had erection trouble—usually it was with a partner he did not know very well, when he pushed himself to have sex sooner than he was ready.

The Fundamentals of Sex

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A Problem With the Word "Dysfunction"

Even when erection difficulties are persistent enough to meet clinical criteria, the word dysfunction tells an incomplete story.

In most cases, some function remains. A man may have difficulty with a partner but no problem when alone. He may experience arousal and partial erections without full rigidity. He may get hard for some period of time.

That's function. It matters because where we focus our attention shapes our experience. When the negative absorbs our attention, we feel discouraged and hopeless. When we consider what's going right, we create room for progress.

No one’s anxiety is going to turn off like a light switch. Although Mark wanted that exact outcome, he instead learned how to accept his body as it showed up and navigate his anxiety in a new way. It was true that when he waited a few dates before having sex with a new partner, he felt more comfortable and had fewer erectile issues. And, even when he did experience normal variability, he was able to take it in stride, stay connected to his partner, and focus on other forms of pleasure.

This is a simple and important fact: Even with significant erectile difficulty, men can still reach orgasm and ejaculation. More importantly, they can experience intimacy, connection, and pleasure. Those are not consolation prizes. They are the foundation of a satisfying sex life.

You don't have to meet the clinical threshold for ED to deserve support. If you experience changes with your erections and they’re bothering you, that's enough of a reason to talk to someone.

If erection difficulties are persistent, distressing, or affecting your relationship, seek help. Effective treatments exist—both medical and psychological. Regardless if you are experiencing an erectile disorder or just an unexpected variation, know that you are having a normal experience, and you don’t have to go through it alone.

To find a therapist, visit the Psychology Today Therapy Directory.

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

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